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During a recent group meeting, questions were raised regarding supplementing with Vitamin K1 or Vitamin K2 along with anticoagulant treatment. The table below provides a generalized summary of the Vitamin K1 and K2. The forms of Vitamin K in dietary supplements may differ depending on the supplement and the choice of the supplements may affect their absorptive behavior. This creates a challenge in regulating lab values, especially in patient who require anticoagulation therapy.
In summary K1 and K2 counteract the function of the anticoagulant medications. You should consult the physician prescribing the anticoagulant before taking any vitamin K1 or K2. Even as we think of K2 having less to do with coagulation pathways, it is recommended that the patients do not take any vitamin K supplements unless cleared by their physician, since K2 may also affect the anticoagulation treatment. As a patient who is prescribed anticoagulation treatment you should make your prescribing physician aware of ANY changes in your medications or supplements either over the counter or prescribed.
Vitamin K1 is a found in dark green leafy vegetables, asparagus, brussels sprouts, some grains, olive oil, prunes, soy bean oil, and canola oil. The body has limited storage capacity for Vitamin K and uses a recycle system to reuse it.
Vitamin K1 is a fat-soluble vitamin that after Duodenal Switch is not as easily absorbed due to the limiting contact of the food product with the bile until the common channel. Bile is needed to absorb fatty acids and fat-soluble vitamins.
Duodenal Switch patients in need of Vitamin K1 supplements should take “Dry” or water miscible type of Vitamin K1, such as Biotech brand. The patients laboratory studies will determine if a patient requires Vitamin K1 supplement. Duodenal Switch patients should have laboratory studies drawn and evaluated at least on a yearly basis. Vitamin K works in a delicate balance with other supplements and should be monitored by a physician, in at risk people.
Vitamin K1 is most know for it’s coagulation effect and the clotting cascade. Vitamin K1 works with calcium and proteins in order to accomplish coagulation synethesis. Care should be taken with Vitamin K supplementation and anti-coagulation (blood thinners) therapy. Please see your physician regarding any supplementation of Vitamin K and blood thinner medications.
A discovery of Vitamin K dependent proteins has led to research on Vitamin K1 in bone health. Bone matrix proteins, specifically osteocalcin, undergo gamma carboxylation with calcium much the way coagulation factors do; this process also requires Vitamin K. Osteocalcin is a Gla-protein that is regulated by Vitamin D. The calcium binding ability of osteocalcin requires several Vitamin K carboxylations to exert it’s effects on bone mineralization.
In adults, the causes of Vitamin K1 deficiency include the following :
Multiple abdominal surgeries
Long-term parenteral nutrition
Parenchymal liver disease
Inflammatory bowel disease
Medications: Antibiotics (cephalosporin), cholestyramines, warfarin, salicylates, anticonvulsants, Cefamandole, cefoperazone, salicylates, hydantoins, rifampin, isoniazid, barbiturates, and certain sulfa drugs, higher Vitamin E can antagonized Vitamin K)
Disseminated intravascular coagulation (DIC) – Severe
Chronic kidney disease/hemodialysis
Additional information: https://lpi.oregonstate.edu/infocenter/vitamins/vitaminK/
As always, discuss with your physicians and/or surgeon any changes in medications and supplements. This is not meant to be an all inclusive discussion of Vitamin K.
There has been extensive discussion on the importance of Vitamin D published over the last few years in regards to bone health, immune health and Calcium physiology. The importance of vitmain D and bone structure has been discussed extensively. It is also important in the absorption of Calcium. It further plays role in immune modulation.
What is new is the possible correlation of Vitamin D and COVID 19. Recently it is been shown that low vitamin D may increase the risk of a poor outcome with Covid-19 exposure and infection.
There are different standard recommendation for the Vitamin D levels.
In our practice we aim to maintain a Vitamin D level of 0ver 60 in post weight loss surgical patients.
