Dr. Tom Brown, bariatric surgeon at the Colorado Bariatric Surgery Institute (CBSI) and expert for Doctors of Weight Loss, is now extending his Lap-Band fill clinic and aftercare program for individuals with the Lap-band who might be traveling, have relocated, or their surgeon may have moved or retired.  Dr. Brown is highly experienced, with more than 25 years in surgical practice, the past 10 years specializing in bariatric surgery. He has performed more than 3000 weight loss procedures, almost all of which have been performed laparoscopically, minimizing pain and scarring for his patients.  He and the other Doctors of Weight Loss experts are committed to providing supportive, innovative, professional care for bariatric surgery patients. Dr. Brown's comprehensive weight loss program at CBSI has an emphasis on long-term attention to dietary and lifestyle issues that contributes to highly favorable outcomes and has earned its reputation as one of the leading programs in the Rocky Mountain Region.

A recent review of research on the physiology of the adjustable gastric band has shed some light for me on how to properly manage eating after this procedure and how to educate patients on proper eating for success after surgery. 

First, one of the keys to success after surgery is to be at an appropriate fill level.  To assess adequate fill levels in the band researchers in Australia developed the Green Zone Chart:

 

The goal after surgery is to get to and maintain residence in the green zone.  This means understanding when it is time to get a fill and when you are overfilled.  Your eating habits can also have an impact on what zone you are in, as you will see later. 

Dr. Paul Burton, a bariatric surgeon in Australia has done studies on the pressure provided by the band while patients were in the green zone.  It was found that each bite of food should completely cross the band before another bite is swallowed.  Food passes the band through esophageal peristalsis (contractions or waves of the muscles in the esophagus which force food to move).  The goal is that a small, single bite of food is chewed until it is mush.  Then through peristalsis it will move across the band, taking multiple squeezes (usually 2-6), in green zone adjusted patients.  In patients who are underfilled or overfilled it will take less or more waves to push the food past the band.  It was found that the squeezes of the esophagus are what cause the sensation of no longer being hungry and that each squeeze adds to the satiation signal. 

It is hypothesized that sensors called intraganglionic laminar endings (IGLEs) are responsible for the feelings of satiety.  IGLEs are known to detect tension within the wall of the stomach and may be responsible for recognizing the compression of the gastric wall associated with squeezing of the bite of food across the band.  Therefore, the several squeezes that allow for the transit of a bite may stimulate the IGLEs further.  The IGLEs in turn signal the hypothalamus (the part of the brain in charge of hunger control) and the urge to eat is decreased.  According to Burton, a properly adjusted band provides adequate resistance to flow and the well-chewed bite of food generates more signals and yields increased satiety on less food.  When one is not eating properly:  not chewing food thoroughly to mush, eating too quickly, or taking too large of bites, the segment of the esophagus which contracts can be stretched, resulting in a decrease in peristaltic power and ultimately causing a return of hunger.

The article also highlights the “Eight Golden Rules” of eating after placement of an adjustable gastric band.  I agree with these eight rules as they are also included in the initial recommendations we provide and are consistently reviewed at your follow up appointments:

1.  Eat three meals per day
2.  Do not eat anything between meals
3.  Eat slowly and stop when no longer hungry:  One should be taking small bites       
and chewing thoroughly.  Small utensils should be used.  Each bite should be chewed for at least 20 seconds to allow for food to be chewed to mush as well as allow for the tasting of food.  Once a bite is swallowed one should wait 1minute before taking another bite to allow for the 2-6 peristaltic waves it will require to completely force the food across the band.  A meal should not last more than 20 minutes, therefore, at one bite per minute it would consist of 20 SMALL bites and 40-120 peristaltic waves or satiety signals. The number of signals produced depends on the consistency of the food, the tightness of the band, and esophageal power.  It is enforced that eating should discontinue when one is no longer hungry as opposed to being full.  Eating to being full means that there is food above the band which can cause distension of the contractile portion of the esophagus which enables optimal eating behavior and appetite control.  
4.  Focus on nutritious foods:  one should consume a protein rich diet with high quality sides such as vegetables, fruits, and whole grains.   
5.  Avoid calorie-containing liquids:  Foods should be solid since liquids pass too quickly across the band and do not provide the peristaltic waves needed to induce satiety.  
6.  Exercise for at least 30 minutes each day
7.  Be active throughout each day
8.  Always keep in contact with us

Along with the “Eight Golden Rules” for eating there are eight words that you should constantly repeat to yourself as a reminder of how to eat properly after Lap-Band surgery “Eat a small amount of good food slowly.”

