are dry ADEKs sufficient/useful? is low fat diet increasing problems?

OK...please actually read my post before blasting me for questioning dry ADEK vitamins.

In considering surgery, I've been reading up on the fat soluble vitamins and their water-soluble (dry) forms.  So I have a question for all you experienced DSers (rather than BSers).  Everyone is adamant that only the dry forms should be used because after DS we absorb so little fat.  As far as I can tell the water soluble forms (often through microencapsulation or binding with a hydrophylic substance) allow the vitamin to disperse in water and form the miscelles that transport the vitamin to the barrier of the intestine wall.  Normally fats interacting with bile create these miscelles that are hydrophilic on the outside.  There are studies for vitamin E showing the water solubilized form works.  Vitamin A palmate is the water-soluble form of vitamin A.  I am having trouble finding any studies showing dry D and K are actually absorbed and bioequivalent and anything relating to the stability of these forms.

My concerns are:

1) There is insufficient scientific info showing vitamins AD&K in dry forms are stable and equivalent in their actions and how well/quickly/completely they are absorbed.

 2) Literature on short bowel syndrome does not mention using these forms of vitamins.  BPD-DS is an induced form of short bowel syndrome, so it seems to me that the reduced fat absorption problems being the same, should result in the similar nutritional guidelines.  And since doctors/nutritionists/nurses/dieticians have been aware of short bowel for much longer shouldn't the references be there?

3) Why shouldn't we be focused on maintaining a healthy fat intake (not excessive, just 20-30% of calories), as long as it does not result in unacceptable incontinence problems.  Even if only 20-50% of the fat is absorbed it would allow more vitamins to be taken in from food and, in terms of time and surface contact, this gives more opportunity for maintaining healthy vitamin levels.  Literature surrounding Dean Ornish's diet plan suggest you run into problems with vitamin absorption when you run below 10% of daily calories from fat.  So in theory a 30% of calories from fat diet that is rich in nutrients and includes 2 multivitamins (one with breakfast, on with dinner) should get me most, if not all, of the ADEK I need.

I understand that excess fat, (meaning the amount we don't absorb) seems to bind with calcium, leading to problems (leaching out this important mineral).  But isn't this PART of the reason for taking so much calcium?  Why eat a diet lower in fat than the healthy levels for a normal person?

So essentially my question is why not have a moderate level of fat intake to promote absorbing vitamins from a healthy diet?  If you get 20-30% of calories from fat and absorb only 30% of fat, you still get significant portions of ADE from the diet.  Most K should be made in the colon anyhow.  Taking dry ADEK as a supplement, if the tablets contain forms that are not only dry, but include some substance forming the miscelles in water, sounds like a good precaution, but has anyone found scientific studies showing dry ADEKs are actually useful (for all 4 vitamins)?

Looking forward to your lambasting,

Cai

Are you under the impression that DSers are supposed to eat low fat?  We eat LOTS of fat.

The diet instructions from most of the programs I've found on-line talk about maintaining a low-fat diet.  There are a few sites where they seem to be advising patients to have a significant bit of fat with every meal, but most of the physician, nurse, and dietician sources are promoting a low-fat lifestyle (usually justified in terms of either weight loss or inability to absorb fat meaning fatty foods produce bowel problems).  When I've read comments from DSers some are following a low-fat diet, some moderate, others intentionally high fat.   So I am under the impression that DSers are told to eat a low-fat diet, but most do not.  

My impression is that DSers are generally well-educated on the process and implications, but the rationale for a higher fat diet is mainly that there is no need to restrict fat if you don't need to worry about the calories, not that higher fat intake keeps you healthy.  Am I mistaken?

If most DSers are eating lots of fat, why take dry ADEK vitamins?  Enough fat will be absorbed that taking 10 times your necessary amount of ADEK should mean no problems in getting enough absorbed with the 20-50% of fat absorbed.  With one to three multivitamins on top of that, why are people still having vitamin deficiencies?  I guess the problem I'm having is in figuring out whether people who eat more fat are having fewer nutritional problems.  Can you think of a way to figure this out?

Part of the reason for my concern is that I've looked at the extreme megadoses of vitamins, mainly A and D, that some DSers take and worry that either they are absorbing none of it, or are at risk for the dangers of excessively high levels.

Thanks,

Cai

DSers NEED the fat.  Most surgeons offices and dieticians spout RNY stuff.

Good to know.  That the official recommendations are from a RNY perspective explains so much.  Thanks.

Cai

Okay---I'm going to wing this one. (*grin*)

DSers usually eat a HIGH-fat diet, for several reasons. Many of us find we can't poop unless we eat a lot of fat. There's also the hope of absorbing sufficient 'good' fats from out diets. And, of course, there's always the 'because we CAN' thing. (*grin*)

Most of us DON'T take ADEKs---because they simply don't give us what we need. Most of us take individual doses of 'dry' A, D, E, and K, because this allows us to adjust our intakes of these vites separately. We also take tons of OTHER things, and we get 18-20 vials of blood drawn every 6-12 months to insure we're taking what we, as individuals, need.

Experience has shown that it's simply impossible for a DSer to intake enough fat-soluble vitamins through diet alone. That's why we check, and check, and CHECK. And then check again.

Every BODY is different. Some people CAN eat enough fat, but most can't, and no one wants to find out the hard way. (*grin*)

If you look at intake alone, you're only seeing half the equation. Testing is as important as ingesting. I'm almost 9 years post-op, and during that time I've both increased and decreased my dosage of certain supps. Most folks do. The important thing is staying on top of YOUR needs.

Good to know.  Do most start with standard ADEK and adjust based on test results?  Do you take only physically dry versions or the water soluble gel caps (glycerine or other media)? 

Yes, they are physically a dry powder in a capsule. I guess some could come in a tablet, but I have not seen it.   If it is in a gel cap, it needs to say water miscible.  Personally I only buy dry capsules to stay on the safe side.

I had a full DS set of labs drawn months before my surgery and supplemented based on that (for example my D was in the toilet).  Then after surgery I went to vitalady's plan and have tweaked based on labs.  I have added LOTS of vitamin K though and use hydroxyapatite calcium.

Is the extra vitamin K due to lab results directly or to promote retention of calcium?  Sounds as the ADEKs could be ok to start, but most people spend years gradually adjusting vitamin levels.  Have your levels fluctuated over time or  has this been a single process of still trying to find your new equilibrium?  I guess I'm curious if vitamin problems settle into a pattern, or if it is a constantly changing issue where you are always trying to reach a goal without ever really expecting to reach it permanently?

By the way, thanks for sharing your knowledge,

Cai

I'm 9 years out, and, yes, way back when, we DID start with ADEKs---but we've learned better.

Go to VitaLady's website. She's got it ALL together. You don't have to buy from her, but you really should follow her ideas. She's been there, done that, survived it all. And she's a really cool chick. (*grin*)