Protein Issues

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Vitamin Issues

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Surgical and Mechanical Questions

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Thoughts

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Why do we use protein supplements?

(see testimonial on why Nancy supplements now)

Protein is initially broken down in the upper small intestine, just outside the lower stomach, using an enzyme manufactured there called trypsin. Once broken down, protein best is best absorbed in that first 12 to 18 inches out of the stomach. If the food doesn’t go by there any more, how will you break down and extract the protein from the tiny bit of food you can eat? While you can absorb some broken down (pre-digested) protein throughout the intestinal tract, the most absorption takes place right at the beginning, where ALL bypass and RNY patients are not going to get it.

Supplemented protein is already pre-digested for almost instant absorption. It’s liquid form makes it easier to get in, even into an irritated pouch, and the pre-digestion means you can count on absorbing at least most of it (unless you are very, very distal).

Each person needs a minimum of 60g of protein per day. It’s hard for any stapled stomach people to get it in their food, as the high protein foods are so dense, we simply can’t get enough IN to ever reach 60g. Also, since many foods must be combined with bread or grains to be complete, what happens if you can’t eat bread yet?

Protein is best absorbed in amounts of no more than 30g at one time. Professional athletes can do a little better, but for weight loss surgery patients, 30g would be a good try. More protein won’t hurt, but is just wasted. Unless you are very distal, two drinks of 30g each is an excellent start toward a healthy protein intake.

Protein is the main foundation of our health. If the supply becomes depleted, malnutrition will result. But before that, we’d experience deficiencies in many other vitamins or minerals that show themselves more vividly, such as calcium.

Another benefit to supplemented protein is that it satisfies cravings. While we are losing, the sugar cravings can drive us nuts. Part of it is sugar’s hold on us. Part of it is low protein, very common for any of us and part of it is lack of general nutrition. By being well nourished, don’t’ ever go into starvation mode. It keeps the body thinking everything is fine and it is relaxed about allowing us to lose. Let it go into starvation mode, and it retaliates by hoarding even more calories than before surgery.

The proteins we offer here are all considered “complete” and contain the full branch chain of amino acids, a smattering of vitamins & minerals and are lactose free, as well as very, very low in carbs, sugars, fats and calories. We also try to stick with smooth and tasty ones. The soys are rather gritty, so we can special order them, but do not stock them. The whey proteins are more flavorful, rarely chalky and never gritty. Most will shake up easily in 4 oz of water or sugar free juice or pop. If your surgeon forbids carbonation, flat pop will still give interesting flavors.

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What's the difference between all in one capsule and separate element vitamin and mineral form?

Those patients with a malabsorptive bariatric procedure lose seven elements due to malabsorption, besides protein. Vitamins A, B-12, D & E and the minerals Iron, Calcium & Zinc. The following comparison is based on Dry Form product rather than the more common Oil Soluble Form which is not recommended for people with malabsorptive procedures.

Comparison (based on minimum suggested for distal RNY)

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What should I ask a surgeon at the consultation?

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Why did/should I have Weight Loss Surgery?

Copied with permission, I thought it might help some fresh post-ops or about to be reaffirm their reasons for having this done. This patient belongs to Dr. Marcus' support group in the MD-DC area. Barbara and her sister sat down one day and devised this list to help her decide to go ahead with her surgery. It is so powerful that again that I want to share it. Please pass it on as you see fit.

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Making a Decision
By Barbara Cummings

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Why do we need calcium?

Since my diagnosis with osteoporosis in August, 2000, I am NOW, belatedly,trying to learn a little more about it. I drank milk til I was 45, and a lot of it. I have taken calcium carbonate faithfully since my surgery. I had kidney stones in 1997, too much carbonate. Did I learn? No, took citrate for 3 months, then right back to carbonate. It's cheaper. As I learn things through the Osteoporosis Foundation and through literature on the subject, I add the summaries here.

I've learned that we put calcium into our "bank" until early adulthood, then we start taking it out. Caffeine, carbonation and some meds hurry the process. Losing weight also helps this along. Normally we shed/regrow bones cells like other cells. However, with the ever lightening body weight, the bone cells think they don't need to regenerate, so they don't! AND we don't absorb calcium as well as we did when we were younger. And we don't absorb it without a stomach.

Tums are carbonate less and may or may not contain Vitamin D. Also, some acid is required for absorption of calcium. What do Tums do to acid?

I do not offer any products which do not contain calcium citrate. I had special calcium citrates capsules made for us. They are swallowable as is, or they can be opened and stirred into something. They are 240 pills for $15 (about $5/month) for 3 per day. Each cap contains 500mg calcium citrate, 200 IU D, 250 mg magnesium. We can only absorb 500 mg of calcium at one time, so they are made to be as much calcium per pill as we can manage. Citracal is the only brand name that I know is formulated correctly. It runs about $13/month and if the bottle is the one that says "2 tablets = 630mg", then you would need to take 5 per day.

