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Nutrients: Calcium, Protein and Vitamins

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HOW PROTEIN WORKS IN YOUR BODY AND WHY YOU NEED IT:

The protein is interesting. Briefly - you eat a juicy steak (for example) and enzymes break it down into specific amino acids. There are 20 amino acids and these can be arranged in infinite ways...the body requires 50 000 proteins which are composed of hundreds of amino acids. So each protein is tailor made for specific body function.

So the body breaks down the protein - then reassembles it into amino acids. Acid and enzymes break it down into amino acids. Amino acids are delivered to the liver which then manufactures its own proteins...other amino acids go into the bloodstream where they circulate around the body being used as required.

Any that are not not used within a short time are excreted through the kidneys or burned as energy.

Amino acids are divided into 2 groups, 9 essential (because we need to get them from food) and 11 none essential, because the body produces these inside our own body cells.

The essential proteins are important to us WLS people and particularly DSers. It is important that we try to eat quality protein from various sources to ensure maximum range of the amino acids. Different proteins break down into different Amino acids. Animal sources are more digestible usually, than plant source with 97% of animal protein being absorbed but only 78-85% of plant protein being absorbed. Not that plant proteins aren't healthy - they are excellent for those struggling with meat - but just be sure to combine to make them complete: beans and milk, rice and sunflower seeds, rice and pea's or beans etc.

A tip for those that struggle with meat, is to marinade it in a tenderizer overnight(buttermilk or papaya are good examples, but wine or lime juice are good too!). Use natural tenderizers. This step disasembles and breaks the cross links that form on the side chains of the various amino acids making them a lot more digestable. Other trick is not to overcook as this creates enzyme resistant linkages within the protein chains interfering with our absorption of the protein.

My personal feeling is that we Dsers could do well to have one portion veg-protein everyday if possible. And in my diet I am going to actively work on doing this.

In effect protein is not stored for any great length of time...this is why it is so vital to eat it daily...any shortage and the body starts breaking down internal protein sources, including cells lining the intestine. (This occurs quite normally but may be accelerated in times of protein shortage).

It is not clever to diminish the pool of amino acids available to the body at any given time. It's talked about as nitrogen equilibrium - negative balance is undesirable, because when it occurs the body struggles to, for example, replenish tissues.

Therefore I shouldn't really use the word 'storage' of protein which brings to mind fat deposit storage type thing. 'Maintaining constant daily balance' might be more accurate.

BTW - fat is important to prevent negative nitrogen happening & so are carbs, but in the DSers case if healthy fats are consumed (the omega's 3 & 6) it facilitates protein health and balance in the body. I like to add a few tablespoons of carb a day also just for good measure! If one is smart, the carb can be worked into a nice protein rich combo ie - rice & lentils/beans & cheese - multifunction for the DSers.

One function is to ensure tissue growth and maintainance. Protein forms major body tissues. Also it makes enzymes and even some regulating hormones. Insulin for example is a protein! Moreover some proteins are critical for the immune system.

Others transport nutrients. Proteins are vital for the bodies water balance too. Protein is also related in energy use though not as much as fats and carbs.

What happens when we don't take in enough protein?

Immune system breaks down, in particular antibody formation is depressed. Wounds take ages to heal increasing infection risks. Skin lesions may develop. Tissues cannot replenish. Edema occurs along with changes in hair colour. Anemia may occur as hemoglobin is an iron bearing protein. Internal cells may break down in a bid to supply the body with protein. In short - a sad sad state of affairs.

MY PERSONAL PROTEIN EXPERIENCE:

Thinking I could be smart and apply the dieticians way of working out protein grams for each pound in weight and coming out with a custom built daily allowance as I was nearly normal BMI, I discussed this with a dietician. We agreed that in the light of the malabsorption we should not go too low so we settled on 65grams for me daily. Within 2 weeks I felt sluggish, my hair lost it's condition and was falling out prolifically, I gained weight due to water retention I believe, my face was puffy, my skin dull. I countinued only for a week after that before kicking it in as a learning experience for myself & one I shall not repeat. I got back onto my 85 - 100grams a day. My hair is having regrowth and is not falling out in an alarming fashion, my energy is up, puffiness is gone, weight is down. Moral of my story - we need 85-100grams even if our BMI is normal. Also - hairloss and protein are seemingly connected - at least for me!

