Introduction

Protein
   Grams in Meat
   How much to Eat
   Calculate Protein
   *Protein Supplements
   *Whey Protein
   *Casein Protein
   *Soy Protein
   *Egg Protein
   *Protein Hydrolysates
   *Protein Quality - BV
   Deficiency Symptoms

Fat
   How much to Eat
   Deficiency Symptoms

Carbohydrates
   Fiber
   Insulin and Glucagon
   Diabetes
   How much to Eat

Vitamins & Minerals
   B-Vitamins
   Iron
   Chromium
   Calcium& Magnesium
   Potassium

Water
   How much to Drink 

Nutrition and Macronutrients  

Introduction  

Weight Loss Surgery patients hear a lot about Protein.  Knowing the grams of Protein taken in per day becomes a part of our daily lives.  Doctors preach to their patients to stay away from Carbohydrates, limit the Fat, and eat more Protein; at least mine does.  What is so special about protein and what is the deal about carbohydrates?... after all, athletes load up on carbs before marathons. Further, isn’t fat the enemy in our diets?  Well, understanding a little about these macronutrients go a long way in seeing what is important for helping our bodies become healthy.

As far as our bodies are concerned, the things we ingest fall into one of six categories: carbohydrate, protein, fat, mineral, vitamin, or water.  There are a couple of other categories such as alcohol, but we won’t go into that here.  What we are interested in here are the things called macronutrients; the things our bodies use as fuel and how they are used and stored.

Protein

Protein is the most plentiful and most required nutrient in the body.  Proteins are the fundamental building blocks in the human body.  They help build muscles, blood, skin, hair, nails, internal organs, work to synthesis tissue, and help burn and store energy in the body.  Proteins are made up of amino acids.  There are about 20 amino acids that are required for growth in the human body.  However, all but about eight are produced by the body.  The amino acids that the body does not produce are called essential amino acids and must be taken in from food sources.

 Foods that contain all of the essential amino acids are called complete proteins.  These foods include beef, chicken, fish, eggs, milk and just about anything else derived from animal sources. Incomplete proteins do not have all of the essential amino acids and generally include some vegetables, fruits, grains, seeds, and nuts. 

 As you can imagine, protein is essential to the human body.  Without protein, the body will die quickly.  However, when it comes to weight loss, an essential hormone is glucagon.  Protein helps produce and increase this hormone.  Glucagon will be discussed in more detail later in this article.

 Grams of Protein in Meat:                         

 How much Protein Should You Eat?                 Top
Most surgeons suggest 45 to 60 grams of protein per day as a minimum.  However, for most people that amount of protein is not enough to protect lean muscle and tissue.  The actual amount of protein required each day should be based on your Lean Body Mass (LBM) and your Activity Level.   

 How do you Calculate how much Protein?

Use the Calculator provided on this Website to calculate your LBM and Required Protein level. 

 Protein Supplement Powders and Shakes

There are hundreds of protein supplements that are available and my best advise to you is to bye several and find one that you like. I like the Adtkins Shakes found at grocery stores or at Adtkins.com.  They are low carb and have about 20 grams protein per shake.  I get the premixed canned shakes and I like the Chocolate Delight and the Chocolate Royale.  Some people think they are too sweet and others dump on them, but these work nicely for me.

I have also used Vita4life found at vita4life.net . The nice thing about Vita4life is it comes in 2 ounce packs that can be taken like a dose of medicine and Bam!, you have just taken 30gm of protein.  Downside is the taste, but if you can take liquid medicines, you can take this.  Some folks mix this up as shakes and really like the taste.  I used the orange-creamsicle flavor and just downed it like taking Nyquil.

Some surgeons don't want their patients to use protein supplements, but other surgeons encourage their patients to use them.  Whether you use protein supplements or not, you have to get your protein in.

Whey Protein

Protein Quality and  Biological Value
Protein Quality is determined by the biological value or BV. The higher the BV value the higher the protein quaility.  BV is a measure of protein quality based on the percentage of protein retained by the body. Whey has a BV of 104, while egg is 94, casein is 77, and soy is 73. So, if 100 grams of whey protein are consumed, 100% will be retained by the body (the only reason whey's BV is over 100 is due to a margin of error in calculation). In comparison, only 77% of casein is retained.

