WLS in the news

On January 22, 2010, in Uncategorized, by Andrea

A surgeon on a local news channel discusses the four types of surgery:

From WZZM13.com:

Vitamins from A-Zinc — Vitamin A

On January 2, 2010, in Fat Solubles, Vitamins, by Andrea

Vitamin A

Vitamin A — What is it?

Vitamin A is a generic term that refers to compounds with the biological activity of retinol.  These compounds include the precursor, or provitamin A carotenoids – principally beta-carotene, alpha-carotene, and beta-cryptoxanthin, which are provided in the diet by green, yellow, or orange vegetables and by some fruits, and preformed vitamin A, namely retinyl esthers (such as retinyl palmitate and retinyl acetate) and retinol itself which are present in foods of animal origin – mainly in organ meats such as liver, other meats, eggs, and dairy products.

Rarely in research, you may come across connotations of vitamins A1 and A2.  Vitamin A1 is retinol as mentioned above, while vitamin A2 is dehydroretinol, an oily yellow alcohol found in some fish that is 40% less active in mammals.  These differentiations are rare in common usage – retinol is typically called as such rather than vitamin A1 and the other vitamin A analogues such as beta-carotene do not have such distinctions as they are not technically vitamin A – just precursors to the vitamin.

What is it good for?

Vision

Regulation of gene expression

Immunity – commonly known as the anti-infective vitamin, it is required for normal function of the immune system; plays a central role in development and differentiation of white blood cells

Growth and Development – essential for embryonic development; during fetal development, retinonic acid (RA) functions in limb development and formation of heart, eyes and ears; RA has been found to regulate expression of the gene for growth hormone

Red Blood Cell Production – stem cells are dependant on retinoids for differentiation into red blood cells; vitamin A appears to facilitate mobilization of iron from storage to developing red blood cells for incorporation into hemoglobin

Where do I get it?

As a fat-soluble compound, beta-carotene’s absorption in the GI tract depends on the fat content of the meal with which it is eaten.  It is less easily absorbed than retinol and must be converted to retinol and retinal by the body.  For this reason, a conversion factor has been created to represent this.  The most recent international standard of measure for vitamin A is Retinol Activity Equivalents (RAE) which represent vitamin A activity as retinol.

2 micrograms (mcg) of supplemental beta-carotene can be converted by the body into 1mcg of retinol, giving it an RAE ratio of 2:1.

1 mcg of dietary vitamin A     =     1mcg retinol     =     1:1 RAE ratio
1 mcg supplemental vitamin A     =     1mcg retinol     =     1:1 RAE ratio
2mcg supplemental beta-carotene     =     1mcg retinol     =     2:1 RAE ratio
12mcg dietary beta-carotene     =     1mcg retinol     =     12:1 RAE ratio
24 mcg dietary alpha-carotene     =     1mcg retinol     =     24:1 RAE ratio
24mcg dietary beta-crytoxanthin     =     1mcg retinol     =     24:1 RAE ratio

1 IU = 0.3mcg of retinol


Food Sources

Food Vitamin A (IU)* %DV**
Liver, beef, cooked, 3 ounces 27,185 545
Liver, chicken, cooked, 3 ounces 12,325 245
Milk, fortified skim, 1 cup 500 10
Cheese, cheddar, 1 ounce 284 6
Milk, whole (3.25% fat), 1 cup 249 5
Egg substitute, ¼ cup 226 5
Food Vitamin A (IU)* %DV**
Carrot juice, canned, ½ cup 22,567 450
Carrots, boiled, ½ cup slices 13,418 270
Spinach, frozen, boiled, ½ cup 11,458 230
Kale, frozen, boiled, ½ cup 9,558 190
Carrots, 1 raw (7½ inches) 8,666 175
Vegetable soup, canned, chunky, ready-to-serve, 1 cup 5,820 115
Cantaloupe, 1 cup cubes 5,411 110
Spinach, raw, 1 cup 2,813 55
Apricots with skin, juice pack, ½ cup 2,063 40
Apricot nectar, canned, ½ cup 1,651 35
Papaya, 1 cup cubes 1,532 30
Mango, 1 cup sliced 1,262 25
Oatmeal, instant, fortified, plain, prepared with water, 1 cup 1,252 25
Peas, frozen, boiled, ½ cup 1,050 20
Tomato juice, canned, 6 ounces 819 15
Peaches, canned, juice pack, ½ cup halves or slices 473 10
Peach, 1 medium 319 6
Pepper, sweet, red, raw, 1 ring (3 inches diameter by ¼ inch thick) 313 6


