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Mercury is just one of the many possibilities. Beneficial effect of vitamin E administration on nitric oxide function in subjects with hypercholesterolaemia. They lived in pristine environments and everything grew around them until they were rediscovered again. And just before I ate the livers, I ate a about 9 ounces of cranberry sauce. As a result DMAE is generally very useful in treatment of high dopamine low histamine, overmethylated persons, but can seriously harm low dopamine, high histamine, undermethylated persons.
Commentary on Nutritional Treatment of Mental Disorders
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Because bariatric surgery involves complex procedures that often rearrange the anatomy of the digestive system various complications and deficiencies in the fat-soluble vitamins, vitamin B12, iron, calcium, and folate can occur in addition to decreases in protein and fat absorption. These realities plus the growing prevalence of obesity and weight loss surgery in the United States make it more important now than ever for dietitians to familiarize themselves with the different procedures available and the most common nutritional deficiencies associated with each of them.
Becoming knowledgeable about the intricacies of weight loss surgery and the nutritional issues involved will help dietitians better counsel and treat patients as they embark on the long road to recovery.
Calculating Weight-Loss Goals Weight-loss expectations for patients who have undergone bariatric surgery are calculated in the surgical literature as a percentage of their excess weight, whereas in the medical literature a percentage of initial weight is used to calculate goals. So if her initial weight was lbs, she started with lbs of excess weight. If her lowest weight was lbs after surgery, that number would be her excess body weight loss at her lowest point. Typically, this would be considered a good result for adjustable gastric banding and vertical sleeve gastrectomy procedures since the patient was well within an average weight loss.
However, this is considered a suboptimal weight loss result for both the Roux-en-Y gastric bypass and biliopancreatic diversion BPD with or without duodenal switch procedures.
In , Buchwald and colleagues1 published a meta-analysis on the mean percentage of excess weight loss among common bariatric procedures. The researchers reported that the mean percentage of excess weight loss was BPD patients lost 84 lbs for every pounds they had to lose, while gastric bypass patients lost 64 lbs for every lbs of excess weight.
A patient who loses lbs and regains even 20 lbs after a sleeve procedure is considered one who experienced a greater-than-average weight loss. Dietitians can help prevent patients from gaining additional weight by educating them about diet and physical activity, the importance of adequate sleep, and stress management. Weight loss is more sustained after biliopancreatic diversion with duodenal switch than Roux-en-Y gastric bypass in superobese patients.
Surg Obes Relat Dis. Long-term outcomes of laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass in the United States.
The following are the most common questions dietitians should ask:. If the answer is yes, the RD should recommend the patient get screened for vitamin A deficiency, as this is typically the first sign and symptom after biliopancreatic diversion BPD with duodenal switch and gastric bypass surgery. New-onset numbness may be related to the surgery, although chronic numbness may be linked to diabetes if this was a preexisting issue for the patient.
However, numbness that worsens in patients with diabetes could be a sign of a deficiency in vitamin B12, thiamin, or copper, depending on the area of numbness. This may be a symptom of a thiamin deficiency. The numbness or burning, erythema, or redness in the feet will travel upward from the feet to the calves to the knees.
The numbness can progress from the toes to the entire leg within hours and may be potentially life threatening. So if an RD suspects a thiamin deficiency, he or she should refer the patient to a medical provider for immediate treatment.
If the answer is yes, the patient could be deficient in vitamin B12 or thiamin or have low blood glucose levels. Carbohydrate goals for patients could be the following: General guidelines are available to help lower the risk of ketosis and other side effects related to suboptimal carbohydrate intake, such as metabolic bone disease or the exacerbation of bone disease after bariatric surgery.
In addition, patients with inadequate carbohydrate intake may not be able to engage in regular physical activity due to chronic lethargy.
Sliming is a term sometimes used by the lay public to describe the white foamy discharge resulting from eating too quickly or consuming too much. This typically subsides or disappears when the patient begins to consume moist foods, eats slowly, and avoids drinking with meals.
