The Secret to WLS Success

 

 

What is the secret to being a weight loss surgery success?  

When aspiring writers ask me, “How can I become a writer?” my answer is invariably, “Be one. Write.” I’m a writer not because want to be one, but because I write. I’m constitutionally unable to not write. It’s not always easy, but I always do it. Writing keeps me alive and vital. In that sense, it’s a big part of healthy living for me. 

So, do you want to know how to be a successful WLS patient?  

The answer is: “Be one.” Make your health a top priority, not because you’re so ridden with medical problems, but because it will help you thrive. 

Sounds so simple, doesn’t it? But exactly what does that mean? It means that I write every day. Other than finding or making the time to do it, it’s not hard, because I love to write. So to be a writer, I practice the art of writing every day. What I write varies, just as what you eat varies, depending on how much time I have and what I’m in the mood for. Within 15-30 minutes of getting up each morning, I write something. I write e-mails to my accountability partners, telling them about my eating, exercise, and perhaps some funny, or infuriating, or interesting stories about my daily life. I write down the thoughts I have about magazine, newsletter and blog articles. I write lists of things to do and things to think about. At some point during each day, I write sentences or paragraphs or chapters of articles, essays, stories and books. I write journal entries that help me muddle through puzzling situations and relationships. 

I also love being slim and healthy, so I practice the art of being slim and healthy every day. This too varies, but within 15-30 minutes of getting up each morning, I practice my healthy lifestyle. I update my food log and report my food plan and eating behavior to my accountability partners. I get dressed in workout gear and spend 45 minutes at an exercise class, 5 days a week. I write a weekly menu plan and I write my grocery list. Even when I’m doing something that isn’t directly related to weight and health, I’m practicing. I see a plate of home-baked cookies on the break room table at work and think about whether I want to eat one or if I’ll regret doing that. In a short 15 minute break, I practice good eating skills as carefully as I can despite feeling hurried. When I get in my car to go home and notice I’m thinking wistfully of Chicken McNuggets or Dulce de Leche ice cream, I take a deep breath and ask myself if I really need those things or just want them as a quick fix. I try to see myself driving home and preparing the healthy meal I’ve planned. I try to remember how good I felt when I did that the day before. I think about how happy my dogs will be if I get home on time (anybody who claims animals can’t tell time has clearly never lived with a dog).

The key words in the two paragraphs above are “love” and “practice”. 

If you’re thinking, “But I don’t love to diet!” maybe it’s time to adjust your thinking. Instead of thinking, “I hate dieting,” try this on for size: “I love being a WLS success.”  

And it’s definitely time to discard the notion of being “on a diet”. A diet is something you do for a finite period (a week, a month, 3 months). It’s temporary, and when it ends, your eating goes back to the way it was before the diet, and lo and behold, the weight you lost comes back, and often it brings all its friends, and its friends’ brothers, sisters, and cousins. I know that for an absolute fact because it’s happened to me so many times since I was 14 or 15 years old. 

Being a weight loss success means practicing healthy eating every day of your life, for the rest of your life. Some days may be healthier than others, and that’s OK. You’re just practicing, right? It doesn’t have to be perfect; it just has to be regular and ongoing. I don’t think about weight loss and health and all that good stuff every waking minute, and not all my thoughts are virtuous. I spend quite a lot of time thinking things like, “Why doesn’t that pickup truck just pass me rather than riding on my tail?” or “If he spits toothpaste on the bathroom mirror one more time, I’m gonna be one happy widow.” But thoughts about weight and health go through my mind every day. I’ve heard WLS patients say they never want to have to think about that stuff ever again. I don’t think I could succeed that way, and those thoughts are not a burden for me. The real burdensome thoughts I bear are ones like, “I should have hugged Mom more often before she died.” 

Oh, I know that “shoulda, coulda” thoughts are a waste of time and energy. That’s probably why they’re so hard to bear. But that’s a topic for another article. 

So, do you want success? I want to hear you say it, loud and proud:

I WANT TO BE A WEIGHT LOSS SUCCESS!

I WILL BE A WEIGHT LOSS SUCCESS!

I AM A WEIGHT LOSS SUCCESS! 

And give yourself three cheers for your effort, even if you feel you haven’t yet achieved success. Sports teams get cheered at every game, whether they win it or not. When they win, they want to win the next game, and the next. When they lose, they go back out on the field to practice the next day, and to play another game the day after that. They don’t do that just because they owe it to their coach and teammates. They do it because they love to practice, play and win. 

