A perusal of any community hospital’s website will give testimony to the growing popularity and availability of gastric banding surgery. Lately, even local politicians and potential presidential candidates are going for “the band.” Public image notwithstanding, gastric banding is a little bit like “nutrition tough love.” Recently, I attended training for an adult weight-management certificate provided by the Academy of Nutrition and Dietetics, where dietary guidelines were addressed for gastric banding—an issue which is becoming more and more common in my private practice.
Several clients in my care have opted out of the more conservative traditional weight-loss methods and have gone for a gastric-band procedure. I’ve stayed in touch with them to monitor their post-operative progress, and to coordinate their nutritional needs related to their weight loss. Since the New Jersey governor’s recent announcement about his own banding operation has created a certain amount of buzz, I thought I’d review this timely topic.
Who qualifies for banding?
Previously, the gastric-band procedure was considered only for those who are severely obese; that is, those having a body mass index (BMI) of from 35 to 40, which translates as being 45 pounds overweight to being 100 pounds above the upper limit of healthy. (A body mass index of 40 or above is classified as “morbid obesity.”)
As of February 2011, however, the Food and Drug Administration relaxed the qualifications for the gastric band so that those who are just slightly obese—i.e., those with BMIs above 30—can be eligible for the procedure if they have a health-compromising complication like diabetes or heart disease. All candidates for bariatric surgery must undergo psychological screening tests to ensure that they are mentally prepared for the many changes they will have to cope with after the surgery.
What is it and how does it work?
Using an incision through the belly button, as well as several other small cuts in the abdomen, a laparoscope is guided into the abdominal cavity. A surgeon then places a narrow silicon band around the upper section of the stomach. This band is then inflated (filled with air) and tightened to create a dime-sized opening into what is now a very small stomach pouch. The stomach’s volume is thus restricted to just barely an ounce (about the volume of an egg). Eventually, this pouch’s volume will expand to about 1 cup. A normal stomach’s volume can be up to 4 cups.
Initially, the diet consists of small amounts of soft foods, which the patient must chew very thoroughly or drink an energy boosting spinach smoothie. Meals must be eaten very slowly—over a period of 20 to 30 minutes—to prevent distention and pressure on the band, which can be uncomfortable. To avoid nausea and gastric pain, fluids should only be consumed between meals. Over time, as weight loss is achieved, the band will need to be refilled with air and tightened to maintain the effect.
In general, gastric banding has a low incidence of complications. The two most common complications of gastric banding are band slippage and erosion. Band erosion means that the band has started to work its way through the stomach wall. If this happens, the band must be removed and replaced with a new one, again by means of safe and minimally invasive laparoscopic surgery. Lung complications (such as aspiration of food into the lungs) can also occur, but these are rare.
What are the results?
On average, a lap-band patient can expect to shed 25 percent to 40 percent of their excess weight within the first year. The final weight loss achieved with gastric banding is not as large as with gastric bypass.
Pros and cons
Pros: Because gastric banding is done through the skin with a small surgical instrument (the laparoscope), recovery time is short, scarring is minimal, and exercise and activity can be resumed more quickly than after more extensive surgery. Compared with more invasive gastric-bypass procedures, which involve stapling or surgically pulling up part of the duodenum, the lap band has fewer complications, and less likelihood of post-operative infection, blood clots, blood loss, or other serious problems.
Cons: The lap band is not a panacea. The gastric band diet, for example, is an extremely limiting one. Therefore, candidates for this procedure must re-think their attitudes toward food and genuinely accept and adopt a healthy and balanced approach to food. In other words, their diet plans after gastric banding should allow no room for junk food.
Furthermore, some patients think they can continue to rely on the restrictive qualities of the band forever. In fact, though, weight loss is not a never-ending effect of this procedure, and the rate of weight loss tends to stagnate after about 12 to 18 months. With time, as body mass diminishes, calorie needs are reduced and weight loss stops, and sometimes a plateau may be reached before the target weight can be lost. Banding, then, is not a “forever” deal—it offers a limited window of opportunity for the patient to achieve maximum weight loss.
The bottom line
The gastric-banding procedure is an extreme measure. It compels patients to make drastic changes in the timing of their meals, in food quantities, and, as was mentioned above, in their attitudes toward food. Gastric-band patients must initially re-learn how to eat miniature meals (i.e., quantities of less than 4 ounces) and, for someone who may have been accustomed to eating outsized feasts, this can be a drastic and wrenching change.
Overall, I still believe that this option should be considered only for people who are morbidly obese, when and if they have not responded successfully to other nonsurgical strategies. Furthermore, these patients need to be fully briefed on the realistic outcomes of this procedure. At the end of the day, it’s really a case of shared accountability: Patients must hold themselves accountable for the food they consume for nourishment. The band itself is also accountable to the patients, since it is monitoring what and how they eat and is then sending feedback to them.