Your Calcium Requirements After WLS

Your Calcium Requirements After WLS

Calcium is one of the major supplements that all bariatric centers of excellence require their post-ops to take for life. We’re going to take a look at why it’s so important for us.

Recommendations for WLS Post-ops of Calcium supplementation is approx. 1200-1500 mg daily. Your body can absorb 500-600mg at one time; therefore, you will probably have to take Calcium a minimum of twice a day. Calcium supplements must contain Calcium Citrate which is a form of Calcium that can be absorbed without the requirement of stomach acids.

Do not use Calcium Carbonate supplements. (Post-op Gastric bypass patients do not have large enough stomachs to generate enough acid to effectively absorb calcium carbonate) Carbonate forms of calcium can not readily be absorbed by Gastric Bypass Post-ops and is next to useless for WLS Post-ops.

Vitamin D aids calcium absorption in your body. If your supplement already comes with Vitamin D, consider it a free bonus thrown in with your calcium, but like all things free, it isn’t much use to most of us. You need to know as a WLS Post-op that your body will not effectively absorb Vitamin D unless it is “oil based” All WLS Gastric Bypass patients must take Vitamin D “oil based” capsule supplements separately from their calcium citrate vitamins. Last, but not least, Magnesium added to the Calcium supplement may help to prevent constipation that can occur with Calcium supplementation.

The creation of the extremely small stomach pouch during bariatric surgery results in a significant decrease in the production of hydrochloric acid. Combine with acid reducing drugs that most RnY patient must take for the rest of their lives to prevent stomach ulceration results in a critical reduction of absorption of calcium and iron for all of us.

Thankfully, absorption can be increased by using supplements or manipulating gastric pH. Calcium carbonate depends on acid for its absorption and for this reason is useless for gastric bypass Post-ops. Calcium citrate is not dependent on acid levels for absorption and is THE only effective calcium supplement for Post-ops
One study compared the bioavailability of both types of calcium in patients who lacking hydrochloric acid (achlorhydric). They found the bioavailability of calcium carbonate to be 4% and calcium citrate to be 45%. While calcium citrate is more expensive than calcium carbonate, you don’t have to be a rocket scientist to know that calcium citrate should be the only calcium supplement used by gastric bypass Post-ops.

Decreased calcium absorption can increase the risk of osteoporosis. Check out our article on “Why Gastric Bypass Post-ops Need Calcium” for more on the complications of osteoporosis. There are no guidelines to monitor bone density related to WLS Post-ops, but I recommend you get early bone densitometry testing after your WLS to set a bench mark for the future so your doctor has a comparison to base changes on. (We highly recommend this test)

If you’ve been following along, you probably have gotten the point by now that Calcium citrate is the only form of calcium that is effective for Post-op. Most of the calcium supplements found in stores are the calcium carbonate form. It doesn’t work so don’t waste your money. That includes those candy type chews many WLSers love. Viactive for example, which happens to be loaded with trans fats and high fructose corn syrup. Who wants that in your body anyway? Also do not waste your money on the ones that have vitamin D in them. Besides being the WRONG type of vitamin D. It is also not in an oil based form so it won’t be absorbed, PERIOD. You need to read the labels on vitamins just as closely as all the food labels out there.

Since we are at a risk of calcium deficiency—this can lead to osteoporosis. Since osteoporosis is a known problem for Post-ops, many GPs automatically want to put you on some of the meds to combat it. This is not a good idea.

The oral bisphosphonates (drugs for osteoporosis) are another class of medications that could present problems due to a reduced pouch size. They may increase the risk of gastrointestinal ulceration. Since gastric bypass Post-ops can be at risk for osteoporosis because of decreased calcium absorption, other treatment options (e.g., calcitonin salmon nasal spray, synthetic parathyroid hormone [teriparatide], raloxifene [for women]) should be considered.

These drugs are caustic to our pouch just like NSAIDS. We’ve all heard the horror stories about bleeding ulcers, ER trips, etc after taking NSAIDS. So the best thing to do is prevent the deficiency of calcium in the first place. The research is out there to prove it. We’re not going to include all the research here, but you need to know that Metabolic bone disease after gastric bypass surgery for obesity is well know and well documented. Don’t become a footnote in some researcher’s study. TAKE YOUR SUPPLEMENTS!

