Category: Vitamin D
Vitamin A, Absorption, and Wound Healing
September 25, 2019 8:39 am
Vitamin A is one of the 4 fat soluble vitamins along with vitamin D, Vitamin E and Vitamin K. It is multifunctional and essential which means that it is not produced by the body. In this article we will touch on aspects of Vitamin A absorption and it’s effect on wound healing as well as its metabolism.
We often think of Vitamin A as the critical vitamin for vision, however it has several other roles that related to immune function, protein synthesis, and cellular communication. Vitamin A deficiency is a concern world wide because of the natural of the side effects. Vitamin A deficiency is the leading cause of preventable childhood blindness in the world according to UNICEF and sometimes it may be undetected until there is irreversible damage.
There are 2 chemical forms of vitamin A in diet:
Retinoids (Preformed vitamin A) This group include retinol, retinyl esters, and retinal they are mostly found in animal sources like liver, egg yolk or fish oils.
Carotenoids (Provitamin A) This group includes beta-carotene, alpha-carotene and lycopene, mainly found in plant sources like leafy vegetables or yellow/orange vegetables and fruits.
The Physiology of the Vitamin A is as follows:
1.- Ingested food is digested in the stomach where retinyl palmitates (esters) are released from proteins. Retinol and beta-carotene are absorbed directly into the small intestine where retinyl esters and betacarotene are transformed into retinol . Retinol is the most easily absorbed form of vitamin A.
2.-That retinol absorbed by the enterocytes in the ileum (small intestine) along with bile is then transported to the liver with the help of chylomicrons a protein that transports fat.
3.-Fifty to 80% of the vitamin A is stored in the liver and the remaining is deposited into adipose tissue, lungs and kidneys.
4.-When stored retinol is released from the liver into the circulation to target organs, it is bound to plasma retinol-binding protein (RBP4) a transporting protein produced by the liver that requires ZINC, which is synthesized by the liver; This complex is stabilized by transthyretin (TTR), which reduces renal excretion.
Retinol is a crucial component for reproduction, embryological development, cellular differentiation, growth, protein synthesis, and immunity in the form of retinoic acid and vision in the form of retinal.
One of Vitamin A additional roles is in epithelial health of skin and mucous membranes. It increases epithelial turnover which is crucial during would healing. It also has anti-oxidative effects which prevent cell damage and can prevent or reverse the effects of other damaging agents. In addition to these benefits it has also been associated with increasing collagen, fibronectin, keratinocytes and fibroblast, all important in wound tissue structure. There have been some studies that suggest giving higher doses of Vitamin A in patients with non or slow healing wounds.
It is important to remember that we have documents delayed diagnosis of adult vitamin A deficiency leading to significant night blindness in adults. It is critical that the patients and their primary care physicians are acutely aware of this possibility. In majority of the patients with low vitamin A, post weight loss surgery, aggressive supplementations, including injections need to be considered as a part of the treatment regimen.
We would like to thank Miguel Rosado, MD for his significant contribution provided for this Blog.
Sunscreen
June 27, 2019 3:03 am
Recently there has been some research and concern regarding sunscreen and the chemicals within them. This has led to findings that can be concerning but that need further research.
Post weight loss surgical patients, and in general patients who suffer with obesity, before or after weight loss surgery, have low vitamin D level. This may be caused by a number of factors. One such factor may be the reluctance to get skin exposed to sunlight in order for the bodies natural Vitamin D pathways functioning.
The recommendations are for daily exposure to sun. This not only is critical to the vitamin D metabolic pathways, but also help with bone health, immune function, mood, counteracting depression.
In a recently published online article, concerns were raised that some of the ingredients of some of few sunscreens are absorbed in the blood stream. This is a small study, and as the results indicates, it is not recommending to stop using the sun screens. Be aware of your sun exposure, timing exposure, and the ingredients in your sunscreen.
You can find past blog posts on Vitamin D, Bone health, etc here
Osteoporosis Medications, Action and Side Effects
May 25, 2019 3:40 pm
Treatment options should be approached is a global and systemic fashion. It is critical that the nutritional status is at its best possible and optimized for important healthy bone vitamins and minerals. Low protein needs to be corrected. Special attention should be given to nutrients, minerals and vitamins. These include Protein, Calcium, Magnesium, Vitamin D, and Vitamin K1/K2to name a few.
Healthy bones require ongoing and routine force in the form of exercise to remain health. Just as exercise improves muscle strength, it also improves bone health. Exercise is also critical in improving bone structure and density. Ideally, exercise should be weight bearing and resistance. Examples include: hiking, walking, jogging, climbing stairs, playing tennis, and dancing. Resistance type exercise is weight lifting and resistance bands. These exercise work by creating a pull or force on the bone either by gravity, movement or weight. Always check with your physician before beginning an exercise routine, start slowly and building up to longer periods of time. The ideal goal would be at least 30 minutes a day, every day, if you are able.
