Category: Vitamin D
Patch or Spray Vitamins
August 15, 2014 10:37 pm
At the last group meeting, there were several questions whether vitamin D and other vitamins would be absorbed via patch (transdermal) and spray (buccal/sublingual) routes. After reviewing several resources, the only article I could find was for transdermal Vitamin D absorption. However, if we look at the mechanism for each route we can make an educated assumption.
Transdermal route of absorption (without additional absorption enhancers) (ref) requires a molecular mass less than 500 g/mole, high lipophilicity (affinity to fat or lipids), and low required daily dose (less than 2mg). The fat-soluble vitamins are definitely lipophilic, all of them have molecular weights less than 500 g/mole and daily dose is under 2mg. It seems that hydrophilic medications (that have an affinity to water) may have less ability to be absorbed with this route unless a chemical enhancer is added to the product. Most vitamins and minerals have lower molecular weights except Vitamin B12 which has too high of a molecular weight unless an enhancer is added. The transdermal route has slower absorption than buccal (oral mucosa) but faster than usual tablet oral route. The down side to transdermal route is possible skin issues due to medication, adhesives, and also different rates of absorption due to skin thickness and condition.
Buccal/sublingual route of absorption is dependent on lipid solubility, oil to water partition coeffincient, saliva pH, small to moderate molecular weight, and oral mucosa thickness. The mechanism of action is osmosis, which means items that readily dissolve in water are easily absorbed. Unlike orally ingested medicates, that take time to absorb and need to be filtered and/or processed in the liver, sublingual route is fast absorbing and the liver is bypassed. The down side to this route is it disrupts eating and drinking and is not efficient with smoking due to vasoconstriction.
An e-mail was sent to the companies inquiring about the outcomes of their products with people with malabsorption issues. No response was received from the spray vitamin companies.A request was also sent to obtain any research articles they may have but a response has not been received at this time. The following is the response I received from the maker of Patch MD.
“I am the president and founder of Patch MD. We design Patch MD to help people that have digestive issues and malabsorption. Our whole premise is to avoid the digestive track, by doing so we avoid dealing with conditions such as short bowel syndrome, acid reflux, and bariatric surgery to name a few. People also with Crohn’s disease and iliac disease are challenged with digestion and absorption every day of their life. Our patches are designed specifically to pass nutrition through the skin into the bloodstream. We get letters every day from people that have had bariatric surgery and were unable to get vitamin D, calcium, the B’s and Vitamin A and K, our product works because we use the skin as our delivery system, absorption is through the skin, avoiding all digestive potential issues. The only problem that we may have is we tell our customers to use no lotions or cream in the patch application area, as you may understand it will prevent absorption. We are going to be at a national convention this weekend in Manhattan Beach California to take part and display our products at the ObesityHelp conference. They ask us to take part as they were getting great reviews from their members that are using the patch. All were improving their blood work after taking Patch MD patches.”
Earl Hailey, President Patch MD
In light of the review of data, it would seem that the transdermal route would be beneficial to people who are having issues maintaining blood levels of fat-soluble vitamin levels. The other vitamins also have a good prospect of absorption via transdermal route. Buccal or sublingual (sprays) would seem to have a better outcome for water-soluble vitamins unless there is an additive added to the product to increase the solubility of the fat-soluble vitamins and make them water miscible. We must realize that there is no data for Duodenal Switch patients and very little data regarding these routes of absorption with vitamins specifically. If you are going to try these types of vitamins you should be extremely diligent in following your laboratory studies for vitamin levels with greater frequency until it is determined they are maintaining your blood levels.
Also, it should be noted that water miscible (dry) Vitamin A, D, E, K are the only type of these vitamins a DS patients should be taking. Over the counter Vitamin A, D, E, K are fat-soluble and due to the fat malabsorption after DS these type of vitamins are not appropriate to maintain blood levels. Water miscible (dry) vitamins should NOT be taken with fatty or oily foods and should also be taken 30 minutes prior or 30 minutes after eating. The water miscibility makes them water soluble and therefore will not have optimal absorption if taken with fat. Fat also increases the rate of digestion through the small bowel after DS and decreases the amount of time the vitamin has in the bowel and therefore, decreases absorption. They are best absorbed when taken on their own.
The good news patches and spray routes of administering medications and supplements is an up and coming area of research. There are several ongoing research studies and new developments on the horizon for increasing absorbability of transdermal route with different types of additives and techniques.
