Laparoscopic Adjustable Gastric Band Nutrition: How to Achieve Weight Loss Success

by Liz Goldenberg, MPH, RD, CDN

Ms. Goldenberg is from New York Presbyterian Hospital, Weill Cornell College of Medicine of Cornell University, Department of Surgery, New York.

INTRODUCTION
Since approved for commercial use by the US Food and Drug Administration in 2001, the laparoscopic adjustable gastric band (LAGB) has been placed in over 300,000 procedures worldwide. Thirteen years of studies, including six years of pre-approval trials, have taught healthcare practitioners much about the pros and cons of LAGB. While there is still disagreement with regard to who the best candidates for undergoing this procedure are,[1] we do have a fair amount of consensus on how best to care for our banded patients. Practitioners agree that patients need to change their eating habits, exercise regularly, follow up, get timely adjustments, and, in many cases, get emotional support in order to succeed in losing weight with LAGB.[2] The challenge is how do we help them to make these changes and use their band to win the fight against the disease of obesity?

How is the band different?
The key components of successful weight loss and maintenance as listed in the Introduction, with the exception of the actual adjustments, apply to all bariatric procedures. However, the LAGB is probably more dependent on behavioral compliance than other operations. This is likely due to the effects of other popular operations like Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy, biliopancreatic diversion (BPD), and duodenal switch (DS) on nutrient absorption and gut hormones. For example, levels of ghrelin, a gut hormone that stimulates food intake and suppresses fat oxidation, may be modified favorably by operations that manipulate the gastrointestinal tract or resect the stomach. The role of ghrelin, and the numerous other gut hormones, is complicated. More studies are underway to help determine how these hormones impact appetite and weight loss.[3,4]

The ability to adjust the size of the stomach outlet is unique to the LAGB. Proper and timely band adjustments are believed to have a significant impact on weight loss success.[5] Every practice should develop a customized protocol. The protocol should include information on when, where, and how adjustments are to be done. Many programs do adjustments in the office, some use radiographic assistance, and some use a combination of both. Some practices use discreet time intervals for adjustments, while others base the timing of adjustments on patients’ responses to routine questions. Questions may be about the presence of specific food intolerances, heartburn, vomiting, and weight changes.

Please see the referenced articles by Sonnanstine[6] and Ponce[7] for help with guiding you in the development of your protocol.

LAGB eating
There is very little evidence-based information available on post-surgery dietary guidelines. The recently published American Society for Metabolic and Bariatric Surgery (ASMBS) Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient is an excellent nutrition resource, but falls short of making specific recommendations for how patients should be eating after surgery.[8] In Patient Management after LAP-BAND® Placement, Favretti et al[9] list their program’s key eating rules as the following:

*    Eat three small meals per day.
*    Eat only good, solid food. (“Good” refers to foods that are high in protein or complex carbohydrates; “solid” means not liquid. The food should be of sufficient texture to pass only slowly through the banded area.)
*    Eat slowly; stop when comfortable (1/2 hour per meal).
*    There must be no eating between meals.
*    Take no liquids with a meal. (Liquids may be consumed up to 10 minutes before meals, but not for at least 90 minutes after meals.)
*    All liquids must be zero calories (with the exception of 2–4 glasses per week of alcohol due to the possible health and weight loss benefits).

Listed next are a few slightly different and/or additional recommendations from the website for the REALIZE™ adjustable gastric band, which is the newer American version of the Swedish Band (www.realizeband.com).

*    Eat approximately 4oz (1/2 cup) of food at each meal and note that protein will stay in the upper stomach longer than other foods.
*    Sip 64oz of low-calorie, non-carbonated fluids daily.
*    Do not drink anything 15 to 30 minutes before a meal and do not drink during a meal. Wait 30 to 60 minutes after a meal before drinking anything.
*    Avoid foods that may block the stoma, such as bread, pineapple, celery, fibrous foods, and non-tender cuts of red meat.

