Calcium question---again!!

I recently read a post which was a response to someone wondering if their dental problems were a result of GP--that lead to a response from another member suggesting that we 3-4000 units of Calcium citrate, (I get why the citrate), but wonder about the amount...she also suggested 50,000 of dry vitamin D3.  I wonder what other nutritionists think of this and if I should be out there looking for more calcium citrate and D3..... Thanks! Betty

First of all, I'm not sure what this person's dental problems are - I'm thinking maybe bone loss since calcium and vit D are being offered as solutions. The majority of dental bone loss is caused by things that happen over time.  I checked with a dental hygienist for this answer -  There are a few ways bone can be lost quickly (like trauma or infection), but most are a cumulative problem caused by poor oral health, decay, neglect, smoking, tooth loss without replacement, poor diet, etc.  In order to re-mineralize the area, the person has to do more than just take supplements (we are talking dental procedures here) For everyone else who is thinking about megadosing on Vitamin D -  Let's start with this, Vitamin D is not really a vitamin at all, but rather in its active form - a steroid hormone.  Vitamin D has no daily requirement because your body is able to produce it with exposure to the sun.  Vitamin D was added to food to improve calcium absorption mainly to assist people who live in cloudy and dark places (no sun...)  Vitamin D can reach toxic levels in your body - this is always caused by over-supplementation.  The result of too much vitamin D: too much calcium goes to your bloodstream (hypercalcemia) which is then spilled in your urine (hypercalciuria), anorexia, nausea, vomiting, thirst, polyuria (you have to urinate frequently), muscular weakness, joint pain, de-mineralization of bones (contradicts the whole reason for taking it - eh?), general disorientation, and death. So what do I think - having a calcium and vitamin D combo is fine. To take large doses of Vitamin D - foolish (unless you have been diagnosed with rickets or osteomalacia and this is part of your prescribed medical therapy). If you take extra calcium and your body doesn't need it, it will just get sent out in your urine (your urine can get very expensive...).  I don't see many reasons to ever go over 2000-2500 mg of calcium in a day, particularly if you eat dairy foods. Thanks for asking!

Thank you so much!--what a prompt reply! The writer I referred to was responding to a series of other members who discovered they had increasing dental problems, (teeth crumbling, lots of cavities, etc,) and they all were wondering if that was a result of gastric bypass surgery, since it was not a problem before.. I could send you the post, as the person, who seemed very knowlegable of nutrition, had discovered herself that her own bones were weak and fragile and attributed that to not being given proper advice on GBypass  patients advanced needs for much higher amounts of calcium and D3, as I referenced in my first post.  Her position seemed to be that dairy is not a good source of calcium and that we are being lead down a path that will end in our bones and teeth being compromised....I truly am confused, as I have come to respect alternative ways of viewing nutrition and health, but also bow to the knowledge of trained professionals, RD's such as your self....do you have any further clarification on your thoughts in regard to gastric bypass patients needing more than conventional wisdon indicates? Thanks again! Betty

I would be very interested in seeing her post - thanks for the offer. I think it needs to be recognized that recommendations for WLS patients have changed dramatically over the past few years.  In the early days, supplementation was not pushed like it is today.  Physicians knew that nutrients needed to be added back, but I think they over-estimated the amount of adaptation the gut can do in nutrient absorption and how long it takes for that adaptation to occur.  In the meantime we have had tons more research emerge - not only in WLS, but also in intestinal transplantation which also alters the gut's ability to absorb nutrients. There are definitely associations between oral health and nutrition.  Lack of key nutrients can affect your gums, teeth, and bones - no doubt about it! There are a lot of different WLS procedures that have been done over the years - some extremely malabsorptive.  There have also been large variations in the types of supplements to take.  I would imagine that across the wide range of members that are present on OH, there are thousands of differing recommendations - and varying side-effects and long-term complications as well. I absolutely respect alternative therapies and understand the value they offer.  I do take issue with large doses of Vitamin D.  All of the fat soluble vitamins (ADEK - though we know D isn't really a vitamin...) have the potential for toxicity.  From a biochemistry perspective, vitamin D absorption is not dependent on your gut.  Vitamin D is dependent upon your liver, kidneys and parathyroid - too much can alter calcium and phosphorus absorption and distribution in your body.  I don't think it is wise to over-do this particular compound because it does present an opportunity to do harm. Calcium absorption is dramatically altered with WLS.  I think the evidence is pointing to calcium supplementation for life post-op WLS, even with good intake of calcium rich foods.  There is another key issue that should be addressed here - calcium absorption is also dependent on the body's need for strong bones.  If a person is exercising, doing weight bearing exercise more specifically, they will maintain higher bone density and will absorb calcium better - research in aging and osteoporosis has shown us that.  I know that not every WLS patient is good at maintaining a good exercise program - but isn't this also a critical factor to consider in long-term bone health?  If you are putting demand upon your muscles, your body will make maintaining your bone a priority (since muscle attaches to bone via tendons - weak bones can snap.) I will research this further - I'll let the world know if I find something that changes my mind about vitamin D. good discussion!

