The carb controversy after bariatric surgery

Dawn (00:00):

Hello and welcome to the Gastric Health Show. My name is Dawn Boxell, and I have been a Bariatric Dietitian for 27 years, and I’m working with tens of thousands of bariatric patients and excited to share this next topic with you, and it’s titled The Carb Controversy After Bariatric Surgery. This is definitely something that has ebbed and flowed over the years, and I would say when I first started into bariatrics, I probably didn’t believe that we needed to decrease carbon intake. Then as we kind of continued into a decade of it, I really found that people did better with a lower carbohydrate diet, and the evidence was coming out that low carb was beneficial.

Dawn (00:59):

But what has really shifted my brain is genetics. And I will tell you this has really opened up information and really paints a different picture for me as a practitioner that I no longer believe that every person after bariatric surgery truly has to remain low carb because of your genetics, and I’ll kind of dig into this, but I want you to see the positives of a low carb diet.

Dawn (01:34):

So I’m not against ’em but not everybody needs a low carb or very low carb diet to be successful with weight loss and health goals after bariatric surgery. So hang tight with me and we will get through all this where you see the positives, the negatives how your genetics do influence this and how you have choices. And this gives you an opportunity to, one, improve your relationship with food because you’re no longer be going to be tempted to jump on every fad diet bandwagon just to see.

Dawn (02:14):

if you can lose a few more pounds because you will know that that is not something that’s going to benefit you. So let’s work through all this so that you guys can I’ll give you some new food to think on your carbs and maybe not be so afraid of introducing a few more carbohydrate rich foods. So again, carbs after bar bariatric surgery is quite controversial, and some say that you should be very low carb.

Dawn (02:48):

Others say your body needs the carbs, and I totally get it. You just want to be successful after bariatric surgery and you’re confused, scared, unsure of the right answer. So I would say especially if you’re noticing changes in your appetite, your hunger cravings, or just the way clothes are fitting, the fear escalates and not to mention the thoughts of restricting fill your head because your friend was just so successful following a very low carb diet, aka keto diet. So you question if you shouldn’t lower your carbs even more.

Dawn (03:35):

which creates more confusion and fear. So here’s the thing, learning more about genetics helped open my eyes so that I could see that there’s no one formula that is going to work for everyone. So just because your friend was successful at her ketogenic diet, which may have been the perfect fit for her genes, family history, genetic wrist all of those things, and her current health conditions, it might have been the perfect thing but for you, it may not be the right thing.

Dawn (04:14):

And I recently did covered this topic on why you shouldn’t follow your friend’s successful diet, and I dig into that as well and kind of sharing three case studies of patients who did a genetic guided diet compared to a conventional diet. So check that post out if you want to learn the details of that, but it’s very enlightening and actually pretty exciting because there was no carb restriction in the genetic guided diet. They were doing 45 to 48-47% carbohydrates so several hundred grams of carbohydrates a day and were successful with lowering their blood glucose levels.

Dawn (05:02):

their weight and their A1C and their health conditions we’re improving. So again, I think we have to dial into us, and again, this is why it’s important to work with a practitioner like myself who can really help personalize it and help dial in your intake so that how many cards you truly can consume and not worry about what it could be contributing to.

What is a normal carb intake?

Dawn (05:35):

So hear me out on why some of you may need to increase your cards after bariatric surgery because I will tell you a lot of patients and understand, I completely understand this, that they come in and they’re following a low carb diet. And again, I’m not against this. It’s definitely a personal decision when it comes to choosing carbohydrates and how your diet and lifestyle, how you live your diet and lifestyle. Because for example, my mom has dementia, Alzheimer’s disease, and this disease is directly related to blood sugar and insulin regulation.

Dawn (06:23):

And I do know my genetics and I want to still minimize my risks for developing this later in life. And although I do not have the APOE jean, the high risk variant it’s still important to me to adopt a prevention lifestyle when it comes to my brain and metabolic health because I do know studies show there are many practitioners that I am that are colleagues that utilize diet and lifestyle approaches to help slow the progression and have even reversed these types of symptoms from dementia and Alzheimer and people.

