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Updated 6/8/09ASMBS Bariatric Nutrition Guidelines(American Society of Metabolic and Bariatric Surgeons)Society of Obesity and Related Disease Publication - August 2008(L. Aills et al. / Surgery for Obesity and Related Diseases)Information compiled by a panel of bariatric surgeons, bariatrician MDs,nutritionists, nurses and nutrition scientists.Excerpt taken from full report. (Pages 7-8)SupplementMultivitamin-mineral supplementAGBRYGBBPD/DS(Adjustable GastricBand)(Roux-en-Y)(Duodenal Switch)Comment100% of dailyvalue200% of dailyvalue200% of dailyvalueBegin on day1 afterhospitaldischarge Available forms include sublingualtablets, liquid drops, mouth spray ornasal gel/spray Intramuscular injection---1000ug/mo---Begin 0-3months aftersurgery Oral tablet (crystalline form) Supplementation after AGB and BPD/DSmight be required---300-500 ug/d--- A high potency vitamin containing 100%of daily value for at least 2/3 ofnutrients Begin with chewable or liquid Progress to whole table/capsule astolerated Avoid time-released supplements Avoid enteric coating Choose a complete formula containingat least 18mg iron, 400 ug folic acid, aswell as selenium and zinc in eachserving Avoid children’s formulas that areincomplete May improve gastrointestinal tolerancewhen taken close to food intake May separate dosage Do not mix multivitamin containing ironwith calcium supplement, take at least2 hours apart Individual brands should be reviewedfor absorption rate and bioavailability Special bariatric formulas are availableAdditional cobalamin(Vitamin B12)1

AGBRYGBBPD/DS(Adjustable GastricBand)(Roux-en-Y)(Duodenal Switch)SupplementAdditional Elemental Calcium1500 mg/day1500-2000mg/day1800-2400mg/dayCan begin onday 1 afterhospitaldischarge orwithin 1month aftersurgery---Minimum18-27 mg/dayelementalMinimum18-27 mg/dayelementalBegin on day1 afterhospitaldischarge Choose a brand that contains calciumcitrate and Vitamin D3 Begin with chewable or liquid Progress to whole tablet/capsule astolerated Split into 500-600mg doses; be mindfulof serving size on label Space dose evenly throughout day Suggest a brand that containsmagnesium, especially for BPD/DS Do not combine calcium with ironcontaining supplements: 1) to maximizeabsorption and 2) to minimizegastrointestinal intolerance Wait 2 hours after taking multivitaminor iron supplement Promote intake of dairy beveragesand/or foods that are significantsources of dietary calcium in additionto recommended supplements, 3servings daily Combined dietary and supplementcalcium intake 1700mg/day might berequired to prevent bone loss duringrapid weight lossAdditional elemental iron Recommended for menstruating andthose at risk of anemia Begin with chewable or liquid Progress to tablet as tolerated Dosage may need to be adjusted basedon biochemical markers (lab results) No enteric coating Do not mix iron and calciumsupplements, take 2 hours apart Avoid excessive intake of tea due totannin interaction Encourage foods rich in heme iron Vitamin C may enhance absorption ofnon-heme iron sourcesCommentSociety of Obesity and Related Disease Publication - August 2008(L. Aills et al. / Surgery for Obesity and Related Diseases)2

AGBRYGBBPD/DS(Adjustable GastricBand)(Roux-en-Y)(Duodenal Switch)SupplementFat-soluble Vitamins------ With all procedures, highermaintenance doses may be required forthose with history of deficiency Water-soluble preparations of fatsoluble vitamins are available Retinol sources of Vitamin A should beused to calculate dosage Most supplements contain a highpercentage of beta carotene which doesnot contribute to Vitamin A toxicity Intake of 2000 IU Vitamin D3 may beachieved with careful selection ofmultivitamins and calcium supplements No toxic effect known for Vitamin K,phytonadione (phyloquinone) Vitamin K requirement varies withdietary sources and colonic production Caution with Vitamin K supplementsshould be used for patients receivingcoagulation therapy Vitamin E deficiency is not prevalent inpublished studiesOral Vitamin B ComplexComment10,000 IUVitamin A2000 IUVitamin D300 ugVitamin K1 per day1 per dayB-50 dosageLiquid form is availableAvoid time released tabletsNo known risk of toxicityMay provide additional prophylaxisagainst B-Vitamin deficiencies,including thiamin, especially forBPD/DS procedures as water-solublevitamins are absorbed in proximaljejunum Note: 1000mg of supplemental folicacid, provided in combination withmultivitamin, could mask B12deficiency 1 per dayMay begin onday 1 afterhospitaldischargeSociety of Obesity and Related Disease Publication - August 2008(L. Aills et al. / Surgery for Obesity and Related Diseases)3