This could be a symptom of a deficiency in thiamin, copper, or vitamin B Learning Objectives After completing this continuing education activity, nutrition professionals should be able to:. Distinguish the most common micronutrient deficiencies associated with weight loss surgery, and employ nutritional management strategies. Which procedure may result in iron deficiency due to lower acid content in the stomach?
Adjustable gastric banding b. Vertical sleeve gastrectomy gastric sleeve c. Roux-en-Y gastric bypass d. Biliopancreatic diversion BPD with duodenal switch. A female patient presents with strong cravings for ice, new-onset heavy menstrual periods six months after gastric bypass surgery, and severe lethargy and shortness of breath.
What nutritional deficiency does the patient probably have, and what would be the possible treatment? Folic acid deficiency; B complex daily d. A patient had gastric bypass surgery about four weeks ago and presents with severe nausea. He complains of dry heaving and notes that his primary care physician has ruled out any vitamin or mineral deficiencies.
What treatment will alleviate his nausea? Drinking warm water with meals to help digest his food b. Drinking cold water right before meals c.
Sucking on frozen lemon or lime wedges d. Sucking on hard candy. Which of the following is not involved with the vertical sleeve gastrectomy procedure? Removal of the fundus c. A decrease in peptide YY and glucagonlike peptide-1 production. Mary had vertical sleeve gastrectomy surgery three months ago.
She admits to eating too quickly, usually within 10 to 15 minutes, and then feeling overly full afterwards. Which of the following is most likely not a cause of the foam? Eating foods that are too dry b. Eating too quickly c. Vomiting due to a surgical issue. Folic acid deficiency c. Which of the following is not involved in Roux-en-Y gastric bypass surgery? Bypass of the duodenum and the proximal jejunum as well as the majority of the stomach c.
Malabsorption of macronutrients, including carbohydrates d. Anastamosis of the biliopancreatic limb above the ileocecal valve, which becomes the common limb.
Jill began experiencing hair loss 12 months after undergoing bariatric surgery. To remedy the problem, she started taking hair and nail formula supplements. Which of the following is probably the cause of her hair loss? He presents with memory loss, decreased night vision, achiness, lethargy, a clumsy gait, and numbness and tingling in his fingers and hands. James is exhibiting possible signs and symptoms of all the following micronutrient deficiencies except: Of the lab results below, which gives the best and earliest indication of suboptimal calcium levels?
Low ionized calcium b. Elevated parathyroid hormone c. Low 1,25 dihydroxyvitamin D levels d. Obesity among adults in the United States—no statistically significant change since Increases in morbid obesity in the USA: Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. In most therapeutic kidney foods, the fat content is increased to compensate for the lower protein levels.
Some senior cat foods also have relatively high levels of fat and relatively low levels of protein; as a bonus, they often also have low phosphorus levels. Therefore, if your cat won't eat a therapeutic kidney diet, it is worth considering senior foods, although do check the protein level is not too low.
The kidneys cannot process sodium as effectively in CKD, which increases the risk of hypertension high blood pressure in humans. It used to be thought that the same applied to cats, and it was therefore recommended that sodium intake should be restricted.
Research in Applied Veterinary Medicine 7 4 pp found that sodium intake appeared to have no effect on in blood pressure in CKD cats, but that levels of BUN, creatinine and phosphorus were higher in the cats eating a high sodium diet compared to those eating a low sodium diet. Even in cats with creatinine over 1. These results are consistent with the majority of other studies evaluating sodium intake in cats, as well as with the National Research Council's assessment, all of which indicate that sodium at 1.
Effects of dietary salt intake on renal function: The study concludes "The results of this 2 year study do not support the suggestion that chronic increases in dietary salt intake are harmful to renal function in older cats.