One of the best references available for vitamins and minerals is the Linus Pauling Institute.

Calcium is the most common mineral in the human body. About 99% of the calcium in the body is found in bones and teeth, while the other 1% is found in the blood and soft tissue. Calcium levels in the blood and fluid surrounding the cells (extracellular fluid) must be maintained within a very narrow concentration range for normal physiological functioning. The physiological functions of calcium are so vital to survival that the body will actually demineralise bone to maintain normal blood calcium levels when calcium intake is inadequate. For this reason, adequate dietary calcium is a critical factor in maintaining a healthy skeleton.

Calcium is a major structural element in bones and teeth. Bone is a dynamic tissue that is regenerated throughout life. Bone cells called osteoclasts begin the process of regeneration by dissolving or reabsorbing bone. Bone-forming cells called osteoblasts then synthesize new bone to replace the bone that was reabsorbed. During normal growth, bone formation exceeds bone reabsorbing. Osteoporosis may result when bone reabsorbing exceeds formation.

Calcium plays a major role in bone formation, this everyone knows. But calcium is so much more than that. The human body is a complex being. There are many checks and balances on the cellular level. One little thing gets out of whack, the whole system is messed up. Here are some functions of calcium:

Calcium plays a role in regulating the constriction and relaxation of blood vessels (vasoconstriction and vasodilation), nerve impulse transmission, muscle contraction, and the secretion of hormones like insulin. Excitable cells, such as skeletal muscle and nerve cells, contain voltage-dependent calcium channels in their cell membranes that allow for rapid changes in calcium concentrations. For example, when muscle fibres receive a nerve impulse that stimulates them to contract, calcium channels in the cell membrane open to allow a few calcium ions into the muscle cell. These calcium ions bind to activator proteins within the cell, which release a flood of calcium ions from storage vesicles inside the cell. The binding of calcium to the protein, troponin-c, initiates a series of steps that lead to muscle contraction. The binding of calcium to the protein, calmodulin, activates enzymes that breakdown muscle glycogen to provide energy for muscle contraction. So calcium controls cell membranes, muscles, enzymes and hormones too. But it also plays a role in blood clotting. Calcium is necessary to stabilize a number of proteins and enzymes, optimizing their activities. The binding of calcium ions is required for the activation of the seven “vitamin K-dependent” clotting factors in the coagulation cascade (see vitamin K). The term, “coagulation cascade,” refers to a series of events, each dependent on the other that stops bleeding through clot formation. Regulation of calcium in the body is tightly controlled, through a vast series of checks and balances.

All of the above is described so you can understand how the body strictly regulates calcium. As WLS Post-ops, we become deficient simple because we don’t absorb enough. To make the situation even worse there are other vitamins and minerals that are required by the body and are also not readily taken up by WLS gastric bypass post-ops.

Other causes of abnormally low blood calcium levels include chronic kidney failure, vitamin D deficiency, and low blood magnesium levels that occur mainly in cases of severe alcoholism. Magnesium deficiency results in a decrease in the responsiveness of osteoclasts to PTH. Of course vitamin D deficiency and low magnesium levels are also common in gastric bypass post-ops who are not taking supplements appropriately. Calcium uptake in the body is seriously compromised without vitamin D. Without vitamin D and magnesium, the body has no chance to absorb calcium.

Several things can also play a part in the utilization of calcium by the body, sodium, protein, phosphorus, and caffeine.

Sodium(salt)

High sodium intake results in increased loss of calcium in the urine, possibly due to competition between sodium and calcium for reabsorption in the kidney or by an effect of sodium on parathyroid hormone (PTH) secretion. Each 2.3-gram increment of sodium (6 grams of salt; NaCl salt) excreted by the kidney has been found to draw about 24-40 milligrams (mg) of calcium into the urine. Because urinary losses account for about half of the difference in calcium retention among individuals, dietary sodium has a large potential to influence bone loss. In adult women, each extra gram of sodium consumed per day is projected to produce an additional rate of bone loss of 1% per year if all of the calcium loss comes from the skeleton. Although animal studies have shown bone loss to be greater with high salt intakes, no controlled clinical trials have been conducted to confirm the relationship between salt intake and bone loss in humans. However, a 2-year study of postmenopausal women found increased urinary sodium excretion (an indicator of increased sodium intake) to be associated with decreased bone mineral density (BMD) at the hip. Additionally, a longitudinal study in 40 postmenopausal women found that adherence to a low sodium diet (2 grams/day) for six months was associated with significant reductions in sodium excretion, calcium excretion, and aminoterminal propeptide of type I collagen, a biomarker of bone resorption. However, these associations were only observed in women with baseline urinary sodium excretions equal to or greater than 3.4 grams/day (i.e., the mean sodium intake for the U.S. adult population).