One thing that WLS folks should be aware of is that the stomach plays a large role in breaking down the Molecules into peptides (small chains of amino acids) and these are absorbed in the intestines.  My concern with WLS is how much of the protein is being broken down into peptides for absorption because of the lack of stomach... Whey protein is probably best raw protein as it has the highest BV normally and breaks down faster than other proteins.

Whey Protein Hyrolysates
However, One thing that WLS folks may Really want to consider is whey protein hydrolysates.  Some manufactures sell whey protein hydrolysates, meaning the whey is predigested into peptides (small chains of amino acids). These supposedly help the protein be absorbed better. The use of hydrolysates is based on a study involving internal nutrition, meaning the protein was supplied directly to the patients' intestines via a tube. Most people don't bypass their stomach's and so Hydrolysates are not that important, because the stomach does an excellent job of breaking protein into amino acids...  But for us WLS folks... we are basically dumping the protein straight into our intestines. SO, Hydolysates is probably the best protein we could get.  Here is a Link to a site that sells the  Stuff... http://www.vita4life.net/protein.html   I have tried it and one nice thing about it is that it comes in 2oz packets that can be mixed or taken straight... I took it straight and its and Instant 30 grams of protein  full absorption.

So,  what does this all mean... I know... I get carried away... sorry, but it means that YOU need to eat more and more protein.  With the Malabsorption or the fact that our stomachs can't break down the Protein so quickly causing the Malabsorption, it does mean we need to consume More protein.

A couple of links where I got some of this information: http://www.bodyandfitness.com/Information/Fitness/protein5.htm, http://www.vita4life.net/proteinfacts.html, http://www.vita4life.net/protein.html

Here is another good link to a discussion on protein.  http://www.vitalady.com/why_protein.htm

This link talks about protein being broken down not only in the stomach, but also in the first 12 to18 inches of the intestines by an enzyme called trypsin.  This section  of the intestines, of course, is the area that has been removed in gastric bypass patients.  This link goes on to suggest that all supplements are predigested.  I do not believe that is the case as discussed above.  The only predigested protein supplements that I have found will be in the form of Whey Protein Hydrolysates and will say that they are predigested.  I do believe that most supplements are much more easily absorbed as they require very little work in order to be absorbed, especially whey protein supplements.

Protein Deficiency Symptom                          Top

• Increased secretions from the mouth, nose, and eyes

• Edema of the hands and feet

• Muscle and/or menstrual cramps

•  Low tolerance for exercise

• Cold hands and feet

• Bleeding gums

 Fat

Fat is a required macronutrient.  The body actually requires a small amount of fat in order to survive. Fat is made up of fatty acids.  The body can produce most of the required fatty acids, but those that it cannot produce are called essential fatty acids.  There is only one true essential fatty acid and that is linoleic acid.  Linoleic acid is the only fatty acid that must be obtained from an outside source.  Linoleic acid is found in many food sources and should not be a problem unless fat is totally eliminated from the diet. 

 Fat content in a diet plays a major role in the production of items called eicosanoids. Eicosanoids are created in very low levels inside individual cells.  They play an important role in blood pressure regulation, blood clotting, inflammation response, pain and fever response, sleep cycles, the release of gastric acid, and many other cellular responses.

 Fat is either burned as energy in our cells or is stored in fat cells.  Once in our body, fat  travels through the blood as a molecule composed of three fatty acids called triglycerides. Cell surfaces break down the molecule and the fatty acid can enter the cell.  The cell’s mitochondria is the power plant of the cell and can burn up the fatty acid.  However, the mitochondria can only burn fatty acid if it can enter into the mitochondria.  Fat enters the mitochondria via a shuttle called carnitine.  The hormone Glucagon, mentioned earlier, facilitates this fat-carnitine shuttle. In essence glucagon says,” We need energy, lets break that fat down and get it into the furnace”.  On the other hand, the hormone Insulin works as a blocker to the fat-carnitine shuttle.  It is like insulin is saying, “the mitochondria is full, you can’t come in”. The fatty acid is then sent back to be stored in fat cells.

 To recap what has been said, fat is a required macronutrient and is essential for the production of eicosanoids.  Fat can also be burned as energy or stored in fat cells.  Fat is regulated by glucagon, which facilitates it to be burned as energy, or is regulated by insulin, which blocks its burning and causes it to be stored in fat cells.

