Surgery Snacks Series:

high fibre, low sugar double chocolate chip protein bars

When I had my first endometriosis surgery, I was the last to be allowed to leave the hospital room because my recovery was so slow. I couldn’t lift myself up and I ended up being wheelchaired out of the hospital. For a good 24-48 hours, I couldn’t get myself up and out of bed and I had to be lifted up to get to the bathroom. My recovery took about six weeks before I felt anywhere close to normal.

After my second surgery, I was painting our house by day four, and by day five, I was hosting my sister’s hen do and dancing until 3am.

The difference? The second time around, I had prepared my body in advance and I knew how to support my body with nutrition afterwards.

Now, I am not recommending that you paint the house or party a few days after surgery (seriously!). I would have stayed resting if I could, but it was my sister’s hen do and I was hosting, so I was under pressure to get things ready. But the point is, I could.

And there’s good reason behind why. Your body needs nutrients to heal…

Did you know that dietary therapy was shown to be just as effective as hormonal therapy for improving pain and quality of life post-surgery, in patients with stage III–IV endo?

Why? Because what we eat actually affects our inflammation levels, the speed in which we heal, our pain, our energy levels, etc.

So this Endo Awareness Month, I wanted to offer you guys some easy ways to get in some of these key nutrients for surgery recovery, that you can make and freeze ahead of time, or ask your loved ones to make for you.

Now, these recipes are just snacks to brighten your day (because after all, who doesn’t want a little comforting treat post-surgery that also doubles up as a recovery tool?!), but it’s most important to focus on your main meals, which I’ve discussed more below in the notes.

So, without further ado, let’s get to this week’s recipe; Double Chocolate Chip Protein Bars.

This recipe…

• Is high protein, at approximately 15g per bar, 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.

• Is rich in anti-inflammatory nutrients and antioxidants to help lower inflammation post-surgery.

Each bar is a good source of magnesium from the cacao, flaxseed and almond 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.

The olive oil and almond butter also provides vitamin E. Vit E was used in the study, post-operatively on patients with endo, due to its antioxidant properties which have been shown to counteract oxidative stress in people with endometriosis (oxidative stress is a contributor to endo development). Vitamin E has also been shown to reduce pain, pain duration and blood loss in people with primary dysmenorrhea.

Finally, these bars are also rich in various antioxidants like flavonoids, lignans and polyphenols from the flax, cacao, olive oil, dates and almonds, all of which can fight oxidative stress and inflammation, and have numerous benefits for overall health.

• Is a source of iron to aid tissue recovery and improve energy levels post-surgery.

This recipe is also a source of non-heme iron from the cacao, flaxseed and almond butter, and though iron wasn’t specifically focused on in the research on endometriosis post-surgery, it is absolutely essential for transporting oxygen around the body and aiding in tissue recovery. In fact, it’s so important that there is much research dedicated to the negative effects of anaemia for surgery recovery and outcomes, prompting recommendations for treatment.

Low levels of iron are extremely common in general, but even more so in people with heavy menstrual bleeding and can occur after major surgery or when there’s been significant blood loss during surgery. Iron plays a key role in preventing fatigue, and so can also help us recover our energy levels post-surgery.

Iron is typically difficult to absorb from plant foods, and pairing with vitamin C aids uptake. So, one way to really benefit from this brownie is to enjoy it with a side of vitamin C rich food, like berries.

• Is a great source of 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.

As I mentioned already, these bars are a great source of polyphenols. Polyphenols are types of antioxidants found in certain plant foods that not only have a profound effect on reducing inflammation levels and improving 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. 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 blood sugar balancing to help keep inflammation down following surgery, improve wound healing time and reduce complications.

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 (which is then followed by a crash), we experience a slow drip of sustained energy (because glucose is fuel for us).

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).

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! In fact, blood sugar dysregulation post-surgery can actually impair healing and increase the risk of complications.

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.

• 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).

These constipation hacks are also low FODMAP and typically well tolerated, preventing bloating and IBS issues, however, like everything, tolerances are individual, especially if you’re prone to IBS symptoms, so scroll on down to learn what to consider with flax and psyllium and when you may want to make swaps.

Additionally, each bar is low FODMAP, so in theory, you should be able to better tolerate these protein bars without it causing too much bloating (a.k.a endo belly) and causing you further discomfort post-surgery. However, remember that every person is different, and if you have small intestine bacterial overgrowth, this is especially true because it really just depends on what you tolerate and what your SIBO likes to eat, and the low FODMAP diet is not always enough for people with SIBO.

And just to be clear, I am not suggesting you go totally low FODMAP after surgery. But because these recipes are designed to help you with post-surgery symptoms and recovering, I didn’t want to make a recipe which could cause a lot of bloating and pain!

May support healthier hormones and menstrual cycle after surgery.

A common complaint I hear after surgery is cycles behaving oddly and feeling particularly hormonal. This is likely to do with the physiological stress that the surgery triggered, which can actually affect hormone production, as well as the localised inflammation from the surgery itself, which can affect ovarian function.

