Section 19: Other considerations

Travel and the gastric band 

Some people find that their band tightens up on flights, particularly those that are long haul (more than 4 hours). This can also be the case when visiting high altitude areas, such as on skiing holidays, or under water, for example when scuba diving.  

The tightening of the band can result in discomfort when eating/drinking, regurgitation and acid reflux. This is partly due to the fact that is common for all body tissues to swell to varying degrees at altitude/under water, including the stomach.  As you have a gastric band around your stomach, if the stomach swells, the band can feel tighter.   

There is also a theory that if you have any air trapped in your band, this can expand when in an environment with altered air pressure.  However, we try to make sure that there is no air in your band, only saline.   

In our experience, it seems to particularly affect people who are experiencing discomfort/heaviness/tightness/pressure on eating and/or regurgitation more often than is considered safe, i.e. more than once or twice a week, although as advised in Risks of surgery / potential complications and side effects, anyone experiencing discomfort on eating and/or regurgitation more than once or twice a week should always have fluid removed from their band 

There are a number of things to consider: 

1. As mentioned in Gastric band adjustments, if you need fluid added to your band, this should take place at least 2 weeks before flying. This will ensure you have enough time to check the band is not too tight and will give you time to arrange an aspiration (deflation) if necessary. It is your responsibility to inform your dietitian/nurse of any plans to travel prior to arranging an appointment to have your band tightened, in order to reduce the risk of the band becoming too tight. 

1. As a precautionary measure, you should eat at least 4 hours before flying.  Don’t eat directly before boarding – if you were to do so and were to experience discomfort eating, this causes unnecessary swelling around the band, which could potentially worsen during the flight. 

1. While flying, it is advisable to take fluids only; ensure you keep hydrated and consider purchasing nourishing milkshakes (e.g. Slimfast, Celebrity Slim) or soups at the airport if you are going on a long flight.   

1. Any changes occurring with the band while flying usually return to normal when back on the ground, but you should take extra care when staying in high altitude areas.  

1. As a precautionary measure, have liquids only for 12-24 hours after the flight, and soft foods for another 12-24 hours before moving back to normal challenging/textured foods. 

1. Consider a small aspiration (deflation) of the band prior to a long haul flight if you are experiencing discomfort/heaviness/pressure/tightness on eating and/or regurgitation more than once a week (see above), and/or your band tightens in other situations (e.g. when stressed/anxious, when premenstrual). This may indicate that you are more likely to experience discomfort whilst flying. 

1. Make sure you are aware of A&E departments at your destination in case of emergencies. 

1. Always carry our 24-hour urgent advice line number with you (see section 21). 

1. Always carry identification material with you whilst travelling that provides an explanation of the gastric band device. 

1. Inform your travel insurance company that you have a gastric band fitted. 

1. If you are travelling to an area where food/water contamination is endemic, it may be sensible to consider loosening the band slightly prior to departure.  We advise this because if you develop vomiting as a result of consuming contaminated food/water and swelling occurs around the band, you are at much lower risk of developing complications such as pouch dilatation or band slippage if your band is looser. If you do not have the band loosened, the swelling could result in the band feeling too tight, which in turn increases your risk of pouch dilatation and band slippage. 

1. It is advisable to have an aspiration (deflation) if you are travelling to an area of high altitude or are going on a parachute jump or scuba diving, as anecdotal evidence suggests these can all be associated with the band feeling tighter. 

Operations 

If you decide to proceed with any further surgery with The Hospital Group, your preoperative nursing assessment will include an assessment of your current status with your band. If there is any concern regarding your nutritional status and/or any negative symptoms related to your band, it may be recommended that you have the band loosened slightly prior to surgery. This is to reduce anaesthetic complications, enable you to get adequate nutrition for wound healing, and be able to take painkilling medication. The band is refilled following surgery on the condition that we are happy you are healing satisfactorily, but this occurs gradually, depending on how much was removed. Each patient is assessed individually.  

If you are having a general anaesthetic for a procedure not carried out by The Hospital Group, such as gall bladder removal with the NHS, speak with the surgeon who is performing the procedure. They will advise you as to whether or not they feel the band needs to be loosened. 

Endoscopies 

If you are having an endoscopy (a camera down your throat under sedation to look at the inside of your stomach and small intestine), it is sensible to have 1-2ml removed from your band so that the endoscope can pass easily into your stomach. 

Pregnancy 

 
Significant weight loss can actually boost libido and fertility. 

