Episode 64: Role of Nutrition in a Successful Hernia Surgery | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hernia talk Tuesday. We have a weekly session of hernia talk live questions and answers. You’re joined by me, your host, Dr. Shirin Towfigh. I’m a hernia and laparoscopic surgery specialist. Thanks to all of you that are following me live on Facebook and on Zoom at Dr. Towfigh on Facebook. And then afterwards I’ll make sure that you can all follow me and watch the rest of this session on YouTube. I’ll post all those on my Instagram post at Hernia doc and on Twitter at her also at Hernia Doc. I’m super excited to share with you one of my close friends and colleagues, Dr. Adrienne Youdim is our guest panelist today. She is a board certified specialist in nutrition and obesity medicine right here in Beverly Hills. I’m very privileged to have her and be able to share patients with her. You can follow her on Facebook at Adrienne Youdim on Instagram, at Dr. Adrienne Youdim and on Twitter, Dr. A Youdim. So please, I’ll join and say hi to Dr. Youdim. Hey there.

Speaker 2 (00:01:04):

It’s so nice to be with you again. We’ve been, thanks for sharing patience for over a decade is what I calculated.

Speaker 1 (00:01:13):

That’s true. That’s true. Because I started Cedars, well I started Cedars in 2008. That’s where I met you. When were you in charge of, you were in charge, you were the medical director of the Center for Weight Loss at Cedar Sinai.

Speaker 2 (00:01:31):

Correct. And that’s started around 2006 and then became a few years later we became suite mates and then started doing great work together, getting people ready for surgery,

Speaker 1 (00:01:47):

And then we both decided to expand what we like to do and become our own bosses. And it’s been great.

Speaker 2 (00:01:55):

It’s been wonderful.

Speaker 1 (00:01:57):

So like me, you have a very narrow niche. I only do hernia surgery and hernia related stuff, chronic pain and obstructions and so on. And you have a very narrow niche, which is not that common for a physician who’s gone through internal medicine and so on. Maybe you can explain a little bit about what you do and what kind of patients you see.

Speaker 2 (00:02:18):

No, so I am a board certified internist and nutrition is not a subspecialty of internal medicine. So people always confuse me with nutritionists, which is maybe a master’s or a bachelor’s degree. But there is recently a couple of board certifications in obesity medicine. I’m actually a question writer for that exam as well as finishing nutrition specialists. And so it allows us, those of us who have a medical background to gain a greater understanding in obesity medicine and in clinical nutrition. So I do see a wide range of patients. The patients I used to see at Cedars when we were together tended to be sicker patients. So we saw patients who needed to lose weight in order to be listed on transplant lists, right, because there’s a B M I criteria or cutoff in order for people to get listed for heart transplant transplant. And I see a lot of people now who have metabolic conditions as a result of excess weight or just people who life has gotten in the way.

Speaker 2 (00:03:30):

And so they’ve had weight gain particularly over this last couple years. That’s something that really everyone has experienced, myself included, despite the fact that I’m a specialist, I am not immune to the human condition. Yes. So I do a lot of my own counseling. I use FDA-approved weight loss medications when indicated, and I do a lot of which we can get into a lot of practical, I would call doctory stuff. And I do a lot of emotional spiritual work, which is not very doctory. And I really came into after I left Cedars and started working for myself or on my own. Understanding that our hungers are emotional and there’s great science behind it. So it’s not just like, oh, I’m an emotional eater. My boyfriend broke up with me and I’m eating a pint of ice cream. But we know that physiologically that our stress and negative emotions literally hijack our hunger hormones and that’s neurobiology. So there is some fascinating science and I like to talk about it because I think there’s a lot of stigma around excess weight and if we can understand the science behind it, we can have more compassion for ourselves and for each other.

Speaker 1 (00:04:50):

So probably most people who see you are overweight. Do you also see underweight people?

Speaker 2 (00:04:55):

I do some, I do. It’s not a big part of my practice, but I do. And I also see people who have had nutritional issues postoperatively as when I was at Cedar Sinai, a bulk of my work was post bariatric surgery patients and I actually was involved in the international guidelines on the perioperative care and nutritional care of these patients. And so if they’re not very diligent about their vitamin and mineral supplementation, they can have significant nutritional complications that can result in crazy stuff. I mean, we saw a patient, I remember, who had blindness from vitamin A deficiency. I mean that’s kind of unheard of, but it happened in a patient who had not the newer kind of surgeries but the old kind of surgery in which they really bypassed a significant amount of colon and intestine, intestine rather. And that resulted in nutritional deficiencies. So there is that too, but the bulk really is overweight and obesity.

Speaker 1 (00:06:10):

And just a quick plug, Cedar Sinai Medical Center, as many of is the hospital I work at, the US News and World Report just announced today, I think they came out with their report where they rank all the hospitals. So we are number six in the nation and what you talk about, which is bariatric surgery, weight loss surgery, GI surgery, we’re number two in the nation. So that’s kind of our part of the hospital. So we’re very proud of working there.

Speaker 2 (00:06:40):

Yeah, they do

Speaker 1 (00:06:41):

News from today. So tell me a little bit about the nutrition versus obesity. Some people think, I just know in some cultures you want to fatten up your kid or historically if fat that meant you were rich and therefore better access to food and so on. But what’s the link between nutrition and obesity?

