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Results for : "Calcium "

Phytates the anti-nutrient?

June 20, 2014 3:33 pm

Phytic acid is phosphorus stores in nuts, edible seeds, beans/legumes, and grains.  It is often referred to as anti-nutrient. Phytates (phytic acid) have been shown to decrease absorption of minerals, including iron, calcium, zinc and manganese.  Phytates decrease the absorption by binding to the minerals before their uptake in the stomach and intestines. 5-10mg of phytic acid can decrease iron absorption by 50%. 1 This research done on non-WLS patients but is something to be aware of if you are having iron deficiency anemia or low calcium issues.

There are ways to combat the effects of phytic acid such as heat, soaking, fermenting, Vitamin C, protein, probiotics, and sprouting. 2

Phytic acid has many benefits such as preventing kidney stones, anti cancer effects, cardiovascular health protectant, binding with heavy metals and free radicals.  It becomes an antioxidant and is a secondary messenger in cellular activity.

Phytate intake is something to be looked at if you are experiencing iron or calcium deficiencies.Adjusting your intake of phytates containing foods, combining them with high Vitamin C containing food items, and/or prepping them before consumption can decrease the mineral binding capacity. It would also be prudent to be aware of the timing between eating phytic acid containing foods and any vitamin or mineral supplementation.

The following tables list the content of physic acid in food items:
Grains:

phytic acid whole grains All About Phytates (Phytic Acid)

Source: Schlemmer U, et al. Phytate in foods and significance for humans: Food sources, intake, processing, bioavailability, protective role and analysis. Mol Nutr Food res 2009;53:S330-S375.
Legumes:

phytic acid beans All About Phytates (Phytic Acid)

Source: Schlemmer U, et al. Phytate in foods and significance for humans: Food sources, intake, processing, bioavailability, protective role and analysis. Mol Nutr Food res 2009;53:S330-S375.
Nuts:
phytic acid nuts 1024x361 All About Phytates (Phytic Acid)
Source: Schlemmer U, et al. Phytate in foods and significance for humans: Food sources, intake, processing, bioavailability, protective role and analysis. Mol Nutr Food res 2009;53:S330-S375.
Seed Oils:

phytic acid oils 1024x326 All About Phytates (Phytic Acid)

Source: Schlemmer U, et al. Phytate in foods and significance for humans: Food sources, intake, processing, bioavailability, protective role and analysis. Mol Nutr Food res 2009;53:S330-S375

Protein Metabolism Optimization

June 09, 2014 5:08 pm

It’s confusing out there in the world of protein supplements and nutrition.  Hopefully we can clear up some of the information with this blog post. Part I will be about protein utilization and supplementation and Part II will be about Protein Energy Malnutrition (PEM). So let’s get started with the basics of protein utilization and metabolism. This will clarify what our goals are and what we need to achieve them.

Protein_-_Primary_Structure
Protein_-_Primary_Structure

Protein Metabolism:

There are 23 Amino Acids (AA) that combine to form peptide chains.  These peptide chains link together to make polypeptides, which are the building blocks of many proteins sources. These types of proteins are called proteinogenic.

Essential vs Non-essential:

Nine of these proteinogenic AA’s are essential meaning that the human body cannot make them.  They must be taken in by food sources.  The other AA’s are considered non-essential because  the body can produce these without an outside food sources.

Complete Protein vs Incomplete Protein:

A complete protein contains all of the essential amino acids and an incomplete protein does not have all nine of the essential amino acids.

Essential Amino Acids
Non-essential Amino Acids
Leucine
Alanine
Isoleucine
Arginine
Valine
Asparagine
Histidine
Aspartic Acid
Lysine
Cysteine
Methionine
Glutamic acid
Phenylalanine
Glycine
Threonine
Ornithine
Tryptophan
Proline
Selenocysteine
Serine
Tyrosine
Threonine
Glutamine
Protein Image
Protein Image

Branched Chain Amino Acids (BCAA’s) are an incredibly important subgroup of the essential Amino Acids.  Three of the nine essential AA’s are BCAA’s.  They are leucine, isoleucine and valine.  These three AA’s make up 40% of the protein required by humans. Muscle protein is made up of 35% of these three BCAA’s. Any protein supplement after weight loss surgery should contain these three amino acids, Isoleucine, Leucine and Valine.

