Jean McMillan

You're very welcome. You've probably noticed by now that humor makes my world go 'round!

I used to cringe when I saw photos of Fat Jean, but now I want to hug that unhappy girl and tell her that life is good. When I look in the mirror now, I see a "normal" sized woman who strangers would never guess had once been morbidly obese. I think we all need to remember where we came from, and to forgive ourselves for our pre-op weight loss failures. But halfway through the first sentence of this article, I thought of an equally important aspect of Memorial Day that turned this article's theme upside down. The meaning of "lest we forget" is more complicated than you might think. It represents more than three sappy words and planting a flag and a geranium on your grandfather's grave. It expresses an important message for a bariatric patient like me and you. The phrase "lest we forget" forms the refrain of "Recessional," a poem by Rudyard Kipling (1865-1936). It warns about the perils of hubris and the inevitable decline of British imperial power. After World War l, "lest we forget" passed into common usage as a plea not to forget past sacrifices and was often used on war memorials and as an epitaph on tombstones. So it’s an appropriate title for a Memorial Day article. Hubris is the extreme haughtiness, pride and arrogance that makes us think we're as invincible and all-powerful as Great Britain thought it was back in the days when it was taking charge of big countries (India) and small (Singapore) all over the world. One of my jobs in life is to resist the urge to be conceited about my weight loss success and to remember that I’m not invincible. I don’t ever want to lose sight of the fat girl deep inside me who's just waiting to get out again. Losing 100 pounds is such an enormous accomplishment that at times it seems like the most magnificent and significant achievement of my entire life. I'm justifiably proud of that achievement, but having weight loss surgery is not a guarantee of continued weight loss and weight maintenance success. As a boss once told me on the occasion of my promotion to management, "Remember, you're only as good as your last act." In other words, my great performance won me a place on the stage, but I'm going to have to repeat that performance over and over again in order to stay on the stage. WLS is a wonderful tool that will improve my ability to manage my weight for another 30 or 40 years, but it doesn't make me bullet-proof. Weight loss is no longer the centerpiece of my life, and I think that's a healthy thing. Some days I even ask myself why I'm still writing about eating, obesity and weight management. Why can't I let go of it? What will happen to me if I run out of things to say about it? But while I'd like to know the future, or at least know it will be a happy one, a long, straight road with the same scenery for mile after mile sounds boring to me. I'll stay on this road, with its twists and turns and steep hills, and trust God to keep me from getting too far off course. Writing about obesity is one of the things that keeps me going in the right direction. When other bariatric patients ask me questions about how to live and succeed with the adjustable gastric band, it forces me to think, and being forced to think is much healthier, and more interesting, than switching on the cruise control for the rest of my life. Along the road to your weight goal, I hope that you, too, will be able to acquire new interests and activities that you can take with you into your new life as a "normal" weight person, but don't forget to look backward every now and then. Don't throw out all the fat photos and fat clothes. They're memorials to your past obesity.

If you’re once a fatty, are you always a fatty? THINK THIN, BE THIN I think I’m well qualified to speak on this subject, since once upon a time my schoolmates chanted, “Fatty, Fatty, two by four, can’t fit through the kitchen door!” when I walked into the gymnasium for a physical education class with a teacher who, after weighing and measuring each kid, announced to her captive audience that Jean was the shortest and heaviest girl in the class. After which I was the last kid (once again) to be chosen for a volleyball team. I believe that in order to become a thin person, we must learn to think like one. It’s a tall order, I know. You might as well ask my dogs to learn to think like cats (I’m pretty sure my cats can think like dogs, but it doesn’t seem to work the other way around, to the everlasting detriment of the dogs). At the same time, I believe that we must never forget our inner fat person. If we do forget, the fat folks may burst out of us and take over again. I know mine did last year, for six months and 30 pounds of regain. She was aided and abetted by the loss of my beloved Lap-Band®, but once she was out of her cage, she took charge so fast it made my dizzy blonde head spin. That’s not a pretty sight when that head is busy gobbling all the food in the western hemisphere and the body attached to it is rejoicing, “Starvation has ended at last! It’s party time!” (which is what my gastroenterologist said my metabolism was doing, although not in those exact words). I lost the weight I had regained, plus another 10 pounds. I know (or I hope) I don’t look like a fatty any more, but a fatty still lurks inside me somewhere. My fat demon is hidden from view, but she’s still my demon. Exactly what every girl needs, along with a good bra and a good hairdresser. Seriously, though, my fat potential lives on, mainly because obesity is an incurable, chronic disease that no surgery today can cure. As long as my inner fatty threatens to take over, it’s hard for me to think and act like a thin person. But I refuse to give up the quest for Thin Jean, and I strive every day to emulate her. I believe that practicing thin behavior will eventually teach me thin thinking, and I believe that practicing thin thinking will keep my body thin. FAKE IT UNTIL YOU MAKE IT We have now arrived at the bad-tasting course in this home-cooked meal of advice. In order to practice thin thinking, we need to do things that we’ve done over and over again in the past without long lasting results, like making good food choices, practicing portion control, and exercising. I know that this concept frustrates many of us and infuriates some of us. Some people scorn the practicing part of the WLS journey. They say, “It’s just another diet.” A friend of mine declared a week before her band surgery, “I refuse to diet.” Perhaps it’s a matter of semantics or personal preference, but I persist in believing in the importance of practice because thin thinking and thin acting don’t come naturally to me. I wasn’t born with piano-playing skills. I had to take lessons and practice every day just to be able to play “Chopsticks”. Even famous concert pianists must practice every day. The same is true of being thin. This reminds me of the “fake it until you make it” slogan repeated in 12-step groups. The 12-step tradition recognizes that sobriety or abstinence doesn’t come naturally to people with addictive tendencies. It doesn’t expect its members to leap from the first to the 12th step in one week, one month, or even one year. All it asks is that we practice desirable behaviors every day, day after day, while the struggle to do that gradually lessens and we gain some control over the undesirable behaviors. Eventually we discover that we don’t have to “white knuckle” it anymore because the desirable behaviors have become habits. Assuming that you had WLS because you don’t want to be a fatty any more, I’d like to suggest that you begin by not eating like a fatty any more. You don’t have to do it perfectly, because you’re just practicing, right? As far as I’m concerned, you can leave the perfection stuff to God. All you need to do is do your best, day by day, to work with your strengths and work around your weaknesses. Even if practice doesn’t always make perfect, it’s got to help you with the fake it part until you get to the make it part. Yes, it’s a lot of work, but you can do it!