***THE LIVER THING:

I am going to be frankly purist and say that here in the UK we really seem to have a skewed idea of surgery and alcohol. I don't get it when a person shows great concern as to whether they will be able to continue drinking after surgery. I just think when you get a gift and a chance like this then stopping alcohol consumption is a very small price to pay. At least for year one. In year two I am sure the occassional glass of good wine won't hurt from time to time & I have the odd drop of port which goes a looong way-lol! We are cheap dates indeed!

The liver is under stress in year one. We know this because very often we see elevated enzyme levels. It's regarded as quite normal & usually the levels go down all by themselves. This stress is due not only to the actual surgery but also to the rapid weightloss and often prior to surgery the patient has fatty liver syndrome. Now why would we want to put more strain on an already struggling organ? We should be doing EVERYTHING possible to support it not harm it further. Things that can be done are to increase fluid intake and to keep the colon in good nick too - this will help prevent toxic build ups. I take milk thistle supplements from time to time. Other good liver tonics are dandelion. It's yuck but good!

Here is a link to Sandra Cabots(MD) Website. I think it is well worth a browse:

Eat foods to increase nutrients beneficial to liver function. These are:

Vitamin K - green leafy vegetables and alfalfa sprouts. Arginine - this helps the liver to detoxify ammonia, which is a toxic waste product of protein metabolism. Arginine is found in legumes (beans, peas, and lentils), carob, oats, walnuts, wheatgerm and seeds.

Antioxidants - found in fresh raw juices such as carrot, celery, beetroot, dandelion, apple, pear and green drinks like wheatgrass and barley-grass juice, and fresh fruits, particularly citrus and kiwi fruit.

Selenium - sources of the antioxidant selenium are brazil nuts, brewers yeast, designer yeast powders (very good source), kelp, brown rice, molasses, seafood, wheatgerm, whole-grains, garlic and onions.

Methionine - is essential for detoxification. Is found in legumes, eggs, fish, garlic, onions, seeds and meat.

Essential fatty acids - Seafood, cod liver oil, and fish oil. Seafood may be fresh, canned or frozen such as sardines, salmon, mackerel, tuna, trout, mullet, blue mussels, calamari, tailor, herring, blue eye cod, gemfish. Fresh avocado, fresh raw nuts and seeds, legumes (beans, peas, lentils), wholegrain, wheatgerm, green vegetables such as spinach, green peas and green beans, eggplant, cold pressed fresh vegetable and seed oils, freshly ground seeds, especially flaxseeds (linseed), evening primrose oil, black-currant seed oil, star flower oil. Essential fatty acids are required for healthy membranes in every cell of the body and plentiful amounts are required for healthy liver function. This is why strict low fat diets are not beneficial for general health, weight control or liver function.

Natural sulphur compounds - are found in eggs (preferably free range), garlic, onions, leeks, shallots and cruciferous vegetables such as broccoli, cauliflower, cabbage and Brussels sprouts.'

IS IT OKAY TO EAT FAT?

Yes! - Dr Hess said "Fat is your friend!" Some surgeons do not agree!

DS patients malabsorb fat. We only absorb 25-30% of any fat we eat, so imo fat is a good food for us. It can no longerharm us and for some DSers it appears to accelerate weightloss as well as shift plateaus. However, I recommend we try to eat as many good nourishing fats as we can, fats such as the omega's found in fish,nuts and seeds. These are healthy fats and they play an anti inflammatory role in the body. They may support liver function too. I avoid the transfats. I don't like the idea of rancid fats hanging out for too long in my bowel! I stick with natural products such as cold pressed oils and butter instead of marg. I feel it is truly not necessary to add EXTRA fats to your diet however. Just get rid of the old diet mentality of 'low fats' and enjoy your full cream yogurts and suchlike. We run no risks of high cholesterol either. I eat 3 eggs a day as a cornerstone to my overall health - a fact that would be ordinarily be frowned on by dieticians.

