There has been extensive discussion on the importance of Vitamin D published over the last few years in regards to bone health, immune health and Calcium physiology. The importance of vitmain D and bone structure has been discussed extensively. It is also important in the absorption of Calcium. It further plays role in immune modulation.

What is new is the possible correlation of Vitamin D and COVID 19. Recently it is been shown that low vitamin D may increase the risk of a poor outcome with Covid-19 exposure and infection.

There are different standard recommendation for the Vitamin D levels.

In our practice we aim to maintain a Vitamin D level of 0ver 60 in post weight loss surgical patients.

There are a number of theories as to how the Vitamin D deficiency may play a role in this. An emerging observation is that low Vitamin D may cause abnormal and excessive blood clot formation. Mohammad et. al. in 2019 published a study on the association of low vitamin D and “…Pathogenesis of Thrombosis”

This pathologic blood clot formation in COVID-19 patients may explain the extensive lung injury and  multi system organ failure in some patient. It is also one of the reason that some COVID-19 patients have loss limbs or appendages.

Please follow all supplement recommendations based on your laboratory studies and all COVID-19 recommendations. We would recommend frequent hand washing, surface cleaning, social distancing, and wearing face masks as the most basic precautions and increase precautions based on your health status.

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.

 

It’s important to understand Vitamin D metabolism and deficiency potential following weight loss surgery Vitamins after DS need to be followed via laboratory blood studies. There are basic vitamin needs but individual needs should be based on medical history, genetics, alimentary limb length, common channel length and other surgical and physiologic determinations. Vitamins after DS are a life long commitment as well as protein needs and hydration. Duodenal Switch is a malabsorptive procedure which requires at least yearly laboratory blood studies, daily vitamins/minerals, daily high protein and daily hydration intake. There is not an all in one vitamin that is adequate for a DS patient or tailored to your individual needs. (example: you may need more Vitamin D and less Vitamin A if you are taking a all-in-one vitamin you can’t get more of one and less of another vitamin)

DS patients are recommended to take Dry forms (water miscible form) of Vitamin A, D3, E, K due to the fat malabsorption after DS. Dry formulations by Biotech are processed so they can be absorbed by a water soluble method after the DS procedure. Vitamin D seems to be the vitamin that can become deficient the easiest, followed by Vitamin A. Take these vitamins away from dietary fat.

In some cases, patients may need injectable Vitamin A or D to improve vitamin levels.

Click the links to view the information below and within the comments of this file:
Vitamin D3 50 by Biotech:  Amazon
directly from BioTech:

Many DS surgeon’s do not recommend Children’s vitamins or chewable vitamins unless there is a specific reason or need for them.
DS Surgeon Blog on Vitamin D:
Webinar on Vitamin D metabolism:
Medications that effect Bone health:
This does not constitute medical advice, diagnosis or prescribing. It is simply a compiled list of gathered information. If you are in doubt or have questions please contact your medical healthcare professional.

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 Protein, Calcium, 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).

 

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.

 

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.

A Parathyroid scan or Sestamibi scan may be needed if the typical weight loss surgical reasons for elevated PTH levels have been addressed. Sestamibi is a small protein which is labeled with the radio-pharmaceutical technetium-99. This very mild and safe radioactive agent is injected into the veins of a patient with overactive parathyroid and is absorbed by the overactive parathyroid gland. If the parathyroid is normal it will not absorb the agent. The scan below shows the uptake of the agent.

Calcium, Vitamin D and Parathyroid hormone are routinely measured on yearly follow up for most post weight loss surgical (WLS) patients. Elevated parathyroid hormone (PTH) may be caused by Vitamin D deficiency or calcium deficiency (most common in post WLS) or by over active parathyroid gland(s). In the latter case, if one of the four glands is overactive then this is knows as a parathyroid Adenoma. If all 4 are over active and are secreting too much PTH, this is known as hyperplasia. Ultrasound of the neck, may identify an enraged parathyroid gland (adenoma) which is located behind the thyroid gland. Given the large area where the parathyroid gland may be located, additional tests are needed to not only identify the location of the gland(s) but also to distinguish between single gland (adenoma) or multiple glands (hyperplasia) cause for the elevated PTH. It is important to investigate all avenues and testing in parathyroid hormone elevation and in some cases, not to rely on one test for your diagnosis. It is also imperative that weight loss surgical patients take their supplements routinely and consistently and have their laboratory studies followed at least yearly.

