Signs you’re under fueling your workout after bariatric surgery

Dawn, RD (00:00:00):

Hello and welcome to the Gastric Health Show. My name is Dawn Boxell and I have the privilege today to introduce to you Kim, and she is a Registered Dietitian and is going to have a good conversation today on signs that you are under fueling your workouts after bariatric surgery. So welcome, Kim.

Kim, RD (00:00:22):

Thank you. I’m so happy to be here.

Dawn, RD (00:00:24):

Yeah, why don’t you share a little bit about yourself so people kind of know your background and what you focus most on.

Kim, RD (00:00:33):

Sure. So I’m a bariatric dietitian, but I actually specialize in active individuals that have had bariatric surgery and now are wanting to change their nutrition to optimize their fitness levels. And how I got into that, I was always an athlete growing up and I was always interested in sports nutrition, but once I became a dietitian, I went into clinical and my first floor that I ever covered was actually the surgical floor that did the bariatric surgeries. And so my first position for the first three years of being a dietitian, and I’ve been a dietitian for 16 years now, was working with bariatric patients in that immediate, basically the discharge phase where they came to me, they’d have their surgery, I’d go in, I’d review their discharge menu, that kind of thing, how they’re going to be fueling and eating after the bariatric surgery. And really just stayed with that for quite a long time.

(00:01:23):

I really enjoyed that. And then again, being interested in sports nutrition, I actually was a division one of sports dietitian for a university here where I’m at Fresno State University for about seven years. And still during that time I worked with bariatric patients. And then in my last position, I worked in a surgical center for the last 10 years in a bariatric surgical center here where I’m at and really worked in both the pre-op and the post-op phases of bariatric surgery. And what I found the missing kind of gap or lack of information was someone that’s had bariatric surgery and now is wanting to have all these exciting new fitness goals. Maybe they want to increase their muscle masks, they want to start training for a half marathon or a cycling event, and there just wasn’t a lot of information out there.

Dawn, RD (00:02:12):

So

Kim, RD (00:02:12):

Having had the sports nutrition background, I could apply the sports nutrition guidelines, but basically had to kind of overlap that with the bariatric nutrition guidelines and how those interacted with each other, how I helped folks. And so in the last two years, I actually left my full-time clinical position and opened up my own private practice, which is called Active Bariatric Nutrition, and I work one-on-one with individuals who have those fitness goals after bariatric surgery.

Dawn, RD (00:02:40):

Awesome. That’s exciting because that is such a needed area because so many individuals do get excited about moving their body. They feel so much better, but yet they don’t know how to fuel it appropriately. Sometimes it is confusing when you have a very small pouch, how do you get enough energy in when you’re burning it on the backside with all the activity? So that’s amazing that you’ve combined those two and serve the bariatric population because there probably aren’t many sports dietitians that have actually been helpful in the bariatric community. So this is great.

Kim, RD (00:03:26):

It’s definitely a unique kind of niche area and I can’t tell you the number of the folks that are like, yeah, I didn’t know who to turn to. There’s just not a lot of information or education out there for active bariatric individuals. So yeah, it’s been great. I’ve really enjoyed it.

Dawn, RD (00:03:40):

Yeah. Well, I’m excited to dig into this topic. I do feel like I see this with a lot of patients now. I’m definitely not a sports dietitian, so I don’t have that background and knowledge, but I feel like a lot of the patients that are active, they lack in the energy requirements. And so that’s why I really wanted to dig into this topic because any way that we can show them that it’s okay to have more calories, it’s okay to have more protein or carbs, I think is helpful and we’re just keeping that line less blurred and less confusing when it comes down to fueling their body. So I want to get into our first question and just what are some maybe physical or mental or just signs that someone would have a clue that, hey, maybe I’m not fueling my body appropriately?

Kim, RD (00:04:44):

Yeah, it’s such a great question because certainly after we have bariatric surgery and we’re thinking about keeping our overall energy intake low really for life, right? Because that’s kind of the message that is out there. We start doing that, we’re maybe increasing exercise and then maybe you start having these signs and symptoms and you think, is this related to just my exercise? AM something else going on? And so there are definite signs and symptoms that can be identified that indicate some low energy availability. One being persistent fatigue. So if you’re just chronically tired all the time, just have low energy levels throughout the day, that can certainly be a symptom of low energy availability, muscle weakness or loss of power and strength in your workouts. If you’re noticing that you really just don’t feel like you have the power to be moving the weights that you had been doing.

(00:05:34):

Or for example, in the clients that I work with, if they’re not seeing any gains, they’ve been doing resistance training for some time and they’re just not seeing any increase in muscle mass, that can be an indication too that overall energy needs are not being met for those types of goals mentally. Some mood disturbances, so irritability, irritability, confusion or that brain fog, some depression, anxiety, lack of concentration, those can all be symptoms that again, overall energy intake is inadequate and then increased some GI issues even. So these can sometimes be confused for some of the things that can be experienced after bariatric surgery, but another sign of low energy intake can be some GI issues like bloating, cramping, nausea. Those can also be an issue that maybe your gut microbiome is off, and that can be due to chronic levels of stress from low energy availability, higher levels of cortisol.

(00:06:30):

So that can be a problem for ladies if you’re having missed periods. So think of usually what we hear, which is exciting, is that sometimes there’s menstrual dysfunction before you have bariatric surgery, especially if ladies have PCOS, polycystic ovarian syndrome. But if after surgery you regain normal functioning with that weight loss and everything’s going well, but then all of a sudden we’re starting to have maybe irregular or missed periods, that absolutely can be a sign of inadequate energy intake. And so we definitely want to address that before it really worsens. And then just a few other ones, reduced sleep quality, increased incidences of illnesses. If you’re chronically having upper respiratory tract infections, you get over it and then you’re just sick. Again, that tells us that you’re not taking an adequate calories protein to create those antibodies to fight off infection. And then just incidents of injuries.

(00:07:22):

So we see increased risk of stress fractures, especially if you’re having bone density issues due to overall low energy intake and then inability to recover from your training sessions. So for example, if you work out, and typically if we start a new workout session or a workout program, you’re going to be sore in the beginning, but if you’ve been training and you just feel like you don’t recover, well, it’s 3, 4, 5 days and you’re sore all the time again indicating we need to look at what we’re taking into our body in terms of calories, carbohydrates, protein, et cetera.

