Monday, June 27, 2011

Obey the Stop Signals!

Stop signals aren't there just to make you late for work. They're there for your protection. Some of the worst car accidents in my town happen at a major intersection on a busy road where some drivers seem to be ignoring the stop signals. As those drivers are sped away from the scene in the back of an ambulance, I wonder how badly they're hurt or whether they'll survive. I think it's good that our town has installed cameras at that intersection.

Stop signals are equally important to bandsters. How?

In addition to the 4 signs of restriction explained above, you will also get hints to stop eating that I call "stop signals". As newly-filled or newbie bandsters, we expect our bands to give us good, loud, clear stop signals with clanging bells and flashing lights, but eventually learn (if we work on it) to recognize the quiet stop signals such as mild queasiness, fullness or pressure in the back of the throat, difficulty swallowing, burping (or the urge to burp), sneezing, sighing, hiccups, watering eyes, runny nose, and so on. If we heed those signals, we stop eating before something more drastic and uncomfortable happens. You may not experience any soft stop signals, but don't stop looking for them just because you aren't noticing any; they could sneak past you at any time. And if you experience no hard stop signals (like stuck episodes, PB's, sliming), don't go looking for trouble! The absence of hard stops does not mean that your band isn't working or that you have no restriction. It just means you're doing a good job!

Restriction: the bandsters' Holy Grail

Restriction seems to be the Holy Grail of bandsters, a sacred thing that we hunt for with a level of passion and persistence that we may never have experienced before in our lives. In our minds, restriction is endowed with the magical power to make us lose weight. But exactly what is it?

We bariatric patients use the word "restriction" in every other sentence we speak, write, or think, but do we truly understand what it means?
In my 50+ pre-op years, the word restriction basically meant "no can do" or "you can do it, but within externally-imposed limits." To use extreme examples, that means "Thou shalt not kill" (no can do) or "Drive no faster than 55 mph on this stretch of road" (55 mph being the imposed limit).
Keeping those examples of restriction in mind, it's reasonable to say that a restrictive WLS procedure is one that allows you to eat, but in quantities no greater than ½ cup at a time (or whatever your surgeon's food amount limit is). That's clear enough, isn't it?
It's clear, but it's not specific enough to ensure safe and effective use of the "restrictive" WLS tool called the adjustable gastric band. For one thing, it implies that the band comes equipped with a monitoring feature, like the radar guns used by police to measure the speed of passing cars. It doesn't make it clear that the only monitoring feature that will work safely with the AGB is a conscientious, hard-working patient's conscious mind. Surgeons and patients who aren't aware of this aspect of the band are headed for accidents such as stuck episodes, PB's, sliming, esophageal or stomach dilation, band slips, or weight loss failure.

The adjustable gastric band was first approved for use in the USA in 2001. A decade later, we are just now beginning to understand the true function of the band. A decade of struggle and learning has gone by. Ten long years! How could that happen?
When the adjustable gastric band was first marketed in the USA, it was positioned as a restrictive WLS procedure. In the world of marketing, a product's "position" determines how its features and benefits are communicated to customers and how they compare to similar products in the market. When introducing a new automotive vehicle to the market, an automobile manufacturer must present it in a way consumers will understand: Is it a sedan or an SUV? Is it a sub-compact or a full-size vehicle? A car or a truck?
Manufacturers of medical devices like the adjustable gastric band must also educate their customers (surgeons) and end-users (patients) when they market a new product. They ask themselves: Is this a completely new concept? How can we make customers understand it and want to buy it? What other products on the market can we compare it to? In the case of the AGB, Allergan compared it to other bariatric surgical procedures: RNY (gastric bypass, which combines restriction and some malabsorption), DS and BPD (duodenal switch and bilio-pancreatic diversion, which combine restriction and a lot of malabsorption) and VSG (vertical sleeve gastrectomy, considered a restrictive procedure). The AGB doesn't cause nutrient malabsorption, therefore it fell into the restrictive category.
As a result of this perfectly ordinary business approach, thousands of surgeons and their patients were not fully informed about the mechanism through which AGB patients lose weight. It's quite possible that even Allergan didn't fully understand at the start just how the band works. If the makers of medical devices and pharmaceutical products waited until every last detail is known about a new device or a drug, some life-saving products might never reach the people who desperately need them.
So for the last decade, we all believed that the band is supposed to restrict the amount of food we can eat and cause weight loss through reduced caloric intake, but that's changing now. In the past year or so, Allergan has refined the band's market position and has been teaching surgeons that it should not be used as a restrictive device. Allergan, Endo Ethicon, and the bariatric medical community are realizing that a patient who eats until she or he "feels" restriction is far too likely to experience complications. They are coming to the understanding that the band's chief weight loss mechanism is reduced caloric intake through the reduction of hunger and appetite, with early and prolonged satiety after a small amount of food is eaten.

