Vitamin Supplementation Post-Bariatric Surgery

Vitamins are nutrients obtained primarily from diet. They are grouped into vitamins A, C, D, E, K and the B vitamins that include thiamine, riboflavin, niacin, pantothenic acid, biotin, vitamin B-6, vitamin B-12 and folate. Each vitamin is an essential requirement for proper health and well-being.

Vitamin A plays a role in promoting bone growth, vision, immunity, and in keeping the reproduction system healthy. Vitamin C helps the body in absorbing iron, protecting it against free radicals, and in keeping the skin and connective tissue healthy. Vitamin D is necessary for the absorption of calcium for bone growth. Vitamin E is a very important antioxidant that protects the body from harmful free radicals. Vitamin K is essential for making proteins that enable blood clotting. The B group of vitamins is required for generating energy from the food we eat and in the formation of red blood cells.

Vitamins and Post-bariatric surgery patients

The level of vitamin or micronutrient deficiency after bariatric surgery depends to a large extent upon the pre-operative nutritional status. The type of surgery is also very important as procedures such as the laparoscopic gastric band or the laparoscopic gastric sleeve do not have the same degree of malabsorption as the laparoscopic gastric bypass or more extreme bypass procedures. Vitamin absorption occurs throughout the gastrointestinal tract but mostly in the small intestine.

Water soluble vitamins are absorbed in the jejunum and upper ileum. Fat-soluble vitamins are absorbed in the jejunum. Vitamin B12 is absorbed in the terminal portion of the ileum. Thus, a bariatric procedure that involves the bypass of the jejunum can lead to vitamin malabsorption; the severity of malabsorption will depend upon the extent of bypass. A biliopancreatic diversion with or without duodenal switch is considered a high-risk procedure for fat-soluble vitamins A, D, E, and K. Conversely, as a general rule, routine Vitamin A supplementation is not as important after an RYGB procedure. However, periodic screening is recommended. Post-bariatric surgery Vitamin A deficiency can be caused by a number of reasons such as poor diet, poor digestion, malabsorption, and poor liver function. Generally, Vitamin E levels remain normal after surgery and one should guard against overcompensation as it can exacerbate blood clotting issues related to Vitamin K deficiency.

Because water-soluble vitamins have to replenished on a very regular basis; patients have to guard against water-soluble vitamin deficiency metabolic complications that may arise in the immediate aftermath of bariatric surgery. Intravenous and parenteral doses of these vitamins may be given early on to manage deficiency. Vitamin C increases iron absorption; iron and Vitamin C supplements are usually given together.

Vitamin B12 deficiency is sometimes observed in patients that have undergone gastric bypass procedure and usually results from the bypass of the lower portion of the stomach which makes an enzyme required for absorption. Folate deficiency is less common as this vitamin is absorbed across the entire small intestine however because intestines are often bypassed, folate supplementation is especially important in women who have had bariatric surgery and become pregnant.

Apart from regular screenings to test for vitamin deficiency, symptom-based tests may also be carried out. Liver functioning should be monitored to ensure proper synthesis of fat-soluble vitamins, particularly Vitamin D. Vitamin D deficiency affects calcium uptake by the body and can lead to osteoporosis. Poor absorption of Vitamin K can prevent the blood from clotting at the site of a cut; therefore Vitamin K status has to be monitored as there is a chance of the deficiency occurring in 2-4 years from the surgery.

In order to ensure a proper supply of vitamins to the body, doctors recommend a lifelong intake of multivitamins for bariatric surgery patients. Apart from these, individual vitamin supplements can be taken based on individual profiles.

Vitamin deficiency and obesity

Obese individuals have been reported to have low concentrations of Vitamin D, Vitamin B6, B9, and B12, Vitamin C, and Vitamin E. The relationship between obesity and options for post-surgical supplementation is an active topic for researchers. More information and data is required to understand how vitamin deficiencies can contribute to obesity and the manner in which obesity induces vitamin deficiency.