“But I’m not an athlete!” you say? Me neither. But I do love being a WLS success!

Why Does WLS Fail?

Bariatric surgery can fail. No one wants to talk about that, especially when we’re filled with hope about what bariatric surgery can do for us. Why does weight loss surgery fail, and what does that mean for each of us? 

In the bariatric community, we spend a lot of time debating about which WLS is the best – that is, which one yields the best outcome (my own definition of that is optimal weight loss with minimal complications). I think we can all agree that there’s no such thing as a perfect or one-size-fits-all bariatric surgery. If we’ve all fought weight battles long and hard enough to need or choose WLS, we can surely agree that obesity is tough to overcome. And that is, I think, the grounds for further agreement, about why WLS fails. 

Here’s my premise: weight loss surgery fails because of obesity. If you’re thinking you need not read further because you already knew that, please wait until I explain a bit more. And those of you snickering in the back of the room, simmer down. I’m a natural blonde (duh) as well as an old fogey who needs time to make her point, but like Ellen DeGeneres, I do have a point. 

OK, let’s continue. Some disappointment or failure can be attributed to the inadequacy of a bariatric medical device or surgical procedure or surgeon or patient, but underlying all that is the basic reality of obesity: it’s a chronic and currently incurable disease, caused by a mixture (unique to each patient) of genetics, behavior, environment and biology. Weight loss surgery may address some aspects of those factors, but not enough to cure obesity. So it fails because of obesity.

In the past, I’ve given a lot of thought to how genetics, behavior, and environment have contributed to my own case, but no more than a passing glance at the biology of it. I’m the daughter of a gifted scientist who passed on not one single gene of scientific aptitude to me (instead, I got his nose and the name McMillan). 

I realize that saying that WLS fails because of obesity is like saying the ocean is wet because it contains water, but as with many obvious facts of life, it’s easily overlooked. We go into WLS believing or at least hoping that surgery will fix enough of what’s wrong in us to help us lose weight and maintain that weight loss, but we need to remember that no WLS will cure our obesity. We need to remember that our obesity is at least partly caused by factors that are invisible to us. 

Those factors were invisible to me until a few months ago, when I was asked to write a magazine article about some recent research studies that found a link between obesity and fibromyalgia. I’m uniquely qualified to write that article because I’m a veteran of both wars. 

When I began researching the article, I was astounded by the dense mountain of information: scientific data, theories, probabilities and conjectures that I’d heard little or nothing of before despite my exalted status as the World’s Greatest Living Expert on the Adjustable Gastric Band. I’ve had WLS, talked to dozens of bariatric medical professionals, attended three bariatric conferences, read countless books, articles, blogs and reports, but suddenly I felt like a babe in the bariatric woods. Why hadn’t either of my bariatric surgeons (never mind my primary care physician) mentioned any of this to me? Are they unaware of it? Are they hiding it from me and the rest of their patients? Is there a conspiracy afoot?  

This information is of enormous importance if only because it knocks a big hole in the old-school blame-the-patient approach. The paranoid in me wonders if the information is hidden to protect an industry or to further a political cause, but I put those thoughts aside and instead considered the very real possibility that bariatric surgeons are well aware of the obesity mountain but are practicing a form of medicine that circumvents it. They don’t climb the mountain and they don’t hike around it. They cut right through the middle of it. 

THE OBESITY OCTOPUS

To explain myself now, I’ll have to resort to another simile. In a sense, bariatric surgeons treat obesity by stuffing a many-armed octopus in a sack and bludgeoning it with an axe. I’m not criticizing the surgeons. Surgery of any kind requires a breathtaking degree of confidence, skill, and audacity. Although surgery doesn’t address every waving octopus arm, it is the only effective long-term treatment for obesity available in the United States today, and I’m very grateful that I was able to have WLS and lose my excess weight as a result of it. At the same time, I sometimes worry about the future. This spring, treatment of a medical problem required removal of my band. I’ll soon have vertical sleeve gastrectomy surgery, but what if obesity takes over my life again in spite of my band and all my hard-won lifestyle changes? Are researchers working on an obesity cure now that can help me with that in the future?

WHAT CAUSES OBESITY?     

