How the Lap Band Really Works

[rbholt80 0]

It is Not about Restriction

Terry Simpson, MD

The Lap-band is NOT about Restriction.

When talking about the band, some patients talk about restriction. Let's first be clear about one thing: the purpose of the band is not restriction; the purpose of the band is to lose weight by suppressing the appetite.

When band professionals talk about restriction we are talking about something totally different than "restricting what a person eats." In fact, many band surgeons avoid talking about restriction so as to not confuse patients. The band works by dimming the appetite, and this provides a conscious control and decision made by the patient, it does not work by "making" a person do something, or keep them from eating too much.

The Lap-band works by suppressing your appetite.

As a result, you are less interested in food between meals, making it easier to resist temptation. The analogy is when you are near a vending machine when you are hungry-- what do you do? Probably find yourself with some junk food that is not a part of your plan. But, when you pass a vending machine when you are full, it may not even catch your eye. Having the appetite dimmed makes you less tempted by the many food choices modern living throws at you - -this is what the band does, by suppressing appetite you become less interested in food.

What you should not feel, with the band, is the sensation of being "stuffed."

When you eat Thanksgiving dinner, you can feel stuffed. Contrast that with the sensation two hours after you eat your big meal, at that point your appetite is suppressed. It is the subtle dimming of the appetite that the band should provide. Being stuffed after a large meal is a complicated sensation of the abdominal wall stretching and a lot of gas in the bowel, in addition to feeling a diminution of appetite. You will not, and should not, feel the abdominal wall stretch with the band. You should not feel the "near nausea" and you should not feel bloated.

Key point:

You should NEVER eat until you feel full. It is best to stop eating before you "feel full." If you do eat until you feel full you will most likely be overstuffed. This leads to the universal key to success -- patients who eat a small volume of food (which, if you measure, is consistent) will be successful with the band. If you want to succeed, you need to know how much you are eating, and then stop eating -- it is in your control, but the band will help you -- not by stopping you, but by allowing you to feel satisfied after the small volume.

Early on, most Lap-band patients do have a sense of "restriction", particularly, after the first fill. When we place the band on a patient the stomach above the band typically will hold one to two ounces (by volume, not by weight). The stomach has a lot of muscle fibers, and the wall of the stomach is fairly thick. When food is consumed, it arrives in the pouch, and meets some resistance, first against the newly adjusted band, and then against the stomach which does not stretch easily. People love this feeling! It is a sense of control over food -- a leash. But it is not permanent. It makes it difficult to eat more, because the top part of the stomach and the band will resist it. If you over eat you will feel uncomfortable.

This is the honeymoon phase, you feel full with less, no appetite, and if you try to eat more it doesn't work. They eat a small amount of food, they feel satisfied, and they are losing weight.

For patients who rely on this sensation, they will find it will take ever increasing volumes of food to obtain this sensation. The initial response is to have their band adjusted so that they can "feel full again." Against a tighter band, the upper stomach stretches a bit (and if they eat fast it stretches more)and they again have the sensation of "feeling full." This becomes a cycle, a tighter band, the stomach stretches more-- and then instead of going back to its original size, the stomach stretches more and more, to where it takes more to fill it.

The person, who continues to eat until they have this sensation, will find that it takes more and more food to obtain this feeling. Two things happen -- first the stomach stretches to where it accommodates more food, and to stretch it means you have to eat more. The second is that to "feel full" it takes the brain time to register this sensation -- this is not the sensation registered by the hypothalamus, but registered in the conscious cortex. So your stomach can be full, but your brain won't register it for a while, and if you keep eating you can overeat. As a result, the pouch dilates. Similar to a balloon, when you first start to blow up the balloon it takes a bit of force. As you continue to fill the balloon, the wall of the balloon stretches (thins out), it is easier to blow it up -- the same is true with the upper pouch. Early on, before the pouch is stretched, it takes a little bit of food to cause it to stretch, but with chronic over-eating the pouch will accommodate more and more food. The stomach wall is thinner, it is easier to stretch, and to get that sensation it takes more food than at first. Often patients will complain that they "don't feel restriction," and wish to have the band made tighter.

