Always bear in mind that your own resolution to succeed is more important than any one thing.
-Abraham Lincoln
Once you have a band you need to learn how to make it work for you in your effort to develop your new lifestyle. Adjustments to the band (known as fills) will help, but they must be combined with a learning process to change the way you eat. This process is critical to your successful weight loss and is the focus of this chapter.
The First Few Weeks Post-op
The first few weeks following placement of the band are unique because you're not likely to repeat them, and they are usually fairly structured. Our patients are provided a postoperative diet to follow. While the diet may seem stringent, most people are unaware that their stomach moves continuously as they digest food. So we encourage patients to carefully follow the reintroduction of foods listed in Chapter 9 so as to create as little stress as possible on the sutures during the healing process. We've found that at least for the first few weeks, almost everyone is all smiles because they are not hungry and continue to lose weight.
There are a few patients who after surgery do not experience restriction in their ability to eat, or those who experience total restriction for a few days postop. Frankly, while it may be uncomfortable or frustrating to be in one of the extremes, it doesn't matter long term. The course of action is the same. You and your body must grow accustomed to the band, and the band eventually has to be adjusted to suit your unique requirements. In addition, you face the task of learning a new lifestyle and new strategies for eating.
As I have mentioned, the norm is that post-op patients don't experience hunger at all, and are usually very restricted in their ability to eat. Most have to stay on liquids in the beginning and gradually graduate to solid foods. While it may be hard to believe when you first get the band, after a few weeks the tightness of the band decreases significantly. The functional opening typically enlarges enough that in six weeks or so patients are able to eat nearly the same as they did before surgery. That is because the wall of the stomach remodels itself by stretching and thinning out under the band. Eventually the size of the banded opening becomes about the same size as the esophagus, and virtually anything that can be swallowed will pass through the band.
There is usually fat between the stomach and the band. The removal of this fat during surgery is not attempted, because it's dangerous and lengthens the surgery. And the body will naturally metabolize the fat as it uses up these extra energy stores over time. However, the fat does affect the shape of the opening, and that can become significant in the fill process, as you'll see later in the chapter.
As the stomach opening returns to normal, patients also notice a gradual return of hunger between meals. It's at this point that many will come into the office complaining, "This thing isn't working. Are you sure you put a band in there?" We expect patients to experience hunger the way they did preoperatively. While this can be cause for alarm to someone who may be, for the first time, experiencing some control over hunger, we see it as a sign the healing process is progressing normally.
Most surgeons wait until about six weeks after the surgery to perform the first adjustment to the band. If an adjustment is done earlier, there is risk of actually creating an obstruction. Six weeks seems to be a reasonable time to wait, but I have to admit that I have adjusted a few patients in the four- to five-week period. I've had others that seemed to be doing very well losing weight with no adjustment, so I've waited several months before tightening their bands.
Up to this point, the process is more or less the same for each band patient. But when it comes to adjusting the band, every patient is different. In part this is due to variations in anatomy. As I have already mentioned, some people have a large amount of fat around the stomach, which causes the band to be more restrictive.
But even more important is the fact that each patient tends to change their behavior at a different rate. The same size opening in the band may feel very tight for someone who is still eating too fast, taking large bites, and not chewing adequately. In comparison, someone who has begun to make more progress to change their eating behaviors will find the same opening less restrictive. So the process of tightening the band must be individualized to meet the needs of each patient.
Ten Rules for Eating with the Adjustable Gastric Band*
1. Eat slowly and chew thoroughly (approximately 15 to 20 times a bite).
2. Eat only three small meals a day.
3. Stop eating as soon as you feel full.
4. Do not drink while you are eating.
5. Do not eat between meals.
6. Eat only fresh food.
7. Avoid fibrous food.
8. Drink enough fluids during the day.
9. Drink only low-calorie liquids.
10. Exercise at least 30 minutes a day.
How Adjustments (or Fills) Are Accomplished
It is clear that simply placing a band around the stomach has limited effectiveness, because the stomach wall adapts to a static restriction. The beauty of the AGB is its flexibility. The tightness can be modified for a custom fit to suit each individual's needs. This process is called getting an "adjustment" or a "fill," meaning that saline is added to the band to contract the size of the opening.
The adjustment procedure is actually very simple. A special needle is used to inject a solution of sterile saline into the port, which was placed under the skin as part of the surgery. At that time, the port and the band tubing were filled with saline before they were implanted, so that when the patient has their first fill, and the fluid is injected into the port, it causes the balloon inside the band to inflate. The enlarging balloon acts like a tourniquet around the stomach, narrowing the opening between the small upper stomach pouch and the rest of the stomach.
As part of the adjustment process, the skin over the port is cleaned with an antiseptic solution, and then a small amount of local anesthetic is injected into the skin to numb the area. A larger, specialized needle is then inserted through the skin and through the silicone portion of the port. Saline solution is then injected into the system.
