Sally Johnston

I recently came across an article online titled ‘5 Things We Can Learn About How to Eat by Watching Kids’. Interestingly, four of the five tips are topics I often discuss with my clients undergoing weight loss surgery. I recently came across an article online titled ‘5 Things We Can Learn About How to Eat by Watching Kids’. Interestingly, four of the five tips are topics I often discuss with my clients undergoing weight loss surgery. The five tips were as follows: 1. Be picky - only eat your favourites 2. Slow things down 3. Keep it simple 4. Eat with your hands 5. Eat when you’re hungry and stop when you’re full. Whilst eating with your hands is one I tend to skip, the other four tips are very relevant. 1. Be picky - only eat your favourites Have you found yourself scouring the supermarket for the perfect fat free, sugar free but still deliciously tasty chocolate? Dark chocolate of course, so it still provides all the antioxidants. How did that search go? I’m guessing you’re still searching. There is no substitute for the real thing and that is not only true of chocolate, but a whole range of foods. After weight loss surgery you have less space to fill with food, so it makes sense to fill it with food you enjoy. Sure, you need to make sure you are eating a balanced range of foods to get all the nutrients you need, but you should be doing this with food that is pleasurable. Tania, a gastric bypass client puts it very simply: “I do what the French do, I eat everything I want, but I eat in small portions." 2. Slow things down Eating too quickly and not chewing foods properly are both problematic after weight loss surgery. Many of you would have learnt very quickly what happens when you eat too quickly – discomfort, pain and possibly regurgitation. Have you ever told your child to hurry up when they are eating? Well perhaps they are the ones that have it right. I’m currently feeding a nine month old baby. I happened to watch the clock last night as she ate. Dinner took us about 20 minutes. Perhaps these children are on to something! It should take up to 20 minutes to eat a small meal. If there is food left on your plate after this time, discard it. Concentrate while you are eating. Sit up straight and avoid slouching. Set aside time for meals and avoid doing other things whilst you are eating. Put simply, slow down. 3. Keep it simple Many clients of mine will have heard me say that there is 21 meals in a week, so they don’t all have to be perfect. Do you need to serve meat and three different coloured vegetables every night? No. Do you need to cook a full roast meal every Sunday? No. Do you need to know exactly how many grams of carbohydrate you eat each day? No. Sure, you need to ensure you eat a balanced range of foods and your dietitian can guide you with that. But if you can’t be bothered cooking is there a problem with throwing a tin of tuna and some pre washed salad leaves in a wrap for dinner? No. Keep a supply of simple foods on hand that you enjoy for those times when you just need to throw something together. Here are a few of my favourite staples I keep on hand to throw together a whole array of meals: § Eggs § Tinned tuna or salmon § Lean sliced meat § Oven ready/microwave ready frozen fish § Baked beans § Pre-washed salad leaves § Avocado § Mixed frozen vegetables § Tinned corn § Tinned 3 bean mix § Tinned beetroot § Diced tinned tomatoes § Wholegrain/multigrain crackers § Wholegrain/multigrain wraps or mountain bread. 4. Eat when you’re hungry and stop when you’re full. Have you noticed that a child can eat almost all of a sandwich, pushing away the last two mouthfuls announcing that they are full? Our instinct is often to tell them to finish what is on the plate, remind them of the starving children in Africa, but is this doing more harm than good? Children have an innate ability to interpret their hunger and satiety signals, but we often encourage them to override this. What does this teach the child? To eat whether you are hungry or not. I have spoken to hundreds of people undergoing weight loss surgery and many were told to finish the plate, or were not allowed to leave the table until they were finished their meal. Many have also said that they have felt truly hungry for some time. To successfully manage our weight we must be able to interpret the hunger and satiety signals our body gives us. (Satiety is the feeling of satisfaction after eating.) No matter how healthy food is, too much of it is not good for us. Do you need to spend some time following surgery re‐learning how to listen to your body’s signals? Perhaps you need to watch a child eat and follow their lead.

