Vitamin and Mineral Absorption with the Duodenal Switch (DS)
April 4, 2016As discussed in the Anatomy and Physiology of the DS, the changes in the anatomy created by the Duodenal Switch operation create altered absorption of various vitamin and minerals which can lead to deficiencies if you are not eating properly and taking the proper supplements. This article will discuss these deficiencies as well as the appropriate supplements required for optimal health. It will also discuss what tests are appropriate to ensure proper nutrition, and lastly, will give some tips on weight management.
Normal Vitamin and Mineral Absorption
The body is a very complex structure and various specific vitamins, minerals, and nutrients are actively absorbed at various places in the GI tract by complex biochemical mechanisms. In addition, the body is partially able to overcome deficiencies in absorption due to removal or bypass of parts of the intestinal tract by passive absorption of these vitamins and minerals distally in the intestinal tract.
With normal anatomy vitamins and minerals are absorbed in specific areas of the gastrointestinal tract as very nicely depicted in the diagram above. Specifically concerning to duodenal switch patients are vitamins which are either absorbed in the duodenum or need the bile which enters the duodenum to achieve absorption. Although the stomach is made smaller, the most absorption that would take place in the stomach will continue albeit with a less total absorptive area.
Calcium, iron, and many B vitamins are preferentially absorbed in the duodenum. The fat-soluble vitamins, A, D, E, and K require bile that is secreted into the duodenum to achieve absorption. Vitamin B12 requires intrinsic factor produced in the stomach to allow absorption in the ileum.
Most minerals are primarily absorbed in the duodenum. But, as I previously mentioned, the body has a remarkable ability to adjust to changes and the more distal small intestine is able to overcome absorption concerns with proximal resections or bypasses by allowing passive absorption to occur. Because the absorption is passive, larger amounts of these vitamins and minerals are required to allow satisfactory amounts to be absorbed.
Nutrition and Vitamin/Mineral Deficiency Concerns After DS
The Duodenal Switch in being a very powerful tool for weight loss also has the potential to be a destructive tool to the human body if you are not taking in adequate amounts of fluids (water), eating correctly (high protein diet), and taking your vitamins and minerals appropriately.
Again, the good thing about our body is that it is somewhat forgiving to those who don’t follow the proper dietary intake every day. While the list of potential problems related to deficiencies is enormous, we will try to focus on the most common and concerning ones related to DS patients. Note, although mal-absorption of the fat-soluble vitamins are more specific to the DS patients, gastric bypass patients have similar concerns with mal-absorbing many vitamins and minerals, and in some cases where the stomach is needed for absorption, it has an even greater concern.
Fluid Deficiency (dehydration)
Drinking adequate fluids throughout the day, for the rest of your life may be one of your biggest challenges. Sip, Sip, Sip. Water flavored with lemon or citrus flavor is the best while that flavored with sugar or carbonated is the worst. Staying adequately hydrated will help prevent kidney stones.
Alcohol should be avoided the first year post-op and only with minimum social drinking in the future. Alcohol is quickly absorbed and can cause elevated alcohol levels in the blood and affect vitamin absorption.
Symptoms (SX) of dehydration include lethargy, frequent headaches, dark, concentrated urine, and kidney stones. The best treatment is prevention by drinking plenty of non-caffeinated, non-carbonated fluid. But if these symptoms occur, then drink a minimum of 2 liters of fluid/day to make your urine light yellow, and if necessary, call your bariatric surgeon or primary care physician.
Protein Deficiency
One of the best benefits of having the DS is “normal eating.” Meats, fish, eggs, and nuts are great sources of protein and are well tolerated by most DS post-op patients. Daily requirements of protein vary by age, height, sex and activity.
Generally speaking, 50-100 grams/protein/day is sufficient depending on your size and activity level. SX of protein deficiency is swelling in both ankles and feeling weak. Blood work will show low protein levels and low albumin levels. This may come on slowly and will take time to repair.
The treatment is to increase protein intake, small amounts every 2 hours. A handful of nuts or beef jerky is often very handy. Foods high in protein are meats, fish, nuts, lentils, beans, eggs, cheese, and dairy. Remember some patients can be lactose intolerant (SX-gas, cramps, diarrhea).
