Monday, December 13, 2010

Dangerous advice from people who should know better

There's a lot of nonsense spewed on the Interwebz -- everything from the Flat Earth Society to Holocaust deniers -- but unfortunately not all of it is so obviously the work of crazies. Sometimes people with credentials or organizations with official sounding names are the ones spewing the nonsense.

As an example, we have a famous WLS surgeon who had a reality tv show, has written books on the subject and gives speeches at various WLS conferences around the country. Said "expert" has recently become a convert to the vegan lifestyle. Which is fine. For him. But said "expert" is not content just to wipe dairy, eggs and meat from his own diet. No, he wants you and I to eat that way too.

Like most fanatics, he tells us that it's good for us. That meat is bad for us. That no one, not one person, needs more than 60 g of protein a day.  That there is no such thing as a protein deficiency. That there are no symptoms of this imaginary deficiency. Oh and if we need to get more protein our diet, a good source is... Broccoli!

He also tells us that we should listen to the Physicians Committee for Responsible Medicine.

The problem with this advice is simple: it's bullshit.

First of all, of course there is such a thing a protein deficiency. Serum protein levels have a normal range that is 6.4-8.2 g/dL (at my lab anyway; the range at your lab may be slightly different). Some people will tell you that you want to be at least 7.something to have optimal levels, but what I posted is the standard range. If your protein levels are below that, you are considered deficient.
 The symptoms of this (supposedly imaginary) deficiency include brittle and thinning hair and nails, ridges in the nails, and hair loss. Another symptom is weakness from a loss of muscle mass (because the body will pull protein from the muscles if it's lacking in the diet). Other symptoms are edema (retaining fluid under the skin), skin rashes, slowness in healing wounds, skin ulcers, and a host of others that are vaguer and could be anything (like headaches), so I'm not going to list them all.

For myself, I have the thin hair, hair loss (which comes and goes) and ridges in my nails. I also have edema, particularly around the ankles. I also have sleep issues (one of the vague symptoms) but I suspect that's an age issue and it started pre-op so it's not 100% surgery related. I definitely don't have muscle cannibalization or fatigue or most of the other symptoms. Okay, I have headaches. Who doesn't? But I realize that mine have been more frequent lately and right around the time my hair loss came back. I had assumed the headaches were from seasonal allergies but now I'm going "Hmm." (Something to think about, anyway.)

So, yes, you can be protein deficient and there are symptoms to look out for. It's not some made-up thing.

As for eating broccoli to improve our protein levels? Please. A cooked cup of broccoli has 4 grams of protein. To get as much protein as a typical egg, you need to eat 1.5-2 cups of broccoli. That's a freakingly large amount of broccoli. If I ate nothing but broccoli all day, I could probably eat 5 cups -- half a cup at a time, 10 "meals" a day -- which would get 20 grams of protein into me. And nothing else. In other words, offering up broccoli as a protein food is as ridiculous as it is insulting to my intelligence.

Then we get to the 60 g a day advice. A lot of people will tell you that women don't need more protein than that so that part isn't outrageously off-base. But it's not the greatest advice either, in my opinion. For one thing, there really isn't one right number that works for everyone. In fact, our protein needs vary based on our weight and our activity level.

The official recommendation from reputable health agencies is .8 g per kg of body weight. (For those of us stuck with the Imperial system, that's our weight in pounds / 2.2 x 0.8) Some athletes, these agencies and other mainstream nutritionists tell us, may need more.

So anyone who weighs more than 165 pounds needs more than 60 grams of protein a day. So do smaller people who work out intensely. So do people on a very low calorie diet (according to some anyway). So do people who don't absorb everything they eat. You know, like people who've had weight loss surgery.

So when Dr. Garth Davis says he doesn't need more than 60 g a day, maybe he doesn't. I don't live in his body so I'm not going to tell him he's wrong about his own nutritional needs and I also don't know how much he weighs or what his activity level is like. But when he says his patients don't either? There's no getting around the fact that that's bad advice.

