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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Organic Produce: Is it worth the price?

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, explains when the higher cost of organic produce is a good value.

Incorporating a variety of fruits and vegetables into your daily eating plan is an essential component of a healthy diet. Organic produce has become more widely available in major grocery stores, but it is often sold at a higher price. When is organic produce worth the price?

The Environmental Working Group (EWG), a nonprofit research and advocacy organization, developed lists of the most and least important fruits and vegetables to buy organic. The “Dirty Dozen” lists the produce containing significant amounts of pesticides even after high-pressure washing. The higher price of organic produce is worthwhile for all of the items on this list.

Choosing organic for produce on the “Dirty Dozen” list can reduce pesticide exposure by as much as 80 percent, according to the EWG. Pesticide exposure has been linked to cancer, nerve damage, reproductive problems, birth defects and more.

The “Clean 15” refers to the fruits and vegetables containing the least amount of pesticides. The EWG recommends foregoing the higher price of organic produce for these items since they are safe to eat even when conventionally grown.

Next time you’re in the produce section at the grocery store or farmers’ market, refer to the “Dirty Dozen” and “Clean 15” lists to determine when it is worthwhile to buy organic and when it is not. For quick reference, download the EWG’s “Shopper’s Guide to Pesticides.”

Dirty Dozen

• Peaches
• Apples
• Sweet bell peppers
• Celery
• Nectarines
• Strawberries
• Cherries
• Pears
• Grapes (imported)
• Spinach
• Lettuce
• Potatoes

Clean 15

• Onions
• Avocado
• Sweet corn (frozen)
• Pineapples
• Mango
• Asparagus
• Sweet peas (frozen)
• Kiwi fruit
• Bananas
• Cabbage
• Broccoli
• Papaya

- Cara Stewart, RD, LDN

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Banana Berry Smoothie: Healthy, Tasty and Easy to Make!

Homemade fruit and yogurt smoothies make a refreshing and tasty addition to your diet. They can be a healthy breakfast option or replenishing post-workout snack. Quick and easy to make, fruit and yogurt smoothies are a good source of protein and fiber. They can even be part of a post-operative liquid diet. For an extra nutritional boost, use Greek yogurt in place of regular yogurt to double the protein content without increasing the volume or calories.

Ingredients:

• 6 ounce container of fat-free plain Greek yogurt
• ½ cup frozen berries (any type, organic if possible)
• ½ frozen banana
• ½ cup skim, 1 percent or soy milk

Optional additions:

• 1 packet of no-calorie sweetener such as Splenda® or Truvia™
• Dash of cinnamon or nutmeg
• Splash of vanilla extract

Directions:

1. Put ingredients in blender and blend until smooth
2. Pour smoothie into glass or to-go cup
3. Enjoy!

The recipe produces one serving and contains 215 calories, 20 grams of protein and 3.5 grams of fiber.

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Super Foods for Supercharging Your Diet

Karen Buzby, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, explains the nutritional value of “super foods.”

Take your pre- or post-surgical diet to the next level by incorporating these nutritious and delicious super foods in your meals. For those who have had weight loss surgery, it may be necessary to reduce portion sizes. Consult your dietician to determine the appropriate portion sizes for you.

Oatmeal – Start your day off right with oatmeal as a healthy breakfast cereal. Oatmeal is a whole grain containing soluble fiber, which has been shown to lower blood cholesterol and low density lipoprotein (LDL) in the arteries. A serving size of 1.5 cups has three grams of soluble
fiber, 225 calories and nine grams of protein.

Blueberries – Blueberries make the perfect snack or topping for salads or cereal. They are packed with phytochemicals, the disease-fighting antioxidants that are linked to heart health. Available all year long, blueberries can last up to 10 days when refrigerated. Purchase organic blueberries when possible to reduce pesticide exposure. A serving size of one cup contains 80 calories.

Beans – Add beans for extra color, flavor and protein to soups, salads, side dishes and entrees. Linked to decreased risk of certain cancers, beans contain soluble fiber, which controls cholesterol, and antioxidants. The Dietary Guidelines recommend having three cups of beans weekly. Start with a quarter of a cup daily and work your way up to the three cups recommended, allowing your system to gradually adjust to the fiber. A serving size of half a cup is approximately 110 calories and has seven grams of protein.

Almonds – Almonds are a great snack or garnish on salads, cereal, yogurt and grain dishes. They have heart-healthy mono- and polyunsaturated fatty acids, phytoserols and are rich in protein and fiber. Studies also suggest that eating almonds may help reduce LDL cholesterol. A standard serving is one ounce or 23 almonds, containing 160 calories and six grams of protein.

