Section 9: Follow-up and general guidelines on healthy eating and living with a band

The key to a positive weight loss outcome with weight loss surgery is to work closely with the Specialist Dietitian and Specialist Nurse. Follow the advice given, and be honest if you are having any problems with sticking to the regime. They will work with you to achieve the best result possible.

The key areas are:

1. Modifying your diet, eating patterns and eating habits
2. Altering your relationship with food
3. Gradually increasing your activity and fitness levels

Aftercare is fundamental to your success, and the Specialist Nurse and Specialist Dietitian will work with you to help you achieve your goals safely and efficiently.

How does the follow-up work?

o A nurse will call you 2-4 days after surgery. Please contact your Patient Advisor if you have not heard from a nurse within 4 days of your surgery.

o You will receive an email confirming the date and time of your first dietitian appointment, which will take place around 2-3 weeks after surgery.

Once you have spoken with the dietitian, they will book your first gastric band adjustment appointment a minimum of 5 weeks after surgery, which will again be confirmed via email. More details on gastric band adjustments can be found in Gastric Band Adjustments.

Please note that appointments may change from time to time, and you will always receive a new email confirming the new appointment. If you ever need to check or change an appointment, please call us.

After your initial post-operative appointments, your dietitian will usually book a follow-up appointment. Occasionally, we may  request that you call in to arrange further appointments, or you yourself may prefer to do this.

Patients generally do not need to see the surgeon after surgery, but the nurse/dietitian will refer you if a consultation is required. You will then see the specialist nurse and/or dietitian regularly in clinic, although some patients prefer telephone or email consultations.

If you have telephone consultations, we strongly encourage you to ensure you are in a suitable environment. Avoid speaking whilst driving (even on hands-free!), out shopping or distracted by children or work colleagues. Let us know when it is most suitable for you to have your appointments, and we will make sure that these fit into your schedule.

Your progress will be monitored by checking your weight and BMI (Body Mass Index), as well as changes to your medication and co-morbidities (e.g. diabetes or high blood pressure). We will also assess your dietary intake and track your activity levels.

It is important to be honest, even if you have had bad days! Sometimes we may ask you to keep a food/activity diary. Our specialist team has a wealth of experience with patients who have undergone weight loss surgery and are extremely conscious of providing a useful, non-judgemental and supportive service. This will be very different to any kind of weight loss advice you may have received before - it is geared to weight loss surgery specifically, so try to leave any preconceptions about dietitians behind you.

IMPORTANT: Attend all your follow-up appointments (phone call or face-to-face). If a proposed date is not convenient, then contact us and we can reschedule it to a more convenient time. By cancelling and rescheduling in advance, your appointment can then be offered to another patient who may need our help. Tell us if you are struggling with any part of your band journey - we are here to help, but can only do so you if you tell us about anything that you are finding difficult. Evidence shows that patients who attend regular follow-up appointments are more likely to achieve weight loss.

o Remember that you have access to advice on urgent challenges 24 hours a day if required.

o Stay positive! Everyone loses weight at a different rate. This is especially important to remember when you come into contact with other patients when attending clinic or using internet forums.

If your surgery was after August 2018, you also have access to a year's free membership to BandBoozled.co.uk. This is an online support centre specifically for patients following weight loss surgery. If you haven't been offered this, please contact [email protected].

The first few weeks after surgery

It takes a minimum of 4-6 weeks, on average, to get used to the feel of having your gastric band. You should adopt a staged approach to eating after surgery to ensure the stomach can heal and the band settles properly into its correct place.  Usually, stitches hold the band in place and these must not be disturbed until they heal, otherwise there is a chance of band slippage (see risks of surgery, potential complications, side effects).

Eating solid food too soon may cause you to vomit and/or put pressure on the band and lead to pouch dilatation or slippage (see Risks of surgery, potential complications, side effects).

The staged approach is as follows:

o Weeks 1 and 2:  liquid diet

o Weeks 3 and 4: soft/sloppy diet

o Weeks 5: post-operation onwards - gradually incorporating solid food

REMEMBER: As healing occurs and the swelling disappears, it is NORMAL for your appetite to return, your food intake to increase and therefore your weight to plateau or even increase slightly. The initial liquid phase often results in weight loss; however, this stage is not aimed at losing weight but is to allow the stomach to heal from surgery. The majority of patients do not lose more weight until after a number of adjustments to the band. You must be patient during this time. Think of any weight loss before the band is optimally adjusted as a bonus! In the meantime, try to eat as healthily as you can and exercise regularly. These will maximise your chances of losing weight at this time.

