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Category: Vitamin K

Overfed But Undernourished

October 01, 2019 11:27 am

Obesity is related to as many as 400,000 deaths each year in the US and it has increasingly been recognized as a risk factor for several nutrient deficiencies. This may seem surprising given the likelihood of over consumption of calories, however these additional calories are not from nutritious sources. One of the main reason for these nutritional deficits is the greater availability of inexpensive foods that are rich in calories and are nutrient deficient. This has led some medical professional to conclude that there is a certain group of people who are overfed but undernourished.  Even with the epidemic of the obesity, there is significant nutritional deficiencies noted.

Obese subjects have increased blood volume, cardiac output, adiposity, lean mass and organ size all of which can influence volume of distribution, in addition, treatment for severe obesity involving surgical procedures can worsen these nutrient deficiencies and in some cases may cause new ones to develop.

This table shows the percentage of population below the estimated average requirement (EAR) by body weight status in adults more tan 19 years old, showing that almost 90 to 100 percent of people including normal weight (NW) are below the EAR of vitamin D and Vitamin E.

Nutrition TableNutritional deficiencies in obese patients may promote the development of chronic diseases including increased insulin resistance, pancreatic B-cell disfunction and diabetes, this is because specific micronutrients are involved in glucose metabolic pathways; There are other chronic diseases related to obesity that are being investigated such as decrease in focal grey matter volume and cognitive impairment or inadequate sleep due to low intake of antioxidant vitamins.

We would like to thank Miguel Rosado, MD for his significant contribution provided for this Blog.

Vitamin A, Absorption, and Wound Healing

September 25, 2019 8:39 am

Vitamin A is one of the 4 fat soluble vitamins along with vitamin D, Vitamin E and Vitamin K. It is multifunctional  and essential which means that it is not produced by the body.  In this article we will touch on aspects of Vitamin A absorption and it’s effect on wound healing as well as its metabolism.

We often think of Vitamin A as the critical vitamin for vision, however it has several other roles that related to immune function, protein synthesis, and cellular communication.  Vitamin A deficiency is a concern world wide because of the natural of the side effects. Vitamin A deficiency is the leading cause of preventable childhood blindness in the world according to UNICEF and sometimes it may be undetected until there is irreversible damage.

There are 2 chemical forms of vitamin A in diet:

Retinoids (Preformed vitamin A) This group include retinol, retinyl esters, and retinal they are mostly found in animal sources like liver, egg yolk or fish oils.

Carotenoids (Provitamin A) This group includes beta-carotene, alpha-carotene and lycopene, mainly found in plant sources like leafy vegetables or yellow/orange vegetables and fruits. 

The Physiology of the Vitamin A is as follows:

1.- Ingested food is digested in the stomach where retinyl palmitates (esters) are released from proteins. Retinol and beta-carotene are absorbed directly into the small intestine where retinyl esters and betacarotene are transformed into retinol . Retinol is the most easily absorbed form of vitamin A.

2.-That retinol absorbed by the enterocytes in the ileum (small intestine) along with bile is then  transported to the liver with the help of chylomicrons a protein that transports fat.

3.-Fifty to 80% of the vitamin A is stored in the liver and the remaining is deposited into adipose tissue, lungs and kidneys.

4.-When stored retinol is released from the liver into the circulation to target organs, it is bound to plasma retinol-binding protein (RBP4) a transporting protein produced by the liver that requires ZINC, which is synthesized by the liver; This complex is stabilized by transthyretin (TTR), which reduces renal excretion.

Retinol is a crucial component for reproduction, embryological development, cellular differentiation, growth, protein synthesis, and immunity in the form of retinoic acid and vision in the form of retinal. 

One of Vitamin A additional roles is in epithelial health of skin and mucous membranes. It increases epithelial turnover which is crucial during would healing. It also has anti-oxidative effects which prevent cell damage and can prevent or reverse the effects of other damaging agents.  In addition to these benefits it has also been associated with increasing collagen, fibronectin, keratinocytes and fibroblast, all important in wound tissue structure. There have been some studies that suggest giving higher doses of Vitamin A in patients with non or slow healing wounds.

It is important to remember that we have documents delayed diagnosis of adult vitamin A deficiency leading to significant night blindness in adults.  It is critical that the patients and their primary care physicians are acutely aware of this possibility.  In majority of the patients with low vitamin A, post weight loss surgery, aggressive supplementations, including injections need to be considered as a part of the treatment regimen.

We would like to thank Miguel Rosado, MD for his significant contribution provided for this Blog.

