Bariatric Nutrition: Suggestions for the Surgical Weight Loss Patient (Summary Part 4)

Continued from Part 3. Protein: "Protein malnutrition (PM) is usually associated with other contemporaneous cir****tances that lead to decreased dietary intake, including anorexia, prolonged vomiting, diarrhea, food intolerance, depression, fear of weight regain, alcohol/drug abuse, socioeconomic status, or other reasons that might cause a patient to avoid protein and limit calorie intake.  All postoperative patients are, therefore, at risk of developing primary PM and/or protein-energy malnutrition (PEM) related to the decreased oral intake."  In other words - all WLS post-ops, no matter what surgery they had is at risk for this.   "As a result of decreased caloric intake, hypoinsulinemia allows fat and muscle breakdown to supply the amino acids needed to preserve the visceral pool."  In other words - if you aren't getting in the calories you used to, your body can break down fat and muscle to get the amino acids (protein) it needs. "Protein sparing is eventually achieved as the body enters into ketosis.  Initially weight loss occurs as a result of water loss resulting from the metabolism of liver and muscle glycogen stores.  Subsequent weight loss occurs with the breakdown of muscle mass and a reduction of adipose tissue as the body strives to maintain homeostasis."  In other words - Intial weight loss is water weight.  (Duh, right?)  After water weight is lost, "real" loss starts as the body begins to break down muscle and fatty tissue as the body tries to maintain stability. "Eventually, without adequate intake, a deficiency will occur, characterized by decreased hepatic proteins, including albumin, muscle wasting, asthenia (weakness), and alopecia (hair loss).  Protein-energy malnutrition is typically associated with anemia related to iron, B12, folate, and/or copper deficiency.  Deficiencies in zinc, thiamin, and B6 are commonly found with a deficient protein status.  In addition, catabolism of lean body mass and diuresis cause electrolyte and mineral disturbances with sodium, potassium, magnesium, and phosphorus."  In other words - if you are protein deficient, you probably have a host of vitamin/mineral deficiencies as well.  This makes sense considering that you'd really just have to ignore your post-op rules all together to go protein deficient. "If the protein deficit occurs in conjunction with excessive intake of carbohydrate calories, hyperinsulinemia will inhibit fat and muscle breakdown.  When the body is not able to hormonally adapt to spare protein, a decrease in visceral protein synthesis will result, along with hypoalbuminemia, anemia, and impaired immunity.  If left undiagnosed, this can result in an illness in which fat stores are preserved, lean body mass is decreased, and appropriate weight loss is not seen because of the accumulation of extracellular water."  In other words - if you choose to eat carbs instead of your protein, your body will go into a state where it is unable to use the little protein it IS getting in the proper way.  Your body will start digesting its own muscles to try to produce its own amino acids.  Since the body is concentrating solely on breaking down its muscle to get that protein, it leaves the fat alone.  Hence, you will lose some weight, but not as much weight AND the weight you are losing will be muscle instead of fat.   "Brolin et al. [84] reported that 13% of patients who had undergone distal RYGB as part of a prospective randomized study were found to have hypoalbuminemia >= 2 years after surgery."  "The investigators noted the few cases of hypoalbuminemia that did occur resulted from patient "noncompliance" with nutrition instruction and were treated with protein supplementation."  In other words - if protein deficiency happens to you, it is probably your fault because you are not following the advice of your bariatric eating plan which all have in common one rule - PROTEIN FIRST. "When a deficiency occurs and no mechanical explanation for vomiting or food intolerance is present, patients can often be successfully treated with a high-protein liquid diet and a slow progression to a regular diet [76].  Reinforcement of proper eating style (small bites of tender food, chewed well, eaten slowly) is always important to address during patient consultation in an effort to improve intake.  As a protein deficiency is corrected and edema is decreased around the anastomosis, food tolerance and vomiting may resolve."  In other words - if you are protein deficient due to food intolerances and there is not a mechanical reason for it (something wrong with your surgery), you can get rid of the food intolerances by "rebooting" your body so to speak - going back to the immediate post-op high-protein liquid diet stage and slowly moving forward through the stages again to a regular diet, emphasizing the proper way to eat as a post-op.  (This can also be used by someone who is NOT protein deficient and just wants to NOT have food intolerances.)  