Long Boring Post About Tweaking Vitamins with Latest Labs

I had my 8th year post-op appointment with my dietitian yesterday, so I thought I'd share how the tweaking and info sharing went. Much of what I've learned has been from Vitalady back when she was active here, my own research on sites such as vitamintestsonline.org and linuspauling (http://lpi.oregonstate.edu/mic/nutrient-index) and other DSrs' experience. When you read the web sites and studies you have to keep in mind they're talking to normal people with normal absorption, so what you read you have to put through your malabsorption filter, as Vitalady calls it. 

Dietitian:  Hemoglobin and hematocrit look good. Hematocroit is a little high, you may have been a little dehydrated. You were fasting right?
Me:  Yes, I was fasting. I didn't know hematocrit could be high due to dehydration. [made a note on my lab tracking spreadsheet as we talk] Hemoglobin is 14.8 and hematocrit is 46.9, right where I like them.

Dietitian: Your AST and ALT are elevated.
Me: Yes, they've been mostly high in the past 8 years. Likely from all the vitamins.
Dietitian: Maybe so, talk to your primary care about these.
Me: Ok. [thinking my primary will be totally clueless...]

Dietitian: Protein, albumin and prealbumin look good. Prealbumin is a little high but ok.  How much protein have been drinking and eating?
Me:  Lately it's been 60 to 90 or so grams a day. Still using protein shakes and protein coffee some. 
Dietitian: That's good. Do they help long term DSrs maintain their weight? I have some long term folks who want to lose weight. Do you see people taking herbal remedies or doing anything special to lose?
Me: [thought a long time about how to answer]  No, I see nobody on herbal medicines or taking diet drugs. I do see them trying to use intermittent fasting and low carbing to bring weight back down. But I also see them seeking surgical help--re-sleeving to get the restriction back. Protein shakes are a good idea too, they might help curb cravings and overeating.

Dietitian: Your vitamin D3 is good at 84.
Me: I like it a little higher but 84 isn't too bad.

Dietitian: Your B12 is good at 876.
Me: I like it over 1000.
Dietitian: What?
Me: We can drop B12 like a rock, so I like it over 1000. 
Dietitian: How much were you taking?
Me: 5000mcg every other day, sublingual.
Dietitian: Do you keep a list of all the vitamins you take?
Me:  Hand her a copy of my lab tracking spreadsheet with the vitamins taken to return the most current labs.
Dietitian: [eyes popping]  Wow! This is great! [She refers to it for the rest of the appointment and puts it in my file at the end]
Me: Anyway, nothing much changed in what I was taking on B12 except Vitalady switch from Superior Source B12 to Kirkland brand.
Dietitian: Well, that could be it. Quality, etc.
Me: I'll check Amazon for Superior Source and switch back to that brand and start taking it every day for 3 months and then go to every other day.
Dietitian: Ok [she makes a note]
Me: When my first labs were taken pre-DS my B12 was almost too low. Vitalady says to take the B12 at 5000mcg to bring it up. Also, as we age B12 is harder to absorb. 
Dietitian: Doctors say DSrs don't nee to take B12.
Me: They're wrong.
Dietitian: Why would they say that?
Me: In theory, we "might" have enough intrinsic factor in the tiny sleeve to absorb and process B12, but that really hasn't been proven to be true for most DSrs or sleevers from what I've read.
Dietitian: We only recommend 1000mcgs a day. 
Me: I would follow those people closely, keeping in mind how fast a  DSr can drop.

Dietitian: Ferritin looks great at 237.
Me: Yes, but it's dropped nearly 200 points this year from being at 484 last year. I stopped all carbonyl and now only take 2 Proferrin ES a day. I think I need to add some carbonyl iron back to maintain. 
Dietitian: Ok [she makes a note]  I think you might want to add 1 capsule of Vitalady's tender iron.
Me: Ok, sounds right. Ferritin and iron are great but that was a big drop and I don't want to screw up my iron levels.
Dietitian: Any signs of tiredness?
Me: Not yet, and don't want to go there.
Dietitian: Yes, you might be prone to anemia. 
Me: [Thinking....where did she pull that from? I've never been anemic.]

Dietitian: PTH just came in. PTH is 36, that's normal.
Me: What? That's going in the wrong direction! Last time is was a healthy 26. [thinking...what did I do or not do to make this big of a change?]  Crap!
Me: I'll get a dexa scan this year and see where my bone density is.
Dietitian: Could it just be age?
Me: [give her the evil eye]
Dietitian: But, your calcium is good at 9.3
Me: Calcium will always try to be good if the parathyroid is working properly.