The needle used to adjust the band is designed specifically to pass through the silicone part of the port without damaging it. If someone were to use a typical hypodermic needle, like the ones used to give you an antibiotic shot into muscle, that needle would actually remove a small core of silicone, which would leave a hole where the saline would eventually leak out. If the saline leaks out, the band becomes loose and ineffective. That is the single most important reason you should never have the band adjusted by anyone who is not thoroughly familiar with the process and has the appropriate equipment.
The Band Is Not a Magic Bullet
Jessica Walker, Dietitian, M. S., R.D., L.D.
I've been working with band patients for several years now in the role of helping them with nutritional counseling. What I've learned is that the band is not a magic bullet. I didn't think it would be, but the more experience I get the more I see that the band as a tool works very well for weight loss.
Most people are pretty enthused in the beginning, because they lose with almost anything they do simply because they're taking in fewer calories no matter what they're eating. But as time goes on, the weight loss slows or stalls when people fall back into old habits, such as poor food choices, drinking with meals, and the like. Most people don't continue to lose because they're taking in too many calories, which may indicate that they need a fill. But I do see people on occasion who are not losing because they take in too few calories. One woman was eating only vegetables and dried cereal, which amounted to between 500 and 600 calories a day. She wasn't losing. Her body was hanging on to the fat. I tried to figure out a way she could add protein through beans or some meat, so she could up her calorie count and get her body back to using up those fat stores.
There are plenty of ways around the band, and people find them. From my experience, if patients cannot figure out the main issue or issues they have that caused food problems to begin with, the band won't help them. Usually I'm the last resort for those people. Out of the hundreds of successful patients in our band program, I often see the small percentage who haven't lost much after two years or who are back up to where they started; they are in my office desperate to figure out why.
In a nutshell, my experience is that people have problems when they move away from the band eating guidelines. The most successful patients are the ones who avail themselves of the monthly support group. Those folks are often self-correcting by taking a look at what they're doing and not doing as they listen to other band patients share their experiences. And in almost every case in which band patients are stalled with their weight loss, they identify a band guideline or two they've either not followed or gotten away from.
We see people needing fills periodically during their band journey. I've seen the surgery, and it's amazing how much fat is packed between the organs and around the stomach that the surgical team has to work around to place the band. So while people talk about how their band has loosened up, it's not actually the band that has changed, it's everything around it. One of the clues there's been a change and a fill is needed is that patients notice they can eat more. So we encourage them at that point to come in for a fill.
We don't encourage calorie counting. But what I've seen is when people get frustrated about their weight loss they go back to a lot of old diet practices such as calorie counting. Band patients are better off eating solid foods, but they often go to oatmeal or yogurt, both of which are good, nutritious foods, but not foods that will stick with you from one meal to the next. Sometimes you have to shift your mindset. We encourage people to stop worrying about calories, have something you want since you'll have only a couple of bites, but make sure that overall you're making good, solid food choices, such as getting the necessary protein.
We have speakers come to the support group and talk about topics of interest to patients, such as plastic surgery or new information on exercise. Daily exercise is important. People often get to where they don't want to be without it.
Sleep is also an important issue, since obesity and lack of sleep are linked. We are having someone come from the sleep disorders center to talk to our latest support group meeting. We often see that people who work third shifts or who have trouble sleeping also have trouble with their weight. One reason is that the body doesn't work correctly without enough sleep. But the other, more probable reason for weight gain in sleepdeprived people is that they're often looking for a pick-me-up. No one reaches for a vegetable or a piece of fruit when they're tired-they reach for high-calorie foods and usually foods that are sweet.
Another thing I see a lot is that people have a list of 30 foods they can't eat. I encourage people to make note of a food they don't tolerate, eliminate the food for now, but try a small amount again in a week or two. Sometimes people find out that they can tolerate a food but they took too big a bite the first time or they didn't chew it enough. In other words, they find out the problem wasn't the food at all. There might, however, be just a couple of foods that always give you trouble.
Finally, I've seen hundreds and hundreds of people get the band, but I've not once seen anyone say, "I wish I'd never gotten this band." That is true even with people who didn't lose as much as they thought, or with people who gained a little back. And while I've seen published statistics that say people stop losing after two years, I'm seeing people continue to lose past two years out. And I think that's great.
How Much Fill Do You Need?
The key to making the band a useful weight-loss tool is to create restriction without obstruction. If the band is too tight the patient may have trouble even swallowing liquids. If it is too loose, the patient will be able to eat too much. So, what is the right amount? Frankly, each patient is different. Should you have one major adjustment or multiple small adjustments? These are matters of considerable debate, even among surgeons who do this every day. Compelling arguments can be made to support a variety of adjustment styles.
Some surgeons suggest that the best way to adjust the band is to tighten it to a specific, predetermined size. To do so requires the use of fluoroscopy to watch the adjustment process while the patient swallows X-ray contrast material. The contrast material can actually be seen passing through the banded opening. The amount of fluid in the band is then precisely adjusted to create the desired size opening. This type of adjustment is considerably more expensive to perform because of the use of fluoroscopy; sometimes it is spoken of in shorthand as an "adjustment under fluoro." Also, since the procedure involves X-ray imaging, many surgeons have the adjustment performed by a radiologist rather than doing it themselves.
