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Category: protein

Calcium Lab Results

June 05, 2018 3:26 pm

Calcium is measured to evaluate function and adequacy of a physiologic processes. Calcium plays a critical role in several body functions such as, coagulation pathways, bone health, nerve conduction, and other functions. It is important whenever you are evaluating laboratory results that you look at the whole picture of the person, including medications, other laboratory studies and health history.  One value is not a stand alone result.  There are many factors that effect calcium results.

Factors that effect calcium results: (not an all inclusive list)

pH

Albumin

Lactate

Heparin

Vitamin D deficiency

Magnesium depletion

Anticonvulsants

Renal Disease

Pancreatitis

Parathyroid

Thyroid

The two most common issues following Weight loss Surgery  or Duodenal Switch may be albumin level and Vitamin D level.  Please see past blogs on Vitamin D. Magnesium may also play a role in a Duodenal Switch patient.

The most common calcium result drawn is the total calcium level. Laboratory results may not explicitly label it as such, however, it measures the calcium that is bound to protein. Ionized calcium is the free calcium that is representative of the true total calcium. Ionized Calcium can be measured by ordering specific lab. Alternatively, the Ionized calcium can be calculated by the following formula: Corrected calcium mg/dL = (0.8 * (Normal Albumin – Pt’s Albumin)) + Serum Ca  ) or use the calculator at the bottom of this post.

 

The low Albumin level accounts for the low calcium level. This may be the reason for a patient with a low albumin/protein level, also having their calcium level reported as low. However, when adjusted for the protein deficiency the corrected calcium comes into normal range. Video of Trouseau’s sign of a patient with calcium deficiency. Calcium bound to albumin Keshishian

The first step in a patient who has low calcium reported, is to make sure their protein and albumin levels are normal, along with Vitamin D.

Calcium levels are managed by two processes major regularly hormones and  influencing hormones. Controlling or major regulatory hormones include PTH, calcitonin, and vitamin D. In the kidney, vitamin D and PTH stimulate the activity of the epithelial calcium channel and the calcium-binding protein (ie, calbindin) to increase calcium absorption. Influencing hormones include thyroid hormones, growth hormone, and adrenal and gonadal steroids.

Further information on protein.

Further information on calcium. 

Videos/Webinars on several of the above topics.

calcium metabolism
Duodenal Calcium Metabolism

Corrected calcium = 0.8 * (4.0 – serum albumin) + serum calcium

Corrected Calcium Level Calculator

2018 Back on Track

January 28, 2018 11:38 am

back on track 2018 keshishian
2018 Keshishian BOT

Join our 2018 Back on Track challenge and let’s get back on track for 2018! The holidays were wonderful but if you find yourself with a few extra souvenirs don’t feel alone. The average American gains between 1-8 pounds during the holiday season and I am no exception. Let’s get back on track 2018 together.

Time to clear out the kitchen! Disposing of temptations and high trigger foods is the first step to getting back on track. Throw it all away and don’t allow them back in. If foods are difficult to acquired then they are less likely to be consumed.

Stock up on high protein and whole, unprocessed foods that are low carbohydrate and nutrient dense. When quality foods are easily available we are more likely to stay on track with the types of foods we should be eating. Simple sugars/carbohydrates are the biggest culprit of holiday weight gain. We need to go back to the basics of hydration, high protein, low carbohydrate/sugar, vitamin/mineral supplements and exercise. Simple sugars and carbohydrates are easy for our bodies to use and absorb. Cutting them out can jump start your weight loss. Each individual needs to identify the daily carbohydrate intake that works for them. Some people stay under 50 grams of carbohydrates daily and some can tolerate more daily grams. You may also need to look at your protein and fat intake. All excess nutrients absorbed have the potential to turn into fat mass and inhibit weight loss. Metabolism video.

Hydration is an important ways to start getting back on track. Water is essential to life functions. The brain is 85% water, blood is 80% and muscle is about 70% water. Hydration aids in digestion, eliminating waste, byproducts and toxins. It also can decrease the feeling of hunger. Lack of hydration can increase fatigue which can lead to craving high carbohydrate foods to increase energy.