Speaker 2 (00:07:10):

Yeah, I mean like you say this, it’s such a fascinating area, food, because it is health and nutrition, it is love and comfort and emotion. It is cultural and intergenerational and I go into a lot of that in the book Hungry for More. It really is this beautiful connection and interplay between all these facets of life. When we talk specifically about nutrition and obesity, they are different in terms of when we give dietary interventions for good nutrition, it doesn’t necessarily translate into weight loss. And so a great example of that is, for example, the Mediterranean diet is very well studied, probably the best studied diet for health and wellbeing in terms of cardiovascular risk reduction, reduction in mortality from cardiovascular disease, cognitive improvements, reduction and prevention of Alzheimer’s disease. And the list is really endless, but sometimes that gets translated to people and we all know that the Mediterranean diet is high in good fats, olive oil, nuts, seeds, avocados.

Speaker 2 (00:08:32):

But those foods are still calorically dense. And so if we’re not mindful and we’re replacing our bag of chips for a bag of almonds, and I always think about those bag of almonds when we go on road trips at the gas station, they’re like this big. They’re thousands of calories. And so yes, almonds are healthy, but if we’re consuming thousands of calories then it and it results in weight gain, then that’s not healthy. So I mean that’s just one piece of it. It’s a complicated interplay. But I would say that while overall good nutrition is going to lead to good health, a nutritionally sound diet does not necessarily result in weight loss. And I think that’s one of the misconceptions that people have.

Speaker 1 (00:09:17):

We have tons of questions that would’ve been submitted already and there’s some coming in, so I’m just going to start shooting them at you if you’re okay with that and we’ll learn from your knowledge. Okay. This is a live question. Can you discuss what other sources of the B vitamins should you eat if you’re gluten-free because you have non Celiac gluten hypersensitivity?

Speaker 2 (00:09:39):

So actually B vitamins is a big category. There’s several different kinds of B vitamins from B one to B12, but there’s not 12 of them. Some people don’t know that that folate, for example, is a B vitamin and they come from various sources. So the biggest distinction is between B12 and everything else. B12 comes primarily from animal protein. So chicken, fish, eggs, milk, so if you’re a vegan or if you’re a vegetarian, you need to supplement a vegetarian who may eat eggs, may not need to supplement. Vegans definitely need to supplement. You can’t get B vitamins from plant-based sources. There are some spirulina and algae, but usually not sufficient. And B12 deficiency can have a wide range of consequences. It can result in anemia, it can result in nerve conduction issues and neuropathy or numbness and tingling and nerve pain, nerve dysfunction. And in really severe cases, B12 deficiency can result in major depression and even psychosis.

Speaker 2 (00:10:51):

Something to keep in mind, crazy like frank psychosis and cognitive issues. So somebody who goes in for cognitive decline, like an older person who may be worried about do a full nutritional workout, which includes B one, which is thymine and b12, just to aside, I spend a lot of time on B12 because it is important. There are drugs out there like metformin, which is very common for pre-diabetes and diabetes as well as our proton pump inhibitors, which are very common, which result in B12 deficiencies. So if you are on those medications, you should be mindful and have those checked and not wait until your anemic before you have your doctor check a B12 level. In terms of the other B vitamins, yes, they come fortified in your grains and such. So I understand the question of if I’m gluten free, but actually B vitamins come from mostly leafy greens. So your spinaches, even beets like the leaves of beets you can chop up and put in salad. Those are more nutritious than the beet itself. So they come from other sources, primarily the leafy greens with the exception of B12.

Speaker 1 (00:12:04):

Oh, really good. Okay. The next question has to do with hernias. What food should I stay away from if I have an inguinal hernia? Usually we say that you have abdominal pressure that worsens hernia. So I always tell my patients to not get constipated, but is there anything about bloating or gassiness or constipation that can be treated with change in diet?

Speaker 2 (00:12:28):

I was going to say, I mean that was the primary link that I would make as well is constipation to worsening your hernia, whether it’s inguinal or otherwise. I would say that the best, we always talk about prunes and prune juice, which is like, do you prune juice Dr. Towfigh?

Speaker 1 (00:12:47):

If it’s cold, but I don’t choose it, right? I like prune, I like prunes,

Speaker 2 (00:12:53):

So I’m not a huge ginormous fan. I can do prunes, but yeah, something that is not well known is that beets are actually an excellent laxative. So if you could buy those little beets in the store or what I like to do is go with my kids to the farmer’s market and buy them and then roast them and just keep ’em in the fridge. I put them in my salad every single day and it’s an excellent laxative or a way to keep regular. Just keep in mind that that does turn the stool colors. So if you have, don’t freak out and think that you’re having a GI bleed when it’s just the beets. But a high fiber diet, which includes a lot of veggies and high fiber foods, which also speaks to our carb fear. We are so petrified of carbs, and I always say carbs are a big category. They include Twinkies, donuts, asparagus, and garbanzo beans. So let’s not lump all of those together. But having a diet that’s rich in high fibrous grains and carbohydrates like beans and legumes and such is also good for good gut health. And it also has been shown to prolong life. So don’t be afraid of your carbohydrates.

Speaker 1 (00:14:08):

That’s pretty cool. I didn’t know about beets. They have beet chips. Is that okay for so

Speaker 2 (00:14:13):

Much? Not so much.

Speaker 1 (00:14:16):

Someone wrote prunes mixed with tart cherry juice. Watch out. What do you recommend for constipation? I’ve heard of Senna tea, like natural stuff because there’s always the over-the-counter MiraLax, milk amnesia, mineral oil, but from a food or nutrition standpoint.

