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Clinical Biochemistry Volume 36, Issue 8, November 2003, Pages 585–590 Elevated levels of serum cobalamin may be a sign of a serious, even life-threatening, disease. Hematologic disorders like chronic myelogeneous leukemia, promyelocytic leukemia, polycythemia vera and also the hypereosinophilic syndrome can result in elevated levels of cobalamin. Not surprisingly, a rise of the cobalamin concentration in serum is one of the diagnostic criteria for the latter two diseases. The increase in circulating cobalamin levels is predominantly caused by enhanced production of haptocorrin. Several liver diseases like acute hepatitis, cirrhosis, hepatocellular carcinoma and metastatic liver disease can also be accompanied by an increase in circulating cobalamin. This phenomenon is predominantly caused by cobalamin release during hepatic cytolysis and/or decreased cobalamin clearance by the affected liver. Altogether it can be concluded that an observed elevation of cobalamin in blood merits the a full diagnostic work up to assess the presence of disease.

http://www.doctorweight.com/bariatricsurgery/narrowingstomach/antirefluxsleevegastroplasty/ At the same time, it is known that 30% of patients complain of heartburn after the procedure, necessitating administration of omeprazole (a drug reducing gastric acid production). This is because the original sleeve gastrectomy procedure destroys the valve mechanism of the junction between the esophagus and the stomach, converting it into a direct tube. If a sleeve gastrectomy is performed as the first stage of gastric bypass, then after the second stage (gastrojejunal bypass) the heartburn disappears. But if a sleeve gastrectomy is planned as a sole operation, then persistent heartburn might be a serious problem for the patient.

http://ncp.sagepub.com/content/27/6/788.full.pdf+html Nystagmus : An Uncommon Neurological Manifestation of Thiamine Deficiency as a Serious Complication of Sleeve Gastrectomy

Do people get their copper checked? Mine went high. http://www.ncbi.nlm.nih.gov/pubmed/17727313 Clin Chem Lab Med. 2007;45(10):1402-10. Clinical significance of the laboratory determination of low serum copper in adults. Kumar N, Butz JA, Burritt MF. SourceDepartment of Neurology, Mayo Clinic, Rochester, MN55905, USA. kumar.neeraj@mayo.edu In six of the 57 patients with low serum copper, the low copper was due to Wilson disease. In the remaining 51 patients, copper deficiency due to an underlying cause was identified in 38 as a reason for the low serum copper. The most commonly identified neurological manifestation of copper deficiency was myeloneuropathy. Coexisting nutrient deficiencies and hematological manifestations of copper deficiency were often but not invariably present. CONCLUSIONS: Copper deficiency, Wilson disease (or a carrier state), and aceruloplasminemia are all associated with low serum copper. The presence of coexisting neurological or hematological manifestations that are recognized sequelae of copper deficiency should be considered prior to making a diagnosis of copper deficiency. Gastrointestinal disease or surgery is a common cause of acquired copper deficiency. Even in patients in whom low serum copper is indicative of copper deficiency, the cause of the copper-deficient state may not be evident. http://www.ncbi.nlm.nih.gov/pubmed/15249607 Neurology. 2004 Jul 13;63(1):33-9. Copper deficiency myelopathy produces a clinical picture like subacute combined degeneration. Kumar N, Gross JB Jr, Ahlskog JE. SourceDepartment of Neurology, Mayo Clinic, Rochester, MN, USA. kumar.neeraj@mayo.edu RESULTS: Thirteen such patients were found, 11 of them in a 15-month period. All patients presented with prominent gait difficulty, reflecting a sensory ataxia due to dorsal column dysfunction and lower limb spasticity. All patients had polyneuropathy. A high or high-normal serum zinc level was seen in 7 of the 11 patients for whom this information was available. Somatosensory evoked potential studies done in eight patients showed impaired conduction in central proprioceptive pathways. Dorsal column signal change on spine MRI was present in three patients. An initial clue to the diagnosis was a very low ceruloplasmin level; further tests of copper metabolism excluded Wilson disease. The cause remained unexplained in most patients. Oral copper supplementation restored normal or near-normal copper levels in 7 of the 12 patients in whom adequate follow-up data were available; parenteral supplementation restored normal level in 3 further patients. Copper supplementation prevented further neurologic deterioration, but the degree of actual improvement was variable. CONCLUSIONS: Unrecognized copper deficiency appears to be a common cause of idiopathic myelopathy in adults. The clinical picture bears striking similarities to the syndrome of subacute combined degeneration associated with Vitamin B12 deficiency. Early recognition and copper supplementation may prevent neurologic deterioration. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3432875/ J Obes. 2012; 2012: 608534. Published online 2012 June 13. doi: 10.1155/2012/608534PMCID: PMC3432875The Neurological Complications of Nutritional Deficiency following Bariatric Surgery http://www.ncbi.nlm.nih.gov/pubmed/19365170 Am J Med Sci. 2009 Apr;337(4):256-8. doi: 10.1097/MAJ.0b013e31818ad0ff. Copper deficiency after gastric surgery: a reason for caution. Prodan CI, Bottomley SS, Vincent AS, Cowan LD, Greenwood-Van Meerveld B, Holland NR, Lind SE. SourceFrom the Department of Neurology, Veterans Affairs Medical Center and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA. calin-prodan@ouhsc.edu BACKGROUND: : Acquired copper deficiency in adults leads to hematological and neurological manifestations that mimic vitamin B12 deficiency. A significant number of patients with copper deficiency syndrome have a history of gastric surgery, often remote. We sought to determine whether copper deficiency is present in a population of individuals with longstanding partial gastric resection. RESULTS: : Hypocupremia and symptoms of copper deficiency were detected in patients with partial gastric resection in contrast to controls (3/20 versus 0/50, P = 0.02). Serum copper and ceruloplasmin levels were significantly lower in individuals with partial gastric resection than in controls (P = 0.04 and P = 0.001, respectively). The mean interval between gastric surgery and testing was 20.7 years. CONCLUSIONS: : Our results indicate that a significant number of individuals with longstanding history of partial gastric resection have undiagnosed hypocupremia. Screening for copper deficiency after gastric surgery may prevent the development of hematological and neurological complications in these patients.