Because, if you have gastric bypass and you malabsorb 20-30% of your calories, you have to take the protein formula and divide by .2-.3. That's because, if you eat 60 g protein, only 42-48 grams get into your system. So, for the first couple of years at least, you need more than what an unaltered person needs. And really early out you need even more because you are healing from surgery and protein promotes healing. Those with the duodenal switch malabsorb even more protein and so need to take even more than the original formula says.

But, you may be thinking, I have a band! or a Vertical Sleeve Gastrectomy! My intestines are intact so I don't malabsorb, right? For the band, this is true. Your intestines and your stomach is intact. Does having a band change how food is digested? I really don't know. But I assume it doesn't or at least not too drastically.

But I do know about the sleeve because I've got one and so I researched the heck out of it. If you have a sleeve, you are at risk for malabsorption of certain nutrients because of the small size of the stomach. That doesn't mean you definitely will be deficient, but you could be so you need to watch for it.

One such nutrient we have issues with absorbing is calcium. Most forms of calcium we encounter in our food require acid to be absorbed and our tiny tummies haven't got a lot of it. Calcium deficiencies are a well-known side-effect of partial gastrectomies -- of which the sleeve, bypass and DS are forms -- which is why we're supposed to take more calcium than the average bear and to take calcium citrate because it doesn't require acid to be absorbed.

Other deficiencies are rarer. They include possible B12 and iron deficiencies due to a lack of intrinsic factor. Even rarer, but still possible, is a protein deficiency. So, yes, even with intact intestines, it's possible to be protein deficient. It's unlikely, but the possibility is not zero.

As my own case shows.

Finally, we get to the Physicians Committee for Responsible Medicine. Who are these fine sounding experts? Well, it turns out, they are a fanatical fringe group with ties to PETA whose mission is convince the rest of the world to eat vegan too. Oh and to stop animal testing (something I can get behind, but not using PETA's methods.)

Not only that but you don't have to be a physician to join and most of their members aren't. Something like 5% claim to be but no verification is done and physicians get free membership so there is incentive to lie about it. [Read all about it here.]

Yeah, these are people I'm going to take nutritional advice from. Only not.

The thing is, Dr. Davis is, by all accounts, a fine surgeon with a great track record in bariatrics. His patients adore him. (Which means I'm probably going to get lynched for this blog post, but it can't be helped. There are certain types of misinformation that I just can't let stand unchallenged.)

So what exactly happened? I don't know. I just know that a lot of people become vegetarians and get a kind of religion about it, at least at first. Luckily, most of them mellow out about it eventually. But in the meantime they can be annoying as heck if you have to eat with them.

Most of the time they aren't dangerous though. That's because they don't have a platform or, if they do, they don't have a built-in credibility that a doctor has. But what many don't realize is: doctors don't get a lot of training in nutrition in medical school. If they are lucky, they get a class and some places they just get a few lectures as part of a class.

So anything a doctor is telling you about nutrition is stuff they've read somewhere or studied up on. Which means they may know what they are talking about or they may not. In that regard, they are like anyone with an opinion on nutrition.
 For nutritionally advice, I don't consider myself an expert, but I do read up on it because it personally impacts me. I also read up on it because it's an area with a lot of confusion and controversy so I want to have a point of view on some of the advice that gets tossed around. Because, when it comes to nutritional advice, it's definitely caveat emptor out there.

As part of that reading, I have found a few sources I find to be pretty credible. That includes someone who has studied way more about nutrition than most doctors and a lot of nutritionists, but doesn't happen to have a degree in it. I have to say... degree or no degree, I'd be more inclined to believe what Miss Andrea of the WLS Vitagarten blog has to say about nutrition than even my own surgeon -- who actually isn't half bad about nutrition -- but, as much as I respect him, he's not as knowledgeable about nutrition and supplementation as Andrea.

As for Dr. Garth Davis? If only he were just unknowledgeable. But his bad advice (which you can get from his own mouth here) goes beyond that and, in my opinion, borders on dangerous. Which is why I decided to say something about it and not let it pass.
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