Bariatric Nutrition: Suggestions for the Surgical Weight Loss Patient (Complete Revised n Big...

AS PROMISED IN THE MEETING TONIGHT... HERE IS THE COMPLETE REVISED VERSION IN BIG PRINT. Bariatric Nutrition: Suggestions for the Surgical Weight Loss Patient

 

http://download.journals.elsevierhealth.com/pdfs/journals/15 50-7289/PIIS1550728908001639.pdf

 

I just finished this article and thought I'd highlight/summarize some of the stuff I found most interesting.  This is NOT COMPLETE and the article goes into MUCH more detail, but I'd thought I'd summarize just SOME of the stuff I found most interesting (or thought I needed reinforcement of in my own life).  Most of it is related to RNY only because that's the parts I highlighted for myself (sorry lapbanders, DSers, VSGers, etc).  I just wanted to put this all somewhere where I could have it all in one place!

 

GENERAL VITAMIN INFO

 

"Most characteristic physical findings are seen late in the course of nutrient deficiency."  In other words - by the time you are actually symptomatic of vitamin/nutrient deficiency, you have already been deficient for a while.   "Vitamins and minerals are essential factors and co-factors in numerous biologic processes that regulate body size.  The include appetite, hunger, nutrient absorption, metabolic rate, fat and sugar metabolism, thyroid and adrenal function, energy storage, glucose homeostasis, neural activities, and others."  In other words - if you are not getting the recommended doses of vitamins and/or minerals, your weight loss and/or weight maintenance will probably be at risk because your body cannot function like it is supposed to.   Supplements for AGB and RNY: 1) Multivitamin-mineral supplement - a high-potency vitamin containing 100% (for AGB) or 200% (for RNY) of daily value for at least 2/3 of nutrients

 

- avoid time-released supplements - avoid enteric coating - choose a complete formula containing at least 18 mg iron, 400 ug folic acid, as well as selenium, and zinc in each serving - avoid children's formulas that are incomplete - do not mix multivitamin containing iron with calcium supplement, take at least 2 hr apart 2) Additional elemental calcium (1500 - 2000 mg/d) - choose a brand that contains calcium citrate and vitamin D3 - split into 500 - 600 mg doses; be mindful of serving size on supplement label - space doses evenly throughout day - suggest a brand that contains magnesium, especially for BPD/DS - wait >= 2 hr after taking multivitamin or iron supplement - combined dietary and supplemental calcium intake > 1700 mg/d might be required to prevent bone loss during rapid weight loss 3) Additional elemental iron (18 - 27 mg/d elemental) - recommended for menstruating women and those at risk of anemia - do not mix iron and calcium supplements, take >= 2 hr apart - vitamin C may enhance absorption of non-heme iron sources 4) Vitamin B-12 (for all RNYers and some AGBers)

 

- via passive absorption method (shot, sublingual, etc)

 

5)Optional B complex - B-50 dosage - avoid time released tablets - no known risk of toxicity

 

6) Fat Soluable vitamins

 

- 10,000 IU vitamin A every 2 weeks

 

- 500 mg of vitamin E daily "RYGB increases the risk of vitamin B12 and other B vitamin deficits."  In other words - since there is no know risk of toxicity (see above) and RNY post-ops are at an increased risk of vitamin B deficits, you are better off just to take a B complex daily.  Better safe than sorry considering the side effects of deficiency.   "It is important for the bariatric patient to take vitamin and mineral supplements, not only to prevent adverse health conditions that can arise after surgery, but because some nutrients such as calcium can enhance weight loss and help prevent weight regain."  In other words - making sure you take all the necessary vitamins and minerals helps you not only stay healthy, but lose the weight and MAINTAIN the weight loss.  

 

THIAMIN (VITAMIN B1)

 

"Beriberi is a thiamin deficiency that can affect various organ systems, including the heart, gastrointestinal tract, and peripheral and central nervous systems.  Although the condition is generally considered rare, a number of reported and possibly a much greater number of unreported or undiagnosed cases, of beriberi have occurred among individuals who have undergone surgery for morbid obesity.  Early detection and prompt treatment of thiamin deficits in these individuals can help to prevent serious health consequences.  If beriberi is misdiagnosed or goes undetected FOR EVEN A SHORT PERIOD, the bariatric patient can develop IRREVERSIBLE neuromuscular disorders, PERMANENT defects in learning and short-term memory, coma, and EVEN DEATH."  In other words - take a B complex vitamin whether your surgeon recommended it or not.  (Yea, I really said that.)  Better safe than sorry with B vitamins.