 How many Grams of Fat should you Eat?         Top
If you watch your carbohydrate intake then it is not necessary to count the grams of fat.  It is not fat that makes you fat. See the section on Insulin and Glucagon.  Good quality fats from meat and oils such as olive oil provide the necessary required fatty acids.

Fatty Acid Deficiency Symptoms:

• Seborrheic dermatitis
• Dry dermatitis of skin
• Ringing of the ears
• Fatigue
• Acne
• Dry stiff hair
• Hair loss
• Anemia
• Thickened skin
• Dry skin
• Diarrhea
• Eczema
• Redness of skin
• Gallstones
• Growth impairment
• Chronic gooseflesh type of skin
• Decreased immune function
• Frequent infections
• Impaired protein utilization
• Increased permeability of the skin & intestines
• Poor wound healing
• Dry eyes
• Poor visual acuity
• Frequent urination
• Problems with infertility
• Kidney dysfunction
• Fatty infiltration of the liver
• Brittle nails
• Excessive thirst
• Irritability

 Carbohydrates                                               Top

Carbohydrates are not required by the body. In other words, there are no essential carbohydrates as there are in protein and fat.  You can survive and live quiet well on fat and protein alone and never eat carbohydrates.  However, most of the foods that are readily available are carbohydrates and are a big part of the American diet. Carbohydrates come in two forms, simple and complex. Simple carbohydrates are simple sugars and can be identified by the sweet taste.  Simple carbohydrates are things like table sugar.  Complex carbohydrates usually do not have a sweet taste and are things such as potatoes, grains, vegetables, and fruits.  Complex carbohydrates require an enzyme named amylase in order to be digested.  Amylase is produced in the saliva glands in the mouth where the digestion of carbohydrates begins.  The pancreas also produces amylase and secretes the enzyme through the duodenum, which is located in the lower stomach. 

 Fiber

Another form of carbohydrate is cellulose or fiber.  Though a carbohydrate, cellulose or fiber cannot be digested in the human body.  An example of this type of carbohydrate is grass.  Cows produce the enzymes required to digest and extract nutrients from grass, but humans do not produce these required enzymes.  Many foods that we eat contain fiber in the form of cellulose and do benefit the human body in digestion, but do not provide nutritional or caloric contributions.  Some examples are lettuce and broccoli. Examples of low-fiber, complex carbohydrates are banana, tomato, squash and all cereals and grains (therefore bread and pasta), potatoes and rice.

 Insulin and Glucagon                                      Top

The high-carbohydrate diet is the way of life for most Americans as most of our foods contain high amounts of carbohydrates.  The problem with carbohydrates is that they cause the pancreas to produce large amounts of insulin.  Insulin's action is to drive glucose into the cells to be burned as energy.  However, insulin also works as a blocker to prevent fat from being burn as energy.  Excess portions of glucose is converted into triglycerides and sent to be stored as fat in fat cells.  Insulin becomes the deciding factor between fat being used as energy or glucose.  Glucose always wins out.  When attempting to diet, carbohydrate actually prevent weight loss as insulin is produced to process the carbohydrates.

Insulin and glucagon are opposite hormones. Glucagon’s action is to facilitate the burning of fat and is produced and increased by eating protein.  Insulin’s action is to facilitate the burning of glucose and to block fat from entering the mitochondria to be burned as energy.  Insulin is produced and increased by eating carbohydrates.

Diabetes
The way insulin works is to notify receptors, which are part of every cell, to take in glucose.  However, because most diets are so high in carbohydrates, the pancreas actually produces excess amounts of insulin.  As a result of the excess insulin, the receptors on the cells actually become resistant to insulin and no longer function properly.  When receptors become resistant to insulin, more insulin is required in order to get the receptors to respond and drive glucose into the cells. When the pancreas can no longer produce enough insulin to make the cell receptors function, the disorder is called type 2 Diabetes.  So type 2 Diabetes is when cell receptors no longer respond to large amounts of insulin in the blood.  Type 2 Diabetes is not that the pancreas does not produce insulin, but that the receptors have become resistant to the insulin.  Type 1 Diabetes is when there is a problem with the pancreas and it no longer produces insulin.

An excess amount of insulin in the blood is called Hyper-insulin-anemia and can cause many other health problems.  Symptoms and conditions of Hyper-insulin-anemia include hypertension, high cholesterol, high triglycerides, gout, arteriosclerosis, heart disease, hypoglycemia, and diabetes.

