Jean McMillan

David Letterman isn’t the only one who composes top 10 lists. Here’s my top 10 list of the things you need to know about gastric band surgery, served with a generous helping of GJTL™ - Genuine Jean Tuff Luv™. TIME FOR SOME TOUGH LOVE? Genuine Jean Tuff Luv™? What’s that? It’s my version of the kind of love that hurts so good, because it gets you going in the direction you want to go. Stern but caring parents, teachers and coaches who maintain strict rules and demanding training regimens are said to practice tough love. Those rules and regimens may not be fun, but they can turn around kids, students or athletes who’ve gotten off track or are underachieving. Tough love may seem too severe, too tough. It works best when the parent, teacher or coach believes in, proclaims, and respects the inherent value and purpose of the person they’re trying to help. Sometimes all we need is a wakeup call to shake us out of our stupor and pull us out of a rut. The drills and discipline of tough love can help (even as they hurt) when our bandwagons have gotten lost or stalled somewhere along the way to success. A bandster once said of me, “Jean tells people the things they don’t want to hear.” I chose to take that as a compliment. Many times in my life, I’ve benefited from a slap upside the head by a concerned friend. When I do the slapping, I try to do it with just enough emphasis to get a friend’s attention long enough to deliver an important message, followed by a gentle and loving kick in the butt. So here’s my top 10 list of things you need to know about adjustable gastric band surgery. Consider yourself kicked! THE GJTL TOP TEN LIST 1. You will not wake up in the recovery room at your goal weight. Average weight loss with the band is 1-2 pounds per week, and virtually no one loses weight at a nice steady pace of (say) 1.75 pounds per week. Some weeks you’ll lose, some weeks you’ll stall and some weeks you’ll gain, but as long as the overall trend is downward, you’re doing great! 2. Slower weight loss with the band does not prevent sagging or excess skin. How your skin reacts to massive weight loss depends mostly on your genetics and your age. As we age, our skin loses elasticity. If the possibility of sagging or excess skin worries you, start tossing your change into a plastic surgery piggy bank. 3. Weight loss surgery (of any type) does NOT cure obesity. Obesity is a chronic and incurable disease characterized by relapse and recurrence. Although bariatric surgery is currently the most effective way of treating obesity, obesity is something you’re going to have to manage for the rest of your life, with or without surgery. For most of us, a tool like the adjustable gastric band makes that a lot easier, but it’s not effortless, either. 4. Most eating problems after band surgery are due to user error, and can be prevented by using good band eating skills. Read an article about those skills by clicking here: How to Eat Like a Bandster. 5. In order to decrease your weight and increase your health, you must decrease your food intake and increase the quality of your food choices and the time you spend exercising. While you may be able to lose weight for a while by just eating much smaller portions of Chicken McNuggets, potato chips, and candy bars, eventually that approach will stop working, and at the same time it will start biting your health in the butt. And though it may be difficult for you to exercise at first, each pound you lose will make it easier, and each additional hour you spend exercising will not only burn calories but improve your physical and mental health. 6. No weight loss surgery procedure will cure eating disorders, eating demons, emotional eating, boredom eating, stress eating, celebratory eating or food addiction. Changing those behaviors is your job. If it’s too hard to tackle yourself, consider getting some counseling with a therapist experienced with eating disorder and WLS patients, and/or joining a 12-step group like Overeater’s Anonymous. 7. The band rarely works without fills. Even if you initially lose weight with one or no fills, sooner or later, you’re going to have to face the fill needle. And if you’re too needle-phobic to tolerate a fill needle, why did you choose band surgery in the first place? 8. The restriction “sweet spot” is a myth. There is no such thing as “perfect” restriction, or if there is, you can’t count on it to last more than one hour, one day or one week. This is because the band is an inert silicone object implanted in a living, breathing human body that changes constantly in reaction to the time of day, time of month, time of year, hydration, illness, medication, stress, you name it. Restriction variability is part of the gastric band package. 9. There is nothing magic in the band that makes you lose weight. Changing your eating and exercise behavior is what makes you lose weight. All the band does is make that work easier for you by reducing your physical hunger and increasing your satiety. 10. YOU are responsible for your weight loss. Not your band, not your surgeon, and not the server at McDonald’s who invariably asks you, “Want to supersize that?”

