web analytics

Acid Taste In Throat After Eating

Perfect. All right so I know I mentioned if you guys had any questions, feel free to ask quick ones in class, but if you have a very personal question or a more detailed question, please make sure to email me or call me up and then I can get to you and we can talk in more detail. All right. Excuse me Yes. Why are they taking a picture We’re filming this class for future webinars and future filming for our website. Yah. Yah. Okay. All right, it’s all for our website and for future webinars so that patients have.

Access to this a year down the road or two years down the road, or at anytime they need it on the website. All right, so where was I Questions. Questions. We got that. The next thing I want to let you guys know is that we’re going to be starting in your binders on a tab that says First Taste. So that’s where we’re starting. Oh, I’ll grab that. Excuse me. All right. Thank you. All right, so we’re starting there. Now folks, everything on the presentation is indeed in your binder. Now if you have a pen, keep it handy, because.

These are your binders moving forward. Make notes, scribble in it, do whatever you need to do because these are your binders, moving forward for the rest of your life. There are some things on here that I’ve updated that is on the presentation, but is not in that version of the binder. So, here we go. Blossom Bites, this is your first taste after surgery. I’ll be going a month after surgery. All right folks, so after surgery there’s three things we need you to focus on. The first one is making sure that you’re getting plenty of.

Diet After Weight Loss Surgery Blossom Bariatrics Las Vegas

Protein and those will be coming from your protein shakes. Who all is doing the preop two shake and a meal lean and green Perfect. So you’re very well versed in those protein drinks right Okay. So you’re going to keep doing those after surgery. That’s going to give you the most protein that you can absorb after surgery. Now we’re going to talk about the slip and slide funnel diet list and that is coming up in the next couple of slides, but the goal is to get 4060 grams of whey protein a day, every day. The second thing.

We really need you to focus on is to make sure you’re drinking plenty of fluids and we’re going to talk about how much and what kinds in the next couple of slides. And the third thing we need you to focus on is to get up and walk around every hour that you’re awake. Now, of course if you go to your hotel room, or you go home after surgery, this just means walking around the house or walking up and down the hallway, maybe once or twice, just every hour. This will help make sure that your circulation is working the way we.

Need it to. Alright, so after surgery, we need to treat your new stomach, or your new pouch like a brand new baby stomach in training. It’s going to be a newborn stomach. Protein is the most important nutrient you need after surgery. Not only does it help you heal, it does help repair tissues and it really helps you stay full longer and it helps stabilize your blood sugars. All right So you’re going to consume 4060 grams of whey protein a day and, of course, after about two weeks that protein will increase to about 6080 grams.

A day. I know 80 is a lot, but it’s going to give you enough, particularly my guys, depending on your activity level. You can go higher than 80 grams if you start exercising. So we can talk about that. After surgery we need you to consume at least six cups or 48 ounces of fluid a day. Now that is only to prevent dehydration. Water is always best, but if you’re tired of water, again try the 8020 rule. 80 percent could be water and 20 percent could be sugarfree fluids. We’re going to talk about those in a minute. So.

Try Crystal Light PURE. For those of you that are familiar with Crystal Light, I always recommend Crystal Light Pure. They’ve come out with that, it’s been out for about a year now. They utilize natural sweeteners, natural flavors and natural colors and they are less irritating to the stomach lining. Also, Sobe Lifewater, zero calores. A lot of patients like that after surgery. That is also sweetened with natural sweeteners called Stevia and they don’t put in any artificial colors or flavors in all of that too. Also, green tea,.

Herbal teas, these tend to work really well too. All right Great. All right, so here we go with the funnel diet list. All right, so the Slip and SlideFunnel Diet list is for the first 2 weeks after surgery. You can pick and choose out of this list for the rest of your life if you like the foods, all right So the reason why is because we want to prevent solid and heavily textured foods from putting too much strain and pressure on your new stomach and possibly rupturing those sutures. So examples of the funnel diet foods would be no sugaradded.

Applesauce or lowfat Greek yogurt. items that are not a good example of the funnel diet would be rice, oatmeal, and mashed potatoes. They just stick and clump. So here is the list and you’ll notice in your binders, if you’re following, that some of the list is not in there and you’re page says Blossom Bites examples, it should say Examples of FunnelSlip and Slide foods. Yes, it is right here my dear, this next page. Yah, right there. Yes, so feel free to add or shoot a picture of this as well. Obviously your whey protein.

Shakes, low sodium broth works really well. Lowfat or fatfree Greek yogurt can work, lowfat or fatfree cottage cheese without fruit, a soft scrambled egg, believe it or not, low sodium V8 Juice, maybe some tomato soup, no sugaradded applesauce. Now here we go, sugarfree Jello and sugarfree popsicles, please keep in mind that these are artificially flavored, artificially colored and not really food, but sometimes after surgery your throat hurts, it gets dry and scratchy. These feel good going down, so I left those on there. Of course water, almond milk, rice milk, coconut milk, and water. These are approved drinks.

As well and approved to mix your protein powder with to make your shakes. Notice there is no dairy milk or soy milk, okay So no cow milk and no soy milk. If you have any questions regarding soy I can certainly talk with you at the end of this or maybe at another time, but again it’s very irritating to the stomach and hard to digest and can cause some allergies etcetera and dairy milk same thing. You could have symptoms of lactose intolerance and irritating liquid after surgery to try to break down and digest. Most of our patients love almond.

Milk. It makes your shakes really creamy, yah, it sure does. All right, so for those of you who find that they’re craving things that are spicy after surgery or if you really love spicy food, you can go for it after surgery, but here’s the trick, because you are dealing with a brand new stomach. So what I want you to do is try a little drop of your favorite hot sauce on maybe a little bit of a soft scrambled egg, or maybe a little bit of cottage cheese and you’re going to take that little bite and you’re going to chew it 2030 times.

And you’re going to swallow and you’re going to wait and you’re going to wait and you’re going to wait even long until that stomach of your gives you the green light. All right That’s the trick. What we’re doing folks is reintroducing foods back to your stomach to see if it likes it, because you are going to have a brand new stomach with new likes and dislikes. Right here is where I’m going to share with you, and this is the extreme, but it happens very frequently. Many foods after surgery will either taste too sweet,.

