Nutritional Management of the Bariatric Athlete

| October 13, 2014

by Silvia Leite Faria, MSc, RD, PhD; Orlando Pereira Faria, md; Mariane de Almeida Cardeal; and Caroline Soares Menezes

Silvia Leite Faria, MSc, RD, PhD; Orlando Pereira Faria, MD; Mariane de Almeida Cardeal; and Caroline Soares Menezes are from Gastrocirurgia de Brasília, Brasília, Brazil.

FUNDING: No funding was provided.

DISCLOSURES: The author reports no conflicts of interest to the content of this article.

Bariatric Times. 2014;11(10):10–14.

ABSTRACT
The aim of this article is to present a review of current literature on treating of the post-surgery influence of physical activity and, based on the findings, propose recommendations directly related to the needs of the physically active bariatric patient.

Introduction
Obesity is seen as a global epidemic,[1] a chronic, multifactorial disease provoking comorbidities and elevated mortality rates.[2] Physical activity (PA) plays an important role in the success of any weight loss program since levels of PA are inversely associated with weight gain. Reasonable levels of PA and exercise should be fundamental components of any weight loss plan.[3]

Though opinions vary on the specific amounts of PA needed to prevent weight gain, it is known that PA increases the likelihood of successful weight loss.[4] The point of consensus for successful post-surgery weight loss is the loss of at least 50 percent of excess weight, associated with the maintenance of weight over the long term.[5] Weight loss cannot be based on PA alone. It must evolve to the practice of PA beyond a minimum recommended level. Some forms of PA may be more beneficial than others in relation to their impact on excess weight.[3] The American College of Sports Medicine (ACSM) and the American Heart Association (AHA)[6] recommend that 30 minutes or more of moderate PA be practiced on at least five days of the week to prevent chronic diseases; to achieve substantial weight loss, the recommended time is approximately 60 minutes of moderate to intense PA.

Bariatric surgery today is widespread and is being performed with growing frequency to lose excess and maintain desired weight.[7] According to Delany et al,[8] a postoperative increase in PA results in optimized weight loss and maintenance and greater adherence to caloric restrictions, along with lower caloric intake.
PA is currently recommended as part of postoperative clinical practice in bariatric services around the world; however, the intensity, duration, and best type of exercise specific to this population are not yet established.[9] Both bariatric surgery and PA have characteristics that lead to specific nutritional needs. Attending to these specific and new nutritional needs so as to achieve optimal results presents a challenge.

Physical activity, food intake, and supplements in periods of weight loss and muscle mass gain
There are mechanisms that explain how exercise can assist in weight loss and maintenance, such as the increase in daily energy expenditure, resting metabolic rate, muscle mass, the thermal effect of a meal, oxygen consumption, and the optimization of fat mobilization and utilization rates, as well as a sense of self-sufficiency and well-being.[10,11]

PA associated with a healthy diet provides more effective weight loss during short or long periods than either of them alone.[6,8]

Dietary adequacy helps to avoid fatigue, improve recovery, and lower the risk of injury, while ensuring a proper replenishment of energy. To recover lost nutrients or to complement a food shortage, it is often necessary to use supplements.[6]

Food intake remains crucial in cases of hypertrophy, approaching levels of 60 percent in promoting muscle mass gain.[12] For a greater change in body composition, resistance training is considered highly efficient since after several weeks of training an increase in lean mass can be observed. A study by Menon and Santos[12] showed an increase of two percent in lean mass after 12 weeks of weight lifting.

Adequate food intake before, during, and after physical activity
Food intake of an athletic and/or physically active bariatric patient must be monitored before, during, and after PA so as to maximize performance and improve recovery time. Before exercising, it is ideal to follow a diet that achieves the following: 1) provides sufficient amounts of liquids, 2) is relatively low in fat and fiber to facilitate gastric emptying and prevent gastrointestinal distress, 3) is relatively rich in carbohydrates to maintain proper blood glucose levels, and 4) has moderate levels of proteins. The diet should also include foods regularly consumed and well-tolerated by the athlete or the physically active bariatric patient.[6]
Liquids lost along with carbohydrates should be replenished when the PA session lasts longer than one hour; when feeding or hydration during pre-training is inadequate; or when PA is performed in extreme heat, cold, or at high altitudes.[6]

After a PA session, the aim is to replace liquids, electrolytes, energy, and carbohydrates to replenish muscle glycogen and promote faster recovery. The carbohydrate intake should be approximately 1.0 to 1.5g/kg of body weight during the first 30 minutes of PA and then every two hours for the next 4 to 6 hours to restore muscle glycogen.[6]

Proteins should also be consumed along with carbohydrates after exercise. They contribute to the repair of muscle damage caused during exercise (especially from strenuous and high-intensity exercise), assisting in the process of muscle hypertrophy.[13]

Throughout the PA cycle (before, during, and after the session), foods or supplements can provide an adequate supply of nutrients.

