True or False? Bariatric Nutrition Myths

In November 2018, the American Society of Metabolic and Bariatric Surgery held its annual meeting at Obesity Week in Nashville. There were so many great presentations, and I want to share what I learned.   As a bariatric surgeon, I get these questions A LOT. It was a great opportunity to hear what the research and consensus is among my colleagues across the nation.

Myth 1:  Caffeine in a No-No after surgery, and it can increase dehydration.

The question of caffeine comes up quite frequently in my practice. There is actually not much research that supports the avoidance of caffeine after surgery. And, very little that supports the myth that it causes dehydration. While there are some diuretic properties to caffeine, most patients who ingest caffeine has developed a tolerance and a homeostasis with it. This means that if you have drinking a cup or two of coffee a day for years, then you have built up a tolerance and don’t have diuretic effects from the caffeine.

On the other hand, caffeine has been shown to be a colonic stimulator. For a lot of patients, their morning coffee or tea helps to keep them regular. For these patients, continuing caffeine AFTER surgery can potentially help with issues of constipation.

On the other hand, caffeine is a gastric stimulator and has been shown to exacerbate reflux/heartburn and acid secretion. This can aggravate an existing ulcer.

FINAL WORD: MYTH BUSTED!! Caffeine use does NOT support the dehydration myth. However, there may be some benefit to limiting caffeine while the stomach is healing. In my practice, I stop caffeine for the first two weeks after surgery. Once soft foods are started on week three, patients can resume caffeine. While this myth debunks the idea of dehydration, it does support my concerns for healing tissues and why patients should abstain in the early post-operative period.

Myth 2:   Carbonation should be avoided because it stretches the pouch.

I get the concern of a stretched pouch on an almost daily basis during clinic. There is limited research to support the clinical practice of avoiding carbonation. There is NO evidence that it stretches the pouch permanently. There is some anecdotal evidence that it can cause reflux, bloating, belching, and abdominal discomfort.

When counseling patients, I explain that carbonation can give them feelings of fullness quite quickly (because of their smaller stomach). For that reason, carbonation should be limited, because there is a greater risk of discomfort. Additionally, many carbonated beverages are high in sugar or calories. What I have found is that patients don’t stretch their pouches, but they certainly learn to “eat through” their pouches. If you sip on a high calorie drink all day, the size of your pouch doesn’t matter, you WILL GET ALL THE CALORIES IN! It doesn’t matter if it takes 4-5 hours to drink a 40-50 oz drink. If it’s loaded with calories, you will drink them all in. Patients often do not take into account the high calorie liquids that they are drinking. It’s not usually a milk shake, either. It is high calorie coffee drinks, sweet tea, fruit juices, alcohol, and even high calorie protein shakes (after they have added berries, yogurt, milk, etc).

FINAL WORD: MYTH BUSTED!!   Carbonation is okay in limited quantities, and patients should certainly avoid high calorie carbonated beverages.

Myth 3: Use of straws and chewing gum should be avoided

There is no evidence that gum can cause an obstruction or that straws should be avoided because of air inhalation. In fact, some patients report that using a straw can help them in the early post-operative period. In my practice, I don’t have an issue with patients using a straw. On the other hand, I do prohibit gum the same way that I limit certain dense foods during the six week post-operative diet. While the literature did not report obstruction from gum, I have personally had to endoscopically remove meats, bread, and pills from patients’ pouches. These patients are at a much higher risk for ulcer from the food that is lodged in the stomach and developing a subsequent stricture (or narrowing).

FINAL WORD: MIXED RESULTS: Straws are okay and may help patients take in their fluids. While there hasn’t been a study looking at obstruction from gum, I recommend that patients ABSTAIN from gum chewing. (The same way that I recommend no dense meats or breads during the post-operative period)

Myth 4: Patients always lose their hair

During my initial consult with patients, the question about hair loss always arises at some point. Research shows that hair thinning can occur within the first couple of months secondary to the sharp change in diet and calories. However, this is not typically a permanent issue. Hair loss can be related to deficiencies in iron, protein, and zinc. Bariatric patients must supplement their diet with extra protein. I recommend that bypass and sleeve patients take in 60-80 gms daily in protein supplement, and duodenal switch patients take in 100-120 gms daily. In my practice, patients complaining of hair thinning are typically non-compliant with their protein and/or iron supplementation. Often, they will take biotin but not their bariatric vitamins!   Biotin can make hair strong, but it won’t stimulate new hair growth. Hair growth will begin again once they begin to take their daily supplements. Patients experiencing hair loss/thinning should have their vitamin and protein levels checked to address any deficiencies.

