Surgery Snacks Series:

High Fibre, Blood sugar balancing Omega 3 Protein Cookies

I can’t think of much better than enjoying a cookie when you’re in bed and recovering from endo surgery.

Oh wait, I can.

Cookies that help you recover!

Yes. I did it.

I’ve been in a bit of a pit of despair with cookies for a while. I’m always trying to make low sugar cookies or cookies with sugar alternatives, with extra fibre and protein, and they just don’t come out well. I gave up the ghost, but then, when testing for a different recipe the other day, I kept thinking the mix might make a really good cookie. So I took some of the dough and tested my theory, and lo and behold, I made soft and gooey cookies without even trying. That my boyfriend loves.

And what’s even crazier, is that I really, really wanted to bring you guys cookies as part of my Surgery Snacks series, but I didn’t even attempt it, because I didn’t think I could do it. Well, the universe works in mysterious ways endo friends, and it wanted you to have cookies.

So, here they are.

These cookies are the soft, gooey, melt in your mouth kind. Chris said they remind him of Levain cookies (though they don’t have the crisp outer ‘shell’) - I’ll take that.

This recipe is…

• Blood sugar balancing to help keep inflammation down following surgery, improve wound healing time and reduce complications.

  Blood sugar dysregulation is common after surgery, even in people without diabetes, due to numerous factors, including our body’s stress response to surgery and medication such as anaesthesia.

Hyperglycaemia (high blood sugar) can affect surgery outcomes, from slowing wound healing time to raising inflammation (which worsens pain) and causing complications. It can even impair the immune system, resulting in an increased risk of wound infections at the incision area.

The blood sugar dysregulation (due to insulin resistance) following surgery can last to up to 21 days, so my goal is to provide you with comforting foods that don’t spike blood sugar and help it to normalise.

Two star ingredients for this purpose are psyllium husk and flax seeds. Psyllium husk and flax seeds both provide viscous fibre, a type of soluble fibre that forms a gel in the gut, and is particularly beneficial for blood sugar because it slows down digestion of glucose from carbohydrates, such as the dates in this recipe. So instead of experiencing a big surge in blood sugar (hyperglycaemia), we experience a slower, steadier and lower rise.

I’ve also packed this recipe with fat, fibre and protein from the protein powder, cashew (or other nut/seed butter), oat bran, olive oil and coconut oil, and the hemp seeds. Fat, fibre and protein all help to slow down the release of glucose from carbohydrate foods, minimising the blood sugar spike.

Additionally, this recipe is sweetened only with deglet noor dates, which are much lower in sugar than medjool, at about 3-5g per date (medjool are about 18g per date) and are considered low glycemic (find out what that means here). I’ve used two dates per cookie, and this is literally the only source of sugar in the recipe (if you use cacao nibs not chocolate chips) - so the sweetness is coming from fruit, with all that lovely fibre thrown in.

I’ve also given you two options regarding the chocolate chips - either cacao nibs, which are literally bits of roasted cacao bean and have no added sugar, or a very high percentage dark chocolate, which is low sugar. Blood sugar reactions vary from person to person, so tailor according to your body, but be reassured that I have taken a lot of care to reduce the spike with the added fibre, fat and protein.

And finally, this recipe is rich in nutrients that help stabilise blood sugar, such as manganese, zinc and magnesium.

Keeping blood sugar levels stable helps to prevent oxidative stress, which leads to more inflammation in the body and that may trigger further pain and symptoms. None of which we want after surgery!

Additionally, constant blood sugar swings can take their toll on hormones, leading to issues like elevated androgens (think testosterone), which can affect ovulation and cycle length. Blood sugar swings may also cause oestrogen excess or dominance and low progesterone if ovulation is interrupted or stopped entirely.

• High protein, at approximately 17g per cookie, to support a healthy surgery recovery.
  Protein is essential for tissue repair, and whilst we need lots of nutrients to recover after surgery, protein is the key component to rebuilding tissue and in short, knitting us back together!