Dietitian: Vitamin A is too high at 118.
Me: I'm only taking 25,000IUs once a month.
Dietitian: Stop and see if the A in your multi lowers it and keeps you normal
Me: Ok.

Dietitian: Selenium is too high at 208.
Me: It is but I don't supplement it extra. I did reduce my multi from 2 per day to 1 per day. [Show her the Vitalady bottle of Vita-Min multi she has on her display shelf]
Dietitian: [reads the label and says yes this should be enough to keep you level]
Me: Ok.  There are a few things that some DSrs have some trouble getting to leave their systems--vitamin B6, selenium and vitamin A.
Dietitian: Yes, I know about the B6. Don't know why that happens though.
Me: Vitalady has seen it over the years but she doesn't know why that is either.

Dietitian: Vitamin K1 came back really high at 2094. You should stop K1.
Me: I've had this lab return bad number on vitamin K1 before. I don't trust it. I'm only taking 1000mcg a day.
Dietitian: Stop and retest in 6 months.
Me: How about I go to 1000mcgs every other day and retest? There's no evidence of toxicity with K1 according to the studies I've read.
Dietitian: Ok.

Dietitian: This lab just came in. Osteocalcin is normal at 14.
Me: What? That's almost double what is was the last 2 times! I really need to get a dexa scan. I'm taking 4 capsules of vitamin K2 a day and I don't want to increase it. They're expensive and I don't want to go back on the osteoporosis drugs. 
Dietitian: Best talk to your primary care about that.

Dietitian: Some of your B vitamins have come back but not many.
Me: The folks doing the blood draw for the B vitamins don't seem to know how they are supposed to process those since the older lady retired. [sigh] But, my B vitamins have been running high in the past and I only take 1 B-complex a month.
Dietitian: Stop the complex and see if the 1 multi will hold you. 
Me: B1 is the only one that doesn't skyrocket. I take 100mg every other day. 
Dietitian: Maybe take only 3 a week and retest.
Me: Ok.

Dietitian: I'm leaving at the end of the month and hiring a new dietitian. The baby is due in 2 months. 
Me: Are you doing the interview?
Dietitian: Yes, tomorrow.
Me: Please, please, please tell her she should listen to us and not preach at us from an old textbook that is 40 years out of date.
Dietitian: I will. I've learned so mush from you and the other long term DSrs.
Me: Thanks for taking the time to listen.
Dietitian: Can I pass along your contact info to DSrs having issues? And, would you write down those boards and stuff you frequent? 
Me: Sure. Here's ObesityHelp.com DS board, and the ObesityHelp Lightweight board. 
Dietitian: Why a lightweight board?
Me: Lightweights, regardless of surgery, have their own set of issues and sometimes other board-members bully them.
Dietitian: What qualifies them as lightweights?
Me: Easy answer, 35 - 40 starting BMI with comorbidities.
Dietitian: Interesting. I had no idea.

That's it. I hope I didn't put you guys to sleep.

--gina

Very illuminating. Always good to have someone open to a discussion about what and why you do certain things and willing to learn. I bet she'll be missed. Good luck training the newbie.  

I wondered about your ferritin level. At what level do you like to keep it at. I too stopped my regular iron supplements because my ferritin was in the high 500's. Will retest in a couple of weeks since I've been off now for about 2 months. Still taking the occasional FerroFood capsule.

Pete

I like to keep ferritin in the 200's, but overshot it last year. Who says DSrs can't absorb iron?  haha

I recall a similar dialogue about D3 where they appeared to be listening....then published a book recommending an extra 400 iu of D3 for DSers.  I gave up depending on anyone from there on such topics.

Really helpful post, Gina, thanks!

I would love to clone someone's lab spreadsheet. My first lab is still some ways out, so if anyone would be willing to post a template in the "cloud" somewhere, with a link, it would be wonderful to be able to download it!

Just got my shipment of PatchMD vitamins/supplements. Going to start using them tomorrow. My surgery date was August 6th.

Karen

I'm over 50, so posting something to the "cloud" is a mystery to me. Would you send me a PM with your email address? I'll forward a template to you.

--g

Thanks for sharing Gina.  I made some notes on my lab sheet.  And I see I have never had labs drawn for Osteocalcin, so that is on my list of TODO.

I really appreciate all the info you have shared the last couple of years.  I don't know where I would be without you.

Janet

Awww! You're welcome. Osteocalcin is like PTH, you want to see lower numbers rather than higher.

--g

Thanks for taking the time to write this all out.  It is SO important and helpful!

Thanks as always Gina! This post has been incredibly helpful.  I'm so appreciative of all of your advice throughout the years.