Vitamins after Gastric Bypass

This was my first year (at nine years post-op) not being deficient in some vitamin or another.  I definitely have a crazy vitamin regiment.  I wanted to pull all of my vitamin related posts into one.  So here we go:

April 2011:  http://lolorashel.blogspot.com/2011/04/vitamins-and-gastric-bypass-surgery.html

November 2011 (guest post):  http://lolorashel.blogspot.com/2011/11/taking-care-of-ourselves-in-gastric.html

January 2013:  http://lolorashel.blogspot.com/2013/01/pole-sweat-and-magnesium.html

March 2013:  http://lolorashel.blogspot.com/2013/03/bone-spurs-calcium-heart-attacks-and.html

March 2013:  http://lolorashel.blogspot.com/2013/03/update-vitamins-and-gastric-bypass.html

March 2013:  http://lolorashel.blogspot.com/2013/03/malabsorption-after-gastric-bypass.html

March 2013:  http://lolorashel.blogspot.com/2013/03/vitamin-d3-dry-and-gastric-bypass.html

April 2013:  http://lolorashel.blogspot.com/2013/04/vitamin-d-and-sun.html

Here's a photo of the vitamins I take everyday and I'm actually light a few pills...need to get to the store soon

Vitamin D and the Sun

I am a child of the summer.  I was born on August 31...right at the end of summer, and usually during the hottest part of the season.  If I could live my life in a bathing suit and flip flops, I would.  Yeah, I know, I should be worried about skin cancer.  But I remember being a kid and having the outline of my swimsuit suntanned into my skin well into winter time.  I miss those days.

Now that I've had gastric bypass, one of the vitamins I seem to be deficient in is Vitamin D.  That comes from the sun, right?!  I definitely struggle in the winter without my sun.  I also struggle now that I'm an adult that has to go to a job all day, every day and I get much less time to lay around by the water, relaxing and soaking up the rays. 

I have often justified going to tanning booths to help with my psoriasis.  Studies show that some of the beds aren't the same as the sun when it comes to helping kill psoriasis (the funny thing is, the doctor's offices DO offer a certain type of tanning bed but it is generally NOT the same one in your run of the mill tanning salon), but the real reason I was going was for the brown skin.  Yeah, I'm sure, I'm dealing with wrinkles and all that, but I do love being tan. 

A couple of years ago, I decided that since I was in my mid-30's, I should be taking better care of my skin.  No more tanning.  I now look like a vampire.  In fact, when we go to Disneyland and the rides take photos of us, you usually can't see my nose or mouth because I am SO white.  There has to be some middle ground.

I wrote about Vitamin D recently and wondered how much sun you "need" to get enough Vitamin D the natural way.  And so, as per my usual protocol, I Googled it.  I love Google...that bitch knows EVERYTHING. 

http://nutrition.about.com/od/askyournutritionist/f/sunlight.htm

Your body makes vitamin D when your skin is exposed to the ultraviolet B (UVB) rays in sunlight. You probably need from 5 to 30 minutes of exposure to the skin on your face, arms, back or legs (without sunscreen) two times every week.

http://www.drweil.com/drw/u/QAA400732/How-Much-Sun-Exposure-for-Vitamin-D.html

Dr. Holick advises estimating the time it would take your skin to turn pink in the sun. Then divide that time by 25 to 50 percent, depending on your skin type. So, someone like you who has fair skin, burns easily and lives in Pennsylvania would be advised to spend 20-30 minutes in the sun with your arms and legs exposed (not your face) between the hours of 11 a.m. and 3 p.m. two to three times a week from March through May and September through October but only 15-20 minutes in July and August when the sun in strongest. If you remain outdoors longer than the specified time, apply sunscreen. (Don't even try to get sun time from November through February; in your area, you won't get enough UV to help, and you'll probably get pretty cold outside with bare arms and legs.)

http://www.shanghaiexpat.com/article/vitamin-d-and-sun-exposure-20667.html

Given that there is a matrix of variables that need to be considered, it is impossible to prescribe a one-size-fits-all guideline that would balance the sun exposure needs versus risks for all people. However, because there are diseases related to both insufficient and excessive exposure, it is important for each of us to get a sense of how much sun our skin needs to produce adequate amounts of vitamin D without increasing the risk for skin cancer.

