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NETCARE ST ANNE’S HOSPITAL
NEWSLETTER 2 of 2010
How time flies – it is again time for our latest update on the banding newsletter.
The news from the Banding Team is that we have now got 182 patients who have undergone a Laparoscopic Adjustable Gastric Band. We have now also introduced the Laparoscopic Sleeve Gastrectomy and for more information on this please visit the website which gives a complete and detailed overview of this operation (www.kznsurgeons.co.za).
The Laparoscopic Sleeve Gastrectomy to date is being offered to those patients who have had the full benefit of the Laparoscopic Adjustable Gastric Band but have run into problems in the form of an erosion. These patients face the dilemma of having to have the band removed and then possibly going back to their original weight which is really very unacceptable where they have lost their weight and had all the health benefits of having a normal body mass index. For these patients the Laparoscopic Sleeve Gastrectomy has been introduced and it is certainly gratifying to know that a band erosion is no longer the end of the road for them.
The happy outcomes still far exceed the unhappy ones which are the band erosions or the stomach slippages and in essence it remains very exciting as a Team to see patients walking in at goal weight or even lower who 2 years before had never thought they would move out of the ranks of being morbidly obese.
One remains absolutely grateful to Anlie Evetts for her sterling work in putting together this our second newsletter as well as being available and giving all the support to the patients in the pre and post op periods.
Here’s wishing all the band patients well and do keep in touch.
Kind regards
Dick Brombacher
SIXTY-one percent of South Africans are overweight, according to a survey released on Wednesday the 7th of September 2010. Cape Town was the worst affected with 72 percent of those surveyed there overweight, obese or morbidly obese. This was followed by Pretoria (68 percent), Johannesburg (59 percent) and Durban (52 percent). GlaxoSmithKline interviewed 500 people in the study. Of those surveyed, 47 percent said the government should play a more active role in targeting obesity, and 46 percent felt obesity would economically affect South Africa. The survey found that 60 percent of obese, and 62 percent of morbidly obese people considered themselves merely overweight; 49 percent of South Africans did not exercise; 71 percent had never dieted; and that lifestyle, food, poverty and demographics played a role in the weight of the nation. Of those interviewed, 65 percent had the perception that healthy food was more expensive than unhealthy food; 39 percent looked at cost when purchasing food; and 87 percent ate a home cooked dinner. SAPA, 9 September 2010.
Understanding the problem is half the battle won. Dr D. Brombacher a resident General Surgeon at Netcare St Anne’s with one of his specialties being performing Gastric Banding Surgery (A procedure that reduces the capacity of food intake) has made a huge impact on changing peoples lives that have been living with obesity. Not only do these patients no longer have the urge to be eating so much anymore but they also get educated in ensuring that they change their lifestyle and diet to give them a new lease on life. The Dietician and other team members all play an important part in their lives to ensure that they follow a healthy diet and to ensure that their weight loss is sustainable.
Louis Joubert
Hospital Manager
Netcare St Anne’s Hospital
Lets start at the very beginning – you’ve made the big decision, gotten the all clears and you are going to get the LAGB !
How can you best prepare yourself even before the operation?
Firstly your medical health is very important. If you are diabetic, you must ensure that you get your blood sugars under control. Do not adjust your medication without your specialists input. As smoking slows healing and increases the risk for blood clots, infections and other serious complications after surgery, you must stop smoking at least one month before and after surgery (ideally permanently). Also avoid garlic, Ginseng and Ginkgo Bilobo for at least two weeks pre-op, as they can increase bleeding tendencies. Confirm with Dr if you are taking Warfarin, for specific instructions. Avoid Aspirin and aspirin containing products for two weeks before surgery.
Follow the green diet for three days prior to surgery to make the liver easier to manoeuvre during surgery (a fatty liver makes surgery more difficult). Do not take anything after 12 midnight pre-op.
You can also get yourself ready by starting to practice the new way of eating:
- Check your portion sizes (go for smaller plates and servings)
- Make sure you have three meals a day
- Switch to sugar-free drinks and limit fruit juices (if you have them – dilute 50:50 with water)
- Become aware of your environmental cues, try to reduce or manage them where possible, learn to plan ahead if possible
- Take your time over meals and get into the habit of chewing your food very well
- Check your food choices (not “last meal” mentality)
- Protein will be needed for recovery, so choose your meals wisely up until the three days before – think “nourishing” and “healthy”
- Cut back on intake of sweet and oily things (see green diet) – you are getting your body ready for surgery
- When making healthy meals at home, start freezing extras in case needed later (small serving quantities)
- Make sure you have enough fluids daily (between meals, sipped and not gulped)
- Avoid alcohol
- Start your exercise routine, if you are not already active
- Get what you need post op (e.g. vitamin and mineral supplements)
After the operation it is important to follow the various diet stages.
I sometimes have patients phoning about dizziness initially, which is often related to dehydration. Make sure you drink enough, but watch the quantities. You have to check how YOUR pouch is feeling. Go for smaller quantities, but often. Remember to start off and proceed slowly as the fullness sneaks up on you. Stop before you feel full.
By the time you get to the puree stage, you may feel more settled. Remember to only eat when you are hunger and to stop when you are full. Fluids should be stopped 15 – 30 min before meals and only restarted 30 – 60 min after meals. (The more “solid” the meal, the longer it takes in the pouch, and if you overfill with fluid you may vomit).
