Bariatric Surgery Nutrition

First off, what is a ketogenic diet? The ketogenic diet is a very low carbohydrate, very high fat, low-moderate protein diet. Historically, it has been used to control epilepsy in children. When you don’t give your body carbohydrates (your body’s preferred fuel source), it begins to use and break down body fat as a source of energy, which is called ketosis. The breakdown of fat leads to the production of ketones, and the ketones are what begin to fuel your body (instead of the carbohydrates you were feeding it before). This process can take a few days to achieve, and when done correctly, can be tested by measuring the ketones in your urine with a dipstick. If ketones are present, this means you’re in ketosis. What does the macronutrient profile look like? FAT – A ketogenic diet should include healthy fats such as fats from fish, seafood, eggs, nuts, vegetable oils, dairy, and some meats. There is a lot of poor information on the internet that encourages people to have the majority of their fats in the form of cream, lard, bacon, and fried foods, which are not good for our heart. CARBOHYDRATES – The ketogenic diet is described differently depending on the source, but on average it means limiting your carbohydrates to 5-10% of total daily calories. For bariatric patients eating around 1200, 1500, or 1800 calories/day, this works out to 22, 28, or 34 g of carbohydrates/day, respectively. That’s very little! Foods rich in carbohydrates that are limited/eliminated in a ketogenic diet include: grain products (e.g. pasta, rice, bread, etc.), fruit, many vegetables (e.g. potatoes, corn, carrots, squash, etc.), some dairy products (e.g. milk, yogurt), legumes (e.g. chickpeas, beans, lentils), and sweets and sweetened beverages (e.g. chocolate, ice cream, pastries, juice, soda, etc.). That’s a lot of food groups being restricted! PROTEIN – On a ketogenic diet, protein is considered low-moderate (depending on your protein requirement), or around 15-20% of total calories. For bariatric patients eating around 1200, 1500, or 1800 calories/day, this works out to 52, 65, or 78 g of protein/day, respectively. Are these protein targets in the range that your dietitian has recommended for you? For many of you, likely not. FIBRE – Fibre falls under the umbrella of carbohydrates. Because you now know that carbohydrates are very limited on a ketogenic diet, you can guess that fibre will also be very limited. A diet very low in grain products, fruits, most vegetables, and legumes means that constipation is going to be a real issue! I heard that a ketogenic diet leads to rapid weight loss. It’s true in the beginning, but the important factor here is to understand what kind of weight loss this is. Yes, it’s true that reducing carbohydrates leads to weight loss, however the weight that’s initially lost is mainly water weight, not fat. Here’s a behind the scenes look at what’s going on: Your body always wants to keep your blood sugar well controlled, so it stores some sugar (or glycogen) in your liver. When you’re sleeping, or fasting, your body uses this stored glycogen to send some sugar into your blood, to be sure that your blood sugar doesn’t drop too low. Glycogen is stored in your body by attaching glucose to water. So when we empty our glycogen stores, we’re actually losing a fair bit of water as well, and that’s the initial weight loss that you see. The weight loss that follows from there is partly muscle loss if you’re not meeting your protein needs (which as discussed above, might be the case) and fat. While ketogenic diets have been shown to be better for weight loss than other low fat diets, the results are only true in the short term. In the long-term, there doesn’t appear to be any difference. You’re also more prone to rebound weight regain on a ketogenic diet once you re-introduce carbohydrates again (whether by choice, by cravings, or by obligation because you feel unwell without them). But I thought that the ketogenic diet was proven to be effective? The ketogenic diet isn’t a new diet at all. It’s actually been used for almost 100 years to treat children with severe epilepsy who don’t respond to medication. However, even these children don’t stay on the ketogenic diet their whole lives, they only do so for a temporary amount of time. These children are followed very closely by their doctor and dietitian to very slowly bring carbohydrates back into their diet. Despite what you dietitians say, I want to try the ketogenic diet! Ultimately, it’s entirely your decision to try what you want. We (as dietitians) are only here to guide you through the evidence that’s out there, and as of now, there’s no research on the ketogenic diet after bariatric surgery. There’s also not enough long-term research to know and understand if the ketogenic diet is safe for your heart in the long-term (i.e. more than 12 months of being on the diet). Three of our biggest concerns as dietitians are: 1) Are you meeting your protein needs? 2) Are you emphasizing healthy fats; 3) Are you just looking for a quick fix? If you’re using the ketogenic diet as a “reset” just like the last fad diet you tried, you’re only feeding the yo-yo dieting pattern (just playing devil’s advocate here!). Can I be on a ketogenic diet my whole life? The honest answer is we don’t know. We don’t have research on the long-term effects of following a ketogenic diet. It’s suspected that it may lead to higher cholesterol levels which may lead to heart disease, but more research is needed to conclude this. Does being on a ketogenic diet guarantee that I’ll keep the weight off? While more research is needed, one study showed that the participants who were very strict about following the ketogenic diet were able to keep off the initial weight loss for up to 56 weeks (or a little more than one year). We don’t have the research to say if in 10 or 20 years that their weight will still be stable or not. We do know however, that if you don’t find the ketogenic diet realistic for your lifestyle and you end up coming off of it, you will regain the weight (if not more), as with any temporary diet. Is the ketogenic diet safe? While it may be generally safe (meaning you’re not going to die) for most people, you should always check with your doctor, especially if you have heart disease, liver disease, and diabetes, as this diet may put your health at risk. The ketogenic diet is not considered safe for those who have chronic kidney disease. The ketogenic diet has received a lot of criticism because it’s a very restrictive diet, eliminating many foods and therefore many nutrients that are important for health. Following this diet puts you at high risk for micronutrient deficiencies. Make sure you discuss additional vitamin supplementation with your family doctor or dietitian. What are the benefits of a ketogenic diet? Aside from weight loss, following a ketogenic diet has been shown to improve blood sugar control in those with type 2 diabetes, lower