Having a Baby After Weight Loss Surgery

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, and Monica A. Mainigi, MD, fertility specialist at Penn Fertility Care, provide important information for women trying to become pregnant and maintain a healthy pregnancy after weight loss surgery.

Many women struggle with fertility as a result of their weight. In fact, obesity puts women at greater risk for ovulation dysfunction and menstrual irregularity, both of which can interfere with fertility. In addition, obesity can lead to an increased risk of miscarriage and decreased success with fertility treatments. For overweight women who are having a hard time conceiving, weight loss surgery may be an option to consider.

For women considering pregnancy after they have had bariatric surgery, it is important to keep the following information in mind.


Fertility boost
Obesity can interfere with hormone production, making it more difficult to get pregnant.  Weight loss after bariatric surgery can lead to regular cycles and ovulation, and improved fertility. In fact, a 2005 study published in the Journal of Clinical Endocrinology and Metabolism found that surgical weight loss for women with PCOS often resolved their reproductive and metabolic abnormalities. 

Healthier pregnancy, healthier baby
After weight loss surgery, medical conditions such as high blood pressure and diabetes are significantly improved or resolved leading to a lowered risk of developing serious complications during pregnancy or delivering a baby born with complications.  Many women are still obese after weight loss surgery which places them at a higher risk for gestational diabetes and preeclampsia, but the risk is far less than before surgery.  Pregnant women who have had bariatric surgery should see a high-risk obstetrician to best manage prenatal care.

Give it time
It is important to wait at least 18 months after surgery to start trying to get pregnant. In the period immediately following gastric bypass or sleeve gastrectomy, rapid weight loss causes stress on the body, including diminished nutrition intake, which can cause complications for an expecting mother and growing baby. Effective contraception is absolutely critical for women pursuing weight loss surgery.  For women with an adjustable gastric band, fluid may be removed from the band during pregnancy to accommodate the need to eat more calories.

Keep supplementing
Good nutrition is especially important for women trying to conceive.  After weight loss surgery, patients are at a higher risk for deficiencies of certain nutrients, including vitamin B12, folic acid, calcium, iron, and vitamin D. It essential to continue taking vitamin and mineral supplements as recommended by the bariatric team.

Be ready for weight gain
After having weight loss surgery, it can be difficult to accept that pregnancy is a time when it is normal, healthy and necessary to gain weight.  Healthy weight gain during pregnancy is important to nourish a growing baby, but work with the program dietitians to avoid unhealthy weight gain during pregnancy.

The Penn Metabolic and Bariatric Surgery Program offers lifelong follow-up care and nutritional support for patients who have had weight loss surgery. Women considering pregnancy after weight loss surgery should discuss their plans with the bariatric surgery team.

For more information on fertility services at Penn Medicine, visit the Penn Fertility Care website.

- Cara Stewart, RD, LDN and Monica Mainigi, MD

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Get the Facts about Healthy Fats: Omega-3 and Omega-6 Fatty Acids

Rachel Griehs, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, explains the nutritional importance of essential fatty acids.


For years experts have been saying that all fats are bad, but it turns out that is not the case. Among the healthy fats are omega-3 and omega-6, which are considered essential fatty acids. Although the body needs them, it cannot produce them itself, which is why they must be incorporated into your diet.

There are three types of omega-3 fatty acids:
1.    Alpha-linoleic (ALA)
2.    Docosahexaenoic (DHA)
3.    Eicosapentaenoic (EPA)

ALA is found in plant foods and flaxseed is the richest source. EPA and DHA are found in similar foods, including seafood, algae and higher fat cold water fish, such as mackerel, albacore tuna, salmon, sardines, Atlantic herring, swordfish and lake trout. Enriched eggs are also a good source of omega-3 fatty acids because the egg-producing hens are fed a diet that includes flaxseed and algae. As a result, these eggs contain all three types of omega-3 fatty acids. 

Omega-6 fatty acids are made up of linoleic acid. They are found in nuts, seeds and vegetable oils, specifically soybean, safflower and corn oil. Experts recommend that 5 to 10 percent of your total caloric intake should come from omega-6 fatty acids.

How do these fatty acids benefit health?

Omega-3 fatty acids thin the blood, reducing the risk for blocked blood vessels, heart attacks and strokes. They also prevent hardening of the arteries, lower triglycerides and help reduce blood pressure.

Omega-6 fatty acids lower cardiovascular disease risk by decreasing total cholesterol, including “bad” cholesterol (LDL—low density lipoprotein). However, by reducing the total cholesterol, omega-6’s also lower “good” cholesterol (HDL—high density lipoprotein), which functions like a sponge and carries “bad” cholesterol and other lipids to the liver for excretion.

The American Heart Association recommends that people who do not have coronary heart disease (CHD) eat a variety of fish, specifically oily fish, at least twice a week. For those with CHD, they recommend one gram of EPA and DHA from oily fish a day. It can be hard to obtain sufficient omega-3 from your diet alone. If so, talk to your physician about adding a fish-oil supplement.

- Rachel Griehs, RD, LDN

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Tips for Healthy Holiday Eating After Weight Loss Surgery

Karen Buzby, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, provides tips for managing your post-surgical diet during the holidays.

There is no getting around it. Food is a central part of the holiday season. Whether you’re enjoying holiday food with friends and family or inundated with unhealthy treats at the office, it is hard to maintain your healthy eating goals over the holiday season, but it is possible.

These tips can help you stay on track with your post-surgical diet and lifestyle changes while still allowing you to enjoy the holiday festivities.

Don’t skip meals
Always make time for breakfast, lunch and dinner. Going long stretches without eating can lead to eating too much or too quickly and cause nausea or vomiting in people who have had weight loss surgery. It can also result in unhealthy food choices due to overwhelming hunger.

Be selective about food choice
Resist the temptation to try foods that are high in sugar and fat. After gastric bypass surgery, fatty and sugary foods can cause “dumping syndrome,” resulting in severe abdominal pain and cramping, diarrhea, nausea and vomiting. Instead, choose low-calorie party foods such as raw vegetables, fruit with yogurt dip or boiled shrimp with lemon or cocktail sauce.

Stay well hydrated
Stay hydrated by drinking water and low-calorie beverages. Avoid alcoholic beverages and try to separate eating and drinking by 30 minutes.

Keep a food diary
Research* shows that recording what you eat helps you stay on track during the holidays. It also helps you meet your protein and fluid goals. Take a minute each night to record your food and fluid intake for the day.