Speaker 2 (00:14:39):

So again, first of all, I would say yes, the high fiber foods, lots of fruits and vegetables, things of that sort we discussed. In terms of supplements, I would say that senna tea, be careful with that. It’s fine okay to take, but actually in someone who’s never used it can be quite stimulating and cause churning of the stomach. So just be mindful. Okay. I would also say that things like Metamucil or fiber can be problematic if you’re poorly hydrated. So actually Metamucil and fiber can make you more constipated if you’re dehydrated. So you got to drink a lot of water and not just after the thing because it tastes gross, but all the time generally dehydrated, be urinating a couple every couple hours. And then MiraLax and magnesium or milk of magnesia are also very safe. I mean we recommend MiraLax to our infants and my son was on it for the first two years of his life. So those are safe and they are okay. The stuff like dolcolax or the stimulating things and even Senna comes as a stimulating comes can come in capsule. You just want to be careful with chronic use of that. Those medications, they are medications even though they’re over the counter because they can make your colon lazy so to speak. So be cautious of taking too much of that. I mean the beets, I’m going to put that as my primary.

Speaker 1 (00:16:21):

I love beets. I think beets and salads and everything are really delicious. I love all sorts of, what about other teas or other teas that are branded as weight loss, but it’s really to prevent constipation or diuresis.

Speaker 2 (00:16:38):

I stay clear of all that stuff. So we know that these supplements aren’t regulated and specifically when it comes to three classes of supplements, weight loss, sexual enhancing supplements and sports enhancing, they have widely when checked by the F D A, be known to be what’s called adulterated, which means they have other stuff in it. So be careful when you’re taking these things because they can have afedra, bitter orange, and things that are actually, what’s the word? They’ve been taken off the market because of risk.

Speaker 1 (00:17:13):

Okay, interesting. There’s a lot of talk about collagen supplements. So I’m told hernias are due to lack of collagen. Will collagen supplements cure my hernia?

Speaker 2 (00:17:24):

I’m going to say you think

Speaker 1 (00:17:25):

Of collagen.

Speaker 2 (00:17:26):

I don’t have the data on collagen and hernia issues, but I mean you can speak to this better than I can. It’s a functional issue. And even if it was a result of tissue laxity or what have you, that ship is sailed once you have a hernia. And so I don’t know that collagen is going to do anything. I think there’s DA good data for col or there’s some data. There’s some data for collagen and tears and muscle musculoskeletal issues. So I don’t think there’s any harm in doing it, particularly in more advanced cases of musculoskeletal issues. It can be helpful. There is also some data in terms of beautifying yourself and collagen, but I don’t know that there’s anything, not that I know of for hernia, is it? Do you know of any? No,

Speaker 1 (00:18:20):

Not that we know of. But I was always suspicious of this collagen supplement trend because the minute you ingest a collagen, we have enzymes in our stomach that will probably just get rid of it immediately. So it didn’t make sense. But then there was this one study that came out that said, oh, people noticed they looked younger or felt younger. Their skin was

Speaker 2 (00:18:44):

Exactly, so there is data in terms of wrinkles, fullness under the skin, so there is data for that. I think it also depends on the kind of collagen and so somebody just writes collagen on the label again, what does that really mean? I would say that preoperatively if people want to build their stores, and when I think of collagen, I also think of protein stores and that is something that is important for wound healing and I always recommend diet first, get it from your diet. But I’m also a huge fan of protein powder, high quality whey protein powder.

Speaker 1 (00:19:30):

Yeah, yeah. I’m kind of losing you. I dunno if I’m losing you or you’re losing me.

Speaker 2 (00:19:56):

I think we froze for a second, but it seems like you’re

Speaker 1 (00:19:59):

No problem. Yeah,

Speaker 2 (00:20:00):

I think we’re

Speaker 1 (00:20:01):

College and supplements like orally. Is there any evidence it’ll help with healing for surgery or anything like that?

Speaker 2 (00:20:11):

To be honest, I don’t know the data for that right now, but I can tell you that when I did do a lot of this work around surgery and bariatric surgery, which nutrition obviously is super important because it’s a gastrointestinal surgery and you’re altering the gastrointestinal tract, there was no good data for it. It’s not supported in the guidelines. And I would suspect that that’s still the same.

Speaker 1 (00:20:38):

And is the collagen that you eat, does that actually even get absorbed or does it just get denature the minute it hits the stomach acids?

Speaker 2 (00:20:45):

I think it It’s both.

Speaker 1 (00:20:47):

Yeah. Just not enough. Yeah, I think that’s right. Talking about here, I’ll show you talking about whey protein. So every morning I have my shake.

Speaker 2 (00:20:58):

Oh yeah, this

Speaker 1 (00:20:59):

Is your Dehl Nutrition,

Speaker 2 (00:21:02):


Speaker 1 (00:21:04):

Plant-based whey protein powder. I’ve tried a lot of, I mean I do this every single morning. This is my thing. So

Speaker 2 (00:21:13):

When it comes to, and weight loss obviously is my thing, so I always want to inch towards that. But speaking about weight loss, I’m not a fan or I don’t promote the keto diet or an ultra protein diet, and I’m not afraid of carbs as I mentioned. But higher protein diets do promote weight loss in several ways. One is that it helps suppress hunger hormones. So if all the macronutrients like carbohydrate, fat, protein being the three protein is the one that suppresses those hunger hormones best. And the second thing that it does is it helps preserve muscle mass, which when we’re losing weight, we can lose muscle and fat. Obviously you want to lose more fat than muscle. Some of that may be physiologic, but you can control kind of the degree to which you waste muscle during weight loss. Of course, for people who are not ambulatory or more sedentary because they’re obese or because they have hernias and they can’t do the activity they used to, the body starts to condition quite quickly.

