Low-calorie but not a Freebie: Get the Scoop on Sugar Alcohol

Sugar alcohols, or polyols, are carbohydrates that get their name from their chemical structure. Adding sweetness and texture to foods like sugar-free candy, gum and desserts, sugar alcohols contain fewer calories than regular sugar -- 2.6 calories versus 4 calories per gram – and do not contribute to tooth decay.

The body absorbs sugar alcohols slowly and incompletely, reducing their effect on blood sugar. This can be helpful for people with diabetes or those who are limiting caloric intake. Sugar alcohols do not cause dumping syndrome for people with gastric bypass, although their abnormal absorption can cause cramping, bloating and diarrhea when consumed in large quantities. Studies indicate that people can tolerate 10 to 15 grams of sugar alcohols per day without gastrointestinal distress, although some individuals can experience side effects from less.

It is important to remember that sugar alcohols are typically used in foods that have little nutritional benefit but still contain calories, such as desserts and snacks. Therefore, portion control remains very important for long-term, sustained weight loss.

Products containing sugar alcohols list the grams per serving on the nutrition fact label. The sugar alcohol content can also be found by looking for ingredients ending in “-tol,” such as sorbitol, mannitol and xylitol.

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Feeling Tired or Sluggish? The Culprit Could be Iron

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, discusses the impact bariatric surgery has on iron levels and provides tips for iron supplements.

Your body uses iron to produce red blood cells. Insufficient iron in your diet may put you at higher risk for developing iron deficiency or iron deficiency anemia. Iron deficiency is a condition in which the body does not produce enough normal red blood cells for optimal health. Symptoms of iron deficiency include:

• Tiredness
• Shortness of breath
• Decreased physical performance
• Learning problems in children and adults
• Increased risk for infection

People who have had bariatric surgery are more prone to iron deficiency because of their reduced intake of iron-rich foods, such as red meat, seafood, and poultry. In addition, gastric bypass and sleeve gastrectomy patients produce less stomach acid, which can interfere with iron absorption. Maintaining an optimal iron level is particularly challenging for people who have had gastric bypass, as the surgery circumvents the primary site of iron absorption.

While some people with bariatric surgery are still able to obtain adequate iron from food, others rely on iron supplements to maintain a healthy iron level. For those who require iron supplements, the following tips can help maximize iron absorption while minimizing any unpleasant side effects.

• Take 250 mg of vitamin C or consume foods rich in vitamin C when taking an iron supplement. Examples of good sources of vitamin C include:

- Bell Pepper
- Broccoli
- Brussel sprouts
- Citrus fruits
- Cantaloupe
- Cauliflower
- Kale
- Parsley
- Strawberries

• Take iron supplements with food to prevent nausea or abdominal discomfort.

• Prevent constipation by consuming adequate fiber through your diet and supplements, drinking enough fluids and exercising regularly.

• Avoid calcium supplements and dairy when taking an iron supplement or consuming iron-rich food. Calcium can inhibit the absorption of iron. Separate consumption of calcium and iron by at least two hours.

• Avoid tea, cola, coffee, red wine, pomegranates and berries when taking an iron supplement or eating iron-rich food. These foods and beverages contain tannins, which can inhibit iron absorption.

Make sure to check with your healthcare team to determine whether an iron supplement might be helpful for you.

- Cara Stewart, RD, LDN

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Take Control of Your Blood Pressure

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, offers advice for managing hypertension with diet and exercise.

Healthy lifestyles play a major role in the prevention and treatment of hypertension or high blood pressure. For those who have high blood pressure or those at risk for hypertension, small diet and exercise changes can help you control your blood pressure without medication.

These simple lifestyle tips can help prevent or manage hypertension:

Eat plenty of fresh or frozen vegetables and fruits. When using canned vegetables, choose products with “no salt added.”

Skip the salt when cooking. Use herbs, spices, herbed vinegars and fruit juices to add flavor instead.

Choose foods that are low in sodium. If you have hypertension, you should consume no more than 1,500 mg of sodium per day. That is the equivalent of just under two-thirds of a teaspoon of salt.

Read the nutrition facts on the label to determine sodium content in packaged food. The sodium content is usually listed in milligrams per single serving. Look for the products that say:

• Unsalted
• No salt added
• Reduced sodium
• Sodium-free
• Low in sodium

Spend at least 30 minutes a day doing physical activity. Take a brisk walk around the neighborhood or join a fitness class with a friend. If you have physical limitations, try seated exercise programs.

Be mindful of calorie intake and gradually increase exercise to facilitate weight loss. Your blood pressure rises as your body weight increases, so weight reduction often helps lower blood pressure.

When eating out:

• Request that your food be prepared without added salt.
• Ask for sauces and salad dressings on the side since they are often high in sodium. When eating a salad, use a twist of lemon, a splash of vinegar or a light drizzle of dressing, or dip your fork in the dressing before getting a bite of salad.

