Why is vitamin supplementation after Bariatric Surgery so important?

The World Health Organization has declared obesity as one of the most serious public health issues. The number of individuals undergoing bariatric surgery for severe obesity and associated metabolic diseases is rapidly increasing. Despite their effectiveness in reducing weight and improving health outcomes, all bariatric surgery procedures alter the anatomy and physiology of the gastrointestinal tract. As a result, there is an elevated risk of developing vitamin and mineral deficiencies due to a combination of preexisting deficiencies, reduced absorption in the gastrointestinal tract and changes in the microbiome and hormonal balance. Furthermore, nutritional intake changes after bariatric surgery which can also lead to micronutrient deficiencies.

Common deficiencies and specialized vitamins supplements

Iron, vitamin D, vitamin B12 and folic acid are the most prevalent micronutrient deficiencies. These deficiencies can lead to a range of health problems, from fatigue and muscle weakness to osteoporosis, hematological and neurological complications. To optimize long-term health after bariatric surgery, it is crucial to screen and recognize symptoms of a deficiency and to prescribe lifelong use of a specialized bariatric surgery vitamin supplement. These specialized formulas are tailored to the specific nutritional needs after surgery. These formulas are continuously improved and adapted based on the results of scientific research.

Numerous studies show that daily use of specialized supplements is significantly more effective in maintaining normal serum micronutrient concentrations than regular over-the-counter supplements. Approximately 53% of regular supplement users presented one or more nutrient deficiency 4 years after surgery, whereas this number was only 15% in the specialized supplement users’ group. Moreover, serum concentrations of almost all evaluated micronutrients were lowest in the group of regular supplement users throughout the follow-up period.

The challenge of compliance

While vitamin supplementation after bariatric surgery is crucial for preventing these deficiencies, research indicates that many patients become less consistent over time. Numerous patients discontinue taking specialized supplements despite their proven effectiveness. Adherence to multivitamin supplement intake is generally defined as the degree to which patients take medications as prescribed by their healthcare professionals. The percentage of patients with poor adherence can range from 22% to even more than 50%, the majority of whom no longer use supplements at all. This is concerning as we have discovered that patients still develop deficiencies despite supplement use. I will delve the reasons behind this poor adherence and suggest strategies to improve it.

Why compliance is difficult for patients

Bariatric surgery often entails significant lifestyle changes, including diet, eating behavior, exercise, and mental processes. These changes can be overwhelming, making it challenging for some patients to incorporate new routines, including taking vitamin supplements. Consistently taking supplements daily requires discipline and commitment.

Barriers for compliance

• Many patients struggle to remember the intake, particularly if the new behavior has not become integrated into their daily regimen.
• Gastrointestinal side effects after taking supplements, including nausea, excessive belching, hiccups, vomiting, difficultly with swallowing, a bloated feeling and reflux.
• Incorrect intake of vitamin supplements or at the appropriate time. This can cause problems too. Therefore, information and advice are essential. Customer services can assist patients with this, but patients do not always reach out to them.
• Unpleasant taste, odor, and size of the supplements. Manufacturers need to further optimize the supplements to improve tolerability. A proper supplement formula is necessary to ensure adequate absorption. This requires considering all drug substances and pharmaceutical ingredients, which becomes a major challenge after bariatric surgery due to anatomical alterations.
• The higher costs for specialized supplements compared to a regular over-the-counter supplement. The high costs are a major reason why many patients discontinue taking specialized supplements. In general, we are dealing with a population with a low socio-economic status. It often occurs that patients are in debt restructuring and cannot afford these supplements.

Patience are aware but not always convinced

Specialized supplements are a crucial part of the treatment after bariatric surgery and need to be taken lifelong. Most patients understand this, but not everyone seems convinced of the advantages.

• Some patients believe that their diet provides sufficient micronutrients. Or they feel fit and therefore do not perceive the need to use special vitamin supplementation.
• One of the paradoxes of vitamin and mineral deficiencies is that they don’t always manifest immediately. Patients can feel well even if they have a deficiency. The absence of symptoms may cause some patients to underestimate taking supplements.
• A lack of comprehension about the potential consequences of deficiencies and how to prevent them can lead to poor adherence. The provision of information from healthcare professionals plays a vital role in this.
• Numerous patients strongly feel that information provided by healthcare professionals is insufficient.Patients miss explanations about different supplement options, side effects or gastrointestinal symptoms, the correct way of taking the supplements, and the associated benefits and costs.
• Many patients indicate that the information is too general, their personal preferences are not considered, and there is insufficient time during medical consultation.
• Gastrointestinal complaints following supplement intake often go unrecognized or undiscussed during medical consultation. It appears that healthcare professionals do not possess enough knowledge in this area and do not attentively listen to patients to offer suitable advice.
• Patients are concerned if healthcare professionals have the experience and skills to interpret laboratory results and adjust the supplements appropriately.