Vitamin Sources

Most multivitamins contain vitamin A as a combination of a retinyl esther and beta-carotene.  There have been some studies showing a higher risk of osteoporsis in older adults taking more than 5,000 IU of retinol per day, which has led many companies to reduce the retinol content in their multivitamin supplements to 750mcg (2,500 IU).  Additionally, there have been some studies showing supplemental beta-carotene as a pro-oxident, meaning it helps grow free radicals in the body rather than reduce them.  However, there has not been a push to reduce or limit beta-carotene from multivitamin supplements as of yet.  In fact, there are some experts that still believe a separate RDA should be set specifically for beta-carotene should be set — one that is set approximately 6x the current RDA for the entire vitamin A RDA is today.

The current RDA for vitamin A is:

Age
(years)
Children
(mcg RAE)
Males
(mcg RAE)
Females
(mcg RAE)
Pregnancy
(mcg RAE)
Lactation
(mcg RAE)
1-3 300
(1,000 IU)
4-8 400
(1,320 IU)
9-13 600
(2,000 IU)
14-18 900
(3,000 IU)
700
(2,310 IU)
750
(2,500 IU)
1,200
(4,000 IU)
19+ 900
(3,000 IU)
700
(2,310 IU)
770
(2,565 IU)
1,300
(4,300 IU)

Keep in mind that the RDA is the amount needed to avoid deficiency symptoms – not to achieve an optimum level.  Unfortunately, there have been no studies conducted to determine what the optimum vitamin A level is as of now.

Deficiency

Severe zinc deficiency often accompanies vitamin A deficiency.  Zinc is required to make retinol binding protein (RBP), which transports vitamin A, so a zinc deficiency limits the body’s ability to move vitamin A stores from the liver to body tissues where they are needed.  Zinc also helps to protect against potential toxicity of retinol.  Additionally, a zinc deficiency results in decreased activity of the enzyme that releases retinol from it’s storage form, retinyl palmitate, in the liver.  Zinc is also required for the enzyme that converts retinol into retinal.  Despite these well-documented associations between zinc and vitamin A, the health consequences of zinc deficiency on vitamin A nutrition status in humans is still unclear as of now.

Vitamin A deficiency may exacerbate iron deficiency anemia.  Vitamin A supplementation has beneficial effects on iron deficiency anemia and has been show to improve iron nutritional stores status among children and pregnant women.  A combination of supplemental vitamin A and iron seems to reduce anemia more effectively than supplemental iron or supplemental vitamin A alone.  Additionally, there have been some studies in which iron deficient anemia has been helped by supplemental vitamin A, even in the absence of a vitamin A deficiency.

Night blindness is one of the first symptoms of vitamin A deficiency.  Vitamin A deficiency contributes to blindness by making the cornea very dry, which damages it and the retina.

Deficiency in A also diminishes the body’s ability to fight infections.  In vitamin A deficient individuals, the cells lining the lungs lose the ability to remove disease-causing microorganisms.  This may contribute to a larger amount of pneumonia cases seen in vitamin A deficient individuals.

Keep in mind that a subclinical deficiency does not exhibit the signs and symptoms of a deficiency, but still may have the adverse effects of the deficiency.  A mild form of deficiency may increase the risk of developing respitory or diarrheal infections, decrease growth rate and slow bone development in children, and decrease the liklihood to survive a serious illness.

A vitamin A deficiency early in life could have adverse effects on neurologic and behavioral development and function later in life.  Some researchers even believe that schizophrenia may result from vitamin A deficiency.