Dawn, RD (00:07:54):

Yeah, yeah, yeah, I think that’s good because I think it can be confusing, especially the early post-op. A lot of these symptoms can be normal after bariatric surgery. And I know as a bariatric dietitian for so many years, you do promote, Hey, let’s move your body. Let’s get that routine, develop that behavior right out of the gate because you have that reinforcement of weight loss that you’re seeing, and when you get that behavior connected, you can develop that longer term when you’re motivated and motivation is the highest right after. So yet you have maybe some symptoms that you’re like, okay,

Kim, RD (00:08:47):

Well

Dawn, RD (00:08:47):

I’m not really eating, but a few ounces of food, so how much exercise can I really do realistically and not have these side effects? So if we broke down the beginning after surgery, when do you see these pre-op patients? When do you see them at a stable state to move past just general walking and pretty mild and low intensity workouts? Is it several months or do you require certain amount of food for them to be consuming, or what do you do in that scenario?

Kim, RD (00:09:30):

Yeah, typically really the first six months, you’re really still going through those. I mean, of course the first three months is really that post-op diet phase where you’re progressing through the different phases, but really I see in the years that I’ve been working with bariatric patients that usually around six months we’re tolerating a little bit wider variety of food. Our intake is increasing gradually, and then even beyond that nine months to 12 months where we might start doing more than just walking. And it’s not that people don’t start some resistance training earlier on around that six month mark or so, but typically the energy intake is not even nearly sufficient enough to really get a lot out of those workouts in that first six month period. So typically, and everyone’s different, these are general, but I typically see people starting to feel a little bit better having more energy after six months. And then from there, it’s going to be highly dependent upon what type of surgery you had, how you’re feeling, what foods you tolerate, and how much timing, all those things play a role in fueling properly. And it takes some time. And I’ve had patients that were like, it really took me after a year before I really had a good consistent eating pattern where I could really start to push myself a little bit. And so again, it’s just going to be independent on how you are feel and everyone’s so unique.

Dawn, RD (00:10:49):

Yeah, yeah, agreed. Yeah, and I think that as they kind of dive into movement, I mean for a lot of people it’s new to ’em. They’ve not been into this area for maybe a period of time or ever. They’ve never adopted these types of behaviors, which is totally fine, but as you’re experimenting and finding fun things that you enjoy, do you think it’s bad to right out of the gate, say just walking like say 30, 45 minutes, all that’s great, even though your calorie intake is maybe 500 800 calories at that time, maybe we’re getting to a thousand if we’re having a lucky day, what would be the negatives of doing more than walking? Or can you do yoga? Could you do Pilates? Could you do those types of workouts and not compromise your energy availability and have more fatigue and more problems by doing something more intense?

Kim, RD (00:11:55):

Yeah. I have a podcast that I’ve had on where I’ve had physical therapists come on and in listening to them and in their areas of expertise, talking about really giving your body that chance to, again, the rapid weight loss phase kind of changes how our body moves itself. And so typically what I have relied on is their recommendations, which is really the first three months of walking is such a great, you’re moving your body, you’re relearning the balance of your body in its new shape as you lose weight. And that changes throughout that first year and even beyond. And so typically after about the three month mark, I have had people start doing some very low weight resistance training or band work just to start moving their body in a new way. And typically that’s tolerated well with the intake that they’re focusing on as long as they’re getting in their protein and they’re taking their daily bariatric vitamins and minerals, the meeting their fluid goals, et cetera.

(00:12:52):

Beyond that, if we start increasing intensity level, frequency, duration of workouts, maybe moving more into longer duration and endurance activity or aerobic activity, that’s where we start needing now more carbohydrate to be able to fuel those workouts. So because specifically the first three to six months is really primarily is you’re really trying to meet your protein goals because you’re in such a low energy intake state, you will notice more fatigue if you start trying to right out of the gate increased intensity level and duration and frequency because you’d need carbohydrate to do that type of activity. Now your body can utilize fat as an energy source, but at low to moderate levels, once we get moderate to higher intensity, carbohydrate is the energy source that our body needs to fuel our muscles. And so without that, you’re not going to be able to push yourself because you’re going to fatigue. That’s the way it will happen if we don’t have those muscle glycogen stores to fuel the workout. So I would say really you have to get through those initial phases of, like I said, at least three to six months before you’re starting to push yourself past just generally walking or lower intensity activity.

Dawn, RD (00:14:03):

Yeah, and that makes sense to me. I mean, keeping it just beginning things and finding joy and going on a hike and a bike ride and not an intense bike ride, but tool around the neighborhood or a walk, those, to me, those seem doable for their intake.

Kim, RD (00:14:23):

Absolutely. And always when I work with my clients, I teach ’em kind of a hierarchy and the low level on the hierarchy is meeting your bariatric nutrition basics. We can’t layer on sports nutrition guidelines to fuel high intensity workouts if we aren’t even just doing the basics of meeting our daily protein goals, taking inadequate fluids, taking our bariatric vitamins and minerals. If we can’t even do those things first, we don’t even want to go to the next tier up until we can hit those. So that is kind of what I hammer home to start with. And then we layer on additional strategies to fuel exercise sessions or movement sessions.

Dawn, RD (00:14:59):

Yeah, no, that’s great. I think that’s valuable information that they can always just lay that good foundation. I mean, really that’s where everything begins, get the foundation, and then as you build, then everything just moves easier and it’s just flows so much better for how you feel and your results.

Kim, RD (00:15:24):

Totally. Absolutely.

Dawn, RD (00:15:25):

Yeah. Have you had clients that come to you and they’re doing pretty intense workouts for a pretty low intake of calories?

Kim, RD (00:15:38):

Yes, and honestly, typically when I have someone that’s less than six months post-op in terms of working one-on-one with me to optimize their nutrition, I usually say we need to get through that phase first. You’re not even at an energy level intake that we can even really manipulate or optimize much because we’re just focused on meeting our bare, bare minimum needs, which is your protein goals, your fluids, your vitamins, et cetera. So in those phases, I will tell folks, Hey, let’s just work on that first. Let’s just get that daily movement going your base. Let’s get those things established first. Then as you increase activity, then we do need to look at how to optimize the fueling strategies for that. And again, people have to be at a place where they’re able to tolerate carbohydrate foods. Do they have enough room in their pouch after they eat their protein to incorporate those yet if we’re not even at that phase yet, then we need to look at what we’re doing for exercise, what the demands of exercise are asking or your movement goals, whatever that might be, your fitness goals, and are you able to even tolerate that much nutrition yet?

