Protein Needs Post-op - Scientific Explanation

[phatgirl]

I found this scientific explanation for protein needs post-op so I thought I would share:


Why we need protein
Weight loss for any individual can only occur through a reduction of calories. The general rule to follow is 1 gram of weight loss for every reduction of 7 calories needed to maintain existing weight. This means that a person with a daily calorie requirement of 2,000 calories will be expected to lose approximately 72 grams (2.5 ounces) of overall body weight if he (or she) reduces their caloric intake by 500 calories, and ingests only 1,500 calories. This equates to about a pound of weight loss a week.

PLEASE NOTE: If a person takes in less calories a day than is needed to maintain his or her existing weight, and does not take in adequate protein, the overall weight loss does not mean that only fat is being lost. On the contrary, the body will first lose retained water (about half the total weight lost the first 3 weeks is water), and then the body will lose muscle. Fat loss will be last.
Basically, the body will compensate for the reduction of calories by first taking energy from stored carbohydrates (1,500 to 2,000 calories), and will then convert muscle or Lean Body Mass into needed energy. Even though fat is eventually lost, the body tries to store fat reserves, and draws on other available energy sources first.


This type of weight loss from simple calorie reduction is ineffective. The end result is that people who lose weight through simple reduction of calories actually end up increasing their total body fat percentage because of the loss of lean body mass. This is further compromised if the original weight is gained back. Studies have shown that those individuals who gain their weight back after dieting by simple calorie reduction gain their weight back as fat. If the cycle is repeated several times (as is often the case), the overall body composition of those individuals changes dramatically. In addition to being overweight, they now have a much higher percentage of fat than normal, and have a much lower percentage of lean body mass. This leads to strength loss, as well as to possible health risks.

PROTEIN REQUIREMENTS FOR REDUCED CALORIE DIETS
The most important fact to realize is that the reduction of calories does not mean that the body requires less protein. The reality is that the protein requirements on reduced calorie diets to preserve lean body mass while promoting effective weight loss (i.e., fat loss) dramatically increases. In general, on low calorie diets (700 – 1,000 calories per day), the minimum protein requirements are 80-90 grams per day for women, and 100-120 grams per day for men. This is calculated by assigning roughly .6 grams of protein for every pound of “ideal” body weight. The added protein acts to preserve the lean body mass, while the body draws the energy it needs from the fat stores to offset the daily caloric reduction.


WEIGHT LOSS AND PROTEIN REQUIREMENTS FOR BARIATRIC SURGERY PATIENTS
There are three very important things to consider when reviewing our recommendation for protein intake for bariatric surgery patients (post surgery): First, there is the fact that the initial body mass of the bariatric patient is quite high (along with the assumption that total body fat percentage is above normal, and lean body mass is low). This means that the energy (calorie) requirement to maintain this body mass is also very high.
Second, there is the fact that the subsequent drop in caloric intake after surgery is obviously dramatic, and will result in significant weight loss, especially during the first year. As discussed above, however, the significant weight loss that occurs will be the result primarily of the loss of lean body mass, not fat loss, because of the body’s natural reaction to use lean body mass as a source of energy to compensate for the calorie depletion. Unless adequate amounts of protein are taken, overall fat percentage will remain high, resulting in ineffective weight loss.
Third, the weight loss phase following surgery is the most critical time for patients with respect to maintaining lean body mass, and to ensure fat loss. It is truly their “window of opportunity” given to them as a result of the surgery. Weight loss during this time is inevitable. The goal, however, is to make sure that the weight loss during this time is effective by ensuring adequate amounts of protein are taken by surgery patients to preserve lean body mass. This goal cannot be achieved if proper eating habits are not learned and implemented by the patients immediately following surgery.