So, it appears that I can get my Vitamin D from the sun but I will probably have to continue my Vitamin D3/dry supplements, as I am probably not going to be able to increase my time in the sun any time soon.  I have started back to the tanning beds, but only once a week.  I don't do that for the vitamins or my psoriasis.  I just do that because it makes me happy.  And sometimes you have to do that for yourself. 

Tan and in Mexico in 2007

Pale in 2012

Vitamin D3 (dry) and Gastric Bypass

Yesterday, I updated my vitamin list and today, I wanted to talk about why Vitamin D dry (or at least a non-softgel) is a better fit for gastric bypass patients.  We are malabsorptive in general of vitamins and nutrients after our intestines are re-routed, so certain vitamins don't absorb as well as others.  That includes Vitamin D in a softgel. 

I found a link comparing various Vitamin D supplements for gastric bypass patients.  Why re-invent the wheel?  Check out that article HERE. 

The American Society for Metabolic and Bariatric Surgery points out that gastric bypass patients are at greater risk for vitamin D deficiency due to having part of their small intestine bypassed. They should get regular blood tests to monitor their vitamin D levels and supplement as necessary.

Linus Pauling Institute explains that D3 is absorbed best by everyone, including but not limited to gastric bypass patients.

...softgels filled with oil ... don't work well for gastric bypass patients since they malabsorb fats.

And from the ThinnerTimes forum, read the entire post HERE.

50,000IU gelcaps of vitamin D are always D2 (Ergocalciferol).

We absorb the dry form D3 (Cholecalciferol) far better. D3 is the human form; D2 is the non-human form found in plants and is cheaper!

But apart from that, people with malabsorptive procedures absorb the dry forms of the fat soluable vitamins A, C, D and E over the oil based supplements.

Regarding vitamin D, this is from the American Journal of Clinical Nutrition: The case against ergocalciferol (vitamin D2) as a vitamin supplement -- Houghton and Vieth 84 (4): 694 -- American Journal of Clinical Nutrition

The top two bariatric supplement companies: Celebrate and Bariatric Advantage only use D3 (Cholecalciferol).

The cheapest 50,000IU dry form D3 I know of is from vitalady - $21.49/100 tabs: Vitalady.com - Protein Supplements, Vitamins & Minerals and Safe Snacks!

So, there you go.  Sounds like dry Vitamin D3 is our best option for absorption.  What I need to research next is whether sitting in the sun is as effective or better than taking a supplement.  I'm always looking for reasons to get a little extra sunlight. 

Does anyone else have anything to add to this?  I had to add Vitamin D into my vitamin regimin two or three years ago.  I was low and my doctor said to add it in.  My levels are back to normal but I still take a dry D3 every day. 

Update: Vitamins and Gastric Bypass

In 2011, I wrote a post about the vitamins I take.  Although I mostly take the same vitamins (so you can read the old post HERE about why I take them), I wanted to post an update to types and amounts. 

I still take a Target/generic brand prenatal pill as my multi-vitamin.

I, for a short time, started taking iron due to slight anemia last year, but am back to normal and have discontinued taking iron.

I also still take echinacea.  Who knows if it works, but I take an immuno-suppressant to help with my psoriasis and I feel like any help I can get to ward away colds is a necessary evil.  The Stelara shot suppresses my immune system and can make me stay sick longer.  So I try to avoid getting sick.

I also still take a daily dose of L-Lysine (1,000 mg) to ward off cold sores.  Since I have a stressful job, keeping those at bay is one of my number one concerns.  I know it seems silly, but I REALLY hate cold sores.