It turns out that researchers have indeed been busy searching out the causes of obesity in the hope of finding a better way (or ways) to treat it, prevent it, and/or cure it. 

As I mentioned above, several studies have reported a link between obesity and fibromyalgia. It’s easy to get caught up in a chicken & egg debate about that – does one disease cause the other? I don’t want to go down that road right now. Instead I want to talk about some factors that are associated with (and may be contributing to) both conditions. They are: 

Non-restorative sleep – Sleep affects the production of hormones (leptin, grehlin, cortisol) that are key to the experience of hunger, appetite, and satiety. Poor sleep tends to decrease leptin (satiety hormone) production and increase grehlin (hunger hormone) production. It also seems to increase sensitivity to pain. If you have sleep apnea or another type of sleep disorder, or even subclinical sleep disturbance, it’s likely that your physical hunger is increased and your sense of satiety is decreased. The adjustable gastric band can intervene on your behalf, but it doesn’t correct the hormone production problem.  

Neuroendocrine dysfunction – the nervous system (neuro) and endocrine system (glands) control all physiologic processes in the human body. The nervous system works by sending messages through nerves, as if it’s a hard-wired telephone system. Nervous control is electrochemical in nature and is rapid. The endocrine system sends messages by the secretion of hormones into the blood and extracellular fluids. Like a radio broadcast, it requires a receiver to get the message. To receive endocrine messages, a cell must bear a receptor (a receiver) for the hormone being sent in order to respond to it. If the cell doesn’t have a receptor, it doesn’t “hear” or react to the message. 

Researchers studying neuroendocrine interactions discovered (among other things) that in fibromyalgia and obesity patients, certain cells have damaged or malfunctioning receptors for the leptin, the satiety hormone. It’s the one that tells your brain you’ve had enough to eat. So one of the reasons you rarely feel satisfied by a reasonable amount of food (or in my case, an infinite amount of food) may be that satiety messages are going astray because your cells’ in-boxes are locked or absent. 

Dysregulated HPA is a factor contributing to both obesity and fibromyalgia. HPA stands for hypothalamus-pituitary-adrenal, three glands (part of the endocrine system) that are crucial to healthy functioning of many bodily processes. The HPA axis is a grouping of responses to stress. When you experience stress (whether it’s physical, like an injury or illness, or mental, like a fight with your spouse), your body produces a biomarker (messenger cell) that stimulates your HPA axis. Your hypothalamus (in your brain) then sends a message to your pituitary gland (also in your brain), where it triggers the release of ACTH (adrenocorticotrophic hormone) into your bloodstream and causes the adrenal glands (on your kidneys) to release the stress hormones, particularly cortisol. Cortisol increases the availability of the body's fuel supply (carbohydrate, fat, and glucose), which is needed to respond to stress. However, prolonged elevation of cortisol levels can cause havoc: muscle breaks down, your body’s inflammatory response is compromised, and your immune system is suppressed. If you’ve ever taken a corticosteroids medication like Prednisone to treat an inflammatory problem (like an allergic reaction) or disease (like lupus), you’ve probably learned the hard that it can turn you into a bad-tempered eating machine. 

Inflammation, as mentioned above, is another culprit in both chronic pain and obesity. A European study of showed that obese rats have chronic low-grade systemic inflammation that sensitizes them to pain. Immunological vulnerability is common to obese and chronic pain patients and contributes to pain, fatigue, sleep disturbance, and depression. All of those are factors that can prevent us from exercising and are associated with the neuroendocrine dysfunction described above. 

Mitchondrial dysfunction may also play a role in both chronic pain and obesity. According to Karl Krantz, D.C., “mitochondria are the power house of the cell. If energy is not being produced, logically it can lead to or contribute to chronic fatigue and pain.” A Finnish study of identical twins (each pair including a normal weight and an obese twin) found that the fat cells of the obese twins contained fewer copies of the DNA that’s located in mitochondria. This DNA contains instructions for energy use by the cell. The lead researcher of the study says, “If one were to compare this cellular power plant with a car engine, it could be said that the engine of the fat individual is less efficient.” So it’s no wonder that obese people are not able to burn or use all the calories they consume. Some medical professionals believe that chemical toxins (such as the preservative sodium benzoate, used in many soft drinks) and biotoxins (such as mold) can damage the mitochondria, increase inflammation, and aggravate both obesity and chronic pain.