Salmon – Enjoy salmon for a healthy and tasty lunch or dinner. As a good source of omega-3 fatty acids, salmon reduces the risk of heart disease by lowering cholesterol levels. The American Heart Association recommends eating a four ounce portion of a fatty fish, such as salmon, twice a week. When possible, look for wild Alaskan salmon, which contains an even greater amount of omega-3 fatty acid than farmed salmon. Fresh filets should be bright orange or red with a firm texture and mild aroma. Prepare salmon by grilling, baking or poaching. A four ounce portion of salmon contains approximately 200 calories and 28 grams of protein.

- Karen Buzby, RD, LDN

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Create a Tempting Color Palette for Your Palate

Karen Buzby, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, offers ideas for incorporating colorful, nutritious foods into your diet.

March is national nutrition month. To promote healthy nutrition, the American Dietetic Association urges people to “Eat Right with Color.” Incorporate a wide variety of colorful food in your diet ranging from fruits and vegetables to lean protein and whole grains.

Following weight loss surgery, calorie restrictions can make maintaining a nutritious and colorful diet challenging. In the early post-operative stages, the recommended diet consists mostly of high protein drinks and foods, such as lean meat, poultry, fish and low-fat dairy. As you recover from surgery, colorful fruits and vegetables can gradually be integrated into your diet to provide nutritional variety.

Try these creative ideas to add colorful food at each stage of your post-operative diet:

Full-Liquid Diet

• Vegetable juice or 100 percent fruit juice diluted with water
• Strained vegetable-based cream soup
• No sugar added whole fruit ice pops

Pureed Diet

• Unsweetened apple sauce
• Cranberry-raspberry or pomegranate apple sauce purees
• Frozen pureed squash
• Whipped baked sweet potato

Soft Diet

• Cooked vegetable such as tender broccoli florets or asparagus tips
• Soft canned fruits packed in water or light syrup, such as sliced peaches or a fruit cup
• Salsa on chicken or fish

Regular Diet

• Fresh fruits and salads
• Slices of avocado, apples or kiwi
• Baby carrots or cherry tomatoes

**Remember to remove high-fiber skin and peels from fruit and vegetables to avoid digestive problems.

- Karen Buzby, RD, LDN

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Counting Down the Days Until Spring? Enjoy this Late Winter Dish

Stay warm and cozy during the last week of winter with a delicious and healthy meal from the slow cooker. Combining vegetables, beans, pasta and herbs, minestrone soup is tasty, easy to make and rich in protein and fiber, which means it will keep you satisfied for hours after eating.

Recipes for minestrone soup vary from cook to cook, so feel free to make substitutions or additions to fit your family's preferences.

You will need a medium round or oval slow cooker. Total cooking time is seven to eight hours.

Ingredients:

• 3 tablespoons olive oil
• 1 medium-sized yellow onion, chopped
• 2 small carrots, diced
• 2 ribs celery, chopped
• 2 small zucchini, ends trimmed and cubed
• One 15-ounce can red kidney beans, rinsed, drained and half the beans mashed
• 1 teaspoon salt**
• 1 bay leaf
• Freshly ground black pepper to taste
• 1/4 cup packed fresh flat-leaf parsley leaves, chopped
• One 28-ounce can whole tomatoes, mashed, with their juice
• One 10-ounce package frozen baby lima beans
• 2 ½ cups chicken or vegetable broth
• 5 leaves Swiss chard, chopped or 1/2 small head Napa cabbage, cored and chopped
• 1/2 cup dry red wine such as Chianti, Merlot or Pinot Noir
• 1/3 cup whole wheat elbow macaroni or little shells
• Freshly grated parmesan cheese for serving

**To reduce sodium, skip the salt and use canned beans and tomatoes with “no salt added.”

Directions:

1. In a large skillet, heat the olive oil over medium heat. Add onion, carrots, celery, and zucchini. Cook, stirring often, for about five minutes or until just softened. Transfer to the slow cooker and add kidney beans, salt, bay leaf, peppers, parsley, tomatoes and juice, lima beans and broth. Add enough water to rise about one inch above the vegetables. Cover and cook on low for five hours.
2. Add Swiss chard and wine, cover and continue to cook on low for another two to three hours. Remove the bay leaf.
3. Stir in pasta, cover and cook on high for about 30 minutes or until the pasta is just tender.
   
4. Ladle into soup bowls, top with parmesan cheese and enjoy!
   

The recipe produces 12 servings. Serving size is one cup and contains 125 calories, six grams of protein and four grams of fiber.

Adapted from Not Your Mother’s Slow Cooker Cookbook by Beth Hensperger and Julie Kaufman (The Harvard Common Press, 2005)

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