I hate to rain on your parade, but a total weight loss of 50 lbs by Christmas sounds like a big stretch to me. Average weight loss with the band is 1-2 lbs/week, so 40 lbs might be do-able. And at any rate, you're doing great so far and I don't want you to conclude that you're a failure if you don't hit the 50 lb goal by Christmas. How many calories a day does your surgeon/nutritionist want you to eat? I wouldn't be panicking over eating 1000 calories a day, especially if those calories consist of healthy foods (lean Protein, complex carbs, etc.).

I stand corrected. Is the 9 cc Realize band no longer used?

Wow, these are some very specific and interesting questions from a LBT newcomer!

Thanks!

Exactly! Whatever causes our obesity, it's still our job to manage our eating and weight, and to take responsibility for our general health.

Thanks! It's funny that you mention getting your life back, because just yesterday I was thinking about writing an article about that!

I sure hope you were being sarcastic when you said that stuck episode made you happy, because judging restriction by the number of eating problems you have is a really bad idea. I've seen too many bandsters who rejoiced at frequent eating problems later cry very big tears when they learned that careless eating or a too-tight band had caused a band slip. Don't go looking for trouble!

Cutting off the port is not adequate treatment. A port site infection is very often a sign of band erosion, from bacteria traveling from the band down the tubing to the port. Band erosion requires band removal and plenty of healing time before additional surgery is performed. So cutting off the port only cuts off part of the problem. The source - your eroded band - could still be infected and getting worse. You literally could die from an untreated infection like that. So I'd be booking a flight back to Mexico ASAP. Good luck.

As the old saying goes, "laughter is the best medicine." If your brother-in-law tries to scare you again, I would clasp his hand, shake it, and exclaim, "Congratulations, Egbert! I didn't realize you had graduated from medical school. The next time I have a bad case of diarrhea, I'll be sure to give you a call."

Making you nervous is probably exactly what your dear brother-in-law intended, and I have a strong suspicion that he got his sister's story a bit mangled. When people repeat stories like "his sister almost died from the band. She lost about 100 pounds and gained it all back then she exercised like crazy and lost it again. The band slipped after she lost it the second time and her stomach rotted. She only has 5% of it left!!", I'm terribly tempted to tell my own story. Here it goes: "Jean lost 92 pounds with her band, had a band slip and a port flip, regained 25 lbs, land then a spaceship landed in her front yard and a very small Martian crawled into her left nostril, swam down about 10", put a rope around her esophagus, and pulled it tight so that her band flew out her mouth, taking 95% of her stomach with it, which her dogs then proceeded to eat with gusto while Jean sobbed pitifully..." The moral of the story being that the only incidence of a band slip and band erosion (rotted stomach) at the same time in the same patient that I ever heard was posted by someone strongly suspected (by many) of being a troll. So when it comes to the risks associated with band surgery, you need to talk to your surgeon, not your brother-in-law. Every surgery known to man carries some kind of risk. Surgical mortality with the band is extremely rare (less than 1%). Complications are possible but not certain. On the other hand, serious medical problems, including mortality, have proven association with obesity. That's why they call it "morbid obesity".

You have to wonder why she didn't give you a 10cc band in the first place. If yours is a Realize band, it's my understanding that its advantage is a greater range of fill levels. You still are nowhere near the maximum fill level, and the band can be filled beyond its official capacity if necessary, so I think it's too soon to give up on your 14cc band.

Crackers are crunchy and in small amounts, don't have the icky-sticky-gummy potential of a donut to clog things up in there. If G.W. refuses to send Dr. Weaver your records, he is breaking the law. As long as you sign a waiver, he is legally obliged to give copies of your records to her as well as to you. But I wouldn't worry about that, because it's very unlikely that he's the one that's going to make copies of your records and send them to Dr. Weaver. And if she calls his office wanting to speak to him about you, he's probably going to treat her with more respect than he does his patients, because we're all lowly slugs, while she at least has MD after her name. Dr. Weaver is extremely busy and her partner doesn't do bands, so you may have to wait a while for an appointment with her. Also, you'll probably have to pay a patient transfer fee, but it'll be worth it, I promise you.

