WHAT YOU NEED TO KNOW ABOUT WEIGHT LOSS SURGERY AND NUTRITION

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1 WHAT YOU NEED TO KNOW ABOUT WEIGHT LOSS SURGERY AND NUTRITION

2 Weight Loss Surgery A BIG DECISION. A NEW LIFESTYLE. A NEW YOU. You may be thinking about having weight loss surgery, or possibly already decided to have it. You might feel a bit nervous, maybe even a little scared. But most of all, you probably feel hopeful. This brochure will help you prepare for the upcoming changes in your life, including knowing what to expect from weight loss surgery. Vitamin B 12 is a good example of this. Weight loss surgery can limit the amount of vitamin B 12 that is absorbed in your body. It can be common to have vitamin B 12 deficiency after surgery. It is important to know what vitamins and minerals you will need to take before and after surgery; what your nutritional needs will be; and what adjustments you will need to make to your lifestyle to help you stay healthy, including learning how to eat differently to get the nutrition your body needs. You have a lot to look forward to. After having this surgery, you may be closer to your goals than before whether it is being healthy enough to keep up with the kids or just wanting to feel better. You will probably lose weight, which can help if you have weightrelated conditions, such as type 2 diabetes, sleep apnea, high blood pressure, acid reflux, and high cholesterol. 2 3

3 WHY VITAMINS AND MINERALS ARE IMPORTANT Before weight loss surgery, you may have taken in all the vitamins and minerals you needed from your diet. But it is a little different after weight loss surgery, because surgery often changes how your body processes nutrients. For example, if part of your digestive tract has been altered or removed, your body may not be able to absorb several important vitamins or minerals the way it did before. Vitamin B 12 is a good example of this. Weight loss surgery can limit the amount of vitamin B 12 that is absorbed in your body. There are a few reasons this happens. Your new diet might have fewer vitamin B 12 -rich foods. Vitamin B 12 is released from food by acids in the stomach and if food bypasses the stomach completely, vitamin B 12 may not be released. Vitamin B 12 attaches to a substance called intrinsic factor (IF) and is carried into the small intestine, where it is absorbed into the body. After weight loss surgery, the amount of IF made by the stomach may be limited. It can be common to have vitamin B 12 deficiency after surgery. WHY VITAMINS AND MINERALS ARE IMPORTANT You may be wondering if you really need to take these supplements for the rest of your life. The answer is absolutely yes! You should take your vitamins as your healthcare provider recommends. Signs and symptoms of vitamin deficiency can be non-specific. These may include: uuvitamin B 12 : tingling in fingers and toes, fatigue, poor memory/confusion uucalcium and vitamin D: cramping, weak bones, abnormal heart rhythms uufolic acid: fatigue, gray hair, mouth sores, poor growth, swollen tongue uuiron: feeling tired or weak, dizziness, chest pain, headache DID YOU KNOW? Get in the habit! People who have had weight loss surgery need to take vitamins and minerals to help them stay healthy. Talk to your doctor about being screened for vitamin deficiency before and after surgery. You will have to take more vitamins and minerals to make sure your body gets the right amount. The American Society for Metabolic and Bariatric Surgery (ASMBS) has specific guidelines* that tell you exactly which vitamins and minerals you will need. * ASMBS Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients 4 5

