This class of vitamins may be low in weight loss surgery patients who have had either a distal RNY or duodenal switch surgery. However these vitamins are stored in the body and toxic overdose can occur. Some is good, but more is not better. Polar bear liver (seriously) has high concentrations of Vitamin A, so much so that B12 deficiency in patients who have had weight loss surgery can be a real issue, however, and one which is easy to prevent.cases of toxicity have been reported from eating their liver. I don’t know if you add Fava beans what would happen.

Vitamin A is needed for the eye, but lately importance has been placed on the carotene portion it, and its use as an anti-oxidant to prevent chronic diseases. But eye changes have been well studied, and they go from poor dark adaptation to scarring and softening of the cornea. There has also been some evidence that Vitamin A facilitates wound healing, especially in weight loss surgery patients who use steroids. Certain additives in food can decrease absorption of it, such as the cholestyramine (which some patients are taking for a bile salt diarrhea), mineral oil, and the popular ingredient olestra. Vitamin A levels may be ordered directly, and take a lab a couple of weeks, usually, to return. One fellow who had a duodenal switch, didn’t take his supplements terribly often, and woke up one morning blind. Swanson vitamins A and D bottleFortunately it reversed, but this is not always the case. Take your supplements, and make sure your levels are checked regularly.

Vitamin D deficiency has been noted in surgical residents,people who live in northern climates, and during the winter time. Vitamin D is an essential component in calcium metabolism. There has been some thought that seasonal affective disorder (SAD) may be related to a deficiency of it. This can be examined directly with the 1, 25-Dihydroxyvitamin D assays. Serum alkaline phosphatase levels become elevated in vitamin D deficiency, although this is a relatively non-specific test, in weight loss surgery patients who have had gastric bypass this is one of the factors which needs to be examined. The main concern is bone reduction (or demineralization) over time. Bones can lose calcium, while the body maintains a normal serum level, and weight loss surgery patients can develop osteoporosis. So, again, some bariatric patients think that because their blood level of calcium is “normal” that they are taking enough supplements, or are getting enough from their diet—a very dangerous and incorrect assumption. Again, the deficiency is easy to prevent, but once manifested is difficult to treat.

Vitamin E is one of those things that has been looking for a reason to exist. I remember when it was suppose to enhance your sex life—then it was suppose to be good for the heart, then it fought cancer. Well, it The fat soluble vitamins are often sold in one pill called, strangely enough, ADEKmight do all of those things, but in weight loss surgery patients with distal bypass or the DS, this is a vitamin that might be a bit low. Some people have a genetic inability to transfer vitamin E to tissues, and these individuals have some neurologic problems. Vitamin E is thought to have great anti-oxidant properties, and have beneficial effects with a wide range of diseases. Since it is a catch-all for Swanson vitamins E and K-1 bottles“tocopherols” it may be that we will have more specific information about this class of vitamin as time goes on. Suffice it to say, there are a lot of good reasons to take this drug, and there is no simple assay to measure it. Again, too many fat soluble supplements can be toxic. Do not take more unless you are under a physician’s instruction and care.

Vitamin K is the last of the fat soluble vitamins, and is the deficiency which most weight loss surgery patients manifest. People who have easy bruising and problems clotting blood (wondered why when you shaved there was blood in the bathroom?). Most often weight loss surgery patients will come into my office and show me bruises on their arms and legs, and wonder why they are having them. Vitamin K is a necessary component of the clotting mechanism, and checking a prothrombin time (PT or protime) is an easy way to tell if there is a deficiency.

The fat soluble vitamins are often sold in one pill called, strangely enough, ADEK—and weight loss surgery patients who have had a distal bypass or a DS sometimes need to take these, in addition to a regular multivitamin.

Weight loss surgery and calcium deficiency

Strong bones, teeth, and skull

Calcium is required in a lot of complex biochemical reactions, it is required in your bones, and it is not present in a lot of foods. Hence, most people who have undergone weight loss surgery should be onWe highly recommend that people who undergo weight loss surgery have bone density measurementssupplementation. Since it isn’t absorbed that well, and since there is loss of it in the urine and in the stool, this is one of the most common deficiencies physicians see in bariatric patients. Most weight loss surgery patients are on high protein diets, and high protein intake causes an increase of calcium in the urine. So the best way to have a deficiency is to have a high protein diet without supplementation of calcium, have had a weight loss operation so you cannot take in a lot of it, develop lactose intolerance so you lose your major source of it, and be on a diuretic that causes an increase of it in the urine— in other words—the average post op bariatric patient. To differentiate be-tween liver and bones get a GGTP level. If the GGTP is normal, the alkaline phosphatase is most likely from bones, if it is high then consider a more extensive work up of the liver.

Foods which contain calcium include milk (about 280 to 300 mg per cup), cheese, (200-280 mg. per ounce), spinach (1 cup is about 240 mg of it—and you get great looking forearms), sardines, and salmon.

Serum calcium levels can be normal, when the body is removing it from bones to keep blood levels normal. Alkaline phosphatase levels can be elevated if calcium is being leached from the bones, although this is somewhat non-specific. We highly recommend that people who undergo bariatric operations have bone density measurements, and that these be followed by the primary care physician. The DEXA test (okay, for those of you who are nerds this would be the dual-energy absorptiometry) is the most common one used today.

There are a few things to remember: first, calcium citrate is better absorbed than calcium carbonate. Second, supplements should not be taken at the same time as iron—which makes me wonder why some companies put iron and calcium in the same pill. In fact, calcium can interfere with a number of other medications, and should simply be taken by itself, and not with any other medicines (atenolol, tetracycline, aspirin, etc.). Most weight loss surgeons recommend far more calcium than the upper limit set by most standards—the upper limit being 1200 mg/d while most bariatric surgeons recommend 1800 to 2000 mg/d.