Increased dietary sodium increases urine output and may decrease the risk of forming calcium oxalate uroliths due to the decrease in relative supersaturation of solutes. However, caution should be used in increasing the sodium intake of patients with renal disease as increased dietary sodium may have a negative effect on the kidneys independent of any effect on blood pressure.
So should you restrict sodium intake or not? Treatment recommendations for CKD in cats International Renal Interest Society states on page 5 that there is no evidence that reducing sodium intake is helpful for CKD cats, and that it should certainly not take the place of medication for hypertension , but if you do opt to reduce your cat's sodium intake, you should do it gradually. The food data tables provide information about the sodium content of many cat foods available in the USA and UK.
This occurs because potassium is easily lost through increased urination and vomiting. Therapeutic kidney diets contain extra potassium all cat foods need some potassium , and this is usually in the form of potassium citrate, because potassium citrate may help with a problem seen in some CKD cats called metabolic acidosis. If your cat refuses to eat a therapeutic diet, your vet can give you a potassium supplement instead, if appropriate; some cats need a potassium supplement whether or not they eat the therapeutic kidney diet.
Many commercial cat foods are acidified in order to reduce the risk of FLUTD feline lower urinary tract disease. These foods often say that they are designed to maintain urinary tract health; or they may contain cranberries or additional Vitamin C. However, these foods which are actually designed to treat a different kind of problem to CKD may have the effect of increasing the amounts of potassium lost in the urine, which is bad for CKD cats.
It is therefore best not to feed acidified foods to CKD cats, who tend to have quite high acid levels anyway. Please see the Potassium page for more information about potassium. It also states "Our analysis indicates that cats have a ceiling for carbohydrate intake, which limits ingestion and constrains them to deficits in protein and fat intake relative to their target on high-carbohydrate foods.
In The carnivore connection to nutrition in cats Zoran D Journal of the American Veterinary Medical Association pp, Dr Zoran writes "It is clear that cats have a greater need than dogs or other omnivores for protein in their diet. Cats also have several physiologic adaptations that reflect their expected low CHO [carbohydrate] intake These specific differences do not mean cats cannot use starch.
In fact, cats are extremely efficient in their use of simple sugars. However, it does underscore their development as carnivores and the expected low amounts of grain in their typical diet. These digestive differences may mean that high amounts of CHO in diets may have untoward effects on cats. Therefore, if you are trying to reduce your CKD cat's protein intake, I would recommend increasing the fat in the diet see above rather than the carbohydrates.
If you are feeding a therapeutic kidney diet, this will often be done automatically - many of these diets increase the fat content rather than the carbohydrates in order to offset the reduced protein content. Pet Education has an interesting article about carbohydrates in the feline diet.
Fibre is the non-digestible component of complex carbohydrate. It is important for good digestive health. Increased fibre may help with elevated calcium levels in the body hypercalcaemia , although one type of fibre, fructooligosaccharides or FOS, may actually increase calcium levels in the body see below. It may also assist with two commonly seen CKD problems, toxin reduction and the control of constipation.
There are a number of ways of categorising fibre types, but one way is to divide it into fermentable and non-fermentable. Which fibres are fermentable depends upon the species of bacteria eating the fibre in the cat's gastrointestinal tract. Diet and large intestinal disease in dogs and cats JW Simpson The Journal of Nutrition SS has a table showing soluble and fermentable fibres. In terms of general health, you do not necessarily want the most fermentable fibres.
Dietary fiber for cats: It concludes that the diet "which contained the most fermentable fibers, severely decreased nutrient digestibility and resulted in poor stool characteristics. Diets that contain moderately fermentable fiber provide fermentation end products that may be important in maintaining the health of the gastrointestinal tract of the cat. There has long been interest in whether other bodily mechanisms might be useful for relieving the load on damaged CKD kidneys.