I have been lax on the acidophilus.  It's in my fridge.  I kind of forget about it. 

I take B12 daily.  1,000 mcg.  Post-surgery instructions suggested twice a week, but I figure it can't hurt to take it more often. 

Even though I find myself to be a bit sensitive to niacin (B3), I am back to taking a B-complex vitamin.  I was low in B1 awhile back, so its one of those vitamins that I need to take.  Sometimes if I'm vitamin shopping at somewhere like Target, I can't find B1 alone, so I'll just lazily grab a B-complex.

I also take calcium-citrate (500 mg) with Vitamin D and Magnesium.  Read HERE about calcium.

I still take a Vitamin D3 (2,000 IU) pill, but have switched to the "dry" version.  Most Vitamin D pills are oily capsules that look like mini Vitamin E's.  Apparently gastric bypass patients can have a hard time absorbing those (I'm hoping to write a post about that soon). 

I still take a Vitamin E dl-alpha (400 IU) pill.  It is an oily capsule, so who knows if I am absorbing it properly.

I have stopped taking the joint supplement.  It's expensive and I'm not sure it was helping that much.

I am still taking an omega-three supplement.  I have switched from regular fish oil to krill oil.  It contains 420 mg of Phospholipids.  The switch is due to my newly-found heart issue (I was also informed that my new issue is not necessarily related to my old issue....I now have an inflamed heart.  Before I had an enlarged heart.).  Anyway, the krill oil is supposed to help with inflammation.

I have added magnesium to the mix (250 mg each...but I take two to three per day).  You can read about my adventures with magnesium and sweat HERE.

I also added 50 mg of zinc and a CoQ10 supplement (100 mg).  I try to remember to take a little Vitamin C from time to time as well. 

I basically take my cache of pills and eat them at work with dried apricots and almonds or pistachios (I do not take most vitamins on the weekend).  Some vitamins are fat-soluble so eating a little fat with them will help with absorption.  Along with everything else, I'm taking a daily baby aspirin for the heart issue and take Aleve for body aches -- mostly my foot issue (yes, I am aware I shouldn't take either).  I rarely get headaches but will take Tylenol for that.  I take allergy pills for my year-round "seasonal" allergies. 

Vitamins are VERY important post-surgery.  (Read Melissa's story HERE.)  I am nine years post-op and still get my blood tested every year.  Every year I'm low in something new.  I am hoping to be in normal ranges for all tests this year.  I am certainly taking more than enough pills to make that happen!

What vitamins are you taking and are there some you think you should be taking but aren't?  Tell me about them here!

Malabsorption after Gastric Bypass Surgery

So in one of our support group meetings, one of our more knowledgeable members mentioned that gastric bypass patients are only malabsorptive in the calorie department for a year or so after surgery.  The body apparently has an amazing ability to adapt and the lower intestine will "re-grow" villi.  Funny that we seem to gain back the ability to absorb calories, but not necessarily the ability to absorb nutrients. 

Anyway, I went on the hunt for some information.  I had a hard time really finding anything concrete.  I see message boards were people are asking and answering questions, but not much "real" authority.  Here's some of what I found:

http://care.diabetesjournals.org/content/28/2/481.full

Protein deficiency is easy to recognize by following albumin. Fat malabsorption manifests its presence by loss of fat-soluble vitamins. Patients can present with a number of problems after this procedure. In our clinic, the most common presenting complaint is fractured bones or a bone density study showing “severe bone loss.” Due to fat malabsorption, severe vitamin D deficiency will develop along with an already reduced ability to absorb calcium (23).

                

In general, fat-soluble vitamins A, D, and K will be deficient in two-thirds of these patients within 4 years after surgery. Up to 50% will have hypocalcemia, and all of these patients with low vitamin D levels will have secondary hyperparathyroidism (24,25).