Or too salty, or too something after surgery. Your taste will change. Your favorite food that you crave right now, you may lose that craving after surgery, which could be a good thing, right So that’s the neat thing about surgery, so be open to trying and introducing foods back into your life again. I had a patient say that before her surgery she could not stand seafood. She wouldn’t cook it in her house, she wouldn’t go to Red Lobster, she didn’t like the smell of it and guess what she ate after surgery and she craved Seafood.

That’s all she wanted to eat. So your stomach will do a complete 360, so try new things. I know, yah, got a brand new stomach. All right, here is your sample menu for the first two weeks after surgery. So here’s, here’s, this is key folks. I want you to get up and you’re going to start sipping your water. I need you to keep your water by your bedside table, in your car, at your kid’s soccer practice, at work. If you’re retired, keep it with you on the golf cart, okay That sipper or that water fluid needs to be with you at all times.

It’s going to help you prevent dehydration because we have to sip, sip, sip, sip. When I’m on my computer doing this, I brought this in here, so you’re just going to sip, sip, sip, all day, because right now we gulp this down, we get it over with, we slug it down, right After surgery and pretty much for the rest of your life, you’re just going to be sipping, sip, sip, sip. It’s going to take you about twenty to thirty minutes just to drink 8 ounces of fluid okay So you’re sipping all day. Now, so it’s really important to.

Try and prevent dehydration and that’s the key. So get up in the morning and start sipping that fluid. Start sipping that water. If you like hot tea or herbal tea, that’s fine too. Please make sure that it’s not too hot. Let it cool on the counter alright Who likes coffee Alright, I knew there’d be a few, awesome. I do to. You can still have your coffee, but keep in mind you’re just going to be able to sip a few, maybe a few ounces of it alright So don’t let it be too hot either, okay All right. So, and then, here’s.

The thing I want you to continue sipping your fluid and then when you realize its time to start making your protein drink for breakfast, I need you to stop sipping for about 15 minutes. Let all that fluid pass through your new stomach. Then after about 15 minutes or so I want you to sip your protein drink, which is indeed your meal. Just because it’s fluid, at this point, does not mean that it is fluid. It’s your breakfast, or your lunch, or your dinner, alright So, you’re going to sit back down. It’s going to take you about 2030 minutes.

Just to sip that, you know, 46 ounces of thinned whey protein shake. All right, that’s you’re breakfast. And then you can resume sipping again after 15 minutes. Let that protein go all the way through your stomach, okay About 15 minutes should do it and then resume sipping your fluid again. That’s how it’s going to be for a while. And lunch, 46 ounces of thinned whey protein shake. Dinner is the same thing. So you can see how this would be pretty boring, right So this is where the funnel diet food list comes in handy.

So, if you’re getting a little bit bored of just sipping on your protein drink for breakfast, lunch, and dinner, this is where this comes in really handy. You can add one or two of those things on that list, so it could be maybe a tablespoon or just a bite of lowfat Greek yogurt, maybe a tablespoon or two, or just a bite of some lowfat cottage cheese, or anything on that funnel diet list. That will help kind of break it up a little bit, alright Any questions about how to, you know, maneuver through your first two weeks.

I have a questions. Yes. Okay, when you say that the first two weeks, right after surgery we can start doing this You got it. Yes. He asked if we can start doing the funnel diet foods right after surgery and between your whey protein drinks and that is yes. Keep in mind, you’re just going to have a few little tastes, and few little bites. Well, right, right, but I mean like the next day If you feel like it, you bet. It’s on the approved list. Yep. Okay. Thank you.

Yep. Keep in mind these funnel diet foods are very, they’re semi solid or they’re liquid, so yes. Hi, yes. Is iced tea okay Absolutely. How are you going to sweeten it Are you going to do it. No. I don’t like sweetener. Okay, yes. Iced tea is great. You bet. Hi, yes. That’s perfect too. Yes. When you say thinned protein shake, what do you mean Well, eventually, she asked what does thinned mean I put thinned on here for your protein shake. I mean it needs to be thin enough you.

Can sip it. Eventually you’ll be making smoothies out of these things. You can make them as delicious and creamy as you want, but right now let’s keep them thin so you can just sip it down, okay Can we mix our protein with coffee I don’t recommend that because coffee can dehydrate, if that’s how your doing it. I do prefer almond milk, rice milk, coconut milk, or just water, yah. If you do like coffee, you know, obviously just have it before or after as part of your fluid, like in the morning.

And stuff. I love coffee too so, yah, so coffee’s always good. All right, any other questions I always hit the wrong one, sorry. It’s always a little funny coming back and doing it live when I do it from my home office for months and months on end, so. All right folks, remember to sip fluids throughout the day and in between meals. This is going to be for the rest of your life. Okay, how about some troubleshooting You probably will vomit once or twice. You’ll get, your stomach, no it’s okay. Your stomach is just telling you that it didn’t like what.

You put in it the first time. Most often when you eat too quickly you take too large of a bite, or you don’t chew well enough. That’s really all it is. And it’s your new stomach or your new pouch telling you whoa, wait a minute. I didn’t like that. Try it again. And it will just come right back up, okay Nothings going to tear or nothing No. You should be just fine. You should be just fine. Now these are just random vomiting if you. Sometimes folks, if they take a big gulp of water. or their fluid because they.

Forget. You know, because we’ve been gulping stuff and eating quickly for most of our lives. We eat and drink really quickly in America don’t we We just slug stuff down without thinking about it. So your stomach is going to be your new best tool. It will tell you how much it can handle at one time and that’s one way it will tell you, all right Okay. So just make sure you’re chewing your food well and of course avoid sweets and carbonated drinks. These will typically cause that response as well. So anybody having gastric bypass.

Oh, two, three, okay perfect. Now dumping syndrome is a little bit more prevalent in gastric bypass, but and that’s when you get into a food that you know you shouldn’t have gotten into. I’m talking the ice creams, the apple pie, the fried mozzarella sticks, the fried chicken, all right These things, these fats, these rancid fats and these high sugar foods are tough in your new digestive system to break down and assimilate. So what your body does is it will pull fluid from your tissues and then dump it into your bowel to.

Get rid of the offending food, so just get rid of it the fastest way it knows how, alright So that’s what that is. All right, all right, so let’s talk more about dehydration, because dehydrations is the number one reason why postsurgery bariatric patients get admitted to the E.R. okay Dehydration can sneak up on you. So please make sure you’re drinking at least 68 servings up to 64 ounces of fluid a day and I do hear from patients that it’s hard to do because you have to keep sipping. So please, please, please keep sipping. Now.