 

WHERE DO WE GO FROM HERE?

Your own brain may in overload now after working its way through all the biological business I’ve ineptly but earnestly tried to explain. Even if nothing else is clear, I hope you’ve grasped the message that the causes of and factors in obesity are extremely complicated and well beyond the means of any currently existing medical device or surgical procedure to cure. I also hope you can see that blaming yourself for your obesity doesn’t go very far in treating it. You are not in conscious control of your neuroendocrine system. But neither are you entirely helpless. You have, or will soon have, a bariatric tool that when carefully used, can bring your appetite under better control and increase your sense of satiety. You can learn as much as possible about the factors that can improve your overall health and counteract the misbehavior of your nerves, hormones, and immune system. For example, I know for a fact that regular exercise helps me manage not just my weight but my depression and pain. You may feel defeated by the very idea of that, but according to an article in the July-August 2011 issue of IDEA Fitness Journal, as little as 5 to 15 minutes of exercise a day can yield health benefits and also increase your self-control when it comes to food choices.

At the end of the day, I still suffer from obesity and fibromyalgia, both puzzling and difficult to treat, but I try not to think of myself as a victim of those diseases. I can curl up in a chair with a box of chocolates and weep about my situation, or I can go on learning about my medical conditions and experimenting with ways to improve my health and quality of life. The author of one of the obesity-fibromyalgia studies, Akiko Okifuji, recommends that patients adopt healthier lifestyles and take more positive attitudes toward symptom management. That may sound condescending, but as Dr. Krantz wryly pointed out, “every person in America would benefit from that approach.” I know that’s easier said than done, but I’m willing to try it…are you?

My Band-to-Sleeve Experience

A lot of people (especially those considering first-time bariatric surgery or revision surgery) have asked me about my band-to-sleeve revision, and how my sleeve compares to my band. Below is a summary of my experience so far. I'll warn you in advance that I'm not happy with my sleeve. I do know several sleevesters (band-to-sleeve patients) who love their sleeve, but I have a strong suspicion that they feel that way because their experience with the band was unhappy, not because the sleeve is intrinsically better than the band. When they had their band removed and revised to the sleeve, the euphoria they felt was a bit like the relief you feel when you stop banging your head against a wall.

I was banded in September 2007. I lost 100% of my excess weight (90 lbs) in one year. I had a minor band slip (cured with a complete unfill and 6-week rest period) and a port flip (fixed with outpatient surgery) and loved my band. When it was properly adjusted, it drastically reduced both my physical hunger and my appetite (desire) for food. Food just did not taste as wonderful to me as it had in the bad old days. I also experienced the early and prolonged satiety that is the band's #1 claim to fame.

Unfortunately, I lost my band in April 2012 because of damage from 20+ years of silent reflux, which my band may have been aggravating. My surgeon and gastro doc agreed that my band had to come out, so I opted to revise to the sleeve in the same procedure. That didn't happen because my surgeon couldn't pass the bougie (the sleeve "calibration" tool) through my esophagus because of an undiagnosed stricture, so I was bandless until my 2nd attempt on August 16, 2012. I had the stricture dilated during an EGD in May 2012.

I had thought that the sleeve would be a good 2nd choice for me because I wasn't crazy about the malabsorption aspect of RNY or DS, because one of the best features of the sleeve is that the reduced stomach size drastically reduces production of the hunger hormone, ghrelin, and because the idea of a surgery that wouldn't require fills to achieve optimal restriction was appealing.

Unfortunately, it didn't work out that way for me. I am now ferociously hungry on an hourly basis no matter what, how much, or when I eat. I have to eat 8-10 times a day in order to keep my blood sugar steady. I've had to start taking metformin for my type 2 diabetes after easily managing it with diet and exercise for 7 years. I've discovered that sleeve patients can dump just like gastric bypass patients. The official term for dumping is rapid gastric emptying. My surgeon says that my sleeve is too small to hold food long enough for the stomach to start digesting it, so it passes rapidly into my intestines, causing my blood sugar to spike and then dive. It gives me miserable symptoms of nausea, dizziness, drenching sweats, and fatigue. That happens not just when I eat something with sugar in it but also when I eat so-called healthy foods (protein bars, milk, cottage cheese, yogurt, protein shakes, many fruits). And it happens when I eat too fast or too much.