Weight loss failure after Lap-Band surgery can occur because the band is not placed correctly, the band is not adjusted properly, or the patient does not adhere to the guidelines of proper eating and exercise.  Out of these, the most common reason for weight loss failure is poor eating behavior which leads to esophageal enlargement above the band.  These poor eating behaviors include:

1.  Not chewing food adequately.  Food MUST be chewed to MUSH before swallowing.  If the food is of the texture that it can not be reduced to mush it should be spit out rather than swallowed.  
2.  Food is being eaten too quickly.  Time should be allowed for each bite to be completely squeezed across the band before another bite is taken.  One minute appears to be an appropriate amount of time to wait between swallowing one bite and placing another bite in your mouth.
3.  Bites are too large to pass through the band. 

When these behaviors occur, food builds up above the band where there is no space to accommodate it.  To make room for this food, enlargement of the lower portion of the esophagus occurs.  This inhibits the lower esophagus from squeezing properly which prevents it from generating the signals of satiety explained above.  Hunger continues, more food is eaten, more stretching occurs, etc. . .and weight is regained or simply never lost.  Chronic stretching yields vomiting, heartburn, and decreased ability to sense when one is no longer hungry.  Eventually, this can cause enlargement of the esophagus to a point where it may prolapse over the band, and the band will either need to be replaced or removed. 

As you can see it is very important for your weight loss and maintenance that you achieve and maintain your adequate fill level as well as follow the eating recommendations so that the Lap-Band will be able to do its job.  Remember that the band is only a TOOL.  You are the one that is making all the appropriate decisions which allow it to function properly. 

References:
O’Brien P.  Gastric Banding and the Fine Art of Eating.  Bariatric Times September 2011:  1, 18-21.

 

Research has shown that obesity has a genetic component AND that poor sleep habits play a role in the development of obesity.  At the SLEEP 2011 Meeting of the Associated Professional Sleep Societies, there was a presentation about a recent study providing further support that we should be getting more shut-eye.  The study found that sleeping less at night may increase the expression of genetic risks for obesity.  The study's finings revealed that lower Body Mass Index (BMI) was linked with longer stretches of sleep at night.  The researchers focused on heritability.  Heritability basically looks at how much variation between individuals is due to genetics, versus factors like environment.  One of the most interesting findings of the study was that when participants slept for only 7 consecutive hours, the heritability of BMI was more than twice as large as the heritability of BMI when participants got 9 uninterrupted hours of sleep.  This means that the heritability of body weight decreased as sleep duration increased.

The study was made up of 1,811 sets of twins with an average age of 37-years-old.  The researchers gathered the participants weight, height, and normal sleep habits through a survey.  The participants were on average categorized as slightly overweight, with an average BMI of 25.4 and on average slept 7 hours and 11 minutes each night.  The findings led the researchers to determine that not sleeping for long enough seems to increase expression of genes involved in regulating body size.

The team at the Colorado Bariatric Surgery Institute finds this study interesting because since sleep duration is largely under our own control, it is potentially a modifiable risk factor for obesity.

So remember that getting a good amount of sleep at night is a great way to work towards better physical and mental health!

STOP, THINK and CHANGE

(is not just a behavior curriculum for elementary children with impulse control)

 

STOP the shame ….     STOP the negative thoughts ...

STOP the tape recordings:

“You can’t”  …. “You won’t” …….

“I should have ….. could have …… would have…”

STOP 

“Be vigilant; guard your mind against negative thoughts.”  ~ Hindu Prince Gautama Siddharta

You are NOW ready to build the new YOU after bariatric surgery                                                (even if It took you a minute to get there or you need to start again)

THINK

Why you chose to have surgery ……

 

YOU KNOW …..

 

SO

PLAN, SEARCH, ORGANIZE, GET SUPPORT

And then transition your

THINKING

into

 

 

Getting pregnant after having a weight loss surgery like the lap-band or the gastric bypass surgery may be somewhat frightening.  There are many questions that may arise and it is very important to do some research and talk to your physician before considering having a baby. What you should know is that you can get pregnant, and it can be a healthy, wonderful experience. Just so you are prepared, here are some things to know about pregnancy after weight loss surgery.

1. You may get a boost in fertility
Bariatric surgery can produce a sudden positive change in your fertility. A report in a November 2005 issue of the Journal of Obstetric, Gynecologic, and Neonatal Nursing found that women with fertility problems linked to obesity who have the surgery can start ovulating regularly for the first time in years.
Important caveat: This newfound fertility can raise your chances of getting pregnant by accident if you haven't been using birth control — a problem if you're in the initial 18-month post-surgery period (see below).