Let’s talk about constipation because that is one of things that can happen as well. Now usually it’s the pain medication anesthesia that will cause some constipation right after surgery. Typically if it kind of keeps up for three or four days after your surgery, we can go a number of routes. Obviously anything over the counter will be fine, like Colace or, I think there’s Benefiber, Metamucil, you know, over the counter fiber supplements. These will work really well. Some other things that work very well, of course, would be ground.

Flaxseeds, or flaxseed meal, for those of you who are feeling familiar with flaxseeds and their benefits. It’s like natural and delicious Metamucil. You can add that to your protein powder in your shakes, yah, you can pretty much add it to your Greek yogurt, it will make it really creamy and nutty flavored. It’s really delicious. We’re going to talk about probiotics in the supplement segment and magnesium, magnesium citrate is another product, or another mineral that will really help with constipation. Yes Hi. With that flaxseed that you were saying you can add it to the, do you have to worry about.

That getting caught anywhere Yes, good question. She was wondering about the flaxseeds getting caught. Please make sure that they are ground. You can buy flaxseed meal already ground up, but they should be the consistency of sawdust. Or, if you buy them whole, they even have them at Winco in the bulk section now. Take those guys home, grind them up in a coffee grinder or your blender. They should be the consistency of sawdust. Okay Keep them in the fridge too. Keep them in the fridge. What about the gel, the pill Oh, the flaxseed oil Well it’s going to be.

Hard to swallow the big gel caps. I know those are big, yah. So if you feel like it, you can poke a hole in that gel cap and squirt it in to your protein drink. Yah, yah, you bet, good question. All right, so, some more troubleshooting things. You can stretch your new baby stomach, but you have to try really hard. Your stomach will give you your own specific unique signal of fullness. Your signal of fullness will be much different than anybody else who has had the surgery. If you’ve had family members or coworkers that have had.

A bariatric procedure and they’ll tell you oh I know I’m full when I get the hiccups. Right I can guarantee that’s not going to be your full feeling, okay So be very aware that your full feeling is there. Be aware of it every time you eat and don’t try to eat past it. Either you’ll vomit it up, or you could stretch your stomach. Okay All right. So we’re going to talk quickly about reasons why patients gain weight after the surgery or why they stop losing weight. Usually its anywhere from a couple of months to a.

Year after surgery. The biggest culprit is those darn starchy carbohydrates. They sneak back in to your life again. They got everybody into this pickle and will continue to do so if you allow them back into your life. Basically all the starchy carbs, all bread, all pasta, all cereal, all potatoes, all rice, all grains, all chips, crackers, cookies, bagels, muffins, english muffins, pies, candies, cupcakes, all that deliciousness, alright These got everybody in the pickle, alright Not just you guys, everybody in America, okay We eat a lot of them. They’re nutrient devoid and they turn to sugar within 30 seconds to two.

Minutes, depending on the source in which they came from. That’s pretty fast. That’s a lot of sugar that we’re eating, okay It doesn’t matter how brown and scratchy it is, it’s still turning to sugar. That’s the information your body is getting. So, when that happens your cells are still not that good at taking in that sugar, alright We still are struggling with a little bit of insulin resistance and guess what Your body will stop burning fat and store fat that’s on you that you’ve been doing so well with. It will start burning.

On that sugar again and not mess with the fat anymore. So that’s usually what happens. Of course, there’s a long biochemical process that goes into this. For the sake of the large class today I won’t, I promise you I won’t go into it, but basically we do not want that sugar being converted into fat in your liver. Now you will get in to starches, throughout your life, so starches happen right They’re in Mexican dishes, they’re in casseroles, they’re in chicken noodle soup. I don’t expect everybody to pick out every noodle or every.

Kernel of rice. I understand that, but it’s the starches that your eating by themselves on purpose that get you. They’ll sneak up on you. I’m talking the bowl of pretzels on your coworkers desk. The delicious little mini cupcakes in the break room at work, alright, just a couple of MM’s everyday from your coworkers desk, or from the holiday, from the Halloween candy. These are the things that will get you. Okay All right. Some cereal every morning, a muffin, they’ll get you. All righty. Very cool. Okay, so let’s talk.

A little about some pain management. Basically folks just take your prescribed pains meds as directed. Now when you run out of that prescription and feel free to keep some liquid Tylenol on hand at home and if you have some additional discomfort. You could easily just sit back down. What about like Aleve Yah, typically that works well if you don’t have a history of ulcers, or you haven’t had gastric bypass, okay So everything you take has to be liquid Right now, right after surgery, you bet. You’ll be able to take, you know, capsules, or pills.

And stuff. Later Absolutely yah. And plus it gets absorbed more quickly. It’s a quicker delivery system. Basically folks, when to call us, or when to go to your nearest E.R. If you have any of these symptoms on the monitor, or one or two of them or all of them, alright If you have a fever of greater than 100.5 degrees Fahrenheit and it is not being lessened by your Tylenol, redness and hot to the touch at the wound site, green pus and drainage, uncontrolled nausea and vomiting, bleeding, abdominal pain, shaking and sweating, okay.

These are just symptoms that you need to seek treatment for. So for those of you here in Las Vegas, feel free to go to North Vista, if it’s close to your house, if it’s safe and it’s close to go there to North Vista. If you are from the surrounding area, like Bullhead City or Pahrump or somewhere, go to your nearest E.R. and for those of you out of town, just go to your nearest urgent care or E.R. If they don’t have a bariatric program in that hospital, or in that clinic, the awesome thing about Dr. Umbach is that.

Yes, this is his personal cell phone number, up here on the monitor. It is in your binders as well. Feel free to have the E.R. doctor or the E.R. staff on call to have them call Dr. Umbach’s personal cell phone number to seek out the best treatment plan for you, okay He does answer it. When I’m here live and in person and in my office, his office is next door to mine, so I hear him answer it. All right, so basic tips for life. Eat slowly and chew your food thoroughly. Eating quickly will cause severe pain and agony along.

With nausea, vomiting, and irritation to your new baby stomach. So you’re going to take a tiny, tiny little bite of your food. You’re going to chew that 2030 times and you’re going to swallow, okay It’s going to have to be that slow. With your liquid again sip, sip, sip. Alright Introduce that fluid very slowly. I left this slide on here because it works. Many patients have told me and they’ve confirmed that if you’ve got kids, or grandkids at home, or they come and visit a lot, then you still have a little training utensil,.

