Reasons for Obesity:
In the US, obesity has reached epidemic proportions, with over 30% of the population having a BMI over 30. While there are a few medical reasons such as thyroid disorders or other hormonal stimulants of hunger, the vast majority of overweight people have simply eaten more calories than their bodies have burned. People spend a lot of time looking for another explanation for their weight problems, but it is usually pretty straight forward. By the time you have gained enough weight to be at risk for major health problems, you are faced with losing a tremendous amount of weight. What this means is that in order to lose weight you will have to burn more calories than you take in and by definition, you will be in a state of starvation. This state will stimulate hunger. If healthy weight loss is considered to be about 5 lbs per month, that would mean staying hungry for about 20 months if you were 100 lbs overweight. While many people can maintain themselves in a state of hunger for awhile, it is hard to keep up and so dieting almost always leads a return to over eating and weight gain. The main issue is eliminating or reducing the drive to eat (hunger or cravings).
While there are multiple factors that have led to our overweight culture, most of the problem, in my opinion, is caused by our nation’s consumption of large amounts of processed, high calorie foods. Healthy menus and low calorie meals are rarely a reason why a restaurant stays in business and low fat, low carbohydrate products didn’t pave the way for the success of our corporate food giants. In fact, it has been the opposite, since adding fat and carbohydrates to food products usually has equated to return customers and fatter bank accounts. And, restaurants stay in business by selling us as much food as possible to each unit (customer), so why not pile on huge portions to justify the cost of the meal. It’s the same as selling two meals for the price of one. The result of being raised in the modern US, is a palate that is used to consuming large portions of high calorie foods. Again, the key points of this opinion are that America is obese because of the following factors:
1) Readily available high calorie foods “supplemented” with carbohydrates and fat.
2) Standard servings of large portions
3) Repeating 1) and 2) over and over again (What I mean is that, if a person eats large portions of high calorie foods over and over again this behavioral pattern becomes a normal part of the program).
The result is the formation of what many people call habit. I call it a behavior pattern that is prompted by suffering (hunger) and reinforced or rewarded by the chemical experience of pleasure (satisfaction/satiety). Human beings are “programmed” to repeat behavior that avoids suffering and leads to pleasure. It is the basis for what makes us work, procreate and compete. Food stimulates the pleasure center of the brain and over time habits are generated by the repeated coming together of “reward” (carbohydrates and fat) with “behavior” (opening up the cookie jar). For some, it may become fairly hard to walk by the cookie jar without having a physical reaction. So, the environment (cookie jar) stimulates the physical experience of want (craving). If you want to know what I mean, walk into your favorite fast food restaurant when you NOT hungry. Sit there and smell the aroma and see how long it takes you to be become interested in eating. The environment stimulated a memory which then caused your brain to go into the “hunting” mode, which was spurned by the emotion of hunger. The whole experience is chemical and programmable.
So the problem is in how we have been raised. Americans have been “programmed” through repeated exposure to large amounts of high calorie foods to the point where it becomes hard to walk down the street without wanting to eat. Food is EVERYWHERE. Asking an obese person to control his or her eating EVERY DAY and maintain that is a little bit like torture.
Understanding why people are obese is the main reason why I have been such a staunch advocate of the lap band. I recommend it to all of my obese patients regardless of whether or not they go out of the country for their surgery. Here is why:
Every dietary program is extremely simple and based on the following principles.
1) Reduce portion size
2) Eat foods low in carbohydrates and fat
3) Decrease total calories
(But, what do we do about our hunger?)
Yet despite all of our efforts, diet and exercise alone has a long term 3% success rate. I hate to be negative, but it is almost a waste of time. As a society, we spend massive amounts of money unsuccessfully lose weight. What we need is to have our brains rewired to that of a person that is not stimulated to want to eat at every turn in life. We need brains that are satisfied and content ( and not hungry) with eating smaller portions of healthy foods.
Here is how the lap band works:
A surgeon places an inflatable adjustable band around the top portion of your stomach. The result is that the stomach is divided into two chambers separated by a small channel (the width of the channel is determined by the “tightness” of the band). The upper portion of the stomach is very small, only enough to hold about 5 ounces of food.
So here is what happens when you have a lap band in place that is working correctly: You sit down at the dinner table and begin eating. You are instructed to chew your food slowly and eat your meal over 20 minutes. You start to eat and an amazing thing happens, after only eating four ounces of food (about the size of a deck of cards), you FEEL FULL (emotion). You feel like you just ate a big meal. And, you are not hungry (emotion) any more. And, if you have followed directions and did not drink any liquids with your meal, the food stays in the upper stomach pouch for the next hour or two, giving you the constant sensation of satisfaction (emotion). If you repeat this behavior over and over again; feel hungry, eat a small amount of food-feel satisfied an interesting thing happens; you become completely comfortable eating a small amount of food. It becomes “normal” to you; you have become reprogrammed.