Are you afraid of an unhappy outcome of your weight loss surgery? You're not alone. Use your fear to conquer obstacles rather than letting it conquer you For most of us starting a WLS journey, bariatric surgery is vast, uncharted territory, full of unknowns. We long for a happy outcome – maximum weight loss with minimum problems. We listen to stories told by other patients with a combination of hope (to be as successful as they’ve been) and fear (that we won’t experience the side effects or complications they talk about). No one wants to be haunted by the specter of anxiety and dread, but I think a little bit of fear is a good thing. I don’t want fear to dominate my life, but without it, I’m likely to become complacent about my weight loss success and/or revert to the old, all-too-comfortable ways that made me obese in the first place. In small doses, fear keeps me on my toes. Like pain tolerance, fear tolerance varies from one person to the next. Perhaps I’m able to tolerate and use fear because my childhood and adolescence were so full of fear-provoking experiences. By the time I was in my late 20’s, I actually got a little thrill out of fear, possibly because it stimulates adrenalin production. There’s nothing quite like a knife coming at you to activate your fight-or-flight system, causing a perverse fear “rush”. At the same time, prolonged exposure to fear has also taught me to respect it. I don’t play with fear the way daredevils like Evel Knievel did, risking life and limb for the brief thrill of jumping 14 buses at a time with his motorcycle. But I do like the way fear can clear my mental field, forcing me to draw a line between important and unimportant. When the choice is survival or surrender, I’d rather choose survival. I’m not a quitter. When challenged, I’m going to fight back, especially if something precious like my health is at stake. If fear tends to paralyze rather than mobilize you, you may have to use your own compass to navigate a problem, or play follow-the-leader (provided you have a trustworthy leader) instead. Whatever you do, don’t give in. Giving in turns you into a victim (click here to read an article about victim mentality: http://www.lapbandta...-of-obesity-r79), which is not a position of strength in any battle worth fighting. And your health is worth fighting for, isn’t it? So, how can you make fear a working partner in your WLS journey? Let’s take a closer look at two of the more common faces of fear. FEAR OF FAILURE Somewhere between my first, mandatory pre-op educational seminar and my pre-op liver shrink diet, I became uncomfortably aware of a shadow that followed me everywhere. It was dark and scary, and even bigger than I was. It was my fear of failure. After decades of struggle – diets, weight loss, weight gain – I felt that WLS was my absolute last chance to be healthy. And after slogging through all those pre-op tests, evaluations, consults and procedures, I danged well was not going to fail this time. Since I had to admit that my weight management skills were sadly lacking back then (as amply proven by the number on the scale and the numbers in my medical files), the only option available to me was to become the most compliant patient my surgeon ever had (click here to read an article about patient compliance: http://www.lapbandta...g-deal-abo-r112). I had to believe that he and his staff knew what they were doing and would guide me well. I’m a very curious and often mouthy person, so I asked a lot of questions and did my best to understand what was going on in me and around me, but I spent very little time trying to second-guess the instructions I was given. That approach freed up a lot of time and energy that I was then able to devote to changing my eating and other behaviors in ways that helped my weight loss. FEAR OF COMPLICATIONS Compliance served me well I this area also. I can’t claim that I was never tempted to cheat on my pre or post-op diets or to test my band’s limits. I can’t claim that I believed I’d be forever exempt from the side effects and complications I heard about from other WLS patients. But when my dietitian told me (for example) that I’d be mighty sorry if I accidentally swallowed a wad of chewing gum and had to have it scraped out of my stoma, I quickly lost my interest in chewing gum. When I observed that many bandsters experienced certain types of side effects and complications after engaging in certain types of risky behaviors, I resolved not to follow them down the road of no return. Eventually I discovered that life after WLS can deliver some unpleasant surprises, just as in every other aspect of life. I had to learn some things the hard way, like: If you swallow a large antibiotic capsule that can’t pass through your stoma and slowly dissolves into a corrosive mess, you will end up in the ER thinking you’re having a heart attack (and end up with a big unfill). And no, liquid antibiotics don’t taste good, but they taste a lot better than the weight I regained after that unfill. Most of the mistakes I made were the result of impatience or carelessness, but I did my best to learn from those mistakes and keep moving on. A handful of mistakes was about all it took for me to decide not to challenge the validity of my surgeon’s and dietitian’s instructions, and that kept me trudging along the bandwagon trail, getting ever closer to my weight goal. And once I reached that wonderful place, I was determined to stay there!