The drawback to using fluoroscopy, in which the band is tightened all at once, is that most patients experience considerable trouble eating. In other words, they are forced to make major changes in their eating habits without any preparation. When you've been eating a particular way for many years, it isn't easy just to suddenly slow down, take small bites, and stop when you are full. Old habits, and in particular the automatic process of eating, die very hard. Even the most highly motivated patients often find it difficult to cope with a sudden and major change in how they feel every time they try to eat.
One method that some patients employ to deal with this sudden problem is to resort back to a liquid diet. Obviously, though, that defeats the whole purpose of the band. But when patients feel as though they are starving, and everything they eat comes back up, they will eat whatever they can keep down. This includes high-calorie creamed soups, ice cream, chocolate, and other liquids. Not surprisingly this can lead to failure to lose weigh, protein deficiency, and even depression.
Certainly not everyone struggles to the point of having to resort to a liquid diet, but some do. An alternative style for adjusting the band involves multiple smaller saline injections over a period of time. These adjustments are typically performed in the surgeon's office and do not require fluoroscopy. By adding fluid to the band gradually over several weeks or even months, the patient is able to change their eating habits in smaller steps. It usually takes several adjustments of this type to reach the same level of tightness that is achieved with one fluoroscopic adjustment. However, patients spend less time spitting up and are somewhat less likely to resort to high-calorie liquid foods. But the down side is that early on, patients are still able to eat relatively normally, so their weight loss is often somewhat slower than anticipated.
Either approach to adjusting the band can be used effectively, provided that patients are instructed as to what they should expect. Personally, I prefer the gradual method, with adjustments being made no more often than every two or three weeks. I typically start out with an initial adjustment of 1.5 milliliters for patients with a standard 4 ml band, or 5 milliliters if they have one of the larger bands. After each adjustment the patient comes back into the office in two weeks to be weighed. At that time they meet with the dietitian to discuss their changing eating behaviors. If their weight begins to plateau, or if they are not feeling much restriction, I'll add 0.2 to 0.3 milliliters if it is a standard band, or 0.5 to 1.0 milliliters if it is a larger band.
It is surprising how sensitive some patients are to even minor adjustments to their band. It is possible to go from feeling only minimal restriction to being unable to keep anything down with only a small change in the volume of fluid in the band. Immediately following each adjustment I have each patient swallow 1 or 2 ounces of liquid, just to make sure they are still able to swallow. Despite passing this ritual, every once in a while I'll have a patient return within 24 to 48 hours complaining that they just can't keep anything down, and I'll have to take some of the fluid out.
The band, the tubing, and the port compose a closed system, so once fluid is injected into this system it remains there until it is removed. However, sometimes a small amount of air can become trapped in the port or in the tubing, taking up a small amount of space. During the initial adjustment, as fluid is added to the system, this air is flushed out into the balloon portion of the band. Here the Silastic membrane allows the air to leak slowly out of the system. The result is a gradual loss of restriction, and patients come in a few weeks later with the story that they felt much tighter right after the adjustment, but then it seemed to get loose again. When another adjustment is performed the amount of fluid in the band is less than expected. When that happens, it was not the saline that leaked out, only the air.
Joyce's Story
I've been overweight ever since I was a five-year-old kid. At age 16 I went to a diet doctor, did the pills and the shots, and got down to a size 9. I remember eating everything and still lost weight. Back then it took me a year to take off the weight, but I couldn't stay on the pills forever. Once I went off, it took only six months to put the weight back on.
When I had gallbladder surgery two years ago, at 4 feet, 11 inches and 250 pounds, I was too big for the surgeon to do it laparoscopically. Afterward, my doctor told my brother and my family I'd never see 80, even though my mom had just turned 80. I'm 56.
I had a lot of problems, such as blood pressure issues, cholesterol, and diabetes. Diabetes runs in my family, so it was a foregone conclusion I'd have it.
I'd read about the band, saw Dr. Sewell, and decided to have the surgery in April of 2005. I started at 241 pounds, with a BMI of 48. Back before the surgery, I went to the store and couldn't get halfway through, I was so tired. I'd waddle instead of walk.
Now at about a year and a half out, I'm down 61 pounds to 180 and my BMI is 36.4.
My biggest challenge is bread. I can eat it, but it's rough, so I stay away from it, even though I miss it a lot. I also stay away from sodas, when before I'd have six to eight of them a day. Pasta works for me, but I sometimes have a hard time with eggs.
I have not been as strict on myself as I probably should be. I figure it took me all this time to get this weight on, so if it takes me some time to get it off, then that's okay. As a consequence, I haven't watched everything I eat.
In addition, I've increased my exercise. I go to a fitness center where I walk on the treadmill and do water aerobics. Exercise makes me feel better. And I notice a big change in my energy level. I've been doing ballroom dancing for about 30 years, and I can do a lot more now and enjoy it more. Before I'd do two or three dances and I'd be pooped. Now I can dance the whole evening. I will have to start looking for some new gowns, though, because my old ones are getting too big.