Common Nutrient DeficienciesThis information refers to the general population, not just the WLS community.Also remember that after gastric bypass surgery we are not fully able to absorb micronutrients (vitamins andminerals) from the food we eat – thus the need to a lifetime of taking vitamins and supplements.NutrientIncidence of DeficiencyTypical Symptoms and DiseasesNatural Sources of Nutrientchard, tomatoes, romaine lettuce,carrots, almonds, chicken eggs,onions, cabbage, cucumber,cauliflower, goat's milk, cow's milk,raspberries, strawberries, halibut,oats, and walnuts.BiotinUncommonDermatitis, eye inflammation, hair loss, loss ofmuscle control, insomnia, muscle weaknessCalciumAverage diet contains 40 to 50% ofRDA*blackstrap molasses, Swiss chard,Brittle nails, cramps, delusions, depression,insomnia, irritability, osteoporosis, palpitations, yogurt, kale, mozzarella cheese,cow's milk,goat's milk, Basil, thyme,periodontal disease, rickets, tooth decaydill seed, cinnamon, and peppermintleaves, romaine lettuce, celery,broccoli, sesame seeds, fennel,cabbage, summer squash, greenbeans, garlic, tofu, Brussel sprouts,oranges, asparagus and criminimushrooms.Chromium90% of diets deficientAnxiety, fatigue, glucose intolerance, adultonset diabetesCopper75% of diets deficient; average diet Anemia, arterial damage, depression, diarrhea,contains 50% of RDA*fatigue, fragile bones, hair loss,hyperthyroidism, weaknesscalf's liver, crimini mushrooms, turnipgreens, molasses, chard, spinach,sesame seeds, mustard greens,kale, summer squash, asparagus,eggplant, and cashews, peppermint,tomatoes, sunflower seeds, ginger,green beans, potato, and tempehOmega 3 FattyAcidsVery commonDiarrhea, dry skin and hair, hair loss, immuneimpairment, infertility, poor wound healing,premenstrual syndrome, acne, eczema, gallstones, liver degenerationSalmon, flax seeds and walnuts,scallops, cauliflower, cabbage,cloves and mustard seeds, halibut,shrimp, cod, tuna, soybeans, tofu,kale, collard greens, and Brusselssprouts.Folic acidAverage diet contains 60% of RDA*;deficient in 100% of elderly in onestudy; deficient in 48% ofadolescent girls; requirementdoubles in pregnancyAnemia, apathy, diarrhea, fatigue, headaches,insomnia, loss of appetite, neural tube defectsin fetus, paranoia, shortness of breath,weaknessromaine lettuce, spinach, asparagus,turnip greens, mustard greens, calf'sliver, parsley, collard greens,broccoli, cauliflower, beets, andlentils, squash, black beans, pintobeans, garbanzo beans, papaya andstring beans.IodineUncommon since theCretinism, fatigue, hypothyroidism, weight gain Sea vegetables, Yogurt, cow's milk,eggs, strawberries, mozzarellasupplementation of salt with iodinecheeseIronMost common mineral deficiencyAnemia, brittle nails, confusion, constipation,depression, dizziness, fatigue, headaches,inflamed tongue, mouth lesionsromaine lettuce, onions, tomatoes,brewer's yeast, oysters, liver, wholegrains, bran cereals, and potatoeschard, spinach, thyme, turmeric,romaine lettuce, blackstrapmolasses, tofu, mustard greens,turnip greens, string beans, shiitakemushrooms, beef tenderloin, lentils,Brussel sprouts, asparagus, venison,garbanzo beans, broccoli, leeks, kelp4

