Lactose Intolerance And Sensitivity After February Issue: Bariatric .

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February 2019Bellevue BariatricProgramLactose Intolerance and Sensitivity afterFebruary Issue:Bariatric Surgery by Kat Cozza , PA-CTaming Your TummyPatients who have had bariatric surgery may experience a variety of gastrointestinal changes. In particular, some bariatric bypass patients may experience GI symptoms due to an intolerance or sensitivity to lactose found in dairy products, such aswhey protein shakes, milk, cheese, and yogurt.Lactose Intolerance .1-3Symptoms of lactose intolerance can include:Support Group locations .7Healthy Pizza . .4-5Daily Vitamins .6Apps for Healthy Habits .6Clinic contact Info . .8abdominal paindiarrheaflatulencebloatingBariatric Team . .8The severity of symptoms differs, often depending on theamount of lactase (lactose digestive enzyme) remaining in thebody and how much lactose has been consumed.Dumping Syndrome vs. Lactose IntoleranceDumping Syndrome is difference as it is a whole-body response: rapid heart rate, sweating, nausea and then the diarrhea& cramping occurs. The most common cause is eating or drinking high sugar foods or beverages. Lactose intolerance symptoms show up in the lower GI system with bloating, crampingand flatulence when certain dairy products are consumed.Food for Thought:Get out of bedWorkoutImprove everydayBe kind to yourselfExplore new things& just get out of bed.Continued on page 2 & 3

What is Lactose?Lactose is a natural sugar found in dairy products and digested in the small intestine by an enzyme called lactase.When a person with a normal stomach eats or drinks dairy products the lactose accumulates in the stomach and is released slowly into the small intestine where the digestive enzyme lactase is located.The stomach will release the lactose slowly into the intestine to allow enough transit time for lactase to do its digestivework before it reaches the colon.In the post gastric bypass population, the stomach has been modified and is much smaller whichallows milk and dairy products to transit quite rapidly into the small bowel.The dairy can overwhelm the available lactase enzyme resulting in intolerance symptoms becausethe undigested lactose reaches the colon before being fully digested. Similar symptoms can occur ifyou have had a sleeve gastrectomy but not at as high of a frequency.Are dairy products still an option after surgery?It’s important to know the amount of lactose in the foods and beverages you are consuming to helpavoid developing GI symptoms. The table on the next page provides a few examples of foods containing lactose andhow much lactose is in these foods.You may notice that you do not tolerate high lactose containing foods, but you do tolerate lower lactose containingfoods. Use your food records to track the foods that may be causing symptoms and reduce your intake to a level wherethe symptoms resolve.Another strategy is to eat and drink lactose containing foods slowly, choose thicker products such as yogurt or cheeserather than liquid dairy products such as milk or dairy based protein shake. The transit time from pouch to intestine will be much slower.If you find you have symptoms with several dairy products you may be one of the estimated 30—50million American adults who lack the lactase enzyme and have difficulty digesting lactose.GI symptoms with dairy may have been present prior to surgery. If you had symptoms prior to surgery or find thatyou are sensitive to several dairy products after surgery consider eating and drinking dairy alternative products such aswhey protein isolate, plant-based sources, lactaid or plant-based milk sources.Regardless of dietary tolerance to dairy it’s important that all bariatric patients take a calcium supplement, if you areunable to eat or drink any dairy products because of intolerance you may need a little extra calcium supplementation,talk with your provider and dietitian before changing your vitamins.2

Amount of Lactose in Milk & Dairy ProductsLactose grams20Milk & Other Dairy ProductsQuantitySweetened, condense milk½ cupWhole, 2%, 1%, skim, or chocolate milk1 cup12Evaporated milk½ cup12Yogurt, plain¾ cup10.8Goat milk½ cup10Buttermilk1 cup9Ice milk, vanilla½ cup8Kefir¾ cupIce cream, vanilla½ cup3Yogurt with probiotics¾ cup2Cottage cheese, creamed½ cup2Sherbet, orange½ cup1.5Cream cheese & swiss cheese1.5 oz1.2Bleu & Colby cheese1.5 oz1.1Mozzarella cheese1.5 oz.9Gouda cheese1.5 oz.8Cheddar and processed cheese1.5 oz.6Half & half cream & light cream1 Tbsp.5Sour cream1 Tbsp.5Dry curd cottage cheese½ cup.4Whipping cream, unwhipped1 Tbsp.2Parmesan cheese, grated1 Tbsp.2Camembert or limburger cheese1.5 oz.1Lactaid milk1 cup12.55-6Source: Manual of Dietetics, 6th Edition, American Dietetic Association and Dietitians of Canada, 2000.The lactose content t may vary depending upon the brands and amounts of milk solids added.3