I'm still taking medication for Type 2 diabetes, but my blood pressure has gone down quite a bit and I think I'll be off that medication soon.
I will be paying on the surgery for 10 years, but I have no regrets about doing this. I have to consider myself lucky, as a lot of people who get the band have to do it completely on their own. My insurance at least paid part of it. I do notice significant savings on what I used to spend on food and clothing, especially since I've gone from a size 22 to a size 16.
There have been a few issues. At one point I thought my port might have a leak, because I was restricted after my last fill then suddenly I didn't feel any restriction. When he checked the fill, I was supposed to have 3.3ccs and I had only 3.0. He filled it again, then asked me to come back and be checked in a couple of weeks. When I went back, I still had restriction and the fill was at 3.3ccs, so there was no leak. If there had been a leak, it would require day-surgery in which Dr. Sewell would take out the old port and put in a new one.
My port has moved since I lost weight. It's at my waistband now. Since I have a sitting job, the placement of the port is sometimes an issue, and I've talked to Dr. Sewell about moving it.
If I had any advice to someone considering a band, it would be to go for it. Personally, I wouldn't have considered the gastric bypass because I think it's too dangerous. There's danger in anything you do, but the risk was too high for me. With the band, I was comfortable with the risk. And I've heard too many stories about gastric bypass patients gaining their weight back, and some bypass patients are even going for the band on top of their bypass.
I would also recommend a support group of some kind. I signed up for the two-year support plan with the psychologist in Dr. Sewell's program. I am part of an online group, and I also go to Dr. Sewell's band support group meetings. I find the live support group very helpful, and I really enjoy it a lot.
Can You Lose Your "Sweet Spot"?
Once the proper amount of restriction is obtained, the so-called sweet spot, most patients lose between 1 and 2 pounds each week and everything is as it should be-right? Well, not exactly. Things inside the body have a habit of changing. It is quite common for patients to go along very well for several months after getting just the right amount of fluid in their band, but then gradually the band seems to be less restrictive. This may be in part caused by a gradual thinning of the stomach wall. However, the most logical explanation is that the fatty tissue that occurs naturally around the upper part of the stomach and is actually inside the band is decreasing as the patient loses weight. As this fat disappears it allows the stomach channel to enlarge, even though the amount of fluid in the band has remained unchanged. This explains why additional minor adjustments to the band may be needed every now and then until the patient's weight stabilizes.
It has been interesting for me to observe how many patients tend to become obsessed with the exact amount of fluid in their band. This may be a product of the nearly continuous discussions that go on between band patients, each one comparing every aspect of their situation with the experience of other patients. There are numerous Internet chat sites where band patients describe in detail the exact volume that they have in their band, as well as how much they think they should have, how much their friend has, and so on. But, as I stated earlier, every patient is different. An amount that seems to be just right for one patient may not provide anything close to the proper restriction for another.
After several years of doing adjustments I have discovered an unanticipated problem with the multiple adjustment approach. I refer to it as "adjustment addiction," and it is somewhat difficult to describe. Obviously, some patients who suffer from morbid obesity also have truly addictive personalities. Virtually anything and everything they get involved with has the potential to become an addiction. This can even include band adjustments. Despite doing quite well, losing a pound or two a week, these patients believe that continually adjusting the band helps to ensure their continued success. I believe that these patients are not so much craving another "needle stick," but instead are simply insecure in their own success. Generally these patients have not yet accepted the fact that it is their behavior, not the band, that is causing them to lose weight.
In many instances, individuals with addictive personalities don't recognize their own behaviors as addictions and invariably deny it when confronted. That is the source of potential conflict between the patient and the team of professionals attempting to deal with this situation. The easiest thing for the surgeon to do is provide another fill. Put a little in-take a little out-the process can become an endless quest, searching repeatedly for just the right amount of fluid in the band. In this situation the surgeon actually becomes the "adjustment addiction" enabler.
Reversing the patient's fixation on the band and their "need" for an adjustment requires recognizing the problem, and then approaching the patient honestly with positive reinforcement. Everyone within the comprehensive program the surgeon, the dietitian, the exercise physiologist, the psychologist, and the supporting staff members-must recognize the situation and provide the patient with a consistent, positive message, emphasizing the patient's role in their own success.
Another problem I see is other patients who come in for regular adjustments but never seem to achieve the weight-loss success they expected. Typically these are individuals who expected the band to do all the work for them. By getting another adjustment they hope to lose weight and avoid the need to change their lifestyle. These patients have not yet accepted the fact that they will never be successful until they change their behavior. And the biggest behavior change is in eating. I'll talk about that next.
Eating Strategies
All human beings are sensory driven. We have five senses-taste, touch, smell, sight, and hearing and to some extent we enjoy having each of them stimulated, sometimes all at the same time. When we go to the movies the experi ence includes not only the visual effects and the surround sound with volume up so that it literally moves us in our seats, but also the smell and taste of the popcorn. That's what I mean by stimulating all our senses at once.