Protein breakdown begins in the stomach with the addition of enzymes and acid then continues into the small bowel where absorption takes place.  Protein must be broken down by these enzymes and acid to single Amino Acids or peptide chains no longer the 4 AA’s in order for the intestinal absorptive cells to absorb the protein. The 4 chain peptide chains are further broken down within the intestinal absorptive cells.

Protein absorption takes place easily but the most important factor is protein utilization.  Protein utilization is how much of the protein ingested is actually utilized by the body.  The body may absorb a great deal of a protein food source but can only utilize about 30-40g of a high quality protein source at a time.  The body does not store protein as it does with other nutrients.  Therefore, whatever the body doesn’t utilize is metabolize through the liver and converted to urea.  Urea is excreted through the kidneys via urine.

Different proteins absorb at different rates, amounts and in different parts of the small bowel. i.e. Milk protein is 50% absorbed in the proximal small bowel, with 90% of the absorption taking place by the time it reaches the ileum. 1 It’s important to understand this because of the rearranging of the small bowel in the Duodenal Switch.  Protein is no longer being exposed to the mucosa of the proximal small bowel due to the altered anatomy of the duodenal switch. This altered anatomy results in much lower absorption of protein, thus the increase levels of protein one needs to consume after WLS.  Post WLS the body will compensate and increase protein absorption in the other areas of the small bowel. This may also explain why some weight is regained several years after WLS. 2

Reduced protein absorption is why Bioavailability or Biological Value (BV) is so important when deciding on a protein source. Biological Value is the measure of how efficiently the body utilizes the protein from the food source.  You will find this BV number on some protein supplemental products.  The higher the BV numbers the better utilization of the protein source by the body. Whey protein and egg protein are considered the highest BV. The daily requirements of protein are 0.80 gram of protein per kilogram of ideal body weight calculating to approximately 50-65 grams a day. 3  However, after weight loss surgery (WLS) a person should get 80-100 grams per day, 1 gram per kilogram of weight and in some cases even higher amounts of protein.

Protein Type
Protein Biological Value
Net Utilization
Efficiency Ratio
Beef
80
73
2.9
Whey Protein
104
92
3.2
Soy Protein
74
61
2.2
Egg
100
94
3.9
Black Beans
0
0
Milk
91
82
2.5
Casein
77
76
2.5
Poultry
80
Fish
70-80
Brown Rice Concentrate
70-80
76

Adapted from: U.S Dairy Export Council, Reference Manual for U.S. Whey Products 2nd Edition, 1999 and Sarwar, 1997

 Protein Supplements: First clarify the terminology in supplements.

Isolate: Is chemically purified to 90% pure protein.  100g scoop=90g protein intake.  Isolates have a High BV rate.

Concentrate: 35-80% protein 100g scoop=35-80g protein intake Also contains fat, carbohydrates and in the case of Whey Concentrate, lactose. Concentrates  have a high BV rate.

Blends:  Combination of protein sources and purity levels.  Varies in how many grams of protein are available in each product. They are lower in cost and quality in some cases. Blends have a medium/high BV rate.

Hydrolysate: enzymatically predigested for maximal speed of absorption and utilization. Very water-soluble but can have a bitter taste.  Hydrolysates are high in cost and BV rate.

Branched Chain Amino Acids: contains the 3 essential AA Leucine, Isoleucine, and Valine that make up 1/3 of skeletal muscle and are vital in protein synthesis. Easily absorbed and utilized by the body. BCAA’s have a high BV rate and cost.

