Vit D deficency and Weight loss
The case against ergocalciferol (vitamin D2) as a vitamin supplement1,2
Lisa A Houghton and Reinhold Vieth
1 From the School of Nutrition and Dietetics, Acadia University, Wolfville, Canada (LAH); the Department of Nutritional Sciences, University of Toronto, Toronto, Canada (RV); and the Mount Sinai Hospital, Toronto, Canada (RV)
Supplemental vitamin D is available in 2 distinct forms: ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3). Pharmacopoeias have officially regarded these 2 forms as equivalent and interchangeable, yet this presumption of equivalence is based on studies of rickets prevention in infants conducted 70 y ago. The emergence of 25-hydroxyvitamin D as a measure of vitamin D status provides an objective, quantitative measure of the biological response to vitamin D administration. As a result, vitamin D3 has proven to be the more potent form of vitamin D in all primate species, including humans. Despite an emerging body of evidence suggesting several plausible explanations for the greater bioefficacy of vitamin D3, the form of vitamin D used in major preparations of prescriptions in North America is vitamin D2. The case that vitamin D2 should no longer be considered equivalent to vitamin D3 is based on differences in their efficacy at raising serum 25-hydroxyvitamin D, diminished binding of vitamin D2 metabolites to vitamin D binding protein in plasma, and a nonphysiologic metabolism and shorter shelf life of vitamin D2. Vitamin D2, or ergocalciferol, should not be regarded as a nutrient suitable for supplementation or fortification.
Vitamin D2 Is Much Less Effective than Vitamin D3 in Humans
VitaminsD2 andD3 are generally considered to be equivalent in humans. Nevertheless, physicians commonly report equivocal responses to seemingly large doses of the only high-dose calciferol (vitaminD2) available in the U.S. market. The relative potencies of vitamins D2 and D3 were evaluated by administering single doses of 50,000 IU of the respective calciferols to 20 healthy male volunteers, following the time course of serum vitamin D and 25-hydroxy vitamin D (25OHD) over a period of 28 d and measuring the area under the curve of the rise in 25OHD above baseline. The two calciferols produced similar rises in serum concentration of the administered vitamin, indicating equivalent absorption. Both produced similar initial rises in serum 25OHD over the first 3d, but 25OHD continued to rise in the D3-treated subjects, peaking at 14d, where as serum 25OHD fell rapidly in the D2-treated subjects and was not different from baseline at 14d. Area under the curve (AUC) to d28 was 60.2ngd/ml (150.5nmold/liter) for vitamin D2 and 204.7 (511.8) for vitamin D3 (P < 0.002). Calculated AUC indicated an even greater differential, with the relative potencies for D3:D2 being 9.5:1. Vitamin D2 potency is less than one third that of vitaminD3. Physicians resorting to use of vitamin D2 should be aware of its markedly lower potency and shorter duration of action relative to vitamin D3. (J Clin Endocrinol Metab 89:5387–5391,
2004)
Does this help?
I have to respectfully disagree with the recommendations on this board regarding vitamin D (but I absolutely admire your dedication for trying to have and give the best recommendations).
Firstly, Vit D2 (ergocalciferol often prescribed as 50000 IU a week by MDs) vs Vit D3 (easily found OTC as 1000 IU to 5000 IU tablets) have not been proven to be one better than the other in Roux-en-Y patients nor in anyone for that matter. Now one can easily find small studies supporting one or the other, and this goes for both sides of the fence. However, those studies are over all small, have certain flaws, different patient populations, and give the vitamin D in a particular way that is not considered standard of care (especially the older studies). It is important that we base recommendations upon the best, most recent medical studies... hopefully limiting that to randomized placebo controlled studies and not just someone's personal opinion... and opinions do change over time based upon study results. Here are the most recent facts:
1. The website mentioned above by Pam has a lot of great information, however, that particular doctor's recommendations are currently 4 years old and older.
2. There has been absolutely no randomized, placebo controlled study to prove that either one or the other works better, however, there have been studies to show that either one can work well in Roux-En-Y patients (a special case since they do have malabsorption). Here are the 2 most recent studies, each showing that one or the other works (in fact the most recent study was done less than a year ago using prescription Vit D 2 successfully and concluded that one can not be recommended superiorly over the other):
http://www.springerlink.com/content/q13268222575l26n/ (using OTC Vit D3)
& http://www.soard.org/article/S1550-7289%2808%2900623-0/abstract (using prescription Vit D2)
3. The best, comprehensive article on Vitamin D supplementation is by Dr. Holick who is considered the world's Vitamin D guru currently. Here is his most recent review and recommendations. Certainly, Vit D2 is more effective than VitD3 unit for unit, that is a moot point. It is like saying that one antibiotic is more effective than another because you have to use more mg than the other one. Here is his most recent article:
http://www.vitamindhealth.org/wp-content/uploads/2010/03/holicknejm2007.pdf
4. Vit D3 and Vit D2 are both fat soluble. (both are better absorbed when taken with fat in your intestinal system to enhance absorption). It is absolutely incorrect to say the prescription green gel caps are worthless. The fat in the capsule aids Vit D absorption, without fat, there is less absorption of both forms of Vit D.
5. OTC supplements are not allowed to be FDA regulated. The supplement industry says that they will do their own quality control. However, study after study has shown that many supplements do not have the amount of supplement in them they are supposed to have in them (in fact most studies show some supplements have 0 amount... for example, studies on DHEA and glucosamine), plus can have unwanted other ingredients such as heavy metals. So with OTC Vit D, you really know exactly how much you are getting. With prescription Vit D2 you know you are getting what you are supposed to get.