Protein’s importance in almost every bodily function and muscle mass can not be ignored. High quality complete Protein sustains muscle mass during weight loss, aids immunity, antioxidant function, and enhances leptin and insulin function. Filling up on protein first will help with carbohydrate carvings and give a sustained satisfied feeling. A prior blog post gives additional information on the importance of protein and the effects of protein malnutrition. WLS makes daily protein intake important but especially after Duodenal Switch, protein is a necessity of daily life.

Vitamins, minerals and supplements will ensure the body has the nutrients it needs to function adequately and can keep cravings at bay. Deficiencies in vitamins and minerals can cause cravings for foods. Vitamin and minerals are essential to muscle function, red blood cell production, bone health, and numerous other physiologic functions. We may all slack off on our supplements occasionally but now is the time to get back into the habit of daily vitamins and mineral supplements. A daily vitamin, mineral, and supplement routine is a lifetime commitment after Duodenal Switch or any WLS. Here is a list of commonly used supplements. If you haven’t kept up with your minimum yearly laboratory studies, now is the time to be seen and have your labs done.

Exercise can increase weight loss, overall well being, mental well being, mood, alertness, improve digestion, improve sleep, and increases energy levels. Exercise does not have to be a daunting task. Simply adding 15-30 minutes of activity can give added benefits. Yoga, walking, dancing, lifting weights, hiking, and sports activities can be included or added to more traditional forms of exercise. There are many free online videos for all types of exercise available. This year we are teamed up with The Kinesis Centre to offer a 4 week training program that can be accessed from anywhere. A 4 week training program will be included in our 2018 Back On Track Grand prize.

Finding a new hobby can keep both your hands and mind busy, curbing the unconscious eating of foods that are high in sugar and carbohydrates. Adult coloring books, drawing, painting, knitting, crocheting, sewing, dance lessons, gardening, learning to play an instrument and many others are great ways to use your time and expand your quality of life and brain function. New hobbies can also help establish new coping skills. Our previous post on Coping Skills After Bariatric Surgery can be found here. There are a whole host of online videos for “how to” on new hobbies.

Teaming up with others can also help increase weight loss and compliance. Support from friends, family and other groups will assist you. There is a whole gamut of support group online and in person. If you have fallen out of the habit of attending our support group or webinars get back to them. You can find our schedule and announcements regarding webinars here. Our Central Valley Bariatric Facebook page also gives daily inspirational messages, protein recipes and articles and any new information or research available. There is also our Duodenal Switch Facebook Group. Anything that increases accountability is a benefit and motivates us to stay on track.

Experiment with new recipes and flavors that are bariatric friendly and within your dietary needs. There are so many options for quick and easy meals that are whole foods, high protein, and low carbohydrate. We have several recipes on our page for all stages following weight loss surgery and Duodenal Switch. However, there are endless option on the internet in Paleo, low carb, and high protein type recipes.

In the spirit of new starts and getting back on track 2018, we are having a giveaway with the basics to get back into the swing of things. This year we are looking for before and after weight loss surgical journeys for our Grand Prize. Share your weight loss journey! Don’t be shy, your journey can inspire others and/or motivate yourself. To enter the Back on Track 2018 Giveaway, please submit your weight loss surgical journey with before and after pictures to contact@dssurgery.com or you can also post your before and after pictures on our Facebook page. You will also need to sign a release for the use of your story on our website. We will draw 2 names from those that enter by announcing it on our FaceBook page or by e-mail on February 14, 2018. You must submit your mailing information to contact@dssurgery.com in order to claim the prize. You must be a verifiable patient of Dr. Ara Keshishian.

We are also doing 3 prizes of a 4 week training with the Kinesis Centre if you share an achievement picture on our FaceBook page . This achievement picture can be a milestone in your journey, something you’ve haven’t done before, a non-scale victory, a goal that you reached, anything that you are proud of achieving. Let’s do this 2018 Back on Track challenge!

