Vitamin Confusion

[MrBeeswax 6]

I'm preOP. After reading form the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Manual of Metabolic and Bariatric Surgery (December 2024) I am confused by the diet supplement recommendations there which are very different than those from my program which they say are from ASMBS (and of course different than the statements of the Vitamin sellers). The SAGES Manual of Metabolic and Bariatric Surgery says 1 or 2 regular Multivitamins, calcium citrate 1200-1500, 2000-3000 IU Vitamin D, at least 18 mg of Iron, at least 12 mg of B1, and 350-500 mcg B12. I talked to dietician from my program today and she admitted they recommend the bariatric vitamin to everyone to keep things simple and she said it helped with compliance. I kinda feel misled because. The bariatric Vitamins are not cheap, and aside from the Calcium, Kirkland or Equate multi-vitamins with iron, a B1, and B12 would meet the basic needs per the SAGES Manual. The price of those three pills for a year costs as much as one month of some of the bariatric specific Multivitamin supplements (not including Calcium Citrate).

[Alex Brecher 10,516]

There’s a lot of confusion around which bariatric Vitamins are “approved” or recommended by groups like ASMBS or SAGES. The truth is, these organizations publish nutrient guidelines based on research, but they don’t certify or endorse specific brands. BariatricPal Multivitamin ONE was developed to meet or exceed those core guidelines in one simple capsule a day.

It includes high levels of key nutrients like ADEK, Iron, and B12 that are essential after surgery. It doesn’t try to cut corners with gummies or “bariatric friendly” labels that don’t actually meet requirements. And unlike chewables that some people struggle to tolerate long term, this is just one flavorless capsule a day.

A 12-month supply is $99, which breaks down to just $8.25 a month:
https://store.bariatricpal.com/99

Because it contains iron, it’s best to take Calcium separately to avoid absorption issues. You can find a full range of calcium options here:
https://store.bariatricpal.com/collections/calcium

And if you’re comparing formulas, there’s a full selection of bariatric Multivitamins here:
https://store.bariatricpal.com/collections/multivitamins

[MrBeeswax 6]

My concern is that SG patients don’t need all of that supplementation. In reality since absorption isn’t changed long term SG patients don’t need extra high doses oh ADEK like the GB patients do.

[SpartanMaker 1,218]

45 minutes ago, MrBeeswax said:

My concern is that SG patients don’t need all of that supplementation. In reality since absorption isn’t changed long term SG patients don’t need extra high doses oh ADEK like the GB patients do.

I feel like you may be overthinking the malabsorption component of RNYGB?

Yes, this does elevate the risk of nutritional deficiencies for some Vitamins & minerals since absorption sites are somewhat bypassed. You've got to keep in mind though that ALL bariatric surgery patients are going to be nutritionally deficient, at least during the weight loss phase when you'll be eating a very low calorie diet. Very low calorie also means very low amounts of most vitamins and minerals.

Even if your diet were perfect (virtually no one has a perfect diet), you just can't consume sufficient food to make up for your nutritional needs. Yes, you'll eventually get back to eating more normal amounts, but until then, bariatric Multivitamins have been formulated to make sure you don't suffer from nutritional deficiencies.

Keep in mind too that the supplementation recommendations are all based on averages and in reality very few of us are average. The volume of food and the nutritional quality of said food, as well as genetic and epigenetic factors all influence what you'll be able to get from diet alone, as well as how well supplementation works for you. As a result, ALL supplementation recommendations are set up to ensure ~95% of patients will have no nutritional issues.

Bariatric Multivitamin manufacturers also tend to over-rotate on anything that does not have an established upper limit since they know that their consumers will be having frequent labs done. If someone were to be deficient in a particular Vitamin, then they're likely to seek out a different product. You can see this pretty clearly by simply looking at something like the ASMBS recommendations vs the massive amounts of many vitamins found in bariatric multivitamins.

Know too that it's entirely likely your bariatric team will have you adjust your supplementation after your labs are done post operatively. Many will want to do labs around 90 days, 180 days, then annually thereafter to monitor for nutritional deficiencies (or sometimes even excesses). I for example had to modify what multivitamin I took because my B12 level was sky high.

