Restriction: the Holy Grail

Restriction seems to be the Holy Grail of bandsters, a sacred thing that we hunt for with a level of passion and persistence that we may never have experienced before in our lives. In our minds, restriction is endowed with the magical power to make us lose weight. But exactly what is it?

THE MEANING OF RESTRICTION

We bariatric patients use the word "restriction" in every other sentence we speak, write, or think, but do we truly understand what it means?

In my 50+ pre-op years, the word restriction basically meant "no can do" or "you can do it, but within externally-imposed limits." To use extreme examples, that means "Thou shalt not kill" (no can do) or "Drive no faster than 55 mph on this stretch of road" (55 mph being the imposed limit).

Keeping those examples of restriction in mind, it's reasonable to say that a restrictive WLS procedure is one that allows you to eat, but in quantities no greater than ½ cup at a time (or whatever your surgeon's food amount limit is). That's clear enough, isn't it?

It's clear, but it's not specific enough to ensure safe and effective use of the "restrictive" WLS tool called the adjustable gastric band. For one thing, it implies that the band comes equipped with a monitoring feature, like the radar guns used by police to measure the speed of passing cars. It doesn't make it clear that the only monitoring feature that will work safely with the AGB is a conscientious, hard-working patient's conscious mind. Surgeons and patients who aren't aware of this aspect of the band are headed for accidents such as stuck episodes, PB's, sliming, esophageal or stomach dilation, band slips, or weight loss failure.

IS RESTRICTION JUST A MARKETING TERM?

The adjustable gastric band was first approved for use in the USA in 2001. Over a decade later, we are just now beginning to understand the true function of the band. A decade of struggle and learning has gone by. Eleven long years! How could that happen?

When the adjustable gastric band was first marketed in the USA, it was positioned as a restrictive WLS procedure. In the world of marketing, a product's "position" determines how its features and benefits are communicated to customers and how they compare to similar products in the market. When introducing a new automotive vehicle to the market, an automobile manufacturer must present it in a way consumers will understand: Is it a sedan or an SUV? Is it a sub-compact or a full-size vehicle? A car or a truck?

Manufacturers of medical devices like the adjustable gastric band must also educate their customers (surgeons) and end-users (patients) when they market a new product. They ask themselves: Is this a completely new concept? How can we make customers understand it and want to buy it? What other products on the market can we compare it to? In the case of the AGB, Allergan compared it to other bariatric surgical procedures: RNY (gastric bypass, which combines restriction and some malabsorption), DS and BPD (duodenal switch and bilio-pancreatic diversion, which combine restriction and a lot of malabsorption) and VSG (vertical sleeve gastrectomy, considered a restrictive procedure). The AGB doesn't cause nutrient malabsorption, therefore it fell into the restrictive category.

As a result of this perfectly ordinary business approach, thousands of surgeons and their patients were not fully informed about the mechanism through which AGB patients lose weight. It's quite possible that even Allergan didn't fully understand at the start just how the band works. If the makers of medical devices and pharmaceutical products waited until every last detail is known about a new device or a drug, some life-saving products might never reach the people who most desperately need them.

So for the last decade, we all believed that the band is supposed to restrict the amount of food we can eat and cause weight loss through reduced caloric intake, but that's changing now. In the past few years, Allergan has refined the band's market position and has been teaching surgeons that it should not be used as a restrictive device. Allergan, Endo Ethicon, and the bariatric medical community are realizing that a patient who eats until she or he "feels" restriction is far too likely to experience complications. They are coming to the understanding that the band's chief weight loss mechanism is reduced caloric intake through the reduction of hunger and appetite, with early and prolonged satiety after a small amount of food is eaten.

IF IT'S NOT RESTRICTIVE, WHAT IS IT?

So if the AGB is not a restrictive WLS procedure, what the heck is it? How can we explain it without using the word restriction?

A better term for the true function of the AGB might be something like "optimization" - the process of modifying a system to make aspects of it work more efficiently, use fewer resources, and/or produce the most beneficial results. In a bandster, the system is made up of several important components: the band, the saline fill, the bandster's food choices and exercise level, with a few parts that are so top-secret, nobody knows what they are. Optimization is a clumsy-sounding word, though, and it makes the bandster sound like a machine instead of a human being. For the time being, we don't have a better term than restriction, so we'll go on using it until something better presents itself.