Please remember that medications, health status, age, bowel motility, genetics, and diet all play a role in weight and weight maintenance. Please have a physician review your health history and medications.

*NOTE: Giveaway items may or may not be identical to the pictured items.
We are not affiliated with any of the products nor do we endorse any one type of product. There is no cash value to the prizes.

Fat, Protein – Post Duodenal Switch Diet

May 23, 2016 6:43 am

Fat and Protein after weight loss surgery…. This is a subject that seems to come up all the time.

What I recommend is “…Water, protein, vitamins, supplements and every thing else….”

Dehydration can cause a lot of problems, stay hydrated.

Weight Loss Surgery (WLS) is a surgically imposed catabolic state (surgical induced starvation).  The weight is lost by not allowing enough caloric intake/absorption and forcing the body rely on stored sources of energy, mostly fat mass.  The rationale for the high protein intake is to minimize net muscle mass loss during the catabolic state.   Low carbs and low fat further push the body into catabolizing the fat mass, and reducing the net loss of protein content. As the fat mass is broken down it will release hormones and other byproducts that the body will eliminate. Hydration is crucial to every bodily function and even more so in the weight loss phase to allow for elimination of some of these byproducts.

The mechanism by which Duodenal Switch works during the weight loss phase is by limiting the caloric intake.  Long term  Duodenal Switch keeps the weight off due to the malabsorptive component as the caloric intake increases. Protein intake, Vitamin/Mineral supplementation and diligence in surveillance of vitamin/mineral levels is imperative and a life long commitment after WLS.

There are a number of different types of  Fatty Acids.  Our bodies naturally produce, from other components,  all but 2 essential fatty acids: Omega 3 and Omega 6.  Most fatty acids require bile salts to be absorbed within the small intestines.  Those are the fatty acids that are absorbed to a lesser degree after Duodenal Switch.  Medium chained fatty acids do not require bile salts and can be absorbed into the blood stream from the small intestines. Medium chained fatty acids are used for energy as they are processed in the liver. Medium chained fatty acids are actually given to patients with Short Bowel Syndrome to decrease fatty stool and increase their body weight.  This is also a possible reason some fats cause DS patients more loose stools and others do not (medium chained fatty acids). Adding fats is a purely individualized process.  Each person has a different length of small bowel, alimentary limb, common channel, percentage of excess weight to lose and metabolism. Patient’s tolerance for fat in regards to vitamin/mineral levels, stool consistency and frequency is completely individualized.

Fats and Fatty acids can be divided according to their structure in groups:

A) Saturated  Fat (animal fats, butter, lard- solid in room temperature)

B) Unsaturated Fat (liquid in room temperature)

           1-PolyUnsaturated Fats
                    a)Omega 3-fattty acids (fish, shellfish, soybean, walnut, flaxseed)
                    b)Omega 6-fatty acids (corn oil, sunflower oil)
            2-Monounsaturated fats
                    a)Omega 9-fatty acids (olive oil, avocados, peanuts, almond

The main focus in the weight loss phase should be hydration, hydration, hydration, protein, low carb, low fat and vitamin/mineral supplementation (page 22).  Rest is key in the early post op phase but gradually adding exercise is also important in ensuring the body does not breakdown muscle mass.  Adequate intake of protein and use of muscles diminishes the bodies natural response of breaking down muscle mass in a low caloric intake state.

Post Surgical Needs for the first 90 days in order of importance:
This is to allow healing to take place before adding additional stress on the body and surgical sites.
Minimum of 64 ounces of fluids daily
Minimum 80-100 grams of protein daily (protein requirements are based on ideal body weight)
30 gms by 30 days post-op
60 gms by 60 days post-op
90 gms by 90 days post-op
Vitamin/Mineral Supplements
Low carb
Low fat
Rest (early Post-op)
Exercise

Proteins are important, not only for structure (muscle) but for functions. We know that proteins and amino acids are involved in all aspects of our body’s function. This is even more critical during the rapid weight loss phase. Protein needs may increase and change based on health status, pregnancy, surgeries, healing, etc.

