Vitamins: Sources, Amounts and Important Issues


The Food and Nutrition Board of the National Academy of Sciences is the governing body in charge of setting the minimum vitamin levels in order to prevent deficiencies in healthy adults also known as the RDA (recommended daily amounts).

We now know that vitamins are important for maintaining health and preventing disease. No one knows what the RDA is for a gastric bypass patient due to altered anatomy and a low calorie post-operative diet.

We have seen vitamin deficiencies before surgery despite adequate calorie intake but likely due to poor eating habits. For bypass patients, in order to maintain good nutritional status, we have learned from measuring blood levels that a vitamin supplement that exceeds the RDA can provide adequate serum levels.

Vitamin A
Vitamin A is a fat-soluble vitamin also known as retinol (fat soluble-animal source) and beta-carotene (water soluble-plant source). It functions in the body; to aid in tissue growth and repair; to improve and maintain normal vision, to maintain healthy skin and mucous membranes, and to fight against infection and boost immunity. If you are deficient in vitamin A possible symptoms could include night blindness, skin type eczema, weight loss, poor bone growth and diarrhea. Toxicity is rare, but if taken in excess, you could experience headaches, hair loss and have anorexia. Common food sources of vitamin A: cod liver oil, beef, liver, eggs, any dark green, red, or orange vegetables like sweet potatoes, pumpkins, broccoli and apricots.
For Bypass Patients it is Important to Know
Alcohol can decrease vitamin A stores. Drugs that affect the liver such as steroids and Dilantin may effect vitamin A stores. Low vitamin A levels when protein intake is low can correlate with poor nutritional status. Vitamin A stores can be maintained within normal limits if a vitamin supplement is taken. Some deficiencies have been seen if there is excessive fatty stools or the vitamins aren’t taken. Vitamin A levels can decrease transiently after an operation but return to normal after recovery and supplementation. Vitamin A can be lost from foods during cooking, preparation and storage. Olestra can lower vitamin A levels due to fat malabsorption.








Vitamin B-1 (Thiamin)




Needed for: Normal function of the heart, nerves, muscle tissue and digestive system; aids in carbohydrate metabolism and energy production. Its functions include maintaining normal function of the central nervous system, muscles and heart, promoting normal growth and development, and is a co-factor in carbohydrate metabolism (by releasing energy). If you are deficient in vitamin B1, you may experience visual changes, an unsteady gait, a loss of appetite, have fatigue or nausea and perhaps some mental confusion. Ingestion of high amounts of thiamine may cause drowsiness. Common food sources of B1 are liver, beans (like navy and black eye peas), peanuts, raisins and whole grain products.




For Bypass Patients it is Important to Know
Supplementation is suggested since the post-operative diet is low in calories. Antibiotics and oral contraceptive agents can decrease B1 levels. Avoid over cooking meals, since B1 can be destroyed by heat. Excess alcohol increases risk for B1 deficiency. Large amounts of raw fish and shellfish can increase your risk for a B1 deficiency. Eating an excess amount of refined carbohydrates and not taking your vitamin can potentially lead to a sub-therapeutic level of B1 and produce deficiency symptoms.










Vitamin B-2 (Riboflavin)




Needed for: Energy production, immune system function, healthy skin.








Vitamin B-3 (Niacin)




Needed for: Energy production, healthy skin, and digestive system function. The body can manufacture niacin from the amino acid tryptophan.








Vitamin B6 (Pyrodoxine)


Needed for: Energy production, red blood cell formation, immunity, nervous system and hormone function.






Vitamin B-12

Needed for: Energy production, red blood cell production, utilization of folic acid, nervous system function. Vitamin B12 is also known as cobalamin. Cyanocobalamin is the synthetic form. B12 has many functions with the most important being the nerve function. B12 and folate are metabolically interrelated. B12 converts folate to an active form. B12 is responsible for the manufacturing and normal functioning of red blood cells. It also helps metabolize carbohydrates and fats and synthesize proteins. B12 binds to Intrinsic factor, produced in the stomach. This no longer happens in the pouch which is left after gastric bypass, causing B-12 deficiency in many patients. Deficiency symptoms can be manifested as anemia, nerve damage, fatigue, dementia and even coronary artery disease. There have been no reported toxic effects with high does of B12.
Vitamin B12 for Bypass Patients
Heat and moisture may change the action of the vitamin. Store in a cool dry place. High intake of vitamin B6 reduces B12 absorption. Smoking decreases vitamin B12 metabolism. For improved absorption, take B12 one hour before meals. Colchicine reduces absorption of B12.