Speaker 2 (00:22:14):

And so protein supplementation and also just aging, we start to lose muscle mass in women as early as our thirties. I mean really, I hope to God that’s not synonymous with aging your thirties, but so if you’re not getting it through the diet, that’s a good way to do it. And we recommend 20 to 30 grams per meal. Now an egg is seven grams, so it’s hard to do, which is why I recommend the protein shakes or the protein bar that we’ve created. I’ve actually created a line of protein bars called dehlbar specifically so that it’s as much protein as possible with the fewest calories so people can get the protein they need without it being a caloric load. Some of the over the counter bars, read your labels on those because some of them are like 400 calories. I mean, yikes. You might as well eat a Big Mac.

Speaker 1 (00:23:10):

So this I actually learned from you. So when you came out with your Dell Nutrition protein powder, I bought it just to see how it’s different from the other ones that I use, which are also really great, but yours is kind of tasty actually. I thought it was very tasty. I prefer vanilla. And then I think yours is a finer powder because the other ones, by the time this gets home, it’s got so much chunks of protein powder in it, but with yours, it’s super clean. Anytime I’m done. Yours like a finer powder, is that right? There is

Speaker 2 (00:23:45):

An important point to that because again, nobody’s really checking the labels. So what is whey? Whey is the protein. So when you make cheese or you know curdle milk, the protein that comes out of that is whey and it needs to be purified in order for it to be pure. But a lot of people don’t purify it. They just put all of that, dry it and put it in there and you’re not actually getting the purified concentrated protein out of that. Another thing, protein powders is that they’re not always just whey. Our flavored ones will have a little bit of vanilla, organic vanilla flavoring and stevia, but some of them can have a bunch of other stuff. So again, if you’re using it as a clean replacement for something else, you need to be mindful if it’s bogged down with a bunch of stuff that’s caloric and not useful to you. And

Speaker 1 (00:24:39):

If you’re gluten free, can you have this?

Speaker 2 (00:24:42):


Speaker 1 (00:24:43):

Yeah. And then just so you know, I have these in my drawer right here. Let’s see, this is vegan cherry, turmeric, mint chocolate brownie and but my favorites of chocolate chip, just so you guys know. So this is the Dehl bar and then the protein shake that I use is the Dehl Nutrition. So yeah,

Speaker 2 (00:25:11):

Thank you for the

Speaker 1 (00:25:13):

I’m a fan, that’s why you’re on this show.

Speaker 2 (00:25:16):

Thank you. We worked, I mean, I worked really hard to create that and it’s not easy to create something that’s shelf stable and has all the nutritional value that you want in it. I think people are looking for, again, I promote whole food, real food. I cook, I try and cook dinner almost every night, so it’s important to me, but the reality is that we live quick lives and so you want to be able to pick up something and go, and there’s a lot of junk out there, so we have to be careful that what we consume, I tell my patients, make it matter that what we consume really has some kind of value, either it’s totally yummy like an ice cream sundae, and that matters because it’s yummy, right? You choose to eat it once in a while, but if you’re eating for the purpose of nutrition, you want it really to have that nutritional value.

Speaker 1 (00:26:07):

The next question has to do with making sure that you have the best diet so you can heal from surgery. So do you recommend any particular foods or to include in a diet the first few weeks following surgery in addition to the standard good diet? Anything in particular?

Speaker 2 (00:26:23):

Yeah, so protein is important before and after. Like we said, high

Speaker 1 (00:26:29):


Speaker 2 (00:26:30):

High protein omegas are important and you can get omegas from fish, fatty fish. You can also get omegas from nuts and seeds. You can get omega from spirulina. That’s actually the highest. Algae is the highest plant-based form of Omega. Is that okay?

Speaker 1 (00:26:50):


Speaker 2 (00:26:51):

It’s a powder, but it comes from algae. It’s like a green, see it as I find it as a green powder. We have it at Dehl Nutrition. So protein omegas, vitamin C is very important. I don’t necessarily recommend vitamin C supplements, but just getting it from fresh fruits and vegetables. And then the B vitamins, which we already discussed.

Speaker 1 (00:27:15):

I have a little bit of a complicated question for you. I don’t know how much, so we’re dealing with Mesh reactions and this kind of inflammatory autoimmune reaction that people are getting from implants. You’ve seen it with breast implants, we see it in Mesh and it really takes people off kilter. They’re just very imbalanced and it affects all quality of life. So they’re people also get food sensitivities as part of a reaction to these meshes. The question is how do you navigate sensitivity that develop after hernia repair due to Mesh reaction? I’ve been through medical medium protocols, intro gaps, elimination, and now the wahls protocol, W A H L s, and I’m trying to find some way to get good nutrition in without sparking like an inflammatory or autoimmune worsening. What do you recommend?

Speaker 2 (00:28:13):

So there are some diets out there that are specifically kind of geared towards an anti-inflammatory effect, and sometimes they’re advocated for things like Crohn’s disease, which has an inflammatory component and also some autoimmune conditions. What I found is that it’s very variable on the person and probably it’s also variable to the degree that people can follow these diets. But I can tell you one of the ways in which we measure inflammation is C R P. So this is an inflammatory marker that goes up in the blood, and that doesn’t necessarily correlate to the inflammation per se or even Mesh reactions, but it is some kind of surrogate to inflammation. We know that the Mediterranean style diet is anti-inflammatory and C R P levels go down. So the pyramid for that is the bottom is whole grains and breads and cereals, which we have to be careful because our bread is packaged bread and obviously that’s not the same as the Mediterranean style bread, but cereals and oats and things of that sort.