I get the cost concern, and you may be fine with just a regular multivitamin, but keep in mind your overall food bill should drop since you'll be eating so little. This should more than cover the cost difference, so personally I'd err on the side of caution and take a bariatric specific multivitamin at least while you're in the fat loss stage. Once you're in maintenance, you might be able to adjust that (with your doctor's blessing).

[SpartanMaker 1,218]

1 hour ago, MrBeeswax said:

My concern is that SG patients don’t need all of that supplementation. In reality since absorption isn’t changed long term SG patients don’t need extra high doses oh ADEK like the GB patients do.

You're confusing RNYGB with DS/SADI. DS/SADI patients are the ones that need additional supplementation of the fat soluble Vitamins, not GB.

Edited May 22 by SpartanMaker

[Arabesque 7,565]

@SpartanMaker is on point as usual. 😊

Many surgeons initially patients on a fairly general supplement regime to begin usually including a multi Vitamin, Calcium and Iron. There are variations. Some may include Vitamin D and/or vitamin Bs as well. However, your regular blood tests, medical history, type of surgery all will influence what supplements you’ll need before surgeon, post surgery or in the long term.

Plus some surgeons have restriction on swallowing tablets in the initial weeks post surgery which will dictate how you take the supplement (gummie, patch, …).

While sleeve surgery usually does not usually require long term supplementation due to malabsorption you may be someone whose body reacts in a way that means you will need specific supplements. Or it may be discovered you are lacking in a particular vitamin, or your diet is lacking in certain nutrients. Another consideration is if you also have gall removal with your surgery or after as that can result in malabsorption issues in some. For example, I had a sleeve I was required to only take a Multivitamin and a Vit D/K. My pre surgical blood work and subsequent 3 monthly tests (actually I was having more as my GP was monitoring them too) showed I wasn’t lacking in anything. At around 8 months my surgeon okayed going off the Vitamins. The regular blood tests did eventually historically show I had a drop in vitamin D in winter (when I hibenate and bundle up). Consequently I take a Vit D/K (as a mouth spray) in winter. My gall was removed two years post sleeve and I now have issues absorbing Protein and certain medications.

Yes supplements are expensive especially if you are taking a lot & taking them long term. Finding a balance between economies and quality can be a challenge. I do recommend looking for a reputable brand (ask for referrals from your doctor, dietician, pharmacist or people here like Alex Brecher) as it is an industry in which quality and standards are not defined nor monitored like with prescribed medications.

[MrBeeswax 6]

20 hours ago, SpartanMaker said:

You're confusing RNYGB with DS/SADI. DS/SADI patients are the ones that need additional supplementation of the fat soluble Vitamins, not GB.

Actually, all three are gastric by passes. But RY is the least malabsorption.

[SpartanMaker 1,218]

1 hour ago, MrBeeswax said:

Actually, all three are gastric by passes. But RY is the least malabsorption.

By your logic we should also call DS & SADI sleeve gastrectomies. Heck, it's even in the name for SADI-S: single anastomosis duodeno-ileal bypass with sleeve gastrectomy. Either way, both surgeries probably have more in common with sleeve than traditional bypass in that they retain the pyloric valve and the bulk of the stomach is removed.

Yes, they all bypass a section of the small intestine, but RYGB only bypasses the duodenum whereas traditional DS bypasses the duodenum, jejunum, and proximal ileum. SADI-S sort of splits the difference. Where and how much of the small intestine is bypassed makes a HUGE difference in nutrient absorption since the various parts of the small intestine affect absorption differently.

Grouping them all together just because they bypass a part of the small intestine makes as much sense as grouping them in with sleeve gastrectomy since they also are pyloric-sparing surgeries.

Aside from the technicalities of the surgeries themselves, In practice DS/SADI are pretty rare, so trying to group them in with RYGB just seems really odd to most of us here. Heck, the name of the surgery specific board here is "Gastric Bypass" not "Roux-en-Y gastric bypass". If that's not enough for you, just do a Google search for "gastric bypass". Pretty much every result you get is going to be one that is using the term interchangeably with Roux-en-Y gastric bypass.