Proteins
Proteins are important in the formation, growth, and development of body tissues and in the formation of enzymes that regulate energy production and generation, especially when carbohydrate stores are low.
Studies indicate no greater gain in muscle mass occurs among patients who did not undergo bariatric surgery and who followed diets with more than 1.7g protein/kg of body weight.[13] However, the studies by Menon and Santos12 and Nailza et al[14] have shown that individuals who ingested a diet with levels of protein between 1.5 and 2.5g/kg of body weight obtained a significant increase of strength and muscle mass.
The recommended amount of protein is 1.2 to 1.7g/kg of body weight6 due to increased protein oxidation (for endurance athletes) and to greater support for muscle growth (for strength athletes).[15]
Protein supplements. Protein supplements are associated with muscle hypertrophy and anti-catabolic activity, promoting the conservation and/or increase of fat-free mass (FFM). A greater amount of FFM is responsible for an increased basal metabolic rate, and the higher the energy expenditure the greater the loss of adipose tissue.[16]

Protein supplements are also associated with loss of weight and fat[17,18] due to high levels of calcium stimulating lipolysis, the thermogenic effect of protein,[19] the increased satiety with decreased appetite, the oxidation of amino acids20 and higher blood concentrations of CCK and GLP-1,[20,21] and the increased FFM leading to increased energy expenditure.[20]
Protein supplements have specific functions and recommendations. The following are a few of the most common:
Glutamine. Glutamine is the most abundant amino acid (20%) in plasma and tissues. It can be synthesized by the body from other amino acids, including glutamic acid, valine, and isoleucine. It is classified, however, as being conditionally essential because it can drop by 50 percent in cases of extreme physical exertion. Exercise-induced stress seems to provoke an imbalance between the uptake and utilization of glutamine, leading to its lower availability for immune system cells, possibly weakening this system, making athletes more susceptible to infectious processes.22

Whey. Whey protein offers high nutritional value; has elevated levels of essential and branched-chain amino acids, calcium, and bioactive whey peptides;[23] stimulating lipolysis, thus reducing body weight and adipose tissue. This leads to greater muscle strength and reduced loss of muscle mass during weight loss.[24]

Casein. Casein, which represents about 80 percent of milk proteins, has shown a lower level of digestibility because, contrary to other milk serum proteins, it precipitates in rennin, forming a stomach coagulate. Thus, plasma concentrations of many amino acids take longer to reach higher values when compared with ingestion of milk serum proteins,[23] producing less impact on protein synthesis.

Branched-chain amino acids. Branched-chain amino acids (BCAAs) provide energy to skeletal muscles during periods of metabolic stress and promote protein synthesis, prevent protein catabolism, and serve as a gluconeogenesis substrate. When catabolized, BCAAs stimulate the synthesis of glutamine, alanine, and other substances.

Studies suggest that BCAA supplementation can aid in muscle hypertrophy, provide anti-catabolic action, delay central fatigue, increase plasma glutamine levels after intense PA, and decrease muscle damage during prolonged endurance exercise.[23,25]

Protein blends. Protein consumption is facilitated by blends of various types of whey protein (isolate, concentrate, and hydrolysate) with casein, which is associated with recovery and muscle growth,[44] offering the convenience of using a single supplement with various kinds of proteins for their different functions. There is a limited amount of literature on these supplements.[44]

Carbohydrates and Fats
The use of carbohydrate-based products by individuals who are physically active is on the rise. These products can be taken before, during, or after PA, depending on the needs and goals of the individual. They also play a role in lipid catabolism as activators of this process.[26]

The carbohydrate recommendation for athletes is 6 to 10g/kg of body weight.[6] Carbohydrates supply energy, maintain blood glucose levels during PA, and replenish muscle glycogen, thus conserving proteins. The food intake of an athlete should also contain fats in a ratio of 20 to 30 percent of energy consumed to provide the essential fatty acids and fat-soluble vitamins, in addition to contributing to hormone production. Diets having 20 percent or less of lipids (hypolipidic) do not benefit performance.[6] There are various carbohydrate supplements on the market, such as maltodextrin, dextrose, and waxy maize.