Dig them out again and use them for yourself. Because what we’ve done in America is that we’ve created a normal huge serving sizes, like our plates are huge. Our serving utensils, now we’re eating off of tablespoons, you know I mean we really do things fast and pretty big. So what this is going to do is going to help you slow down and create a new neural pathway for your brain and your eyes. Because if you’re going to look at your little quarter cup of food, okay It’s on a big plate and you’ve got a big fork coming at it, you’re.

Eyes and your brain aren’t going to realize and believe that this is going to fill you up. You’re just going to be that full, like what This food, this is not going to fill me up. This is crazy, but many patients find when they start adding textured foods back in to their life, they start with a little baby serving size, utensils, and plates and bowls and things like that, because it’s going to take you about 30 minutes to eat a full textured meal, okay All right. Drinking to stay hydrated, because we need to touch upon.

This again. Basically folks, six to eight servings of water or your fluid a day. Drink between meals. You’re going to be sipping, sip, sip, sip. Do not gulp. All right. So, another thing that I like to share is for folks who are concerned about becoming dehydrated. Keep some Pedialyte in the fridge or keep some Pedialyte at your house, alright There’s a lot of different delivery systems with Pedialyte nowadays. There’s powders you can add to your water or you can just get a big liter of Pedialyte and put that in your fridge. And basically.

That is the correct ration of electrolytes to hydrate you quickly, much more so than Propel and G2 and all of that stuff, okay Those are not the correct ratio. They’re not medically formulated to introduce the electrolytes into your cells quickly, okay That was the G2 Yah. Laughter Alright guys. All right we have to talk about bubbles. We have to talk about carbonation alright Bubbles do irritate your stomach. They cause a lot of pain, gas, distention, heart burn, nausea, right So you’re thinking, oh, she’s probably talking about soda. I’m also talking about beer, champagne,.

Peligrino, ginger ale, soda water, anything sparkly. For those of you who know what Combuga is, that’s fermented too. That will cause a lot of discomfort, anything carbonated. All right. Is that forever, or just for the next two weeks You know what, mostly it’s forever, mostly it is and everybody is different though, but mostly it’s forever. Laughter No drinking forever The sparkly, yes. Yes. It also means beer and champagne, I know. New Year’s is coming up. The holidays are coming up, so I have to throw that out there with the champagne. Okay. Laughter You know you’re dehydrated.

When you have these symptoms up here on the monitor, thirst, decreased urine output, strong smelling urine, dark urine, dizziness, or light headedness, a dry sticky mouth and a headache. These are all reasons, or they’re all symptoms of dehydration. All right, so we kind of talked about alcoholic beverages, but as your Bariatric nutritionist, this is what I have to say. I am supposed to say that. I am also supposed to say this, right I am also supposed to say that. I would be a bad nutritionist if I said Oh hey, go for it, okay. But I know.

Why it happens, because we know there is no nutritional value in alcohol. We know it’s loaded with empty calories, but guess what I know life happens. Life does. You want to go out and enjoy it, right Part of the reason why you’re getting this surgery is so you can go out and have a fun and energetic vivacious life again. All right So for those of you that do enjoy some alcohol now and again, a nice glass of wine, a nice cocktail, you can certainly do that for sure. The one thing to think about though is to please make sure.

That they are not carbonated. Another thing to think about folks is that anything that is blended, like a frozen margarita, a frozen blended margarita, a frozen strawberry daiquiri, a pina colada, anything that’s like that is just like a frozen sugar bomb and can cause dumping syndrome and a lot of discomfort. You don’t want that if your out with friends or family. Another thing to please keep in mind, you guys, is when you are trying a new drink, a new cocktail, maybe on the menu, or it’s your first time out, the holidays.

Are coming up, let your family members, your friends, your husband, your wife, your partner know that hey, this is the first time I’m going to start having a little bit of a drink. Keep an eye on me. I’m not sure how I’m going to react, because it hits you very quickly. What used to take a glass of wine, or maybe a nice cocktail, right, is probably going to take you a quarter of it. Okay So be very careful, but enjoy yourselves, okay. Laughter All right. So, any questions about the first two weeks after surgery All right.

Perfect. So we’re going to move on to weeks three and four. So in addition to your 4060 grams of whey protein shakes a day, because we definitely have to keep up with these, right We have to get our protein in. How else are you going to get up to 60 grams of protein every day, right You’re going to start adding some textured foods back into your life, but the goal is to continue picking and choosing from that funnel diet list that we spoke about earlier and the goal is also to keep chewing those foods 2030 times, okay.

Slow it down. Basically, and I threw this up here because this usually helps my patients when they start transitioning into textured foods. My patients find that they can do very well with one meal, maybe a quarter cup, or a half cup of textured food, which would equal a couple of bites of the protein and a couple of bites of a soft vegetable or something, and then they continue with their protein shakes and smoothies. Because now you can make smoothies. See now you’ve passed that two week mark, you can start making smoothies.

Out of your protein drinks, make them fun again, okay, because they’ve been pretty boring. Laughter All right. In your binders folks when you start leafing through that, there’s some really great recipes for smoothies in there and they’ve actually been passed down to me from prior patients so, they are Bariatric patient approved, I promise. All right. All right, so foods in this stage can include ground or shredded low fat meats. Now the texture we’re looking for is perhaps tuna fish, or that Swanson’s canned chicken. You don’t have to eat it, but that’s the texture we’re looking for, ground meats, shredded.

Meats, flaky fish, you know, halibut, tilapia, cod, and salmon. That works really well, if you like it. Now, you can certainly have lean or white poultry like chicken breast or turkey breast, or lean beef, but I put if tolerated on there for both of them because sometimes those two meats, if they’re not prepared well, if they’re too dry, they can feel like they’re sticking, kind of sticking in your esophagus, or they stick in your stomach a little bit. They are just really hard to, they are tightly bonded protein. They’ve got a lot of protein.

Bonds in there and it takes a lot of enzymes in your stomach to pull them apart and create peptides and dipeptides. So, yah, but, usually the meat found in soup, like chicken vegetable, or beef vegetable, slow cooked meats, found is stews and soups, those work really well, okay Okay. Okay. Obviously we’re very familiar with this Greek yogurt and by the way I’m going to talk a little bit about Greek yogurt, because I forgot to do it earlier on. Folks, for those of you that do yogurt, please, please, please, do only Greek yogurt, if you do yogurt.