Your surgeon's comments are very interesting, and explain a bit more about the phenomenon of how microscopically different fills in the same size band in different patients can have such different effects on the patient. I have to say, for the sake of bandsters reading this thread whose surgeons do not routinely do fills under fluoroscopy, that while fluoro fills can help ensure a tolerable and effective fill level, they don't guarantee it. I have never had a fill under fluoro and don't feel that my band's effectiveness was compromised because of that. Fluoro gives the radiologist or surgeon a snapshot of your esophagus, band and stomach at one point in time. A few hours or days or weeks later, the effect of that fill can feel quite different because of perfectly ordinary physiological events and processes, including hydration, hormones, time of day, allergies, medications, etc. etc. Often bandsters get what seems to be a "perfect" fill under fluoro and a few weeks later feel as if they didn't get a fill at all. The stomach expands and contracts to aid digestion by breaking food down into pieces that can be absorbed properly by the intestines, and that necessary movement can affect the position of the band enough to affect the patient's experience of restriction. Also, as you lose weight, the visceral fat clinging to the stomach shrinks, so that your band feels looser and you need more fill. And finally, a new fill can feel extra tight in the first few days but feel less tight as the patient learns to adjust their eating skills to accommodate the new fill level. Also, bandsters can get what seems to be a perfect fill and hours or days later find themselves struggling even to drink liquids. That can be because the fill itself, and the newly increased pressure of the band against the stomach, can cause enough irritation to cause the patient discomfort. Eventually the band settles more comfortably against the stomach, everything calms down, and life goes on. Jean

Lauren, Have the fills and unfills been done to deal with side effects or complications? I've experienced long weight loss plateaus as well as weight regain during my 5+ year WLS journey. I do know how frustrating it is. Personally, I think it's too soon for you to give up on your band, and the potential for weight regain will be just as real after a revision as it is now. WLS does not cure obesity, it only treats it. From my perspective, the only advantage the sleeve has over the band is that it doesn't require fills. It is what is is the moment you're wheeled out of the OR...whether you like it or not. No possibility of fine-tuning or adjusting, and 75-80% of your stomach is gone forever. I wrote about my band-to-sleeve revision experience in a length blog post, here: htp://jean-onthebandwagon.blogspot.com/2013/03/a-lot-of-people-especially-those.html: Good luck! Jean

Can you remember doing anything unusual or that would put extra strain on your abs? Have you talked to your surgeon or fill person about this? My port flipped and I had no symptoms. I didn't know what was happening until my surgeon's NP had a harder and harder time accessing my port for fills. I wouldn't wish a port flip on anyone, but in the grand scheme of things, it's a relatively minor blip. My port flip was fixed with same-day surgery. Not fun, but totally worth it because when I was able to resume fills afterwards, my appetite and physical hunger nose-dived.

De nada!

I'm sorry to hear that you're having to deal with this. You're contemplating a big decision that could have a big consequence, and making the "right" WLS choice can be overwhelming. Sometimes I think that's aggravated by doing so much research online - you're overloaded with information and it all seems confusing. I've had both the band and the sleeve, so I'm uniquely qualified to respond to this thread. Because my response is so lengthy, I'm going to give you a link to a blog post I wrote about this a few months ago. http://jean-onthebandwagon.blogspot.com/2013/03/a-lot-of-people-especially-those.html I think the bottom line is this. When contemplating a medical decision, it's just not possible to accumulate and process every tiny piece of data that could influence that decision. We have to make the best decision we can based on the information available to us at the time. If the problem we're having isn't acute or life-threatening, we have more time to consider the best course of action, but that doesn't mean our choice is guaranteed to work out perfectly. If you have more questions that you don't feel comfortable posting on the forum, send me a private message and I'll do my best to answer or to send you in the right direction. Good luck! Jean