Speaker 2 (00:29:37):

The second tier is obviously fruits and vegetables. The tier above is beans and legumes. So getting your protein primarily from those sources having a good amount or some of the nuts and the seeds and the olive oils and the omegas and the good fats, the poly and poly and monounsaturated fats are anti-inflammatory, keeping things like meats and obviously packaged foods to a minimum. I also want to point though to some of the lifestyle factors. And so this is a fascinating study. And it’s funny Shirin because when we were together, we were both super hardcore academic women working in primarily a male field. And so everything I feel like at least for me was very scientific. I remember one time somebody told me I should meditate, and I was really sister, I mean, my eyes rolled back so far into my head, I was like, girl, I am not going to meditate.

Speaker 2 (00:30:42):

But I’ll tell you, they’ve done this amazing, they’ve done great studies on mindfulness meditation, and there was actually a study that was done in at the Y M C A for men, like average guys who were coming in who had diabetes. And they found that a regular practice of mindfulness meditation over the course of, I think it was six weeks actually reduced therapy levels, reduced inflammatory markers in the blood. So this is one of the examples of the mind/body connection, and I wholeheartedly believe in this. I think this is still a new and emerging field, but when I talk about nutrition to my patients, I don’t only talk about food, I talk about exercise, I talk about sleep. I actually think sleep is a nutrient. I talk about mindfulness. So I would say that if this person in particular sounds like she’s super savvy and has done a lot with her diet, try these other lifestyle factors that may be contributing to kind of a sympathetic response in your body, a high stress state that you could manage and potentially could help you in conjunction with the clean diet, manage some of these symptoms.

Speaker 1 (00:32:01):

That’s awesome. We’re getting a lot of positive feedback on what is this Facebook Live because you’re bringing in such holistic practices to your medical practice, which I think is great. Someone’s asking about the Wheat Belly book. Have you heard of the Wheat Belly Book? Wheat Belly Book? What are your thoughts? Rolling eyes.

Speaker 2 (00:32:25):

I am in this field. There are so many different commercial and there’s so many things out there, it’s really hard for even an expert in the field to keep abreast of these things. I will also say though, that it’s difficult because our perspective as doctors is to really be evidence based. And a lot of these diets, it’s not that maybe they’re not good, but it’s hard to say with certainty that it’s good or bad because there’s no true rigorous evidence to support it. And oftentimes these things are so difficult, they ask so much of people. And so my question is this, why when we know that there are balanced diets that get the job done, and we have hundreds and thousands of studies, again, Mediterranean style diet to show that they’re effective, why do we pee on a keto stick? Why, right? I mean, there’s no data for that. So I really don’t go searching for the zebras, the things that are kind of random and obscure. I like to go for words. It’s easy. Make it easy, make it easy, and it doesn’t have to be painful in order for it to be effective.

Speaker 1 (00:33:48):

Now the great question coming up, which is for someone with severe diarrhea dependent irritable bowel syndrome, who has gotten relief from the FODMAP diet, what are the risks with the complications in someone who cannot progress much from the elimination phase of the FODMAP diet? We discussed the FODMAP diet with Leo Trayzon, the GI specialist. Yeah, last year. But can you explain what it is? And from what I understand, you can’t stay on it forever, right? It’s a short term.

Speaker 2 (00:34:17):

FODMAPS is a it pretty restrictive diet that does eliminate a lot of the foods that we think are high in nutrition. It eliminates a lot of beans and legumes. It eliminates a lot of good vegetables that are high in nutrients and antioxidants. And I don’t usually recommend a daily multivitamin. I don’t know that everybody needs one, but if there’s gaps in the diet, and this would definitely be one of those circumstances where there’s gaps in the diet, I would recommend a multivitamin to address the nutritional gaps. I would also be mindful of fat soluble vitamins, A D E and K. So most general doctors are not going to do a lot of that testing. But if it’s someone who’s having chronic diarrhea, that’s something to be mindful of maintaining or checking the nutrition. And then the question I think was in terms of how do you reintroduce, if you’re reacting to everything, that’s really tough.

Speaker 2 (00:35:31):

But what I would say is that in my experience with patients when people are reintroducing things, there are so many factors at play. And so I would really be careful in terms of reintroduction. For example, let’s talk about something very common to people like reflux. And so there’s certain things we know that cause reflux, caffeine causes reflux. So people eliminate their coffee and then they say, I still have reflux, but maybe they’re eating chocolate. And people don’t think about the fact that chocolate has caffeine in it. So just be really clear about how you’re reintroducing things. And then I would also really be mindful of everything else that’s going on. Again, going back to the holistic approach, because our mind gut kind of connection is super connected, for lack of a better word. And even people without irritable bowel syndrome or any of these disorders will have colonic reaction to stress and anxiety. Anyone who’s given it a lecture for the first time notices they’re in the bathroom a million times before they’ve done it. And so make sure that other factors are not red herrings and you’re not attributing your diarrhea to a food group that could be valuable to you when there’s something else going on.

Speaker 1 (00:36:52):

That’s a great point. I never made that connection, but that’s a really great point. Going back to deficiencies and so on, what supplements can someone take for healing? So in our residency, we’re taught zinc, vitamin C and vitamin A, if you’re on steroids, can help promote healing. Is that still something true? And

Speaker 2 (00:37:17):

Those are ones that still we recommend or they’re vitamins that we know to be important in wound healing, right? But I don’t usually recommend these supplements in isolation. Zinc, excess supplementation can give you copper deficiency actually, which is also important in wound healing. Too much copper can also affect your zinc, so you can actually interfere with the absorption of one by taking another. So I would say, again, taking just a multivitamin postoperatively is not a bad idea. If you’re concerned about nutritional issues or if you’re not getting it from food, you get zinc from, it’s tough, but you can get it from walnuts, you can get it from oysters and seafood, I think. And so I really believe in getting it from the diet. I wouldn’t get into this thing of replacing it with supplements because it interferes. I think calcium vitamin C up to 500 milligrams is fine over that. You worry about stones and things of that sort. So I would be mindful of that. And the jury is out on the collagen, like I said, and we about protein, so I know there’s a lot of interests around that. And I would just say good nutrition is good nutrition and try and get it from the safest way is to try and get it from food.

