Stop Obesity in it’s Tracks!
What You Need to Know About Vitamin D after Bariatric Surgery
J.K Champion MD
January 2010
There has been renewed interest by the medical community recently in the role of Vitamin D in the maintenance of good health that needs to be shared with our patients. Let me first begin by stating that Vitamin D absorption from the diet is not affected by weight loss surgery, however, over 50% of the entire population of the United States has a vitamin D deficiency. This article will review facts about vitamin D; including how we get it, what happens to our body when it gets low, and how do we prevent and treat vitamin D deficiency.
Vitamins are organic substances which are essential for normal metabolism, growth and development of the body. We get vitamin D in our diet and from exposure to sunlight. It is present in milk, fatty fish such as salmon, tuna and cod, and eggs, butter, and dietary supplements.
Vitamin D’s principal function is related to our body being able to use calcium and phosphorous, which are the minerals which make up our bones. Vitamin D is essential for the normal absorption of calcium and phosphorous from our GI tract. In addition, vitamin D is necessary for normal muscle function, cardiovascular health and the function of our immune system. Deficiency of vitamin D is best known for its effect on our bone strength or bone density and can cause osteoporosis which leads to fractures of the hip and spine as we grow older. These fractures heal poorly in thin bone and are very painful. At present 50% of women and 20% of men will develop osteoporosis by age 50 (this is in patients who haven’t undergone bariatric surgery) and experience a fracture related to their poor bone density in their lifetime. Low vitamin D also results in an increase in autoimmune disorders like type 1 diabetes, multiple sclerosis and Chron’s disease and can interfere with our body’s defense against bacterial or viral infections. Deficiencies also increase the risk of some cancers (prostate, pancreas, colon, ovary and breast) and can lead to higher rates of hypertension and cardiovascular disease. Chronic muscle pain and fibromyalgia has been reported to resolve in up to 90% of patients when their vitamin D deficiency is corrected. We are just coming to understand the role of vitamin D which was rarely tested in the past. Current testing has revealed that 50% of the current population has a vitamin D deficiency. A major reason testing is not done more frequently is the current cost of the lab exam which can run from $160-400, and is rarely covered by insurance.
Vitamin D can be obtained in our diet, but requires we eat a fatty fish such as salmon 2-3 times weekly. Other foods such as milk and diary products which contain vitamin D are actually fortified artificially with the addition of vitamin D by the supplier of the product. It was previously thought that we needed only 400 units of vitamin D daily along with 800 mg of calcium, and many of the over the counter supplements contain this quantity in 2 tablets daily. We have since learned this isn’t enough and the government has suggested 800 units of vitamin D and 1500 mg of calcium daily. Even this amount may not be enough and we often have to prescribe a super strength vitamin D with 50,000 units which is taken either weekly or every other week.
It has been documented that patients who undergo gastric bypass surgery are at higher risk of metabolic bone disease such as osteoporosis due to reduced absorption of calcium, however, we have monitored our patients with bone density testing yearly in the office and our incidence of osteoporosis has decreased after surgery due to our insistence our patients take the calcium and vitamin D supplements and be monitored closely. Patients who don’t return to our office for follow up should ask their family physician to order a bone density study yearly to insure adequate calcium replacement. Blood tests which measure calcium are not adequate to monitor calcium supplements. Routine vitamin D blood test can be reserved for patients with demonstrated abnormal bone density tests or known vitamin D deficiency due to the cost of the test at this time.
We are just beginning to understand the importance of vitamin D for good health in all people. Remember: it’s extremely important for our patients to take their calcium supplements with vitamin D and have routine testing done yearly to insure adequate replacement of nutrients in their diet.
Words from a Gastric Sleeve Patient
My weight loss seems steady at about 1-3 pounds weekly. I have occasional stalls where the scale doesn’t move for a couple weeks but then it moves again. I don’t weigh myself more than once a week. Fortunately, I have yet to see the scale go in the wrong direction. I would say my total weight loss is around 45-50 pounds thus far. I am in the low 180lb range.
I must confess, I have only recently started working out regularly so the aforementioned weight loss would probably be greater had I not been sedentary. The good news is, I recently joined a fitness club and am doing 45 minutes of intense cardio 4-5 days a week. I will soon be incorporating strength training 3 days a week into the mix to help with muscle tone. I can’t begin to tell you how much better I feel. Especially my energy level!
