When you start the puree diet keep in mind the following guidelines:

1. All foods should be a baby food consistency. You should be able to eat anything you puree with a spoon.

2. Use lowfat and/or fat free products. For example if you puree chicken or tuna fish you can add lowfat mayonnaise. You can also add reduced fat salad dressings, mustard or low sodium chicken broth to moisten the proteins.

3. Try to eat 3 meals per day. If you get full it is normal but the idea is to give structure to your meal plan and do not skip meals. The portions should be between 2 and 4 ounces.

4. Drink the protein supplements between meals. Take the protein powder and add 4 ounces of skim plus milk. Try adding ice in the blender and cinnamon, equal or an artificial sweetener if you need flavor.

5. It may help to make a schedule and keep a food diary so that you avoid drinking to close to your meals. Remember liquids can be consumed 30 minutes before the meal and an hour and a half after the meal.

6. It may be challenging to get your liquids in since you are now eating meals and using the supplement. The goal is to drink at least 48-64 ounces of water or crystal light or any non caloric beverage per day.

Coffee is one of the most widely consumed beverages worldwide. Population studies suggest that coffee consumption protects against the progression of chronic liver disease and development of certain cancers and diabetes, but the mechanisms are not clear. Despite the ubiquity of coffee, the question as to whether coffee can cause ulcers or if it is safe after bariatric surgery is still ambiguous.

Coffee is a very popular beverage and consumed on a regular basis by millions. Most people who drink coffee daily will not deny that if they drink too much they will develop an upset stomach and indigestion. The question as to whether low doses or 'coffee in moderation' is healthy or unhealthy remains unanswered. The lack of scientific evidence in one direction or the other is actually surprising.

Coffee can induce dyspepsia and indigestion. Coffee directly and indirectly activates the cells of the stomach to secrete their hormones including signals to increase acid levels. Coffee stimulates gastrin release and gastric acid secretion. Therefore on one level, coffee should be avoided on the basis of its strong stimulatory effect on acid secretion. Decaffeinated coffee has an acid stimulating effect as well. Whether non-coffee caffeine-containing beverages induce ulcers is unknown, but they are still acid secretion stimulators.

The most conservative recommendation is to have any patient after bariatric surgery avoid coffee, decaffeinated coffee and all caffeine-containing beverages. However, the association between peptic disease, gastric irritation and symptoms remains unclear.

It has been suggested that drinking coffee on a regular basis can increase your chances of H pylori infection. H pylori is a bacteria that is known to be associated with ulcers and its eradication with triple therapy is typically enforced prior to gastric bypass.

Coffee has also been suggested to cause gastroesophageal reflux disease or GERD. Studies are not clear in this issue as well. Some experiments suggest that the ingredients in coffee may cause the muscular opening at the esophagus to open, thus increasing reflux, while other studies suggest no correlation.

The idea that coffee speeds digestion and increases the emptying of the stomach has also been examined. Compounds that were impregnated with radioactivity were used to assess the emptying times of the stomach. Different results have been reported by multiple labs. The consensus is that although coffee may change the contractility of various portions of the stomach and in some cases promotes gastric motility, it has an opposite effect on the small intestine and the net result is one that is not significant. Coffee increases the motor activity of the large intestine, or colon, within a few minutes after ingestion in some people. In affected subjects, its effects on the colon are found to be comparable to those of a very large meal. Coffee induces cholecystokinin release and gallbladder contraction, which may explain why patients with symptomatic gallstones often avoid drinking coffee.

Even though coffee is not considered to be responsible for development of peptic ulcer, it may, however, prolong its healing by increasing acidity of gastric content. A study has suggested that the detrimental effects of coffee on the irritation of the cells of the stomach reverse after 48 hours of abstinence from coffee.

Potential detrimental effects of caffeine consumption on exercise performance include gastric upset, withdrawal, sleep disturbance, and interactions with other dietary supplements. Caffeinated coffee should be assumed to share these same detriments.

Coffee does seem to have some beneficial aspects. Coffee drinking has been suggested to decrease the rates of stomach, liver, colon and some gynecological cancers.

Some people attribute indigestion to drinking coffee, suggesting that coffee affects one or more functions of the proximal gastrointestinal tract. Researchers have demonstrated that coffee, in comparison with water, enhances the relaxation of the top part of the stomach, but has no effect on its wall compliance, wall tension, or sensory function.

In conclusion, coffee has both benefit and detriment. The first few months after your operation represent a sensitive time both psychologically and physiologically. Depending on your operation, it is very important to allow any connections between the stomach and the intestine to heal. The first few months post-op are also complicated by problems with judging adequate hydration. Caffeine is a diuretic which means that it increases the amount that you urinate. If you are having trouble judging how much liquid to drink each hour means that coffee and caffeine will just complicate the situation.

Decaffeinated coffee can still cause some problems during the first few months after your operation as it also increases acid activity and may complicate the healing of any connections. If you are more than a few months after your operation then you most likely can resume moderate consumption of coffee. You must remember however to listen to your intestines and pay attention to any new pains or discomfort that may develop. If you start having diarrhea, epigastric pain or feelings of fullness and discomfort after drinking coffee then you either need to stop or decrease the amount that you are drinking considerably. If you develop an ulcer or a marginal ulcer than you definitely need to stop.