(00:16:39):

And so there’s got to be a balance there as to what you’re expending and what you’re able to take in, especially in those early phases. So I try not to get into the fitness guidelines outside of just, Hey, we need to be able to fuel what the movement is that you’re doing, and you need to address your movement goals with what you can take in at this point.

Dawn, RD (00:17:04):

Good. So let’s go over what are some of the lab tests that someone could look at or their bariatric center may already be doing or they could ask to have done to give them insight? Maybe someone’s listening today and they’re like, okay, I’m past six months. I am doing workouts. I’m not sure I’m fueling myself appropriately. What kind of lab data would give me insight into knowing more about my current state?

Kim, RD (00:17:38):

So the labs that I’m going to review. So first I would just say the labs that I’m going to review. There are many reasons as to why these labs may be high or low, that could be unrelated to low energy availability, so need to be interpreted by your doctor. But some labs that have been shown to kind of indicate or maybe correlated with overall lower energy availability. So if you have a C B C done, which most of the time is a very easy panel that are run in almost all panels that are done by doctors, a C B C, which is your complete blood count can be run, and basically any abnormalities in your red blood cell count, your hemoglobin and hermatocrit levels, it can indicate anemia, which we need to look at. Of course an iron panel as well, but that can be associated with low energy availability.

(00:18:20):

So in connection to that, an iron profile, so low levels of serum iron ferritin transparent saturation can also suggest an iron deficiency. And I always just kind of relate this to, as you increase your exercise, your need for red blood cells are increased because red blood cells are what carry the oxygen are on there, and they carry that oxygen containing energy to the muscle cells for energy and for chemical reactions to occur. And so as our red blood cell need increases with exercise, then that means we need to either making sure that we’re taking our bariatric vitamins and minerals, but also overall energy intake from red meats and other iron containing foods is important to help maintain our iron levels and again, early out as well as with just bariatric surgery in general, we know that you’re already at an increased risk of an iron deficiency due to the surgery itself.

(00:19:11):

That also can be something to take a look at. Certainly thyroid function tests are another big one that are associated with overall low energy intake. For example, you might want to have your T-3, T-4 and T S H, which is thyroid stimulating hormone, a full panel run. So any abnormalities there might indicate some endocrine issues that could be related to overall low energy intake. Another one just for ladies, so luteinizing hormone as well as follicle stimulating hormone. Those two, again, if those are abnormal, that can indicate hormonal disturbances due to overall low energy intake and those are really important. So definitely ladies, if you’re, again, just having a lot of these signs and symptoms, you’ve been increasing your exercise over time, those are two that you can ask to have run as well. And then I’ll just a couple other ones. Cortisol can be elevated when we’re in a chronic stress state, and that can be due to inadequate energy intake insulin like growth factor low IGF one levels can be indicate impaired growth and recovery due to energy deficits. So those are some. And then I’ll just lastly finish with bone turnover markers. Those really are due to long-term low energy intake. Now we have hormonal imbalances, and so you can have some tests run that look at vitamin D level bone specific alkaline phosphatase, which is known as BAP or cross-linked C telopeptide, which is C T X. Those can indicate bone marker turnover rate that if they’re abnormal, we want to take a look at what’s happening with our nutrition,

Dawn, RD (00:20:50):

Which is great because you think of the population of the bariatric community being so heavy in females and the high risk of osteoporosis with females in general. I mean anyone but especially females because of the estrogen loss, our bone health changes with menopause. So now you throw in I’m improperly fueling my body. So now, and I recently, I’ve had three patients come to me with osteoporosis,

Kim, RD (00:21:29):

And

Dawn, RD (00:21:29):

So it’s on my four thoughts right now of supporting them in a way that maybe if we had worked together sooner, we could have changed the outcome of them already being in osteoporosis. But in the end, I think being aggressive in how you approach this prevention phase is super important. So the more you can advocate for yourself and ask for those lab tests, I think is critical.

Kim, RD (00:22:02):

And I’ll just add to that, just your typical bariatric panel that should be run annually for life. I want to reiterate that paired with taking your vitamins and minerals every day, because as you just mentioned, if someone’s, of course, low energy intake is going to impact these micronutrients, but also remember that bariatric surgery is already increasing your risk of deficiency in things like calcium and vitamin D and iron and B 12. So those are critical to be taking. And then paired with the fact now that you’re moving more, those are also very important for energy metabolism and for bone density and things like that and neuromuscular contractions, things like that. So there’s so many layers that when you’ve had your bariatric surgery, your overall intake is lower, now you’re exercising more. The demand for these micronutrients are even more critical that you’re meeting those through your supplements and through your intake.

Dawn, RD (00:22:53):

Yeah. Do you find that it’s hard for active bariatric patients to actually meet that intake demand because their pouch is so small?

Kim, RD (00:23:07):

So what I run into is I’ll get folks that come to me and they’re like, Hey, I start working out at the gym and my personal trainer wants me to be eating some really high number from where they’re at. Okay, I eat right now 12 to 1400, but my trainer said I have to be at 3000. Well, here’s the thing that may be the case based on if we did indirect calorimetry and we look at someone’s resting metabolic rate and then we factor an activity factor, absolutely. The calories are your day-to-day needs are going to be higher than usually, especially in those first few years, not able to take that much in. And so where I kind of come in is, listen, we have to start with where we’re at, but we want to work gradually towards increasing your intake because you are going to need that based on whatever your movement goals are to meet the demand of what you’re asking your body to do.

(00:23:55):

And so my strategies with clients is really to do it in an incremental stepwise fashion. We gradually increase and it takes time because they have to work on that. And maybe it might mean we have to implement a snack, pre post-workout snacks, maybe an additional snack. It just depends because again, everyone will be different with how much they can take in at one time. And then how do we meet the goals in a day by distributing those calories in multiple settings? That’s typically what I try to focus on with my folks. And we look at of course, timing of protein and carbohydrates around workouts and being consistent with that, but it is very challenging. And so there is that gap with what your body really needs, but what you’re able to tolerate are two different things. And so I always just recommend doing it in a very incremental way.

