Gastric Band - advice for week 5 onwards

[Justel_ 19]

Gastric Band- advice for week 5 onwards

Weight loss

You may lose some weight in the first 2 weeks post-surgery, but this is more due to the low calorie liquid diet and the fact that sometimes, appetite is reduced due to the area around the band swelling initially after surgery. Your weight is therefore likely to plateau or even go up slightly by 4 weeks post-surgery. By the time week 5 comes around, it is highly likely that you will be feeling hungry again; this is because the swelling will have most likely subsided, therefore the top of the stomach is no longer being compressed by the band to the same degree.

The process of gastric band adjustments is required in order to ensure adequate compression of the stomach and hence adequate appetite reduction, reduced portion sizes and weight loss. However, the band needs very fine-tuning to provide optimal reduction in appetite and satisfaction on small portions (sometimes described as ‘restriction’), and you should expect to need 4-6 adjustments to the band in the first 6 months post-surgery before this is achieved, although everyone is different and a small minority of people can even feel the effects of the band with only 1 or 0 adjustments.

Band adjustments

One of the best features of the Gastric Band is its ability to be adjusted to ensure of a sensible and successful weight loss. The members of the multi disciplinary team will assess your need for the band to be adjusted during your follow up consultations.

We do not perform adjustments unless they are genuinely needed. We will always carefully review your status before deciding on a ‘fill’ because the aim of the band is to reduce capacity, not completely restrict you. Problems related to the band are often associated with it being ‘over filled’.

What is a gastric band adjustment?

An adjustment is the process whereby Fluid is added to the silicone band, which then tightens the band itself and makes the stoma (opening) between the upper and lower parts of the stomach smaller. This results in food flowing through the stomach more slowly and therefore the band squeezes on the vagus nerve at the top of the stomach to a greater degree, thereby meaning you feel satisfied on less food.< /span>

Fluid can also be withdrawn from the band at an adjustment – this may be needed if weight loss needs to slow down or if it is suspected that the band may be too tight.

Everyone is individual and usually patients require several adjustments to gain and maintain optimum restriction.

The members of the multi disciplinary team are trained to assess whether or not you require a band adjustment. You are likely to require a band tightening or ‘fill’ if one of the following is the case, usually in combination with lack of weight loss:

1) You are hungry sooner than 4-5 hours after meals.

2) You are able to comfortably consume a large quantity of textured food within a 20 minute period.

You are likely to require a band loosening or ‘aspiration’ if one or more of the following is the case:

1) Symptoms of discomfort/pain on eating, regurgitation, night cough, acid reflux/heartburn (especially at night)

2) Difficulty tolerating solid foods despite appropriate eating behaviours, and reliance on soft/high calorie foods that are easy to eat, resulting in sub-optimal weight loss or even weight gain.

If either of the above is the case, you MUST contact your local clinic without delay to arrange an appointment.

A competent practitioner will add the amount that he/she feels is clinically required based on your weight changes, your appetite after eating and the volume of food that you can manage.

There must be a minimum of 3 weeks between band fills in order to allow you to adjust to the altered level of restriction, and for the Dietitian to review your progress.

What is involved?

You will most likely be asked to lie on the couch, however sometimes it is easier to access the port whilst standing. The practitioner will ask you to expose the area where your port is sited. You may be asked to raise your legs or raise your head because this pushes the port closer to the surface, which can make it easier for the practitioner to feel it.

The practitioner will wash their hands and then clean the port area with an antiseptic wipe.

A needle will be used to puncture the skin and gain access to the port area and Fluid will be added or removed using a syringe attached to the needle.

You will be asked to drink some Water whilst the needle is in situ so that the practitioner can ensure there is adequate restriction or the band has been adjusted appropriately.

Some patients may experience “burping” after the procedure.

Will I be able to eat afterwards?

It is essential you progress gradually with your diet during the initial 3 days after an adjustment.

Phase 1: fluids for the first 24 hours

• This minimises the risk of any complications associated with tightening the band.

• The practitioner who performed your adjustment may advise you to extend this phase to 48 or 72 hours, especially if they checked how much fluid was in the band initially before replacing it and adding more fluid, as this can cause additional swelling to simply adding fluid. You will usually only require this ‘fluid check’ at your first adjustment to provide a baseline level.

• Fluids are defined as anything liquid that can pass through a straw.

• Fizzy drinks are not allowed during this period.

• You should aim for about 2-3 litres of fluid per day, or enough to ensure your urine is pale straw-coloured from around 4 hours after waking onwards.

• Follow the same regime as you did during the first 2 weeks after your operation.

Phase 2: soft/pureed food for the next 24 hours

• Follow the same regime as you did during the second 2 weeks after your operation.