At 6-1/2 mos post-op, I'm still trying to learn my satiety signals. They are not as clear as the stop eating signals I got with my band. All I've identified so far is that when I start feeling slightly nauseated, I've probably eaten one bite too many. Other sleevesters have told me that with their sleeve, they never have a stuck episode or a PB (productive burp or regurgitation). With my sleeve, 2 times I've felt like I was ready to PB, but I didn't. My strategies for dealing with all this are to serve myself half of my planned portion of food, eat that, and if I still feel physically hungry, I eat the rest. When I was banded, I used a salad plate (8") instead of a dinner plate (10"). Now I use a small bread plate (6").

I've become anemic and have to take an iron supplement twice a day in order to give me enough energy to function. Turns out that micronutrient malabsorption isn't unique to RNY & DS patients (anemia and other conditions related to micronutrient malabsorption have been documented by scientific studies; to read an abstract of one study, click here.

Also, a few months after my sleeve surgery I developed a gastric bleed. When doing an EGD to locate the source of the bleed, my gastro doc discovered a gastric polyp (probably the cause of the bleeding) and duodenitis (inflammation of the duodenum), neither of which were present when I had an EGD 3 months before my sleeve surgery. He theorizes that those were caused by surgical trauma.

I'm not able to be objective about my sleeve at this point, and it's probably too early for me to decide it was a mistake. But even if I decide it was a mistake, I'm never going to get that missing chunk of stomach back. It's gone forever. I do know that I absolutely refuse to go back to the land of obesity, and I'm grateful that my sleeve has helped me avoid that. I've lost the 30 lbs I had regained after losing my sleeve (plus another 7 lbs), and that is wonderful thing.

One difference between my band surgery and my sleeve surgery is that my sleeve surgery was much harder to recover from. It wasn't more painful, per se. My port site was very sore because my surgeon used the incision she had made to remove my port in order to remove the big chunk of stomach she had cut off, but my port site was the most uncomfortable incision from my original band surgery, so that was no surprise. My surgeon says that any revision surgery is difficult because she's not operating on a "virgin" belly. I thought that the slow recovery was due to my age (59) because an older friend (age 61) who revised to the sleeve at the same time also found it difficult, but I met a younger woman (mid 30's) in my surgeon's waiting room whose sleeve was her 1st (and we hope last) WLS was also finding it difficult. I think the length and ease of recovery is also related to the patient's age, pain tolerance, general health, and amount of time spent under general anesthesia. My surgeon keeps band patients overnight in the hospital for one night, and sleeve and RNY patients for 2 or more nights. I hate being in the hospital but I was a mess even after 2 nights there. After my band surgery, I felt fine after one night in the hospital and was bored and restless and ready to go back to work (I worked at home then) within 3-4 days. After my sleeve surgery, just lifting a glass of water to my lips was a struggle. I felt like I'd been run over by a truck, and I needed the whole 3 weeks my surgeon insisted on off work, and even then I was dragging.

The other thing I want to say is that while my food capacity now is small (depending on the consistency of the food), my desire for and enjoyment of food is like it was before my band surgery. I feel like I get way, way too much pleasure out of eating. I believe that food tastes good for a reason (to keep us eating enough to survive and perpetuate the species), but that extreme enjoyment is a very mixed blessing. I constantly have to fight with myself to not take another bite so as to prolong the pleasure of eating. With my (adjusted) band, I did have some intrusive food thoughts, but nothing like it was in the bad old days. Now I think about food far too often than is good for my weight management.

I wish I had a happier story to report. I've been told that I'm not trying hard enough to like my sleeve because I loved my band. That may be true, but I sincerely wanted the sleeve and sincerely wanted it to work. I thought I knew what I was getting myself into. Ask me again in a year or so, and I may be waving the sleeve banner. And as the advertising hacks would say, "Your mileage may vary."

STOP EATING SIGNALS

The band gives almost instant feedback about your eating behavior. The feedback comes in the form of Soft Stop and Hard Stop signals. In order to learn and recognize your own stop signals, you’ll need to slow down and pay very close attention to how your body feels when you eat.  If you usually eat with a crowd (family, friends, coworkers), you might need to try eating by yourself so you won't be distracted. Full signals can be subtle and they can come from unexpected parts of your body. It's better to heed a gentle reminder than wait for a hammer to hit you on the head.

