February 2008

Don’t Abandon the Basics — Maximizing Success with the Adjustable Gastric Band
By Kathryn M. Lito, MPH, RD, LD
Today’s Dietitian
Vol. 10 No. 2 P. 40

From food preparation to texture, patients who have undergone a gastric band procedure have much to consider when it comes to making the dietary adjustments necessary for success.

As the obesity trend continues, surgical solutions have become more prominent. Gastric bypass surgery has been an option for patients since the 1960s and is the most commonly performed operation for weight loss in the United States.

Since the introduction of the LAP-BAND System in 2001, an increasing number of individuals struggling with obesity have joined the bandwagon (pun intended). This option appeals to those who desire a less invasive, adjustable, and reversible alternative compared with other options.

The laparoscopic adjustable gastric band (LAGB) is a purely restrictive procedure. It consists of a silicone band lined with an inflatable inner balloon connected by tubing to an access port placed beneath the skin of the abdomen. Placing the band around the upper part of the stomach, just below the esophagogastric junction, partitions the organ into two compartments: the small pouch above and the remnant stomach below. The size of the stoma between the two compartments is adjusted through the addition or removal of saline through the access port. As saline is added, a smaller stoma is created, slowing the passage of food and increasing restriction. Patients lose weight by eating less total calories while not feeling deprived.

Sounds easy, right? Not necessarily. As with all other weight loss surgeries, food choice, behavior modification, and a commitment to make enduring lifestyle changes are crucial to success. Obesity surgery was not designed to serve as a bandage or quick fix for obesity. Sustained weight loss, alleviation of comorbidities, and improved quality of life can only be achieved via permanent changes.

This article discusses key points to review with your banded patients to maximize their postoperative success. Many of these key points should be repeated throughout the preoperative, perioperative, and postoperative phases to help keep patients on track.

Consider Composition
Patients must be observant of the texture of their food choices. Liquids will always pass more rapidly across the banded area than solids; therefore, liquid sources of calories should be strictly limited. This includes regular soda, juice, alcohol, and any sugar-sweetened beverages. Fried, greasy foods, often referred to as sliders, have a tendency to empty quickly from the pouch due to their slippery nature. Foods to shy away from include French fries, chips, fried meats, and greasy, cheesy foods often served at Mexican restaurants. Another texture to be wary of is that of “soupy” foods such as high-fat, creamy soups, ice cream, and high-fat dips such as queso and ranch dressing.

Instruct patients to wait approximately 90 minutes after finishing solid meals before drinking fluids to prevent foods from exiting the pouch too quickly. Encourage your patients to choose foods that have “natural bulk” such as those rich in protein, complex carbohydrates, and unsaturated fats. To help patients remember this guideline, teach them to choose “protein and produce” at meals such as lean meats, beans, eggs, salads, and other tolerable vegetables and fruits. These foods will remain in the pouch for several hours after the meal, leading to increased postprandial satiety and decreased hunger.1

Garth Davis, MD, a bariatric surgeon and star of TLC’s Big Medicine, has been performing LAGB surgery for 11/2 years. “Organic whole food like fruits, vegetables, and lean meats are the staple of a good diet. Processed foods break down easily and thereby slide through the band too easily. For instance, crackers, ice cream, etc, can go right through the band, especially when we keep the band loose enough for a piece of chicken to get through,” he says.

Speaking of Chicken…
One common food intolerance many LAGB patients encounter is to dry meat. It is important that patients learn the basics regarding appropriate cooking methods, preparation, seasoning, and selection to create moist and tender meats. Since protein is a macronutrient that we ask patients to consume at all meals, we want the meat eaters to be able to do so without difficulty.

Dave Fouts, a renowned bariatric chef, offers the essentials in bariatric cooking to pass along to patients.2 He recommends using dry cooking methods such as rotisserie, roasting, grilling, broiling, and sautéing for meats such as chicken, beef, pork, lamb, and fish and meats with a higher percentage of fat to retain moisture. Moist cooking methods such as stewing, braising, poaching, and boiling should be used for leaner cuts of meat and fish. (See Table 1 for further explanation of these cooking methods.2,3) Since fish can be prepared with dry or moist cooking methods, it is a versatile protein source that is typically well digested. When in doubt, clients should order the fish.