There are two potential results to this: one is the patient will passively stretch the stomach and esophagus and not be eating a small amount of food. These patients simply do not lose the weight that the surgeon expects. The other is that the band will be forced down the stomach, the band will slip, which generally requires operative intervention to reposition it.

For those patients who are rigorous about the volume of food they eat, and do not let the stomach to tell them when to stop eating - they do very well. This is one of the keys of successful patients: only eat a certain portion of food - period. If the band is properly adjusted, the appetite will be dimmed for several hours. Once your brain realizes that a small amount of food keeps you satisfied your eyes will adjust to the amount you eat.

Some describe a "soft stop." Where before a sense of fullness occurs, there is a signal from your body -- this can be a runny nose, a sigh, or a subtle ache in the left shoulder. Patients who find this "soft stop," do very well with the band.

The other advantage of eating small portions is it becomes a lifestyle change -- you will have the ability to gauge the amount of food you can comfortably eat, knowing it will keep you satisfied for several hours.

You can always -- always, always, always, -- eat more food, because, contrary to what we believed for a long time-- food passes by the band within a minute and then into your stomach. But the key to successful patients is not how much they can eat, but how little they can eat to suppress hunger.

The band goes around your stomach, not around your brain, or your lips.

This simple concept, of eating a specific volume of food -- eating it slowly, and then walking away, is the key to successful eating habits of patients. This means that the band works with effort from you -- not by it doing everything for you. You have to make the decision to eat a small volume of food, and let the band work with you.

The sensation that we would want the band to produce is the "soft stop." The soft stop is when you eat a small portion of food and walk away. Sometimes this is difficult, like most things, practice makes perfect. To set yourself up for success -- we recommend you use smaller plates, along with smaller utensils. If you go out to eat, ask for the to-go bag immediately, and remove the excess food from your plate. You can physically always eat more food, but the advantage about practicing small portions and walking away, is ultimately your eyes will get use to what the stomach is telling it, and it will be much easier to eat smaller portions as time goes on.

It isn't uncommon for patients to want an adjustment because they say they can eat more.

The first question we ask is, "Why are you eating more?" The typical answer is, "Because I can." The typical response, "Just because you can does not mean you should." Since the band's job is not to restrict the amount of food you eat, do not leave that to chance -- that is your job. Part of personal accountability is to account for, to measure, to know how much you are eating at a time. The band is empowering; if you eat an appropriate amount and make appropriate food choices, you will be satisfied for several hours. This results in either weight loss, or weight maintenance (if you are at your goal). The purpose of the band is to assist you to lose weight -- and this occurs only with active participation by you: you chose what to eat, you choose how much to eat, and you practice walking away after eating that amount. The band is a tool to allow you to eat less and have your appetite dimmed resulting in weight loss, or maintenance. It is a tool to help you adopt a healthy lifestyle -- you still have the choices to make, but the band allows you to be satisfied with those choices.

"If I could eat less and walk away, what would I need this band for?" -- a common question we are asked. Without the band, if you eat a small amount of food and walk away your appetite would rise within a couple of hours -- you would find yourself hungry and wanting more food, possibly leading to unwanted snacking. You would also find, if you willed yourself to withstand the hunger, your weight loss gradually decreases. The band fools your brain into thinking you ate more.

Think of it another way -- the hypothalamus does not have eyes -- it doesn't know how much you ate, it doesn't know if there is a lot of food around and you are not eating it, or if there is a band on your stomach. The hypothalamus reacts very simply to the stimulation provided by the upper part of your stomach. Stretch that thermostat, it thinks you are eating a lot -- do that consistently over time, and it behaves as if you are eating a lot all the time and will allow your body to release fat stores and not cause your body to go into a metabolic slow-down. Conversely -- if you go on a diet, without the band --and that part of the stomach is not stretched, your hypothalamus thinks you are in a famine -- it doesn't know that there is a lot of food around you.