While spicy food tastes good and may have many positive health attributes, the fact that it is an irritant is undeniable. Think of any time that you have accidentally rubbed your eye after handling anything spicy and you won’t forget. Just as spicy food irritates mucous membranes, spicy food also irritates your stomach and intestines. Spices may produce feelings of dyspepsia or indigestion. In particular black pepper, red pepper, and chili powder, may produce indigestion.

Although some studies suggest that red chili powder has no detrimental effect on ulcer healing and that daily pepper ingestion may have a beneficial adaptive response for your immune system, both red pepper and black pepper cause significant increases in secretions in the stomach that typically increase acidity- specifically parietal secretion and pepsin secretion. The spices tested increased acid secretion in the following declining order: red pepper, fennel, omum, cardamom, black pepper, cumin, coriander. This suggests that red pepper is much worse than black pepper or coriander for your stomach.

Direct administration of red and black pepper on the cells in the stomach has also been observed to cause them to shed their out layers. Bleeding from the stomach lining has also been directly visualized after both red and black pepper administration. One study suggests that red and black pepper might be just as bad for your stomach as aspirin and therefore should be avoided. Other studies have also reported epigastric pain and dyspepsia. The mechanism of epigastric pain and dyspepsia induced by red and black pepper is not well understood.

During the first few months after a gastric bypass or a sleeve, the stomach and in the former, the intestines are healing and anything that irritates the stomach should be avoided. If you are years after your operation, your connections have stabilized and it is important that you pay attention to any feelings of intestinal discomfort. If you develop abdominal pain or indigestion after spicy food, that is a sign that you should avoid spices. If you have ever developed an ulcer or a marginal ulcer, then spicy food should also be avoided.

While still controversial and under evaluation, bariatric patients should avoid any spice that causes discomfort, especially during the first few months after their surgery.

As a general rule the foods during phase II require less chewing that those at a later stage of the diet. If you are feeling comfortable after a few days on the puree diet you can try a small piece of a baked white fish and the fish does not have to be pureed.

Sardines are very high in sodium and also remember that you are unable to drink with or immediately following a meal. The sardines in tomato sauce contain approximately 550mg of sodium per serving. As you are reading food labels, please try to avoid foods that have more than 300mg of sodium per serving. This is a basic guideline used to help people limit sodium intake as part of a heart healthy regimen.

Juices have calories and sugar which is why we suggest dilution. When possible you should consume juices more sparingly. Crystal Light and Wyler’s are no calorie beverages made with artificial sweeteners so they are actually preferred for long term use. Crystal Light and Wyler’s are beverages that are not actually juices and therefore do not have to be diluted from a calorie perspective or as a strategy to avoid dumping syndrome. Crystal Light and Wyler’s can be diluted or made with less water if you prefer since many people find artificial sweeteners to be sweeter than actual sugar. A successful diet requires reduced calories and limited sugar.

Keep in mind that typical ‘diet’ natural juices are really just juices that have been diluted at the factory prior to packaging. The calories are typically reduced just because there is less juice and more water. There is no difference between diluting the normal juice yourself and buying one that is already diluted.

You should continue to drink water between your meals to remain hydrated. It is suggested that you continue to drink 4 to a maximum of 8 ounces every hour so that you consume a minimum of 64 ounces per day. At least half of the daily fluid intake should be water. Do not rely on your thirst to guide your fluid intake.

You can expect to feel hungry at times. Hunger is a natural feeling and should not be consider abnormal. Since you are not drinking protein supplements continuously, it may be a good idea to use the protein shakes as a snack between your meals as you did during phase 2 of the post bariatric meal plan. Also choose nutrient dense foods that will provide a feeling of fullness without too many calories or fat grams. An example would be a single serving of hummus and carrots, 4oz. of a low fat or fat free yogurt or cottage cheese with ½ cup berries. The latter will add flavor, fiber and vitamins and minerals to your snack.

Biotin is commonly sold as doses approximating 1, 3 or 5mg capsules and there are no reported cases of adverse effects from taking high doses of the vitamin. Keep in mind that 5000 mcg is the same as 5mg and correspondingly 1 and 3 mg is the same as 1000 mcg and 3000 mcg respectively. Although Biotin is often recommended for strengthening hair and nails, the exact dose is not known. Taking extra doses of water soluble vitamins such as Biotin is not dangerous however your body will not be able to use the additional vitamin. You are very unlikely to get any benefit from taking a higher dose and the higher dose costs more without any additional benefit.

There is no magic formula to weight loss other than burning more calories than you consume. One strategy to minimize calories is by trying to add 4 ounces of Skim Plus milk and some ice in a blender with the protein powder. You can add an artificial sweetener like splenda for flavor and this will limit the calories to a total of 155 calories per serving. It is acceptable to add fresh fruit and make it more of a smoothie. In order to limit calories use 1/2 cup fresh berries. Make sure the berries if frozen have no added sugar. One cup of fresh strawberries sliced is only 50-60 calories. This will keep the shake at around 200 calories.