I have recently developed another product for use by those who already have their diagnosis or who want to just be more careful. I'm calling them Super Calcium, but they have a really boring name on the label. EACH PILL contains the same as the above, 500mg calcium citrate, 250mg magnesium, 200IU of vitamin D PLUS 1 mg of boron and 33mg of ipriflavone 240 for $20

Along with using a good calcium citrate, my PCP's office recommended SIMPLE weight bearing exercise. Just heft a can of veggies in each hand. Now, even I can do that.

My osteoporosis is fairly advanced and I only got the DEXASCAN due to peer pressure. I'd never have known it if it hadn't been a constant topic of conversation. I had a foot scan which showed me to be so far superior that I'd NEVER have to worry. However, I was told that isn't a true reflection. Tragically, my peer group was right and now, for my little economy ride for 6 years, I will pay dearly. Instead of just taking the citrate, I'll also take Tri-boron to increase absorption, ipriflavone to decrease bone loss, as well as trying to take the prescription preparations.

So far, I am unable to tolerate the side effects of either one.

Don was also diagnosed recently. He has taken much larger doses of calcium, but that makes no difference since it was the wrong kind. He took both carbonate and oyster shell. Some brand names that are NOT citrate are Caltrate 600 & OScal.

I strongly recommend that anyone over 40 or post-op have this scan done ASAP. It's painless and not even expensive. You don't have to have all of these, just one or two is enough. Your justification for having it might include:

August 2001 dexascan shows no change whatsoever. In my case, without the ability to use the prescriptions available, that is GOOD news. That means that the mineral preparations have at least held the line.

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What’s the difference between distal, medial and proximal procedures?

Let's assume that we all start with 300" of (small) intestine. We don't, but we need to have a figure, so that's it. If you've seen pix you've seen of RNY/gastric bypass, you know there is a left side, right side and tail of the Y. The "junction" of the sides is the determiner if a procedure is proximal or distal.

The original intestine comes out of the old stomach and carries the digestive juices that are manufactured in the old stomach. This piece is called the bileo-pancreatic limb because it carries bile from the gallbladder and pancreatic juice from the pancreas. There is no food here. This is the LEFT side of the Y. This is the portion that is bypassed.

The alimentary limb connects to the pouch and only carries food, but cannot digest or absorb. This is the RIGHT side of the Y.

The tail of the Y is where both elements mix together and where digestion (if any) and whatever absorption will occur. This is the part that is still in use and is also referred to as the common channel.

If the junction of the Y occurs in near proximity to the stomach, it is said to be proximal. If the junction occurs at a far distance from the stomach, it is said to be distal. That said, neither word describes any actual measurements of anything, so the meaning is in the mind of the person speaking of the procedure. What is proximal to my doctor is considered distal by another.

Generally speaking, ALL RNY people will have to supplement at least the basic 8 elements, though in varying doses. We are all missing the stomach and its normal digestive function.

Truly distal (with a lot bypassed, and a short common channel) people need to supplement in larger volume, but will achieve and maintain the better weight loss over time. Proximal (less bypassed, longer common channel) people still need to supplement the basics and can reach a reasonable weight, but after 2 years may have to work a little harder to maintain their goal weight.

My doctor measures what is in use, not what is not. So, in my case, I have a 40" common channel, then 60" was used to reach the pouch. The bypassed portion is then ABOUT 200".

Most procedures performed are measured backwards from that. The doctor will bypass 12 to 72", use 60-80" for the right side of the Y, and the common channel will be 100-200".

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What is the Gastric Bypass/RNY surgery?

The gastric bypass (RNY) procedure is a combination of the old intestinal bypass and the VBG, taking the best features of both, but leaving the worst features behind. In a routine RNY, the pouch is stapled OR separated off from the balance of the stomach. From the lower stomach, the intestine continues down for a length, and this is the LEFT side of the “Y”. The digestive juices from the lower stomach, pancreas and gallbladder travel down this route. Normally, most of the absorption of food takes place in the first 12 to 18 inches here. The intestine is cut and the lower section is brought up to the pouch and attached. The food travels this route, down the RIGHT side of the “Y”. The digestive juices and the foods meet at the junction of the “Y” and the distance they travel together for digestion and absorption is called the common channel or common limb.