Animal Protein Supplements:

Animal proteins contain the 9 essential amino acids the body needs for skeletal muscle formation. It’s important to note that high fat in protein will decrease the amount of absorption and, therefore, utilization of protein due to altered anatomy after DS.

Whey Protein is a byproduct of cheese production. It has a high BV rate and is the most popular protein supplement. It is rich in muscle essential amino acids and has a fast digestion rate.  It needs to be taken more often because the ease of digestion.  It contains 5% lactose within the product. Whey products come in a wide variety of flavors and styles.  Unflavored protein products can be added to other protein foods, such as yogurt, cottage cheese, etc. to increase the protein. Be wary of artificial sweeteners in protein supplements as they can give you unwanted side effects, such as gas or loose stool.

Whey Protein Isolate: (WPI) has one of the highest BV rates 104. WPI can be slightly more expensive but seems to be the most  tolerated by WLS (weight loss surgery) patients. There are many flavors and styles with less fat and lactose than other whey protein  products.

Whey Protein Concentrate: has a high BV rate 85-90. Concentrate has more fat and lactose, which may not be well tolerated by WLS patients.

Whey Protein Blends: Blends contain a mixture of both isolate and concentrate whey proteins.  Which means the BV rate is higher than concentrate on it’s own. Because of increased fat and lactose this too may not be tolerated as well by WLS patients.

Casein Protein is a milk protein and has a BV rate of 91.  Casein is the trigger in most milk allergies.  It is more slowly digested and more filling than whey protein.  It may be more difficult to tolerate after WLS.

Egg Albumin is very high in essential and nonessential AA’s.  Eggs are also a great natural food source for protein.  Does not have lactose but some people do have egg allergies.  It is a cost effective source of protein. Supplement powders come in several flavors. This is probably nature’s perfect protein source with the highest utilization.

Goat Milk: One of the highest BCAA available food sources. Is better tolerated by people with lactose intolerance.

Beef, poultry, fish all have varied degrees of bioavailability.  Please see the table above regarding each items BV rate.  While beef may have a higher BV rate there may be other issues to deal with higher fat content that goes along with eating most cuts of beef.  After DS higher fat content can mean looser stool or even diarrhea.

Vegetable Protein Supplements and Natural Food Sources:

Plant Protein may contain most or all essential amino acids but the amount is far less thank other protein sources particularly in the amounts of BCAA needed for skeletal muscle formation. It is best to combine or vary plant proteins to ensure adequate protein nutrition.

Soy Protein: has a BV rate of 74. It is fast digesting, lactose free and comes in a variety of flavors and unflavored.  It is also cost effective and contains all the essential AA’s. Soy beans are commonly a GMO crop, so if that is concerning look for organic sources. Soy is also a high allergen food and can inhibit calcium absorbtion.

Pea Protein: 100% gluten free and lactose free.  Pea protein is very easy to digest, rich in Amino Acids and is a high satiety protein. Pea Protein can be found with high levels of carbohydrate and low levels of carbohydrates.  After WLS always choose lower levels of carbohydrates.

Brown Rice Isolate: BV of 70-80.  Is easily digested and is a good vegan choice.  Again with Brown Rice Isolate watch your carbohydrate content. Brown Rice Isolate can be chalky in texture.

Pea/Brown Rice Isolate:  BV of 70-90 Combining these two gives a good profile of BCAA that rivals whey and egg proteins.  It is easily digestible without allergy issues. When used in combination, rice protein and yellow pea protein offer a Protein Efficiency Ratio and BCAA’s that is comparable to dairy and egg. In addition, the texture of pea protein helps the chalkiness of rice protein.

Spirulina: Blue-green algae is easily digested and high in AA 80-95% of proteins can be digested.  BUT is very allergic prone. It is also expensive and the taste can be hard to handle.

Hemp Protein: 30-50 BV rate. Hemp contains 21 amino acids and is considered a complete protein.  The proteins in Hemp seeds are easily digestible, absorbed and utilized by the body. Hemp seeds are great to add to natural food products to increase protein and essential fatty acids. It is vegan friendly and low allergy rating.

