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!

Band Myth #5

#5: NO SIDE EFFECTS MEANS MY BAND ISN'T WORKING

 

Equating side effects with a properly working band is very common, and potentially very harmful. The two most significant signs of the band’s proper functioning are (1) early satiety and (2) prolonged satiety. Those signs are rarely expressed in large, bold, uppercase letters, such as

STOP EATING NOW!

Those signs won’t be accompanied by clanging bells or flashing lights, either. In fact, the less noise and distraction (such as “Why don’t I have stuck episodes?”), the more likely you are to be able to recognize early and prolonged satiety. 

Before I tell you why the no side effects = broken band worry is a sign of mythical thinking, let’s make sure we agree on the definition of a side effect, and how that relates to complications. A side effect is an unintentional or unwanted effect of a medical treatment, and it’s usually exceeded (or at least balanced) by the benefits (the intentional, wanted effects) of that treatment. For example, antibiotics can cause diarrhea. That’s an unpleasant side effect, but an untreated infection can have far worse consequences for the patient. Side effects can often be managed by tweaking or changing the treatment, and they are rarely worse than the original condition.  

 

A complication, on the other hand, is a more acute, serious consequence of a medical treatment, and usually needs a more aggressive approach, including surgery to fix the problem. Now let’s go back to the antibiotic example. An allergic, anaphylactic reaction to the antibiotic can be fatal without prompt medical treatment. That’s a complication, and it’s far worse than the original condition.  

So in the context of all that, it seems strange to me when bandsters long for side effects like regurgitation (PB’s), stuck episodes, and sliming. Instead of looking for more subtle clues from their bodies (like early and prolonged satiety), they go looking for problems, and worse than that, they tend to “test” their band with foolish eating and/or overeating, hoping to provoke a side effect that will signal to them that they really do have a band in there. One of the many problems with that approach is that it can also provoke a complication.

Band Myth #4 - The Sweet Spot

 

Band Myth #4 – TO LOSE WEIGHT, YOU HAVE TO FIND YOUR SWEET SPOT

I used to wonder how the Sweet Spot Myth could survive in the face of so much clinical evidence against it, but last year I heard the “you gotta find your sweet spot” claim uttered by a bariatric dietitian, so apparently this is a myth being validated by medical professionals who ought to know better.  

Instead of the sweet spot, Allergan (the first to introduce the band in the USA) uses a zone chart to illustrate band restriction, with not enough restriction in the yellow zone, good restriction in the green zone, and too much restriction in the red zone. In other words, restriction happens in a range of experience, not at a single static point. That experience changes over time as we lose weight, deal with ordinary processes such as hormonal fluctuations, hydration changes, stress, medications, time of day, and so on. It’s also affected by our food choices (solid vs soft/liquid food). 

In my banded days, I traveled through and around a sweet spot many times. It might last for 30 minutes, 3 days, 3 weeks, but it never stayed exactly the same, and yet I still lost weight! I don’t actually want to stay exactly the same for the rest of my life (throat wattles notwithstanding). As any Parkinson’s disease patient will tell you (if they’re able to speak), a body that gets stuck in time is a very big problem (and with my luck, I’d get stuck in the worst sinus infection or case of the flu of my life). Some people who are very sensitive to their band and its fills find sudden or unexpected changes in restriction to be very, very frustrating, and I wouldn’t wish that on anyone, either.  

To read more about the sweet spot, click here to go to an article, The Elusive Sweet Spot.

http://www.lapbandtalk.com/page/index.html/_/support/post-op-support/the-elusive-sweet-spot-r59

Band Myth #3

#3 – THE BAND’S SLOWER WEIGHT LOSS PREVENTS SAGGING SKIN

   This is another fairy tale. According to several plastic surgeons I’ve heard speak on the subject, the effect of weight loss on skin depends mostly on your genetics and your age (because skin loses elasticity as we age). Other factors can be how obese you were, how long you were obese, how you carried your weight, and how much (and how) you exercise as you lose weight. 

    I’ve heard obese women say that they’d rather be obese than have sagging or excess skin. To my mind, that’s a sad statement, because I’d rather have sagging or excess skin (as long as it didn’t interfere with my ambulation or activities) than excess weight. Don’t get me wrong: I loathe the excess flab on my midsection (whose nickname is “The Danish Pastry”) and I’m not thrilled about my batwings, throat wattles, or anything else that’s happened to my skin in the past few years (during which I’ve undergone the double-whammy of weight loss and the fast approach of my 60’s). On the other hand, I think I look pretty good for a woman my age, especially when I conceal my figure flaws in flattering clothing which, I might add, no longer needs to be purchased at Lane Giant.