Bowel as a substitute in renal failure EA Friedman American Journal of Kidney Diseases 28 6 pp states "Extraction, modification, or recycling of nitrogenous wastes by the gastrointestinal tract is a potentially low-cost means of substituting for missing renal function.
Multiple approaches to the bowel as a substitute kidney have been attempted. One way of doing this may be via increased fibre intake in the form of fermentable fibre prebiotics.
Fermentable fibre provides a source of carbohydrate for the bacteria in the gut. These bacteria, which are essential to health, increase in number when provided with additional fermentable fibre, and the more bacteria there are, the more nitrogen is excreted in the faeces.
This increased faecal excretion may help to reduce the load on the kidneys by diverting the excretion of urea from the kidneys. You can read more about this in the Treatments chapter. Non-fermentable fibre can be helpful for CKD cats because it reduces the risk of constipation, a common problem in CKD cats, by holding water in the stool.
Most commercial cat foods have sufficient levels of fibre for a healthy cat, but if your cat suffers from constipation you may wish to add more fibre in the form of something such as pumpkin, baby peas or psyllium.
Please see Constipation for more information on dealing with constipation. Feline Constipation explains more about fibre and gut health. Side Effects and Interactions. Some forms of fibre, such as fructooligosaccharides FOS , may also bind calcium in the small intestine and lead to an increase in calcium levels in the body hypercalcaemia. This can be a problem for cats who already have high blood calcium levels. Inulin and guar gum may do this, as may slippery elm bark and lactulose , two treatments commonly used for constipation in CKD cats.
Fibre may also affect taurine levels in some foods. I would therefore recommend discussing additional fibre with your vet before adding it, and avoiding its use in a cat who already has high calcium levels. They are essential because the cat's body cannot synthesise them in sufficient amounts, so they have to be obtained from food. Commercial diets tend to contain far more Omega-6, partly because Omega-6 EFAs are cheaper and more stable, but this may create a potentially harmful imbalance.
The correct balance is not yet known, though some believe it is probably around 5: Essential fatty acids are important for many bodily functions. It has been known for many years that they have an effect on the skin - the first signs of an imbalance or deficiency are usually a dry coat, itchy skin or matted fur.
Recently it appears that they may have an important role in controlling inflammation. Research in rats and humans indicates that the addition of omega-3 fatty acids to the diet may delay the progression of CKD.
Small Animal Practice 38 1 pp added essential fatty acid supplements in the form of fish oil to dog foods. It concludes "newer data indicate that dietary supplementation with specific antioxidants is an important consideration for limiting renal oxidant stress and progression of CKD. Nutritional management of renal disease: Dietary omega-3 fatty acid supplementation in the form of fish oil can have beneficial effects in reducing GCP.
This ties in with what one kidney specialist vet has informed me, that oversupplementation can throw off the correct ratio of Omega-3s to Omega-6s, and might be detrimental in some cases.
Omega-3 fatty acid supplementation for dogs and cats with heart disease Nutrition Service at Cummings Veterinary Medical Center at Tufts University states "Potential risk factors include decreased platelet function and coagulation, and possibly suppressed wound healing Other potential effects include soft feces, diarrhea, flatulence, vomiting, and halitosis. Nutrition and renal function: At higher levels of supplementation, renal function was actually increased in normal cats.
These data support the assertion that this dietary maneuver is safe for normal cats and provides some encouragement for further consideration for dietary n-3 PUFA supplementation in cats with renal disease, systemic hypertension, or hypersensitivity reactions.
Almost everybody I know of who has added essential fatty acids to their cat's treatment plan, whether in a therapeutic kidney diet or as a supplement, has been happy with the results, reporting an improvement in general wellbeing. Additional EFAs do cause vomiting in some cats though, and I've heard from a number of people whose cats had pancreatitis and who felt essential fatty acids did not agree with these cats, causing problems such as diarrhoea.
However, there are no reports of omega-3 fatty acid or fish oil supplements causing pancreatitis in dogs, cats, or humans. Theoretically, omega-3 fatty acids could prevent pancreatitis because of decreased blood triglyceride concentrations.