Let's get back to the question at hand and why I called this out. By you grouping all three of these surgeries together and claiming they all need additional supplementation of Vitamins ADEK is factually incorrect. Gastric Bypass patients do not need this. For someone that seems concerned about taking vitamins that "aren't needed", please don't spread misinformation about what others need.

[learn2cook 620]

After the initial giant weight loss, your individual blood tests dictate what you actually need.

[MrBeeswax 6]

16 hours ago, SpartanMaker said:

By your logic we should also call DS & SADI sleeve gastrectomies. Heck, it's even in the name for SADI-S: single anastomosis duodeno-ileal bypass with sleeve gastrectomy. Either way, both surgeries probably have more in common with sleeve than traditional bypass in that they retain the pyloric valve and the bulk of the stomach is removed.

Yes, they all bypass a section of the small intestine, but RYGB only bypasses the duodenum whereas traditional DS bypasses the duodenum, jejunum, and proximal ileum. SADI-S sort of splits the difference. Where and how much of the small intestine is bypassed makes a HUGE difference in nutrient absorption since the various parts of the small intestine affect absorption differently.

Grouping them all together just because they bypass a part of the small intestine makes as much sense as grouping them in with sleeve gastrectomy since they also are pyloric-sparing surgeries.

Aside from the technicalities of the surgeries themselves, In practice DS/SADI are pretty rare, so trying to group them in with RYGB just seems really odd to most of us here. Heck, the name of the surgery specific board here is "Gastric Bypass" not "Roux-en-Y gastric bypass". If that's not enough for you, just do a Google search for "gastric bypass". Pretty much every result you get is going to be one that is using the term interchangeably with Roux-en-Y gastric bypass.

Let's get back to the question at hand and why I called this out. By you grouping all three of these surgeries together and claiming they all need additional supplementation of Vitamins ADEK is factually incorrect. Gastric Bypass patients do not need this. For someone that seems concerned about taking Vitamins that "aren't needed", please don't spread misinformation about what others need.

I'll assume noble intent and not trolling, so here's a good attempt at civility. NIH has a good history and it is very informative and you may find it interesting https://pmc.ncbi.nlm.nih.gov/articles/PMC6806981/ My point was actually that it's wrong to group SG with any of those, because it lacks the magnitude of malabsorption potential. So yes SG is different than any of the ones that rearrange the small bowel. Some surgeons do not consider RYGB to be really malabsorptive, but some do. It is generally accepted that BPD/DS and SADI-S/Loop/SIPS are malabsorptive. For example those patients may need the full ASMBS recommended arsenal of supplements but SG patients don't, and RYGB patients do not unless the RYGB was done very differently than normal practice. There are also variations of all of these surgeries. RYGB patients may need more supplementation than SG patients nevertheless, which is what SAGES details in their surgical manual. Nevertheless my point stands. ASMBS should adopt the approach that SAGES has adopted and have procedures based supplementation guidelines vs one blanket one. The most performed surgery is SG, yet ASBMS's guidelines are closer to what SAGES recommends for BPD/DS. SG patients don't need that level of supplementation, and neither do RYGB patients for the most part. It is bizarre to me that the market is being set by one of the least performed procedures. That's the point.

Edited Saturday at 04:29 AM by MrBeeswax

[MrBeeswax 6]

On 5/22/2025 at 2:36 AM, Alex Brecher said:

There’s a lot of confusion around which bariatric Vitamins are “approved” or recommended by groups like ASMBS or SAGES. The truth is, these organizations publish nutrient guidelines based on research, but they don’t certify or endorse specific brands. BariatricPal Multivitamin ONE was developed to meet or exceed those core guidelines in one simple capsule a day.

It includes high levels of key nutrients like ADEK, Iron, and B12 that are essential after surgery. It doesn’t try to cut corners with gummies or “bariatric friendly” labels that don’t actually meet requirements. And unlike chewables that some people struggle to tolerate long term, this is just one flavorless capsule a day.