  The Enhanced Recovery After Surgery (ERAS) guidance recommends 1.2–2.0 grams per kilogram of body weight per day, prior to surgery, beginning 7-10 days before the operation, which works out to be, on average, between 20 to 40g of protein per meal.
  Following surgery, the ERAS recommend a minimum of 1.6g of protein per kilogram of bodyweight, going as high as 3g protein if necessary (for extensive surgeries), for 4 weeks or longer if the surgery was particularly invasive.

  Additionally, it was stressed that the first 24 hours after surgery were particularly important, and simpler forms of protein, such as branch chain amino acids or protein shakes may be beneficial, especially for those who are struggling to eat (which can certainly be the case when you’re bloated and sore from surgery).

  The ERAS also emphasise spreading protein out across meals. This is because research indicates that protein is better absorbed over the day, rather than in one large sitting.

  For that reason, this recipe is tempting (because it’s goodness disguised in chocolate!) which can help with low appetite, and it offers protein in the form of protein powder (as well as seeds and nuts) for easy absorption. Whilst I am not one for defaulting to protein shakes all day long (hence why I emphasise quality protein with your main meals below), making your own protein bar, that utilises a minimally processed protein powder and isn’t full of artificial flavourings and sweeteners, is a good way to get a high amount of protein in across your day whilst recovering.

• A great source of omega 3 fatty acids, with a healthy balance of omega 3 to omega 6, to lower inflammation and improve endo symptoms (and maybe even help suppress growth rate).

  Omega 3 fatty acids were used as part of the dietary intervention to reduce pain and improve quality of life in endo patients post-surgery. Additionally, an animal study showed reduced adhesion formation post-surgery in mice treated with omega 3, with the researchers concluding that omega 3 fatty acids could play a role in preventing adhesion development both after surgery in people with endo.

  To add to this, a large body of research has shown links with endo and low omega 3 intake, and significant improvements in endo pain and period pain with increased intake or supplementing with omega 3. In fact, numerous research is now showing dietary intake of omega 3 as a helpful treatment for endometriosis inflammation and symptoms. Additionally, research has shown that a higher omega 3:omega 6 ratio suppressed endo cell survival, whilst another study showed suppression of growth.

Why are omega 3 fatty acids so beneficial? It’s mainly to do with their effects on immune compounds called prostaglandins. Prostaglandin E2 and F2α are elevated in people with endometriosis and people with dysmenorrhea. It’s these inflammatory prostaglandins that are the key cause of our pain with endometriosis, they also play a major role in the development and progression of endo. And whilst we need a health inflammatory response to heal after surgery, elevated levels of prostaglandin E2 can also make surgery recovery more painful and slow down wound healing time.

The good news is, we can actually lower the amount we make by the we eat (and supplements we take). A type of omega 6 called omega-6 fatty acid arachidonic acid makes prostaglandin E2 and prostaglandin F2α, but omega 3 makes anti-inflammatory prostaglandins. I have deliberately ensured that these cookies have a healthy balance of omega 3 to 6, which helps us to keep inflammation levels at bay and prevents excessive production of prostaglandins E2 and F2a.

• Rich in gut supportive prebiotics to repair the gut microbiome after antibiotics.

  Some of us are treated with antibiotics post-surgery with endometriosis, which unfortunately can significantly deplete our good gut bugs and can cause unpleasant side effects like diarrhoea. People with endo have already been shown to have microbiome dysbiosis, with lower levels of some beneficial bacteria and higher levels of pathogenic (bad) bacteria, which can not only fuel IBS symptoms like bloating, but also inflammation.

These bars are a great source of polyphenols from the cacao, olive oil, and flax. Polyphenols are types of antioxidants found in certain plant foods that not only reduce inflammation levels and improve overall health, but they are also a favourite food for our gut microbiome, which means that can support our good gut bugs to thrive.

