Your Daily Dose: Vitamin B12 Supplements after Weight Loss Surgery

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, explains the importance of the vitamin B12 supplements after weight loss surgery.

Vitamin B12 is the most common vitamin deficiency people experience after weight loss surgery. That is why it is important to supplement your diet with vitamin B12, especially after gastric bypass and sleeve gastrectomy.

Vitamin B12 is essential for proper nerve function, metabolism and red blood cell production. Deficiency can lead to B12 deficiency anemia, which causes fatigue, rapid heart rate, easy bruising and bleeding, stomach upset and diarrhea or constipation.

If the deficiency remains unaddressed, it can result in permanent nerve damage, including tingling or numbness in fingers and toes, difficulty walking, mood changes, memory loss and dementia.

Weight loss surgery reduces the acidity in the stomach, which makes absorption of vitamins and nutrients more difficult. That is why vitamin B12 deficiency is particularly common after surgery and supplementation is often required long after recovery.

Proper supplementation involves taking a daily form of vitamin B12 that dissolves under the tongue or getting a monthly injection, which is typically done by your primary care physician. 

To prevent vitamin B12 deficiency, follow the dietary recommendations for supplementation after weight loss surgery and get your blood work checked regularly by a primary care physician or bariatric care team.

If you experience the symptoms associated with B12 deficiency, please check with your health care team.

- Cara Stewart, RD, LDN

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Healthy Mexican Cuisine: Black Bean and Cheese Enchiladas with Ranchero Sauce

This recipe for enchiladas combines various traditional Mexican flavors into one exceptionally delicious and healthy dish. Black beans provide protein, fiber, folic acid and magnesium, while the corn tortillas, chiles and cheese add crave-worthy Mexican taste.

So get cooking and thank your South of the Border neighbors for this delicious dish!

Nutritional Information:
Amount per serving

• Calories: 302
• Fat: 12.9 g
• Saturated fat: 5.3 g
• Monounsaturated fat: 3.9 g
• Polyunsaturated fat: 1.3 g
• Protein: 17.3 g
• Carbohydrate: 36.1 g
• Fiber: 6.4 g
• Cholesterol: 32 mg
• Iron: 1.7 mg
• Sodium: 574 mg
• Calcium: 426 mg

Ingredients:

• 2 dried ancho chiles, stemmed and seeded
• 2 cups water
• 2 teaspoons olive oil
• 1 cup yellow onion, chopped
• 5 garlic cloves, sliced
• 1/4 teaspoon kosher salt
• 2 cups organic vegetable broth
• 2 tablespoons fresh oregano, chopped
• 2 tablespoons no-salt-added tomato paste
• 1/2 teaspoon cumin, ground
• 1 tablespoon fresh lime juice
• 1/8 teaspoon red pepper, ground
• 1 (15-ounce) can black beans, rinsed and drained
• 2 cups (8 ounces) reduced-fat Mexican-4-cheese-blend, divided and pre-shredded
• 3 green onions, divided and thinly sliced
• Cooking spray
• 12 (6-inch) corn tortillas
• 6 tablespoons light sour cream

Preparation:

1. Preheat oven to 400 degrees.
2. Combine chiles and 2 cups water in a saucepan; bring to a boil, reduce heat and simmer for 5 minutes. Remove from heat; let stand for 5 minutes. Drain chiles in a colander over a bowl, reserving 1 cup cooking liquid.
3. Heat oil in a medium saucepan over high heat. Add onion; sauté for 1 minute. Reduce heat to medium; add garlic and salt. Cook for 5 minutes or until golden, stirring occasionally. Add broth and next 3 ingredients (through cumin); cook for 8 minutes or until thickened, stirring occasionally.
4. Pour onion mixture into a blender; add chiles and reserved liquid. Remove center piece of blender lid to allow steam to escape; secure lid on blender. Place a clean towel over opening in lid. Blend until smooth; stir in lime juice and red pepper.
5. Combine the beans, 1 cup of cheese and half of the green onions in a bowl. Spread 1/2 cup of sauce in the bottom of a 13 x 9-inch glass or ceramic baking dish coated with cooking spray. 
6. Warm tortillas according to package directions. 
7. Spoon 3 tablespoons bean mixture down center of each tortilla; roll up. 
8. Place seam-side down in prepared dish. 
9. Pour remaining sauce over filled tortillas. Top with the remaining cheese. Bake at 400 degrees for 15 minutes or until lightly browned. Sprinkle with remaining green onions; serve with sour cream.