Click here for more healthy eating tips for you and your family.

- Karen Buzby, RD, LDN


*Cornett R, Akers J, Salva J, Zoellner J, Davy B. Daily self-monitoring during the winter holiday period: a feasible strategy for holiday weight maintenance. SCAN’s PULSE. Fall 2011, Vol 5, No 4: 1 – 6.

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Eat Right When Eating Out

Karen Buzby, RD, LDN, and Cara Stewart, RD, LDN, members of the Penn Metabolic and Bariatric Surgery team, offer these tips for eating healthy when dining out.

Dining out can be a challenge for anyone trying to follow a healthy eating plan, but it is especially difficult if you have had weight loss surgery. Restaurant portions are notoriously large and the meals are often packed with sodium and hidden calories from fats, sugars and sauces. Before weight loss surgery, larger portions may have tempted you to eat more than you wanted or needed. After weight loss surgery, the food may go to waste or cause discomfort. 

The following tips can help you enjoy your meal out while sticking to your diet plan.

Limit calories:

• Be conservative with food selection, especially during the first few months after surgery. Stick with simple prepared foods.
• Before ordering, ask yourself: “Is this food pouch worthy?” Make sure you order foods that are a good source of protein and fiber.
• Look for heart-healthy, low-fat or light options. U.S. Food and Drug Administration (FDA) regulations require restaurants to back up their health claims. Feel free to ask for nutrition information if it is not already provided.
• Stay away from the bread and chip baskets as well as dessert and alcohol menus. Ask the server not bring out the dessert cart. If you choose to eat bread, opt for a small, plain yeast roll and avoid items with added fat like garlic bread, cornbread, croissants and muffins.  
• Salad dressings are often high in calories and fat. Always order dressing on the side and ask for low-fat dressing, a lemon wedge or flavored vinegar instead of the full fat and calorie version. 
• Don’t drink your calories. Quench your thirst with calorie-free drinks like water or unsweetened iced tea. Limit or avoid alcoholic beverages.
• If your job requires socializing or doing business over meals, call ahead or go online to learn about your options in advance. Inform the restaurant manager of your dietary restrictions and make special requests ahead of time if necessary.
• Savor each bite of food, enjoy the company and take your time. Allow at least 20 to 30 minutes for each meal. Remember, conversation is calorie-free!

Control portion sizes:

• Watch your portion size. People who have had bariatric surgery receive a “restaurant card” to request smaller portions when dining out. Use it to make sure your meals are an appropriate size.
• Share a meal or order a smaller portion. This reduces portion size and the expense as well.  
• Order from the lunch menu if it is available. Often the lunch menu offers smaller and less expensive entrees.
• Order from the children’s menu if there are healthy selections available.
• Order an appetizer as a main entrée. The portions of appetizers are usually two to four ounces, which is the ideal meal size after weight loss surgery. 
• Ask the waiter to split the main dish and box half before serving it. You can also request a “doggie bag” as soon as you feel satisfied to avoid the temptation of overeating. 
• Try a tapas restaurant, which serves snack-sized appetizers and entrées.  

Manage leftovers:

• When you take home leftovers, remember to refrigerate the food promptly to avoid food-borne illness. Food left out for more than two hours may not be safe to eat.
• Write the date of purchase or preparation on leftovers and remember to discard the food after three to five days. Always follow the mantra: “When in doubt, throw it out.” Plus, you don’t want your refrigerator to turn into a jungle of leftover containers. 
• Reheat food thoroughly.

- Karen Buzby, RD, LDN and Cara Stewart, RD, LDN

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Warm Up This Fall with Peasant Stew

As the temperature drops and winter draws near, there is nothing cozier than a bowl of warm, delicious stew. Dust off the crock pot and serve up a satisfying meal that takes little effort but offers plenty of healthy nutrients.

Ingredients:

• 1 teaspoon ground cumin
• 1/4 teaspoon salt
• 1/4 teaspoon black pepper
• 6 chicken thighs (about 1-1/2 pounds), skinned
• 1 cup chopped onion
• 1 (14.5-ounce) can Mexican-style stewed tomatoes with jalapeño peppers and spices, undrained
• 1 (4.5-ounce) can chopped green chile peppers, undrained
• 1 (15-ounce) can pinto beans, rinsed and drained 1 (15-ounce) can kidney beans, rinsed and drained
• 1/4 cup fresh cilantro, minced
• 1/4 cup reduced-fat sour cream 

Preparation:

1. Combine cumin, salt and pepper; sprinkle over chicken.
2. Place chicken in an electric slow cooker; stir in onion, tomatoes and chiles. Cover and cook on high-heat setting for three hours. Stir in beans, cover. Cook on high-heat setting one hour. 
3. Place one chicken thigh in each of six soup bowls. Ladle 1-1/4 cups stew into each bowl. Top each serving with two teaspoons cilantro and two teaspoons sour cream.

Nutritional Information:Amount per serving

• Calories: 214
• Calories from fat: 16 percent
• Fat: 3.9 g
• Saturated fat: 1.4 g
• Monounsaturated fat: 0.9 g
• Polyunsaturated fat: 0.9 g
• Protein: 21.5 g
• Carbohydrate: 23.7 g
• Fiber: 6 g
• Cholesterol: 61 mg
• Iron: 3 mg
• Sodium: 773 mg
• Calcium: 85 mg

The recipe yields six servings.

This recipe is adapted from Cooking Light (August 2002).

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Bottled Water: Is It Worth It?

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, explains the benefits of drinking tap water instead of bottled water.

Water is the best beverage for staying hydrated and avoiding extra calories, but it’s not necessary to buy it in a plastic bottle. The bottled water industry promotes bottled water as being healthier, yet the reality is that bottled water is less regulated for quality than tap water. Plus it is more expensive and can be environmentally unfriendly, too.