                

Manifestations of all the different fat-soluble vitamins can be seen, ranging from unusual rashes, to osteomalacia, to easy bruising. Fortunately, there is a rather simple solution: pancreatic enzyme replacement. When pancreatic enzymes are replaced, there is some weight regain, and physicians often observe patient noncompliance as a result. The hyperparathyroidism may be difficult to treat and may require separate treatment or even surgery.

                

Other problems associated with this type of procedure include severe hair loss, liver disease (usually transient), kidney disease, and unusual body odors (26). The lifestyle after this procedure can be difficult due to the frequent bowel movements (over 10 times a day) and the foul-smelling stool that the fat malabsorption causes.

http://www.obesityhelp.com/forums/rny/4253502/Malabsorption-How-long-does-it-last/

No one knows for sure; each person has their own experiences. However, since weight loss tends to slow for most around the 18 month mark, that is a safe benchmark I suppose.

*****

Studies on this topic are mostly done on patients who had cancer or some other form of a diseased intestinal tract and had to have a portion of their intestines removed to save their lives. The body is pretty amazing and can "heal" itself to a certain extent. The micro-nutrient malabsorption (vitamins/minerals) will never fully repair, but the macro-nutrient (calories/protein/fat/carbs) malabsorption will eventually be repairs completely. This process is called adaptation.

From what I've read, it looks like the adaptation process begins almost immediately after surgery - within 4 days. But it can take up to 2 or 3 years to complete depending on your body and how much was bypassed. The remaining intestine will grow longer and stronger and more dense villi - the little finger-like tentacles that grab nutrients from food as it brushes by. It's also called the brush border. But since vitamins/minerals have assigned locations of absorption, no amount of extra villi will make us absorb vitamins that had their assigned location bypassed. Here's a diagram [note: link no longer valid] that explains those locations.

For more reading about Adaptation. Here's some links: http://www3.interscience.wiley.com/journal/122341206/abstract http://www.springerlink.com/content/m6h3622488510617/ http://jn.nutrition.org/cgi/content/full/133/11/3703

This doctor claims that there is no caloric malabsorption at all:  http://www.thinnertimesforum.com/topic/59658-calories-in-normal-stomach-vs-gastric-bypass-stomach/?p=730692

Your food is absorbed by your small intestine. The stomach churns up your food, and the stomach juices start the digestive process. After a gastric bypass you will probably still absorb 100% of the calories that your eat. There is less absorption of B12 and Iron, possibly of Calcium, but unfortunately not of calories.

http://www.thinnertimesforum.com/topic/59753-no-calorie-malabsorption/

Web MD: "Gastric bypass
Gastric bypass surgery makes the stomach smaller and allows food to bypass part of the small intestine. You will feel full more quickly than when your stomach was its original size, which reduces the amount of food you eat and thus the calories consumed. Bypassing part of the intestine also results in fewer calories being absorbed. This leads to weight loss.

Medline Plus: "Your diet after gastric bypass surgeryURL of this page: http://www.nlm.nih.g...ions/000173.htm
You had gastric bypass surgery. This surgery made your stomach smaller by closing off most of your stomach with staples. It changed the way your body handles the food you eat. You will eat less food, and your body will not absorb all the calories from the food you eat.

Laproscopic MD: "This technique is called a roux-en-Y intestinal bypass. Once in place, food passes from the stomach pouch directly into the jejunum, bypassing the duodenum. Because of this bypass, there is reduced absorption of calories and nutrients.

ASMBS association says "Treatment of morbid obesity and obesity related disease and condition: limits the amount of food the stomach can hold and/or limits the amount of calories absorbed.

*****

Any malabsorption from calories wouldn't last for long anyway.

The body is a miraculous thing and our intestines grow additional villi to compensate for the RYN's bypass. Villi are finger-like projections in the small intestine that help absorb food more efficiently in the body.