NutrientIncidence of DeficiencyTypical Symptoms and DiseasesNatural Sources of NutrientSwiss chard, spinach, mustardgreens, summer squash, broccoli,blackstrap molasses, halibut, turnipgreens, pumpkin seeds, peppermint,cucumber, green beans, celery, kaleand a variety of seeds, includingsunflower seeds, sesame seeds, flaxseedsMagnesium75 to 85% of diets deficient: average Anxiety, confusion, heart attack, hyperactivity,diet contains 50 to 60% of RDA*insomnia, nervousness, muscular irritability,restlessness, weaknessManganeseUnknown, may be common inwomenAtherosclerosis, dizziness, elevated cholesterol, mustard greens, kale, chard,glucose intolerance, hearing loss, loss of muscle raspberries, pineapple, romainelettuce, spinach, collard greens,control, ringing in earsturnip greens, kale, maple syrup,molasses, garlic, grapes, summersquash, strawberries, oats, spelt,green beans, brown rice, garbonzobeans, ground cloves, cinnamon,thyme, peppermint, turmeric, leeks,tofu, broccoli, beets, beets, wholewheat, tempeh, cucumber, peanuts,millet, barley, figs, bananas, kiwifruit,carrots black beansNiacin (B3)Commonly deficient in elderlyBad breath, canker sores, confusion, depression, mushrooms, tuna, beef liver, halibut,asparagus, sea vegetables, venison,dermatitis, diarrhea, emotional instability,chicken, salmonfatigue, irritability, loss of appetite, memoryimpairment, muscle weakness, nausea, skineruptions and inflammationMushrooms, cauliflower, broccoli,Pantothenic acid Average elderly diet contains 60% of Abdominal pains, burning feet, depression,RDA*eczema, fatigue, hair loss, immune impairment, calf's liver, turnip greens, sunflower(B5)insomnia, irritability, low blood pressure, muscle seeds, tomato, strawberries,spasms, nausea, poor coordinationyogurt, eggs, winter squash, collardgreens, chard and corn.PotassiumCommonly deficient in elderlyAcne, constipation, depression, edema,excessive water consumption, fatigue, glucoseintolerance, high cholesterol levels, insomnia,mental impairment, muscle weakness,nervousness, poor reflexesPyridoxine (B6) 71% of male and 90% of female diets Acne, anemia, arthritis, eye inflammation,deficientdepression, dizziness, facial oiliness, fatigue,impaired wound healing, irritability, loss ofappetite, loss of hair, mouth lesions, nauseachard, crimini mushrooms, spinach,fennel, kale, mustard greens,Brussel sprouts, broccoli, wintersquash, blackstrap molasses,eggplant, cantaloupe, tomatoes,parsley, cucumber, bell pepper,turmeric, apricots, ginger root,strawberries, avocado, banana,tuna, halibut, cauliflower cabbage.spinach, bell peppers, turnipgreens, garlic, tuna, cauliflower,mustard greens, banana, celery,cabbage, crimini mushrooms,asparagus, broccoli, kale, collardgreens, Brussels sprouts, cod, chard5