Protein drinks can be a very good supplement and be sure to purchase “whey isolate” protein drinks, which are lactose-free. If protein deficiency continues then the addition of pancreatic enzymes can be ordered by your physician to help increase absorption. If needed, revisional surgery could be considered to lengthen the common channel for even more absorption. Protein malabsorption is rare and treatable if known about.
Mineral Deficiencies
Iron Deficiency (Anemia)
Iron and Calcium tend to be absorbed in the duodenum primarily, and compete for absorption. Iron supplements should be taken separately from calcium supplements. Anemia may result if your iron absorption is inadequate and this may be more problematic in heavily menstruating women. Note, if you are anemic do not just assume that the cause is poor iron absorption. If appropriate, evaluation for bleeding in the GI tract with colonoscopy and possibly upper endoscopy should be done.
SX of iron deficiency are: feeling cold, shortness of breath, fatigue, cravings (pica-ice chewing, eating dirt or laundry detergent). You may develop weight regain due to fatigue. Four lab values are necessary for diagnosis: Iron, Ferritin (Iron storage in the body), hemoglobin and hematocrit.
Good food sources are meat (pink, not over cooked beef has highest levels of heme iron which are the best food source), and liver. Plant sources are not as efficient. Cooking with cast iron pots may help.
Iron supplements that have the word, “chealated” written on the bottle generally are absorbed best. Ferrous fumarate is over the counter (OTC). Prescription strength (Proferrin, Multigen or Anemagin) may be needed as well as possible IV iron infusions. Dosing will depend on your lab values and regulated by your primary care physician, bariatric team or hematologist. Iron oral supplements are best absorbed with Vitamin C or orange juice and NOT taken with your calcium supplements. High iron levels in the body which is quite rare in DS patients can result in damage to the heart and liver.
Calcium Deficiency (Osteopenia/Osteoporosis)
Calcium is needed to maintain strong bones. Absorption is improved in the presence of magnesium and vitamin D. Certain foods like cereals, many green vegetables, nuts, and sweet potatoes can limit absorption as these foods contain chelating agents which will bind with the calcium and prevent absorption. It is the most abundant and important mineral in the body.
Unfortunately, low calcium absorption is not generally discovered until it is diagnosed as osteopenia or osteoporosis. Bone density scans and annual labs are necessary for evaluation. Serum blood calcium is a poor indicator of absorption. Low vitamin D 25-Hydroxy and magnesium, an elevated parathyroid hormone (PTH) and alkaline phosphatase levels are indicators of poor calcium absorption.
We must remember that aging is a natural process that weakens our bones. Exercise and especially resistance exercise will help strengthen bones as well. Foods high in calcium include dairy products (remember many DS patients are lactose intolerant) sardines and some vegetables.
Calcium citrate in doses of 500 mgm/dose (can be 2-3 tablets) up to 4-6 times/day may be required as well as added doses of vitamin D3. Only 500 mgm of calcium will be absorbed at one time and again, avoid taking with iron.
Calcium supplements come in two forms—carbonate and citrate. Calcium carbonate needs stomach acid to achieve absorption and taking it with food to stimulate stomach acid production is necessary. If you are on acid suppressive medication (either histamine blockers like Tagamet or proton pump inhibitors like Omeprazole) then the carbonate form may not be absorbed.
The citrate form although more expensive to purchase does not need the acid and is, therefore, a more reliable form to take. Be aware: Vitamin B6 is often included in many brands of calcium as well as other minerals (magnesium) so, reading labels of supplements is critical to avoid toxicity.
Copper Deficiency
Copper is required for normal iron transport and if deficient may present with persistent anemia. Symptoms of deficiency may accompany chronic diarrhea, malnutrition, and high dietary intakes of iron or zinc, which many of our DS patients are taking. Fatigue, easy bleeding, hair loss, pale skin and neuropathy (numbness) may occur.
Lab values may need to be monitored. Foods high in copper are legumes, beans, nuts, seeds, oysters, avocados and whole grains. Supplements are OTC with recommended daily allowance (RDA) to be 2mg/day if deficient. Do not take with a zinc supplement. Toxicity is rare.