Before buying bottled water, consider these facts:

• Bottled water can cost nearly 2,000 times as much as tap water.
• Environmental Protection Agency (EPA) guidelines for regulating municipal tap water are far more rigorous in terms of control, disinfection and monitoring than those used by the U.S. Food and Drug Administration (FDA) to oversee bottled water. In fact, a National Resource Defense Council (NRDC) study of the bottled water industry, tested over 1,000 bottles of water, and concluded that bottled water is not guaranteed to be any cleaner or safer than tap water. The study found that approximately 25 percent of bottled water was tap water packaged in a bottle and 22 percent of the samples contained chemical contaminants above the strict state limits on municipal tap water.  
• Bottled water companies are not required to disclose information about their products. A recent report released by the Environmental Working Group (EWG) indicates that more than half of the bottled water products surveyed failed EWG's transparency test. According to the report, 18 percent of the companies failed to reveal the source of the water and another 32 percent did not disclose any information about the treatment or purity of the water.
• Studies have also shown that chemicals called phthalates, which disrupt testosterone and other hormones, can leach into bottled water over time.  Although there are regulatory standards limiting phthalates in tap water, there are no legal limits for phthalates in bottled water.  
• Although plastic bottles are recyclable, nearly 90 percent of them end up as litter or garbage contributing more than 2 million tons of plastic to landfills each year. 

A comprehensive list of the tap-water contaminants in your area is available on the EPA website. If you are concerned about the quality or flavor of your tap water, purchase a water filter to put on your tap. It is both easier on your wallet and on the environment. To keep filtered water accessible to drink when you’re on the go, put it in your own reusable bottle to carry with you throughout the day.  

• Complete guide to purchasing a water filter 
• More details on the NRDC study results

- Cara Stewart, RD, LDN

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Penn Advancing Bariatric Surgery with Clinical Research

Jacque Spitzer, MSEd, research project manager at the Center for Weight and Eating Disorders and member of the Penn Metabolic and Bariatric Surgery team, explains the various ways patients can stay connected with the program after surgery.

There are many ways to stay connected with the Penn Metabolic and Bariatric Surgery Program after your surgery. In addition to regular follow-up appointments and an annual visit, many people choose to join Penn’s post-operative support groups or participate in clinical research programs.

As one of the leading research programs in the country, Penn Metabolic and Bariatric Surgery is deeply committed to advancing medicine by finding new, improved ways help people with morbid obesity. At any given time, the Penn Metabolic and Bariatric Surgery Program conducts multiple research studies aimed at better understanding the underlying cause of severe obesity, developing new surgical techniques and finding optimal strategies for improving post-operative outcomes and success.

The first step in participating in clinical research involves learning about the study, asking any question you may have and providing informed consent if you choose to participate. Informed consent means getting all the information about the study and then making an educated decision about whether you want to participate. The decision is all yours and it does not affect the quality of care you receive from the program.

The next step in the process is a screening interview or visit to make sure you fit all of the requirements to participate in the study. Research studies vary greatly in the number of visits and types of activities that they involve. Some involve filling out a one-time survey while others involve repeated visits over months or even years. You learn about all of these parameters before deciding whether to participate.

Participating in clinical research provides the unique opportunity to contribute to the growing understanding of obesity and obesity-related diseases as well as obtaining access to the latest treatments. Click here for a list of all obesity and weight loss surgery research studies currently under way at Penn Medicine.

In addition, support groups provide an opportunity to meet other people who are on a similar weight loss journey, share experiences and offer support to one another. Staying in close contact with the team also allows them to quickly address any problems you may be having so you can stay on track with your post-operative lifestyle changes and achieve your weight loss goals.

- Jacque Spitzer, MSEd

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Bariatric Surgery's Halo Effect: Weight Loss for the Whole Family

Bariatric surgery improves the health and well-being of those who undergo surgery, but a recent study at Stanford University School of Medicine shows the positive impact actually extends to the entire immediate family. 

Researchers found that one year after a family member's gastric bypass surgery, other obese adults in the family lost an average of eight pounds and obese children had a lower body mass index than expected for their growth curve. The family members and children that participated in the study accompanied the bariatric patient to all pre- and post-operative clinic visits, including diet and lifestyle counseling. 

Adult family members reported improved eating habits with less uncontrollable eating, emotional eating and alcohol consumption. Both adults and children reported a significant increase in their activity levels. 

The results of this study come as no surprise to members of the Penn Metabolic and Bariatric Surgery team who have witnessed this pattern many times. After bariatric surgery, patients often report that their pursuit of a healthier lifestyle spurred changes for their whole family, including kitchen cabinet makeovers, healthier home-cooked meals and family fun nights that involve physical activity.

Family members and friends are always welcome to attend Penn Metabolic and Bariatric Surgery Program information sessions and support groups to help their family members and to help themselves as well. 

Note: The study was published on Oct. 17, 2011 in the Archives of Surgery. 

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Savor the Tastes of Fall: Roasted Pumpkin and Sweet Potato Pilaf

Roasted pumpkin and sweet potato pilaf presents the perfect opportunity to mix warm, cozy and delicious fall flavors with healthy ingredients. Pilaf is a form of grain that gets its flavorful taste from cooking in broth. With fiber-rich brown rice and vitamin-packed vegetables like pumpkin and sweet potato, this tasty side dish adds important nutrients to your meal.

Ingredients:

• 2 cups (1/2-inch) cubed, peeled fresh pumpkin (about 12 ounces)
• 1 1/2 cups (1/2-inch) cubed, peeled sweet potato (about 1 medium)
• Cooking spray
• 2 teaspoons olive oil
• 1 cup diced onion (1 small)
• 1/3 cup diced celery (about 1 rib)
• 2 teaspoons minced garlic
• 4 cups fat-free, less-sodium chicken broth
• 1 cup brown rice (not instant)
• 2 teaspoons chopped fresh sage
• 1/2 teaspoon freshly ground black pepper
• 1/4 teaspoon salt
• 1 bay leaf

Preparation:

1. Preheat oven to 400 degrees.
2. Arrange pumpkin and sweet potato in an even layer on a jelly-roll pan coated with cooking spray. Bake at 400 degrees for 18 minutes, stir and return to oven for another 17 minutes or until the vegetables are tender and begin to brown.
3. Heat oil in a large saucepan over medium-high heat. Add onion, celery and garlic to pan; sauté 3 minutes or until onion is tender. Add broth and remaining ingredients to onion mixture, stirring to combine; bring to a boil. Cover, reduce heat and simmer for 50 minutes or until rice is done and liquid is mostly absorbed. Remove from heat; discard bay leaf. Add pumpkin mixture; stir gently to combine.

Nutritional Information:
Amount per serving

• Calories: 200
• Calories from fat: 11 percent
• Fat: 2.5g
• Saturated fat: 0.4g
• Monounsaturated fat: 1.4g
• Polyunsaturated fat: 0.5g
• Protein: 5.9g
• Carbohydrate: 38.8g
• Fiber: 3g
• Cholesterol: 0.0mg
• Iron: 1.3mg
• Sodium: 428mg
• Calcium: 45mg

The recipe makes 6 servings. Serving size is about ¾ cup.