One of the most important points to emphasize to patients is not to overcook meats. A meat thermometer helps prevent overcooking, which would result in a dry, tough piece of meat. (See Table 2 for common food temperatures.4) Fouts recommends marinating meats in an acidic marinade for four hours to overnight. A marinade will not only infuse flavor but also break down muscle tissue. A typical marinade consists of an acidic liquid to tenderize, seasoning to add flavor, and oil to add moisture. A quick, homemade marinade he recommends consists of a citrus fruit (eg, orange, lemon, lime), a seasoning (eg, oregano, salt, pepper, garlic), and olive oil.2

For patients who have limited time to spend in the kitchen, options include buying premarinated meats, purchasing a rotisserie chicken, using canned meats (eg, chicken, tuna, salmon, crab) for meals, and crock pot cooking. When dining out, Fouts encourages patients to order fish and expensive cuts of meat. “The expensive cuts such as the tenderloin, rib eye, and top loin are all muscles that are worked the least and contain the most marbling of fat between the muscle to help baste the meat as it is cooking,” he explains. While these cuts will be higher in fat, keep in mind that the patient will be eating only a small portion of it.

Don’t Bypass Breakfast
To maintain consistent, permanent weight loss, patients should incorporate a morning meal into their diet. Research from the National Weight Control Registry, the largest prospective, ongoing study of long-term successful weight loss maintenance, reveals that 78% of their participants eat breakfast every day.5 For many banded patients, a solid breakfast is difficult to tolerate, and many complain of feeling “tight” in the morning. If this is the case, encourage patients to drink a balanced liquid meal replacement. They can purchase ready-to-drink varieties for convenience or make their own at home. Drinking a warm beverage in the morning before breakfast, such as tea or coffee, may help alleviate some tightness, especially if it is due to phlegm or mucus buildup in the stoma.

Keep It Real
It is important that patients have realistic expectations regarding anticipated weight loss and the time frame in which to achieve their goal. Weight loss success is measured by percent excess weight loss (%EWL). A collection of studies on banded patients in the United States have shown %EWL ranging from 39% to 50% at one year, 43% to 61% at two years, and 51% to 65% at three years.6-9 Some European and Australian studies have demonstrated 47% to 60% EWL at four years and beyond.10-13 To put that into perspective, if a patient who has 100 pounds to lose has lost 45 pounds within the first year, he or she would be considered successful by United States data standards.

Let your patients know that it will most likely take them a couple of years to reach their goal weight. Emphasize the notion that the weight did not come on overnight; therefore, all will not be immediately lost. Also, stress the concept of permanence. As the majority of patients will say, “Diets don’t work.” They have all experienced the yo-yo phenomenon and are looking for a permanent solution, which the band can certainly aid in providing. However, the band cannot function alone. I often describe the patient/band relationship as one of symbiosis—one cannot work effectively without the other. The band cannot create weight loss on its own; thus, the patient is responsible for making appropriate changes. Likewise, the patient, while choosing nutrient-dense, naturally bulky foods, relies on the band to be responsible for keeping portion sizes in check while taming hunger. The patient is in charge of quality while the band is in charge of quantity. Together, they can reach desired goals.

One Is the Loneliest Number…
Some patients can have success without the help of others, but I would venture to say those individuals are few and far between. When counseling, be sure to ask patients whether they have an adequate support system of family, friends, coworkers, etc. If your program offers support groups, be sure to invite them to attend, even before the surgical event. Participating preoperatively will help them prepare for surgery while establishing a solid support network.

Support is not only intended for those who lack it at home. All postoperative patients, whether they experience smooth sailing or a bump in the road along their journey, can benefit from a support group. Studies have demonstrated the effect that support groups have on weight loss. Specifically, Elakkary et al found that LAGB patients who attended more than 50% of biweekly meetings over 12 months achieved more weight loss than nonattendees.14 “Support groups can foster correct eating patterns and compliance, improve psychosocial outcomes, and identify the need for further counseling,” the researchers conclude.

Monica Tweel Agosta, PsyD, a psychologist specializing in weight loss surgery, says, “Support, whether it be in a group or individual setting, is vital following bariatric surgery. In order to address issues associated with eating habits, plateaus, emotional struggles, changes to relationships, etc, it is very important patients have access to a support network that is familiar with obesity and weight loss surgery, months and even years after the procedure.”

In today’s technologic age, online support groups are becoming more common. Our program offers online support in addition to our live meetings, and it has been popular. This may be something you and your team of experts may want to launch to keep everyone connected and provide support that can be accessed at all times.

Tighter Is Not Better
Talk to your patients about the importance of proper band adjustment. Oftentimes, we encounter patients who believe “the tighter, the better.” As Figure 1 illustrates (see below), patients who have too much saline in their band are at greater risk for developing maladaptive eating behavior, including increased intake of soft or liquid foods (eg, ice cream, chocolate).15 These textures will pass easily through the excessively narrow stoma. Oftentimes, this maladaptive eating leads to weight loss plateaus. I review this chart with patients to help them understand when and why adjustments are necessary. I also stress the importance of paying attention to their body and looking for signs of needed adjustments to promote safe and steady weight loss.