NutrientIncidence of DeficiencyTypical Symptoms and DiseasesNatural Sources of NutrientRiboflavin (B2)Deficient in 30% of elderly BritonsBlurred vision, cataracts, depression, dermatitis,dizziness, hair loss, inflamed eyes, mouthlesions, nervousness, neurological symptoms(numbness, loss of sensation, "electric shock"sensations), seizures. sensitivity to light,sleepiness, weaknessmushrooms, calf liver, spinach,romaine lettuce, asparagus, chard,mustard greens, broccoli, collardgreens venison, turnip greens,chicken eggs, yogurt, cow's milkSeleniumAverage diet contains 50% of RDAGrowth impairment, high cholesterol levels,increased incidence of cancer, pancreaticinsufficiency (inability to secrete adequateamounts of digestive enzymes), immuneimpairment, liver impairment, male sterilityBrazil nuts, button mushrooms,shiitake mushrooms, cod, shrimp,snapper, tuna, halibut, calf's liver,salmon, chicken's eggs, lamb,barley, sunflower seeds, turkey,mustard seeds, oatsThiamin (B1)Commonly deficient in elderlyConfusion, constipation, digestive problems,irritability, loss of appetite, memory loss,nervousness, numbness of hands and feet, painsensitivity, poor coordination, weaknessasparagus, romaine lettuce,mushrooms, spinach, sunflowerseeds, tuna, green peas, tomatoes,eggplant and Brussels sprouts.Vitamin A20% of diets deficientAcne, dry hair, fatigue, growth impairment,insomnia, hyperkeratosis (thickening androughness of skin), immune impairment, nightblindness, weight lossCalf liver, Cow's milk, eggs, carrots,sweet potatoes, spinach, kale,collard greens, and tomatoesVitamin B-12Serum levels low in 25% of hospitalpatientsAnemia, constipation, depression, dizziness,fatigue, intestinal disturbances, headaches,irritability, loss of vibration sensation, lowstomach acid, mental disturbances, moodiness,mouth lesions, numbness, spinal corddegenerationSnapper, calf's liver, venison,shrimp, scallops, salmon, and beef.Plant sources are less consistentlygood sources of B-12: sea plants(like kelp), algaes (like blue-greenalgae), yeasts (like brewer's yeast),and fermented plant foods (liketempeh, miso, or tofu)Vitamin C20 to 50% of diets deficientBleeding gums, depression, easy bruising,broccoli, bell peppers, kale,impaired wound healing, irritability, joint pains, cauliflower, strawberries, lemons,mustard and turnip greens, brusselsloose teeth, malaise, tiredness.sprouts, papaya, chard, cabbage,spinach, kiwifruit, snow peas,cantaloupe, oranges, grapefruit,limes, tomatoes, zucchini,raspberries, asparagus, celery,pineapples, lettuce, watermelon,fennel, peppermint and parsley.Vitamin D62% of elderly women's dietsdeficientBurning sensation in mouth, diarrhea, insomnia, salmon, shrimp, vitamin-D fortifiedmilk, cod, eggsmyopia, nervousness, osteomalacia,osteoporosis, rickets, scalp sweatingVitamin E23% of male and 15% of female diets Gait disturbances, poor reflexes, loss of position mustard greens, turnip greens,deficientsense, loss of vibration sense, shortened redchard, sunflower seeds, almonds,blood cell lifespinach, collard greens, parsley,kale, papaya, olives, bell pepper,brussels sprouts, kiwifruit, tomato,blueberries, broccoli6

NutrientIncidence of DeficiencyTypical Symptoms and DiseasesNatural Sources of NutrientVitamin KDeficiency in pregnant women andnewborns commonBleeding disordersspinach, Brussels sprouts, Swisschard, green beans, asparagus,broccoli, kale, mustard greens, greenpeas, carrots.Zinc68% of diets deficientAcne, amnesia, apathy, brittle nails, delayedsexual maturity, depression, diarrhea, eczema,fatigue, growth impairment, hair loss, highcholesterol levels, immune impairment,impotence, irritability, lethargy, loss ofappetite, loss of sense of taste, low stomachacid, male infertility, memory impairment, nightblindness, paranoia, white spots on nails, woundhealing impairmentCalf's liver, crimini mushrooms,spinach, sea vegetables, basil,thyme, spinach, pumpkin seeds,yeast, beef, lamb, beef, lamb,summer squash, asparagus, venison,chard, collard greens, miso, shrimp,maple syrup, broccoli, peas, yogurt,pumpkin seeds, sesame seeds,mustard greens.7

(This diagram represents a typical bypass amount of 150cm.)8

Which Vitamins, When?(From Pam Tremble’s OH Profile)Here are the basic interaction rules when figuring out when to take your vitamins:With food or without? -- In general vitamins and supplements are best taken with a meal orsnack because the molecules can bind with food and be better absorbed in the body. The onlyexception to this rule is iron – iron likes an empty, acid tummy, so take it at least 1 hour before orafter a meal.Calcium and Vitamin D are Friends --- take them together, they help each other absorb better.Your body can only deal with 500mg at a time, so split up your doses into 3 or 4 doses per day toreach your 1500-2000mg daily goal. Calcium tends to absorb better when taken with a meal, soschedule it that way if you can.Iron and Vitamin C are Friends --- Iron needs an acid environment to break down and Vitamin Cdoes that job so make sure they are in your tummy at the same time. Iron does not like food, sotake it on an empty stomach. However, if you get an upset tummy because of the iron, pick anon-dairy snack.Iron and Calcium are Enemies --- iron and calcium fight for the same cell receptors in the bodyand calcium is “bigger and badder” and always wins. Which means the iron is simply excreted infeces and not used at all. Keep iron and calcium at least 2 hours apart from each other.Vitamin B's are a Family --- they work together as a team and are best taken at the same time.Your Multi-Vitamin has many B's in it, so take it together with your biotin, B12, B-50 Complex andany other individual B’s you might be taking.Some foods and drugs interfere with vitamin absorption. Here are some basic guidelines:CalciumAids in Absorption Vitamin DIron Vitamin C or other acid-creatingdoes not need to be in tummy atsame time, but serum levelsshould be within normal rangefor best utilization of calcium Magnesium - 2:1 ratio to calcium(ie: 2000mg calcium to 1000mgmagnesium, based on your body’stolerance) LactoseHinders Absorption Iron – food or supplementsHigh fiber dietTannins (in tea and coffee)Caffeine (over 400mg/day)Excess Phosphoric Acid (containedin soda, bottled tea and someflavored waters) Ratio should be 1:1 Excess soy intake (contains highphosphorus)agent (i.e.: orange juice) Calcium – food or supplement over 300mgTannins (in tea and coffee)CaffeinePhytates (found in beans)High fiber diet9