When it comes to fat, I do not recommend patients consuming excessive amounts of fat- At the same time I do not recommend patients go on a low fat diet.  There is this misconception that since DS is causing fat and fat soluble vitamin malabsorption, then taking more fat (in excessive amounts) can solve the problem of vitamin deficiency. How about the possibility that some patients are causing their own vitamin deficiency by taking large volumes of fat which may results in more frequent bowel movements and decreased vitamin absorption.

It is not to be forgotten that each patient will respond differently with dietary changes after duodenal switch. Some patients may tolerate more and some less fat in their diet.  After the initial 90 day post op phase I recommend that patients go slowly in adding new food items by giving it several days before adding another food item. i.e.; add carrots for 3-5 days to see how your body handles it before attempting to add another new item.  The above is not the entire weight loss process or education and is only a small portion of the education needed before undergoing any WLS procedure. These recommendation are my recommendations for my patients with the Hess technique for Duodenal Switch.

Optimizing Pre-operative Health Status

November 12, 2014 1:23 pm

The outcome of any weight loss surgery is dependent not only on the operation but also the extend and depth of preparation before surgery and adherence to the post operative recommendation. The operation should be considered a planned injury to the body. We should enter the operating room in the best physical and mental condition possible to secure the best possible outcome. Optimizing your Pre-operative health status is the best plan for going into surgery in the best shape possible. Here are some basic steps to maximize the odds for a good outcome. Physical preparation:
  • Maintaining a healthy diet
  • Cessation of ALL tobacco and alcohol use
  • Do not use NSAIDS prior to surgery or after surgery until cleared by surgeon
  • Getting plenty of rest
  • Staying Hydrated
  • Pulmonary embolus prevention exercises such as ankle circles and point and flex toes
  • Maintaining or starting a regular activity level. Any amount of increase in activity will benefit you after surgery. Walking, squats, lifting weights with arms
  • Full laboratory blood studies and vitamin levels as ordered by the surgeon
  • Start and optimize your vitamins, calcium and other mineral and supplements. Vitamin D deficiency increases surgical complications. (Another Vitamin D article)
  • Manage preexisting health conditions (diabetes, sleep apnea, high blood pressure etc..) Follow instruction in regards to what medication to stop or continue before surgery i.e. Aspirin, blood thinners, medications that interfere/interact with anesthesia, etc.
  • Two forms of Birth Control if indicated.

Mental preparation:

  • Have a clear understanding of the procedure
  • Study all information provided to you regarding your surgery
  • Remember that surgery is one of many tools to assist in weight loss and improved health. It does not fix other issues.
  • Realistic expectation of the outcome of surgery
  • The role of family involvement for support
  • Be prepared with all the purchases for the post operative diet, vitamin and mineral supplements.
  • There is also a number of other variables that will improve the long term outcome of the weight loss surgery:
  • Investigate Protein Supplements for the highest bioavailability
  • Try and eat whole, unprocessed foods
  • Read labels on all food items
  • Look for high protein recipes
  • Network with supportive people who will provide a positive influence
  • Long term success also depends on:
  • Maintain daily protein requirements
  • Maintain daily vitamins, calcium, minerals and other supplements
  • Routine follow up with your bariatric surgeon.
  • Routine laboratory studies to surveil vitamin and mineral levels.
  • Get your medical advice from your surgeon.
  • Get suggestions from other patients. Do not confuse this with medical advice.
Weight loss surgical procedures are not an easy way out. On the contrary, weight loss surgical procedures are complex operations, from technical, metabolic, nutritional and psychologic perspective. A patient has to be prepared to deal with all aspect of the surgery for the best possible longterm outcome.

Protein Malnutrition Protein Part 2

July 31, 2014 1:25 pm

Protein energy malnutrition (PEM) or Protein Malnutrition is a problem that can effect a few after weight loss surgery (WLS) and Duodenal Switch (DS). In our previous blog post on protein  we discussed  the types of essential and non-essential Amino Acids and  possible sources. We also discussed  how to choose the best bioavailable protein and to vary protein sources to achieve adequate protein levels.  There are cases even with adequate protein intake that can result in PEM due to inadequate protein absorption. The early signs of low protein may be low energy, muscle weakness, moodiness, inability to sleep well, joint pain, changes in hair and nails and carb craving. It is imperative after WLS that you maintain your protein levels throughout your lifetime. The minimum protein intake is 80-100 grams per day after WLS.  There is no leeway where protein is concerned.  It is important in almost ever function in the body.