Based on the three facts above, and based on clinical experience that adequate protein amounts for those on low calorie diets actually helps curb hunger and promotes energy and well being, it is our recommendation that the minimum amount of daily protein to preserve existing lean body mass during the weight loss phase for post surgery patients is 90 grams, and that this minimum should be increased for larger patients. This is especially true for male bariatric patients, who start out usually with a larger lean body mass profile than females. If this minimum is not met, then weight loss becomes ineffective in that lean body mass and fat will both be lost, resulting in loss of strength, as well as possible health risks.



source: SmartForme - The Role of SmartForme Supplements for Effective Weight Loss

 

[gaelic girl]

Thanks for that Nic very helpful its a big debate and again every surgeon/team seem to give out different advice x

 

[Mixman]

That is a brilliant post and totally understandable. Straight talk, I likes it lots

Thank You xx

 

[Emma Louise]

Thank you!!

xxx

 

[Mazza]

Thanks Nic

I eat plenty of protein and according to the fancy scales at WLS Group 39lbs of my 43lbs loss is fat!

Maz x

 

[Lisa J]

thanks so much nic for taking the time to post, i found the thread really interesting and has given me a kick up the butt to get my proteins in!!!!

 

[julia in bath]

brilliantly informative post, thanks so much for posting, makes perfect sense in understandable language! i am so off to get some protein shakes!

 

[zetacatty]

Thank you for posting that Nic, very interesting - and useful!

 

[Snow Angel]

Thanks for posting Nic, can we put this in a sticky along with the protein shots info? Its one not to get lost in the forum.

 

[katstofat]

thanks nick wen i lost 4st at sliming world i did it on green days (carbros) and i now realise why it all came back so quickly and more besides.........kath x

 

[salski]

Excellent post again Nic, thanks for this.
I would like to know how much fat I have lost out of my 5 stones...wonder is Mazza could borrow me her posh scales! hehe

 

[Mazza]

Excellent post again Nic, thanks for this.
I would like to know how much fat I have lost out of my 5 stones...wonder is Mazza could borrow me her posh scales! hehe

Oh I wish they were my scales lol they belong to my surgery providers bariatric nurse, they must cost a blooming fortune, they even provide a print out.

Not sure but I think Boots scales are similar if you wanted to see form now on how much fat you are losing

 

[phatgirl]

Here is some more science, way more technical and only for those who like medical jargon:

[FONT=&quot]Protein and the Bariatric Patient[/FONT]
[FONT=&quot]October 2008, [/FONT]
[FONT=&quot]by Laura Frank, PhD, MPH, RD, CD
[/FONT]
[FONT=&quot]INTRODUCTION[/FONT][FONT=&quot]
All macronutrients (proteins, carbohydrates, and fat) have interrelationships in terms of bioenergetics.[/FONT]
[FONT=&quot]Amino acids, primarily alanine and glutamine, interact with glucose metabolism both as carbon substrates and by recycling glucose carbon via transamination/deamination reactions. Therefore, protein metabolism provides the body with essential building blocks from amino acids to provide carbon substrates for energy metabolism and/or nitrogen compounds needed for nitrogen balance.When nutrition is scarce, or when humans experience anorexia, prolonged vomiting, diarrhea, food intolerance, depression, alcohol/drug abuse, or other reasons for food deprivation, protein-energy malnutrition (PEM) will most likely ensue.When inadequate protein intake occurs (especially inadequate intake of indispensable amino acids), coupled with adequate carbohydrate and energy intake, this condition is termed [FONT=&quot]protein malnutrition[/FONT] (PM).[/FONT]

