Nutritional deficiencies are a major concern after weight loss surgery.

• You eat less food, so you eat fewer nutrients.
  
• Sleeve and bypass patients absorb fewer nutrients.
  
• You eat less fat, which makes it harder to absorb fat-soluble nutrients like vitamin A.
  

Some bariatric surgery patients take one or two multivitamins, plus an entire barrage of high-dose vitamin and mineral supplements. Others barely take any supplements. Which should you be taking? How do you even know whether you need a supplement? Can you prevent deficiencies just by eating a better diet?

VITAMIN A – Vision, immunity, and healthy red blood cells

Risk for Deficiency

• Nutrient malabsorption procedures: Roux-en-Y gastric bypass, gastric sleeve, BPD-DS
  
• Very low-fat diet
  

Food Sources

• Orange fruits (mango, cantaloupe)
  
• Orange vegetables (carrots, sweet potatoes,
  
• Green vegetables (kale, spinach)
  
• Liver
  

Deficiency Information

• Blood test: serum retinol (vitamin A)
  
• Consequences of deficiency: impaired vision; changes in iron metabolism
  

Supplement Notes

• High doses can be toxic – take only if your doctor prescribes them.
  

VITAMIN D – Calcium metabolism and bone health, affects immune function and heart health

Risk for Deficiency

• Nutrient malabsorption procedures: Roux-en-Y gastric bypass, gastric sleeve, BPD-DS
  
• Very low-fat diet
  
• Little skin exposure to sun, live in northern climate, or older age
  

Food Sources

• Fatty fish (salmon, herring, mackerel)
  
• Fortified milk
  
• Egg yolks (if you are a bariatric surgery patient, you might mostly be eating egg whites)
  
• Some fortified cereals
  

Deficiency Information

• Blood test: 25-hydroxyvitamin D
  
• Consequences of deficiency: osteoporosis (low bone mineral density and higher risk for fractures); possible higher risk for heart disease
  

Supplement Notes

• High doses can be toxic – take only if your doctor prescribes them.
  
• Need for supplementation is very common.
  

VITAMIN B12 – Healthy red blood cells, homocysteine metabolism (important in heart health)

Risk for Deficiency

• WLS that reduces nutrient absorption: gastric bypass, gastric sleeve, BPD-DS.
  
• Plant-based diet.
  
• Heavy bleeding: e.g., complication after WLS)
  
• Older age
  

Food Sources

• Animal-based foods: meat, fish, poultry, dairy products, eggs
  
• Some fortified cereals
  

Deficiency Information

• Blood test: vitamin B12
  
• Blood test: CBC (complete blood count)
  
• Consequences of deficiency: risk of heart disease; megaloblastic anemia; permanent neurological damage; osteoporosis; depression
  

Supplement Notes

• High doses not likely to be toxic.
  
• Supplements may be necessary if you are on antacids such as proton pump inhibitors
  

FOLIC ACID – Healthy red blood cells, homocysteine metabolism (important in heart health), prevention of neural tube defects (for pregnant women)

Risk for Deficiency

• Nutrient malabsorption procedures: Roux-en-Y gastric bypass, gastric sleeve, BPD-DS
  
• Low dietary intake – especially when grain intake is low after weight loss surgery
  

Food Sources

• Fortified grains (most grains in the U.S.): including spaghetti, bread, cereal
  
• Lentils
  
• Asparagus
  
• Orange juice
  
• Spinach
  
• Lima beans
  

Deficiency Information

• Blood test: serum folate
  
• Blood test: homocysteine
  
• Consequences of deficiency: cognitive dysfunction; neural tube defects; megaloblastic anemia
  

Supplement Notes

• High doses can hide vitamin B12 deficiencies.
  

CALCIUM – Bone health, muscle function

Risk for Deficiency

• Nutrient malabsorption procedures: Roux-en-Y, gastric bypass, BPD-DS
  
• Diet low in dairy products – either because of lactose intolerance or other reasons (such as avoiding milk because of the calories).
  

Food Sources

• Dairy products: milk, cheese, yogurt (choose fat-free)
  
• Fortified milk substitutes (almond milk, soy milk)
  
• Fortified orange juice
  
• Canned bony fish (salmon, sardines)
  
• Green leafy vegetables (absorption is poor)
  
• Some fortified cereals
  
• Tofu
  

Deficiency Information

• Blood test: calcium levels – note: this is not a good test for adequate calcium! You can have normal test results and still not have enough calcium in your diet!
  
• Dietary intake analysis: see if you get at least 1,200 to 1,500 milligrams per day from your diet.
  
• Rough estimate of dietary intake: at least 4 servings of high-calcium foods each day
  
• Consequences of deficiency: decreased bone mineral density (osteoporosis and higher risk for bone fractures)
  

Supplement Notes

• Taking too much calcium can cause kidney stones and be bad for the heart.
  