So if the AGB is not a restrictive WLS procedure, what the heck is it? How can we explain it without using the word restriction?
A better term for the true function of the AGB might be something like "optimization" - the process of modifying a system to make aspects of it work more efficiently, use fewer resources, and/or produce the most beneficial results. In a bandster, the system is made up of several important components: the band, the saline fill, the bandster's food choices and exercise level, with a few parts that are so top-secret, nobody knows what they are. Optimization is a clumsy-sounding word, though, and it makes the bandster sound like a machine instead of a human being. For the time being, we don't have a better term than restriction, so we'll go on using it until something better presents itself.

How will you recognize restriction? If you were hunting for the Holy Grail, you could equip yourself with a picture of a chalice to guide you, but there's no picture of restriction. Don't kid yourself into thinking that a fill under fluoroscopy (x-ray) is going to yield a picture of your very own restriction. That x-ray image is just a snapshot of part of a living, breathing, changing human body, and while it might illustrate a theoretically good fit on the band on the stomach, it cannot illustrate what's happening in your nervous system. It can't track the production of hormones that triggers hunger or satiety messages between your brain and your body.
To recognize, utilize, and safeguard your restriction, you're going to have to start paying attention to dozens of things that you took for granted or didn't even know existed before. I don't go on and on about eating slowly just because it helps prevent unpleasant side effects, but because it's mighty hard to pay attention to your body's signals when you're gobbling your meal.
I didn't realize this until perhaps 6 months post-op. Until then, I was eating carefully only to prevent stuck episodes, PB's, and sliming. Very gradually, over the next 6-12 months, I learned to listen to my body, not just when I was eating but between meals. It wasn't until after my 15th fill, at almost 3 years post-op, that I had mastered mindful eating enough to actually enjoy my experience of restriction. Three years is a long time, but don't let that scare you. I lost 100% of my excess weight with far less "restriction" than I have now. And when you remember that I spent over 50 years eating carelessly and excessively, changing my eating in only 3 years is pretty good!
So, what signs of restriction you should be looking for?
1. Early satiety after eating a small portion of food. You lose
interest in eating, feel that another bite would just be too
much, and/or feel a sudden distaste for the food.
2. Prolonged satiety after eating a small portion of food. You
are not physically hungry, and have no appetite (desire to
eat) for several hours after you eat. How many hours? It's
going to vary by person, and will be affected by many factors,
such as food choices (solid versus liquid, for example). For me,
3-4 hours is a very long time to experience satiety and I'm
delighted by that. Another person might not care to eat again for 5-6 hours after a meal.
3. Reduced appetite. You're just not as interested in food as you
used to be. You think about it less and you might even forget
to eat. The food may not even taste as wonderful as you
remember it.
4. Reduced physical hunger. You're just not as hungry, and not
hungry as often, as before.

All that sounds marvelous, doesn't it? A dream come true! It is indeed, but it's also very complicated because the human body and human behavior are very complicated. We're constantly changing, in changing circumstances. While our unconscious brain and body are trying to communicate hunger and satiety, our conscious brains and our lifetime habits are also at work. So even though you weren't especially hungry for that chicken dinner at 6 pm, it's quite possible that a phone call from a troublesome family member will trigger some comfort eating at 6:15 pm, or that boredom will send you looking for snacks at 8:00 pm, or that craving will send you looking for chocolate at 9:00 pm.

Sunday, June 26, 2011

NSV of the week

I realize it's a lousy photo, but take my word for it...these are size 9 shorts!

