TABLE 4.
Postoperative vitamin and mineral supplementation
| Postoperative vitamin and mineral supplementation | Grade, evidence level (EL), (range of evidence) |
|---|---|
| Recommendations | |
| •Vitamin and mineral supplements should be reviewed regularly and adjusted accordingly | GPP |
| •A complete multivitamin and mineral supplement (containing thiamine, iron, selenium, zinc and copper) is recommended daily after all bariatric procedures | GPP |
| Iron | |
| •Following AGB, consider recommending a multivitamin and mineral supplement containing iron to people, especially adolescents, as oral dietary intake of iron may be low | GPP |
| •Following SG, RYGB or malabsorptive procedures such as BPD/DS, recommend that people take additional elemental iron | Grade B EL 2 (1+ to 2−) |
| •Consider starting with 200‐mg ferrous sulphate, 210‐mg ferrous fumarate or 300‐mg ferrous gluconate daily and twice daily in menstruating women and adjust depending on blood results | Grade B EL 2 (1+ to 2−) |
| •Consider advising people to take iron supplements with citrus fruits/drinks or vitamin C | GPP |
| •Consider advising people to take calcium and iron 2 h apart as one may inhibit absorption of the other | GPP |
| Folic acid | |
| •Advise people to take a complete multivitamin and mineral supplement providing 400‐ to 800‐μg folic acid per day | Grade D EL 4 (1+ to 4) |
| Vitamin B12 | |
| •Following SG, RYGB or malabsorptive procedures such as BPD/DS, recommend routine supplementation with vitamin B12 intramuscular injections | Grade B level 2 (1+ to 2−) |
| •Following SG, RYGB or malabsorptive procedures such as BPD/DS, recommended frequency of vitamin B12 intramuscular injections is every 3 months | GPP |
| Calcium and vitamin D | |
| Vitamin D | |
| •Adjust vitamin D3 supplementation to maintain serum 25‐hydroxyvitamin D levels of 75 nmol L−1 or higher | Grade D EL 4 (2 to 4) |
| •Maintenance levels of between 2000 and 4000 IU oral vitamin D3 per day may be required following SG and RYGB and higher following malabsorptive procedures such as BPD/DS | Grade D EL 4 (2 to 4) |
| Calcium | |
| •Ensure good dietary calcium intake, recognizing that requirements may be higher in individuals who have SG, RYGB or malabsorptive procedures such as BPD/DS. If PTH is raised, despite adequate serum 25‐hydroxyvitamin D levels and calcium is normal then consider a combined vitamin D and calcium supplement | GPP |
| •To aid calcium absorption, advise that calcium taken as equally divided doses; calcium carbonate with food; calcium citrate with or without food | GPP |
| •Calcium citrate may be the preferred supplement for people at risk of developing kidney stones | GPP |
| Vitamins A, E and K | |
| Vitamin A | |
| •Following bariatric surgery, recommend that individuals take a complete multivitamin and mineral supplement containing U.K. government dietary recommendations for vitamin A | GPP |
| •Following RYGB, especially in people, consider that some may require additional routine oral vitamin A supplementation, especially if symptoms such as deterioration in night vision and dry eyes are present | Grade C EL 2 (1− to 4) |
| •Following malabsorptive procedures such as BPD/DS, recommend daily supplementation with additional oral vitamin A | Grade B EL 2 (1+ to 3) |
| •Following malabsorptive procedures such as BPD/DS, we suggest starting at 10 000 IU (3000 μg) oral vitamin A daily and adjust as necessary | GPP |
| Vitamin E | |
| •Following malabsorptive procedures such BPD/DS, recommend daily oral supplementation with additional vitamin E | Grade C EL 2 (1+ to 4) |
| •Following malabsorptive procedures such BPD/DS, we suggest starting with 100‐IU oral vitamin E daily and adjust as necessary | GPP |
| Vitamin K | |
| •Following malabsorptive procedures such BPD/DS, recommend daily oral supplementation with additional vitamin K | Grade C EL 2 (1+ to 4) |
| •Following malabsorptive procedures such BPD/DS, we suggest starting with 300‐μg oral vitamin K daily | GPP |
| Water‐miscible forms of fat‐soluble vitamins | |
| •Water‐miscible forms of fat‐soluble vitamins may improve absorption especially after malabsorptive procedures | Grade D EL 4 |
| Zinc and copper | |
| •Recommend a multivitamin and mineral containing at least the government recommended daily allowance for zinc | Grade B EL 2 |
| •Following RYGB and SG, the optimal level of zinc supplementation is not known; however, we recommend 15‐mg zinc oral daily, which may be contained within the multivitamin and mineral supplement | GPP |
| •Following malabsorptive procedures such BPD/DS, the optimal level of zinc supplementation is not known but will be higher than that for RYGB or SG. We recommend starting with at least 30‐mg oral zinc daily, which may be contained within the oral multivitamin and mineral supplement | Grade C EL 2 |
| •Following RYGB, SG and BPD/DS, recommend complete multivitamin and mineral oral supplement containing 2‐mg copper | Grade D EL 4 |
| Selenium | |
| •Recommend a complete multivitamin and mineral supplement containing selenium | Grade D EL 2 (2−) |
| •Following malabsorptive procedures such as BPD/DS, additional routine oral supplementation with selenium may be needed to prevent deficiency | Grade B EL 2 (1+ to 2−) |
| Thiamine | |
| •Recommend a complete multivitamin and mineral supplement containing at least government dietary recommendations for thiamine | Grade B EL 2 |
| •Consider recommending oral thiamine or vitamin B co strong tablets for first 3‐ to 4‐month post‐surgery | GPP |
| •Prescribe oral thiamine 200–300 mg daily, vitamin B co strong 1 or 2 tablets, three times a day to people with symptoms such as dysphagia, vomiting, poor dietary intake or fast weight loss | Grade D EL 4 |
| •Clinicians should be educated about the factors, which may predispose to thiamine deficiency and the importance of initiating immediate treatment | GPP |
| •People should be educated about the risks of potential thiamine deficiency and asked to seek early advice if they experience prolonged vomiting or poor dietary intake | GPP |
Abbreviations: AGB, adjustable gastric band; BPD/DS, duodenal switch; EL, evidence level and depicts where the majority of evidence lies; GPP, good practice point; RYGB, Roux‐en‐Y gastric bypass; SG, sleeve gastrectomy.