Dawn (07:13):

And I don’t want to wait until if this is something, even though I don’t have those high risk variants I don’t want to risk since it’s in my family history, I don’t want to risk having this and I don’t want to wait until I show up with the signs and symptoms. They do know that in multiple studies they’re showing that dementia and Alzheimer’s can be delayed. So with medications, there’s no reversal. But I do know of Dale Brenson. He’s an MD who does a lot of Alzheimer research and he has been able to reverse with diet and lifestyle.

Dawn (07:56):

and things and different approaches with improving cognition after an Alzheimer or dementia diagnosis. So I say all that to say that I understand personalizing this and I understand when you want to choose a certain way of eating and back people on that. I understand that because you’ve maybe watched people in your family live something that you don’t want to, and I think that’s great.

Dawn (08:33):

I think that’s an awesome way to make health decisions because you’re the only one living in your body and you what you feel, what you’ve experienced and what your family members have lived through. So again, there’s nothing wrong with that, but I also want to take the fear away from carbohydrates when it’s totally not necessary. So this will help improve your relationship with food because you’re not going to feel that need to restrict unnecessarily, and it will help prevent you from jumping on the next fad diet bandwagon.

Dawn (09:16):

because if you know your genetics, you were not going to be tempted to do that because you already will be educated to know that that’s not, that’s the opposite of what will help. And I will say with the low carbohydrate diets, I find frequently that a lot of bariatric patients feel like they have to be very low carb.

How did low-carb become a thing?

Dawn (09:39):

And I’ll get into the differences in a minute, and that means they’re doing a lot more fats and which I have absolutely no problem with. So following a ketogenic diet, you definitely do very low carbs and high amounts of fats. Again, tons of evidence behind this, but what I don’t like when I have discussions with patients on this is that they’re very they’re not picky about their fats. They just eat any type of fat and they do very little fibers and they don’t consume adequate fiber.

Dawn (10:23):

So there’s lots of gaps. So just saying, okay, I’m following a ketogenic diet. If you truly do it wrong, you can harm your health and your genetics can tell you that. So if you would benefit, say you have the APOE gene and you have a high risk variant, then you would want to follow a higher fat diet.

Dawn (10:47):

But I would be very specific on the fats because saturated fats do not provide for some people with certain genetic pathways and combinations of genes the worst thing you can do is high amounts of saturated fat with those genes. So that’s where I think you have to understand the full picture and you can’t just jump on a keto diet and think that this is what’s best for me, and you have no guidance in making the right fat choices.

Dawn (11:24):

So again, I think I’m for following your genetic risk factors and limiting those types of foods and diet and lifestyle things. But if you don’t know your genetics and you’re just guessing or you’re doing it because it’s the latest and greatest I would challenge you on this invest in yourself in this one genetic test that is literally a few hundred dollars that you can find out so much information that it’s your roadmap for life.

Dawn (12:06):

And you can, as you ebb through life and go through seasons of life, if jeans get turned on what we can work together again and turn ’em back off and kind of work through that. So to me, it is a roadmap that is so exciting that you no longer have to guess. It is literally your way of knowing how to eat and live your life for optimal health. So let’s kind of dig into carbohydrates and what is a normal intake? And the dietary guidelines for Americans recommend that carbohydrates make up 45 to 65% of total calories.

What’s considered low-carb?

Dawn (12:52):

And for example, if you consumed a 2000 calorie diet, then you would be consuming around 900 to 1300 calories in carbs, which translates into grams to be about 225 to 325 grams of carbs a day. So how did you know low carb become a thing? And first off, low carb diets have been promoted as a primary focus on weight loss.

Dawn (13:25):

However, a significant rise in popularity for low carb diets resulted after decades of focus on low fat diets and a parallel rise in the national obesity rates. So as we pulled fat from the diet, starch was replaced in removing the fat in ingredients in foods, and it was promoted to really consume 12 servings of grains a day, and it paralleled with the obesity rates. So as of that, those guidelines were being pushed. Then obesity rates rose at the same level.

Dawn (14:16):

So it’s the low carb thing kind of became a quest to understand if this was truly what was happening. So what is considered low carb? The studies show it’s somewhere between 20 to 150 grams of carbs per day is considered a low carb intake. So essentially a low carb diet of 20 to 50 grams of carbs would be considered very low carbs. And anywhere between the greater than 50 to 150 grams of carbs would be considered just low carb.

