Sunday, September 16, 2012

Eight Bites on a cruise ship

I just returned from a ten day cruise to Alaska. I will not say on which cruise line because I was a bit disappointed in them. But going on a cruise after weight loss surgery (WLS) can be a bit scary. Cruising is really just about wasting time between meals. They feed you often and a lot on cruise ships and you can get carried away. I set out to be sure that I did not over eat and yet enjoy the culinary offerings of the various dining areas.  
Breakfast can be eaten either in the dining room (Deck 6) or at the buffet on Deck 14. Sitting up on the higher deck gave you a great view of wherever you were and was almost always very busy for breakfast. On the trip we ate breakfast at the buffet every morning but one. The buffet always included lots of fruits, hot and cold cereals, toast, croissants, muffins, bagels, and a wide variety of sweet rolls and Danish. The main menu items ranged from breakfast staples like pancakes, French toast, sausages, bacon, and eggs in various forms. They also had fish, including smoked fish and a variety of ethnic dishes, which included fried rice, oriental eggs (deep fried hard boiled eggs in a crust), and vegetables.  

After my WLS and the subsequent removal of my gall bladder last year, the volume that I am able to eat has been reduced substantially. At home breakfast is my major meal due to the fact that my stomach (or what is left of it) is empty. I often eat eggs, a piece of toast, or oatmeal or granola. So at breakfast at the buffet with its wide selection I was able to take small amounts of a variety of food items and then eat what I wanted. I would take a single egg (fried, oriental or poached), a small croissant, some butter and jam, a sausage link or a small spoonful of corned beef hash. I always skipped the pastries, and took only small amounts of fruit. I ate slowly and instead of focusing on cleaning my plate, I concentrated on enjoying the flavors and talking with strangers sitting next to us. The conversations were almost always lively and interesting. And the side benefit was to slow down the eating.  

I bought a ticket for specialty coffee drinks so I had my morning capuchinno (and maybe and afternoon one as well).  

Lunch was normally at the buffet as well. Lots of meats, cheeses, breads, pre-made sandwiches, fruits and a lot of hot dishes as well. I was singularly unimpressed with the majority of the hot dishes at the buffet. For some reason they didn’t keep them hot and often they were lukewarm and often cool. I realize that cooking 10,000 meals per day is a logistical problem; I do believe that hot food should be served hot. I normally took a few pieces of cold meat and cheese or the individually made sandwiches (a vitello tonnato sandwich was quite good), and a diet soda. The cookies were my downfall. They made a molten chocolate chocolate chip cookie and an excellent oatmeal raisin cookie and we offer took 4-6 cookies back to the cabin for later.  

Dinner was always in the main dining room and was ordered off the menu. There were dishes that were always available (fettuccini alfredo, medallions of beef, and shrimp cocktail) as well as daily dishes that included three appetizers,  a couple of soups, and salad, three main courses, and three to five desserts. The appetizers were normally small and in general were good. A smoked duck breast and a small filled puff pastry shell with chicken, sweetbreads and wild mushrooms in a cream sauce were nice. I decided to limit my main dishes to those I have not had before or have not had in a long time. Some were successful (a shrimp curry) and others were not (roast pheasant with a cranberry sauce).   

Actually it was pretty easy to maintain my Eight Bites eating. The buffets allowed me to take a bit of different things and try them. If I didn’t like them, I just left them on the plate. It made it easy to eat limited amounts and yet try a lot of different things. Lunch was lunch. I just focused on eating sufficient protein and not eating too much. Dinner was by definition an exercise in limited consumption. The appetizers were generally small bites. I normally didn’t eat the soup or a salad, and while the main courses were OK they were nothing to write home about.  

In discussions with other passengers, some were enthusiastic about the food and others had the same problems I did. Working as a chef did not give me any great insight onto why things weren’t that great. Foods were often not served at the correct temperature, and flavors were bland and under-seasoned. So while I enjoyed the trip, I did not particularly enjoy the food. This allowed me to eat the things I wanted to eat in the amounts that made sense. I did not eat the overly sweet desserts at lunch and dinner, and never left the table overly full and uncomfortable. 
When I got home I found out that I had lost an additional three pounds so not only was I able to eat Eight Bites I was able to do so, enjoy the trip, and not over-indulge.  