Summary

So what does this all mean? It is important when looking for a protein supplement or natural food source to look for the highest bioavailable rating and BCAA levels.  Most protein supplements have these listed on their labels. Read the labels on supplements to find low fat, carbohydrate and lactose for best tolerance after WLS. Consuming high amounts of fat after duodenal switch decreases the absorptive time the food products due to the altered anatomy after DS.  When taking your protein it is best for absorption to have low fat to optimize your protein absorption.  Be wary of artificial sweeteners in protein product. They may also cause WLS patient issues, such as increased loose stools or gas. Also, try getting trial sizes of several different supplements to see how your body tolerates the supplement and your taste. If you are not tolerating one brand of supplements try another.  Isolate, Egg or Blends are best tolerated after WLS and give the highest bioavailability.

The best routine of taking your supplements after WLS is on an empty stomach in the morning or when you first wake.  This is a good time to use an isolate, or blend supplement shake or natural food source such as egg.  Have a midmorning protein snack or shake, lunch with high protein foods, a mid afternoon protein snack or shake, dinner of high quality protein and after dinner or as close to bedtime as you can tolerate protein supplement shake. For your meals choose the best BV rating food and also listen to what your body tolerate.  Your natural food sources should be low fat, low carbohydrate and low lactose food choices. Also consider adding one of the plant protein supplements or unflavored animal supplements to your natural food sources to give an additional protein boost.  The unflavored varieties can be added to nearly any food or recipe.  Take care in adding protein powders to higher temperature foods, as high temperatures destroy the proteins. The key is frequent small meals and snacks with the highest quality protein. Varying your protein sources increases your chances of absorbing a variety of amino acids and nutrients.

After surgery, you should expect to be able to consume the same amount of grams of protein as the number of days post op that you are. i.e.; 30 grams of protein at the end of the first month, 60 grams of protein by 60 days post op, etc.  Treat your body as you would an infant just starting to eat new foods. Try small amounts of food and only progress with a new item after several days of tolerating an old food.  As always follow your surgeon’s guidelines and recommended diet. Do not progress until your surgeon has given you the go ahead.

Sunshine, Water, Rest, Air, Exercise and Diet

May 23, 2014 4:10 pm

Sunshine, Water, Rest, Air, Exercise and Diet

Of course this is over simplified, but we can’t forget the importance of the basics in our general well being. Weight loss surgery and especially Duodenal Switch have distinctive supplement requirements that need to be individualized based on your individual needs.

Sunshine is essential to life. It provides the light that wakes us and helps to regulate wake/sleep cycles and provides us with a feeling of well being. Sunlight is not only the basis of all living things but crucial in boosting the bodies Vitamin D supply. Most Vitamin D deficiencies in the general public are caused by lack of sun exposure. It is important to note that our bodies can not accomplish Vitamin D metabolism if we are wearing sunscreen. Without adequate Vitamin D stores bones will not form properly, muscle strength is impaired and osteoporosis.  Vitamin D 1,25(OH) accumulates in cell nuclei of the intestine, where it enhances calcium and phosphorus absorption, controlling the flow of calcium into and out of bones to regulate bone-calcium metabolism. However, after weight loss surgery this mechanism can be impaired.  Addition supplementation of Vitamin D is usually required based on laboratory studies following weight loss surgery.  Duodenal Switch patients should take a dry “water miscible” type of Vitamin D3 daily. 

Water comprises 50-60% of our adult bodies.  Water is essential in cell life.  It aids in transporting vitamins, nutrients and minerals to our cells. Chemical and Metabolic reactions rely on water to remove waste products including toxins that the organs’ cells reject and removes them through urine and feces. Our body temperature is regulated by sweating and the evaporation of water on the skin. Also, effectively Lubricating our joints and acting as a shock absorber for our brain, eyes, and spinal cord. Decreased stomach size, after weight loss surgery,  limits the amount of water a person can drink at one time.  It is imperative that patients ingest enough waters and fluids after surgery. We like to see our patients consume a minimum of 64 ounces of fluids a day, more on warmer days.

