019 Your Questions Answered

by reeger on February 24, 2014


Your Questions Answered.Success Questions

Elizabeth: Questions about vitamins after WLS. She knows a number of people who have had different types of WLS. Her question is regarding the vitamins they are taking because they seem to be on very different vitamin regimes. Now, I can’t speak to those individuals and you know the rules and regs, I can’t tell any of my listeners specifically what to take to meet their unique needs: your bariatric provider or primary care provider is the person who can do that.

But what I can do is go over the general recommendations.
I know, I understand, that Vitamins can be confusing and seem overwhelming.
There can be some variability between who is taking what and why. Always factor that into the equation.
But as a general guideline for what a person should be taking as their foundation of vitamin regime we can turn to the WLS Clinical Practice Guidelines published in 2013.
I went over these guidelines in detail back in episode #10 but for right now I am going to focus on the vitamins only.

Everyone before WLS and forever after WLS, everyone should be taking a multivitamin with minerals. Most people know what I mean by a MVI with minerals, (it is one pill that has many vitamins and minerals all put together. Its like the expression 2 Birds/ One stone but with a MVI with minerals you hit like 75 Birds with one stones) but when you look at the label of 2 different MVI it can get overwhelming and confusing very quickly. This one 10,000mg Vitamin A, another one has 5,000. Then there is Zinc, Niacin, Magnesium, all the other vitamins and minerals listed, and some of them have herbs, or Blueberry fruit, or cranberries, and and on and on. And some talk about RDA and other talk about %DV. I totally acknowledge it is enough to make one go crazy, or worse, get paralyzed by confusion and simply not buy anything.

DONT be the paralyzed person. Buy a MVI with minerals from a company that formulates bariatric vitamins and take the dose they recommended by the company, or, better yet, bring your vitamins to your bariatric provider or PCP ask them. I have my patients do this all the time.

How many? LB take one daily (if its a 1/day). VSG, RYGB, BPDiversion with DS TAKE TWO

As I just alluded to, Not all MVI are created equally.

In episode #11 I interviewed Jacqueline Jacques, a ND who is a clinical expert in the field of medical nutrition and WLS vitamins, and we went over vitamins in detail.

Quality matters when it comes to your vitamins after WLS. Your internal anatomy is different. You ability to absorb nutrients is reduced. So given these facts, why would you, One) not take your vitamins (TAKE YOUR VITAMINS), or TWO put low quality vitamins, not formulated for your WLS body? Don’t. Your worth more.

The good news is there are many great brands of bariatric formulated vitamins out there. The top on my list is the vitamin company Bariatric Advantage.  They have a number of MVI to choose from but my favorite is their Ultra Multi Formula with Iron. This vitamin, meets the latest CPG recommendations for vitamins and minerals. It is a 3 capsule a day MVI.

I know, I know: I just said that the CPG recommends 1 – 2 MVI’s per day. Right? The BA MVI is three capsules a day because it includes all the other recommended vitamins including Iron, B12, Vitamin D, Thiamin, and folate. The only supplement not included in this formula is calcium. We’ll go over calcium in a second but….

…one topic we need to get out of the way right off the bat, is the cost of  bariatric vitamins. They’re expensive. I hear this a lot. And I get it. I do. And to date I have not heard of any bariatric vitamins being covered by insurance. If you know otherwise, please let me know.

Ok so far we have established
1) You have to take your vitamins, 2) You really should take bariatric formulated vitamins, and 3) Because They are such awesome quality, they are more expensive than regular ol’ name brand vitamins and they are definitely more expensive than generic brand.

But here’s the rub, there is no doubt that a person after WLS is at risk for vitamin deficiencies. This is no longer a debate. There is also no doubt that vitamin deficiencies can be prevented by taking vitamins.

So given this fact, let me ask you? How much is your health worth? I’m willing to bet you feel your health is pretty priceless. Right? And how much where you spending on your prescription medications before you had WLS? $50/mo? $75/mo. $100 or/month. How much would your pre-diabetes have cost you when it became full on diabetes, if you had not had WLS? How much would the knee replacement you where going to need but now don’t have cost you? How much did your work-up and ongoing care for sleep apnea cost you? But now, that your sleep apnea is gone, it doesn’t cost you anything. How much money are you saving on X-rays, medical visits, and prescriptions now that your back doesn’t hurt ALL THE TIME? How much money have your saved because your risk for cancer, heart attack, and stroke have significantly gone down?

You see where I’m here right? When you do the math on how much you health is worth and how much you are now saving not paying for all your prescriptions, not paying for your disease management, not paying for the diseases you might have gotten, I think buying quality vitamins to ensure your ongoing health is a bargain. A Bargain I tell you.