triglycerides, lower LDL cholesterol (the ‘bad’ cholesterol), and raise HDL cholesterol (the ‘good’ cholesterol). Although these benefits sound attractive, know that other low fat diets have produced similar results, and would be safer in the long-term since they’ve been better studied and are less restrictive overall. What are the risks of following a ketogenic diet? Liver disease? – More research is needed, but several rat studies have shown an increased risk of developing liver disease. While results from rat studies don’t 100% translate into humans, animal studies often give an indication or at least a starting point for how something will affect the human body. More research is needed in human subjects. Muscle loss. – Another risk of following a ketogenic diet is muscle loss, because most patients aren’t able to meet their protein goals. Losing muscle may put you at risk of weight gain. Working with a dietitian while following a ketogenic diet can help you be sure you’re meeting your protein needs. Earlier death? – Like we’ve mentioned, there isn’t enough research yet on the long-term risks of following a ketogenic diet, but a recent study found that low carbohydrate diets (less than 40% of calories from carbohydrates) was linked to earlier death, compared to having a moderate-carbohydrate diet (50-55% of calories from carbohydrates). Remember that a ketogenic diet has around 5-10% of calories coming from carbohydrates. How did they explain this increased risk? The risk with a low carbohydrate diet seems to be because the carbohydrate calories are often replaced with more animal protein and unhealthy fats, rather than plant-based protein and healthy fats. Note that this study was not on bariatric patients, but again, the findings are interesting. What are the side effects of a ketogenic diet? Side effects during the adaptation period (i.e. in the beginning of following a ketogenic diet) include: brain fog, fatigue, headaches, nausea, strong smelling sweat and urine, constipation or diarrhea, and poorer exercise performance. Long-term side effects include: bad breath, micronutrient deficiencies, and muscle loss. What are common misconceptions of the ketogenic diet? Many people believe that it’s a carbohydrate-free diet, meaning no carbohydrates at all. This isn’t the case. You can have in the range of 20-50 g of carbohydrates per day (depending on how many calories you’re eating). If you don’t know what this looks like in terms of food, speak with your dietitian. Another misconception is that a ketogenic diet is high in protein. This also isn’t the case. A ketogenic diet is moderate in protein for the average person (who hasn’t had bariatric surgery), and is therefore typically low in protein for a bariatric patient. As you likely know, low protein puts you at risk of losing muscle which will affect your overall weight loss, and put you at higher risk of weight regain in the future. Other than muscle loss, what are other negative nutrition consequences of following a ketogenic diet after bariatric surgery? Low in fibre – The smaller food intake that you have after surgery already makes getting in enough fibre difficult. This partly explains why so many people are constipated after surgery. A ketogenic diet significantly limits most fibre-containing foods including fruit, most vegetables, grain products, and legumes, so your fibre intake decreases even more. Constipation is therefore even more of an issue! High in unhealthy fats – Many people don’t follow a ketogenic diet correctly and include too much saturated fats (or unhealthy fats) in their diet. For example, they may choose bacon, sausages, and lard, over fish, nuts, and vegetable oils. A diet high in saturated fats has been linked to heart disease. Low in many micronutrients – A ketogenic diet is also low in important vitamins and minerals such as thiamine, folate, vitamin A, calcium, magnesium, iron, and potassium. While you’re prescribed vitamins and minerals supplements after bariatric surgery, these standard prescriptions don’t account for you following a ketogenic diet. If you do decide to follow a ketogenic diet, it’s important to have your doctor or dietitian re-assess your vitamin and mineral supplements and for you to continue doing blood work regularly. Will I be able to exercise just as much while on a ketogenic diet? The downside to following a ketogenic diet is that it may actually reduce your exercise performance (across anaerobic, aerobic, and strength related exercises) in the short-term. If you’re doing low intensity exercises such as walking or a leisure bike ride however, you shouldn’t notice a difference. More research is needed to understand how a ketogenic diet affects exercise performance, especially in the long-term. I’ve been having episodes of low blood sugar after bariatric surgery. Can I follow the ketogenic diet? If you’ve been experiencing low blood sugar after surgery, it’s not recommended to start a ketogenic diet. It’s important to understand why you are experiencing low blood sugar as soon as possible. Here are some of the most common reasons for low blood sugar after bariatric surgery: Dumping syndrome due to high sugar intake Going long periods of time without eating Not eating enough carbohydrates or not spacing your carbohydrates out during the day Excess exercise An overactive pancreas Diabetic medication that is not adjusted properly Speak with your dietitian to figure out why your blood sugar keeps dropping. I plan to try the ketogenic diet for a few weeks and then come off of it. If that’s the case, then don’t bother. The reason this diet works for weight loss is because you are in ketosis (which in itself takes a couple of days to achieve because you need to use up your glycogen stores). If you come out of ketosis, you will no longer see the effects, and thus begins the yo-yo dieting effect. Always remember – Temporary changes yield temporary results! I’m already on the ketogenic diet, how can I come off of it safely? If you’ve already started the diet, reintroducing carbohydrates can lead to bloating, unstable blood sugars, and weight regain. To minimize these effects, begin by including whole grain products, rather than refined processed carbohydrates (e.g. white bread, breakfast cereals, pretzels, etc.). Whole grain foods include quinoa, brown or wild rice, oatmeal, bulgur, and barley. Sweet potatoes would also be appropriate. Include 1 to 2 tablespoons at only one meal per day for up to one week. If you’re feeling okay, begin including one fruit at one snack for a few days, and then try reintroducing yogurt and milk. But aren’t there doctors and health gurus out there promoting the ketogenic diet? Yes, there are, but there also were doctors and health gurus promoting the Atkins diet, the Pritikin diet, and the Dukan diet back in the day. There will always be people out there trying to capitalize on the newest fad diet to sell you on the weight loss dream and to take your money. It’s easy