At all, okay Greek yogurt is processed much differently in that it’s left in the vats of, the big old vats in the manufacturing plant and they allow the bacteria, the beneficial bacteria to ferment much longer then the typical yogurts out there right And then these bacteria chomp away, like pac mans, for those of you that remember pac man, at that lactose, that milk sugar and any remaining milk sugar is strained off throughout the rest of the process of making Greek yogurt. You are left with that delicious heavy whey protein. So that’s.

Why whey protein is a better choice than the regular proteins out there. We’re not counting calories. I don’t care if it’s fit and light and 90 calories. It’s still sugar. It’s still lactose. It’s still flavored with a bunch of funny stuff and colored with a bunch of funny stuff, okay So if you do Greek, if you do yogurt, please do Greek yogurt. You’re going to get more bang for your buck as far as protein. All right. So scrambled eggs we know, no sugaradded applesauces. Now we’re going to start adding vegetables back into.

Our life. All right Now, I never thought in a million years that I would ever, ever to tell people to cook the heck out of their veggies. What nutritionist tells people to do that right But I’ve noticed that in bariatrics, this phase, weeks three and four, people do better with vegetables when they are well cooked. You know, steam the heck out of them, grill the heck out of them, stir fry the heck out of them, okay Make them soft. Break down that cellulose and that hemicellulose, and it’s going to be easier to break down and.

Digest in your stomach. Clear broth, soups and pureed soups. Yah, you can start adding some beef vegetable soup and some chicken vegetable soup back in to your life, if you want that, okay Chicken, or yah, chicken noodle, no not chicken noodle, but chicken vegetable, split pea, if you like that. Those are the things we are looking for. All right. So beware of some of the following. We haven’t really talked about fruit have we Okay. Let’s talk a little bit about fruit. I’m going to make it fast. Fruit is sugar. It’s candy.

So be very careful about fruit, okay Now a true serving size of fruit, before surgery is the size of a tennis ball. So you know everybody in America over eats fruit, when they have your apple a day or their orange, or whatever, because the fruit we have nowadays is huge. They’re the size of softballs in the store, okay If you can keep your fruit size to, after surgery, okay, to 14 cup, which is the serving size approved for bariatric patients, that would be fine. Another thing to keep in mind, peel your apple. If you’re.

Craving a few slices of apple, peel it first. Again, we are only on weeks 3 and 4 and never eat fruit by itself. Always have it with a protein or a fat. Have that apple with a little bit of natural peanut butter, or throw it in your protein drink and blend it up, okay, or with some cheese even, okay Always have your fruit with a protein or a fat. Yes Hi. I have a question. Sure. What about canned fruits Yah, same thing, and almost a little worse,.

Because a lot of the fibers are denatured and broken down, so if you want to eat a few bites of canned fruit, are we talking like canned peaches Yah. Yah, please have that with a protein or a fat or put that in your protein drink and blend it up, okay Make a smoothie with it. Alright, very cool. The key, yes, the key is to keep that serving size to be around 14 of a cup. It’s just the sugar. Okay It’s just sugar, it’s fructose. All right. So,.

Corn is not a vegetable. It’s a grain, okay Corn, corn is my nemesis. I think corn makes everything bad it touches. Corn is horrible for people. So it’s a grain, a starch. Try to stay away from it if at all possible. It’s in a lot of food so it’s almost impossible. Watch out for celery, all right Cook it very, very well, or celery in soups are okay, or cooked in a slow cooker is okay. And again asparagus stems and asparagus stalks are very, very fibrous, so you might want to watch out for those as well, okay You can have the.

Tips. You can also have broccoli and cauliflower, but I would chop off the floret and just have the floret right now. Eventually I promise, you’ll have raw veggies, but right now on weeks three and four, let’s just eat the florets. Let’s just eat the tips of the asparagus, okay There we go. Alright, let’s talk about fats because fat is a macronutrient, just like carbohydrate and just like protein. You need to eat it every day to survive, okay Now fat has gotten a bum rap. So dietary fat, healthy fats, like fats found in olive oil,.

Which is a monounsaturated fat is very nourishing for your body and it’s easy to digest in your stomach. Coconut oil, another power house. That’s a very healing and nourishing fat as well. If you like dressings or mayonnaise, pick the olive oilbased ones, okay Very nourishing for your body and easy to digest and break down, okay Avocados, for those of you who like avocados, again, very rich in monounsaturated fats, very nourishing and easy to digest and break down and we’re going to talk about fish oil and or flaxseed oil.

In the supplement segment. These are a great source of omega three fatty acids, which are great for antiinflammatories properties and other things. All right. Any questions about weeks three and four Awesome, you guys are good. Okay. Okay, so let’s talk quickly about supplements. Supplements are required every day for the rest of your life and I’m going to make it as brief as possible. I get a little long winded on this because there’s so much information. So basically folks, supplements are insurance for complete nutrient intake for the rest of your life. Food is where we ideally get our nutrients, but if we eat less.

Food, which is the beauty and the magic of our surgery, right If we eat less food, we’re getting less nutrients, okay It goes hand in hand. Food is where we’re supposed to get our nutrients, but we’re not eating a lot of food, so we’re not going to get a lot of nutrients. This is where, folks, we see hair loss, okay, for those of you concerned about hair loss, weak nails, osteoporosis. So we want to make sure that our body is getting the building blocks and the nutrients it needs to maintain those functions. Hair loss and.

Those kinds of things can be a source of malnutrition. That’s all it is. See if you have, of course, a thyroid condition, definitely work with your primary care doctor about that. That can also cause some hair loss, and maybe some anemia, but again, that’s something you’d be working with your primary care practitioner with. All right, very good. So you have to take your vitamins every day, you just do. You’re never going to be able to eat enough food to get those vitamins. All right. Whoops. Okay, so, you’re going to start your supplement.

Regimen about weeks one or two after surgery. Many folks find that if it takes you on to week two after surgery, that’s completely fine. There’s a lot of stuff to remember for the first week or two after surgery. We want to make sure that you’re getting your water. We want to make sure that you’re protein. We want to make sure that you’re healing well. It’s a lot to take in and worry about. Most folks find that they definitely start their supplement regimen about week and a half to two weeks after surgery and you’re going to.