[FONT=&quot]Hormonal state is an important covalent modulator for metabolic processes in the body. In PEM, the body is generally in a hypoinsulinemic and hyper-gluconemic state. Low levels of insulin allow for a shift in substrate utilization to stored body fuels, such as muscle and liver glycogen and stored fat. Initially, weight loss occurs as a result of water loss due to the metabolism of liver and muscle glycogen stores. Muscle protein breakdown also occurs in order to supply the amino acids needed to preserve the visceral protein pool. Carbon liberation from either fatty acid oxidation or from the deamination of amino acids, such as glutamate, glutamine, and alanine (process of gluconeogenesis), help to supply fuel for the body and to maintain vital organs (brain, heart, and kidney). The body eventually enters a “protein sparing” state as ketone-bodies (byproducts of fat breakdown in the absence of carbohydrate intakes) increase in abundance. This condition is called ketosis. Weight loss occurs with the breakdown of muscle mass and a reduction of adipose tissue as the body strives to maintain homeostasis.[/FONT]
[FONT=&quot]
Continued negative nitrogen balance will result in decreased hepatic proteins, including albumin, with concomitant muscle wasting, asthenia (weakness), and alopecia (hair loss). PEM is typically associated with anemia related to iron, B12, folate, and/or copper deficiency. Deficiencies in zinc, thiamin, and B6 are commonly found with a deficient protein status. In addition, catabolism of lean body mass (LBM) and diuresis cause electrolyte and mineral disturbances with sodium, potassium, magnesium, and phosphorus. [/FONT]
[FONT=&quot]
During PM, the protein deficit occurs in conjunction with excessive intake of carbohydrate calories, resulting in a hormonal state of hyperinsulinemia, inhibiting fat and muscle breakdown. When the body is not able to hormonally adapt to spare protein, a decrease in visceral protein synthesis will result along with hypoalbuminemia, anemia, and impaired immunity. If left undiagnosed, this may result in an illness where fat stores are preserved, LBM is decreased, and appropriate weight loss is not seen due to accumulation of extra-cellular water. This edema is associated with PM.[/FONT]

[FONT=&quot]Preoperative Risk [/FONT][FONT=&quot]
No risk of preoperative PM among pre-gastric bypass and duodenal switch patients has been reported; however, a thorough history and physical is needed in the preoperative patient. It is also prudent medical or dietetic practice to complete a thorough screening of nitrogen balance and body composition in the preoperative bariatric patient. Note that increased body mass index (BMI) does not ensure that a patient does not have PM. It is important to emphasize that an obese patient can still have low muscle mass (sarcopenia) and/or PM.[/FONT]
[FONT=&quot]
Routine preoperative screening, including laboratory measures of visceral proteins, can be used to assess the risk of PM. Serum albumin (normal range 3.5–5.0g/dL) can be used as an indicator of long-term protein status (half-life approximately 3 weeks). Serum transferrin and serum transthyretin (or thyroxine-binding prealbumin) are referred to as intermediate- (half-life 8–10 days) and short- (half-life 2 days) term indicators, respectively. Retinol binding protein (RBP) may also be useful in diagnosing acute changes in protein status.[/FONT]
[FONT=&quot]
Body composition measures, such as fat free mass (FFM) or lean body mass (LBM) versus fat mass (FM) (or the ratio of FFM:FM or LBM:FM), are helpful to assess functional nitrogen balance among patients. Sophisticated models of body composition assessment, such as underwater (hydrostatic) weighing or air displacement plethysmography (e.g., Bod-Pod), are generally more practical in academic settings. Dual-energy absorptiometry (DEXA) and computed tomography (CT) can also be used to measure total body fat and intraabdominal or visceral adiposity, respectively. A less expensive option to measure body composition includes bioelectrical impedance (BIA) (e.g., Tanita body-fat analyzer, Arlington Heights, Illinois). Good agreement between BIA measures and DEXA has been reported by some but not all researchers. In addition, creatinine-height index is reflective of somatic or skeletal muscle protein and can be used as a surrogate biomarker for LBM. Clinical signs of PM may also include excess hair loss, edema, anemia, and impaired wound healing. Protein deficiency may be masked by the adipose tissue, edema, and general malaise potentially shown by the patient.[/FONT]
[FONT=&quot]It would not be appropriate to assume that the obese patient has good nutritional status and appropriate dietary intake. Therefore, a complete dietary assessment is also recommended for the preoperative bariatric patient in order to determine typical protein intakes and determination of patient’s protein food preferences. This information can then be used to recommend an appropriate food plan with adequate healthy proteins prior to the patient’s surgery.[/FONT]

