Ok, thanks to CowgirlJane, I'm starting a thread on long term supplementation.

I think I was going to go over Calcium and Vitamin D first. Then Iron supplementation and heme/non heme types. Vitamin K would be another one, as I bet people didn't know that some supplements don't have it.

Any other suggestions?

B12 ...found to be the second most prevalent deficient nutrient (after iron) 10-20 years postop for gastrectomy patients. And why SQ or injectable is required for VSG patients.

Good thread! And great timing...I went for my monthly B12 shot last week and my Dr. said, let's check it first....since last time I checked it, it was high. Thinking I had my blood work done just after my shot. Turns out my B12 levels were over 1200 (normal is 138-652). My last shot was 6 weeks ago. So now he is only going to give it to me every 2 months (1000 mg) which is fine with me. But I wonder why my B12 would be high? Does anyone else experience this?

Yup, my b12 is always high off the charts at 1500+. I think it is because b12 is in a lot of different food items (eg shakes) I consume and I normally do not go out of my way to take a subliminal tab.

I think we are all different and require different vitamins. I was taking the recommended 1500 mg daily of calcium, and my calcium levels were off the charts. My PTH was high, and at first they wanted me to have my parathyroid checked because of it. After I stopped the calcium, it came down to a high normal range. My B12 levels are also OK without SL supplementation. However, I need iron, and not everyone does. Pre-op my vitamin D level was non existent, and now with about 8000 IU a week, I'm normal. It takes a watchful eye and careful dosing to get it right, and blindly taking supplements can be harmful, particularly with iron, calcium, and fat soluble vitamins.

My b12 and D were low, they are now ok with suplimentation. B12 is an even bigger problem if you are a vegetarian. Calcium levels are not always represented well by the test... it is looking like some long term problems(bone loss) can show up with good blood levels. There is more and more research that shows supplementation may not work that well... whole food is your best bet when ever possible. (I try and do both...)

I am most interested in the calcium topic too. Mostly because it doesn't seem to show up on tests AND because i think it is the hardest supplement to "stomach"

All my blood work since surgery is "perfect" but calcium is my nemisis. I hate the pills, I feel the chewables are crazy expensive and I guess I have a little worry about it.

I was always vit D low prior to losing weight - now it is normal even though I take less Vit D then I used to! My Iron is always really good so I personally don't need to take that supplement.

I also switched from high quality multi Vitamins to chewable gummies once I got to maintenance since I eat pretty healthy and most vitamins make me feel kinda ill. The gummies are almost like candy...

About 2 months ago, when my appetite problems started, I stopped taking all vitamins except for the B complex sublingual drop that I do a few times a week. Everything else just seemed like more than I could deal with. Now, I am taking vitamins again but barely choking down 500 a day dosage of calcium citrate. I know i should have about twice (taken separately) that but they kill my appetite for hours.

I appreciate you starting this thread... I am ready to be educated!

MichiganChic got it right.

So that being said, I'll going to address a few things I learned with whatever medical resources I have. Please note that I have a local medical school with the best librarians in the world, and I use those resources a lot. I realized I don't have all of them on me, so I'll go this weekend and get specific references. Always pays to ask your doctor as the references I have come to 2 different conclusions (regarding Protein binding of calcium, whether or not its charged on the negative areas or truely is free of the protein molecule itself). I'll try to keep to the "lighter" end of things so you get useful info rather than a lot of scientific snooze material (or as my sister calls it, my reading & video material).

Calcium:

Several ways calcium can be measured:
Serum blood
Ionized
Urine (24 hour collection)

Differences between blood levels and ionized levels is serum blood calcium (what you find in a BMP (basic metabolic panel)) is your total calcium level, whereas the ionized calcium is the free in plasma type only.

** My sources differ on this** Serum blood calcium measures calcium that is attached to albumin/globulins or Proteins AND the free or ionized calcium in plasma
OR it attaches to the negative charged sites on protein
OR it is bound to proteins, bound to anions, and free/ionized.

Parathyroid hormone & Vitamin D regulate your calcium. However, the kidneys assist in getting rid of the excess, so if they are not functioning right, you can find this out by doing urine studies.

Many molecules attach to proteins or other blood particles and use them as a sort of "ferry" to get to where they need to be.

If you have problems with abnormal levels of proteins like albumin or globulin, this may be one reason you need ionized levels checked. I'll list some items here that would be pertinent to us.

Normal ionized calcium levels with high total calcium levels is called pseudohypercalcemia. It can happen due to hyperalbuminemia (basically an edema type condition where the Fluid leaks from your cells surrounding the tissue) or excess Vitamin D.

Normal ionized calcium levels with low total calcium levels is called pseudohypocalcemia. It can happen due to hypoalbuminemia from liver/kidney disease.

Low ionized calcium levels with low total calcium levels can happen due to parathyoid issues, Vitamin D/Magnesium deficiencies, and high phosphate levels.