Toxicity

Hypervitaminosis A refers to a high storage level of vitamin A in the body that can lead to toxic symptoms.  Severe cases may result in liver damage, hemmorrhage, and coma, and may generally only occur in individuals with long-term consumption in excess of 8,000-10,000 mcg/day or 25,000-33,000 IU/day.

Acute toxicity is relatively rare.  Symptoms include nausea, vomiting, headache, fatigue, loss of appetite, dizziness, dry skin, desquamation, cerebral edema, bone and joint pain, blurred vision, lack of muscular function, and abnormal liver function.

It is important to note a few things about vitamin A toxicity.  First, the Upper Limit (UL) does not apply to malnourished individuals receiving vitamin A either periodically or through fortification programs as a measure of preventing a vitamin A deficiency.  Additionally, beta-carotene and other carotenoids in foods, even when consumed in high levels have not produced toxicity; therefore, the UL does not include the carotenoids.

Age
(years)
Children
(mcg)
Males
(mcg)
Females
(mcg)
Pregnancy
(mcg)
Lactation
(mcg)
0-1 600
(2,000 IU)
1-3 600
(2,000 IU)
4-8 900
(3,000 IU)
9-13 1,700 (5610 IU)
14-18 2,800 (9,240 IU) 2,800 (9,240 IU) 2,800 (9,240 IU) 2,800 (9,240 IU)
19+ 3,000 (10,000 IU) 3,000 (10,000 IU) 3,000 (10,000 IU) 3,000 (10,000 IU)

There are some troubling concerns with the two major forms of vitamin A found in supplements today.

Intakes of retinol not far above the RDA, but well under the UL may reduce bone mineral density and increase the risk of osteoporatic disease and breaks.  It is speculated that perhaps retinol increases the bone resorption response or perhaps interferes with vitamin D in the maintenance of calcium within the bones.  This problem has only been found with the retinol form of vitamin A and not with beta-carotene, which has caused some multivitamin manufacturers to limit the amount of retinol in their product to 750mcg (2,500 IU).  In fact, my bottle of Centrum has a warning about taking too much vitamin A in the form of retinol on the label.

My bottle of Centrum...

The picture for beta-carotene isn’t a bed of roses, either.  Believing beta-carotene to be a powerful anti-oxidant, researchers gave patients supplements of both retinol and beta-carotene supplements to ascertain exactly how good it really was.  The findings of the Beta-Carotene and Retinol Efficacy Trial (CARET) shocked everyone.  Results suggest that high-dose supplementation of vitamin A and beta-carotene should be avoided in people at high risk of lung cancer.  One hypothesis had to do with the high amount of oxidation in the lung tissue – but there were no definative conclusions reached except the spike of lung cancers in high risk individuals who received the extra supplementation.  Despite this higher risk, there has been no push to remove or reduce beta-carotene from multivitamins.  However, a quick Google search will find a few tailor-made vitamins without beta-carotene for smokers, at a premium price of course.

Miscellaneous

Under conditions of vitamin A adequacy, most mammals, including humans, store more than 90% of their total vitamin A in their liver.

The safety of vitamin A is frequently questioned during pregnancy.  With vitamin A, there is such a thing as “too little” as well as “too much.”  Vitamin A is important in fetal development during cellular and tissue differentiation.  Excess retinol during pregnancy is known to cause birth defects.  There have been no birth defects observed at doses of preformed A from supplements below 3,000mcg (10,000 IU/day), but since foods are commonly supplemented, it is advised to stay under 5,000 IU/day.  It should be noted that vitamin A from beta-carotene is not known to increase the risk of birth defects.

WLS Concerns

Beta-carotene is a poor supplement of vitamin A for those who have had RNY, DS, and VSG.