The purpose of banding is weight loss. Patients who are successful do not "feel tight," or "feel restricted." Instead, successful patients report that they rarely have an issue with the band; they do not "feel restriction." Successful patients come for adjustments when they notice that their appetite is returning between meals -- patients who are not successful rely upon the band to tell them when to stop eating.

The band, in successful patients, is empowering. While, on occasions, the band is "fickle" the proper way for the band to work is for it to allow you to eat less and not be moved by an appetite.

There is another group of Lap-band patients who do not like any sensation of restriction

-- a group we call volume eaters. They want to eat a lot, when they want to eat, and they do not like the sensation of a "hard stop." Nor does this group want to eat a small volume and walk away and allow their appetite to be suppressed. One patient even asked for pills for nausea, because she could not eat "a quart of chili." Yes, this person thought a quart was a normal serving size -- not a cup, a quart! Sometimes these patients come in for an adjustment, then come back thinking that the band is too tight, because when they overeat they become acutely uncomfortable, or feel as if they are "obstructed." Often these patients will come in for a fill, then an unfill, then another fill.

It does take a bit of work to change a person's perspective about the volume of food they eat. For some there is a feeling of deprivation, a period of mourning, but ultimately the band can become a tool to overcome this sensation, and allow the patient to eat. Remember, if you want to be a 125 pound person, you have to eat like one. The band allows your body to re-set the thermostat to the amount of food that it takes to keep you satisfied between meals.

To be more specific - food does not stay in the pouch above the band for a long period of time. Typically it travels through this area fairly quickly, usually less than a couple of minutes. The effect of the band is NOT to have food stay above the stomach in that small pouch - the effect of the band is on your appetite after a small amount of food stimulates that. Does this mean you can eat more -- yes, you can. That is always in your control.

Edited September 16, 2010 by rbholt80

[BlessedTwice 1]

Very Informative! This will be alot of help to many.

[rbholt80 0]

yea i was wanting to take some of the mystery out of the pouch misconception and restriction ideas. i do hope this helps.

oh and im down 34 pounds in 8 weeks and its by knowing the rite info upfront and not by going with unfounded ideas found in forums around the net. but this is the best forum iv found with the best info so im not bashing this place.

Edited September 16, 2010 by rbholt80

[BetsyB 9]

I think that "restriction" must mean different things to different people.

I didn't have surgery with the idea that I would be restricted in what I eat. I did plan for restriction--physical narrowing of the stoma that slows the emptying of the upper portion of my stomach so that satiety with a smaller volume of food is achieved and maintained for a period of time.

To assert that the band is not about this type of restriction is erroneous.

That said, I lost a huge portion what I've lost before I achieved this restriction--because I measured my food and told myself NO a lot. I very quickly learned, simply by virtue of the fact that my stomach configuration had been vastly altered, that "full" means something completely different post-banding. And I listened to that. Never mind that the sensation only lasted a short time (because the upper portion of my stomach emptied rapidly)---I told myself NO when it wasn't mealtime.

Nevertheless, achieving that restriction---the physical narrowing of the stoma that slows stomach emptying---is in fact a very important part of banding.

Otherwise, why bother? Why have fills? Why be banded in the first place?

[sewwant2loose 0]

Betsy and Terry,

Do you both feel as though the "amount" of food you eat per meal is about the same as when you started with your band as it is at your current weight? I was just banded a week ago and am very confused to what the proper "amount" of volume should be per meal. I have read 1/2 cup to 1 cup to amounts in ounces? I obviously am working towards this point (still on liqueds, getting ready for mushies tomorrow) but any suggestions for serving sizes per meal would be a great help. Thanks, Kim

[elcee 3,340]

I'm with Betsy.

