by Paul O'Brien, MD, FRACS

The following is a special excerpt from The LAP-BAND Solution - A Partnership for Weight Loss.

We have formulated eight “Golden Rules” for getting the best result from the procedure. It is of vital importance that you follow these rules. The success of the procedure requires us to place the band correctly, but it equally requires that you follow these rules.

I have been tempted to call them guidelines rather than rules. They are not absolute. A thunderbolt will not come from the heavens and strike you down if you break one of them. And, almost certainly, every patient has at one time or another broken each of the rules.

However, they are more than guidelines. They do need to be followed to get the best results. If you do transgress one of them, I want you to feel guilty, admit to your sins and work out how you will avoid doing something so terrible ever again.

But do remember that if the band is not correctly adjusted you will not be able to follow the rules. You must be in the green zone to follow them. So, before being consumed by self loathing at your weakness, do consider if correcting the adjustment is needed and come in to talk to us about it.

We have already discussed these rules within the preceding chapters. Within these rules is a condensation of the advice in those chapters. We are repeating the key elements of the advice. We state the rules, briefly expand on what each rule intends and then restate them. If you are unsure about what they mean, reread the earlier chapters on eating, exercise and adjustment, and if still unclear, talk to us.

THE EIGHT GOLDEN RULES

1. Eat three or less small meals per day
2. Do not eat anything between meals
3. Eat slowly and stop when no longer hungry
4. Focus on nutritious foods
5. Avoid calorie-containing liquids
6. Exercise for at least 30 minutes every day
7. Be active throughout the day
8. Always keep in contact with us

1. Eat three or less small meals per day
The Lap-Band works primarily by taking away your appetite. If it is adjusted correctly you should not feel hungry. You may eat up to three times a day. We don’t mind if you eat less than three times per day. Many people do not feel like breakfast and some will miss a midday meal. If you don’t feel inclined to eat, don’t eat. If you find you are getting hungry between meals, tell us. We will probably consider adjusting the band a little tighter.

There is not much room for food as there is a virtual stomach rather than a real space above the band. As you eat, the food seeks a space and you need to keep that space quite small. Therefore each meal should be about the amount of food you can get into half a glass. If you eat more than that you will not lose weight so easily and you will gradually stretch the stomach. This can lead to the need for a further surgery later on to reduce the enlarged stomach.

The adjustability of the band is the key to allowing you to be happy with this small amount of food. If you find that you are tending to eat more than that, tell us and we will consider adding more fluid to the band. Always use a small plate, put a small amount of food on the plate and always try to leave some. Remember the angels. They need their share.

2. Do not eat anything between meals
No snacks, no biscuits with your coffee, no fruit, nothing. All food must be restricted to meal times. One of the most frequent causes for failure is the taking of snacks between meals. If you are getting hungry between meals and are tempted to have a snack you must tell us. It is probably due to inadequate adjustment and you may need more fluid added to the band. Between meals you can only have zero calorie liquids – water, mineral water, tea, coffee, low calorie sodas.

3. Eat slowly and stop when no longer hungry
When you have eaten enough you will no longer be hungry and signals from your stomach to your brain tell you that you do not need any more. These signals take time to be generated. Give them that time. Each meal should be stretched out over 15 – 20 minutes. If you eat rapidly you will already have eaten too much before you realize that you have had enough. However, do not eat beyond 30 minutes. Throw away whatever you haven’t eaten at that time. That is the end of that meal and you must have nothing else until the next meal.

Try to make each meal last for 15 - 20 minutes. Try to sense when you have had enough and stop before you feel at all uncomfortable. Use a small plate, put a small amount of food on the plate, and develop the habit of always leaving some of it uneaten.

Once the meal is finished it is essential that you take no further food until the next meal time. This has to be avoided absolutely. The slow emptying of the stomach gives you a feeling of fullness which should make it easy for you to achieve this. You must ensure that this indeed does happen.