Like liver disease, an elevated Vitamin B12 level cannot adequately provide a diagnosis of leukemia. But it may indicate the need for further testing. Leukemia is a type of cancer in which white blood cells are higher than normal in either your blood or bone marrow. It also causes a reduction in red blood cells and platelets, cells needed for clotting blood. This basically means that your body will not hold on to the vitamin unless it is used. The unnecessary vitamin remaining in your body will be excreted in your urine. As stated above, there are instances where a person's kidneys are not filtering properly & may cause an abundance of a multitude of substances. That being stated, the BUN & Creatine levels would have been out of the normal range indicating your kidneys are not functioning properly.

http://www.ncbi.nlm.nih.gov/pubmed/20202584 Postoperative metabolic and nutritional complications of bariatric surgery. Patients who have undergone bariatric surgery require indefinite, regular follow-up care by physicians who need to follow laboratory parameters of macronutrient as well as micronutrient malnutrition. Physicians who care for patients after bariatric surgery need to be familiar with common postoperative syndromes that result from specific nutrient deficiencies. http://www.ncbi.nlm.nih.gov/pubmed/20152742 Medical follow up after bariatric surgery: nutritional and drug issues. General recommendations for the prevention and treatment of nutritional deficiencies. The risk of nutritional deficiencies depends on the percentage of weight loss and the type of surgical procedure performed. Purely restrictive procedures (AGB, SG), for example, can induce digestive symptoms, food intolerance or maladaptative eating behaviours due to pre- or postsurgical eating disorders. Iron deficiency is common with the three types of bariatric surgery, especially in menstruating women. Rare deficiencies can lead to serious complications such as encephalopathy or protein-energy malnutrition. Long-term problems such as changes in bone metabolism or neurological complications need to be carefully monitored. In addition, routine nutritional screening, recommendations for appropriate supplements and monitoring compliance are imperative, whatever the bariatric procedure. Key points are: (1) virtually routine mineral and multivitamin supplementation; and (3) regular, life-long, follow-up of all patients. The role of the general practitioner has also to be emphasized: clinical visits and follow-ups should be monitored and coordinated with the bariatric team, including the surgeon, the obesity specialist, the dietitian and mental health professionals. http://www.ncbi.nlm.nih.gov/pubmed/20363593 Micronutrient deficiencies after bariatric surgery. The literature suggests that bariatric surgery patients are at risk for deficiency of the following nutrients after surgery: Vitamins B(12), B(1), C, folate, A, D, and K, along with the trace minerals iron, selenium, zinc, and copper. Over-the-counter multivitamin and mineral supplements do not provide adequate amounts of certain nutrients such as Vitamin B(12), iron, or fat-soluble vitamins and patients will require additional doses of prophylactic supplementation life-long to maintain optimal micronutrient status. In addition, preconception care for adequate prenatal supplementation is critical for pregnant women who have undergone bariatric surgery, as iron, vitamin A, vitamin B(12), vitamin K, and folate deficiencies are associated with maternal and fetal complications, including severe anemia, congenital abnormalities, low birth weight, and failure to thrive. All bariatric surgery patients would be best served by receiving regular monitoring of serum nutrient levels starting at 3 mo after surgery and periodically thereafter.