Start with a gummy or chewable, all right Now many folks find that after a couple of months, maybe six months down the road, they’re more comfortable taking capsules, but right now, or small gel caps, but right now, right after surgery, folks, for the next couple of months, I want you to stick with the gummies or chewables, alright This starts the digestion in your mouth and it’s easier to swallow, so you don’t have to slug a bunch of water down, okay All right, so there’s three levels in the vitamin world, I’m going to make this.

Clear. There’s practitioner grade, which is what I would ideally like everybody to aim for. These are therapeutically dosed to meet the needs for bariatric patients. So any formula that’s made for bariatric patients is ideally what you should be looking for. They’re therapeutically dosed to meet any deficiencies that you may find in a bariatric patient post surgery, okay They have also been tested for cleanliness, for potency, for purity, and for absorption in a simulation, very, very important folks because there’s a lot of dirty out there on the shelves. There are no regulations for supplements out there, except for some very.

Self regulated groups out there. So, be very careful. The brands that I recommend, you should be able to get anywhere, okay I’ve done my shopping for you guys, so I’m very brand specific with our program. You can pretty much get them anywhere regardless of what your monthly budget is, because I know most folks have different monthly budgets and trying to fit it all in can be a challenge for many folks. So here we go. The practitioner brands that are recommended are the Celebrate brand, the Bariatric brand, the Journey Bariatric.

Brand. There’s also a brand out there called Bariatric Fusion. Again folks, these are tested to make sure that you’re going to absorb them, regardless of what procedure you had, okay You’re also knowing that they’re clean. The products are clean. They didn’t get them from some country from far away that didn’t test for cleanliness. Many of the stuff that comes over from Asia and China has impurities in them, fungus, cadmium, and lead. So you want to make sure that these companies have done their homework for you. So you’re guaranteed.

A good product when it’s a practitioner grade. Another level to think about for wherever you shop, of course, would be stuff in a health food store, and I’m talking GNC, not so much GNC, vitamin shops, Browns Whole foods, Vitamin Cottage, whatever your local health food store is, if you like to hang out at the crunchy granola local health food store, the coop, go for it. You’re always going to find a good clean product in those stores because they have high standards. They’re not going to let any old thing come in and be on their.

Shelves, okay They have high standards for cleanliness, and for sourcing etcetera. The third, I guess, level of vitamins out there or supplements would be OTC or drug mass. This is where the dirty lives. A lot of dirty lives on these shelves. These are the stores I’m going to name, Walmart, Target, Walgreens, Costco, Sam’s Club. Everybody shops there right We all find stuff we need at Walmart. So I’ve done my shopping for you. There’s a couple of clean brands that are on the shelves at Walmart and Costco and things like that.

So, these are the brands that typically work very, very well for everybody, Celebrate, Bariatric Advantage, Journey Bariatric. Now the Alive, by Natures Way you can find that at health food stores, online, and at Target, and Walmart and Walgreens. I’ve seen them in all three. All right, they are a very, very good clean company and I recommend them, okay Smiths too Smiths Perfect, you bet. Yah, many grocery stores now have like a little health section, you bet, absolutely. The VitaFusion Gummies, come on, you know you’ve seen those everywhere,.

Right Costco, Walgreens, Walmart, yah, Sam’s Club, they’re everywhere and you can definitely find these as well. They’re all good clean companies. I actually have been through the manufacturer plants at both those companies. They do have high standards and do pass all the regulations that they place upon themselves. What I’m going to show you in your binders folks is on pages sixty, ah, let’s see, sixtysix, yes, pages 66, 65, 67, right here. You’ll notice that everything I’m talking about is right here in bright colors. So you’ll know.

When you go to whatever retailer, you’ve got it right here. Because you know when you go there there’s shelves and shelves and sets of vitamins everywhere. It’s a little bit overwhelming, isn’t it You never know what to get. So this is why I have done this. So you’re guaranteed to get some good clean product if you stick with these brands. Okay. Good. So you’re going to start with a multivitamin okay That’s the first one. The second one you’re going to take is a calcium citrate or a bone health blend, okay Now the calcium.

Citrate is best absorbed by all bariatric patients. It’s cobonded with a citrate cofactor basically, and we really encourage folks to get a bariatric formula, really encourage it. Many folks have a hard time absorbing calcium anyway. You do not want to take a poorly formulated calcium, okay You do not. It won’t go into your bones, it will bounce around off your bones and end up being in your blood system causing kidney stones, uric acid crystals and calcification of the arteries. A poorly formulated calcium will cause you more grief than a fairly good formulated calcium, like this. So the Bariatric Advantage, Celebrate,.

The Celebrate one is my favorite. You can get that on their website, on our website. We do have an estore and, or on our shelves here. That’s a really good one. If you notice, if you go out into the waiting room there, you’ll notice that it has a bunch of other things in there. It’s going to have boron, magnesium, D3, phosphorous, all of these things work together to get that big calcium molecule into your bones, where it should go. You don’t want it floating around in your blood. We want it to go right into your bones. That’s where it’s supposed to.

Go. So a good bone health formula will have other things in it besides just calcium citrate. So if you like the chewy caramelly things, Bariatric Advantage has a good one that’s well tolerated by most bariatric patients as well, okay So you are going to look for a chewable or a gummy, for sure, for sure. Alright, we are going to talk about B vitamins. This is the third one you’ve got to take every day and is very, very important folks. Yes your multivitamin will have a nice even amount of your B vitamins, but because you are a.

Bariatric patient you will be at risk for having less B vitamins, alright You’re going to burn through them pretty quickly. Anybody on Metformin or any other, yep, any other diabetic medication, yes, anybody who is on pain medications, birth control, hormone replacement therapy, these medications burn through your B vitamins, particularly B12. You burn through B12 anyway, all day. I take extra B12 because I burn through B vitamins. I burn through my B vitamins just living. If you’re a little keyed up. If you’re a little stressed out, you’re burning more B12. You’re burning more magnesium too. So keep in mind as a post surgery.

Bariatric patient its always good to take extra B vitamins, even though you’ve got it in your good multivitamin formula, because those are the first vitamins that your body will utilize for so many functions in your bodies, especially if you’re stressed out or busy or not eating what you should be eating and things like that, taking some medications, things like that. So I am going to be a little picky though. Your B12, all right, your B complex has eight B vitamins in there. There’s eight of these guys in the B family. B12 is.