High ionized calcium levels with normal total calcium levels can happen due to hypoalbuminemia, parathyoid disorders, or acidosis.

High ionized calcium levels with high total calcium levels can happen due to parathyroid issues.

I'll stay away from high levels because lower levels would make more sense to us, excess Vitamins A & D would probably be the main causes for us. If you have lower levels, hypoparathyroidism, malabsorption, osteo types of problems, but mostly Vitamin D deficiency would be the big issues.

Increases in pH levels in the blood, aka alkalosis, will cause more of the calcium to bind to the protein molecules and will decrease your ionized calcium levels. Decreased in Ph levels in the blood, aka acidosis, causes less of the calcium to bind to the protein molecules and will increase the free calcium levels. I add this due to authors' interest, as since the surgery, metabolic acidosis and alkalosis seem to be my buddies. Acidosis in the hospital after the surgery, alkalosis doing a number of endurance athletic competitions.

When you get these tests done, make sure to review things such as your other electrolyte levels, PTH levels, Vitamin D, and phosphorus & magnesium. A change in this electrolyte can cause or be influenced by changes in other electrolytes.

Calcium is excreted out of the body in urine and feces (a few other things but those are the most important).

An increase in pH, alkalosis, promotes increased protein binding, which decreases free calcium levels. Acidosis, on the other hand, decreases protein binding, resulting in increased free calcium levels.

Total calcium measurements, as you've seen, can be misleading. If you have hypoalbuminemia, you will have normal ionized calcium levels but total calcium levels decrease. There are ways to compensate for that, what I cheat and do is look online for the medical calculators.

If you have kidney or low bicarbonate or serum albumin levels, you should measure the ionized free calcium to diagnose hypo/hypercalcemia.

A few of the reasons to test the ionized calcium would be liver or kidney issues, abnormal total calcium issues, parathyroid issues, numbness or muscle spasms around the mouth, hands or feet.

Drugs that can increase your ionized calcium levels would be things like thyroxine.

Drugs that can decrease your ionized calcium levels would be things like heparin, epinephrine, alcohol.

Urine tests measure how much calcium gets excreted out by the kidneys. It can look for problems with the parathyroid glands or the kidneys, or to check and see where the body is getting calcium from.

Normal levels for urine calcium can be anywhere from 100-150 to 300. A calcium free diet goes from 5-40, low diets are 50-100 or 150.

High levels can be caused by kidney issues, taking too much calcium, too much parathyroid hormone, and very high Vitamin D levels. Low levels can be caused by too little parathyroid hormone, low Vitamin D levels, and not enough calcium and/or malabsorption.

If you show up with higher levels of serum calcium, lower levels of urine calcium, and possible bone loss changes, what is happening is that your body is leeching calcium from the bones (bone loss), causing the higher levels of blood calcium, the kidneys are holding on to the little bit you have and not urinating it out (low urine calcium).

I am most interested in the calcium topic too. Mostly because it doesn't seem to show up on tests AND because i think it is the hardest supplement to "stomach"

All my blood work since surgery is "perfect" but calcium is my nemisis. I hate the pills, I feel the chewables are crazy expensive and I guess I have a little worry about it.

I was always vit D low prior to losing weight - now it is normal even though I take less Vit D then I used to! My Iron is always really good so I personally don't need to take that supplement.

I also switched from high quality multi Vitamins to chewable gummies once I got to maintenance since I eat pretty healthy and most vitamins make me feel kinda ill. The gummies are almost like candy...

About 2 months ago, when my appetite problems started, I stopped taking all vitamins except for the B complex sublingual drop that I do a few times a week. Everything else just seemed like more than I could deal with. Now, I am taking vitamins again but barely choking down 500 a day dosage of calcium citrate. I know i should have about twice (taken separately) that but they kill my appetite for hours.

I appreciate you starting this thread... I am ready to be educated!

even though my iron has always been good without supplementation, and I am in menopause... at my last visit to my doc and nut they wanted me to start a multi with iron because of suspicions of "problems down the road"...they also said NO GUMMIES, but Flintstone with iron would be fine. (I miss my gummies!) The calcium chews are expensive, I find if I use the Bariatric Advantage chewables in the giant bottle, it really helps with the daily cost. As a variation I use the generic chocolate soft chews from Target. VERY CANDY-ish. Vitamin K (as found in many greens) will mess with blood thinners and clotting, so watch that.

Edited May 14, 201412 yr by feedyoureye

Here is where there is a problem I see with bariatric patients, that I think is totally correct from Michigan chic.

Some of us do NOT need the supplementation based on WHAT you eat. I eat healthier than pretty much most vegetarians I know as pasta's and rices figure heavily in their diet. I use Vega, which tends to work better for me vs. pills.

I have had all my levels tested and they are good. Each body is different. The problem I found was that my former surgeon only wanted to test his list, not what might be a problem for me. Another reason to find someone who is willing to be flexible as you are an individual person and not some cookie cutter "this is what everyone checks for, standard pat list, cattle call" type of thing.

