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Parathyroid Scan

July 09, 2018 11:48 am

A Parathyroid scan or Sestamibi scan may be needed if the typical weight loss surgical reasons for elevated PTH levels have been addressed. Sestamibi is a small protein which is labeled with the radio-pharmaceutical technetium-99. This very mild and safe radioactive agent is injected into the veins of a patient with overactive parathyroid and is absorbed by the overactive parathyroid gland. If the parathyroid is normal it will not absorb the agent. The scan below shows the uptake of the agent.

Calcium, Vitamin D and Parathyroid hormone are routinely measured on yearly follow up for most post weight loss surgical (WLS) patients. Elevated parathyroid hormone (PTH) may be caused by Vitamin D deficiency or calcium deficiency (most common in post WLS) or by over active parathyroid gland(s). In the latter case, if one of the four glands  is overactive then this is knows as a parathyroid Adenoma. If all 4 are over active and are secreting too much PTH, this is known as hyperplasia. Ultrasound of the neck, may identify an enraged parathyroid gland (adenoma) which is located behind the thyroid gland. Given the large area where the parathyroid gland may be located, additional tests are needed to not only identify the location of the gland(s) but also to distinguish between single gland (adenoma) or multiple glands (hyperplasia) cause for the elevated PTH. It is important to investigate all avenues and testing in parathyroid hormone elevation and in some cases, not to rely on one test for your diagnosis.  It is also imperative that weight loss surgical patients take their supplements routinely and consistently and have their laboratory studies followed at least yearly.

Informative Video on Vitamin D: here

 

Hyperparathyroidism and Weight Loss Surgery

March 13, 2015 5:57 pm

Hypoparathyroidism refers to elevated level of parathyroid hormone levels (elevated or high PTH).  Parathyroid glands are two small glands that are located behind the thyroid gland.  The primary function is regulation of the calcium level in the bloodstream. Parathyroid levels may be abnormally elevated for a number of reasons.

1-Primary Hyperparathyroidism

There may be abnormalities within the parathyroid glands themselves including benign and malignant tumors.    Laboratory studies to assist in identifying Parathyroid hyperplasia are calcium, phosphorus, magnesium, PTH (parathyroid hormone), Vitamin D and possibly a 24 hour urine, kidney x-ray, and Dexa scan. The calcium levels in parathyroid hyperplasia are usually elevated and Vitamin D levels low. Patients can present with hypercalcemia symptoms such as kidney stones, nausea, vomiting, peptic ulcer, constipation, bone pain, bone weakness, depression, lethargy, fatigue. There are two types of Primary Hyperparathyroidism parathyroid hyperplasia and parathyroid adenomas.  These both can at times be genetically linked.

Once the cause of elevated parathyroid hormone has been identified as primary hyperparathyroidism, the treatment involves surgical removal of one or more of the adenoma(s) or removal of 3.5 off all of the parathyroid glands if hyperplasia is diagnosed.

Parathyroid hyperplasia: When the growth involves all 4 of the glands.  These may effect either one of the glands or all 4 of them.  Majority of these are benign.

Parathyroid adenoma(s) refers to the abnormality or benign growth of one or more of the parathyroid glands.

2- Secondary Hyperparathyroidism

This is probably the most common cause of hyperparathyroidism imposed on a  weight loss surgical patient.  The elevated parathyroid hormone is the physiologic response all of the parathyroid glands to low calcium level.  The parathyroid hormone is elevated in order to favor bone breakdown and make available for calcium to be circulating in the bloodstream.  Parathyroid hormone also facilitates reabsorption of the calcium from the urine and improve absorption of the calcium from the GI tract.