HOW CAN I FIND IT IF I DON'T KNOW WHAT IT LOOKS LIKE?

How will you recognize restriction? If you were hunting for the Holy Grail, you could equip yourself with a picture of a chalice to guide you, but there's no picture of restriction. Don't kid yourself into thinking that a fill under fluoroscopy (x-ray) is going to yield a picture of your very own restriction. That x-ray image is just a snapshot of part of a living, breathing, changing human body, and while it might illustrate a theoretically good fit on the band on the stomach, it cannot illustrate what's happening in your nervous system. It can't track the production of hormones that triggers hunger or satiety messages between your brain and your body.

To recognize, utilize, and safeguard your restriction, you're going to have to start paying attention to dozens of things that you took for granted or didn't even know existed before. I don't go on and on about eating slowly just because it helps prevent unpleasant side effects, but because it's mighty hard to pay attention to your body's signals when you're gobbling your meal.

I didn't realize this until perhaps 6 months post-op. Until then, I was eating carefully only to prevent stuck episodes, PB's, and sliming. Very gradually, over the next 6-12 months, I learned to listen to my body, not just when I was eating but between meals. It wasn't until after my 15th fill, at almost 3 years post-op, that I had mastered mindful eating enough to actually enjoy my experience of restriction. Three years is a long time, but don't let that scare you. I lost 100% of my excess weight with far less "restriction" than I had at 3 years post-op. And when you remember that I spent over 50 years eating carelessly and excessively, changing my eating in only 3 years is pretty good!

So, what signs of restriction you should be looking for?

1. Early satiety after eating a small portion of food. You lose interest in eating, feel that another bite would just be too much, and/or feel a sudden distaste for the food.

2. Prolonged satiety after eating a small portion of food. You are not physically hungry, and have no appetite (desire to eat) for several hours after you eat. How many hours? It's going to vary by person, and will be affected by many factors, such as food choices (solid versus liquid, for example). For me, 3-4 hours is a very long time to experience satiety and I'm delighted by that. Another person might not care to eat again for 5-6 hours after a meal.

3. Reduced appetite. You're just not as interested in food as you used to be. You think about it less and you might even forget to eat. The food may not even taste as wonderful as you remember it.

4. Reduced physical hunger. You're just not as hungry, and not hungry as often, as before.

All that sounds marvelous, doesn't it? A dream come true! It is indeed, but it's also very complicated because the human body and human behavior are very complicated. We're constantly changing, in changing circumstances. While our unconscious brain and body are trying to communicate hunger and satiety, our conscious brains and our lifetime habits are also at work. So even though you weren't especially hungry for that chicken dinner at 6 pm, it's quite possible that a phone call from a troublesome family member will trigger some comfort eating at 6:15 pm, or that boredom will send you looking for snacks at 8:00 pm, or that craving will send you looking for chocolate at 9:00 pm.

OBEY THE STOP SIGNALS!

Stop signals aren't there just to make you late for work. They're there for your protection. Some of the worst car accidents in my town happen at a major intersection on a busy road where some drivers seem to be ignoring the stop signals. As those drivers are sped away from the scene in the back of an ambulance, I wonder how badly they're hurt or whether they'll survive. I think it's good that our town has installed cameras at that intersection.

Stop signals are equally important to bandsters. How?

In addition to the 4 signs of restriction explained above, you will also get hints to stop eating that I call "stop signals". As newly-filled or newbie bandsters, we expect our bands to give us good, loud, clear stop signals with clanging bells and flashing lights, but eventually learn (if we work on it) to recognize the quiet stop signals such as mild queasiness, fullness or pressure in the back of the throat, difficulty swallowing, burping (or the urge to burp), sneezing, sighing, hiccups, watering eyes, runny nose, and so on. If we heed those signals, we stop eating before something more drastic and uncomfortable happens. You may not experience any soft stop signals, but don't stop looking for them just because you aren't noticing any; they could sneak past you at any time. And if you experience no hard stop signals (like stuck episodes, PB's, sliming), don't go looking for trouble! The absence of hard stops does not mean that your band isn't working. It means you’re doing a good job!