4 WHAT IS NASCOBAL NASCOBAL (Cyanocobalamin, USP) Nasal Spray is a prescription medicine used as a supplement to treat vitamin B 12 deficiency. NASCOBAL is the only FDA-approved vitamin B 12 nasal spray. People who have had weight loss surgery may not absorb enough vitamin B 12 from food. That is why NASCOBAL is a good option. NASCOBAL dosing is simple: 1 spray, 1 nostril, 1x a week Here are some features of this product: uuonce-weekly nasal spray Fewer visits to the doctor s office for vitamin B 12 dose Not a painful shot uutasteless and odorless fine mist NASAL SPRAY? uuincreases and maintains vitamin B 12 levels uuabsorbed directly into the bloodstream designed to bypass the digestive tract uuself-administered IMPORTANT SAFETY INFORMATION for NASCOBAL Do not use NASCOBAL if you are allergic to cobalt, vitamin B 12, or any of the ingredients in NASCOBAL. Severe allergic reactions and death have occurred with other types of vitamin B 12 supplements. If you have Leber s disease, NASCOBAL can cause serious nerve damage in your eyes. Talk to your doctor if you have vision problems before or during treatment. Life-threatening side effects may occur in people with a certain kind of anemia (a blood problem), treated aggressively with vitamin B 12. Additionally, taking a drug called folic HOW TO USE NASCOBAL Before you take NASCOBAL uuthe unit contains only 1 spray: DO NOT prime before use uublow nose gently to clear both nostrils uuhold the unit with your thumb, supporting it at the bottom, and your index and middle fingers on either side of the nozzle Taking NASCOBAL uugently close 1 nostril with your other index finger. Insert the nozzle into open nostril approximately ½ inch, or as far as feels comfortable, and tilt your head slightly forward. Do not press the plunger yet uubreathe in gently through your nose, close your mouth, and at the same time, press the plunger firmly with your thumb After you take NASCOBAL uuremove the nozzle from your nostril. At the same time, keep your head level for 10 to 20 seconds while gently breathing in through your nose and breathing out through your mouth Do not drink hot liquids or eat hot foods 1 hour before and 1 hour after taking NASCOBAL Nasal Spray. IMPORTANT SAFETY INFORMATION for NASCOBAL (continued) Since NASCOBAL is inhaled by nose, tell your doctor if you have breathing problems such as stuffy nose, allergic rhinitis, or upper respiratory infection. Your doctor may choose to delay your treatment. Tell your doctor if you are pregnant or planning to become pregnant (it is not known if NASCOBAL will harm your unborn baby). However, vitamin B 12 is an essential vitamin and requirements are increased during pregnancy. Tell your doctor if you are breastfeeding. Tell your doctor about all of the medicines you take, both before and during your treatment with NASCOBAL. Certain medicines can affect blood test results and how NASCOBAL works. Side effects include weakness, headache, sore throat, common cold, swollen tongue, nausea, tingling and rhinitis. acid in place of vitamin B These are not all the possible side effects of NASCOBAL 12 can lead to worsening and permanent nerve damage.. Talk to your doctor about any side effects you experience. Your doctor will check your blood before starting NASCOBAL and during therapy. It is Please click here for full Prescribing Information. Learn more at important to return for follow-up visits as directed by your doctor to make sure 6 NASCOBAL is working. 7

5 NUTRITION DIRECT TM IS MADE ESPECIALLY FOR PEOPLE LIKE YOU Making lifelong nutritional support easier After surgery, part of your digestive tract and stomach will be gone. Your body will not be able to absorb several important nutrients the way it did before. And because your stomach will be smaller, it will not take as long to feel full, so you will be eating less. If you are eating less, you are also getting less nutrition. That is why it is more important than ever to take vitamin and mineral supplements. Nutrition Direct TM was designed to help give you the supplements you need. It has the required nutrients in recommended amounts for people who have had weight loss surgery. With Nutrition Direct TM, you get the supplements delivered to your home each month through ProCare PharmacyCare. The following supplements will be shipped with NASCOBAL vitamin B 12 Nasal Spray: uu Multivitamin uu Calcium + D 3 & Magnesium uu Iron + Vitamin C It is good to know that everything in the Nutrition Direct TM kit is free of milk, egg, fish, shellfish, tree nuts, peanuts, wheat, and soy. DID YOU KNOW? These supplements are specifically for people who have had weight loss surgery. They meet the ASMBS guidelines for nutritional support. Please see Important Safety Information for NASCOBAL (Cyanocobalamin, USP) Nasal Spray on Pages 6 & 7. Please click here for full Prescribing Information. 8 9

6 TWO GREAT OPTIONS FOR GETTING THE NUTRIENTS YOU NEED FOR LIFE Chewable Can be started soon after surgery as discussed with your healthcare provider Used for lifelong nutritional support Great-tasting fruit flavor Tablet/Capsule When chewable tablets are no longer required, tablets/capsules can be started as discussed with your healthcare provider Used for lifelong nutritional support HOW TO TAKE BARIACTIV Also Available! Tablet/Capsule (Can be easily swallowed with water.) Multivitamin Capsule SUPPLEMENTS (continued) Calcium + D 3 & Magnesium Tablets Iron + Vitamin C Tablet HOW TO TAKE BARIACTIV SUPPLEMENTS Chewable (Can be chewed or dissolved without the use of water.) Multivitamin Calcium + D 3 & Magnesium Iron + Vitamin C uutake one serving (1 capsule) once a day uutake one serving (2 tablets) twice a day* u u Take one serving (1 tablet) once a day* *It is very important NOT to take the calcium and iron pills at the same time. uutake one serving (2 u utake one serving (2 tablets) uutake one serving (3 Take them at least 2 hours apart. 10 tablets) once a day twice a day* tablets) once a day* 11