Total preparation time, one hour and 10 minutes. Hands-on time is 55 minutes. 

This recipe is provided courtesy of David Bonom, Cooking Light (October 2011).

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Study Finds Magnesium-Rich Diet Lowers Stroke Risk

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, reports on study findings that link increased magnesium intake to reduced stroke risk.
Stroke is the fourth leading cause of death in the U.S. and a leading cause of adult disability. Nearly 80 percent of strokes are preventable through personal risk-reduction measures, according to the National Stroke Association.

Maintaining a healthy lifestyle is one key to reducing the risk of stroke. In fact, a recent Swedish study suggests that the mineral magnesium may also play an important role.

Increased consumption of magnesium reduced the risk of stroke by 8 percent, according to the study published in the American Journal of Clinical Nutrition. Every additional 100 milligrams of magnesium led to increased risk reduction for stroke, the study shows.

The findings are based on a meta-analysis of seven studies from the past 45 years that looked at magnesium intake and incidence of stroke. In total, it included data from more than 240,000 participants.

The recommended dietary allowance of magnesium is 400 to 420 mg/day for an adult male and 310 to 320 mg/day for an adult female. The best food sources of magnesium are whole grains, green leafy vegetables, nuts and beans. 

The following foods provide approximately 100 mg of magnesium:

• Almonds (1 ounce)
• Beans (1 cup)
• Brown rice (1 cup)
• Cooked spinach (3/4 cup)

These foods are low in sodium and high in potassium, dietary components that have also been linked to a reduced risk of stroke.

Keep in mind that a healthy diet consists of an assortment of nutritious foods, not a single item or nutrient. While magnesium has been shown to reduce the risk of stroke, it must be incorporated in a nutritious, balanced diet for optimal health.

- Cara Stewart, RD, LDN

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Struggling to Lose Weight? SuperTracker to the Rescue!

Karen Buzby RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, introduces a new online weight management tool to help people achieve and maintain their weight loss goals.
You have probably heard before that weight loss is a matter of eating less and exercising more. Easier said than done – right? Anyone who has attempted to diet knows that translating healthy lifestyle advice to practical changes isn’t always so simple or straightforward.

SuperTracker is a new online tool that can help you plan, calculate and record caloric intake and physical activity, making weight loss easier than ever before. As part of the U.S. Department of Agriculture’s MyPlate program, SuperTracker is user friendly, interactive and contains a wealth of information to help you make smart choices about food and exercise. And it’s free.

Key features of SuperTracker include:

Daily calorie limit - Calculated based on height, weight and personal weight loss goals.

Food tracker - Record food items and portion size from an extensive database in an electronic food diary to review eating patterns and calorie balances each day.

Food group targets and graphs – Provides recommendations about number of servings from each food group based on a person’s daily caloric allowance. It also graphs food choices to show how dietary choices measure up to goals.

Personalized nutrient report – Customized reports of individuals’ average carbohydrate, protein, fat, vitamin and mineral intake. Helps identify which foods to eat more of and which to cut back on.

Physical activity tracker – Compares weekly physical activity totals to pre-set targets for moderate-intense and muscle-strengthening exercise.

Virtual healthy lifestyle coach – Advice, inspiration and support from a virtual coach helps people stay motivated and reach their weight loss goals.

Don’t wait another day. Start tracking your diet and activity goals with the SuperTracker today! 

- Karen Buzby, RD, LDN

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Having a Baby After Weight Loss Surgery

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, and Monica A. Mainigi, MD, fertility specialist at Penn Fertility Care, provide important information for women trying to become pregnant and maintain a healthy pregnancy after weight loss surgery.

