Macronutrients and Weight Loss/Health: Overemphasis of protein AFTER weight loss surgery

Hello everyone,

I'm scheduled for Roux-En-Y Gastric Bypass surgery November 21st, 2014 and I am preparing for surgery as well as for after surgery. I understand the need for a high protein and very low carbohydrate diet before surgery is required to put the body in ketosis to shrink liver fat so the surgery is safer. To my knowledge, and I assume to the medical and nutritional community at large, putting your body in ketosis is the fastest way to reduce a fatty liver. BUT, like many of you, I've done low carb, high protein diets several times in my life but always gained the weight back and felt terrible while depriving my body of fruit and certain higher carb veggies. I intend on following the pre-surgery instructions perfectly so that I do go into ketosis, shrink liver fat, and make the surgery safer. But I don't really have any intention of over emphasizing protein above other macro nutrients after surgery which goes way against what 100s of websites, doctors, and succesfull post-op patients are saying.

I've found several published and peer reviewed studies on the effects of diets with varying macro nutrient composition. The following link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278241/ is a thorough study comparing 1) a low-fat, average-protein diet (20% fat, 15% protein, and 65% carbohydrate, 2) a low-fat, high-protein diet (20% fat, 25% protein, and 55% carbohydrate), 3) a high-fat, average-protein diet (40% fat, 15% protein, and 45% carbohydrate), and 4) a high-fat, high-protein diet (40% fat, 25% protein, and 35% carbohydrate). Other goals for all diets were saturated fat ≤8%, dietary fiber ≥20 g/d, and cholesterol ≤150 mg/1000 kcal. Low–glycemic index foods were used in all diets. Every diet was the same energy intake i.e. calorie amounts. The results showed every group lost more fat than lean muscle. The high protein diets did not preferentially affect the amount of fat versus muscle mass lost.

Another study examines the results of similar conditions to that of most post bariatric surgery patients are told to follow -- an 800 calorie liquid diet. Think you need tons protein to maintain muscle mass? Look at the 4th study down on the following webpage of compiled studies titled "Effects of Resistance vs. Aerobic Training Combined with an 800 Calorie Liquid" Link: http://www.unm.edu/~lkravitz/Article%20folder/researchreview .html  Weight training kept their metabolism up on a calorie reduced/starvation diet and helped burn fat over muscle whereas the group eating 800 calories a day and doing cardio decreased the amount of lean muscle mass and decreased their metabolism. Another study on that page which is well known to a lot of people, is about the positive effects of weight training on bone density. All in all, I think weight training and nutrient dense food such as fruits and vegetables and some protein are going to be really important in an 800 calorie diet to stay healthy.

What I'm trying to say is that it is pretty obvious to me the bariatric surgery causes weight loss because of extreme reduction in the amount of calories consumed/absorbed. And I'm ready, mentally, to accept that I will be eating very little. Of course I want to loose weight, but I want to be as healthy as possible.

I'd really like to hear from people who emphasized fruit over protein? I plan on always eating and emphasizing extremely ripe fruit and veggies (of course cooked and mushy until raw is allowed by surgeon).  Is there anyone who has even experimented with different macro nutrient ratios other than the high protein, low carb/fat after WLS? I'd really like to hear from you. I don't see any evidence of people getting sick and/or lose their hair because of lack or protein; scientifically, it appears to be lack of nutrients. High-carb low-protein low-fat vegans don't have hair falling out, in fact, they have very healthy hair, skin, and nails. I don't plan on going full vegan nor do I intend to not eat protein or healthy fats but my intent is to have at least 2 to 4 mono meals per day of fruits or veggies and only 1 to 2 meals of protein with healthy fat like coconut oil. I will use a protein powder for the liquid phase but again, I intend to have 1 or 2 protein drinks and 1 or 2 fruit based liquids (water and ripe fruit thoroughly blended).

Okay, I'm done now. I'm also prepared for everyone who is going to disagree for this post. I just ask that everyone remain respectful :)

Thank you

Laura

I'm a vegetarian but I do get a fair amount of protein daily.  I average 70 to 90 grams a day.  My blood work indicates this is a good amount for me.

The ASMBS recommends 1.5 grams per kilogram of ideal body weight for WLS folks, and according to my surgeon and dietician, 140 lbs is a very good weight for me, so about 70 grams a day would be just right according to the ASMBS recommendation.

I really think we should base our protein intake on our labs.

I don't avoid complex carbs, though - I eat a lot of beans for protein.

no science - but experience:  higher carbs - no matter if they came from natural fruits and veggies or low fat crackers - make me hungry and make me put on weight...

I do have insulin resistance... and I do deal with my body making more insulin if/ when I eat carbs post op (again - my body does not care  where the carbs came from..) 

for me to lose and maintain - I eat low carb, moderate fat and proteins.. (some may call that high fat) diet. If is what it is...  the only fruits that I can tolerate without triggering severe insulin response (and RH that follows) are berries - and even that - needs to be limited qty eaten with fats and proteins... 

Some people do great on low protein - vegetarian type diet... my body - not so much... 

Most post-op hair loss is due to something called telogen effluvium, not post-op diet. Google it for more info.

I chose the DS, so even ten+ years out, I still malabsorb a significant per centage of the foods I eat. I only absorb about half the protein I eat, about 60% of the complex carbs (nearly 100% of simple carbs, but then, so does everyone), and only 20% of the fat I eat. I eat a high-protein, high-fat, moderate-carb diet. Based on the extensive labs I have done every few months, I require about 140 grams of protein each and every day to maintain a good protein level. I don't count my fats---I just eat what I want in that area. I can tell if I'm not getting enough if I get constipated. When it comes to carbs, and yes, I'm including fruits and veggies, if I eat more than a moderate amount I get some horrific gas, bloating, and loose stool.