Magnesium Deficiency
Magnesium helps with the formation of bone and assists absorption of calcium and potassium. Symptoms of deficiency are fatigue, irritability, and poor memory. It may be used as a laxative and if you have diarrhea, then look to see if your calcium supplement has magnesium in it, and change your supplement if appropriate.
Lab tests may be appropriate to determine dosing. Good food sources are dairy, fish, meat, seafood, legumes, avocados, bananas, nuts and whole grains. Supplements are OTC, 750-1000mgm/day, as instructed by a physician. Toxicity can occur causing nausea, emesis, lethargy, weakness and cardiac problems.
Zinc Deficiency
Zinc helps with all bodily functions and can be depleted after surgery quickly as there is no zinc storage system in place in the human body. Large amounts of iron can decrease zinc absorption. Zinc is needed for skin, nails, and hair maintenance as well as wound healing. Symptoms of deficiency include diarrhea, hair loss, and white spots on fingernails.
Labs are needed to diagnose deficiency. OTC supplements, 25-50 mgm/day. Zinc is not to be taken with copper supplement. A high zinc intake can lead to copper deficiency and neuropathy.
Selenium Deficiency
Selenium is a mineral found in soil, water, and some foods. It is required in trace amounts for normal health and in helping support a strong immune system. Selenium has been found to be deficient in surgical patients, both pre-op and postoperatively. SX of deficiency are muscle weakness and pain.
Vitamin Deficiencies
Fat-Soluble Vitamins A, D, E, and K
The fat soluble vitamins are probably the most common deficiencies which occur in DS patients. Thankfully, these deficiencies occur over a much longer period of time and the symptoms are much less severe and easier to treat.
Vitamin A
Vitamin A is needed for vision and more specifically to be able to see at night. It is found easily in most natural foods with the color of orange, such as carrots, sweet potatoes, apricots, cantaloupes and in dark leafy greens. The Recommended Daily Allowance (RDA) is 5000 IU’s/day and is available in most multivitamins.
Doses of 10,000 IU’s-25,000 IU’s/day can be easily taken in oral supplements. Remember that any extra vitamin A, D, E and K should be taken in a ‘dry’ source, not in an oil based supplement. Soloray or Bio-Tech Pharmacal brands online are dry sources. The Vitamin Shoppe also carries dry Vitamin A. SX of vitamin A deficiency are night blindness and vision problems, skin sensitivity and may correlate with an iron deficiency. Toxicity can happen but is rare in a DS patient.
Vitamin D
Vitamin D s needed for good bone formation and prolonged deficiencies in this vitamin may cause osteoporosis and osteopenia. The only food sources of vitamin D are fish and fortified dairy. Sunshine is the purest form of vitamin D. Obesity, aging, darker skin pigmentation, sunscreen and latitude of where one lives (equator providing the best source of sunshine) can affect the body’s ability to absorb it. Chronic deficiency may be serious and the signs of it, broken bones from osteoporosis and osteopenia, may take years to occur.
Regular vitamin D supplements come in an oil based form (remember you are malabsorbing fat). Vitamin D supplements also come in two forms, vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol).
The most powerful form is the vitamin D3 and this is available online in a “dry” form at Bio Tech.com as well. Labs required to diagnose a deficiency are calcium, (poor indicator, can be low or normal), low vitamin D 25 hydroxy, high alkaline phosphatase, and high PTH. If one presents with a high parathyroid hormone level (PTH) referral to an endocrinologist and obtaining a bone density scan may be appropriate. Dosing of vitamin D3 is done by your bariatric surgeon or endocrinologist and the recommended dose is 50,000 IIU’s/day depending on your individual labs. These bone markers then should be monitored every 3 months until stabilized.
Vitamin E
Vitamin E helps our health in many ways. It stabilizes the red blood cell, helps neurologically with balance, maintains healthy skin and hair, and helps with healing. We have large Vitamin E stores in our body as it is stored in fat cells and significant vitamin E deficiency is rare. Vitamin E levels can be obtained, but can often be expensive.
Vitamin K
Vitamin K is needed for optimal clotting of your blood. With deficiencies, you will notice easier bruising and prolonged bleeding from trivial injuries. Because you may bleed more than the usual person, you need to tell your medical provider about this tendency.
