Great!  Something that all RNY patients need to hear.. a study that links pernicious anemia — a condition that results from a low level of B12 leading to a form of anemia that is very common in post-RNY patients and hip fracture — something that is already a heightened risk due to the malabsorption of vitamin D and calcium.


I’m so screwed…

From Medscape:

Hip Fracture Risk Elevated With Pernicious Anemia: Study

Megan Brooks

January 8, 2010 — Patients with pernicious anemia have significantly higher risks for hip fracture, research shows.

Compared to age- and sex-matched controls, patients with pernicious anemia had a 73% greater risk of hip fracture (3.4 vs. 2.0 hip fractures/1000 person-years of follow-up). The elevated risk was even greater with newly diagnosed pernicious anemia (HR, 2.63).

“These data suggest that physicians need to carefully follow the bone health of patients with pernicious anemia,” senior author Dr. Yu-Xiao Yang of the University of Pennsylvania School of Medicine in Philadelphia noted in an email to Reuters Health.

Additionally, Dr. Yang and colleagues found that the increased risk of hip fracture persisted for many years even after vitamin B12 repletion therapy was started.

“Physicians should recognize that correction of their vitamin B12 deficiency alone is probably insufficient in reducing the risk of fractures in these patients. The persistent nature of the elevated fracture risk in these patients suggests the presence of underlying mechanisms independent of vitamin B12 deficiency,” Dr. Yang said.

There are physiologic reasons to suspect that patients with pernicious anemia (who are by definition achlorhydric) may have impaired bone strength and increased fall risk (i.e., due to vitamin B12 deficiency), but there have been no definitive epidemiologic data to confirm an increased fracture risk in these patients, the researcher explained.

The new findings stem from an analysis of data from the United Kingdom’s General Practice Research Database. Included were 9506 adults with pernicious anemia who received vitamin B12 therapy for at least 1 year. Each case patient was matched with four controls without pernicious anemia (n = 38,024). The average follow-up time in both groups was slightly more than 5 years.

As reported online December 18 in Gastroenterology, the increased risk of hip fracture appeared to persist well beyond 5 years after the diagnosis of pernicious anemia and initiation of vitamin B12 therapy. Pernicious anemia was associated with a threefold increased risk of hip fracture when follow-up years 3 through 10 were combined in the analysis.

“One potential mechanism,” Dr. Yang said, “may be related to the achlorhydria-induced hypergastrinemia in these patients that could lead to parathyroid hyperplasia, which could result in increased parathyroid hormone secretion or altered parathyroid hormone secretion pattern.”

Another possibility is that their lack of gastric acid may compromise calcium absorption in the intestine. “Therefore,” Dr. Yang advised, “physicians should at least ensure that these patients maintain daily recommended calcium intake appropriate for their age, and preferably by taking water-soluble calcium supplements (e.g., calcium citrate) or through dairy products. If they must take water-insoluble calcium supplements (e.g., calcium carbonate), they should take them with a meal.”

Both of these potential mechanisms, Dr. Yang noted, may also be relevant to the reported association between acid suppressive therapy and increased risk of fractures.

“Further research is urgently needed to investigate these potential mechanisms so that effective preventive measures can be developed both for patients with pernicious anemia and for the large population of patients who require chronic acid suppressive therapy,” he concluded.

Gastroenterology. Published online December 18, 2009. Abstract

Reuters Health Information 2010. © 2010 Reuters Ltd.

Calcium and the Achlorhydriac

On December 13, 2009, in Minerals, by Andrea


Achlorhydria: A lack of hydrochloric acid in the digestive juices in the stomach (in technical terms, so that the pH of the stomach contents fails to fall below 4.0 under maximal stimulation). Hydrochloric acid helps digest food.

There’s quite a debate about the correct calcium to take in post a post-WLS world.  Given how very important our bones are, this is a very important topic to know about.

First off, keep in mind that the RNY, VSG, and DS are basically surgically-created achlorhydriac states.

Two studies are important to note:

From the New England Journal of Medicine:

Calcium absorption and achlorhydria

RR Recker


Defective absorption of calcium has been thought to exist in patients with achlorhydria. I compared absorption of calcium in its carbonate form with that in a pH-adjusted citrate form in a group of 11 fasting patients with achlorhydria and in 9 fasting normal subjects. Fractional calcium absorption was measured by a modified double-isotope procedure with 0.25 g of calcium used as the carrier. Mean calcium absorption (+/- S.D.) in the patients with achlorhydria was 0.452 +/- 0.125 for citrate and 0.042 +/- 0.021 for carbonate (P less than 0.0001). Fractional calcium absorption in the normal subjects was 0.243 +/- 0.049 for citrate and 0.225 +/- 0.108 for carbonate (not significant). Absorption of calcium from carbonate in patients with achlorhydria was significantly lower than in the normal subjects and was lower than absorption from citrate in either group; absorption from citrate in those with achlorhydria was significantly higher than in the normal subjects, as well as higher than absorption from carbonate in either group. Administration of calcium carbonate as part of a normal breakfast resulted in completely normal absorption in the achlorhydric subjects. These results indicate that calcium absorption from carbonate is impaired in achlorhydria under fasting conditions. Since achlorhydria is common in older persons, calcium carbonate may not be the ideal dietary supplement.

From The Journal of Nutrition:

Nutritional Aspects of Calcium Absorption1

Felix Bronner2 and Danielle Pansu*

“For this reason, calcium carbonate, when ingested alone, is a relatively poor source of calcium (Fujita et al. 1995) and, in patients with achlorhydria, is absorbed very poorly (Recker 1985)”

So it’s important to note that we should take citrate, not carbonate, as those with lowered stomach acid will not fully absorb calcium carbonate.