Eating is one of the most enjoyable sensory-based activities in our lives. This is in no small part because it involves at least three of our five senses. Taste and smell are obvious, but don't discount the importance of the tactile sense, such as the smoothness of cream cheese, the crunch of a fresh taco, or the combination of textures in your favorite pizza. What's more, eating is something we can enjoy several times each day, and when we don't experience it we miss it. Is it any surprise that we have a tendency to overindulge, if for no other reason than to enjoy the experience?
Our enthusiasm for getting maximum sensory input is frequently manifested by eating as fast as possible. We take big bites of food, chew it a couple of times, and swallow. This is not because we are necessarily through with it as much as it is that we want the experience of the next bite. Each big bite is promptly followed by a similar big bite, often without a pause. We become automated eating machines, and what fuels the machine is the desire for sensory input.
Well, once the band is in place you will need to modify your love affair with the sensations of eating. This is not to say that you can't enjoy food, but the way you eat simply must change. What is interesting is that many patients say they actually enjoy food more when they slow down. While that may be true, I suspect for some the enjoyment comes from avoiding the discomfort that accompanies eating too fast.
The fact is that you, along with everyone else, enjoy putting food in your mouth. If you didn't, you wouldn't have a weight problem. This presents a major psychological problem once the band is in control of your portion size. Suddenly, instead of putting fork to mouth 30 or 40 times during a meal, and garnering all that sensory input, you are now down to what looks like no more than four or five bites. Even if your stomach is saying "I'm full," your sensory satisfaction center is crying out for more. The trick is to provide more sensory input without actually eating more. That is where smaller bites come in.
The tactic to keep yourself satisfied is to eat your small portion of food using the same number of bites you would normally have used to eat a large plate of food. Also, take at least the same amount of time to eat this small amount as you used to take to eat a large meal. Each time you put even a small amount of food in your mouth and chew it, be sure to experience the taste, the smell, and the texture.
Small bites also make it easier to chew the food into particles that are less likely to get stuck on the way down. Our dietitian tells patients to chew each bite until it is the consistency of apple sauce. Well, if you start out with a huge bite, by the time you chew it enough (if you can chew it enough) you are totally bored with it and it has lost all of its taste. Starting with small bites avoids this problem.
What Is a Small Bite?
If you're having trouble adjusting your bite size, get a baby spoon and put enough food on it to cover only the front half. Then chew this bite 15 to 20 times until it's the consistency of apple sauce before swallowing. Put your spoon or utensil down between bites. This is a great exercise to do every so often, especially if you find yourself having trouble with food coming back up.
What do we mean by small bites? Start with a baby spoon, and put enough food on it to cover only the front half. That sounds ridiculous I know, but it works. Remember, you are in training to develop new eating habits, so consider this a training exercise. Eventually, as you develop your new style of eating, you won't need the baby spoon. But I've had patients who occasionally need an eating refresher course with their trusty baby spoon.
Dr. Sewell's Golden Rules forAGB Patients*
• Eat until you are comfortable, NOT FULL!
• Choose protein first you need 50 to 70 grams of protein per day.
• Eat slowly and chew your food well.
• Don't drink 15 minutes before or during meals, and avoid drinking for two hours after eating.
• Liquids will not satisfy your hunger, so you need to eat something.
• Exercise daily.
All this sounds easy enough, right? Well, most of the time it is. But just like before surgery, there will be stress in your life and you'll feel the need for a release. There will be times when you feel depressed and you'll naturally seek comfort. Or when you achieve a goal, you'll still feel that you deserve a reward. In each of these situations, without even thinking, you will resort to what has always helped relieve your stress, raise your mood, or provide immediate gratification-food. But, with a band, if you resort to your usual eating habits, the results will be quite different than what you are used to. The band is going to let you know immediately if you eat too fast, eat too much, or don't chew your food adequately. It is your "drill sergeant" and is with you constantly.
When the small upper stomach pouch is full, you will sense you'd better not eat any more. The band is telling you that any additional food you swallow has no place to go. If you keep eating, the food will remain in the lower end of the esophagus. The muscles of the esophagus will continue to contract aggressively in an attempt to push everything through into the stomach. Since the band will not allow the food to pass through, this muscular effort creates tremendous pressure inside the esophagus. This leads first to a sense of fullness in your chest and throat and eventually causes chest pain. While that is going on, the lining of the esophagus is producing more mucus and the output of saliva is increased, both in an attempt to provide further lubrication to help the food pass.
There are only two ways to relieve the pressure from having food stuck in the lower esophagus: either wait until the food passes or bring it back up. When it comes up it isn't really like the kind of vomiting that you do with an upset stomach. It is less violent and generally more of a voluntary act. Patients describe it in a variety of terms, including spitting up, a productive burp, regurgitation, and others I've heard that I won't repeat. When the food comes up it is usually accompanied by considerable foaming mucus. Often the amount of food is relatively small, but the amount of mucus can be considerable. The message is clear stop eating when you first get a sense of fullness.