WHY DOES WEIGHT LOSS SURGERY FAIL? In the bariatric community, we spend a lot of time debating about which WLS is the best – that is, which one yields the best outcome (my own definition of that is optimal weight loss with minimal complications). I think we can all agree that there’s no such thing as a perfect or one-size-fits-all bariatric surgery. If we’ve all fought weight battles long and hard enough to need or choose WLS, we can surely agree that obesity is tough to overcome. And that is, I think, the grounds for further agreement, about why WLS fails. Here’s my premise: weight loss surgery fails because of obesity. If you’re thinking you need not read further because you already knew that, please wait until I explain a bit more. And those of you snickering in the back of the room, simmer down. I’m a natural blonde (duh) as well as an old fogey who needs time to make her point, but like Ellen DeGeneres, I do have a point. OK, let’s continue. Some disappointment or failure can be attributed to the inadequacy of a bariatric medical device or surgical procedure or surgeon or patient, but underlying all that is the basic reality of obesity: it’s a chronic and currently incurable disease, caused by a mixture (unique to each patient) of genetics, behavior, environment and biology. Weight loss surgery may address some aspects of those factors, but not enough to cure obesity. So it fails because of obesity. In the past, I’ve given a lot of thought to how genetics, behavior, and environment have contributed to my own case, but no more than a passing glance at the biology of it. I’m the daughter of a gifted scientist who passed on not one single gene of scientific aptitude to me (instead, I got his nose and the name McMillan). I realize that saying that WLS fails because of obesity is like saying the ocean is wet because it contains water, but as with many obvious facts of life, it’s easily overlooked. We go into WLS believing or at least hoping that surgery will fix enough of what’s wrong in us to help us lose weight and maintain that weight loss, but we need to remember that no WLS will cure our obesity. We need to remember that our obesity is at least partly caused by factors that are invisible to us. Those factors were invisible to me until a few months ago, when I was asked to write a magazine article about some recent research studies that found a link between obesity and fibromyalgia. I’m uniquely qualified to write that article because I’m a veteran of both wars. When I began researching the article, I was astounded by the dense mountain of information: scientific data, theories, probabilities and conjectures that I’d heard little or nothing of before despite my exalted status as the World’s Greatest Living Expert on the Adjustable Gastric Band. I’ve had WLS, talked to dozens of bariatric medical professionals, attended three bariatric conferences, read countless books, articles, blogs and reports, but suddenly I felt like a babe in the bariatric woods. Why hadn’t either of my bariatric surgeons (never mind my primary care physician) mentioned any of this to me? Are they unaware of it? Are they hiding it from me and the rest of their patients? Is there a conspiracy afoot? This information is of enormous importance if only because it knocks a big hole in the old-school blame-the-patient approach. The paranoid in me wonders if the information is hidden to protect an industry or to further a political cause, but I put those thoughts aside and instead considered the very real possibility that bariatric surgeons are well aware of the obesity mountain but are practicing a form of medicine that circumvents it. They don’t climb the mountain and they don’t hike around it. They cut right through the middle of it. THE OBESITY OCTOPUS To explain myself now, I’ll have to resort to another simile. In a sense, bariatric surgeons treat obesity by stuffing a many-armed octopus in a sack and bludgeoning it with an axe. I’m not criticizing the surgeons. Surgery of any kind requires a breathtaking degree of confidence, skill, and audacity. Although surgery doesn’t address every waving octopus arm, it is the only effective long-term treatment for obesity available in the United States today, and I’m very grateful that I was able to have WLS and lose my excess weight as a result of it. At the same time, I sometimes worry about the future. This spring, treatment of a medical problem required removal of my band. I’ll soon have vertical sleeve gastrectomy surgery, but what if obesity takes over my life again in spite of my band and all my hard-won lifestyle changes? Are researchers working on an obesity cure now that can help me with that in the future? WHAT CAUSES OBESITY? It turns out that researchers have indeed been busy searching out the causes of obesity in the hope of finding a better way (or ways) to treat it, prevent it, and/or cure it. As I mentioned above, several studies have reported a link between obesity and fibromyalgia. It’s easy to get caught up in a chicken & egg debate about that – does one disease cause the other? I don’t want to go down that road right now. Instead I want to talk about some factors that are associated with (and may be contributing to) both conditions. They are: Non-restorative sleep – Sleep affects the production of hormones (leptin, grehlin, cortisol) that are key to the experience of hunger, appetite, and satiety. Poor sleep tends to decrease leptin (satiety hormone) production and increase grehlin (hunger hormone) production. It also seems to increase sensitivity to pain. If you have sleep apnea or another type of sleep disorder, or even subclinical sleep disturbance, it’s likely that your physical hunger is increased and your sense of satiety is decreased. The adjustable gastric band can intervene on your behalf, but it doesn’t correct the hormone production problem. Neuroendocrine dysfunction – the nervous system (neuro) and endocrine system (glands) control