A 12-month supply is $99, which breaks down to just $8.25 a month:
https://store.bariatricpal.com/99

Because it contains Iron, it’s best to take Calcium separately to avoid absorption issues. You can find a full range of Calcium options here:
https://store.bariatricpal.com/collections/calcium

And if you’re comparing formulas, there’s a full selection of bariatric Multivitamins here:
https://store.bariatricpal.com/collections/multivitamins

That's awesome thanks!

[SpartanMaker 1,218]

6 hours ago, MrBeeswax said:

I'll assume noble intent and not trolling, so here's a good attempt at civility. NIH has a good history and it is very informative and you may find it interesting https://pmc.ncbi.nlm.nih.gov/articles/PMC6806981/ My point was actually that it's wrong to group SG with any of those, because it lacks the magnitude of malabsorption potential. So yes SG is different than any of the ones that rearrange the small bowel. Some surgeons do not consider RYGB to be really malabsorptive, but some do. It is generally accepted that BPD/DS and SADI-S/Loop/SIPS are malabsorptive. For example those patients may need the full ASMBS recommended arsenal of supplements but SG patients don't, and RYGB patients do not unless the RYGB was done very differently than normal practice. There are also variations of all of these surgeries. RYGB patients may need more supplementation than SG patients nevertheless, which is what SAGES details in their surgical manual. Nevertheless my point stands. ASMBS should adopt the approach that SAGES has adopted and have procedures based supplementation guidelines vs one blanket one. The most performed surgery is SG, yet ASBMS's guidelines are closer to what SAGES recommends for BPD/DS. SG patients don't need that level of supplementation, and neither do RYGB patients for the most part. It is bizarre to me that the market is being set by one of the least performed procedures. That's the point.

For the record, the ASMBS guidelines do differentiate between surgeries. For some nutrients, the recommendation is the same and for others it varies. At this point in time, their recommendations do not vary between RYGB and SG. It's only for DS/SADI that they recommend higher levels of certain nutrients. This is why the market has approached things in the way they have. There are "generic" bariatric Vitamins, as well as ones specifically for DS/SADI that meet the needs of those patients.

I do feel like you may still be missing that these vitamins are intended specifically for patients during the immediate post-surgical phase when they are probably eating very little food. The bulk of the nutrients they are receiving are from these products. Those needs don't vary for SG and RYGB patients.

I'm certainly not trolling. To be frank, I have a real problem with several things you've stated as I feel they are irresponsible. You need to keep in mind that for every one of us responding to this thread, there are hundreds, if not thousands of people reading this. When misinformation is spread, especially as it relates to something critical like nutritional needs post-surgery, that may lead people astray and can create a real danger.

Look, you do you. If you want to take a Vitamin from the grocery store, that's your choice and I wish you the best. For most people the smart choice is to take a bariatric vitamin, at least until given clearance by your surgical team to modify or stop doing so. There is really very little downside to taking "too much" of these nutrients, whereas there is significant risks of some pretty nasty side effects involved in taking too little. Feel free to research some of the nasty things that have happened to real people that failed to meet their nutritional needs post-surgery. It's not pretty.

[MrBeeswax 6]

2 hours ago, SpartanMaker said:

For the record, the ASMBS guidelines do differentiate between surgeries. For some nutrients, the recommendation is the same and for others it varies. At this point in time, their recommendations do not vary between RYGB and SG. It's only for DS/SADI that they recommend higher levels of certain nutrients. This is why the market has approached things in the way they have. There are "generic" bariatric Vitamins, as well as ones specifically for DS/SADI that meet the needs of those patients.

I do feel like you may still be missing that these Vitamins are intended specifically for patients during the immediate post-surgical phase when they are probably eating very little food. The bulk of the nutrients they are receiving are from these products. Those needs don't vary for SG and RYGB patients.

I'm certainly not trolling. To be frank, I have a real problem with several things you've stated as I feel they are irresponsible. You need to keep in mind that for every one of us responding to this thread, there are hundreds, if not thousands of people reading this. When misinformation is spread, especially as it relates to something critical like nutritional needs post-surgery, that may lead people astray and can create a real danger.