Allergan, maker of the Lap-Band® and many other medical devices, made the bariatric headlines on October 30, 2012, when a news article (click the link below to read it) revealed that they’re considering selling the Lap-Band® part of their business. I don’t have all the details behind the story, but I do have plenty of opinions about it, so I’m sharing those opinions with you in this article. http://www.reuters.com/article/idUSL3E8LU46K20121030 BIG NEWS IN THE BAND WORLD On October 30, 2012, a Reuters article revealed that Allergan is considering selling the Lap-Band® to another medical device company due to declining sales of the band. Not surprisingly, this news has caused some excitement in the bariatric surgery community. When I first read the article, my immediate thought was that I don't have enough information to make it the subject of an article of my own. I'm still missing a lot of information, but have plenty of opinions about it (which can come as no surprise to you), so I've decided to give you my opinions with you in this article from today’s special edition of the Bandwagon® on the Road e-newsletter. ALLERGAN PEDDLES THE BAND I have a hard time drawing any conclusions (pro or con) about the band itself based on the Reuters report. The decline in Lap-Band® sales could be the result of management or other business problems rather than due to a problem with the band itself. It's highly unlikely that Allergan will ever reveal the whole story to anyone but their team of attorneys and board of directors. So, what could this hot news story mean? As you read on, please remember: these are only personal opinions from an ex-bandster who’s fairly well-informed but not a medical professional and in no way associated with Allergan or any other medical device or other company in the world of bariatric surgery. For what it’s worth, here’s my take on the story. The US economy is in tough shape, the popularity of bariatric surgery in general is leveling off, and insurance coverage for bariatric surgery is still a challenge. Allergan is not alone in this - Johnson & Johnson must face the same challenge in marketing the Realize™ Band. The story of what's really behind all this is clouded by the reactions of the media and of band-bashers who sing the "I told you so" song because they assume (without any credible basis at this point) that Allergan's decision is related to the safety and/or efficacy of the band. SO, WHAT’S THE REAL STORY? All the other bariatric surgery procedures now performed in the USA can have serious complications and failure rates, but it's easier to point the finger of blame at a single manufacturer of a medical device than it is to blame the thousands of surgeons who are doing bariatric procedures that don't happen to use a medical device. The FDA isn't looking over the shoulders of all those surgeons the way it scrutinizes Allergan or Johnson & Johnson. When Dr. John Doe stops doing bariatric surgery and goes back to yanking out gall bladders, no one leads a parade down Main Street waving banners about the dangers of the procedures Dr. Doe was doing. Except in rare cases (such as the sad story of my original surgeon), nobody's even discussing Dr. Doe's surgical expertise or behavior. It's an example of what I call the David & Goliath Syndrome. A big company like Allergan is an easy target thanks to its size and visibility. The general public may step on Dr. Doe's fingers but otherwise will kick him to the curb in eagerness to throw rocks at Allergan. One of the hurdles facing any manufacturer of an adjustable gastric band is that it is (in my opinion) the bariatric procedure that requires the most patient education, aftercare, and support. In the 5 years since I was banded, I have encountered plenty of evidence of bariatric clinics doing a great job of that, but I've also encountered clinics that are failing at it, to the detriment of their patients. Not because they're doing something wrong, per se, but because they're directed by a surgeon (or team of surgeons) who was trained to think of surgery of any nature as an in-and-out deal. They're used to seeing the patient 3 times: a pre-op visit; in the operating room (with an unconscious patient); one post-op visit; and never again unless the patient experiences a complication that requires more surgery. That's fine when the surgery involves removing a gall bladder or a mole or a wisdom tooth, but it's a set-up for failure with band patients. The bariatric surgeon who vetted Bandwagon told me several years ago that the band manufacturers make few demands on the surgeons or clinics that buy their products because they don't want to marginalize the customers who don't follow the manufacturer's advice but have acceptable patient outcomes. Avoiding marginalization of customers is a smart business decision but a poor medical decision, and I think it's a mistake for us to view surgeons only as super-wealthy, super-powered medical demi-gods anointed by a Supreme Being and the ASMBS. They're also customers, and just like you and me when we're shopping for a new car, they're looking for a product that has reliable quality and performance at a price they can live with. They are business people who want to make money (to pay their staff, their malpractice insurance premiums, their colossal student loans, and their kids' college funds). Sure they want to practice the art (and science) of medicine, but they can't do that very well if they can't pay their bills. Finally, keep in mind that someone, somewhere is going to end up with the Lap-Band in some form. It is highly unlikely that Lap-Band® research & development, its technology and FDA approval, to say nothing of the existing customer base, will drop to the bottom of the bariatric pond and never be seen again. Both Allergan and the new owner will legally and ethically have to stand behind their product, with the details of that worked out to the last detail by teams of expensive attorneys and insurance companies. Even surgeons who stop doing band surgery to concentrate on other procedures will still have the basic skill and knowledge to provide fills and other aftercare to their band patients. Although I lost my beloved band in April 2012, I do not regret having Lap-Band® surgery and if I were starting my WLS journey today, I would ask my surgeon's opinion about the Allergan decision and also ask how (or if) it will affect his/her practice. The answers to those questions would be towards the top of a long list of questions I'd be asking before deciding to have surgery. And if I still had my band, I'd be asking my surgeon the same questions so that I could go forward with some degree of comfort (if not 100% satisfaction) that I'd have someone to turn to should I need band help in the future. I most certainly would not be rushing off to make an appointment with the Speedy Weight Loss Surgery Revision Center, or at least not until I'd done plenty of homework on the procedures offered by the quacks at Speedy. Trading in a car just because it's 2 years old has never made sense to me, and if it isn’t broke, why fix it? Although my journey from Lap-Band® to vertical sleeve gastrectomy ended up taking 6 months, I'm still nagged about it by a little doubting voice, especially when my sleeve is giving me trouble. Should I have chosen the sleeve, or not? Should I have risked the return to morbid obesity, or gamble on more surgery? There are no easy answers to questions like that. If there were a cure for obesity, I'd be first in line for it, but until that cure is invented, I'm making the best of what I've got.

You're very welcome. I think that the eating skills we learn as a result of WLS can become ingrained in us to help us manage our weight for the rest of our lives. But I know from my own experience of having 2 complete unfills and then losing my band that I had been taking for granted all that my band had been doing for me.