Calcium Citrate vs. Calcium Carbonate(From Pam Tremble’s OH Profile)After RNY our pouch no longer produces gastric acid (scientifically known as hydrochloric acid).And after surgery most surgeons have their patients take a proton pump inhibitor for severalweeks/months after surgery to "kill of" any remaining acid producing cells that might causeulcers. I took Prevacid for 12 months post-op.The diagnosis for lack of gastric acid in a patient’s stomach is called Achlorhydria. This disorder isoften seen in elderly patients, but since WLS has become increasingly popular, doctors haverecognized that RNY patients need the same alternative treatment as elderly patients who havethe same diagnosis.Calcium carbonate requires gastric acid in order to break down and be used by the body. It doesnot break down in a neutral pH environment -- meaning it is not water soluble, it requires a highlyacid environment to be bioavailable.Calcium citrate is water soluble and dissolves quickly and easily in a neutral pH environment. Noacid is required. In fact, a calcium citrate supplement tablet will dissolve in plain water in about5 to 7 minutes.In 1985, R. R. Recker published a study in the New England Journal of Medicine that showed theabsorption rates of calcium carbonate vs. calcium citrate in patients with normal stomach acid vs.patients with achlorhydria. Patients with achlorhydria absorbed calcium carbonate at a rate of 4%and absorbed calcium citrate at a rate of 45%. Patients with normal hydrochloric acid levelsabsorbed calcium (either type) at about the same rate with no significant difference inabsorption. Calcium citrate is also recommended by the American Society of Metabolic andBariatric Surgeons (ASMBS) due to proven absorption rates in the post-op pouch.So what does all this mean?It means that after RNY we must use calcium citrate as our calcium supplementation. Calciumcarbonate does not dissolve and is not used by our body after WLS. The ASMBS Guidelines forBariatric Nutrition recommends we take 1500-2000mg of calcium citrate supplement per day inaddition to whatever calcium we get from food (1500mg for gastric band patients). It is commonknowledge among the medical community that doses of calcium must be no larger than 500-600mg at a time, spaced at least 2 hours apart.Tums, Viactiv, Caltrate and the generic versions of all these brands.are calcium carbonate.Stay away from them. Look for Citracal, Bariatric Advantage, UpCalD, TwinLabs Calcium Citrateand others that are calcium citrate. Read the label carefully not only for the type of calcium, butalso for the serving size. Many calcium citrate brands require 2 pills per dose, so do the mathaccording to your daily requirements. For instance, Citracal Petites have 200mg calcium perpill. so to get 2000mg of calcium per day you'll need 10 pills in 4-5 doses throughout the day.My mom had RNY 5.5 years ago. She was never taught the difference between calcium carbonateand calcium citrate. She was simply told to "take calcium" -- not even told a certain amount perday, just to take the supplement. She took calcium carbonate since it was cheaper and easier tofind – when she remembered to take it at all. This past year she was diagnosed with osteoporosiswith an 18.1% bone density loss in her spine. She is only 54 years old and faces a very difficultroad ahead with brittle bones, fractures and dental problems. I preach about calcium sopassionately because I don't want any other WLS patient to be faced with the same fate.10