Dawn, RD (00:24:42):

So let’s talk about some of those pre and post-workout fuelings that someone could tap into. So how do they know they need them? Should everyone do a pre-workout snack or do you do it fasted? Is it bad to do a fasted workout or not?

Kim, RD (00:25:03):

Yeah, so there’s debatable research out there on fasting and utilizing fat stores and all these things. And really at the end of the day, what it really comes down to is how you feel in your workout, your performance goals, et cetera. And what we know as fact is that carbohydrate does help improve performance. It helps decrease your time to fatigue meaning, or I should say increase time to fatigue, meaning you can work out harder longer before that kind of fatigue sets in where we’re having to slow down. Carbohydrates are king for that. And so in my practice with my active individuals, I really hone in on strategizing timing of meals and to really optimize the workout because again, we’re overall limited in our intake. We want to strategize with the timing. So I do recommend if someone can try to get in about 15 to 30 grams of carbohydrate in the one to two hours pre-workout, and that can be something as simple as just a half banana or for my runners, they do an applesauce pouch, they squeeze in.

(00:26:02):

Or for those that have a little bit more time and they have time to do a little bit of toast or maybe some oats or things like that, they have a little bit more time. Or if it’s like a lunch meal and they’re going to work out at three hours later, they can have a more well-balanced meal that incorporate both carbohydrates and proteins. That’s fine. Now to answer your question about fasting, I don’t see it beneficial there already. Overall intake is low and to just be putting yourself in a more prolonged state of no energy intake is not going to help with your workouts, how you feel. But also in the long-term with recovery with muscle protein synthesis and muscle gains going long periods without eating is not helping you to build it is actually helping you to break down because your body is having to just use its stored energy if it’s not getting any from the intake. And so I really recommend trying to get something in pre-workout and then post-workout, trying to fuel as quickly as you can with carbohydrates and protein because both are necessary to begin that muscle glycogen restoration. So putting the carbohydrates back into the muscles and then also taking in amino acids so that our muscle protein synthesis can begin, it can heal, we can grow and hopefully over time increase our muscle mass,

Dawn, RD (00:27:15):

Which I think is so important for them to understand the priority of that muscle that’s like their metabolic power. That is the thing that we have to preserve and in some instances really rebuild because I feel like that first three months is so depleting when it comes to their muscle mass that it’s like we got to rebuild this

Kim, RD (00:27:45):

A hundred percent. And I would just add even many surgical centers require a weight loss prior to even their surgery. So patients have already been on a somewhat low caloric intake prior to surgery. Then we go into this really rapid weight loss phase of really low energy and take that first three to six months or longer. And so again, you’re losing in that both fat loss as well as muscle loss in that rapid weight loss phase. And as you just mentioned, I totally agree with you, muscle is that driver of our metabolism and long-term, it’s going to help with functionality and mobility and strength, and we want to maintain that as long as possible. So the sooner that folks, people that are listening if you’re exercising, fueling, really helps with all of these things and taking in carbohydrates and then carbohydrates and protein post-workout as well as at your meals consistently really help with just preventing future losses of muscle, but also in that gaining and then stimulating metabolism.

Dawn, RD (00:28:44):

How many minutes before a workout or hours or what’s the timeframe for, say you have a banana before you go, if you did it 10 minutes before, is that bad or does it need to be 30 minutes or an hour?

Kim, RD (00:29:03):

So everyone’s different. No, so perfect time, but what I always teach my individual athletes is, so if you have a long period of time, so if you have three to four hours before a workout, let’s say you’re working out in the afternoon or evening, you’re going to eat your regular eating pattern. But in that three to four hour meal, it can contain more whole grains or slower to digest carbohydrates that are going to provide energy for our muscles in three to four hours. That’s okay. And that’s where you’re going to keep having your protein. You can have some fruit. It’s a more well-balanced plate because we have more time to digest that. But as you get closer to the start of your workout, the priority is going to focus on mostly just carbohydrates, more rapidly available. Carbohydrates are easier to digest, but we want to reduce our overall intake of fat and fiber because those do take longer to digest And remember, the key is we want energy available to the muscles when they need it.

(00:29:52):

And so if we’re eating things that are high on fat and fiber, it’s not going to empty out and be available in time. And also you can start having some GI issues if you have something like a high fat or high fiber meal in a workout point is if you’re getting closer, what I usually say is if we’re within an hour or so, you want to be focused on just basically carbohydrate rich beverage or food, small volume so that it is able to be digested and absorbed and ready for the muscles to use once you start moving.

Dawn, RD (00:30:20):

Yeah, okay. I think that’s good because I have some patients who are morning workout people, and so they get up and they go work out and they’re fasted. So it’s kind of like, okay, let’s throw in a small snack. And then they’re like, okay, well, I take my thyroid medicine, so how do I balance all of these moving pieces to fuel myself before the workout?

Kim, RD (00:30:49):

Yes. So I literally had a session yesterday with one of my clients who also takes thyroid medication. And so in her case, she backed it up just 30 minutes, basically backed it up, and that gave her that time to wait the minimum of 30 to an hour before she can start eating. And so she just, again, just something small. And even if you can’t tolerate something, what I always tell folks is you can train your body to get used to that having some fuel because I can tell you the number of folks that I have that are like, I cannot have anything. And so there’s two trains of thought to that. So basically if you are doing a great job at your meals throughout the day, you’re incorporating carbohydrates at every meal. Most bariatric patients as you get farther out are typically can consume at least about 30 grams, maybe 45, maybe more grams per meal of carbohydrate, just depends on where you’re at and what type of surgery you had. But if you’re doing a good job of taking in overall carbohydrates, that’s a good thing that can help you. But I still recommend, even if it’s just a small sip, if it’s just one squirt, anything would be beneficial to prolonging your time to fatigue and giving your muscles a little bit of an energy source to rely upon. So it is a beneficial strategy. I’m not a big fan of fasting because again, it’s just not helping you with recovery and in the long-term with muscle protein synthesis and growth.