To me restriction is not being unable to eat certain foods or having a stuffed feeling. But it is about being able to feel satisfied on smaller amounts.

I went for a fill recently because I was getting hungry quicker as it points out in the article but also because the smaller portions of food were no longer satisfying me. I normally eat 1 egg on 1 slice of toast for Breakfast and feel fine until lunchtime. I was eating the egg on toast and was still HUNGRY. I wasn't trying to see how much I could eat or looking for a hard stop but I knew that I needed an adjustment because of this.

It is interesting that the article talks about how quickly the food passes into the stomach. For a long time we were told that it sat there for ages which didn't make sense when you could eat something and get that instant stuck feeling. If it was supposed to be sitting there then why would you feel this sensation immediately after eating too big a bite - theoretically the sensation should have only occurred a lot later.

It would be interesting to know exactly how long it does take for the food to pass through with a properly adjusted band.

The article is also interesting in what it omits. Nowhere does it scientifically explain how it creates the feeling of being satisfied on the smaller amounts for a long period.

[Cleo's Mom 257]

I have a 4cc band and have been totally unfilled (now) to filled to 3cc (lots of problems - had to have a slight unfill) and the band has NEVER, EVER, EVER reduced my appetite. Not for one minute, not for one second. Even at 3cc filled I never reached anything near to satiety. Just pain, pressure and the inability to eat to satisfaction.

So, if that is the real purpose of the band then mine is a total failure. I have followed all the lapband rules, and I exercise daily and all the food I eat is healthy. I count calories and keep a food journal. I have gone as far as I can go with the healthy food and exercising part of this process.

I have lost about 75 lbs but it has been due to dieting - including on my own, the 6 month pre-op diet, the liquid diets before and after surgery.

I cannot emphasize enough that my band has never affected my appetite (no it's not head hunger) and that was the ONLY reason I got the band because it was promoted as doing so. Big disappointment on my part.

Edited September 17, 2010 by Cleo's Mom

[Jachut 487]

I agree with elements of what you say but I think a fair bit of it is a bit misleading and even inaccuate.

None of us could really lose weight permanently without a "leash" to some degree, because we're disordered eaters. Most of us can lose 30, 40lb for a while without a band, but keeping going to 100, 150 or even 200 and keeping THAT off permanently is a whole different ball game.

I wonder, do I "listen to my body" or "rely on my stomach to tell me its stuffed"? I eat till I feel satisfied. If you ask me, and you didnt really, lol, measuring out a volume of food and telling yourself that you will eat no more no matter how you feel is the kind of disordered eating that puts us out of touch with our bodies and landed us where we are. It makes you afraid of food, unable to trust your body to tell you what it needs. Well, that's how it works for me. Sometimes I'm hungry and I eat more than other times when I"m only a bit peckish. That's what NORMAL people do. I've been very successful doing this, so again, whilst what you're saying may well be true for you and many others its definitely not black and white , a fact anymore than I can claim that what I just said is true for everyone. It simply isnt. We all have different issues.

I do however agree completely that seeking ever tighter fills is not the way the band is meant to work. No wonder the band is seen as such a dicey and uncertain piece of equipment. People cause their own erosion and slippage problems much of the time by being simply too tight and people that truly cant behave in the way you're describing would probably be better with another surgery. You're right, the band DOES take self control. Restriction does not mean a choke hold, it means help to stop when you're satisfied on a smaller amount of food. And you're 100% right, just because you can eat something doesnt mean you should.

[rbholt80 0]

im glad that article got everyone thinking. im on my second fill already and this one is tight. cold Water stops at my band for a about 2 seconds then trickles on by. now that may sound tight and bad but its not for me. when i chew my food like i should it goes down just like the Water does.

at this point in my adventure with the band iv already learned that 6 ounces is my hard limit but 3 or 4 onces will hold me for about 5 hours if i drink water during that time.

i don't eat unless my stomach is trying to eat itself lol you all know the feeling. if my stomach isn't doing that and i start wanting food ill drink something and i tend to forget that i was thinking about food.

im dropping 4.25 pounds a week on average by this simple plan iv developed for myself and i don't feel hungry much at all and to top it off i haven't even started my p90x yet cause i was scared to stress myself and cause a band problem. so next Friday ill start the p90x with the wife.