Rest is something we can all use more of.  Lack of sleep can cause a whole host of health issues ranging from altered levels of hormones involved in metabolism, appetite regulation, stress response to cardiovascular health, insulin resistance, immune function and most importantly post-operatively tissue repair, muscle growth and protein synthesis.  It’s easy to take rest for granted but  do not underestimate the power of sleep.

Air is an obvious essential of life.  It is important in about every function of our cells.  After surgery it is important to lung health and tissue repair. Be aware of the type of air you are breathing.  Pollution and contaminants in the air can impair lung function.  After surgery your breathing and breathing exercises will prevent complications such as pneumonia and atelectasis.  Long term air contaminants can cause asthma and long term lung health. In addition, post surgical patients will need to use their incentive spirometers to combat lung complications.

Exercise’s health benefits can not be denied. Exercise combat health conditions and disease such as stroke, metabolic syndrome, diabetes and cardiovascular disease. It also improves emotional outlook and mood. Physical activity stimulates the brain to release chemicals that involve increasing memory function.  Exercise helps maintain healthy weight, improves energy, promotes better sleep, lowers stress and anxiety.  Needless, to say after surgery exercise is extremely important for all the above reasons but also to ward off complications such as pulmonary embolism and deep vein thrombosis.

Diet is last but definitely not least. Balance along with moderation and eating whole unprocessed foods are best ways to ensure your health.  We derive most our building blocks for cell growth from the nutrients we consume. The quality of the food we put into our bodies is important in lowering health risks such as cardiovascular disease, cancer, and weight control. Protein is crucial in muscle growth, hemoglobin, cell structure and enzymes formation.  It is extremely important after weight loss surgery to remain diligent about protein intake throughout your lifetime.

It is interesting to see how all these elements are so intertwined in their synergy to maintain health.  Most are easily found or done in nature. When engaging in one of these elements,  many of the others are needed or benefited by the doing the first. Exercise requires that you stay hydrated, deep breath, possibly out in the sunlight and therefore you will rest better. Always follow your surgeon’s orders and recommendations based on your individual health status and laboratory studies.

Our First Featured Success Story

May 16, 2014 9:47 am

Patricia Welborn

Screen Shot 2015-04-07 at 1.41.10 PM
In 2002, I weighed 336 lbs. I have been heavy all my life, no matter what diet I did I would gain it all back and more. In 1981 after living on pain pills and shots for my gall bladder, no one wanted to do surgery on me because at the time I weighed 450 lbs. The doctor, besides taking out my gall bladder, also did gastric stapling on me. I did get down to 225 lbs, but never lower.
In 2001 I had a friend tell me about a doctor in Delano that was doing a surgery called Duodenal Switch (DS).  I knew that I could out eat the RNY Gastric Bypass, which is when I met Dr. Keshishian; he gave me all kind of tests and said he believed the Duodenal Switch would help me.
On Jan 7, 2002, I had the surgery that has changed my life forever. When I had the surgery I could barely walk across the street and back without being out of breath. When I got down to 199 lbs I cried with Dr. Keshishian. He asked me what was wrong. I told him I just never believed I would ever weigh less than 200 lbs, considering I was a revision case,  he had told me that I might only lose 100 lbs.
As of this date, I have lost 195 lbs I am smaller than I was in the 8th grade. I really feel if I had not had the DS I would not be alive to meet my 7 beautiful great grandchildren. You are the only one to take care of yourself. This procedure is a tool and if you are not ready to take care of yourself, don’t have the surgery. You will be on vitamins and calcium for the rest of your life. I just know without this surgery I would not be alive today. I could have out eaten any other surgery. As far as I am concerned the DS is the Platinum of weight loss surgeries. What is really neat is Dr.Keshishian will be my doctor for the rest of my life, he cares about his patients. Thank you Dr.Keshishian for giving me my life back!

