The Most Common Nutrient Deficiency in Bariatric Patients

If you’ve had bariatric surgery, congratulations on the new you! Now its time to learn to take care of the different nutrition needs brought on by your surgery. Though surgery will help you take and keep weight off, it also increases your risk of developing several nutrient deficiencies. And, because the best defense is a good offense, it is wise to talk to your physician and dietitian about the nutrient deficiencies common in bariatric patients.

The most common nutrient deficiency you are likely to experience is iron deficiency anemia. And, a related issue to this deficiency is pica – a condition where a person craves and eats non-food substances such as laundry starch, ice, dirt, clay, cigarette ashes and more. Patients who have undergone operations such as Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BD), with or without duodenal switch are at an increased risk of developing pica.

Additional reasons bariatric surgery increases your risk of developing iron deficiency anemia and pica include:

• Immediately post surgery your intake of iron rich foods may be minimal
• Surgery means decreased hydrocholoric acid production in the stomach and this acid is essential for the absorption of some micronutrients
• Food and supplements now bypass the typical iron absorption sites in the small intestine
• There are fewer receptors to transport iron and change iron to the form that is absorbed best by the body

All of these issues make it essential that you talk to your physician about getting checked for iron deficiency anemia and how best to supplement if you are low in iron.


Reference: Bariatric Times 2010;7(11)22–23

Do Supplements Work?

Friday night, while looking at the Dali exhibit in the High Museum, my friend’s cousin asked me “do multivitamins work?” Startled I responded, “wow that’s one loaded question. Work for what? What result are you looking for?”

Neither supplements or the entire broad topic of nutrition for that matter, are cut and dry like an algebra problem. For x + y = z in your body, you must take the right form of the supplement, take it at the right time (with or without food; noting attention to specific types of foods that may help or hinder your supplement’s absorption) and look at how much you are taking at a time. In addition, to notice a benefit, many supplements need to be taken for a period of time, not just a one stop, pop it and bam! you feel amazingly better. Because of all of these factors, part of the responsibility of taking supplements falls on you, the consumer. But, here’s a quick cheat sheet for some common nutrition supplements.

In addition, I encourage people to follow this train of thought when considering a dietary supplement:

Restless Leg Syndrome: Tips for Prevention

A few years ago I first heard about restless leg syndrome and just couldn’t imagine it was a real phenomena. An urge to move your legs at night because it feels like something is crawling up them, they ache or feel pulled? That would constantly make a person wake up! Indeed, it does... and restless leg syndrome is one of those things that scientists just don’t know much about, which makes it really tough to treat. However, there are a few key things you can do (this list is compiled from a mix of the research and what my dietitians colleagues, with decades of combined experience, have uncovered from working with their clients):

1. Avoid emotionally upsetting events. Or rather, learn coping skills since life can throw you a curveball sometimes.

2. Get a good bed. After all, your sleep will improve no matter what if you have a good mattress, sleep in a room cool in
temperature with no lights (cover up those bright red displays on TVs, clocks etc. and turn your phone off or put something
over it so it doesn’t light up incessantly).

3. Get your storage form of iron, your ferritin, checked (this is a must, don’t settle for only having your hemoglobin and
hematocrit checked). Iron deficiency anemia can cause restless leg syndrome. Your ferritin levels will likely need to be
above the lower limit (12 ng/mL) to alleviate your RLS symptoms. A ferritin level above 50 ng/mL is necessary.

4. Consider a nighttime calcium/magnesium supplement to help you sleep.

5. Relax before bedtime, avoid any stimulants (caffeine, nicotine) and of course, avoid alcohol.

For more information restless leg syndrome, check out this blog.

Micronutrient Smackdown: The Best Time to Take Your Vitamins and Minerals

When I meet with people for nutrition coaching, I always ask about their medicine and supplement intake in addition to what they are eating. Why? Because I can quickly spot gaps in their diet and want to be sure they are filling those gaps with supplements. Especially if they don't plan on adding food sources of the missing nutrients in the near future. And, I want to be certain they are taking their supplements the right way because many people were never told by their physician (or the supplement bottle doesn’t mention this) how to take a particular mineral.

You see, like sorority girls, minerals are finicky. There are many forms for each one (calcium carbonate, calcium citrate, calcium phosphate for example) and some just don’t like each other (calcium interferes with iron absorption) or certain medications (calcium decreases the absorption of some antibiotics) and others have formed a team and help one another (magnesium and calcium for example). So, how do you know what to take when? Here’s a quick rundown of some of the common ones people need and how to take them:

Multivitamin – take with food and preferably food with a little fat (to enhance the absorption of fat soluble vitamins you need fat in your gut).

Calcium – take up to 600 mg at a time. If your physician told you to take 1,200 total mg/day, take them in two separate doses of 600 mg, spaced apart. Your body only absorbs up to 500-600 mg at a time.

Calcium carbonate – take with food to enhance absorption.
Calcium citrate can be taken at any time of the day.