Dawn (15:00):

So there’s very low carb and there’s low carb. And in my opinion, I would say there’s probably a fewer percentage of the population that truly need a very low carb diet or a 20 to 50 gram carb diet than there are people who can do just a low carb diet, more like 75 to 150 grams of carbs a day. And again, this is where working with a practitioner like myself could be helpful because if you’re following a very low carb diet of 20 to 50 grams, you have to be super intentional about your choices or you are going to have malnutrition, you are going to be missing nutrients and properties of food.

Dawn (15:53):

that you are going to mess up your health more, then improve it. So don’t do it blindly or don’t just follow some random guideline you found with Dr. Google. I would encourage you to work with a practitioner that is skilled in making sure we’re hitting all of your nutrient goals and paying attention to your signs and symptoms that understand how to correlate malnutrition symptoms with your current food intake.

Dawn (16:27):

So that would be my best recommendation that if you are choosing that, you may not have your genetics, but you’re choosing to follow low carb diet work with someone that you can truly map out something that is going to be meeting all your nutrient needs. Now what are the positives of following a low carb diet? And like I said, I am not against very low carb and low carb diets because to me, the genetics warrant it for certain populations of people. But when you don’t know your genetics and you’re just picking and choosing the next best fad diet coming along, then you are unnecessarily well, one, you’re creating a very poor relationship with food and you are potentially robbing yourself of nutrients that your body needs and creating some health conditions that you may not need to have experience.

Dawn (17:34):

So a recent study published in 2022 found that those following a low carb high protein diet had better blood sugar balance and overall weight loss and then low carb stem primarily from the hypothesis that lowering insulin, which is a critical hormone that produces an anabolic fat storing type state. And we’ve talked about this before, how insulin and can tell your fat stores to stay locked away but it also improves. So low carb diet improves cardio cardiometabolic function and induces weight loss as shown in a 2018 study.

What are the positives to following a low-carb diet?

Dawn (18:23):

A low carb approach has been recently called the carbohydrate insulin model, and studies have shown that low car approaches to be superior to other dietary methods in producing rapid weight loss for the first six to 12 months. And to clarify further I do discuss more about insulin and blood sugar regulation in a couple of different posts on why bariatric patients should care about blood sugar and why insulin levels matter for appetite and weight. Or you can learn more about your insulin and blood sugar in those posts. So when lowering carbs from the diet, typically you’re going to replace it with other foods or other macronutrients.

Dawn (19:15):

So typically we see an increase in fat and protein to compensate for the reduction of carbs, which is totally appropriate because you have to feel satisfied. You can’t just cut those calories and nutrients and not replace it with something, but they don’t equally replace each other in nutrient profiles. So that’s where I think you have to work with somebody who understands how to nourish you by following these type of approaches. The ketogenic diet is a very specific low carb version.

Dawn (19:55):

and keto diets restrict carbohydrates to induce ketosis. And typically you range anywhere from 20 to 50 grams of carbs per day and restricting carbs under 50 grams induces glycogen depletion and keto production because the ketones are the byproduct of fats the of mobilizing those fat stores in your adipose tissues. So it’s taking the fats out of your cells and utilizing it for fuel.

Dawn (20:37):

That’s what your brain and body is fueling off of as opposed to carbohydrates or sugar. And the keto diet has been found to lower the risk of Alzheimer’s and dementia, diabetes and insulin resistance and improved weight loss for a few of the benefits. So there is compelling evidence around following a low carb lifestyle, but there are negatives too. There’s not perfect for every person. It doesn’t mean that just because you have bariatric surgery that you should automatically be following a low carb diet and that’s just not true.

Dawn (21:20):

Some of you really truly need more carbohydrates and you are restricting way too much. So what are the negatives? Typically? I find that all or nothing mindset around carbs creates a unique environment when making food choices. And I’ll have people be afraid of eating whole real food choices like fruit or potatoes or beans or lentils because of the sugar or carb content.