Monday, June 20, 2011

Seeing the world through fat-colored glasses

I'm sure you've heard the term, "seeing through rose-colored glasses." That would probably describe me, the eternal optimist. Many of us also see the world through fat-colored glasses, with lenses that look clear but drastically distort our perception of fat and thin. I've been going through a strange and frustrating period of seeing myself as fat every time I look in the mirror even though my weight has not changed. The other day I realized that my vision is also distorted when I look at other people, thanks to a lesson I learned from my friend Lisa B.
Lisa lost 114 pounds after having RNY (gastric bypass) in 2001. She was proud to be thin, and with obnoxiously big (her term) augmented breasts and movie-star smile, she was smokin' hot.
But eventually her stomach pouch stretched out, she ate more and more, and her weight shot back up, a 44 pound increase. In May 2009, Lisa had what's known as BOB surgery - band over bypass. Since then, she's lost 70 lbs. and is back to being that smokin' hot lady. Because I'm always recruiting before/during/after photos to help inspire other bandsters, Lisa kindly gave me permission to publish hers in the Bandwagon on the Road newsletter and in the 2nd edition of Bandwagon. When I first saw Lisa's after photos, I was disturbed and told her, "You look very scrawny. Have you seen your doc lately, and does he/she think your current weight is healthy?"
Lisa's reply was illuminating on several levels. She wrote (in part):
"I still see my surgeon every 3 months as well as my NUT and they both said that because I am small-framed, I am at a really healthy weight (I always thought I was big-boned, turns out I was just fat LMAO). All of my stats are where they should be...body fat percentage, waist-to-hip ratio, etc., and my labs are perfect each time too.
"This is the exact weight that my body stopped losing at 18 months ago and has remained at ever since...literally haven't fluctuated more than 2 lbs up. So my doctor said this is where my body is happy - this is my 'normal' now. He also said early on that if a "normal" (meaning never obese, I guess) person was my size their whole life, it would not be an issue...they would be considered a "naturally thin person," (you know, the ones we grew up hating lol) but since I have never been a normal size until now, I can expect people to comment that I'm too thin (rather than normal and/or healthy). Which did happen when I first reached this weight a long time ago...but now everyone around me is used to it - not to mention they see how much I eat (7-8 times per day) and what I eat (healthy food choices 95% of the time) and so they all know that clearly this must be my body's 'normal'."
Well, those 2 paragraphs gave me a brand new view of body image! And who am I to judge what's normal for another person? Lisa's words immediately reminded me of one of my coworkers at JCPenney, a “naturally thin” college girl named Hailey. Her mom is short and heavy while her dad is tall and thin, and Hailey looks nothing like her mom and quite a lot like her dad. She’s in good health, with beautiful skin, good muscle tone, thick shiny hair, clear eyes, lots of energy, and as far as I’ve been able to see, eats well (for a college kid, anyway). As much as I tend to focus on body size, I've never thought much about Hailey's body size or shape. Her prominent characteristics to me are her kindness, intelligence, sense of humor, and (in terms of appearance) her great sense of color in her clothing choices.
The other day a customer (an elderly man) said to Hailey, “Girl, you gotta put some weight on you,” and Hailey laughed and said, “I think this is the way my body is meant to be.” When I look at Hailey, I don’t think, “She’s too thin.” She looks normal to me. I've known her for 2 years, she's been thin the whole time, and thin is her "normal". So it’s really interesting that I looked at Lisa's “after” photos and thought, “She’s too thin”!
Why do I look at 2 thin, attractive, healthy women and think one looks normal and the other looks too thin? The only difference is that I know Lisa is a WLS patient, and with that ID tag on her, I assume a host of things about her, including a tendency of some WLS patients to develop anorexic behavior and become too thin. And we all know what happens when you assume, right? Assuming makes an ass out of you and and ass out of me. So shame on me! If Lisa walked into my JCPenney store tomorrow (which would make my day!), I'd just be blown away by her slim good looks and that movie star smile. "Too thin" wouldn't even be on the horizon!

Monday, June 13, 2011

The Clean Plate Club

Are you a member of the clean plate club? Perhaps even its president?

I belonged to the CPC (Clean Plate Club) for over 50 years, so I consider myself something of an expert on it (and I am, after all, The World’s Greatest Living Expert on Everything). I thought it was a lifetime membership, but my bariatric surgeon rescued me from the CPC Cult – oh, excuse me, Club - and deprogrammed me so that I’m able to function more or less like a normal person now. Here’s my story.

I was inducted to the CPC as a child, when I was too young to realize that the promise of going to heaven if I always cleaned my plate was a bit more complicated than it sounded at the time. All I wanted to do at the time was to please the cult leaders: my mother and my grandmother.

I have reason to believe that my grandmother, whom I called Dranny, was the original founder of the CPC. Orphaned as a small child, she was passed around the family like an unwanted piece of furniture, and she raised her own children during the Great Depression. Through the combination of those circumstances and her own peculiar (and wonderful) character, Dranny was a pack rat. She didn’t live in filth and disorder (just the opposite, actually), but she couldn’t bear to throw anything away, especially not food. If three green peas were leftover from a meal and she hadn’t been able to persuade someone to eat them, she would lovingly place them in a custard cup covered with a shower-cap style cover (this was in the days before Glad Wrap), and store them in the fridge, where they would remain until someone ate them (or my mother threw them out while Dranny was in another room).