Canned veggies, soups, and pre-packaged meals are loaded with sodium. So are deli meats. These are things everyone needs to avoid.

Protein

As dietary protein intake increases, the urinary excretion of calcium also increases. Recommended calcium intakes for the U.S. population are higher than those for populations of less industrialized nations because protein intake in the U.S. is generally higher. The RDA for protein is 46 grams/day for adult women and 56 grams/day for adult men; however, the average intake of protein in the U.S. tends to be higher (65-70 grams/day in adult women and 90-110 grams per day in adult men). Weaver and colleagues have calculated that each additional gram of protein results in an additional loss of 1.75 mg of calcium/day. Because only 30% of dietary calcium is generally absorbed, each one-gram increase in protein intake/day would require an additional 5.8 mg of calcium/day to offset the calcium loss. At the other end of the spectrum of protein intake, the effect of dietary protein insufficiency on bone health has received much less attention. Inadequate protein intakes have been associated with poor recovery from osteoporotic fractures and serum albumin values (an indicator of protein nutritional status) have been found to be inversely related to hip fracture risk.

Most WLS post-ops are told to get in at least 70gm of protein a day. A Low carb diet is really the only way to eat after WLS.

Phosphorus

Phosphorus, which is typically found in protein-rich foods, tends to decrease the excretion of calcium in the urine. However, phosphorus-rich foods also tend to increase the calcium content of digestive secretions, resulting in increased calcium loss in the feces. Thus, phosphorus does not offset the net loss of calcium associated with increased protein intake. Increasing intakes of phosphates from soft drinks and food additives have caused concern among some researchers regarding the implications for bone health. Diets high in phosphorus and low in calcium have been found to increase parathyroid hormone (PTH) secretion, as have diets low in calcium. While the effect of high phosphorus intakes on calcium balance and bone health is presently unclear, the substitution of large quantities of soft drinks for milk or other sources of dietary calcium is cause for concern with respect to bone health in adolescents and adults.

It’s ironic that the main sources people use for their daily calcium intake also contain phosphorus which inhibits calcium uptake. This of course, is dairy products, milk, yogurt, and cheese. In addition one of the highest sources of phosphates is pop (soda). Every bariatric center tells their clients–NO MORE SODAS–but very few listen. Most are addicted to them. Now you know why you need to give up pop.

Caffeine

Caffeine in large amounts increases urinary calcium content for a short time. However, caffeine intakes of 400 mg/day did not significantly change urinary calcium excretion over 24 hours in premenopausal women when compared to a placebo. Although one observational study found accelerated bone loss in postmenopausal women who consumed less than 744 mg of calcium/day and reported that they drank 2-3 cups of coffee/day, a more recent study that measured caffeine intake found no association between caffeine intake and bone loss in postmenopausal women. On average, one 8-ounce cup of coffee decreases calcium retention by only 2-3 mg. So, for WLS gastric post-ops, a cup of coffee won’t kill you, but a better choice is de-caf.

One final comment. Bones are typically thought of as calcified, inert structures, but researchers at Columbia University Medical Center recently identified a surprising and critically important novel function of the skeleton. They’ve shown for the first time that the skeleton is an endocrine organ that helps control our sugar metabolism and weight and, as such, is a major determinant of the development of type 2 diabetes. This means that if we take proper care of our skeleton, we can affect our weight too. Hopefully all of this is enough to persuade you to make sure your take your vitamins and mineral supplements.

Related posts:

1. Why Gastric Bypass Post-ops Need Calcium Ron Merk Author One of the reasons Gastric bypass surgery...