I thought Calcium citrate was pretty much the one that is absorbable... which is why I don't use the normal calcium chews.

I also hate the flintstone chewables... there is something in Vitamins that make me feel not good in the tummy. The gummies are the only ones that don't do that which is why I switched. I eat pretty healthy - albeit not much fruit so i know I am missing some trace elements. I do eat a fair amount of veggies though.

Calcium carbonate depends on stomach acid for absorption, and is absorbed better with food. Citrate doesn't have that problem.

Carbonate is 40% calcium by weight: citrate is 21% calcium by weight. You need more citrate than carbonate.

Don't go higher than 500 mg at one time, it won't be absorbed.

Carbonate can cause more GI problems than citrate.

For all the yak on Tums, it has carbonate not citrate.

http://www.medscape.com/viewarticle/412220

calcium citrate Shown to Have Superior Bioavailability and Protects Against Bone Loss

Random B12 information (includes some folate)

Causes of non-megaloblastic macrocytosis (megaloblastic meaning large immature erythroblasts that come from the bone marrow, due to defective DNA synthesis, normally either B12, folate or both deficiencies. Macrocytosis refers to a blood condition in which red blood cells (RBC) are larger than normal)

Liver disease can cause these items, as B12 can be stored for years in the liver. Unless released due to problems with the liver, it is normally good for 2-5 years.

Serum folate levels are normally taken but red cell folate is more specific.

Serum B12 is NOT not always an accurate reflection of deficiency at a cellular level. This is why some patients have symptoms when the injections or pills are reduced, even with normal B12 levels.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1570488/

http://www.medscape.com/viewarticle/410469_4

"A low serum folate level may indicate only a decrease in folate intake over the preceding few days. [26] A better indicator of tissue folate status is RBC folate concentration, which remains relatively unchanged while a red cell is in the circulation and thus provides an assessment of folate turnover during the 2 or 3 months preceding measurement. Also, low RBC folate levels correlate better with the degree of megaloblastic changes in the bone marrow than do low serum folate levels. When there is coexistent Iron deficiency, liver disease, serum and RBC folate levels may be normal -- and serum B 12 levels may be normal or even elevated -- but tissue Vitamin deficiency can be present. This is only demonstrable via subtle hypersegmentation and/or deoxyuridine suppression test and is subsequently confirmed by response to vitamin therapy. Decreased serum total folate-binding capacity is another test that may indicate hidden folate deficiency."

An elevated MCV can be associated with alcoholism (and if you look for signs & symptoms of alcoholism, malnutrition, vitamin deficiencies, you will see bariatric patients that mimic those symptoms when deficient!

Vitamin B12 and/or folic acid deficiency has also been associated with macrocytic anemia (high MCV numbers).

I want to highlight this - wonder how I can do this?

http://www.medpagetoday.com/Endocrinology/Obesity/40490?xid=nl_mpt_DHE_2013-07-17

Gastric Sleeve Works Long Term

In terms of complications, one patient had a leak, two had incisional hernias -- which were deemed unrelated to treatment -- and 11 patients had new onset gastroesophageal reflux disease, which typically resolved with proton pump inhibitor therapy.

Over 5 years of follow-up, 77.9% of patients developed Vitamin D deficiency, 41.2% had Iron deficiency, 39.7% had zinc deficiency, 39.7% had a vitamin B12 deficiency, 25% had a folic acid deficiency, and 10.3% developed anemia.

***These deficiencies occurred "despite routine supplementation, in a higher rate than we had expected," the researchers wrote.***

Those are very high rates of deficiencies - don't you think??? Were these all diagnosed through standard tests - if I understood your previous post sometimes you can test normal and still have deficiencies.

Zinc and Iron are correlated with hair loss so interesting... I think Brown mentioned a re-occurance of hair loss, wonder if any of the other long term vets have seen that?

vit D - well I was always low no matter how much I supplemented previous to weight loss. I am puzzled by that except it seems that obesity interferes with either Vit D absorption OR the test.

I want to highlight this - wonder how I can do this?

http://www.medpagetoday.com/Endocrinology/Obesity/40490?xid=nl_mpt_DHE_2013-07-17

Gastric Sleeve Works Long Term

In terms of complications, one patient had a leak, two had incisional hernias -- which were deemed unrelated to treatment -- and 11 patients had new onset gastroesophageal reflux disease, which typically resolved with proton pump inhibitor therapy.

Over 5 years of follow-up, 77.9% of patients developed Vitamin D deficiency, 41.2% had iron deficiency, 39.7% had zinc deficiency, 39.7% had a vitamin B12 deficiency, 25% had a folic acid deficiency, and 10.3% developed anemia.

***These deficiencies occurred "despite routine supplementation, in a higher rate than we had expected," the researchers wrote.***