[FONT=&quot]Postoperative Risk[/FONT][FONT=&quot]
Bariatric patients can be at risk for PM due to inadequate protein intakes possibly from food intolerances to good quality protein, such as meat. This can occur after restrictive surgeries (e.g., adjustable gastric band [AGB] or gastric sleeve [GS]) and restrictive/malabsorptive surgeries (e.g., Roux-en Y gastric bypass [RYGBP]). Other reasons why bariatric patients are at risk for PM and/or PEM depend upon the type of surgery that they have undergone and include small upper stomach pouch with an approximate 20–30mL capacity, decreased intestinal limb length (and therefore decreased and compromised absorption capacity), and increased protein needs due to wound healing immediately post-surgery. For post-RYGB patients, the degree of protein malabsorption will depend on the length of the bypassed segment of the small intestine. Nutritional deficiencies in patients after RYGB operations have been mainly attributed to dietary restriction. Other variables include the patient’s food adversions or food faddisms, failure to comply with or ignorance of post-surgical nutrition guidelines, and/or the inability to recognize or afford high quality protein.[/FONT]
[FONT=&quot]
Outcomes of studies investigating the incidence of protein malnutrition after surgery have been equivocal. Furthermore, several of these studies have been performed during the period of greatest caloric restriction. In a recent review of the literature, Shah et al stated that protein deficiency, assessed by serum albumin levels, is less common than most other nutrient deficiencies among post-surgical patients. To confirm these findings, other investigators have reported that PEM and PM are rarely found among patients after RYGBP. Two hundred patients who were morbidly obese were followed for 6 to 8 years (mean: 6.7 years) after RYGBP surgery. Meat intolerance was observed in 51 percent, 60.3 percent, 59.5 percent, and 55.1 percent of the patients during zero to 12 months, 13 to 24 months, 25 to 72 months, and 73 to 96 months after surgery, respectively. However, these patients had no caloric malnutrition or protein deficiency. Moize et al studied 93 patients retrospectively over 12 months post-RYGBP. Significant differences in total calorie intakes occurred comparing three-month (849±329 calories) to 12-month intakes (1,101±400 calories) (p=.009) and significant differences in protein intakes (g/day) were also observed over the 12-month period (45.6±14.2 g/day at three months versus 58.5±17.1 g/day at 12 months). Although protein intakes met the minimum recommendation of 0.8g/kg/day, these intakes were significantly different than the recommended 1.5g/kg/day (p=0.01). At 12 months, protein intakes were significantly lower among patients with protein intolerance (p=0.02). However, despite low energy and protein intakes, normal protein status (as measured by serum albumin) was reported throughout the 12-month follow-up.[/FONT]
[FONT=&quot]As stated, the degree of protein malabsorption will depend to some extent on the length of the bypassed segment of the small intestine.14 In a prospective, randomized, clinical study, Brolin and LaMarca et al reported that 13 percent of patients status-post-two-years distal (long-limb) RYGB had hypoalbuminemia (albumin <3.5mg/dL) compared to normal albumin levels reported among patients with short Roux limbs (<150cm). In agreement with this study, Nelson et al18 followed 257 super-obese patients after receiving a long Roux limb of 400 to 500cm and a 100-cm common channel (for digestion and absorption). Eighty-two percent of patients returning the survey an average of 48 months postoperatively (range 12–148 months) lost greater than 50 percent of excess body weight. Nine patients (4%) who developed or were developing impending protein/calorie malnutrition required proximal relocation of the enteroenterostomy with symptom resolution. In contrast, protein deficiency was not found in long-limb super-obese (BMI>50kg/m2) patients who were a mean 43 months out from surgery.[/FONT]
[FONT=&quot]