7 ABOUT BARIACTIV Nutrition Direct TM : Designed to meet the ASMBS Nutritional Guidelines* ASMBS Recommended Nutritional Supplementation Adult multivitamins and minerals Chewable tablets Thiamine (Vitamin B 1 ) Folic acid Copper Ferronyl iron Vitamin D 3 Calcium Citrate in divided doses Vitamin B 12 VITAMINS AND MINERALS Nutrition Direct TM 12 mg/day 800 mcg/day 2 mg/day 54 mg/day 3800 IU/day 1200 mg/day 500 mcg/week GET SUPPLEMENTS DELIVERED RIGHT TO YOUR DOORSTEP You may feel overwhelmed by all the changes that are coming. Nutrition Direct TM can help. It is easy to enroll your doctor faxes the enrollment form. Then you can start getting all of your supplements, month after month, to help you stay healthy after surgery. DID YOU KNOW? Nutrition Direct TM gives you the nutrients you need in one convenient, affordable, monthly delivery. vitamins are specifically for people who have had weight loss surgery. * ASMBS Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients The only way to get all these vitamins and minerals offered by Nutrition Direct TM delivered right to your home is through your doctor. Ask about Nutrition Direct TM. You will also receive lots of support, including educational materials, reminders, and more. For all types of surgery, including Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve 12 gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB). 13

8 IT IS EASY TO GET NUTRITION DIRECT TM Here is how, in just a few easy steps: Ask your doctor for the fax enrollment form. Complete the top half of the form. Then give it to your doctor to sign. The office staff will fax the completed form to ProCare PharmacyCare at You will get a welcome call from the pharmacy to confirm your order. After that, ProCare PharmacyCare will ship your nutrients to you within 3 to 5 days. You will get an confirming shipping with tracking information so you can track your shipment. Your order will be automatically refilled each month. The pharmacy will help you with insurance claim processing each month so that the nutrients in Nutrition Direct TM arrive at your home. DELIVERING SUPPLEMENTS FOR LESS THAN YOU WOULD EXPECT Enrolling in Nutrition Direct provides you with NASCOBAL, a prescription vitamin B 12 nasal spray. In addition, you will receive supplements designed to meet the ASMBS Nutritional Guidelines with easy monthly delivery. The program keeps your wallet healthy, too. Many people are eligible to get Nutrition Direct TM for $25 or less per month.* That is a 30-day supply of supplements delivered right to your home. NASCOBAL Nasal Spray prescription with enrollment in Nutrition Direct : ONLY $ 25 PER MONTH TO RECEIVE SUPPLEMENTS THAT MEET * Patients may redeem this offer ONLY when accompanied by a valid prescription. Offer is valid for costs exceeding $25 up to a maximum benefit of $100. In certain circumstances this offer may also cover the first $25 of costs up to a maximum benefit of $150. Offer is not valid for patients whose prescriptions are reimbursed in whole or in part under Medicaid, Medicare, Medigap, VA, DoD, TRICARE, or any other federal or state programs (such as medical assistance programs) or where otherwise prohibited by law. Offer is not valid in VT or where prohibited in whole or in part. This offer may be amended or ended at any time without notice. WHAT IS NASCOBAL NASAL SPRAY? NASCOBAL (Cyanocobalamin, USP) Nasal Spray is a prescription medicine used as a supplement to treat vitamin B 12 deficiency. ASMBS NUTRITIONAL GUIDELINES IMPORTANT SAFETY INFORMATION for NASCOBAL Do not use NASCOBAL if you are allergic to cobalt, vitamin B 12, or any of the ingredients in NASCOBAL. Severe allergic reactions and death have occurred with WHY PAY MORE? other types of vitamin B 12 supplements. Please see Important Safety Information for NASCOBAL (Cyanocobalamin, USP) Nasal Spray on Pages 6 & Please click here for full Prescribing Information. 15

9 Nutrition Direct is made especially for people like you. Get Nutrition Direct delivered right to your doorstep for less than you would expect. It is easy to get Nutrition Direct. Rx Only NASCOBAL is a registered trademark of Endo International plc or one of its affiliates Endo Pharmaceuticals Inc. All rights reserved. Malvern, PA NS-05200/June ENDO (3636)