 

"Chronic or acute thiamin deficiencies in bariatric patients often present with symptoms of peripheral neurophathy or Wernicke's encephalopathy and Korsakoff's phychoses [21, 48 - 54]."  In other words - signs of B1/thiamin deficiency can include numbness in the extremities (hands or feet or arms or legs), hypothermia, memory loss, etc.  

 

"A deficiency in thiamin for only a couple of weeks or less, caused by persistent vomiting, can deplete thiamin stores."  In other words - if you have a sickly spell, it is especially important that you make sure you get your B complex vitamins in.  

 

VITAMIN B12

 

Preoperative Risk:  "Patients with obesity have a high incidence of gastro esophageal reflux disease (GERD), for which they take proton pump inhibitors, thus increasing the potential to develop a vitamin B12 deficiency."  In other words - if you take certain antacids, you are at an increased risk of B12 deficiency.  Note: It might be worth it for banders who may still have GERD issues to supplement B12 since it has no toxicity level. 

 

"Factors that increase the risk of vitamin B12 deficiency relevant to bariatric surgery include the following: An inability to release protein-bound vitamin B12 from food, particularly in hypochlorhydria and atrophic gastritis Malabsorption due to inadequate IF, such as in pernicious anemia Gastrectomy and gastric bypass" In other words - you must supplement vitamin B12 because you cannot absorb through food the way you used to.

 

"Gastric bypass patients have both a decreased production of stomach acid and a decreased availability of IF; thus, a vitamin B12 deficiency could develop without appropriate supplementation.  Because the typical absorption pathway cannot be relied on, the surgical weight loss patient must rely on PASSIVE absorption of B12, which occurs independent of IF."  In other words - you must supplement vitamin B12 in a passive way (such as sublingual or injection, etc) and NOT in simple pill form.  

 

"Vitamin B12 deficiency has been frequently reported after RYGB.  Among these patients, the prevalence of vitamin B12 deficiency is estimated to be 12 - 33%."  "After the first postoperative year, the prevalence of vitamin B12 deficiency appears to increase yearly in RYGB patients [89]."  In other words - don't get lazy when it comes to taking your B12 (or any other supplements).  

 

"Vitamin B12 deficiency after RYBG has been associated with megaloblastic anemia [92].  Some vitamin B12-deficient patients develop significant symptoms, such as polyneuropathy, paraesthesia, and permanent neural impairment.  On occasion, some patients may experience delusions, hallucinations, and even, overt psychosis [93]."  In other words - vitamin B12 deficiency could suck big time.

 

"Deficiency of vitamin B12 is typically defined at levels < 200 pg/mL.  However, about 50% of patients with obvious signs and symptoms of deficiency have normal vitamin B12 levels [31]."  In other words - since B12 has no toxicity levels (meaning you can't OD on it), best to keep your B12 levels as high as possible.  

 

"Supplementation of RYBG patients with 350-500 ug/d will prevent most post-operative vitamin B12 deficiency."  In other words - those of you doing 2 sublinguals a week are NOT TAKING ENOUGH.  I don't do shots, but I do 2 sublinguals per DAY (1000 ug/d).  

 

"Patients should be monitored closely for their lifetime, because severe anemia can develop with or without supplementation [98]."  In other words - get your labs done when you're supposed to, even if you feel fine and are doing all your supplements like you're supposed to.  

 

FOLATE

 

"Boylan et al. [26] found folate deficiencies PREoperatively in 56% of RYBG patients studied."  In other words - it is more likely than not that you were probably folate deficient as a pre-op.