Once the protein deficiency is resolved (through the high-protein liquid diet stage), the swelling of your anastomosis should subside - hence the vomiting and food intolerances should improve. "During the early postoperative period, incorporating liquid supplements into a patient's daily oral intake provides an important source of calories and protein that help prevent the loss of lean body mass.  Experts have noted that adding 100 g/d of carbohydrates decreases nitrogen loss by 40% in modified protein fasts [34].  In other words - Liquid supplements are a vital part of early post-op life that help prevent the loss of muscle.  (Who can really get their protein in from solids at that point?  I always feel sorry for those people who have NUTS who tell them that they must get in all their protein from food - no shakes.  WTF?  Does these people even READ?  But I digress.)  Pure protein is NOT the way to go though.  (Sorry my bullet using friends.  I too was a bullet woman for a long time.  No more.)  Nitrogen loss = muscle loss.  You DO NOT WANT a negative nitrogen balance.  Our bodies constantly get bleed nitrogen.  We must always ingest enough protein to keep the INCOMING nitrogen >= the OUTGOING nitrogen to prevent muscle loss.  Adding carbohydrates slows down nitrogen loss, making it easier to stay in balance with INCOMING nitrogen.  Does that make sense? "On popular myth is that only 30 g/hr of protein can be absorbed.  Although this is commonly found in both lay and some professional reports, there is NO scientific basis for this claim."  In other words - that 30 gram-per-dose maximum protein absorption rumor is just that... a rumor.  I've been saying all along that I have never found any evidence to support that.  May that myth RIP.   "Although convenience, taste, texture, ease in mixing, and price are important considerations that can improve intake compliance, the product's amino acid profile should be the first priority."  In other words - there are enough protein products on the market that SURELY you can find one that is not only convenient, tastes good, etc - but one that actually meets all your body's needs.  That is the main reason to TAKE a protein supplement - to meet your body's needs. "The PDCAA score indicates the body's ability to use that product for protein synthesis.  The PDCAA score is equal to 100 for milk, casein, whey, egg white, and soy."  In other words - the higher a product's PDCAA score is, the better your body's ability to actually USE the protein contained in that product.  The proteins listed at 100 are the absolute best proteins as far as how easy it is for your body to use them.   "The highest quality protein products are made of whey protein, which provides high levels of branched-chain amino acids (important to prevent lean tissue breakdown), remain soluble in the stomach, and are rapidly digested."  In other words - the best protein powders, etc are made from whey.  (Duh, right?) "Whey concentrates can contain varying amounts of lactose, while whey protein isolates are lactose free."  In other words - if you have trouble with whey concentrates, it may be a lactose intolerance issue and you should give whey protein isolates a try.   "Meal replacement supplements and protein bars typically contain a blend of whey, casein, and soy proteins (to improve texture and palatability), varying amounts of carbohydrate and fiber, as well as greater levels of vitamins and minerals than simple protein supplements."  In other words - protein supplements are not the same as meal replacement products.  Meal replacement products contain more of a balance of everything needed to replace an actual solid food meal.  Protein supplements usually contain mostly protein and typically do NOT have vitamins and minerals added: hence they are NOT made for solid meal replacement.   There are some cool vitamin charts in the back of the paper (much of which just rehashes the vitamin issues discussed in the actual text of the paper, but they are cool charts all the same).   I had to put it all down somewhere to make sure I understood everything.  Hope it helped someone.  I know it helped me!  LOL

Thank you very much for taking the time to 'regularize' the language of this report. I know I have many topics to discuss with my PCP, surgeon, NUT and naturopath. Again, many thanks!!!

You're welcome!  Glad it helped someone in addition to me!  LOL

this is awesome! thank you for  putting it into myspeak!!!!!

You're welcome!  I'm glad people are getting something out of it! 

Do you know where to find the PDCAA score? Will it be on the protein itself? I'm getting curious. I'm feelign a little like a pre-op all full of new information. Good thing I have the day off and can go browsing!!

It won't be listed on the product.  There ARE lists of different types of foods (nuts, legumes, eggs, milk, etc) and their PDCAA score.  (You can google PDCAA and the word protein and get some of the lists.)  But these lists are never product specific (that I have seen).  Good luck!