Maltodextrin. Maltodextrin, a complex carbohydrate, has glucose polymers in its composition, and thus it is absorbed more slowly by the body. Ingestion may be indicated before and during the exercise to provide energy for PA or after exercise as a carbohydrate supplier.[27]

Dextrose. Dextrose is a monosaccharide—a simple carbohydrate—known as glucose. It has a small molecular structure, which provides rapid absorption and a high glycemic index, raising plasma glucose levels rapidly. Glucose is used as the body’s main energy source.

Waxy maize. Waxy maize is a carbohydrate supplement, extracted from the starch from a variety of United States corn. It has huge molecular weight and low osmotic concentration, which facilitates starch digestion and provides a more rapid and steady supply of energy since it has a low GL index.

Manufacturers of this supplement claim it is free of sugar and gluten, substances associated with intestinal discomfort and water retention. Its main indication is for post-training replenishment of muscle and liver glycogen; however, it can also be used in pre-training. A limited number of studies examine this supplement.[45]

Micronutrients and Adequate Hydration
Micronutrients have a fundamental role in energy production, hemoglobin synthesis, maintenance of bone structure, and immunity, and act as antioxidants. Some studies justify that PA may increase the loss of micronutrients, thereby increasing their need of their replacement among athletes.[6]

Dehydration impairs performance, so consuming the proper amount of liquid is essential before, during, and after exercise. At least four hours before a PA session, it is recommended that between 5 and 7mL/kg of body weight of water or sports drink be consumed.[6] During exercise, liquids should not be consumed beyond the rate of transpiration. After exercise, 450 to 675mL of liquid for every 0.5kg of weight lost during exercise is recommended.[6]

Physical activity after bariatric surgery: What evidence do we have?
Bariatric surgery appears to be a motivating factor for the practice of PA since, after undergoing the operation, individuals become more active. The acquisition of this new habit is one of the factors that optimize weight loss and improve the quality of life experienced by bariatric patients.[28] Some authors propose that those patients who have the habit of practicing PA are also more motivated to meet the postoperative dietary guidelines than those who do not exercise.[9]

PA benefits bariatric patients in several ways.9 A small meta-analysis by Egberts et al[29] showed that there may be a difference of more than three kilograms in weight loss among patients engaged in PA at least 30 minutes per day and 150 minutes per week compared to patients who do not engage in PA. This is higher than the 1.5 kilogram difference found in a similar meta-analysis of studies using non-surgical weight loss programs, as in the review conducted by Cochrane in 2006.[30] Josbeno et al[31] studied patients operated 2 to 5 years previously, and Ewans et al[32] studied patients in the immediate postoperative period. Both Josbeno and Ewans examined patients who practiced more than 150 minutes of PA per week and found similar results. In this sense, it seems logical that a similar recommendation should be applied for bariatric patients to obtain better results.[29]

Moreover, beyond the benefit of weight loss, several studies[28–33] have correlated the practice of PA with improved physical ability/function and better range of metabolic homeostasis, providing better endocrine and immunological health, as well as improving mental health. These benefits suggest that PA plays an important role in the improvement of comorbidities after bariatric surgery, regardless of weight loss.[33]

Common Nutritional deficiencies AMONG THE BARIATRIC POPULATION
Nutritional deficiencies among individuals with obesity are not rare, and after any bariatric procedure this risk increases radically.[34] The highest prevalence of nutritional deficiencies occurs among bariatric procedures having a higher malabsorptive component. The main causes for these deficiencies are as follows: gastric restriction, exclusion of the stomach and intestine from the gastrointestinal tract, lesser contact of food with digestive enzymes, and possible food intolerances. The bioavailability of nutrients should also be assessed in this context and depend on the following:
•    pH (acid or alkaline)
•    Form of presentation of supplements
•    Dependence on enzymes, gastrointestinal tract (GIT)
•    Integrity and intestinal absorption surface
•    Route of administration: oral, intramuscular, or intravenous (depending on the severity of malnutrition)
•    Amount and type of this micronutrient in the forms administrated.