Lately, I think my brain is finally syncing up with my revised stomach. That was the hardest thing at first. I am now able to distinguish between true hunger and the hunger in my head. I can definitely feel the difference without Grehlin. I don’t feel ravenous or deprived anymore. My stomach sort of growls like it used to if I’m truly hungry but I don’t feel the need to eat everything but the kitchen sink. I feel like I have advanced past the experimental phase with food. I am naturally making better choices, no sweets except fruit. I am sticking to 3 meals a day and no grazing especially now that the holidays are over. I don’t miss the old eating days anymore. I did at first though. My relationship with food has changed dramatically.
I take one Women’s Ultra Mega vitamin from GNC daily. I still need to get in more protein. It’s hard as I’m single and on the go. I also need to get in more water than I should. It’s hard because I can’t chug-a-lug anymore. Especially after a workout! Although I can never finish a whole can in a given day, I do have a vice and that’s sipping on diet Coke at work. I know!… It’s bad! I’m working on it and trying to replace it with crystal light but I miss the carbonation.
I plan to get a physical once I find a good PCP here so I can get some blood tests and see how those look. When I do, I will have them forwarded to your office.
I am also still smoke free and have been since Last August. I smell better, look better, and most importantly, I feel better! And I owe it all to Dr. Champion and his wonderful staff! You have all given me a new lease on life and I will be forever grateful! I have absolutely no regrets on the surgeon or the procedure I chose.
I’m so sorry for the lengthy e-mail. I just figured since you only have a couple sleeve patients, my feedback would be helpful to you. There is so much to talk about!
Thanks again for everything and I will keep you posted from up here in Massachusetts!
Take care for now. Warmest regards,
Val C.
Winder Support Group Important Notice
We are looking for a stellar patient to become our new Support Group Facilitator for our Winder Group. If you are interested, please contact the office for more information.
Vitamin Supplements after Weight Loss Surgery
We recommend all weight loss surgery patients take vitamin and mineral supplements ( 2 multivitamins with iron, 1500 mg calcium with 800 units vitamin D, and oral iron 100 mg daily if a menstruating female) and have routine blood test performed at least yearly to confirm your body has an adequate supply and you are in good health. The gastric bypass procedure bypasses the first portion of the small bowel (duodenum) where iron, calcium and “B” vitamin prefer to be absorbed. These vitamin and minerals can be absorbed in other areas of the small intestine, but it requires patients to take larger doses than non surgical patients. In addition up to one third of weight loss surgery patients have vitamin deficiencies before surgery and their diet may not include adequate supplies of some nutrients after surgery, so we recommend supplements even for Lap-band patients where no portion of the bowel is bypassed.
Recent studies have demonstrated that 50% of the US population has a vitamin “D” deficiency and 50% of women will develop osteoporosis by age 50 in patients who haven’t undergone weight reduction surgery. While Vitamin D absorption isn’t affected by weight loss surgery, our lack of adequate intake in modern diets requires everyone to take a calcium supplement of at least 1500 mg daily with at least 800 units of vitamin D for good health.
Your calcium supplements with vitamin D may all be taken together at the same time. It doesn’t have to be taken in multiple doses, and you can’t absorb more than 1500 mg daily, so increasing your dose won’t improve your bone strength beyond the 1500 mg recommended. There is no real difference in bone strength between the different calcium preparations, so chose the one you like best. A Vitamin D in a prescription strength of 50,000 units may be required if patients have a severe D deficiency or bone thinning (osteoporosis or osteopenia) on a bone density study.
Calcium shouldn’t be taken at the same time as iron, or it will block the absorption of iron. We recommend taking your multi-vitamin and iron together and then take your calcium at least 4 hours later. Iron is usually better tolerated with food, and may cause nausea if taken on an empty stomach. Constipation sometimes occurs with iron and can be treated by taking 2 stool softeners daily, like Colace of Miralax.
Some patients may require additional Vitamin B-12. We test blood levels before prescribing additional B-12, since not everyone will require additional supplements. B-12 may be given by injection, nasal spray, or orally by tablet. We recommend 1000 ug oral vitamin B-12 for patients preferring the oral tablet method.
Medication Absorption after Bariatric Surgery
Our patients often wonder if medications are absorbed differently after weight loss surgery, and do they need to adjust their dosage.
The answer is no!
Patients who undergo a Lap- Band procedure will not have any of the small intestines bypassed, so they shouldn’t worry about medication absorption. Many will ask why we place them on supplemental vitamins and calcium if the upper portion of the small bowel is not bypassed like after the Roux-en-Y Gastric Bypass. The answer to that question is many patients don’t eat a balanced diet which is high in iron such as green leafy vegetables, or avoid some food groups such as milk products which are high in calcium. About one out of every three patients is found to have low iron, calcium or “B” vitamins before surgery. In addition 50% of women over age 50, who haven’t had weight loss surgery, will develop osteoporosis in their lifetime or have vitamin D deficiency, so taking supplements is a good idea.