BAND MYTH #2

Adjustable Gastric Band Myth #2:

BAND WEIGHT LOSS TAKES TOO MUCH WORK

   Aside from the desire for instant and effortless weight loss (which is a fairy tale if I ever heard one) that so many obese people share (me among them), this is a myth that often turns people away from the band and towards other WLS procedures. While this myth may be true in the first 12-18 months after surgery, eventually everyone ends up in the same boat, rowing hard against the powerful tide of obesity.

   Weight loss and weight maintenance is hard no matter how you achieve it. A dietitian who spoke at a band support group meeting I attended a few years ago said that while band patients must change their lifestyle immediately in order to succeed, every WLS patient must do that sooner or later. It’s a pay-me-now or pay-me-later deal. You can slice it, dice it, sauté it and serve it on your grandmother’s best china. However you serve it, weight loss and maintenance is a lifetime project because obesity is a chronic disease with no cure. No matter how successful we are as new post-ops, all of us must face the possibility of regain. That’s why I cringe when someone proudly crows, “XXX pounds gone forever!”

6 Myths about the Adjustable Gastric Band: MYTH #1

   The world of bariatric surgery is full of myths. Every time myths are repeated, they gain strength and credibility (deserved or not), so it’s important to look at them closely before accepting them as true. I'll post this material in chunks, one myth at a time.

TIME TO THROW OUT SOME OLD MYTHS

   It’s time to throw out some old myths about the adjustable gastric band, but before we start flinging those myths around, let’s all agree on what a myth is.
   The traditional definition is that a myth is an ancient story of unverifiable, supposedly historical events. A myth expresses the world view of a people or explains a practice, belief, or natural phenomenon. For example, the Greek god Zeus had powers over lightning and storms, and could make a storm to show his anger.
   If you think myths are dry stuff found only in schoolbooks, think again. They surround just about every aspect of our lives, and travel much faster now, in the age of technology, than they did in the dusty old days of ancient Greece and Rome. They’re a way for us to make sense of a chaotic world, both past, present and future. They affect thoughts, beliefs, emotions and assumptions in our everyday lives, coming alive in our minds as we, and the people around us, seem to act them out.
   Some myths are helpful because they give us a shared sense of security and express our fundamental values and beliefs, but some myths are just plain wrong and can be harmful to us and to others. A good example is the myth that having weight loss surgery is taking the easy way out. Every time I hear that one repeated, I want to laugh and scream at the same time. If you’re a post-op, you know why. Weight loss is hard no matter how you do it (surgery, diet pills, prayer, magic cleanses, and so on). On the other hand, WLS is supposed to be easy, compared to the dozens or hundreds of weight loss attempts in our past. Why on earth would I put myself through a major surgery if it wasn’t going to help me lose weight and keep it off?
   Now that we’ve shared a little laugh (or scream) over a WLS myth we can all agree upon, let’s test out some band myths whose validity may not be as clear. This kind of examination can be uncomfortable, but believing in a falsehood is almost guaranteed to make your WLS journey bumpier than it needs to be. Let’s start with the myths that are easiest to digest and end with the ones that can be tougher for a bandster to swallow.

MYTH #1 – THE BAND IS THE LEAST INVASIVE WLS PROCEDURE

   I believed this one at first, mainly because I knew little about the other WLS procedures back in 2007. It’s still a widely-circulated myth, one that even my surgeon’s well-intentioned dietitian endorses. So, what’s the truth according to Jean? Face it: any surgery done on an anesthetized patient, during which a surgeon cuts into the belly in several places, does some dissection (more cutting) and suturing (stitching) of the internal anatomy, and implants a medical device (the dreaded “foreign object”), is invasive. It is true that band placement generally involves less internal dissection and suturing than other weight loss surgeries, but neither is it on the same level medically as having your teeth cleaned. So while the invasiveness of a surgery is worth considering, you do yourself a disservice if you let that override other considerations. A bariatric surgery might last 45-60 minutes, with recovery lasting a week or so, but its effect on your health and lifestyle last a lifetime. Or I sure hope it does.
   Some people associate invasiveness with irreversibility. Although the band is meant to stay put once clamped to your stomach, it can indeed be removed if medically necessary. Gastric bypass (RNY) surgery can also be reversed, while the sleeve (VSG) cannot and only the “switch” (malabsorptive feature) of the duodenal switch (DS) can be reversed. Removal or reversal is not as easy as operating on a “virgin belly” (as my surgeon so colorfully puts it), so it’s important to weigh the benefits against the risks of reversal or revision surgery.