The most common causes of secondary hyperparathyroidism is Vitamin D deficiency, weight loss surgery, kidney failure, Celiac or Crohn’s Disease.  Lower levels of Vitamin D decrease the intestinal calcium absorption and thereby increasing PTH secretion. Vitamin D is the transport molecule for calcium. Symptoms may include bone or joint pain, muscle weakness, osteomalacia,  low to normal blood calcium levels. The treatment of secondary hyperparathyroidism is correction of the underlying low calcium, low vitamin D levels. We have our Duodenal Switch patients take calcium citrate and  dry water miscible type of Vitamin D3.  Some people may require vitamin D injection in order to overcome deficiencies. You can find a list of supplements on our website and/or our starting point supplement recommendation in our patient workbook

Articles on Secondary Hyperparathyroidism following Weight Loss Surgery:

https://www.ncbi.nlm.nih.gov/pubmed/23015268

https://www.ncbi.nlm.nih.gov/pubmed/16354517

https://www.ncbi.nlm.nih.gov/pubmed/18063076

https://www.hindawi.com/journals/jobe/2011/634614/

Calcium Lab Results

June 05, 2018 3:26 pm

Calcium is measured to evaluate function and adequacy of a physiologic processes. Calcium plays a critical role in several body functions such as, coagulation pathways, bone health, nerve conduction, and other functions. It is important whenever you are evaluating laboratory results that you look at the whole picture of the person, including medications, other laboratory studies and health history.  One value is not a stand alone result.  There are many factors that effect calcium results.

Factors that effect calcium results: (not an all inclusive list)

pH

Albumin

Lactate

Heparin

Vitamin D deficiency

Magnesium depletion

Anticonvulsants

Renal Disease

Pancreatitis

Parathyroid

Thyroid

The two most common issues following Weight loss Surgery  or Duodenal Switch may be albumin level and Vitamin D level.  Please see past blogs on Vitamin D. Magnesium may also play a role in a Duodenal Switch patient.

The most common calcium result drawn is the total calcium level. Laboratory results may not explicitly label it as such, however, it measures the calcium that is bound to protein. Ionized calcium is the free calcium that is representative of the true total calcium. Ionized Calcium can be measured by ordering specific lab. Alternatively, the Ionized calcium can be calculated by the following formula: Corrected calcium mg/dL = (0.8 * (Normal Albumin – Pt’s Albumin)) + Serum Ca  ) or use the calculator at the bottom of this post.

 

The low Albumin level accounts for the low calcium level. This may be the reason for a patient with a low albumin/protein level, also having their calcium level reported as low. However, when adjusted for the protein deficiency the corrected calcium comes into normal range. Video of Trouseau’s sign of a patient with calcium deficiency. Calcium bound to albumin Keshishian

The first step in a patient who has low calcium reported, is to make sure their protein and albumin levels are normal, along with Vitamin D.

Calcium levels are managed by two processes major regularly hormones and  influencing hormones. Controlling or major regulatory hormones include PTH, calcitonin, and vitamin D. In the kidney, vitamin D and PTH stimulate the activity of the epithelial calcium channel and the calcium-binding protein (ie, calbindin) to increase calcium absorption. Influencing hormones include thyroid hormones, growth hormone, and adrenal and gonadal steroids.

Further information on protein.

Further information on calcium. 

Videos/Webinars on several of the above topics.

calcium metabolism
Duodenal Calcium Metabolism

Corrected calcium = 0.8 * (4.0 – serum albumin) + serum calcium

Corrected Calcium Level Calculator

Vitamin D2 Vs D3

March 24, 2016 9:17 am

Thank you to Contributor: Mariam Michelle Gyulnazaryan

Vitamins are organic, essential nutrients that are necessary to keep your body in good health. Most vitamins must be obtained through diet because they cannot be synthesized in the body. However, the human body is able to make its own vitamin D in the skin through sun exposure or it can be obtained by food and supplements of Vitamin D3.

Vitamin D is a fat-soluble vitamin that is responsible for regulating muscle contraction, immune function, bone health, and intestinal absorption of magnesium, calcium, phosphate, iron, and zinc. Good sources of Vitamin D include sun exposure, dairy products, fatty fish, fortified orange juice, cod liver oil, mushrooms, and supplements.

