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Category: calcium deficiency

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

Bowel Length in Duodenal Switch

November 09, 2015 6:25 am

Malnutrition is one of the most feared complication of the duodenal switch operation. It may present years after surgery. What is common is a mix of nutritional deficiencies which include fat soluble vitamins, and protein calorie malnutrition. These all point to possible excessive shortening of the common channel. In my practice we have seen patients that have had lengthening of their common channel to improve their metabolic picture. What is very obvious to us, is that we see disproportionately higher number of cases coming to us for revision from practices where the common and alimentary lengths are done as a “standard” numbers with no specific adjustments made for the patient, their anatomy and situation. I have said for years, that the length of the bowel that is measured to be become the common and the alimentary limb should be a percentage of the total length of small bowel, rather than a pre-determined measurement. Here is a visual description of how this works.

If a common channel and the alimentary limb is measured to be a percent of the total length then the chance of protein calorie malnutrition is minimized since this will take into account the bowels absorptive capacity which is being reduced. This decrease in the absorption is done as a fraction of the total length.

Raines et al. published  a study in 2014, that showed how small bowel length is related more closely to a patient’s height and not weight.  And yet, some surgeons totally based the length of the common channel and the alimentary limb arbitrarily based on the patient pre operative BMI and nothing else. Could this be the cause of why I see some patients coming to us for revision of their duodenal switch for malnutrition?

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.

Vitamins And Minerals

March 29, 2014 5:26 pm

Vitamins -Minerals
Function
Source
Problems with deficiency 
B1 (Thiamine)
Carbohydrate conversion, breaks down fats and protein, digestion, nervous system, skin, hair, eyes, mouth, liver, immune system
Pork, organ meats, whole grain and enriched cereals, brown rice, wheat germ, bran, brewer’s yeast, blackstrap molasses
Heart, age-related cognitive decline, Alzheimer’s, fatigue
B2 (Riboflavin)
Metabolism, carbohydrate conversion, breaks down fat and protein, digestion, nervous system, skin, hair, eyes, mouth, liver, antioxidant
Brewer’s yeast, almonds, organ meats, whole grains, wheat germ, mushrooms, soy, dairy, eggs, green vegetables
Anemia, decreased free radical protection, cataracts, poor thyroid function, B6 deficiency, fatigue, elevated homocysteine
B3 (Niacin)
Energy, digestion, nervous system, skin, hair, eyes, liver, eliminates toxins, sex/stress hormones, improves circulation
Beets, brewer’s yeast, meat, poultry, organ meats, fish, seeds, and nuts
Cracking, scaling skin, digestive problems, confusion, anxiety, fatigue
B5 (Pantothenate)
RBC production, sex and stress-related hormones, immune function, healthy digestion, helps use other vitamins
Meat, vegetables, whole grains, legumes, lentils, egg yolks, milk, sweet potatoes, seeds, nuts, wheat germ, salmon
Stress tolerance, wound healing, skin problems, fatigue
B6 (Pyridoxine)
Enzyme protein metabolism, RBC production, reduces homocysteine, nerve and muscle cells, DNA and RNA, B12 absorption, immune function
Poultry, tuna, salmon, shrimp, beef liver, lentils, soybeans, seeds, nuts, avocados, bananas, carrots, brown rice, bran, wheat germ, whole grain flour
Depression, sleep and skin problems, elevated homocysteine, increased heart disease risk
B12 (Cobalamin)
Healthy nerve cells, DNA/RNA, RBC production, iron function
Fish, meat, poultry, eggs, milk and milk products
Anemia, fatigue, constipation, loss of appetite, weight, numbness and tingling in the hands ad feet, depression, dementia, poor memory, oral soreness
Biotin
Carbs, fat, and amino acid metabolism (the building blocks of protein)
Salmon, meats, vegetables, grains, legumes, lentils, egg yolks, milk, sweet potatoes, seeds, nuts, wheat germ
Depression, nervous system, premature graying, hair, skin
Folate
Mental health, infant DNA/RNA, adolescence and pregnancy, with B12 to regulate RBC production, iron function, reduce homocysteine
Supplementation, fortified grains, tomato juice, green vegetables, black-eyed peas, lentils, beans
Anemia, immune function, fatigue, insomnia, hair, high homocysteine, heart disease
Eyes, immune function, skin, essential cell growth and development
Milk, eggs, liver, fortified cereals, orange or green vegetables and fruits
Night blindness, immune function, zinc deficiency, fat malabsorption
Calcium and phosphorus levels, calcium absorption, bone mineralization
Sunlight, milk, egg yolk, liver, fish
Osteoporosis, calcium absorption, thyroid
Vitamin E
Antioxidant, regulates oxidation reactions, stabilizes cell membrane, immune function, protects against cardiovascular disease, cataracts, macular degeneration
Wheat germ, liver, eggs, nuts, seeds, cold pressed vegetable oils, dark leafy greens, sweet potatoes, avocado, asparagus
Skin, hair, rupturing of red blood cells, anemia, bruising, PMS< hot flashes, eczema, psoriasis, cataracts, wound healing, muscle weakness, sterility
Calcium
Bones, teeth, helps heart, nerves, muscles, body systems work properly, needs other nutrients to function
Dairy, wheat/soy flour, molasses, brewer’s yeast, Brazil nuts, broccoli, cabbage, dark leafy greens, hazelnuts, oysters, sardines, canned salmon
Osteoporosis, osteomalacia, osteoarthritis, muscle cramps, irritability, acute anxiety, colon cancer risk
Chromium
Assists insulin function, increased fertility, carbohydrate/fat metabolism, essential for fetal growth/development
Supplementation, brewer’s yeast, whole grains, seafood, green beans, broccoli, prunes, nuts, potatoes, meat
Metabolic syndrome, insulin resistance decreased fertility
Magnesium
300 biochemical reactions, muscle/nerve function, heart rhythm, immune system, strong bones, regulates calcium, copper, zinc, potassium, vitamin D
Green vegetables, beans & peas, nuts and seeds, whole unprocessed grain
Appetite, nausea, vomiting, fatigue, numbness, tingling, cramps, seizures, personality changes, heart rhythm, heart spasms
Selenium
Antioxidant, works with vitamin E, immune function, prostaglandin production
Brewer’s yeast, wheat germ, liver, butter, cold water fish, shellfish, garlic, whole grains, sunflower seeds, Brazil nuts
Destruction to heart/pancreas, sore muscles, fragility of red blood cells, immune system
Zinc
Supports enzymes, immune system, wound healing, taste/smell, DNA synthesis, normal growth & development during pregnancy, childhood adolescence
Oysters, red meat, poultry, beans, nuts, seafood, whole grains, fortified breakfast cereals, and dairy
Growth retardation, hair loss, diarrhea, impotence, eye & skin lesions, loss of appetite, taste, weight loss, wound healing, mental lethargy
COQ10
Powerful antioxidant, stops oxidation of LDL cholesterol, energy production, important to heart, liver, and kidneys
Oily fish, organ meats, and whole grains
Congestive heart failure, high blood pressure, angina, mitral valve prolapsed, fatigue, gingivitis, immune system stroke, cardiac arrhythmias
Carnitine
Energy, heart function, oxidize amino acids for energy, metabolize ketones
Red meat, dairy, fish, poultry, (fermented soybeans), wheat, asparagus, avocados, peanut butter
Elevated cholesterol, liver function, muscle weakness, reduced energy, impaired glucose control
N-Acetyl Cystein (NAC) & Glutathione
Glutathione production, lowers homocysteine, lipoprotein, heal lungs, inflammation, decrease muscle fatigue, liver detoxification, immune function
Meats, ricotta, cottage cheese, yogurt, wheat germ, granola, and oat flakes
Free radical overload, elevated homocysteine, cancer risk, cataracts, macular degeneration, immune function, toxin elimination
Alpha Lipoic Acid
Energy, blood flow to nerves, glutathione levels in brain, insulin sensitivity, effectiveness of vitamins C, E, antioxidants
Supplementation, spinach, broccoli, beef, brewer’s yeast, some organ meats
Diabetic neuropathy, reduced muscle mass, atherosclerosis, Alzheimer’s, failure to thrive, brain atrophy, high lactic acid

