We should be aware that being physically active is part of being healthy. Health is a combination of being physically active, having a healthy diet are all parts of the variables that contribute to our physical and mental well-being long-term.

The restrictions and the stressors caused by COVID-19 have resulted in our inability to maintain a healthy diet and be physically active. However, we must be vigilant with maintain our activity levels to combat health issues.

It is timely that the British Medical Journal has just published an entire issue regarding the significance of activity and our health as individuals and public health worldwide.

There are a few articles that are outlined here.

Ekelund et al. Reviewed published articles and correlated the activity level and mortality. They Concluded, “Higher sedentary time is associated with higher mortality in less active individuals when measured by accelerometry. About 30–40 min of MVPA per day attenuate the association between sedentary time and risk of death, which is lower than previous estimates from self-reported data.”

Written By: Maria Vardapetyan, Eric Baghdasaryan, Osheen Abnous

Vitamins are chemicals that facilitate many processes in the human body such as blood clot formation, good vision, fight infections etc. There are two classes of vitamins. Water soluble vitamins and fat soluble vitamins. Water soluble vitamins dissolve in water. This makes it possible for them to be absorbed through all mucous membranes. Fat soluble vitamins on the other hand do not dissolve or pass through mucous membranes. Fat-soluble vitamins are absorbed in the intestine along with fats in the diet. These vitamins have the ability to be stored in the fat tissues of the human body. Water-soluble vitamins are not stored in the body and have to be taken in daily with the food and dietary supplements. Solubility of a vitamin is not a function of its physical state. There are fat soluble vitamins that have a liquid form and almost all of the water soluble vitamins come in form of pills or powders.

In this article, we are going to focus on fat soluble vitamins. They are all complex molecules made of carbon, hydrogen, and oxygen in different arrangements (see figures 1, 2, 3 and 4). These fat soluble vitamins are vitamin A, D, E and K.

Vitamin A

Vitamin A has a major role in vision, immune function, cell growth, and maintenance of organs such as heart, kidneys, lungs, etc. It plays a pivotal role in the health of our eyes, specifically the retina¹. Rhodopsin protein, a major protein that has the leading role in the process of vision, is found in the retina where it allows us to perceive light. This protein requires vitamin A to function properly. Without vitamin A, rhodopsin cannot sense light and thus cannot initiate the process by which vision occurs.

 

Figure 1: Chemical structure of Vitamin A molecule

 

Vitamin D

Vitamin D regulates different chemical reactions that are associated with bones, muscles, and the immune system. The simplified way it does this regulation is it helps absorb calcium from dietary nutrients which in turn strengthens the bones, helps neurons exchange signals to move muscles and helps the immune system to fight against viruses and bacteria². 

Figure 2: Chemical structure of Vitamin D molecule

Vitamin E

Vitamin E acts as an antioxidant. Antioxidants are naturally occurring chemicals that neutralize toxic byproducts of many chemical reactions in the human body. When food is consumed and digested, the human body converts it into energy. As a result of metabolism free radicals (toxic byproducts) are formed and are neutralized with the help of vitamin E. In addition, free radicals are also in the environment. Furthermore, vitamin E stimulates the immune system to fight against bacteria and viruses³.

Figure 3: Chemical structure of Vitamin E molecule

Vitamin K

Vitamin K can be obtained from food and dietary supplements. There are two forms of vitamin K: phylloquinone (Vitamin K₁), which is found in spinach, kale and other greens and menaquinone-4 (Vitamin K₂), which is found in animal products. Vitamin K₁ is involved in blood clotting, and Vitamin K₂ is involved in bone tissue building. Vitamin K₁ is the main Vitamin K in human diet (75-90% of all vitamin K consumed), however, it is poorly absorbed in the body^4,5. 

Figure 4: Chemical structures of Vitamin K₁ and K₂ molecules

Absorption of fat soluble vitamins

Polarity describes the inherent charge(positive or negative) or lack of charge for any given substance or molecule.  Molecules that are charged are referred to as “polar”, while those that lack charge are “nonpolar”. When discussing solubility, it is important to remember the phrase “like dissolves like”. That means polar (charged) substances like to interact with a polar environment like water, since water contains a slight negative charge. Hence, charged substances are water-soluble. Nonpolar substances on the other hand readily interact with nonpolar environments such as fat, which contains no charge. Therefore, molecules that lack a charge such as vitamins A, D, E, and K are referred to as fat soluble. 

