Jean McMillan

Did you know that obesity can be fatal? Yes, it’s depressing and inconvenient and unlovely, but the worst part is that it can kill you. So listen up! Anyone who’s known me for more than 10 or 15 minutes knows that I love to laugh. I even laugh about my obesity, when otherwise I might cry. But obesity is not a laughing matter. Obesity is serious. Dead serious. As serious, in fact, as a heart attack. And that’s why we all need to take it seriously. We need to keep the Grim Reaper in mind even as we journey to a new life free of excess weight. Yesterday I showed a friend (who never knew the obese Jean) a photo of me taken 95 pounds ago. She said, “Wow. Talk about reinventing yourself!” Bariatric surgery, and the weight it helped me lose, didn’t just help me reinvent myself. It saved my life, and I’ve heard many other people say the same, using the exact same words: “It saved my life.” So it puzzles me to see other people acting as if weight loss is a hobby rather than a career, a hobby they’ll discard once they arrive at their goal weight and go on to something fun and easy, like a party or a vacation. They’re not stupid people, so why don’t they recognize the gravity of their situation and the life-changing importance of weight loss surgery? Do they not know what “morbid obesity” really means? I know what it means to me. I know that it’s a matter of life and death, but I freely admit that sometimes I want to forget it altogether. I’m a new woman, enjoying a new life, making up for lost time. I’m tired of worrying about food and eating and the numbers on my bathroom scale. I don’t want to think about the Grim Reaper any more, but I can’t afford to forget him, because he follows me everywhere. That’s because weight loss surgery doesn’t cure obesity. All it does is treat it. It merely helps us manage the chronic disease of obesity. That management is a lifetime job. We all know what obesity is – it’s the excess weight that drove us to bariatric surgery in the first place. We know how miserable obesity makes us look and feel, but none of us can afford to ignore the morbid part, because that’s the part that drives us to the grave. It’s the part that increases the risk of heart disease, diabetes, cancer, and other potentially fatal conditions. Morbid obesity may not be listed as the cause of death on your death certificate, but it’s the cause that’s lurking around the corner. Your friends and family aren’t going to pay much attention to that, because all they’ll care about is that you’re gone long before they ever dreamed they’d have to say goodbye to you. Wearing plus-size or big-and-tall clothing while we watch our kids enjoy carnival rides that we’re too fat to fit on is lousy today, but morbid is lousy forever. Even if you have no or mild co-morbidities (conditions caused or aggravated by obesity) today, chances are you’ll develop them in a day or a year or in 10 years. Morbid obesity is morbid because it’s been proven to shorten our lives. Even if you can overcome the heartache and shame of being excluded from life’s joys, you can’t overcome death. That’s forever. And I can’t ignore Forever. Can you? So this is your wake-up call. Obesity can be fatal. It’s serious. Dead serious. It’s time to buckle down and do something about it…right this minute, before the Grim Reaper gets an inch closer…Hey! Get moving, now. Here he comes!