Figure 1
Band Adjustment Chart

— Figure reproduced with permission from the Australian Centre for Obesity Research and Education

D.I.E.T.
Having weight loss surgery is not equivalent to dieting. Our patients equate dieting with failure; therefore, we need to help them transform what the word diet means. One definition I like is Develop Intelligent Eating Techniques. I often hear preoperative patients say they struggle with their weight because they lack discipline and willpower. One of my goals as an educator is to teach patients that weight management has little to do with willpower and more to do with skill power, strategies, and intelligent eating techniques. It is important to review helpful skills such as meal planning, nutrient-dense convenience foods to have on hand, tips for dining out, and pointers for holiday eating.

The Big Picture
These topics are not exhaustive of everything to review with your banded patients; however, they are significant to achieving success. In my experience, the patients who have the best weight loss success are those who view and utilize the band as a tool in their efforts to make permanent lifestyle changes. As practitioners, it is our job to educate and reinforce this notion to patients over and over again, as making true lifestyle changes does not happen overnight. Amy Freeman, an active participant in our program, has lost 84 pounds since her surgery in December 2006. “Learning my limits and what I could tolerate was a difficult period. My new way of eating did not really sink in until five months after being banded. The band restricts food intake and helps by making some foods impossible to eat, but it is still a dietary life change,” she says.
I couldn’t have said it better myself.

— Kathryn M. Lito, MPH, RD, LD, is the program dietitian for the University General Hospital bariatric program in Houston. She has been counseling weight loss surgery patients for more than two years, both preoperatively and postoperatively.

Bariatric Resources for RDs
American Society for Bariatric & Metabolic Surgery: www.asbs.org

Bariatric Nutrition Dietitians Yahoo! Group: health.groups.yahoo.com/group/BariatricNutritionDietitians

Bariatric Times: www.bariatrictimes.com

BariMD: www.barimd.com

References
1. Favretti F, O’Brien PE, Dixon JB. Patient management after LAP-BAND placement. Am J Surg. 2002;184(6B):38S-41S.

2. Brieter A, Fouts D. Culinary essentials to maximize dietary intake for post operative bariatric patients. Presentation of BariMD Ask the Experts; October 11, 2005.

3. Allergan Summer Newsletter 2007. Available here. Accessed September 19, 2007.

4. USDA Food Safety and Inspection Service, FDA Center for Food Safety and Applied Nutrition. Use a food thermometer. September 2002. Available here. Accessed October 6, 2007.

5. Wyatt HR, Grunwald OK, Mosca CL, et al. Long-term weight loss and breakfast in subjects in the National Weight Control Registry. Obes Res. 2002;10(2):78-82.

6. Holloway JA, Forney GA, Gould DE. The Lap-Band is an effective tool for weight loss even in the United States. Am J Surg. 2004;188(6):659-662.

7. Galvani C, Gorodner M, Moser F, et al. Laparoscopic adjustable gastric band versus laparoscopic Roux-en-Y gastric bypass: Ends justify the means? Surg Endosc. 2006;20(6):934-941.

8. Spivak H, Anwar F, Burton S, et al. The Lap-Band system in the United States: One surgeon’s experience with 271 patients. Surg Endosc. 2004;18(2):198-202.

9. Cottam DR, Atkinson J, Anderson A, et al. A case-controlled matched-pair cohort study of laparoscopic Roux-en-Y gastric bypass and Lap-Band patients in a single US center with three-year follow-up. Obes Surg. 2006;16(5):534-540.

10. Suter M, Calmes JM, Paroz A, et al. A 10-year experience with laparoscopic gastric banding for morbid obesity: High long-term complication and failure rates. Obes Surg. 2006;16(7):829-835.

11. Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg. 2002;12(4):564-568.

12. O’Brien PE, Dixon J, Brown W, et al. The laparoscopic adjustable gastric band (Lap-Band): A prospective study of medium-term effects on weight, health and quality of life. Obes Surg. 2002;12(5):652-660.

13. Angrisani L, Lorenzo M, Borrelli V. Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial. Surg Obes Relat Dis. 2007;3(2):127-132.

14. Elakkary E, Elhorr A, Aziz F, et al. Do support groups play a role in weight loss after laparoscopic adjustable gastric banding? Obes Surg. 2006;16(3):331-334.

15. Dixon JB, O’Brien PE. Permeability of the silicone membrane in laparoscopic adjustable gastric bands has important clinical implications. Obes Surg. 2005;15(5):624-629.