Gastric Bypass patients do have around 20% of the small bowel bypassed along with the portion just beyond the stomach called the duodenum. This will decrease the absorption of iron, calcium and “B” vitamins, so they must take supplements to remain healthy. This bypassed intestine only represents around 20% of the bowel, so medications can be absorbed normally in the remaining 80% of the distal bowel. No medications, vitamins, or nutrients are absorbed in the stomach; it simply serves as a mixer to grind up the food particles into smaller pieces. This is why you must chew your food until it is almost liquid to make up for the bypassed stomach.
We are not aware of any medications that are absorbed better or worse after Gastric Bypass Surgery. We occasionally see a reduction in thyroid medication, but we believe this is due to a change in the patient’s metabolism and weight loss, not a change in absorption. Requirements for other medications like for diabetes, high blood pressure or cholesterol may also decrease after Gastric Bypass due to weight loss and changes in the body’s metabolism, but it is not due to a change in absorption. Birth control pills are absorbed normally as far as we are aware, but must be taken as prescribed. Fertility often increases with weight loss, so remember to be diligent with birth control methods the first 18 months. All methods of birth control including the pill have a known failure rate of at least 1%.
So remember, take your medication as prescribed and do not make adjustments or changes without clearance from either your Primary Care Provider or Dr. Champion. Please call our office at 770-425-5525 if you have any questions.
Dumping Syndrome after Gastric Bypass
A number of patients inquire at our office about symptoms they begin to have 12-18 months after gastric bypass. They describe symptoms of feeling light headed, dizzy, nauseated, sweaty, or achy all over with crampy abdominal pain which occurs about 45 minutes to 1 hour after a meal. This is called “late dumping syndrome” and is caused by a low blood sugar in response to carbohydrates in the meal.
Most patients are aware of “dumping syndrome” which may occur in patients who consume sweets or desserts after gastric bypass surgery. Dumping syndrome actually occurs in 2 different forms: Early and Late.
Early dumping syndrome is due to eating sweets which are high in sugar. This occurs usually immediately after eating something like ice cream and results in nausea, vomiting, diarrhea, and possibly lightheadedness or feeling faint. Early dumping is due to a large sugar load hitting the intestine all at once, so the bowel pulls in water from your blood stream to try and dilute the sugar. As you rapidly lose water from your blood your blood pressure drops so you feel faint and sweaty. As the GI tract fills with water and distends the bowel you begin to cramp, become nauseated, vomit, or have diarrhea. It will last 1-2 hours then go away on its own. You only think you’re going to die. This will occur in around 90% of patients after gastric bypass. Unfortunately it’s not in everyone, and some patients can eat sweets after surgery. The treatment is to not eat sweets again.
Late dumping begins to occur about 12-18 months after gastric bypass surgery, and it is due to a low blood sugar. The GI tract and intestine are very sensitive to carbohydrates after weight loss surgery. If you eat a meal which is high in simple carbs like mashed potatoes, and especially if you drink fluids with the meal, you may experience adverse symptoms. Typically about 45 minutes after a meal you feel sweaty, lightheaded and nauseated. This is due to the carbohydrates making your blood sugar increase rapidly after a meal and extra insulin is produced in response to the meal. The insulin then makes the blood sugar drop too low and causes the symptoms. Treatment is to drink a small amount of orange juice or eat a couple of lifesavers to raise the sugar slightly. The long term solution is to eat a diet which is high protein and low carbohydrate and avoid all simple carbs which are white foods (potatoes, rice, bread, pasta) and don’t drink fluids with the meal. The symptoms almost always go away with time by year 2 or 3 post-op.
Calcium, Kidney Stones and Baby Aspirin
I want to address two issues we encounter frequently in the office and both of which are associated with a great deal of misinformation and “internet myths”. Please be aware there is no one in charge of regulating the content of web sites and anyone can say anything on the internet and about half of it is wrong. Let’s talk about calcium supplements after bariatric surgery and the use of low dose aspirin to prevent heart disease.
There is a literal internet war going on over opinions regarding the best calcium supplements. Let me settle it for you. There is no “best calcium supplement”. The two most common calcium products in the United States are calcium carbonate and calcium citrate. You can chose either and feel good about your choice. We routinely recommend at least 1500 mg of calcium with 800 units of extra vitamin D for patients who have had bariatric surgery. Vitamin D absorption isn’t decreased by bariatric surgery, but we now know 50% of the US population is vitamin D deficient and Vitamin D helps with absorption of calcium in the diet. .