If undergoing surgery, discuss with your surgeon about taking additional supplemental Vitamin K before the procedure. People that need to be anti-coagulated can be of specific concern. In particular, people taking Warfarin (Coumadin) which blocks vitamin K from working can have their ability to form blood clots severely altered. These people may then develop spontaneous bleeding events which can become life threatening. Therefore, if you are on Warfarin and had a DS, your blood tests to look at your ability to clot should be followed very closely or you should use a different type of anticoagulant.
B Vitamins
Vitamin B1 (Thiamine) deficiency is probably one of the most worrisome problems as it can come on quite quickly because our body does not maintain much Thiamine reserves. Therefore, even though people are less likely to become deficient in this vitamin compared to others, the ramifications can be severe and lasting.
Thiamine is usually absorbed in the duodenum. Much of the duodenum is bypassed in the DS limiting its absorption.
Secondly, thiamine is contained in many leafy green vegetables which are sometimes avoided after DS surgery. In particular, if you have prolonged episodes of vomiting for whatever reason, your thiamine level may get depressed further. People abusing alcohol may also develop this deficiency. The combination of a DS and significant alcohol intake can be particularly troublesome.
SX of thiamine deficiency includes burning or tingling of your feet and legs, reduced energy, vision problems, and eventually confusion, difficulty walking, coma and death. Usually, the first signs are those of the burning and tingling of your feet and legs. These symptoms can be very slow to resolve even with prolonged treatment with high doses of thiamine. So, the take-home message here is to always take extra thiamine. There is no toxicity for this vitamin.
Vitamin B3 (Niacin) is available through a healthy diet and a general multivitamin. Deficiency is rare, but deficiency can be seen with malnutrition and alcoholism. Deficiency causes Pellagra and the symptoms are the 3 D’s-- rashes of your palms and soles (dermatitis), dementia, and diarrhea. If untreated this deficiency can result in death.
Vitamin B6 (Pyridoxine) is generally well absorbed in the DS patient. More commonly is the compliant patient who gets too much vitamin B6 which is often added to supplements and processed foods.
Symptoms of vitamin B6 toxicity are numbness in the lips and extremities, difficulty coordinating movement and sensory changes. It is not uncommon for 700% RDA of B6 to be included in just one dose of Calcium Citrate (Costco Calcium Citrate). Our compliant patients are taking sometimes 4-6 doses/day. Vitamin B6 is often added to food and other supplements as well.
Toxicity can be stopped by stopping all food and supplements containing vitamin B6, but this may take months. All symptoms of numbness and tingling should be discussed with your medical team as soon as experienced.
Vitamin B7 (Biotin) is needed for good skin and hair growth. It is recommended to take extra Biotin when you start to have thinning of your hair although there is no proof that it will help. Generally, if you are getting adequate amounts of protein, your hair will thicken up again after your weight loss slows down. Generally speaking, you will absorb enough biotin from your foods and your multivitamin.
Vitamin B9 (folate) is found naturally in foods and folic acid is the synthetic form found in supplements and fortified foods. Folate needs to be followed very carefully in women trying to conceive and those who are pregnant. Deficiency during the first few weeks of gestation may cause midline birth defects in the developing fetus.
Folate is generally well absorbed in the DS patient and typically can be elevated in patients compliant with taking their vitamins. Usually taking a multivitamin and eating well will give you enough folate although extra folate is recommended for those planning a pregnancy and while pregnant. Folate toxicity, although rare, can cause nausea, loss of appetite, bloating, an unpleasant taste in the mouth, irritability, and depression. In severe cases, psychotic behavior, numbness or tingling, confusion, fatigue, and seizures may occur.
Vitamin B12 Cobalamin is quite complex. Usually, this is not a problem in a DS patient (as compared to a gastric bypass patient) because intrinsic factor produced in the smaller stomach is usually adequate to allow satisfactory absorption. Deficiency can cause tiredness, burning or tingling in your extremities and other nonspecific symptoms like diarrhea, anxiety and anemia. Because we can see deficiencies years out with vitamin B12, it too should be monitored. Daily doses of 350-500 mgm orally are preventative. Intra muscular injections, nasal sprays and sublingual sources of vitamin B 12 are also available.