Chronic or long-term vitamin deficiency is termed avitaminosis. Not getting enough sufficient vitamins or defective metabolic conversion mechanism can lead to vitamin deficiency.

Vitamin A deficiency is most commonly characterized by night blindness and is a cause of concern for children in developing countries.
Vitamin C deficiency leads to scurvy. Spongy gums, bleeding from mucous membranes are some of the symptoms. Loss of teeth and open wounds can result in advanced cases.
Vitamin D deficiency leads to soft bones and poor bone mineralization. Rickets is a childhood condition that results in poor bone growth and deformation of the long bones.
Vitamin E deficiency usually does not have diet-related reasons. Disorders related to fat metabolism are associated with this deficiency. The deficiency leads to impaired nerve conduction and neuromuscular problems.
Vitamin K deficiency due to poor nutrition is rare. Usually, it is caused by obstructions in the intestinal uptake of the vitamin. The subject risks blood loss from wound sites and cartilage calcification.
Vitamin B1 (Thiamine) deficiency causes Beriberi, a wasting disease that affects the nervous system.
Vitamin B2 (Riboflavin) deficiency causes Ariboflavinosis which is characterized by sore throat, cracked lips, and decreased red blood count.
Vitamin B3 (Niacin) deficiency causes pellagra which leads to poor tolerance to cold and is characterized by diarrhea, dermatitis, and dementia.
Vitamin B5 (Pantothenic Acid) deficiency can lead to acne and poor energy levels that are characterized by irritability and fatigue.
Vitamin B6 (Pyridoxine) deficiency is characterized by depression, conjunctivitis, and may lead to microcytic anemia.
Vitamin B7 (Biotin) deficiency is characterized by hair loss, conjunctivitis, depression, hallucination, etc.
Vitamin B9 (Folic Acid) deficiency is characterized by glossitis, diarrhea, depression, confusion, and anemia.
Vitamin B12 (Cobalamin) deficiency leads to memory loss and cognitive defects. It is usually found in the elderly population.

Hypervitaminosis

Excessive amounts of vitamins in the body or hypervitaminosis can lead to vitamin poisoning. This is invariably an occurrence with fat-soluble vitamins A, D, E, and K; water soluble vitamins are excreted by the body, and hence cannot accumulate to dangerous levels. Hypervitaminosis is rarely caused due vitamins consumed through diet; high supplement intake is usually the reason for the condition.

Hypervitaminosis A can cause impaired liver functioning, birth defects, discoloration of the skin, and hair loss.
Hypervitaminosis D can lead to a high level of calcium in the blood and kidney stones.
Hypervitaminosis E can cause internal bleeding because of the vitamin's anti-coagulant properties.

Dietary sources of vitamins

Vitamin A – Sources of vitamin A include raw carrots, calf liver, milk, and eggs.
Vitamin B1 – Asparagus, Brussels sprouts, tomatoes, mushrooms, watermelons, and carrots are good sources of vitamin B1.
Vitamin B2 ¬- Romaine lettuce, asparagus, chard, mustard greens, broccoli, and collard greens are good for meeting the body's requirements of vitamin B2.
Vitamin B3 – Halibut, beef liver, mushroom, and tuna are good sources of vitamin B3.
Vitamin B5 – Mushrooms, cauliflower, calf liver, eggs, and strawberries are very good sources of Vitamin B5.
Vitamin B6 – Sources of vitamin B6 include yellowfin tuna, chicken breast, banana, salmon, snappers, halibut, etc.
Vitamin B7 – Sources of vitamin B7 include chard, tomatoes, almonds, chicken eggs, onions, etc.
Vitamin B9 – Lentils, squash, calf liver, papaya, and cauliflower are good sources of vitamin B9.
Vitamin B12 – Dietary sources of vitamin B12 include salmons, sardines, shrimp, eggs, and milk.
Vitamin C – Good sources of vitamin C include parsley, papaya, lemon, orange, strawberries, mustard green, and bell pepper.
Vitamin D – Salmons, sardines, milk, egg, sunflower seed are good sources of vitamin D.
Vitamin E – Broccoli, tomatoes, mustard green, sunflower seeds, papaya, and olives are regarded as good sources.
Vitamin K – Sources of vitamin K include spinach, carrots, green beans, asparagus, kale, tomatoes, and mustard greens.