Look, you do you. If you want to take a Vitamin from the grocery store, that's your choice and I wish you the best. For most people the smart choice is to take a bariatric Vitamin, at least until given clearance by your surgical team to modify or stop doing so. There is really very little downside to taking "too much" of these nutrients, whereas there is significant risks of some pretty nasty side effects involved in taking too little. Feel free to research some of the nasty things that have happened to real people that failed to meet their nutritional needs post-surgery. It's not pretty.

Listen, I believe you honestly believe you mean well and are somehow helping. I honestly believe you believe that. Unfortunately, your efforts are proving instead to be high handed at best. I'm dumb, I'am not spreading misinformation. I'm not accusing you of spreading anything. I just think you're mistaken. I'm not attacking you character, or am I even finding anything wrong with you personally. My point is proven by the market place, the information provided in my program and countless others. The information from many bariatric dietitians, and surgeons that have information all over the the internet with rare exception. Patients are told you will need to take bariatric vitamins for the rest of your life. We are not told for the first year. But for the rest of our lives, we are pointed to or even given free samples of the ASMBS approved levels, and the vast majority of the brands closely mimic each other. They even say they are IAW ASMBS guidelines. That is what they say. Some formulations for example only offer 45 MG Iron. most offer way more B16 then is stated is needed. Celebrate is one of few brands that even has a sheet specifically for SG patients. I literally have put them in a spreadsheet and compared them. So unfortunately, what you say isn't true. Patients are by and large in most programs to take one of the standard formulations. For example again with iron of the ten brands surveyed, including the most popular brands 40% sold only the 45 mg iron formulation. Even the ones that sell 18mg version most of their products have only 45mg. There is no study that I've found that says men or non-mensurating women w/o other issues need more than 18mg of iron. yet most of the products have 45mg. It's worse when you look vitamin B12 which most studies say should be 500 mcg for SG patients as the upper limit, but most exceed 500mcgI only found 2 that didn't. Again, this isn't my opinion it's based on data from the marketplace from the vitamin companies themselves. This isn't misinformation. You can look it up. Again, I'm not accusing you of anything I'm telling you where I'm getting my data, it's right there as plain as day. SG patients when told to take these vitamins are being over supplemented for some of micros. SAGES is clear, multiple studies are clear about the levels of iron needed, and B13. The upper limit of iron in men or non-mensurating women is 45mg. Yet most formulations start at the upper limit despite the dangers of taking too much iron. None of this is my opinion. You dismissing me by saying you do you or accusing me of spreading misinformation or disinformation, is simply not good. You telling me I' wrong by calling the other types of bypass, by pass. You saying that some programs don't still say RYGB is malabsorptive is just wrong. Patients are provided inconsistent, overly simplified information. There is also a terrible follow up rate after a few years. ASMBS has talks about that, I watched one on YouTube last night. Again, I appreciate that you responded. But the attacks and dismissiveness are not acceptable behavior. Not on this forum or anywhere to me. We can disagree on concepts, but don't accuse me of being nefarious, do not accuse me of spreading misinformation or disinformation, dismissing as being confused. Unlike a boat load of patients I've spent countless hour, days, weeks, months, of hours reading peer reviewed studies, watching lectures talking with multiple dietitians, reading the program materials from multiple programs. The variation between programs is startling and disturbing. The lack of consistency regarding follow-up is basically alarming. SAGES in terms of 2024 manual actually calls a lot of this out. Lastly, here's a presentation from UK NHS showing multiple variations of surgical interventions. The "History of bariatric surgery" presentation from St James University has illustrations of about 14 of them. Since per ASMBS SG the most popular surgery performed, it is startling that the vast majority of vitamins exceed what's recommended for SG patients. Again, not opinion you can look up most of the manufacturers websites.

[WendyJane 44]

I have been keeping up with this thread and Vitamin supplements can easily be confused. I can only tell you what I know.

I took advice from my surgeon's team, including the nutritionist. Initially I was told to take 45 of Iron, then later to take 18 due to my age and being post-menopause. I was also told that the over the counter medications for the Multivitamin may not be enough as the bariatric Vitamins. Bariatric vitamins are specifically made for the bariatric patient, so it follows the ASMBS standards usually, but you need to look at the "fine print" and look how many mcg, mg, IU, etc of each of the vitamins are in each of the multi-vitamins.