This recipe is courtesy of Jaime Harder, MA, RD, Cooking Light (October 2007).

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The Essential Kitchen Tools, Utensils and Appliances for Successful Weight Loss

Karen Buzby, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, discusses kitchen tools that can help you eat healthier and lose weight.
Whether you’re trying to lose weight or recovering from weight loss surgery, healthy meal preparation is critical for weight loss.  Follow these recommendations to make sure your kitchen is set up with the right appliances and utensils to help you successfully shed the pounds.

Use the right utensils

• Measuring spoons: The tablespoon is useful for portion control and the ¼-, ½- and 1-teaspoon measurements are commonly used in recipes.
• Measuring cups: The ¼-, ⅓-, ½-, and 1-cup measurements are frequently used for solids, and an 8-ounce glass or clear plastic measuring cup works best for liquids.
• Food scale: A scale is helpful to weight meat, poultry and fish for portion control

Slow the pace of eating

• Mini or baby spoon and fork: The small surface area of small utensils reduces consumption by making bites smaller.
• Tea cup saucer: The bigger the plate, the bigger the serving. A smaller plate size often means eating less. 
• Cup warmer: Place a cup warmer under a ceramic plate to keep food hot so you don’t feel rushed when you eat.
• Egg or kitchen timer: Use the timer to slow down the pace your meals and to remind you to drink plenty of water.  

Use storage items to keep healthy meals on hand and promote small portions

• Insulated, reusable water bottle and brush: A portable beverage container allows you to keep your protein drink or beverage with you at all times. The brush is useful for cleaning your container.
• Small non-stick frying pan and ceramic baking container: The small size helps you regulate portion size.
• Extra small, reusable, plastic storage containers: Use the environment-friendly containers to store lunches and on-the-go snacks in the refrigerator and freezer.

Handy kitchen gadgets and countertop appliances make healthy meal preparation easier

• Meat thermometer: The thermometer allows you to ensure that entrées are cooked appropriately to help avoid food-borne illness.
• Vegetable peeler: A peeler removes tough skin from produce such as potatoes.
• Blender: Helpful for making protein drinks and low-calorie smoothies, you can choose a counter-top blender, hand-held stick blender, wire whisk or shaker.
• Food processor: A food processor is a kitchen essential during the pureed food phase of the post-surgical diet.

- Karen Buzby, RD, LDN

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Convenient and Healthy, Too! Finding Diet-Friendly Frozen Food

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, provides tips for finding healthy frozen food.

Although it gets a bad rap, the supermarket’s freezer section is actually brimming with time-saving, nutritious food choices: as long as you know what to look for on the label.  By learning about healthy frozen foods, you can stock up on diet-friendly options to have on hand when you do not have time to cook.

Produce – Frozen fruits and vegetables are often more nutritious than fresh produce because they are frozen shortly after harvesting, preserving nutrients.

• Vegetables: Look for plain frozen vegetables without added butter, cheese or sauce.  Heat them in the microwave for a quick side dish or tasty addition to your favorite soup or casserole.
• Fruits: Look for products without added syrup or sugar.  Add frozen fruit to yogurt, smoothies and cereal or eat them straight from the freezer as a snack.

Frozen meals – Although they typically do not taste like a fresh, homemade dish, frozen meals can be helpful for those times when you do not have the time or energy to cook.  Choose products with no more than 3.5 grams of fat per 100 calories and 600 mg of sodium or less.  Make sure the frozen entrée has at least 4 grams of fiber and 15 grams of protein to keep you satisfied.  Reliable brand options include Kashi, Lean Cuisine, Healthy Choice and Smart Ones. 

Waffles – Choose 100 percent whole grain varieties.  The first ingredient listed on the label should be whole wheat flour.

Pizza – Choose a pizza product with a thin, whole wheat crust if possible.  Avoid high-fat toppings like pepperoni and sausage. Opt for vegetable toppings or get a plain pizza and top it with your own favorite vegetables at home. 

Desserts –Choose pre-portioned novelty ice creams with 150 calories or less, like Skinny Cow or Weight Watchers varieties. Sugar-free or 100 percent fruit popsicles are also good options.

Vegetarian – There are several options for vegetarian burgers, patties and sausages.  Choose varieties with 300 mg of sodium or less per serving.

- Cara Stewart, RD, LDN

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Avoiding Food-borne Illness after Weight Loss Surgery: What You Need to Know

Karen Buzby, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, discusses the importance of prevention and fast recovery from food-borne illness, especially after bariatric surgery. 


Contracting a food-borne illness, or food poisoning, is distressing for anyone, but it is particularly dangerous after bariatric surgery. When recovering from bariatric surgery, the pace of drinking and eating is often limited and makes rehydration difficult. For people who had the adjustable gastric band procedure, there is also an increased risk for the gastric band to slip out of position if vomiting is severe or prolonged.

Food-borne illnesses are caused by bacteria, viruses or parasites in food. They are the result of mishandling during processing or preparation, failure to cook items to the recommended temperature or improper storage. Foods from animals and unpasteurized milk are particularly at risk for food poising. This includes raw or undercooked meat, poultry, fish, shellfish and eggs. Although less common, fresh fruits and vegetables can also contain harmful bacteria from contaminated water or soil.

Food poisoning causes flu-like symptoms, including nausea, vomiting, diarrhea and fever. Symptoms usually appear four to 48 hours after eating and pass after one or two days. However, some cases of food-borne illness can be severe and even life-threatening. It is important to seek immediate medical attention if you experience any of the following symptoms:

• Light-headedness when standing
• Persistent vomiting
• Fever higher than 101 degrees Fahrenheit
• Blood in bowel movements
• Diarrhea for more than three days

Keep in mind that after bariatric surgery, food intolerance and dumping syndrome cause similar symptoms to food poisoning, such as nausea and vomiting. The difference is that symptoms from food intolerance and dumping syndrome typically occur immediately or soon after eating and resolve within several hours. Symptoms from food poisoning tend to have delayed onset and longer duration.