Eating behaviors and non-compliance
Helping patients to follow these or any guidelines is a challenge for even the most experienced health professionals. Most of us have encountered patients who do the following:

*    Develop maladaptive eating behaviors (covering vegetables in high fat dressings so that they “slide” down more easily; soup for lunch, which means hunger returns one hour later instead of a meal that actually takes time to chew); eating so slowly that dinner can last for over an hour, thus enabling a much larger portion; picking on high-carbohydrate or low-density snack foods like chips, pretzels, and crackers between meals to avoid a feeling of fullness).
*    Learn that frequent vomiting is acceptable or even helpful; or develop full-blown eating disorders, such as bulimia.
*    Believe that the only way they will lose weight is by making the band tighter and tighter.
*    Fail to admit to heartburn or vomiting.

There is an extreme example of noncompliance in a case report of a women who lost, and went on to regain, 40kg in the year following her surgery. She developed a way to empty her stomach by pushing her fist below her sternum and forcing the food in the upper pouch down to the lower stomach. Before she developed this habit, she would vomit if she ate too much, but after this, she found a way to eat as much as she did preoperatively and she gained back her weight.[10]

Dealing with noncompliance
Just about every possible complication of LAGB, from failed weight loss to band prolapse to gastric erosion of the band, has cited noncompliance as a possible culprit.[11] While looking at the issue of noncompliance, it is important to note the irony of the situation. Most of our patients have been battling the disease of obesity for many years, if not a lifetime, and have sought out surgery after having been unable to comply with dietary advice.

If someone is going to go on a diet, that implies that one day they will go off of it—potentially gaining back any lost weight. Thus, the concept of dieting may indeed set our patients up for failure from the very start. Even the word diet can be a way of starting off on the wrong foot. There is no great substitute for the word diet but the terms lifestyle changes, guidelines, eating plans or programs, or modifying habits can be used and are perhaps better suited for this population. In my experience, it is best to be honest and acknowledge that it can be difficult to make changes and modify habits. Let them know that there are many resources available to them, including the band itself, to help. Make them aware, prior to surgery, of the two things that will specifically predict their success—following up with the program and making changes.[2]

One of the most common and frustrating situations can be the times when you and your patients do not agree about adjusting the band. Most likely this will be a situation where your patient wants the band tighter/fluid added, but you believe it should be made looser/ fluid removed. The concept of “Eating Zones” described by Favretti, O’Brien, and Dixon in 2002[9] and later in an article in Bariatric Times by Ponce[7] is a useful aid for this situation.

The zones use color-coded areas on a continuum, from yellow to green to red. The zones help to identify whether the correct amount of fluid is in the band. The yellow zone suggests adding fluid for a patient who is eating large meals and hungry between them. Being in the green zone means the band should not be adjusted for patients who experience early and prolonged satisfaction with small meals and are losing or maintaining their weight. Patients in the red zone should have fluid removed due to heartburn, swallowing difficulties, night cough, vomiting, or poor (maladaptive) eating behaviors. Patients can learn about the zones at the website www.lapband.com/life_after_surgery and clicking on “Optimizing your weight loss through adjustments.”

In the instance of disagreement as to how to adjust the band, help patients to see for themselves how their situation falls into the red zone. Explain to them that taking out fluid will help them to lose weight by allowing them to eat more satisfying, heavier foods, instead of those that slide through easily. Performing an annual upper gastrointestinal series (UGI) to evaluate the band and the esophagus can also help to demonstrate whether band adjustment is appropriate.
Motivational interviewing (MI), used correctly, is an effective way of combating poor compliance. Some examples of MI are the following:

Situation #1: A patient is drinking with their meals.
Not using MI: Remind the patient that they have to separate the two things (drinking and eating) for their band to work properly.
Using MI: Ask the patient if he or she is aware of the benefit of having these separately, then find out what is making it hard for the patient to do this. Before offering solutions, see if the patient can come up with ideas him or herself of how to make the change. Remember (and remind the patients) that they know themselves better than anyone and may realize, for example, that when they eat foods that are less salty, they do not need to drink with their meals. If they can come up with the solution and make goals for themselves, they are more likely to feel empowered and more likely to implement any changes. Another way is to begin slowly and get rid of the all or none idea. Instead of trying to drink zero fluids with meals, ask them if they think they could try to cut the amount they typically drink in half, and then monthly aim to decrease this amount.