BOTTOM LINE:
-Both OTC Vit D3 (1000 IU to 5000 IU) per day and prescription strength Vit D2 (anywhere from 50000 IU every other week, up to 50000 IU every day) are both effective in gastric bypass patients.
-As long as the physician ensures the patient is on one or the other, monitors the patient's level, and adjusts their vitamin D dosage based upon the results, then it is a moot point on which one to take.
-So we need to stop saying that doctors who give prescription vitamin D to their post-WLS patients don't know what they are doing. There is more than one way to do things, and it doesn't serve a good purpose on this board to say negative things about someone's doctor when they maybe doing things exactly right.
-I just hope we all see that it is OK to do etither treatment style (and keep an open mind), accept it as such, and change recommedations to our peers on the bb to give the best, most up to date information (which you contributors have absolutely done well over and over again on many issues.)
-If one uses an OTC Vit D3 supplement, make sure it says USP (US Pharmacopoeia) or NF (National Formulary). GMP supplements by the way are supposed to be pharmaceutical grade quality.
-Personally, I prefer the more regulated and high quality prescription vitamin D3 which has taken my levels from a very low level of 9 to my current normal levels.
Therefore it is now no longer dependant on fat in order to absorb properly. Therefore it works properly.
I still, however, do not see how you can say that D2 is as effective as D3 when there is a clear difference between the two. The rate of exchange from the non-active form to active form is 3:1 in the study referenced above, plus the malabsorption of the oil-based solution of the Drisdol.
Regardless, I'll take the years of post-op hands-on studies of actual lab sheets to guide me on this: Drisdol Does. Not. Work. In. PostOps. Especially when given at a dose of 50,000 iu 1x per week for 8 weeks given our malabsorptive component. It's a ridiculous dose.
Also, I would encourage you to continue to take Vitamin D3 yourself. I am just saying that it is incorrect to misguide other postops saying that Drisdol, Vit D2, ergocalciferol doesn't work (as that is incorrect and not based upon the latest medical evidence). It is impossible for you to show me a better study than the ones I mentioned that disprove it (ie... you do can not show me at least 2 large double blind placebo controlled studies on Roux-en-Y patients comparing VitD3 5000 IU/d vs prescription Vit D2 50000 IU/wk over a long period of time showing that the Vit D2 doesn't work.) The studies thus far clearly show that both do work, and that certainly work in clinical practice. It is perfectly fine for the experts to hem and haw and have intellectual discussions saying why they theorize one practice may be better than the other; but theorectical opinion is a far cry from basing medical practice upon the medical evidence.
btw... I am a rheumatologist who just happens to treat lots of Vitamin D deficient patients as we also have an osteoporosis center, and I have taken care of quite a few WLS patients who unfortunately were in horrible shape from Vit D def osteomalacia. They do incredibly well on Vit D2 50,000 IU a week and get their lives back after correction (ie... bone pain, muscle pain, muscle weakness resolve and bone density corrects).
I just feel that a healthier stance is to be aware that both methods do work. It is better to encourage patients to be compliant with their supplement and get their labs drawn to guide therapy. It doesn't serve anyone well to tell folks that their doctor doesn't know what they are doing when it clearly does work. We are here to give good advice, hope, and encouragement.
It is also important for us to realize what we may not know. Although I keep up on the latest and best research in areas such as this, I do realize that there is a lot that I and other docs and nutrionists do not know. There is a ton of active research being done on this important matter as Vit D deficiciency runs rampant in modern society. What we recommend in 10 years may be vastly different than what we recommend now; medical care must continue to grow and improve over time, but it must be based upon objective evidence of newer and better studies.
There are dry formulations of ADEK. The D is made from lanolin (sheep) and unfortunately I can't pull a study right off hand. I've not found one yet but rest assured, I keep looking for one!
I can pull one showing that dry forms of A are stronger than their oil-based bretheren.
Water-miscible, emulsified, and solid forms of retinol supplements are more toxic than oil-based preparations
http://www.douglaslabs.com/pdf/trials/Aqua-E%20Clinical%20Study.pdf - Study dealing with CF patients with water-miscible E. While it showed that those without lipid malabsorption do better with regular E, those with lipid malabsorption (such as RNY and DS patients) do far better with a specialized formulation.
While these are small studies, and not the best (let's face it, the 2nd one had few patients because it's CF.. but they are the closest to us in terms of malabsorptive qualities, but it could be concieved as a bias) they do show a correlation that there, is, in fact, a dry-form available and that there is a difference in a small sub-set, at least with E.
I wish I could find info on the D. I've not given up. No worries. Vitalady says that if there's a study out there that I'm the one that will find it (because I'm really good at finding them...)
But some annectdotal evidence -
Years out, we've seen the Drisdol NOT work. Even for normies. I had a girl approach me while in Savannah at a M&G. She's a preop. On Drisdol. Her D dropped from 16 to 9. Her dr? Dumbfounded. Can't figure it out. And she hasn't had the gut rerouting yet. Explained the differences. And no, did not tell her to go massive dosing -- just told her to go with regular D3 and daily doses versus the Drisdol (which is in line with the Vitamin D Council's recommendations). I hope to hear from her soon as to both her Op status and her D status.
And you heard from RBB -- here on the board. Dave Chambers is another one.
There are others that have similar stories if you just asked.