There are a number of theories as to how the Vitamin D deficiency may play a role in this. An emerging observation is that low Vitamin D may cause abnormal and excessive blood clot formation. Mohammad et. al. in 2019 published a study on the association of low vitamin D and “…Pathogenesis of Thrombosis”
This pathologic blood clot formation in COVID-19 patients may explain the extensive lung injury and multi system organ failure in some patient. It is also one of the reason that some COVID-19 patients have loss limbs or appendages.
Please follow all supplement recommendations based on your laboratory studies and all COVID-19 recommendations. We would recommend frequent hand washing, surface cleaning, social distancing, and wearing face masks as the most basic precautions and increase precautions based on your health status.
We are all aware of the many roles that Vitamin D plays in our bodies. This includes immune function in addition to all the regulatory roles that Vitamin D plays in several physiologic reactions. There may be a correlation of low Vitamin D and COVID-19 infection increasing death risk as looked at in research articles.
Covid -19 in a subset of patience causes significant lung injury. These patients require mechanical ventilation.
Previously reported publications have suggested a possible correlation between ace inhibitors and increased risk of pulmonary complications of Covid -19. Some researchers suspect that the Covid-19 may be able to enter lung cells by the ACE receptors.
Vitamin D may positively implact the receptor ACE2. This study, report clear correlation between the high death rate with low vitamin D levels in Covid infected patients. There are limitation to this study that the attached abstract outlines.
Our take home message would be to please make sure you have updated labs and that you are all taking the recommended Vitamin D based on your surgical anatomy and laboratory values, not just an average non-bariatric person recommended dose.
Written By: Maria Vardapetyan, Eric Baghdasaryan, Osheen Abnous
Vitamins are chemicals that facilitate many processes in the human body such as blood clot formation, good vision, fight infections etc. There are two classes of vitamins. Water soluble vitamins and fat soluble vitamins. Water soluble vitamins dissolve in water. This makes it possible for them to be absorbed through all mucous membranes. Fat soluble vitamins on the other hand do not dissolve or pass through mucous membranes. Fat-soluble vitamins are absorbed in the intestine along with fats in the diet. These vitamins have the ability to be stored in the fat tissues of the human body. Water-soluble vitamins are not stored in the body and have to be taken in daily with the food and dietary supplements. Solubility of a vitamin is not a function of its physical state. There are fat soluble vitamins that have a liquid form and almost all of the water soluble vitamins come in form of pills or powders.
In this article, we are going to focus on fat soluble vitamins. They are all complex molecules made of carbon, hydrogen, and oxygen in different arrangements (see figures 1, 2, 3 and 4). These fat soluble vitamins are vitamin A, D, E and K.
Vitamin A has a major role in vision, immune function, cell growth, and maintenance of organs such as heart, kidneys, lungs, etc. It plays a pivotal role in the health of our eyes, specifically the retina1. Rhodopsin protein, a major protein that has the leading role in the process of vision, is found in the retina where it allows us to perceive light. This protein requires vitamin A to function properly. Without vitamin A, rhodopsin cannot sense light and thus cannot initiate the process by which vision occurs.
Figure 1: Chemical structure of Vitamin A molecule
Vitamin D regulates different chemical reactions that are associated with bones, muscles, and the immune system. The simplified way it does this regulation is it helps absorb calcium from dietary nutrients which in turn strengthens the bones, helps neurons exchange signals to move muscles and helps the immune system to fight against viruses and bacteria2.
Figure 2: Chemical structure of Vitamin D molecule
Vitamin E acts as an antioxidant. Antioxidants are naturally occurring chemicals that neutralize toxic byproducts of many chemical reactions in the human body. When food is consumed and digested, the human body converts it into energy. As a result of metabolism free radicals (toxic byproducts) are formed and are neutralized with the help of vitamin E. In addition, free radicals are also in the environment. Furthermore, vitamin E stimulates the immune system to fight against bacteria and viruses3.