Practical tips for healthcare professionals to improve vitamin supplementation after bariatric surgery

• Discuss post-bariatric surgery complaints that may arise because of vitamin intake.
• If there are complaints, try to find out when patients take their supplements and whether adjustments are possible.
• If adjustments are not successful, advice your patient to contact the customer service of the specialized supplement manufacturer.
• Gastrointestinal complaints may vary over time. Patients may encounter numerous nutrition-related issues too that indirectly affect multivitamin intake. Therefore, address this topic during each medical consultation.
• Consider additional training if you need more experience in this area. Obesity centers routinely offer training in bariatric surgery, nutritional challenges, vitamin deficiencies, and the use of vitamin supplements.
• Find the latest news about bariatric supplementation and scientific publications on the FitForMe Research website.
• Recognize the limitations of healthcare professionals in a complex healthcare system with time constraints and mandatory protocols.

Other improvements

Postoperative consultations with healthcare professionals play a crucial role in patients’ vitamin supplementation journey. Here’s what else can help improve vitamin supplementation:

• Patients need more support from skilled professionals for patient-centered care.
• It’s essential to understand the illness experience within current healthcare systems.
• Non-directive communication with open-ended questions encourages patient input.
• Training in non-directive communication skills is valuable for healthcare professionals.
• Implementing shared decision to create more effective treatment plans aligned with the needs and preferences of patients.

Conclusion

There is no doubt that adhering to supplement intake after bariatric surgery constitutes a multifactorial issue. Gaining an understanding of the reasons behind poor adherence might result in more effective strategies for improving this behavior. By integrating education, fostering non-directive communication, and adopting a patient-centered approach, we can strive for an improved healthcare professional-patient relationship. However, the primary challenges are often related to the education of healthcare professionals in managing patients who have undergone bariatric surgery. It is evident that a reduction in the occurrence of micronutrient deficiencies can only be achieved if patients reasonably closely adhere to the prescribed treatment regimen.  

Would you like to learn more about this research study?

Simply contact us using the button below:

Source:

• Allen LV. Dosage form design and development. Clin Ther. 2008; 30 (11): 2102-11.
• Ciobârcă D, Cătoi AF, Copăescu C, Miere D, Crișan G: Bariatric surgery in obesity: effects on gut microbiota and micronutrient status. Nutrients. 2020, 12: 10.3390/nu12010235
• James H, Lorentz P, Collazo-Clavell ML. Patient-reported adherence to empiric vitamin/mineral supplementation and related nutrient deficiencies after roux-en y gastric bypass. Obes Surg. 2016; 26 (11): 2661-2666.
• Joosten EA, DeFuentes-Merillas L, de Weert GH, Sensky T, van der Staak CP, de Jong CA: Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother Psychosom. 2008, 77:219-26.
• Heusschen L, Schijns W, Ploeger N, Deden LN, Hazebroek EJ, Berends FJ, et al. The true story on deficiencies after sleeve gastrectomy: results of a double-blind RCT. Obes Surg. 2020; 30 (40): 1280-1290.
• Heusschen L, Berendsen AM, Deden LN, Hazebroek EJ, Aarts EO. Nutritional deficiencies 3 years after sleeve gastrectomy can be limited by a specialized multivitamin supplement. Obes Surg. 2022; 32 (11): 3561-3570.
• Lizer MH, Papageorgeon H, Glembot TM. Nutritional and pharmacological challenges in the bariatric surgery patient. Obes Surg. 2010; 20 (12): 1654-1659.
• Mahawar KK, Clare K, O’Kane M, Graham Y, Callejas-Diaz L, Carr WR: Patient perspectives on adherence with micronutrient supplementation after bariatric surgery. Obes Surg. 2019, 29:1551-6.
• Mechanick JI, Apovian C, Brethauer S, et al.: Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures – 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring). 2020, 28:O1-O58.
• Minvielle E, Waelli M, Sicotte C, Kimberly JR: Managing customization in health care: a framework derived from the services sector literature. Health Policy. 2014, 117:216-27.
• Osterberg L, Blaschke T: Adherence to medication. N Engl J Med. 2005, 353:487-97. 10.1056/NEJMra050100
• Schijns W, Schuurman LT, Melse-Boonstra A, van Laarhoven C,Berends FJ, Aarts EO. Do specialized bariatric multivitamins lower deficiencies after RYGB? Surg Obes Relat Dis. 2018; 14 (7): 1005-1012.
• Sjöström L: Review of the key results from the Swedish Obese Subjects (SOS) trial – a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013, 273:219-34.
• Smelt HJ, Pouwels S, Smulders JF, Hazebroek EJ: Patient adherence to multivitamin supplementation after bariatric surgery: a narrative review. J Nutr Sci. 2020, 9:e46.
• Smelt HJ, Heusschen L, Theel W, et al.: Factors affecting patient adherence to multivitamin intake after bariatric surgery: a multicentre survey study from the patient’s perspective. Obes Surg. 2021, 31:4316-26.
• Smelt HJM, Pouwels S, Heusschen L, Hazebroek EJ, Van Rutte PWJ, Theel W, Smulders JF. Factors affecting patient adherence to multivitamin intake after bariatric surgery: thematic analysis of qualitative data from a multicenter study. Cureus 15(8): e42928. DOI 10.7759/cureus.42928
• World Health Organization: Obesity and overweight . (2021). Accessed: June 24, 2023: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight.
• Zarshenas N, Tapsell LC, Neale EP, Batterham M, Talbot ML: The relationship between bariatric surgery and diet quality: a systematic review. Obes Surg. 2020, 30:1768-92.