The body keeps adequate calcium circulating in the body to maintain vital functions, in two ways: obtaining calcium from the foods you eat or by drawing calcium from your bones. The ideal is to obtain calcium from foods or supplements, sparing the calcium stored in the bones.

Why Is Calcium Important After Bariatric Surgery?
Calcium is absorbed in the first 3-4 feet of small intestine and in the last 8 feet of small intestine. The small intestine is approximately 20 feet long! Malabsorptive bariatric surgery will cause food to bypass parts of the small intestine that are the main calcium absorption sites. This causes supplementation needs to increase.

Consuming a high amount of protein can also increase urinary calcium loss by 50% possibly due to the sulfates binding with the calcium. Calcium is not only excreted in the urine, but in the feces. Amounts can range from 145-340 mg per day.

How Much Calcium Do I Need?
The recommended calcium intake for optimum bone health, as per the National Academy of Sciences, is 1000-1300 mg daily. Based on these recommendations, it is impossible to obtain all the necessary calcium for bone health, with diet alone. The average American obtains approximately 700 mg of calcium per day from the diet, as reported by the United States Department of Agriculture (USDA).

After malabsorptive bariatric surgery, higher doses of calcium are recommended. Recommendations range anywhere between 1000-2000 mg daily. The National Academy of Sciences recommends a maximum of 2500 mg calcium daily for all ages. This level should be exceed ONLY with medical supervision. It is important to give careful consideration not only to the amount of calcium supplemented, but also the form.

Which Type of Calcium Is Best?
After bariatric surgery, calcium citrate should be the calcium of choice. After gastric bypass surgery, the pouch contains a very small amount of acid, if any. Calcium citrate is absorbed better because it can be absorbed well in a non-acidic medium. Calcium citrate also decreases risk of kidney stones because it is better absorbed.

A Few Things To Remember About Calcium Supplementation
Calcium citrate comes in liquid, powder, chewable, tablet and capsule form. Regardless of which form you choose to take, make sure you know how much elemental calcium your supplement provides. Elemental calcium is the portion of the calcium supplement that your body absorbs. Some supplements will include that on the label, but you may have to contact the manufacture and ask.
Be sure to split your total daily dose into several doses, as the body can only absorb 500 mg at a time. Take calcium at least 1 hour apart from your iron supplement, as calcium can block iron absorption. The calcium supplement should contain vitamin D to improve the absorption. Also, vitamin D deficiency following malabsorptive bariatric surgery has been well documented. Do not use calcium supplements made from oyster shell, dolomite, or bone meal as they may contain toxic amounts of aluminum and/or lead.

Remember, serum (blood) calcium does not reflect bone health. Some health professionals encourage patients to have a baseline dual energy X-ray absorptiometry (DEXA) of their hip and spine before surgery. This is also a good way to measure body fat. If you weigh 300 pounds or less, this can be done. Otherwise, have a DEXA of your forearm / wrist. For labs, have an intact parathyroid hormone (PTH) done as this will track your bone status.

What Is Iron?
Iron is a trace element nutrient that the body uses for several discrete areas of normal health and function. The primary role of iron is in the formation of hemoglobin and myoglobin. Hemoglobin is the protein in your red blood cells that transports oxygen around the body. Myoglobin is a protein that is similar in structure to hemoglobin that is important for the storage and usage of oxygen by muscles, including the heart. Additionally, iron also plays a role in regulating the response of the body to low-oxygen conditions or hypoxia.
The body also uses iron in many enzymes that are critical for metabolism. These enzymes, called cytochromes are required for the metabolism and detoxification of many natural compounds in the body as well as chemicals, drugs and environmental pollutants. DNA synthesis also requires an iron-containing enzyme, which is why iron is so important for growth, development and wound healing.

Iron In Food
Iron is found in two primary forms in food. The form typically thought to be the best – meaning it is the form that the human body can most easily absorb and utilize - is heme iron. This is the form of iron found in animal sources such as lean red meat, dark poultry, shrimp and tuna.
Iron is also found in plants. These non-heme irons are typically considered to be harder to absorb because it takes extra effort by the digestive system to free them from the foods they are in. This process depends both on contact with stomach acid and with enzymes. Stomach acid contact helps to stabilize plant irons in what is called the ferrous (Fe+2) state. Ferrous iron is more readily absorbed in the small intestine than the ferric (Fe +3) form, which is not very soluble.
Absorption of non-heme iron can be either further inhibited or enhanced by other substances that are ingested at the same time. Substances that inhibit the absorption of non-heme iron include tannins in tea; oxalates in green vegetables, chocolate, berries and other foods; and compounds in grains, soy protein and egg yolks. Coffee and tea when consumed with iron can reduce absorption by 40% and 60% respectively.
Absorption of plant-iron can be enhanced by simultaneous ingestion of heme iron. Other substances that naturally improve absorption include vitamin C; organic acids such as citric acid, lactic acid, or malic acid; and frucooligosaccharides (FOS).

