Proteins are the fundamental building blocks of our body. In addition to being building blocks, many biological functions are carried out through proteins. They can also serve as an energy source in times of hunger.

Obesity and metabolic surgery (bariatric surgeries) are primarily divided into two groups: volume-restrictive and malabsorptive surgeries. Both types of surgery put the body into a controlled state of hunger. The goal in the post-operative period is to prevent proteins from being used as an energy source by ensuring sufficient protein and energy intake. The aim is to preserve muscle tissue while losing fat tissue.

The loss of muscle tissue reduces the body’s basal calorie needs. Patients lose weight rapidly; however, the rate of regaining weight may increase.

According to the American Metabolic and Bariatric Surgery guidelines and the Bariatric Surgery Guidelines of the Turkish Endocrinology and Metabolism Association, it is recommended for patients undergoing obesity surgery to consume 60-120 grams of protein daily.

In surgeries that reduce stomach volume or cause malabsorption, sufficient protein intake may not be achieved due to complications such as inadequate food intake, malabsorption, or vomiting/food intolerance.

Studies have shown that during the initial months (especially during liquid and puree phases), patients often fail to reach the targeted protein intake. It has been observed that patients can only tolerate about two-thirds of the targeted protein amount (approximately 30-50 grams). Therefore, it has been determined that PROTEIN SUPPLEMENTATION MUST BE USED IN THE FIRST MONTH AFTER SURGERY.

There are some products specifically produced for post-bariatric patients. With these products, it is often possible to achieve adequate protein supplementation.

Additionally, protein supplementation can also be done through various recipes that can be made at home.

Whey protein is the most nutritious protein among other food proteins (egg, soy, etc.). Whey protein’s bioavailability is approximately 15% higher than that of egg protein. It is supportive in preventing sarcopenia (muscle loss, decrease in muscle strength and function).

Obese individuals can consume whey protein. It has effects that keep you full and accelerate fat burning. It is also beneficial for stomach issues and helps relieve bloating.

Thanks to the vitamins and minerals it contains, regular consumption can help balance blood sugar levels.

To make whey protein, cheese must first be made. To obtain cheese, milk must be curdled with an acidic substance like lemon or vinegar and then strained. After curdling and straining the milk, the cheese remains on top, while the slightly sour yellowish liquid at the bottom is the whey.

If the whey is to be consumed quickly, it should be stored in a glass jar in the refrigerator. It is very important to keep it sealed while storing.

If you want to keep it for more than 5 days, you need to put it in the freezer.

How can you utilize whey at home?

• You can use it as a thickening agent in soups.
• You can create a protein-rich diet by using whey in recipes like pancakes or omelets.
• It can be used in meat marinades.
• Whey consumed with fruit can be taken as a natural protein drink.

Whey Soup Recipe

Ingredients:

• 4 cups of whey
• Salt
• 1 egg
• Juice of half a lemon
• 3 tablespoons of yogurt

All ingredients are added to a soup pot. It is whisked with a whisk until smooth. It should be continuously stirred until it boils. After 10 minutes, the heat is turned off. If it becomes too thick, hot water can be added. If it is slightly thick, about half a cup of water can be added.

RED PANCAKE

• 2 tablespoons of ground oatmeal
• 1 cup of flavorless whey protein
• 1 whole egg
• 1 egg white
• 1 red bell pepper
• Salt

All ingredients are taken in a bowl and mixed until smooth. A frying pan is greased with a small amount of olive oil and left to heat over high heat. Once the pan is hot, the heat is reduced to medium. A portion of the mixture is added to the pan and spread out to cover the pan. After both sides are cooked, it is placed on a plate. This process is repeated until the mixture is finished.

After preparing the pancakes, you can fill them with chicken, vegetables, or cheese to increase their nutritional value.

TOMATO SAUCE

• 1 kg tomatoes
• 4 cloves of garlic
• ¼ chopped onion
• ¼ cup of whey
• Fresh basil
• Salt, black pepper

All ingredients except the whey are blended until smooth. It is cooked over medium heat for 5-10 minutes until boiling. Once removed from heat, slowly add the whey while stirring. This sauce can be used for meat/chicken dishes and as a substitute for tomato paste in vegetable dishes.