VITAMINS ADEK:

YOUR SURGEON SHOULD PROVIDE YOU WITH INFORMATION ABOUT ADEK. SADLY THIS IS OFTEN NOT THE CASE. IF HOWEVER HE DOES, STAY WITH THAT ADVICE.

SURGEONS DIFFER ON THIS TOO....HESS WHO DEVISED OUR DS PORTION OF THE OPERATION STATES WE PARTICULARLY NEED A&D WITH E&K BEING SECONDARY. I KNOW OF A DS SURGEON IN THE USA WHO DOES NOT PUT HIS PATIENTS ON ADEK BUT HE CONSISTANTLY DOES LABS. IF ONE IS NOT GETTING REGULAR LABS I WOULD BE DUBIOUS ABOUT NOT TAKING ADEK.

WHEN DO WE BEGIN TO TAKE THESE?

At week 5/6 you should start taking the vitamins in earnest. I recommend capsules as the taste of any vitamins and calcium can make us gag! Because we malabsorb fat we also may not get in enough of the fat soluble vitamins,

Vitamins ADEK. We need to supplement these everyday.

We need ADEK in water soluble/miscuble form preferably. I worry because I know some DS ers in the UK are being given fat soluble vitamins on prescription - does this mean they are only absorbing 30% of the ADEK? It might well be. The doses are not high enough potentially to compensate for this? I contacted a nutritionist at Unigreg-the manufacturers of forceval and was told that some of the vitamins are indeed solubilized in oil and they are the ADEK componant of the forceval. All adek are fat soluble at core but there are 3 ways they are carried - in oil, emulsified in water and dry form.

IF YOU HAVE NO GUIDANCE, STAYING WITH THE FOLLOWING SHOULD GIVE YOU YOUR BASIC NEEDS:

***BARIATRIC VERSUS 'PUT TOGETHER' VITAMINS

Bariatrics :

Put together:

PHYTATES:

Phytates in tea and fibre may hinder absorption of vitamins. However unless I had a deficiency I would not worry about this.

ABSORPTION OF VITAMINS:

For max absorption of most of the vitamins it is best to take them with meals. The exception to this rule is Vitamin C. The digestion process is active then which means your body is receptive to taking up nutrients...much more so than when you just swallow the pills with water. It's a simple tip but you would be amazed how few of us know this. Having small doses of vitamins more often might be better than larger doses less often. Tea (you don't want to hear this! - has the unfortunate effect of containing phytates that can bind your minerals so don't take vits/minerals with a good old cuppa too often!

Keep your vits out of reach of children!!! They can cause death.

However, unless you are madly swallowing huge doses of these vits...as a DSer you should be fine. Surgeons differ on the approach to ADEK. A few do not feel patients even need ADEK but they do then monitor the levels very regularly.

I personally go by what the surgeon Hess says as he has been involved with the DS for ages & has great experience of longerterm dsers as well. According to Hess A & D are very important. E & K are of lesser importance but best to take to be on the safe side. Be sure you take a water soluble type as the fat soluble ones will just pass through your body. Hess says to take 3 water soluble ADEK a day.

Hess reports that 10% of DS patients will need to take iron medication at some time.

As we all absorb slightly differently, labs are very important to have done regularly at least every 3 months at least, in the first year.

If you can, I urge you to have regular monitoring. This way you will know the exact levels in your body and your supplements can be lowered or raised. These levels are an individual thing and can differ from person to person.

Here are some links related to vitamins:

I take the vita4life as I find it convenient and very comprehensive. Although not DS optimal they are in my view as good as any bariatric formula gets. They work well for me. As my labs are a joke I probably overcompensate but cannot take risks without the monitoring.