Among patients with malabsorptive surgeries (e.g., biliopancreatic diversion [BPD] and duodenal switch [DS]), the degree of malabsorption will determine the patient’s risk status for PM. Secondary PM caused by malabsorption of protein has been reported to be more common after BPD/DS procedures compared to RYGBP procedures, especially during the first or second year postoperative. Overall, the incidence of PM after BPD has been reported to be approximately 15 percent. Scopinaro et al reported that intestinal albumin and nitrogen absorption was 73 percent and 57 percent, respectively, among BPD patients (N=15). It was concluded that loss of endogenous nitrogen (approximately 5-fold the normal value) plays a significant role in the development of PM after BPD, especially during the early postoperative period when restricted food intake may cause a negative balance of both calories and protein. In a prospective study of 65 RYGBP versus 65 BPD patients (BMI range 35–50kg/m2), Scroubis et al showed negligible risk of protein deficiency (as measured by albumin) after two-year follow-up; hypoalbuminemia occurred in one (1.5%) RYGBP patient and in 6six (9.2%) BPD patients. In a 15-year follow-up using questionnaires on BPD patients (N=858), there were 32 re-hospitalizations for severe protein deficiency. Revisions were performed in 54 (6.3%) patients mainly due to recurrent protein malnutrition. Totté et al followed 180 BPD patients (using Scopinaro’s method with a 50cm common channel) and found that protein deficiency, unrelated to the surgery, developed in only two patients at 16 and 24 months postoperative, requiring parenteral nutrition, conversion of the alimentary tract, and psychiatric counseling for correction. They concluded that metabolic complications after BPD were the result of patient non-compliance with dietary recommendations (70–80g protein per day) during preoperative counseling administered by a registered dietitian. Other researchers have reported sporadic cases of recurrent late PM requiring 2 to 3 weeks of parenteral feeding for correction and/or elongation of the common limb. Scopinaro et al has reported that by varying the length of the intestinal limb and the common channel, varying degrees of protein malabsorption can be increased or decreased.[/FONT]
[FONT=&quot]
In DS patients, the common channel is 75 to 100cm or 125cm in length for absorption of nutrients. Protein malnutrition occurs in 3 to 5 percent of this cohort. Rabkin et al followed a cohort of 589 sequential DS patients (with a gastric sleeve and common channel of 100cm) and found annual laboratory measures of serum markers for protein metabolism to slightly decrease at one year postoperative but then stabilize at two and three years postoperative well within normal limits.[/FONT]
[FONT=&quot]
The relationships between body composition and dietary protein intakes have been studied by few researchers. Several researchers have reported that the weight loss associated with bariatric surgery results in appropriate proportions of lean body mass (LBM) versus fat mass (FM).26-28 In contrast, in a prospective study, Carey et al measured body composition and metabolic changes for one year following bariatric surgery without concomitant dietary intake data in 19 bariatric patients (14 female, 5 male). Data collection occurred within one week preoperatively and one, three, six, and 12 months postoperatively. Two female subjects were lost to the study between six months and one year, resulting in 17 subjects (12 female, 5 male) completing the entire 12-month follow-up. Significant losses in LBM were observed in all time periods except 6 to 12 months, where no change in LBM (60.6 vs. 61.1kg) was observed. The equivocal results of these studies emphasize the need to establish an optimal evidence-based level of protein intakes among bariatric patients for maximal LBM preservation.[/FONT]
[FONT=&quot]
Based on the outcomes of most of these studies as indicated by serum protein markers, with and without dietary intake data, it does appear that bariatric surgery poses a relatively low risk of developing obvious signs of protein malnutrition. However, evidenced by substantial LBM loss and below-standard creatinine-height index values, clinicians should also use body composition and somatic protein assessments in order to detect early signs of low protein nutriture. It also appears that the BPD procedure has the greatest impact on protein nutrition. However, prospective, longitudinal, randomized, clinical studies are needed to determine the effects of all types of weight loss surgeries on the risk of protein deficiency, negative nitrogen balance, PM, and/or PEM. Frequent continued monitoring of signs of PM or PEM are necessary in this population.[/FONT]