to point fingers and put the blame on specific foods or food groups, but ultimately the only way of eating that has been proven effective time and time again, is moderation. As dietitians, we know very well that ‘moderation’ (which means something different for each of our clients) isn’t sexy, but it’s key to having a healthy long-term relationship with food. I’m pregnant and I want to follow a ketogenic diet. Following a ketogenic diet during pregnancy is not recommended. While your body can handle being in ketosis, the production of ketones is harmful to your baby’s development, particularly their brain development. SUMMARY… – A ketogenic diet is very low carbohydrate, very high fat, low-moderate protein diet. – A ketogenic diet should emphasize healthy fats, but many sources online emphasize online unhealthy fats (e.g. bacon, sausage, lard, cream, etc.). – A ketogenic diet is very low in carbohydrates. This means that it’s not only grain products that are limited (e.g. pasta, rice, bread, etc.), but also fruit, many vegetables, some dairy products, legumes, and sweets. – By default, a ketogenic diet is also low in fibre which results in constipation in many patients. – A ketogenic diet is considered low-moderate in protein. Most bariatric patients aren’t able to meet their protein needs on ketogenic diet which results in muscle loss. – We don’t know the effects of a very high fat diet on health long-term, but it likely isn’t good for heart health. – Many of the benefits of a ketogenic diet (e.g. weight loss, improved blood sugars, lower triglycerides, lower LDL cholesterol, increased HDL cholesterol, etc.), are similarly seen in low-fat diets (while being way less restrictive overall). – There are many unpleasant side effects to following a ketogenic diet including constipation, poorer exercise performance (at least short-term, no research on long-term performance), muscle loss, bad breath, and micronutrient deficiencies. – You likely need to take additional vitamin and mineral supplements while following a ketogenic diet. Regular blood tests are still very important. – A ketogenic diet is not recommended in a variety of health conditions, and is even considered dangerous for some (e.g. patients with chronic kidney disease and pregnant women). Always check with your family doctor and dietitian before making drastic changes to your diet. – The ketogenic diet has not been studied in people who have had bariatric surgery, so the short-term and long-term effects are unknown. – The ketogenic diet is very restrictive and is therefore not sustainable for the majority of people. Eating out and socializing around food become almost impossible. Our final thoughts… Many patients are quick to blame carbohydrates for weight regain. Instead of jumping to a ketogenic diet, we recommend reviewing the bariatric basics and booking an appointment with your bariatric dietitian. If you absolutely insist on trying a ketogenic diet, we suggest a “modified keto diet” that consists of more plant-based protein and healthy fats, with enough protein to be sure you’re maintaining your muscle mass. What are your thoughts on the ketogenic diet? Have you been tempted? Are you currently following a ketogenic diet? – Lisa & Monica, your bariatric dietitians P.S. For more tips on healthy living after bariatric surgery, follow us on Facebook (@bariatricsurgerynutrition) or check out our highly praised book HERE!

I heard I should be avoiding carbohydrates, is this true? This is 100% false! Carbohydrates are the body’s preferred source of fuel. Just as your car needs gas to run, your body and brain rely on carbohydrates to give you the physical and mental energy that you need to get through your day. What are carbohydrates actually? The majority of patients identify carbohydrates simply as grain products (e.g. bread, pasta, and rice). When dieters say they’re going on a low carb diet, they typically plan to eliminate or reduce their consumption of these grain products. In reality, carbohydrate sources include many other foods, like milk, yogurt, fruit, plenty of vegetables, and legumes. Did you know that one cup of milk has the same amount of grams of carbohydrates as a piece of toast? Or that a large apple has twice as many grams of carbohydrates as that same slice of toast? Or that a 1⁄2 cup of chickpeas has three times the amount of carbohydrates as the toast? Confused? This is why we challenge our patients in why they want to experiment with low-carbohydrate diets. What does that mean to them? And which foods are they planning on restricting? A lower carbohydrate diet is not necessarily a healthier one! In a world where our food apps can track everything, it’s sometimes hard to make sense of all of the numbers they give us. You shouldn’t be blindly trying to decrease your total grams of carbohydrates or total grams of fat per day without understanding how that translates into food choices and your overall health. The type of carbohydrate is more important than the amount of carbohydrate.Not all carbohydrates are created equal. The most common forms of carbohydrates are:  Fibre (for the purposes of this book, we will refer to fibre as a ‘complex carbohydrates’);  Sugar (for the purposes of this book, we will refer to them as ‘simple carbohydrates’).  Starch. Starch is calculated by taking the total carbohydrates and subtracting both the fibre and sugar from it (for the purposes of this book, we will refer to starches as ‘complex carbohydrates’). Foods that are high in carbohydrates but contain a fair amount of fibre and starch, and a low amount of sugar (i.e. high in complex carbohydrates and low in simple carbohydrates), are typically healthier choices. Complex carbohydrates take longer to digest, which is why they make you feel fuller longer. Examples include:  Barley;  Oats;  Quinoa;  Whole-grain products;  Legumes. Similarly, foods that are high in carbohydrates but contain high amounts of sugar and low amounts of fibre and starch (i.e. high in simple carbohydrates and low in complex carbohydrates) are typically less healthy choices. Simple carbohydrates are quickly digested, which is why they give you a quick boost of energy, but also why you don’t feel satisfied for very long. Examples include:  Pastries;  Donuts;  Chocolate;  Candy;  Juice;  Regular soda;  Sugary cereals. After WLS, protein should always be eaten first, followed by your vegetables and then your grain products (e.g. rice, quinoa, pasta) or starch (e.g. potato, sweet potato, squash). Eating in this order will naturally limit the amount of carbohydrates you consume at each meal because of the limited space in your stomach. Patients who restrict their carbohydrate intake, in our experience, typically have a harder time finding a healthy balance and joy in eating again. One of the biggest consequences of skipping out on carbohydrates at mealtime is that your blood sugar is less balanced, which can result in sugar cravings later on in the day. Remember: All foods fit, but it’s the portions of food that should be the focus in a healthy diet, post WLS. - Lisa & Monica