FINAL WORD: TRUE…SOMEWHAT! Hair loss is not uncommon in the first couple of months. However, if hair loss continues, then patients need to have their vitamin levels checked to address deficiencies.

Exercise 101 – Part 1

By Dr. Charlotte Hodges

At the beginning of every year, thousands of Americans (myself included) make a list of resolutions. Eating right and exercise are usually in the top five. However, after the glow of New Year’s has worn off, the Christmas tree is put up and the kids are back in school, we always seem to fall back into the “old routine.” While we all know the benefits of exercise, sticking with an exercise program is much trickier. It is so very easy to say, “I don’t have the time” or “I don’t have the energy.” I say this ALL THE TIME. However, in November of 2018, I thought that I had a new diagnosis of rheumatoid arthritis (RA). As I researched the disease (yes, doctor’s do it too), I was surprised to see the detrimental effects this autoimmune disease had on your cardiovascular system. I knew that if I did in fact have RA, I was going to need to do everything I could to protect my heart. I knew with my schedule (and energy level), I would need to find the most efficient means to increase my activity. During this time, I attended Obesity Week sponsored by the American Society for Metabolic and Bariatric Surgery (ASMBS). At the conference, there was a lot of research being performed in the areas of fitness and weight maintenance / regain. I had a wonderful opportunity to speak with a researcher and her graduate student about the benefits of exercise. I knew that whatever could work for me would certainly work for my patients! A week after I returned from the conference and saw two different rheumatologists, I found out that I did not have RA. Rather, I had parvo! Yes, it occurs in dogs and humans! While my symptoms from parvo and my fears of cardiovascular disease have subsided, I did have a huge wake-up call about my need to incorporate exercise somehow into my daily life. So, for the next few posts, I want to speak to the types of exercise that give the most bang for your caloric buck and what the research shows.

How does exercise help?

Regular exercise has been shown to have health benefits in almost every body system, from your heart and lungs to lowering stress and improving depressed mood and symptoms of anxiety. If you are trying to lose weight, you need to focus first on your diet and caloric intake (this is the easiest way to a calorie deficit). However, you will lose a greater percentage of weight and have better long term weight loss by incorporating routine exercise. But, how much exercise do you need and what do you need to do? And, do you have to have a gym membership? What if your knees hurt or you have some other health issues keeping you from exercise? Over the next couple of posts, I want to address all of these.

How much do you need?

The American Heart Association has a wonderful website. They have basically broken the time you need down into 150 minutes a week of moderate intensity exercise (this includes walking, running, swimming, strength training). Go to https://www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-infographic for additional information. The Obesity Medicine Association not only reiterated the importance of at least 150 minutes to start, but for long term fitness increasing the time to 300 – 450 minutes/week is best. What they also reported is that if you break down the 150 minutes into separate sessions, as long as each session is at least 10 minutes, you can get the same benefit. For instance, you can walk briskly for 30 minutes at least 5 times a week or fifteen sessions at just 10 minutes each. You just need to keep the same intensity at each session. Now, a 10 minute session, that is totally doable!

I have found that counting steps can be incorporated into your 150 minutes of exercise. Tracking your steps is a way to ensure personal accountability. There are a plethora of fitness trackers on the market. You can get a Fitbit, pedometer, even most phones now have a built-in step tracker. Your ultimate goal is 10,000 steps a day. So, what’s more important, 30 minutes of exercise or 10,000 steps? The best is if you can incorporate both. Remember to bring your fitness tracker when you are working out (like on the treadmill, stairmaster, etc.). This will add to your daily step goal.

New Year’s Resolutions Tips

1. Make a resolution for improving your fitness in the new year. Aim for 150 minutes a week (this can include 10,000 steps a day).
2. On average, people take 3000 – 5000 steps a day. If you are just starting out, have a short term goal of adding an additional 1000 steps daily. Increase this goal every few weeks, until you are to your 10,000 step goal. If you have a bad back or knees, use a walker. My grandmother uses her shopping cart. This really helps her go further.
3. Track every step! Keep your fitness tracker on you! There are great apps, like Myfitness Pal, that can send rewards and invite friends to track with you.
4. Every step counts! To reach my goal of 10,000 steps, I take the stairs whenever I can and park further away in the parking lot.
5. On my work-out day, I don’t always get 10,000 steps. THIS IS FINE!! I’ve done my 30 minutes of activity. If it’s not a scheduled workout, then the goal is 10,000 steps. So, get to stepping!!