Ok, moving right along: Calcium. Your body needs calcium. Every living cells in your body needs calcium in order to function: everything from your beating heart to your blinking eye lids. If the body does not get calcium from what we eat, guess what? It takes calcium from ours bones. E Non bene. No bueno. Its not good. We all need calcium left inside our bones, that what helps keeps them strong, healthy, and resistant to fractures when we fall down.

What’s the best Calcium for a post-WLS person? Calcium Citrate because it is the more bioavailable (aka better absorbed) than other forms of calcium, especially calcium carbonate, which is often used in calcium supplements because it costs less than calcium citrate. But again, you get what you pay for.

What is the dose of Calcium citrate the CPG recommend? 1200-1500mg daily. Ideally this is divided into two doses during the day, so 600mg in the morning and 600mg at night. And Calcium should not be taken at the same time as iron because they like each other. They bind to each other and then a person, in theory, is not benefiting, as much, from either.

Calcium citrate comes in a number of different forms, as capsules, as chewable tablets, and as chewy form. Which one is right is a matter of personal preference. You need to try different forms to see which you like. However, the most important thing is that you look on the back of the bottle to see how many milligrams there are per pill and then figure out how many you need to equal 1200-1500mg. To date, I have not seen a vitamin product that 1200-1500mg in a single pill. If you know of one, please let me know.

Next Vitamin D. The CPG recommend 3,000iu (international units) of D3, also known as cholecalciferol. A question I get is what is the different between VitD, Vit D3, or D2. Vit D is the catch-all term for all D. Vitamin D2 is what foods are fortified with (milk, breads, cereals) In the US, if D2 is needed it comes as a prescription.  Not as bioavailable so the dosing is much higher per pill: like 50,000IU.

How do you know if you need Vitamin D? A blood test. In our office we test all of our bariatric patients for Vit D def. Majority are def.

The dose range most of our pt end up on is 3000-5000iu QD

That keep their blood level test greater than 30ng/ml and I usually shoot for around of 50ng/ml.

So these are the vitamins and doses that the CPG specifically recommends but they do not stop there. As you know there are numerous other vitamins and minerals to consider such as B12, Iron, B1 (thiamin), Folic Acid, Zinc, selenium, copper, Vitamins A, E, and K, etc.

In general I find that if a person is taking a bariatric formulated vitamin as directed and is eating a well balanced, healthy, whole foods diet, the vitamin levels that we routinely screen for (B12, Folic Acid, Thiamin, Vit D) remain stable and w/in normal range. The one exception is Iron, especially for menstruating females. I talked about Iron def in episode # 16 so Im not going to go into detail here beyond saying, I find that 18-60mg of Ferrous Fumerate is often not enough to keep ferritin levels in the normal range for menstruating females.
Now before I move on to other topics, I often get questions about taking B-Complex vitamin? B-Complex, as the name implies, is made of the spectrum of B vitamins. This is certainly an option for people to consider and would be a great conversation for you to have with your bariatric provider.

Final Recap: The minimum requirement for vitamin supplements after WLS surgery is:

  1. A MVI with minerals: 1 daily for LapBand, 2 daily for all other WLS patients, unless your specific MVI indicates a different dose, like in the case of Bariatric Advantage Ultra Multi Formula with Iron.
  2. Calcium citrate 1200-1500mg, ideally in 2 divided doses and 2-3 hours separate from Iron supplements or Iron containing foods.
  3. Vitamin D3 3000iu for a treatment goal of greater than 30ng/ml as determined by blood levels.
  4. The vitamin regime a person takes should be formulated for someone who has had WLS.
  5. B12 and Folic Acid should be in either the MVI, the B complex, or as individual supplements..
  6. Iron in the form of ferrous fumerate or a form that is specifically formulated for someone who has had WLS is often dosed between 18-60mg but menstruating females often need higher doses as needed to keep ferritin within a normal range.


On to another question I received on my website from Emily. Emily listened to Episode #2 where I talked about the Lap Band. She had some questions based on that episode. So I thought I’d take this opportunity to answer those questions here because if one person is wondering, it probably means more people are as well.
Emily has had some struggles with her band.  She has lost weight, but has had a lot of PBing (productive burping), she has needed some unfills, which resulted in weight gain, she also went through a pregnancy and then after the birth of her child, needed to have another unfill because she couldn’t drink water. It sounds like this over restriction was not in association to have a resent adjustment but rather simply no longer being pregnant.
Emily went on to ask what do I mean when I say eating “whole foods is best?”
What is a proper portion size and should one snack between the meals?
What is the best exercise?
What is the best mix for cardio, strength training, and stretching?
What is the optimal length of time for each, amount of days per week, and intensity?
Ok so these are all great questions:

Lets break them down

1) PBing, Unfills, Weight gain, and more unfills.
My first question is have you had your band checked under fluoroscopic X-ray? Bariatric providers don’t have X-ray eyes. If someone is struggling with their band sometimes the best way to help diagnose the problem is to look at it under X-ray.

