Can You Be Vegan/Vegetarian after Bariatric Surgery?

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1 Can You Be Vegan/Vegetarian after Bariatric Surgery? By Laurie Shank, RD, LDN Bariatric Dietitian All Bariatric surgery patients know that we must be diligent with our nutrient intake after surgery. It just makes sense that we would need supplementation once a large portion of our digestive system is bypassed. As a bariatric patient, your vitamin regimen becomes a way of life: multivitamin, Calcium, Vitamin B12, Iron, Vitamin D, etc. We should also remember: Protein! Protein! Protein! But what about those who follow a diet that is already typically difficult to reach proper intake of these key nutrients? Many Americans believe that vegetarian or vegan diets are lacking in many nutrients; the most easily identifiable being protein. Without meat, how do you get enough protein in? This is a common question in our meat-based society. And with the malabsorption after surgery, plus the limited choices of vegetarian diets, is it possible for a vegetarian to have bariatric surgery and stay healthy? Let s start by clarifying a few key definitions: Vegetarian refers to those who abstain from animal products. There are several types: lacto-ovo vegetarians eat eggs and dairy, but no meat. Lacto-vegetarians eat dairy, but not eggs or meat. Vegans are stricter, abstaining from meat, dairy, eggs, and sometimes other animal-derived products such as gelatin and honey. There are also pescatarians, who abstain from meat, but do eat seafood, as well as varying degrees of vegetarianism such as those who eat white meat but not red meat. People choose a vegetarian diet for many different reasons. They may be vegetarian out of concern for cruelty to animals or other similar ethical reasons. Others may be vegetarian for religious reasons. People may also choose the vegetarian lifestyle for health reasons. The Academy of Nutrition and Dietetics notes that vegetarians tend to have lower risk of death from ischemic heart disease, lower LDL-Cholesterol (bad cholesterol), lower blood pressure, lower rates of hypertension and type II Diabetes, By Laurie Shank, RD, LDN 1

2 lower BMI s, and overall lower cancer rates. Still others may choose a vegetarian lifestyle because they do not prefer the taste of meat. For time s sake, let s focus on the strictest form, veganism, so we can cover all of our nutrient bases in one shot. The most typical nutrients which are difficult to achieve optimal levels in the vegan diet include: Protein, Vitamin B12, Iron, Calcium, Vitamin D, Omega-3 Fatty Acids, Zinc, and Iodine. Protein It is true that meat is a good source of protein. After bariatric surgery, we emphasize to concentrate on lean meats for protein, and always eat your protein food first. Almost all unrefined foods contain some amount of protein. Vegetables, beans, whole grains, nuts, and seeds all contain protein. Fruits, sugars, and fats do not contain protein. It is very easy to meet daily protein needs if these foods are incorporated at each meal daily. I m sure some people have heard the concept of complete proteins. This refers to a protein that contains all of the essential amino acids that our body needs. Amino acids are the building blocks that make up a whole protein. Each serves different functions in our body. Many amino acids our bodies can make ourselves. However, there are nine of them that we need to consume from food. Studies have found that isolated soy protein can meet protein needs just as effectively as animal-based proteins. However, most whole-grain sources of protein such as cereals tend to be low in the essential amino acid lysine. To ensure adequate lysine intake, include more beans and soy products in your diet. The protein recommendation after bariatric surgery is grams per day for women and grams per day for men. This is easier to meet than you may think. 1 cup of cooked soybeans is 29 grams of protein. 1 cup of cooked lentils is 18 grams of protein. Most beans contain 15 grams of protein per cup. 2 tablespoons peanut butter contains 8 grams protein, 1 cup broccoli or spinach contains 4 or 5 grams. Two slices of whole wheat bread contain 7 grams protein. A medium bagel contains 10 grams. Again, the bariatric patient wants to make sure that half of their plate is filled with these high-protein foods, and the protein food is always the first eaten during a meal. By Laurie Shank, RD, LDN 2