The daily dose I take is as follows

When you look on the average bottle of vitamins to check the dosage it is often laughable next to the dosage I take. So please check dosage levels as they can be ridiculously low and you could just be fooling yourself you are accomplishing any good with them.

*** UPDATE August 29th

I have finally been able to get my labs done on ADE by going private. All are in NORMAL range.

I recently discovered Vita4Life uses oil soluble vitamins in high doses. There are three ways these are administered - in water miscible form, in oil form or in dry form. I was worried but reasssured by the CEO Greg that the body will not store more than it should and that Vit A excess will be excreted? That seems to be the case with my labs. Please don't take the V4L if you are not going to have regular labs.

I shall continue to take it until something better comes along. I believe the fact that my labs all look good speaks volumes - I also feel the product is made from quality Vitamins - in dry form. There are no fillers used. Absorption is rapid - it does not lie the system for hours on end. In my view these are still good reasons to take it.

CALCIUM IS VERY IMPORTANT

When I hear of the poor advice been given to DSers by some medical professionals no less - I could weep. Surgeons are surgeons and lately with the surge of interest in the DS, many of them are on a learning curve. If they used to do RNY's you could end up getting the RNY requirements, not DS requirements. I am not blaming the surgeons, it's understandable as surgeons never qualified to be nutritionists!

Some surgeons simply do not have time for the nutrition side and expect you to empower yourself with knowledge. It is not rocket science and to get the basics should not be beyond the mental means of most people. DS should not be performed on those who cannot grasp & implement the nutrition aspect.

In my opinion the DS is 60% of the job - the other 40% has to do with aftercare and nutrition. It is useless having a beautiful surgery in a malnourished sickly body.

Research the calcium for yourself. Research the vitamins for yourself. Study what the EXPERIENCED surgeons prescribe nutritionally - they have done the DS for many many years. Become your own best nutritionist. Know your body and make the effort to work with your body. Also know when you need the help of professionals and seek out the right ones, not the timewasters many of us encounter. Find people who like the fact that you are empowered and taking responsibility for your health.

THE GREAT CALCIUM CONTROVERSY:

Calcichew might be nearly free on the NHS but it may not be best for our absorption. If you are taking antacids, I would seriously logic out the use of carbonate that requires stomach acid for absorption. You may be putting the calcium into an environment that cannot utilise it effectively. According to DSers in the USA, calcium carbonate is no good!!! (There is huge speculation & debate on this but the longerterm evidence seems to not be for calcium carbonate. ) Personally at this stage I go with the citrate, my feeling is prevention is a lot better than cure. Wrongly or rightly, the way I see it, the carbonate is controversial. I do not wish to take a controversial supplement. Especially one that I make the effort to swallow a truckload of everyday! On the other hand I believe the citrate requires a lot more investigation too. In the ideal world if I was not getting my citrate neatly wrapped up in a bariatric formula - I would probably go for apatite that has been produced from as clean a source as possible. I can find no side effects listed for apatite as yet but I am still researching. If you know of any please let me know. In fact if you have any data about calcium I would love to see it. Especially if it can prove anything wrong in what I have written here. I will be glad to get such material to ensure I am seeing the biggest picture possible. I am pretty upset that we are taking huge doses of calcium daily and yet there is scant information about the potential side effects of each type of calcium - health professionals should be doing tests and studies on this stuff to ensure it is truly safe for human consumption. Consensus should be reached after a panel of researchers are put on the job. Data should be collected from all over the world. Then the surgeons should take a long look at it. It's not just DSers who have to take a bigh daily whack of calcium - it is also other WLS patients and also people with Osteoporosis & other bone diseases.

A 100% safe calcium with as little risk as possible is every patients right, right now it seems to be a case of trying to make do with lesser evils where-ever possible. That said the risks of not taking calcium are way too high and the DS patient must just try to make do until further strong medical/scientific evidence is available to indicate the best choice of calcium. In the meantime we do need to consider absorption when we choose the calcium we are going to use.