Friday, August 17, 2012

Cook big, eat small

It is hard to cook Eight Bites for one or two people. The stores simply don’t sell products in small volumes. You have to buy pork chops in a family pack, chicken breasts-6 per package, or 2 pound bags of carrots. It is very hard to shop when you are cooking small bites and have limited storage space in the freezer.  But sometimes it is really necessary to cook big and then eat little. Just because these recipes make a fair amount of food, it is however not necessary to overeat. The remaining food can be put in the fridge for leftovers or frozen in good storage containers for later use.
Each recipe here is designed to be eaten at the time you cook it, and then suggestions for leftovers are discussed. Since proteins are important to the WLS eater the three main recipes are meat recipes. The first is lamb shoulder chops, cooked in a braising liquid of garlic wine, and stock. It cooks low and slow in the oven for about 3 hours at 300 degrees. The second is an interesting Asian-flavored ground turkey meatballs in a sweet, sour and spicy sauce. And the third dish is a pork shoulder roast.

Braised lamb with garlic wine
This dish uses the relatively inexpensive lamb shoulder chops. Buy them and freeze them when they are inexpensive.
6-8 lamb shoulder chops
2 large onions, slices
6 cloves of garlic chopped fine
2 carrots, sliced
2 roasted red peppers (peeled. seeded and chopped)
Olive oil
Salt and pepper
1 cup Garlic wine (Put 10 cloves of garlic into a bottle of a reasonably priced red wine, recork and allow to sit for 1 month). I sometimes take a half gallon of Burgandy and add 20 cloves of garlic then reseal it and put it under the sink.
Saute onions, garlic, carrots and peppers in olive oil in a heavy oven proof pan until they are wilted and nicely browned. Dredge the chops in a seasoned flour and saute in a small amount of vegetable oil to brown. Place the chops on top of the vegetables. Add 1 cup of the garlic wine, two cups of beef or chicken stock and then water to bring the fluid up to the meat, but do not cover the meat with the braising liquid. Cover the pan well with foil to seal and place in a 300 degree oven for three hours.
Remove the chops and keep them warm, then bring the pan juices to a boil on top of the stove and cook the braising liquid down by half or more. Serve the meat with scalloped potatoes and some of the sauce.
Leftovers: These lamb chops are very tender and when removed from the bone and heated in a saucepan  can be served over wide noodles and sprinkled with chopped green onions. Or make the meat into a hash with potatoes for a terrific breakfast.

Asian spicy meatballs
These meatballs are relatively soft and easily digestible for the WLS eater. They are relatively low in fat and can be seasoned to a very spicy level or toned downed using the red chili sauce and cayenne.  Serve the first night with steamed rice. Two or three of these meatballs is the perfect size to meet you Eight Bites needs.
For the meatballs
1 pound ground turkey
4 cloves garlic
½ baked sweet potato
2 inch grated fresh ginger
½ cup sweet red chili sauce
2-3 Tablespoons sriracha sauce Add to taste, it’s hot
½ cup chopped parsley
½ cup chopped green onions
1 teaspoon salt
Several good grinds of black pepper
¾ cup fine cracker crumbs
1 egg
1 roasted red pepper (seeded and chopped fine
Place all the ingredients for the meatballs into a food processor with a steel blade.
Process until meat mixture is relatively smooth.
Make into 24 small meat balls and refrigerate for 30 minutes.
Roll the meat balls in a seasoned flour mixture, shake off excess.
Saute until brown in vegetable oil.
Place in a large baking dish, and pour sauce over the meatballs
Bake in a moderate oven (350 degrees) for 30 minutes or until meatballs are done.
For the sauce
1 small can of crushed pineapple
Rice wine vinegar or apple cider vinegar
Sweet red pepper sauce (found in most grocery stores in the Asian food section)
1 cup of water or chicken stock
Salt and pepper to taste
½ Cup sugar
½ Cup catsup
Mix the pineapple, catsup, sugar, and stock together. Bring to a boil. Add chili sauce and vinegar to create the sweet, sour and hot flavor you want. Start with ½ cup of the vinegar and pepper sauce then taste and add more as desired. Cook for five minutes to thicken. Pour over meatballs.
Leftovers: These little spicy meatballs make a great sandwich when warmed and placed on a toasted hamburger bun. Put some of the sauce over the meatballs. Or cook some noodles and serve the meatball over the noodles.