February 9 National Pizza DayTraditional pizza is not bariatric patient friendly but that doesn’t mean youhave to give up pizza forever. With a few substitutions, you can eat a pizzathat is healthy, easy on your new stomach and still delicious!Chicken Pizza CrustIngredients1 lb. ground chicken breast3 oz shredded mozzarella cheese2 large eggssalt and pepper to tastepinch of Italian seasoning (optional)Directions:1. Pre-heat the oven to 400F.2. Line a sheet pan (18x13 in) with parchment paper.3. Add the ground chicken, cheese, eggs, salt & pepper to a bowl. Mix thoroughlywith your hands.4. Dump the mixture on parchment paper lined pan and spread into a pizza shapeabout 1/2 inch thick.5. Place the pizza crust and the parchment paper directly on the oven rack. Bakefor 20 minutes6. Remove from the oven and add your favorite pizza toppings.7. Bake for an additional 10 minutes.8. Remove from the oven and cool slightly. Slice and serve.Cauliflower Pizza CrustIngredients1 head cauliflower, stem removed2 eggs, lightly beaten¼ cup shredded mozzarella¼ cup grated Parmesan½ tsp dried oregano¼ teaspoon garlic powderpinch salt or to tasteDirections1. Preheat the oven to 400 degrees F. Line a baking sheet with parchment paper.2. Cut cauliflower into small florets and Steam in a steamer basket and drain well.3. Pulse in a food processor until fine. Let cool.4. In a bowl, combine the cauliflower with the mozzarella, Parmesan, oregano,salt, garlic powder and eggs. Transfer to the center of the baking sheet andspread into a circle, resembling a pizza crust. Bake for 20 minutes.2

Suggested Pizza ToppingsSauces: tomato or low sugar BBQ sauceLeaner meats: chicken sausage (sweet or hot Italian), grilled chicken, turkey baconbits, lean ground beef, Canadian baconVeggies: artichokes, arugula, basil, black or Greek olives, broccoli, cilantro, garlic,green or red peppers, jalapenos, onions, pepper, mushrooms, pineapple, spinach,tomatoesCheeses: asiago, bleu cheese, feta, goat, gorgonzola, mozzarella, parmesan, ricottaLow Sugar BBQ SauceIngredients1 Tbsp olive oil1 large minced onion2-3 cloves garlic, minced2 beef bouillon cubes½ cup hot water3 (6 ounce) cans tomato paste1 cup granular sucralose sweetener (i.e. Splenda )¾ cup Worcestershire sauce¾ cup Dijon mustard3 Tbsp hickory-flavored liquid smoke1 tsp salt1/3 cup cider vinegarHot pepper sauce to tasteDirections1.Heat the oil in a large saucepan over medium heat, and cook and stir until the onion is translucent, about 5 minutes.2. Add water and beef bouillon cubes into saucepan and stir to dissolve the cubes.3. Mix in the tomato paste, sucralose sweetener, Worcestershire sauce, Dijon mustard, liquidsmoke flavoring, salt, cider vinegar, and hot pepper sauce.4. Stir until the sweetener has dissolved.5. Bring the sauce to a simmer, reduce heat, and simmer until the flavors have blended, 25 to 30minutes. Stir frequently.6. For best flavor, cover and refrigerate overnight. Store in refrigerator up to 1 week.3

Daily Vitamins for the Bariatric PatientYou need to take these vitamins DAILY and for the REST OF YOUR LIFE.Gastric Bypass (RNY) & Sleeve GastrectomyVitamins & SupplementsServings per Day*Bariatric formulated multivitamin-mineral with18 - 60 mg iron and 500 mcg Vitamin B121 servingVitamin B complex (with 50 mg thiamin)1 servingCalcium Citrate with Vitamin D3(total 1200 - 1500 mg daily)2 servings of 600 mg per serving3 servings of 400 or 500 mg per servingProbiotic1 serving*Serving sizes vary with different brands, READ THE LABEL Bellevue Pharmacy is now carrying Bariatric Advantage & Celebrate Vitamins. Buy them at your convenience after the Bariatric Education class or your follow up visits! They’re also available online. Bariatric Advantage has a special offer for Kaiser patients. Receive Kaiser member pricing ofroughly 20% discount & free shipping with validation code: KAISER.For a full list of our recommended vitamins: bariatric/meds.pdf For more information on brand recommendations, please refer to theBariatric Vitamins: Recommended Brands & Daily Requirements HandoutsApps for Healthy Habits 6BaritasticWaterloggedFooducateMy Diet CoachHappy ScaleWatch Me Eat