Want to know what no one else will tell you about life with the band? The NITTY GRITTY of WEIGHT LOSS SURGERY Nobody can predict the course or outcome of your weight loss surgery, but I’m going to try anyway, starting with a simile that most of us can understand. WLS is like a marriage, with your band as your lifetime partner. At times you’ll thank your lucky stars you found each other. At other times you’ll wish you’d never met, never mind married. You’ll never walk alone again, but you alone will be captain of your ship. You will lose weight and gain a new lifestyle, but some of your losses and gains will be bittersweet. You’ll wonder what on earth you got yourself into, as well as why on earth you didn’t do this a long time ago. Most of all, you’ll scratch your head and say, “Why didn’t anyone tell me how much work this would take?” I’m not telling you all this to scare you. A little fear is fine if it makes you a compliant patient, but I don’t want fear to rule you. I just want to remind you that like every other human endeavor, the WLS journey has ups and downs. I believe that my band surgery saved my life and I’ve never regretted my decision to do it, but I can’t claim that every moment of my journey has been sunny and carefree. If you don’t want to hear about the tough stuff, that’s fine. You have my permission to move on to another article (preferably one by me). But if you want to hear about some of the things I wish I’d known at the start of my journey, read on. Knowing these things in advance wouldn’t have changed my WLS decision, but it sure would have helped me stick it out more easily when my weight goal seemed a million miles away. 1. The band is not magic. There is nothing in it that – hey, presto! - will make you lose weight. Changing your eating behavior and lifestyle, plus dozens of other factors that vary from one person to the next, will make you lose weight. 2. Your band won’t do all of the work. If you don’t (metaphorically) grab hold of it and use it as a tool, it will be about as useful as a cordless drill without a battery. 3. For most people, the band doesn’t start working right away. As a new post-op, surgical swelling and/or a small “primer” fill may or may not kill your appetite (desire to eat) and physical hunger (physical need to eat), but most bandsters need several fills to get the weight loss going, and more fills after that to keep it going. 4. If you don’t eat carefully, will you will suffer temporary, extremely uncomfortable side effects that can, if ignored, turn into permanent, expensive, and unhappy complications. 5. Once you achieve an optimal fill and restriction level (which will last for 30 seconds, 30 minutes, 30 hours, but probably not for 30 years), your restriction is very likely going to vary, for reasons too numerous to explain here. In this area you must remember that the human body is alive and always changing, whereas the adjustable gastric band is inert and changes only with the addition or subtraction of fluid. One day you can hardly eat, the next day you can eat anything and everything, and the day after that, you can eat just the right amount (remember Goldilocks and the Three Bears?). 6. Restriction may also vary according to the time of day (or time of month, if you’re of the female persuasion). Morning “tightness” is very common, and it may limit your morning food choices. That is not, however, a good excuse for skipping breakfast and thereby depriving your body of the fuel it needs, and doing so can set you up for a monster binge when hunger suddenly hits you at 11:38 a.m. So you will have to be willing to stay flexible, try new foods, and practice patience (which is something I have to practice every day in every way anyway). 7. You will have to deal with restriction even when you wish you had none at all, when you’re at a party or on vacation or sitting down to Thanksgiving Dinner at Mom’s overloaded dining table. At times you will want to go on eating because the food tastes so good, but you’ll have to stop because you physically can’t eat more, and because eating more would cause uncomfortable and undesirable side effects (to say nothing of weight loss plateaus or regain). That experience of food “deprivation” has been very frustrating for me. Not every day, not at every meal, but often enough to remind me again and again that my upper GI tract is no longer the free and easy party girl it once was. That reminder is often a good thing, but sometimes it makes me want to put my fingers in my ears and chant, “I can’t hear you, Stomach!” 8. This next piece of WLS Nitty Gritty is such a big, important one that I left it for last so that it will (I hope) stay burned into your brain a good, long time. NO WEIGHT LOSS SURGERY OF ANY DESCRIPTION WILL KILL THE EATING DEMONS IN YOUR HEAD. Vanquishing, subduing or managing those demons is something you’ll have to do yourself, possibly with the help of a counselor or support group, with daily practice for the rest of your life. But that’s OK, because you are worth all that effort.