all physiologic processes in the human body. The nervous system works by sending messages through nerves, as if it’s a hard-wired telephone system. Nervous control is electrochemical in nature and is rapid. The endocrine system sends messages by the secretion of hormones into the blood and extracellular fluids. Like a radio broadcast, it requires a receiver to get the message. To receive endocrine messages, a cell must bear a receptor (a receiver) for the hormone being sent in order to respond to it. If the cell doesn’t have a receptor, it doesn’t “hear” or react to the message. Researchers studying neuroendocrine interactions discovered (among other things) that in fibromyalgia and obesity patients, certain cells have damaged or malfunctioning receptors for the leptin, the satiety hormone. It’s the one that tells your brain you’ve had enough to eat. So one of the reasons you rarely feel satisfied by a reasonable amount of food (or in my case, an infinite amount of food) may be that satiety messages are going astray because your cells’ in-boxes are locked or absent. Dysregulated HPA is a factor contributing to both obesity and fibromyalgia. HPA stands for hypothalamus-pituitary-adrenal, three glands (part of the endocrine system) that are crucial to healthy functioning of many bodily processes. The HPA axis is a grouping of responses to stress. When you experience stress (whether it’s physical, like an injury or illness, or mental, like a fight with your spouse), your body produces a biomarker (messenger cell) that stimulates your HPA axis. Your hypothalamus (in your brain) then sends a message to your pituitary gland (also in your brain), where it triggers the release of ACTH (adrenocorticotrophic hormone) into your bloodstream and causes the adrenal glands (on your kidneys) to release the stress hormones, particularly cortisol. Cortisol increases the availability of the body's fuel supply (carbohydrate, fat, and glucose), which is needed to respond to stress. However, prolonged elevation of cortisol levels can cause havoc: muscle breaks down, your body’s inflammatory response is compromised, and your immune system is suppressed. If you’ve ever taken a corticosteroids medication like Prednisone to treat an inflammatory problem (like an allergic reaction) or disease (like lupus), you’ve probably learned the hard that it can turn you into a bad-tempered eating machine. Inflammation, as mentioned above, is another culprit in both chronic pain and obesity. A European study of showed that obese rats have chronic low-grade systemic inflammation that sensitizes them to pain. Immunological vulnerability is common to obese and chronic pain patients and contributes to pain, fatigue, sleep disturbance, and depression. All of those are factors that can prevent us from exercising and are associated with the neuroendocrine dysfunction described above. Mitchondrial dysfunction may also play a role in both chronic pain and obesity. According to Karl Krantz, D.C., “mitochondria are the power house of the cell. If energy is not being produced, logically it can lead to or contribute to chronic fatigue and pain.” A Finnish study of identical twins (each pair including a normal weight and an obese twin) found that the fat cells of the obese twins contained fewer copies of the DNA that’s located in mitochondria. This DNA contains instructions for energy use by the cell. The lead researcher of the study says, “If one were to compare this cellular power plant with a car engine, it could be said that the engine of the fat individual is less efficient.” So it’s no wonder that obese people are not able to burn or use all the calories they consume. Some medical professionals believe that chemical toxins (such as the preservative sodium benzoate, used in many soft drinks) and biotoxins (such as mold) can damage the mitochondria, increase inflammation, and aggravate both obesity and chronic pain. WHERE DO WE GO FROM HERE? Your own brain may in overload now after working its way through all the biological business I’ve ineptly but earnestly tried to explain. Even if nothing else is clear, I hope you’ve grasped the message that the causes of and factors in obesity are extremely complicated and well beyond the means of any currently existing medical device or surgical procedure to cure. I also hope you can see that blaming yourself for your obesity doesn’t go very far in treating it. You are not in conscious control of your neuroendocrine system. But neither are you entirely helpless. You have, or will soon have, a bariatric tool that when carefully used, can bring your appetite under better control and increase your sense of satiety. You can learn as much as possible about the factors that can improve your overall health and counteract the misbehavior of your nerves, hormones, and immune system. For example, I know for a fact that regular exercise helps me manage not just my weight but my depression and pain. You may feel defeated by the very idea of that, but according to an article in the July-August 2011 issue of IDEA Fitness Journal, as little as 5 to 15 minutes of exercise a day can yield health benefits and also increase your self-control when it comes to food choices. At the end of the day, I still suffer from obesity and fibromyalgia, both puzzling and difficult to treat, but I try not to think of myself as a victim of those diseases. I can curl up in a chair with a box of chocolates and weep about my situation, or I can go on learning about my medical conditions and experimenting with ways to improve my health and quality of life. The author of one of the obesity-fibromyalgia studies, Akiko Okifuji, recommends that patients adopt healthier lifestyles and take more positive attitudes toward symptom management. That may sound condescending, but as Dr. Krantz wryly pointed out, “every person in America would benefit from that approach.” I know that’s easier said than done, but I’m willing to try it…are you?