Some patients find that the initial fullness they had after the op has worn off by week 5 – 6 and they have the urge to eat huge meals. Remember, the band is still settling in and you only have a small pouch above it. If you overeat, you will do damage. Vomiting (frequent, uncontrolled) at this stage is not good. If you are really battling, have 3 small meals, with small snacks in-between, until your band is filled and you get the proper effect. HOWEVER, make sure that you are eating slowly to make sure that your body has time to register that you are getting full. Remember also that you are getting used to a totally new way of eating i.e. you are now seeing the small plate of food that previously would have registered as “deprive” on the diet scale of doing things. (See my book review later in the newsletter).
Once the band fill has taken place you will get the full effect. You will be able to cope and feel satisfied with smaller meal portions. Check the guidelines, as these will now be very important. I always tell my patients that I don’t like the word “rules” because true to human nature, when we see the word “rules”, we want to break them….. right? In this case, one could say it’s a case of look after your band, and your band will look after you !
When we look at studies done to explain why some patients didn’t have successful weight loss after LAGB, they found that some patients were not aware of their own role, while others couldn’t effectively turn their awareness into action. The practical implication of this is that patients are all individuals and should not hesitate to make use of the multi-disciplinary team, so that their post operative guidance can be tailored to ensure continued weight loss within their individual situations.
When asked about eating patterns and the triggers for emotional eating, many of the patients with whom I’ve worked have commented on their difficulty discerning and perceiving hunger signals and their sense of fullness and satiety. Indeed many have commented on their difficulty distinguishing hunger from thirst from other internal experiences, such as their shifting emotions. Further exploration often reveals a more general pattern of difficulty with internal monitoring and regulation, including the ability to identify and detect shifts in ones’ emotional states, resulting in difficulty responding to the changing internal emotional landscape.
The pattern of compulsive over-eating as a form of emotion regulation is well-known (whether we’re eating in response to anger, fear, anxiety, excitement or boredom), but it would seem that such automatic patterns take hold in the context of poorer skills of self-awareness. The following article, sourced in the Bariatric Times November/ December 2007, deals with the concept of mindfulness as a psychological skill and tool that can be taught to bariatric patients, with positive effects on the maintenance of adaptive lifestyle and weight-loss goals.
“Although bariatric surgical procedures are powerful tools in the treatment of obesity, patients and healthcare providers alike can feel frustrated by the difficulties of actually
achieving postoperative weight loss objectives, particularly postoperative weight loss maintenance. One result of these surgical interventions is to bring the feeling of fullness into the patient’s consciousness in a dramatically amplified way. However, many obese patients have learned to actively ignore their inner regulatory signals concerning eating. Well established habits of disordered eating and dieting are supported by, and inextricably connected to, a chronic lack of attention to the psychophysiologic experiences of hunger, eating, and satiety. Although surgery can be extremely helpful in reversing these habits, it has limitations in combating years of dysfunctional eating patterns. In order to fully benefit from surgery, patients must retrain themselves to be attentive to their subjective experiences of hunger, eating, and satiety. Learning to eat mindfully—with full attention to the experience of eating—is an invaluable skill for individuals who have had, or are considering, bariatric surgery.
WHAT IS MINDFULNESS?
The word mindful is synonymous with paying attention or taking care. Mindful eating can be a powerful tool for individuals embarking on lifestyle changes. The Centre for Mindful Eating published The Principles of Mindful Eating, which describes mindfulness as being composed of three parts. The first aspect of mindfulness is deliberately
paying attention, without judgment, to one’s experiences. The second aspect of mindfulness is cultivating an openness to, and acceptance of, all experience. The third
aspect of mindfulness is that it happens in the present moment.
Most individuals who have struggled with obesity for much of their lives are accustomed to judging themselves, their food cravings, and their food choices. Consequently, these individuals tend to experience strong emotional responses to anything involving food, eating, or weight. This emotional activation can interfere with the ability to make deliberate, wise decisions. Becoming a non-judgmental witness to one’s own thoughts and reactions is an important step in creating the opportunity for change. When incorporating mindfulness, a person begins to train the mind to non-judgmentally observe reactions during the stages of meal planning, food preparation, and eating. This lack of internal self criticism supports the ability to increase, sustain, and broaden his or her awareness, leading to more empowered decisions with regard to food.
The second aspect of mindfulness is cultivating an openness to and acceptance of all experience. Thus, mindful eating involves an awareness of the whole eating experience,
including emotions, thoughts, judgments, tastes, colours, aromas, and textures. By remaining more receptive to the multi-layered experience of eating, an individual
can learn what foods might satisfy his or her hunger, be guided to stop eating by his or her own inner experience of satisfaction and satiety, and, finally, experience the pleasures of eating. Both preoperative and postoperative patients can benefit from learning what it feels like to be satiated rather than “full.”
The third aspect of mindfulness is to put aside events from the past and thoughts and hopes for the future, and instead focus for the moment on the here and now. Eating then becomes the activity of the moment and the mind is fully engaged in it. The individual attempts to recognize and let go of worry, anger, fear, rushing, or other mental states that distract from the eating experience. By doing so, he or she can be truly attentive to his or her experiences while eating and can be guided by the understanding of nutritional needs, hunger, and satiety, rather than by hopes, fears, and past experience. The benefits of eating slowly and chewing fully also become apparent.
To help patients bring the concept of mindfulness into their daily eating habits, they are encouraged to adopt an understanding that they have the power to make their own food decisions, even immediately postoperative. Although these choices may be extremely limited at first, choice does exist. Awareness of choice is essential in encouraging the individual to take control.
BRINGING MINDFULNESS TO PROBLEMATIC EATING
Long-term patterns of disordered eating can diminish an individual’s capacity to attend to cues about appetite, enjoyment, and fullness. Many people, including postoperative
patients, find it difficult to stop emotional eating. This coping mechanism is not always broken by surgery. Fortunately, using mindfulness to teach awareness of the emotional