• Ask your doctor how much calcium you should take in a multivitamin and as a calcium (or calcium and vitamin D or calcium and magnesium) supplement.
  
• Don’t take your calcium supplement at the same time as iron because you will interfere with absorption
  

IRON – Healthy red blood cells, energy and other metabolism

Risk for Deficiency

• Nutrient malabsorption procedures: Roux-en-Y, gastric bypass, BPD-DS
  
• Vegetarian or vegan (plant-based) diet
  
• Adolescents and women of child-bearing age.
  
• Individuals with excessive bleeding (such as with a post-op complication)
  

Food Sources

• Fortified grains (most grains in the U.S.): including spaghetti, bread, cereal
  
• Meat, seafood, and poultry (animal-based sources have a more absorbable form of iron)
  
• Beans and lentils
  
• Green vegetables, such as spinach, kale, broccoli
  
• Potatoes
  
• Raisins
  
• Deficiency Information
  
• Blood test: serum iron/Fe
  
• Blood test: ferritin
  
• Blood test: total iron binding capacity (TIBC) (high value means low iron status)
  
• Blood test: hemoglobin and hematocrit
  

Supplement Notes

• Iron supplements can be toxic even if your dose is not that high. Don’t take them unless your doctor prescribes them.
  
• That includes iron in multivitamins.
  
• Don’t take iron supplements at the together with calcium supplements.
  
• Try to take supplements with vitamin C (in food or as a supplement) to increase absorption.
  

THE OTHERS

The above deficiencies are most common among weight loss surgery patients, but other deficiencies are possible. You are at risk because of your low food intake as you restrict calories. Malabsorptive procedures, such as gastric bypass and gastric sleeve, also put you at risk. Ask your doctor if you are concerned about any of the following vitamins and minerals. Often, a simple blood test or even a run-through of your daily diet can help you figure out if you need an additional supplement over your daily multivitamin and mineral supplement.

• B vitamins: B1 (thiamin), B2 (riboflavin), B3 (niacin)
  
• Vitamin C
  
• Vitamin K
  
• Magnesium
  
• Zinc
  

The Bottom Line

Nutritional deficiencies are a big risk after weight loss surgery, but they depend on a few different factors.

• Type of weight loss surgery – sleeve and bypass patients are more prone to nutrient deficiencies than lap-band patients.
  
• Your diet – eat protein first and choose nutritious foods to lower your risk of deficiencies.
  
• Genetics and other uncontrollable factors – women are more likely to need iron supplements, for example, than men.
  

Megadoses of vitamin and minerals can be toxic, so don’t prescribe them for yourself. Instead, contact your surgeon or regular doctor. Simple tests can often let you know your nutrient status so you can know which nutrients to supplement.

This is very good info, Alex. Thank you. I wanted to add a few things that people may want to consider. I am 12-yrs out from gastric bypass and I believe can speak to some of the long term effects on nutrition of the altered anatomy.

Several years ago, I cannot recall when, I developed celiac disease and then lactose intolerance, both with causal links to gastric bypass.

I also suffered Iron deficiency anemia about two years after I stopped taking iron supplements under the advice of a bariatric surgeon (not my surgeon). It took a very long time for me to begin feeling normal and an even longer time for my blood work to normalize.

More recently I was having very disruptive digestive issues which went on for 4-months or so and are yet to be diagnosed -- although I have received lots of theories -- but there is no doubt in my mind they are related to my gastric bypass. There were times that the pain was so bad that I nearly went to the ER or felt as though I would pass out. I should add that all of my nutritional labs were good, I even tested trace minerals, because I take a boatload of supplements.

What seemed to help were the following:

Two different digestive enzymes and an herbal hepacleanse from a naturopathic doctor as well as energy work/massage to release blockages. I also added Probiotics, zyflamend, powdered magnesium citrate that gets added to Water, psyllium husk that gets added to water, and super aloe in capsules. And I upped my consumption of mineral water (versus spring water). And lest I not forget that I added prayer and meditation -- the mind body spirit connection is real.

Finally the inflammation, bloating, upper abdominal PAIN, constipation, abdominal distention, lower bowel PAIN seem to be resolved.

I hopes this helps someone!

@@My Bariatric Life @@Alex Brecher

Thank you both for the article and response. I was hospitalized for malnutrition about 7 months after surgery. I literally was going to die from cachexia. I've had problems ever since then. I had GI issues before the surgery and the surgery was to fix a problem. Not only did it not, but caused a bunch of other issues.

My bariatric surgeon did not test for all the items above. Only for what was "general for their patients". They also didn't know how to deal with complications, or, it appears, how to listen to a patient and not say everything was all in their heads.