Iron, B12, B50, B1, Calcium etc. should be based on your surgeon's recommendations.

I have had the RNY Gastric Bypass 2 weeks ago, and I had options to choose from regarding my vitamins, but I followed what my surgeon's team recommended. At my 1 month appointment I am to bring my vitamins with me for the nutritionist to review, and to ensure that I am taking what I am to be taking.

As for what is considered a by pass and what is not....Sleeve is not a bypass, but it is the first part of the SADI. That's all I know because a SADI patient told me this. Otherwise, I don't think it matters. I don't like to get into arguments online.

I wish you well as you determine what vitamins that you should be, or not be taking.

[SpartanMaker 1,218]

For anyone that may be confused by this thread, here are some things to think about related to Vitamin supplements:

1. The most important thing is to follow your doctor's recommendations. All bariatric programs I've seen have specific recommendations and you would be well advised to follow these. The vast majority seem to recommend a bariatric specific vitamin supplement. Some may also recommend specific brands of over-the-counter Vitamins as well. That said, at least from what I've seen, typically when recommending over-the-counter options, they will suggest taking these twice a day (AM & PM) instead of just once.
2. There are a few reasons for the above recommendations. First of all, you'll be eating a very low calorie diet and thus vitamin supplements formulated for "normal" people may not be sufficient. Also, while malabsorption for bypass patients is a concern, sleeve patients aren't immune to reduced absorption. Some vitamins & minerals are dependent on stomach acid to be properly absorbed. Since all WLS patients will have reduced stomach acid production (at least for a while, if not forever), higher than normal amounts of some vitamins are needed.
3. From a cost perspective, yes, bariatric vitamins tend to be more expensive, but if you have to take twice as many of an over-the-counter supplement, the costs aren't very different after all. Especially if you take advantage of subscriptions like those offered by sites like bariatricpal, the cost of a good quality bariatric Multivitamin isn't that much. Keep in mind your food bill should also drop, so at the end of the day you should still be spending less per month.
4. If for some reason you still think vitamins are just too much for your budget, please discuss this with your surgical team. They may be able to help you find a less expensive option that still meets your needs. It's never a good idea to make decisions that can impact your health simply based on things you may have seen on the web.
5. Aside form the cost concerns I mentioned above, there is very little to no downside of taking bariatric specific vitamins, even though some have really high levels of certain vitamins. For some specific vitamins, there is no established upper limit, meaning there's no health risk in taking too much. If you take in more than your body needs, then you'll just safely eliminate the excess. Yes, there are established upper limits for a few vitamins & minerals and this is taken into account in the vitamin formulation. Iron, is an example. The established upper limit is 45 mg/day, which is also the max you'll see in most supplements. Keep in mind this upper limit was established because some people had digestive upset at higher doses. You'd have to take considerably more than 45 mg/day to actually have a significant impact on your body. Further, remember when I said that some vitamins & minerals need stomach acid to be properly absorbed? Iron is one of those, meaning that you're probably not actually getting a full 45 mg/day dose as a bariatric surgery patient.
6. Regardless of which surgery you have, you should be getting regular blood tests for life that check for nutrient deficiencies. if you don't get these from your surgeon (for example, you went out of country for surgery), then please get them from your primary care physician. This is really important because some studies have shown up to 30% of WLS patients end up with nutritional deficiencies post-surgery. Don't be a statistic.
7. Human bodies are not all the same, nor are our diets. This means one person may be successful stopping vitamin supplementation, whereas someone else that had the exact same surgery from the same doctor won't be able to do that. Please don't decide what you should do based on another person, even if it's your best friend, a family member, etc.
8. Only with your doctor's blessing should you consider changing or stopping your vitamin supplementation routine. Regardless of which surgery you have, there is a real possibility you may need to take at least some form of supplements for life.
9. The effects of nutritional deficiencies can be severe, so think of your vitamin supplements as insurance against potentially debilitating or even life threatening problems.

Best of luck.