Bariatric Nutrition: Suggestions for the Surgical Weight Loss Patient (Summary Part 2)

Continued from Part 1. Calcium and Vitamin D: "Calcium... absorption is facilitated by vitamin D in an acid environment."  "Low vitamin D levels are associated with a decrease in dietary calcium absorption."  "In a low acid environment, such as occurs with the negligible secretion of acid by the pouch created with gastric bypass, absorption of calcium is poor [128]."  In other words - calcium is better absorbed with vitamin D.  This is especially important for RNY post-ops as we no longer have the "acid environment" to facilitate absorption. "As blood calcium ions decrease, parathyroid hormone levels increase."  "In addition, a positive correlation exists between a greater BMI and increased parathyroid hormone [110]."  In other words - a decreased calcium level is associated with being fatter. "Buffington et al. [19] found that 62% of women and 25-hydroxyvitamin D [25(OH)D] levels at less than normal values, confirming the hypothesis that vitamin D deficiency might be associated with morbidy obesity."  "Flancbaum et al [21] completed a retrospective analysis on 379 PREoperative gastric bypass patients and found that 68.1% were deficient in 25(OH)D."  In other words - low levels of calcium as well as low levels of vitamin D are BOTH associated with being obese.  More and more research is stating that vitamin D deficiency can actually be a CAUSE of morbidly obesity.  This is just another reason to make sure that you take your calcium & vitamin D as indicated. "If dietary calcium is not available or intestinal absorption is impaired by vitamin D deficiency, calcium homeostasis is maintained by increases in bone resorption and in conservation of calcium by way of the kidneys.  Therefore, calcium deficiency (low serum calcium) would nto be expected until osteoporosis has severely depleted the skeleton of calcium stores."  "An increased long-term risk of metabolic bone disease has been well documented after BPD/DS and RYGB"  In other words - if you are not taking in the proper amounts of calcium, your body will pull it out of your bones to maintain adequate levels.  You could actually not show up as calcium deficient (because your body is pulling calcium out of your bones to maintain adequate levels****il osteoporosis has started ruining your body. "In addition to skeletal disorders, calcium and vitamin D deficits increase the risk of malignancies (in particular, of the colon, breast, and prostate gland), of chronic inflammatory bowel disease, multiple sclerosis, rheumatoid athritis), of metabolic disorders (metabolic syndrome and hypertension), as well as peripheral vascular disease [115, 116]."  In other words - calcium and/or vitamin D deficiency can kill you through an array of various horrific conditions/diseases. "The increased incidence of vitamin D deficiency and secondary hyperparathyroidism has also been found in gastric bypass patients oweing to the bypass of the duodenum."  "Dietary supplementation with vitamin D and 1200 mg calcium daily did not affect these measures, indicating a need for great supplmentation [120]."  "The subjects were found to have significant changes in total hip, trochanter, and total body bone mineral density as a result of increased bone resorption beginning as early as 3 months postoperatively.  These changes occurred despite increased dietary intake of calcium and vitamin D."  In other words - 1200 mg of calcium with D per day is not enough.  If that's all you're getting in... you're setting yourself up for osteoporosis and other bone problems.   "Supplementation with calcium and vitamin D during all weight loss modalities is critical to preventing bone resorption [121]."  "A meta-analysis of calcium bioavailability suggested that calcium citrate is more effectively absorbed than aclcium carbonate by 22-27%, regardless of whether it is taken on an empty stomach or with meals [130].  These findings suggest that it is appropriate to advise calcium citrate supplementation..."  In other words - calcium citrate works for us: calcium carbonate does not.   "It is no longer acceptable to assume that postoperative prophylaxis calcium and vitamin D supplementation will prevent an increase in bone turnover.  Therefore, life-long screening and aggressive treament to improve bone health needs to become integrated into postoperative patient care protocols."  In other words - you can't assume that just because you're taking the recommended calcium & D regimen that your bones won't have some calcium sucked out of them.  It is a good idea to get bone density scans every so often to make sure that you are getting enough calcium to prevent bone resorption from occurring.   "It appears that 1200 mg of calcium supplementation daily and the 400 - 800 IU of vitamin D contained in standard multivitamins might not provide adequate protection for postoperative patients against an increase in PTH and bone resorption [120, 121, 132].  Riedt et al. [122] estimated that >= 50% of RYGB postoperative, postmenopausal women would have a NEGATIVE calcium balance even with 1200 mg of calcium intake daily."  In other words - 1200 mg of calcium per day w/ 400 - 800 vitamin D is not even enough to sustain calcium levels. "Increasing calcium citrate to 1700 mg/d (with 400 IU vitamin D) during caloric restriction was able to ameliorate bone loss in NONoperative postmenopausal women, but did not prevent it [125]."  In other words - even in NONops, 1700 mg/d of calcium (with 400 IU vitamin D) was enough to make bone loss a little better, but did not prevent it.  If 1700 mg/d of calcium (with 400 IU vitamin D) was not enough to prevent bone loss in NONops, do you really think 1700 mg/d of calcium (with 400 IU vitamin D) is going to be enough to prevent it in us? "Weight loss can help to eliminate many co-morbid conditions associated with obesity; however, without calcium and vitamin D supplementation, it can be at the cost of bone health."  "The promotion of physical activity such as weight-bearing exercise, increasing the dietary intake of calcium and vitamin D-rich foods, moderate sun exposure, smoking cessation, and reducing one's intake of alcohol, caffeine, and phosphorus are additional measures the patient can take in the pursuit of strong and healthy bones [133]."  In other words - don't go through WLS to get rid of your co-morbidities just to end up in a wheelchair from osteoprosis.  Take your supplements as directed and live a healthy life.   So, in summary on calcium (from parts 1 & 2). Calcium supplements should: 1) be calcium citrate (NOT calcium carbonate) 2) contain vitamin D3 3) contain magnesium 4) be split throughout the day into 500 - 600 mg doses 5) not be taken with iron and/or multivitamins that contain iron I take Citracal Plus.  That contains vitamin D3 and magnesium.  I take 2 at a time (250 mg each for a total of 500 mg combined).  I usually take the 3 or 4 times a day for a total of 1500 - 2000 mg per day.  But I have been taking the 1st 2 with my multivitamin Vitaplex which may contain iron (it's an Rx multivitamin so I don't have an ingredient list to know if it contains iron).  So I need to start making SURE I do 2 Citracal Plus 4 x per day and that 1 of those is NOT with my multivitamin.   Continued in Part 3. 

Ineresting...I take 4 horse pill calciums a day, but I need to say exactly how many mg that comes to as I can honestly admit, I can't remember all of the specific dosages I take. This makes it tough to take vitamins and eat...lol. I try not to take vitamins within an hour of eating so that my absorption is optimal but shee****here's only enough hours in the day! I'm going to have to start getting up through the night to take pills...kidding

I eat 4 "meals" (meals & snacks total 4) per day, so I just always time my calciums between my meals.  But I have occassionally taken my calcium WITH meals too.