I like to see surgery as a fresh start so to speak, and to me, it’s important to kick that fresh start off with healthy and balanced hormones, especially when we know that endo is an oestrogen dependent disease, so we want to minimise the risk of recurrence where possible, and one of those ways is by managing our hormone levels.

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 - with nothing else in it, which also happens to be low FODMAP.

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 protein powder with this recipe, but I suspect you could swap for almond protein powder as it is fairly similar in texture though I would say a bit lighter and less absorbent, so you may need less water. I have not tried this recipe with any other powders, and so results might vary and I recommend you start with a little less water and build up if needed, because rice protein is typically very absorbent.

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

Almond butter alternatives

For those with an allergy, sunflower seed butter makes a good allergy friendly alternative at low FODMAP serving sizes. Read more about sunflower seed butter and the FODMAP diet here.

FODMAP considerations

Each bar is low FODMAP, unless you use my carob bar to coat it, in which case, each protein bar has slightly over the low FODMAP serving size for carob, moving the bars into moderate FODMAP levels. Also, it’s worth noting that cacao nibs have not been measured by Monash yet, but are thought to be low FODMAP in small servings, and each bar will give you 5g, so not much at all, however, adjust if you know you don’t tolerate them well, or swap for chocolate.

If you’re sensitive to flax

This recipe contains 7g of flax and makes six bars, so each bar 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 fibre, so if you’d like, you could increase the psyllium husk or use ground chia seeds instead, but there’s a chance doing so may affect the texture or flavour and I’d make sure you tolerate the psyllium husk before you increase it.

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).

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 bars, 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 bar, 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 bars 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 bar 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 bar, 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.

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 bar significantly reduces your appetite, halve the amount of psyllium.

If you want to swap out the psyllium husk entirely, you could use ground chia seeds or 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.

Cacao powder vs. carob powder

If you have histamine intolerance, interstitial cystitis or dysautonomia, cacao may bother you. For some with histamine issues, 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 cacao (unfortunately, I am one of the few who can’t have much).

If you’re sensitive to cacao, you could swap the chocolate for a carob bar (I have a recipe here, just omit the lion’s mane), or swap the cacao powder entirely for carob powder. Carob powder is similar to cacao but tastes more date like and a little bit like molasses. I tend to need a blend of cacao and carob to soften the effects of cacao but soften the taste of carob!

Sweetness

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 roughly one date per bar or a little more if you go for 8 dates. The bars 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 bars taste a bit ‘healthy’.

If you want to go sweeter, and you haven’t tried the carob powder in the recipe, I really encourage you to do so because carob is naturally sweet and adds that boost. However, if preferred, you could increase the dates to 12 deglet noor dates, which would be two dates per bar, which with the amount of fibre and protein and being low GI, shouldn’t affect blood sugar, but everyone is different of course.

Additionally, I’ve suggested cacao nibs as the chocolate chips to keep added sugar down, but if you’d prefer to go for actual chocolate, try to aim for 90% or higher, which is often very low sugar, or 85% (but check the labels, because some 85% bars are still up there at 20g of sugar or more per 100g, whereas others are around 15g).

For the coating, I use my own carob bar recipe (just omit the mushroom powder), which contains naturally occurring sugar but no actual added sugar. If you’d rather use chocolate, again, I encourage you to go for the higher amounts!

You can also skip the chocolate coating entirely if you want to save on some of the sugar.

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 red or white 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 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:

• 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 rice protein, cacao and carob (or just cacao) powder, ground flax, psyllium husk powder and salt into a large mixing bowl and stir to combine. If using a vanilla bean, scrape the seeds out and add too.

• 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 almond butter, vanilla extract (if using), 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.

• In increments, pour the liquid into the protein mix and stir to combine, then add more and repeat, until the liquid and dry ingredients have formed a dough. If the dough is dry or there is still powder, etc. remaining in the bowl, add more water, 10 to 20 ml should be sufficient, but it will depend on your protein powder. 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 sticky, don’t worry, keeping kneading and the flax/psyllium will absorb the water.

• Add the chocolate chips or cacao nibs and knead or mix to evenly distribute.

• Press the protein mix into silicone bar moulds, the number you make will depend on the size of your moulds, but for me, it makes six large protein bars (the size is equivalent to the ones you buy in the shop). You can also press into a brownie tray and cut evenly into bars, I recommend doing this before freezing.

• Place the bars into the freezer and leave to set for an hour.

• Once the bars are set, melt the chocolate  and coconut oil on a double boiler or gently in the microwave on a low heat, in 10 second increments, to prevent burning, stirring between heating.

• Take your bars, and one by one, roll them in the chocolate, using a fork on each end to lift them out and transfer onto a tray/chopping board lined with baking paper.

• Pop back in the freezer for at least one hour. If you leave them for longer in the freezer, you may need to remove them 5-10 minutes before eating (if you value your teeth!). I keep mine stored in the freezer, and just wait five minutes or so before eating.