Folic Acid




Needed for: Energy production, red blood cell formation and growth. Essential for prevention of certain birth defects.





Pantothenic Acid




Needed for: Carbohydrate, fat, energy and protein metabolism.





Biotin




Needed for: Energy production, fatty acid synthesis and the breakdown of certain amino acids.

Vitamin C (Ascorbid Acid)
Needed for: Normal growth, wound healing, disease and infection resistance, bone and teeth formation, more efficient iron absorption. The best and most common sources of vitamin C are fruits and vegetables. Vitamin C is a water-soluble vitamin, that is important if formation of collagen (a protein that gives structure to bones, cartilage, and muscle). It maintains the capillaries and aids in the absorption of iron. Vitamin C is a known antioxidant that prevents cell damage. Eating a variety of fruits and vegetables ensures appropriate intake of the vitamin. If you are deficient in vitamin C, you may experience muscle weakness, loss of teeth, easy bruising, nosebleeds and frequent infections. Vitamin C assists in calcium absorption and can increase iron absorption. Smoking increases requirements for vitamin C.





Vitamin D




Needed for: Normal growth; healthy bones, teeth and nails; proper absorption of calcium and phosphorus.




Vitamin E (tocopherol)


Needed for: Cell membrane integrity and protection.






Folate
Folate and Folic Acid are interchangeable terms. Folic acid is the synthetic form of folate, which is found naturally in some foods. Folate is primarily known for preventing neural tube defects, a form of spinal cord deformity in newborns, preventable by taking folate. Folate is essential for the synthesis of RNA and DNA, the genetic material of cells. It plays a vital role in growth and development of cells. Folic acid is necessary for aiding in protein metabolism. It also may be protective against heart disease by lowering homocysteine levels. Folic acid is absorbed from the small intestine.




Of all vitamins, a folate deficiency is most common due to a diet poor in vegetables, primarily dark green leafy vegetables, increased alcohol consumption, and also contributing is folate increased sensitivity to heat and light. Symptoms of folate deficiency include loss of appetite, inflamed tongue and diarrhea. A folate acid deficiency can damage the lining of the gut and lead to further malnutrition.




Folate for Bypass Patients
NSAIDS (Motrin, Advil and Aleve) and anticonvulsants elevate folate requirements. Excess alcohol intake can lead to a deficiency. Of vitamins are not taken daily and increased risk for a deficiency exists. Taking additional B vitamins in a daily supplement form rather than through food only ensures proper micronutrient nutritional status. If you are of childbearing age, please take a folic acid supplement to prevent neutral tube defect. Prenatal vitamins contain twice the RDA for folate.



Vitamin K


Needed for: Production of proteins required for normal blood clotting.






Note: In addition to their other roles, vitamins C, E and beta-carotene (which the body converts into vitamin A) are known as "antioxidants." Certain minerals and other substances also act as antioxidants. Antioxidants can offset the damage caused by free radicals, the unstable, highly reactive molecules formed during the metabolism of glucose and fatty acids to provide energy. Free radicals are also produced in the body by pollutants, ultraviolet light from the sun and drinking alcohol. Free radicals react with and damage many components of tissues, including cellular DNA, or genetic material. Damage from free radicals may lead to conditions such as cataracts, cancer, heart disease and even aging.



Minerals


The minerals we need in our body are those found in rocks, metals, soil and water, though they may be in slightly different forms. While each mineral plays a unique role, collectively they support the body's enzyme systems and keep blood and other body fluids balanced and healthy. Minerals, the major components of bones, also help regulate blood pressure and heart muscle contraction, heal wounds and conduct nerve impulses. The minerals needed in relatively large amounts are: calcium, phosphorus, magnesium, sodium, potassium, chloride and sulfur. Other minerals needed in smaller amounts, called "trace elements," consist of iron, copper, fluorine, iodine, selenium, zinc, chromium, cobalt, manganese and molybdenum. Although the body can't produce any minerals of its own, minerals are found in a large variety of fruits, vegetables, beans and grains.