The proximal type procedure is the least radical. In this procedure, only a short amount of the LEFT side of the Y is bypassed, leaving the longest amount of common channel. The weight loss is the least of these procedures, but carries the least nutritional risk, if properly supplemented. The distal bypasses the most intestine, leaving the shortest common channel, which gives the best weight maintenance long term, but poses the most serious nutritional risks if supplements are not used properly. The medial is somewhere in between.

It is important to recognize that what Dr. A may call a distal, DR B may call a proximal. The terms in themselves do not designate any specific limb measurements. Some doctors will quote only a 5% difference in long term weight maintenance between a proximal and distal. However, that may be using THEIR measurements. Other doctors will quote as much as 50% difference in long term rates. But again, the definition is all in the meaning of the speaker.

It is helpful to know either how much you have bypassed OR how much common channel you have.

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How does RNY affect nutrition?

All RNY procedures will still affect nutrition to a degree. Digestion occurs in the stomach, then absorption in the intestine. So, all RNY will lose SOME amount of the same elements. The elements digested in the lower portion of the stomach include: protein, calcium, iron, zinc, B12 and the fat soluble vitamins, A, D and E. Some people experience shortages in magnesium and potassium, as well.

Proximals have a better chance of absorbing with their common channel. The food spends a longer time exposed to digestive agents. They can usually supplement with just a small dosage of the above mentioned elements and a multi-vitamin. Even 2 or 3 multi-vitamins alone may not cover these elements with enough of the most absorbable forms. Distals will be able to absorb very little of these elements, so much use larger doses of supplements. But just taking more multivitamins won’t work as some elements would then be too high.

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How many grams of protein supplement a day do we need?

This discussion goes on indefinitely. “Health nuts” maintain that 1g per pound of body weight is ideal. Of course, they’re not dealing with a body that may weigh 450 lbs today, either! Other figures that are tossed around are .8g of protein per kg of body wt. That’s .8g of protein per 2.2#. What does that mean? If you weighed 150 lbs, you’d need 55+g. BUT then other sources insist that we need 1.2 g per kg during rapid weight loss. So, for the same person of 150 lbs, the need would be 83g per day.

All that said, let me say that men lose their weight so fast that they often lose muscle at the same speed as fat. My personal bias is that a man shouldn’t consider taking less than 120g a during the rapid weight loss stage, even if he is very proximal.

In general, for women with a proximal, we suggest 60g of protein a day. When on a plateau, we suggest adding another 30g dose of protein, as well as another glass of water.

Any food proteins or bars are in addition to the counted supplements.

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Would we be okay in taking in more protein supplement than the required amount?

It would be difficult for ANY weight loss surgical patient to get TOO MUCH protein. In general, the more protein you get in, the better the weight loss, and the more muscle and hair retention. The skin tone and tautness also seems to be better with those who are generous with their protein supplement.

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How do I take my protein supplement?

We suggest taking it in 30g increments, roughly. It doesn’t do any good to take more at one time as it cannot be absorbed. Bearing in mind that these products are made for the sports nutrition industry, which is geared toward building and maintaining muscle, we listen to their guidelines as well. They do not use milk unless they are planning to GAIN. We do not use milk with them. Milk (even skim) is packed with sugar, so it will cause weight GAIN, which is what most of us don’t want. Also, using them with straight fruit juice may cause weight gain or dumping from the high sugar content. We suggest using them with water or sugar free pops (flat is good, too) or juices, such as Crystal Light or sugar free Tang. Although the directions may call for 12 to 16 oz of liquid, we recommend starting with 4 oz and adjusting to taste.

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When do we start protein supplements? Should we start before surgery? How long after surgery should we start consuming them?

The sooner the better! Pre-op, they will merely strengthen tissue and muscle and prepare you for healing. The latest we would suggest would be Day 7 after surgery. If your doctor would normally permit milky type products, start as soon as he would allow those.

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What is the best tasting protein powder you have found?

This is a toughie! I am a chocoholic! I like chocolate for my first choice, followed by an easy second of chocolate, with perhaps a different chocolate in positions 3-10, with a follow up in vanilla and grape! I personally use ProScore 100 chocolate as my favorite for home use. It’s thick ‘n rich and blends up beautifully with water & ice. For the time I spend in the car, I use the ProBlend 55 chocolate and vanilla, 50/50. I don’t know, it just tastes creamier to me that way. I have about 50 disposable plastic bottles (such as those in which diet pop is sold) pre-filled with 30g of my combo and carry some in each car. I can add cold water wherever I am, shake and go. I also use the ProBlend 55 vanilla with diet root beer and ice for a treat every now and then. I use others periodically, but these are my best friends.