We frequently see patients immediately started on osteoporosis medications without checking or improving some of the nutritional markers noted above or without looking at exercise history. In some case, the medication recommended are contraindicated due to nutritional status.
The medications can be grouped in to those that help with new bone formation (Anabolic agents) or those that help by suppressing the bone breakdown phase (Antiresorptive agents).
National Osteoporosis Foundation has an exhaustive list (below) of medications for treatment of Osteoporosis.
The table below outlines the side effects and mechanism of the actions of the common medications used for treatment of osteoporosis which was published by the University Health News Publication on August of 2014.
With all this information, the few points to remember is that the most important factors in healthy bone structure are the nutritional status Protein, Calcium, Magnesium, Vitamin D, and Vitamin K1 levels.
This is an animation of normal bone Metabolism. It shows how bone structures is taken down and rebuilt continuously. This allows for a healthy bone maintainence as we age. The key is the balance of breakdown (osteoclast) and the build up (osteoblast) activity is regulated. Osteoporosis develops when there is more breakdown that build up. 
With permission of Dr. Susan Ott of University of Washington.
Additional information available on her site.
Past blogs on Bone Health.
Parathyroid Scan
July 09, 2018 11:48 am
A Parathyroid scan or Sestamibi scan may be needed if the typical weight loss surgical reasons for elevated PTH levels have been addressed. Sestamibi is a small protein which is labeled with the radio-pharmaceutical technetium-99. This very mild and safe radioactive agent is injected into the veins of a patient with overactive parathyroid and is absorbed by the overactive parathyroid gland. If the parathyroid is normal it will not absorb the agent. The scan below shows the uptake of the agent.
Calcium, Vitamin D and Parathyroid hormone are routinely measured on yearly follow up for most post weight loss surgical (WLS) patients. Elevated parathyroid hormone (PTH) may be caused by Vitamin D deficiency or calcium deficiency (most common in post WLS) or by over active parathyroid gland(s). In the latter case, if one of the four glands is overactive then this is knows as a parathyroid Adenoma. If all 4 are over active and are secreting too much PTH, this is known as hyperplasia. Ultrasound of the neck, may identify an enraged parathyroid gland (adenoma) which is located behind the thyroid gland. Given the large area where the parathyroid gland may be located, additional tests are needed to not only identify the location of the gland(s) but also to distinguish between single gland (adenoma) or multiple glands (hyperplasia) cause for the elevated PTH. It is important to investigate all avenues and testing in parathyroid hormone elevation and in some cases, not to rely on one test for your diagnosis. It is also imperative that weight loss surgical patients take their supplements routinely and consistently and have their laboratory studies followed at least yearly.
Calcium Lab Results
June 05, 2018 3:26 pm
Calcium is measured to evaluate function and adequacy of a physiologic processes. Calcium plays a critical role in several body functions such as, coagulation pathways, bone health, nerve conduction, and other functions. It is important whenever you are evaluating laboratory results that you look at the whole picture of the person, including medications, other laboratory studies and health history. One value is not a stand alone result. There are many factors that effect calcium results.
Factors that effect calcium results: (not an all inclusive list)
pH
Albumin
Lactate
Heparin
Anticonvulsants
Renal Disease
Pancreatitis
The two most common issues following Weight loss Surgery or Duodenal Switch may be albumin level and Vitamin D level. Please see past blogs on Vitamin D. Magnesium may also play a role in a Duodenal Switch patient.
The most common calcium result drawn is the total calcium level. Laboratory results may not explicitly label it as such, however, it measures the calcium that is bound to protein. Ionized calcium is the free calcium that is representative of the true total calcium. Ionized Calcium can be measured by ordering specific lab. Alternatively, the Ionized calcium can be calculated by the following formula: Corrected calcium mg/dL = (0.8 * (Normal Albumin – Pt’s Albumin)) + Serum Ca ) or use the calculator at the bottom of this post.
The low Albumin level accounts for the low calcium level. This may be the reason for a patient with a low albumin/protein level, also having their calcium level reported as low. However, when adjusted for the protein deficiency the corrected calcium comes into normal range. Video of Trouseau’s sign of a patient with calcium deficiency.
The first step in a patient who has low calcium reported, is to make sure their protein and albumin levels are normal, along with Vitamin D.
Calcium levels are managed by two processes major regularly hormones and influencing hormones. Controlling or major regulatory hormones include PTH, calcitonin, and vitamin D. In the kidney, vitamin D and PTH stimulate the activity of the epithelial calcium channel and the calcium-binding protein (ie, calbindin) to increase calcium absorption. Influencing hormones include thyroid hormones, growth hormone, and adrenal and gonadal steroids.
Further information on protein.
Further information on calcium.
Videos/Webinars on several of the above topics.