Some surgeons & dieticians say carbonate is okay and they give it to DS patients. I truly hope they are right, because we have a lot of Dsers out there on it. Will these surgeons and dieticians be taking the rap if in a few years from now it has not worked??? We can only hope that they are using proper labs to test it as I have heard that as calcium floats freely in the blood it can test nice and right even when in reality the bones are not utilising it. Again I better add, I cannot find evidence to prove this conclusively, but it is yet another controversy over calcium carbonate. It must be said though that carbonate is not unabsorbed - it is absorbed, the thing is we really just don't know how much. But it is certainly better than nothing. Side effects of carbonate can be quite gastric actually - bloating is among side effects - so perhaps DSers suffering significant bloating might want look into this. Also I was quite amazed to find in AdCal which is prescribed here in the UK it has xylitol in it - DSer beware! This is one that could distress & irritate your digestive system no end! In the Calcichew we find aspartame - and this is a huge controversy in its own right with 92 side effects listed, some are gastric related too. According to WHO, calcium carbonate is specifically mentioned as being toxic in high doses. Before you panic if you are taking the carbonate, remember that these are probably VERY high doses even by DS standards. Other forms are not mentioned as having this risk by WHO.

It probably seems like a minor point to quibble on - if one is not a DSer doing the daily ongoing swallowing of the stuff - but I just don't understand why if there is supposedly less risk with the citrate and apatite forms of calcium & greater absorbability versus possible risks and great speculation with carbonate it is so difficult for a surgeon/dietician just to go with the less risky options wherever possible? I suspect it has to do with taking the easy option - in the UK it is now very difficult to get citrate whereas carbonate lines every shelf in the pharmacies.

Hess, who devised the DS portion of the BPD, and whom is a long term experienced surgeon, recommends the use of cal apatite or citrate calcium for the best absorption. He does not say that the carbonate is not absorbable because it is to a degree - but it seems clear what he is saying in this excerpt from his paper below:

SPECIAL NOTE ON CALCIUM

Calcium is the most important mineral for you to take after this surgery. Most of the bodyâ\u20ac\u2122s calcium is stored in bones, which are very important in your strength, function, and body stability. Calcium plays a vital role in many basic physiological processes, including blood coagulation, the sending of messages along nerves, maintenance of muscle tone, preservation of cell membrane integrity and permeability, and certain glandular functions. Less than one percent is available in extracellular fluid (body fluid outside cells) for these important functions, the rest of the calcium is found in bone. If your serum (blood) calcium is low, your body will take the calcium that it needs from your bones and over a long time will make the bones soft and easier to break. Thus, it is important to take the proper calcium supplementation. If you do not take your calcium regularly you could develop osteoporosis, especially if you are a post-menopausal woman. Microcrystalline hydroxyapatite (Cal apatite) is 20% more absorbable than calcium carbonate (tums) and even more absorbable than calcium citrate (Citracel).

20% extra absorbability is actually high for a DSer considering the volume of calcium we swallow. When bones begin to soften and crumble it is a really scary thing - don't let it happen. It is not reversable although it can be stabilized. Men get this too. Pay for quality calcium and take it everyday.

***Update May 2004:

I have been on citrate at two years out my labs show levels are good. Next year I will do a dexa scan again even if it is self pay - I still believe every one of us distal surgeries should have these. I better add a lot of my DS is turning out to be self pay so be aware of this! I was delighted recently to read a book by a bariatric sugeon who actually has his patients monitored in this way & who advises it strongly - a bloke after my own heart. I discussed it with a surgeon here in the UK and the worry seems to be about the costs attached as so many NHS considerations are. I can see the logistics. However the costs attached to caring for a patient who has bone disease have to make it worth our while to catch it early?