Bariatric Support Group LocationsBellevueKaiser Permanente Bellevue Medical Clinic, Room E101/105Held quarterly, the 3rd Wednesday of the monthJanuary, April, July & October, 6:00 - 8:00 pmMarch 20th at 6:00 pmPlease call 425-502-3454 for more information.Overlake Bariatric Support GroupHeld twice monthly: 2nd Thursday; 6:00 - 8:00 pm and 4th Saturday; 10:00 - 12:00 pmOverlake Medical Center - PACCAR Education CenterInsight Conference Room1035 116th Ave. NE, Bellevue, WA 98004Please call (425) 467-3957 for more information.TacomaMultiCare Center for Weight Loss and Wellness in TacomaHeld on the 4th Monday of every month, 5:30 - 6:30 pm2202 S Cedar St. Suite 300 Tacoma WA 98405Please call (253) 301-5280 for more information.Sumner (led by MultiCare Center WLW staff)YMCA in SumnerHeld on the 2nd Wednesday of every month, 5:30 - 6:30 pm16101 64th St E Sumner WA 98390Please call (253) 301-5280 for more information.7

We want to hear from YOU! What do you want included in themonthly newsletter?Send us your ideas to:bariatricpatients@kp.orgBariatric TeamBariatric Surgeon: Dr. Gupta MD, FRCSC,FACS,FASMBSDiplomate, American Board of SurgeryDiplomate, American Board of Obesity MedicineKaiser Permanente Bellevue BariatricProgram DirectorContact UsNurse: 425-502-3454Listen to the Prompts.Press 3.Routine Appointments:Bariatric PAs: Kat Cozza, PA-C Lynda Crescenzi, PA-C Travis Sears, PA-C Heather Vincent, PA-C William Young, PA-C425-502-3454Listen to the Prompts.Bariatric Nurse Practitioner :Press 1 Consulting Nurse:1-800-297-6877*Call the Consulting Nurse line ifafter 4:00 and weekends, with anysymptoms/concerns.Lori Gokee, ARNPBariatric Nurse: Sarah Chan, BSN, RN Elizabeth Puckett, RNBariatric Dietitian: Lisa Stariha, RDNBariatric Team Email:bariatricpatients@kp.orgMedical Assistant: *For specific questions regardingyour health, please email us throughKaiser’s MyChart to ensureprivacy.Karen Kucera, MA-CClinical Operation Manager: Liam Malpass, RN8

Bellevue Bariatric Program February 2019 Lactose Intolerance and Sensitivity after Bariatric Surgery by Kat Cozza , PA-C Patients who have had bariatric surgery may experience a varie-ty of gastrointestinal changes. In particular, some bariatric by- pass patients may experience GI symptoms due to an intoler-ance or sensitivity to lactose found .

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Use a lactose free infant formula or LactofreeTM milk – full cream or semi-skimmed LactofreeTM yogurts, hard/ soft cheese, cream, spread or other lactose free brands Plant alternatives e.g. soya, oat, coconut, hemp, nut milks and products are lactose free but should not be used for the diagnostic 2 week trial period.

Current AOAC LC Methods 984.22 Purity of lactose Lactose 2000.17 Raw cane sugar Glucose, fructose Glucose, fructose, sucrose, lactose Cane & beet final molassess 996.04 Glucose, fructose, sucrose, maltose 982.14 Presweetened cereals Fructose, glucose, lactose, maltose, sucrose 980.13 Milk chocolate 977.20 Honey Fructose, glucose, sucrose

_ Recessive X Dominant X Inherited _ X-linked 3. Use the data in the pedigree and the terms listed in questions 1 and 2 to make a claim about how lactose intolerance is inherited. Provide at least two pieces of evidence in support of your claim. The inheritance pattern of lactose intolerance is autosomal recessive. Evidence may include:

Food intolerance: non-immune, enzymatic defects such as lactose intolerance, transport defects such as fructose, pharmacological such . Nutritional approach to treatment is desired . (Fructan in the bulb); onion powder or salts Legumes ¼cup canned:rinsed and drained chickpeas or ½ cup canned lentils

is caused by contact of acidic, watery stools with the skin [15,16]. Lactose intolerance rates are significantly increased in children with a history of recent diarrhoea [17], and dehydration due to osmotic diarrhoea may be common [14]. In one study, milk intolerance presenting as diarrhoea was significantly more common in children with giardia .

sensitivity or intolerance as the different terms are often used interchangeably, which leads to misinterpretation. Allergy and sensitivity are not the same. Of course if someone is allergic to a food item it could be described as being 'sensitive' however as a health condition allergy is different from sensitivity or intolerance.

– Lactose intolerance – Fructose intolerance – Fructan consumption – Consumption of sorbitol or other nonabsorbable sugars – Carbohydrate intake – Gluten sensitivity Celiac disease Chronic constipation Irritable bowel syndrome Disturbances in colonic microflora Small intestinal bacterial overgrowth

seperti dengan adanya dana pensiun setelah masa kerja habis ataupun jaminan hari tua. Pada indikator kebutuhan sosial yaitu kurangnya interaksi antara karyawan . ix dalam bekerja dan sikap acuh tak acuh antar karyawan. Diharapkan dari kebutuhan sosial dapat diatasi dengan perusahaan mengadakan tour atau rekreasi dengan karyawan agar hubungan antar karyawan makin erat, membuat kelompok kerja .