I’m a lot like my grandmother in various ways, and also something of a pack rat. So after eating my way through hundreds of childhood meals with Dranny and my mom (who was not a pack rat, but who was offended by the idea of wasting food that she’d worked so hard to procure and prepare), I emerged into adolescence with warring impulses – part of me still wanted to clean my plate, and part of me wanted to starve so that I could lose weight and be as skinny as the British supermodel, Twiggy.

One of my problems with meal planning and storage is that it's hard for me to predict how much food I'll be able to eat at a future meal. Often I don't know that until I've eaten several bites. My basic strategy for dealing with this unpredictability is to keep my plate clean from the very start so that the food I leave behind doesn't overwhelm me or provoke an attack of guilt that could bring down Dranny's wrath upon me.

A simple way to keep your plate clean is to prepare smaller batches of food so you won't be tempted by serving dishes overflowing with food or burdened with an excess of leftovers. I can't speak to recipes for baked goods (not my department), but most other recipes can be easily cut in half, thirds, or even quarters through the use of simple arithmetic.

Sometimes I prepare the whole recipe, subdivide into 2 or 3 batches, serve one batch immediately and freeze the other 2 for future use. When we lived in the northeast, the elderly widow who lived next door was delighted when we shared excess food with her. Sharing food with family, friends, and coworkers can yield multiple benefits. When I'm craving a food or recipe whose leftovers would be a problem for me to store (or resist), I prepare a big batch of it for whatever social event is on the horizon and keep only one or two portions of it at home so that we get to enjoy it without having to worry about to do with all that food. I use cheap, throw-away packaging so that no one can insist that I take my corning ware, Pyrex or Tupperware container of leftovers home with me.

You can also keep your plate clean by using the portioning technique I recommend for bandsters who are still learning their band eating skills, food portion sizes, and stop signals. Here's how it works for me. When planning my day's food (which I commit to my food log and my accountability partner every morning), I might decide that I'll eat 4 ounces (by weight) of chicken thigh and 1/2 cup of barley and veggy salad for dinner. Come dinner time, I grab my small plate (a salad plate) and put half of my planned meal on it: 2 ounces of chicken and ¼ cup of the salad. If I'm able to finish that, great. If I'm still physically hungry when I'm done with it, I go back to the kitchen and dish up the remaining 2 ounces of chicken and ¼ cup of salad. At the end of the meal, I'll probably have only 1 or 2 tablespoons worth of food to save or throw out instead of a plateful of food, therefore much less guilt to deal with.

When I do have a plateful of food leftover, I usually scrape it into a small plastic container that I can quickly grab and stick in my lunch bag when I go to work the next day. Fortunately, we actually like leftovers at our house, and arguments occasionally break out over unauthorized consumption of leftover food ("Who ate the rest of the eggplant Parmesan?!?"). The same approach works with restaurant meals. We're happy to take leftovers home in what used to be called a doggy bag (as if I'd share my Maryland crab cakes with a dog!).

My sister-in-law used to scrape leftover food into a bucket to add to her garden compost pile. I have no idea if that's a good practice. We'd have to have a 40' high electrified fence dug 20' into the ground and topped with razor wire in order to keep dogs, cats, deer, rats, raccoons, and other critters out of that kind of compost pile. I've also known people (including my mother) who fed leftover food to their 4-footed garbage disposals (dogs & cats), another practice that we avoid because why would you want to cultivate a fussy eater? Our pets have survived eating (stolen) candies (complete with foil wrappers), latex paint, and kip tails (fishing flies), and at our house, a fussy eater will end up starving because someone else is always willing to clean your plate for you, sometimes long before you've decided you're finished with it.

But what about the starving children? After over 3 years of banded life, I'm now able to detach myself from my emotional attachment to the food on my plate enough to throw out what's left. If it didn't taste right because my band was in an odd mood, if it caused me symptoms, if it wouldn't reheat or store well, I let it go. I haven't been struck by lightning for doing that, nor has God punished me with plagues, floods, or infestations.

Like many, I was raised to eat every meal while listening to a chorus singing the Children Are Starving in (fill in the blank) hymn. I agree that in world where so many children (and adults, and animals) go hungry, it is just plain wrong for an overfed middle-class person like me to waste or throw out food. But the fact is that me eating more food than my body needs (rather than throwing out) is not the solution to the problem of world hunger. The solution to world hunger, and to diminishing global food resources, is far, far more complicated than that. Working in your community (be it a village, a city, a country, or a planet) to solve that problem is a worthwhile effort, but you taking personal responsibility for causing the death of a starving, unknown child in India or Appalachia because you threw out a chicken wing and 5 green beans last night is a misguided and foolish use of your energy.

