Can You Have Bariatric Multivitamins with Calcium?

With so many different types of multivitamins out there, it is hard to know what is the best product for you as a bariatric surgery patient and what your body can actually absorb. Unfortunately, not all companies (including many over-the-counter brands and some bariatric vitamin brands) follow the rules of how the body absorbs various nutrients. The multivitamins some of these companies create might include nutrients that cannot be absorbed when taken together or they might include nutrients that need to be provided within a certain ratio for optimal health and in order to prevent deficiencies. Specifically, one of the questions I get asked quite a bit is, "Should my multivitamin contain calcium?" Of course, the answer to this question is not a simple "yes" or "no" and a few questions must be asked before an answer can be provided.

Does the Multivitamin Contain Iron?

The first question that must be asked is, "does the multivitamin also contain iron?" If the multivitamin contains both iron and calcium, the body does not absorb the iron as well. While this might be acceptable for the general population (that is not at risk for an iron deficiency), this is not ideal for a bariatric surgery patient. For optimal absorption of iron, it should be taken separate from calcium. In fact, iron and calcium should be separated by at least 2-4 hours. This is critical for bariatric surgery patients as their risk of iron deficiency actually increases over time. Most, if not all, bariatric surgery patients will eventually develop an iron deficiency if they do not properly supplement with iron long-term.* In fact, about 20-52% of patients will develop an iron deficiency within 3 years following their bariatric surgery, with some patients experiencing an iron deficiency as soon as six months post-op (1-6).  Menstruating women, the super obese, and long limb roux-en-Y gastric bypass patients have an increased risk of iron deficiency compared to other patients.

How Much Calcium is Included?  

If the answer to the above question is, “No, my multivitamin does not contain iron” then it is feasible for your multivitamin to contain calcium.  However, the amount of calcium should also be considered.  The human body can only absorb about 500 milligrams (mg) of calcium per dose period (meaning 500 mg over a 2-4 hour period).  I have seen some products on the market that contain as much as 1,000-1,200 mg of calcium that is designed to be taken as one dose.  The sad truth is that the body will still only absorb 500 mg of the included 1,000-1,200 mg in the product, so you are just wasting your money and doing a disservice to your bone health.  If your multivitamin does NOT contain iron, it may contain up to 500 mg of calcium per dose period.

What is the Form of Calcium?  

It is also important to consider the form of calcium included in your multivitamin (or calcium supplements for that matter).  Calcium citrate is the recommended form of calcium supplementation for bariatric surgery patients (7,8).  There are many multivitamins out there for bariatric surgery patients that contain other forms of calcium supplementation such as calcium carbonate, which is more difficult to be absorbed in a low acid environment (which is often caused from having bariatric surgery).  This means that you may not be absorbing the amount of calcium that you think you are getting.  While this will not show up in your blood work immediately, it can have detrimental, long-term effects on your bone health and may lead to osteoporosis and/or an increased risk of bone fractures.  Calcium citrate is the preferred form for bariatric patients for the following reasons:

• Calcium carbonate needs an acidic environment to be absorbed.  While this is fine for the general population, this is one of the main reasons calcium carbonate is not the preferred form for bariatric surgery patients.  After bariatric surgery, the stomach is smaller (regardless of which procedure) and therefore produces less stomach acid.  Calcium citrate can be absorbed regardless of the amount of stomach acid.  Also, many patients take medications such as proton pump inhibitors or acid-reducers (such as prevacid, nexium, protonix, prilosec, etc.) following their bariatric surgery and this further increases the need to take calcium citrate.
• Calcium carbonate must be taken with meals.  Calcium citrate can be taken at any time (with meals or without).  This is beneficial for bariatric surgery patients because sometimes just taking their bariatric vitamins is enough to fill them up and there is not room for a meal plus bariatric vitamins.
• Calcium citrate reduces the risk of developing kidney stones when compared to calcium carbonate.  While this is not the only reason that kidney stones may develop, it is certainly beneficial to reduce the risk of kidney stone development.

Getting Down to the Mechanics

Calcium, biochemically, is a large molecule, especially when you are talking about the recommended form, calcium citrate.  It takes up a lot of space and this is why most multivitamins do not contain calcium and if they do, they usually contain calcium carbonate (since it is smaller).  Think about one of our chewable Multivitamins and one of our chewable Calcium Plus 500s – if you put those two together it would be one HUGE chewable that most bariatric patients would not take.  

* Proper supplementation should be viewed as an individualized regimen based upon each patient’s individual medical history, laboratory studies, and current medication use.  Patients should follow the instructions of their bariatric surgery team.  Patients should also be sure to follow-up with their bariatric surgery team at frequent intervals as recommended and stay up-to-date with requested lab work.

References:

1. Brolin RE, Gorman RC, Milgram LM, et al.  Multivitamin prophylaxis in prevention of post-gastric bypass vitamin and mineral deficiencies.  Int J Obes.  1991;15:661-7.

2. Amaral JF, Thompson WR, Caldwell MD, et al.  Prospective hematologic evaluation of gastric exclusion surgery for morbid obesity.  Ann Surg.  1985;201:186-93.

3. Brolin RE, Gormon JH, Gorman RC, et al.  Prophylactic iron supplementation after Roux-en-Y gastric bypass: a prospective, double-blind, randomized study.  Arch Surg.  1998;1333:740-4.

4. Halverson JD, Zuckerman GR, Koehler RE, et al.  Gastric bypass for morbid obesity: a medical-surgical assessment.  Ann Surg.  1981;194:152-60.

5. Brolin RE, Groman JH, Gorman RC, et al.  Are vitamin B-12 and folate deficiency clinically important after Roux-en-Y gastric bypass?  J Gastrointest Surg.  1998;2:436-42.

6. Brolin RE, LaMarca LB, Henler HA, et al.  Malabsorptive gastric bypass in patients with super-obesity.  J Gastrointest Surg.  2002;6:195-203.

7. Mechanick JI, Youdim A, Jones DB, et al.  Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient – 2013 Update:  Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery.  Surg Obes Related Dis.  2013;9:159-91.

8. Aills L, Blankenship J, Buffington C, et al.  American Society for Metabolic and Bariatric Surgery Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient.  Surg Obes Related Dis.  2008;4:S73-108.