Does the reward & punishment approach really help your weight loss? REWARD & PUNISHMENT Yummy food rewards for good behavior, and severe punishment or deprivation for bad behavior, go back a long way in my psyche. With every good intention, my mom trained me using the classic reward-punishment technique from the time I was a very small girl. As soon as I was old enough to think for myself – at age 40 or so (just kidding!) – I applied the same technique to managing (or should I say mismanaging) my weight. Even a tiny infraction of whatever diet plan I was following at the moment was punished severely with hours, days, or weeks of self-loathing and recrimination which would be followed by much bigger eating crimes (I’m a hopeless screw-up because I ate a donut yesterday, so I’m going to eat a dozen donuts today) or by extreme deprivation (I ate a donut yesterday, so I’m going to eat nothing at all today, and if I’m a very, very good girl, I’ll earn half a carrot stick as my reward tomorrow). I learned a bit about behavioral science in college, and goodness knows I’ve read enough self-help books and articles to have picked up a thin smattering of knowledge about it, but none of it meant very much to me until the past five or six years. As I moved towards my weight loss surgery decision, I had to admit that the good girl, bad girl system had not been working very well for me. I just couldn’t seem to responsibly give myself one “cheat” a week as recommended in women’s magazines. The authors of these magazine articles claimed that one serving of cheesecake on Sunday would keep me from bingeing out of desperate deprivation for the rest of the week, but one serving was never enough for me. I guess I’m an all-or-nothing kind of gal, and for me, the only alternative to eating an entire cheesecake was to (mentally) beat myself with heavy chains and a medicine ball covered with spikes. Neither approach yielded the results I wanted, but what other way is there to live as a responsible, law-abiding adult? Without laws and law enforcement, don’t we suffer the chaos and degradation of anarchy? POSITIVE & NEGATIVE REINFORCEMENT Sad to say, I’ve learned more about reward and punishment from living with dogs than from living with myself. I can plainly see that screeching at them for bad behavior is more likely to get them cranked up than to get them to behave. They have taught me that a positive or negative response to a behavior, be it good or bad, reinforces the behavior. We humans are not doing ourselves any favors by punishing our own “bad”, negative, or counter-productive behavior with more negative behavior. All that does is reinforce the bad stuff and use up all the extra energy we really need for the good stuff. When all we hear is an internal voice crying, “bad girl!” (or “bad boy!”), eventually we become resigned to being a bad girl (or boy, as the case may be), and the bad stuff goes on and on. Nor are we doing ourselves any favors by molly-coddling ourselves after an eating infraction. You say you don’t do that? Well, I sure do. I eat five cookies off the plate on the break room table at work, sigh, and grab a sixth cookie while thinking, “It’s just too hard to resist those cookies, you’ve had such a trying day, you deserve a treat, you poor thing.” That kind of response also reinforces the very behavior that’s can keep me from maintaining my hard-won weight loss goal. The reward-punishment cycle is hard to stop when it’s so deeply ingrained in us, but it is possible to end or at least reduce the occurrence of the negative stuff. One of the things that’s helped me regain control over my eating behavior (on many levels) is keeping a food log. Entering my food intake (including time of day, amounts, the eating environment, my physical hunger, any eating problems, and how I felt emotionally before, during, and after eating) has forced me to put on my scientist hat. I’ve always thought of myself as an intuitive, creative person, not a scientific one, but sometimes when I act a part, I become a part. When I’ve written down all this data about my eating, it’s easier for me to see it with an objective eye. Patterns that are invisible to me when I’m in the middle of a situation become clear when I’ve backed far enough away from it. Things that I didn’t understand when they happened to me yesterday have new meaning when I study them today. Things that I don’t really want to understand also become clearer to me when I see them in my food log. For example, after my weight loss surgery it became increasingly difficult for me to eat when sharing a meal with my elderly mother. Twenty years earlier, eating with her was a joy because we both loved food and the conversation that surrounds a meal. As she grew older, fussier, more confused, more demanding, the joy drained away and I found myself in the middle of painful stuck episodes every single time we ate together. A few hours after each incident, I would find myself seeking comfort in food, like stopping at Baskin-Robbin’s for a 670-calorie Cappuccino Blast after leaving Mom in the capable hands of her assisted living facility staff. I loved my mom, I loved our old ritual of enjoying meals together, but it just wasn’t working any more. Time to make a change, Jean! After that realization, when it was time for a family meal, I spent the time fussing over Mom instead of trying to eat my own meal. I ate my meal later, when Mom was safely tucked in bed. The take-home message here is this. Try to avoid the extremes of “good girl, bad girl” thinking, not just in your eating but in your exercise, work, parenting, and anything else you undertake. Sometimes a little bit good can be good enough, and a little bit bad doesn’t necessarily signify the collapse of western civilization. Try to be a kind, tolerant, but firm parent to yourself. Instead of screaming, “Bad girl!” when you fall off the bandwagon, give yourself a boost back up onto the wagon by saying, “That wasn’t good, but I know you can do better, so go prove it.”

The people who've responded to your question all mean well, but none are medical professionals. Nor am I. I just want to reinforce that you should call your surgeon, and until you've gotten some guidance from him, I suggest that you stick to a liquid diet to avoid irritating your esophagus, stoma and stomach any further. Good luck, and let us know what happens. Jean

Wow. You do your own un-fills? Were you a medic when you were in the service? What kind of needle do you use, and where do you buy it?