One of them, okay B12 is one of them. Look for the methylcobalamin version, especially for my patients who are having gastric bypass, okay It’s very important that you make sure that your B12, if you take it separately or if it’s in the B complex is indeed methylcobalamin with an M, not a C, not cyanocobalamin, M as in methylcobalamin. This is the active version of B12 and you will absorb it, okay The other forms are cheaper. They’re not as well formulated and you’re at risk of becoming short in B12, or deficient in B12, okay So.

Look for methylcobalamin, this is the active version. So Bariatric Advantage has a pretty good one. Celebrate has a good one. Celebrate B50 in your binder, that’s a really good formula and it’s a wonderful price point you guys. I think we retail it at 11 bucks, so it’s a really good one. It’s a tiny, tiny, little capsule. You could swallow that down with a little sip of water. And folks anything, any vitamin or supplement that you get in capsule form, feel free to break them open and sprinkle them into your protein drink.

Okay, so VitaFusion makes a gummy. It doesn’t have the B12, methylcobalamin B12 in it, but you know, you may consider taking one of the other, just B12, yes, B12 sublingual, sprays, drops, and injectables work really well, okay For those of you that get your B12 shots ask your pharmacist or ask your doctor if it is indeed methylcobalamin, okay Alright, let’s talk about probiotics. This is where I geek out on nutrition. Here we go. Probiotics are so important for your immune system and for your overall health that both the doctor and.

I want you to start your probiotics right when you get to your hotel room or right when you get home after surgery, all right It is just that important. It is just that important. All right. So, probiotics, 80 percent of your immune system happens in your gut, in your intestines, 80 percent of your immune system. 70 percent of your serotonin production, that feel good neurotransmitter is produced right in your intestines. These guys are so important they actually help you absorb and assimilate the food, or the supplements that you’re taking.

They do a lot for us. Anybody that has been on antibiotics, which is all of us, anybody that has been on pain medications, pharmaceutical meds, anybody that has been stressed out, eaten incorrectly, I mean come on, we’ve all done that right These guys will help realign the mucosal barrier in your intestinal walls and help repair anything that’s going on, because we’ve all heard of E.coli right We’ve all heard of Salmonella. We’ve all heard of H.Pylori, although he likes to hang out in our stomach. He causes a lot of grief in your.

Stomach, but most of these guys like to hang out in your large intestine. Many guys like to hang out in your colon. They’re very spot specific, all right They have jobs to do and some of them hang out in your small intestine, a lot of them hang out in your large intestine and a few hang out in your colon, okay But we have all taken antibiotics and we’ve all been stressed out and we’ve all eaten incorrectly throughout life, because life happens right Right So this wipes out the good guys, just kind of wipes them out, all right So we need.

To replace the good ones. Now because 80 percent of your immune system happens right here, from the beneficial bacteria, this is the main reason why we encourage patients to take the probiotics right after your surgery. You don’t have to wait the two weeks, okay All right. For those who struggle with constipation, there’s a couple of key strains that like to hang out in your colon and they do help with bowel movements, okay. So you’re going to look for a formula that has oh, at least 812 highly researched bacterial strains,.

Alright A lot of the ones I recommend are indeed those wellresearched strains you’re going to get about 1215 of the ones I recommend. Where am I at, right here. Oh no, there we go. All right, so we’ve got orthobiotics, which you’ve noticed in the waiting room. That’s that little jar, that little plastic jar out there that’s orthobiotics. This is a powder form and there’s a little scoop in there. You can take one little scoop a day, throw that in your protein drink. You’re not going to know their there and that’s the best.

Way to take it. However, if you have a favorite probiotic, let me know, you know. Shoot me an email or dig around in your cabinets at home and see if you have one that you’ve taken that has worked before and let me know and I’ll see if it’s going to work for you after surgery. Renew life is another very, very, good one. I’ve seen it at Walmart. I’ve seen it at Walgreens and enzymatic therapy pearls. That’s a really good one as well and that’s a tiny, tiny little pearlshaped pill. It’s a slippery little guy and that goes down with.

Just a sip of water. Those are very good ones and I have seen those at Walmart and Walgreens as well. But you’re always going to find these at health food stores too, except for the orthobiotics. You’re going to have to go directly to their website or to amazon. That’s a practitioner grade. It’s one of those practitioner grade ones I mentioned earlier, okay All right, so any questions about probiotics All right, so last one, number five, every day, your omega 3 fatty acids. These are found primarily in fish oils. If anybody is vegan or vegetarian,.

Or allergic to fish, then there’s also flaxseeds or chia seed oil that works very well, that still gives you your omega 3 fatty acids. Omega 3 fatty acids are antiinflammatory, that’s the main reason why folks take them. Many cardiologists recommend omega 3 fish oils nowadays. It helps keep the arteries pliable. It helps the cell membranes to be receptive to the knock of insulin. It helps build hormones. It helps protect and maintain your neurotransmitters. It also helps with osteoarthritis, this antiinflammatory. Yes, Hi. So you can take the chia seeds.

Yes, absolutely. Do you have to crunch them up Well, not on, after week two you should be able to take them or eat them any way that you like to, you bet, yah, you’ll be all healed by then, yah, perfect. Okay, so, yes, and many times they also help with bowel movements. They help repair diabetic neuropathy or just nerve damage. Their good stuff. We need them every day. I know you guys don’t want to eat sardines and coughing every day. Who wants to do that every day right Right So it’s.

Always good to take a supplement. All right, so VitaFusion has a really good gummy and you know you’ve seen it at Walmart and Target. You know you’ve seen that at Costco. That’s a really good gummy. I’ve had great response from that from our patients. The Schiff Krill Oil is another really good one, again, very easy to find at any major retailer. And again that’s a really good one. It’s a small, small, small, little slippery gel cap. You can sip that down with a sip of water. Now for those of you who say, oh I hate taking them, I burp.

Up fish all day, I smell fish. They give me heartburn. More than likely you grabbed a cheap product, one that has been maybe left in the sun too long on a pallet in some random warehouse, okay You wanted to save a couple of bucks you got a really cheap product they didn’t test for impurities, right So those are factors to think about. And most of us have impaired digestion, so those are tough to break down too if you have impaired digestion. So they kind of bounce around laughter. All right you guys. We all know about vitamin.

D3. Many of you are on it already from your doctor. The thing about iron, I always encourage folks to get tested for it. If you’re fatigued it’s usually from another reason, please make sure that your doctor did diagnose you as anemic or low in iron before you take iron willy nilly, okay Calm Magnesium powder, I mentioned magnesium earlier. We burn through magnesium really quickly, okay Magnesium is the first one that gets burned through it. It’s a very popular mineral in your body. It’s used in over 500 functions in your body.