To begin with, beta-carotene requires an acidic environment to absorb properly.  A study was conducted to measure the absorption of retinol, retinyl palmitate, and beta-carotene in an achlorhydriac, or low gastric acidic environment.  To test the supplements, subjects were given a proton pump inhibitor (PPI) to neutralize gastric acidity over a period of time, then tested with a gastric probe to ensure the pH level.  Once a low gastric level was reached, individuals were given supplements, then serum levels were checked.  Serum concentrations of beta-carotene were significantly greater at a low gastric pH (ie normal) than those at a high gastric pH (ie achlorhydria, or low gastric acid environment).  Serum concentrations of retinol and retinyl palmitate were not significantly different between the low gastric pH and high gastric pH.  Those with a lower acid content will not absorb beta-carotene fully, if at all.  It is also important to note that as we age, even those of normal stomachs will begin to neutralize their gastric acidity.  This was confirmed by a study published in the New England Journal of Medicine in reference to the breakdown of calcium citrate versus carbonate — but the problem of acidity remains the same.

Additionally, beta-carotene is absorbed in the duodenum, which is bypassed in the RNY and DS procedures.  Since this absorption site is bypassed completely, beta-carotene does little-to-no good to patients with either surgery – especially coupled with the lower gastric-acid component present in both surgeries as well.

Those with Adjustable Gastric Bands (AGB’s) should take note as well – beta-carotene absorbs better when eaten with some fat.  Those who have been extreme in removing fat from their diets should note this key interaction.

For post-WLS patients who become deficient in vitamin A, one can find dry-form, or water-miscible forms of the vitamin.  It should be noted that labs should be watched carefully, as always, when supplementing.  There is some evidence that water-miscible forms of retinol vitamins can be more toxic than their oil-based counterparts – but the study conducted was on non-bypassed individuals who had no level of malabsorption.  There are many rules in the nutrition world that simply do not apply to us – but I’m not going to be the one to say which ones are which.  Labs are really your only guide to know where you stand nutritionally and you should follow them accordingly.

Information compiled from:

Handbook of Vitamins, 4th Edition
Linus Pauling Institute
Advanced Health and Life

Office of Dietary Supplements
Gastric acidity influences the blood response to a beta-carotene dose in humans
Water-miscible, emulsified, and solid forms of retinol supplements are more toxic than oil-based preparations
NEJM — Calcium absorption and achlorhydria

http://www.amazon.com/Handbook-Vitamins-CLINICAL-NUTRITION-DISEASE/dp/0849340225/ref=sr_1_1?ie=UTF8&s=books&qid=1262205681&sr=8-1

Good comparison of surgeries

On December 28, 2009, in Uncategorized, by Andrea

I’ll even agree that after the “honeymoon period” that RNY is primarily a restrictive surgery — except when it comes to vitamins.  Those we will malabsorb for life.

I only wish they had represented that DS was for all BMI’s — it can be modified for lower BMI’s if desired with a longer common channel, but alas, nothing in life is perfect.

Metabolic Surgery Statistics — 2008

On November 29, 2009, in Uncategorized, by Andrea

This morning, I came across this article by Buchwald and Oien (thanks Bonamy) outlining worldwide WLS statistics for 2008.  According to the authors, the last evaluation was done in 2003 and this evaluation was done by sending a survey to 39 nations or national groupings (of which 36 responded).  Given this was a survey, it will be somewhat biased based on the person answering the survey, as well as the fact that the numbers are worldwide — some procedures are done in other parts of the world that are not performed in the US routinely (such as Vertical Banded Gastroplasty {VBG}) or the Scopinaro Biliopancreatic procedure.  Of course, I am a numbers girl and wish that all numbers are exact figures, but let’s face it — it’s not realitySo given that, I have to concede that these are not going to be 100% exact.

Some direct quotes and figures from the report:

  • In 2008, 344, 221 bariatric surgery operations were performed by 4,680 bariatric surgeons, 220,000 of these operations were performed in USA/Canada by 1,625 surgeons
  • Seven other countries or national groupings with more than 100 bariatric surgeons: Australia/New Zealand (118), Brazil (700), Chile (100), France (310), Italy (300), Mexico (150), and Spain (400)
  • 91.4% of world bariatric surgery was performed laparoscopically
  • Considering all gastric bypasses together (distal and prox, open and lap), number of RNY exceeds AGB’s.
  • In Europe, relative percent of AGB decreased from 63.7% to 43.2% from 2003 to 2008, while RYGB increased from 11.1% to 39%.  In USA, AGB increased from 9% to 44% and RYGB decreased from 85% to 51%.  In both Europe and USA, VSG went from 0% in 2003 to 4%.
  • Most common type of procedures were purely restrictive (AGB, VSG, VBG) (48.6%), restrictive/malabsorptive (RNY) (49.0%), and primarily malabsorptive (BPD/DS) (2%).