 

Due to their water fearing nature, these fat soluble vitamins cannot simply be absorbed directly into the bloodstream (which is mostly water) like the sugars and amino acids in our diet. As their name suggests, these fat soluble vitamins like to be embedded in fatty droplets, which facilitate their absorption in the following way. Fat soluble vitamins group together with other fat molecules to form fatty droplets, effectively reducing the amount of interaction with the watery environment of the intestines. Therefore, without an adequate amount of fat in your diet, your body is unable to effectively absorb these fat-soluble vitamins. This may be true in an intact anatomy, however, post weight loss surgical patients can not increase their fat soluble vitamin levels by increasing their fat intake. This is due to the fact that a high fat diet causes excessive bowel movement which in turn washes away any vitamins taken by mouth. DS limits fat absorption (thus the great weight loss) which can cause vitamin A and D deficiency that can not be easily corrected with oral supplementation.

As mentioned before, fat soluble vitamins are hydrophobic and nonpolar, which means they are also fat loving or lipophilic. Excess fat soluble vitamins can be stored in the liver and fat tissue. Therefore, these vitamins do not need to be eaten every single day since stores of these vitamins can sustain a person for some time. It may take several weeks or months for our body to deplete these stores of fat soluble vitamins which is why it generally takes a longer amount of time for fat soluble vitamin deficiencies to manifest themselves. The ability to store these fat soluble vitamins in tissues can also lead to vitamin toxicity – marked by an excess of vitamin stores in our body. 

Clinical manifestations of A, D, E, K deficiency

Vitamin	Clinical Deficiency manifestations
Vitamin A	Vision Problems Night blindness  Dryness of the eye
Vitamin D	Softening and weakening of the bones Decreased bone formation  Bone shape distortion Bowed legs (generally in children) Hypocalcemia
Vitamin E	Damage to red blood cells  Tissue/organ damage due to inability to supply enough blood Vision problems Nervous tissue malfunction
Vitamin K1	Excessive bruising Increased bleeding time Small blood clots under nails Increased bleeding in mucous membrane
Vitamin K2	Weak bones Increased plaque deposits along gumline Arterial calcification

 

 

References

1. Office of Dietary Supplements – Vitamin A. NIH Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/VitaminA-HealthProfessional/#. Accessed April 26, 2020.

2. Office of Dietary Supplements – Vitamin D. NIH Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/VitaminD-Consumer/. Accessed April 26, 2020.

3. Office of Dietary Supplements – Vitamin E. NIH Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/VitaminE-Consumer/. Accessed April 26, 2020.

4. Vitamin K. The Nutrition Source. https://www.hsph.harvard.edu/nutritionsource/vitamin-k/. Published July 2, 2019. Accessed April 26, 2020.

5. Beulens JWJ, Booth SL, van den Heuvel EGHM, Stoecklin E, Baka A, Vermeer C. The role of menaquinones (vitamin K₂) in human health. The British journal of nutrition. https://www.ncbi.nlm.nih.gov/pubmed/23590754. Published October 2013. Accessed April 26, 2020.

There are a number of lectures, posting that we have done over the years on this topic. However the questions of osteoporosis medications and their benefits and risks comes up often.

The links are attached:

Osteoporosis

Osteoporosis Medications, Action and Side Effects

Here is an updated list of medication that I had previously published. I made some clarification to explain how the medications work. There are different classes of medications and the detail of the action and soda effects were described earlier at a blog post.

List of medications that effect bone health.

The table is obtained from https://www.nof.org site.

 

Our practice has long discouraged the consumption of diet soda and carbonated sugary beverages for anyone, but especially our weight loss surgical patients. These products’ detrimental effects on bone health, gut microbiome, increase appetite, diarrhea, inhibited weight loss and regain shouldn’t be ignored. In addition, in the situation of limited space post Bariatric surgery, a WLS patient needs nutrient rich, protein foods. These beverages provide no nutritional value.