2. You should wait 18 months before getting pregnant
It's safe to get pregnant after bariatric surgery — after your weight stabilizes. After surgery, your body goes through potentially stressful changes and significant nutritional upheaval, which can pose problems for a growing baby.
To protect women and their babies from potential malnutrition, doctors recommend that women not get pregnant until 18 months after surgery. A report in a November 2005 issue of the Journal of Obstetric, Gynecologic, and Neonatal Nursing explained that getting pregnant at least 18 months after surgery reduces the "potential for maternal and fetal malnutrition and small-for-gestational-age infants." By then, Schauer says, a woman should have reached a stable weight and be able to provide her baby

3. You'll need to monitor your nutrient intake closely
Even past the initial post-surgery period, many women have nutritional deficiencies that can be problematic during pregnancy. A study in the April 2006 issue of the American Journal of Medical Science found that the most common nutritional complications associated with bariatric surgery are deficiencies in B12, iron, calcium, and vitamin D. In some cases, post-surgery patients can experience protein-calorie malnutrition and fat malabsorption. After surgery, many women eat as few as 500 calories a day and often have to take extra vitamins to compensate for the ways in which their bodies no longer metabolize nutrients.
It may be extra difficult to get the nutrients you need during pregnancy because of nausea — a common post-surgery complication that morning sickness can exacerbate. If nausea has killed your appetite or you can't keep food down, talk to your healthcare provider about antinausea drugs that you can safely take during pregnancy.
To make sure you and your baby are getting enough nutrients, see your dietitian, who's knowledgeable about weight-loss surgery. You should also have your provider check your vitamin levels regularly. They may suggest that you take additional vitamin supplements.

4. You may need to educate your ob-gyn
Since the weight-loss surgery boom is relatively recent, many ob-gyns don't know how to treat women who've had it.
If you've had weight-loss surgery and you recently got pregnant or want to get pregnant, start the ball rolling by talking to all your healthcare providers early. This will give them a chance to do some research and have the most up-to-date facts at hand when caring for your health.

5. Your risk of complications drops, but doesn't go away
A 2005 study in the journal Obstetrics and Gynecology found that women who had weight-loss surgery developed pregnancy-induced hypertension and gestational diabetes at rates similar to those of healthy-weight women who'd never been obese or had weight-loss surgery.
But since many women who get weight-loss surgery are still plus-size to some degree when they become pregnant, moms-to-be can expect their doctors to keep a closer watch on their pregnancies, says Sharon Phelan, an obstetrician in Albuquerque, New Mexico, who has treated many plus-size women during pregnancy, including women who have had weight-loss surgery.
"You're still at risk for gestational diabetes [if you're plus-size but have had weight-loss surgery], but the risk is far less than before surgery," says Phelan.

6. You may face a body-image battle
One of the biggest emotional effects of pregnancy for post-surgery women, says Phelan, arises from body image. Not only does a woman have to get used to the idea that her belly will grow again, but she may also have some scars from the surgery that don't stretch very well as she grows.
"Psychologically, a lot of women who've had surgery to lose weight have a very hard time accepting that they have to gain weight," says Phelan. "They have to get comfortable with the fact that 'Yes, now is the time to gain weight.' Another emotional part of pregnancy is that it's stressful and people tend to eat when they're stressed."
So women run the risk of going to extremes — either dieting while pregnant, which can have serious nutritional consequences for the baby, or gaining back some of the weight they lost because they're eating more food. There's also the problem of food pushers, Phelan notes. These are the people who, seeing you're pregnant, say, "Go ahead, have another slice of cake!" 

7. You're more likely to have a cesarean
Pregnant women who've had bariatric surgery are more likely to end up with a c-section, according to a 2004 study published in the American Journal of Obstetrics and Gynecology. It's not clear exactly why this is the case and what factors are involved, but it helps to talk to your healthcare provider.
Does your provider consider you at high risk for a c-section, and if so, why? Ask about your provider's c-section rate and  philosophy about c-sections in general. If you have no serious health problems, is the provider fine with trying vaginal delivery? During a vaginal delivery, what might cause your provider to order a c-section intervention?
Also, you may be able reduce your odds of having a c-section by following your doctor's weight-gain recommendations, exercising during pregnancy, and taking childbirth preparation classes.

 

Erica Van Hamme, RD