An extremely high dosage of omega-3 fatty acids or a fish oil supplement in addition to a very high fat diet would likely be required to induce pancreatitis. An increased level of essential fatty acids compared to standard cat foods is one of the features of therapeutic kidney diets. If you wish to give additional essential fatty acids, ask your vet if they are appropriate for your cat.
Since cats as obligate carnivores benefit from animal-based products, the most appropriate form of essential fatty acid supplement is fish oil.
Oils from the liver, such as cod liver oil, are not suitable because they contain too much Vitamin A and D. Omega-3 fatty acid supplementation for dogs and cats with heart disease Nutrition Service at Cummings Veterinary Medical Center at Tufts University states "We also recommend avoiding cod liver oil for this purpose as it is too high in vitamins A and D when administered at this dose and can cause toxicity of these vitamins.
If fish oils are given, extra vitamin E is also required in order to avoid a problem called steatitis. Waltham International Symposium ppSS discusses this. Many products, especially veterinary ones, already contain vitamin E in an appropriate dosage it may be referred to as tocopherol , in which case you do not need to supplement Vitamin E. However, I would ask your vet how much to give, because too much vitamin E can be dangerous. It has been on the market since January The manufacturer states that the product was tested on an informal basis on 18 CKD cats in the Montreal area over a period of about eight months.
This product is basically a combination of essential fatty acids, Vitamin E which you need to add when you are supplementing fish oils, but which is also an antioxidant and CoQ10 ubiquinol , also an antioxidant, but in a concentrated formula. You can read more about it in the Treatments chapter. Some people prefer to give krill oil to their cats because they find their cats tolerate it better.
Krill oil is made from crustaceans rather than fish and contains additional antioxidants called astaxanthin and canthaxanthin. The essential fatty acids in krill oil are phospholipids in fish-based oils they are triglycerides. This was due to increased urinary P excretion associated with the phospholipids content of these oils sources. Although further studies are needed, susceptible individuals should be aware of a potential risk of increasing phospholipids consumption on renal health.
Personally, I think I would be more comfortable using fish oil. If you are in Europe, especially Italy, you may be offered a new product called Nefrokrill, which contains potassium citrate , lanthanum carbonate a phosphorus binder and essential fatty acids. You can read more about it here.
Vegetable-based oils , such as coconut oil or olive oil or flax seed linseed oil , are not recommended, because they do not contain the essential fatty acids which a cat needs.
Essential Fatty Acids Dosage. It can be a bit tricky working out an appropriate dose of essential fatty acids for cats. The National Research Council gives an upper limit for dogs but gives no upper limit for cats.
As far as fish oils are concerned, Pet MD discusses the dangers of giving too much but says that if you take the NRA recommendations for dogs, "Translating the data suggests that a dose between mg combined EPA and DHA per pound of body weight is safe for dogs and cats.
This dose is far less than those used to treat serious conditions where the risk of side effects is less important. Top 5 therapeutic uses of Omega-3 fatty acids Chandler ML Clinician's Brief Feb pp states "the amount to supplement is somewhat empiric and depends on the amount in the diet. The higher dosages often are used to lower serum triglyceride concentrations in patients with hypertriglyceridemia, whereas lower dosages are more commonly used for inflammatory conditions, renal disease, and cardiac disease.
There are a small number of commercial pet foods that contain this dose for example, the Royal Canin Early Cardiac Diet for Dogs. However, in most cases, supplements are needed to achieve this dose. As you can see, there is no definitive dose, and many of the recommendations relate to a particular amount of EPA eicosapentaenoic acid. So if your cat weighs 8 lb 3. You will need to check the product you're considering to see how much EPA it contains.