How big is your band? Did your surgeon put any fill in it during your surgery? Different surgeons have different fill philosophies, but generally speaking, the safest approach is to add small amounts gradually over time. If you have a 14cc band and your first fill was 13cc, you'd have an extremely difficult time getting used to eating after that fill. It would be like driving at 100mph into a brick wall.

I understand all your fears, but chances are, there's nothing wrong and you just need a fill. And if you don't keep that appointment, I can almost guarantee you that nothing is going to get better. The longer you leave a problem, the harder it is to fix.

I think you need to talk to your surgeon or fill person about this, and also trust them to know how much fill to add. An upper GI study/barium swallow x-ray should show whether your band is in the right position and the condition of your esophagus and stomach. It may just be that weight loss has caused the visceral fat surrounding your stomach to shrink enough to make your band feel looser, and a fill should take care of that.

Thanks for the kind words, Arlene. I'm not thrilled with my sleeve, but we're gradually learning to get along better.

Quite right. It's hard to proofread text that you've written yourself and looked at a hundred times!

Hey, Terry, no fair quoting me in your signature line without attribution! How about this? Bariatric surgery of any description is meant to make weight easier, but no WLS procedure makes it automatic. (c.2013 by Jean McMillan).

What is the green zone, and how do we get there from here? GET INTO THE GREEN ZONE Bandsters tend to obsess about finding their sweet spot** or perfect restriction, and in the process torturing themselves with the idea that weight loss won’t start until they reach that magic place. That’s kind of like trying to balance yourself on the pointy peak of a pyramid, where you’re all too likely to fall off and crash into the ground. Focusing on finding that one special spot (instead of appreciating what our bands are doing for us right now) is short-changing yourself. It’s kind of like sex: if you don’t pay close enough attention to how you feel now, you’re not going to appreciate the many small, pretty-good moments that lead up to and follow the one great moment. To my mind, it’s more helpful to use the term Green Zone. Allergan, the manufacturer of the Lap-Band®, developed the Green Zone chart as a simple, visual way to explain the band’s performance without using the terms sweet spot or restriction. I agree with that approach. In my personal experience, it’s far better to think of restriction as a range of experience rather than a single point on a line. I’d really like to drop the term restriction altogether because it’s an outdated term from the olden days when adjustable gastric band was labeled a “restrictive” device that automatically limits how much the patient can eat. I prefer the term “optimization” - a band system functioning at its best. That system consists of the band and the patient who is taking responsibility for good food choices (both for satiety and for health) and portion control, plus fighting the good fight against emotional and addictive eating. But having said all that, I’m going to go on using the term restriction because it’s more easily recognized by bandsters than the term optimization. Just keep in mind that when I mention restriction, I'm referring only to the signals the band system uses to communicate its status and/or need for adjustment. Let’s take a look at some of those indicators. They are signposts that can be hard to read until you’ve learned your band’s and your body’s idiosyncrasies. ** To read more about the sweet spot, click here: http://www.lapbandtalk.com/page/index.html/_/support/post-op-support/the-elusive-sweet-spot-r59 YELLOW ZONE - hungry; eating big meals; looking for food Ü add fluid This is territory that new bandsters often find themselves in – also known as “bandster hell.” We don’t have enough fluid in our bands yet, and at this point, the patient has to work harder at weight loss. The yellow zone is very frustrating, but it doesn’t mean that your band is broken. It just means that your band system needs some tweaking. GREEN ZONE - early & prolonged satiety; satisfactory weight loss or maintenance J no fluid adjustment needed The Green Zone is the bandster’s Promised Land, where the patient and his/her band work in tandem to achieve weight loss or weight maintenance. It isn’t a worry-free or work-free zone – like many other good things, it needs attention, consistency, and plenty of work – but it’s a wonderful place to live. RED ZONE - difficulty swallowing; reflux-heartburn; night cough; regurgitation; poor eating behavior Ü remove fluid. You may find yourself in the red zone when your band is too tight. That can happen even when you haven’t recently had a fill, and for a variety of reasons, many of them benign if frustrating. BE YOUR OWN TRAVEL GUIDE I can’t over-emphasize how important it is for you, the patient, to participate in reaching the Green Zone and staying there. Being your own travel guide during your WLS journey is well worth the effort, because if all goes well, you’re going to be traveling with your band for the rest of your life. You need to be able to recognize your restriction signals and make good decisions for your weight, nutrition, and general health***. I told you that the Green Zone is a wonderful place to live, but no one can guarantee that your residence there is or will be permanent. Even when you believe you have the “right” amount of fluid in your band, you can find yourself in the Yellow Zone again for several reasons: 1. You’ve lost enough weight for the visceral (internal) fat clinging to your stomach to shrink, so the band puts less pressure on the stomach and feels too loose. 2. You’ve been making poor food choices – that is, eating foods that are too soft to give you early and prolonged satiety. This can be sign of what I call Soft Calorie Syndrome. To read more about it, click here: http://www.lapbandtalk.com/page/index.html/_/support/post-op-support/tighter-isnt-always-better-r118) Or perhaps you’ve been eating foods that by their very nature are not conducive to weight loss, (like fast food), or you’ve been overeating or snacking because of neglected emotional issues (often called self-medication). Likewise, you can find yourself in the Red Zone even when you’ve been doing every little thing “right.” Your band can start feeling too tight when seasonal allergies are flooding your upper GI tract with excess mucus, illness has been making you cough or vomit a lot, you’ve been dealing with a lot of stress, you started taking a new medication, you haven’t been drinking enough clear liquids, and so on. Whatever the reason, the best course of action is to remove some or all of the fluid to allow inflammation of the esophagus and stomach to calm down, then gradually start adding fluid again until the patient moves back into the Green Zone. Does all this sound like an awful lot of work? It is hard work. Bariatric surgery of any description is meant to make weight easier, but no WLS procedure makes it automatic. For me, there’s nothing quite as satisfying as achieving a goal I worked hard for. And once I have the prize in my grubby little hands, I’m going to hold onto it for dear life, because my life and my health are both very dear to me. ***Note: Jessie Ahroni’s book, Laparascopic Adjustable Banding, includes an excellent guide to determining if you and your band are properly adjusted, with questions to help you understand that adding or removing fluid is not the only way to adjust the band system: you may also need eating, behavior, activity, attitude adjustments.