*****

At a recent follow up I asked my doctor about villi regrowth and she said it doesn't happen. She also said if your tool stops working completely it's due to human error - not measuring or eating the appropriate foods, fluid intake, etc. 

*****

Patients who have had a part of their intestine removed by surgery undergo a process called intestinal adaptation. During intestinal adaptation, the intestine may grow in size after surgery. The surface area inside the intestine increases as the mucosa (lining of the intestine) becomes thicker. The villi (the lining of the intestine responsible for intestinal absorption) become longer and denser, helping to promote absorption of nutrients. The diameter of the intestine may also increase.

Here is a diagram from the posting above, which shows were things are absorbed. 

So according to what I found, you may be malabsorptive for 12, 18 or 24 months, or not at all.  Who knows...but I do know that whether I am absorbing my calories, I do have to be very careful with my vitamins.  I still have my blood labs on a yearly basis and each year I am somewhat deficient in something.  So I just "up" that vitamin and by the next year, I'm good.

Have you ever heard about calorie malabsorption?  If you have links to articles, please post them!

Bone spurs, calcium, heart attacks and gastric bypass

I recently reported that I have a very painful bone spur in my right heel.  It affects me every day.  I have spent a ton of money trying to make this thing right.  I don't know if it ever will be.  I've had two cortisone shots and they only seem to last about three weeks.  I had been told that bone spurs form due to an over-abundance of calcium in your system.  The calcium supposedly doesn't know where to go, so it attaches to your bones.  Apparently this is NOT true.  So I started researching bone spurs and calcium, and that lead to some studies, and my realization that gastric bypass surgery has potentially caused ANOTHER health issue for me. 

I had gastric bypass to AVOID health problems.  I was in my 20's.  I didn't have high blood pressure or diabetes.  I did not yet have ANY of the "fat diseases."  I was just fat.  But I thought I better ward them off by completely rearranging my insides.  Sounds like a great idea. 

My very first issue was waking up with staples holding my guts together.  I had gone to sleep thinking I was going to have laporoscopic surgery.  The intestine they had chosen to attach to my new pouch was too short, so they had to open me up at the last minute, leaving me with a much longer recovery than expected. 

My next issue, about nine months out, was blacking out.  My blood pressure and blood sugar would drop so low that I would black out if I stood up too fast.  I literally had to stop reporting it to my doctor because my driver's license was going to be yanked for losing consicousness (even though it never happend when I was just sitting).  I also had to go back to my surgeon and ask for more calories.  Our program told us that every person should eat 1,000 calories per day for life after surgery.  I insisted that since I was six feet tall, perhaps I should get a few more calories than a five foot tall lady.  I was given 1,500.  By the way, 9 years later, I maintain my weight on about 2,300-2,500 calories a day.

I also ran into tons of vitamin deficienies.  Each year was something new.  You want to know how you know you have a B12 deficiency?  The tops of your feet go numb.  Want to know how you know your protein is low?  Your hair falls out. 

Anyway, I don't want to bore you with all of my issues.  But I definitely ended up with more health issues AFTER surgery.  I'm not saying I wouldn't do it again, but it is something to point out...this surgery doesn't fix everything.

Back to the bone spur.  So, the doctor says, hey you have a bone spur, and they take a long time to grow.  At first I was thinking, well maybe I had it when I was even fatter.  But then I realize, I had surgery 9 years ago, and that IS a long time already, so I start researching bone spurs.  According to the Mayo Clinic:

Wear-and-tear arthritis (osteoarthritis) is the most common cause of bone spurs. As osteoarthritis breaks down the cartilage cushioning the ends of your bones, your body attempts to repair the loss by creating bone spurs near the damaged area. The extra bone may help increase the amount of surface area for load bearing.

According to Livestrong.com:

Calcium is essential in the formation of strong and healthy bones as well as in maintaining the health of your bones. According to "The Vitamin Book," a lack of calcium can contribute to the formation of bone spurs by not allowing your bones to form as they should. A lack of calcium can cause your bones to form abnormally, leading to the possible formation of bone spurs.