Speaker 1 (00:38:49):

So there’s a lot of sodas and stuff that people drink in the United States especially. Does that actually prevent you from absorbing good nutrition?

Speaker 2 (00:38:59):

Not that I know or believe in and I don’t like. Some people talk about sparkling water and bone loss and things of that sort that’s not really substantiated.

Speaker 1 (00:39:09):

There’s a question about dysautonomia, which something we’ll call POTS syndrome. Being hydrated is one of the ways to kind of help control your symptoms from dysautonomia or POTS syndrome. What are your thoughts about salt tablets and increasing electrolytes? Is that ever something that works or does your kidney just flush it all out and

Speaker 2 (00:39:32):

No, it depends on the person. I don’t recommend it. I have had some patients who’ve had postural hypotension and who have consistently low blood pressures, in which case I do recommend salt tablets. And no, it doesn’t get flushed out. It gets preserved. I mean, it does help bring up the blood pressure. Is fiber

Speaker 1 (00:39:54):

On the counter or is that prescription? Does salt tablets?

Speaker 2 (00:39:57):

I’ve, when I’ve given it, I have prescribed it.

Speaker 1 (00:40:00):

Okay. There’s a question about chronic fatigue. I haven’t been diagnosed with chronic fatigue, but I think I might have a mild form. However, after my open hernia surgery, definitely I definitely got worse fatigue and lower back pain, joint pain. Do you see chronic fatigue after operations or is there an inflammatory component to it? Is it,

Speaker 2 (00:40:25):

What I would say is, and this is one of those areas where it becomes difficult, what is the diagnosis or the definition of chronic fatigue and chronic fatigue syndrome? And some of us who are very western trained physicians don’t really have a clear definition of that. But I’m not going to dismiss the symptom of fatigue. And whether we’re diagnosing it as chronic fatigue or not really is it doesn’t really matter because there’s no true treatment for chronic fatigue. And yet fatigue is a symptom that has so many causes, right? Organic and non-organic causes. So anything from anemia to vitamin deficiencies to hypothyroidism to an inflammatory condition like lupus can give you fatigue. And then so much psychosocial emotional can give you fatigue. And what I will say is that it’s not just fatigue, but also lack of focus, which is sometimes perceived as right, you feel drained, but it really is this inability to maintain attention, which we have universally suffered.

Speaker 2 (00:41:44):

So there have been studies that looked at COVID, the post COVID syndrome, and of course this is one of the symptoms of the post COVID syndrome, but in this particular study, they found that people who didn’t have COVID were having similar fat fatigue, post COVID fatigue syndromes and lack of focus and concentration. And that’s because of many things are routines have been disrupted, our lives have been disrupted. We are in a state of chronic stress. And I would even say chronic trauma. I mean, what is trauma? We think of trauma as the big stuff, abuse and rape. But trauma is a state in which your nervous system, your sympathetic nervous system, which is meant to just get you out of the line of danger, like a lion is in constant state of hyperactivity. And so this is where the holistic stuff or the other stuff becomes really important.

Speaker 2 (00:42:45):

Clean nutrition is really important in regulating your homeostasis. So fresh, clean stuff, not packaged food. Taking the time to cook, it sounds like it’s so unsexy, right? Because yeah, we all know we roll our eyes, but it is impactful. Having adequate sleep is so important. And Corona-somnia, it’s a thing. People are suffering insomnia. Some of that is organic, but some of that is because we’re on our screens. Everyone’s watching Netflix, alcohol use has gone up, severe alcohol use has gone up 17% and 43% in women during this time. So making sure those things are out of our environment. And then also having some form of rejuvenation. So whether that’s mindfulness, meditation or soulful activity. And for me, my soulful activity, I mean, I do a lot of things, but writing and journaling is a big one. And actually journaling has been shown to even impact medical conditions, like improved lung function in asthma, reduce fatigue in chemotherapy, patients who have cancer. I mean, it’s crazy. And I think it’s because it helps people regulate their nervous system because they’re just, they have an outlet. Yes, good one is coloring. So coloring actually increases acetylcholine in the brain, which is a neurotransmitter that’s involved in focus and memory. So whether you have chronic fatigue or you just have fatigue or you just feel like tamped of your, I think these practices are important. And so I would really lean into them.

Speaker 1 (00:44:37):

These are all great. I love coloring. I love puzzles. I do a lot of puzzles. This is very much right up your alley. I hope that you can shed some light. So we have a lot of, we had multiple sessions on, we lost loss surgery and effective weight on hernias and so on. So this patient says, I am 100 pounds overweight, but I’m afraid of weight loss surgery. That’s usually the number that kind of sparks people being referred to for bariatric surgery. Is medical weight loss futile for me? So what is your recommendation? Because you do work with bariatric surgeons, you’re very well aware of that side of the world, but at the same time, you’re very successful at the medical weight loss.