Kidney stones aren’t more common in bariatric surgery patients and calcium supplements don’t cause kidney stones in most patients. Most kidney stones are calcium oxalate stones, but it is the oxalate which is the problem. Poor hydration or excessive amounts of foods high in oxalate such as ice tea will lead to kidney stones. Any post-op patient who has a kidney stone needs to try and have the stone analyized by a professional lab so we can determine what chemicals are in it. Your kidney doctor will know how to do this. There are rare cases where the stones are pure calcium and the patient is absorbing too much calcium, and in that case we would stop the calcium supplements.
Calcium carbonate with extra Vitamin D is in Viactive and Caltrate. It is the most common and most popular calcium product. It is inexpensive and more concentrated than calcium citrate so the pill is usually smaller, which is nice if you have a small stomach outlet. It is better absorbed with food, so take it with meals.
Calcium citrate which is in Citracal can be absorbed without food so it can be taken anytime. It has been reported to be better absorbed than calcium carbonate, but no one has shown any difference in bone density, so it doesn’t appear to matter. Calcium citrate has been reported to cause more intestinal gas and bloating, so avoid it if this is an issue.
Calcium of any type interferes with iron absorption, so take the iron and calcium at different times at least an hour apart. The calcium supplements can be taken all at once and doesn’t need to be divided into multiple doses over the course of the day.
A low dose of aspirin (81mg or a baby aspirin) has been suggested to reduce the risk of heart disease. It appears to be effective in men but it definitely increases the risk of bleeding or ulcers after gastric bypass surgery. Aspirin in women under the age of 65 has not been shown to prevent heart disease, so there is no cardiac reason to take it. About one in four patients who take aspirin or plavix after gastric bypass surgery will have an episode of bleeding from the GI tract or stomach. Aspirin can also cause Lap-band or VBG patients to have a band erosion and the band will need to be removed. Antacids medications called proton pump inhibitors such as Nexium, Prilosec or Prevacid may reduce the risk. In summary we recommend low dose aspirin after bariatric surgery only in patients who have a proven need for it such as having had a heart attack, coronary bypass or stent placed, and then they must take medication to protect the stomach.
Hints for Healthier Cooking – Roasting Vegetables
Roasting Vegetables
By roasting veggies, you’ll caramelize the natural sugars that they contain and add a depth of flavor that naked veggies lack.
Set the oven to 450 degrees. Slice the veggies about ¼ to ½ inch thick lay them in a single layer. Lightly spritz with olive oil to prevent them from drying.
Beets: 1 to 1 ½ hours
Winter squash: 8 to 12 minutes
Carrots: 15 to 20 minutes
Green beans and read peppers: 12 minutes
Onions: 30 minutes
Sweet potatoes: 15 minutes
Summer squash or zucchini slices: 5 to 8 minutes
Eggplant: 10 to 15 minutes
Hints for healthier cooking:
Use sun-dried tomatoes in recipes to add the mellow richness and smokiness that fatty pork adds to soups, stew, and pizzas.
Swap fruit for most of the fat in baked goods: Reduce the amount of fat to about ¼ of the original amount and replace the rest with prune pill filling (lekvar) or applesauce.
Brown butter to use less: Heat a bit of butter in a skillet until it becomes fragrant and turns nutty brown. This increases its flavor so you’ll need to use less. A little bit drizzled over corn, eggs, or vegetables tastes like you’re using a lot.
“I knew I had to do something about my weight!”
When my husband died in 2005, I knew I had to do something about my weight. My husband was morbidly obese and died from a massive heart at the age of 49. I was terrified that I was on the same path. I did a lot of soul searching and finally decided to contact Dr. Champion. I truly believe he saved my life. At 5′3″, I weighed 246 lbs, had high blood pressure, Type 2 diabetes, osteo arthritis, and couldn’t walk to the end of my driveway without stopping to catch my breath.
I had RNY on 3/12/08 and after one year feel like a new person. I now weigh 140 ( on my scale) and am able to walk without pain, and garden again. I can play outside with my yorkies now! Dr. Champion gave me my life back - there is no way I can thank him enough.
I can not say enough good things about Dr. Champion – he is truly a caring, professional man. His program WORKS and he has an excellent staff made up of people who can answer all your questions quickly and efficiently. Thank God for Dr. Champion.
Kim
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