You should then start to notice a reduction in appetite and reduction in the quantity of food required to stop you feeling hungry when you first start to eat normal/textured foods again, although it should be stressed that an exact degree of appetite reduction and reduction in portion size can never be guaranteed following an adjustment, and if you are in the early stages of your weight loss journey, it’s important to remember that several adjustments are usually required to gain and maintain optimal restriction.

Continue to take your Multivitamin and mineral supplement. The supplement and any medication will need to be crushed, soluble or chewable during the initial 2 days after a band adjustment.

Are there any complications?

There can be complications, which is why we ask that you do not eat normally for 3 days. There have been reports of band slippage or gastric erosion associated with over-tightening and hence we take the process of performing band adjustments very seriously and only arrange them when clinically indicated.

If you do require fluid removal or a review of the band, you MUST contact your local clinic without delay to arrange an appointment.

We do not advise that you fly within 2 weeks of having your band tightened - this will ensure you have enough time to check the band is not too tight and to give you time to arrange an aspiration if necessary. Furthermore, the change in air pressure may affect the tightness of the band, and so it is recommended that you do not have fluid put back into the band for at least one week after flying in case the band has tightened up during the flight.

Increased stress/anxiety can sometimes make the band feel tighter than usual, and the nurse will not be able to tighten the band in this instance.

Hot weather can also cause the band to feel tighter than usual – with this in mind, we do not recommend you travel to a hot climate within 2 weeks of having the band tightened.

Some women find that the band feels tighter during menstruation, hence it may not be appropriate to tighten the band at this time of the month.

What are the risks of this procedure?

Immediate

• Slight discomfort/pain.

• Bruising

• Punctured port tubing.

• Inability to access the port – in this instance, you will be referred to an alternative practitioner in the first instance. If the second practitioner is unable to access the port, we may consider referral for an x-ray guided band adjustment; charges may apply.

Soon after

• Bruising.

• Heartburn and/or reflux.

• Infection.

• Over-restriction, characterised by sickness/vomiting, inability to swallow fluids, nocturnal acid reflux & pain

Over 48 hours

• Infection.

• Over-restriction – as above.

• The band may become “unclipped” – this can usually be rectified by a surgical procedure.

• Port may become detached – this can usually be rectified by a surgical procedure.

• The following (commonly caused by an over-restricted band):

o Erosion.

o Slippage.

o Oesophageal dilatation.

o Pouch dilatation.

o Achalasia/oesophageal dysmotility – these are pre-existing conditions, the symptoms of which the band can exacerbate.

How can I tell if my band is too tight/I am over-restricted?

There are a number of signs or symptoms that might indicate your band is too tight.

They would usually become apparent within 24-48 hours of a band adjustment.

They include:

• You cannot swallow your own saliva

• You cannot drink sufficient fluids (leading to a risk of dehydration)

• You are unable to eat solid food

• You are experiencing frequent heartburn, belching and regurgitation

• You are having reflux more than one night a week (when food or fluid comes into your mouth or nose when you lie down)

• You are experiencing difficulty swallowing even well-chewed food

In any of these cases, you MUST contact your local clinic without delay to speak with a nurse or dietitian as you may need to have some fluid withdrawn from your band.

Do NOT struggle with an over-restricted band – doing so puts you at unnecessary risk of complications. Call your clinic within 48 hours if symptoms of over-restriction become apparent following a band fill.

Choosing the correct texture

From 4 weeks post-surgery onwards, it is essential that you progress onto a diet of solid/textured foods.

Solid food requires thorough chewing, meaning that not only are you less likely to rush your food, but you are more likely to feel satisfied and enjoy your meals. In addition, firm/crunchy foods tend to be more nutritious and lower in calories and fat than softer foods. Opt for wholemeal/wholegrain products where possible, as these are higher in fibre and other nutrients.

Most importantly however, the number of times the oesophagus has to contract to get solid foods through the band is greater than with soft foods, so you will experience a reduction in appetite far sooner, hence eat less. However, it is important to remember that appetite and portion size reduction is unlikely to occur to any great degree until the band is adjusted appropriately.

Things to be wary of:

1. Dishes where lots of sauce is used as this will make the dish less suitable and more likely to slip through the band too quickly, so you can eat more and not stay satisfied for long. Good examples would be sauce on Pasta and gravy on a roast dinner. You can overcome this by reducing the amount of sauce used and adding chunky vegetables, Beans and/or lentils to the sauce to improve its texture.

2. Soft ‘complete meals’ e.g. fish pie, shepherd’s pie, lasagne. Ideally avoid these meals, but if and when you do choose them, they should only fill ½ of the plate; fill the rest of the plate with crunchy steamed vegetables or salad.