http://www.ncbi.nlm.nih.gov/pubmed/22525731 Nutritional deficiencies after bariatric surgery. The major macronutrient deficiency after bariatric surgery is protein malnutrition. Deficiencies in micronutrients, which include trace elements, essential minerals, and water-soluble and fat-soluble vitamins, are common before bariatric surgery and often persist postoperatively, despite universal recommendations on multivitamin and mineral supplements. Other disorders, including small intestinal bacterial overgrowth, can promote micronutrient deficiencies, especially in patients with diabetes mellitus. Recognition of the clinical presentations of micronutrient deficiencies is important, both to enable early intervention and to minimize long-term adverse effects. A major clinical concern is the relationship between vitamin D deficiency and the development of metabolic bone diseases, such as osteoporosis or osteomalacia; metabolic bone diseases may explain the increased risk of hip fracture in patients after RYGB. Further studies are required to determine the optimal levels of nutrient supplementation and whether postoperative laboratory monitoring effectively detects nutrient deficiencies. In the absence of such data, clinicians should inquire about and treat symptoms that suggest nutrient deficiencies.

http://www.ncbi.nlm.nih.gov/pubmed/20842487 Prevention and treatment of peripheral neuropathy after bariatric surgery. As a result, deficiencies in vitamins, minerals, and trace elements may develop, leading to a variety of neurologic complications. The peripheral neuropathies best described with a clear-cut cause are an acute, frequently painful neuropathy or polyradiculoneuropathy associated with thiamine deficiency, and an isolated neuropathy or myeloneuropathy associated with deficiencies of either vitamin B12 or copper. Thiamine deficiency tends to occur in the first weeks or months after surgery, vitamin B12 deficiency may develop at any time from a few years to many years after surgery, and copper deficiency tends to be a fairly late complication, developing several years to many years following surgery. Patients who have undergone bariatric surgery may also have an increased risk of developing focal neuropathies, though these are less clearly related to specific nutritional deficiencies.Ideally, one would like to prevent these neuropathies, but there is no consensus of opinion as to what vitamins and micronutrients need to be taken following bariatric surgery. In addition, many patients who take supplements early on fail to maintain the regimen even though some of the neuropathies can occur fairly late. Supplements frequently recommended include a multivitamin, iron, vitamin D, folic acid, calcium citrate, and vitamin B12. Although thiamine is typically included in a multivitamin, the amount is fairly small, so I recommend adding 100 mg daily for at least the first year. Some have suggested zinc supplementation, but this is potentially problematic because exogenous zinc may interfere with copper absorption. Obtaining blood work every 6 months after surgery will help to identify and treat nutritional deficiencies early.For those patients who have had a bariatric procedure and then develop a neuropathy, evaluating levels of thiamine, copper, vitamin B12, methylmalonic acid, and homocystine is indicated. In addition, since one deficiency is frequently associated with others, obtaining levels of vitamin A, C, D, K, and E, as well as iron, zinc, selenium, and magnesium is worthwhile. Checking total protein, albumin, and cholesterol also gives a sense of general nutritional status. Occasionally, no clear-cut deficiency of a vitamin, mineral, or trace element can be identified in patients with various peripheral nervous system manifestations. Nevertheless, these patients may have at least some recovery with improving nutritional intake and vitamin supplementation, suggesting that we still do not fully understand how nutritional status affects the peripheral nervous system.