Situation #2: A patient is having desserts such as chocolate cake almost every night.
Not using MI: Tell the patient that he or she should try to stop eating those desserts so often.
Using MI: The patient probably already knows that eating cake is getting in the way of weight loss, but perhaps start by asking if he or she can think of any other ideas for desserts that are healthier or lower calorie. Maybe the patient will surprise you by sharing that he or she loves fruit. Perhaps the patient thinks that only fresh fruit is acceptable and he or she finds that it always goes bad before getting a chance to eat it. You can then let the patient know that even no added sugar canned or frozen fruit would be a better choice than the cake. Instead of making a goal of less cake for dessert, suggest more fruit for dessert. This is a way of being positive.

As busy professionals, we are often frustrated and pressed for time; we cannot always demonstrate the most ideal counseling skills. Incorporating just a few small things into your interactions with patients can go a long way to improving compliance. Making eye contact and doing more listening than speaking are two things that are easy to forget when the next patient is right outside your door. Do not forget to give praise for accomplishments and use positive reinforcement: “It’s great that you are not eating sweets every night of the week! It must be hard for you to resist the temptation.”

Keep in mind that MI can also be used incorrectly when there is no recognition of the individual’s stage of change. Patients who are not ready to make any changes—in other words, they are in the contemplation stage of change—need to progress to the action stage before the above strategies will be helpful.[12] For example, a patient who does not see a problem with stopping on the way home from work at the drive-through window would not respond well to you asking how he or she could go about cooking dinner more often. Instead, you can try to increase awareness of the correlation between the patient’s fast food choices and slow weight loss. First discuss what meals he or she selects at the drive-through. Then, use this information to show the patient, for example, the difference in calories between baked chicken and fried chicken, the amount of salty (and therefore thirst-promoting) items on the fast food menu, or the amount of times the patient may end up eating quickly in the car and vomiting versus eating meals in a more leisurely fashion at home. Having these discussions first may help the patient to progress to the point where he or she then wants to make that positive change to more home-cooked meals. Then, at last, you can find out what will help the patient to stop at the drive-through less often. You might be surprised by the fact that it is as simple as driving a slightly different route home to avoid the temptation.

Nutrient adequacy
A discussion of LAGB nutrition would not be complete without a note on nutrient adequacy. Some practices “sell” the band as an operation that does not require any supplementation since it does not impart malabsorption. This has been proven to be untrue. Even though LAGB is a purely restrictive operation, patients undergoing the procedure do need supplementation, especially as the band is made tighter. Poor eating behavior, low nutrient-dense food choices, food intolerance, and a restricted portion size contribute to the risk of developing nutrient deficiencies. As food variety and portion sizes decrease, it is harder to meet the recommended dietary intakes for all nutrients. The best example of this is iron deficiency anemia. Intolerance to red meat, a highly absorbable source of heme iron, is common. Another serious concern is thiamin deficiency. The half-life of this water-soluble vitamin is only 9 to 18 days; thus, a period of prolonged vomiting, especially in patients who are not compliant with supplements, can lead to deficiency fairly rapidly.[8,13]

In addition to the band’s impact on food volume and variety, one should consider the available evidence of vitamin and mineral deficiencies in the (non-operated) obese.[14, 15]

Current guidelines for postoperative daily vitamin supplementation are the following:[8]

*    1 high-potency adult multivitamin-mineral supplement containing 100 percent of daily value for at least two-thirds of nutrients, including 18mg of iron, 400mg folic acid, zinc, and selenium.
*    1,500mg additional elemental calcium split into doses of 500 to 600mg each
*    (Optional: B50 complex)

Patients will be less likely to feel good enough to be compliant with physical activity recommendations if they are tired or not sleeping well, problems which may stem from low levels of iron or B vitamins. In a circular pattern, poor and shortened sleeping cycles also lead to weight gain through mechanisms that are both behavioral and biological.[16]

Patients may stop their supplements as their bands are tighter and pills become more difficult to swallow. Making your patients aware of chewable and liquid forms of supplements early on will help to prevent problems.