Dawn (21:52):

But we’ll have no problem eating a weight watcher ice cream bar because it’s low carb or a bag of Quest chips because it’s high protein, low carb. And to me that’s kind of mind boggling because it’s really exactly what the food industry loves. They have made a food or manufactured a food that really in some instances truly have no food properties or nutrition or nutrients that can fuel your body and they’ve got your money.

Dawn (22:28):

So you’ve bought into, you’ve you, you’re continuing this funding of the food industry on outsourcing your food and I want you to insource your foods. I want you to be the one making those choices. I want you to be the one who is making the positive choices towards your health and not relying on the food industry to tell you what you should eat and offer you what you should eat.

Dawn (23:05):

I do understand your rationale with choosing those. Wait, watch your ice cream bar Quest chips. I do understand the rationale, but it comes from a lack of education around carbs and how your body works as well as kind of knowing the tips and tricks around mini minimizing the glucose and insulin spikes when you are consuming higher carb foods. So there are things you can do to help lessen or blunt that spike in your blood sugar or insulin surge that will prevent you from needing to be so restrictive with carbs.

Dawn (23:41):

So, I want you to have a good relationship with, and I want you to not have that all or nothing mindset that is having a certain carb is going to derail everything you’re doing. That is not a great way to live your life. But if truly, if your genes, your genetic risk, your family history, your health conditions warrant following a low carb or a very low carb diet you need to make sure of important things are not missed.

What are the six negatives of a low-carb diet?

Dawn (24:18):

So here are some of the negative things by following a low carb diet if you’re doing it inappropriately and one is getting adequate fiber because you have to be super intentional about getting fiber if you’re following a 20 to 50 gram carb intake day. And I would say I rarely find somebody in that carb range who meets all their fiber goals. And then two, you can increase cortisol levels in some individuals when carbs are too low. So that means your stress hormones spike which can impact sleep causing that two to 4:00 AM wake up and causing more issues with that your cravings the next day and your appetite and hunger because your sleep was disrupted or you get poor sleep.

Dawn (25:20):

And four, it doesn’t always work well with those with thyroid dysfunction. So following a very low carb diet, if you have hypothyroid disease is not recommended. So keep that in mind if you are in that category. And then also you risk short chain fatty acid production, you won’t have adequate short chain fatty acid production because you won’t have adequate fiber. So again, this is something that’s super important because this regulates that GLP-1 appetite suppression hormone, this helps heal that gut lining, strengthening all of tho that barrier in your gut preventing.

Dawn (26:06):

what people have heard as leaky gut and research. We call it increased intestinal permeability all from a lack of fiber and short-term fatty acids are super impactful for our health. It has the ability to have communication from our nerve to our brain. It’s beneficial, it’s something that we want to occur. We want short chain fatty acid production when it doesn’t happen.

If you don’t have adequate short chain fatty acid production

Dawn (26:38):

If you don’t have adequate short chain fatty acid production, your gut takes it from the mucin lining. So all this mucus, that’s when those bacteria consume that to produce the short chain fatty acids or they take it from the fat and the protein. And what they find is when you’re utilizing protein and fat sources, you get the wrong metabolites, the metabolites that are associated with disease and poor health.

Dawn (27:12):

So again, you want short chain fatty acid production to occur from undigestible fibers. And that does not occur with if you don’t get the right types of carbs, even following a low carbohydrate diet or if you’re following a very low carbohydrate diet, it’s super hard to get adequate fiber unless you’re being super intentional, which I have yet to find a person who does that at least in the bariatric community. I don’t know. Most of my patient base is in the bariatric community.

Dawn (27:48):

I do have some that are out but I have more in the bariatric community. So again, I base it off of that. So there could be people outside of the bariatric community who are great at doing the fiber piece on a very low calorie diet or a very low carb diet but I would guess that would be a very, very small percentage. And then number six, difficult for perimenopausal menopausal females because it impacts your hormones negatively. If you go way too low, so would say most of these are because you would be on a very low carbohydrate diet.

Dawn (28:31):

So the 20 to 50 grams of carbs for long periods of time, that’s when it would be an issue could be difficult in those with no gallbladder. If you are taking away the carbs and adding in more fats that might be harder because you’re not going to adequately digest those fats well unless you’re adding support some bladder adding some type of gallbladder support. And then number eight, liver support may be needed for those following a keto diet if you have a history of fatty liver disease because your liver may not be able to handle high volumes of fat without some support.