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.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.

Injectable Vitamin D

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.

Carbonated Drinks and Weight Loss Surgery

August 11, 2012 3:56 pm

The consumption of carbonated drinks is discouraged after weight loss surgery. In fact, there is a wealth of information that documents the detrimental health effects of carbonated drinks for each individual. These include osteoporosis, obesity, and premature dental decay, just to name a few.  Indirectly, carbonated drinks have been found to increase risk of stroke and Cardiac events. There are studies that show a 48% increase in heart attack and stroke rates for individuals who drink diet sodas vs. those who drink it rarely or not at all.

There is also no health benefit to diet carbonated drinks.  In fact, there are animal studies that show that rats who consume no-calorie sweeteners found in diet sodas experience an increased appetite (Susan Swithers, PhD- 2004).

There are also other factors to consider. The carbonation comes from a mixture of dissolved gasses that are released when the container is opened.  The Carbon Dioxide gas dissolved in the drinks, amongst others, can distend the stomach. Potentially, stretching your stomach. There is also acidity that needs to be corrected by the body. This has been shown to result in changes in the bacterial population in the GI track, resulting in significant bloating and reduced absorption of nutrients.

Calcium loss is caused by the leaching of the calcium from the bones with carbonated drinks, which can cause osteoporosis.

Ask Dr. K: Problems over the years

September 09, 2010 10:42 pm

There are numerous sources available on the internet for patients to search for information. The information that one can find ranges from scientific to anecdotal. Patients individually have asked me a number of questions and I will peridically address them in an “Ask Dr. K” newsletter. I would also like for my opatients to submit their questions by emailing it to me.

“Problems Over The Years”

Question:
“What are the main things we should be looking for “symptom wise” at 3, 5, 7, or 10, etc. years out.
I’d like to know how the duodenal switch effects teeth? On hydration as I think my body pulls water from my stool when I’m not drinking enough. Actually – it’s not “enough” it’s that my body passes it out my kidneys if I am not sipping constantly throughout the day. Is that normal? Omega Fatty Acids – are we screwed? What do those deficiencies look like?”

Answer:
I do not know of any particular study that looks at the health of the
teeth specifically, however, I would assume that if a patient is not
complaint with their Calcium, or even complaint, and they are deficient
in minerals such as Calcium, Vitamin D, Magnesium, and others, then
one can develop poor teeth. Hydration is a very important issue. Surgery or not, most of us tend to run around a little “dry”. Constipation may be a side effect of inadequate water intake.
For the Omega fatty acids, see the next newsletter dated 9/22.

Question:
I would love to know what types of problems are seen in post operative patients and what the distributions are by years post-op.

Answer:
In very broad terms, I can classify them in both time frame, and in term of causes of complication (mechanical vs. nutritional). See table 1.

Please note that this is by-no-means a complete list, only a brief, very brief, overview of some of the potential problems that may surface. This list is not meant to be all inclusive or complete.

Table 1
Post operative
Time Frame
Nutritional Mechanical
Days Dehydration Leaks, abscesses,
infection (urinary,
pulmonary) DVT, PE,
Wound dehiscence, Bowel
Obstruction
Weeks Dehydration, protein
calorie malnutrition-acute
Wound infections, DVT,
PE, Bowel Obstruction
Months Protein Calorie Malnutrition, mineral deficiency, Kidney stones Bowel obstruction,
Cholecystitis (if your
gallbladder not removed)
Years 1-3 Protein Calorie Malnutrition, mineral deficiency, Kidney stones Bowel obstruction,
Cholecystitis (if your
gallbladder not removed)
Years 3-5 Occasional mineral
deficiency, Kidney stones
Bowel obstruction, Skin
Rashes (if applicable)
Years over 5 Occasional mineral
deficiency, Kidney stones
Bowel obstruction, Skin
Rashes (if applicable)

Deep Vain Thrombosis (DVT) Where a blood clot is formed in the deep venous system of the lower legs and can travel and block the flow of the blood to the lungs. If large enough in it a common cause of death in post operative patients. DVT’s are not the same as varicose veins.