Decreasing the amount of carbohydrates in the diet lowers the production and level of insulin in the blood.  As a result of the lower insulin level, cell receptors become less resistant and actually respond to lower levels of the hormone.  In addition, the other symptoms of Hyper-insulin-anemia such as high blood pressure are reduced.

How many Grams of Carbohydrates should you Eat?           Top
It is recommended for maximum weight loss that you limit your carbohydrate intake to less than 55 grams per day or less than 15 grams per meal.  When figuring the amount of carbohydrates, subtract the fiber from the total carbohydrates.  Example: If a label reads 20 gm Total Carbohydrates,  5 gm Dietary Fiber  your actual grams of digestible carbohydrates are 15 gm. In this case, 15 grams of the total carbohydrates are insulin producing.

Vitamins, Minerals and Potassium
Following WLS, most surgeons recommend taking two multivitamins everyday.  The reason that that two multivitamins are required is mal-absorption.  The vitamins should be taken with food and the vitamins should be liquid or chewable.  I take Centrum Liquid at night and take a Flintstones Chewable every morning.  I suggest that you read the label on the back of the vitamin container before purchasing them.  Many of the vitamins do not contain the recommend daily amounts, so make sure the vitamins that you purchase do. 

Vitamins are important because they function in your body to facilitate certain chemical reactions.  For example, your body must have vitamin C to build strong collagen. Collagen is the main protein that builds bone, muscle fiber, skin, hair, nails, and tissue to heal wounds. It is suggested that you take 1 gram (1,000 mg) of vitamin C each day.

Other vitamins to consider as supplements are Vitamin E and Beta-carotene.  These vitamins form a group called Antioxidants.

B Vitamins
The B vitamins are very important in that they facilitate the use of protein, carbohydrates, and fats, to turn these into muscle, blood, enzymes, and energy.  Most surgeons suggest that you take a B complex or a B12 supplement.  

People who have had WLS have a more difficult time absorbing vitamin B12 as the surgery interferes with the stomachs ability to produce a substance called Intrinsic Factor.  Intrinsic Factor binds with Vitamin B12 and allows it to be absorbed by the small intestine. If intrinsic factor is absent, vitamin B₁₂ is poorly absorbed in the body.  It is suggested that a sublingual (taken under the tongue) supplement be taken so that the intrinsic factor does not come into play with the absorption of the vitamin.

Symptoms of low levels of B12 include: Weakness, Fatigue, Light headedness, A pale appearance, Diarrhea, Abdominal pain, Forgetfulness, Depression, Disorientation or confusion, Difficulty thinking and concentrating, Impaired judgment, and poor control of impulses.

 Iron                                                                              Top
If you are eating meat and especially red meat chances are that you will not have to take an Iron supplement.  Some Multivitamins contain an iron supplement.  There is a Flintstones vitamin with Iron.  If you have a tendency to be anemic or develop anemia, your doctor may suggest a vitamin with iron or provide you with a prescription for an iron supplement.

Red meat is a natural supplier of iron to the human body.  Red meat contains iron in the form of heme iron.  This form of iron is easily absorbed in the human body and is one of the best sources of iron to be consumed.

Iron should not be taken at the same time as Calcium as the two bind together and prevents proper absorption.  However, Vitamin C helps to promote iron absorption.  Wait about 4 hour between taking Calcium and Iron supplements.

Chromium
Chromium is a mineral that is required by the insulin receptors on the surface of cells in order to work properly.  Because of the high quantity of carbohydrate consumed, high demands are place on receptor cells and causes a chromium deficiency.  It has been stated that about 90% of American have a chromium deficiency.  As stated above, if receptor cells are working properly, less insulin is required to force glucose into cells.  Remember, insulin is a blocker that keeps fat from being burned as energy.

A symptom of chromium deficiency is a craving for sweets.  If you have a sweet tooth, it could be a sign of a chromium deficiency.  This in return creates a vicious cycle of eating to many carbohydrates, which create higher levels of insulin, which put higher demands on receptor cells that cause more chromium deficiency.

It is recommended that you have 200 micrograms per day.  Check your multivitamin to see if it contains chromium.  I take the Centrum Liquid vitamin because it does contain chromium.

Calcium and Magnesium
99% of your body’s calcium is stored in your skeletal framework.  Calcium is used for building your bones and teeth, but it also involved in the transmission of nerve fiber and in muscle contraction.  Further, a deficiency in calcium plays an important part in causing high blood pressure.