Speaker 2 (00:45:19):

So I am for both, and I’m for individualized care. I don’t like to give people blanket statements because everyone is unique. If you take a hundred people in a medical study and put them on medical weight loss or surgical weight loss and look at them a year or even five years later, by and large, the people in these medical studies, the ones who’ve had surgery, are going to be more successful at losing and maintaining weight. And that’s kind of obvious, right? You’ve reduced the stomach size, you’ve bypassed the intestines, you’ve caused metabolic changes that help promote satiety. And so if I have a patient who’s tried everything and is suffering from excess weight, by all means go have bariatric surgery in good hands. And our surgeons at Cedar Sinai are phenomenal. I wouldn’t recommend to just everyone. But that being said, there are also a lot of people who are like, oh, I’ve tried everything, but they really haven’t tried everything.

Speaker 2 (00:46:23):

They really haven’t gone through the really intense process of working with a trained specialist like meat in this area with or without weight loss medications, with the counseling component, with all of the pieces that it requires. And I also think that we have to adjust our, first of all, one more thing about surgery is that keep in mind that in these studies where the surgeries are successful, they are still following these patients. And so that accountability piece is huge for a lot of people who have the surgeries and then go out into the wonderland, they may not be as successful. So the accountability, you have to follow up. You have to maintain what you would without surgery in order to get the maximal benefit from surgery. There’s also a huge, so there’s definitely a practical point part. And so I’ve been successful with dietary plans and with F D A approved medications.

Speaker 2 (00:47:28):

I mean, I have patients who I’ve seen since I was at Cedars, I’ve known them for 10 years. They still see me regularly because this is something, it’s not one and done. You don’t lose weight. And I say this in my book, nobody lost 60 pounds to the sound of trumpets and confetti. It doesn’t work like that. Anyone who’s lost weight, and I have had three kids, and so I’ve done it at least three times. It’s not like you get to this point where you’re like, woo-hoo, lost weight, and now I’m going to put my feet up and eat bon-bons. It’s like lifelong work. And so what I do is I talk about the practical side, but I also talk about the emotional side. And that’s what this book is about, hungry for more. And I do want somebody asked in the chat about the bars and the protein powders, and we can put that information out there.

Speaker 2 (00:48:20):

You can go to DrAdrienneYoudim.com or dehl nutrition.com. But Dr. Adrienne Youdim is where all my things are. But I really recommend this book, which I wrote and I just released on Amazon about a month and a half ago. It’s called Hungry for More Stories and Science to Inspire Weight Loss from Within. And I’ll tell you why I think it’s so important, because for 15 years, I’ve been treating patients with medical interventions, with medications for loss, with dietary plans. And always in the back of my mind, I wanted to be like, and by the way, can you ditch that guy or that job or that, yes. Right? Because I noticed that yes, we eat, we snack a lot in the afternoon and we have sweet tooth, but there’s also a hunger. There’s a hunger that people are trying to fill. And being on this side of the desk being the beneficiary of hundreds and thousands of patients and stories, I have seen the common thread between these hungers, hunger for self-compassion because you’re a perfectionist, hunger for autonomy because you’re in a job where you’re not seen and you’re not allowed to shine and show your genius hunger for belonging because you were a frizzy haired Middle Eastern girl living in Texas.

Speaker 2 (00:49:53):

And we all have these hungers. And in the book, I share my patient stories, but I also share personal stories on each and every one of these hungers to say that there is common humanity in all of this. And there’s science there too, which I describe because when we are stressed, when we are sad, emotional, lonely, tired, bored, frustrated, whatever the emotion is, negative emotions do hijack our hunger hormones. So we talked about bariatric. One of the benefits to bariatric surgery we know is that GLP one, a hormone that is released that signals fullness to the brain, goes up after bariatric surgery. That is one of the ways in which it’s effective. It’s actually metabolic. We know that when people are emotionally stressed, these hunger hormones go in the direction that promote more hunger, even if we’ve consumed food and nutrients. That’s so powerful. I mean, it’s super powerful to think that your emotions can actually hijack your hunger hormones. So I mean, that’s a really long-winded answer. I could talk about this for day’s, sister, but what I would say is that surgery, I believe in a comprehensive approach. I think if you’ve done everything, then surgery is not, there’s nothing wrong with it in the right hands. It can be very effective. But I’ll also say that no matter what you’re doing, you have to address that emotional piece because quite frankly, it’s going to bite us in the ass if we don’t. And that’s the truth.

Speaker 1 (00:51:31):

It’s so true. I changed jobs from my first job to my second job, and I immediately lost weight. I went to a meeting afterwards, everyone was like, oh, you’re doing, what are you doing? I’m like, I literally am doing nothing different. I just changed jobs. And it was so kind of crazy to me that that’s what happened. But I was gaining weight for no reason. I got a trainer. I was gaining weight with the trainer. I mean, it was the craziest thing. And then I changed jobs and the weight just kind of went down. Just so crazy.

Speaker 2 (00:52:01):


Speaker 1 (00:52:02):

Okay. Can we do a couple more questions? Sure. And okay, the next question has to do with, again, weight loss. My surgeons told me to lose weight before they would operate on me. What does that mean? What’s an appropriate weight? Do you go by charts or does that mean anything? Well,

Speaker 2 (00:52:18):

So he is so right. It’s like not only surgeons, but doctors in general are so guilty about this. We talk about diabetes, this, that, and the other. And then as the patient is walking out the door, we’re like, oh, by the way, can you lose some weight? Thanks without any guidance, right? It’s kind of an

Speaker 1 (00:52:40):


Speaker 2 (00:52:41):

Right? And so I don’t know that there’s a standard weight loss goal for every single surgery because the person is different. The comorbidities or medical conditions are different, and the surgery is different. If you’re talking about intraabdominal surgery, where in a man where there’s a lot of visceral fat, that’s going to be very different than obviously bunionectomy or even knee surgery. But I will say this, that the body is super forgiving so that even five to 10% of weight loss, so imagine you’re 220 pounds, 5% translates into about 10, 12 pounds or 11 pounds that, or you’re 180 pounds, it translates into under 10 pounds. That amount of weight loss will improve cardiometabolic abnormalities. It’ll reduce your hemoglobin a1c. If you have type two diabetes, it will change cholesterol levels. It will bring down your blood, your systolic blood pressure. There is data that shows that degree of weight loss will shrink the fat in the liver.