Crisp Roast Pork
This luscious garlicky roast pork works especially well with the less expensive shoulder roast, and it gives you a nice crispy skin. Some cooks like to remove the skin and cook it separately, but I like the mix of textures that you get when you roast the pork with the skin on. The fat layer under the skin continually bastes the meat as it roasts.
2 tbsp. cumin seeds
1 tbsp. black peppercorns
2 tbsp. dried oregano
1⁄4 tsp. cayenne
12 cloves garlic
Kosher salt, to taste
1 bone-in skin-on pork picnic shoulder (about 8 lbs.)
1 cup fresh orange juice
1⁄2 cup fresh lime juice
2 tbsp. olive oil
Toast cumin and peppercorns in a skillet over medium heat, 2–3 minutes. Transfer to a small food processor along with oregano, cayenne, garlic, and 1 tbsp. salt; process to a paste. Cut about twenty-five 1 1⁄2"-wide slits in the pork about 1" deep. Rub garlic paste all over pork, pressing it into slits. Transfer pork to a roasting pan. Whisk together orange juice, lime juice, oil, and 2 tbsp. salt in a bowl; pour over pork. Cover and refrigerate, turning occasionally, for 18–24 hours.
Remove pork from refrigerator 2 hours before you are ready to roast, to allow it to come to room temperature. Heat oven to 325°. Roast, basting every 30 minutes, until a meat thermometer inserted in thickest part of pork registers 160°, about 3 hours total. (Add 1 cup water to pan when liquid evaporates; cover loosely with foil if skin gets too dark.) Let rest for 15 minutes, then carve and serve.
Leftovers: Roast pork is one of the most useful of meats for creating a great dinner and then some amazing leftovers. Chop the pork into small cubes and mix with salsa and heat. Place in a toasted tortilla for a terrific lunch. Chop up some roasted potatoes and place in a saute pan with a bit of olive oil. Saute until the potatoes start to crisp and add some coarsely chopped roast pork, serve with some steamed vegetables for dinner.
As I stated in the beginning of this entry, it is difficult to cook small amounts of food to satisfy the nutritional demands of the WLS eater. These recipes make a fairly large amount of food, but using inexpensive cuts and cooking for prolonged periods you can get a wonderful initial meal and then several days of leftovers. I often cook two or more of these dishes at the same time, because I don’t really like to eat leftovers from the previous day. I eat one of the dishes and then over the next few days can vary the meals using a variety of meats. Just remember that you need to eat Eight Bites at these meals. Never think that if you don’t eat more you are wasting food. One of the down sides to the WLS is that as our digestive system changes, and we can eat more. It is important to remember why you had the surgery in the first place. Mangia but respect where you have come from.

Friday, June 8, 2012

A Wake-up Call

Yesterday I received a significant wake up call. When I had my WLS in 2008 I stopped taking the insulin which I was injecting four times a day. The night before my surgery on June 4th 2008 I took my last night time injection. Immediately after surgery my blood sugar started to drop along with the rapid weight loss. Within a couple of months my fasting blood sugar taken in the morning was below 100 which is generally considered the “normal” morning blood sugar. For a few years that blood sugar level stayed fairly constant.

However in 2010 as I was getting ready to leave Italy my weight had started to inch upwards. I noted that, but felt that my weight was just “redistributing”. Then as my clothing stopped fitting as well and my weight moved from 165 up to 180 I realized that this was not redistributing but I was putting on weight again. I had promised myself that I would never go back to where I had been before the surgery and my concern mounted. I assessed my diet and found that in general I was still eating small portions at meals, and that should have been sufficient to control the weight gain, however I realized I was also eating snacks between meals. My calorie count went from approximately 1200 calories per day to 1800. I was also working in a relatively sedentary job and my activity level had gone down. I wrote about this issue in an earlier blog entry and then did relatively little to alter the trajectory of the problem.