Danielle, Many of us on the grad boards, myself included, have had very low D levels.  My recent level was 21.  I'm now taking 50,000 of dry D3.  This seems to be an increasing common problem for people 2 + years out.   I've also experience more problems with my teeth, even though myh calcium levels are fine, I do everything the dentist tells me to and of course I exercise. My opinion is that a lot more research needs to be done on D and calcium and the effects long term on WLS people. Michele

my dentist has lot of bariatric postop patients and she said it is contributed to the wls. i have never in my life had a cavity, tooth decay or softening of the teeth, let alone chipped away as it did recently. i have been a patient of my dentist for years and since my last visit to her office back in march, my tooth enamel has changed. it most affected my last tooth in my mouth the wisdom tooth. as a DS post-op i have to take large amount of vitamin A & D, as well as calcium citrate. i am on prescribed drisdol with is megadose vitamin d of 50,000 units that i take once a week. due to the malabsorption, i have to take larger amount of calcium citrate and vitamin d. as i said, i had perfectly healthy teeth, never an issue before and here i am now at age 44 with recent tooth decay and my first tooth extraction.  i have spoken to various postops of different surgery and stages some as far out as 6+ years postop and they all spoke about concern of their teeth and its condition since having wls. my calcium level and vitamin d are within range thanks to the dosage level i am on and will continue therapy of drisdol as per my bariatric surgeon. i have always had good dental hygiene, i do not even chew gum, am not into sweets, do not smoke, do not drink any acoholo, have always done my regime of brushing and flossing and having 6 months periodic checkup and this now happens. my dentist confirms it since she has lots of postops that it is due to the wls. more research and study has to be done since i never was aware of this condition in the 4 yrs that i have reasearched wls that it can affect your teeth. i realized it now speaking to many who are postop of various methods of wls.

Thank you for this information Danielle. I also read the threads about folks whose teeth are falling apart and it's pretty scary to me as a new post-op. My vit D are on the lowish side but nothing worrisome yet, my surgeon saw the labs and didn't suggest changing my supplements. I've been eating sardines and eggs and taking walks outside, but increasingly I have to exercise indoors because it's too cold. I do exercise at least 3 times a week, mostly cardio however as I don't want to bulk up. Vitalady says vit D ingested with fatty foods (such as sardines and eggs I suppose, but she didn't specify) isn't absorbed because of the bypass, so she says we need to supplement with dry vit D, the more the better. From Danielle's response it would seem maybe not, but I'm still a little confused about it.  My question is: Is there a safe dose of dry Vit D supplementation for those of us who would like to get back into normal Vit D ranges? Should I just ask my surgeon? Thanks!

I did a little more research on this - I got curious! I'm sticking to my story about vitamin D supplementation.  From my research: Because vitamin D3 can be endogenously produced by the body and because it is retained for long periods of time by vertebrate tissue, it is difficult to determine with precision the minimum daily requirements for this secosteroid (remember from earlier - it is not really a vitamin).  The requirement for vitamin D is also known to depend upon the concentration of calcium and phosphorus in the diet, age, sex, degree of exposure to the sun, and the amount of pigmentation in the skin. In the US, adequate amounts of vitamin D can be readily obtained from the diet and from casual exposure to sunlight.  However, in parts of the world where food is not routinely fortified and sunlight is often limited during some periods of the year, obtaining adequate amounts of vitamin D becomes more of a problem.  As a result, incidence of rickets in these countries is higher than in the US. Blood tests only measure what is in the blood.  Vitamin D levels measured by blood are not an accurate measure of what your body has stored.  I know people think that blood levels tell the whole story - THEY DON"T.  Blood levels are one piece of the puzzle - there are many nutrients that are stored in the bones, the liver, the fat tissue, or vertebral tissue, etc.  To treat a blood level is irresponsible, unless you have other evidence that leads you to suspect a deficiency.  We treat patients, not lab work. But you asked about the safe levels for supplementation. Doses of 400-600 IU (10-15mcg) vitamin D3 have been used safely.  There are preparations of up to 1000 IU, but those are reserved for parathyroid dysfunction and renal bone disease.  An upper limit (do not exceed) of 2000 IU is recommended.  With total body sun exposure, your body can produce 10,000 IU (250 mcg) of vitamin D Doses that reach "intoxication" are caused by large amounts of vitamin D3 and its conversion in your body to a form called 25(OH)D3 - this is an unregulated step, meaning if you put too much D3 into your body, this is what your body will do with it.  Patients suffering from hypervitaminosis D have been shown to have a 15 fold increase in blood levels of 25(OH)D3 and can lead to a massive stimulation of intestinal calcium absorption, increased leaching of calcium from the bones, deposition of calcium in the soft tissue, and development of kidney stones. Back to teeth. I read some interesting articles about this topic (5 today) and there is good research emerging regarding tooth problems and WLS.  There are many possibilities, but there was a general concensus on two causes: 1. Xerostomia - technical term for dry mouth.  It is well known that people with dry mouths have more tooth decay and higher oral bacteria levels.  A wet mouth washes the "cavity creeps" out of your mouth.  Post WLS people often have dry mouths - consider the thick saliva, foamies, things getting stuck in your throat... 2. Increased oral acid levels - this condition is in part a result of #1 since higher oral bacteria counts means there are more bacteria producing acid in your mouth.  There also appears to be higher amounts of acid, maybe of gastric origin getting into the mouth (I would think this would be limited to those that vomit though) Incidentally, xerostomia is a cause of tooth decay in people who have received chemotherapy and the problem can often arise years after the treatment is concluded.

Thank you so much, Danielle.  Your research really shed some light on things.  It means a lot to me, It is so helpful that someone is willing to look into these things! Betty

Thank you so much Danielle for sharing your reseach with us and for telling us what a safe range of supplementation is! Much appreciated!