Pulmonary Embolism (PE) A clot or a tumor that is dislodged from one part of the venous circulatory system and blocks the flow of the blood to the lungs. The most common source for the PE is a DVT.

Wound Dehiscence Complete or partial breakdown of the suture line at the deep layers where the bowel may become unprotected. In some cases this needs re-operation on an urgent fashion.

Vitamin D Structure

July 30, 2010 10:41 pm

Walking out into the daylight we sometimes complain about the sun’s rays hit our eyes or burning our skin. Most people overlook the importance of the sun, for they are unaware of its benefits. Vitamin D is a natural resource produced from the ultraviolet light waves from the sun hitting our skin. As a result, this allows normal bone growth and development to take place. In addition, vitamin D can be found in various foods, such as seafood and milk. Also, vitamin D’s main function is to maintain consistent levels of calcium and phosphorus.

What are the major sources of vitamin D?
The major sources are food and exposure to sunlight. Important food sources are:

  1. Fortified foods with major dietary sources of vitamins and minerals. For example, Milk in the United States is reinforced with 10 micrograms (400 IU) of vitamin D per quart.
  2. Fatty fish and fish oils.

Exposure to sunlight is an important source of vitamin D as well. Ultraviolet (UV) rays from sunlight generate vitamin D composition in the skin. There is some evidence that the body can make 10,000 iu to 25,000 iu in a single short sun exposure if the sunlight is adequate and appropriate amount of skin is exposed.

What is Vitamin D’s function? Calcium and phosphorus are two vital minerals which are constantly controlled and conserved by vitamin D in our bodies. Calcium is responsible for managing our body’s bones and keeping them stable. In addition to keeping our bones healthy, phosphorus assists with keeping nerves and muscles working together efficiently. In many countries, such as Alaska where sunlight is scarce, many people develop skeletal deformities, or muscular vulnerability. Without vitamin D, bones can become brittle and soft, also known as rickets.

Lack of Vitamin D Minimal amount or deficiencies are major causes of rickets and osteomalacia. An absence of vitamin D develops when dietary intake is insufficient, little exposure to sunlight, the kidneys not modifying it to its active form, or when the individual isn’t capable of absorbing vitamin D from the gastrointestinal tract. In addition, Americans over the age of 50 may be at risk of deficiency because the ability of skin to manipulate vitamin D into its active form slows as we grow older. As a result of various diseases the reduction of a person’s ability to absorb dietary fat decreases. Also, the kidneys which convert vitamin D to its malleable form decrease in efficiency as well. This is a brief over view of the many functions and uses of this important vitamin. Over the last few years there has been a wealth of information that has been published.

Excess Vitamin D Too much vitamin D can cause nausea, vomiting, poor appetite, constipation, weakness in fatigue, pain in the bones and weight loss. Also, vitamin D stimulates the formation of kidney stones, stiffening of soft tissue, and rise in blood levels of calcium. It is however realize that being that vitamin D is a fat soluble vitamin, it is very hard, if not impossible to get excessive amount of calcium after Duodenal switch operation. In order to avoid this very rare complication, patients on Vitamin D supplements should have their Vitamin D 25-OH levels check regularly.

Difference between D2 and D3 Vitamin D is present in two forms, cholecalciferol (D3) and Ergocalciferol (D2). D2 is manufactured by plants or fungus. D3 is formed by the body as a result of sunlight exposure and to some degree by animal products. Other differences about them is that D3 has a longer shelf life, and D2 can be toxic in most patient at high doses. Most of the beneficial effects of the Vitamin D have been contributed to D3. Further discussion here.

vitamin-d
Chemical structure of Vitamin D2 and Vitamin D3