 

"Folic acid stores can be depleted within a few months postoperatively unless replenished by a multivitamin supplement and dietary sources (i.e., green leafy vegetables, fruits, organ meats, liver, dried yeast, and fortified grain products)."   "Low serum folate levels have been cited at anywhere from 6% to 65% among RYGB patients [26, 86, 101].  Additionally, folate deficiencies have occurred postoperatively, even with supplementation.  Boylan et al. [26] found that 47% of RYGB patients had low folate levels 6 months postoperatively and 41% had low levels at 1 year.  This deficiency occurred despite patient adherence to taking a multivitamin supplement that contained at least the daily value for folate, 400 ug [26].  Postoperative bariatric patients with rapid weight loss and/or malnutrition might be at especially high risk of micronutrient deficiencies."  In other words - folate needs to be resupplied with supplements AND dietary sources.  Since it is difficult immediately post-op to get in some foods rich in folate, supplements become even more important - especially for the immediate post-op.  Also, since many go deficient with "at least the daily value for folate", this adds further support to their contention that RNY post-ops take vitamins with 200% of the daily value included daily.  

 

"The folate contained in the multivitamin supplementation essentially corrects the deficiency in the vast majority of postoperative bariatric patients [103].  Therefore, persistent folate deficiency might indicate patient lack of compliance with the prescribed viatmin protocol [32]."  "It is gernally agreed that folate deficiency is corrected with 1 mg/d folic acid [32] and is preventable with the amount typically found in a multivitamin that provides 200% of the daily value (800 ug)."  In other words - take your vitamins like you're told and this crap won't happen to you.  

 

 

"Patients with folate deficiency often present with forgetfulness, irritability, hostility, and even paranoid behaviors [29]."  In other words - if you are like me, then you won't even KNOW if you have symptoms unless you start experiencing paranoid behaviors.  The rest of that stuff is pretty normal.  So it's important to make sure you get your folate because (if you're like me) you may not even recognize "symptoms" of folate deficiency.  

 

IRON

 

"Iron deficiencies, which would significantly hinder energy use, have been reported in nearly 50% of morbidly obese PRE-operative candidates [21]."  In other words - half of morbidly obese people can thank (in part) iron deficiency as a possible contributing factor to their obesity since their bodies cannot properly use the energy it is being given.

 

 

"In 1 retrospective study of consecutive cases, 44% of bariatric surgery candidates were iron deficient [21]... as determined by abnormal hemoglobin values."  "79% of younger patients versus 42% of older patients presented with preoperative iron deficiency, as determined by low serum iron values."  In other words - many of us were probably iron deficient as pre-ops.  The younger you are, the more likely you are to be deficient.   

 

"The data have consistently pointed toward the risk of iron deficiency and anemia after bariatric procedures.  Iron deficiency is defined as a decrease in the total body content.  Iron deficiency anemia occurs when erythropoiesis is impaired as a result of the lack of iron stores.  In the absence of anemia, iron deficiency is usually asymptomatic.  Fatigue and a diminished capacity to exercise, however, are common symptoms of anemia."  In other words - you can be iron deficient without being anemic.  (Who knew?)  If you are iron deficient and not anemic, you probably have no symptoms.  

 

"Iron deficiency is common after gastric bypass surgery, with reports of deficiency ranging from 20% to 49% [32, 98, 107, 108].  Up to 51% of female patients in 1 series were iron deficient, confirming the high-risk nature of this population [87].  Among patients with super obesity undergoing RYGB with varying limb length, iron deficiency has been identified in 49 - 52% and anemia in 35 - 74% of subjects up to 3 years postoperatively [84]."  In other words - anyone who had RNY is at risk for iron deficiency - especially women (which account for most bariatric procedures performed).  So almost ALL RNY post-opS should be taking additional iron supplements.

 

”One randomized study of premenopausal RYGB women demonstrated that 320 mg of supplemental oral iron (ferrous sulfate) given twice daily prevented the development of iron deficiency but did not protect against the development of anemia [107].  Notably, those patients who developed anemia were not regularly taking their iron supplements (>= 5 times/wk) during the period preceding diagnosis.  In that study, a significant correlation was found between the resolution of iron deficiency and adhering to the prescribed oral iron supplement regimen.”  “…suggesting dietary intake and 1 multivitamin (containing 18 mg iron) might be inadequate to maintain iron stores in RYBG patients.”  “Two thirds (67%) of those who did develop iron deficiency later became anemic.  Their findings suggest that the amount of iron in a standard multivitamin alone is not adequate to prevent deficiency.”  In other words – if you miss 2 days of iron supplements a week, you are at increased risk of iron deficiency and anemia.  In most cases, it’s important to take a ultivitamin with 18 mg iron IN ADDITION TO a seperate iron supplement.