There are two types of Vitamin D: D2 (ergocalciferol) and D3 (cholecalciferol). Both types have the same mechanism of action, but different sources and kinetics.

vitd_sourcesCaption: Vitamin D sources
Source: 2012Books.com

Ergocalciferol is easily obtained through Vitamin D-rich foods in normal anatomy. However, a post Duodenal Switch patient will have less absorption of Vitamin D via food due to fat malabsorption.  Ergocalciferol is hydroxylated to ercalcidiol [25(OH)D2] in the liver. Its second hydroxylation takes places in the kidney, where it is converted to the active form of Vitamin D2 known as ercalcitriol [1,25(OH)2D2]. Now in it’s active form, Vitamin D2 can bind to the Vitamin D receptor (VDR) and help the body where it’s needed.
In the epidermis of the skin, precursor 7-dehydrocholesterol (7-DHC) forms cholecalciferol as a result of UVB radiation. Several factors such as increased skin pigmentation, age, and sunscreen application reduce the skin’s production of choleciferol (6). Cholecalciferol is hydroxylated in the liver to become calcidiol [25(OH)D3]. It is then moved to the kidney for further hydroxylation to Vitamin D3’s active form known as calcitriol [1,25(OH)2D3], also called calcifediol. The active form allows binding to VDR for biological activity.

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Caption: The mechanism and effects of Vitamin D.
Source: jennyrosepaul.com

Both forms of Vitamin D have been shown to effectively increase 25(OH)D levels. Research shows that after administering a single dose of 50,000 international units (IU) Vitamin D2 or D3, both experienced a similar increase in serum 25(OH)D concentration. However, Vitamin D2 levels rapidly declined while Vitamin D3 levels remained high (1). Further studies have confirmed that Vitamin D3 is more effective in elevating and maintaining 25(OH)D levels for a longer amount of time (5). Scientists believe the most reasonable explanation for Vitamin D3’s substantial efficacy is its higher affinity to metabolites, which results in a longer circulating half-life than Vitamin D2 making it more potent(4). For a post Duodenal Switch patient, due to fat malabsorption, it is important to use “Dry” Water Miscible form of Vitamin D3.

Example of a Dry Water Miscible form of Vitamin D3
Example of a Dry Water Miscible form of Vitamin D3

A 25-hydroxy Vitamin D blood test is the most accurate way to measure levels. A level between 20 ng/mL-50 ng/mL may be  considered sufficient, however in our bariatric practice we would like to keep the levels in 60-80 ng/mL.  It is worth nothing that recently the reference ranges was increase to 30-100 ng/mL.  Treatments of Vitamin D deficiency include frequent sun exposure, fortified foods, supplements, and injectables. in addition to 50000IU of vitamin D on daily basis in emulsified (water soluble) formulary or unto 600,000IU in injection form. The parallel guide for adequate vitamin D supplementation is normalization of PTH levels. Monitoring these levels is imperative in a post bariatric patient.

In conclusion, studies have shown that Vitamin D2 and D3 are not interchangeable. Although they have comparable absorption, Vitamin D2 has a shorter duration of action which makes it less potent than Vitamin D3. Researchers have shown that neither form is harmful to treat Vitamin D deficiency, but they should not be considered bio-equivalent.