To prevent contracting food-borne illness, take the following precautions:

• Wash your hands. Make sure to wash your hands with soap and water before preparing or eating food. If you are unable to wash your hands, use an alcohol-based hand gel that is at least 60 percent alcohol.
• Cook meat, poultry, fish and eggs thoroughly and serve hot. If a restaurant serves an undercooked item, send it back and request a new plate.
• Meat and poultry: Cook to an internal temperature of 160 degrees Fahrenheit. Make sure the meat is no longer pink inside and the juices are clear.
• A whole chicken or turkey should be cooked to an internal temperature of 180 degrees Fahrenheit. Make sure the poultry joints move easily.
• Poultry breasts and roasts can be cooked to 170 degrees Fahrenheit.
• Egg: Yolks and white should be firm, not runny. Avoid food with raw egg, including salad dressing, sauces, homemade ice cream, uncooked cake batter or cookie dough.
• Fish: Cook fish until the internal temperature is 145 degrees Fahrenheit. Make sure the fish is opaque and easily flakes with a fork.
• Only drink pasteurized dairy products. Avoid foods made from unpasteurized milk.
• Refrigerate perishable food promptly. Food that is left out for more than two hours may not be safe to eat. Store perishable foods in a refrigerator that is below 40 degrees Fahrenheit. In the summer, when the temperature can be over 90 degrees, do not leave food out for more than an hour.
• Wash fruits and vegetables before eating.

If you do fall victim to a food-borne illness, follow these tips for a quick recovery:

• Hydrate with water or low-calorie fluids. Clear broths, diluted juice, weak tea, diet gelatin or sugar-free ice pops are good sources of hydration. Start with small sips and gradually increase the pace of drinking.
• Reintroduce food slowly. Start with bland foods that are easy to chew and digest.
• Separate drinking and eating by 30 minutes. Take several days to progress to your regular bariatric diet.
• Talk to your doctor. Tell your provider about your symptoms to avoid a long-term impact on your health.

- Karen Buzby, RD, LDN

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Enjoy this Fall Favorite: Fresh Apple Salsa

Apple salsa brings together the fresh flavor of delicious fall apples and healthy nutrients. Apples are packed with a soluble fiber called pectin and powerful antioxidants called polyphenols. These two key nutrients reduce blood cholesterol levels and prevent the formation of artery-clogging plaque.

Serve fresh apple salsa with roasted chicken or pork, black beans or with tortilla chips as a dip.

Ingredients:

• 2 cups diced peeled Fuji or Jonagold apple (about 3/4 pound)
• 1/2 cup diced red bell pepper
• 1/3 cup fresh lime juice
• 1/4 cup diced red onion
• 1/4 cup minced fresh cilantro
• 1 tablespoon honey
• 1/4 teaspoon salt
• 1/4 teaspoon freshly ground black pepper
• 1 jalapeño pepper, seeded and minced

Preparation:

1. Combine all ingredients, stirring well.

Nutritional Information:
Amount per serving

• Calories: 21
• Fat: 0.1g
• Saturated fat: 0.0g
• Monounsaturated fat: 0.0g
• Polyunsaturated fat: 0.0g
• Protein: 0.2g
• Carbohydrate: 5.7g
• Fiber: 0.8g
• Cholesterol: 0.0mg
• Iron: 0.1mg
• Sodium: 50mg
• Calcium: 4mg

The recipe makes 12 servings.

This recipe is courtesy of Kathy Farrell-Kingsley, Cooking Light (October 2010).

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Coping with Constipation after Weight Loss Surgery

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, provides tips for achieving bowel regularity after weight loss surgery.

It may not be an appropriate topic of conversation in many circles, but constipation is relatively common among people who have had weight loss surgery, especially immediately following their surgery. Irregularity can be caused by a lot of things:

• Decreased fluid and fiber intake
• Reduced physical activity
• Narcotic painkillers
• Iron or calcium supplements
  

Many people report only having a bowel movement every two or three days following weight loss surgery. This can lead to constipation. It is important to keep track of your bowel habits and try to have a bowel movement every day.

To relieve constipation:

If it has been more than three days since your last bowel movement, you can take one dose of milk of magnesia or two Dulcolax^® tablets. Repeat every four to six hours. If you do not have results within 24 hours, you should call your bariatric nursing team to discuss.

To prevent constipation and promote bowel regularity:

• Stay hydrated. Drink adequate fluids to help soften your stool. You should drink at least 48 ounces per day.
• Exercise. Take frequent short walks throughout the day, as tolerated.
• Consume adequate fiber. Because your eating is primarily focused on high-protein foods following bariatric surgery, your consumption of high-fiber food is limited. Take fiber supplements as needed to help you get at least 15 grams of fiber per day.
• Use laxatives when necessary. Stick with Metamucil^® and other bulk-forming laxatives based on whole psyllium. Make sure to follow the mixing instructions for optimal results.
  

- Cara Stewart, RD, LDN

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Versatile, Easy and Protein-Packed: Mushroom Frittata

Eggs are a versatile source of protein and are great for any meal: breakfast, lunch, or dinner. One egg contains 70 calories and 6 grams of protein. This simple recipe combines whole eggs and egg whites to decrease the calorie, fat and cholesterol content without compromising taste. Pair this dish with a salad for a light, late-summer meal.

Ingredients:

• 1 (8-ounce) package exotic mushroom blend or white button mushrooms
• 1/2 cup shredded Parmigiano-Reggiano cheese
• 1 1/2 teaspoons chopped fresh thyme
• 3 large egg whites
• 2 large eggs

Preparation:

1. Preheat broiler.
   
2. Heat an 8-inch ovenproof skillet over medium-high heat. Coat pan with cooking spray.
   
3. Add mushrooms to pan; sauté 12 minutes or until lightly browned.
   
4. Place mushrooms in a medium bowl; cool slightly.
   
5. Wipe pan clean with paper towels.
   
6. Combine mushrooms, cheese, thyme, 1/4 teaspoon freshly ground black pepper, 1/8 teaspoon salt, egg whites and eggs in a medium bowl, stirring well with a whisk.
   
7. Heat pan over medium heat. Coat pan with cooking spray.
   
8. Add mushroom mixture; cook, covered, for 3 minutes or until almost set.
   
9. Broil 3 minutes or until egg is set.
   
10. Cut into 4 wedges.
11. Enjoy!
    

Nutritional Information:
Amount per Serving

• Calories: 122
• Fat: 6.4g
• Saturated fat: 3.2g
• Monounsaturated fat: 2.2g
• Polyunsaturated fat: 0.4g
• Protein: 13.3g
• Carbohydrate: 3g
• Fiber: 0.8g
• Cholesterol: 116mg
• Iron: 0.9mg
• Sodium: 401mg
• Calcium: 195mg

The recipe makes 4 servings.