Additionally, both flax seeds and psyllium husk contain prebiotic fibre, which is fibre that resists digestion and ends up in the large intestine, where it feeds gut bugs. In fact, each cookie offers 5g of fibre! This in turn increases levels of short chain fatty acids (SCFA), beneficial gut compounds which are produced when good bacteria eat fibre. These guys help to keep inflammation down in the gut and the body, help to keep blood sugar levels healthy, inhibit bad bacteria and foster good bacteria growth.

Because research suggests that people with endo may have gut inflammation, high levels of unhealthy gut bacteria and low levels of beneficial bacteria, as well as blood sugar issues, and often low levels of short chain fatty acids, replenishing SCFA levels and restoring the microbiome management is essential to endo belly and endo management overall, especially after antibiotics.

• Is rich in anti-inflammatory minerals that support the immune system and improve wound recovery time.

  Each cookie is a great source of magnesium from the hemp seeds, flax seeds, cacao nibs, oat bran and cashew butter.

  Magnesium, alongside other nutrients, was used post-surgery to lower endo related pain and improve quality of life. The researchers specifically selected and highlighted magnesium because it inhibits the production of inflammatory prostaglandins, that are elevated in people with endo, but also relaxes uterine muscles.

  Magnesium also helps reduce PMS symptoms, supports healthy oestrogen metabolism (clearance), healthy progesterone production and is a treatment for period pain. Additionally, magnesium is often depleted during times of stress, both physical and emotional, which arguably, surgery is both, so keeping magnesium levels topped up is important.

  These cookies are also a significant source of manganese, from the cashew butter, cacao nibs and flax seeds.

  Low levels of manganese are associated with blood sugar dysregulation and diabetes, but manganese also helps to protect us from inflammation and oxidative stress (both affect healing), and can improve wound healing.

  They’re additionally an incredible source of copper (50% of your RDA!). Copper is a mineral that is crucial in collagen production and tissue repair, so supports our wound healing process. It also vital for a healthy immune system (and we need the immune system to be working well for optimal recovery) and is an antioxidant. Antioxidants fight oxidative stress, a process that can slow down wound healing, but can be counteracted with sufficient antioxidants, like copper.

  This recipe also gives you up to almost a quarter of your zinc RDA (AI generated) from the hemp seeds, flax seeds, cashew butter, oat bran. Zinc plays a crucial role in blood sugar management/insulin regulation, but also in wound healing and collagen formation. Low levels of zinc have been demonstrated in the research on endometriosis and may be involved in the immune dysfunction that allows endo to grow. Zinc has also been shown to help with period pain and PMS, and also is crucial to healthy progesterone production.

• Can help with post-surgery constipation and bloating.
  One of the most common complaints after surgery for endo is the bloating and constipation. The air they use to inflate the abdomen to allow them the space and room to do their work can trigger gas and bloating for a couple of days, whilst the combination of medications, lack of movement and the trauma/inflammation sustained to the pelvic area, can really slow down bowel movements, worsening the bloating.

  For this reason, I’ve included both flax and psyllium husk. Both psyllium husk and flax seeds are stool bulking, which stimulates bowl motility in people with constipation. In fact, both psyllium and flax have been shown in multiple studies to be evidenced based tried and tested tools for constipation (and even diarrhoea).
  
  

• May support healthier hormones and menstrual cycles after surgery.

  These cookies are a great source of B6 and vitamin E.

  B6 supports healthy progesterone levels and reduces PMS, whilst vitamin E has been shown to reduce pain with endo, as well as support progesterone output. Vitamin E is also a powerful antioxidant and supports the immune system, so another bonus for surgery recovery.

  And if that wasn’t enough, B6 and vitamin E were both used as part of a dietary protocol post-surgery in patients with endo, for their anti-inflammatory and hormone supportive properties. In fact, this dietary intervention was shown to be just as effective as hormonal treatment for pain and quality of life.

  Whilst a number of these studies were conducted on supplemental intake, research has shown that women with endo have a 40% lower dietary intake of vitamin E than those without endo, and that vitamin E levels improved and inflammatory oxidative stress markers reduced with a high antioxidant diet across three months, that included adequate intake of vitamin E.

