Everyone who knows me a little bit, knows that I have strong opinions about vitamins.

I had my surgery 4 years ago with a *wonderful* surgeon.  I truly love Dr. Burry.  His supplement advice was to take two flintstones and tums for the rest of my life.  And I trusted him.  Keep in mind that 4 years ago, there was little nutritional evidence that has since come out about multivitamin regimens in RNY patients.

Surgery was August of 04.  I had regular blood draws.  And in those draws, I was normal for the most part, but slowly trending downwards.  Was I told?  Nope.  Did I ask to see my lab sheets?  Nope.  I *trusted* my healthcare providers.

4 years later, 2 kids later, and my ferritin sucks, my D was in the toilet, and I was in serious pain from my bones being leeched of their calcium.  Osteomalacia is not very fun, let me tell you.  And the zombie-like feeling of not having any iron reserves is pretty crushing as well.  I started to study vitamins, read everything I can get my grubby paws on (and hey, I have a ton of stuff to still go through), and share this info with others in hopes that someone will listen to my advice and not travel this road.  Avoiding a defiency is much easier than recovering from one.


So now what?  Oh.  I thought I'd share and site some info for you.  Take note, JinPA.. this is the kinder, gentler Andrea (don't blame me, I have narcotics floating through my system).


Flintstone vitamins

Ahh yes, the most controversial of the subjects are flintstone vitamins.  First off, let me say right here and now that an adult dose of flinstones (and I'm not talking gummies.. yet) is 2 tablets.  The American Society of Metabolic and Bariatric Surgeons recommends two times the adult dose, so that makes 4 Flintstone chewables a day.  Got it?  Not two.  Not three.  Four.  As in 2+2 == 4.

Perhaps the lamest excuse I see for taking Flintstones vitamins is price.  Yes, times are tough.. but are you really willing to relegate your health to the lowest priced vitamins on the market?  I mean, we had surgery to be in better shape.. and you are willing compromise that health on crap vitamins?  Give me a break.

But, ok.  Let's look at price.
Amazon.com has a bottle of 200 Flintstone Complete vitamins for 17.99.  For ease, let's call it $18.00 ok?  4 a day (remember, bariatric dosing), makes for 50 days, each day costing 36 cents.

Amazon.com has a bottle of 100 Centrum Adult vitamins for $13.16.  For ease, we'll call it $13.20.  2 per day (because they are adult vitamins), makes for 50 days, each day costing 26 cents.

So don't tell me you buy Flintstones for the cost factor, kay?  That argument does not fly when you are taking a bariatric dose of vitamins.  Period.  Moving on.

Additionally, the flintstone complete vitamins are, in fact, missing some key things.  Even Centrum's KIDS vitamins are better for you than flintstones.  Period.


Flintstone Gummies (or any other child's gummy vitamins)

These are not vitmains -- they are candy.  I *cringe* when I even see these in the store.  I would not give these to my toddler.

Why?  Because they are only good in the yummy b-vitmains.  They have no iron, no copper, no selenium, etc.  I mean, really, they are deficient in so many things, it's not even funny.  The first two ingredients are sucrose and fructose.  So two forms of sugar are the first ingredients?  Oh, and the adult dose is 6 vitamins, so 12 per day for a bariatric patient?  Give me a break.. not only is it an insuficient vitamin, it's even more expensive than the bariatric vites that people shy away from due to price tags.


Tums and Viactiv

Note: these are the wrong calciums.  Period.  No discussion.  Calcium carbonate requires a high amount of stomach acid in order to break down into usable parts.  No ifs, ands, or buts.  In a study conducted on post-menopausal normal-gutted women, calcium citrate was found to be 27% more absorbable than carbonate -- and that's with a full complement of stomach acid that RNY, Fobit, and DS'ers don't have at their disposal.  Take calcium citrate.  Chew it, melt it, swallow it, whatever.. but calcium citrate is what you need, and you need 1500-2000mg every day in addition to food sources.


My labs are fine...