This recipe is adapted from Cooking Light (October 2009).

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Taking Vitamin and Mineral Supplements: Make time even if you feel fine!

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, outlines the important vitamin and mineral supplements to take after weight loss surgery.

After weight loss surgery, you need to commit to taking a regimen of vitamin and mineral supplements for the rest of your life. Eating smaller amounts of food means your body receives fewer nutrients. In addition, after gastric bypass or sleeve gastrectomy surgery, your system does not absorb some vitamins and minerals as well.

This table highlights the functions of several key nutrients and the symptoms of their deficiency. The damage to your body from many of the deficiencies is permanent, so be sure to follow your dietician’s instructions for taking supplements and have your lab values checked routinely with your primary care physician.

NUTRIENT	WHAT IT DOES	DEFICIENCY
Vitamin B1 (thiamine)	Helps all cells of the body produce energy from carbohydrates	Fatigue, weak muscles, nerve damage
Vitamin B12	Works with folate to make red blood cells Vital part of every cell Helps body use fatty acids and some amino acids	Anemia, fatigue Permanent nerve damage including tingling or numbness in hands and feet
Folate (folic acid)	Plays essential role in making new body cells Works with B12 to form hemoglobin in red blood cells Helps reduce risk of neural tube defects (spina bifida) in developing fetus	Anemia caused by malformed blood cells that won’t carry as much oxygen Increased risk of neural tube defects in developing fetus
Vitamin A	Promotes normal vision, helps eyes see normally in the dark Promotes growth and health of all cells Keeps tissues healthy to prevent infection Works as an antioxidant	Night blindness Dry, scaly skin Reproductive problems
Vitamin D	Promotes absorption of calcium and phosphorus Regulates amount of calcium in blood	Osteoporosis (loss of bone mass) Osteomalacia: softening of bones
Calcium (**NOTE: Supplements are still needed even if blood levels are normal)	Helps bones remain strong by slowing rate of bone loss with age Helps muscles contract and heart beat Promotes normal nerve function	Osteoporosis
Iron	Essential part of hemoglobin that carries oxygen in blood Supports healthy immune system	Iron deficiency anemia Fatigue Infections

- Cara Stewart, RD, LDN

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Providing Support, Education and Advocacy for People with Obesity

Rebecca Dilks, RD, LDN, research coordinator at the Center for Weight and Eating Disorders and member of the Penn Metabolic and Bariatric Surgery team, explains the mission of and Penn's involvement with the Obesity Action Coalition.

Obesity is a disease and its patients require support, education and access to treatment. Several members of the Penn Metabolic and Bariatric Surgery team had the privilege of learning about expanding access to obesity treatment, ending weight bias and preventing obesity through education, awareness and advocacy at the 28th annual meeting of the American Society for Metabolic and Bariatric Surgery, the largest bariatric society in the world.

At the annual meeting, we learned about the Obesity Action Coalition's (OAC) website, magazine, newsletter, support groups and other methods being used to increase education about obesity, including a "Walk from Obesity." It was clear to us that the OAC offers a unique opportunity for bariatric health care providers and patients to team up and improve the lives of people affected by obesity. In fact, we were so impressed by the OAC that several members of the Penn Metabolic and Bariatric Surgery Program joined the coalition.

A major focus of the OAC is advocating for widespread recognition of obesity as a disease. Patients can be denied access to important medical treatments, including medically managed weight loss or bariatric surgery, because insurance companies do not recognize obesity as a disease. The OAC wants to change this by encouraging patients and providers to contact elected officials, legislators and employers and emphasize the importance of treating obesity as a disease. They also provide guidance for those seeking insurance coverage for bariatric surgery.

With tools provided by the OAC, people affected by obesity can help eliminate the negative stigma and encourage key decision makers to recognize obesity as the medical disease that it is.

We encourage you to consider joining the OAC as part of your bariatric surgery experience with the Penn Metabolic and Bariatric Surgery Program.

For more information about the Obesity Action Coalition, visit the website.

- Rebecca Dilks, RD, LDN

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Hearty and Healthy: Huevos Rancheros with Zucchini and Green Pepper

Take advantage of the delicious, abundant summer vegetables to create a meal hearty enough for a hardworking rancher and healthy and tasty enough for you. With lots of vegetables, protein-packed eggs and melted cheese, this recipe makes an energizing breakfast, brunch or even dinner. To top it off, it has only 250 calories! So, head to the garden, farmers market or grocery store to pick up summer vegetables while they last and add this southwestern staple to your upcoming menu plan.



Ingredients:

• 1 teaspoon olive oil
• Cooking spray
• 1 1/2 cups diced zucchini
• 1/2 cup diced green bell pepper
• 1/4 cup water
• 1/4 teaspoon salt
• 1/4 teaspoon ground cumin
• 1/8 teaspoon freshly ground black pepper
• 1 (10-ounce) can diced tomatoes with green chiles, undrained
• 4 (6-inch) corn tortillas
• 4 large eggs
• 1/3 cup (1 1/4 ounces) pre-shredded, reduced-fat cheddar cheese
• 2 teaspoons chopped fresh cilantro

Preparation:

1. Heat oil in a large nonstick skillet coated with cooking spray over medium-high heat. Add zucchini and bell pepper. Sauté for six minutes or until lightly browned. Add water and next four ingredients (water through tomatoes). Stir to combine. Cover and simmer for three minutes.
   
   
2. Warm tortillas according to package directions.
3. Break one egg into a small custard cup. Slip egg onto tomato mixture. Repeat procedure with remaining eggs. Cover and simmer for three minutes or until eggs are done. Sprinkle with cheese. Cover and cook for 30 seconds or until cheese melts.
4. Place one tortilla on each of four plates. Spoon one egg and 3/4 cup tomato mixture onto each tortilla. Sprinkle with 1/2 teaspoon cilantro.
   
   

Nutritional Information:

Amount per serving

• Calories: 248
• Calories from fat: 31%
• Fat: 8.5g
• Saturated fat: 2.1g
• Monounsaturated fat: 2.9g
• Polyunsaturated fat: 0.9g
• Protein: 13.2g
• Carbohydrate: 31.5g
• Fiber: 4.1g
• Cholesterol: 214mg
• Iron: 2.6mg
• Sodium: 679mg
• Calcium: 155mg

The recipe is courtesy of Jean Kressy, Cooking Light (May 2003).