General guidelines on eating and drinking

Changing the way you eat is just as important as changing what you eat so that you can avoid any discomfort/ regurgitation when eating.

Remember:

o The "20, 20, 20, 20 Rule" - see How the Gastric Band Works. Smartphone apps such as "Bariatric Meal Timer" (Apple), "20 Minute Eating - Eat Slower" (Apple) and "Time Your Bites" (Android) can help.

o Serve yourself small portions - using a small 6-inch plate is about right

o Switch to children's sized cutlery to help ensure you take small mouthfuls, or try a small dessert fork or teaspoon instead.

o Sit down to eat, savour your meals and avoid eating on the move.

o Start the day with a drink, ideally hot - this can help "warm up" the muscles in the pipe that leads from your mouth to your stomach, which in turns reduces the likelihood of problems with eating.

Eat your first meal as soon as you start to get hungry. This might not be for 3-4 hours after waking, so use this time to have plenty of fluids. Try to avoid waiting until you are very hungry, as this can lead you to not following the 20/20/20/20 rule which can in turn lead to issues.

Avoid leaving a gap of longer than 4-5 hours between meals, as this can also cause you to feel uncomfortable when eating or experience regurgitation (see Risks of surgery, potential complications, side effects for more information on problem-solving.)

The concept of Mindful Eating can be very helpful – find information on this ater in this section.

Drinks

Everyone has slightly different fluid requirements depending on factors such as gender, lifestyle, and body weight. 1.5 to 2 litres of fluid every day is sufficient for most people, but you will need to increase this the more physically active you are, or when the weather is warmer. The best way to check if you are drinking enough is monitoring the colour of your urine, which should be pale straw-coloured from 4-5 hours after waking onwards.

Suitable drinks include:

• Still water or still no-added sugar / sugar-free flavoured water
• No added sugar / sugar-free cordial/squash
• Tea, coffee and fruit teas with no sugar added; use artificial sweeteners instead. Limit milk to 1 pint per day once you have completed the liquid-only stage (weeks 1 & 2) and choose skimmed, 1% fat, semi-skimmed, lactose-free equivalents or calcium-enriched soya milk (avoid nut-based milks as these contain very little protein)

Drink slowly. Take small sips, not big gulps. Do not take a mouthful of fluid immediately after a mouthful of food, because you need to give the mouthful of food time to be squeezed through the band via the muscular contractions of the oesophagus (the pipe from the mouth to the stomach).

Based on the band's mechanism (described in How the Gastric Band works), it is only necessary to wait a minute after your last mouthful of food before having a drink. However, some patients find that waiting 10-15 minutes after meals before having a drink is more comfortable. Drinking and eating together can cause discomfort and regurgitation, which can result in complications such as pouch dilatation and band slippage if they occur too often

You may find that, if you are unable to drink large amounts quickly, you drink less than you did before the operation. Try setting an alarm on your phone every hour to remind you to have a drink, or use a Smartphone app such as "Water Your Body" to help remind you.

Fizzy drinks

Avoid fizzy drinks for the first 4 weeks and limit your consumption of them thereafter. The gas cannot be easily expelled, and this can cause discomfort and bloating. Some surgeons believe that this difficulty in expelling the air can cause distension of the stomach wall, which could lead to potential complications such as pouch/oesophageal dilatation and band slippage (see Risks of surgery, potential complications, side effects).

We consider there to be little risk in consuming fizzy drinks after the first 4 weeks, providing you follow the following guidelines:

• You may consume 'diet' or 'sugar-free' fizzy drinks occasionally - once or twice a week. Do not have them regularly. Avoid sugary fizzy drinks.
• You must sip fizzy drinks slowly; never gulp. Gulping could cause the drink to be held above the band for too long, potentially disturbing the sensitivity of the stomach above the band. This could cause the area to stretch, hampering the band's ability to reduce your appetite and therefore portion size. This could also lead to pouch dilatation and slippage.
• If you feel any discomfort and/or experience excessive burping from consuming a fizzy drink, you should stop and avoid fizzy drinks permanently. Many patients find that this is the case once their band is optimally adjusted.

Chewing gum

Avoid chewing gum as this can create trapped wind, which can be uncomfortable. Additionally, if you were to accidentally swallow the gum this could cause an obstruction, potentially requiring an urgent deflation of the band and possibly even removal of the band altogether (charges may apply).

Vitamin and mineral supplement

Take a complete multivitamin and mineral supplement every day, as you will be consuming a greatly reduced volume of food especially once your band is optimally adjusted. However, it is still important you consume a varied diet and follow the advice of the dietitian to achieve a healthy balanced intake.