If you're in the Memphis area, and your surgeon is an arrogant a**hole, I think I know who he is (his initials are G.W.) and I strongly suggest that you consider transferring to another surgeon, such as Dr. Virginia Weaver at St. Francis Hospital. I have never heard a single positive word about your doc. Dr. Weaver, on the other hand, is an excellent surgeon and a patient, compassionate person with a great support staff.

Your doctor threw a fit over only 20 lbs lost in 8 weeks?! That's 2.5 lbs/week, and the average with the band is 1-2 lbs/week, so in my opinion, you're doing great, and he needs to chill. I too have a job that allows me only a very short break (usually 15 minutes). There is no way I could safely eat solid food in such a short amount of time. You may have to sip on a Protein shake (unless it's in a clear beverage container, who's going to know it isn't water?) so you don't get too hungry by lunch time, and stick with pureed foods at lunch time. Also, as others have said, going on eating after a stuck episode is a bad idea. It perpetuates a cycle of stuck-irritation-more stuck-more irritation-worse stuck-worse irritation. Give your innards a break by doing liquids for 24 hours, and do NOT go back to eating when you have a stuck episode.

That depends on the terms of his United insurance policy. For example, the policy might not cover any kind of services until 3 months after enrollment. Call the United customer service line and ask about that, and while you're at it, ask about the policy's weight loss surgery coverage - what (if any) surgery does it cover, what do you have to do to qualify, etc.

Welcome! Losing 6 kg (13.2 lbs) in a bit less than 4 weeks is actually better than average. Average weight loss with the band is 1-2 lbs/week. Why are you not eating bread? Did your dietitian forbid it? Bread generally isn't a problem to get past the band until you've gotten some fill in your band, and even then it might be do-able if you toast it first. But if bread is a binge food for you, you might as well stay away from it. Congrats on starting your weight loss surgery journey!

Orlando, Welcome, and congrats on being banded! Your body is probably in shock over the big initial weight loss. Everybody experiences a weight loss plateau sooner or later. Going back to a liquid diet never helped me because it's only solid food that provides the early and prolonged satiety that helps you lose weight with the band. There's nothing in the band that's going to prevent or interrupt mental (or head) hunger. All the band does is reduce your physical hunger and increase your satiety (the sense of having eaten enough food). Eating right (making good food choices, practicing portion control) and exercising are exactly what you need to be doing. Your first fill make take the edge off physical hunger and help reduce how much you can eat, though most people need several fills to achieve optimal restriction. In the meantime, hang in there!