Let’s get back on track after the holiday season! The holidays  were wonderful but if you find yourself with a few extra souvenirs don’t feel alone. The average American gains between 1-8 pounds during the holiday season and I am no exception. Let’s get back on track together.

Time to clear out the kitchen! Disposing of temptations and high trigger foods is the first step to getting back on track. If the food isn’t easily acquired then it is less likely to be consumed.

Stock up on high protein and whole, unprocessed foods that are low carbohydrate and nutrient dense. When quality foods are easily available we are more likely to stay on track with the types of foods we should be eating. Simple sugars/carbohydrates are the biggest culprit of holiday weight gain. We need to go back to the basics of hydration, high protein, low carbohydrate/sugar, vitamin/mineral supplements and exercise. Simple sugars and carbohydrates are easy for our bodies to use and absorb and cutting them back can jump start your weight loss. Each individual needs to identify the daily carbohydrate intake that works for them.  Some people stay under 50 grams of carbohydrates daily.  You may also need to look at your protein and fat intake.  All excess nutrients absorbed have the potential to turn into fat mass and inhibit weight loss. Metabolism video.

Hydration is an important ways to start getting back on track. Water is essential to life functions. The brain is 85% water, blood is 80% and muscle is about 70% water. Hydration aids in digestion, eliminating waste, byproducts and toxins. It also can decrease the feeling of hunger. Lack of hydration can increase fatigue which can lead to craving high carbohydrate foods to increase energy.

Protein’s importance in almost every bodily function and muscle mass can not be ignored. High quality complete Protein sustains muscle mass during weight loss, aids immunity, antioxidant function, and enhances leptin and insulin function. Filling up on protein first will help with carbohydrate carvings and give a sustained satisfied feeling. A prior blog post gives additional information on the importance of protein and the effects of protein malnutrition. WLS makes daily protein intake important but especially after Duodenal Switch, protein is a necessity of daily life.

Vitamins, minerals and supplements will ensure the body has the nutrients it needs to function adequately and can keep cravings at bay. Deficiencies in vitamins and minerals can cause cravings for foods. Vitamin and minerals are essential to muscle function, red blood cell production, bone health, and numerous other physiologic functions. We may all slack off on our supplements occasionally but now is the time to get back into the habit of daily vitamins and mineral supplements. A daily vitamin, mineral, and supplement routine is a lifetime commitment after Duodenal Switch or any WLS.

Exercise can increase weight loss, overall well being, mental well being, mood, alertness, improve digestion, improve sleep, and increases energy levels. Exercise does not have to be a daunting task. Simply adding 15-30 minutes of activity can give added benefits. Yoga, walking, dancing, lifting weights, and sports activities can be included or added to more traditional forms of exercise. There are many free online videos for all types of exercise available.

Teaming up with others can also help increase weight loss and compliance. Support from friends, family and other groups will assist you. There is a whole gamut of support group online and in person. If you have fallen out of the habit of attending our support group or webinars get back to them. You can find our schedule and announcements regarding webinars here. The Central Valley Bariatric Facebook page also gives daily inspirational messages, protein recipes and articles and any new information or research available. There is also a Duodenal Switch Facebook Group. Anything that increases accountability is a benefit and motivates us to stay on track.

In the spirit of new starts and getting back on track, we are having a giveaway with the basics to get back into the swing of things. Please post a link on our FaceBook page of your favorite blog post and comment with whether you are pre or post operative to be entered into the giveaway. We will draw 2 names from those that enter by commenting on our FaceBook page on January 29, 2016. Giveaway items may or may not be identical to the pictured items.

NOTE: Giveaway items may or may not be identical to the pictured items.
We are not affiliated with any of the products nor do we endorse any one type of product.

Zinc is the most abundant intracellular trace mineral. The body does not have a zinc reserve due to the majority of the stores being in muscle, skin, and bone.  It is essential in the synthesis of muscle, DNA, cell membranes, cell signaling, nerve impulse, and hormone release.  It also plays a role in immune function, anti-oxidant, reproduction, blooding clotting, vision, growth, wound healing, thyroid function and insulin response to carbohydrate metabolism.  Zinc works with Vitamin A in several ways; converts retinol to retinal and is essential for liver synthesis of retinol binding protein that transports Vitamin A in the blood.  It is also important in maintaining levels of transport proteins; albumin, transferrin and pre-albumin. The zinc fingers have numerous functions, including Vitamin D , estrogen and androgen protein binding.