Magnesium – no single pill multivitamin contains 100% of your magnesium needs per day (it is a very big mineral) and according to population based data, many people don’t consume enough magnesium through their food intake. Diuretics and antibiotics can contribute to magnesium depletion. Magnesium can decrease the absorption of tetracycline (an antibiotic); so take it at a different time of the day. Many antacids and laxatives contain magnesium –be careful consuming these due to the potential for elevated blood magnesium levels. Enteric coating of magnesium supplements can decrease their absorption.

Iron – there are two types of supplements.
Non-heme iron is the most popular (all over the counter kinds of iron unless it says it contains heme iron) and should be taken with vitamin C rich foods, a heme iron source (meat) and not taken close in proximity to calcium containing foods or supplements. In addition, it’s best not to take this with leafy greens or bread as each has compounds that decrease the absorption of non-heme iron.

Heme iron – easy, take anytime of the day. You don’t need to worry about what you take it with or without.

Zinc – taking an iron supplement with large quantities of iron may decrease zinc absorption. According to NIH, taking iron between meals will help (see note above about iron). High intakes of iron can impair absorption of copper.

Potassium – found in very minor amounts in multivitamins. Don’t take extra potassium unless your physician tells you to do so. Having too much or too little potassium can be very serious.

Given that so minerals are picky and like to be treated a certain way, you are probably wondering why you should even bother taking a multivitamin mineral supplement. However, I do believe in multis and take one myself and I supplement with minerals as needed. After all, I try to eat a wide variety of foods but, I realize that there are probably vitamins and minerals I am missing out on.

Dr Oz. on Exhaustion

Exhausted? Pale, dizzy and cold? Check out Dr. Oz's top tips on anemia support, anemia research and anemia treatments by clicking here.

Even better though, I love this clip from Dr. Oz's show that shows : click here to view the video.

Top Vegetarian Sources of Iron

The best sources of iron are from meat, poultry and fish – all of which contain heme iron. Heme iron is absorbed better than the type of iron found in plants – non-heme iron. For vegetarians of course, this is a moot point since animal foods aren’t an option. Therefore, you’ll need to be extra aware of your iron intake.

The top vegetarian sources of iron include:
- Fortified cereals (look for 100% DV for iron)
- Instant oatmeal
- Lentils
- Lima, navy, lima, black, pinto
- Molasses
- Spinach
- Black-eyed peas

Be sure to include several of these foods in your diet and consume them with vitamin C to enhance the absorption of non-heme iron. Also, take your calcium supplements and antacids separately since they can inhibit the absorption of non-heme iron. Though the absorption of heme sources of iron are not affected by what is eaten concurrently, the absorption of non-heme sources is affected by what you concurrently.

Why is Anemia More Common in Some Ethnicities?

There are many, many types of anemia with iron deficiency anemia the most common. And, anemia isn't really one of those nutrient deficiencies that is tied to certain ethnicities (the way vitamin D is for instance; where ethnicities with darker skin have a greater risk of deficiency). But, a study published a few years ago made me re-think the fact that some ethnicities may have an increased risk.

Among women, there's been a decline in the prevalence of iron deficiency anemia and folate deficiency related anemia. However, there's a tremendous difference by ethnicity: 3.3% for whites, 24.4% for blacks and 8.7% for Mexican Americans. Unfortunately, I'm left wondering and trying to figure out what is going on. According to this study, patient demographics, lab testing methods and known causes of anemia can't account for the differences. So, what's left? Is the data wrong? Have studies misinterpreted the prevalence data or have other factors contributed to this data? One potential factor mentioned is lack of adherence. For all the clinicians out there, we know this all too well. You can give someone a prescription or supplement and instructions, but, this doesn't mean they will indeed follow-through and take it as prescribed. Follow-up and monitoring are absolutely crucial with any deficiency.

Right now we have more questions than answers but hopefully future research will tell us why some populations have a higher incidence of anemia. Right now though, public health interventions can at the very least, target these groups to make them aware of iron deficiency anemia and increase testing in those who are displaying signs and symptoms of deficiency.

Am J Clin Nutr 2008;88(6): 1457-1458.

Heavy Period? The Top Causes of Debilitating Menstrual Cycles Uncovered

Some people share a little TMI (too much information). As one of my good friends said, as a dietitian, you are part nutrition expert, part behavioral expert and part therapist. And granted, I’d expect my female clients to ask me questions about their bodily functions (from constipation to the color of pee). But when random girls I don't know well start telling me about their heavy menstrual cycles and asking about herbal remedies, it’s TMI. I’m not a doctor, you’re okay and it's Friday night and we are at a bar for crying out loud. But, naturally curious, I began to wonder why some women complain about abnormally long periods, debilitating cramping, bloating and a 1-week a month total meltdown.