1. Here's some reassurance: it's way, way too soon to call yourself a failure. 2. Now for the tough love: your band not going to do all the work for you. If you truly want to make the best of your band, now's the time to start following the rules - portion control, good food choices, etc. The longer you go on cheating, the harder it will be for you to lose weight, and you're only cheating yourself. Here's a link to an article that address some of the issues you're facing: http://www.lapbandtalk.com/page/index.html/_/healthy-living/whats-so-bad-about-cheating-on-the-post-op-r78 Time to get on the bandwagon!

You got some good responses to your post, even if you didn't enjoy reading them. Sometimes tough love is hard medicine to swallow, but our potential for growth, change, and success is compromised if we don't take the medicine. The other day a dear friend of mine gave me some feedback about my behavior that was not at all easy to take, but I know she loves me and since I very much admire her, I managed to survive the experience having learned something I need to know. You are very new to this forum, so it's too soon for you to have established a rapport with anyone here like the rapport I have with my friend. I think if you stick around a while, you'll find that LBT members dish out delicious praise just as often as they dish out bitter medicine. And as they say in 12-step programs, take what you need and leave the rest.

Silly is good with me. As big as my middle was, it must've taken a lot of energy for me to ignore the way it got inbetween me and the washing machine, my car's steering wheel, the kitchen counter, you name it. I also somehow managed to ignore the high tide mark of dropped and dribbled food grunge on my clothes. I think I'd rather have 10 silly little NSV's than 1 big one. Not saying I'd refuse 1 big one, but the little ones sure make me appreciate my new and improved quality of life. Whoever would've thought that weight loss would improve your relationship with your washing machine?!

Sounds to me like you're doing fine. I also tend to overthink and overanalyze, but I think it's good that you're aware of the adjustment process. and I think that people who expect to change their eating behavior overnight are facing a much tougher journey.