This is what makes MY body happy. I suggest you listen to YOUR body post-op, and feed it what makes it happy and healthy. It may not turn out to be the things you think it needs and wants right now.

Thanks for the replies everyone. I definitely agree every person is unique and different methods will work for some and not others. I think that's why some people thrive on vegan low or average carb, some on paleo, and some on high protein low carb. I am trying to stay open minded and hope to find what makes me feel happy and healthy.

Thanks again,

Laura

A diet high in fruit would make me hungry, irritable, and feel unwell. Reactive hypoglycemia is a possibility after wls, so emphasizing fruit over protein may not work for you.

 Post op, I eat a protein forward diet and limit grains and fruit. I do eat non starchy vegetables and dairy. I eat a good bit of fat as well. I am very healthy, and my skin, hair and nails haven't suffered in the least. I also don't eat only 800 calories a day at three years out. I eat about 1400 calories a day on average. Protein increases my satiety, whereas fruit would go right through me and leave me looking around for food in an hour. Post op, too much sugar in any form is bad for me. Sugar from fruit is still sugar. My body makes no distinction.

There are many post ops here who eat high protein, high fat and are quite successful. There are also folks who never supplemented with protein anything and worked on getting protein from food. Fat in and of itself isn't the devil it is portrayed to be. Sugar is, IMO. That's not to say I eat sticks of butter, but fat on my meat or some avocado or nuts are in my eating plan.

You may find that such a high consumption of fruit stalls out your loss as well.

WLS doesn't only work due to an extreme reduction in calories. There are also metabolic changes that take place. Also, as time goes by your capacity will naturally increase. I eat about a cup of food at a meal. I can eat far less dense protein. So you will not have the same capacity for every food. This is important when you consider calorie dense foods. At a year out, for example, you could likely eat a LOT of fruit versus beans and vegetables. That much fruit a sitting may leave you feeling like hell as your blood sugar rises and then plummets.

It's great that you've done your homework, I  PubMed. That being said, AFAIK none of those studies consider WLS patients who are eating 600 calories per day and have undergone the other metabolic changes associated with bariatric surgery (i.e. absorption, amount of stomach acid, etc.). Particularly, the meta-analysis from Souza et al. doesn't address the calorie issue. The nutrient ratio by percentage likely assumes 1,200 - 1,500 calories per day. When you scale that to 600 calories per day, I'm skeptical that the same trends would remain, much less hold at .05.

I can't dig further into the math at the moment (professional data analyst/statistician reporting for duty!) but I'm concerned about the ability to generalize these results to the WLS population. Not only are the metabolic factors different, but I imagine there's a notable difference in the use of supplements between surgery and non-surgery patients. The studies of bone density, for example, wouldn't address the fact that many WLS patients take calcium supplements.

Bottom line? The NIH is great. But your doctor knows your body, his other patients, and is presumably up on the latest studies from ASMBS. I'm not trying to discount your research, but I think the best approach is to ask your surgeon and let him provide specific advice, especially regarding post-op nutrition, as he has FAR more experience and training than you (or any of us) do.

Thank you for the info and thoughtful reply :) That makes a lot of sense.

Also, note that you indicated that the first set of studies you cited utilizes all low-glycemic foods. That immediately eliminates MANY kinds of fruits, so in order to duplicate their results, you would have to limit the types of fruits.

I doubt that you will find anyone who has eaten more fruit than protein and successfully lost the weight and maintained the loss (You could eat small amounts of almost any kind of crap, high calorie, high fat foods during the first six months post-op and still lose weight initially.) The carbs in fruit are simply too high, and almost everyone who has had RNY will tell you from experience that excessive carbs mean regain. Every time.

Additionally, you need a certain amount of protein in order to keep your body (including your heart) functioning and if you don't get enough from food, your body will take it from muscles  and organs.  So if you are eating more fruit than protein and need to increase your protein because your labs are low, you will be increasing your calories... which will also lead to regain.

Finally, once hunger returns after surgery, protein will keep you feeling fuller much longer than fruit.  If you eat too often, you will likely eat too much.... Again, leading to regain.  

See the pattern?

There are very good, scientific reasons for the post-op eating plan that emphasizes protein.  They didn't just pull it out of a hat or come up with it to sell diet books.  That doesn't mean you cannot eat any vegetables and fruit.  It just means you need to focus more on protein than on fruit.

I really don't understand your approach, though.  Why would you go into surgery intending NOT to follow the post-op eating plan that surgeons KNOW works? That sounds pretty arrogant in the sense that you seem to think that your can read a few isolated studies, circumvent the post-op eating plan "system", and not pay the price (lack of adequate weight loss or, more likely, regain).

I hate to see people come back here 2 or 3 years out complaining that their surgery "didn't work" (when they didn't follow the post-op eating rules or followed them long enough to lose the weight and thought they had this obesity thing "kicked" and then stopped following the rules and gained weight.) I fear that love of fruit will lead you to that path.

Have you discussed your research with your surgeon...?  What does (s)he say?? 

Lora

You need preop counciling and you should tell your surgeon that you plan on doing it your way...then you will get big as a house and blame everyone but you.   First off tell him your are going to eat fruit over protein and watch him cancel your surgery.  You need to understand the mechanics of this surgery...and what you are asking your body to do.. If you don't agree with it, don't get on the table.  You will just end up a statistical failure!