There are two main reasons bariatric patients are at risk for developing vitamin and mineral deficiencies: 1. First of all, and most obviously, you’re no longer able to consume large enough amounts of foods to meet your micronutrient (i.e. vitamin and mineral) needs. 2. Secondly, your body now absorbs and processes foods differently. For example, if you had a malabsorptive weight loss surgery (e.g. gastric bypass or duodenal switch), in addition to eating smaller portions of foods, you’re also not absorbing 100% of the nutrients in the foods that you’re eating. Interestingly, even in the non-malabsorptive procedures (e.g. sleeve gastrectomy and band) we see changes in nutrient processing. For example, you may no longer have enough stomach acid in your small stomach to efficiently absorb the natural calcium found in dairy products, which is why you’ve been prescribed a special type of calcium, calcium citrate, that doesn’t require stomach acid to be absorbed. The signs and symptoms of vitamin and mineral deficiencies can be mild to severe. Some take only weeks to occur, while others take years to develop. While many deficiencies are reversible (e.g. anemia, or low iron), several micronutrient deficiencies are irreversible (e.g. osteoporosis, or bone decay due to inadequate calcium and vitamin D, and neurological damage due to inadequate B vitamins). Moral of the story? Take your vitamins! How often should I be going for blood tests? Your bariatric team will tell you how often you should have blood tests done. It’s most likely that you’ll have a blood test after your surgery, while you’re still in the hospital. Following this, your next blood test will be in three to six months and continue every three to six months until your first year after surgery, depending on the type of surgery you had. If your blood tests are looking great at one year after surgery, this is a good sign and means that you managed to get through the first risky year after bariatric surgery without having developed a deficiency! But this doesn’t mean that blood tests are no longer needed. You’ll need to do blood tests to check for nutrient deficiencies for the rest of your life. As you get older, your body needs more of some nutrients and less of others as your body changes. Some deficiencies also take a longer time to develop. For this reason, you may still develop deficiencies over time, even five to ten years after surgery. We’ve seen many patients who stopped doing their blood tests because they felt fine only to find out years later that they have multiple severe deficiencies. Feeling good doesn’t mean everything is good. And there’s a reason why. Before feeling tired, lethargic, weak, or sick, because of a nutrient deficiency, your body goes through the following stages: You’re not getting enough of a nutrient from your diet and your vitamins; Your body doesn’t have enough of the nutrient stored; You begin to have low levels of the nutrient in your body; Your organs begin to have trouble working properly; You begin feeling unwell and develop symptoms of deficiencies. Feeling unwell is the last step in this process. These steps can take only a few weeks for some nutrients, and up to several months for others. When you begin to feel unwell, your body has already been through weeks—or months—of missing an important nutrient. Blood tests can catch these deficiencies at a much earlier stage. For example, say you stopped taking your iron pill. You wouldn’t feel an anemia, or an iron deficiency, developing. Gradually, over time, you’ll begin to get tired and you might figure it’s just your busy lifestyle. You’ll begin to feel worse and wonder if you’re just not getting enough sleep. Then you’ll become increasingly lethargic and notice your hair has lost its shine and is getting brittle. Lastly, you’ll notice that you can hardly get through your morning routine without having to sit down and take a break. You’ll go to your doctor who will order blood tests. The blood tests will come back diagnosing you with anemia. Luckily, you’ll restart your iron supplement which will reverse this condition, although it’ll take about three months until you feel like yourself again. However, some deficiencies aren’t reversible which can leave you unwell permanently. The bottom line: Have your blood tests done regularly as suggested by your bariatric team. You’ll eventually only have one blood test per year, but this will only be the case at two years after bariatric surgery or until your blood tests routinely come back normal. If you no longer see your bariatric team, or live too far from your bariatric center, make sure that your family doctor is testing you for bariatric surgery-related deficiencies. The routine blood tests that your family doctor performs aren’t the same ones that your bariatric team orders. We look at so much more. Ask your family doctor if he/she is looking for all the nutrients necessary for bariatric surgery. They can receive this information from the bariatric clinic where you had your surgery.

Drinking water after surgery can cause some discomfort (like a rock hitting your stomach), sometimes it doesn’t taste right because of taste changes after surgery, and sometimes the temperature of the water can leave you feeling uncomfortable. Other times, you may simply just forget to drink and you just don’t feel as thirsty. Not drinking enough water can leave you dehydrated. How do you know if you’re beginning to get dehydrated? There are 3 main ways of figuring this out: Do I pee 3 times per day, or less? Is my pee dark yellow in colour and smells more than usual? Do I get dizzy when I stand/sit up or bend over? If you’ve had bariatric surgery and answered yes to one or more of these questions, there’s a chance you may be dehydrated. Some of these symptoms can be related to other causes as well, so check with your doctor, bariatric dietitian, or nurse if you’re unsure. Here are our tips for drinking more water after surgery: Make water more convenient by… Buying a fun new water bottle for work and home that gets you excited. Ideally, something colourful that catches your eye; Keeping a water bottle or water glass within arm’s reach at all times, regardless of where you are (e.g. at work, in the car, on the couch, in bed, etc.); Keeping cold water in the fridge at all times. Buy a water pitcher or a water filtering jug and place it at the front of your fridge. It needs to be visible and easy to reach to be convenient; Knowing your environment. Do a tour of your workplace to remind yourself of where the water fountains or coolers are. Check if the cafeteria charges for hot water or if there’s a vending machine that sells water bottles close by; Buy a smaller water bottle to carry in your purse or backpack for when you’re on the go. Ideally, it should hold no more than one to two cups. Large water bottles are often