[FONT=&quot]Protein Prescription for the Bariatric Patient [/FONT][FONT=&quot]
Usual protein recommendations for the post-bariatric surgery patient are anywhere from 1 to 2g protein per kg of adjusted body weight—calculated as current body weight (CBW) minus ideal body weight (IBW) multiplied by 25 percent plus IBW [CBW-IBW x 25% + IBW]).25 A minimum of 60 to 70g of protein per day should be ingested. Many programs recommend a range of 60 to 80 grams total protein intake per day or 1.0 to 1.5g/kg IBW, although exact needs have yet to be defined. The use of 1.5g/kg IBW/day beyond the early post-surgical phase is probably above metabolic requirements for non-complicated patients and may prevent the consumption of other macronutrients in the context of volume restrictions. An analysis of the RYGB patient’s typical nutrient intake at one year postoperative found no significant changes in albumin with daily protein consumption at 1.1g/kg IBW.12 Following BPD/DS procedures, the amount of protein should be increased by approximately 30 percent to accommodate for malabsorption, making the average protein requirement for these patients approximately 90g/day.30[/FONT]

[FONT=&quot]Treatment for Protein Malnutrition in the Bariatric Patient[/FONT][FONT=&quot]
Unfortunately, loss of muscle mass is an inevitable part of the weight loss process after obesity surgery or any very low calorie diet (VLCD). Patients, especially those undergoing BPD/DS, should be encouraged to focus on protein-rich foods of good quality protein (providing a complete protein of all IAAs). Patients need to eat slowly and to masticate their food well to compensate for the reduced grinding capacity of the stomach. Foods that are moist, either by preparation methods or by saliva, can also facilitate food to pass from the esophagus to the pouch.[/FONT]
[FONT=&quot]When a deficiency occurs and there is no mechanical explanation for vomiting or food intolerance, patients can often be successfully treated with a high-protein liquid diet and slow progression to a regular diet. As the protein deficiency is corrected and edema is decreased around the anastomosis, food tolerance and vomiting may resolve. If protein deficiency cannot be corrected with dietary protein intake, the patient may require hospitalization for enteral or parenteral treatment to sufficiently return the total body protein to normal levels. Patients may also require psychological evaluation and/or counseling to determine the degree to which a psychosocial etiology is involved. It is important to rule out or treat all possible underlying mechanical and behavioral causes before considering a surgical revision such as lengthening of the common channel or surgery reversal.[/FONT]

[FONT=&quot]Conclusion[/FONT][FONT=&quot]
Due to the equivocal nature of current research, clinicians need to continually assess the prevalence and incidence of PM pre- and post-bariatric surgery. Clinicians need to screen and monitor pre- and post-bariatric patients for protein malnutrition using tools, such as dietary assessment, serum biomarkers of protein status, and body composition measures. Recommendations of types and amounts of good quality protein from food and supplemental sources can assist in the prevention and treatment of protein malnutrition.[/FONT]

Source:
Protein and the Bariatric Patient | Bariatric Times

 

[salski]

Hahaha - I just hurt my brain...and didnt get halfway through! hahahahaha

 

[cindy1]

Hi I can across this great thread that hasnt been looked at for a while and thought it was great for explaining the protein info and thought others might like to have a read too so added a post to get it back at the top of the threads pages.

 

[Sarah Metcalf]

What a really useful thread, thanks x

 

[Big an Bouncy]

All makes great sense to me,I always lose better on a high protien low carb diet.Also I have got very little muscle strength,over the years I must of damaged my body by 'dieting'I have a weak back and joints.I will have to eat lots of protien and do stregthening exersize.Would anyone recommend Pilates?

 

[hsmel]

Yes Big and Bouncy pilates is great. I too have had bad back problems from being overweight (a lot of it round my middle - and bad posture). I have done pilates since around eight weeks post op and it has really helped my core strength and the way I hold my stomach. I think it has really helped with the 'loose skin' problems that many people have - I seem so far, to have avoided. I have slightly flabby upper arms but nothing that some cans of bean exercises and swimming wont help - and a little bit of a tummy overhang - but I honestly think it may well improve (and I am over 50).

I was told by my dietician to aim for 80 gm of protein a day and I have tried to stick to it as much as I can but I do find it hard. I am now a baby bel snacker and I also eat thin slices of rare roast beef wrapped up with a bit of pickle or cherry tomatoes as my snacks of choice!

 

[chrriss88]

Excellent I have read this before but was well worth reading again. I worry because I am finding it difficult to eat much so I may revert back to the protein shake for at least one meal per day! Have my first clinical visit (3 months since my RNY op) so will see if I am becoming deficient in anything!

 

[dylis]

thank you