Exercise 101 – Part 2

I wanted to follow up on my article “Exercise 101.” In that article, I discussed the benefits of exercise and starting a walking program. However, research shows that conditioning and resistance training are the keys to greater weight loss and improvements in your metabolism. In Part 2 of my Exercise 101 series, I plan to delve deeper into the science and benefits behind resistance training.

Last November, I attended Obesity Week in Nashville. This is the annual conference held by the American Society for Metabolic and Bariatric Surgery. I had a wonderful opportunity to speak with a researcher, Dr. Maria Fernandez Del Valle, who is affiliated with Southern Illinois University Edwardsville. Her expertise is in exercise science, and she is specifically looking at the beneficial effects of resistance training. At the conference, she presented some preliminary findings comparing aerobic activity to resistance training on females. I was impressed with her results.

Dr. Del Valle was looking into the effects of high intensity resistance training (HIRT). To be honest, I had never heard of HIRT prior to meeting her. Like high intensity interval training, the work out sessions are based on circuits of high intensity followed by short periods of rest. However, in HIRT, you are focused on performing only a few exercises that involve more than one joint (i.e., performing a leg press, where you are bending at both the knee and the hip). With this training in mind, Dr. Del Valle compared two groups, one which performed HIRT and the other performed simple aerobic activities. Both groups’ activities were matched in intensity and in number of daily calories consumed. Both groups worked out three times a week for three weeks. In just this short amount of time, her pilot studies have shown that patients ** who performed HIRT had a reduction in their cardiac fat and visceral abdominal fat ** significantly in excess of those patients who performed simple aerobic exercises. (Visceral fat is the fat contained inside your abdomen around your organs as opposed to subcutaneous fat which is found between the skin and muscle). She also has found that weight loss seemed to occur first in the chest (thoracic cavity around the heart). Next, internal/visceral fat loss occurs in the upper region of the trunk and moves down in response to high intensity. Interestingly, she did not find any change in subcutaneous fat.

So, what made these findings pique my interest? For one, visceral abdominal fat is associated with high rates of:

  • Cardiovascular disease
  • Type 2 diabetes mellitus
  • Colorectal cancer
  • Sleep apnea
  • High blood pressure

While calorie restriction causes overall weight loss, I was excited to find an exercise regimen that could zero in on areas of body fat that pose the most risk to my patients. So often we hear that there is no such thing as exercises to “reduce fat in one area.” While HIRT might not solely target your saddlebags, the research does seem to show that you can target that hard-fought belly fat. Her research also supports what I find clinically. I often have patients that tell me that after surgery, they seem to “lose weight from the top down!”

My next question was “how do I do HIRT??” I have read articles online, read Dr. Del Valle’s research, and even had my first personal training session. Initially, I tried to do an online HIRT video…..to no avail. It’s hard! You really need to know what you’re doing!! (See my before and after video of my first session…)   I want to share with you the HIRT regimen that was used in research. I also want to share with you the information from my fantastic personal trainer, Anthony. I plan to focus on my personal experience in Part Three of this series.

What the internet says….

HIRT is based on performing exercises at high intensity with periods of rest.   In HIRT, you perform shorter reps with the goal of getting to near complete exhaustion (to momentary muscular failure). For example, when performing a leg press, you first select a weight and for 4 seconds you perform your first press. You will repeat this 8-12 times.   You need to focus on good form and control. If you get to your 12th rep and you feel like you can do more, then you probably needed a higher weight in the beginning.

  • Use a rep duration that best represents good form in each exercise
  • If you are moving too quickly (and form shows signs of degradation), SLOW DOWN
  • If you are moving too slowly and movement becomes a series of segmented stops and starts, then SPEED UP
  • You can start with only one HIRT session a week and work up to two sessions

What the research showed……

In the study listed above, participants in the HIRT group performed the following regimen three times a week which lasted 50 minutes. The workout started with 5 minutes of warm up (full body) – this can be moderate speed on a tread mill or elliptical machine, followed by a conditioning circuit of seven exercises. Participants performed 3 sets of 10 repetitions at a moderate rate. They would rest 30 secs between each exercise and then 2 minutes between each set.