Many women struggle with fertility as a result of their weight. In fact, obesity puts women at greater risk for ovulation dysfunction and menstrual irregularity, both of which can interfere with fertility. In addition, obesity can lead to an increased risk of miscarriage and decreased success with fertility treatments. For overweight women who are having a hard time conceiving, weight loss surgery may be an option to consider.

For women considering pregnancy after they have had bariatric surgery, it is important to keep the following information in mind.


Fertility boost
Obesity can interfere with hormone production, making it more difficult to get pregnant.  Weight loss after bariatric surgery can lead to regular cycles and ovulation, and improved fertility. In fact, a 2005 study published in the Journal of Clinical Endocrinology and Metabolism found that surgical weight loss for women with PCOS often resolved their reproductive and metabolic abnormalities. 

Healthier pregnancy, healthier baby
After weight loss surgery, medical conditions such as high blood pressure and diabetes are significantly improved or resolved leading to a lowered risk of developing serious complications during pregnancy or delivering a baby born with complications.  Many women are still obese after weight loss surgery which places them at a higher risk for gestational diabetes and preeclampsia, but the risk is far less than before surgery.  Pregnant women who have had bariatric surgery should see a high-risk obstetrician to best manage prenatal care.

Give it time
It is important to wait at least 18 months after surgery to start trying to get pregnant. In the period immediately following gastric bypass or sleeve gastrectomy, rapid weight loss causes stress on the body, including diminished nutrition intake, which can cause complications for an expecting mother and growing baby. Effective contraception is absolutely critical for women pursuing weight loss surgery.  For women with an adjustable gastric band, fluid may be removed from the band during pregnancy to accommodate the need to eat more calories.

Keep supplementing
Good nutrition is especially important for women trying to conceive.  After weight loss surgery, patients are at a higher risk for deficiencies of certain nutrients, including vitamin B12, folic acid, calcium, iron, and vitamin D. It essential to continue taking vitamin and mineral supplements as recommended by the bariatric team.

Be ready for weight gain
After having weight loss surgery, it can be difficult to accept that pregnancy is a time when it is normal, healthy and necessary to gain weight.  Healthy weight gain during pregnancy is important to nourish a growing baby, but work with the program dietitians to avoid unhealthy weight gain during pregnancy.

The Penn Metabolic and Bariatric Surgery Program offers lifelong follow-up care and nutritional support for patients who have had weight loss surgery. Women considering pregnancy after weight loss surgery should discuss their plans with the bariatric surgery team.

For more information on fertility services at Penn Medicine, visit the Penn Fertility Care website.

- Cara Stewart, RD, LDN and Monica Mainigi, MD

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Taking Vitamin and Mineral Supplements: Make time even if you feel fine!

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, outlines the important vitamin and mineral supplements to take after weight loss surgery.

After weight loss surgery, you need to commit to taking a regimen of vitamin and mineral supplements for the rest of your life. Eating smaller amounts of food means your body receives fewer nutrients. In addition, after gastric bypass or sleeve gastrectomy surgery, your system does not absorb some vitamins and minerals as well.

This table highlights the functions of several key nutrients and the symptoms of their deficiency. The damage to your body from many of the deficiencies is permanent, so be sure to follow your dietician’s instructions for taking supplements and have your lab values checked routinely with your primary care physician.

NUTRIENT	WHAT IT DOES	DEFICIENCY
Vitamin B1 (thiamine)	Helps all cells of the body produce energy from carbohydrates	Fatigue, weak muscles, nerve damage
Vitamin B12	Works with folate to make red blood cells Vital part of every cell Helps body use fatty acids and some amino acids	Anemia, fatigue Permanent nerve damage including tingling or numbness in hands and feet
Folate (folic acid)	Plays essential role in making new body cells Works with B12 to form hemoglobin in red blood cells Helps reduce risk of neural tube defects (spina bifida) in developing fetus	Anemia caused by malformed blood cells that won’t carry as much oxygen Increased risk of neural tube defects in developing fetus
Vitamin A	Promotes normal vision, helps eyes see normally in the dark Promotes growth and health of all cells Keeps tissues healthy to prevent infection Works as an antioxidant	Night blindness Dry, scaly skin Reproductive problems
Vitamin D	Promotes absorption of calcium and phosphorus Regulates amount of calcium in blood	Osteoporosis (loss of bone mass) Osteomalacia: softening of bones
Calcium (**NOTE: Supplements are still needed even if blood levels are normal)	Helps bones remain strong by slowing rate of bone loss with age Helps muscles contract and heart beat Promotes normal nerve function	Osteoporosis
Iron	Essential part of hemoglobin that carries oxygen in blood Supports healthy immune system	Iron deficiency anemia Fatigue Infections