These tips can help you manage high blood pressure, but please consult your health care team before making any adjustments to your hypertension medications.

For more information on managing hypertension, visit the National Heart, Lung and Blood Institute or the American Heart Association.

- Cara Stewart, RD, LDN

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I’m Not Crazy, I Just Want to Lose Weight

David Sarwer, PhD, director of clinical services at the center for weight and eating disorders, explains the importance of psychological evaluations before bariatric surgery.

When considering weight loss surgery, many people wonder why they need

a pre-surgical psychological evaluation. It is a good question with several answers. Psychological evaluations have become a routine part of pre-surgical care. In 1991, the National Institutes of Health recommended psychological examinations prior to bariatric surgery when the health care team was concerned about a patient’s readiness to make the necessary lifestyle changes after bariatric surgery.

Over the past 10 years, organizations such as the American Society of Metabolic and Bariatric Surgery have strongly supported pre-surgical psychological evaluations and extended the recommendation to all bariatric surgery candidates. Today, nearly all insurance companies recognize the value of pre-surgical psychological evaluations and require them for all potential candidates as a part of the preoperative approval process.

The Penn Metabolic and Bariatric Surgery team believes that a psychological evaluation before bariatric surgery is critical to improve patients’ post-surgical success. The evaluation is an opportunity to identify motivations, address psychological challenges that may contribute to a person’s obesity or impact preparedness for surgery and arrange for appropriate follow-up support. It is not designed to be a barrier to surgery.

The Penn Metabolic and Bariatric Surgery Program is committed to providing the highest quality care to help patients reach their weight loss goals. As part of that mission, the pre-surgical psychological evaluation allows the health care team to optimize individuals’ chance for long-term weight loss success.

- David Sarwer, PhD

• For more information, visit the the Stunkard Weight Management Program website
• For more information, visit the Center for Weight and Eating Disorders website
• Learn more about Dr. Sarwer

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Choosing healthy breakfast cereal: How to be a smart consumer

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, explains what to look for in a healthy cereal.

Eating a healthy cereal for breakfast is one of the easiest ways to start the day off on the right foot. Making a healthy cereal choice in the expansive maze of options can be confusing and difficult. Do not be fooled by misleading health claims, catchy names or colorful boxes. Next time you are strolling down the cereal aisle at the grocery store, use the nutrition facts and ingredient list as your fool-proof guide!

Here are some things to look for to make a healthy cereal choice:

Whole grains: 100 percent whole grain product

Whole grains contain fiber, which means they are not as rapidly digested as refined grains. In addition to keeping you satisfied throughout the morning, fiber helps regulate blood sugar, keep the intestines functioning smoothly and lower LDL cholesterol.

Fiber: 3 grams or more per serving

Food makers are required to list ingredients in descending order by weight, so look for a whole grain or bran, an integral part of whole grains, as the first item on the ingredient list. Examples include whole grain wheat, wheat bran, whole grain oats and whole grain corn.

Sugar: 6 grams or less per serving

Many cereals contain large amounts of added sugar. In fact, nearly half of calories in some cereal come from sugar. High sugar content makes these cereals no healthier than eating cookies and milk for breakfast. Avoid a cereal if any form of sugar is one of the first three ingredients. The average American consumes 22 teaspoons of sugar daily, which is 350 extra calories a day and 35 pounds a year! The American Heart Association recommends that women consume no more than 100 calories (6 teaspoons or 24 grams) of added sugar per day and men consume no more than 150 calories (9 teaspoons or 36 grams). Keep in mind that for cereals with dried fruit, such as raisins, the natural sugar content in the fruit is reflected on the label.

Sodium: 150 mg or less per serving

Cereal can be surprisingly high in sodium. Some popular brands contain twice as much sodium as a serving of potato chips. In fact, salt is more commonly added to cereal than sugar. Excess sodium can lead to many health problems, including high blood pressure. While Americans consume over 3700 mg of sodium per day, the Dietary Guidelines for Americans recommends no more than 2300 mg of sodium per day. For African Americans, people with hypertension, diabetes or chronic kidney disease and those over 50 years, the guidelines recommend consuming less than 1500 mg of sodium per day.

Calories: 150 to 200 per serving

Serving size can vary from ½ cup to 1 1/3 cups. Make sure to do the math so you can control how many calories you are consuming. Remember, if the serving size is ½ cup and you eat one cup, you are consuming twice what is listed on the label.

- Cara Stewart, RD, LDN

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Recovering from weight loss surgery? Take your vitamins!

Karen Buzby, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, explains the importance of vitamin and mineral supplements after weight loss surgery.