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Tips for bringing your diet on vacation

Karen Buzby, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, offers tips for maintaining your post-surgical diet during your vacation.



Following the recommended post-operative diet after bariatric surgery is always a challenge, but it is especially difficult when traveling. By planning ahead, you can maintain good eating habits and continue to meet your nutritional goals – even on vacation.



If you are traveling by car, here are tips for healthy eating on the road:

• Pack plenty of water. If you are traveling by car, pack an insulated cooler filled with water, sugar-free beverages and protein drinks.
• Bring high-protein foods. Light yogurt, cheese, cottage cheese singles, hard-cooked eggs and individual packets of tuna or lean deli meats can be kept in the insulated cooler with ice packs or frozen water bottles to keep them cool.
• Always keep healthy snacks on-hand. Protein bars, nuts and soy crisps are easy, nutritional snack choices that also are high in protein. Fresh fruit, light fruit cups, vegetable medleys and cherry tomatoes make excellent are also great choices.
• Read the nutrition facts. Before making any purchases on the road, use the nutrition label to guide your selection and portion size to make sure you stay on track with your diet. Highway rest stops carry a variety of calorie-free beverages, but their healthy snack options are often much more limited.
• Stick to plain or simply prepared foods. When purchasing meals on the road, simple is usually best. If you have any questions about sugar content, ingredients or method of preparation, ask the restaurant for clarification. Many restaurants have brochures with nutrition information available upon request.
  
  
• Find a nearby grocery store. Once you reach your final destination find a local grocery where you can replenish your beverages and diet essentials.
• Request an in-room refrigerator. It it easier to eat healthy if you have a place to keep your healthy beverages and snacks. Also, take advantage of the complimentary ice machine to fill your beverage container or cooler when you pack up to leave.
  
  

If you are traveling by plane, here are tips for healthy eating in the air:

• Buy a calorie-free beverage after you are through the security checkpoint. The Transportation Security Administration (TSA) requires that all carry-on liquids fit inside a 3.4-ounce or smaller container that is stored in a quart-sized, clear, plastic, zip-top bag. Each passenger is limited to one zip-top bag of liquids. Purchase calorie-free beverages to bring on the flight after you have been cleared by security.
• Pack protein powder in your carry-on bag. Dense foods items like peanut butter and sugar-free preserves should be packed in your checked luggage, but carry a quick protein fix in your carry-on. Just remember to leave time for any additional screening.
• Order special in-flight meals in advance. Many airlines offer meal accommodations for passengers with specific dietary needs on long or international flights, including low-fat and sugar-free meals. Special meals need to be ordered at least 24 hours before your flight.
  
  

Regardless of your means of traveling, keeping a food diary is a foolproof way of ensuring that you meet your nutritional needs no matter how far you are from home.



It may take extra planning on your part, but it is possible to stay on-track with your diet on vacation.



Safe travels!



- Karen Buzby, RD, LDN

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Considering bariatric surgery? Quit Smoking. Today.

Anyone who smokes knows they should kick the habit. But quitting smoking is especially important for people considering bariatric surgery. The guidelines for bariatric surgery require patients to quit smoking 60 days prior to surgery.

The health consequences of smoking are well known and well documented, but these dangers are amplified for people with obesity. Along with the associated higher risk for cancer, heart disease and stroke, smoking increases the risks associated with surgery, including anesthesia-related complications, infections, heart attack, stroke, pneumonia and death. It also slows down healing time by narrowing blood vessels, restricting blood flow to the surgical site.

Smoking after bariatric surgery puts patients at significantly higher risk for a host of complications, such as ulceration of the gastric pouch, gastritis, infection and increased shortness of breath.

It is never too late to quit and Penn has several options to help people break their smoking habit. The health benefits of smoking cessation occur almost immediately and have a long-lasting impact.

Effects of quitting smoking* after:

• 20 minutes: Heart rate and blood pressure drop.
• 12 hours: Carbon monoxide level in the blood drops to normal.
• 2 weeks to 3 months: Circulation improves and lung function increases.
• 1 to 9 months: Coughing and shortness of breath decrease; cilia (tiny hair-like structures that move mucus out of the lungs) start to regain normal function in the lungs, increasing the ability to handle mucus, clean the lungs and reduce the risk of infection.
• 1 year: Excess risk of coronary heart disease is half that of a smoker.
• 5 years: Risk for cancer of the mouth, throat, esophagus and bladder are cut in half; cervical cancer risk falls to that of a non-smoker; stroke risk can fall to that of a non-smoker after two to five years.
• 10 years: Risk of dying from lung cancer is about half that of a smoker; risk for cancer of the larynx and pancreas decreases.
• 15 years: Risk for coronary heart disease is that of a non-smoker's.
  

For smokers who are interested in bariatric surgery, enroll in a smoking cessation program to begin the quest to a healthy lifestyle.

Local resources:

• Penn’s Comprehensive Smoking Treatment Program: A multidisciplinary team of specialists offers state-of-the-art, individualized treatment to help smokers quit safely and comfortable.
• Quit Smoking Program at Pennsylvania Hospital: The respiratory care team offers a five week program with counseling and support to help smokers overcome their addiction.
  
• Pennsylvania’s Free Quitline: The Philadelphia Department of Public Health offers a variety of resources to help residents quit smoking, including a free one-month supply of nicotine patches through the PA Free Quitline telephone counseling program at 877-724-1090.
  

Additional resources:

• American Cancer Society, 800-ACS-2345
• American Lung Association, 800-586-4872
  

Get help to begin the journey to health - today!

*American Cancer Society, Guide to Quitting Smoking.

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Eat More to Lose More: Healthy Snacks for Weight Loss

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, explains the benefits of healthy snacking.

Don't overlook the benefits of snacking when trying to lose weight. Snacking helps you fuel up between meals and can prevent you from overeating and making unhealthy food choices. The healthiest snacks include a mix of complex carbohydrates and protein to keep you feeling full throughout the day.

In fact, many nutrition experts suggest shifting away from the traditional three-meals-a-day diet. Instead, they recommend eating small, nutritious meals every three hours or eating five to six times a day. Although it may seem counter-intuitive to weight loss, eating smaller, more frequent meals helps you maintain consistent blood sugar levels throughout the day, and prevents ravenous hunger that often leads to overeating and poor food choices.