Right in what sense? You've lost 159 pounds!

I follow the instructions on the package. Metamucil: 1 teaspoon dissolved in 8 oz of Water, 3 times a day. My gastro doc's NP told me that using fiber powder can make you uncomfortable at first. Maybe you're extra uncomfortable because you're only 2 weeks post-op. You might also want to talk to someone at your surgeon's office about whether it's OK to start using fiber powder now. Hope you feel better soon!

Ya think? I don't know what went wrong with it. I've studied English, French, Spanish, Portuguese and Chinese, but html is a foreign language to me. Anyway, I think it's fixed now. Thanks!

Do you ever feel that you’ve eaten enough food? Do you even know how that feels? RETRAINING MY OVEREATER’S BRAIN Early and prolonged satiety (the sense of having eaten enough food for now) is the name of the band’s game, and restriction (the feelings that communicate satiety to a bandster) is a greatly misunderstood term. I talk a lot about what a bad idea it is to eat until your band’s alarms flash and bells clang, but let me step off my soapbox for a moment and tell you about my own satiety experiences. When I was obese, I could never eat enough food. Aside from my love of its smell and taste, of chewing and swallowing, I wanted a full belly. The problem with that was that there isn’t enough food in the entire universe to fill the hole in my belly, never mind the hole in my soul. As a pre-op, I had the vague idea that my band would help me eat less, but I had no recent experience of eating small amounts and no idea of how that would feel. I blindly committed to weighing and measuring small portions of food despite the sense of deprivation that aroused in my overeater’s heart. It wasn’t until perhaps six months post-op that I realized I wasn’t actually hungry after eating my measured meal. Often I wanted to eat more – because the food tasted so good, I’d looked forward to it so much, I deserved it even more, or because I was a good girl who always cleaned her plate. But none of that “head hunger” was related to an empty, hurting, grumbling tummy. That was a shocking discovery for someone who had eaten to the point of Thanksgiving Dinner Full every day, every meal, every snack, for over 20 years. I suppose that until I came to that realization, I had been doing as much (if not more) of my weight loss work as my band had been doing. It didn’t really matter, because by then, as I inched closer and closer to my goal weight, I was also realizing that my band and I would have to go on working together for the rest of my life. So whether lessons came to me early or late, they were all valuable. Looking back now, I think my band and my conscious commitment to my dietitian’s food plan were both helping me to retrain my brain. No matter what you’re trying to do – lose weight, run a marathon, raise a child – survival and success depends a great deal on practice. Like a concert pianist playing scales, you have to practice over and over and over again in order to keep your skills sharp. To feel that I had regained some control over my eating with the help of my band, to no longer feel enslaved to food, was worth all the risk and trouble of weight loss surgery. So imagine my delight as time went on and my brain-band partnership got even stronger and better. HOW TO RECOGNIZE SATIETY Eventually I progressed to my next band lesson: learning to recognize satiety and stop eating as soon as I felt it, even if that meant leaving food on my plate. It was easy enough to weigh and measure my food when I was at home, but I needed more portable skills to take with me to social events and on business trips. First, I’ll re-state a definition: when you’re satiated with food, you're no longer hungry and more food doesn't interest you. You’ve just had enough for now. Hard to imagine, isn’t it? Satiety is registered by both conscious and unconscious processes, and the two may not always be in synchronization, especially in an obese person who's been overeating consistently. It's entirely possible to be physically satisfied but mentally unsatisfied after a meal, for reasons that are unique to everybody and shared by some of us. Each brand and model of the adjustable gastric band is clearly defined in its specifications, executed in the manufacturing process, and policed by quality assurance technicians, but human beings are very unique, so we respond to the band in different ways. So, how do you know when to stop eating? Do you eat until you're full? No, you don't. You have to figure out a new stopping point. The overeater's definition of "full" is the normal eater's definition of "stuffed". Most of the time, the normal eater stops eating when they've had enough, not when they're full, but the control center in an overeater's brain doesn't get the "enough" message soon enough, or it exerts a powerful override, so the overeater keeps eating long after the normal person would have stopped. That person keeps on eating until all the food is gone, then goes looking for more. Also, overeaters often use food for emotional rather than physical nourishment. While there certainly is some psychic (non-physical) value in the experience of eating, food cannot fill you up emotionally. When you eat for reasons unrelated to physical nourishment, you will never experience “enough”. For a bandster, satiety is not quite the same as being full, nor should it be. Full means your upper stomach has reached its maximum capacity. Satiety happens on your way to being full. With a properly adjusted band, you will be comfortable if you stop eating when you're satiated, but you experience discomfort if you eat until you're full. The band gives almost instant feedback about your eating behavior. The feedback comes in the form of the Soft Stop and Hard Stop signals. In order to learn and recognize your own stop signals, you’ll need to slow down and pay very close attention to how your body feels when you eat. If you usually eat with a crowd (family, friends, coworkers), you might need to try eating by yourself so you won't be distracted. Stop signals can be subtle and they can come from unexpected parts of your body. It's better to heed a gentle reminder than wait for a hammer to hit you on the head. Soft stops are your early warning system, gentle reminders from your body that it's time to stop eating. Because they don't hurt much, they're easy to ignore. Your job is to recognize them (even though they may vary by the meal or the day) and heed them every time you recognize them. Hard stops are the equivalent of running into a brick wall. They can happen without any apparent warning, but usually you have sped heedlessly past a soft stop before you hit the wall. Hard stops are the painful and sometimes embarrassing reminders that you have eaten too much, too fast, in bites that were too big, without chewing enough. To see lists of common soft and hard stop signals, click here: http://jean-onthebandwagon.blogspot.com/2013/03/stop-eating-signals.html