  These cookies also provide flax to support hormonal health. Flax contains a type of plant compound called lignans. Lignan’s are phytoestrogens, meaning they  are similar in structure to oestrogen, and can bind to oestrogen receptors (think about the oestrogen being the key, the receptor being the lock, and turning that lock performs an oestrogen related action in the body). However, they are much weaker than oestrogen, so as a result, by blocking our real oestrogen from getting to all of the receptors, flax can actually help those of us with excess (high) oestrogen or oestrogen dominance. One study even showed that the participants who consumed flax seeds for three cycles had longer luteal phases and a higher progesterone to oestrogen ratio in the luteal phase as well.

  However, there is a flip side. If you’re low in oestrogen, it’s possible that flax may actually boost levels - though in theory, this shouldn’t be a bad thing, if you’re low or if your ovaries have decided to slow down production thanks to the shock of surgery!

  Now, that’s the theory and the research, but everyone is different, and clinically, we see that some people feel more oestrogen dominant with flax (though I wouldn’t say I see this frequently), so it’s about you and your personal response. See below for tweaks if you’re sensitive to flax and additionally, have a listen or read of this episode all about flax and hormones.

Important notes to help you tailor this recipe to your own body and needs (and tastebuds!)

Protein powders

A lot of protein powders have added fillers and are heavily processed, I really try to avoid that where possible, so for this recipe, I went for a minimally processed 100% rice protein powder and almond protein - with nothing else in them.

This means it’s better for the gut because it has less ingredients to react to (like gums and fillers), but also it doesn’t fall under the category of ultra processed because it doesn’t have lots of added extras.

I’ve only used rice and almond protein powder with this recipe, and I think this works for the best cookie texture. If you wanted to go all rice protein, it might require more water because rice protein is very absorbent. If you want to go full almond, you’ll probably need less. I don’t recommend hemp, pea or chia because I think the flavours will be too overwhelming in this recipe, but I can’t comment on collagen, whey or beef.

If you’re looking for low FODMAP protein powders, check out this and this.

Cashew butter alternatives and bloating considerations

I normally avoid cashew butter for my recipes because it’s not low FODMAP and I want these recipes to be as endo belly safe as possible. However, cashew really works in cookie recipes so I wanted to at least make the original recipe with cashew butter, and then give you options to adjust.

If you want a low FODMAP replacement, peanut, sunflower and almond butters would all be low FODMAP at these serving size recommendations (one large cookie or two small).

For those with an allergy, sunflower seed butter makes a good allergy friendly alternative.

FODMAP adjustments

The only ingredient that is high FODMAP is the cashew butter, which I have made recommendations for above if you want to swap. Almond protein powder has not been tested so we don’t know if it’s low or high FODMAP, so you can see how you respond. Alternatively, you could go full rice protein (but I haven’t tried that and you’ll need to adjust water intake) or choose from another low FODMAP protein powder (see above) but you will need to take their tastes and textures into account, as they may change the cookie quite significantly.

If you’re sensitive to flax

This recipe contains 8g of flax and makes six large cookies, so each cookie provides just over 1g of flax, which isn’t very much at all. To give you some context, seed cycling, which uses flax alongside other seed to help regulate hormones and the menstrual cycle, use 1 tbsp flax for 14 days per cycle, which is roughly about 11g give or take, and we’re not using anywhere near that amount.

So, given that we’re using a small amount, it’s unlikely to trigger oestrogenic symptoms in those who are sensitive to flax, however, if you’re concerned, you could reduce the amount of flax or remove it entirely. You’ll be reducing the binding properties and the fibre, as well as the omega 3 content, so if you’d like, you could increase the psyllium husk or hemp seeds, but there’s a chance doing so may affect the texture or flavour. I’d make sure you tolerate the psyllium husk before you increase it (see below).

If you remove the flax entirely and don’t replace it, consider reducing the water a little, otherwise the mix may be too wet (because flax is absorbent).