And you eating that extra bite of food just because you can't bear the thought of throwing it away is also foolish from a medical standpoint. If that extra bite causes you to PB, get stuck, or over-pack your pouch, it could lead to messy and expensive medical complications like esophageal or pouch dilation and/or band slips, especially if you eat that way on a regular basis.

Tuesday, June 7, 2011

My Cup Runneth Over

I overate for something like 50 years, never feeling that there was enough food in the entire universe to fill the hole inside me. Now, my cup finally runneth over, in the sense of Psalm 23:5 - I have more than enough for my needs.

Psalm 23 is the "The Lord is my shepherd, I shall not want" psalm, nowadays often recited during funeral services as grieving family and friends send the deceased off into the valley of the Shadow of Death. Its message is that as long as we dwell in the house of the Lord, our tables will be filled for us while our enemies watch and perhaps starve. Of course, this scene of a table piled high with food and overflowing with wine is symbolic rather than literal. Christians (among others) seek spiritual as well as physical nourishment. But as in many songs, poems, and stories, the message of Psalm 23 is powerful because the symbols it uses are such important and recognizable ones, at least for me. Few humans can fail to grasp the ideas of "want" (meaning "lacking" rather than "desire) and of plenty ("my cup runneth over") when it comes to food and eating.
But although I was baptized as an infant, confirmed as a Methodist at age 13, and confirmed as an Episcopalian at age 49, I failed to grasp the concept of "plenty" for a very long time, especially in reference to food. It's truly a miracle to me now to feel that I have enough food for my needs.

What has changed? I'm still a well-educated middle-class citizen of a country so overflowing with food that a third of its population is overweight. I've never had to worry about where my next meal was coming from, though at times it felt that way to me. What's changed is that I now have an adjustable gastric band that is interfering (in a good way) with the satiety signals that zip back and forth between my brain and my body.

When bandsters complain that their band isn't working because they never experience satiety, I have to wonder what their definition of satiety is, and sometimes I want to say in a quiet, nerdy, Zen-esque way, "You're not listening closely enough." While it's true that a great deal of my weight loss success is related to my conscious meal planning, food choices, and portion control (just like dieting in the bad old days), another big chunk of it is a mystery to me, perhaps beyond my capacity to ever understand. I don't think it's simply a placebo effect (in which the efficacy of my band is caused by my belief in its power to work), because pieces of the mystery are revealed to me in such a haphazard way. For example:

Yesterday I made a beautiful dinner of teriyaki pork kebabs, edamame cakes, and roasted peaches. It smelled divine while it was cooking and I was well-supplied with both appetite and physical hunger when we sat down at the table to eat. The first bite of the pork tasted very bland to me despite the teriyaki sauce and I wondered if I'd forgotten an ingredient. The second bite tasted the same as the first bite, plus its texture was unpleasant. It was moist and tender, but I wanted to spit it out. I think I was probably a toddler the last time I spit food onto the dining table (or high chair). I finished chewing the bite of pork and said to my husband, "I'm sorry, this pork is nothing special." And he said, "What are you talking about? It's delicious!"

Suddenly I heard the flapping of tiny wings in my band fairy waving her magic wand and singing in a twinkling little voice, "You don't have to eat it!" So I didn't. I enjoyed my edamame cake and roasted peach half very much instead, and although I'd eaten perhaps half a cup of food altogether, I felt very satisfied. I was still a bit puzzled about my "rejection" of the pork, but on the whole, my cup runneth over. I had more than enough for my needs, and the uneaten food on my plate went into the mouth of our electric pig. Throwing out uneaten food is no small deal for me, and I've promised my friend Claudia to devote a future newsletter to that subject, so all I'll say right now is that although I felt a slight twinge of disappointment as I scraped the food off my plate, as soon as it was gone my mind moved on to the next thing (cleaning the kitchen) without any regret.

Hmmmm...I seem to hear some murmuring from your're muttering, "That's all very well for Jean to say, but I've only had my band for 3 months and I'm not feeling anything like satiety yet!" All I can tell you is, hang in there. You might need more fill, or different food choices, or more frequent meals/snacks. Unfortunately success with the adjustable gastric band is not an exact science. Individual patients don't react identically to the band any more than individual patients react identically to a dose of a pain killer. After taking 30 mg of codeine, some people experience blessed pain relief, some people get high, and some people get sick to their stomach. This is one of the reasons that there is no such thing as DIY bariatric surgery or DIY pharmaceuticals (or legal ones, anyway).