Daily Recommended Vitamin and Mineral Supplements With a DS
The following is a summary of recommended vitamin and mineral supplements we recommend for maintenance.
Note, there may be many variations in the exact preparations you take as well as your specific absorption, so adjustments in your vitamin/mineral regimen annually are expected.
1. One general multivitamin (MV) or prenatal vitamin (a good MV supplement that is complete in minerals and vitamins with at least 100 % daily RDA allowances.
2. Calcium Citrate /day – 1800-2400 mg/day (no more than 500 mgm at one time) taken separately from iron.
3. Vitamin D3 (dry form)- 5,000=10,000 IU’s day (depending on lab values) www.bio-tech-pharm.com
4. Iron (chelated, polysaccharides, ferrous fumerate) 60-300mg/day (depending on lab values)
5. 1 daily ADEK (dry form) supplement www.axcan.com Amazon or AquADEK’s
6. 1 daily probiotic ( up to several/day, depending on personal preference)
Bariatric Supplements specifically designed for bariatric surgical patients such as Bariatric Advantage and Celebrate are also good websites for DS patients. They have an MV which includes extra vitamin A, D, E, and K which may be substituted for an MV and ADEK. VitaLady.com may be helpful as well.
Annual Lab Panel for a DS Patient
The annual lab panel for a DS patient may include the following and need to be discussed with their doctor.
Total Protein, Albumin- determines protein absorption
Complete Blood Count (CBC)- hematocrit, hemoglobin, (determine anemia), white blood count (WBC) infection
Kidney function, creatinine, potassium
Liver Function tests, cholesterol (LDL/HDL)
Vitamins: Vitamins A, B1, B3, B6, B12, Folate, D25-OH
Minerals: Calcium, Copper (Ceruloplasmin), Iron, Ferritin (Iron Stores), Magnesium, Phosphorous, Selenium, Zinc
Thyroid (TSH)
Tips on Weight Management
We have several long-term studies that show the average weight regain of a DS post-op patient going out 10-20 years may be as high as 25% of their excess weight (which is generally better than the other weight loss operations).
Patients may, in fact, have actually lost too much weight at their lowest level and this weight regain is frequently healthy. It is very common for their weight to stabilize after this 10-15 pound weight regain.
The annual follow-up you have with your surgeon or primary care physician, how tight your pants get and attending support group meetings can all help in preventing too much of this weight regain. Patients who have gained 20, 30 or even 50 pounds years later can lose this just by getting back to the basics---water first, protein second, veggies and fruits third. Staying away from sugar and refined white carbohydrates is the key. Too much weight loss years out can generally be helped with frequent small high protein meals, adding pancreatic enzymes and revisional surgery to lengthen the common channel.
Long-term follow-up is critical for the lifetime of a bariatric surgical patient despite what surgery you had. Annual blood work and weight checks should be done and shared with your primary care physician and other medical providers. You have taken the leap to health choosing weight loss surgery and in this case, the DS. You must be your own best advocate and be responsible for eating right, taking the proper vitamins and minerals, and even educating all who are helping you to a healthier lifestyle.
 | ABOUT THE AUTHOR David F. Greenbaum, MD, FACS is the past director at LMCBC and currently at Virtua Health Systems, Virtua Memorial Hospital in Mt Holly, NJ. Dr. Greenbaum is a member of the American Society for Metabolic and Bariatric Surgery (ASMBS), a past chairman of the Public and Professional Committee and a member of several other committees at the ASMBS.Read more articles from Dr. Greenbaum! |
 | ABOUT THE AUTHOR Barbara Metcalf RN, CBN, entered bariatrics in 1995 with Dr. Robert A Rabkin and Dr. Ara Keshishian in 2000, where the DS was the primary procedure. She has published in “The Benefits of Exercise with Bariatric Surgery,” pioneered the first “Walk From Obesity” in 1999 and helped to develop the national “Walk From Obesity.” She has been on faculty for ASMBS since 2000 teaching, “Motivating Patients with Exercise,” “Facilitating Group Support Meetings” and “DS Nursing.” She retired in 2013 but continues to volunteer for Drs. Rabkin and Keshishian & online for patients with questions on the DS. |