It is important to vary your diet. You may get bored by eating the same foods daily. Think about the long term results you desire and why other programs did not succeed in the past. It is possible that limited selections did not allow you to stay on a particular meal plan. Now start experimenting with new foods but remember to introduce them one at a time. This will allow you to see how new foods are tolerated. Try egg whites scrambled, oatmeal or cottage cheese as an alternative to yogurt and rotate your selections daily.

The recommended portion size is 2-4 ounces during the puree phase of the diet. Each person’s intake will vary and may change daily or from one meal to the next. When ready, you will not stretch the pouch by eating approximately 4 ounces at a time. If you are feeling hungry and limiting liquids; increase your fluid intake between meals. This will give you a feeling of satiety. It can be dangerous to advance your diet too quickly.

We suggest that you start by making a schedule for the liquids. Try increasing your fluid intake from 4-6 ounces every hour to 8 ounces every hour. The absolute maximum that you can consume is approximately 8 ounces at each meal. Now that you are consuming puree foods and protein supplements between meals it may be helpful to track your intake daily. This will help you to maintain adequate hydration while separating liquids from solids. Also, create a meal plan that includes precise hours of the day and use this to guide your daily intake.

Ideally the foods you choose should have less than or equal to 8 grams of sugar per serving. Foods like dried fruits and juices may have high natural sugar content and should be avoided. Natural sugars from fruits or fruit juices do not have any fewer calories than table sugar and should not be considered low calorie substitutes. If the sugar content is high in proportion to the other carbohydrate content then it may not be a good choice.

Sugar is a carbohydrate. On food labels total carbohydrates include both complex carbohydrates such as starch and simple sugars such as table sugar and fruit sugar. For example; if a food label indicates 20 grams of carbohydrate and 15 grams of sugar then you know that the carbohydrates are the unhealthy kind and made mostly of sugar. Yogurt is a dairy product and sugar grams come from lactose which is milk sugar. Choose low sugar yogurts and avoid the fruit on the bottom and full fat products. It is important to ask questions and review your food diary with your dietitian.

If you are unable to attend a group meeting you can call the office or email questions at any time. You can schedule a phone consult with the dietitian during office hours. You will not have the same experience as meeting with other patients in person. You may benefit from listening to their ideas and questions as well. There is no sense of urgency for the group meetings and you can come when it is convenient for you to attend.

Patients who undergo weight loss surgery sometimes complain of problems with their hair and fingernails during the first year or so after the operation. They are a few possible explanations related to the stress state after the operation as well as possible nutritional deficiencies.

Immediately after a gastric bypass, you may lose as much as a pound or two of weight each day. When the body is losing weight this quickly, it sometimes goes into a stress state in order to conserve resources. The result of this is that hair and fingernail growth might not be the same as it was before the operation. Typically this is stress-state after the operation is temporary and once your weight once again stabilizes then your hair and nail growth will return to its pre-surgery level.

One nutritional deficiency that can cause problems with fingernails is iron deficiency. Signs of iron deficiency include brittle nails, constipation, depression, headaches, fatigue and mouth lesions. Some patients can develop severe anemia, even with supplements and can be treated with parenteral iron therapy. This may occur more often in menstruating women. It is very important that you take your vitamins after you have your operation and continue to drink protein supplements between meals.

Another possibility to explain problems with fingernails and hair growth is Biotin deficiency. Biotin deficiency may cause problems with hair and nails and therefore cause them to become brittle and weak. There are no known common side effects for biotin supplementation. An adequate amount should be somewhere between 30 and 100 micrograms. To improve hair and nails, an effective dosage would be 1000 to 3000 micrograms per day. Any concerns should be discussed with both your doctor and dietitian so that you receive appropriate recommendations.

The group meetings that you attended prior to surgery are available to all patients post surgery. We encourage you to remain part of the bariatric patient community. It is a good idea to come and ask questions and network with other patients. As you lose weight and gain confidence and enthusiasm it is important to remember that the surgery is not a cure for obesity. Attending group meeting will remind you that weight gain is a possibility and weight maintenance is hard work. If you have specific food related questions and already a patient of Dr. Belsley that please feel free to reach out to our team.

Post surgery you may find foods that are easy to prepare and easily digested. Many patients stick with the foods that personally work. If you feel that you are in a rut and bored by the same foods consumed daily it would be a good idea to explore new foods. Remember to introduce new foods one at a time to see how they are tolerated.

You are allowed and encouraged to experiment but please follow the guidelines, read the food labels and act with information. Your stage 3 diet is in actuality how you will be eating for the rest of your life to maintain your weight. It will be up to you to experiment with recipes and spices to make the food more interesting. There are unlimited free resources online where you can find heart healthy, low fat, low sugar recipes and ideas. Remember to pay attention to the serving sizes and consume only one portion. During stage 3 Post gastric bypass surgery you may only be able to eat ¼-1/2 of a serving.