There are two types of protein energy malnutrition,  Kwashiorkor and Marasmus:

Kwashiorkor is a lack of protein intake with adequate or slightly lower caloric intake.  It’s symptoms are edema (swelling in legs, ankles, feet) enlarged abdomen, irritability, anorexia, hair discoloration and loss, muscle weakness, changes in psychomotor function, mental lethargy, ulcerations, brittle nails, rash or discoloration of the skin, bradycardia (slow heart rate), non-tender parotid enlargement, enlarged liver with fatty infiltrates that are similar to alcohol liver disease.  The edema is caused by osmotic imbalance in the intestinal system causing swelling of the gut.  Protein, primarily albumin is responsible for the colloidal pressure within the circulatory and tissue systems.  The lack of protein within the circulatory systems cause fluids to “leak” into tissues causing edema. Gastro-intestinal symptoms can include nausea, vomiting, dehydration, diarrhea and increases in appetite.  People who have pathological bacteria or parasites and/or after WLS diarrhea can precipitate lower levels of protein. If left untreated can lead to protein malnutrition.

Marasmus is characterized by a lack of protein and caloric intake.  The symptoms are an emaciated appearance with edema. There is no liver changes as in Kwashiorkor.  This is a starvation mode and can be difficult to treat and can progress to a point of no return.

Catabolysis is the bodies response to lack of protein and or nutrition.  This biologic process breaks down muscle and fat to maintain bodily functions. Catabolysis is the body’s last resort to keep it alive.  It is a starving body eating itself to keep vital organs alive.

Laboratory Studies are needed to determine the level of malnutrition and treatment routes.  These studies include:

Protein is an extremely important nutrient within our bodies and is considered the workhorse in cells and organs.  They are responsible for catalysts, messenger duties, structural, immunoprotectors, transporters, buffers, fluid balancers and many other roles. Protein has a hand in synthesizing other proteins, regulates protein turnover, enzyme activity, neurotransmission, gene transcription, transport of other nutrients, messenger and signals for growth hormone and insulin, structure, storage for other nutrients and immunity.

The muscular system is the most obvious structural protein in our bodies, 40% of the total body protein, as is hair, fingernails and cells. Our organs also require protein in order to function appropriately. However, protein’s role in red blood cell formation, size and health is extremely important.  If you don’t have adequate protein levels your body can not make red blood cells. Transferrin is a protein that carries iron to receptors.  Ferritin is an intercellular protein that stores iron until it is needed. Glycine is a protein for heme synthesis. B12 is also transported via a protein for red blood cell production. Protein is also important in blood clotting and plasma.

Cardiovascular health is also reliant on protein for structure and function. Also, proteins can have a protective effect at the mitochondrial level.

Kidney function relies on protein to regulate the acid base balance and ammonia disposal. The kidneys are also the site of amino acid production.

Protein is also important in bone health as a carrier for Vitamin K and calcium binding, tissue repair, healing and growth. Proteoglycans play a role in extracellular structures such as skin, bone, and cartilage. Also related to the skeletal system are glycoproteins, which also aid in building connective tissue, collagen, elastin and bone matrix.

Central Nervous system relies on proteins for neurotransmission, hormone production and other functions.  Protein deficients can lead to neurologic problems such as altered behavior and mental function among other manifestations. The neuorpeptides have actions on transmission functions, mood and behavior. They can also effect a wide range of functions such as blood pressure, body temperature, pain sensation, and learning ability.

Immonoproteins are the group of proteins that provide immune protection such as immunoglobulins and antibodies.

Protein also have storage roles for copper, iron and zinc called metalloproteins. Copper and zinc are considered neurotransmitters, important for iron metabolism, and connective tissue formation in heart, blood vessels and skeletal.