Blood tests done a year ago showed that my fasting blood sugar was 110 to 115 and while this was not a major issue it should have caused me to reassess what was going on. The correlation between weight and blood sugar levels is very strong and Type 2 diabetes is a significant problem for overweight people. After 15 years of injecting insulin to control my diabetes and then having the syndrome disappear after the WLS I became a bit less conscious of the effects this “weight redistribution” was having on me.

Which brings me to yesterday. I have moved to a new city and was initiating a new relationship with a primary care physician and after my first visit I had blood work done. Yesterday I found out that I had gained about 30 pounds and that my fasting blood sugar level was 145. 145!!!! The doctor began discussing diabetes medications again and that was my wake up call. I reread what I had written a year or so ago and realized that I was still snacking. That stops today! I will eat my normally small eight bite meals and then if I want to consume anything between meals I will drink a glass of water. Next week I will redo my fasting blood sugar and see where it is. But from today I will focus on losing weight, eating the high protein diet I did so well on, and getting some more exercise.
If I want to live up to my own expectations I will lose 10-15 pounds and drop the blood sugar back to normal. I promised myself that when I was losing weight and now must actively take that admonition to heart. 

Wednesday, April 11, 2012

One surgery or two?

I watched the Today Show last week and saw Carnie Wilson (of Wilson Phillips) discussing her need for a second WLS. In 2001 she had a gastric bypass and lost about 150 pounds.  Due to a weight gain of almost 50% of what she had originally lost, she decided to have a second surgery this last January. That surgery entailed the placement of a Lap Band probably around the pouch attached to the intestine created during the previous surgery. I consulted with my surgeon and he was not particularly optimistic about the value for the additional surgery. I have previously discussed the surgical options available and also their limitations. I have also discussed the role of the individual changing their lifestyles and their eating habits in order to maintain their weight loss.

What it really comes down to is that it is your responsibility to ensure that you have taken all of the steps necessary to lose the weight and keep it of to the greatest extent possible. If you are a compulsive overeater or compensate for stress in your life by eating to excess, you will not have the success that you anticipate after WLS. Your surgeon can give you most of the physical tools to lose the weight and you will initially lose weight. But if you back slide into your old eating habits the weight will return. I have seen it in patients who start out with the best intentions, and who know they have to save their own life. They have the surgery and then in the years following, slowly (or sometimes rapidly) regain the weight. You simply cannot make a soup out of cheesecake in the blender and wash it down with a milkshake and still expect to maintain your weight loss.

The stories about weight gain after surgery are common and are one of the reasons that insurance companies are reluctant to pay for the surgery. Even though the data supports the effective control of diabetes and other health related problems post-surgery, the frequent result of the weight gain holds back the insurability of the procedures.  So what has to happen? Frankly it is time that we as the post-surgical patient stop expecting someone else to solve our weight problem.
We have to honestly look at ourselves and ask:
1) Were we ready to have the surgery?;
2) Did we reconciled why we are heavy and really understand and agree to actively do something about it? ; and
3) Do we have the institutional tools as well as the courage to allow us to succeed with the weight loss as well as to know how to keep it off?

My surgeon told me that he could create inside of me the physical conditions to help me lose weight, but he added that it would be my responsibility to ensure that I kept it off. While I have not been as successful as I expected, I know what I have to do. I need to exercise more  and watch my food habits. I am not eating to excess and I still eat about eight bites per meal. I have not lost the enthusiasm for that amazing change in my body and my health. I simply have gotten sloppy.

So back to Carnie Wilson. Her second surgery may or may not help her. From her words, she has a hard time controlling her diet. Eating seems a bit compulsive for her. I wish her well but I feel that her success (or failure) will depend more upon a psychological change in her behavior and not so much on the second surgical "magic bullet". I wish her well but frankly I am not overly optimistic. Change has to occur in her head as well as in her abdomen.

Tuesday, February 7, 2012

Smaller servings and balanced meals.