Dawn, RD (00:32:08):

Yeah, I think that all the intermittent fasting and ketogenic diets, I feel like it creates so much confusion for people and they feel like, okay, I’m supposed to fast. I’m not supposed to eat to lunch, and so now let’s do my workouts. I have to do my workouts in the morning or they’ll never do ’em. And so now they’re like, well, that doesn’t work for fasting. So it’s like, and if I’m hearing you correctly, and I a hundred percent agree with this, you can’t be on this low calorie diet and fast too. Your body, that’s too many stressors. Your cortisol is going to be through the roof

Kim, RD (00:32:50):

And

Dawn, RD (00:32:52):

Guess what? You’re going to put on body fat and it’s going to stop your ability to lose weight, it’s going to increase your insulin, it’s going to do the total opposite of what you want to occur.

Kim, RD (00:33:06):

Yeah, I totally agree with you. And that is exactly what I will remind my folks too, is that we want to break down that catabolic state. We want to stop that catabolic state. We want to fuel on a consistent schedule so that again, you’re providing your muscles the fuel when it needs it. And so it’s really important both pre and post-workout to come into your workout well fueled, because again, as you just mentioned, we’re already at a low overall intake and then layering on these other dietary restrictions just makes it even more challenging to meet your needs. And so I always just tell folks when they’re like, Hey, I’m going to do fastening your chemo. I’m like, well, but you have the bariatric surgery tool in place. We have that tool to use. Let’s maximize that tool. We don’t need these other strategies because as long as we’re fueling properly and utilizing the tool and listening to our body when it tells us we’re hungry or when we’re full, that’s our one tool. And it doesn’t mean that there aren’t other tools that can help, but those dietary restrictions just kind of make it worse for you to meet your needs. And it’s just a lot more challenging if you’re trying to be active.

Dawn, RD (00:34:05):

Yeah, yeah, exactly. And don’t misinterpret and say, okay, well then I’m not going to work out. So that I

Kim, RD (00:34:13):

No, that’s helpful. That’s a helpful tool to do as long as you are then putting the nutrition back in that your body needs to move your body.

Dawn, RD (00:34:20):

Right. Yeah, I read, it was some research article I have every day. I have emails that come from PubMed on different topics and one came in on muscle mass and it just really struck me as, wow, the whole purpose of weight loss has all been about fat loss and maybe we’ve looked at it wrong and maybe it should be focused more on muscle mass loss, that that’s the driver of why so many people have issues with an increase in body fat. So we should focus more on increasing our muscle mass and less on the body fat, and you would get the results you actually wanted. So it’s very interesting because probably you and I both were trained that the calories in calories out model was how you lost weight. But being in bariatrics, we understand that it’s definitely more than just a calories and calories out model. We’re not math equations that you plug in these numbers and you automatically lose weight. It doesn’t. Absolutely.

Kim, RD (00:35:37):

The hormonal influences alone are a whole nother layer that impact how much you’ll lose after bariatric surgery. And I would argue too that I think moving forward, I’m really, it seems like we’re moving in this direction, it feels like it, but moving away from body mass index, meaning just looking at the weight on the scale and your height and judging that as your measure of outcome or success after bariatric surgery versus body composition and really looking at what is actually changing in our body? What are the compartments that we are increasing or decreasing because it is not ideal to be losing muscle mass. So when you hear that 60 to 80 grams of protein a day, it’s because the research that had been done looked at that’s like the bare minimum that people need to consume to prevent muscle wasting during a low energy intake state.

(00:36:23):

And so I would argue that hopefully moving forward, we utilize more body composition measurements, trends, things like that as an indicator of how things are going. And like you just mentioned, minimizing muscle loss, which drives our metabolism. So then the long-term, if you’re wanting to change your body composition and you want to gain more muscle and be stronger and all those things, it’s going to come from taking an adequate protein, adequate calories to maintain muscle, and the fat loss will come as well if you’re striving to increase your muscle and you’re moving your body and you’re taking an adequate nutrition. So I’m hoping that as we move forward, that that’s kind of the direction that the big surgical centers and our research will look at as an outcome measure.

Dawn, RD (00:37:03):

So let’s talk about body composition. I mean, what type of tools do you recommend for people to utilize to monitor that? Do you like some of the BIAs? Are you against them or what’s your thoughts on ’em?

Kim, RD (00:37:21):

Yeah, I’m totally for BIA bioelectrical impedance, I think there are good way that our available right there are of course more highly technical and more maybe accurate ways to do it, but it requires a laboratory setting or a hospital setting, and that’s not going to be easily accessible to the masses to understand what’s happening in my body. So BIA you can find these types of the InBody scans, and SECA is really a worldwide company that looks at body composition, but their scales and BIA are very accurate. They’re just typically found in medical offices, but you can certainly ask your primary care or your surgical center to incorporate those. But I think that it’s the best way to go about it in terms of understanding how things are happening after surgery. Because as we know, and I actually just talked about this in my podcast, there are so many things that impact our scale day to day that have nothing to do with calories and calories out.

(00:38:19):

It can be a high salt intake. It can be you worked out really hard and your body’s retaining fluid to help with healing. It can be that you increased your carbohydrates. So now when we store carbohydrate in the muscles, we draw water in, there’s just so many things menstruation with, we gain weight as we come into when we’re going to have our period. There’s so many things that impact the day-to-day scale, and I just find that it’s so frustrating because folks, we’ve been kind of ingrained to use the scale and it doesn’t give us the accurate picture as to what’s happening. So to go back to your original question, I am a big fan of body composition measurements, and I would recommend those as more of a tool to measure your progress.

Dawn, RD (00:39:00):

Yeah, I love it. I think, and they are, I mean, some gyms have it for free access. I, and I know my doctor’s office, they offer it. And so I free twice a year I can get a done and monitor how my body is changing and know where I’m lacking or weak or need to improve.

Kim, RD (00:39:27):

Absolutely.

Dawn, RD (00:39:27):

Yeah,

Kim, RD (00:39:28):

Because if you’re getting having B I H and you’re okay, my weight went down, but it’s coming from muscle, that means we want to look at a nutrition strategy. We want to change what you’re eating. We want to increase your protein intake. Maybe we need to increase your overall intake to fuel what you’re doing for this movement goals that you have. And so I think that’s a much better indicator because it tells us, oops, that’s a nutrition intervention point. We need to look at how we can optimize the nutrition so that we’re not losing muscle mass as we lose weight or lose body fat.