So I went searching and found some common causes of heavy periods include:

- Hormone imbalances - the pill can help, sometimes.
- Uterine fibroid tumors - these are typically benign (non-cancerous). The causes are not known but these tumors rely on estrogen for growth.
- Cervical polyps - small growths on around the cervix
- Pelvic Inflammatory Disease (PID) - typically caused by a STD though some women get PID after childbirth or a gynecological procedure.
- Cervical cancer - yearly pap smears are vital for catching this cancer early!
- Endometrial cancer
- Bleeding disorders
- Diseases such as lupus, cirrhosis of the liver, diabetes, thyroid and pituitary disorders

If you have heavy bleeding and/or cramping and pain, don’t just wait it out while popping Advil. Instead, talk to your physician to rule out any medical conditions that may be causing changes to your cycle. In addition, may sure your physician runs lab tests including CBC, thyroid functioning and an iron panel.

Anemia - There are Several Kinds!

The word anemia typically makes people think of iron. However, there are actually over 400 kinds of anemia. Anemia is a condition characterized by a lack of healthy red blood cells. Because red blood cells transport iron to your body’s tissues, anemia will often lead to fatigue. The most common types of anemia related to dietary deficiencies are:

Iron deficiency – over time, inadequate iron intake will hamper the body’s production of hemoglobin, a protein in red blood cells that carries oxygen. Iron deficiency can result from inadequate dietary intake (especially in vegetarians, children and teenagers), increased demand for iron (pregnancy and breastfeeding), heavy menstrual periods and digestive diseases such as Crohn’s and ulcerative colitis.

B-12 or folate (folic acid) deficiency – both of these vitamins play an important role in the production of red blood cells. Folate is found in food and folic acid is the syntheic form of this vitamin. Megaloblastic anemia is due to a deficiency in vitamin B12 or folate or both. Pernicious anemia results from inadequate B12 absorption.

Vitamin E deficiency – hemolytic anemia, from a vitamin E deficiency, is rare but can occur in newborns and people who have problems absorbing fat.

Iron for the Over 65 Crowd

I’ve seen two diametrically opposite personality types in the over 65 crowd. The first type focuses on their aches and pains and believes that age is slowing them down so there’s really no use in trying to figure out why they feel sub-par. People that fall into the second personality type believe they can overcome aches and pains, age doesn’t matter and they are enthusiastic about all that life has to offer. As a dietitian and exercise physiologist, I think everyone will feel better if they are physically active and eat a healthy diet. And oftentimes, elderly people fall short on several nutrients, making their diet, and not necessarily age, the root cause of some of their health issues.

The elderly often take in fewer total calories, protein, vitamins B6 and B12, folic acid, iron and zinc than they need. All of these play critical roles in good health. Iron deficiency anemia, the second most common cause of anemia in the elderly, can make you feel tired, breathless and decrease your ability to focus. Iron deficiency anemia can also decrease immunity leaving you susceptible to infections and illness.

If you feel fatigued or you’re having trouble concentrating, get checked for anemia. There are many causes of anemia in the elderly so your physician will likely run a few different tests to find out what is ailing you. Talk to your physician about all of your symptoms, what medicines (prescription and over the counter) and dietary supplements you are taking. After all, you deserve to feel energetic every day!


References:
Am J Clin Nutr. 2004 Mar;79(3):516-21.
J Nutr Health Aging. 2004;8(1):2-6.
J Am Geriatr Soc 1992;40:489-96.

How Much Iron do You Get from Cooking in a Cast Iron Skillet?

For years I’ve heard that cooking in a cast iron skillet can increase the iron content of your food. And then I realized all the work involved in maintaining an iron skillet. Storing one would be cumbersome, I’d have to season it with some sort of grease (after all, if you aren’t using non-stick pans you have to make the stuff not stick somehow) and it could rust. That’s just a little to high maintenance for a skillet in my opinion. However, I still wondered about the iron content. Does it really make a dent in a person’s diet?

In an effort to find the truth about the iron content in cast iron cooking utensils, I turned to my partner in research, google scholar. Luckily, a typewritten and scanned thesis from 1984 appeared that examined this very topic! After reading through this study I came to a chart that outlined how much the iron content increased if a particular meal was cooked in an iron utensil versus a non-iron utensil.

A few items on this list were not a surprise to me. Stew, chili with meat, applesauce and spaghetti sauce (all of which contained some acidic ingredients) gained a significant amount of iron if cooked in an iron versus non-iron utensil (applesauce was the all time leader in iron gained). However, there were also many surprises to me: scrambled eggs, rice and a white sauce. In fact, eighteen of the twenty foods cooked in iron and non-iron skillets absorbed significantly more iron than when cooked in the non-iron skillet. This study found that foods with a higher moisture content, more acidity and a longer cooking time take up more iron from the iron cookware.

I have to thank Cheryl Eileen Nossaman’s work for finally answering that question I’ve always wondered about. I’m still not going to use iron cookware because I prefer using oil versus grease in my pans. But at least I now know that iron utensils can in fact add iron to one’s diet!