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?

There is a new publication in the British Journal of Medicine that has raised questions about the benefits of Calcium supplements and  Calcium from food sources and Bone Mineral Density.

This article is a “meta analysis” of a number of studies. This means that the researches have taken number of other research articles and have “analyzed” and summarized the data.

I will start by saying that there is nothing in this article that suggest post weight loss surgical patients should stop taking their calcium supplements.

This article studied a number of other publications and looked at a number of variables that were common in those articles. The authors themselves outlined a number of limitation to the study. More importantly they recognized these limitation and their conclusion were limited to those that can be justified by the significant limitations  and variability amongst those articles.

Calcium, Magnesium, Vitamin D, and various supplements are recommended for Duodenal Switch and other weight loss surgical patients for the offsetting the malabsorption that is caused by weight loss procedures. There is nothing in this article that addressed decreased absorption of calcium. The reduced absorption maybe because of the sopanification of calcium with fat, decreased absorption because of the small bowel, or other reasons.

In Summary I recommend Calcium, Magnesium, Vitamin D, and other supplements to be taken on regular basis as it has been recommended to each patient based on the specific lab results.

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 https://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 https://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.

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.Please be aware that these are compounded and are not covered by insurance.

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 .

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 the vitamin D is 100,000 IU, deep IM every 2-6 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.

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.

The vast bulk of mineral absorption occurs in the small intestine. The best-studied mechanisms of absorption are clearly for calcium and iron, deficiencies of which are significant health problems throughout the world.

Minerals are clearly required for health, but most also are quite toxic when present at higher than normal concentrations. Thus, there is a physiologic challenge of supporting efficient but limited absorption. In many cases intestinal absorption is a key regulatory step in mineral homeostasis.

Calcium

The quantity of calcium absorbed in the intestine is controlled by how much calcium has been in the diet during recent periods of time. Calcium is absorbed by two distinct mechanism, and their relative magnitude of importance is set by dietary calcium “history”:.

1. Active, transcellular absorption occurs only in the duodenum when calcium intake has been low. This process involves import of calcium into the enterocyte, transport across the cell, and export into extracellular fluid and blood. Calcium enters the intestinal epithelial cells through voltage insensitive channels and is pumped out of the cell via a calcium- ATPase.The rate limiting step in transcellular calcium absorption is transport across the epithelial cell, which is greatly enhanced by the carrier protein calbindin, the synthesis of which is totally dependent on vitamin D.
2. Passive, paracellular absorption occurs in the jejunum and ileum, and, to a much lesser extent, in the colon when dietary calcium levels have been moderate or high. In this case, ionized calcium diffuses through tight junctions into the basolateral spaces around enterocytes, and hence into blood. Such transport depends on having higher concentrations of free calcium in the intestinal lumen than in blood. Additional Calcium information here.

Phosphorus

Phosphorus is predominantly absorbed as inorganic phosphate in the upper small intestine. Phosphate is transported into the epithelial cells by contransport with sodium, and expression of this (or these) transporters is enhanced by vitamin D.

Iron

Iron homeostasis is regulated at the level of intestinal absorption, and it is important that adequate but not excessive quantities of iron be absorbed from the diet. Inadequate absorption can lead to iron-deficiency disorders such as anemia. On the other hand, excessive iron is toxic because mammals do not have a physiologic pathway for its elimination. Iron is absorbed by villus enterocytes in the proximal duodenum. Efficient absorption requires an acidic environment, and antacids or other conditions that interfere with gastric acid secretion can interfere with iron absorption.

Ferric iron (Fe+++) in the duodenal lumen is reduced to its ferrous form through the action of a brush border ferrireductase. Iron is the co-transported with a proton into the enterocyte via the divalent metal transporter DMT-1. This transporter is not specific for iron, and also transports many divalent metal ions.

Once inside the enterocyte, iron follows one of two major pathways. Which path is taken depends on a complex programming of the cell based on both dietary and systemic iron loads:

1. Iron abundance states: iron within the enterocyte is trapped by incorporation into ferritin and hence, not transported into blood. When the enterocyte dies and is shed, this iron is lost.
2. Iron limiting states: iron is exported out of the enterocyte via a transporter (ferroportin) located in the basolateral membrane. It then binds to the iron-carrier transferrin for transport throughout the body.

Iron in the form of heme, from ingestion of hemoglobin or myoglobin, is also readily absorbed. In this case, it appears that intact heme is take up by the small intestinal enterocyte by endocytosis. Once inside the enterocyte, iron is liberated and essentially follows the same pathway for export as absorbed inorganic iron. Some heme may be transported intact into the circulation. Additional Iron information here.

Copper

There appear to be two processes responsible for copper absorption – a rapid, low capacity system and a slower, high capacity system, which may be similar to the two processes seen with calcium absorption. Many of the molecular details of copper absorption remain to be elucidated. Inactivating mutations in the gene encoding an intracellular copper ATPase have been shown responsible for the failure of intestinal copper absorption in Menkes disease. A number of dietary factors have been shown to influence copper absorption. For example, excessive dietary intake of either zinc or olybdenum can induce secondary copper deficiency states. Additional Copper information here.

Zinc

Zinc homeostasis is largely regulated by its uptake and loss through the small intestine. Although a number of zinc transporters and binding proteins have been identified in villus epithelial cells, a detailed picture of the molecules involved in zinc absorption is not yet in hand. Intestinal excretion of zinc occurs via shedding of epithelial cells and in pancreatic and biliary secretions. A number of nutritional factors have been identified that modulate zinc absorption. Certain animal proteins in the diet enhance zinc absorption. Phytates from dietary plant material (including cereal grains, corn, rice) chelate zinc and inhibit its absorption. Subsistence on phytate-rich diets is thought responsible for a considerable fraction of human zinc deficiencies. Additional Zinc Information here