We strongly advise that you wait until you have reached your weight loss goal and your weight has stabilised before planning a pregnancy – this will usually be at least 2 years after surgery. An ideal weight at conception will be healthier for you and the baby.   

If you fall pregnant, inform your midwife and GP. We also recommend that you contact us to arrange to speak to or see a dietitian, as your nutrition will require assessing. 

Placing your aftercare on hold 

If you do fall pregnant within your aftercare package, we can place your aftercare on hold. In order for this to occur, we require written confirmation of your pregnancy from your GP or midwife. We will re-commence whatever aftercare you have remaining within your package, or 12 months (whichever is less) when you contact us after the birth. This will need to be used within two years of your original aftercare expiration date.  

We will only place your aftercare on hold once. If your original aftercare was more than 2 years in duration, it is in your best interests not to place it on hold and, instead, benefit from the support of our specialist dietitians and nurses throughout your pregnancy. 

Band adjustments 

If you find out that you are pregnant, please contact us to discuss your surgeon’s individual recommendations. 

Our surgeons vary in their advice on band adjustments during pregnancy. Some suggest that you have all the fluid removed from the band for the entire pregnancy. Others advise that fluid removal is only needed if you experience hyperemesis (excessive vomiting – morning sickness), while others advise a “watch and wait” approach. There is an increased risk of pouch dilatation and band slippage if you do not have the band loosened when experiencing morning sickness.  Furthermore, the baby is most susceptible to nutritional imbalance in the first trimester, and so you may require fluid removal to ensure adequate nutrition – although if you have been taking a multivitamin & mineral supplement daily and managing a varied diet, you shouldn’t have any nutritional issues. 

You may be able to have the band re-inflated slightly during the second trimester, especially if you are particularly hungry, able to eat large portions and therefore gaining too much weight (see below for acceptable weight gain during pregnancy). 

If you plan to give birth naturally, your band will need to be emptied by 36 weeks gestation at the latest. If you are having a planned caesarean section, this is not required. 

If you have the band loosened prior to or during pregnancy, it may be re-filled 2 weeks after delivery of the baby, unless you had a caesarean section and/or are breastfeeding, in which case you will need to wait at least 6 weeks. This takes into consideration the recovery time following the caesarean section, and/or to ensure you are well established with breast-feeding. 

X-ray guided band adjustments/assessments will not be performed if you are, or may be, pregnant. 

Dietary advice 

It is vital that you are healthy and well nourished before and during pregnancy to make sure the baby develops as it should. 

The following is essential during pregnancy: 

• Eat a well-balanced and varied diet  
• Eat regular meals 
• Limit consumption of fat-rich and sugar-rich foods 
• Take the appropriate supplements (see later) 
• Observing strict hygiene procedures to lesson the risk of food borne illnesses: 

• Ready-prepared meals should be cooked thoroughly to ensure that all bacteria are killed. This is especially important in meals containing poultry.  
• If fruit and vegetables are being eaten raw, they should be washed thoroughly.  
• Any leftover cooked food should be discarded after 24 hours.  

You should limit: 

• Consumption of oily fish (including tuna) to 2 portions per week to reduce the risk from food contaminants, such as dioxins and heavy metals. 
• Alcohol intake to 1-2 units per week - or avoid altogether. One unit equals: 

• ½ pint bitter (3-4% ABV (Alcohol By Volume)) 
• Small glass (125mls) of wine (9-10% ABV) 

• One pub measure of spirits (25ml) (e.g. plain vodka, gin, rum, whisky, brandy).  

• Caffeine intake to less than 300mg per day. The caffeine content of foods and drinks is listed below. Additionally, you should always read the labels of headache, cold and flu medications to avoid caffeine-containing analgesics.  

You should avoid: 

• Foods which may increase the risk of Listeriosis: 

• Soft ripened cheese such as Camembert, Brie and goats’ and sheep’s milk cheeses. Care must also be taken with mould-ripened cheese. Hard cheeses, yogurts and butter are safe because of their low pH and lack of moisture, and processed cheeses and cottage cheeses are likely to be free of the bacterium too. 

• Unpasteurised milk (from cows, sheep or goats) and any products made from it.  
• Pre-cooked or ready prepared cold foods which will not be re-heated, e.g. purchased salads, quiches, and meat pies eaten cold. 