http://www.ncbi.nlm.nih.gov/pubmed/23642197 Annu Rev Nutr. 2013;33:183-203. doi: 10.1146/annurev-nutr-071812-161225. Epub 2013 Apr 29. Nutrient deficiencies after gastric bypass surgery. "Diet and multivitamin use are unlikely to consistently prevent deficiency, thus supplementation with additional specific nutrients is often needed"

http://www.medscape.com/viewarticle/490612 Omeprazole on oral iron replacement in patients with iron deficiency anemia.

http://www.medscape.com/viewarticle/803376 Proton Pump Inhibitors and Risk of Vitamin and Mineral Deficiency PPIs have been associated with an increased risk of vitamin and mineral deficiencies impacting vitamin B12, vitamin C, calcium, iron and magnesium metabolism. While these risks are considered to be relatively low in the general population, they may be notable in elderly and malnourished patients

http://www.ncbi.nlm.nih.gov/pubmed/20842487 Prevention and treatment of peripheral neuropathy after bariatric surgery. As a result, deficiencies in vitamins, minerals, and trace elements may develop, leading to a variety of neurologic complications. The peripheral neuropathies best described with a clear-cut cause are an acute, frequently painful neuropathy or polyradiculoneuropathy associated with thiamine deficiency, and an isolated neuropathy or myeloneuropathy associated with deficiencies of either vitamin B12 or copper. Thiamine deficiency tends to occur in the first weeks or months after surgery, vitamin B12 deficiency may develop at any time from a few years to many years after surgery, and copper deficiency tends to be a fairly late complication, developing several years to many years following surgery. Patients who have undergone bariatric surgery may also have an increased risk of developing focal neuropathies, though these are less clearly related to specific nutritional deficiencies.Ideally, one would like to prevent these neuropathies, but there is no consensus of opinion as to what vitamins and micronutrients need to be taken following bariatric surgery. In addition, many patients who take supplements early on fail to maintain the regimen even though some of the neuropathies can occur fairly late. Supplements frequently recommended include a multivitamin, iron, vitamin D, folic acid, calcium citrate, and vitamin B12. Although thiamine is typically included in a multivitamin, the amount is fairly small, so I recommend adding 100 mg daily for at least the first year. Some have suggested zinc supplementation, but this is potentially problematic because exogenous zinc may interfere with copper absorption. Obtaining blood work every 6 months after surgery will help to identify and treat nutritional deficiencies early.For those patients who have had a bariatric procedure and then develop a neuropathy, evaluating levels of thiamine, copper, vitamin B12, methylmalonic acid, and homocystine is indicated. In addition, since one deficiency is frequently associated with others, obtaining levels of vitamin A, C, D, K, and E, as well as iron, zinc, selenium, and magnesium is worthwhile. Checking total protein, albumin, and cholesterol also gives a sense of general nutritional status. Occasionally, no clear-cut deficiency of a vitamin, mineral, or trace element can be identified in patients with various peripheral nervous system manifestations. Nevertheless, these patients may have at least some recovery with improving nutritional intake and vitamin supplementation, suggesting that we still do not fully understand how nutritional status affects the peripheral nervous system.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3432875/ The Neurological Complications of Nutritional Deficiency following Bariatric Surgery http://www.ncbi.nlm.nih.gov/pubmed/20202584 Postoperative metabolic and nutritional complications of bariatric surgery. Patients who have undergone bariatric surgery require indefinite, regular follow-up care by physicians who need to follow laboratory parameters of macronutrient as well as micronutrient malnutrition. Physicians who care for patients after bariatric surgery need to be familiar with common postoperative syndromes that result from specific nutrient deficiencies. http://www.ncbi.nlm.nih.gov/pubmed/20152742 Medical follow up after bariatric surgery: nutritional and drug issues. General recommendations for the prevention and treatment of nutritional deficiencies. The risk of nutritional deficiencies depends on the percentage of weight loss and the type of surgical procedure performed. Purely restrictive procedures (AGB, SG), for example, can induce digestive symptoms, food intolerance or maladaptative eating behaviours due to pre- or postsurgical eating disorders. Iron deficiency is common with the three types of bariatric surgery, especially in menstruating women. Rare deficiencies can lead to serious complications such as encephalopathy or protein-energy malnutrition. Long-term problems such as changes in bone metabolism or neurological complications need to be carefully monitored. In addition, routine nutritional screening, recommendations for appropriate supplements and monitoring compliance are imperative, whatever the bariatric procedure. Key points are: (1) virtually routine mineral and Multivitamin supplementation; and (3) regular, life-long, follow-up of all patients. The role of the general practitioner has also to be emphasized: clinical visits and follow-ups should be monitored and coordinated with the bariatric team, including the surgeon, the obesity specialist, the dietitian and mental health professionals. http://www.ncbi.nlm.nih.gov/pubmed/20363593 Micronutrient deficiencies after bariatric surgery. The literature suggests that bariatric surgery patients are at risk for deficiency of the following nutrients after surgery: Vitamins B(12), B(1), C, folate, A, D, and K, along with the trace minerals iron, selenium, zinc, and copper. Over-the-counter multivitamin and mineral supplements do not provide adequate amounts of certain nutrients such as Vitamin B(12), iron, or fat-soluble vitamins and patients will require additional doses of prophylactic supplementation life-long to maintain optimal micronutrient status. In addition, preconception care for adequate prenatal supplementation is critical for pregnant women who have undergone bariatric surgery, as iron, Vitamin A, vitamin B(12), vitamin K, and folate deficiencies are associated with maternal and fetal complications, including severe anemia, congenital abnormalities, low birth weight, and failure to thrive. All bariatric surgery patients would be best served by receiving regular monitoring of serum nutrient levels starting at 3 mo after surgery and periodically thereafter. http://www.ncbi.nlm.nih.gov/pubmed/22525731 Nutritional deficiencies after bariatric surgery. The major macronutrient deficiency after bariatric surgery is Protein malnutrition. Deficiencies in micronutrients, which include trace elements, essential minerals, and water-soluble and fat-soluble vitamins, are common before bariatric surgery and often persist postoperatively, despite universal recommendations on multivitamin and mineral supplements. Other disorders, including small intestinal bacterial overgrowth, can promote micronutrient deficiencies, especially in patients with diabetes mellitus. Recognition of the clinical presentations of micronutrient deficiencies is important, both to enable early intervention and to minimize long-term adverse effects. A major clinical concern is the relationship between Vitamin D deficiency and the development of metabolic bone diseases, such as osteoporosis or osteomalacia; metabolic bone diseases may explain the increased risk of hip fracture in patients after RYGB. Further studies are required to determine the optimal levels of nutrient supplementation and whether postoperative laboratory monitoring effectively detects nutrient deficiencies. In the absence of such data, clinicians should inquire about and treat symptoms that suggest nutrient deficiencies.

