What to Look for When You Shop For a Vitamin
If you are considering or have already undergone lap band surgery, you are probably aware that you should take some form of nutritional supplementation for the rest of your life . Actually, you aren't alone. The American Medical Association recently made a recommendation that all Americans take a daily multivitamin and mineral supplement based on evidence that our diets don't really supply the nutrition we need . This is even truer after gastric bypass for two primary reasons: 1) typical bypass surgery changes the way some critical nutrients are absorbed and 2) the reduced food portions and dietary restrictions that are required after surgery mean that even fewer nutrients are consumed.
So the question is not should you supplement, but rather what should you look for when you choose a supplement to take. While new labeling laws have required manufacturers to put more information on their labels to inform consumers, most people would still need a degree in nutrition and a good magnifying glass to decipher it. The following is a list of relatively simple things you can look at when evaluating a nutritional product with some special considerations for gastric bypass patients.
1. Start by looking at the nutrition facts box. This is the place on the label where the amounts and usually forms of the nutrients are listed together with the percentage of the Recommended Daily Allowance (RDA). It is best for vitamins to be at least 100% of the RDA and for minerals except iron, fluoride, phosphorus and electrolytes (such as sodium and potassium) to be at least 50%. Many formulas really skimp on minerals because they take up a lot of space. The average once daily multivitamin contains 100 milligrams or less of calcium, for example. Since bone loss may be more pronounced after gastric bypass, this is important to consider .
2. Many higher quality products are not in once daily preparations. Why? One reason is space for denser nutrients such as minerals. Another thing to consider is absorption. Just as we want to divide our food intake throughout the day to maximize nutrient intake and maintain our energy, the same can be said for vitamins.
3. Are the nutrients labeled as USP and or NF? A USP designation means that the ingredient meets the criteria of the United States Pharmacopoeia. An NF designation means then the nutrient meet the criteria for the National Formulary. These are standards of quality control and reflect pharmaceutical quality for an ingredient. These standards are currently available for around 1800 substances, so not all nutrients are available in this form.
4. Does the product meet the USP requirements for disintegration and dissolution? This is very important after gastric bypass as this means that the product has been rigorously tested to make sure that it breaks down in the digestive system in a certain amount of time. This information may not be on the label – you may need to contact the manufacturer to find out. The USP requirement for capsules is 30 minutes, for tablets 45. For this reason, a USP tested capsule or a chewable formula may be best after bypass surgery.
5. Next look at the total ingredients list. This is a long list of everything that goes into the product. This list should disclose everything including non-nutritional ingredients.
6. Look specifically at the vitamin A. How much is from non-toxic beta-carotene. It is best to get vitamin A in this form, as it cannot be overdosed.
7. Look at the vitamin E. Is it in a natural form? The natural forms of vitamin E are listed as “d” forms such as d-alpha tocopheryl acetate or succinate. If the form is preceded by “dl” then it is synthetic. Natural forms of vitamin E are significantly more bioavailable . You may need to look in the total ingredient listing to see this information.
8. Look at the vitamin D. Is it D2 (synthetic, ergocalciferol) or D3 (natural, cholecalciferol)? This is important for gastric bypass patients because patients with clinical morbid obesity may not be able to convert D2 to the active form of vitamin D needed for bone health .
9. What forms are the minerals in? Many supplements use inorganic oxides that are hard to digest and have relatively poor bioavailability . It is best to see the minerals as citrates, malates, gluconates or amino acid chelates. Some specific minerals have special forms that are more bioavailable such as selenomethionine for selenium and the picolinoate or polynicotinate form of chromium. Many forms of iron can cause constipation – especially ferrous sulfate. Look for a citrate, glycinate or chelate.
10. Does the product contain herbs or herbal extracts? This is important to consider especially if you are taking prescription medications as there may be interactions . While it is becoming quite popular to include herbs in vitamin supplements now, it would be best to seek the advice of your physician before taking something with herbal ingredients.