Dawn, RD (00:39:59):

Do you use at my doctor’s office, they use the InBody, I think seven 70 is the one they use. And I’ve seen some other dietitians comment that they don’t think that the basal metabolic rate that is provided is very accurate on at least the InBody I’ve seen commented frequently. Do you feel in general, because if somebody goes and gets CYS done, they’re going to see this B M R basal metabolic rate there, which is kind of the calories you’re going to see a calorie number. So do you feel they’re accurate? Do you feel like it’s a good place to even hover around for making informed decisions?

Kim, RD (00:40:50):

All testing methods are going to have some inborn error. And what I usually go off with folks is none of these tests are a hundred percent accurate. None of ’em are. And so they’re all going to have some error. So I usually will recommend is just looking at them as trends, utilizing the numbers as which direction are we heading? That’ll give us a better overall picture than saying, this is my B M R right now. Because again, I’ll be honest, I really don’t know how does bariatric surgery though impact outside of, generally we know that after bariatric surgery because muscle goes down, our overall B M R can decrease because we have less muscle mass. So that can impact that reading. But in terms of accuracy and utilizing that is kind of the end all be all in terms of what we should be aiming for.

(00:41:37):

I would say that’s why working with a healthcare professional, like a Registered Dietitian who can use also calculations to estimate your basal metabolic rate plus activity factor so that we get an overall energy expenditure picture, that’s what you really want to use as kind of a better overall understanding of what you should be aiming for. Because again, then we layer in the fact that, great, well, this says I should be at 1600, but I literally cannot eat any more than X, whatever that might be at your phase that you’re in. And so again, it might be a good number to start working towards, but I always just recommend working with a Registered Dietitian because he or her can help you to really understand what your needs are and how to get there,

Dawn, RD (00:42:19):

Which is good because I just had a patient that had an InBody and saw the number and they were eating under that, and I’m like, okay, we at least got to get you to that number and then we’re going to go higher. We’re going to need you to go higher because that’s not even enough. And they’re like, how am I ever going to lose weight if I’m eating more than this number? And I’m just like, okay.

Kim, RD (00:42:46):

Yeah, and that’s such a great question because it’s like I had this surgery and I am losing all this weight. I want to keep losing, and I’ve been kind of educated on this really low calorie level or the 60, 80 grams of protein a day for life is what’s been out there across most surgical centers. But how I try to present it to folks is, okay, again, this is why I work with people. Usually once they’re past that kind of rapid weight loss phase, I’ll say, okay, we’ve gotten through the majority of that rapid weight loss phase. Now we’re starting to fine tune body composition. And to do that, we have to kind of re-strategize with our nutrition. And that might mean we’re going to start slowly increasing your caloric intake, your protein, your carbohydrates, your fats, et cetera to help stimulate metabolism because we’re going to help with muscle growing, and that is what you want because long term, it’s going to mean a better overall metabolism, a better all energy strategy in terms of meeting your adequate needs so that you can do all this movement that you’re wanting to do and feel good doing it.

(00:43:50):

No purpose in doing all these things. If you have all these signs and symptoms that we talked about earlier, that can start really having some real serious physiological repercussions. So I try to just represent it as, Hey, we’ve gotten through that rapid weight loss phase. Let’s now look at how are we going to optimize your body composition. Let’s focus on that and see what we can do with your nutrition.

Dawn, RD (00:44:10):

Yeah, I think diet culture has just taken over in everyone’s mind in thinking less is more and have created such confusion in really understanding even how their body works to know how to support it. So I think it’s like you’re saying, work with a dietitian, start learning how to fuel your body, especially after bariatric surgery because this is such a crucial timeframe that you are going through so many changes. So if you don’t get that care, you really can compromise your results because your intake is so low,

Kim, RD (00:44:58):

Right? Absolutely. And it’s okay to start making slow incremental increases. That’s okay. That’s a good thing. And I always remind folks, over time, you are going to be able to tolerate more overall nutrition. That’s a great thing. And if we can strategize with those calories and carbs and proteins and the timing and all these things, it’s going to help you to get to what your ultimate goal is, which is whatever that might be. Body composition goal is to train for these different events or whatever, and that’s okay. And that’s having a healthful eating pattern is to take in the amount that your body needs to do all these great things. And so that’s kind of a reframe to look at it after your bariatric surgery is we’re developing this new healthful strategy for life that can really help us to move our bodies in a great way.

Dawn, RD (00:45:44):

Agreed. Now, timing of the fuel, we kind of touched a little bit on this, but do you feel like you have some more to add that you could share with the audience and how to fuel your body with the protein, carbs and enough calories during and before workouts? What other tools do you have for them?

Kim, RD (00:46:10):

Yeah, so timing is really important as we mentioned earlier. So number one, overall, if you are trying to increase your muscle mass, the number one most important factor is meeting your overall calorie and protein goals in a day. The second most important factor now is the timing and to put the nutrients in when your body needs them. And so what I teach my folks is we talk a little bit about the branch chain amino acids, leucine being the prime driver of muscle protein synthesis. And just to kind of put that in layman’s turn, it’s an essential amino acid that you basically need to get in from the diet, and it is the main driver that helps us with building protein in our body, building muscle. And so to do that, the timing of protein plays a role. We want to be getting in about three to four grams of leucine at each meal, and that usually requires anywhere between about 30 to 40 grams of protein per meal to really help with stimulating muscle protein synthesis and taking us out of that catabolic state.

(00:47:07):

That can happen when we have our overall energy intake is low, or we’ve had a stressful workout, for example. So what I teach my folks is eating on a consistent pattern is key, and what that means is going to be different for you and for someone else. Their pattern’s going to be different, but trying to eat about three to four hours trying to get in at least that 30 to 40 grams of protein per meal. And again, when you’re earlier out, that’s going to be challenging. I understand that that’s kind of what we want to work towards. As you increase your exercise, that’s going to be a critical goal. And then also incorporating more carbohydrates, again, incrementally as you increase your exercise frequency, duration and intensity level, your need for carbohydrate increases. And so again, without getting into grams, per kilograms and all these things, what I teach folks is let’s start with where we’re at.