Really.  Are they?  Can you say that equivicably?  Is it because you *trust* your doc to have your health as their absolute most important priority in the world?  Or are you now thinking that *maybe* the doc is just looking for numbers that are highlighted by the lab as abnormal results?

Have you done your own independant research to find out what your numbers should be, and how to get them to that point if they aren't there already?  Have you tracked trends to know when you've started sliding down a slippery slope, or have you trusted someone else to look at the data and spoonfeed you the results?  Do you know how long specific nutrients are stored in your body for long-term storage in case of emergency?  Did you realize that b-12 begins to run out at 6 weeks to 6 months?  That the body has no, nada, zip storage for certain micronutrients?

If you can't answer basic questions about your lab values, please do not tell me your values are "perfect" because I will ask you to validate your claim every single time.


Folks -- WLS is a learning thing.  No, no one has the answers.. but there is quite a bit of research showing the no-no's if you are willing to 1) do the research yourself or 2) listen to someone who has.  Do I know everything?  Nope.. and I will gladly admit that fact.  But I can tell you where I get the nuggets of info I do have and will publish my sources if so asked.  I'm not claiming to be a medical expert, but it doesn't take one to read a study about 137 patients, you know?  It's a matter of actually taking the time, doing the footwork, and understanding the data presented.

Just a friendly reminder --

Tums, Optisource, Rolaids, Viactiv, and Caltrate are calcium carbonate.

Calcium carbonate is not bioavailable in pH-neutral environments.  Citrate is 21% more bioavailable in folks without designer stomachs and intestines.

We want to take calcium citrate -- available as Citracal (but not the Bone Density Builder stuff -- that's mostly carbonate), some house branded calcium supplements, and a few specialty companies that make chewable and liquid versions.

Also, be leery of anything that claims a full dose of calcium (500mg +) in a small quantity, such as a 2g scoop or a teaspoon.  Calcium citrate is a very large molecule, and of that molecule only 24% is actual calcum.  Unfortunately, there are some companies that list 500mg of calcium citrate versus 500mgs of calcium from calcium citrate.  It's a subtle difference -- but if it seems too good to be true, then it most likely is.

Take calcium 2 hours away from iron -- otherwise the iron becomes worthless.

Calcium should be taken in doses around 500mg -- while this is not a steadfast number, it is the recommended amount to guarantee absorption.  Some folks may absorb 600 at a time, others 450.  Shoot for 500 to be safe.

The American Society of Metabolic and Bariatric Surgeons recommend the following amounts of calcium:
Gastric Bypass: 1500-2000mg per day
Gastric Bands (and I'd assume VSG as well): 1500mg per day
DS: 1800-2400mg per day

And finally, for those taking citracal -- it *does* dissolve nicely in a glass of crystal light without changing the flavor.  If the pills seem too large, try doing this instead.

So I was thinking about this product after a friend of mine with VSG got it.. and I called Bayer Health, the makers of the product.

The nutrition info:

Serving Size: 2 tablets
	Amount Per Serving	% Daily Value
Vitamin D	400 IU	100%
Calcium (elemental)	600 mg	60%
Magnesium	50 mg	13%
Zinc	7.5 mg	50%
Copper	1 mg	50%
Manganese	2 mg	100%
Molybdenum	75 mcg	100%
Boron	250 mcg	*
Genistein	27 mg	*
*Daily Value not established.

In my studies, I've only seen that zinc and calcium should not be taken together.  Zinc *does* help with the absorption of calcium, but they don't play well with each other.  So I called up Citrical hoping they had some research to show why they put them together.

And guess what I found out?

It's a shocker..


This dose of calcium includes 480mg of calcium carbonate and only 120mg of calcium citrate.

Interesting, yes?


So don't buy it if you had RNY, DS, or have any other conditions that lower the amount of acid in your tum tum.


It's been brought to my attention that Celebrate has a similar product -- yes, I plan on calling them as well.