 

”Similarly, Avinoah et al. [38] found that at 6.7 years postoperatively, weight loss had been relatively stable for the preceding 5 years; however, the iron saturation, hemoglobin, and mean corpuscular volume values had declined progressively and significantly.”  In other words – this isn’t something that is going to resolve itself with time.  Supplement.  Period.  Forever.  

 

 

”Although perhaps less detrimental than consuming starch or clay, the consumption of ice (pagophagia) is also a form of pica that might not be routinely identified.”  In other words – eating ice is a form of pica (the ingestion of non-food substances).  Pica is often a symptom of iron deficiency.  

 

”The use of 2 complete multivitamins, collectively providing 36 mg of iron (typically ferrous fumarate) is customary for low-risk patients, including men and postmenopausal women.”  “In addition to the iron found in 2 multivitamins, menstruating women and adolescents of both sexes might require additional supplementation to achieve a total intake of 50-100 mg of elemental iron daily…”  In other words – if you don’t eat lots of high iron foods (which can be hard after any WLS), you probably need an additional iron supplement in addition to your 200% daily value multivitamins.

 

 

CALCIUM AND VITAMIN D

 

"Studies have found that 60-80% of morbidly obese PRE-operative candidates have defects in vitamin D [19-22].  Such defects would reduce dietary calcium absorption and increase a substance known as calcitriol, which, in turn, causes metabolic changes that favor fat accumulation [23-25]."  In other words - vitamin deficiency may be part of WHY you were morbidly obese to begin with.  

 

 

"Calcium... absorption is facilitated by vitamin D in an acid environment."  "Low vitamin D levels are associated with a decrease in dietary calcium absorption."  "In a low acid environment, such as occurs with the negligible secretion of acid by the pouch created with gastric bypass, absorption of calcium is poor [128]."  In other words - calcium is better absorbed with vitamin D.  This is especially important for RNY post-ops as we no longer have the "acid environment" to facilitate absorption.

 

"As blood calcium ions decrease, parathyroid hormone levels increase."  "In addition, a positive correlation exists between a greater BMI and increased parathyroid hormone [110]."  In other words - a decreased calcium level is associated with being fatter.

 

"Buffington et al. [19] found that 62% of women and 25-hydroxyvitamin D [25(OH)D] levels at less than normal values, confirming the hypothesis that vitamin D deficiency might be associated with morbidy obesity."  "Flancbaum et al [21] completed a retrospective analysis on 379 PREoperative gastric bypass patients and found that 68.1% were deficient in 25(OH)D."  In other words - low levels of calcium as well as low levels of vitamin D are BOTH associated with being obese.  More and more research is stating that vitamin D deficiency can actually be a CAUSE of morbidly obesity.  This is just another reason to make sure that you take your calcium & vitamin D as indicated.

 

"If dietary calcium is not available or intestinal absorption is impaired by vitamin D deficiency, calcium homeostasis is maintained by increases in bone resorption and in conservation of calcium by way of the kidneys.  Therefore, calcium deficiency (low serum calcium) would nto be expected until osteoporosis has severely depleted the skeleton of calcium stores."  "An increased long-term risk of metabolic bone disease has been well documented after BPD/DS and RYGB"  In other words - if you are not taking in the proper amounts of calcium, your body will pull it out of your bones to maintain adequate levels.  You could actually not show up as calcium deficient (because your body is pulling calcium out of your bones to maintain adequate levels****il osteoporosis has started ruining your body.

 

"In addition to skeletal disorders, calcium and vitamin D deficits increase the risk of malignancies (in particular, of the colon, breast, and prostate gland), of chronic inflammatory bowel disease, multiple sclerosis, rheumatoid athritis), of metabolic disorders (metabolic syndrome and hypertension), as well as peripheral vascular disease [115, 116]."  In other words - calcium and/or vitamin D deficiency can kill you through an array of various horrific conditions/diseases.