In practical terms, we know that two multivitamins/multiminerals daily can attend to requirements in most cases of deficiencies.[34] There is need to increase iron (mainly among adolescents, women in a fertile age, and pregnant patients), calcium, vitamin D, copper, and vitamin B12. Protein is important for all patients and most need protein supplementation to achieve adequate levels of ingestion.[34]

Physical, biochemical, and clinical exams should be used to assess the extent of nutritional deficiencies.
The bariatric patient practitioner of PA or athlete has the challenge of maintaining their nutritional status and performance, as they face risks (e.g., malabsorption) associated with bariatric surgery as well as an increased demand due to PA.

Food intake and supplements of physically active bariatric patients: what changes need to be made?
Bariatric athletes, more so than athletes in general, face higher risks of nutritional deficiencies mainly because of increased requirements. Vitamins and minerals facilitate energy production and utilization from carbohydrates, fats, and proteins; transport oxygen and carbon dioxide; regulate fluid balance; and protect against oxidative damage. Low micronutrient intake generally results in subclinical deficiencies characterized by decreased biochemical indicators of nutritional status and impaired physiological functions.

Professional guidance should be sought in determining the dosage of micronutrients that are supposedly rapidly consumed. A summary of the more important micronutrients for the bariatric patient follows.
Micronutrients for the bariatric patient. Thiamin participates directly in the metabolism of carbohydrates and proteins,[35] contributing to energy production for muscles. Riboflavin participates directly in energy production by transporting electrons in the mitochondria. It is also needed for conversion of vitamin B6 to its active form. Niacin (vitamin B3) is metabolized to form nicotinamide-adenine nucleotide (NAD) and nicotinamide adenine dinucleotide phosphate (NADP) that serve as coenzymes. NAD is an electron carrier in the breakdown of carbohydrates, fat, parenteral nutrition (PTN), and glycogen to produce adenosine triphosphate (ATP).[35] Vitamin B6 (pyridoxine) is a cofactor for enzymes that transform amino acids. Folate is critical for DNA synthesis and amino acid metabolism. It also acts in cell repair and growth.[35] Vitamin B12, coenzyme for the transfer of methyl, groups in the formation of DNA, particularly with folate in the formation of hemoglobin. Vitamin C assists in transporting fatty acids to the mitochondria for energy production.[35] Iron is crucial in the formation of hemoglobin, the principal iron-containing compound that transports oxygen to cells. Copper functions for energy production in the mitochondria (cytochrome c oxidase) and as an antioxidant (superoxide dismutase). Zinc-containing enzymes regulate oxygen-carbon dioxide transport and lactic acid metabolism, as well as the breakdown and synthesis of macronutrients’ growth and development.[36] Selenium exists as proteins that protect against oxidative damage to cells (glutathione peroxidase). Evidence suggests that chromium facilitates the action of insulin in cells of individuals with insulin resistance.[46]

It is important to highlight that iron deficiency can occur very frequently among bariatric athletes, mainly among the female population at a fertile age. The risks are associated with increased loss of iron during menstrual cycle, low dietary intake and/or absorption of iron, and loss of iron in sweat.

Dietary recommendations and supplements for physically active bariatric patients
Proteins. To optimize the results of PA after bariatric surgery, a diet and proper supplementation should consider PA and restriction and/or malabsorption caused by the surgical procedure. It is a consensus that bariatric patients need a diet rich in protein to ensure their proper state of health while losing weight.[37,38] Studies have been correlated the consumption of protein with maintenance of muscle mass during postoperative weight loss.[38]

It is important to consider the type of protein supplement and schedule for the bariatric patient engaging in PA. It is recommended that, if using isolated and hydrolyzed supplements, consider that bariatric patients have less protein digestion capacity due to less contact of proteins with hydrochloric acid and stomach digestive enzymes, leading to complications in digestion and absorption.

Studies evaluating types of supplements, composition, and caloric value of the diet geared specifically for physically active bariatric patients are rare. Thus, what is closest to the ideal is the adaptation of existing recommendations for the general population to the bariatric population.