(00:47:53):

Let’s say right now you’re eating 30 grams of carbohydrate per meal. Okay? So I’ll give you an example. One banana is 30 carbs, okay, half banana is 15, or if we’re looking at a half cup of oats is 15 grams. So if we’re going to a whole cup that’s 30 grams. So point is most of the time folks are usually, once they’re out of the initial stages, they’re getting around the 30 carbs and maybe a little bit more. And what I’ll tell folks is, so again, in that immediate post-op phase or post-workout, excuse me phase, try to eat as soon as you can. And again, if we can try to again in protein, if we can bump it up to that 30 grams, that’s awesome. That’s going to help with that muscle protein synthesis. And then I also encourage folks to try to get in about at least 30 grams of carbohydrate as well to help with that muscle glycogen restoration process. And then we’re fueling every couple hours thereafter, because again, when our overall volume is reduced due to bariatric surgery, the frequency can help us to meet our needs. And so I want to just highlight this that I see very frequently with my clients, which is skipping around workouts or not eating breakfast or anything, and then putting all their calories at nighttime or in the evenings.

Dawn, RD (00:49:02):

And

Kim, RD (00:49:03):

That also keeps us in that prolonged kind of catabolic state because we aren’t providing our body nutrients to halt that and be able to grow and build. We’re going these long periods without putting those nutrients in, and we need to not do that right. We want to try to get that fuel in as soon as we can so our body can utilize it. So really to answer your question, I am a big fan of, if you can pre-workout, we’re trying to get in about 15 to 30 grams of carbohydrate in that one to two hours. You can take in some protein, but carbs are going to be more important. And then post-workout window as soon as you can, we’re trying to get up to at least that 30 grams of protein and ideally about 30 grams of carbohydrate to begin the recovery process. And then we’re fueling every several hours thereafter, every maybe three to four hours thereafter.

Dawn, RD (00:49:47):

Do you find that a lot of bariatric patients need to utilize the protein supplements more or do you try to gear them towards just using whole real food as their post-workout quote, meal or pre-workout food? Do you find that one works better than the other or performance is different with shakes and bars or?

Kim, RD (00:50:14):

Yeah, no, it’s a great question. Typically, I always promote food first just because that’s going to increase the variety of nutrients that you’re getting in your diet, reduce constipation because a lot of shakes and bars are very concentrated, and so that can, for some folks lead to some bloating, sometimes some constipation issues from those types of products. If you’re overusing them, meaning you’re taking in several bars a day, several shakes, what I usually say is that because we have increased demand due to increased movement, those types of products have a role and they can play an important role in meeting our needs. Again, they’re secondary to trying to eat balanced plates of real food, and then when we need to increase, we need an extra blast. That’s a great way to do it. I just don’t recommend relying on them as your sole way to meet your protein goals. For example, I wouldn’t be like, yeah, you should be drinking two shakes a day and then one meal of food. No, no, no. We’re trying to eat three meals of food and then we’re incorporating a shake or a bar here or there as needed based on our demands.

Dawn, RD (00:51:16):

Yeah, that’s awesome. Yeah, I agree. I think that’s common to see that they want to use that shake as a meal, and it’s totally not enough fuel. The majority,

Kim, RD (00:51:31):

A hundred percent. And the majority of the time, most protein shakes are low in carbohydrate. And so I always remind my folks, if you’re going to have a protein shake, you need to pair that with some source of carbohydrate as well. So again, half bananas, 15 grams of carb right there. Or if you have the shake and you’re going to have a meal an hour later or something like that, that’s going to incorporate carbohydrates, that’s fine. But again, I want to reiterate it is important, try to get in those protein and carbs as soon as you can after your workout.

Dawn, RD (00:51:58):

So if we go back to the leucine, what are some food sources of leucine that they could actually get that three to four grams when they finish their workout?

Kim, RD (00:52:08):

Yeah, primarily your animal-based proteins are going to be a better source of the branch chains and leucine whey protein powder, casein protein powder, and even soy-based protein powder has the branch chains, but in a lower amount. And also the availability. The absorbability of it in plant-based proteins are going to be less as well as lower overall. So your best sources are going to be coming from your animal-based proteins. Milk egg is another good protein source that you can have, and soy. Soy is also a good source.

Dawn, RD (00:52:41):

But

Kim, RD (00:52:41):

Again, as we get into more of the plant-based proteins, then the concentration of the branch chains are much less, especially leucine. And so then you have to eat a variety of different plant-based proteins in order to get all essential amino acids in. And I want to highlight too, I’ve gotten this question a lot. Can I just take branch chains as a supplement? And the research out there says, yes, we know that leucine plays a critical role in muscle protein synthesis, but you need all nine of the essential amino acids to really gain muscle mass. So you can’t just take those three and be like, that’s all I need, just these branch chains, powder, whatever. You have to get in all the nine essential amino acids from your dietary intake as a whole. So don’t be fooled into just thinking you only need the branch chains. Whey protein is going to have all nine. So is casein, so is soy, and it’s going to have the branch chains as well. So I usually tend to recommend those products over just a straight B, c, a type of supplement as well as of course, eating your animal-based proteins or a wide variety of plant-based proteins.

Dawn, RD (00:53:46):

Yeah. Now, we didn’t talk about this prior, but I’ve been learning more about creatine because of my season of life I’m in and how valuable it’s in menopausal females. I’m like, my mind is blown that the benefit, even with bone health, it’s like I’m really intrigued by utilizing this product even for myself. So how do you feel about creatine for the female population and even males, because we have males too that are bariatric patients that listen. So

Kim, RD (00:54:27):

Creatine, I’m a big fan of it. So creatine monohydrate is the most studied sports nutrition supplement out there. Okay. There is a robust amount of research on creatine monohydrate for its efficacy, its safety, and really they’re looking at creatine in all parts of the lifespan from children all the way up to the elderly and how it impacts not only increasing muscle strength, power size, but also bone health, brain health. So they’re doing more cognitive research on how creatine impacts the brain function, bone density in women, but creatines. So to kind of give a quick exercise, physiology recap, creatine is the first energy system that our body uses when we move at a high intensity level for about up to 180 seconds or so. So it’s an anaerobic system. So if you and I got up right now and started doing squat jumps for the next 30 seconds, our body is using our stores of creatine in the muscle to fuel that movement to provide a t p to the muscle to move our body.