intimidating and if they are too heavy or bulky, they’re more likely to get left behind; Leave a reusable water bottle in your car at all times so that you always have some on-hand. Get excited and add some flavour by… Trying infused water. Add one of the following combinations to your water pitcher or water bottle: Sliced cucumber + fresh mint leaves; Sliced strawberries + fresh basil leaves; Sliced lemon + fresh lavender; Blackberries + fresh thyme; One cinnamon stick (for best results leave overnight in your water bottle); Using flavoured ice cubes. This idea involves freezing concentrated fruit purees, spirals of citrus rinds, and/or fresh herbs into ice cube trays. Adding one to three of these ice cubes into your water not only adds a fun flavour and keeps your water colder, but it’s also a colourful touch. This is a great alternative to store-bought water enhancers that contain artificial sweeteners. Example: puree two cups of chopped watermelon with the juice of one lime. Freeze the mixture in ice cube trays. Add two ice cubes into your reusable water bottle; Making a homemade tea with an added twist. Add eight ounces (one cup) of boiling water to the combinations below. Drink hot or refrigerate overnight and enjoy cold. 1/2 sliced lemon + 1/2 inch piece of peeled fresh ginger + 1 tsp honey; A green tea bag + fresh mint leaves; A black tea bag + orange slices or peach slices; An earl grey tea bag + sprig of lavender + lemon slices +1 tsp honey; A white tea bag + mint leaves + dash of lime juice; Treating yourself to some loose tea leaves or flavoured tea bags at specialty shops. Set reminders by… 1. Downloading an app. There are countless free apps out there to help you track your daily water intake and even ones that will send you constant reminders throughout the day to drink; 2. Add a sticky note to your computer monitor. Be sure to change the placement of the sticky note every week so it doesn’t blend into the background; 3. If you’re someone who does repetitive tasks at work, use this to your advantage! For example, challenge yourself to take three sips of water every time you read a new email and every time you send an email; 4. Buy a ‘time stamped’ water bottle or simply recreate one by writing the hours of your work day down the side of your bottle with a permanent marker. For example, evenly space 9 a.m., 10 a.m., 11 a.m., and 12 a.m. down one side of the bottle and 1 p.m., 2 p.m., 3 p.m., and 4 p.m. down the opposite side of the bottle. This strategy will also help you to pace yourself throughout the day. – Lisa & Monica, your bariatric surgery dietitians

Early vs Late Dumping Syndrome Although different, the symptoms of early and late dumping syndromes are very similar. They include: Nausea or vomiting Abdominal cramps Diarrhea Sweatiness Dizziness Irregular heartbeats However, late dumping syndrome can also lead to low blood sugar. Early dumping syndrome shows up 15-30 minutes after a meal. It occurs when food flushes too quickly through the gut. This could be because of eating too fast, not chewing well or drinking while eating. Late dumping syndrome, on the other hand, happens when you eat a lot of refined sugars or extremely sweet foods. These concentrated sugars absorb water from the body as they pass through the intestines. After a few hours, they lead to a spike in hormones and a drop in blood sugar, making you feel dizzy and shaky. Here are some foods that might trigger late dumping syndrome: Cookies Candy Cakes Ice-cream Fruit juices Soda drinks Sweetened breads If you are experiencing late dumping syndrome, it is best that you speak with your registered dietitian to discuss what to eat after an episode and find the best solutions for your quick recovery. How to Avoid Dumping Syndrome Distribute your meals and snacks evenly throughout the day. Don’t drink and eat at the same time. Drink 15 minutes before and 30 minutes after eating to prevent flushing. Choose foods with less than 25 grams of total carbohydrates and less than 10 grams of added sugar. This is usually shown in the nutrition facts table on food packages! Make sure to eat protein at each of your meals and snacks. Protein stops sugar from passing too quickly through the gut. Be mindful of the amount of sweet foods and refined sugars you eat in a day. An entire box of cookies is different from 1 or 2 homemade cookies. A glass of juice from concentrate is far from a fresh smoothie made with whole fruits, milk and yogurt. Dumping syndrome can seem like an inevitable evil, but many patients are able to successfully avoid it. Well distributed meals and snacks made from wholesome, protein-rich foods is the way to go! Written by: Nadeen Mekhael (Dietetic Intern) – Lisa & Monica

You may also be wondering how in the world do I become more active? I don’t even know where to start, and the gym just isn’t for me. We teamed up with Myriam, a local kinesiologist, to give you tips on how to start to get your joints moving when you’ve been inactive for too long. A kinesiologist is a highly educated health care professional who is an expert in body movement. They’re experts in preventing and managing injuries and help people to get fit and perform at their best, among many other things. In these videos, Myriam will show you exercises that you can do at home to improve the health of your joints and movement to start getting you on a path to being more fit. Practice these exercises in the comfort of your own home. All you’ll need is: A chair, A belt or resistance band, A broomstick or long stick. These exercises are great to start BEFORE surgery, early AFTER surgery, or even LONG TERM after surgery. It’s never too late to start being active. Remember that the number on the scale is only part of the story – fitness and exercise is the other half of the equation when it comes to living a longer and healthier life. How did this activity go for you? Let us know! – Lisa & Monica

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1. My weight does not determine my success nor worth. “If you accept your personal best at everything else in life, why not weight?” – Yoni Freedhoff Isn’t that SUCH a good quote? Is your WLS team happy with your progress, but you aren’t? Why are you still pushing for and obsessing over those next 10 lbs? Reflect on why you feel that you must lose those extra pounds and what will happen if you don’t? 2. I acknowledge that a healthy lifestyle (i.e. eating healthy most of the time and moving my body often) is a part-time job. Some weeks it doesn’t feel like work, but often it does. It is important to accept that doing well after WLS is not an accident. You have to make the time for your new habits. 