Can You Lose Your "Sweet Spot"?

Once the proper amount of restriction is obtained, the so-called sweet spot, most patients lose between 1 and 2 pounds each week and everything is as it should be-right? Well, not exactly. Things inside the body have a habit of changing. It is quite common for patients to do exceptionally well for several months after achieving the optimal amount of fluid in their band, but the band gradually becomes less restrictive over time. This may be in part caused by a gradual thinning of the stomach wall. However, the most logical explanation is that the fatty tissue that occurs naturally around the upper part of the stomach and is actually inside the band is decreasing as the patient loses weight. As this fat disappears it allows the stomach channel to enlarge, even though the amount of fluid in the band has remained unchanged. This explains why additional minor adjustments to the band may be needed every now and then until the patient's weight stabilizes.

It has been interesting for me to observe how many patients tend to become obsessed with the precise amount of fluid in their band. This may be a product of the virtually continuous discussions that go on between band patients, each one comparing every aspect of their situation with the experience of other patients. There are numerous Internet chat sites where band patients describe in detail the exact volume that they have in their band, as well as how much they believe they should have, how much their friend has, and so on. But, as I stated earlier, every patient is different. A restriction that appears to be ideal for one patient may not come close to meeting the needs of another.

After several years of doing adjustments I have discovered an unanticipated problem with the multiple adjustment approach. I refer to it as "adjustment addiction," and it is somewhat difficult to describe. Obviously, some patients who suffer from morbid obesity also have genuinely addictive personalities. Virtually anything and everything they get involved with has the potential to become an addiction. This can even include band adjustments. Despite doing quite well, losing a pound or two a week, these

patients believe that perpetually adjusting the band helps to ensure their continued success. I believe that these patients are not so much craving another "needle stick," but instead are simply insecure in their own success. Generally these patients have not yet accepted the fact that it is their behavior, not the band, that is causing them to lose weight.

In many instances, individuals with addictive personalities don't recognize their own behaviors as addictions and invariably deny it when confronted. This is a potential source of conflict between the patient and the team of professionals attempting to resolve the situation. The easiest thing for the surgeon to do is provide another fill. Put a little in-take a little out-the process can become an endless quest, searching repeatedly for just the right amount of fluid in the band. In this situation the surgeon actually becomes the "adjustment addiction" enabler.

Reversing the patient's fixation on the band and their "need" for an adjustment requires recognizing the problem, and then approaching the patient honestly with positive reinforcement. Everyone within the comprehensive program the surgeon, the dietitian, the exercise physiologist, the psychologist, and the supporting staff members-must recognize the situation and provide the patient with a consistent, positive message, emphasizing the patient's role in their own success.

Another problem I see is other patients who come in for regular adjustments but never seem to achieve the weight-loss success they expected. Typically these are individuals who expected the band to do all the work for them. By getting another adjustment they hope to lose weight and avoid the need to change their lifestyle. These patients have not yet accepted the fact that they will never be successful until they change their behavior. And the greatest behavior change is in eating. I'll talk about that next.

Eating Strategies

All human beings are sensory driven. We have five senses — taste, touch, smell, sight, and hearing — and we enjoy stimulating each of them, sometimes all at once. When we go to the movies the experi ence includes not only the visual effects and the surround sound with volume up so that it literally moves us in our seats, but also the scent and taste of the popcorn. That is what I mean by simultaneously stimulating all of our senses.

Eating is one of the most pleasurable sensory-based activities in our lives. This is in no small part because it involves at least three of our five senses. Taste and scent are obvious, but don't disregard the importance of the tactile sense, such as the smoothness of cream cheese, the crunch of a fresh taco, or the combination of textures in your favorite pizza. What's more, eating is something we can appreciate several times each day, and when we don't experience it we miss it. Is it any surprise that we have a tendency to overindulge, if for no other reason than to appreciate the experience?

Frequently, our desire for maximum sensory input is manifested by eating as quickly as possible. We take large bites of food, chew it a couple of times, and swallow. This is not necessarily because we are finished with it, but rather because we want to experience the next bite. Each large mouthful is immediately followed by another large bite, frequently without a pause. We become automated eating machines, with the desire for sensory input serving as its fuel.

You will need to modify your relationship with the sensations of eating once the band has been established. This does not mean you cannot enjoy food, but your eating habits must change. Many patients report that when they slow down, they actually enjoy their meals more. While this may be accurate, I believe that for some, the enjoyment comes from avoiding the discomfort associated with eating too quickly.

You, like everyone else, take pleasure in consuming sustenance. You wouldn't have a weight problem if you didn't. This poses a significant psychological challenge once the band controls your portion size. Suddenly, instead of placing your fork to your mouth 30 or 40 times during a meal and receiving all of that sensory input, you are now taking only four or five bites. Even if your stomach is telling you, "I'm full," your sensory satisfaction center is demanding more. The trick is to increase sensory input without consuming more food. This is where lesser portions come in handy.

The strategy for maintaining satiety is to consume your small portion of food with the same number of nibbles you would have used to consume a large plate of food. Take at least the same amount of time to consume this small portion as you would a large meal. Each time you put even a small amount of food in your mouth and chew it, be sure to experience the taste, the smell, and the texture.

Small bites also make it simpler to break down food into smaller pieces that are less likely to become lodged in the digestive tract. Our dietitian tells patients to chew each mouthful until it is the consistency of apple sauce. Well, if you begin with a massive bite, by the time you've chewed it enough (if you can digest it enough), you're completely bored with it and it has lost all flavor. Beginning with small bites prevents this issue.

What Exactly Is a Small Bite?

If you are having difficulty adjusting your bite size, use a baby spoon to cover only the front half of the spoon with food. Before swallowing, chew this portion 15 to 20 times until it has the consistency of apple sauce. Place the spoon or fork down between bites. This is a great exercise to do every so often, especially if you find yourself having trouble with food coming back up.