Does the reward & punishment approach really help your weight loss? REWARD & PUNISHMENT Yummy food rewards for good behavior, and severe punishment or deprivation for bad behavior, go back a long way in my psyche. With every good intention, my mom trained me using the classic reward-punishment technique from the time I was a very small girl. As soon as I was old enough to think for myself – at age 40 or so (just kidding!) – I applied the same technique to managing (or should I say mismanaging) my weight. Even a tiny infraction of whatever diet plan I was following at the moment was punished severely with hours, days, or weeks of self-loathing and recrimination which would be followed by much bigger eating crimes (I’m a hopeless screw-up because I ate a donut yesterday, so I’m going to eat a dozen donuts today) or by extreme deprivation (I ate a donut yesterday, so I’m going to eat nothing at all today, and if I’m a very, very good girl, I’ll earn half a carrot stick as my reward tomorrow). I learned a bit about behavioral science in college, and goodness knows I’ve read enough self-help books and articles to have picked up a thin smattering of knowledge about it, but none of it meant very much to me until the past five or six years. As I moved towards my weight loss surgery decision, I had to admit that the good girl, bad girl system had not been working very well for me. I just couldn’t seem to responsibly give myself one “cheat” a week as recommended in women’s magazines. The authors of these magazine articles claimed that one serving of cheesecake on Sunday would keep me from bingeing out of desperate deprivation for the rest of the week, but one serving was never enough for me. I guess I’m an all-or-nothing kind of gal, and for me, the only alternative to eating an entire cheesecake was to (mentally) beat myself with heavy chains and a medicine ball covered with spikes. Neither approach yielded the results I wanted, but what other way is there to live as a responsible, law-abiding adult? Without laws and law enforcement, don’t we suffer the chaos and degradation of anarchy? POSITIVE & NEGATIVE REINFORCEMENT Sad to say, I’ve learned more about reward and punishment from living with dogs than from living with myself. I can plainly see that screeching at them for bad behavior is more likely to get them cranked up than to get them to behave. They have taught me that a positive or negative response to a behavior, be it good or bad, reinforces the behavior. We humans are not doing ourselves any favors by punishing our own “bad”, negative, or counter-productive behavior with more negative behavior. All that does is reinforce the bad stuff and use up all the extra energy we really need for the good stuff. When all we hear is an internal voice crying, “bad girl!” (or “bad boy!”), eventually we become resigned to being a bad girl (or boy, as the case may be), and the bad stuff goes on and on. Nor are we doing ourselves any favors by molly-coddling ourselves after an eating infraction. You say you don’t do that? Well, I sure do. I eat five cookies off the plate on the break room table at work, sigh, and grab a sixth cookie while thinking, “It’s just too hard to resist those cookies, you’ve had such a trying day, you deserve a treat, you poor thing.” That kind of response also reinforces the very behavior that’s can keep me from maintaining my hard-won weight loss goal. The reward-punishment cycle is hard to stop when it’s so deeply ingrained in us, but it is possible to end or at least reduce the occurrence of the negative stuff. One of the things that’s helped me regain control over my eating behavior (on many levels) is keeping a food log. Entering my food intake (including time of day, amounts, the eating environment, my physical hunger, any eating problems, and how I felt emotionally before, during, and after eating) has forced me to put on my scientist hat. I’ve always thought of myself as an intuitive, creative person, not a scientific one, but sometimes when I act a part, I become a part. When I’ve written down all this data about my eating, it’s easier for me to see it with an objective eye. Patterns that are invisible to me when I’m in the middle of a situation become clear when I’ve backed far enough away from it. Things that I didn’t understand when they happened to me yesterday have new meaning when I study them today. Things that I don’t really want to understand also become clearer to me when I see them in my food log. For example, after my weight loss surgery it became increasingly difficult for me to eat when sharing a meal with my elderly mother. Twenty years earlier, eating with her was a joy because we both loved food and the conversation that surrounds a meal. As she grew older, fussier, more confused, more demanding, the joy drained away and I found myself in the middle of painful stuck episodes every single time we ate together. A few hours after each incident, I would find myself seeking comfort in food, like stopping at Baskin-Robbin’s for a 670-calorie Cappuccino Blast after leaving Mom in the capable hands of her assisted living facility staff. I loved my mom, I loved our old ritual of enjoying meals together, but it just wasn’t working any more. Time to make a change, Jean! After that realization, when it was time for a family meal, I spent the time fussing over Mom instead of trying to eat my own meal. I ate my meal later, when Mom was safely tucked in bed. The take-home message here is this. Try to avoid the extremes of “good girl, bad girl” thinking, not just in your eating but in your exercise, work, parenting, and anything else you undertake. Sometimes a little bit good can be good enough, and a little bit bad doesn’t necessarily signify the collapse of western civilization. Try to be a kind, tolerant, but firm parent to yourself. Instead of screaming, “Bad girl!” when you fall off the bandwagon, give yourself a boost back up onto the wagon by saying, “That wasn’t good, but I know you can do better, so go prove it.”

When traveling on a puree diet, I also like to order thick, creamy soups like crab bisque. For breakfast you can usually find yogurt and cottage cheese, but I bring protein powder with me just in case. I buy milk at the hotel shop or a nearby convenience store, mix it with the powder, and I'm good to go. Just ignore the dessert menu with all the exotic ice cream or gelato flavors!

Did you know that full-service restaurants have at least one blender or food processor on hand and can puree your food if you ask nicely?

You are absolutely right that surgeons' protocols vary widely, but anesthetizing a patient in order to perform an expensive, risky, surgical "rescue" that could more easily and safely accomplished with an inexpensive, safe, non-surgical approach (upper GI study & complete unfill) sounds like bad medicine to me. Sometimes I hate the way the insurance industry manipulates the American medical system, but there's a lot to be said for their "choose the conservative option first" approach. If nothing else, it's more consistent with the Hippocratic Oath which bids doctors to "do no harm."

Eating like a fatty is your decision, one that your band can do nothing about. I don't recommend doing a liquid diet unless it gets you out of a sugar or carb addictive cycle. Nothing is going to shrink your stomach (with the possible exception of vertical sleeve gastrectomy surgery, in which about 80% of the stomach is permanently removed). Liquids just do not provide the satiety (the sense of having eaten enough food, which is quite different from feeling "full") that solid foods do, so on a liquid diet you'll be physically hungrier and (if you're anything like me) feeling very deprived. If you go ahead and do a liquid diet, you're going to need a sensible eating plan for when you're done with the liquids, because if you go back to eating like a fatty, your future band success doesn't look promising. I agree with Tom that a meeting with a dietitian is in order.