3. I see meal planning, grocery shopping, and cooking as acts of self-care. This mindset shift is HUGE. Embracing this shift requires practicing gratitude. For example, this means being able to acknowledge that although you may not enjoy cooking, you are thankful to have food to put on the table. Or, as another example, maybe you don’t enjoy meal planning, but you can acknowledge how much smoother getting organized on the weekend makes your week flow. Try viewing these chores from a place of gratitude this week, and watch how much lighter they all of sudden feel. 4. I move my body because it feels good and helps me to re-charge. I don’t exercise to control my weight. If you are exercising solely for the purpose of controlling your weight, it is only a matter of time before you burn yourself out. Moving your body should come from a place of self-care. The activities that you choose should be enjoyable and energizing. They shouldn’t feel forced. 5. I am not on a diet. I eat foods that I enjoy. I practice moderation and flexible eating to the best of my ability. All foods fit. If you feel restricted, if you’re counting your calories daily, if you’re always hungry, or if you often feel guilty or ashamed about your food choices, you are going to burn yourself out! If you have dieted for most of your life, you likely have a lot of baggage in this department to work through. For many of our patients, it takes years to work through this mindset shift, so don’t be too hard on yourself. So, how many of these mindset shifts have you fully embraced? Which ones are still a struggle? Where do you feel stuck? Try posting these 5 mindset shifts up in your office or home to keep them top of mind as you go about your day. Envision and journal about what it would feel like and look like to embrace all of them. Click HERE for a FREE printable of these 5 mindset shifts! Click HERE to read more about this kind of content. Click HERE to follow our Facebook page for up-to-date videos and nutrition information. If you need help working through these shifts, speak with your WLS dietitian or psychologist. Wishing you all much happiness in your WLS journey! – Monica & Lisa

Cooking methods. If you tolerated a saucy chicken pot-pie, it doesn’t mean roast chicken will go down just as comfortably. Dryer methods of cooking (like broiling, roasting, grilling, and pan-frying) tend to be more difficult to tolerate. Moist cooking methods on the other hand (like steaming, braising, stewing, simmering, poaching) that involve liquids or a sauce are typically better tolerated. Also, be careful when microwaving, as the process of reheating foods can dry them out. A good way to keep the moisture in is by resting the lid on the container (not sealed) and stir after each minute until ready. If you’re reheating dry foods remember to sprinkle in some water, broth, tomato juice, milk, or low-fat gravy to add additional moisture. Mechanical reasons like not chewing well enough and taking large bites. You should always be sure to cut your food into small pieces—as small as your pinky fingernail to start—and chew your food until it’s puree in your mouth before swallowing. Remember that digestion starts in the mouth! Emotional stress and anxiety can tighten the upper digestive system which makes food more difficult to tolerate. Do you find you eat more comfortably at home or on the weekends compared to at work? If so, your tolerance issues could be related to stress or anxiety. Always be sure to eat in a calm environment and start your meals by taking a few deep breaths to relax and decompress. Some patients feel more comfortable eating alone at first (i.e. in their office instead of in the cafeteria). Eating while multitasking! When you are eating, you should only be eating. We know that this is a tough one to practice, but eating while driving, watching TV, cleaning, working through lunch, etc. can distract you from taking small bites and chewing well. Do your best to put away distractions during meal times. If you choose to eat lunch in your office, mute the volume on your computer and turn off the monitor so you’re not tempted to check your email in between bites. Posture. It sounds silly to discuss, but it’s true, poor posture can negatively affect digestion. If you are eating while slouched or reclined on the couch or awkwardly propped up on pillows in bed, chances are that you will experience some tolerance issues. When you are eating, you should ideally be sitting in a chair pulled close to the table with your bum as far back as possible and with your back nice and straight. Eating at the table in your kitchen or dining room will also give your meals and snacks more structure. Generally speaking, it’s a good habit to limit food and eating to only the kitchen and dining room. Excerpt from "The Complete Guide to Weight Loss Surgery: Your questions finally answered". Available on Amazon.com, Amazon.ca, or our website (PDF download).

Laughing Cow spreadable cheese triangles versus Philadelphia cream cheese? Is there really a difference? What about harder cheeses? Many of our patients seem to often choose the creamier spreadable cheeses after WLS or bariatric surgery. But are they the best options? Let’s go through the nutrition facts together. We’ve also added in brick cheese and ricotta cheese for comparison. Nutrient Laughing Cow cheese Philadelphia cream cheese Brick mozzarella cheese Ricotta cheese Portion 2 triangles (33g) 2 tablespoons (30g) 3 cm cube (30g) 2 tablespoons (31g) Calories (kcal) 70 100 90 45 Fat (g) 6 10 6 3 Saturated fat (g) 3.5 6 4 2 Trans fat (g) 0.2 0.4 0.2 0.1 Sodium (mg) 310 130 200 35 Carbohydrates (g) 2 2 1 1.5 Protein (g) 3 2 8 3 Vitamin A (%) 6 12 6 3 Vitamin C (%) 0 0 0 0 Calcium (%) 10 4 20 5 Iron (%) 0 0 0 0 Ingredients Modified milk ingredients, cheeses, sodium phosphates , citric acid. Milk ingredients, salt, bacterial culture, carob bean gum, sorbic acid. Pasteurized milk, modified milk ingredients, bacterial culture, salt, calcium chloride, microbial enzyme. Pasteurized milk and whey, lactic acid, salt, maltodextrin, mono and diglycerides, guar gum, carrageenan, carob bean gum Protein:calorie ratio 1:23 1:50 1:11 1:15 So what’s the verdict? Which cheese product is the best nutritionally? Brick-style cheese (any kind, e.g. mozzarella, cheddar, etc.) and ricotta cheese are the healthier choices compared to the creamy spreadable cheeses. And who is the winner between Laughing Cow and Philadelphia? Laughing Cow. How did we come to these conclusions? Although the brick cheese has a calorie content similar to cream cheese, it boasts more protein and more calcium. Brick cheeses are also less processed compared to the creamier spreadable cheeses, which are ultra-processed foods. Ultra-processed means that the food has been processed a step further to extend its shelf-life. Processing typically removes many nutrients (some of which are added back in in later steps) and adds a lot of salt (or sodium). Additionally, the winners can be justified by comparing the protein:calorie ratios (see our previous blog to learn more about this concept: https://bariatricsurgerynutrition.com/2017/07/07/chia-hemp-seeds-are-they-worth-the-hype/). Looking at the chart above, brick cheese and ricotta cheese have protein ratios of 1:11 and 1:15 respectively, which are lower than the ratios of Laughing Cow cheese (1:23) and Philadelphia cream cheese (1:50). This basically means that brick cheese and ricotta cheese provide more protein for less calories. This doesn’t mean that you can’t have the occasional creamy spreadable cheese with your bagels and toast, but between Laughing Cow cheese and Philadelphia cream cheese, choose Laughing Cow cheese more often. Although it has more sodium, it has a bit more protein for less calories and fat. To add a protein boost to both of these spreadable cheeses, add a couple slices of smoked salmon or deli meat. Everything in moderation! – Lisa & Monica P.S. We love ricotta cheese because it is a fairly spreadable cheese like cream cheese, but the perk is that you can flavour it however you please. Prefer salty cheese? Add a sprinkle of salt. Prefer a sweeter spread for your morning toast? Sprinkle some sugar, or a drizzle of honey or maple syrup. https://bariatricsurgerynutrition.com/2018/01/14/is-all-cheese-the-same/