Weeks 1-4

In the first 4 weeks, you should avoid swallowing solid tablets and choose chewable or soluble varieties instead. 

In the UK, there are no off-the-shelf chewable or soluble/liquid varieties that are considered "complete".  From our own extensive research, the variety that is closest to being complete is Centrum Fruity Chewables.

Forceval Soluble (available on prescription or over the counter) is considered a "complete" supplement.

Note - "over the counter" means it is available to purchase without a prescription, but you will have to ask at the pharmacy counter for it - it won't be on display.

4 weeks post-op onwards

Change to a solid tablet/capsule variety. Any brand is suitable providing it is complete - it is essential that the supplement contains both vitamins and minerals.

Good quality off-the-shelf varieties include:

• Tesco A-Z multivitamins + minerals
• Sainsburys A-Z multivitamins & minerals
• Morrisons A-Z multivitamins & minerals
• Lloyds Pharmacy A-Z multivitamins & minerals
• Superdrug A-Z multivitamins + minerals
• Sanatogen A-Z Complete

Forceval Capsules are also an option, but are only available on prescription or over-the-counter.

If you are in any doubt of the type you have purchased, please contact us or discuss this with your dietitian at your next scheduled appointment

Healthy eating and balanced meals

Eating a wide variety of foods ensures you are consuming a range of nutrients and is important for general health. It can reduce the risk of certain cancers, heart disease, diabetes and osteoporosis. Eating a healthy balanced diet also helps you to lose weight, whether you have had weight loss surgery or not! Smartphone apps such as "My Fitness Pal" can be useful in monitoring your intake.

The image below shows the ideal way to balance each of your meals:

¼ carbohydrate-based foods.

¼ protein-based foods – to include dairy products

½ vegetables, salad (fruit can also be included here)

Vegetables / salad / fruit should form half of each meal

They provide vitamins, minerals and fibre. Choose a variety of different-coloured fruits and vegetables. This ensures you are getting the best range of vitamins and minerals, as well as powerful antioxidants.

Protein-based foods should form a quarter of each meal

Protein is important for enzymes, hormones and maintaining muscle mass. Examples of protein-based foods include meat, fish, eggs, beans, lentils, Quorn, tofu and other soya-based products. Milk and dairy foods are also a great source of protein. Aim to include 3 portions per day to provide calcium.  portion is:

• A small individual pot of yoghurt, ideally 0% fat and low sugar options or cottage cheese
• A third of a pint (~200ml) of milk, ideally skimmed, semi-skimmed, 1% fat (or lactose-free equivalents) or calcium-enriched, unsweetened soya milk
• A small matchbox sized piece of cheese, ideally reduced fat.

Carbohydrate-based foods / starchy foods should form a quarter of each meal

They contain fibre, B vitamins, calcium and iron and are a great source of energy.

There are a lot of misconceptions about carbohydrates, specifically that they are fattening. This is not the case!

Why is carbohydrate important?

Carbohydrate-rich foods are the primary source of fuel for all your bodily functions. Your body breaks down carbohydrates (or "carbs"), into glucose (energy) for your cells and muscles to use - that's why eating a moderate amount of carbohydrates is extremely important.

There are two types of carbohydrate:

o Simple carbohydrates - often listed on food labels as 'Carbohydrates (of which

sugars)'. This usually refers to table sugar (added sugars), but it also includes the

natural sugars found in fruit and milk.

o Complex carbohydrates - also called 'starchy' foods. Starchy foods include bread,

cereals, rice, pasta and potatoes. An important factor to remember is that complex

carbohydrates include dietary fibre, which increases satiety of food, helps prevent

constipation and can also help to lower cholesterol levels.

Here are some examples of different carbohydrates:

The complex carbohydrates are a healthier option, so choose these where possible and limit your intake more of the simple carbohydrates.

Keeping blood glucose levels steady is important in weight loss. This is because as you eat a simple carbohydrate food, your body rapidly converts it to glucose. The glucose dissolves in your blood stream, giving you a 'sugar high'. A rapid decrease follows this as the glucose quickly disappears from your bloodstream, leaving you feeling starved of energy and looking for more food. This is another reason why complex carbohydrates are a healthier option, as they digest more slowly, keep you fuller for longer and provide you with lasting energy.

Aren't carbohydrates fattening?

No. If we take in more calories than we burn up, no matter what the source, the excess will be converted into body fat. Since sugary foods taste good and are high in calories, it can be easy to consume too many of these, resulting in a higher calorie intake and thus weight gain. People can mistakenly think that starchy carbohydrates such as bread and potatoes are fattening, but weight for weight carbohydrate contains less than half the calories of fat. Studies show they are much better at satisfying our hunger.

o 1g carbohydrate contains 3.75 calories

o 1g protein contains 4 calories

o 1g fat contains 9 calories

o 1g alcohol contains 7 calories

Can low carbohydrate diets help with weight loss?