3 Vitamin B12 and Iron Vitamin B12 (Cyanocobalamin) and Iron are also commonly thought of as being deficient in vegetarians. It is true that red meats are the most well recognized source of both Vitamin B12 and Iron. Iron from meat sources is mostly heme iron. This kind is more readily absorbed than the non-heme iron found in plant sources. Due to this decreased bioavailability of the Iron found in plant sources, the recommended Iron intake for vegetarians is 1.8 times higher than those for non-vegetarians. Absorption is also a concern for the bariatric patient, which is why we recommend lifelong supplementation. The enzymes responsible for breaking down Iron and B12 for absorption are located in the stomach. It makes sense that a person with percent of their stomach removed would have inhibited absorption. How can you combat this decreased absorption? There are some things which help to increase Iron absorption, such as Vitamin C. Also, it is important to remember that some foods inhibit Iron absorption, such as the tannins in coffee and tea. You can maximize your Iron absorption by avoiding coffee and teas with meals. Vegetarian sources of Iron include dried beans and dark green leafy vegetables such as spinach and kale. Make sure to include a food source of vitamin C with your meal. This can increase non-heme Iron absorption up to six-fold, which makes it just as absorbable as heme Iron. Some vegetables, such as broccoli and bok choy, are high in both Iron and vitamin C. Unfortunately, there is no significant source of Vitamin B12 in the vegan diet. Lacto-ovo vegetarians can obtain vitamin B12 from dairy and eggs. Vegans must consistently consume foods fortified with vitamin B12 such as fortified soy and rice beverages, some breakfast cereals, and meat analogs. The RDA for B12 intake is 2.4 micrograms per day. However, the stomach is also responsible for producing the acidic environment and the enzymes responsible for absorbing vitamin B12. Therefore, the recommended supplementation for bariatric surgery patients is 500 micrograms per day, up to 1,000 micrograms per day if deficient and in need of repletion. This is higher than the nonsurgical vegan supplementation recommendation of micrograms daily. By Laurie Shank, RD, LDN 3

4 Calcium The general view of the American public is that dairy products are the only way to get enough calcium in your diet. The RDA for calcium is 1,000 mg per day, 1,200 mg per day for women. However, the bariatric patient needs mg per day. It is true, dairy sources are good sources of calcium, with approximately 200 mg of calcium in an 8 ounce glass of milk. Good plant sources of calcium include dark green leafy vegetables, tofu made with calcium sulfate, and fortified soy milk or orange juice. Soybeans and soy nuts, broccoli, bok choy, collards, okra, and kale are also good sources. Some higher calcium dark leafy greens contain oxalates, which greatly decrease calcium absorption. These include spinach, rhubarb and chard. Other leafy greens do not have this effect. Plant milks such as soy milk contain mg per 8 oz., while tofu contains approximately mg calcium in 4 oz. Dark green leafy vegetables contain anywhere from mg calcium per cup. As a bariatric patient, it remains important to take additional calcium daily due to the limited absorption from your post-surgical stomach. But what else can you do to help increase absorption? For one, get adequate Vitamin D, which helps Calcium absorption. Following a low sodium diet also helps maximize calcium absorption, as high sodium intake increases kidney calcium excretion. Weight bearing exercises also help to increase Calcium absorption into your bones. So keep up that exercise routine! Vitamin D The main source of natural vitamin D is sunlight exposure. Our bodies produce vitamin D. The only real food source of vitamin D are foods that are supplemented with it, such as fortified orange juice, soy milk, rice milk, and some breakfast cereals. Vegans or vegetarians need to make a conscious effort to include foods fortified with vitamin D if sunlight exposure is inadequate to maintain body stores. If supplementation is necessary, Vitamin D-3 (Cholecalciferol), and Vitamin D-2 (Ergocalciferol) are available. Vitamin D3 is made from animal sources. Vitamin D2 is made from plant sources. Because Vitamin D3 is absorbed more efficiently than Vitamin D2, vegans who choose supplementation with Vitamin D2 may need to take higher doses. By Laurie Shank, RD, LDN 4

5 Overall, a vegan or vegetarian diet can meet all nutritional needs of the average person. However, due to the decreased bioavailability of some plant forms of vitamins, along with the decreased absorption that follows bariatric surgery, the bariatric patient will require careful meal planning to include rich sources of these key nutrients and may require additional supplementation. Sources: 1) Vegetarian Resource Group; Simply Vegan 5 th Edition. 2) Position of the American Dietetic Association: Vegetarian Diets. By Laurie Shank, RD, LDN 5

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