Here is a link to a calcium supplier:
http://www.randallnutritioncenter.com/rcnc2000/calapatite1000.html

MICHELLES STORY

Michelle (who had RNY surgery) from VitaLady has kindly given me permission to print her story here and I feel it is an important experience we can learn from:

Since my diagnosis with osteoporosis in August, 2000, I am NOW, belatedly,trying to learn a little more about it. I drank milk til I was 45, and a lot of it. I have taken calcium carbonate faithfully since my surgery. I had kidney stones in 1997, too much carbonate. Did I learn? No, took citrate for 3 months, then right back to carbonate. It's cheaper. As I learn things through the Osteoporosis Foundation and through literature on the subject, I add the summaries here.

I've learned that we put calcium into our "bank" until early adulthood, then we start taking it out. Caffeine, carbonation and some meds hurry the process. Losing weight also helps this along. Normally we shed/regrow bones cells like other cells. However, with the ever lightening body weight, the bone cells think they don't need to regenerate, so they don't! AND we don't absorb calcium as well as we did when we were younger. And we don't absorb it without a stomach.

Tums are carbonate less and may or may not contain Vitamin D. Also, some acid is required for absorption of calcium. What do Tums do to acid?

I do not offer any products which do not contain calcium citrate. I had special calcium citrates capsules made for us. They are swallowable as is, or they can be opened and stirred into something. They are 240 pills for $15 (about $5/month) for 3 per day. Each cap contains 500mg calcium citrate, 200 IU D, 250 mg magnesium. We can only absorb 500 mg of calcium at one time, so they are made to be as much calcium per pill as we can manage. Citracal is the only brand name that I know is formulated correctly. It runs about $13/month and if the bottle is the one that says "2 tablets = 630mg", then you would need to take 5 per day.

I have recently developed another product for use by those who already have their diagnosis or who want to just be more careful. I'm calling them Super Calcium, but they have a really boring name on the label. EACH PILL contains the same as the above, 500mg calcium citrate, 250mg magnesium, 200IU of vitamin D PLUS 1 mg of boron and 33mg of ipriflavone 240 for $20

Along with using a good calcium citrate, my PCP's office recommended SIMPLE weight bearing exercise. Just heft a can of veggies in each hand. Now, even I can do that.

My osteoporosis is fairly advanced and I only got the DEXASCAN due to peer pressure. I'd never have known it if it hadn't been a constant topic of conversation. I had a foot scan which showed me to be so far superior that I'd NEVER have to worry. However, I was told that isn't a true reflection. Tragically, my peer group was right and now, for my little economy ride for 6 years, I will pay dearly. Instead of just taking the citrate, I'll also take Tri-boron to increase absorption, ipriflavone to decrease bone loss, as well as trying to take the prescription preparations.

So far, I am unable to tolerate the side effects of either one.

Don was also diagnosed recently. He has taken much larger doses of calcium, but that makes no difference since it was the wrong kind. He took both carbonate and oyster shell. Some brand names that are NOT citrate are Caltrate 600 & OScal.

I strongly recommend that anyone over 40 or post-op have this scan done ASAP. It's painless and not even expensive. You don't have to have all of these, just one or two is enough. Your justification for having it might include:

  • Being post-menopausal
  • Lactose intolerance
  • MASSIVE WEIGHT LOSS
  • Having had any obesity surgery
  • It's in your family
  • Recent bone breakage
  • Use of caffeine or carbonation after age 20
  • Use of nicotine
  • Being fair or of Northern European descent
  • being small frame

August 2001 dexascan shows no change whatsoever. In my case, without the ability to use the prescriptions available, that is GOOD news. That means that the mineral preparations have at least held the line.
CALCIUM FOR DSERS:

DSers Calcium dose is 1500mg's - 2000mg's a day.

I take 2000mgs of calcium citrate a day as a dexa scan shows my bone density to be upper limit normal. I HIGHLY recommend that all DS patients get a DEXA bone scan to keep accurate track of bone density.It takes months to do but can be done on the NHS and it is not painful at all. If possible have one done before you have the DS. If not - still have one done!