Why Is Supplementation Important After Bariatric Surgery?
One question about heme iron (form found in animal food sources) that we do not know is whether it continues to be the best source after weight loss surgeries such as gastric bypass. Heme iron is released from foods when it is digested by proteases in the stomach, and somewhat in the small intestine. But is this going to be efficient or occur at all with very little stomach? This is still not yet known.
If iron absorption can not compensate for losses or low dietary intake, then iron stores are used up and iron deficiency sets in. Iron deficiency and anemia are not one and the same, but they often go hand in hand. The distinction between iron deficiency and iron-deficiency anemia is a matter of degree,. May people may be iron deficient, meaning that they have depleted iron stores without being anemic or they may be iron deficient and anemic. With regard to iron, the term anemia refers to severe depletion of iron stores resulting in low hemoglobin. The body that has been severely deprived of iron becomes unable to make enough hemoglobin to fill its new blood cells – anemia results. A person with iron-deficiency anemia lacks “get up and go”. Tiredness, apathy, and tendency to feel cold all reflect the energy deficiency of iron-deficiency anemia. Even at slightly lowered iron levels, physical work capacity and productivity are impaired.

How Much Iron Is Recommended After Bariatric Surgery?
Iron deficiency can be a problem following gastric bypass because iron is partially absorbed in the duodenum. The duodenum is bypassed along with the stomach. Iron deficiency can be a particular problem for women who lose blood (and thus iron) with their menses.
Studies have shown that prophylactic iron supplementation after gastric bypass successfully prevented iron deficiency but did not consistently protect women from developing anemia. On the basis of these results, prophylactic iron supplements are routinely recommended for menstruating women who have gastric bypass.
The recommendation by most dietitians currently is 18 –30 mg of elemental iron daily. However, this is not sufficient. For the short-limb bypass, 50 mg of elemental iron daily seems to work well. For the long-limb bypasses, 150-200mg elemental iron daily seems to work best. Levels should be monitored by your surgeon.

Which Type of Iron Is Best?
There are no studies to date on what type of iron is most effective after bariatric surgery, but observation seems to indicate ferrous sulfate is not effective. Ferrous sulfate is less effectively absorbed as a result of the lack of stomach acid present that is required for absorption, and it has a higher degree of gastro-intestinal complaints than other forms of iron. Iron in the form of ferrous fumerate, gluconate, or polysaccharide appear to be better absorbed post-surgically.
Iron is available in liquid, chewable, and capsule form. Tablets are not recommended since they may not dissolve adequately, decreasing absorption. If you chose to take liquid iron, which is also called an elixir, you have to be careful not to stain your teeth. Mixing the liquid iron with water or other clear liquids may prevent stains. Drinking the liquid iron with a straw may also help. To remove any iron stains, brush your teeth with baking soda or peroxide.

How Much Iron Are You Really Taking?
Many iron supplements will list the amount of pure (elemental) iron on the label. Some may state only the weight of the tablet or capsule. But if you know the type of iron compound – usually listed on the label- you can calculate the actual amount of iron in the product.

Ferrous Fumarate is 33% iron.
Ferrous Sulfate is 20% iron.
Ferrous Gluconate is 11% iron.

Multiply the weight of the tablet by the percentage of iron in the product, based on the type of iron. For example, using this formula, a 200 mg tablet of ferrous sulfate contains 40 mg of iron.
200 mg x 0.20 = 40 mg iron

Improving Iron Absorption
Iron should be taken with 200mg of vitamin C to increase absorption.
Oral iron supplements are usually best absorbed on an empty stomach. However, because iron can irritate your pouch, you may need to take the supplement with food.
Iron supplements should be taken at least 2 hours apart from calcium supplements for maximum absorption. Calcium interferes with the absorption of iron.
Iron supplements can cause constipation, so your doctor or dietitian may recommend a stool softener or a laxative. Iron may also turn stools black, which is a harmless side effect.