2) Whole Foods mean healthy, whole foods that did not require a lot of science to create them. Their main ingredient list is sun, water, and dirt, grains that are fed to them, or creatures they eat in their watery homes. These are food that are not very processed. They are foods that are close to how nature intended them when they grew from the earth, or fell from a tree, or grazed in a field, or swam in a body of water: Whole vegetables, fruits, meats (including birds and eggs), and fish. These are foods one buys from the outer circle of the grocery store. If one follows the periphery, the outside circle of the grocery store and avoids going down isles as much as possible, for the most part one will be choosing “whole foods.” Whole foods are healthier, more satisfying, have more nutrients, more fiber, and more vitamins, All stuff our bodies need. And in a properly adjusted band, whole foods provide more satisfaction at the time of the meal and between meals.

3) As far as portion sizes and numbers of meals: The general literature recommends 1/2 cup to 1 cup per meal for people with a band 3-4 times per day. But that does not consider how dense the foods are: 1 cup of salad is not a lot of food but one cup of cheesy lasagna is very dense. For my patients I usually prefer they eat lower fat proteins (fats cut off and cooked without frying) and salads or vegetables. Often that looks like like eating about every 4-6 hrs during the day.

A meal should be physically satisfying meaning you are no longer physically hungry when it is done. Now hunger can be a tricky thing, many people confuse physical hunger with many different emotional or physical states; Such as boredom, loneliness, sadness, thirst, fatigue, frustration, heck even joy, love, and happiness. People can also confuse hunger as a lack of being physically stuffed. “Well, if Im not stuffed, I must be hungry.”

So next time you reaching into the refrigerator, pantry, cupboards, or going back for seconds, STOP. Ask your self what am I doing and why? Am I really really hungry for food, or is food my substitute for something else Im actually hungry for? If food is your substitute for anything other than physical hunger, you HAVE GOT to dive into those emotional issues and seek healing or the cycle will keep repeating itself. Each and every hour of every day you have an opportunity to free yourself from a vicious cycle.

Remember my all time favorite quote: If you don’t change your way, you are going to get to where you are going. SO ask yourself, is where you are going, where you are going to want to be? Because if it isn’t, change your way.

4) Exercise: Here is the secret to exercise, There is no secret. Im sorry but there isn’t. Everyone needs to move their body through space most days a week, preferably 6-7 days, for at least 30 min, preferably 60min. As far as intensity? You should know that you are exercising: Your heart and breathing rate should go up such that you can still talk but you are effecting enough that you break a sweat.

The best exercise is the one you will do and ultimately enjoy enough, over time, that you feel better when you do the activity than when you don’t.

The reality about exercise is we all need it. Period. Not debatable. And I know, you don’t have time, and other people depend upon you, and your joints hurt. I get it. I really really do. And Im still here to tell you, you need to move your body. You are not going to find the time, you make it. All those other people who depend upon you, they can wait 30 min while you take care of yourself or they can come with you. Put your baby in a stroller, ride your bike with your children (don’t forget your helmets), invite your spouse on a walk. If none of that works, go to bed 30 minutes earlier, and wake up 30 minutes earlier. When you exercise in the morning, you exercise in the morning. Its DONE.

When I look at my patients and all the different forms of moving through space, I can tell you there is a big variety of what they do and when. Some prefer classes like Zumba, Jazzercise, Yoga, etc. Some prefer putting on their headphones at the gym and doing they routines. Some prefer walking, often as a walking group with others. Some prefer swimming or biking. And many do a mixture of things.

The most important thing is to get moving doing something or a variety of things!

Action Items:
What are you doing for exercise? Tell me. I want to know.
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Mentions this Episode:
Bariatric Advantage Vitamins
Clinical Practice Guidelines
The World According to EggFace
Bariatric Foodie
MISS Conference

Podcasts I Love:
NPR Snap Judgement
NPR: TED Radio Hour Podcast
Amy Porterfield
Business Women Rock
Unmistakable Creative
The School of Greatness

My Favorite TED Talks:
Brene Brown: The Power of Vulnerability
Brene Brown: Listening to Shame
Elizabeth Gilbert: Your Elusive Creative Genius
Diana Nyad: Never, ever give up
David Steindl-Rast: Want to be happy? Be Grateful

In Peace and With Connection,

Reeger Cortell, FNP-C

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