For optimal health, the body needs 13 essential vitamins and nine trace minerals daily. Typically, the best way to get these nutrients is through a varied diet, as outlined in the USDA Food Guide Pyramid. The dietary restrictions following weight loss surgery make it difficult to obtain the daily recommendations of vitamins and minerals from food alone. Therefore, people recovering from weight loss surgery are strongly encouraged to take vitamin and mineral supplements for proper nourishment and to aid their recovery.

Vitamin and mineral supplements are particularly important during the post-surgical period. Weight loss surgery restricts the amount and type of food that can be consumed. Solid foods are reintroduced into the post-surgical diet slowly and gradually, which means it can be an extended amount of time before patients are able to eat a healthy, nutrient-rich diet.

In addition, gastric bypass can cause malabsorption of important nutrients, making it even more important to compensate with vitamin and mineral supplements. Gastric bypass and sleeve gastrectomy can impair the release and absorption of vitamin B₁₂. By bypassing part of the intestines, gastric bypass can also lead to intolerance of calcium-rich dairy and impaired iron absorption. Taking sufficient supplements can prevent irreversible nutritional deficiencies.

The American Society of Metabolic and Bariatric Surgery provides guidelines for vitamin and mineral supplementation following weight loss surgery.

Multivitamin and mineral supplement:

• The supplement should contain 100 percent of the daily value for at least two thirds of the nutrients listed on the nutrition facts label. The product you select should be reviewed and approved by your bariatric team before surgery.
• Chewable tablets are recommended for the first two to three months after surgery.
• Start taking vitamin and mineral supplements on the first day home from the hospital.
• After adjustable gastric band surgery, one multivitamin a day is typically required.
• After gastric bypass or sleeve gastrectomy, two multivitamins a day are typically required.

Calcium with vitamin D:

• For optimal absorption post surgery, take a product with calcium citrate and vitamin D₃.
• Chewable tablets are recommended for the first two to three months after surgery.
• Calcium intake should be between 1500 and 2000 mg daily.
• Doses should be divided. Take no more than 500 to 600 mg at one time.
• Do not take calcium and iron supplements at the same time. They must be taken at least two hours apart.
• Start taking calcium supplements on the first day home from the hospital.

Vitamin B₁₂:

• A sublingual (under-the-tongue) tablet containing 500 micrograms of vitamin B₁₂ can be taken daily or monthly intramuscular injections of B₁₂ can be given by a primary care physician.

• While the body does store vitamin B₁₂, it is recommended that supplementation begin on the first day home from the hospital.

Iron:

• Additional iron may be needed for menstruating women or those at risk for anemia.
• The amount of additional iron required is determined on an individual basis.
• Do not take iron at the same time as calcium supplements. They must be taken at least two hours apart.

Essential Vitamins:

1. Vitamin A
2. Vitamin D
3. Vitamin E
4. Vitamin K
5. Vitamin C
6. Thiamin
7. Riboflavin
8. Folic acid
9. Niacin
10. Vitamin B₆
11. Vitamin B12
12. Pantothenic acid
13. Biotin

Trace Minerals:

1. Iron
2. Copper
3. Zinc
4. Fluoride
5. Selenium
6. Iodine
7. Manganese
8. Chromium
9. Molybdenum

Make sure to consult your health care team before starting or changing vitamin and mineral supplementation following bariatric surgery.

- Karen Buzby, RD, LDN

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Eat Meals Slowly: It’s Worth the Time!

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, recommends slow eating for weight loss, especially following bariatric surgery.

Today’s fast-paced world leaves little time for enjoying a leisurely meal. The lack of time for eating meals can be problematic, especially for people recovering from bariatric surgery. Eating slowly is an essential component of successful bariatric surgery. Eating too quickly or not chewing food thoroughly can result in gastric pain, pressure and vomiting.

Health care professionals recommend learning to eat slowly in the months leading up to bariatric surgery. This helps make slow eating a habit. In addition, slow eating often results in a sense of fullness from a smaller portion of food, which contributes to weight loss. It takes roughly 20 minutes for the brain and stomach to register fullness, so taking time to eat a meal can help you realize you are satisfied before you overeat.

Tips to help you slow down:

- Eat smaller but more frequent meals to keep you from feeling too hungry at any point in the day. Focus on protein- and fiber-rich foods to keep you satisfied.

- Sit down when you eat and reduce distractions. Turn off the television or computer and focus on enjoying your food. Take time to appreciate the look, smell, taste and texture of the food.

- Cut food into smaller pieces and use a smaller utensil, such as a baby spoon.

- Put your utensil down and chew thoroughly between bites.

- Look at the clock when you begin and finish eating or use an egg timer. Gradually increase your meal times.

Get more tips on how to slow down your food consumption pace at the next support group meeting. Click here for a list of upcoming support group meetings.

- Cara Stewart, RD, LDN

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