References
1. Armas LAG, Hollis BW, Heaney RP. Vitamin D2 is much less effective than Vitamin D3 in humans. Journal of Clinical Endocrinology & Metabolism. 2004; 89(11) 5387-5391.
2. Creighton D, Ignaszewski A, Francis G. Vitamin D: new d-fence against cardiovascular disease. BCMJ. 2012; 54(3) 136-140.
3. Holick MF, Schnoes HK, DeLuca HF. Identification of 1,25-Dihydroxycholecalciferol, a form of Vitamin D3 metabolically active in the intestine. PNAS. 1971; 68(4) 803-804.
4. Hollis BW. Comparison of equilibrium and disequilibrium assay conditions for ergocalciferol, cholecalciferol and their major metabolites. J Steroid Biochem. 1984; 21(1) 81-86.
5. Houghton LA, Vieth R. The case against ergocalciferol (Vitamin D2) as a vitamin supplement. Am J Clin Nutr. 2006; 84 (4): 694-697.
6. Howick Mf, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM. Evaluation, treatment and prevention of Vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011; 96(7) 1911-1930.
7. Johal M, Levin A. Vitamin D and Parathyroid Hormone in general populations: understandings in 2009 and applications to chronic kidney disease. CJASN. 2009; 4(9) 1508-1514.
8. Tetley EA, Brule D, Cheney MC, Davis Cd, Esslingen KA, Fischer PWF, Friedl KE, Green-Finestone LA, Guenther PM, Klurfeld DM, L’Abbe MR, McMurry KY, Starke-Reed PE, Trumbo PR. Dietary reference intakes for Vitamin D: justification for a review of the 1997 values. Am J Clin Nutr. 2009; 89(3) 719-727.
9. Tripkovic L, Lambert H, Hard K, Smith CP, Bucca G, Penson S, Chope G, Hypponen E, Berry J, Vieth R, Lanham-New S. Comparison of Vitamin D2 and Vitamin D3 supplementation in raising serum 25-hydroxyvitamin D status: a systematic review and meta-analysis. Am J Clin Nutr. 2012; 95(6) 1357-1364.

August 6, 2014 Group Meeting Recap

August 08, 2014 6:35 pm

August’s group meeting/webinar topic was Vitamin D.  Dr. Keshishian will be adding the voice over to the slides and it will be uploaded to  when it’s completed.  But in the meantime here are some highlights. Webinar here.

Vitamin D is a fat soluble vitamin has many important functions including bone health, cardiovascular health, blood glucose regulation, anti-cancer, anti-inflammatory, muscle function, respirator function, brain development and health, and immune function.  There are several very large studies investigating other functions of Vitamin D.  Vitamin D knowledge is in the midst of huge changes due to these upcoming studies.

Vitamin D metabolism is a complicated process whether via photo conversion in the skin or supplementation. Either way Vitamin D metabolism requires cholesterol to be converted to its active form.  The fat-solubility is the primary reason for deficiency after Doudenal Switch, due to malabsorption of fat needed for conversion of Vitamin D. The Parathyroid gland helps to regulate absorption of Vitamin D.  It is an inverse mechanism, meaning a high Parathyroid level signals more absorption of Vitamin D and calcium also.

Vitamin D deficiency is a World Health Organization priority. There are several causes some related to sunscreen use, disease processes, WLS, cola intake, diet related and medications.  These can compound Vitamin D deficiencies.

Dr. Keshishian has new guide lines for Vitamin D levels.  Due to the changing research regarding Vitamin D these guidelines are changing.  There are some endocrinologists in Vitamin D research that are recommending even high standard of Vitamin D. DS patients should be well above the border of insufficient and sufficient due to underlining contributing facts for deficiencies and the lack of absorption. Parathyroid Hormone levels are inversely related.  High PTH level can indicate Vitamin D deficiency and increase need for calcium.  Calcium blood levels are not a good indicator of calcium  or Vitamin D needs as the body is efficient at maintaining Calcium blood levels by breaking down bone mass due to the critic bodies need for circulating calcium.
Supplementation options are as follows: Please note that most over the counter Vitamin D is not appropriate for DS absorption.  DS patients need to take “Dry” water miscible Vitamin D3. Please see the previous blog post regarding http://blog.dssurgery.com/2013/08/vitamin-d-and-dry-water-soluble.html for more information and pictures of this type of Vitamin D. Vitamin D is tied to several other nutrients for metabolism such as protein, calcium, magnesium, zinc and potassium.  Treatment for correcting iron deficiency and phosphorus intake counter act Vitamin D absorption as do other previous discussed dietary issues. Take oral Vitamin D supplements even if you are receiving injectable Vitamin D.