There are situation where your protein needs will increase. In cases of wounds, burns, surgery, stress, sepsis or other illnesses, protein requirements increase. Also age, pregnancy, lactating and increased exercise increases protein needs.

Protein Energy Malnutrition is protein deficit that can and should be avoided after WLS.  PEM, if left untreated, can lead to organ failure and death. Protein is crucial in almost every function of the body and without adequate levels there will be symptoms and side effects. Please take care to maintain your protein levels throughout your life.  We have discussed several of protein’s function, however, there are many more.

Protein Metabolism Optimization

June 09, 2014 5:08 pm

It’s confusing out there in the world of protein supplements and nutrition.  Hopefully we can clear up some of the information with this blog post. Part I will be about protein utilization and supplementation and Part II will be about Protein Energy Malnutrition (PEM). So let’s get started with the basics of protein utilization and metabolism. This will clarify what our goals are and what we need to achieve them.

Protein_-_Primary_Structure

 Protein Metabolism:

There are 23 Amino Acids (AA) that combine to form peptide chains.  These peptide chains link together to make polypeptides, which are the building blocks of many proteins sources. These types of proteins are called proteinogenic.

Essential vs Non-essential:

Nine of these proteinogenic AA’s are essential meaning that the human body cannot make them.  They must be taken in by food sources.  The other AA’s are considered non-essential because  the body can produce these without an outside food sources.

Complete Protein vs Incomplete Protein:

A complete protein contains all of the essential amino acids and an incomplete protein does not have all nine of the essential amino acids.

Essential Amino Acids
Non-essential Amino Acids
Leucine
Alanine
Isoleucine
Arginine
Valine
Asparagine
Histidine
Aspartic Acid
Lysine
Cysteine
Methionine
Glutamic acid
Phenylalanine
Glycine
Threonine
Ornithine
Tryptophan
Proline
Selenocysteine
Serine
Tyrosine
Threonine
Glutamine

Protein ImageBranched Chain Amino Acids (BCAA’s) are an incredibly important subgroup of the essential Amino Acids.  Three of the nine essential AA’s are BCAA’s.  They are leucine, isoleucine and valine.  These three AA’s make up 40% of the protein required by humans. Muscle protein is made up of 35% of these three BCAA’s. Any protein supplement after weight loss surgery should contain these three amino acids, Isoleucine, Leucine and Valine.

Protein breakdown begins in the stomach with the addition of enzymes and acid then continues into the small bowel where absorption takes place.  Protein must be broken down by these enzymes and acid to single Amino Acids or peptide chains no longer the 4 AA’s in order for the intestinal absorptive cells to absorb the protein. The 4 chain peptide chains are further broken down within the intestinal absorptive cells.

Protein absorption takes place easily but the most important factor is protein utilization.  Protein utilization is how much of the protein ingested is actually utilized by the body.  The body may absorb a great deal of a protein food source but can only utilize about 30-40g of a high quality protein source at a time.  The body does not store protein as it does with other nutrients.  Therefore, whatever the body doesn’t utilize is metabolize through the liver and converted to urea.  Urea is excreted through the kidneys via urine.

Different proteins absorb at different rates, amounts and in different parts of the small bowel. i.e. Milk protein is 50% absorbed in the proximal small bowel, with 90% of the absorption taking place by the time it reaches the ileum. 1 It’s important to understand this because of the rearranging of the small bowel in the Duodenal Switch.  Protein is no longer being exposed to the mucosa of the proximal small bowel due to the altered anatomy of the duodenal switch. This altered anatomy results in much lower absorption of protein, thus the increase levels of protein one needs to consume after WLS.  Post WLS the body will compensate and increase protein absorption in the other areas of the small bowel. This may also explain why some weight is regained several years after WLS. 2

Reduced protein absorption is why Bioavailability or Biological Value (BV) is so important when deciding on a protein source. Biological Value is the measure of how efficiently the body utilizes the protein from the food source.  You will find this BV number on some protein supplemental products.  The higher the BV numbers the better utilization of the protein source by the body. Whey protein and egg protein are considered the highest BV. The daily requirements of protein are 0.80 gram of protein per kilogram of ideal body weight calculating to approximately 50-65 grams a day. 3  However, after weight loss surgery (WLS) a person should get 80-100 grams per day, 1 gram per kilogram of weight and in some cases even higher amounts of protein.