Types of CalciumSupplement TypeElemental Calciumby WeightCalcium Carbonate40%Comments Most commonly used Less well absorbed in persons withdecreased stomach acid (e.g., elderly orthose on anti-acid medication or gastricbypass surgery) Natural preparations from oyster shell orbone meal may contain contaminants suchas lead Least expensiveCalcium Citrate21% Better absorbed, especially by those withdecreased stomach acid May protect against kidney stones More expensiveCalcium Phosphate38% or 31% Tricalcium or dicalcium phosphate Used more in Europe Absorption similar to calcium carbonateCalcium Gluconate9% Used intravenously for severehypocalcaemia Well absorbed orally, but low content ofelemental calcium Very expensiveCalcium Glubionate6.5% Available as syrup for children Low content elemental calciumCalcium Lactate13% Well absorbed Low content elemental calciumSOURCE: Gregory, Philip J. (2000) "Calcium Salts." Prescriber's Letter. Document #160313Understanding Calcium Citrate alciumAS Citrate contains 500mg elemental calciumFROM Citrate contains 500mg elemental calciumCitrate contains 21% elemental calcium 105mg it’s probably calcium carbonate, but who knowsfor sure! If it isn’t properly labeled, don’t buy it.READ THE LABEL & DO THE MATHMake sure you read the label to determine serving size of a fulldose. Then do the math to determine how many tablets youneed per day to reach your total calcium goal.11

Why your serum calcium lab results mean nothing99% of the calcium in your body is contained in bones, teeth and cell tissue.1% of your calcium is contained in your blood.When you have blood drawn for labwork, only 1% of your total body calcium is being tested. Thebody needs a perfect calcium level in the blood in order to control essential functions of the bodyincluding cell growth; blood clothing; organ, nerve and muscle function. Basically, the body isgoing to do whatever it has to do to keep the blood calcium level perfect in order to keep yourheart beating and to keep you alive.When your blood calcium level is just slightly off, your body sends a distress signal to theparathyroid that it needs more calcium. The parathyroid will signal to your body to releasecalcium from your bones and teeth to get the blood calcium level back in line immediately.Therefore, your labwork will always show that your calcium levels are “perfect.”Because of its biological importance, calcium levels are carefully controlled in variouscompartments of the body. The three major regulators of blood calcium are parathyroidhormone (PTH), vitamin D, and calcitonin. PTH is normally released by the four parathyroid glandsin the neck in response to low calcium levels in the bloodstream (hypocalcemia). PTH acts in threemain ways: (1) It causes the gastrointestinal tract to increase calcium absorption from food, (2) itcauses the bones to release some of their calcium stores, and (3) it causes the kidneys to excretemore phosphorous, which indirectly raises calcium levels.Vitamin D works together with PTH on the bone and kidney and is necessary for intestinalabsorption of calcium. Vitamin D can either be obtained from the diet or produced in the skinwhen it is exposed to sunlight or taken as a dietary supplement. Calcitonin, a hormone releasedby the thyroid, parathyroid, and thymus glands, lowers blood levels by promoting the depositionof calcium into bone.Most dietary calcium is absorbed in the small intestine and transported in the bloodstream boundto albumin, a simple protein. Because of this method of transport, levels of albumin can alsoinfluence blood calcium measurements.How do you know if your body is leaching calcium from your bones and teeth?If your lab results show a chronic combination of the following, your body is stealing calciumstores from your bones and teeth:Calcium Levels within normal rangeVitamin D (D25hydroxy) low or deficientPTH (parathyroid) highSource: http://www.faqs.org/nutrition/Ca-De/Calcium.html12