Warm up (moderate speed) 5 minutes
Leg press 10 reps at moderate pace and good form, then rest 30 secs
Row 10 reps at moderate pace and good form, then rest 30 secs
Back Squat 10 reps at moderate pace and good form, then rest 30 secs
Weighted Crunches 10 reps at moderate pace and good form, then rest 30 secs
Deadlift 10 reps at moderate pace and good form, then rest 30 secs
Bench Press 10 reps at moderate pace and good form, then rest 30 secs
Squat jumps with weights 10 reps at moderate pace and good form, then rest 2 minutes
Repeat above set two more times

 

References

  1. Fernandez-del-Valle, Maria, et al. (2018). Effects of resistance training on MRI-driven pericardial fat volume and arterial stiffness in women with obesity: a randomized pilot study. European Journal of Applied Physiology.
  2. www.hituni.com

Exercise 101 – Part 3

In the last two posts, I discussed aerobic exercise and resistance training, specifically high intensity interval training (HIRT). What I wanted to focus on in the last of this series is my personal journey into HIRT and having a personal trainer. There are a couple of key points that I want to make.

Most of my patients are going to be at a beginner level for training. THAT’S OK!       You have to start somewhere.       I’ve always been surprised when I hear a physician tell their patients, “you just need to exercise.”       If you are carrying 40lbs, 60 lbs, or over 100 lbs of excess weight, any exercise will be difficult.       For example, when you go to the grocery store, and you are carrying 3-4 plastic bags of groceries, it’s probably anywhere from 15 – 25 lbs. Now image, you are carrying 16 – 20 bags of groceries 24 hours a day, 7 days a week. I can tell you that if I was carrying just 2 bags of groceries, I would find any workout much more difficult. Now, multiply that number of grocery bags by 10. That is the reality of obesity. It changes your perception, doesn’t it?

You have to start somewhere, so your journey starts with a single step! For anyone embarking on a new change, it can be scary, especially if you are beginning your weight loss journey. Even more so, if you have tried before in the past and failed. You need to know that YOU ARE WORTH IT!! After undergoing IVF (multiple cycles) and finally a pregnancy, I gained 35 lbs.       It has taken me three years to finally lose that weight….and I’m a weight loss surgeon. We all have our own stories and our own struggles.       The key is to find a way to climb your own personal mountain. I tell my patients all the time, if you fall off the horse, get back on!       Even if you have bruises…..get back on that horse.

If you have the chance to go to a local gym, YMCA, or better yet personal trainer, I encourage you to do so. Look to see if there is a Groupon or online coupon for a session.       Any insight you can get from a professional will help, especially when it comes to form when performing exercises. One patient gave me an invaluable tip. I have Amazon Prime and can find free videos for prime members.       I enjoy Pilates, so I have downloaded several free videos. I’m sure there are other subscription services or even online videos (YouTube) that have free sessions from trainers that can show you different workouts. I have even found how to do a proper squat on Pinterest….you know you’re on your phone (I’m sure you’re reading this blog on your phone)….just look it up!

When I met my personal trainer, I told him that I was interested in HIRT. He explained that everyone is going to be at a different fitness level. In our first session, he really just wanted to see my form and endurance with each exercise. Additionally, he also took the time to see what the proper weight was for me to get to 70-80% fatigue of my muscle at the end of each set. I used to run and have worked out in the distant past with a trainer. I also have years of doing Buns of Steele 3 with Tamilee Webb (best butt exercises ever!). Very 1980’s….but she really shows you great form)!

I just completed my second session with my personal trainer. During that time, I would do 2 sets of three exercises. The exercises were performed at a moderate to slow pace and very controlled.   In a set, the first two exercises would be focused on several muscle groups (like upper or lower body) and each exercise would have 12-15 reps.   The third exercise would be full body and would last 30 seconds. The idea of the third was to get my heart rate up. (Even though it was beating through my chest during the two first exercises). I was to perform the third exercise quickly with good form, as its purpose was to get my heart rate up. It did.

I would then repeat that set again. I had a total of 4-5 different sets (it was a bit of a blur). We ended on 3 minutes of the row machine. He then told me that two more times this week, he had homework for me to do. It is as follows:

Warm up 5 minutes at a moderate pace
25 secs of 85% max (treadmill) run it out! Then, slow down for 1 minute, repeat this 5 times
REST FOR 2 MINUTES
25 push ups (modified are ok!)
25 crunches
25 rows
25 squats
25 walking lunges Then, rest 2 minutes
Repeat entire set starting with treadmill 2 more times, with no warm up

My goal is to get my last couple of pounds off. I am aiming to make an effort to get in 150 minutes a week and to make an effort to eat better. While I only walked as my homework last week, I have a new goal to do my homework at least one time before I meet with him again! You have to start somewhere, right?!