But everyone is different and im sure what works for me wont work for others. the only thing that's the same amongst us all is that we have bands that we can play with and figure out how to make them work for each of us. no one is going to just get a band and it magically make them thin. if we had wanted that we would have gone with another type of WLS. We wanted the least invasive wls and something that we had some control over.

now for the facts of how the band works and scientific data about it well its out there for anyone who really wants to find it. i just didn't want to bog down this pace with science lingo. its an article that most can grasp without having to have a PHD in the medical field. so take what you want from it and contemplate the things you don't agree with and lets all learn what we can about this plastic thing in us.

ttyl :thumbup:

[Noturningback15 45]

I have a 4cc band and have been totally unfilled (now) to filled to 3cc (lots of problems - had to have a slight unfill) and the band has NEVER, EVER, EVER reduced my appetite. Not for one minute, not for one second. Even at 3cc filled I never reached anything near to satiety. Just pain, pressure and the inability to eat to satisfaction.

So, if that is the real purpose of the band then mine is a total failure. I have followed all the LAP-BAND® rules, and I exercise daily and all the food I eat is healthy. I count calories and keep a food journal. I have gone as far as I can go with the healthy food and exercising part of this process.

I have lost about 75 lbs but it has been due to dieting - including on my own, the 6 month pre-op diet, the liquid diets before and after surgery.

I cannot emphasize enough that my band has never affected my appetite (no it's not head hunger) and that was the ONLY reason I got the band because it was promoted as doing so. Big disappointed on my part.

Yea, I think the band is just very individualized because my appetite has decreased a lot since my last two fills. I don't know if it's because I have increased my exercise or a combo of both, but I know one thing for sure is that my appetite has decreased significantly since my surgery. Before the surgery I would have the desire to eat all day and would actually think about all my meals and Snacks I would have for the next day before I go to sleep. LOL!

[Cleo's Mom 257]

Some Dieters Are Set Up to Regain Weight

Appetite Hormone Levels May Predict Dieters' Success

By Denise Mann

WebMD Health News

Reviewed by Laura J. Martin, MD

Sept. 9, 2010 -- Weight regain is the bane of many a dieter's existence. Often dieters who regain weight after losing it are viewed as failures and judged for their lack of willpower, but new research may put an end to this blame game.

Weight regain may not be solely a willpower issue. Some people may actually be programmed to gain weight back based on their levels of two key appetite hormones, leptin and ghrelin. The new study appears in an online version of the Journal of Clinical Endocrinology & Metabolism.

"This knowledge could be used as a tool to personalize weight-loss programs that could guarantee success in keeping off the weight," says study author Ana Crujeiras, PhD, of Compejo Hospitalario Universitario de Santiago in Spain, in a news release.

Slideshow: Simple Secrets to Portion Control and Healthy Eating

Setting Dieters Up to Win, Not Fail

In the new study, 104 obese or overweight men and women ate a low-calorie diet for eight weeks and were followed up with six months later. Their body weight, ghrelin, leptin, and insulin levels were measured before, during, and after the diet.

Ghrelin is the "go" hormone that tells you when to eat, and leptin is the "stop" hormone that tells you when to stop eating.

On average, study participants dropped about 5% of their body weight while adhering to the low-calorie diet. Six months later, 55 people maintained their weight loss, while 49 regained 10% or more of the weight they had lost. Those individuals with higher leptin and lower ghrelin levels before dieting were more prone to regain weight, the study showed.