While much of the time the problem of spitting up after eating is related to simply overeating, that is not always the case. I've had many patients tell me that they take only one or two bites before they experience the sensation of esophageal spasm and have to spit up what they just ate. Frequently that is followed by an ability to eat much better. This sounds strange, but it is such a common complaint that there must be a reason for it. While I have no proof, I suspect that what is happening is that the patient starts out with a couple of generous size bites, which quickly become stuck above the band. After they go through the uncomfortable process of spitting up these first couple of bites, they take much smaller bites, and thus avoid the previous result. Another possibility could be that their esophagus is initially highly sensitized to any food and spasms quickly with any resistance. The sensitivity may be diminished after the first material has been evacuated. Either way, this is a very common complaint among new band patients. It seems to improve over time, likely as a result of improved eating habits.
Many patients report a somewhat similar situation, stating that they are unable to tolerate anything to eat first thing in the morning. As a result they don't even attempt to eat until midmorning and sometimes not until early afternoon. The strange thing is that these same patients go on to relate that they can eat almost without restriction by their evening meal. Such a contrast must somehow be related to the effects of lying down through the night. Perhaps the esophagus fills up with mucus overnight and is incapable of fully emptying until the patient has been upright for several hours. The effects of gravity would aid in the passage of residual food and mucus out of the esophagus and into the stomach. This is purely speculation on my part, since I don't know the precise reason why so many patients report this phenomenon.
You Can Cheat the Band
G. Dick Miller, Psychologist
Patients are usually shocked when I tell them, "You can cheat the band." But you can, and people do it all the time. What I mean by cheating the band is that you can uncover ways to eat where there's little or no restriction. In other words, you can still find a way to abuse yourself with food and gain weight.
Why am I telling you this? Because you'll find out anyway. And because I want to acknowledge your right to choose. What the band gives you is the ability to make a decision about how you want your life to be. If you're looking for someone or something to "make" you behave the way you "should," with no regard for your choice in the matter, then you're setting yourself up for failure.
If this is scary for you, then you're still operating in your thinking under the old punishment paradigm-"threaten me, control me, tell me what I have to do." Under that paradigm we learn to dislike the task and the person who is requiring us to do the task. After we get done disliking all the people involved, we turn on ourselves, because that's the only person left. We rebel, and because we're in such a bad mood we're still hanging on the image of an adult that "should be able to do whatever they want to do." We haven't taken on the lifestyle change in a good spirit. We've been dragging ourselves, and that creates so much friction.
It doesn't have to be that way. But I see it all the time. People abuse themselves for failing, they go back and eat what they want to eat, they curse themselves, they abuse the diet, then they say it didn't work for them. In reality, they didn't have the kind of thinking that would work going in. They looked from the beginning for something outside themselves to "fix" them. Because, if you think about it, if you cheat the band, who are you really cheating?
What works is deciding to move from "have to" into "want to." From there it's only a short distance to the optimum thinking, which is "it's in my best interest to" or "it would be smart for me to."
What Best Describes Your Thinking?
• Do I have to?
• Do I want to?
• Is it in my best interest (or smart) to?
The truth is that you have options. Ask yourself, Am I willing to tell myself things that are not true, not consistent with my physical health and not consistent with my goals? Or am I willing to acknowledge that I have choices, take a look at them, and make a decision that's in my best interests? If you acknowledge your ability to opt for what you want, you don't have to feel resistance, resentment, or anger toward something or someone else. And then you're setting yourself up for success.
Choosing Foods for Success
To be successful with the AGB, patients need to train themselves to eat differently. The problem is that you have been used to eating way more than what is necessary. The total calorie intake of a morbidly obese person is almost always more than 3,000 calories per day. For some it may be as high as 5,000 calories per day or more. Because of their slow metabolic rate, most obese people don't even begin losing weight until their daily calorie intake falls below 2,000 calories per day, and for some that number is closer to 1,000 calories per day.
It isn't just a matter of calories. Your body needs certain nutrients every day, or nearly every day, in order to function properly. Starvation is not a good option. The dietitian can help you by providing a guide for what to eat and encourage new and better eating techniques, but the bottom line is that you still need to eat. The best approach is to have three small meals each day. It takes only a couple of ounces of food to fill the stomach pouch above the band. Any more and the problem of esophageal spasm and spitting up will occur. Since the volume is necessarily small, it is imperative to choose wisely what you eat to avoid malnutrition.
The most common form of malnutrition following any bariatric surgical procedure is protein deficiency. Your body needs protein, and if it doesn't get it from your diet it will take it from wherever it can get it, including your own muscles. We've all seen pictures of prisoners of war whose muscles have almost completely wasted away. If you look carefully at those pictures, you'll also notice that those emaciated prisoners have little or no hair. Protein is required to grow hair, and so one of the first signs of protein deficiency is hair loss, along with a thin and dull appearance to the remaining hair. That usually occurs long before significant muscle has been lost. Protein deficiency can be avoided by taking in 60 to 80 grams of protein each day. To help ensure adequate protein intake, we recommend that patients eat protein first at each meal.