I would suggest, based on my experience, that people really ask about the aftercare. This is huge problem after surgery, and I've seen it on several forums. I was shocked and surprised when one post addressed it and got a lot of answers feeling the same way. My questions would be how much aftercare is performed, what types of complications have they dealt with and what ones have they dropped? I've seen "ads" that tout how great a place is, but can't take care of problems and end up really dumping them on other doctors. Please, I don't want to see others in that situation. I'm having a number of physical problems that interrupt my life and are expensive, all because a surgeon didn't know the researched complications after the surgery and didn't work with my doctors when his consult was requested (or put it in when it wasn't).

Good luck to all.

I have had excellent bloodwork including a very detailed analysis I had last year. I continue to monitor though....3 years 4 months post sleeve.

A few days ago I was told by my naturopathic doctor that my body is digesting my lean tissue and I needed to add more Protein to my diet. This was shown in a chemical analysis that I had done on my hair. I am using a supplemental collagen in lieu of whey protein that he recommended as I am very excited about the nutritional profile of the collagen. It is 90% protein and has a lot of amino acids One TBS has 6g protein, 0 carbs, 25 calories, and it is easily absorbed by the body. It also seems to be manufactured under very strict conditions.

​To me it looks like a fabulous product for bariatric patients, especially when recovering from surgery owing to the amino acids and the easy assimilation of the protein. But I am not a clinician so do check with your nutritionist. Again, I hope this is helpful!

Here is the manufacturer's description

Hydrolyzed collagen helps regulate the body's metabolism by providing pure protein of low molecular weight that is quickly absorbed in the digestive track. The rapid absorption and distinctive amino acid groups in this formula will positively impact a large number of metabolic pathways. The body's natural ability to repair supporting connective tissue (bone, tendons, ligaments, cartilage, skin, hair, and nails) diminishes after the age of 25. Collagen provides the source in supplying additional amounts of amino acids like glycine, lysine, and proline, which are specifically needed by the body to build connective tissue structure and to regulate the functions of the cells. Hydrolyzed collagen is the same collagen found naturally in bones, skin, and cartilage. it is a bioactive product containing 90% protein easily assimilated by the human body. It promotes rapid Cell growth producing synovial fluids to first lubricate joints, then build tissue. Recommended dosage: Take one rounded tablespoon (10-12 g) in the morning, and the same amount before going to bed in the late evening which will help reduce appetite. This product has a low molecular weight so it will dissolve in cold, warm, or hot liquids. Collagen, the precursor of Gelatin is used today in many pharmaceutical or biotech products to better improve mankind's health condition.

The best deal that I found on Amazon included a jar of the hydrolyzed and a jar of the regular collagen (the difference being that the hydrolyzed will dissolve in cold liquids whereas the regular will need to dissolve in room temp or hot liquid). Plus the deal includes a shaker bottle and free shipping. Cost is $39. Here is the link: http://www.amazon.com/Great-Lakes-Collagen-Hydrolysate-Unflavored/dp/B00UNPJEUY/ref=as_sl_pc_qf_sp_asin_til?tag=bornappe-20&linkCode=w00&linkId=C7AQEWZODLBHV5FS&creativeASIN=B00UNPJEUY

I am a bit concerned over that. Collagen is not the optimal Protein as I do not believe it is a complete protein source, compared to something like whey. I believe it is missing trypotophan, something you get from items like turkey. (In my family we call it the trypotophan high.)

Try https://asmbs.org/resources/integrated-health-nutritional-guidelines. This might help, do a search for collagen. Best of luck.

Dear MyBariatricLife,

So, my gastric bypass was 14 years ago. I have been gluten intolerant OR celiac for ten years. I have Crohn's for over six years. I think I am on the road back to wellness from following a holistic approach. I noticed you see a naturopath, and I think that is wonderful.

I identify mostly with having Crohn's disease. I am on Bariatric Pal to see if I can find other WLS patients who have Crohn's or celiac-or-gluten-intolerance. Ten years ago when I asked the doc to test me for celiac, I was told that was impossible for me to have. So I went gluten free anyway. The surgeon who removed part of my large colon (from the Crohn's) told me they think I am celiac but not to go back on gluten just to be tested.

My problems did show up after the gastric bypass, but I feel they are mostly genetic and not from the gastric bypass surgery. I will add this tidbit: Be cautious about antibiotic use after a gastric bypass. The year before I was diagnosed with Crohn's I was on long-term (very strong strain) antibiotics for six weeks to treat a chronic sinus infection. More people are showing up with IBDs from antibiotics.

I eventually had a sinus ablation which took care of me needing antibiotics for chronic sinus infections ever again.

Now I take Natren Healthy Trinity probiotics every day. I also take many other supplements for the Crohn's. For Iron and minerals I take Angstrom and nano-particle supplements, which are great for WLS and Crohn's.

I tried to look at your blog, but I could not get there. Is it still up?