• Liver and liver products to avoid excess consumption of Vitamin A 
• Supplements containing vitamin A or fish liver oils, unless medically advised 
• Shark, swordfish and marlin due to high levels of mercury 

• Peanuts or peanut products, if you have or a close relative has a history of atopy (allergy) 

Iron  

During pregnancy, iron is needed for the manufacture of haemoglobin in red blood cells, both in the mother and baby. The baby accumulates most of his or her iron during the last trimester (last 3 months). If you become iron deficient (anaemic) during pregnancy, this won’t usually mean that you baby is born anaemic. 

The current Dietary Reference Value (DRV) for iron in an adult female is 14.8mg/day, with no recommended increase during pregnancy as your body adapts to this situation through a number of combined actions: 

1. Your body’s stores of iron are ‘mobilised’. 

1. You absorb more iron from your food than when not pregnant 

1. You lose less iron because you are not menstruating 

When it comes to iron in food, it is more important where you get the iron from that the actual amount of it. “Haem iron” (from animal sources such as meat and fish) is absorbed more efficiently, whereas “non-haem iron” (from non-animal sources such as fortified breakfast cereals, pulses and green leafy vegetables) is affected by a number of other dietary factors that can inhibit or increase its absorption: 

• Vitamin C increases absorption 

• Calcium and polyphenols such as tannins from tea and eggs inhibit absorption.  

Therefore, you should aim to include lean meat within your diet every day, or if you are vegetarian/vegan, aim to consume some form of vitamin C at every meal and avoid drinking tea with meals. Particularly good sources of vitamin C include: 

• Oranges and orange juice (limit juice to 100ml daily) 
• Red and green peppers  

• Strawberries  
• Blackcurrants  
• Broccoli  
• Brussels sprouts 
• Potatoes 

Folate 

Throughout pregnancy, your body has increased requirements of this vitamin. This can be achieved by ensuring adequate supplementation (see recommendations above) and a well-balanced diet containing folate-rich foods:  

• Green leafy vegetables 
• Granary bread 

• Pulses (lentils & beans) 
• Yeast extract e.g. Marmite, Vegemite 
• Fortified breakfast cereals 
• Milk – choose skimmed, 1% fat or semi-skimmed 
• Tomato and orange juice (limit to 100ml daily) 

• Eggs 

Supplements 

During the first 12 weeks of pregnancy, you are advised to avoid vitamin and mineral preparations which contain vitamin A in the retinol form, as retinol may increase the teratogenic risk, especially in the first trimester. This means that the growth and development of the foetus could be disturbed. There are vitamin and mineral supplements containing no vitamin A which are specifically aimed at preconception and pregnancy; these also contain the additional folic acid that is required during pregnancy e.g. Pregnacare, Seven Seas Pregnancy and Centrum Pregnancy Care. If you take Forceval Capsules (the multivitamin & mineral supplement available on prescription), you can continue to do so as the vitamin A contained within it is not in the retinol form (Forceval Soluble is not suitable, however). 

You need to take additional folic acid prior to conception and for the first trimester (12 weeks) of pregnancy because there may be an increased risk of a neural tube defect-affected pregnancy. The amount you need to take depends on your BMI: 

• Over 30kg/m2: an additional 5mg of folic acid per day.  This is recommended for all obese women, not just those who have had weight loss surgery. 
• Under 30kg/m2: an additional 400µg of folic acid per day. 

Pregnancy-specific multivitamin & mineral preparations usually contain at least 400µg of folic acid, but if your BMI is over 30kg/m2, you will need to take additional supplementation as mentioned above. 

Weight gain during pregnancy 

There are no formal evidence-based guidelines from the UK Government or professional bodies on what constitutes appropriate weight gain during pregnancy.  According to the Institute of Medicine (USA) guidelines produced in 2009, acceptable weight gain during pregnancy is as follows, depending on pre-pregnancy BMI: 

Gaining more than the above stipulated amount is not beneficial to the baby and is likely to contribute towards you not being able to get back to a normal weight post-pregnancy.  

Based on this, the common phrase ‘eating for two’ is not true. No extra calorie requirements are advised during the first 2 trimesters (first 6 months) and only an additional 200 calorie increase is recommended during the final trimester (final 3 months). The best advice is to eat according to appetite and monitor your weight gain. Remember that if you have had your band loosened in the first trimester due to excessive vomiting, it is sometimes indicated to add some fluid to the band during the second trimester if you are hungry, eating larger portions and therefore gaining too much weight – contact us if you think this is the case. 

It is important that you inform us if you become pregnant, or think that you may be pregnant.