What are the genetics influencing a choice to follow a low-carb diet?

Dawn (29:16):

And again, this, there’s a genetic base to this as well. We do know that genes influence how well your liver detoxifies and does its job, and that’s when liver support is sometimes super important for certain people that have those genetic SNPs. Even though following a very low carb or low carb diet can produce great weight loss for you, it doesn’t mean that it won’t impact your health negatively in other areas. So just because you get weight lost one doesn’t mean you get fat loss. And two doesn’t mean that all of your health indicators improve automatically.

Dawn (30:07):

Just like I said, if you do more of a keto diet and you do a ton of saturated fat, which I typically see you may do the opposite, you may cause more health conditions and higher health risks by doing that. So again, that’s where the genetics can help guide you so that you’re informed you’re not making your health risks higher. Now, what are the genetics that are influencing a choice to follow a low carb diet?

Dawn (30:42):

So if you did your genetics, if you did a 3×4 genetic test, which is the only one I use. I can’t take your 23andme or your gene site or any of those other. Not gene site, but any of those other genetic tests I am not skilled in those. I am only skilled in trained in the three x four genetic test and I look at the different pathways and see what things based off of your symptoms and health conditions and lab data and then correlate that with your genetic risk to see what is being expressed and what we are dealing with currently. And then we make a plan based off of that.

Dawn (31:22):

But I don’t have the experience with all the different genetic SNPs like the 23andme delivers. I just don’t have that experience. But although your genes are not your destiny. So just because you have a genetic SNP or a genetic risk doesn’t mean that. It’s going to be expressed or it’s going to impact your health and sometimes. It doesn’t impact your health until certain seasons of life or some super stressful eventine occurs. But there are over 19 genetic SNPs that can influence how your body regulates. Glucose and insulin, which is directly related to carbs.

Dawn (32:09):

So that’s exactly what is so controversial that people struggle with. And the diabetes community, it was just like controlled carbs. You do this many carbs at each meal and snack, so you have continuous carbs all through the day. And then other people are like, that’s just the craziest thing. Why would you eat so many carbs if that’s causing you to spike your glucose in your insulin?

Dawn (32:33):

It doesn’t make sense. So again, you have those genetic that can guide you. So why everyone gets a different reaction and why a high carb diet works for a diabetic. A type two diabetic, but it doesn’t work for the other one. It’s probably these genetic SNPs that are influenced or. The combination of that is creating that change or that shift in one person over the other. So it may take very specific combinations of variance for someone. To need a very low carb diet like a keto diet. And one of them is that APOE.

There is advantages to following more of a ketogenic diet

Dawn (33:19):

So the Alzheimer dementia gene that most people are familiar with that one is definitely. There is advantages to following more of a ketogenic diet. But for me, I don’t have that risk variant of APOE. But I still live a lifestyle where I try to be more in the lower carb version. So that I manage my blood sugar balance better.

Dawn (33:50):

And if you’ve followed me long enough, you’ve might have heard me talk about how recently. My fasting glucose has been elevate over this last year and 2022. End of 2021 I had a few elevated glucose, my insulin level rose and my fasting or my a1c. All of those roses, the only one that was in a pre-diabetic range is the fasting glucose. It is in a pre-diabetic range. So I do know if I don’t dial this in, and for me it was triggered with menopause. As I’m transitioning into that season of life that what’s triggered it for me.

Dawn (34:37):

And so I’m actually getting a continuous glucose monitor soon and will be doing just some pulses of following what I’m doing because I think stress is a factor for me that it really influences it and sleep, which are both <laugh>, which is what menopause does, it increases your cortisol and it gives you poor sleep.

Dawn (35:05)
So again, I am dialing this in so I can see how to shift and get better numbers. So again, I’m just managing my risks but I’m definitely not following a ketogenic diet. If I had the APOE gene variant that was at high risk. I would probably be following a ketogenic diet because I already have a family member with it. Which puts me at 50 or 60% higher risk of getting dementia and Alzheimer’s.