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.

Injectable Vitamin A and Vitamin D

June 20, 2013 11:24 pm

Injectable Vitamin A and Vitamin D can improve vitamin status post weight loss surgery. One of the common side effect of all weight loss surgical procedures is nutritional and/or mineral deficiencies.  Patients undergoing weight loss surgical procedures are always instructed to supplement their diet with multivitamin, calcium, iron, vitamin D and other supplements or minerals. If you do not take your supplements regularly you can become deficient. The symptoms associated with vitamin A deficiency is night blindness. Chronic vitamin D deficiency may result in low calcium, osteoporosis and other health-related issues.

Vitamin A and vitamin D, both fat-soluble vitamins, are absorbed by duodenal switch patients only if taken and a dry formulation. An alternative to oral supplement, would be injectable form of these two vitamins.  Both of these vitamins can be formulated and purchased from compounding pharmacies that are equipped and experienced with the interpretation of injectable vitamins and minerals. Your primary care WILL need to contact the pharmacy of their choice for the recommendations and be willing to make the injections available to you.

We will gladly be able to provide  injectable Vitamin A and Vitamin D for patients whose data laboratory studies are available to us and see us in the office.

We will not be able to provide prescriptions for injectable vitamins to be sent to your primary care or other physicians to provide the injections.

Vitamin D supplement has been discussed previously in my Blog .

Injectable Vitamin D

The common dosing for the vitamin D is 600,000 IU, deep IM every 6 months till the levels are normalized. The patient then can take the oral supplements only.

Vitamin A supplements was  also discussed  in my Blog.

The common dosing for injectable vitamin A is 50,000 IU, deep IM every 6 months till the blood levels are corrected, and the patient symptoms are resolved.

Central Drugs Compounding Pharmacy 562-691-6754 , Located in La Habra, California can provide both injectable Vitamin A and D with a prescription and sent to your physician.

Just as a reminder, we have no financial interest in any of the vendors that are recommended on our website. Also, note that this is not in any form or fashion a substitute for an evaluation by your primary care physician or your surgeon. This is for information only, and is not to be taken as a recommendation for any particular patients’ condition.