Corrected calcium = 0.8 * (4.0 – serum albumin) + serum calcium
Compounding Pharmacies
January 22, 2018 2:38 pm
New FDA regulations for compounding pharmacies has spurred changes in our pricing and ability to provide injectable Vitamin A and Vitamin D. The compounding pharmacies are no longer compounding injectable Vitamin A and there is a nationwide shortage of the national brand of injectable Vitamin A. We have a tentative date of February 2018 when we may be able to obtain injectable Vitamin A. We won’t be able to quote pricing on Vitamin A injections until we are able to orders.
We are able to obtain and supply our patients with injectable Vitamin D but with a price increase.
The following is the letter we received from our compounding pharmacy.
“The healthcare industry has continuously undergone changes in regulations and legislation. The compounding industry is no exception and has faced rigorous regulatory requirements this past year such as new testing specifications and compliance standards.
We are set on facing these demanding challenges by meeting and exceeding these new regulatory requirements. We want to assure you we will continue to provide the best products on the market for you and your patients. Quality and safety remain a top priority. We understand that our pharmacy plays a vital role in providing care to your patients. The increase in pricing is a reflection of the additional cost in producing and testing the product based on regulatory specifications.”
Compounding Pharmacy
March 22, 2017 7:40 pm
We have received notice that the FDA and the compounding pharmacy have changed their regulations for several medications. Unfortunately, this affects our office and Duodenal Switch patients in regards to injectable Vitamin D and Vitamin A. In the past, we have been able to have injectable Vitamin A and injectable Vitamin D in bulk in our office. The new regulations require that a patient be assigned to the medication, so we will be unable to have it on hand in our office. This is out of our hands and control.
We are requesting that if you are anticipating the need for injectable vitamins that you have your laboratory results in our office at least 3 weeks prior to your office visit. This will give our staff adequate time to order your injectable vitamins to be available at your visit.
Injectable Vitamin D may be needed in some cases of Vitamin D deficiency or inability to increase Vitamin D level with oral supplements. Vitamin D is a fat soluble vitamin. It plays an important role in bone metabolism and structure. It has also been found to affect the immune regulation, control off- inflammatory reactions, and also be involved in a number of broad cellular functions throughout the body.
Research and information regarding Injectable Vitamin D.
Thank you for your understanding in this manner.
Dental Resources
February 24, 2017 10:55 am
You may have heard that I will be giving a lecture at the California Dental Association’s 2017 meeting. In preparation for the lecture, I have come across some excellent information with the assistance of and dental resources from Dr. Armen Mardirossian of Mardirossian Periodontics and Implants.
The following Dental Resources are part of many of the resources I have used to complete this lecture series for the Dental Association. Periodontal disease can effect every body system and should be addressed to avoid further damage and complications. We can not over emphasize the importance of good dental care. In addition, following weight loss surgery, supplementation of vitamins and minerals is extremely important. Always seek the care of a professional when dealing with dental issues or other physical symptoms.
We are sharing these resources with our patient population in order to shed some light on this topic. You can also find a previous webinar on the topic of Dental Issues After Weight Loss Surgery here.
For complete dental resources click here (385.8 KB).
Thank you Dr. Mardirossian for your assistance.
Vitamin D status for Infertility Treatment
August 03, 2016 8:02 pm
Many people with obesity face infertility issues and seek infertility treatment or procedures. A recent article linked Vitamin D status to improved success rate of IVF (in-vito fertilization) & ICSI (interacytoplasmic sperm injection) in The Journal of Maternal-Fetal & Neonatal Medicine. It is important to check Vitamin D status for infertility treatment.
Here are the researchers results:
- Of the 252 females that completed the ICSI cycle, 42% became pregnant (n = 108).
- The mean vitamin D status was significantly higher in the pregnant group compared to the non-pregnant group (17.74 ng/ml vs 9 ng/ml, respectively; p = < 0.01).
- Vitamin D status was positively associated with both pregnancy (p = 0.001) and endometrial thickness (p < 0.01).
- Higher vitamin D levels was associated with a 21% increase odds of clinical pregnancy (p < 0.05).
The researchers concluded,
“Deficiency of 25-OHD in females hinders the accomplishment of optimal endometrial thickness required for implantation of embryo after ICSI.”
Following weight loss surgery (WLS) there can be improvement of fertility and for that reason we recommend two forms of birth control methods during the first 18-24 months following WLS or until weight loss has stabilized for several months. This helps to ensure the best outcome and health for the mother and infant.
In our office we continue to stress the importance of Vitamin D3 for bone and dental health, pregnancy, breastfeeding and several auto-immune diseases. Vitamin D has also been shown to reduce pre-term birth Duodenal Switch patients require a dry water miscible form of Vitamin D3 due to the fat malabsorption of the DS procedure. There are several past blog posts on the topic of Vitamin D and it’s associated nutrients.
Magnesium QuestionsExclusive Member Content
May 11, 2016 6:07 am