Physical activity
Patients who do not increase their physical activity have been found to have a 2.3 times higher likelihood of not accomplishing a greater than 50-percent excess weight loss.[2] While the focus of this paper is on the nutritional aspects of weight loss, another mention of physical activity is warranted due to its clear impact on weight loss success, as well as the complicated ties between physical activity, eating, and emotions. Many weight loss surgery patients tend to eat in response to emotional cues—such as feeling upset, anxious, or bored—versus eating in response to a hunger signal. Promoting participation in exercise as a better way to cope with negative feelings can have a positive, even synergistic impact on weight loss.[5] For a thorough description of practical physical activity suggestions for surgical patients, please read Zarabi’s recent article on weight loss success.[17]

Bringing about change
Here is a list of a few common situations that may occur with your patients, along with suggestions regarding possible solutions.

Mindless eating, eating too fast. Eating fast and not chewing well will quickly lead to vomiting, often lead to maladaptive eating, and may even cause the LAGB to slip. Teaching patients to use small plates and cut food into small pieces the size of a fingernail can help. Suggest patients practice putting down the fork (or spoon or sandwich) between bites in order to follow this rule: Food should be in the hand or in the mouth, but not both at the same time. Also try to have a patient focus on where the meal is taking place; at a desk at work, in front of a television, or even while driving a car or talking on a phone (or eating while doing both!) can promote mindless eating, which easily causes problems.

Preoperative education. If patients are coming to see you with the idea that LAGB will prevent hunger and minimize food cravings, or that it works by allowing regular consumption of anything they want, only less of it (such as only one-half of the usual portion of fried rice and wings), then there is a considerable area of ground to cover with patient education. A good job of keeping expectations realistic preoperatively will lead to a less disenchanted patient postoperatively. Letting patients hear this firsthand from other support group members—prior to their surgery—may be even more effective than hearing it from a healthcare provider. Some programs even require support group attendance prior to the operation.

If your support groups are divided up according to their time out from the operation (such as separate preoperative, postoperative, and graduate/long-term groups) then you can either a) always have a couple of more senior/long-term postoperative patients at each of the preoperative meetings or b) allow preoperative patients to attend postoperative meetings but reserve a period of time toward the end of the meeting specifically for preoperative patients to ask questions.

Poor follow-up. The concept of follow-up should be broadened to include more than a face-to-face office visit. View this instead as any method of keeping in touch, or keeping weight loss surgery fresh on your patients’ minds. Sending newsletters is a great way to keep in touch with patients so they do not slip away. If cost is an issue, send them by e-mail. Patients can be updated about programmatic and staffing changes, support group meeting topics, times, and locations, and even new services being offered. Some programs offer vitamin B12 shots at support group meetings as a way to get patients there. Having patients sign in and then documenting in their records that they attended a group meeting can count toward meeting difficult patient follow-up requirements. For patients who live far away or have schedules that do not fit your meeting times, some programs audio/teleconference their meetings. There are free online support group meetings and newsletters, as well as reasonably priced subscriptions to printed periodicals, created especially for the weight loss surgery community.

Conclusions
The LAGB is a popular procedure and will likely remain so due to its lower operative risk profile. However, compared to other operations that impact appetite via hormonal changes and/or bring about weight loss via malabsorption, LAGB relies heavily on behavioral and nutritional changes in bringing about weight loss. It can be challenging for the patients, as well as for the weight loss professionals assisting them, to achieve success with this purely restrictive procedure. Some patients will develop maladaptive eating behaviors, vomit frequently, suffer from reflux, and be noncompliant despite repeated dietary and behavior counseling.[18] Weight loss surgery programs that persistently and creatively encourage follow-up and exercise, educate patients thoroughly before and after surgery, and offer on-site as well as promote off-site supportive services will find they have the most successful patients.