I'm a chronic pain patient too. Band surgery is actually a pretty good choice for someone who has to rely on multiple meds, because there is no malabsorption of the medication. The problem is that big tablets and capsules can be hard to swallow after band surgery. When I was banded, I had to cut tablets into smaller pieces with a pill splitter, avoid large capsules, empty large capsules into food (like applesauce), or use liquid meds. I'm taking tramadol and gabapentin for pain. The tramadol is a small tablet, no problem. The gabapentin is a fairly big capsule that I started taking after my band was removed, so I don't know if I'd be allowed to open the capsule into food. Extended or delayed-release meds need to be taken in their dispensed form, but you'd have to talk with your doctor about whether you can alter your existing meds and get them in a different form. The vertical sleeve gastrectomy might also be a good choice for you. It's my understanding that stuck episodes from big pills/capsules rarely happen to sleeve patients.

I started gabapentin (for neuropathy) 3 weeks ago and have had no side effects. As I recall, edema is not a common side effect. The gabapentin isn't free, so if you have no medical insurance, how are you paying for it? Please tell me the neurologist isn't giving you "free" samples. If so, you need to find another career or learn how to say no. If my boss were a doctor who insisted I take Adderall (or any med, for that matter), I say, "OK," flush the meds, and report the doctor to the state licensing agency. If he stood over me to watch while I swallowed the meds, I would employ my secret bandster weapon and puke on him. As for dealing with your weight...I really think you need to deal with everything else going on in your life first, but it might be helpful to attend some Overeaters Anonymous meetings.

I would get a second opinion. I too have a small hiatal hernia. I've also had a band slip (cured by a unfill) and severe esophageal dilation (after which my band was removed). On numerous occasions, I've asked my surgeon if my hernia could have contributed to the band slip or dilation, and if we shouldn't repair it to prevent future problems. She has consistently said no. I am revising to the sleeve next Thursday. Not once during all my discussion about the sleeve with my surgeon has she mentioned that a hiatal hernia of any size is a contraindication for sleeve surgery. Not once in all my own research about the sleeve have I read or heard that a hernia is a contraindication for the sleeve. I'm not a doctor, but I'm having a hard time understanding why your surgeon insists that your band must be removed, unless there is an additional reason that he/she hasn't mentioned to you. After all you've been through, I would hate to see you have your band removed without exploring every other option available to you first. Good luck, and keep us posted!

First, congrats on your weight loss! The band can slip up onto the esophagus or further down onto the stomach as a result of a failed suture, vomiting, coughing, overeating, failure to follow the post-op eating progression (liquids, mushies, solids), stomach dilation, overfilling of the band, and/or an untreated/undiagnosed hiatal hernia. Symptoms of a band slip include: vomiting, heartburn, acid reflux, foaming, chest pain, left shoulder pain, difficulty swallowing. The symptoms may be intermittent or continuous. Symptoms may develop gradually or occur suddenly. Diagnosis of a band slip is usually based on the patient's symptoms and an upper GI study (barium swallow). Treatment of a band slip is usually a complete unfill and rest period, followed by slow, incremental re-filling of the band, plus discontinuation of the behavior(s) (such as overeating) that caused the slip. Some band slips require surgery to reposition and resuture the band to the stomach. A band slip is not a medical emergency unless the patient is unable to swallow Clear Liquids, but it does require prompt attention to prevent the problem from worsening. The longer you leave it, the harder it'll be to fix.

Thankfully, I've never smoked and was never tempted to smoke. My husband has quit smoking many times in the past 25 years, so I know secondhand how hard it is to quit smoking forever. I don't think it's safe to assume that your surgeon will react violently to the news that you've started smoking again. It's quite possible that he/she can actually help you with this problem. The other thing I want to tell you is that my Aunt Jeanne, a lifetime smoker, died a horrible, painful death from lung cancer. I wouldn't wish that on anyone, and I would hope that you wouldn't want that kind of death for yourself.

Follow your surgeon's instructions. Eating regular food now can cause complications. Feeling hungry now is uncomfortable but it's not going to kill you. I promise, you will survive it. Also, you're going to have to revise your idea of what "full" feels like, because you should never again eat until you feel your pre-op idea of "full". Once you're allowed to eat regular food, you should eat only until your physical hunger goes away. Not one mouthful more.