Fancy vinegars and quality olive oils. Aged balsamic vinegars and cold pressed or flavoured olive oils are incredibly trendy right now. They are a great addition to any kitchen pantry and with a simple drizzle can significantly enhance the taste of everyday dishes. These types of products can found at most grocery stores and all specialty food stores. Gourmet coffee beans. Another trendy food item this year is specialty coffee beans. Whether you prefer fair-trade, certified organic or flavoured, there is something for everyone. Just be sure that the recipient actually has the proper coffee equipment to use them. In a world of Nespresso and Keurig fanatics you can never be too sure! Homemade spice mixes. A quick internet search will bring up a never-ending list of DIY spice combinations. We love the idea of speeding up meal prep for friends and family. Some of our favourite examples include: taco seasonings, steak spices, chili seasonings, chai tea spice blends, salad dressing spice mixes, meat rubs, etc. Package the spice mixes in small mason jars or spice bottles and add a ribbon for a festive touch! Potted herbs A small pot of rosemary or thyme this time of year makes a great gift for those who enjoy cooking. Both of these herbs are found in many fall and winter dishes such as turkeys, roasted chickens and stews. These plants can be tricky to find this time of year, but are most often found in select grocery and garden stores. Specialty teas. You can never have too much tea! Around this time of year pretty much all tea shops offer gift sets of tea which make perfect host/hostess gifts. They also usually have several festive limited-time only seasonal blends that are perfect for winter. What are your favourite go to host/hostess gifts? Let us know in the comments below! – Monica & Lisa For more blogs and tips like this, join our monthly newsletter at: http://eepurl.com/c-qfcL

Regardless of how marijuana is taken (i.e. smoked, inhaled or eaten) the effects are the same. The majority of people who use marijuana describe a sensation of relaxation and euphoria (the “high”). Some people however react badly to the drug which can result in a state of panic, anxiousness and fear, or in some cases even hallucinations if they take too much. Of particular relevance to bariatric or weight loss surgery, is the fact that marijuana impacts the part of your brain that controls appetite. Have you heard of the “munchies”? Yep, that’s right, the “munchies” are a real thing! Marijuana can increase your appetite, causing you to eat more, which obviously is not great if your goal is weight loss. Interestingly, a recent study on weight and marijuana use actually showed that marijuana use may very slightly (and we mean VERY slightly) reduce body weight (about a 0.5% reduction in BMI) (1). This study however was conducted on a group of people with an average BMI of 27 kg/m2, which is way below the average bariatric or weight loss surgery patients’ BMI pre-surgery. This unfortunately means that this mild weight loss effect cannot be applied to the typical bariatric or weight loss surgery patient. We did however find one recent study done in 2016 that is more relevant to the bariatric or weight loss surgery population (2). The study was run on a group of 50 patients (62% being RYGB patients) all 2 years after surgery. The results of the study showed that the patients who had smoked marijuana within the last 30 days and the patients who had started smoking more since surgery, were all more likely to have disordered eating habits, specifically “loss of controlled food intake” (2). Although the study did not look at weight outcomes related to marijuana use, we know that disordered eating habits such as grazing and bingeing are risk factors for weight regain after bariatric or weight loss surgery. We asked a Canadian-based bariatric surgeon for his opinion on the subject of marijuana use after surgery. Here is what he said: “Although currently there is a lack of available research on the effects of marijuana on the bariatric surgery population, there are a few concerns to note. Regular marijuana use could increase the risk of postoperative complications including bleeding, infection and pulmonary embolism. Secondly, THC increases feelings of hunger, thus the degree of weight loss post-surgery may suffer due to continued marijuana use.” Dr. Simon Chow, Bariatric Surgeon, MD MSc FRCSC FACS In conclusion, we do not yet fully understand the effects of marijuana use after surgery with respect to weight loss and longer term weight maintenance outcomes. The field of research is still very young (3). Regular marijuana use however may pose medical risks after surgery, therefore speak with your surgeon if you have been prescribed marijuana for medical reasons. Furthermore, if you choose to use marijuana for recreational reasons on a regular basis, it is worth discussing this habit with your bariatric nurse and dietitian. – Monica & Lisa ******* Join our monthly newsletter to receive access to all our blogs and exclusive dietitian-approved tips to optimizing your weight loss and maintaining your weigh long-term! http://eepurl.com/c-qfcL ******* References: 1. http://onlinelibrary.wiley.com/doi/10.1002/hec.3267/full 2. http://www.sciencedirect.com/science/article/pii/S1550728915002063 3. https://www.ncbi.nlm.nih.gov/pubmed/24913244