During Roux-en-Y gastric bypass surgery (gastric bypass) the top of the stomach is stapled to form a small pouch. The small pouch becomes a new, smaller stomach and is totally separate to the rest of the stomach. This small pouch is then ‘re-plumbed’ to the jejunum, the middle part of the small intestine, bypassing the first part of the intestine called the duodenum. During Roux-en-Y gastric bypass surgery (gastric bypass) the top of the stomach is stapled to form a small pouch. The small pouch becomes a new, smaller stomach and is totally separate to the rest of the stomach. This small pouch is then ‘re-plumbed’ to the jejunum, the middle part of the small intestine, bypassing the first part of the intestine called the duodenum. The new, smaller stomach pouch allows you to eat only a small amount of food before feeling satisfied. There are also some hormonal changes that occur help to decrease your appetite. It is important to note that bypassing the first part of the intestine means less vitamins and minerals are absorbed. This is why it is essential that you follow the advice of your team regarding vitamin and mineral supplementation. Maintenance Unlike the gastric band, the gastric bypass does not require any ongoing adjustments. However, follow up is necessary to ensure your weight loss is appropriate, you are receiving adequate nutrition and that the surgery is not having any negative effects on your health. One study has found the most intense weight loss occurs in the first six months following gastric bypass surgery and will slow in the second six months, stabilising in the second year. It is likely, however, that everyone will have a different experience. As with all forms of weight loss surgery, success is not guaranteed. Lifestyle changes including healthy eating and regular physical activity are key ingredients in your long term success following surgery. Whilst the size of the new stomach helps prevent overeating, the food choices you make are important. People who maintain their weight losses long term generally avoid high fat, high-energy foods. As well as improving weight loss and maintenance, it is important to avoid high sugar and/or high fat foods as following gastric bypass surgery they can lead to a side effect called dumping syndrome. See a simple explanation of dumping syndrome here. A 2012 study showed that following gastric bypass surgery, those who kept in closest contact with their support team achieved better results. Your team is there to guide you to get the best results following surgery, so make the most of them and keep in touch! They have all sorts of hints and tips to help you on a successful journey.

Thanks carolinagirl, Glad you liked the article and thanks for sharing your experience. You may also enjoy some of the tips in my free ebook, Top Ten Tips for Success with Weight Loss Surgery. It includes lots of tips from people who have had surgery, just like you! You can download for free at my website. Thanks for reading, Sally

Those who have had weight loss surgery often ask how much they should be eating. Whilst is seems a simple question, there is no simple answer. Those who have had weight loss surgery often ask how much they should be eating. Whilst is seems a simple question, there is no simple answer. How much you should be eating is a hot topic on many online forums or support pages. If you have read the discussions it becomes clear that weight loss surgery clinics and support teams widely differ in how much they are recommending their patients eat. This is also clear when I chat with other health professionals at our obesity surgery conferences. If the professionals working in the area can’t get their story straight, how are people to know what to do? Some surgeons recommend you limit meals to half a cup, some may say one cup, and others will say a bread and butter plate of food. Interestingly, one cup of food nicely fits on a bread and butter plate and this is the guide we use in our clinic. Accredited Practising Dietitians (in Australia, Registered Dietitians in the USA) are university‐qualified experts on food and nutrition. Whilst even their recommendations on what you should eat following surgery will vary, what they will generally agree on is that it is difficult to meet your nutritional requirements eating half a cup of food, three times a day. To date, there are no scientific studies on the exact amount of food people should include after gastric band and gastric bypass surgeries. Hopefully in time this will evolve. Research from Mercy Bariatrics in Perth, Western Australia, provides some excellent data to help guide serving sizes for those who have had a sleeve gastrectomy. Whilst initially very small amounts are tolerated, at six months after surgery most people will manage about half a cup of food at a time. By 12 to 18 months most people will manage about one cup of solid food. This is a guide only and will vary between people as there are different size sleeves. A point relevant to all surgeries is that the people studied found they could indeed ‘fit’ more food in than what they felt satisfied with. After all forms of weight loss surgery, eating to the maximum amount you can tolerate is not recommended. I have a favourite quote from Dr. Teresa Girolamo, one of the GPs in our clinic: “It’s not a matter of seeing how much you can eat and get away with, but how little you can eat and be satisfied.” Testing the limits of how much you can eat increases your intake, particularly if it occurs repeatedly, and can compromise your results. Tune in to your feeling of satisfaction after eating and let that guide the amount of food you need to eat. Always stop eating before you feel any discomfort. Create an environment that makes it easy for you to eat small portions. Ensure family and friends know you use a smaller plate/bowl/cutlery. Take these items with you if you travel. When eating out, order entrée size meals or if there are none available, separate your meal into an appropriate portion before you start eating. Tapas style menus, Asian or Indian eateries are often tailored to meals being shared, allowing you to dish up a small serve to suit your needs. It is fine to leave food on your plate when you have had enough, even if it is a smaller serve. Avoid the temptation to ‘clean the plate’. If ‘wasting’ food concerns you, carry a container with you when you eat out and take a serve home to have for another meal. After gastric band surgery some people may find it takes some time before they feel satisfied on small amounts of food. Many people need their gastric band adjusted several times to help them feel satisfied on small serves. If small meals of solid food do not satisfy you, keep in regular contact with your support team until they do. Some people will find this will occur early in their journey, for others it may take longer. Be patient. Whilst it is not necessary for you to measure or weigh everything you eat, it may be helpful to measure the amount you are usually serving. When you eat a meal, take note how much food it takes for you to feel satisfied and how much it takes to feel full. The aim is to feel satisfied after eating, so if you know roughly how much food this is you can avoid dishing up too much in future. The recipes in my book and on my blog have been designed to provide approximately four, one cup serves. This does not mean a one cup serve is right for everyone, but does allows you to easily adapt the recipes to your requirements.

