After weight-loss surgery, some patients may experience a transient elevation in liver function tests that resolves over time. We have previously reported on this. IT is essential to distinguish between the Duodenal switch and the SIPS/SADI procedure, where some patients are led to believe they are identical. These procedures differ physiologically, and their weight loss and metabolic behaviours vary significantly.

Other than the stress of the weight loss, obesity, and comorbidities of obesity, there may be other anatomical post-surgical causes for elevated liver function test. This has also been discussed extensively.

A recent literature review supports the protective effects of vitamin D supplementation.

Effects of vitamin D supplementation on the glycaemic indices, lipid profile, and liver function tests in patients with cirrhosis: a double-­ blind randomised controlled trial

Low serum 25-hydroxyvitamin D levels are associated with liver injury markers in the US adult population

Exploring the Correlation Between Vitamin D Level and Serological Markers in Liver Diseases: Insights from a Cross-Sectional Study

Elevated liver enzymes may be caused by many factors, including nutritional deficiencies, excessive supplementation (turmeric), medications, alcohol, adhesions causing partial bowel obstruction, and increased enterohepatic bile reabsorption . I would be very cautious about associating vitamin D supplementation with elevated liver function test results, even if the vitamin D level is in the very high normal range, regardless of the  daily dose (much less frequent with injectable).

Vitamin D, as a fat-soluble vitamin, however, protects the liver and improves liver function test even in very high serum level . In rare cases, prolonged, elevated vitamin D levels may strain the liver. In Fact, the association of the vitamin D level and liver disease, including cirrhosis, leads to hepatocellular carcinoma (HCC) and dea h. Vitamin D protects the liver from HCC but cannot reduce the risk of cirrhosis.

There are no known contraindications from a weight-loss surgical perspective to prevent a post-surgical patient from getting the COVID vaccines.

A patient who has had a Duodenal Switch, Lap Sleeve Gastrectomy, RNY Gastric Bypass, or revisions to Weight Loss Surgery should have the COVID vaccine. The vaccination should be avoided for a few weeks after surgery. For other possible contraindications, please consult your PCP.

Here is a summary of the vaccines and the details of each one approved as of the publication date.

Physical activity in the U.S. varies based on geographic location, socioeconomic status and in comparison to other countries. It is important to know that physical activity is an important component of our well-being. However, this does not mean that going to the gym is the only way to be physically active.

Strain et al. Shows that different populations in different countries get their activity from different sources.

His research showed that the United States population ranked as a high-income country, ranks in the lower 1/3 of the number of countries surveyed with regards to the meeting minutes of moderate-to-vigorous physical activity (MVPA) per week.  This may be a contributing factor to the significant rise in obesity in the United States. Individually we should all aim to increase our moderate to vigorous activity significantly.

We are excited to announce we will be having a Zoom group meeting Tuesday, September 22, 2020 at 7:00 PM PST.  We hope to see you online!

Registration is required. Please follow the link to the meeting registration.

We are all aware of the many roles that Vitamin D plays in our bodies. This includes immune function in addition to all the regulatory roles that Vitamin D plays in several physiologic reactions. There may be a correlation of low Vitamin D and COVID-19 infection increasing death risk as looked at in research articles.

Covid -19 in a subset of patience causes significant lung injury. These patients require mechanical ventilation.

Previously reported publications have suggested a possible correlation between ace inhibitors and increased risk of pulmonary complications of Covid -19. Some researchers suspect that the Covid-19 may be able to enter lung cells by the ACE receptors.

Vitamin D may positively implact the receptor ACE2. This study, report clear correlation between the high death rate with low vitamin D levels in Covid infected patients. There are limitation to this study that the attached abstract outlines.

Our take home message would be to please make sure you have updated labs and that you are all taking the recommended Vitamin D based on your surgical anatomy and laboratory values, not just an average non-bariatric person recommended dose.

https://www.dssurgery.com/wp-content/uploads/2020/05/manuscript.pdf

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

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.

The scientific literature is riddled with evidence pointing to the benefit of early metabolic surgery as a superior treatment, remission and possible cure option for diabetes.  Unfortunately, the medical education, pharmaceutical companies, primary care healthcare delivery systems and third party payers (health insurance companies) have not caught up with the published data. The American Diabetes Association has changed their guidelines to reflected the benefit for combating diabetes with weight loss surgery.

There is ample evidence of the superior outcome of surgery as a treatment option for diabetes when compared to medical managment. Cummings et.al, in a published article in Diabetes Care, showed sustained stabilization of the Hemoglobin A1C six years after surgery. In contrast, there was no significant changes noted in the non-surgical group.

Jans et.al. , in November of 2019 showed that the patients who had NOT been on Insulin,  and had metabolic surgery had the highest long term success for resolution and remission of the diabetes. This identifies that having a patient be proactive in their care by having metabolic surgery improves success rates.

The exact mechanism by which the diabetes is resolved is unclear. The weight loss may play a role. There are numerous hormones and neuroendocrine modulators which control the complex metabolic pathways. Batterham et.al., in Diabetes Care (2016),  published a summary overview of the possible mechanism involved in diabetes improvement following metabolic surgery.

There are a number of overlapping and sequential layers for possible reasons why diabetes resolves after weight loss/metabolic surgery. These may be directly related to surgery and the reduction of the calorie intake or absorption. It may also involve the neuroendocrine modulators.

What can be said definitively is that early surgical intervention is best and most likely the only permanent solution to type II diabetic resolution. There is no medical justification in not considering metabolic surgery in diabetic patients who may also have difficulty with meaning a BMI< 35.