In addition, these products are also not recommended for non-WLS patients. Oral health, peak in insulin levels, increase weight gain, increased Type 2 DM, and diarrhea are also issues that can effect patients in addition to the above issues.

Our practice, as well as a recent article on Medical News Today Written by Jon Johnson, encourages people to:

“Saying goodbye to diet soda

Soda, whether regular or diet, is a dietary waste. Sodas have little nutrients, and have a long list of side effects. For people with diabetes, diet soda has been associated with weight gain and symptoms of metabolic syndrome. Some sweeteners in diet soda even cause sugar and insulin spikes in the blood.”

We encourage the use of Stevia, which is a natural sweetener, instead of other artificial sweeteners. Stevia is a herb type plant with leave that can be used for sweetening. It has been used for many years in other countries and cultures. It contains Magnesium, Potassium, zinc, Vitamins A, B3 and C as well as fiber.

A past blog post on Carbonated Beverages and Weight loss Surgery .

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.

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.

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.

The topic for the Glendale group meeting and webinar on September 3, 2014 was Vitamin K2, laboratory studies and their significance.

The webinar video is on our website.

There was an online question regarding night hunger.  In order to abate this, it is best to eat frequent small volume of high protein meals.  Also if possible, a solid piece of protein such as meat, egg, cheese as close to bedtime as tolerable may be better that a protein shake in liquid form.  This will decrease ghrelin production, give the satisfaction of satiety and normalize blood sugar level throughout the night.  Frequent small protein meals, snacks and hydration throughout the day is also necessary to alleviate this feeling.  It is not unusual to need to have something in your stomach every 2-3 hours during the rapid weight loss phase and some people even yeas out.

Protein

Another question asked if staying on limited types of protein was adequate.  The recommendation is to rotate types of protein in food form and supplement form as tolerated to avoid loss of absorptive capacity and development of allergies.  There have been several incidences of people developing an allergy to whey protein after several years when there had not been a history of the allergy previously.

Vitamin K2

Lastly, there was a questions regarding  Vitamin K2.  Vitamin K is a fat soluble vitamin that has two forms, K1 and K2. It has long been thought that the majority of Vitamin K2 was synthesized by the microflora in the gut. But research is revealing that it may involve more processes and is more significant than was previously thought.

Vitamin K 1 and Vitamin K2 are separate vitamins. Vitamin K 1 is found in dark leafy vegetables and plays more of a role in blood coagulation. Vitamin K2 is found in hard cheeses, egg yolk, soft cheeses, natto, chicken liver, other organ meats, ground beef, salami and grass fed beef butter.

Vitamin K2 has a much broader function in directing calcium, via Human matrix Gla protein, to appropriate places to deposit such as bone and teeth and preventing it from depositing in arteries and possibly forming kidney stones.  It is also a antioxidant which has shown to reduce cancer risk and encourage healthy nerve growth and protection. Vitamin K2, however, seems to be another vitamin, similar to vitamin D3,  that is going to be going through a great deal of research in the near future with changing recommendations and knowledge base.

Vitamin K2 controls osteocalcin, which is a calcium regulating protein. Osteocalcin binds to the mineral portion of the bone but in the absences of Vitamin K 2 the result is calcium reabsorption from the bone and osteoporosis develops.  Vitamin K2 is a fat soluble vitamin that comes in several  bacterial menaquinones MK4-MK10. However the majority of research is based on MK4 and MK7.  While both have bone protective properties, MK4 also has the cardiovascular protective attributes and colon cancer growth inhibitory effects.  MK7 is said to have a higher bioavailability and longer half life. Article on MK7 and bone health.

Most of the studies regarding bone health and vitamin K2 the patients were treated in conjunction with Vitamin D and calcium supplements.  For a Duodenal Switch patient, the supplement of choice would probably be a combination of Vitamin K 2 with MK4 and MK7. Again, there is ongoing research regarding Vitamin K2 which may reveal new daily allowances, mechanism of function and recommendations in the future.

Here is an article regarding Vitamin K2.

The recipes for the evening snack.

Pumpkin smoothie was the following protein shake with an addition of a scoop of unflavored protein powder.

Paleo black pepper crackers with goat cheese and walnut crusted cheddar ball.

Bacon wrapped chicken wings.