More recent studies recommend that in order to ensure proper maintenance of muscle mass during weight loss, it is necessary to consume more than 1g/kg of protein. Since the recommendations6 for the general population revolve around 1.2 to 2.0g/kg[6] and that, due to gastric restriction, bariatric patients are unable to consume large quantities of protein, it is recommended that 1.2g/kg of current weight be considered as adequate in order to maintain and gain muscle mass during weight loss.[38]

This protein intake is best achieved through the use of protein supplements.[39] Considering that the first year of surgery an average of 60g of protein per day is consumed,[17,40] 1 to 2 doses of 20g of protein supplement per day in the first year may be necessary to achieve adequate intake.

Certain superiority of whey protein fraction has been demonstrated in a study of the general population,[41] probably due to its rapid absorption, which increases essential amino acids in the blood more quickly. The study[41] found no correlation between the intake of protein in the form of casein and FFM maintenance in bariatric patients.[41] It is therefore recommended that the supplement of choice be mostly in the form of whey protein, with at least 3g of leucine per dose and at least one dose be ingested immediately after PA to stimulate muscle metabolism.[42]

Carbohydrates and fats. There is still no consensus on the appropriate carbohydrate intake after bariatric surgery. What is known is that excessive consumption can hinder weight loss and should be controlled for this population.

However, when carbohydrate consumption is too low, amino acids are deaminated and release carbon skeleton for energy supply. As protein is consumed as a source of energy, there may be a loss of muscle mass. Thus, a certain amount of carbohydrates should be consumed since it acts to conserve protein.[42]
The ACSM[6] recommends 6 to 10g/kg of body weight for the physically active. However, this recommendation seems excessive for the bariatric patient, especially in the first year postoperatively, and may also hinder weight loss and prevent proper protein intake.[43]

Thus, despite the recommendation for the general population, for active bariatric patients consumption levels should not exceed 150g/day,[43] allotting larger doses to pre- and post-workout, when the body has greater need for this nutrient. The decreased consumption of this macronutrient will likely not promote intense muscle mass gain in period of postoperative weight loss, but will help maintain constant fat loss. However, in specific cases, this recommendation may increase depending on the level of PA performed by the individual. If he or she is unable to consume the proper amount due to gastric restriction, carbohydrate supplements can be utilized, but with caution since the most common (i.e., maltodextrin and dextrose) are simple carbohydrates that are rapidly absorbed and can cause dumping in the bariatric patient.[47]

The food intake of an athlete should contain fats in a ratio of 20 to 30 percent of energy consumed to provide the essential fatty acids and fat-soluble vitamins, in addition to contributing to hormone production.[6] Based on food consumption studies,[48–51] 30 percent of total energy intake is common among the bariatric population.

Despite the general recommendations, all adjustments in the intake of the three macronutrients should be made while considering the changes in body composition presented by each individual patient.
Table 1 is a summary with nutritional recommendations for the physically active bariatric patient.

CONCLUSION
Despite of the lack of specific recommendations for duration or type of PA in the bariatric population, the practice of 150 minutes per week has frequently been associated with weight loss results improved after Roux-en-Y gastric bypass surgery.[32] In this context, these patients should be encouraged to adhere to this minimal requirement. They should also be aware that 150 minutes per week of moderate exercise is merely an initial recommendation and that once that level has been reached, it should be surpassed with even more challenging exercises.

The postoperative improvement of weight loss due to PA carried out in accordance with guidelines of the American College of Sport Medicine[6] is most likely the result of the beneficial effects of exercise, especially energetic metabolism during periods of weight loss, including the attenuation of the loss of lean mass, the maintenance of the basal metabolic rate, and the increase of fat oxidation. In view of all this, patients should perceive this habit as an aid in helping them reduce their risk of developing cardiovascular disease and improve their cardio-respiratory capacity, the strength and resistance of their muscles, their mental health, and quality of life, and thus incorporate PA as part of their scheme of postoperative treatment and recovery.
Though no consensus exists on the proper food intake for physically active bariatric patients, we suggest adapting the recommendation for the general population. Based on our experience, protein consumption should remain around 1.2g/kg of body weight, along with high-quality protein supplements. The carbohydrate consumption can remain at around 150g per day, with greater intake before and after PA, and fats should occupy 30 percent of total energy intake.

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