http://www.jaoa.org/content/109/11/601.full.pdf+html Nutritional deficiences after gastric bypass surgery http://www.eje-online.org/content/165/2/171.full.pdf+html The Endocrine Society’s Clinical Practice Guideline on endocrine and nutritional management of the post-bariatric surgery patient: Commentary from a European Perspective http://pen.sagepub.com/content/35/5_suppl/52S.full.pdf+html Nutrition and Metabolic Complications After Bariatric Surgery and Their Treatment http://spectrum.diabetesjournals.org/content/25/4/222.full.pdf+html Standardizing the Evolution of the Postoperative Bariatric Diet

It is. That's why so many lie to them. I would say (and ask to record this encounter) I do have concerns because my husband is deploying in Dec. However I'm addressing that by working with several close friends and a few more that I've found who understand what I'm going through and are supportive of me. You might want to mention that you are setting up financial/power of attorney stuff if you haven't already, so that those things are taken care of before they go. You also want to mention something about how you are going to write, email, call etc, so that you are working on your relationship while they're gone. The other is that you can say you happen to be one of those persons who doesn't believe in airing dirty laundry in public. Tell him you like to eat. Holy cow that's not a sin. Ok ... gluttony is ... but you know, everybody has sins they love. You should see us at church. We're conservative, fundamentalist Baptists. We eat like we need overeaters anonymous at gatherings. We're polite about it but we do stuff ourselves. Our Pastors are solid men, don't look at women other than their wives, etc. but I mentioned food for the office staff and I had the associate pastors face light up like the national Christmas tree. Anyway ... I would say up front that you are looking to have the surgery as a "tool" (use that word) to get healthier and to help you with your eating habits. Tell them what you are going to do about eating afterwards. Mention about portions, types of food, etc. In other words, what you want is a pre made speech about how you have a few things but how you are dealing with them. You want to see why this is a problem and why the methods that you are using to deal with it are wrong or not approved. Challenge them. I did. Dang turkeys. I didn't the psych person but you tell these people the truth and how you handle stuff and there is nothing they can say.

