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

Thanks!  I checked out her lists when researching the surgery.  Also the bariatric surgery societies' consensus statements as a starting point.  I found her list really useful in assessing if I could deal with the financial commitment of protein and vitamin supplements for life.  I'm not sure starting out on that high a regimen would be a good idea, isn't their a risk that oversupplementing from the start hinders your own body's adaptation over the first 6 mo to 1 year?  Still it looks as if I should be prepared to supplement based on lab tests, and consider vitalady's list as one way things could develop.

Cai

The malabsorption is exactly why we take such high levels of vites.  In fact, my program's literature recommends 4 multis daily, six to eight calcium pills, and higher than normal levels of B1 and B12, exactly because of the malabsorption.  As for additional vitamins, I run everything past my dietitian/doctors. based on my lab levels.  It helps that I'm studying dietetics, because I can speak their language in terms of nutrition. Because of the surgery, and my many negative experiences with NUTS (dietitians/nutritionists),  I decided I was going to do a repeat trip through college at middle age and become a RD myself.  I will certainly have the life experience to counsel bariatric surgery patients, and that's what I plan to do.

One question:  where are you getting that up to 50% of fat is absorbed?  With our anatomy, even if we're drinking cooking oil, 15 -20% is all that gets absorbed, maybe even less for some.  The absorption levels are averaged statistics.

Wonderful to hear you are back at college and training to become a RD.  Having more well-trained bariatric dieticians would be marvellous.  At Toronto Western the staff is wonderful and knowledgeable, but they need more dieticians.  They were booking appointments 3 months out, and I imagine the list length is growing.  Having a dietician who has gone through the process would be additionally reassuring.

As for the 20-50% of fat absorbed statement.  I know that the most definitive research uses the 20% figure, but some of the reports on longer common channels suggest channel length is related to proportion of fat malabsorbed.  Even the top figure, that 20% is not fixed in stone.  ASMBS nutritional guidelines (Surgery for Obesity and Related Diseases 4(2008): S73-108) states "as much as 25% of protein and 72% of fat malabsorbed" (S81).  So that figure is relatively recent, something that seems to play a big role in the divergent results of DS studies.  I think the variation is mostly accounted for by the trends 1) additional training and experience in the physicians, 2) better knowledge of need for vitamin supplementation, 3) trend towards longer common channel length.  Some variation also may be because a few of the more hairy research papers I read dealt with types of fats absorbed, whereas for the purposes here it is dietary fat in general with which we are concerned.

So, essentially, I accept that 50% of fat absorbed is unlikely but would argue that assuming 20% as an absolute is not fully justified.  In any case assuming the lowest number 20% is probably wise for figuring vitamin and micronutrient malabsorption, but in terms of weight loss a more conservative 28% or more should be considered.  And, from what you all have taught me, I'll need to be guided by the actual results in my specific case: start vitamin and mineral supplements at the recommended levels (that ASBMS guideline above is a good starting point) and adjust based on lab results and symptoms.  I also get the impression more DSers get to the point where they can estimate the amount and types of food intake that will keep them at a healthy weight.

Looking forward to learning more from you in the future!

Cai

I applaud your educated questions!

I eat fatty foods like a traditional dieter eats rice cakes.  In my world, fat is a FREE food.

I can't point you to a scientific source, but I'm living proof that Dry D in huge dosages (that scare the common medical professional) are the only thing to get my D in the normal range.

 

I also concur that the medical community hasn't caught up with what we DSers have figured out about ourselves over the last 7-8 years.  We learn from each other what works and what doesn't.  

Fat is like free food for us(Hess, a DS pioneer said this first).  Our basic diet is high protein, high fat, and low carb/sugar.  There are very few nutritional guidelines written for DSers.  Mostly we are just lumped in with everyone else.  There are also very few nutritionists willing to do anything but toe the line and repeat the same old tired mantra, low cal, low fat, low sugar, small portions.  Well, very few of us eat like that.  Unless you rely on shakes for your protein, there's no way you can eat like that and get the 100 or so grams per day we need.  I think it was Gagner who did a study a few years ago demonstrating that even years post, we still malabsorb @ 80% of the fat we eat!

 

ADEKS were originally developed for CF patients who also malabsorb fat based vites.   Look for studies on CF patients too. ADEKS are a great idea but they generally don't pack enough of a wallop for us.  We would go broke buying ADEKS.  The majority of what I take is dry but I take fat based too and just count on not getting about 80% of what I take.  I usually buy my dry D, and K from Puritan.   I usually take fat based A and E from wherever it's cheapest.  Water miscible vites are the best but they aren't always available in suitable doses at a reasonable cost.  We have to do the best we can with what's on the market.  Over time, we have all had to tweak a bit here and there to maintain good labs.  I probably take about 30 pills a day.  No big deal, I have 2 organizers and I count them all out once a week. 

 

DSers are the examined few.  Most normies never have their vitamin/mineral levels checked.  I would bet you money that everyone malabsorbs a lot of the D they take orally, even in fortified foods!  It's just logic when you figure there are very few foods out there with naturally occurring D.  We weren't meant to eat D.  We were meant to manufacture our own through moderate sun exposure.  Now they have started testing and surprise, tons of people are deficient.  No shock to me.

 

Read and learn what real postop life is like here.  I don't know any DSers who did low fat long term.  Some do while they are healing and getting used to the new guts and that's not necessarily a bad thing to do.

Thanks for the info!  So far I have found far more information on post-op life from boards like this than all the official recommendations.  Much of the vitamin approach seems pragmatic.  You can get some benefit from regular fat-soluble vitamins, bu****er soluble ones are more predictable, and too expensive.  Am I understanding correctly that DSers are generally not absorbing most of the dry/water-soluble forms as well?

I don't know the science behind all of it but here are some things I learned working with my labs and vitamins. My dietitian and I have experimented with my labs a bit and in the early days, before we had a good dietitian, they even tried me on oil based D2 and dry beta carotene. The oil based prescription D2 brought my D levels up 6 points to 21 in 8 weeks. 50,000IUs a day of dry D3 brought my D3 up to 60 in 8 weeks and 100 by the end of my first year post-op. I was taking 30,000IUs of dry beta carotene and it never got high than 6 on my labs and my vitamin A was still low. I switched to dry vitamin A (palmitate) and brought my vitamin A labs up and over the top of the range. I follow Vitalady's vitamin plan since 9 months post-op with my surgeon's and dietitian's approval. My dietitian and I tweak my vitamins up and down every 6 months to maximize my labs.

I don't limit fat and my dietitian tells her DSrs to limit it according to the practice's instructions the first couple of months until our guts heal and then slowly add fat to our diets and settle in to where we are comfortable. Some DSrs can get constipated if they don't have enough fat in their diets and some get loose stools if they have too much fat. Everyone is different there.

I'm not sure I answered your questions or concerns but please keep asking.

--gina

 

So you use a combo of dry and fat soluble vitamins.  Good to know.  If you use a high dose to bring the levels up quickly, how do you know what dose to reduce it to in order to keep it at the right level, rather than overshooting the range and ending up with too much D or A?

Cai

I do over shoot but not by much. What we do is reduce the number of days a week I take something. If I go over or under too much, my dietitian will have me make adjustments and retest in 6 - 8 weeks. Right now I'm not taking any vitamin A or B-complex, I only take vitamin B1 and B12 3 days a week, folic acid 5 days a week, and I've been able to reduce the amount of carbonyl iron by 1/2. 

No one wants to lambaste you. You have valid questions. There is a lot of bad info out there. It is good to sort it out.