Calcium


Needed for: Healthy bones, nails, muscle tissue; assists in blood clotting and heart and nerve functions.




Chromium


Needed for: Normal release of energy from glucose.


Copper


Needed for: Enzyme reactions, iron metabolism


Fluoride


Needed for: Healthy bones and teeth that are resistant to decay.


Iodine


Needed for: Regulation of body temperature, thyroid hormone synthesis, metabolic rate, reproduction, growth and nerve and muscle function.


Iron


Needed for: Formation of healthy red blood cells and prevention of anemia; helps carry oxygen to cells. The recommended iron intake is higher for women between the ages of 11 and 50 to compensate for iron loss during menstruation.


Magnesium


Needed for: Energy production, normal heart and nerve function and prevention of muscle cramps


Phosphorus


Needed for: Growth; maintain bone density; assists in energy production; and regulates blood chemistry


Potassium


Needed for: Regulation and balance of body fluids, promotes normal heart rhythm; prevents muscle cramping


Selenium


Needed for: Antioxidant properties protect vitamin E and polyunsaturated fats in the body


Sodium


Needed for: Regulation of body fluids and maintenance of acid-base balance; aids in nerve transmission and muscle contraction


Zinc


Needed for: Normal appetite and taste, wound healing, healthy skin and normal growth
The Bottom Line: Vitamin and mineral supplementation is a life long commitment for gastric bypass patients. Knowledge is your best armor. Eating a balanced diet and taking your supplements provides the best route to fulfilling your nutritional requirements.






Did you know that dietary supplements are taken by more than half of the USA adult population? Sales are going up but which supplements are best and more importantly, are they safe for us to take? The Federal Trade Commission (FTC) regulates the advertising of supplements. The Food and Drug Administration (FDA) has set up DSHA or Dietary Supplements Health and Education Act along with the National Institute of Health (NIH) a framework for supplement regulation and research. Additionally, there is an independently appointed commission who provides reports for the claims for the use of supplements (i.e. vitamins, minerals, herbs, etc.). Dietary supplements have to meet certain criteria. Since March of 1999, manufacturers are required to provide an informative dietary supplement panel on the label, which indicates the following information.




· A statement of identity (i.e. Vitamin C




· Net quantity of contents (i.e. 90 tablets)




· Structure-function claim like “Calcium builds strong bones? and the statement “This statement has been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.?




· Directions for use




· Supplement fact panel (lists serving size, amount and active ingredients)




· Other ingredients in order of predominance




· Name and place of business of manufacturer, packer or distributor along with the address to write for more product information





What are vitamins? Vitamins are nutrients that are essential for maintenance of normal metabolic functions. Vitamins are supplements both synthetic and natural and come in many forms. The water-soluble vitamins are Thiamine (B1), Riboflavin (B2), Niacin (B3), Panethanic Acid (B5), Pyridoxine (B6), Biotin, Cobalamin (B12), Folic Acid, and ascorbic acid (Vitamin C). The fat-soluble vitamins are vitamin A, D, E and K.

The water-soluble vitamins are not significantly stored by the body and need to be replaced daily by food or supplement to maintain adequate levels. These vitamins can be rapidly depleted in conditions interfering with intake or absorption. The fat-soluble vitamins are better stored in the body, and if not excreted, toxic levels could occur. For the gastric bypass patient, who malabsorbs fat, fat-soluble vitamins cannot be digested properly, and are excreted without doing their job. Vitamins in dry form only are therefore suggested. If your vitamins are in an oil base, they are doing you no good.










References








Harvard School of Public Health Protein:Nutrition Source

USDA Nutrient Database for Standard Reference, Release 14. US Department of Agriculture. accessed on 18 July 2002.

National Science Teachers Association, SCILinks





University of Michigan, Anatomy & Physiology Gastrointestinal (GI) System





InteliHealth: Harvard Medical School’s Consumer Health Information





Beyond Change, Sally Myers, RD





First Principles of Gastroenterology: The Basis of Disease and an Approach to Management, Thomson & Shaffer, Chapter 7 – Section 9