Lifelong vitamin and mineral supplementation is essential in weight-loss surgery patients to prevent side-effects such as osteoporosis and fractures. However, patient compliance with supplements is known to be poor. New methods of achieving long-term compliance are offering better routes to improving the health of bariatric surgery patients.
Studies have shown that there is an increased incidence of osteoporosis in the years following weight-loss surgery.1 Bariatric surgery has also been shown to be associated with an increased risk of bone fractures.2 These risks are due to patients developing a deficiency in essential vitamins and minerals, in particular iron, vitamin B12, vitamin D and calcium. The cause of the deficiency is two-fold: the change in diet following surgery; and impairment in the body’s ability to absorb vitamins and minerals, due to the bypassing of the small intestine and reduced production of hydrochloric acid and the protein intrinsic factor (IF) owing to the reduced stomach size.
The risk of fractures and conditions such as osteoporosis can be reduced with effective, long-term vitamin and mineral supplementation.
The ‘third challenge’ of bariatric surgery
Dr Ingmar Näslund, from the Department of Surgical Sciences, Örebro University, Sweden, is a specialist in bariatric surgery with over 35 years of experience in the field. He led a group that in 2016 produced guidelines for vitamin and mineral supplementation after bariatric surgery, which have now been adopted by the Swedish and Norwegian societies for bariatric surgery.
He describes the ‘third challenge’ of bariatric surgery: “The first challenge when bariatric surgery started was to develop safe and effective surgical methods. The next challenge was to prove that the surgery benefited patients in terms of reduced mortality and increased quality of life.
“Now we face the third and biggest challenge: how to take care of the long-term, often negative, side-effects of bariatric surgery.”
Essential vitamins and minerals
Following weight-loss surgery, there is an increased risk of deficiency in vitamins and minerals. However, routinely available multi-vitamin supplements do not contain enough of these vitamins and minerals to counter the malabsorptive effects of bariatric surgery, and so numerous different supplements often need to be taken by patients.
The British Obesity and Metabolic Surgery Society (BOMSS) produced guidelines in 2014 on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery. These set out the quantities of vitamins and minerals needed following weight-loss surgery to avoid deficiency.
Vitamin B12 deficiency is one of the most common deficiencies seen following all types of bariatric surgery. Vitamin B12 is essential for the normal functioning of the nervous system. It is absorbed in the small intestine and only if it is bound to IF. With part of the stomach being removed during gastric bypass or sleeve gastrectomy, this reduces the production of IF and therefore the ability of the body to absorb vitamin B12. Injections of vitamin B12 are often needed if patients are found to be deficient. At least 350µg of complete B12 should be taken each day if injections are not indicated.
Vitamin D and calcium are essential to preventing fractures and osteoporosis. The optimal concentration of vitamin D is 75–125nmol/L after measuring of the S-25-hydroxyvitamin D value. This level is difficult to achieve following weight-loss surgery. It is therefore recommended that patients take at least 800 IU of vitamin D supplement a day. It is also recommended that weight-loss surgery patients take at least 1000mg of calcium in citrate form a day.
A compliance problem
Follow up with bariatric surgery patients needs to be lifelong, and patients need to be encouraged to take responsibility for their long-term health following surgery, including ensuring that they take the necessary supplements on a daily basis.
However, compliance with this is a problem.
Dr Näslund said: “Compliance with supplementation regimes is poor. We have seen that 10 years after surgery, very few patients still take any form of multi-vitamin on a daily basis”.3
Patient compliance can be a particular problem as, following surgery, patients will often be feeling so much better in terms of their health that they don’t see why they should need any supplements. They therefore become less diligent and forget to take supplements regularly. If they aren’t having any problems or symptoms, they can’t often see the point of taking these pills.
In addition, if a patient needs to take multiple different pills, in different forms and in different dosages, this makes it even more difficult to follow in the long term, especially when they have no symptoms of deficiency.
Tailoring supplements to weight-loss surgery patients
In 2012 a group of clinicians in Sweden recognised this lack of compliance with vitamin and mineral supplements as being a significant problem for the long-term health of their bariatric surgery patients. Through their own clinical experience and evidence from the Swedish Obese Subjects (SOS) study4, they saw that there was a need for an easy way for patients to take these supplements – a way in which it would become part of their daily routine and therefore possible for it to be maintained for life.
At the time, the only supplement options available were not tailored to weight-loss surgery patients, which meant these patients had to take multiple tablets throughout the day to ensure they got the necessary amounts of vitamins and minerals.
Working with nutritionists, the clinicians developed a supplement that contains all the vitamins and minerals needed, but in single type of tablet to be taken at any time of the day.
Baricol Complete® meets the BOMSS guidelines. The supplements contains 700µg of vitamin B12, meaning that injections of vitamin B12 are not required. Alongside a range of other vitamins and minerals, it also contains 45µg of vitamin D and 1000 mg of calcium, to help protect against side-effects such as fractures.
The minerals (iron, calcium, zinc and magnesium) are in citrate form, which ensures maximum absorption in the intestine. There is evidence to suggest that uptake of calcium citrate is better than from products containing calcium carbonate.5
A new generation of supplements for weight-loss surgery patients
Baricol Complete® is now the most popular supplement in Sweden and is recommended by most bariatric surgery centres in the country. Now available online in the UK, patients can take Baricol Complete® as either a chewable tablet or an effervescent tablet to dissolve in water. These formulations enable the vitamins and minerals to be broken down into their most easily-absorbed form while still in the mouth – as the stomach is smaller (gastric bypass and sleeve gastrectomy) and the small intestine shorter (gastric bypass), absorption needs to take place as soon as possible.
Taking one type of tablet is far easier for patients than having sometimes three or four different boxes of tablets to remember to take pills from.
Dr Näslund believes these new generation supplements will be the future of bariatric surgery nutrition, and will help to solve the ‘third challenge’: “These new products are a very interesting addition that may improve compliance. I’m pretty sure they are going to be the drug of choice for prevention of vitamin deficiency after bariatric surgery.”
- Elias E et al, ‘Bone mineral density and expression of vitamin D receptor-dependent calcium uptake mechanisms in the proximal small intestine after bariatric surgery’, Br J Surg 2014 Nov;101(12):1566-75. doi: 10.1002/bjs.9626
- Nakamura KM et al, ‘Fracture risk following bariatric surgery: a population-based study’, Osteoporos Int 2014 Jan;25(1):151-8. doi: 10.1007/s00198-013-2463-x
- Edholm D et al, ‘Long-term results 11 years after primary gastric bypass in 384 patients’, Surg Obes Relat Dis 2013 Sep-Oct;9(5):708-13. doi: 10.1016/j.soard.2012.02.011
- Aasheim ET et al, ‘Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch’, Am J Clin Nutr 2009 Jul;90(1):15-22. doi: 10.3945/ajcn.2009.27583
- Tondapu P et al, ‘Comparison of the absorption of calcium carbonate and calcium citrate after Roux-en-Y gastric bypass’, Obes Surg 2009 Sep;19(9):1256-61. doi: 10.1007/s11695-009-9850-6
Feature courtesy of Owen Haskins – Editor in chief, Bariatric News