SOFT STOPS

Soft stops are your early warning system, gentle reminders from your body that it's time to stop eating. Because they don't hurt much, they're easy to ignore.  Your job is to recognize them (even though they may vary by the meal or the day) and heed them every time you recognize them. They can include: 

   Mild queasiness

   Fullness or pressure in the back of the throat

   Difficulty swallowing

   Burping (or the urge to burp)

   The urge to take a deep breath

   The urge to cough or clear the throat

   A sigh

   Hiccups

   Pressure in the chest

   Watering eyes

   Runny nose

   Left shoulder pain

   A sneeze

   Excess saliva

   A full feeling just below the breastbone

   A sudden distaste for the food you were enjoying a moment before

As soon as you notice one of these signs, stop eating. If you go on eating past this point, you won't be changing your eating behavior and you're likely to get into trouble…that is, a hard stop. 

HARD STOPS

Hard stops are the equivalent of running into a brick wall. They can happen without any apparent warning, but usually you have sped heedlessly past a soft stop before you hit the wall. Hard stops are the painful and sometimes embarrassing reminders that you have eaten too much, too fast, in bites that were too big, without chewing enough. They can include:

   Chest pain or tightness (note: this sensation is happening in your esophagus, not your heart, but if you experience any symptoms of cardiac arrest, such as severe, squeezing pain that radiates down an arm, put down that fork and dial 911)

   Feeling like you have a rock in the back of your throat

   Food stuck in stoma (for me, that involved pain between my breasts, and when the food moved on through into my lower stomach pouch, it felt like a drain that suddenly opened)

   Productive burps (PB's or regurgitation)

   Sliming (excess saliva and mucus that's so profuse that you have to spit it out) 

Do not go on eating after you experience a hard stop. When the hard stop is over, you may feel fine and want to go back to your meal, but you have irritated your upper gastrointestinal system and will just be perpetuating the PB or other response if you continue to eat. You’ll end up in an endless cycle of eat-pain-eat-more pain. I strongly recommend following a liquid diet for 12-24 hours after each and every hard stop experience. For me, that alone is a motivator because after surviving my post-op liquid diet, I never wanted to drink a protein shake for the rest of my life!

 

 

 

 

 

HOW TO EAT LIKE A BANDSTER

...and other things you need to know about WLS but are afraid to ask...   

I wonder sometimes if bariatric professionals forget to emphasize the importance of good band eating skills because they they've never had to live with a gastric band. Of course, a few bariatric professionals are also bariatric patients, and thank goodness for that. 

I also wonder if bandsters are unaware of the importance of good band eating skills because their brains slipped into neutral during that part of their pre-op education. You'll have a hard time convincing me that's never happened to you, because I am the Queen of Lists and Note Taking. In high school and college, classmates would pay me for copies of my class notes. (Not only were they thorough, they were neatly penned in my prize-winning handwriting and decorated with cunning cartoons depicting my teachers and professors in embarrassing situations.) I take a notebook and a list of questions to every medical appointment, I ask questions, I re-read my notes, but despite all of that, my brain tends to shift gears when I see or hear something that strikes me as unimportant or irrelevant. And aside from being The World's Greatest Living Expert on Everything, what exactly qualifies me to make the unimportant or irrelevant judgment? Nothing. Nada. Nichts. Niente. 

During my pre- and post-op patient education, which was tailored for bandsters and administered by well-prepared bariatric dietitians, nurses, physician's assistants, and so on, I must have heard the eating skills lecture a dozen times. I was told that if I didn't eat carefully, I would end up in pain or with my meal in my lap. I nodded my understanding each time I heard that and could repeat the lecture verbatim, but it wasn't until I took a huge bite of a grilled cheese sandwich 24 hours after my first fill that I truly understood what all those folks had been telling me. And that’s not an experience I’m likely to forget. 

Take Tiny Bites!

I talk about good eating skills a lot. Why do I go on and on about that? Is it because I like the sound of my own (editorial) voice? Well, sure - that's no secret. But for what reason besides that? 

Important information bears repeating, and repetition is one of the ways that we acquire new information and learn new habits. If you doubt that, pay attention to how many times the Geico lizard appears on your television screen each day. Good band eating skills must become a habit if you're going to succeed with your band and avoid side effects and complications. The fact that some side effects and complications can happen to even the most conscientious bandster does not excuse us all from doing our best to avoid them. You'll need good band eating skills every hour of every day, not just as a new post-op or after each fill, but every day for the rest of your life. 