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 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 D Information and Research Articles
July 11, 2014 1:06 am
Injectable Vitamin D may be needed in some cases of Vitamin D deficiency or inability to increase Vitamin D level with oral supplements. Vitamin D is a fat soluble vitamin. It plays an important role in bone metabolism and structure. It has also been found to affect the immune regulation, control off- inflammatory reactions, and also be involved in a number of broad cellular functions throughout the body. Until a few years ago, very little attention was given to vitamin D levels. More recently, we have realized that due to a number of factors, there is a tendency for vitamin D deficiency to be present in the U.S. adult population. This finding is even more pronounced and severe in overweight patients.
The recommended dose for vitamin D supplements is much larger today than it was a few years ago. For example, it is not too uncommon to recommend an average dose of a 50,000 (IU) international unit of vitamin D by mouth on a daily basis after the duodenal switch operation.
Since vitamin D is a fat soluble vitamin, it is important that the appropriate type be utilized. Dry formulation of vitamin D is needed to ensure adequate absorption. There are a number of manufacturers that produce these. When searching for Dry Vitamin D the type a patient should be looking for is “Dry” D3-50. Some larger supplement manufacturer’s carry these products. The links to these manufacturers is located here. The “Dry” type of Vitamin D should NOT be taken with fatty or oily foods. Also to optimizes absorption they should be taken either 30 minutes prior to eating food or 30 minutes after eating.
If you are deficient in Vitamin D after trying “Dry” or water miscible Vitamin D then intramuscular Vitamin D injections might be an effective way to normalize your Vitamin D levels. Vitamin D can be formulated and purchased from any compounding pharmacies that are equipped and experienced in the interpretation of injectable vitamins and minerals. Your primary care WILL need to contact the compounding pharmacy of their choose for the recommendations and be willing to make the injections available to you. UNLESS you have been told to stop taking your daily “Dry” Vitamin D tablet supplement you should continue taking it after the injection.
We are supplying the following so that your PCP will understand the research behind injectable Vitamin D and to hopefully ensure that every patient is armed with this knowledge. Vitamin D deficiencies are becoming more common place in society due to the use of sunscreen and sun shielding clothing and hats, not only Duodenal Switch patients.
This is a research paper out of Finland that discusses injectable Vitamin D for the aged. The information can translate to anyone who finds themselves in a Vitamin D deficit state. https://www.gwern.net/docs/nootropics/1992-heikinheimo.pdf
This research paper is out of Australia where despite then sun drenched climate they are experiencing a large amount of people with Vitamin D deficiencies due to sunscreen, veiling, malabsorption, etc.
https://www.direct-ms.org/pdf/VitDGenScience/Vit%20D%20deficiency%20Australia%20art%20and%20ed.pdf
Below find the order sheet with the Injectable Vitamin D concentration listed. 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.
Finally, this is an except from an another Australian research paper describing the use of Megadoses of injectable Vitamin D in patients after Biliopancreatic Diversion which has a malabsorptive component similar to Duodenal Switch.
Vitamin’s Physical State And Solubility are Two Different Things.
March 29, 2014 6:11 pm
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 |
Vitamin D And A -Dry (Water soluble) Formulary
August 24, 2013 7:57 pm
Vitamin A and D are fat soluble vitamins. This means that in order for them to be absorbed by the GI track, them need to be absorbed by fat globules (chylomicrons). These are then taken up by the lymphatics of the GI track and taken to the blood stream. With the anatomical changes of the Duodenal Switch, the fat absorption capacity is significantly reduced. This results in excellent weight loss. It also results in much diminished absorption of the Fat soluble vitamins A, D, E and K. It is essential to use Dry Water Soluble forms of Vitamins A, D, E, and K. Bio-Tech is a brand that is formulated in this manner.
The Biotech D3-50 has 50,000IU of Vitamin D.
We recommend specific dosages of dry (water soluble) Vitamin A and D. These are not available at most pharmacies. In fact when our recommendations are presented at most pharmacies they are incorrectly dispensed with the fat soluble variety with is worth less becasue it is not absorbed by the duodenal switch patients. It is also important to not that this type of vitamin should not be taken with any dietary fat. Fat can inhibit the absorption of this type of vitamin. When ordering online, please make sure that the “Dry” or “Water Soluble” formulary is ordered.
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.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.
Common Lab Values- Minerals and Vitamins
August 25, 2003 7:59 pm
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Vitamin D and Weight Loss SurgeryPTH and vitamin D levels are closely related to calcium absorption and should not be overlooked or ignored