The most absorbable calcium (but hard to get-I have not seen it here in the UK) is cal apatite. But it is really not that much more absorbable than the citrate which is a pretty close second option. Citrate is really adequate for our needs and I would only take the apatite if my scans showed bone problems. Dosage is the same for men. Men can also get osteoporosis as Michelles story above testifies. Apart from the absorption factor - our high protein intake means we excrete more calcium than most through our urine. The calcium carbonate issue is extremely debatable and I still have not found enough medical papers written on the subject to convince me that it is truly the best option. Vit D helps absorption of calcium as does boron.

A little more info - it is complex...calcium can decrease iron absorption -therefore take the calcium at a different time to the iron...unless you are taking Iron fumerate. Iron Fumerate and calcium citrate are apparently fine together. (This is the simple way forward ) I take 266mg's of Iron fumerate. In the event that you have got an iron other than fumerate, taking Vit C at the same time as the iron helps to buffer the iron from the calcium.

Stress and worry may affect calcium absorption - a net loss of 900mg might occur during times of worry and tension - how's that for inspiration to keep calm!

I read somewhere also that the bones utilise calcium mostly at night - so it might be worth taking some of your dose before you go to sleep.

We need calcium - not only for bone health but recently there is some interesting data speculating that some forms of colon cancers risk might be decreased with increased calcium intake.

The early signs of too much calcium in the blood:

(For Dsers, unless symptoms are severe I would say it would be probably be better to reduce rather than stop the dosage suddenly.)

Late signs:

OTHER VITAMINS YOU MAY WANT TO CONSIDER

MAGNESIUM INFO.

Please remember I am not a medical person and that if in any doubt check out this info with your surgeon or doc.

Most of this is from my nutrition reference book, some from internet sources:

"Several of the symptoms of Mag deficiency are similar to PMS - mood swings, muscle cramps, reduced appetite and some researchers theorize that alterations in estrogen levels intensify marginal magnesium deficiencies and the accompanying symptoms. "

Who may benefit:
Other symptoms:
What it does:

Magnesium citrate is the best absorbed form. It is absorbed best in around 100mg doses 4 or 5 times a day - taken with food. Don't chew or crush. Swallow whole.

Toxicity

Do not take if you have kidney disease.

For those suffering with oesphagus spasms, I found this advice on the internet in a letter written from someone asking a doctor advice for oesophagal spasms:

Magnesium is essential for normal muscle function, and a deficiency can lead to problems with spasm or cramp. If you ever get cramp when you're in bed or exercising, then this points quite strongly to a problem with magnesium deficiency. Because of its role in normalising muscle function, magnesium supplementation is often effective in controlling oesophageal spasm. Take 350-500mg each day.

RECOMMENDED READING: Both are on: http://www.duodenalswitch.com

This information is taken from various sources, books, nutrition references, the internet, newspaper clippings worldwide. The nutrition aspects have been overseen by Prof. Weiner and Dr Blanco - both of whom have said it is fit to be published.

It is a work in progress.

Although every effort has been made to ensure accuracy on the facts contained in this website, I am not responsible for any consequences of the use or misuse of the information by others. My photo's and pictures are strictly copyright and may not be used without permission. Cartoons are done by my daughter and may be bought for a fee. Contact me about them if you require them. At no time may they be used without permission as they are copyright.

The DS Food pyramids and the DS Dietary timeline have never been previously published and belong to the author of this site. They may not be used without my permission as they are my creation. Other material on my website also requires permission to use. I reserve the right to change any information on this site at any time. My nutrition page is posted here for the use of other DSers and they may print off any of the material they need for private use. This page is not free of my opinion because the entire website is based on my subjective experience of living with the DS and my primary concern is that anyone researching the DS understands, in as much as possible, how it actually is. Post op nutrition is a daily exercise for me - nothing goes into my mouth without due consideration. It is especially time consuming initially for the DS patient.

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