Why is Vitamin D so Important?Vitamin D is the gatekeeper of calcium in the body. As long as there is a healthy level Vitamin D in thebody calcium is able to work properly. If you are deficient in Vitamin D, then the body will signal tothe parathyroid gland that you aren’t able to properly absorb calcium and it will begin to pull calciumstores from your bones and teeth.There are two main types of Vitamin D. Ergosterol is the basic building block of vitamin D in plants.Cholesterol is the basic building block of vitamin D in humans. Although the body is able to use eitherform of Vitamin D, it is easier for the body to utilize and store Vitamin D3.VITAMIN D2 - When ultraviolet light from the sun hits the leaf of a plant, ergosterol is converted intoergocalciferol.VITAMIN D3 - When ultraviolet light hits the cells of our skin, one form of cholesterol found in our skincells - called 7-dehydrocholesterol - can be converted into cholecalciferol, a form of vitamin D3.Vitamin D Helps to: Prevent bone fracturesPrevent falls in older people and osteoporosisReduce the risk of cancer, especially colon cancer, prostate cancer, and breast cancerReduce the risk of diabetes, especially in young people and in those living in high altitudeProtect against heart disease, including high blood pressure and heart failureReduce your risk for multiple sclerosisImprove you moodImprove your lung function.If You Don't Get Enough Vitamin D Your bones can become weak and can breakChildren can get "rickets," a disease that prevents their bones from growing properly, delaystheir growth, and causes problems with their immune systemAdults can develop "osteomalacia," a disease that weakens the bones and makes them hurt,and also causes fracturesOlder adults can get osteoporosis, which doesn't cause pain, but makes the bones thin and easyto fractureIt has been said that 85% of all Americans are Vitamin D deficient. That number is even higher inresidents of northern states because of the lack of sunlight in winter months. People with dark skin(African Americans, Latinas, Asians, etc.) are more likely to be Vitamin D deficient because their skinpigmentation blocks the UVB rays needed for the body to convert sunlight into Vitamin D.There are three main sites in the digestive tract where Vitamin D is absorbed (see diagram on page 8).After RNY two of those three sites are bypassed. Vitamin D is a fat soluble vitamin and since wemalabsorb fat after RNY – the likelihood that we become Vitamin D deficiency is even greater.Because gastric bypass patients malabsorb fats in the diet, it is important for us to use a water solubleformulation of Vitamin D3 for the best chance of absorption. This formula is often referred to as“dry” Vitamin D3. Basically all that means is that it’s not suspended in an oil-based formula. You wantto look for a white tablet or a capsule filled with a white powder. Avoid gel-caps as these are oilbased formulations.13

Vitamin D continued What is a Good Lab Result?The lab test is called: 25-hydroxyvitamin D test or 25(OH)D for short. Each lab will has their ownrange of “normal” – but the typical standard is 30-100 ng/ml. However, new studies show thatminimum levels should be 50 ng/ml or above for both adults and children. These new studies foundthat the body does not reliably begin storing cholecalciferol in fat and muscle tissue until 25(OH)Dlevels get above 50 ng/ml. The average person starts to store cholecalciferol at 40 ng/ml, but at50 ng/ml virtually everyone begins to store it for future use. That is, at levels below 50 ng/ml, thebody uses up vitamin D as fast as you can make it, or take it.Additionally, it is being found that the reduction in cancer risks and multiple sclerosis risks are notrealized until the 25(OH)D levels are maintained over the level of 80 ng/ml. (Source: The Vitamin D Council)How Much Do We Need?Humans make at least 10,000 units of vitamin D within 30 minutes of full body exposure to the sun,what is called a minimal erythemal dose. Vitamin D production in the skin occurs within minutes and isalready maximized before your skin turns pink. HOWEVER, remember to balance your need for sunlightfor Vitamin D production with the added risk of skin cancer due to being in the sun without sunscreenprotection.The current U.S. RDA for Vitamin D is 800IU/day. However, we know that the RDA is the minimumamount needed to simply keep us alive not necessarily keep us healthy. The Vitamin D Councilindicates that healthy adults who need to maintain their already ideal 25(OH)D level should take2000IU/day. Individuals who are trying to increase their Vitamin D level should take 5,000IU/day.Current research is showing that higher doses (up to 10,000IU/day) are not causing levels of toxicity.However, you should always consult your doctor for therapeutic dosing when you are Vitamin Ddeficient.Foods that Provide Vitamin DThese are good sources for Vitamin D, but remember that if you have RNY or DS, your body is not fullyable to pull micronutrients from the food we eat.FOODSERVING SIZEVITAMIN D, IUCod liver oil1 Tablespoon1360Salmon, cooked3 1/2 ounces360Mackerel, cooked3 1/2 ounces345

Information compiled by a panel of bariatric surgeons, bariatrician MDs, nutritionists, nurses and nutrition scientists. Excerpt taken from full report. (Pages 7-8) Supplement AGB (Adjustable Gastric Band) RYGB (Roux-en-Y) BPD/DS (Duodenal Switch) Comment Multivitamin-mineral supplement A high potency vitamin containing 100%