Figure 3: Chemical structure of Vitamin E molecule
Vitamin K can be obtained from food and dietary supplements. There are two forms of vitamin K: phylloquinone (Vitamin K1), which is found in spinach, kale and other greens and menaquinone-4 (Vitamin K2), which is found in animal products. Vitamin K1 is involved in blood clotting, and Vitamin K2 is involved in bone tissue building. Vitamin K1 is the main Vitamin K in human diet (75-90% of all vitamin K consumed), however, it is poorly absorbed in the body4,5.
Figure 4: Chemical structures of Vitamin K1 and K2 molecules
Absorption of fat soluble vitamins
Polarity describes the inherent charge(positive or negative) or lack of charge for any given substance or molecule. Molecules that are charged are referred to as “polar”, while those that lack charge are “nonpolar”. When discussing solubility, it is important to remember the phrase “like dissolves like”. That means polar (charged) substances like to interact with a polar environment like water, since water contains a slight negative charge. Hence, charged substances are water-soluble. Nonpolar substances on the other hand readily interact with nonpolar environments such as fat, which contains no charge. Therefore, molecules that lack a charge such as vitamins A, D, E, and K are referred to as fat soluble.
Due to their water fearing nature, these fat soluble vitamins cannot simply be absorbed directly into the bloodstream (which is mostly water) like the sugars and amino acids in our diet. As their name suggests, these fat soluble vitamins like to be embedded in fatty droplets, which facilitate their absorption in the following way. Fat soluble vitamins group together with other fat molecules to form fatty droplets, effectively reducing the amount of interaction with the watery environment of the intestines. Therefore, without an adequate amount of fat in your diet, your body is unable to effectively absorb these fat-soluble vitamins. This may be true in an intact anatomy, however, post weight loss surgical patients can not increase their fat soluble vitamin levels by increasing their fat intake. This is due to the fact that a high fat diet causes excessive bowel movement which in turn washes away any vitamins taken by mouth. DS limits fat absorption (thus the great weight loss) which can cause vitamin A and D deficiency that can not be easily corrected with oral supplementation.
As mentioned before, fat soluble vitamins are hydrophobic and nonpolar, which means they are also fat loving or lipophilic. Excess fat soluble vitamins can be stored in the liver and fat tissue. Therefore, these vitamins do not need to be eaten every single day since stores of these vitamins can sustain a person for some time. It may take several weeks or months for our body to deplete these stores of fat soluble vitamins which is why it generally takes a longer amount of time for fat soluble vitamin deficiencies to manifest themselves. The ability to store these fat soluble vitamins in tissues can also lead to vitamin toxicity – marked by an excess of vitamin stores in our body.
Clinical manifestations of A, D, E, K deficiency
|Vitamin||Clinical Deficiency manifestations|
|Vitamin A||Vision Problems
Dryness of the eye
|Vitamin D||Softening and weakening of the bones
Bone shape distortion
Bowed legs (generally in children)
|Vitamin E||Damage to red blood cells
Tissue/organ damage due to inability to supply enough blood
Nervous tissue malfunction
|Vitamin K1||Excessive bruising
Increased bleeding time
Small blood clots under nails
Increased bleeding in mucous membrane
|Vitamin K2||Weak bones
Increased plaque deposits along gumline
- Office of Dietary Supplements – Vitamin A. NIH Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/VitaminA-HealthProfessional/#. Accessed April 26, 2020.
- Office of Dietary Supplements – Vitamin D. NIH Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/VitaminD-Consumer/. Accessed April 26, 2020.
- Office of Dietary Supplements – Vitamin E. NIH Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/VitaminE-Consumer/. Accessed April 26, 2020.
- Vitamin K. The Nutrition Source. https://www.hsph.harvard.edu/nutritionsource/vitamin-k/. Published July 2, 2019. Accessed April 26, 2020.
- Beulens JWJ, Booth SL, van den Heuvel EGHM, Stoecklin E, Baka A, Vermeer C. The role of menaquinones (vitamin K₂) in human health. The British journal of nutrition. https://www.ncbi.nlm.nih.gov/pubmed/23590754. Published October 2013. Accessed April 26, 2020.