Maintaining your health during a period of rapid weight loss can be a challenging task. It requires thought and care even when moderate weight loss is under way but can be dangerous when dramatic weight loss occurs. It is crucially important to have a coach and a support system in place so that you have the advantage of guidance and encouragement along the way. A center that includes nutritional counseling is a necessity.
Many changes occur with weight loss and they range from a mild shift in calories consumed to a complete shift in the metabolic machinery of your liver depending on the circumstances. With diet and exercise alone these shifts are more subtle and relatively easy to modify and control. The options to dieting and exercise are obviously extensive and too great to go into here. We will focus on the changes that occur as a result of surgical procedures.
LAP-BAND®/ REALIZE BAND™
The adjustable gastric bands that are available function by limiting the amount of food consumed. It is this adjustability that can be a great asset or a potential liability in an individual’s efforts to lose weight. The perfectly adjusted band alerts the individual to a sense of fullness and satiety at a modest volume of food such that the individual stops taking in further foods at that moment. The overly adjusted band can lead to vomiting, reflux, swallowing difficulties, food intolerance and in some cases physical damage to the stomach. An inadequately adjusted band can lead to inadequate weight loss, overeating and frustration.
Multiple factors influence the success of a patient with an adjustable gastric band. One of the most important factors is the mental approach that the patient maintains towards food intake. Have they chosen more dense foods like meats, vegetables and fruits and as a result become satisfied with a relatively small volume, or have they chosen foods that seem to “go down more easily” and are more readily consumed (more calories and less food value) like yogurt, crackers, sugared drinks and desserts?
It is the realization that the patient must still make thoughtful food choices in order to use the band as the tool it was meant to be that determines the degree of success.
Assuming that just having the band and tightening it is the answer is completely false. The message that the band sends to the brain when the pouch is full must be listened to in order to be successful. If the patient’s response is “I’d like to fit just a few more bites of that pie” or “I wonder how much of _ I can eat” then the benefit of the band is vastly diminished and inferior weight loss will be achieved. When this message of working with the band is lost, poor eating behaviors result and the outcome will be disappointing.
The changes that should occur after adjustable gastric band placement begin after the initial post-operative period has been completed. A general rule of thumb has been to allow the tissue beneath the band and surrounding the band to be allowed to adapt to the presence of the band and to form adhesions that may solidify it’s position. This varies according to the surgical program but often requires 2 weeks of a liquid diet followed by a gradual reintroduction of solid foods. Nausea and vomiting is to be avoided and spicy foods are best delayed for some time. As the diet resumes, emphasis should be placed on consuming protein-containing foods, usually in the range of 60 grams per day. This focus on protein replaces stores of proteins within the patient’s body that are used as fuel during the initial period after band placement. It minimizes fat and carbohydrate intake, sources of calories that are less desirable during a diet.
As solid food resumes it is important to realize that food must be chewed much more thoroughly and must be eaten more slowly. As the patient experiences the adjustment process, the capacity of food for each meal will decrease and the speed a patient eats and the size of each bite will become more and more important. A good vitamin and sound nutritional counseling will be essential to making the most out of the surgery. Although the risk of vitamin, mineral or other deficiencies is low with the band, it can happen.
A potential downside of the adjustable band is the historically poor performance of the band when this philosophy is not adhered to.
The dietary changes that accompany the gastric bypass are significantly different than those with the adjustable gastric band. The pouch created with the bypass is a fixed volume and there is no adjustability. Because of this, the focus for nutrition changes to that of making sure efficient use of the pouch is practiced in order to maximize health while the weight loss is occurring. Now, instead of avoiding foods, a patient must make efficient use of the limited space the pouch affords for food.
Now a patient must learn to eat to preserve their health. This means a heavy emphasis on protein, initially only in liquid form, and then as time passes, a gradual shift to solids. It is very important to begin with liquid protein so that the pouch is not stressed and damaged. This stress can result in a leak - a potentially devastating complication. As the weeks go by and more and more food is introduced, it is important to realize that liquid protein should not stop altogether, but continue so as to supplement the solid protein intake. When rapid weight loss occurs, a patient's body must mobilize its resources to meet its energy demands, and this includes some breakdown of muscle mass called “lean body mass”. Without adequate protein intake, a patient will not be able to keep up with this muscle loss and the wrong kind of weight loss will occur. As the diet progresses and more foods are introduced it is critical to maintain a fixed volume of food (measure) and avoid eating until completely full (unless this means stopping before the allotted volume has been reached). Unmeasured food intake over time is the leading cause of weight regain and will lead to stretching of the orifice that leads out of the stomach pouch and into the newly attached small bowel.
The redirection of food to the small bowel (the Roux limb) results in several changes in digestive function. One of these is the relative intolerance of concentrated carbohydrates (sugars) and the resulting cramping, diarrhea, and sometimes lightheadedness known as “dumping”. This is not a complication of the surgery but rather a planned consequence that discourages the intake of these types of foods. Another effect is a loss of efficiency in absorbing iron and calcium from the diet by redirecting the food away from the duodenum, a segment of bowel that normally absorbs these nutrients fairly well. As a result, careful attention must be paid to testing for and supplementing these minerals indefinitely. Another particularly beneficial result of this redirection of food is the improvement in the hormonal regulation of diabetes. This mechanism is not completely understood yet but is being examined carefully.