In a recent study published in the American Journal of Clinical Nutrition (December 2011) the researchers found that feeding preschoolers smaller portions of the main dish at lunchtime meant that they would eat more fruit and vegetables on the side and fewer total calories. The hypothesis of the study was to see if the portion size of the main food serving (in this case macaroni and cheese) affected the consumption of the healthier side dishes of vegetables (green beans) and fruit (applesauce). The children were presented with varying amounts of macaroni and cheese (from less than ½ cup to 1 ½ cups) as well as plenty of green beans and unsweetened applesauce, plus a whole grain roll and milk. The results indicated that the children ate the main dish first, and if they were full would eat the vegetables and fruit last or not at all.

Jennifer Savage (a nutritional researcher) at Pennsylvania State University in University Park and her colleagues found that the bigger the serving size of the macaroni and cheese; smaller amounts of the healthy side dishes were eaten. The preschoolers finished almost all of their smallest portion of mac and cheese, for an average of about 145 calories. But they still ate the majority of the much bigger portions, and put away 390 calories worth of the main course when they started with the most on their plate. When they were served the smallest amount of mac and cheese, kids ate almost half of their healthy side dishes, including fruits and veggies, compared to only a quarter when they were served the biggest mac and cheese portion.

Eating is always a matter of choices. If you give the child an option for a large portion of an entrée food that they really like, they will eat that more and they'll fill up. They'll reach their satiety point and they'll just stop eating thus reducing the nutritional quality of their meal.

So what does this mean to those of us who have a weight problem and have had or are thinking of having WLS? When we were heavy we could choose anything we wanted and eat as much as we wanted. Balancing our nutrition with good food choices was not always high on our agenda. However when you decide to diet or have WLS the concept of nutritional requirements needs to be one of your foremost areas of concern. After weight loss surgery we often find that our restrictive diets often do not allow the inclusion of the balanced nutrition that our body needs. Since we can only eat “Eight Bites” we often look at the main course as all we are going to eat. With so little available room in our stomachs post-surgery we often eat the things we like to eat and leave the “side dishes” alone. That is sort of like the kids who when given a large amount of the dish they prefer will eat it to satiety and then ignore or minimize the ingestion as well as the nutritional value of vegetables and fruit.

As was seen in the research discussed earlier, the kids ate a lower calorie and a more balanced diet when the “main course” was provided at a lower level along with the fruits and vegetables. One of the biggest concerns in the post-WLS eating world is to get sufficient amounts of protein. But how much do we need? The rule of thumb is about 60-70 grams of protein per day. In that light, 3 ounces of beef, pork and chicken all vary generally between 20 to 30 grams of protein; an egg is about 6 grams of protein. Spinach and other cooked greens are about 10-14 grams per cup .

So there are two issues to deal with. The first is to eat the nominal amount of protein necessary to ensure that we remain in balance during our weight loss and weight maintenance; and the second is to ensure that we do vary our diets with vegetables and fruits to get adequate vitamins and minerals. That is a balancing act. Since we can only eat eight bites or thereabouts per meal, how do we ensure that we get the balance we need between protein and vegetables?

I have found that while the largest component of my meals is protein (meats, eggs, cheese) I do add some vegetables and fruit to the meal just to enhance the dining experience. At a restaurant I might order a steak with a baked potato and spinach au gratin. I will cut about 2-3 ounces of the steak up and then I will alternate bites of meat with the vegetables. Eating slowly helps, but at the end of the meal I will need to ask the waiter to bring a take-home box for the remaining steak, potatoes and spinach. I will have consumed about 25 grams of meat protein. If I had a tablespoon of sour cream on my potato that is another gram or so and then the spinach would provide another 3-4 grams of protein. My dinner resulted in the consumption of about half your daily requirement for protein and was balanced nutritionally. It is important that you do not totally focus on the meat portion of your diet but also to provide yourself with a balanced diet.

If we take the children’s study to heart, we would reduce the entrée portion (even though it is already reduced) and add some vegetables and fruits. We would get better overall nutrition, probably lower total calories, and a more varied diet. That is a good thing. You can keep your portion control in check and have the nutrition you need. Remember its only eight bites.