That sounds like a pretty tall order, doesn't it? Don't panic, though. A well-ingrained habit doesn't take as much conscious thought as a brand-new one. Your own behavior has already proven that if you've ever found yourself with a half-finished Twinkie or a cigarette or a beer in your hand and couldn't remember how it got there. It works the other way too. Your healthy new habits will eventually dig themselves into your life and using them will get easier as you go along. 

When you forget your band eating skills, your band will give you a loud reminder in the form of side effects like PB's, sliming, or stuck episodes, but I beg you not to rely on your band's built-in warning system on a regular basis, because doing so will send your bandwagon skittering down the road to complications like esophageal dilation, stomach dilation, band slips and even band erosion. 

One of the problems with the band's alarm system is that the truly destructive behaviors it reacts to may trigger relatively mild warnings so long before the damage is done that it's easy to shrug them off. For example, let's say that you often take big bites, don't chew very well, eat quickly, and/or eat beyond your soft stops (soft stops are gentle stop-eating signals, like hiccups). Each time you do those things, you experience mild discomfort. Nothing horrific. It happens, you think, "Oops," and you go back to whatever you were doing before the discomfort happened. Eventually this mild discomfort becomes just a part of your post-op life - the same as the way you sneeze when you pet a cat, pass gas when you eat beans, or get a headache when you don't wear your eyeglasses. Hey, that's just the way it is, right? 

But one bad day after dozens of ordinary days you can't even swallow your own saliva. You rush to the doctor, who does an upper GI x-ray and tells you your band has slipped. "How can that be?" you cry, "Everything's been fine until now!" 

In fact, everything has not been fine, because your careless eating has been pushing, pushing, pushing at your band's limits, until finally it pushed your band up your esophagus or down your stomach. I don't like finger-pointing any better than you do, but whose responsibility is that band slip? Is it your surgeon's, for not stitching it on there well enough? Is it the band manufacturer's, for not making your band slip-proof? Or is it yours? 

There can be a happy ending to your story, though. Even if the band slip is clearly your fault, you won't get sent to prison to sip brackish water and gnaw on stale bread for the rest of your days. Your surgeon can unfill your band (or, less likely, re-operate to reposition your band), and you can revamp your eating skills, lose weight, and live happily ever after. Or better yet, you can avoid the pain, inconvenience, financial and emotional costs, and pay attention to your eating from now on. 

I ain't gonna lie to you...acquiring and practicing this new habit won't be easy, but I can think of a lot of things that could be worse. A lot worse. 

The official Bandwagon® Eating Skills are: 

1.    Don't drink while you eat or for 30 to 60 minutes afterwards.

2.    Take tiny bites.

3.    Chew, chew chew.

4.    Eat slowly.

5.    Eat the protein first.

6.    Learn your stop signals.

7.    Pay attention to problem foods.

8.    Eat only when you're hungry.

9.    Avoid liquid calories and slider foods.

10.  Use a small plate.

11.  Plan your food in advance.

12.  Don't watch TV or read while you eat.

13.  Don't put serving dishes on the dining table.

14.  Eat sitting down at the dining table.

15.  Follow the HALT rule (don't eat when you're too hungry, angry, lonely or tired). 

You’ll find full explanations of each skill in Chapter 12 of Bandwagon, Strategies for Success with the Adjustable Gastric Band, by yours truly.

The Top 10 Things to Know About the Adjustable Gastric Band (according to Jean)

1. You will not wake up in the recovery room at your goal weight. Average weight loss with the band is 1-2 pounds per week, and virtually no one loses weight at a nice steady pace of (say) 1.75 pounds per week. Some weeks you’ll lose, some weeks you’ll stall and some weeks you’ll gain, but as long as the overall trend is downward, you’re doing great!

2. Slower weight loss with the band does not prevent sagging or excess skin. How your skin reacts to massive weight loss depends mostly on your genetics and your age. As we age, our skin loses elasticity. If the possibility of sagging or excess skin worries you, start tossing your change into a plastic surgery piggy bank now!