Many fish oil capsules are mg strength. I expect your head is spinning by now! Generally speaking, it is probably safe to give your cat one mg fish oil capsule daily. Do check with your vet first though. Therapeutic kidney diets contain increased amounts of EFAs, so if your cat is eating such a food, you may not need additional supplementation, or may need a reduced dose. The dosage for krill oil which is made from crustaceans rather than fish is mg per day.
If you are using Nefrokrill, the dosage is here. Essential fatty acids are commonly available in either capsule form or in pump bottles. Instead, mix the oil you can open the capsule with your cat's food. You don't have to give the daily dose in one amount, you can divide it between your cat's meals. Although most cats like fish, the oils can be a bit strong, and many cats dislike the smell.
Some cats may vomit after eating them. It is therefore wise to start off very slowly, just using one drop at first which you add to a smelly food that may disguise the taste, and gradually increase the dose over several days or even weeks.
If your cat still hates it, you can either decant the oil into a gelcap, try finding a less smelly product, or discuss with your vet whether to continue with the supplement.
Some members of my support group find krill oil is more acceptable to their cats. It takes months to see the full effect of essential fatty acid supplements. If you think they help your cat, you should use them on an ongoing basis. If you don't see any difference, or if your cat seems to react badly to them e. Essential fatty acids can easily go off they become rancid. Store them in the fridge, and be sure to sniff them before giving them to your cat. Many people simply use human products, and in some cases they and their cat use the same one.
If your cat doesn't like the brand you buy, you may need to shop around to find one that is acceptable. Pet Education has a very helpful overview of essential fatty acids, with a comparison of various brands available in the USA. Omega-3 fatty acid supplementation for dogs and cats with heart disease Nutrition Service at Cummings Veterinary Medical Center at Tufts University recommends particular brands for cats and dogs with heart disease.
Consumer Lab has a summary of its findings with regard to the quality of EFAs, including the names of some of the US products which met with its approval, but you need to be a member to read it. Environmental Defense Fund has a table showing which brands remove contaminants from their products.
Welactin is a veterinary product available in both softgel capsules and pump bottle. One pump contains approximately 1. You can often find it on Amazon but a couple of members of my support group have found it does not seem to last too well when purchasing it there. For those in Canada, it is also available from Amazon Canada. Grizzly Salmon Oil is made from wild Alaskan salmon. Twinlab makes a krill oil product called Krill Essentials.
This is also available from other suppliers, such as Vitacost , among others. If you are in Canada, 60 softgels are available from Healthy Planet Canada. A couple of members of my support group have found it does not seem to last too well when purchasing from Amazon in the USA but I have not had any complaints about buying it from Amazon UK.
Salmopet is a salmon-based fish oil which is widely available in Europe. Omega 6 oils which is not ideal. Your vet may also have a suitable product in stock. Amino acids are the components of protein. There are 23 amino acids which cats need, and they can manufacture twelve of these themselves, but the other eleven must be obtained from food.
The ones which the cat cannot manufacture are called essential amino acids. Taurine is one example of an amino acid which cats must obtain from food. Pet Education has a list of the essential amino acids for cats. If you feed a commercial diet, it will contain the correct balance of amino acids for cats. However, if you feed homemade food, it is critical to ensure that the diet has the correct balance of amino acids.
However, they concluded "the magnitude of these changes is mild and of little clinical relevance. Oral supplement of six selective amino acids arrests progression of renal failure in uremic patients Yatzidis H International Urology and Nephrology 36 4 pp found that amino acid supplements appeared to help human patients with glomerulonephritis. An amino acid called L-lysine is sometimes recommended for cats with feline herpes.
Two potential contraindications include renal and hepatic disease in which patients may have difficulty eliminating the large amounts of nitrogen generated from l-lysine metabolism. There are a couple of amino acid supplements that are marketed for CKD cats. There is more information about them on the Holistic Treatments page. The amino acid of greatest relevance to cats is taurine. Taurine is most concentrated in the heart, retinas eyes and the brain.