Protein Type
Protein Biological Value
Net Utilization
Efficiency Ratio
Beef
80
73
2.9
Whey Protein
104
92
3.2
Soy Protein
74
61
2.2
Egg
100
94
3.9
Black Beans
0
0
Milk
91
82
2.5
Casein
77
76
2.5
Poultry
80
Fish
70-80
Brown Rice Concentrate
70-80
76

Adapted from: U.S Dairy Export Council, Reference Manual for U.S. Whey Products 2nd Edition, 1999 and Sarwar, 1997

 Protein Supplements: First clarify the terminology in supplements.

Isolate: Is chemically purified to 90% pure protein.  100g scoop=90g protein intake.  Isolates have a High BV rate.

Concentrate: 35-80% protein 100g scoop=35-80g protein intake Also contains fat, carbohydrates and in the case of Whey Concentrate, lactose. Concentrates  have a high BV rate.

Blends:  Combination of protein sources and purity levels.  Varies in how many grams of protein are available in each product. They are lower in cost and quality in some cases. Blends have a medium/high BV rate.

Hydrolysate: enzymatically predigested for maximal speed of absorption and utilization. Very water-soluble but can have a bitter taste.  Hydrolysates are high in cost and BV rate.

Branched Chain Amino Acids: contains the 3 essential AA Leucine, Isoleucine, and Valine that make up 1/3 of skeletal muscle and are vital in protein synthesis. Easily absorbed and utilized by the body. BCAA’s have a high BV rate and cost.

Animal Protein Supplements:

Animal proteins contain the 9 essential amino acids the body needs for skeletal muscle formation. It’s important to note that high fat in protein will decrease the amount of absorption and, therefore, utilization of protein due to altered anatomy after DS.

Whey Protein is a byproduct of cheese production. It has a high BV rate and is the most popular protein supplement. It is rich in muscle essential amino acids and has a fast digestion rate.  It needs to be taken more often because the ease of digestion.  It contains 5% lactose within the product. Whey products come in a wide variety of flavors and styles.  Unflavored protein products can be added to other protein foods, such as yogurt, cottage cheese, etc. to increase the protein. Be wary of artificial sweeteners in protein supplements as they can give you unwanted side effects, such as gas or loose stool.

Whey Protein Isolate: (WPI) has one of the highest BV rates 104. WPI can be slightly more expensive but seems to be the most  tolerated by WLS (weight loss surgery) patients. There are many flavors and styles with less fat and lactose than other whey protein  products.

Whey Protein Concentrate: has a high BV rate 85-90. Concentrate has more fat and lactose, which may not be well tolerated by WLS patients.

Whey Protein Blends: Blends contain a mixture of both isolate and concentrate whey proteins.  Which means the BV rate is higher than concentrate on it’s own. Because of increased fat and lactose this too may not be tolerated as well by WLS patients.

Casein Protein is a milk protein and has a BV rate of 91.  Casein is the trigger in most milk allergies.  It is more slowly digested and more filling than whey protein.  It may be more difficult to tolerate after WLS.

Egg Albumin is very high in essential and nonessential AA’s.  Eggs are also a great natural food source for protein.  Does not have lactose but some people do have egg allergies.  It is a cost effective source of protein. Supplement powders come in several flavors. This is probably nature’s perfect protein source with the highest utilization.

Goat Milk: One of the highest BCAA available food sources. Is better tolerated by people with lactose intolerance.

Beef, poultry, fish all have varied degrees of bioavailability.  Please see the table above regarding each items BV rate.  While beef may have a higher BV rate there may be other issues to deal with higher fat content that goes along with eating most cuts of beef.  After DS higher fat content can mean looser stool or even diarrhea.