- Cara Stewart, RD, LDN

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Recovering from weight loss surgery? Take your vitamins!

Karen Buzby, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, explains the importance of vitamin and mineral supplements after weight loss surgery.

For optimal health, the body needs 13 essential vitamins and nine trace minerals daily. Typically, the best way to get these nutrients is through a varied diet, as outlined in the USDA Food Guide Pyramid. The dietary restrictions following weight loss surgery make it difficult to obtain the daily recommendations of vitamins and minerals from food alone. Therefore, people recovering from weight loss surgery are strongly encouraged to take vitamin and mineral supplements for proper nourishment and to aid their recovery.

Vitamin and mineral supplements are particularly important during the post-surgical period. Weight loss surgery restricts the amount and type of food that can be consumed. Solid foods are reintroduced into the post-surgical diet slowly and gradually, which means it can be an extended amount of time before patients are able to eat a healthy, nutrient-rich diet.

In addition, gastric bypass can cause malabsorption of important nutrients, making it even more important to compensate with vitamin and mineral supplements. Gastric bypass and sleeve gastrectomy can impair the release and absorption of vitamin B₁₂. By bypassing part of the intestines, gastric bypass can also lead to intolerance of calcium-rich dairy and impaired iron absorption. Taking sufficient supplements can prevent irreversible nutritional deficiencies.

The American Society of Metabolic and Bariatric Surgery provides guidelines for vitamin and mineral supplementation following weight loss surgery.

Multivitamin and mineral supplement:

• The supplement should contain 100 percent of the daily value for at least two thirds of the nutrients listed on the nutrition facts label. The product you select should be reviewed and approved by your bariatric team before surgery.
• Chewable tablets are recommended for the first two to three months after surgery.
• Start taking vitamin and mineral supplements on the first day home from the hospital.
• After adjustable gastric band surgery, one multivitamin a day is typically required.
• After gastric bypass or sleeve gastrectomy, two multivitamins a day are typically required.

Calcium with vitamin D:

• For optimal absorption post surgery, take a product with calcium citrate and vitamin D₃.
• Chewable tablets are recommended for the first two to three months after surgery.
• Calcium intake should be between 1500 and 2000 mg daily.
• Doses should be divided. Take no more than 500 to 600 mg at one time.
• Do not take calcium and iron supplements at the same time. They must be taken at least two hours apart.
• Start taking calcium supplements on the first day home from the hospital.

Vitamin B₁₂:

• A sublingual (under-the-tongue) tablet containing 500 micrograms of vitamin B₁₂ can be taken daily or monthly intramuscular injections of B₁₂ can be given by a primary care physician.

• While the body does store vitamin B₁₂, it is recommended that supplementation begin on the first day home from the hospital.

Iron:

• Additional iron may be needed for menstruating women or those at risk for anemia.
• The amount of additional iron required is determined on an individual basis.
• Do not take iron at the same time as calcium supplements. They must be taken at least two hours apart.

Essential Vitamins:

1. Vitamin A
2. Vitamin D
3. Vitamin E
4. Vitamin K
5. Vitamin C
6. Thiamin
7. Riboflavin
8. Folic acid
9. Niacin
10. Vitamin B₆
11. Vitamin B12
12. Pantothenic acid
13. Biotin

Trace Minerals:

1. Iron
2. Copper
3. Zinc
4. Fluoride
5. Selenium
6. Iodine
7. Manganese
8. Chromium
9. Molybdenum

Make sure to consult your health care team before starting or changing vitamin and mineral supplementation following bariatric surgery.

- Karen Buzby, RD, LDN

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