3. Weight loss surgery (of any type) does NOT cure obesity. Obesity is a chronic and incurable disease characterized by relapse and recurrence. Although bariatric surgery is currently the most effective way of treating obesity, obesity is something you’re going to have to manage for the rest of your life, with or without surgery. For most of us, a tool like the adjustable gastric band makes that a lot easier, but it’s not effortless, either.

4. Many eating problems after band surgery are due to user error, and can be prevented by using good band eating skills. Come back soon to read an article about those skills.  

5. In order to decrease your weight and increase your health, you must decrease your food intake and increase the quality of your food choices and the time you spend exercising. While you may be able to lose weight for a while by just eating much smaller portions of Chicken McNuggets, potato chips, and candy bars, eventually that approach will stop working, and at the same time it will start biting your health in the butt. Though it may be difficult for you to exercise at first, each pound you lose will make it easier, and each additional hour you spend exercising will not only burn calories but improve your physical and mental health. And remember: exercising doesn’t necessarily involve athletic skill or Olympic effort (though it may seem that way at the start).

6. No weight loss surgery procedure will cure eating disorders, eating demons, emotional eating, boredom eating, stress eating, celebratory eating or food addiction. Changing those behaviors is your job. If it’s too hard to tackle yourself, consider getting some counseling with a therapist experienced with eating disorder and WLS patients, and/or joining a 12-step group like Overeater’s Anonymous.

7. The band rarely works without fills. Even if you initially lose weight with one or no fills, sooner or later, you’re going to have to face the fill needle. And if you’re too needle-phobic to tolerate a fill needle, why did you choose band surgery in the first place? But consider this: adjustability is one of the wonderful things about the band.

8. The restriction “sweet spot” is a myth. There is no such thing as “perfect” restriction, or if there is, you can’t count on it to last more than one hour, one day or one week. This is because the band is an inert silicone object implanted in a living, breathing human body that changes constantly in reaction to the time of day, time of month, time of year, hydration, illness, medication, stress, you name it. Restriction variability is part of the gastric band package.

9. There is nothing magic in the band that makes you lose weight. Changing your eating and exercise behavior is what makes you lose weight. All the band does is make that work easier for you by reducing your physical hunger and increasing your satiety (specifically by providing early and prolonged satiety).

10.  YOU are responsible for your weight loss. Not your band, not your surgeon, and not the server at McDonald’s who invariably asks you, “Want to supersize that?”

Band Myth #6

#6 – THE MORE FILL, THE BETTER

I’ve heard bariatric surgeons comment that some band patients seem to be addicted to fills. I can identify with that because I had a good relationship with my band surgeon who not only administered my fills but gave me a lot of encouragement as well as answers to my many questions. I left each fill appointment with a renewed sense of commitment and hope. How can you not get hooked on something good like that? 

The problem with equating fills with weight loss success is that more fill is not always better. In fact, too much fill (which varies from one patient to the next, and also varies in a single patient as time goes on and the patient’s body keeps changing) can be downright dangerous. An overfilled band, and the side effects it causes (see #5 above), can lead to a complication like a band slip, esophageal dilation, or stomach dilation. While complications can come out of nowhere, most bariatric surgeons agree that too much saline in the band puts too much pressure on the stomach. Eventually something’s got to give. That’s often hastened by the patient’s efforts to eat around the problem, and it is absolutely not a guarantee of weight loss. I gained weight several times because of what’s called Soft Calorie Syndrome. My band was too tight and I was dealing with it by consuming mostly soft and liquid calories that offered little or no satiety.  

The human body is an incredible organism, capable of amazing feats of growth and healing that we take mostly for granted, but it’s not endlessly forgiving. Too much fill in your band, too many eating problems, too much inflammation and irritation in the upper GI tract, can compromise your body’s ability to recover from a complication like a band slip. Sometimes a complication can be treated conservatively, with an unfill and rest period, but sometimes it requires a surgical fix, including removal of the band. And after all you’ve gone through to get that band wrapped around your stomach, shouldn’t you be doing your utmost to treat it (and your body) with respect? 

Finally, the fill myth can cause us to overlook a very important guest at your WLS party….you. If you are going to succeed with your band, lose weight and keep it off and keep that band safe and sound inside you, sooner or later you will have to take personal responsibility for your success. Expecting your band alone to carry you to your goal weight is like expecting your car to safely deliver your child to school without anybody in the driver’s seat. And I sure hope that you are a very important person in your life!