 

"The increased incidence of vitamin D deficiency and secondary hyperparathyroidism has also been found in gastric bypass patients oweing to the bypass of the duodenum."  "Dietary supplementation with vitamin D and 1200 mg calcium daily did not affect these measures, indicating a need for great supplementation [120]."  "The subjects were found to have significant changes in total hip, trochanter, and total body bone mineral density as a result of increased bone resorption beginning as early as 3 months postoperatively.  These changes occurred despite increased dietary intake of calcium and vitamin D."  In other words - 1200 mg of calcium with D per day is not enough.  If that's all you're getting in... you're setting yourself up for osteoporosis and other bone problems.  

 

"Supplementation with calcium and vitamin D during all weight loss modalities is critical to preventing bone resorption [121]."  "A meta-analysis of calcium bioavailability suggested that calcium citrate is more effectively absorbed than calcium carbonate by 22-27%, regardless of whether it is taken on an empty stomach or with meals [130].  These findings suggest that it is appropriate to advise calcium citrate supplementation..."  In other words - calcium citrate works for us: calcium carbonate does not.  

 

"It is no longer acceptable to assume that postoperative prophylaxis calcium and vitamin D supplementation will prevent an increase in bone turnover.  Therefore, life-long screening and aggressive treatment to improve bone health needs to become integrated into postoperative patient care protocols."  In other words - you can't assume that just because you're taking the recommended calcium & D regimen that your bones won't have some calcium sucked out of them.  It is a good idea to get bone density scans every so often to make sure that you are getting enough calcium to prevent bone resorption from occurring.  

 

"It appears that 1200 mg of calcium supplementation daily and the 400 - 800 IU of vitamin D contained in standard multivitamins might not provide adequate protection for postoperative patients against an increase in PTH and bone resorption [120, 121, 132].  Riedt et al. [122] estimated that >= 50% of RYGB postoperative, postmenopausal women would have a NEGATIVE calcium balance even with 1200 mg of calcium intake daily."  In other words - 1200 mg of calcium per day w/ 400 - 800 vitamin D is not even enough to sustain calcium levels.

 

"Increasing calcium citrate to 1700 mg/d (with 400 IU vitamin D) during caloric restriction was able to ameliorate bone loss in NONoperative postmenopausal women, but did not prevent it [125]."  In other words - even in NONops, 1700 mg/d of calcium (with 400 IU vitamin D) was enough to make bone loss a little better, but did not prevent it.  If 1700 mg/d of calcium (with 400 IU vitamin D) was not enough to prevent bone loss in NON-ops, do you really think 1700 mg/d of calcium (with 400 IU vitamin D) is going to be enough to prevent it in us?

 

"Weight loss can help to eliminate many co-morbid conditions associated with obesity; however, without calcium and vitamin D supplementation, it can be at the cost of bone health."  "The promotion of physical activity such as weight-bearing exercise, increasing the dietary intake of calcium and vitamin D-rich foods, moderate sun exposure, smoking cessation, and reducing one's intake of alcohol, caffeine, and phosphorus are additional measures the patient can take in the pursuit of strong and healthy bones [133]."  In other words - don't go through WLS to get rid of your co-morbidities just to end up in a wheelchair from osteoprosis.  Take your supplements as directed and live a healthy life.   So, in summary on calcium (from parts 1 & 2). Calcium supplements should: 1) be calcium citrate (NOT calcium carbonate) 2) contain vitamin D3 3) contain magnesium 4) be split throughout the day into 500 - 600 mg doses 5) not be taken with iron and/or multivitamins that contain iron Be sure to check the serving size of your calcium.  Many times one pill IS NOT a whole serving.  So while the dose may say 500mg, you may have to take TWO pills to equal that ONE dose. 

 

 

 

FAT SOLUABLE VITAMINS/MINERALS

 

Vitamin A

 

"In a study comparing the nutritional consequences of conventional therapy for obesity, AGB and RYBG, Ledoux et al. [135] found... The prevalence of vitamin A deficiency was 52.5% in the RYGB group compared with 25.5% in the AGB group (P <.01)."  In other words - if you had RNY or lapband and thought DSers were the only ones who needed to supplement fat soluable vitamins... you were wrong.  We need vitamin A too!  