Vitamin supplements

Vitamin A supplements are available as retinol and retinyl-palmitate.
Vitamin B1 – Most supplements contain thiamin hydrochloride, a non-active form of the vitamin.
Vitamin B2 – This vitamin is a part of most dietary supplements in the simplest chemical form of riboflavin.
Vitamin B3 - Nicotinic acid is a form of vitamin B3 that has been shown to lower cholesterol and is commonly used in supplements.
Vitamin B5 supplements are commonly available as pantothenic acid and calcium-D-pantothenate.
Vitamin B6 supplements are commonly available in the form of pyridoxine hydrochloride. Pyridoxal-5-phophate, the active form of the vitamin is also widely prescribed by medical practitioners.
Vitamin B7 is available in the form of D-biotin. It is usually a part of all dietary supplements.
Vitamin B9 is most likely to occur as pteroylmonoglutamic acid in vitamin supplements.
Vitamin B12 supplements are most commonly administered in the form of cyanocobalmin. Sublingual administration is more effective in delivering the vitamin to the bloodstream as against tablets or nasal doses.
Vitamin C supplements are most commonly given in the form of ascorbic acid; a buffered form of vitamin C is prescribed for those with sensitive stomachs.
Vitamin D is popularly given in the form of cholecalciferol, which is of animal or microbial origin.
Vitamin E supplements usually contain the naturally occurring form of alpha-tocopherol.
Vitamin K dietary supplements include the phylloquinone and menaquinone forms of vitamin K. Your doctor may recommend a full spectrum vitamin K that contains both phylloquinone and menaquinone.

Vitamins and interactions with medication

Vitamins interact with the body and the production of enzymes and proteins needed for daily function. Even over the counter vitamins should be considered a form of medication. Just as problems arise when vitamin levels are too low or too high, certain medications may interfer with the levels and use of vitamins in your body.

Vitamin A – Certain cholesterol-lowering medications may increase blood levels of vitamin A. Antibacterial drugs can decrease absorption of Vitamin A.
Vitamin B1 – Certain diuretics, sulfa drugs, and antibiotics can prevent the conversion of vitamin into its chemically active form.
Vitamin B2 – Anti-malarial drugs, oral contraceptives, and antibiotics and deplete the amount of this vitamin in the body.
Vitamin B3 - Apart from oral contraceptives and an anti-tuberculosis drug there are no known medicines that diminish the body's stock of this vitamin.
Vitamin B5 – There are no known detrimental drug reactions with respect to vitamin B5.
Vitamin B6 – Certain anti-fibrotic drugs, asthma-related drugs, and diuretics are related to vitamin B6 depletion.
Vitamin B7 - Anticonvulsant drugs can affect the absorption of Vitamin B7.
Vitamin B9 – Cholesterol lowering drugs and anti-inflammatory medicine can reduce the amount of vitamin B9 in the body.
Vitamin B12 – Antibiotics, potassium replacement medicine, cholesterol-lowering drugs, and antihypertensive medicine can deplete the body's supply.
Vitamin C – Sulfa drugs and non-steroidal anti-inflammatory drugs can diminish the body's stores of vitamin C.
Vitamin D – Corticosteroids, bile acid sequestrants, and certain anticoagulants affect the activation of vitamin D by the liver.
Vitamin E - Anticonvulsant drugs and cholesterol – lowering medicine can lower the body's stock of this vitamin.
Vitamin K - Anticoagulant medicines and cholesterol-lowering drugs may interfere with Vitamin K metabolism. Broad-spectrum antibiotics affect Vitamin K synthesis in the gut by killing helpful bacteria.