[emphasis added.]
So, did gastric bypass and vitamin deficiency strike again???  Was I not absorbing my calcium supplements, leaving me at a higher risk for bone spurs?  Who knows, but let's talk about some recent studies about calcium and heart disease, and why we have to be careful about taking TOO MUCH calcium. 

High calcium intake has recently been linked to heart disease in men!  Read the entire article HERE.

Over 12 years of follow-up, men who took more than 1,000 milligrams (mg) of daily supplemental calcium were 20% more likely to succumb to heart disease than those who didn’t take calcium supplements. There was no connection between calcium supplements and heart disease in women (which has been seen in earlier studies), and no connection with calcium from food. The results were published yesterday in JAMA Internal Medicine.

But wait, now there are studies to say calcium can lead to issues for women as well!  Read that article HERE.  They reported that women taking more than 1,400 mg of calcium per day were twice as likely to die as those taking 600 to 999 mg. 

What the studies don't seem to address is whether we are talking about calcium citrate (YES for gastric bypass patients) or calcium carbonate (NO for gastric bypass patients), or whether it matters.  They do both seem to suggest that we are only talking about supplements, and not getting calcium natrually from foods. 

I was recently told I have heart inflammation.  I will be writing about that soon, but I am having to increase my exercise, decrease fatty foods, and take...a baby aspirin (no-no for gastric bypass patients -- again, another planned future blog).  So, in response, I have lowered the amount of calcium supplement that I take (one pill instead of two to three...I'll grab the amounts and publish that new blog soon).  Also, we should be taking Vitamin D with calcium to help with absorption (and if you're a gastric bypass patient, you need the dry version, not those cute little oily pills).  I am also taking zinc and magnesium.  It is, in fact, be time for me to re-write my daily vitamin in-take blog, to let people know what I'm actually taking now. 

Ok, back to this bone spur.  I have heard some home remedies about apple cider vinegar dissolving bone spurs.  I have heard a ton of good things about health and apple cider vinegar, actually.  Some of the reports say you should drink a little bit of cider (I get the organic stuff, not the Heinz bottle) with water.  A bodyworker at Twirly Girls warns to do two weeks on, two weeks off.  So, I have been adding it to my morning glass of water for the last couple of weeks (before breakfast, I try to jump start my metabolism by drinking a glass of water anyway).  Now, other reports say to soak a towel in apple cider vinegar and wear it around all day (although I'm not really interested in having a wet sock all day). 

So, there you have it.  Lack of calcium may have lead to a bone spur in my heel, and trying to take additional calcium to fix it could potentially lead to heart issues.  I guess you can't win.  Has anyone else had any experience with any of these issues? 

Vitamins and gastric bypass surgery

After gastric bypass, you're given a list a mile long of vitamins you should be taking.  The American public in general should be taking vitamins since the soils have been stripped of many nutrients and most people eat so much processed food.  However, after weight loss surgery, it is even more important to take your vitamins since you are malabsorptive and won't absorb most vitamins from your food.  I could get into fat and water soluble vitamins here, but that would just make this post way too long.  Just be aware that some vitamins dissolve and absorb better in different conditions (which is why having a little REAL salad dressing on your salad isn't necessarily a bad thing...fat can help you absorb some of those vitamins). 

I wanted to list all of the vitamins I take and why.  Everyone's list will be vaguely different.  I am seven years out from surgery, and each year I go in for my blood work, I'm low in some vitamin or another, and so it gets added to my list of vitamins to take.

I take a multivitamin.  There are many theories about which vitamin is best.  Store brand?  Designer brand?  I find that a prenatal (even a cheap store brand) works best for me.