 

"Supplementation with 10,000 U of vitamin A, in addition to other vitamins and minerals, appeared to be adequate to prevent vitamin A deficiency."  "It is concluded that vitamin A deficiency should be suspected among patients with an unexplained decreased vision and a history of intestinal surgery, regardless of the lenth of time since the surgery had been performed."  In other words - vitamin A deficiency can be prevented; and since it can cause decreased vision, it's better to be safe than sorry." Vitamin K

 

"Vitamin K deficiency was also considered by Ledoux et al. [135] using the prothrombin time as an indicator of deficiency.  The mean prothrombin time percentage was lower in the RYGB group versus both the AGB and conventional treatment group, which suggests vitamin K deficiency [135]."  In other words - we have to pay attention to vitamin K too.   Vitamin E

 

"In a study comparing various surgical procedures, Ledoux et al. [135] found a significant prevalence of vitamin E deficiency among the RYGB compared with the AGB group (P <.05), with 22.5% and 11.8% of subjects presenting with a vitamin E deficiency, respectively."  In other words - almost a fourth of RNYers are vitamin E deficient.  Wow.   Zinc

 

"In RYGB patients, Madan et al. [27] determined that zinc levels were suboptimal among 28% of PRE-operative patients and 36% of 1-year POST-operative patients.”  “They postulated that RYGB patients might have a lower dietary zinc intake in the postoperative period that could put them at a risk of deficiency.”  In other words – zinc levels were lower than they should be in over a third of RNY post-ops, possibly because of decreased dietary zinc intake (possibly due to intolerance of red meat among some post-ops).  This is another reason it is so important to work through your stages to avoid food intolerances all together. 

 

FAT SOLUABLE VITAMIN CONCLUSION & SUGGESTED SUPPLEMENTATION

 

Fat Soluable Vitamin Conclusion

 

”Although BPD/DS patients have been known to be at risk for fat-soluable vitamin deficiencies, the reports cited have illustrated that bariatric patients IN GENERAL, including RYGB patients, may also be at risk.  In addition, rare and unusual complications, such as visual and taste disturbances, might be attributable to these deficiencies, as these reports have elucidated.”  In other words – Dsers aren’t the only ones that have to worry about fat soluable vitamins.  

 

 

 

 

Fat Soluable Vitamin Suggested Supplementation

 

”They proposed that all RYGB patients should be supplemented with multivitamins as complete as possible, including fat-soluable vitamins and minerals.  A recommendation of 50,000 IU of vitamin A every 2 weeks and 500 mg of vitamin E daily, among other supplements, was suggested to correct most cases of deficiency [135].”  In other words – we could prevent most cases of fat soluable vitamin deficiency by simply making sure out multi-vitamins contain fat soluable vitamins AND doing the additional A (bi-weekly) and E (daily).  

 

 

VITAMIN B6

 

"Boylan et al. [26] found that vitamin B6 levels, before surgery, were adequate in only 36% of their surgical candidates."  "These investigators subsequently found that the serum levels might not be reflective of vitamin B6 status [148].  When co-enzyme activation of erythrocyte aminotransferase activities was used as a marker of vitamin B6 status rather than the serum vitamin levels, supplementation of vitamin B6 at the U.S. Dietary Intake recommended amounts (1.6 mg) PROVED INADEQUATE for co-enzyme activation of these enzymes in the early postoperative period.  These findings suggest that greater than the recommended amounts of vitamin B6 might be required for normalization of vitamin B6 status in bariatric patients."  In other words - 1/3 of pre-ops are B6 deficient and 1.6 mg per day is not enough to keep from being deficient.  

 

COPPER

 

"Copper status needs to be examined in RYGB and BPD/DS patients presenting with signs and symptoms of neuropathy and normal B12 levels.  The findings would also suggest mutivitamin supplementation containing adequate amounts of copper (2 mg daily value).  Caution should be used when prescribing zinc supplements because copper depletion occurs when >50 mg zinc is given for a long period of time."  In other words - your multivitamin should contain 2 mg of copper.  Some of the same symptoms for B12 deficiency can also indicate copper deficiency.  Warning: Zinc (in doses of >50 mg for a long time) starts "eating" all the copper out of your body.

 

 

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?  Do 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 “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 R.I.P.   "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.