The NITTY GRITTY of WEIGHT LOSS SURGERY Nobody can predict the course or outcome of your weight loss surgery, but I’m going to try anyway, starting with a simile that most of us can understand. WLS is like a marriage, with your band as your lifetime partner. At times you’ll thank your lucky stars you found each other. At other times you’ll wish you’d never met, never mind married. You’ll never walk alone again, but you alone will be captain of your ship. You will lose weight and gain a new lifestyle, but some of your losses and gains will be bittersweet. You’ll wonder what on earth you got yourself into, as well as why on earth you didn’t do this a long time ago. Most of all, you’ll scratch your head and say, “Why didn’t anyone tell me how much work this would take?” I’m not telling you all this to scare you. A little fear is fine if it makes you a compliant patient, but I don’t want fear to rule you. I just want to remind you that like every other human endeavor, the WLS journey has ups and downs. I believe that my band surgery saved my life and I’ve never regretted my decision to do it, but I can’t claim that every moment of my journey has been sunny and carefree. If you don’t want to hear about the tough stuff, that’s fine. You have my permission to move on to another article (preferably one by me). But if you want to hear about some of the things I wish I’d known at the start of my journey, read on. Knowing these things in advance wouldn’t have changed my WLS decision, but it sure would have helped me stick it out more easily when my weight goal seemed a million miles away. 1. The band is not magic. There is nothing in it that – hey, presto! - will make you lose weight. Changing your eating behavior and lifestyle, plus dozens of other factors that vary from one person to the next, will make you lose weight. 2. Your band won’t do all of the work. If you don’t (metaphorically) grab hold of it and use it as a tool, it will be about as useful as a cordless drill without a battery. 3. For most people, the band doesn’t start working right away. As a new post-op, surgical swelling and/or a small “primer” fill may or may not kill your appetite (desire to eat) and physical hunger (physical need to eat), but most bandsters need several fills to get the weight loss going, and more fills after that to keep it going. 4. If you don’t eat carefully, will you will suffer temporary, extremely uncomfortable side effects that can, if ignored, turn into permanent, expensive, and unhappy complications. 5. Once you achieve an optimal fill and restriction level (which will last for 30 seconds, 30 minutes, 30 hours, but probably not for 30 years), your restriction is very likely going to vary, for reasons too numerous to explain here. In this area you must remember that the human body is alive and always changing, whereas the adjustable gastric band is inert and changes only with the addition or subtraction of fluid. One day you can hardly eat, the next day you can eat anything and everything, and the day after that, you can eat just the right amount (remember Goldilocks and the Three Bears?). 6. Restriction may also vary according to the time of day (or time of month, if you’re of the female persuasion). Morning “tightness” is very common, and it may limit your morning food choices. That is not, however, a good excuse for skipping breakfast and thereby depriving your body of the fuel it needs, and doing so can set you up for a monster binge when hunger suddenly hits you at 11:38 a.m. So you will have to be willing to stay flexible, try new foods, and practice patience (which is something I have to practice every day in every way anyway). 7. You will have to deal with restriction even when you wish you had none at all, when you’re at a party or on vacation or sitting down to Thanksgiving Dinner at Mom’s overloaded dining table. At times you will want to go on eating because the food tastes so good, but you’ll have to stop because you physically can’t eat more, and because eating more would cause uncomfortable and undesirable side effects (to say nothing of weight loss plateaus or regain). That experience of food “deprivation” has been very frustrating for me. Not every day, not at every meal, but often enough to remind me again and again that my upper GI tract is no longer the free and easy party girl it once was. That reminder is often a good thing, but sometimes it makes me want to put my fingers in my ears and chant, “I can’t hear you, Stomach!” 8. This next piece of WLS Nitty Gritty is such a big, important one that I left it for last so that it will (I hope) stay burned into your brain a good, long time. NO WEIGHT LOSS SURGERY OF ANY DESCRIPTION WILL KILL THE EATING DEMONS IN YOUR HEAD. Vanquishing, subduing or managing those demons is something you’ll have to do yourself, possibly with the help of a counselor or support group, with daily practice for the rest of your life. But that’s OK, because you are worth all that effort.

Hmm. Sounds familiar. I got a similar talking-to from my surgeon last fall! It's hard for me to recognize when I'm obsessing and over-thinking things, and I tend to anticipate disaster if I can't control every little detail or calorie.

That's awful. I'm not clear on how you had anything in your stomach to aspirate into your lungs? You were you allowed to (or able to) eat before your surgery and while recovering, despite the nausea, vomiting, and other symptoms? Where was your surgery done? Did they not give you anti-nausea meds?