Topic: Calcium absorption and achlorhydria

Achlorhydria: A lack of hydrochloric acid in the digestive juices in the stomach (in technical terms, so that the pH of the stomach contents fails to fall below 4.0 under maximal stimulation). Hydrochloric acid helps digest food.

This is a study published by RR Recker in the New England Journal of Medicine comparing carbonate and citrate absorption.  Volume 313:70-73, July 11th, 1985, Number 2

Abstract
Defective absorption of calcium has been thought to exist in patients with achlorhydria.  I compared absorption of calcium in its carbonate form with that in a pH-adjusted citrate form in a group of 11 fasting patients with achlorhydria and in 9 fasting normal patients.  Fractional calcium absorption was measured by a modified double-isotope procedure with 0.25 g of calcium used as the carrier.  Mean calcium absorption (+/- S.D) in the patients with achlorhydria was 0.452 +/- 0.125 for citrate and 0.042 +/- 0.021 for carbonate (P less than 0.0001).  Fractional calcium absorption in the normal subjects was 0.243 +/- 0.049 for citrate and 0.225 +/- 0.108 for carbonate (not significant).  Absorption of calcium from carbonate in patients with achlorhydria was significantly lower than in the normal subjects and was lower than absorption from citrate in either group; absorption from citrate in those with achlorhydria was significantly higher than in the normal subjects, as well as higher than absorption from carbonate in either group.  Administration of calcium carbonate as part of a normal breakfast resulted in completely normal absorption in achlorhydria subjects.  These results indicate that calcium absorption from carbonate is impaired in achlorhydria under fasting conditions.  Since achlorhydria is common in older persons, calcium carbonate may not be the ideal dietary supplement.

What this means in plain English
There was a study containing people with normal stomach acid and those who have minimal stomach acid.  They were given calcium citrate and carbonate that was radiologically changed into an isotope to track absorption.  Folks with the lower stomach acid did not absorb the carbonate as well as the citrate.  Folks with normal stomach acid absorbed the citrate better than the carbonate.  Carbonate did absorb normally  in pH neutral tummies when taken with a full meal.  Citrate absorbs better in normal stomachs, as well as stomachs that have limited stomach acid.  If one chooses to take carbonate, they should do so with a full meal.

Some of the things discussed in our post-op health can be a bit confusing.  Iron is one of those things, IMHO.  So how about a session just on iron?


What is iron?
Iron is a mineral that can be found in plants, animals, soil, air, water, meteorites, and rocks, including on the surface of the moon.  Here on earth, plants absorb iron through their root systems; animals eat these plants.  Humans consume these plants and animals.  Many think iron is a heavy metal, which it is not.  Iron is an essential micronutrient.  Essential used in this way means that the body does not produce the nutrient; micronutrient means that the body only requires tiny amounts to function.


Types of iron?
There are two forms of iron - heme and nonheme.  Nonheme iron primarily comes from plants and heme iron comes primarily from meat. 
Nonheme iron represents the majority of iron humans consume in their diets and is the type of iron in most supplements.  Nonheme iron is inorganic and is found in grains such as rice, wheat and oats.  It's also found in nuts, fruits, vegetables, most iron pills, fortificants, or contaminant iron such as from water, soil or cooking utensils.
Meat, especially red meat is the best source of heme iron.  Heme iron is easily absorbed by the body and the best source of iron for people who are iron deficient.


Iron terminology
Transferrin - a protein that is the major transporter of iron and ideally is saturated with 25-35% iron; when working properly, transferrin binds to iron and transports it to all tissues, vital organs, and bone marrow so that normal metabolism, DNA synthesis, and red blood cell production can take place
Ferritin - a protein that acts like a large holding vessel; contains iron that we don't presently need
Hemaglobin (hgb) - a protein that transports oxygen to the body
Hematocrit (hct) - proportion of blood volume that is occupied by red blood cells


So someone who is anemic can still have normal hemaglobin and hematicrit numbers because their ferritin is being depleted in order to maintain those counts.  But if the ferritin is in the toilet and no relief comes, the hgb and hct will eventually fall as well.


Info courtesy of the Iron Disorders Institute