Speaker 2 (00:53:49):

So if you’re having laparoscopic surgery, that’s very important. If the liver’s big, and in the way of the tools, we actually had a patient at Cedars, I remember they had to abort the surgery because the visceral fat was so dense that they broke the trocar during surgery. So you can shrink visceral or belly fat and liver fat with just five, 10% and in two weeks of a restricted diet. So I would say it depends, but any amount is good and the body really responds. So don’t feel discouraged about engaging in that degree or engaging in weight loss preoperatively because it really can make a difference.

Speaker 1 (00:54:32):

Yeah. Next question. Thank you. Next question’s about colonics. What do you know about colonics and their effects on weight control and also before surgery? Is that a bad idea?

Speaker 2 (00:54:44):

I mean, I don’t know that it’s a bad idea, but I don’t think it’s a good idea. I mean, I’m, there’s no data for colonics. Yeah. Our bodies have, this is kind of the detox. People do detox diets. Our bodies were created with liver livers. The liver is a detox organ, and it is working 24 7 to detox your body. Same with your colon and your kidneys. I do not advocate for colonics. I think it’s gross. And yes, any benefit?

Speaker 1 (00:55:19):

Quick question about adhesions. Do adhesions from my hernia surgery affect mal absorption?

Speaker 2 (00:55:26):

I think no. I think if you had adhesions that were so severe, that would cause mal absorption. You would present with an acute obstruction, you’d be vomiting. You wouldn’t be able to pass gas for a stool. But just general adhesions that people have is not linked with absorption.

Speaker 1 (00:55:45):

Yeah, totally correct. Okay. Well, people are already asking how to get your protein powders of bars. I personally like the protein powder, the best of all of the things you sell. And again, I learned this from you because if I just stay at work, I’m going to eat stuff from around here. So to prevent that, I have one in the morning and one in the afternoon. It looks like this. It’s super smooth and creamy. I just add water. It’s boring, but it keeps me well, and I’m totally okay with it. And then just so you guys can see, I’m taking this out of my own stash. This is a Dell bar. You can go to dehl nutrition.com. Is that right? D e l, sorry. D E H L.

Speaker 2 (00:56:34):

Yes. Nutrition all.

Speaker 1 (00:56:36):

And they can buy, what else can they get on that website?

Speaker 2 (00:56:39):

There are some digestive enzymes. The SPI powder and turmeric powder is there, which I’m a huge fan of. Herb, are using Veic medicine that helps randomized controlled trials showing that it helps with cognitive health and mood stability. Of course, we can’t say that it treats any diseases or conditions, but there’s data for that is on there. If people just go to my website, that’s sweet, which is dr AdrienneYoudim.com, you can sign up for my newsletter. I give weekly newsletters. I try and make it really educational for people. I am, the book information is there too. I really recommend it to people who are struggling with weight. The reviews, if you can look at it on Amazon, people are really, I mean, it’s so moving to me that people are being moved by this book. And all I’ll say is that I don’t think it’s come from me. It’s really just come from my observation of people. And so I know that it’s powerful. And then if you’re into Instagram, I do health tips daily. You can listen to my musings. You can see my puppy once in a while, and my three kids and those kinds of shenanigans on Dr. Adrienne Youdim at on Instagram.

Speaker 1 (00:58:02):

And if you can show your book again, I do own it. It’s at home. I bought it from Amazon.

Speaker 2 (00:58:07):

Yeah, it’s called Hungry for More. And you probably need to type in my last name too, because there’s actually a cookbook by Chrissy Tegan. That’s not me, sadly. And it is short, short stories. And so it’s an easy read. It’s stories in science, three to five pages per chapter, so you can take a small bite. I actually have a podcast called Health Bite. And so I like small bites of things because I can’t personally take in too much information at once. So it’s small actionable bites, and I think it’s valuable for a couple reasons, but maybe we can just end with this, which is that the critical aspect of habit change and growing and evolving is self-acceptance. And this is also evidence-based. You can’t change yourself by bullying yourself, by looking at the mirror and talking smack to your belly or your big butt wherever you are. You need to meet yourself with a place of self-compassion. And that is the only way that you’re going to make lasting change. So let’s be kinder to ourselves and kinder to each other. It’s the nice thing to do and the more effective thing to do as well.

Speaker 1 (00:59:27):

So true. What a great way to end this. Thank you so much for your time. Every time I’ve had any session with you has always been so packed with information. I love how you make it so as palatable to non-specialists, but also very evidence-based. So I appreciate your time for that. And everyone, thanks for joining me on another Hernia Talk Live every Tuesday night. We’re joined with a guest panelist. Join me again next Tuesday. Please do follow me on Facebook at Dr. Towfigh and on Instagram and Twitter at hernia doc. I’ll make sure this session is available to you to watch and share from my YouTube channel. And I’ll make sure also that all of the websites and links that we talked about earlier with Dr. Youdim are posted on all of these sessions. So thank you. Thanks for your time. I appreciate back to your family. Say, hire them for me. Well, for sure. Take care. Thank you. Bye-bye.