RUN, SPOT, RUN! The phrase "sweet spot" pushes me into my swirling stream of consciousness, where I hear: Sore spot, hot spot, weak spot, sweet spot. Spot the dog. Run, Spot, run! That's what the bandster sweet spot does. It runs ahead of us, wagging its tail, taunting us, "When you catch me, you're gonna lose weight like never before! But first you gotta catch me!" And off it goes again, dangling that precious weight loss carrot just out of reach while we follow, huffing and puffing and worrying that we may never catch our errant Sweet Spot. What if we don't? Will our weight loss surgery be a waste of time and money? Sweet spot. Just two words. Short words, endearing words, simple words, but loaded words. For such a little phrase, the sweet spot is a very big deal. But is it real? Is it even possible? I can think of other little phrases that are also big deals, and after several decades as a voting citizen of the United States of America, I have to wonder if they're just a dream. World peace. Cancer cure. Justice for all. Sweet spot. THE ELUSIVE SWEET SPOT The concept of a sweet spot was unknown to me until I shortly after my Lap-Band® surgery. It's not a term exclusive to bandsters. In tennis, baseball, or cricket, a swing will result in a more powerful hit if the ball strikes the racquet or bat on its "sweet spot". In the world of music recording, the sweet spot is the focal point between two speakers, where a listener is fully capable of hearing the stereo audio mix the way it was intended to be heard by the mixer. In general terms (that might make more sense to those of us who are athletically or musically challenged), a sweet spot is a place where a combination of factors results in a maximum response for a given amount of effort. That's exactly what we're hoping for when we have weight loss surgery, isn't it? After years of useless struggle and unsuccessful dieting, we want to expend the least possible effort for maximum weight loss results. Unfortunately, there's a trick phrase hidden in the paragraph above: a given amount of effort. It's not “no effort”. A given amount of effort…but an undefined amount. How much effort? How long, how often? Does making the sweet spot work for us take an hour a month, a week, a day? In Bandwagon, I wrote that the sweet spot is a myth that does bandsters a great disservice because it's a mistake to think of restriction as a single point (or sweet spot) on a line. Let's pretend that you've found your sweet spot. It looks like the diagram above. Can you balance on it indefinitely, like the green triangle poised on one precarious corner? I couldn't. All it would take to knock me off that little spot is a strong breeze, and if I had to devote all my attention to keeping my balance, I wouldn’t be able to make good use of the imperfect but quite useful areas to the left and right of my sweet spot. It’s more useful (and balanced) to think of restriction as a range, not a single point, with the sub-optimal yellow zone (not enough restriction) to the left and the sub-optimal red zone (too much restriction) to the right. According to Allergan, the band's optimal performance is in the middle “green zone,” where to greater or lesser degrees you experience early and prolonged satiety and reduced appetite and hunger. Now let’s try thinking of restriction as a river or stream that flows along, sometimes slowly, sometimes fast, and sometimes it's quite still. If you try to catch that river water in your hands, crying, "This is it! My sweet spot!" the water will run through your fingers. If you step into the stream, your restriction is with you all the time, sometimes optimal, sometimes sub-optimal, but always there. DOWNSTREAM WITH JEAN Does my stream analogy sound too much like something Yoda would tell Luke Skywalker? I'll climb out of the stream now, shake off the water, and tell you about my own "sweet spot" experience. The #1 thing I want you to know is that you can lose weight without ever catching hold of your sweet spot. I lost 100% of my excess weight (90 pounds) in my first year post-op, with far less restriction than I had later on. Except at the very beginning, when everything about banded life was a mystery to me (including the Green Zone poster at my surgeon's office), I didn't have a lot of anxiety about whether or not I'd found my sweet spot because I was losing weight without even knowing what my sweet spot looked like. I didn't have to starve myself or take diet pills or any of my rarely effective pre-op weight loss techniques. My band was most definitely helping me even though sometimes I felt as if I didn't have a band at all. As time went on, I sometimes took my band for granted, and only when I had to have unfills to treat symptoms of careless eating or overeating did I realize how much my band had in fact been doing for me. After each unfill, my appetite and my physical hunger immediately increased, which both scared and pleased me. As in many things, it was a matter of perspective. One day I whined about getting hungry 3 hours after eating and being able to eat 1 cup of food. The next day (after the unfill) I whined because I got hungry 1 hour after eating and was able to eat 2 cups of food. There's a popular saying that claims you never appreciate what you have until it's gone, and that's certainly true for me. Hearing my story, you might want to argue that before those unfills, I had reached my sweet spot and just didn't know it. That's entirely possible. After all, how would I know what the weight loss sweet spot looked or felt like? I'd never been there, never held it in my hot little hands - I probably wouldn't recognize it any more than I'd recognize the mayor of Kansas City or the invisible line where the Eastern time zone ends and the Central time zone begins. Of course, one of the reasons we choose WLS is to make losing weight easier. When people criticize WLS patients for "taking the easy way out", I want to laugh and then scream. Of course I chose the easier way, that's the whole danged point! But at the same time, it's not as easy as you might imagine. It's not magic! Losing weight "the hard way" hadn't worked for me, so it wasn't unreasonable of me to want my band to work perfectly right from the start. If it didn't work that way, I really can't complain (much). After all, I didn't learn how to ride a bike, multiply 9 x 7, or play the piano on my first try either. And if I'm completely honest, I'm not sure I would have been able to handle it if I arrived at my so-called sweet spot the day after my surgery or even after my first fill. One of the reasons most surgeons administer fills in small amounts over a period of weeks or months is so the patient can gradually become accustomed to the change in their body and eating, and thereby avoid unpleasant side effects and complications. If I had walked out of the hospital on September 20, 2007 with as much restriction as I had 3 years later, and with virtually no practice of band eating skills, I would've been calling my surgeon the next day, crying, "Take this thing out of me!" Since I'm an extremely stubborn person, I needed plenty of time to adjust to everything going on in my life after surgery. In the year it took me to reach my weight goal, I learned perhaps 50% of what I needed to know to manage my weight for the rest of my life. I hadn't once heard the Sweet Spot bells chiming, but I was mighty happy with myself and my band. I had changed a lot, in my mind, heart and body. Just standing in that river of restriction, going with the flow, was such an enormous improvement over my pre-op life, all I could feel was gratitude.

Your a good aunt to worry about him, but as long as he can't see or admit that he's obese, there's not much anyone can do about it. Very sad.

I didn't delineate morbid obesity from obesity in this article for 2 reasons: (1) I don't think that's necessary when the essay's audience (LBT members) consists of people who are already intimately familiar with obesity criteria and are/were obese enough to qualify for WLS. In other words, I'd be preaching to the choir. And (2) The system currently used by insurance companies and the medical professional to identify obesity and morbid obesity is based on the BMI. The BMI calculation was developed by a statistician as a way to classify weight, wasn't intended to be used as a medical criteria, and doesn't take into account some important factors that skew the validity of a person's BMI - for example, that men have greater muscle mass and that Asians have lesser bone density. In my opinion, focusing on the BMI in evaluating a person's weight is a mistake.

The people who've responded to your question all mean well, but none are medical professionals. Nor am I. I just want to reinforce that you should call your surgeon, and until you've gotten some guidance from him, I suggest that you stick to a liquid diet to avoid irritating your esophagus, stoma and stomach any further. Good luck, and let us know what happens. Jean

Wow. You do your own un-fills? Were you a medic when you were in the service? What kind of needle do you use, and where do you buy it?