A lot of patients have to take iron after surgery.  I do not take iron (other than the prenatal vitamin is supposed to have a little extra in it).  You have to be very careful not to take iron with calcium supplements, and can cause constipation, so be careful if you are advised to take iron.

For the fun of it, I take an echinacea-golden seal supplement.  I know there are conflicting reports about whether it actually helps you avoid colds, but I figure it doesn't hurt to take it. 

Sometimes I get cold sores, so I usually take a daily dose of L-Lysine.  If I have a break-out (which I haven't in a really long time), I take three doses twice a day and it usually helps it clear up quickly.  I am a stress case (and also have psoriasis, which is sensitive to stress), so taking a daily pill seems to help keep them away.

I take acidophilus/probiotic.  This is especially important for women if you are prescribed an antibiotic.  Stripping your body of the good bacteria can cause yeast infections.  You can also get probiotics from yogurt, but a lot of yogurts are very high in sugar, which isn't good for gastric bypass patients.

The number one vitamin a gastric bypass patient should take is B12.  They say you should take a sublingual dose (meaning it is dissolved under the tongue) twice a week.  I sometimes skip this pill (yeah, I know, I just said it was the most important pill), so when I'm taking it, I take it daily.  I was low on B12 early in my post-surgery days.  The tops of my feet tingled.  Getting too low in B12 can cause MS-like symptoms, so I suggest you don't skip the B12.  Some people can go to the doctor for shots if you aren't absorbing the pill or if you get too low.  I also suggest you not get to this point if you can help it.

I take a B1 (Thiamine) supplement as well.  I used to take a B-complex, but I am sensitive to Niacin (B3), and it makes my face red.  I stopped taking the B-complex a few years ago and then I was low in B1 two years ago.  So I added B1 back in.  B1 helps with food absorption.

I take a calcium supplement, which includes Vitamin D and magnesium, to help with absorption.  It is VERY, VERY important that we take calcium citrate, not calcium carbonate (Tums, etc.).  A lot of gastric bypass patients become lactose intolerant after surgery.  Even if you are able to drink/eat milk products, the malabsorpotion issue still gets in the way.  When you are overweight, you have a lower chance of getting osteoporosis (your body weight is keeping your bones strong).  However, once you lose weight, you need to make sure you are doing everything you can to keep your bones strong and healthy.

Last year, after my blood work, I had to add an additional Vitamin D pill.  I was low in Vitamin D (something you should be able to get from the sun but I must be spending way too much time indoors lately).  It's a tiny pill and I hardly notice I'm taking it.

I also take a Vitamin E natural pill.  My chiropractor recommended it years ago before I had plastic surgeries.  He said it helps with skin elasticity and healing. 

I now take a joint supplement.  That has nothing to do with surgery.  I just find that when I work out a lot, I hurt, and that helps keep my joints lubed and happy.

I also take an Omega-Three supplement.  For awhile, I was taking a "wholemega" pill, which claimed something like 16 omegas.  Now I just use the Trader Joe's brand.  It's just fish oil.  Ewww, I know.  But I take it with breakfast and it keeps me from burping fish taste, which would really bum me out.

Of course, another supplement that I try to take daily is my whey protein shake.  I still find that, even after seven years, that's the best way for me to make sure I get enough protein into my system on a daily basis.  I am currently trying to switch up how I eat, so I may be changing this to dinner instead of breakfast.  I use Champion Pure Whey protein powder.  However, there are many good brands out there.  Just make sure its high in protein (25 grams is plenty...the 55 gram shakes are a waste of calories) and low in calories and sugar (mine is 125 calories and I think 3 grams of sugar or less).

I also add whole ground flax seed to my protein shake.  It helps with constipation issues as well.

I take other vitamins and medications on and off but these are the ones I feel are necessary.  Yes, it's a lot of pills.  I usually just pack them into a little container and pop them as I'm driving to work after I've eaten breakfast.  And, as much as I hate popping so many pills, it's better than dying from malabsportion!