Also, what if we gave you a negative experience whenever you eat too much? This would be a lot like scolding a child when it did something wrong or getting fired from your job because you were late all the time. Negative reinforcement is a fairly good training tool (but positive is better). How about we make you feel nauseated every time you eat too fast or eat too much? Walla! The lap band does that too! Try to eat more than the pouch will hold and your stomach will stretch triggering the brain to give you the sensation of nausea (i.e. telling you to stop eating) and if you keep it up, you will vomit.
There are some things that the lap band cannot control, so you do have to participate. You will be instructed to eat low carb, low fat foods. The rule is that you maintain a 2:1 protein to carbohydrate ratio. That means eat a lot of chicken and fish.
Over time, if you “follow” the band, i.e.
1) Chew your food slowly over 20 minutes
2) Limit your total intake with each meal to about 4 ounces
3) Don’t drink liquids with your meals
4) Eat a high protein diet, maintaining a 2:1 protein to carbohydrate ratio.
You, will be successful and the weight will start “falling off”.
If you understanding how the band works, you might also understand how you can “beat the band”, and not lose weight.
Remember our goal is low carbohydrate foods in small portions. The band works by restricting the passage of food from the stomach to the intestines where it will be absorbed. The longer the food stays “hung up” in the upper portion of the stomach pouch, the longer you will stay satisfied. So, the first obvious way to beat the band is to drink your calories. A soda or milk shake is full of carbohydrates and calories and will pass right by the band. Ice cream passes right through. If you chew your food and drink water to “wash it down” the band is useless. You can eat small amounts of high carbohydrate foods all day long and never lose any weight.
So, the right “band patient” is a patient that has the ability to follow a meal plan and stick to it. The band will make it EXTREMELY easy for you to be successful, by eliminating the constant hunger of everyday life, but you must be willing to “follow” a few simple rules to be successful.
Consideration before Lap Band procedure:
Electing to have lap band surgery requires proper consideration of alternatives, understanding the risks and rewards with your surgeon. For successful results with this surgery emotions need to be kept aside and proper preparation for surgery and post operative care needs to be arranged.
The guidelines for surgical candidacy are based on the saving lives not on helping you lose weight for cosmetic reasons. People with BMI’s greater than 35 have shorter life spans on average, so the lap band is considered a “life saving” medical intervention. When your BMI is less than 35, there is less conclusive evidence that we are saving lives by performing this surgery. At least, it is not considered cost effective to perform surgery on patients with a BMI less than 35.
If you have severe depression, bipolarism, personality disorder or other severe psychiatric illness and are obese, you many have a very difficult time losing weight. Any surgery for obesity is not recommended unless your psychiatric illness is under control with medication.
Qualifications for Lap Band surgery:
According to the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgeons, current guidelines for candidacy are:
1) a BMI of at least 35
2) Patients must have tried and failed non surgical weight loss efforts (diet and exercise)
3) Must be willing and able to adhere to a post operative program that includes following a meal plan.
4) There can be no current alcohol or drug abuse.
5) There can be no current or uncontrolled severe psychiatric illness.
6) There must be no underlying medical reason for obesity (thyroid or other hormonal)
7) All patients must understand the risks, benefits, possible adverse outcomes, alternatives, and necessary lifestyle changes associated with the surgery.
Still, based on the merits of any individual case, some US surgeons do choose to operate on patients with a BMI less than 35. Risks and benefits must be fully understood before placing a lap band on a patient with a BMI between 30 and 35.
Financial consideration and qualification for insurance coverage are some other major factors which need to be considered before surgery in the US.
Description of the Lap Band Surgery:
The LAGB utilizes a synthetic fluid-filled, doughnut-shaped band, which is wrapped around the top portion of the stomach. A small port is attached to the band by a thin piece of synthetic tubing and the port is surgically placed just under the skin on the abdomen. The port is therefore easily accessed so that a healthcare professional can inject or remove sterile saline from time to time to adjust the size of the band. This ability to adjust the restrictive nature of the band has eliminated the need for revision surgery that used to be necessary with the VGB procedure. In addition, the stomach is not cut so there is minimal risk of leaking from the stomach. LAGB is the safest of all bariatric procedures and carries a very low 0-0.05% mortality rate. Because the lap band is very simple to perform the cost is generally much more affordable. Weight loss with the LAGB is 42% at one year and about 55% at five years. Weight loss tends to be more gradual compared to gastric bypass procedures but at five years the comparative weight loss between the two types of surgery is nearly identical.
Considerations:
It is very important that you understand that getting a lap band is not a guarantee that you will lose weight. Again, you must be willing and able to follow a meal plan to be successful.
Risks and adverse outcomes:
1) Band slippage: Rare. More common with repeated vomiting.
2) Band Erosion in the stomach: Rare.
3) Clogging of the port or tubing: Rare.
4) Dilation of the Esophagus: Rare.
5) Heartburn/Esophagitis: more common. Especially if the band is too tight or if there is overeating.
6) Standard universal risks for surgery; i.e. Infection, bleeding, blood clot, heart attack, stroke, etc. (to be discussed with the surgeon in Mexico). Rare.
Photo Credit by Foto_Blog on Flickr
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