But you really can’t make YOUR choice based on my taste. If it was up to me, there would BE no other flavors beyond chocolate! Some of the ones that are less pleasing to me are the absolutely height of ecstasy to someone else. I have tried many brands over the years which fit the nutritional profile we aspire to meet. But these are the ones that have proven to be the most popular. I continue to add to the stable as new products are found. There are some products that do not meet our criteria or are sold in packaging designed for the part time user rather than the daily user. These may be too expensive to use for life, so I have not carried them.

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When should we start vitamins and mineral supplementation?

We start on Post Op Day 7.

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What if vitamins seem to get stuck when we try to take them?

Vitamins can be swallowed or chewed. Many take their vitamins with protein, as it is seems to provide a “slide” for the vitamins to slip right through. Some prefer chewables and like the taste & texture and chewing experience. Others will cut their tablets in half or open capsules to take them. Most RNY patients can swallow normal pills.

What is available out there for those of us who can’t take a vitamin ‘pill’ because it seems to get stuck in our pouch?

All One Vitamin powder is a good place to start. Some have mixed it in with their protein, but others find it not very tasty. Even so, one would need to supplement with additional iron and calcium, as again, this is a multivitamin and not geared specifically to someone who doesn’t have the use of their stomach.

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What is available out there for those of us who can’t take a vitamin ‘pill’ because it seems to get stuck in our pouch?

Tablets SHOULD dissolve within 5 minutes in water. If they do, they will dissolve even faster in saliva. Capsules can be "open & dumped" into protein or sugar free drinks, like Tang or Crystal Light. I suggest testing the "empties" in your mouth to see how long they take to dissolve. Not water for these, but in saliva. Then, when you feel comfy doing so, you can swallow an empty or part of an empty to test that.

Also, protein supplement tends to act as a buffer in the pouch and sort of makes the pills slide down more easily. Many will take their vitamins this way and get both done at the same time.

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What is the purpose of the A, B, C, D, E , K vitamins as far as our bodies are concerned?

VERY briefly (as excerpted from Earl Mindell’s Vitamin Bible):

A is for eyes, respiratory strength, builds the immune system

B(many B’s, summarized) include growth, digestion, mental health,, hair, skin, nails, mouth sores, eye fatigue, assimilate protein & fat, skin & nervous disorders, anti-aging, muscle spasms & leg r\cramps, help prevent anemia, increase energy, memory & balance

C heals burns, gums, wounds; decrease cholesterol, boosts immune system, increases the absorption of iron, may reduce allergy suffering & prevents scurvy

D is for bones & teeth, helps assimilate calcium and A.

E is for hair, skin, nails, capillary walls, anti-aging, promotes endurance & alleviate fatigue, prevent leg cramps. For men, it contributes to urinary & prostate health as well as sexual function.

K is for blood clotting

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How do we know which minerals and vitamins (besides the multi) we need to take out of everything that is available out there?

The shortages are listed in any physiology book, under the digestive system. Look for which elements are digested in the lower stomach. Also, most RNY literature will list the expected shortages.

Protein
iron
calcium
fat soluble vitamins A, D & E
zinc
B12
maybe potassium & magnesium

BUT we must supplement in specific ways. Since A, D & E are fat solubles and we are now malabsorbing fats ‘n oils to a degree, it would do us no good to take these in soft-gel (oil filled) forms. They need to be taken in DRY form.

Iron is a very fussy element. We cannot absorb ferrous SULFATE and taking it will negate the absorption of any Vitamin E. It must be taken with Vitamin C, but cannot be taken with antibiotics; caffeine, milk; antacids of any kind, including medication for ulcer; any minerals, such as calcium. It is better taken on an empty stomach, but it can be taken with non-milk food. Think of iron and C as being on a honeymoon, alone but together.

Calcium must be taken with Vitamin D and is best absorbed at night. But only about 500 mg (elemental) can be absorbed at one time, so we suggest taking them over the course of the afternoon, perhaps an hour or two apart.

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What vitamin supplements should we be taking besides a good multivitamin?

iron (not ferrous sulfate)

Vitamin C
1500mg elemental calcium citrate
A (dry form)
D (dry form)
E (dry form)
zinc, 50mg chelated
B12 (sublingual)
Maybe potassium or magnesium, based on the first set of labs

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Why don't your lists of ingredients include the RDA?

The RDA is the RECOMMENDED daily allowance for a person with intact digestion AND the ability to get their basic nutrition from food. That does not apply to any WLS person.

Also, the RDA can change from week to week as new information is learned and published.

Certain are obtainable from food for us, so the supplement value is more accurate, but some are NOT reachable for us. For example, a multivitamin that contains 30IU of E might cover a normie who is able to absorb 100% of her fats & oils. But for RNY or DS or BPD patients, we lose much of our fat soluble vitamins, so 800 to 1600 IU of E would be more for us than the standard issue for a normie.

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