Craving sushi? You likely will not be able to tolerate your favourite sushi rolls because of the rice and seaweed wrap, however there are several other equally satisfying options on every Asian-style restaurant menu to consider. Indulge in an order of tartar or sashimi. These rice-less options are easier to digest. Don’t be afraid to ask if your favourite sushi rolls can be made with a cucumber wrap instead of the traditional seaweed wrap. This is often a ‘low carb’ option on sushi menus. Order a side of edamame beans. These soybeans are not only a good source of protein, but they are also rich in fibre. Try a protein rich Asian soup. Asian-style restaurants often have a traditional soup with eggs, tofu, chicken, and/or shrimp. Prioritize the solid pieces and leave most of the broth behind. Salmon or tuna salad. Most sushi restaurants have a simple green salad with a seared piece of fish and a flavourful salad dressing. Sandwiches & Wraps· Choose a sandwich on toasted bread. If it is a large sandwich, remove the top piece of bread. Great options include: chicken salad, egg salad, tuna salad and deli meats. Wraps are also a good option. Opt for baked chicken rather than crispy chicken. Breakfast egg sandwiches Choose a breakfast wrap or a toasted english muffin sandwich. Skip the bacon and sausage. Salad Almost all restaurants now have a green salad with chicken. Again, opt for grilled chicken instead of crispy chicken. Other high protein options include: taco salads, chickpea salads and bean salads. Chili Whether you choose the vegetarian or meat version, chili packs a lot of protein. They are also very easy to digest making them the perfect option if you have recently transitioned to solid food. Here are some other helpful tips to challenge those old fast food habits: Skip the combo option… yes, even if it’s cheaper! Don’t order a drink. You will be less tempted to drink and eat at the same time if you don’t have a refreshing beverage staring you down during your meal. Eat in the restaurant instead of in the car. If you are driving and eating, food is more likely to block. You can’t be mindful if you are multitasking! Choose foods described as: grilled, baked, sautéed, broiled, steamed, boiled, etc. more often. These cooking methods are lower in calories. Many corner stores and gas stations now have ‘grab and go’ options in their fridges such as sandwiches, salads, protein shakes, yogurt parfaits, etc. Next time you get gas, make a mental note of 3 appropriate meal options you could choose if you were in a pinch. Bon appétit!- Lisa & Monica

Drinking liquid calories (although the stomach limits the volume of food that you eat, it doesn’t prevent you from being able to drink large amounts of calories), Not delaying your fluids from your solids (drinking and eating at the same time - only after surgery - appears to result in the rapid transit of the food you eat, in other words it “flushes” the food out of the stomach the same way flushing the toilet with water empties the bowl. This results in an empty stomach and a true physical hunger leading you to eat more. This is often confused with people thinking or feeling as if they have stretched their pouch), Grazing/Picking and nibbling (surgery operates on the stomach, not the mind, thus the reasons that may have lead some people to overeat before surgery may remain, such as emotional eating, stress eating, using food as a coping mechanism, etc. Some other reasons for weight regain that are less common but still possible include: An enlarged gastric pouch A fistula Intestinal adaptation New medications that may induce weight gain (i.e. anti-depressants, some forms of chemotherapy, etc) A poorly controlled thyroid (synthroid doses need to be adjusted after rapid weight loss). For further nutrition advice or to read our blog, visit our website and like our Facebook page for up-to-the-minute information: Bariatric Surgery Nutrition Bariatric Surgery Nutrition

‘It’ foods are typically foods that many parts of the world have been eating for centuries but are only now being marketed in North America and other first-world countries. They are advertised as ‘good-for-you’ products with the promise of making you healthier and happier than you have ever been! Their marketing claims make you feel like you’ve been missing out and that you NEED to include this ‘perfect’ food in your diet every single day! As dietitians, we are ALWAYS skeptical of these types of promises. Many of our patients this year have been loading up on hemp and chia seeds to supplement their protein intake. Patients brag about sprinkling them on their oats, yogurts, scrambled eggs and even ice cream! While these seeds do boast some great qualities, they have been misrepresented as being high in protein. Yes you heard us right… hemp and chia seeds are NOT considered to be a good protein supplement. Let us explain… If you are struggling to meet your protein needs, a good protein supplement should add at least 6-15 grams of protein to your meal or snack. Additionally, you ideally want this protein source to have the least amount of calories possible. A good way to compare how much protein you are getting for the calories is to calculate the food’sprotein to calorie ratio (protein : calorie). Let's look at the protein to calorie ratios of some common protein supplements: What is this chart telling us? * For every 1 gram of protein from chia seeds there are 29 calories. ** For every 1 gram of whey isolate protein powder there are 5 calories. This means that whey isolate protein powder can give you the same amount of protein for much less calories. More precisely, it can provide the same 6 grams of protein for 1/6th of the calories compared to chia seeds! So does this mean I should stop using hemp and chia seeds? The short answer is no! Hemp and chia seeds do have many positive benefits (see below), however they should not be used to supplement the missing 20 grams of protein in your diet. WHY? Adding 20 grams of protein using chia seeds would mean adding a whopping 585 calories! With hemp seeds this would mean adding 320 calories, which is still quite a bit! Comparatively, adding 20 grams of protein using whey isolate protein powder would only mean adding 100 calories. See the difference? How should I be using hemp and chia seeds then? For those of you looking to boost your protein intake, hemp and chia seeds should not be your only source of added protein. We recommend using them in combination with other lower calorie protein supplements such as protein powders. Adding ½ or 1 serving of seeds per day (see serving sizes in chart above) for example is very appropriate, as hemp and chia seeds contain many important nutrients that are often not talked about. Hemp and chia seeds are… Good vegan/vegetarian source of protein. High in fiber. Make sure you choose whole hemp seeds (i.e. not shelled ones like hemp hearts) if you are looking for the fiber boost. In the early stages postop, adding 1-2 tbsps of these seeds into your smoothies is a great way to help fight constipation. High in several important micronutrients. Hemp seeds are excellent sources of iron, zinc, magnesium, manganese, phosphorus and vitamin E, while chia seeds are high in calcium, magnesium, manganese, phosphorus, omega-3s and omega-6s. The bottom line: Healthy eating is not determined by one ‘superfood’ or seed. As always, the key is variety and moderation! - Lisa & Monica P.S. For those of you who are vegetarian or vegan, we recommend that you speak with your dietitian if you have questions about sources of protein.