There are studies that show calcium citrate, calcium hydroxyapatite, calcium carbonate, calcium citrate malate have no effect on zinc absorption.  However, there are others show a decrease in its absorption and levels.

Higher doses of zinc can decrease copper absorption.  This does not appear to be the case at RDA doses of zinc.

Symptoms of deficiency include loss of appetite; poor growth; weight loss; lack of taste or smell; poor wound healing; skin problems such as acne, atopic dermatitis and psoriasis; hair loss; lack of menstrual period; night blindness; white spots on the fingernails; and depression.

People at risk for deficiency:

• Premature and low-birth-weight infants
• Older breast-fed infants and toddlers with inadequate intake of zinc-rich complementary foods
• Pregnant and breast-feeding women, especially adolescents
• People  receiving Total Parenteral Nutrition
• Malnutrition
•  Severe or persistent diarrhea
• Malabsorption Syndromes (Celiac, short bowel, WLS, etc)
• Inflammatory Bowel Disease
• Alcoholics
• Chronic Renal Disease
• Sickle Cell Anemia
• Medications and/or Supplements
• Elderly
• Vegetarians

Recommended Daily Allowance:

The high daily dose is 40 mg/daily. Common side effects of zinc include stomach upset, nausea, vomiting, and a metallic taste in the mouth. High doses of zinc can cause dizziness, headache, drowsiness, increased sweating, loss of muscle coordination, alcohol intolerance, hallucinations, and anemia.

• Male Adult: 11 mg/daily
• Adult Female: 8 mg/daily
• Pregnant or Breast Feeding Female: 11-13 mg/daily

Medications that may decrease zinc levels are ACE inhibitors, Penicillamine,  and Thiazide diuretics. Medications that increase Zinc are Amiloride.  Quinine and Tetracycline antibiotics decease the absorption of zinc.  Do not take Zinc with Immunosuppressant medications or Amiloride.

Inhibit absorption :

• Phytic Acid
• Oxalate
• Fiber
• Iron Supplement
• Copper
• Calcium Supplement
• Folate

This is not meant to be an all inclusive discussion.  Please refer to your physician and your laboratory studies before beginning any supplement regime.

Copper is a trace element. It is a co-factor and enzyme that regulates iron metabolism and is essential in cell production, immune function, cellular energy storage, anti-oxidative effect, nerve transmission and connective tissue and bone development. There are several research article linking dental bone health, alveolar bone and tooth enamel wear, to copper levels.

Copper’s co-ezymes work with transferrin to transport the iron for red blood cell formation. It is important to also look at copper levels and intake when a patient is at risk for deficiencies when diagnosing anemia. It is interesting to note that anemia can show an abnormal high level of copper on laboratory studies.

People at risk for Copper deficiency are:

• Cow milk fed infants
• Low birth weight infants
• Prolonged diarrhea
• Malnutrition
• Malabsorptive syndromes
• Menkes Syndrome
• Gastric or Weight loss surgery
• Short bowel syndromes
• Sprue’s disease
• Total Parenteral Nutrition need
• Celiac Disease
• Cystic Fibosis

Deficiency can impair red cell production, causing anemia,  and cause iron overload in organs, such as liver, brain, or retina. It may also cause a decrease in neutrilphils, a type of white blood cell. Osteoporosis can also be a side effect of low copper intake. There have also been reports of neurologic syndrome in at risk patient who are deficient.

Recommended Daily Allowance for the average male and female is 900 mcg/daily. Pregnant women daily RDA is 1,00mcg/daily and breastfeeding mothers RDA is 1,300 mcg/daily. The highest tolerable dose for the average person is 10,000 mcg/daily.

Medications and supplements that can increase levels are estrogen, birth control pills, and Tagamet. Medications and supplements that lower levels are allopurinol and nifedipine. Penicillamine may lower copper level and decrease amounts of pencillamine. Copper binds with NSAIDS and may increase their effect. Zinc supplementation over an extended period can decrease absorption of copper.

Toxicity symptoms are nausea, vomiting, abdominal pain, and  diarrhea.

This is not meant to be an all inclusive  or complete discussion. As always, consult with your physician based on your laboratory values regarding any supplementation.

Another article regarding Micro-elements for Bone Health

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.