Normal sources of protein include meat, eggs, fish, poultry, milk, cheese, beans, and nuts. For most Americans, red meat has been a primary source of protein all their lives. Certainly steaks and chops are great sources of protein, but they are also among the most difficult foods to chew into pieces small enough to pass through the band. So, instead of struggling with red meat, we encourage patients to eat protein-rich foods that are easier to chew, such as fish, chicken, and turkey. If their protein intake is still marginal, a protein bar is an excellent supplement. Some patients prefer protein shakes, but it is hard to get the same amount of protein from a shake as you get from a bar. An added benefit of the protein bar is that the solid material helps satisfy the need to chew something.
Recipes for Protein Shakes
(These recipes assume you have protein powder that provides 24 grams of protein per 1-ounce scoop.)
Note: Some people believe that adding a package of Splenda®, Sweet'n Low®, or other artificial sweetener to each recipe improves the flavor. Others find that to be too much sweetness. Much of this is personal preference, so try different amounts or other flavors of fat-free/sugar-free instant puddings.
Basic recipe:
In a blender:
Vanilla/Cinnamon Shake
Pistachio Shake
Banana Shake
Chocolate Shake
Protein Snack List
• One tablespoon peanut butter with two crackers.
• A quarter-cup 1 percent cottage cheese with a quarter-cup unsweetened fruit.
• One piece string cheese with a quarter-cup fresh fruit.
• One ounce reduced-fat cheese and two crackers.
• A half-cup sugar-free yogurt.
• One cup skim or 1 percent milk with one packet of Carnation instant breakfast (no sugar added).
• One hard boiled or scrambled egg with a few sprinkles of shredded cheese.
• One half of a small banana with one tablespoon of peanut butter.
• One tablespoon of peanut butter with one-half cup sugar-free instant pudding.
• A half-cup fat-free refried beans covered with a few sprinkles of reducedfat shredded cheese.
• One half of an AdvanEdge® bar.
• Four to five medium-size steamed or boiled chilled shrimp with two tablespoons cocktail sauce.
• Lettuce wrap with 1 ounce lean, broiled, baked, or grilled chicken breast, turkey, or fish.
• One to two slices lean luncheon meat (chicken, turkey, ham) rolled up with a thin sliced pickle.
• Grilled tomato slices with two tablespoons shredded mozzarella or grated parmesan cheese.
Vitamins
Some people are convinced that by taking a handful of vitamins every day they will remain healthier. While that argument has been made by vitamin manufacturers for decades, I strongly discourage my patients from taking large doses of vitamins. Large vitamin pills can easily become lodged in the narrowed area of the stomach created by the band, obstructing it the same way a large bite of inadequately chewed food would.
Vitamin deficiencies can occur following AGB surgery, but these are far less likely than they are with other bariatric operations, such as gastric bypass. If you are eating anything close to a normal diet, it is unlikely that you will become deficient in any of the common vitamins. Nevertheless, we always recommend to our patients that they take a multivitamin supplement everyday. These come in chewable form, which reduces the possibility of the vitamin pill getting stuck in the band.
Taking in Fluids
For some patients the most challenging change to their typical eating behavior revolves around the need to avoid drinking liquids with their meals. Everybody is used to the idea of having a glass of water, tea, coffee, milk, juice, wine, or something liquid with their meal. However, to achieve success with the AGB, you need to drink fluid before your meal, and wait two hours after eating before drinking anything else. If every time you take a bite of food you "wash it down" with something to drink, you will liquefy the food you just ate. This will tend to "wash it through" the band, and you'll be able to eat much more than the small pouch should allow.
This new way of eating is more typical of animal behavior. Animals don't stop eating to go get a drink and then come back to their food. They drink when they are thirsty and they eat when they are hungry. Isn't it funny how you don't see many obese animals unless, of course, they're under the direct care and feeding of a human being?
It is important to drink plenty of water; that means about 64 ounces a day. To accomplish this you'll need to drink a glass of water or tea before eating. If you wait until after you eat, the food in your pouch will not allow the liquids to pass through the area of the band. This is called the "cork effect." The result is similar to the productive burp, only it will be the water that comes up.
Kristen's Story
I discovered I had a thyroid problem as an adult. I was a normal size kid and teenager and never thought about having a weight problem. But I kept getting bigger and bigger, my bones were aching, and I was just busting at the seams. I got to 250 pounds, and I'm 5 feet, 3 inches with a BMI of 44.3.
I have a petite frame, and my knees, ankles, and feet were hurting so bad I could hardly walk. I kept justifying to myself that lots of people are bigger than me, but I couldn't ignore my huffing and puffing. So I started researching, found the band, and during the four years I tried to figure out how to get a band, I talked to everyone I could find about it.