Surgical types by breakdown (Lap and Open combined)

  1. Proximal RNY – 45.4%
  2. AGB – 42.4%
  3. VSG – 5.4%
  4. VBG – 1.1%
  5. BPD and DS procedures combined – 1.1%
  6. Other – 0.1%

The authors make a few conclusions about the numbers they received in this survey — some of which bother me.  There is quite a disenchantment of AGB in Europe, where there is quite a long history of it’s use there, and a growing trend towards VSG and RYGB there.  USA and Canada, where we want newer and better (and have marketing via TV commercials?  WTF?) is moving away RYGB (which we have a longer history) and are moving towards AGB and VSG.  In no cases are we moving closer to DS — which in many ways to ME seems to be an excellent choice and not given any credit or opportunity to shine.  The authors also clearly bring up the fact that many people would presumably want metabolic surgery if they could get their paws on it — would even, I dunnow, self-pay for it, or change jobs for it, or go work part-time at the Buxx for it?  For those of us in the community, we’ve seen and heard this time and time again so nice to see the professionals recognize it in a published article.  Additionally — patients are getting smarter, using the interwebz and understanding a bit more about what we are doing to our guts when we go and get chopped up — and it’s all for the betterment:

Further involved factors may be the predictable craving for something regionally newer, the imposition of payer mandates, media-derived prejudices and and biases, advertisement campaigns by the bariatric surgery industry, increased patient sophistication and use of websites, and, of course, relative regional economic advantages for bariatric surgeons.

I have to say the thing I’m most concerned about is the complete lack of yeast in the DS numbers.  This is a wonderful surgery — doesn’t have many of the RNY pitfalls (and let me tell you, I know several of them first hand), doesn’t require all that much more work than far-out RNY patients (despite what some may tell you — it’s not all roses and rainbows and unicorns) and just isn’t getting the recognition or the opportunity to shine and show it’s stuff.  I wish more surgeons would learn how to perform it.  I wish more people would learn the stats.  I wish more people would stop spreading misinformation crap about it in hopes of making their own surgery look better.  And I wish many of the surgeons that don’t perform it would also stop this practice — it’s unprofessional as all hell and only perpetuates the problems as their patients then do the exact same thing and continues to spread the misinformation, fear, and, eventually, hatred, around.

Europe at least is performing the DS a bit more than we are -0-  they had a 58.7% increase of surgeries from 03 to 08 — but still that increase only comprised 4.9% of the total surgery population in 08 which is an actual decrease from 6.1% surgical population in 03.  Comparatively, the US went from 4.5% surgical population in 03 to 1%?!? in 08?  with a 52.5% decrease.  WHY? I don’t get it.  There is too much good in the DS for this statistic.  At least the US wasn’t as abysmal as Asia and the Pacific.. those numbers were too depressing to even type out.

So what does all of this mean?  WLS is on the rise, but not as much as it was in 03.  Considering how quickly the rate of obesity is climbing, this isn’t quite proportionate as some critics claim (including many private payers who don’t want to cover WLS as it would “cost too much”) — and given how diabetes costs are going to triple by 2023? This is a way to go to help avoid these ballooning costs.  Some surgeries are growing by leaps and bounds regionally — some are growing regardless (VSG, anyone?)  and some are still performed in areas while considered completely antiquated in others (VBG in the US).

Very interesting.  Somewhat sad.  But very interesting.

ASMBS suggested supplementation

On November 16, 2009, in General Nutrition, Vitamins, by Andrea

The American Society of Metabolic and Bariatric Surgeons has made a series of suggestions for postoperative vitamin supplementation prior to labs dictating otherwise.