While this may seem counter-intuitive based on the actions of these hormones, the researchers suggest that it may be a matter of some people being resistant to the effects of these hormones.

Their brains may not be getting the fullness or satiety messages that these hormones are delivering. You may have a lot of leptin, but your brain is resistant to its effects; much like people with type 2 diabetes become resistant to the effects of the hormone insulin.

Going forward, "these hormone levels could be proposed as biomarkers for predicting obesity-treatment outcomes," the researchers conclude. "Our findings may provide endocrinology and nutrition professionals a tool to identify individuals in need of specialized weight-loss programs that first target appetite hormone levels before beginning conventional dietary treatment."

Fullness Resistance Syndrome

Louis Aronne, MD, founder and director of the Comprehensive Weight Control Program at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York, agrees. "There is something physical going on in people who regain weight," he says.

"Resistance to these hormones is a risk factor for weight regain," he says. Aronne dubs this condition "fullness resistance" and says that your brain is resistant to signals that come from your stomach and intestines telling you that you are full and to stop eating.

Fullness Resistance Syndrome continued...

"With leptin resistance, you don’t feel full and the more you eat, the hungrier you may get," he says.

"We need to stop blaming people and start recognizing the physical basis of weight regain and manage it so people do better," he says.

The new research likely applies to significant numbers of people who are finding the battle of the bulge to be an uphill one.

"We are getting down to some of the final choke points of our weight regulating system, and these should apply to large numbers of people," he says.

Drugs aimed at leptin resistance -- and there are some in the pipeline -- may help, he says.

'Ample Evidence'

"There's no question that most people who easily gain weight, and/or quickly regain weight after losing it are different from other folks," says Scott Kahan, MD, co-director of the George Washington University Weight Management Program in Washington, D.C., in an email. "The general public tends to think of 'fat' people as lazy and as having no willpower [but] it couldn't be further from the truth."

"Ample evidence, now including this study, suggests that there are physiologic reasons for weight gain, difficulty at losing weight, and rapid weight regain after a diet," he says. "There is no question that certain people are preconditioned to gain weight more easily and more quickly regain weight after dieting, just as some people are predisposed to having their blood pressure spike after eating salt whereas others can eat all the salt they want without having problems with hypertension," Kahan says. "This study is another small step toward ultimately ... [devising] new strategies for weight management and disease prevention that work with our bodies' physiologic makeup, rather than against it."

When I brought up the issue of grehlin and leptin with my former surgeon he just rolled his eyes - which is one of the many reasons he is my former surgeon.

I believe that I have a problem with these hormones because it has always taken a lot of food to get me to the point of satiety and that whole "wait 20 minutes" after eating to get full never worked for me. Sometimes if I ever do achieve satiety AFTER eating it can take 90 minutes or more. That's IF. To achieve a satisfied feeling while eating would take way too much food.

Edited September 17, 2010 by Cleo's Mom

[kimkay10 0]

I am brand new, just banded last Friday and i don't know what some of these things mean. what is P90X what is pb, what is sliming

[TheUrbanWasteland 0]

Thanks for posting that... this is exactly the info my surgeon gave me. And he was right!

10 weeks out now... NO hunger. For instance, I had my Protein shake this morning... got busy & forgot about lunch. I had dinner around 7;30 because I was making my father dinner not cos I was hungry... no I dont do that everyday but its just an example of me not having any hunger... its almost bizarre!

Have to wonder about the placement of the band on the vagus (sp?) nerve & whether each surgeon is accurate with this.

Rach.

[lukesdiesel 2]

This is all very interesting info.

[LapNYC 3]

This has definitely been my experience. If I chew well enough I can eat anything I want, including fluffy white bread and Pasta. I don't, and I follow the band rules, and this takes only minimal willpower on my part because I'm not dying of starvation the way I used to be. I feel like a normal person. Of course I'd love those fries and a piece of cake, but my drive to consume those things isn't overwhelmingly powerful. I can walk on by now. It's the greatest!