Use the list below to help guide you to choosing the correct texture.

Avoid – too soft

Rice Krispies, Frosties, Weetabix, Porridge, Readybrek

Mashed potato

Stewed fruit / fruit smoothies

Liquidised Soups

Curries with lots of sauce Drier consistency

Overcooked/soft vegetables, Mushy peas

Overcooked/soft pasta

Better choice

All Bran, Branflakes, Fruit & Fibre, No added sugar muesli, Minibix, Special K –ensure only a splash of milk is used to

ensure they remain crunchy when eaten.

New potatoes (with skin), jacket potato (with skin), oven-baked potato wedges (with skin; use spray oil)

Whole fruit (with skin)

Stew/casserole – with chunks of crunchy vegetables & potatoes with the skin on

curries e.g. tandoori, served with crunchy vegetables/salad

Crunchy steamed vegetables

Wholemeal Pasta cooked so it retains some ‘bite’ (al dente)

Caution foods

There are some caution foods, which are more likely to cause discomfort and/or regurgitation when eaten, particularly if introduced into your diet too early. Always take care when introducing foods back into your diet and take note of any discomfort. It is important to experiment with these foods to identify how your body will react. If a food causes problems, remove it from you diet and then re-trial it again after a few weeks.

The caution foods listed below should be the last attempted when progressing onto solid foods – try other foods first. They should also be avoided for two weeks after each band fill, to give you time to attempt other foods first.

The main caution foods are:

1. bread & bread products

Try none of these foods until week 5 post-op and follow the below staged approach when introducing these foods:

• Try 1st: low fat crackers (e.g. Ryvita, Crackerbread, Finncrisp, Krisprolls)

• Try 2nd: well toasted wholemeal pitta bread

• Try 3rd: wholemeal wrap

• Try 4th: Weight Watchers/Nimble bread, toasted to begin with

• Try last: normal wholemeal/granary bread, toasted to begin with

• Try to avoid: soft doughy white bread

2. Boiled or steamed rice

Do not try until week 5 post-op and ensure you have tried other types of carbohydrate first e.g. potatoes with the skin on, pasta cooked so it retains some ‘bite’ (al dente), couscous, noodles.

• Brown rice is better.

• Ensure you wash it thoroughly before and after cooking to prevent it becoming “sticky”.

3. meat, particularly chicken breast, steak and pork chops

You may have already tried lean (ideally less than 5% fat) minced beef/pork/lamb/chicken/turkey in the soft food stage post-operatively. If not, try this first before attempting anything more solid.

Once you have started eating textured foods from week 5 onwards, start building in other meat products by following the below staged approach:

• Try 1st: Lean (ideally less than 5% fat) minced beef/pork/lamb/chicken/turkey (N.B. as mince has a tendency to be soft and ‘easy to eat’ when cooked, aim to include chunky vegetables, Beans and/or lentils when making meals from these foods)

• Try 2nd: Stewing steak/casseroled/slow cooked meats

• Try 3rd: “Wafer thin” sliced sandwich meats (ideally less than 5% fat)

• Try 4th: chicken or turkey leg meat (no skin)

• Try 5th: Lean sausages (ideally less than 5% fat)

• Try 6th: Lean bacon or turkey bacon (fat cut off)

• Try 7th: Grilled/dry fried/barbequed chicken or turkey breast (no skin)

• Try last: Grilled/dry fried/barbequed beef/pork/lamb

Other caution foods

• Stringy vegetables/fruit such as green beans, sweetcorn and pineapple.

• Fruit with tough skin e.g. apples/pears or pith i.e. oranges/satsumas/tangerines.

• Nuts.

• Dried fruit.

Discomfort/pain on eating and regurgitation

These are common complications that can occur specifically in the first few months after gastric band surgery, but are not limited to this time period. They are usually triggered due to one or more of the following:

1. Taking too large a mouthful.

2. Not chewing enough.

3. Not leaving a gap between mouthfuls.

4. Leaving too long between meals – this can cause you to become very hungry, thereby increasing the chances of points 1 to 3 above. Furthermore, the oesophagus can become ‘lazy’ and sit heavily on the band if you leave too long between meals, meaning it can be difficult to eat. Alleviate this by ensuring you eat every 4-5 hours, and drink plenty of fluids between meals to keep the oesophagus active.

Remember the 20, 20, 20 Rule:

1. Take a small volume of food onto your fork or teaspoon (no bigger than the size of your thumbnail/a 5p piece)

2. Chew the mouthful thoroughly (20 times) before swallowing.

3. Put your cutlery down and count to 20 before putting the next mouthful in.

4. Eat in this way for a period of 20 minutes. At this point, stop and walk away. Give yourself 5- 10 minutes and then consider whether you are still hungry; if not – stop eating. Discard any food that is left or save for another meal. Only go back to the meal if you genuinely still feel physically hungry - try 3-4 more mouthfuls eaten in the same way and then consider your hunger level again.