11. What else is in your vitamin? Many people are shocked to find the number of “other” ingredients in their supplements. Some things that you may find on a label that don't need to be there include:
Artificial colors – these are there for looks alone and have the potential to cause allergic reaction in sensitive individuals. They are not essential for health.
Artificial flavors – most common in chewable formulas
Sugars – common are fructose (fruit sugar), lactose (milk sugar), glucose and sucrose. This is important to consider if you are restricting sugars, have diabetes, or are intolerant to milk sugar/lactose.
Artificial sweeteners – such as acesulfame-K or aspartame. Again, no health benefit and may be harmful to some individuals. A better choice is sucralose, which is derived from sugar, or sugar alcohols such as sorbitol, xylitol, or maltitol in small amounts (although large amounts of sugar alcohols can cause gas and diarrhea).
Other ingredients that sometimes show up are hydrogenated or partially hydrogenated fats, starches, and preservatives.
Bottom line – the shorter the list of “other” ingredients, the better.
12. You might also want to ask you doctor for his or her recommendation. Some physicians recommend additional minerals, sublingual B12, or other special nutrition based on your health and laboratory data.
Choosing a good quality supplement after gastric bypass is an important part of promoting your lifelong health. While this list is not exhaustive, it provides some basic things to help you evaluate the quality and value of what you are purchasing. Higher quality products may come with a higher price tag, but can be worth it if the nutrients are better absorbed, don't upset your digestive system, and don't contain a lot of non-nutritive ingredients.
Regardless of what you choose to take, ultimately the most important thing you can do is to take it. I am fond of telling my patients that an unopened bottle sitting on shelf won't do anything for you. Taking vitamins is a habit, and just as you need to take on new dietary habits after gastric bypass, you will need to learn to fit supplementation into your life. So once you have found a product that works for you, find a regimen that works for you as well.
Even if you are taking your supplements regularly, there is still the possibility of developing nutrient deficiencies. For this reason, it is important to have a regular physical and blood work. Your surgeon may recommend special tests to evaluate nutritional status in addition to standard blood work. If you develop a new symptom such as persistent fatigue, it is important to inform your doctor so that appropriate evaluation can be done.
Some Important Points About Calcium
Calcium is the single most plentiful mineral in the human body, and is very important to many aspects of human health. 99% of the calcium in your body is stored in your bones and teeth. The remaining 1% circulates in your blood stream and helps to regulate functions like the contractions of your heart, the ability to move your muscles, and the signaling of your nerves. There are two ways your body can keep adequate calcium circulating to maintain these vital functions in proper working order: from the food you eat or by removing it from your bones. The ideal is that we get adequate calcium from our food sources so that we never have to take calcium out of storage, but few Americans actually accomplish this. Survey data from the United States Department of Agriculture (USDA) suggests that the average American only gets about 700 milligrams of dietary calcium per day. The National Academy of Sciences tells us to maintain bone health, we need between 1000 and 1300 milligrams daily, far above what most of us can accomplish with diet alone. Under some specific circumstances such as osteoporosis or malabsorption (such as after weight loss surgery), higher doses of calcium may be recommended. The safe upper limit has been set at 2500 milligrams daily for all ages, and should not be exceeded without physician supervision.
Patients who have undergone weight loss surgery need to think carefully about calcium supplementation. Most forms of calcium require contact with stomach acid for proper absorption. With a small stomach pouch, this essential contact is greatly diminished or does not happen at all. Additional concerns with gastric bypass and other forms of weight loss surgery such as duodenal switch, can include higher risk for the formation of kidney stones and malabsorption of fat soluble nutrients such as vitamin D that are critical for bone health and calcium metabolism. For this reason, it is important to give careful consideration not only to the amount of calcium supplemented, but also to the form, and to assure adequate intake of the other nutrients important to bone health. Generally calcium citrate has been shown to be the best-absorbed form in human studies. It may be of special preference following gastric bypass because it requires little or no stomach acid for absorption. Additionally, recent studies on both diet and supplements suggest that calcium citrate may protect against kidney stone formation, which may be an added benefit for this form.