Vegetable Protein Supplements and Natural Food Sources:

Plant Protein may contain most or all essential amino acids but the amount is far less thank other protein sources particularly in the amounts of BCAA needed for skeletal muscle formation. It is best to combine or vary plant proteins to ensure adequate protein nutrition.

Soy Protein: has a BV rate of 74. It is fast digesting, lactose free and comes in a variety of flavors and unflavored.  It is also cost effective and contains all the essential AA’s. Soy beans are commonly a GMO crop, so if that is concerning look for organic sources. Soy is also a high allergen food and can inhibit calcium absorbtion.

Pea Protein: 100% gluten free and lactose free.  Pea protein is very easy to digest, rich in Amino Acids and is a high satiety protein. Pea Protein can be found with high levels of carbohydrate and low levels of carbohydrates.  After WLS always choose lower levels of carbohydrates.

Brown Rice Isolate: BV of 70-80.  Is easily digested and is a good vegan choice.  Again with Brown Rice Isolate watch your carbohydrate content. Brown Rice Isolate can be chalky in texture.

Pea/Brown Rice Isolate:  BV of 70-90 Combining these two gives a good profile of BCAA that rivals whey and egg proteins.  It is easily digestible without allergy issues. When used in combination, rice protein and yellow pea protein offer a Protein Efficiency Ratio and BCAA’s that is comparable to dairy and egg. In addition, the texture of pea protein helps the chalkiness of rice protein.

Spirulina: Blue-green algae is easily digested and high in AA 80-95% of proteins can be digested.  BUT is very allergic prone. It is also expensive and the taste can be hard to handle.

Hemp Protein: 30-50 BV rate. Hemp contains 21 amino acids and is considered a complete protein.  The proteins in Hemp seeds are easily digestible, absorbed and utilized by the body. Hemp seeds are great to add to natural food products to increase protein and essential fatty acids. It is vegan friendly and low allergy rating.

Summary

So what does this all mean? It is important when looking for a protein supplement or natural food source to look for the highest bioavailable rating and BCAA levels.  Most protein supplements have these listed on their labels. Read the labels on supplements to find low fat, carbohydrate and lactose for best tolerance after WLS. Consuming high amounts of fat after duodenal switch decreases the absorptive time the food products due to the altered anatomy after DS.  When taking your protein it is best for absorption to have low fat to optimize your protein absorption.  Be wary of artificial sweeteners in protein product. They may also cause WLS patient issues, such as increased loose stools or gas. Also, try getting trial sizes of several different supplements to see how your body tolerates the supplement and your taste. If you are not tolerating one brand of supplements try another.  Isolate, Egg or Blends are best tolerated after WLS and give the highest bioavailability.

The best routine of taking your supplements after WLS is on an empty stomach in the morning or when you first wake.  This is a good time to use an isolate, or blend supplement shake or natural food source such as egg.  Have a midmorning protein snack or shake, lunch with high protein foods, a mid afternoon protein snack or shake, dinner of high quality protein and after dinner or as close to bedtime as you can tolerate protein supplement shake. For your meals choose the best BV rating food and also listen to what your body tolerate.  Your natural food sources should be low fat, low carbohydrate and low lactose food choices. Also consider adding one of the plant protein supplements or unflavored animal supplements to your natural food sources to give an additional protein boost.  The unflavored varieties can be added to nearly any food or recipe.  Take care in adding protein powders to higher temperature foods, as high temperatures destroy the proteins. The key is frequent small meals and snacks with the highest quality protein. Varying your protein sources increases your chances of absorbing a variety of amino acids and nutrients.

After surgery, you should expect to be able to consume the same amount of grams of protein as the number of days post op that you are. i.e.; 30 grams of protein at the end of the first month, 60 grams of protein by 60 days post op, etc.  Treat your body as you would an infant just starting to eat new foods. Try small amounts of food and only progress with a new item after several days of tolerating an old food.  As always follow your surgeon’s guidelines and recommended diet. Do not progress until your surgeon has given you the go ahead.