Be proactive in Vitamin D supplements by monitoring your yearly DS laboratory studies.  Please call the office with any questions.  If in need of Vitamin D injections please see the previous blog post for related research article and compounding  pharmacies.  Vitamin D injections are not common place.
Please take the Vitamin D injections post to your treating physician if you are unable to see Dr. Keshishian and are in need of Vitamin D injections. If your treating physician has any questions please let them know Dr. Keshishian is available to answer their questions.

Our food selections for the meeting where all high Vitamin D recipes.  Tuna stuff mushroom (Tuna for Vitamin D and mushrooms are a good source of zinc), crustless artichoke and spinach quiche ignore the part of the recipe for the crust and just bake in pie plate without the crust, Panna cotta with a strawberry balsamic compote and toasted flax seed and hemp hulls.   The panna cotta is made with milk or almond milk and gelatin which are all important in bone health.  Hemp hulls are a protein source as is the milk.

Strawberry Balsamic Compote taken from http://nomnompaleo.com
1/4 C balsamic Vinegar
2C hulled strawberries, thinly sliced
2 TBSP honey
1 TBSP fresh lemon juice
1tsp vanilla extract
1/4 tsp salt
In a sauce pan heat Balsamic vinegar until reduced by half and is a thick syrup.  Add the rest of ingredients and simmer over medium heat for 5-10 minutes. Remove pan from heat and use an immersion blender to puree some of the sauce.  The texture is to your liking, so puree as much or as little as you would like.  Store in a sealed container for up to a week or you can freeze it for long term  storage. This site also has a almond milk Panna Cotta but this is not the recipe use at the group meeting.

Panna Cotta Recipe
1/2 C 2% milk mix with 2 1/2 tsp of unflavored gelatin in a bowl to rehydrate the gelatin let sit for 5-10 minutes

In a medium saucepan mix
3 C 2% milk or whole milk
one vanilla bean split in half or 1 tsp vanilla extract
2 TBSP maple syrup
1 tsp salt
heat until steaming but not boiling, about 5-7 minutes.  Take off heat.

Mix 1/4C greek style yogurt into the milk and rehydrated gelatin. Then whisk about 1 C of hot milk mixture into the gelatin/milk. Add this mixture into pan of hot milk and whisk well.  Pour hot Panna Cotta mixture into ramekins.  Refrigerate until set, about 2 hours.

In a small frying pan toast 2 TBSP Flax seed and mix with 2 TBSP hemp hulls. Before serving top with Strawberry  Balsamic Compote and flax seed/hemp seed mixture to your taste.

What does elevated Alkaline Phosphatase level mean?

March 18, 2014 2:17 am

Alkaline phosphatase (ALP) is on enzyme that is produced mostly by the liver and bones.  There are other organs in an adult that produce alkaline phosphatase including the kidneys and the small bowel. Placental of a pregnant female also produces some alkaline phosphatase. The amount of alkaline phosphatase produced by the liver is more than the combined level of alkaline phosphatase by all other sources in an adult.

There are laboratory studies that can distinguish between 2 primary sources of the ALP.  The two “isoenzymes” are bone ALP and liver ALP.

The presence of an elevated level alkaline phosphatase is significant in post weight loss surgical patients because of its relationship to calcium and vitamin D absorption.  When a patient has inadequate calcium and vitamin D absorption (or intake) this will result in elevation of the parathyroid hormone (PTH).   Elevated level of parathyroid hormone will the cause, increased bone breakdown, increased absorption of calcium from the GI tract, increased resorption of the calcium from the kidneys.  All of these measures are to normalize the level of the calcium in the blood.  One of the byproducts of bone breakdown is alkaline phosphatase. 
When the patient has an elevated ALP consideration should be given to liver sources including biliary obstruction.  In post duodenal switch operation this can only be studied by a magnetic resonance cholangiopancreatography (MRCP.)  Patients with a duodenal switch operation cannot have an endoscopic retrograde cholangiopancreatography (ERCP.) Needless to say broader range of liver function tests should also be evaluated.