If you’re not sure if flax is right for you or you have concerns about flax and endo, read or listen to this podcast episode.

Psyllium husk - gut reactivity, constipation and low appetite (PLEASE READ)

This recipe specifically includes psyllium husk for its endo belly fighting benefits (see above). Psyllium husk is generally well tolerated, but it should be consumed with caution as it won’t be right for everyone (have a read or listen to my podcast about its benefits, uses and how to consume it).

I strongly encourage you read/listen to that episode, but at a minimum, drink an extra glass of water with these cookies, because psyllium and flax absorb water, and if you’re not hydrated enough, they could bulk up in the intestines and cause more constipation, not less!

Having said that, the content of psyllium husk is moderate at about 12g for the whole recipe/2g per cookie, so it shouldn’t cause an issue and in theory, should be beneficial. And if you’re someone who is used to higher doses of psyllium (such as 6g per day for constipation, etc), these  cookies should be more than fine, but I would be wary about having your usual amount of psyllium as well.

If you’re new to psyllium husk, it’s always best to build up with psyllium husk, to test your tolerance. One cookie per day is a good amount, however, I recommend you read or listen to my podcast before you get started with this recipe so you can decide. If you’re sensitive, you could halve the amount of psyllium to 6g for the entire recipe, giving you just 1g per cookie, but you’ll need to reduce the water content as well, so the mix is not too wet - try halving the water amount and only add more if needed. It’s also worth considering that the fibre content will be less, which may affect blood sugar, so perhaps add some extra nuts like walnuts or hemp seeds.

If you have a bowel obstruction such as adhesions on the bowel (which I imagine so soon after surgery you shouldn’t have), because psyllium husk is bulking, you should speak to your doctor first before bringing psyllium into your diet.

Additionally, because of the high fibre content, psyllium can reduce appetite, but I want you to be eating lots of nutrient dense foods during recovery, not less! So, if you find one cookie significantly reduces your appetite, halve the amount of psyllium. However, at the amount of psyllium per cookie, it really shouldn’t be a problem.

If you want to swap out the psyllium husk entirely, you could use more flax, but I would imagine the chia seeds may affect the flavour (I haven’t tried). Chia is typically well tolerated and is also low fodmap, but have a listen or read of this episode to make sure it’s right for you.

Alternatives for dark chocolate or cacao if you’re sensitive

If you have histamine intolerance, interstitial cystitis or dysautonomia, dark chocolate/cacao may bother you. For some with histamine issues, dark chocolate/cacao can be flare inducing, whilst for those with IC, it could irritate the bladder and finally, with dysautonomia, it might be too stimulating. However, and this is a big however, everyone has different responses and I have very few clients who can’t tolerate dark chocolate/cacao (unfortunately, I am one of the few who can’t have much).

If you’re sensitive to dark chocolate/cacao, you could swap the chocolate for a carob bar (I have a recipe here, just omit the lion’s mane).

Glycemic load and index per serve

I wanted to keep the sugar content low in this recipe to prevent blood sugar spikes and the resulting inflammation, so I’ve kept the amount of dates to two date per large cookie/two small cookies. With the fibre and other ingredients, each serving is a low glycemic index and load, meaning that these cookies shouldn’t cause a blood sugar spike and in fact, the rise in glucose should be small and slow (however, everyone has individual blood sugar responses). You can learn more about glycemic index and load and what they mean here.

The cookies have a moderate sweetness which if you’ve been reducing sugar, should be enough for you, but if you’re not used to lower sugar foods, might mean these cookies taste a bit ‘healthy’ at first, until you adjust.

If you want to go sweeter, you could increase the dates but of course, this may impact your blood sugar response so please do consider that. Alternatively, you could add a couple of monk fruit drops.