Once I thought the band might work for me, at the beginning of my research, I talked to my dad about helping me pay for it. He said I must be crazy. I told him I was scared of diabetes or a stroke, and scared about the rest of my life being this way. His answer was for me to go on a diet and make it work. So I said okay. I tried diets and prescribed weight-loss drugs, but nothing worked.
Then I got married, and between the two of us, my husband and I, we found a way to pay for a band. So I went back to my dad and told him I was doing it no matter what. At that point, I found out that Dad was on the board of an insurance company and had heard a doctor talk about the band. So he said now he could talk to me about it. After we discussed it, he said he'd pay for part, so that's what we did.
I had my surgery on November 1 of 2005. That date is my wedding anniversary. I think it's great I got my band on such a very important date for me.
I did the pre-op diet. I called it the diet from hell. I did two weeks of no carbs, no vegetables that had sugar, and I was miserable. The day I went in to see the surgeon and start the pre-op diet, I told them I'd had a diet Dr. Pepper that morning, and they said that's the last one. So I got off carbonated drinks, too. I know people who have the band, and they told me carbonated drinks would stretch my new stomach. I wasn't willing to pay for the band and then sabotage myself. But that was one of the hardest things for me to give up.
There were no problems in the surgery. Afterward I did have the referred pain from the gas they used to inflate my abdomen, and the only way to get the gas out is walking. When I wasn't walking, I lay flat on my back and put a bunch of pillows under my legs. It was pretty painful for about two days. But even though I had the surgery on Thursday, I was back at work on Tuesday. Part of the reason I could do that is I have a sedentary job, and I don't have to do a lot of moving and lifting. The only thing I found myself doing was holding my port area at work before I even realized I was doing it, because I had some soreness there.
My first fill I was scared. I looked like a deer in the headlights. I told the nurse I was nervous and I don't like needles. I talked to other patients in the waiting room. I've decided it was the not knowing that terrified me. I waited five weeks before I had the first fill, even though my surgeon probably would have done it sooner because, from the beginning, I never felt like I had a band. Even after a couple of fills, I noticed I could still eat anything I wanted. It took several fills, every four weeks, over a few months' time, before I felt restriction. What I've found talking to people in my surgeon's waiting room while I'm sipping water after a fill is that fills are a very individual process. Everyone is different. I also found it's rare to find someone with no restriction post-op, like I had.
I have noticed that every time I get a fill, it's a learning process. I don't look at it as restriction because I don't like saying, "I can't eat this," and "I can't eat that." I prefer to concentrate on what works. I discovered that fresh ground turkey works well for me after this last fill. And I season it so it doesn't taste bland. Red meat doesn't work for me at all anymore. I enjoy looking for new menu items and recipes I can eat. I tell myself this is a learning process. If one thing doesn't work, I try something else. For example, if the chips and hot sauce don't work for me anymore at the Mexican place, I'll try chips and queso instead and stay focused on that. I want to move out of the place that got me here to begin with.
In the beginning, I did not exercise. I probably could have lost more by now, but I wasn't ready. I didn't want to exercise, but I took it on when I lost enough weight to start feeling better. I started walking and I joined the health club. My husband exercises with me. He's very supportive. We talk the whole time, and the exercise time passes quickly. I tell him, "You don't know what it's like to be fat and keep walking," and he encourages me. My endocrinologist likes it that I walk. He's watching my thyroid because of my weight loss, and he's adjusting my dosage levels downward.
I've always had lots and lots of friends, until I got so overweight, and then I went into hibernation. I was too embarrassed to see anyone. Now that my self-esteem is so much better, I promised my husband I'd get into my jeans and we'd start dancing. I think I'll come out as more of myself as I get more weight off. I've had issues with my mother, and my therapist told me as the weight comes off the issues will resurface.
I usually lose about 1 to 2 pounds a week. Sometimes I lose more. I just got under the 200 pound mark at my current weight of 198. I weigh only when I go to the surgeon's office, and that's on purpose. Weighing is a head game for me. When I dieted, I got to the point where I was obsessed with the scales, and I said to myself this is stupid. With the band, if I stay focused on doing what I'm supposed to do, I lose weight.
I love it that I got the band. It's given me a chance to bring myself back. I was hopeless at the time I had it done. Some people who've been overweight most of their life look at their weight differently than someone like me, who became overweight as an adult. I'd say to myself, Why can't I go to the beach and have fat on me and be perfectly happy like that lady over there who is having a great time? But I couldn't. So now I feel like I got myself back.
Conclusion
Learning to eat with an AGB and avoid the problems discussed here is not easy. Many patients struggle for months before they begin to understand that it isn't really about the band, it's about them. It's about changing behavior. Changing any habit, especially something as firmly ingrained as the way we eat, is a truly daunting challenge. The band is there to help guide you through this change, but it won't make the change for you. You must do the changing yourself. When you do, the rewards can be incredible. As we'll discuss in the next chapter, improved health, better mobility, and a richer, fuller, life unencumbered by obesity make all the hard work worthwhile. But, just as important, is the personal satisfaction of knowing you are the instrument of your own success.