Parathyroid hormone level, vitamin D 25-OH level and calcium level will also be needed in order to evaluate the possible cause off calcium malabsorption as the underlying reason for elevated alkaline phosphatase by the mechanism described above.  A typical patient may have an elevated parathyroid level, low calcium and low vitamin D level.

Study: Vitamin D may boost heart health during weight loss

May 25, 2009 10:27 pm

Supplements of vitamin D may improve cardiovascular health during weight loss, without impacting on how many pounds are shed, suggests a new study.Supplements of vitamin D may improve cardiovascular health during weight loss, without impacting on how many pounds are shed, suggests a new study.

“The results indicate that a vitamin D supplement of 83 micrograms/d does not adversely affect weight loss and is able to significantly improve several cardiovascular disease risk markers in overweight subjects with inadequate vitamin D status participating in a weight-reduction program,” wrote the authors, led by Armin Zittermann from the Clinic for Thorax and Cardiovascular Surgery in Bad Oeynhausen.

With obesity rates still high – not only in developed countries but also, increasingly, in newly wealthy emerging markets, there is considerable attention to ways to trim down waistlines. The results of the new randomised, double-blind, placebo-controlled trial indicate that vitamin D supplements may be useful as a means of boosting heart health during weight loss.

The details on D

Vitamin D refers to two biologically inactive precursors – D3, also known as cholecalciferol, and D2, also known as ergocalciferol. The former, produced in the skin on exposure to UVB radiation (290 to 320 nm), is said to be more bioactive.

While our bodies do manufacture vitamin D on exposure to sunshine,
the levels in some northern countries are so weak during the winter months that our body makes no vitamin D atall, meaning that dietary supplements and fortified foods are seen by many as the best way to boost intakes of vitamin D.

In adults, it is said vitamin D deficiency may precipitate or exacerbate osteopenia, osteoporosis, muscle weakness, fractures, common cancers, autoimmune diseases, infectious diseases and cardiovascular diseases. There is also some evidence that the vitamin may reduce the incidence of several types of cancer and type-1 diabetes.

Study details

Zittermann and his co-workers recruited 200 healthy overweight people with average 25(OH)D levels of 30 nmol/L (12 ng/mL) and randomly assigned them to receive either placebo or vitamin D for one year. All the subjects also participated in a weight-reduction program.

At the end of the study, 25(OH)D levels increased in the D group by 55.5 nmol/L, but by only 11.8 nmol/L in the placebo group. Furthermore, a 26.5 per cent reduction in levels of parathyroid hormone (PTH) were observed in the D group, compared with 18.7 per cent in the placebo group. “High blood concentrations of parathyroid hormone […] are considered new cardiovascular disease risk markers,” explained the authors.

Improvements in triglycerides levels were also observed in the vitamin D group, with a 13.5 per cent decrease noted compared with a 3.0 per cent increase in the placebo group.

Finally, levels of the marker of inflammation TNF-alpha decreased by 10.2% per cent following vitamin D supplementation, compared with 3.2 per cent in the placebo group.

“The beneficial biochemical effects were independent of the loss in body
weight, fat mass, and sex,”
noted the researchers.

On the downside, the researchers noted that participants receiving the vitamin D supplements did experience an average 5.4 per cent increase in their levels of LDLcholesterol.
Source: American Journal of Clinical Nutrition
May 2009, Volume 89, Pages
1321-1327, doi:10.3945/ajcn.
2008.27004
“Vitamin D supplementation enhances the beneficial effects of weight loss on
cardiovascular disease risk markers” Authors: A. Zittermann, S. Frisch, H.K. Berthold, C. Götting, J. Kuhn, K. Kleesiek, P. Stehle, H. Koertke, R. Koerfer
May 25