Dawn (35:37):

it’s something that I take very seriously. And to me, I want to be proactive, not reactive. So once I got out of the denial phase of my fasting glucose is elevated. I realized I’ve got to do something about this. I need to take steps to lessen my risk and delay the onset. If that would ever to occur for myself. So having these genes doesn’t mean it’s your destiny, but you have to be intentional.

It is associated with increased insulin response to sugar and refined carbohydrate consumption

Dawn (36:11)
You have to make different choices. Sometimes for example, the SLC2A2 genetic SNP is involve in the first step of glucose induced insulin secretion. It is associated with increased insulin response to sugar and refined carbohydrate consumption. Therefore compounding your sugar intake and cravings especially for sweets.

Dawn (36:36):

So it kind of makes it difficult because you’ll crave those things. That your body’s not going to regulate very well. Another example is the ADIPOQ, the GG genotype was associate with high insulin. And triglyceride levels compare to the A allele carriers and is associate with. A higher risk of insulin resistance and metabolic syndrome. And again, I have some of these gen. So out of these 19 genetic SNPs, I have some of those. So I know that my risks are there with that piece that my body doesn’t manage. And also I have the family history.

Dawn (37:16):

I have a ton of diabetes in my family obesity in my family. And of course the Alzheimer, dementia Parkinson and my family. So to me, understanding my genetic risks helps me stay informed with choosing how to manage my health better. And then lastly, a very recent study published in 2022 on. How the timing of dinner and genetics affect individual’s blood sugar control. They found eating dinner close to bedtime. When melatonin levels are high disturbs blood sugar control, especially in individuals with a genetic variant in the melatonin receptor. MTNR1B, which has been link to an elevate risk of type two diabetes.

The high melatonin levels and food intake

Dawn (38:08):

The high melatonin levels and food intake associated with late eating impairs blood sugar control in carriers with this genetic. Risk variant through a defect in the insulin secretion. So as you can see, your genes can make you more susceptible to more imbalances in your blood sugar.

Dawn (38:29)
But here’s the thing, having these genetic SNPs that predispose. You to imbalanced blood sugars is not a death sentence or a guarantee. They’ll be express, but you have to understand them to know how to make health decisions. And know if you truly need to follow a low carb lifestyle. I mean, how frustrating if you’ve been following a low carb lifestyle. And you don’t have those risk factors in your history and. Then you do the genes and you don’t really have the genetic risk and you find out .

Dawn (39:03):

I could be eating a couple hundred grams of carbohydrates a day and enj enjoying some of those. Whole grain sources of carbohydrates that you’ve been restricting for no reason at all. So as you can see, we’re going to wrap this up. As you can see, the intake of carbs is very individual. And no two people are going to respond the same. Because there really is only one you even in your family there, even your siblings, you are not alike.

Conclusion

(39:37)
So in choosing how many carbs your body needs, don’t just look at weight loss. Don’t look at how can this help me quickly lose weight because you’ll likely lose muscle with that. And I have content coming on that next on the importance of muscle and why?. That’s equally or more important than fat loss. But you have to consider how it influences your hormones. Your stress response, your sleep, your gut health your thyroid, your liver. All of those things are going to be influence base on how low carbohydrates you take. So that’s why working with a practitioner like myself can be so beneficial. Because we can help you dial in the right amount of carbs. So that you have a positive relationship with food and. You no longer have this all or nothing mindset or restrictive mindset.

Dawn (40:31):

You have a roadmap to what your body needs and only your body needs. And you’ll no longer be tempt to jump on that bandwagon of the next fed fad diet that comes around. Because you know that it’s not going to serve you well. Again, I always like to encourage you to check out our gastric health membership. It truly is the highest value you can get because it provides. You all the resources from a registered dietitian with over 27 years in weight loss bariatrics. And I look at it through a lens of functional and integrative nutrition and diet and lifestyle approaches. So that you can maximize your health and maximize your energy. And how you feel and just your relationship with food. It’s just a better way to approach your health when

Dawn (41:32):

You are utilizing the whole body. So I hope this has helped. I hope maybe this is getting you to think differently about carbohydrates. And maybe allowing you some freedom with your carb choices. Again, I would always choose higher fiber choices when you are adding in carbohydrates. So you get a double whammy of benefits. So you guys have a great week and we will see you next time. Bye-bye.

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