Low carbohydrate diets, which cut out most starchy foods, are sometimes used for weight loss. In the short term they can lead to side effects such as constipation, headaches, mood swings, bad breath and nausea. In the longer term, cutting out any food group can be bad for health because you risk missing out on vital nutrients.

It is also important to note that the weight lost from low-carbohydrate diets is mainly muscle and water, rather than fat mass. When trying to lose weight permanently, losing lean muscle tissue is detrimental as muscle is metabolically active and burns calories even when you are at rest. Therefore, a decrease in the amount of muscle you have will lead to a decrease in the number of calories you need each day to maintain your weight. This makes it much harder to keep your weight under control when you stop following the low carbohydrate diet.

Low carbohydrate diets also tend to be higher in fat, and eating a high fat diet (especially one rich in saturated fat from foods such as meat, cheese, cream and butter) could increase the chances of developing heart disease. Low carbohydrate diets may also restrict the amount of fruit, vegetables and fibre, all of which are vital for good health including reducing cancer risk. Overall, there does not seem to be any advantage in following a low carbohydrate diet which cuts out most starchy foods, as any weight loss is not sustainable.

So, how much carbohydrate should we eat?

About a third of the food we eat should be carbohydrate. Aiming for a quarter of the food on your plate at each meal to be a source of starchy carbohydrate is a good way to ensure you are getting the balance right. Sugary foods such as table sugar, soft drinks and sweets generally contain few other nutrients and are recommended only on a more occasional basis. These are often called "empty calories" due to their lack of other nutrients.

Further points to remember:

• Try to reduce sugar, sugary drinks, refined (white) grains, trans fats (found in cakes, biscuits, pastries, fast food, coffee creamer, palm oil and processed foods in general) and saturated fats (found in butter, ghee, lard and coconut oil)
• Remember that all fats contain a lot of calories and should be limited, although not completely avoided
• Instead of trans fats, saturated fats or processed fatty foods, choose small amounts of polyunsaturated or monounsaturated fats, which are better for heart health, hormone production and the immune system. Sources of these healthier fats include:

• Oils which are liquid at room temperature e.g. olive, rapeseed oil
• Unsalted nuts and seeds
• Linseeds / flaxseeds
• Oily fish such as mackerel, salmon, fresh tuna, pilchards or sardines

Foods/drinks you should limit:

It is crucial that you eat healthily for the band to work. Consuming more calories than your body needs will always result in weight gain, so it's important you limit your consumption of certain foods and drinks, listed below. Most of these foods require very little chewing and so are not ideal choices with the band anyway (see "Choosing the correct texture"), but they also add 'empty calories' to your diet.

When it comes to the sweet and savoury snacks listed below, a good limit to give yourself with these foods is 100kcal (calories) per day – that way, you can still enjoy them, but in moderation.

• Hard cheese – try reduced fat varieties instead such as Quark, Ricotta, cottage cheese or reduced fat cheese spread
• Skin on chicken/poultry & fat on meat - remove these prior to cooking
• Chocolate
• Crisps
• Cakes
• Biscuits
• Ice cream
• Nuts - plain (not salted) nuts eaten occasionally in small amounts as a snack are a good source of protein and minerals. However, as they are high in fat, be careful to keep portions small
• Desserts & puddings - try low fat, low sugar yogurts/mousses or sugar-free jelly instead
• Milkshakes
• Milky coffees - lattes/cappuccinos
• Hot chocolate / milky malted drinks (e.g Horlicks, Ovaltine) – try lower calorie varieties
• Smoothies
• Fruit juice - limit to 1 small glass (100ml) per day
• Spread – all fat spreads are high in calories and should be used sparingly. Choose a reduced fat or ‘light’ variety and try to avoid those which have ‘hydrogenated vegetable oil’ on the ingredients list, as this is a source of harmful ‘trans fats’
• Oil – if you are cooking with oil, choose olive or rapeseed oil and use sparingly, as they still contain as many calories as other types of oil. Try a spray oil instead which will help you to use less

Alcohol

We recommend you avoid alcohol for the first 4 weeks after your surgery and until you are tolerating a normal, textured diet.

If you drink alcohol, make sure it is in moderation. The government guidelines recommend that you do not regularly drink more than 14 units per week. This is the same for both men and women.