If you are tired of your usual snacks or looking for healthier alternatives, here are a few ideas to liven up your healthy snack options:

• Celery sticks spread with one to two tablespoons of almond or peanut butter
• Fresh vegetables (i.e. carrot sticks, cherry tomatoes or fresh green beans) with two tablespoons of hummus
• One serving of whole grain crackers topped with one ounce of reduced-fat cheese and sliced green grapes
• One small apple, sliced with one tablespoon of peanut butter for dipping
• Half a cinnamon raisin, whole-grain English muffin topped with low-fat cottage cheese, no-calorie sweetener (i.e. Splenda^®, Truvia or Pure Via™) and cinnamon
• One serving Greek yogurt with fresh fruit
• One cup homemade vegetable soup
• One brown rice cake with pesto, canned salmon and diced tomatoes
• Three handfuls of air-popped popcorn seasoned with spray butter and herbs
• One brown rice cake topped with a sliced hard-boiled egg, light mayo and fresh herbs
  

- Cara Stewart, RD, LDN

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Greek Yogurt: Energizing, Healthy and It Tastes Good, Too!

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, explains the health benefits of Greek yogurt.

Greek yogurt is all the rage lately – and for good reason. Although it has been a part of Mediterranean and Middle Eastern diets for centuries, Greek yogurt has only recently gained popularity in the U.S.

Strained of most of its whey content (the liquid portion of yogurt), Greek yogurt has a thicker and creamier texture than regular yogurt. It is also higher in protein, which is why Greek yogurt is a mainstay of many people’s diets before and after bariatric surgery. Ounce for ounce, it contains up to twice as much protein as regular yogurt.

As with any packaged food, it is important to read the food label. Beware of the fat and sugar content in some varieties. Full-fat versions can contain up to 20 grams of fat per serving while fruit-flavored versions may contain significant amounts of added sugar.

Stick to the nonfat, plain varieties with no added sugar. Non-added sugar listed on the label is from lactose, a natural milk sugar. Add fresh or frozen fruit or a no-calorie sweetener like Splenda^® to give Greek yogurt a healthy and flavorful boost without adding excess sugar or fat. Greek yogurt can also be a delicious ingredient in other recipes, including fruit smoothies.

See below for comparisons between regular and Greek yogurts.








- Cara Stewart, RD, LDN

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Get Moving! Tips for Exercising – Safely!

Sarah Krebs, DPT, and Pamela Welsh, PTA, members of the Penn Metabolic and Bariatric Surgery team, provide tips for starting an exercise program.

Are you interested in starting an exercise program? Congratulations! Making the decision to start exercising is half the battle. Avoiding injury and staying committed – that’s the other half.

Exercise is an important part of your weight-loss program. But before you jump right in, make sure to take the proper steps to ensure your safety and long-term exercise success. Taking precautions maximizes the efficacy of your workouts while helping you stay healthy and well, which means you can stay on track to your fitness goals.

Follow these tips to expedite your journey to tip-top shape:

1. Clear your workout with your doctor before starting resistive training.
2. Wear proper footwear (i.e. rubber sole sneakers).
3. Set realistic goals.
4. Start slowly.
5. Maintain proper form. Remember to seek quality, not quantity.
6. Warm up and cool down before and after every workout.
7. Stretch after every workout.
8. Focus on breathing techniques. Exhale on exertion and inhale on relaxation.
9. Monitor your heart rate and stay within target heart rate zone.

- Sarah Krebs, DPT, and Pamela Welsh, PTA

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Provençal Cooking Minus the Cost of Airfare: Eggplant, Zucchini and Tomato Tian

Dreaming of a summer getaway to the South of France? Fantasizing about leisurely dinners in the warm, Mediterranean air? Keep dreaming, but in the meantime, try this Provençal recipe for eggplant, zucchini and tomato tian. Tian [TYAHN ] is a French word used throughout Provençe that refers both to a shallow cooking vessel and the food that is cooked in it.

The recipe gives you a taste of delicious Provençal cooking while taking advantage of summer’s bounty of ripe, nutritious and colorful vegetables. An 11 x 7-inch glass or ceramic baking dish works well for this recipe.

Ingredients:

• 1 pound Japanese eggplant, cut diagonally into ¼-inch thick slices
• 1 pound zucchini, cut diagonally into ¼-inch thick slices
• Cooking spray
• 1 pound large beefsteak tomatoes, peeled, seeded and cut into ¼-inch thick slices
• 1 ½ tablespoons extra-virgin olive oil, divided
• ¼ teaspoon salt, divided
• ¼ teaspoon freshly ground black pepper, divided
• 4 ounces French bread baguette
• 1 cup (4 ounces) grated fresh parmigiano-reggiano cheese
• 2 tablespoons fresh flat-leaf parsley, chopped
• 2 teaspoons fresh oregano, chopped
• 1 ½ teaspoons fresh thyme, chopped
• 2 garlic cloves, minced
• ¼ cup fat-free, low-sodium chicken broth

Preparation:

1. Preheat oven to 375 degrees.
2. Arrange eggplant and zucchini in a single layer on a baking sheet coated with cooking spray. Lightly coat vegetables with cooking spray. Bake at 375° for 15 minutes. Arrange half of eggplant in a single layer in an 11 x 7-inch glass or ceramic baking dish coated with cooking spray. Top with half of zucchini and half of tomato. Drizzle 2 ¼ teaspoons olive oil evenly over vegetables. Sprinkle vegetables evenly with 1/8 teaspoon salt and 1/8 teaspoon black pepper.
3. Place bread in a food processor; process until coarse crumbs measure 2 cups. Add cheese and next 4 ingredients (through garlic) to processor; process until combined. Sprinkle 1 ½ cups breadcrumb mixture evenly over tomato. Repeat layers with remaining eggplant, zucchini, tomatoes, oil, salt, pepper and breadcrumb mixture. Pour broth over top. Bake at 375° for 1 hour or until vegetables are tender and topping is browned.
4. Bon appetit!
   

Nutritional Information:

• Amount per serving
• Calories: 191
• Fat: 8.1 g
• Saturated fat: 3 g
• Monounsaturated fat: 3.7 g
• Polyunsaturated fat: 1 g
• Protein: 10 g
• Carbohydrate: 22.3 g
• Fiber: 4 g
• Cholesterol: 12 mg
• Iron: 1.6 mg
• Sodium: 459 mg
• Calcium: 178 mg

This recipe makes 6 servings. Serving size is approximately 1 cup.

The recipe is courtesy of Joanne Weir, Cooking Light (June 2010).

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