Osteoporosis Medications, Action and Side Effects

May 25, 2019 3:40 pm

Recently I had a short live presentation on the subject of osteoporosis, osteoporosis medications, and the treatment options of this deteriorating bone condition. A patient who has had a bone scan may be diagnosed with Osteopenia and/or Osteoporosis. This information is usually conveyed by the forms of a Low T score. Both of these indicated demineralization of the bones, and the end result is  worsening of the bone structure. This leads to weaker bones and higher chance of fracture due to stress or trauma.

Treatment options should be approached is a global and systemic fashion. It is critical that the nutritional status is at its best possible and optimized for important healthy bone vitamins and minerals. Low protein needs to be corrected. Special attention should be given to nutrients, minerals and vitamins. These include ProteinCalcium, Magnesium, Vitamin D, and Vitamin K1/K2to name a few.

Healthy bones require ongoing and routine force in the form of exercise to remain health. Just as exercise improves muscle strength, it also improves bone health. Exercise is also critical in improving bone structure and density. Ideally, exercise should be weight bearing and resistance.  Examples include: hiking, walking, jogging, climbing stairs, playing tennis, and dancing. Resistance type exercise is weight lifting and resistance bands.  These exercise work by creating a pull or force on the bone either by gravity, movement or weight.  Always check with your physician before beginning an exercise routine, start slowly and building up to longer periods of time.  The ideal goal would be at least 30 minutes a day, every day, if you are able.

We frequently see patients immediately started on osteoporosis medications without checking or improving some of the nutritional markers noted above or without looking at exercise history. In some case, the medication recommended are contraindicated due to nutritional status.

The medications can be grouped in to those  that help with new bone formation (Anabolic agents) or those that help by suppressing the bone breakdown phase (Antiresorptive agents).

Groups of Medication

 

National Osteoporosis Foundation has an exhaustive list (below) of medications for treatment of Osteoporosis.

The table below outlines the side effects and mechanism of the actions of the common medications used for treatment of  osteoporosis which was published by the University Health News Publication on August of 2014.

Mechanism Of Action And Side Effects

 

With all this information, the few points to remember is that the most important factors in healthy bone structure are the nutritional status Protein, Calcium, Magnesium, Vitamin D, and Vitamin K1 levels.

This is an animation of normal bone Metabolism. It shows how bone structures is taken down and rebuilt continuously. This allows for a healthy bone maintainence as we age. The key is the balance of breakdown (osteoclast) and the build up (osteoblast) activity is regulated. Osteoporosis develops when there is more breakdown that build up.

With permission of Dr. Susan Ott of University of Washington.

Additional information available on her site.

Past blogs on Bone Health.

Neuromuscular Disease After Weight Loss Surgery

June 08, 2015 11:30 am

Weight loss surgical procedures may result in varying degrees of nutritional deficiencies. Some of these nutritional deficiencies may cause neuromuscular disease if left untreated, these include vitamins, minerals, and protein. The long-term effect of these deficiencies may presents as neuromuscular conditions including, weakness, numbness, confusion and all others if not-diagnosed and untreated. It is important to note that all weight loss surgical procedures require lifetime vitamin, mineral supplements and protein monitoring and possible supplements.

The table below outlines some of the specific neurological and neuromuscular disease complications following bariatric surgery. The most common deficiencies seen with the duodenal switch operation are fat soluble vitamin deficiencies. These include, Vitamin A, D, E and K. Duodenal Switch patients need oral supplements of Dry “Water Miscible” type of Vitamin A, D, E, and K based on their laboratory studies and needs.

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The neurological deficiencies are manifested much more frequently with the Gastric Bypass than the duodenal switch operation. The most common nutritional deficients are that of B1, B12, Folate deficiencies that are common in Gastric Bypass. A list of possible neurologic deficiencies and there associated symptoms were summarized by Becker (2012). Another article with Nutritional Neuropathies.

Nutritional deficiencies are seen in a number of illnesses including weight loss surgery patients.

Vitamin K1

April 08, 2015 7:16 pm

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.

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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.

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In adults, the causes of Vitamin K1 deficiency include the following :

Chronic illness
Malnutrition
Alcoholism
Multiple abdominal surgeries
Long-term parenteral nutrition
Malabsorption
Cholestatic disease
Parenchymal liver disease
Cystic fibrosis
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)
Massive transfusion
Disseminated intravascular coagulation (DIC) – Severe
Chronic kidney disease/hemodialysis

Additional information: https://lpi.oregonstate.edu/infocenter/vitamins/vitaminK/

Intake of Vitamin K1 and K2 and bone fracture risk

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.