What do we mean by small bites? Begin with an infant spoon and place only enough food to cover the front half. I am aware that this sounds absurd, but it works. Remember that you are in training to create new dietary habits.

behaviors, so consider this a training exercise. Eventually, as you develop your new style of eating, you won't need the baby spoon. However, I have had patients who occasionally require a refresher course on infant spoon use.

The Golden Rules for AGB Patients by Dr. Sewell*

Eat until you are comfortable, NOT FULL!

Choose protein first; Daily protein needs range from 50 to 70 grams.

Eat slowly and digest your food well.

Don't drink 15 minutes before or during meals, and avoid drinking for two hours after consuming.

Liquids will not satisfy your hunger, so you need to consume something.

Exercise daily.

All this sounds simple enough, right? The majority of the time, yes. However, similar to before surgery, you will experience tension and the need for a release. There will be instances when you feel depressed and seek comfort as a natural response. Or, when you accomplish an objective, you will continue to believe that you deserve a reward. In each of these situations, you will automatically turn to food because it has always helped you relieve tension, improve your mood, and provide instant gratification. However, if you consume as you normally would with a band, the results will be quite different from what you are accustomed to. The band will alert you immediately if you eat too quickly, consume too much food, or do not adequately digest your food. It is your "drill sergeant" and is with you continuously.

When the small upper stomach pouch is filled, you will feel that you should stop eating. The band indicates that any additional food you consume will have nowhere to go. If you keep eating, the food will remain in the lower end of the esophagus. The muscles of the esophagus will continue to contract aggressively in an attempt to force everything through into the

stomach. Since the band prevents food from passing through, this muscular exertion generates a tremendous amount of pressure within the esophagus. This causes a sensation of fullness in the chest and throat, followed by chest discomfort. During this process, the lining of the esophagus produces more mucous and more saliva in an attempt to provide additional lubrication to aid in the passage of food.

There are only two methods to relieve the pressure caused by food getting stuck in the lower esophagus: either wait for the food to pass or bring it back up. When it comes up it isn't really like the kind of vomiting that you do with an unsettled stomach. It is less violent and generally more of a voluntary act. Patients use a variety of terms to characterize it, including spitting up, a productive burp, regurgitation, and others that I will not repeat. When food is regurgitated, it is typically accompanied by copious amounts of foamy mucous. Frequently, the volume of food is relatively small, whereas the quantity of mucus can be substantial. The message is clear: cease eating as soon as you begin to feel full.

The majority of the time, the issue of retching after consuming is caused by overeating, but this is not always the case. Many patients have reported that they can only take one or two swallows before experiencing esophageal spasm and having to spit out their food. Typically, this is followed by an improved capacity to eat. This may seem odd, but it is such a prevalent complaint that there must be a rationale. Although I have no proof, I suspect that the patient initially takes a few large bites, which soon become lodged above the band. After experiencing the discomfort of spitting up their first few morsels, they take much smaller bites, thereby avoiding the previous outcome. An additional possibility is that their esophagus is initially hypersensitive to all foods and spasms rapidly in response to any resistance. After the initial material has been removed, the sensitivity may diminish. This is an extremely common complaint among new band patients. It appears to progress over time, most likely due to better eating habits.

Many patients state that they are unable to tolerate anything to consume in the morning, a situation that is remarkably similar. Consequently, they

Try not to consume anything until midmorning, and sometimes not until early afternoon. The strange thing is that these same patients report being able to consume nearly unrestrictedly by the evening meal. This disparity must be related to the effects of sleeping through the night. Possibly, the esophagus fills with mucus during the night and is unable to completely evacuate until the patient is upright for several hours. The effects of gravity would facilitate the movement of food and mucous from the esophagus into the stomach. This is sheer speculation on my part, as I am unaware of the precise reason so many patients report experiencing this phenomenon.

Patients are typically surprised when I tell them, "You can cheat the band," but it is possible, and it is done frequently. By "cheating the band," I mean discovering ways to consume food with minimal or no restrictions. That is, it is still possible to abuse yourself with food and acquire weight.

Why am I sharing this with you? Because you will find out regardless. And because I wish to recognize your freedom of choice. The band provides you with the freedom to determine how you want your existence to be. You are setting yourself up for failure if you expect someone or something to "make" you conduct as you "should" without regard for your own free will.

If you find this frightening, you are still operating under the old paradigm of punishment: "threaten me, control me, and tell me what to do." Under this paradigm, we learn to detest the task and the person who is requiring us to complete the task. After loathing everyone involved, we turn on ourselves because we are the only remaining person. We rebel, and because we are in such a foul mood, we cling to the notion that adults "should be able to do whatever they want."

have not adopted the lifestyle modification with a positive attitude. We've been moving at a snail's pace, which creates so much friction.

This is not required to be the case. But I observe it frequently. People abuse themselves for failing, return to eating what they want, condemn themselves and the diet, and then claim that it did not work for them. In reality, they did not initially possess the type of thinking that would be effective. They looked for something external to "fix" them from the outset. Because, upon reflection, if you cheat the ensemble, who exactly are you cheating?

It is only a brief step from "have to" to "want to" to "it's in my best interest to" or "it would be smart for me to" to "want to."

What Best Describes Your Thought Process?

Do I need to?

Do I desire to?

Is it prudent or in my best interest to?

You do, in fact, have options. Ask yourself, "Am I willing to tell myself false information that is inconsistent with my physical health and my goals?" Or am I willing to recognize that I have options, examine them, and make a choice that serves my best interests? You need not experience resistance, resentment, or anger towards something or someone else if you acknowledge your ability to choose what you want. Then you are positioning yourself for success.