(00:55:28):

So creatine is that first energy system that is used. And so it’s important that we have it. And what I think folks kind of misunderstand or the old myths that were out there with, it caused cramping and it causes weight gain and all these things and whatever. I would say, of course, first, make sure you speak to your doctor before beginning creatine, especially if you have any history of kidney or renal dysfunction. You do want to talk to your doctor before beginning creatine. But back to why it’s important is if we don’t have that energy source to draw upon, you can’t produce that energy force at a high rate for a long period of time for someone that’s resistance training, that’s doing weightlifting.

(00:56:07):

Every extra rep you can get in to move that you’re pushing is helping your body to break down as well as rebuild that muscle. So creatine allows you to basically go harder longer. So the people that really benefit, number one, men and women benefit from creatine as well as vegetarians and vegans, why they’re not eating animal-based products. And that is where creatine is found in the diet, is from our animal-based products, just like humans, animals make it as well. So when we eat animal protein, animal foods, we get that creatine. So we do take it in through our diet, but what we have found is that the dietary intake of creatine versus what we use in movement oftentimes either wash each other out, meaning we’re kind of at a net zero. And so the supplementation of it is helpful to saturate and keep the creatine stores in our muscles elevated. So vegetarians and vegans who are not eating it really see typically a good response to creatine monohydrate supplementation because they’re not taking it into their diet. And so to really just summarize this, I’m a huge fan. I actually had Dr. Darren Kow on my podcast recently. He’s one of the world’s leading researchers in creatine, and he has just talking about the explosion of more creatine research in different areas outside of just muscle gaining and the benefits across the lifespan. So highly recommend folks to look into it, speak to your doctor first, but it can certainly help with increasing muscle mass, power size, and then we have the bone in the brain benefits as well.

Dawn, RD (00:57:35):

That’s amazing. Yeah, I think it’s so interesting how over the year, I mean, I’ve been a dietitian for almost 30 years, so how it was perceived when I was becoming a dietitian completely different as it is today. So yeah, so cool to see what research can give us the information that it can give us and how important it is. Especially like we were talking earlier, we need more research on activities with bariatric patients. We need that data so we can understand their needs better. So yeah, I think the more that we can tune into our community with bariatric patients, it’s going to only help them in the future.

Kim, RD (00:58:25):

Absolutely. And to go off of the creatine thing, especially for bariatric folks, of course, overall calor intake, protein intake, all those things are going to be really important for increasing muscle mass. But creatine is an ergogenic aid, meaning it’s a supplement that helps to round out or boost what your body needs. And so I always tell folks, listen, supplements are at the tip of the iceberg. We don’t even touch that until we get the basic dietary strategies in place. There is no supplement that can cover up a poor diet or poor intake. And so to reiterate, with bariatric folks, I would say creatine can absolutely be a very helpful supplement as long as you are doing resistance training and you are eating the optimal amount of calories and protein and carbohydrates, et cetera, to fuel the movements that you’re doing, like your weightlifting or whatever. But it definitely can be a helpful supplement. Talk to your doctor first. Of course.

Dawn, RD (00:59:14):

Yeah, I think that’s a good point to make, that they’ve got to get that foundation first before you start more supplements to maybe not even really help you in that scenario.

Kim, RD (00:59:29):

Totally. Yeah, I agree.

Dawn, RD (00:59:30):

Yeah, that’s awesome. Okay. This has been awesome. So any last thing that you would love to share with the audience that maybe you didn’t get to finish the full thought on or just something that you feel like would be important to them to hear?

Kim, RD (00:59:48):

I would just say it’s exciting that after you have had bariatric surgery and you’re changing, you’re changing your life, you’re changing your body composition, you’re starting these new exciting goals, nutrition plays such a critical role in that process, and really to feel good doing it to meet the goals that you’re striving for. It takes a little bit of focus and some practice, but you can meet those goals through increasing and improving your nutrition over time. Nothing to be afraid of with gradually increasing overall calories, carbohydrates, proteins, fats, all those rules out there about no carbs, especially with my more active folks, I’ll just say there’s a time and place and they play a very critical role in your overall ability to do all these new exciting goals that you have in terms of fitness. So I always just remind folks it can be done. Working with a healthcare professional, like a Registered Dietitian can really help you to sort out the what do I need to take in, how much and when and how’s that going to meet my unique needs as a bariatric individual that now have all these fitness goals. I just want to recommend, always try to find a professional. It’s just really helpful. It saves you time, confusion, all those things that you don’t want to have to be focused on. So I just really appreciate being on today. I thank you so much for having me.

Dawn, RD (01:01:02):

Yes. Awesome. How can people find you, share where your website and maybe all your social media, where can they find you to maybe work with you or learn more about what you talk about?

Kim, RD (01:01:16):

Sure. Yeah. So my business is Active Bariatric Nutrition. I have an Instagram account, my social media, my handle is at Active Bariatric on Instagram. I have a TikTok page, which is Active Bariatric Nutrition. I have a YouTube channel that hosts all of my podcast episodes. So I do have a weekly podcast that’s called the Active Bariatric Nutrition Podcast. And I bring on both bariatric individuals that have fitness goals to kind of help with motivation, inspiration, learning from each other. I bring on professionals, other dietitians and doctors and exercise experts to talk all about this area. And so you can see all the videos of the podcast on my YouTube channel, and you can go and listen anywhere that you listen to your podcast for the Active Bariatric Nutrition podcast. And then I do have a Facebook community. So if you’re wanting to come inside my Facebook community, just search the active Bariatric Nutrition community, and it is a private community. So I will let you in, but we just talk day to day about different topics and questions that you might have. And then lastly, my website, which is www.activebariatricnutrition.com. If you’re ever interested in scheduling a discovery call, you can go there and we can learn more about each other through that call.

Dawn, RD (01:02:27):

That’s amazing. I love it. Thank you so much, Kim. This has been very helpful and I know the audience will love all this information that you’ve provided. You definitely are a wealth of knowledge when it comes to the sports nutrition piece that bariatric patients really do need when they’re so active.

Kim, RD (01:02:49):

Thank you so much. I appreciate it, and thanks for having me on today.

Dawn, RD (01:02:51):

Yeah, awesome.

Kim, RD (01:02:52):

Thank you. You too.

Dawn, RD (01:02:53):

Yeah.
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