If you wanted to eat more than one large cookie or two small cookies, double that amount should in theory still be a low to moderate glycemic load, but as everyone’s blood sugar responses vary, there’s of course a chance that this will have a bigger impact on your blood sugar because you will be eating more carbs/sugar (from the dates and oats) in one serving. It’s also worth noting you’d be eating more flax and psyllium in one go, so make sure you tolerate them well (see above).

Fat content

Yes these cookies are high fat, but that’s not a bad thing. They are rich in healthy fats like monounsaturated, polyunsaturated and omega 3, which have all been linked to lowered inflammation levels and are recommended for people with endometriosis. They also contain some saturated fat from beneficial sources like cacao nibs and coconut oil, and whilst there may be reason to moderate saturated fat intake overall with endo (to manage inflammation), the unsaturated fats far outweigh the saturated fat, whilst still giving us enough saturated fat to support hormonal health (saturated fats are essential to hormone production).

However, it’s worth noting that some research has linked a high fat and low fibre diet to increased circulating oestrogen levels, so we want to balance these cookies with meals rich in veggies, pluses, whole grains, etc. to ensure that we’re reaping the benefits of these functional food snacks. Having said that, I made these cookies rich in fibre, to help you meet your fibre goals!

This is a snack, not a main meal

If you follow my work, I am all about whole foods and nutrient dense meals to help you thrive and manage your endo. I emphasise meals rich in veggies, fruits, nuts, seeds, lean proteins, healthy fats and whole grains; all adjusted to your preferences and individual tolerances, with a focus on blood sugar balance.

The basis of your nutrient and protein intake should be coming from healthy meals, with foods such as fish, lentils, eggs, beans, lean meat, tolerated forms of dairy (check out this to learn more about whether dairy is right for you), nuts, seeds, etc.

However, as I mentioned earlier, it’s advised to spread our protein intake out, to improve absorption rates, and whilst this is important all the time, it’s especially important post-surgery, when our body really needs protein to recover. And this is exactly why I wanted to offer you little treats, to brighten your day post-surgery, whilst also giving you the fuel you need to feel better sooner.

Further resources

If you’re struggling with your endo nutrition or gut health, you might find my courses and one to one coaching helpful. You can find out more here. I’ve also got endless podcast episodes on gut health and blood sugar.

To understand more about the low FODMAP diet, start here.

Method:

• Line a baking tray with baking paper and preheat the oven to 175°C (fan-assisted) or 195°C (conventional).

• Soak the dates in 130ml hot water and leave aside whilst you prepare the other ingredients.

• If using whole flaxseeds, grind in a spice grinder.

• Add the protein, ground flax, psyllium husk powder, hemp, oats, baking powder, bicarbonate soda, salt and cacao nibs if using, into a large mixing bowl and stir to combine.

• Gently melt the coconut oil in the microwave or on the hob, low heat.

• Empty the dates and date water into a food processor with the cashew butter, vanilla, olive oil and coconut oil. Pulse a few times and then blitz on high speed until a smooth liquid. You may find small pieces of dates remain, that’s okay, just get it as smooth as you can.

• Pour the liquid into the protein mix and stir to combine. I find that once the mix is roughly combined, that getting my hands in there and ‘kneading’ the dough is the best way to get the wet and dry ingredients together completely. If the dough feels too sticky, don’t worry, keeping kneading and the flax/psyllium will absorb the water. If you have used different protein powders, you may have to adjust the water content (see notes above).

• If using dark chocolate or carob chocolate, chop into desired chunks and fold in.

• Roll the dough into six or 12 balls, and then place onto the baking tray, with even spacing between each. Press down and shape into thick cookies, you can go thinner if preferred, but they will require less baking time to prevent dryness (try 1-2 minutes less).

• Bake the larger cookies for 8 minutes and the smaller cookies for 6. They will still be soft when removed from the oven, leave for 5 minutes on the tray to cool, before transferring to a cooing wrack for another 15. They can now be eaten warm or left to cool entirely (if you like them even softer, you can eat after 10 minutes).

• Store in an airtight container in the fridge. Will keep for a good couple of days. You could also freeze, and reheat, but I haven’t tried this.