Multivitamin
- Adjustable Gastric Band/VSG: 100% of daily value
- RNY: 200% of daily value
- BPD/DS: 200% of daily value

  • Choose a multivitamin that is a high-potency vitamin containing 100% of daily value for at least 100% of daily value of 2/3 of nutrients
  • Begin with chewable or liquid
  • Progress to whole tablet/capsule as tolerated
  • Avoid time-released supplements
  • Avoid enteric coating
  • Choose a complete formula containing at least 18 mg iron, 400mcg folic acid, as well as selenium, and zinc in each serving
  • Avoid children’s formulas that are incomplete
  • May improve gastrointestinal tolerance when taken close to food intake
  • May separate dosage
  • Do not mix multivitamin containing iron with calcium supplement, take at least 2 hours apart
  • Individual brands should be reviewed for absorption rate and bioavailability
  • Specialized bariatric formulations are available

Additional cobalamin (B12)
- AGB/VSG: Not Applicable
- RNY: 350-500mcg if taken orally, 1000mcg / mo intramuscular injection
- BPD/DS: NA

Additional elemental calcium
- AGB/VSG: 1500mg /day
- RNY: 1500-2000mg
- BPD/DS: 1800-2400mg

  • Choose a brand that contains calcium citrate and vitamin D3
  • Begin with chewable or liquid
  • Progress to whole tablet / capsule as tolerated
  • Split into 500-600 mg doses; be mindful of serving size on supplement label
  • Space doses evenly throughout day
  • Suggest a brand that contains magnesium, especially for BPD/DS
  • Do not combine calcium with iron containing supplements
  • Wait 2 or more hours after taking multivite or iron supplement to take
  • Wait 2 or more hours between doses
  • Promote intake of dairy beverages and/or foods that are significant sources of dietary calcium in addition to recommended supplements
  • Combined dietary and supplemental calcium intake greater than 1700 mg/day might be required to prevent bone loss during rapid weight loss

Additional elemental iron
- AGB / VSG: NA
- RNY: Minimum 18-27mg / day elemental
- BPD/DS: Minimum 18-27mg / day elemental

  • Recommended for menstruating women and those at risk of anemia
  • Begin with chewable or liquid
  • Progress to tablet as tolerated
  • Dosage may need to be adjusted based on biochemical markers
  • No enteric coating
  • Do not mix iron and calcium supplements, take at least 2 hours apart
  • Avoid excessive intake of tea due to tannin interaction
  • Encourage foods rich in heme iron
  • Vitamin C may enhance absorption of non-heme iron sources

Fat-soluble vitamins
- AGB / VSG: NA
- RNY: NA
- BPD/DS: 10,000 IU of vitamin A, 2000 IU of vitamin D, 300 mcg of vitamin K

  • With all procedures, higher maintenance doses may be required for those with a history of deficieincy
  • Water-soluble preparations of fat-soluble vitamins are available
  • Retinol sources of vitamin A should be used to calculate dosage
  • Most supplements contain a high percentage of beta carotene which does not contribute to vitamin A toxicity
  • Intake of 2000 IU vitamin D3 may be achieved with careful selection of multivitamin and calcium supplements
  • No toxic effect known for Vitamin K1, phytonadione (phyloquinone)
  • Vitamin K requirement varies with dietary sources and colonic production
  • Caution with vitamin K supplementation should be used for patients receiving coagulation therapy
  • Vitamin E deficiency is not prevalent in published studies

Optional B complex
- AGB / VSG: 1 per day
- RNY: 1 per day
- BPD/DS: 1 per day

  • B-50 dosage
  • Liquid form is available
  • Avoid time released tablets
  • No known risk of toxicity
  • May provide additional prophylaxis against B-vitamin deficiencies, including thiamin, especially for BPD/DS procedures as water-soluble vitamins are absorbed in the proximal jejunum
  • Note >1000mg of supplemental folic acid provided in combination with multivitamins could mask B12 deficiency
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