No, nothing wrong with ordering soup when you're in a situation like you've described. I learned to order soup whenever I took my elderly mother out to eat. Much as I loved her, she was so needy and demanding that I couldn't possibly pay enough attention to my own meal to avoid eating problems. It's when soup becomes a daily routine that I begin to worry.

The Dunkin Donut drive thru lady?! a) what the heck were you doing at Dunkin Junkin Donuts? I thought southerners all swore to be faithful to Krispy Kreme? But seriously, I'm proud of you for being able to share those comments. Nothing wrong with bragging on something you worked so hard for!

It does take a while for our minds to catch up with our bodies, doesn't it? I think you're doing all you need to do to adjust - take it one meal at a time. And promise yourself that the next time you find your band so tight that soft calories are your only option, call your surgeon ASAP!

No, the old-school bandsters probably wouldn't like this article, but presumably they're focused on something quite different from WLS by now. I think a lot of misunderstandings arise when advice from medical professionals and patients and who knows who else gets jumbled up so much that no one can remember the source of a particular myth, belief, opinion or "fact". Today I had to take one of our dogs to the vet for his annual exam. While we were waiting, I overheard half of a phone conversation between one of the front desk ladies and a pet owner who wanted to know how much it would cost to declaw and spay her cat. She was obviously dismayed by the price and insisted that "someone" had told her it would cost less if it was done in a single procedure, with the cat anesthetized only once. The office lady said, "Who told you that? Someone here? Because that's not correct, and that's the price we've charged for those procedures for years now." Of course, the cat lady couldn't remember who told her that, but felt that the vet's office was lying about it. She just didn't want to hear what they were trying to tell her. The same is true with human medicine. A few months ago when I told a distant family member that I'd lost 90 lbs thanks to my band, this otherwise extremely intelligent and well-informed man said, "Wow! So, how does that work? I mean, you eat as much as you want and you lose weight?" For a minute or two, I thought he was joking. I devote a lot of pages in Bandwagon to explaining how to recognize satiety, and because I would really like people to buy the book to learn about that, I haven't been giving away that advice for free. Also, as you know, satiety is a very individual thing. I think I'd better reconsider satiety as a future LBT article.

By the way, I love the message in your signature.

I was told no alcohol for 6 months after my surgery because beside being empty liquid calories, it's a gastric irritant. My 1st drink was at around 8 months post-op. I was on a business trip and ordered an appletini. I felt fine until I tried to stand up.Oooof!