One of the common mistakes made by patients is using products known as ‘sports supplements’ for protein supplementation. Sports products and post-bariatric protein supplements differ in content. SPORTS PRODUCTS ARE NOT RECOMMENDED FOR POST-BARIATRIC PATIENTS!

POST-BARIATRIC PROTEIN SUPPLEMENTATION vs. SPORTS PRODUCTS

POST-BARIATRIC PROTEIN SUPPLEMENTATION	SPORTS PRODUCTS
Low carbohydrate	Various carbohydrate content
High fiber content	Various fiber content
Essential amino acid content regulated	Variable
Vitamin added	No vitamin content
No sugar	Contains sugar
No lactose	Usually contains lactose

Things to consider when using protein supplements:

• Must be rich in 100% digestible essential amino acids (histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, valine).
• Should include whey, soy, and egg protein as sources of protein.
• If lactose intolerant, isolated whey protein should be preferred.
• Should contain 14-25 g of protein.
• Should have between 150-250 calories.
• Should contain less than 5g of sugar and less than 5g of fat. (High sugar content may lead to Dumping Syndrome.)
• Should contain fiber, and must be free from lactose and gluten (to avoid gas, bloating, and diarrhea issues).

Daily protein intake should not exceed 2.1g per kg. Protein supplementation should be conducted under the supervision of post-bariatric dietitians. The content of protein supplementation, duration of use, and method of consumption are regulated by post-bariatric dietitians.

If sufficient protein is not consumed:

• Weight loss occurs from muscle tissue instead of fat tissue.
• The immune system weakens.
• Wound healing is delayed.
• Hair loss, sagging, and skin problems may occur.
• Intense fatigue is felt.

DYT. TUĞBA GÜNAL

REFERENCES:

• Luca Busetto, Dror Dicker, Carmil Azran, Rachel L. Batterham, Nathalie Farpour-Lambert, Martin Fried, Jøran Hjelmesæth, Johann Kinzl, Deborah R. Leitner, Janine M. Makaronidis, Karin Schindler, Hermann Toplak, Volkan Yumuk, Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management; 2017
• Cris.maastrichtuniversity.nl. (2018). [online] Available at: https://cris.maastrichtuniversity.nl/portal/files/713025/guid-1eacd19b-df59-418a-86f9-f01719b9315f-ASSET1.0 [Accessed 4 Dec. 2018]
• Batar, N. (2019). Bariatric surgery nutrition principles. Bakırköy Medical Journal, 15, 323-32.
• Turkish Endocrinology and Metabolism Association. Bariatric Surgery Guidelines. http://www.temd.org.tr/admin/uploads/tbl_grup- lar/20180618095001-2018tbl_gruplar1b2cd981a1.pdf. (ET: 16.12.2019).
• DYT. Melek Çankaya Cengiz, Nutritional Support After Obesity Surgery, 2018, BİRBES, https://www.birbes.com/wp-content/uploads/2018/12/6-Bariatrik-Cerrahide-Enteral-Parenteral-Beslenme-Dyt.-Melek-Çankaya.pdf
• American Society for Metabolic and Bariatric Surgery
• Whey Protein and Its Utilization in the Beverage Sector, Nuray GÜZELER, Emel Mine ESMEK, Murat KALENDER, Çukurova J. Agric. Food Sci. 32(2): 27-36, 2017
• Hector AJ, Marcotte GR, Churchward-Venne TAJ, et al. Whey protein supplementation preserves postprandial myofibrillar protein synthesis during short-term energy restriction in overweight and obese adults. Nutrition. 2015;145(2):246–52.
• Verreijen, Verlaan S, Engberink MF, et al. High whey protein supplementation enriched with leucine and vitamin D preserves lean mass during intentional weight loss in obese older adults: a double-blind randomized controlled trial. J Clin Nutr. 2015;101(7):1391–401.