Lisa Did they give him a round of IV albumin too?

As for death rates, does he want to see the stats on it being = to hip replacements? The issues with death were like for DVT. They give you shots and leg compression for that, and get you up and moving. That happened in the past, and to a coworkers niece but she did all the wrong things and they didn't know better back then. They do now. So is what he is hearing is up to date? That's why I ask, you need to sit down with him and ask straight out WHAT ARE YOUR SPECIFIC CONCERNS so that you can address those. Otherwise it is going to drive a thorn in your relationship. As for malabsorption that doesn't happen to everyone. It happens specifically with certain items and that's not a bad thing. With DS it is an issue but not the rest. So again, you want to meet this head on but with calm strength so that it heightens his ideas about the surgery.

WIth the sleeve, although they say it does nothing, that is sort of ... non sensical. Look at this logically. Gastrectomy does help those with gastroparesis, like me. It didn't cure it but its better than what it was before. Obviously, when a motility issue is helped by getting rid of the stomach it is going to have an effect on the motility of everything else. Even another GI consult I had said that and they weren't even an expert in it. http://www.columbiasurgery.org/news/healthpoints/2011_winter/p3.html http://nyp.org/news/hospital/gastroparesis-diabetes-surgery.html http://www.columbiasurgery.net/2011/03/22/sleeve-gastrectomy-for-gastroparesis/ http://www.motilitysociety.org/clinician/manuscripts/trtment_of_gastroparesis.pdf https://web.duke.edu/surgery/2014_Bariatric_masters/session6_yoo.pdf http://www.dailyrx.com/gastroparesis-diabetes-treated-sleeve-gastrectomy

So you only have a handful of true friends? Whats the problem with that? OMB. Incredible. There are lots of people I know that only have a handful or less of close friends. I'm my own support system. I've got complications and issues and I still get on & support others. I enjoy it. It helps me. So you are honest about your problems and because of doing so, that's wrong? That's the impression I get. So you are attempting to address something honestly? I personally want to know they're not looking for money. I mean come on ... everybody on this planet is pretty much stressed in one way or another. I'm sorry but I don't see where you have a problem. My family has been married to military from fathers' father, my dad, stepdad, my dad's brothers, my sister (2 of the 3), and my niece and nephew (all but one) are in the military or are military spouses. What the heck????? Sorry but as the PROUD relative of service members, that's bunk. I call crap on that. I'd go back and say I found people to work my stress level out with and I want to know what specific diagnosis you are giving me and why. I want to see DSM IV criteria for it. Start making the buggers work for it.

Yes ma'am!! Will pray for you and send us an update and we're sending our love and will lift you up to Him!

I can feel for you. Seriously well ... You will eventually grow used to it. I normally eyeball stuff. I'm farther out than you are though. It does get better but food can be an issue at times.

I can only say as someone who has a ton of complications that this surgery is worth it. At the same time, so are YOU. Pick your surgeon and their office carefully, not just because you like them but based on more scientific type of stuff. As for that, ask your husband what his specific beefs are and we can point to scientific evidence for him to allay his fears. I mean if I am an outlier and have no care and still tell people to get the surgery, it makes an impact, why should someone else lose a good chance at life?

Hey Georgia, I have a question. I am wondering if a corset would help? I have talked to one person about it and they said it did but they didn't have bariatric surgery. I'm just thinking ... maybe one fitted? What would be your thoughts? This is for any one - maybe we should start a new topic on it? I would love to hear from a lot of people just their ideas or any research. Victoria

DUH, I am so dumb, CowgirlJane - have you tried calcitriol? That might help. I'm trying to find the one baby pills again, I had problems with the big calcium pills and could try to find that mini I used to do before I tried the chews and started to choke on them. Btw, have you been checked for any swallowing disorder or gastroparesis? "Calcitriol will work only if you get the right amount of calcium from the foods you eat. If you get too much calcium from foods, you may experience serious side effects of calcitriol, and if you do not get enough calcium from foods, calcitriol will not control your condition."

http://community.atkins.com/AtkinsDietDownloadableKitTest.aspx Hope that helps someone.