Every day and every night. So we need a lot of it. The Calm Magnesium powder, you’ll notice it next door, if you just want to take a look at it, that is the best way to get your magnesium, because it’s easy to digest and you can add that to your water, just like Crystal Light and use the stevia for the sweetener, or you can just add it to your protein drink. It’s a great way. Yes. I didn’t see the potassium. Potassium Yah, I didn’t see that. So magnesium actually helps more quickly than potassium for leg cramps, calf cramps, even.

Eye twitches, migrane headaches, constipation, yes, a whole host of things, muscle and joint pain, you know stiff tight muscles, fibromyalgia, things like that. Magnesium really, really does help with more things and it helps facilitate any minerals like potassium it helps facilitate those guys into your cells more quickly. Magnesium is the, he’s the mother mineral, yah, yah. Good question though, thank you. All right, so these are some really quick tips you guys, you can definitely add Crystal Light Pure to your whey protein, to, you know, alter the flavor if you like. Coconut oil, we mentioned coconut oil earlier. It works on your skin.

It helps prevent shrinkles, all right When you lose your body fat, I had a patient actually call it that’s why I use it. I’m kind of using her word. When you lose your body fat your skin may not catch up fast enough and so those result in what we call shrinkles. So coconut oil again is a really inexpensive way to give your body essential fatty acids and the oil to help keep your skin supple, okay All right, okay. Let’s talk about whey protein powders. Now ultimately the cleanest way to get your whey is the whey protein powder, the jugs.

Of protein powder. That is the best way to get your whey. I love saying that. If anybody has a dairy allergy, a dairy intolerance, or your just vegan for ethical or religious reasons, come find me later or shoot me an email and I can recommend some plantbased protein powders, okay But, primarily most bariatric patients do very well with whey protein powder, preferably whey protein isolate, because it does go into your cells very quickly with minimal digestion, okay So a lot of the brands that I put in the binder for you guys, you.

Can find it everywhere. They are really in a lot of retailers, or online, or next door in the waiting room. So I know everybody, we have a lot of folks from out of town too, so I want to make sure that folks do have the ability to get your vitamins and your supplements wherever you live. All right Perfect. So these are all some very popular brands, very tasty brands. Now lets talk about those ready to drinks, alright, those ones that are already pre made, like Premier Protein, Pure protein and Isopure. Those are the top.

Ones. Now those are the ones that I would recommend. They’re the least dirty out of all of them, because there’s some dirty ones out there. Ensure, Boost, Glucerna, oh whatever, any equate brand from Walmart. I see some Special K protein stuff, just run screaming from those you guys. Have you seen the ingredients in those Have you seen what’s in them It’s nothing more than Coffeemate Creamer. It’s really bad. It’s poorly digestible protein. It’s very cheap protein. It’s milk protein concentrate, it’s soy protein isolate, these are very irritating and you’re body’s not going to absorb it. All right, so the ones.

I recommended are Pure Protein, Premier Protein, or IsoPure, which you can get it at almost any retailer and we have some. We have some Premier protein in our clinic too. Most patients like that. But also folks, keep in mind that these are handy. These should be used if you’re at your kids soccer practice, you’re at work and you need something in the fridge. If you are running errands, if you’re Christmas shopping in the mall, this is where these are going to come in handy. They do have a lot of preservatives and emulsifiers in them because they have.

To stay fresh a year after they are made. You know these things were made months and months ago and then they get shipped in some hot truck across the country and then get put on a pallet then get forklifted into the warehouse and then they get pulled out again by the forklift and then get shipped to the retailer, and then sit in the retailers distribution center and they get pulled and they get on the retail shelf and they sit there for a couple of months until you pick it up. So they have to put a lot of these things in.

There to keep it delicious and creamy when you open it, okay All right. Now you’re not going to get protein bars until about a month after surgery. The reason why is that there dense and they’re sticky and they’re pretty heavy, but the protein bars that work best are the Qwest bars, which you’ll see next door. You can also get those at GNC or online. Another great brand is the brand called Simply Whey, alright You can see what they are next door as well. All right, you may want to pick up a few just to have. You can order them.

Online as well. So those are some good bars. They’re clean alright The other ones out there do have a lot of junk in them. I’m sorry, they just do. All righty, so, some really great websites. Now if you want to make note of this one right here, the bariatricfoodie.blogspot. This is a website that I put on the presentation really quickly, it’s not in your binder. I have a patient, who is a professional chef and she turned me on about this, so I checked it out. It’s the bariatricfoodie.blogspot. It’s not in there, so write that down really.

Quickly. That has amazing recipes in it and I took her work for it because she is a chef, okay So yah, it’s a really good place to get recipes, the same with bariatriceating. That’s another great place to get recipes. And eventually on our website, we’re going to have really great recipes, submitted by our patients. So we’re working on that, definitely. And, of course, like us on Facebook folks. We have a lot of great patients on there that like to encourage everybody else and it’s one thing to join a blog, or forum and talk.

With other folks, all over the world, or all over the country and get ideas, or encouragement that way, but it’s another thing to talk amongst other patients of Dr. Umbach’s and us. You know, it’s really fun that way for sure. So, like us on Facebook and oh, I think that was it. Oh my goodness. That was it, okay. Laughter There’s usually one more on there, but I think we took it off. So anyway, does anybody have any very quick questions No Yes, hi. What about like medications and stuff like that, can you still take those.

Yes, work very closely with your primary care doc, or the, you know, the physician that prescribed the medication for you. Work very closely with them and, you know, and just be in tight communication with them to see if, you know, if you can down or what you’re going to need as you lose your weight, okay Absolutely, sure. Now, folks, if you are on medication and you’re worried about, and you’re worried about, I don’t know how to make that go away, I don’t know why that’s there, and you’re worried about taking or swallowing your pills, or.

Your capsules, go ahead and if you feel like they are too big and you don’t want to gulp a big bunch of water to get your medication down after surgery, work very closely with your pharmacist or your primary care doctor to see if he can, you know, give you a different delivery system, you know, maybe separate into two small capsules, instead of one big one, okay So there’s some ideas there for sure. Okay, any other questions No Folks, make sure never to break open your medication, your pharmaceutical medication and sprinkle.

Leave a Reply