Magnesium is usually found in water, but many water companies and water softeners filter out magnesium, because of the taste on odor that it adds to the water.  Calcium is difficult to absorb without magnesium.  Often it is a magnesium deficiency that causes mal absorption or deficiency in calcium.  Calcium and Magnesium supplements are often sold together.

When purchasing calcium supplements and other mineral supplements, you should look for supplements that are chelated.  When a mineral is chelated its ions are wrapped in jackets of amino acid which disguise it to the stomach.  The stomach thinks the chelated mineral is a protein and absorbs the mineral.  Chelated minerals usually will have the suffix “ate” in the form citrate-maleate or picolinate.

I suggest that you take a Calcium Magnesium supplement in the form of Calcium Citrate. Calcium Carbonate like Tums are difficult to absorb.  Calcium Carbonate require more stomach acid for absorption and chelated Calcium is designed to be easily absorbed because the stomach thinks that it is a protein.

Iron and Calcium supplements should be taken separately, usually about 4 hours apart.  Iron will bind with the Calcium and prevent absorption.

A couple of reference links:
BariatricAdvantage |
Book: Protein Power by Michael Eades, M.D. and Mary Dan Eades, M.D.
http://www.eatprotein.com/faq.htm

Potassium                                                                       Top

Potassium and salt play an important role in the passage of nerve impulse, in muscle contraction and in maintaining normal blood pressure.  When you first have WLS or start a low carbohydrate diet, your body will go through a metabolic change that will signal your kidneys to release excess sodium and water.  This stabilizes within a couple of weeks.  Also, if you exercise vigorously or sweat profusely, you will lose minerals.  The main lose in this lose of water and minerals is potassium.  If potassium level falls to quickly, you can suffer from weakness, fatigue, muscle cramping and light headedness.

I drank diluted Gatorade to replenish my potassium level.  Potassium supplements are also available, but usually only come in 99mg tablets.  Morton Lite Salt or NoSalt  bran are made of potassium and can be mixed in a drink or used on food.

Water
You will hear a lot about water, but drinking water is one of the most important things to do following WLS or when on a low carbohydrate diet.  Regardless of your diet, water is essential to life and you need to drink at least 64 ounces of water per day. 

Without water our bodies die in their own waste products.  If you do not drink enough water, wastes are not removed effectively and build up in our bodies causing an increase in uric acid.  Nutrients and oxygen do not get carried adequately through the blood.  In addition, fat cannot be metabolized adequately.  Further, metabolized fat cannot be flushed from the body as it should and puts a strain on kidney function.

So, how much water do I need to drink per day?
Doctors usually state that you should drink a minimum of 8 - 8 ounce glasses of water per day for a total of 64 ounces.  However, research has shown that if you are over weight and especially if you are dieting that you should consume 8 – 8 ounces glasses of water plus an additional 8 ounce glass of water for every 25 pounds over your ideal body weight. 

If you want to calculate the total number of ounces you should consume, try my calculator, or do the following:

1.      Determine your ideal body weight based on your height and sex

2.      Subtract the ideal weight from your current weight, which equals your excess weight.

3.      Divide your excess weight by 25.  This equals the number of additional glasses of water to be consumed

4.       8 plus the additional glasses of water for the total number of glasses of water

      Example:   Current weight = 303   Ideal weight = 182     303 – 182 = 121
            Excess Weight = 121,  121/25 = 4.84 or  5 additional glasses
             8 + 5 =  13  -    Total  13 glasses of water per day

Water Facts:

1. 75% of Americans are chronically dehydrated.
2. In 37% of Americans, the thirst mechanism is so weak that it is often mistaken for hunger.
3. Even MILD dehydration will slow down one's metabolism as much as 3%.
4. One glass of water will shut down midnight hunger pangs for almost 100% of the dieters studied in a University of Washington study.
5. Lack of water, the #1 trigger of daytime fatigue.
6. Preliminary research indicates that 8-10 glasses of water a day could
significantly ease back and joint pain for up to 80% of sufferers.
7. A mere 2% drop in body water can trigger fuzzy short-term memory,
trouble with basic math, and difficulty focusing on the computer screen
or on a printed page.
8. Drinking 5 glasses of water daily decreases the risk of colon cancer by 45%, plus it can slash the risk of breast cancer by 79%, and one is 50% less likely to develop bladder cancer.

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