It is important to remember that obesity is a complex disease that goes way beyond a simple lack of self control. In this author’s experience, letting patients know individually and in your program materials that you understand this concept is an excellent way to begin a strong and trusting relationship between health practitioner and patient.

References
1.    Wölnerhanssen BK, Peters T. Predictors of outcome in treatment of morbid obesity by laparoscopic adjustable gastric banding: results of a prospective study of 380 patients. Surg Obes Relat Dis. 2008;4:500–506.
2.    Chevallier JM, Paita M, Rodde-Dunet MH, et al. Predictive factors of outcome after gastric banding: a nationwide survey on the role of center activity and patients’ behavior. Ann Surg. 2007;246(6):1034–1039.
3.    Busetto L, Segato G, De Luca M, et al. High ghrelin concentration is not a predictor of less weight loss in morbidly obese women treated with laparoscopic adjustable gastric banding. Obes Surg. 2006;16:1068–1074.
4.    Garcia-Fuentes E, Garrido-Sanchez L, Garcia-Almeida JM, et al. Different effect of laparoscopic Roux-en-Y gastric bypass and open biliopancreatic diversion of Scopinaro on serum PYY and ghrelin levels. Obes Surg. 2008;18(11):1424–1429. Epub 2008 Jun 10.
5.    Colles SL, Dixon JB, O’Brien PE. Hunger control and regular physical activity facilitate weight loss after laparoscopic adjustable gastric banding. Obes Surg. 2008;18(7):833–840. Epub 2008 Apr 12.
6.    Sonnanstine T. Meet the REALIZE adjustable gastric band. Bariatric Times. 2008;5(11)18–21.
7.    Ponce J. Laparoscopic gastric band adjustments. Bariatric Times. 2007;4(5)15–17.
8.    Aills L, Blankenship J, Buffington C, et al. Suggested postoperative vitamin supplementation: Table 5. In: ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis. 2008;4:S73–S108.
9.    Favretti F, O’Brien PE, Dixon JB. Patient management after LAP-BAND placement. Am J Surg. 2002;184:38S–41S.
10.    Cömert M, Üstünda Y, Erdem O. A technique developed by a morbidly obese patient to eat more despite an adjustable gastric band. Obes Surg. 2002;12(5):703–704.
11.    Shikora SA, Kim JJ, Tarnoff ME. Nutrition and gastrointestinal complications of bariatric surgery. Nutr Clin Pract. 2007;22(1):29–40.
12.    Zijlstra H, Boeije H, Larsen J, et al. Patients’ explanations for unsuccessful weight loss after laparoscopic adjustable gastric banding (LAGB). Patient Educ Couns. 2008 Nov 17. [Epub ahead of print]
13.    Gasteyger C, Suter M, Calmes JM, et al. Changes in body composition, metabolic profile, and nutritional status 24 months after gastric banding. Obes Surg. 2006:16:243–250.
14.    Flancbaum L, Belsley S, Drake V, et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg. 2006;10(7):1033–1037.
15.    Carrodeguas L, Kaidar-Person O, Szomstein S, et al. Preoperative thiamine deficiency in obese population undergoing laparoscopic bariatric surgery. Surg Obes Relat Dis. 2005;1(6):517–522.
16.    Buffington CK. The link between sleep loss and obesity. Bariatric Times. 2008;5(6):36–39.
17.    Zarabi S. Exercise…The key to weight loss success. Bariatric Times. 2008;5(10):27–32.
18.    Doherty C, Maher JW, Heitshusen DS. Long-term data indicate a progressive loss in efficacy of adjustable silicone gastric banding for the surgical treatment of morbid obesity. Surgery. 2002;132(4):724–727; discussion 727–728.

Author Correspondence
Liz Goldenberg MPH, RD, CDN, 525 East 68th Street, Box 294, New York, New York 10065; Phone: (212) 746-5294; Fax: (212) 746-5236; E-mail:  [email protected].

Category: Nutritional Considerations in the Bariatric Patient, Past Articles