This is equivalent to:

• 6 pints of 4% ABV beer
• 6 x 175ml glasses of 13% ABV wine
• 14 x 25ml shots of 40% ABV plain spirit e.g. vodka, rum, whisky, brandy, gin.

It is best to spread these evenly through the week.

Did you know?

o A glass of wine has similar calories to a slice of cake

o A pint of bitter has similar calories to a slice of pizza

o A spirit & cola has similar calories to half a doughnut

o Alcohol contains 7 calories (kcal) for every gram, almost as much as pure fat

o Alcohol contains no nutritional value

o Alcohol can slow down the number of calories you're able to burn through exercise

o Drinking alcohol increases the temptation to eat high calorie snacks

o Exercise won't reverse the damage regular drinking does to your body

Tips:

• Choose lower ABV wines/beers
• Invest in a measure for spirits – avoid free-pouring
• Opt for smaller measures e.g. buy smaller wine glasses
• Add less alcohol but extra low-calorie mixers to your drinks
• Find an alternative to alcohol to relieve stress - yoga, walking, reading etc
• Set yourself a limit before you start drinking and stick to it
• Offer to be the designated driver sometimes so you aren't drinking
• Have at least 3 alcohol-free days each week
• Drink more slowly, alternating alcoholic drinks with water and/or food

Remember: Alcohol adds calories to your diet and ultimately increases your appetite. It can also reduce your willpower, so you may be tempted to come off your healthy eating regime whilst drinking.

Use the below table as a rough guide to how many calories you are consuming per drink:

                                    Source: NHS/Cancer Research UK

Remember, fizzy drinks could cause discomfort, so either use lots of ice and stir to remove some of the fizz, or choose diluted fruit juice or still mineral water with 'no added sugar'/'sugar-free' squash/cordial as a mixer instead of lemonade / cola / tonic /soda water.

Mindful Eating

Mindful eating is based on the Buddhist concept of mindfulness, which involves being fully aware of what is happening within and around you at a moment in time.

Applied to eating, mindfulness includes noticing the colours, smells, flavours and textures of your food; chewing slowly; getting rid of distractions like TV or reading; and learning to cope with guilt and anxiety about food. Practicing mindful eating can be a really useful weight loss tool, as it makes you think about and question your hunger a lot more than you usually would and often reduces the amount of food you would eat even further.

Do these habits sound familiar?

o Eating until you are too full and then feeling guilty

o Emotional eating - eating when you are bored, stressed, upset or anxious rather than hungry

o Eating food without really tasting it

o Mindlessly eating when watching TV / reading / on the computer

o Eating a meal at the same time every day whether you are hungry or not

o Skipping meals, not paying attention to your hunger signals.

If so, try the following:

1. Check-in mindfully

o How hungry am I on a scale of 1-10?

o Each time you go to eat something, ask: 'Am I physically hungry?' 'Do I really need

to be eating this?'

o Aim to eat until you are satisfied (80% full), leaving yourself neither stuffed nor starving.

1. Take mindful mouthfuls

o Have you ever eaten a whole meal and not really tasted it? Slow down; bring all of your senses to the table.

o Think about the smell, taste and texture of the food you are eating. Really chew your food and experience each mouthful.

(This works in line with the 20, 20, 20, 20 rule)

1. Attentive eating

o It is not always easy to give eating your full attention if you have a busy lifestyle, but it is really important.

o Try not to multitask whilst you eat, allow yourself 20 minutes to stop, check-in mindfully and really enjoy eating your meal.

o Concentrating on one thing at a time is key to eating mindfully.

A common mindless eating habit is emotional eating - eating when you are bored, stressed, upset or anxious. The reasons for this will vary from person to person, but recognising the 'triggers' for this kind of eating is the first step to overcoming it.

Your dietitian can work with you to help you recognise what your triggers for eating are and to help you overcome them. However, many can be avoided by following the 3 mindful eating rules above and making practical tools for you to use on a day to day basis.

For example, see the hunger scale printed below. You can use this to question your hunger when you are thinking about having a snack or meal. If you find this useful, speak to your dietitian and they may be able to suggest some further ideas for your individual needs.

Head Hunger vs Stomach Hunger

There are two different types of hunger:

• Head Hunger: this is when you aren’t actually hungry as such, but you “fancy” something specific to eat. Usually only something high in sugar and/or fat will satisfy you, and if you are offered a less “exciting” snack, you may not want it

• Stomach Hunger: this is when you are physically hungry; your stomach could be rumbling as a result. If this is the case, you would eat anything to satisfy your craving, not just something you would regard as a “treat” or a “nice” snack

When measuring your hunger, it is important to measure stomach hunger, not head hunger.