Hi Tara-U, Good question and one best for a doctor or surgeon. The important point is that our oesophagus and stomach can stretch to accomodate lumps of food, a band cannot stretch in this way. Sally

Hi 2muchfun, Thanks for your comments. Yes, it is correct that the thickness of our stomach lining and folds within the stoma would complicate things. The only real way to see what exactly is happening in each individual would be to have an endoscopy. My overall point is to try and give a guide that yes, there is not much of an opening for food to get through and that is why we need to take a lot of care when eating. Cut food small, chew well, eat slowly, etc. As an aside, looking at your ticker however I see you are doing well - 50lb lost - great work! Sally

I have found that sadly there are a lot of misconceptions around gastric bands. Let’s get back to basics to understand how a gastric band should work. I have found that sadly there are a lot of misconceptions around gastric bands. Firstly, there is a misconception that the gastric band creates a small stomach that must be ‘filled’ to feel full. There is also a misconception that a tighter band will result in more weight loss and that the vomitting or regurgitation caused by a tight gastric band is ‘normal’. Another misconception is that you shouldn’t be able to eat certain foods with a gastric band. Let’s get back to basics to understand how a gastric band should work. A gastric band is a silicone device placed around the upper part of the stomach. It was once believed that the gastric band created a new, smaller stomach above the band, where food would sit before passing into the lower, larger stomach. Recent studies at the Centre for Obesity Research and Education (CORE) in Melbourne have shown this to be incorrect. The gastric band actually creates a ‘funnel’ into the larger stomach and exerts pressure on the stomach. Adjusting the gastric band can vary this pressure. The band has an access point called a port, which is stitched to your abdominal muscle deep under the skin. You can usually tell where the port may be as it is likely to sit somewhere under your biggest scar. Your surgeon or weight loss GP uses the port to adjust your gastric band and vary the pressure it places on the stomach. They can inject or remove saline (a salty water) solution via the port to make your band tighter or looser. When food is eaten our oesophagus, or food pipe, squeezes bites of food down towards the band. Once food reaches the band, contractions of the oesophagus, called peristalsis, will squeeze well-chewed food past the band. In a person with a well-adjusted band, it can take between two to six squeezes of the oesophagus to get a bite of food across the band. One study suggests this process takes at least a minute. There are nerves in the stomach that detect when our stomach is stretching, and send a message to our brain that we have had enough to eat. One particular nerve involved in controlling our stomach is called the vagus nerve. With a gastric band sitting around the stomach this squeezes the vagus nerve all the time, and more so when you are eating. The squeezing process triggers a signal to the brain that you are satisfied, or no longer hungry. This means you feel satisfied on a smaller amount of food than you would have prior to surgery. The constant pressure of the band on the stomach also helps you to feel satisfied for a longer period of time, reducing hunger throughout the day. Feeling satisfied is different to feeling ‘full’. Feeling ‘full’ means you have eaten to excess. It may indicate food is sitting above the band, either due to eating too quickly, eating large pieces of food or not chewing food well enough. Try to stop eating when you feel satisfied or no longer hungry, rather than full. Each bite of food must be small and well chewed. An empty, or uninflated band has an opening the size of a twenty-cent piece. A fully inflated band has an opening the size of a five-cent piece. Most people will have their band adjusted somewhere between the two sizes. If you cut food into the size of a five-cent piece size and chew it well, it is more likely to pass comfortably through the band. Eating slowly also helps you to eat comfortably. In theory, you should aim to wait a minute between each mouthful of food, however it is not practical to time every mouthful. It is practical to put your cutlery down between mouthfuls and wait until you have swallowed before cutting the next piece of food ready to eat. People with a gastric band who eat quickly, describe a feeling of discomfort in their oesophagus, like a ‘traffic jam’. Eating slowly will help avoid this. I hope this clarifies how a gastric band works and what you should experience. If your band is not acting like it should, please follow up with your support team.