4. Focus on nutritious foods
Foods that are high in protein (meats, especially fish, eggs, dairy, lentils beans and nuts) and foods that are high in complex carbohydrates (vegetables, some cereals) are best. Simple sugars are worst. Be careful with foods that are high in fats as they are dense form of calories. Be careful with fruits as they contain quite a lot of sugar.
The good foods can come from all the main food groups and include vegetables, meats, eggs, cereals and dairy. There is no need to focus unduly on the particular foods in fine detail. It is not rocket science. It is simply selecting foods that are good (protein and complex carbohydrates), being careful with those that are not so good (fats, alcohol) and avoiding those that are bad (simple sugars). And take a well balanced vitamin and mineral replacement each day.

5. Avoid calorie-containing liquids
Any calorie containing liquids will tend to flow past the restriction of the band and not give you any feeling of satiety. You are then more likely to take too much. You are only allowed to drink:

• water
• mineral water
• tea or coffee (with low fat milk if you wish but no sugar)
• low calorie soft drinks (but be careful with the gas)

An exception to the “no liquid calorie” rule is a glass of wine with meals which we have shown is good for your health and good for your weight loss when taken in a modest amount.

6. Exercise for at least 30 minutes each day
This is at least as important as all of the other rules. Not only must you take in less calories but you must use up more calories. Exercise will improve your general health as well. Initially, while you are severely obese this can be difficult, but, as your weight decreases, it becomes easier. As you become fitter and healthier, you get greater enjoyment from exercise.

We understand that not everybody is sports minded and exercise may be something quite new for you. Start slowly and seek to build up activity progressively. Aim to put together 30 minutes or more of moderate intensity physical activity on most and preferably all days. Walking is ideal to start off with. As your fitness improves, progress to more vigorous walking and even jogging, cycling, aerobics, swimming, and light resistance training. As your weight comes down your exercise capacity will increase and your general activities during the day will increase. This is to be encouraged and the more active you are the better the result will be.

Your exercise program should be aerobic. You should be puffing and, if you check your pulse, generally it should be up around 120 – 140 beats per minute. There are a wide range of activities that will allow you to achieve this. If you can manage it, a personal trainer or fitness consultant can be an excellent assistant. They can provide an individual program according to your specific preferences and lifestyle that is realistic and achievable. Regular exercise requires commitment. The more effort you put in, the greater benefits you will see and feel.

7. Be active throughout each day
Think of movement and activity as opportunities and not as inconvenience. Try to be active every day in as many ways as you can. Make it a habit to walk or cycle instead of using the car. Become active in the garden and do things yourself instead of using machines. Avoid sitting down at all cost. You should see sitting down as an opportunity for activity lost.

Try to spend as much time outdoors as possible. We tend to be more active when outdoors. Use a pedometer as a stimulus to you to show how your activity level is increasing. If you are using a pedometer, aim to get beyond 10,000 steps per day – this represents a very good level of routine daily activity.

8. Always keep in contact with us
We want to follow you permanently. There will never be a time when we say that the job of controlling your obesity is done and we do not need to see you anymore. There will always be a need to check your progress, monitor your health, check for nutritional deficiencies, make sure that you understand the rules, bring you up to date with new developments and adjust the volume of fluid in the band.

There is always going to be a very small loss of fluid from the band over time. For example, if you had 3 ml of fluid present and we checked the volume after a 6 month gap, there would probably be about 2.7ml present. This occurs because the balloon of the band is not totally impermeable. If 3 ml was the correct volume, you would be starting to get hungry and eat more with a volume of 2.7ml. It is important you understand that this can happen and come back to see us for replacement of that small loss. This is the main reason that we want a maximum of 6 months between appointments.

The LAP-BAND Solution—A Partnership for Weight Loss is available from www.thelapbandbook.com and Amazon.com, and may be ordered at your local bookseller.

April 2008