If you are sure you are following the 20, 20, 20 rule, then discomfort on eating and regurgitation may be as a result of attempting caution foods (see above) too early. If a food causes problems, remove it from you diet and then re-trial it again after a few weeks.

There are a number of other factors that can be associated with these symptoms that you need to be aware of:

1. Time of day – during the night, the oesophagus can become ‘lazy’ and sit heavily on the band, meaning it can be difficult to eat first thing in the morning. Alleviate this by having a few Hot Drinks throughout the morning and delay your Breakfast for a couple of hours – don’t eat immediately after waking.

2. Climate – some people find that the band feels tighter in hot weather. The best way to cope with this is ensure you are drinking plenty.

3. Menstrual cycle – some women have reported that the band feels tighter when they are menstruating. This can mean that only a soft diet is tolerated at this time of the month.

4. Stress/anxiety – some people find that the band feels tighter when they are particularly stressed or anxious. Relaxation techniques are useful in this respect, or the use of herbal teas such as camomile.

5. Illness – some people find that the band feels tighter when they have a cough/cold. This can mean that only a soft diet is tolerated, but if it lasts longer than a few days, it would be sensible to have the band loosened slightly to prevent complications.

6. Excessive vomiting – vomiting as a result of food poisoning/stomach bug or pregnancy can cause the band to tighten up. If vomiting continues for more than 24 hours, you

should contact your local clinic without delay to arrange a band deflation (aspiration).

7. Flying – some people find that the band tightens up on flights, particularly long haul (>4 hours); there is a theory that this occurs as a result of the change in air pressure at high altitude causing any air trapped in the band to expand.

There are a number of things to consider:

1) Band fills should take place at least 2 weeks before flying, as this will ensure you have enough time to check the band is not too tight and to give you time to arrange an aspiration if necessary.

2) You should eat at least 4 hours before flying. Don’t eat directly before boarding.

3) While flying, it is advisable to take fluids only; ensure you keep hydrated and consider purchasing nourishing milkshakes (e.g. Buildup, Slimfast) or Soups at the airport if you are going on a long flight.

4) Any changes occurring with the band while flying usually go back to normal when back on the ground but take care when staying in high altitude areas.

5) If you do experience any discomfort whilst flying, consume liquids only for 1 day after the flight, soft foods for another day, and move back to normal challenging/textured foods on day 3.

6) Consider a small aspiration (deflation) of the band prior to a long haul flight if you are experiencing discomfort on eating and/or regurgitation more than once a week, as this may indicate that you are more likely to experience discomfort whilst flying.

Finally, if you are experiencing these symptoms despite every effort to follow the 20, 20, 20 rule and you are sure it is not due to a specific food or any of the above situations, then your gastric band is probably too tight. You should contact your local clinic without delay to arrange a band deflation (aspiration).

Balanced meals

To make sure that your body is getting all the nutrients it needs and to help you maximise the benefits of the band, try and make sure you have the following 3 food groups at every meal.

1. Carbohydrate-containing foods (¼ of your plate)

• Breakfast Cereal

Bran flakes

Minibix

No added sugar muesli

Fruit and Fibre

Special K

All bran

• Bread and bread products – N.B. caution food (see above)

Low fat crackers (e.g. Ryvita, crackerbread, Finncrisp, Krisprolls, oatcakes)

[parisshel 1,892]

This is terrific. I thought I knew a lot about fills, and I was just about to schedule a fill for August, when I return from a vacation (and a 12 hour flight) then I read this! Thank you! I will schedule the fill for 2 weeks after I return, in case I experience band-tightening from the travel.

[Justel_ 19]

This is terrific. I thought I knew a lot about fills, and I was just about to schedule a fill for August, when I return from a vacation (and a 12 hour flight) then I read this! Thank you! I will schedule the fill for 2 weeks after I return, in case I experience band-tightening from the travel.

Thank you :-)

[bsellis 105]

Very helpful! Thank you!

[Justel_ 19]

Very helpful! Thank you!

You are welcome, when did you get banded? How is your weight loss so far going? x

[JOANNE M HOLL 388]

Thanks! Even to a 7 year old Bander this is very useful.

[bsellis 105]

I actually get banded on August 9th. I'm trying to get prepared and learn all that I can before surgery. I have read so much information that it was starting to get overwhelming. This just breaks down everything step by step and covers everything I want to know about food and fills in one place. I will definitly be referring to this many times post surgery!!