NEWSLETTER 1 OF 2010

 

Netcare
 

NETCARE ST ANNE'S HOSPITAL

 

 

 

Welcome to the first Newsletter of 2010 and the first Newsletter on the Web.
Thank you to Anlie Evetts for her hard work in putting it all together.
The Banding programme is certainly up and running with the 169th Band due next week.
The good, bad and uglies are out there but what keeps us going is the vast majority of "goods" - the patients at goal weight - who are maintaining and are well. The band erosions account for the bad and ugly or rather the sad outcome. Our erosion rate is 5.9%. The causes of erosion are 3 fold:
1. surgical techniques;
2. overzealous inflation;
3. overzealous food ingestion.
Avoid pushing the band to its limits, i.e. do not see how much you can get down - rather see how little it takes to get that feeling of fullness -  eat slowly, limit the quantity, and then only continue with more of that meal if after 10 minutes you are actually still hungry.
The "Bandlits" continue to appear as the amount of pregnancies on the programme increases.
A big thank you to the team behind the scene - -Anlie, Jitesh, Di, Shannon, Sarah, Wendy, Devan, Jay.
Keep in touch.
Limit the quantities.
Enjoy your new lease on life.

Kind regards,
Dick Brombacher

 

WHAT IS IN THIS NEWSLETTER:

How Do I Know Whether My Band is Tight Enough?

Gastric Banding: Guidelines for New Eating Habits (Based on information by Dr Karl Miller)

Notes from the Physio (Jitesh Gopal)

Key Behavioural Factors Influencing Post-Operative Outcome (Shannon Lang, Counseling Psychologist)

Practical Ideas for Eating (Shamala Govender)

The Process of Change and the Role of the Psychologist (Sarah van Niekerk, Clinical Psychologist)

Heartburn Guidelines

The Team and their Contact Details

 

 

 

HOW DO I KNOW WHETHER MY BAND IS TIGHT ENOUGH?

 

Your band is too loose and you will need a refill when:

  • You feel as if you can eat anything (food restriction lacking)
  • You are hungry all the time
  • You feel as if you want to eat all the time
  • You feel as if you could eat huge portion sizes
  • You can finish your meal at an unrestrained speed (eat too fast)

 

Your band is too tight and will need to have fluid removed when:

  • You will hear a gurgling sound when you swallow water and you will belch with every sip of water
  • You will suffer from reflux (heartburn)
  • You may get regurgitation or frequent vomiting
  • You cannot eat a normal range of food
  • You may choose unhealthy alternatives to food

 

Your band is well adjusted when:

  • You can satisfy your hunger with small portions of food
  • You stay full for a long period of time
  • You can eat at a restrained speed (20 - 30 min for a small meal) with no vomiting afterwards
  • You can eat a range of foods
  • There is satisfactory weight loss or maintenance

 

 

It is vitally important that you adhere to the following guidelines post band insertion and fills, to reduce the risk of complications and make your experience enjoyable.

This s almost like having received a new car. You can either look after it and service it properly etc, or you can push it to extremes to see what it can do and not look after it, only to find too late that its engine has worn out and it's not performing like it should.

Remember, frequent vomiting or overeating is not ideal, as it can cause the band to slip/erode. This will compromise the desired outcomes. Ideally there should be no vomiting.

 


 

GASTRIC BANDING: GUIDELINES FOR NEW EATING HABITS

Based on information by Dr. Karl Miller (Associate Professor of Surgery), Head of Surgical Dept, Salzburg, Austria.

 

1. ONLY EAT SMALL QUANTITIES
The capacity of the stomach has changed so the amount of food you eat has to change. If you try to eat more than what the stomach pouch can accommodate, you may become nauseous or vomit. If you routinely eat too much, the small pouch may stretch, thus canceling the effect of the operation. This is perhaps the most radical change in your lifestyle. Remember that it takes time for the brain to register that you are full, so eat slowly (20 - 30 min for a small meal), also giving the nerve impulses time to travel to the brain and stop before you feel full. Over time you will get to know how much food you are comfortable with.

2. CHEW WELL
You need more time for chewing. Some foods may need to be avoided as they cannot be broken down enough with chewing. Big chunks of food can block the stomach pouch outlet. Learn to cut food up into small pieces and eat slowly. Only take small mouthfuls at a time as well.

3. NEVER EAT AND DRINK AT THE SAME TIME.
The reduced capacity of the first part of the stomach will no longer permit you to take in both liquid and food at the same time. (This excludes milk, which you may for example have with porridge). Keep yourself well hydrated though by maintaining the minimum fluid intake of approximately 1,6 liters per day which is 6-8 x 200 ml glasses, (easier to divide between meals).
You will soon have realized that you can no longer "down" your liquids. You now have to sip them carefully and pace yourself.

4. DO NOT LIE DOWN OR REST DIRECTLY AFTER EATING
In a horizontal position regurgitation is easier to take place. The food also remains in the stomach pouch for longer and leads to very uncomfortable accumulation of mucus.

5. EAT FIVE TIMES A DAY
This is important, because if you only have 2 - 3 meals a day, it is not possible to have a great variety of food. Consequently, as you only eat small amounts, you do not get enough proteins, minerals and vitamins. In addition, when eating smaller regular meals, you are less likely to be overpowered by sudden hunger attacks where you probably forget the new eating habits. (This cannot be stressed enough. Having a "smaller" stomach may make you feel full and you may be tempted to skip meals. You should try to settle into a new eating & snack routine as soon as possible). Have the smaller meals at least 1.5- 2 hours apart. If you are really feeling full, don't force yourself to eat, or skip the in-between snacks and only have the three small meals. Work out a routine that is comfortable for your body. Eat the next meal ONLY if hungry !

6. Remember to only eat the equivalent of the quantity of a small purity bottle, then STOP eating. If you want to continue eating, ask yourself first whether it is because you are hungry, or because it is out of habit.

 

 


 

NOTES FROM THE PHYSIO

(Jitesh Gopal)

 

  • Remember to continue with your deep breathing exercises.
  • Note that a Cardiovascular workout may not help with weight loss. Add resistant training to your programme to aid in weight loss and to tone your muscles.
  • Start with the treadmill; stepper; cycle and progress to a comfortable "super-circuit" regimen.
  • Be positive
  • Join a dance class / group

 

 

 


 

 

KEY BEHAVIOURAL FACTORS INFLUENCING POST-OPERATIVE OUTCOME

(Shannon Lang: Counseling Psychologist)

 

Over time the academic community has gathered a body of research with regard to post operative outcome for bariatric surgery patients. This research is valuable, not only for prediction of outcome, but also for maintaining health and emotional well being. Some of the key behavioural factors for a positive emotional outcome are:

 

  • monitoring reactivity to stress,
  • emotional resilience,
  • measured responsiveness to the opinion of others, and
  • a healthy self-esteem.

 

All change has a psychological impact on the human psyche. For some this is embraced and engaged with in an aim to integrate the change in the least threatening way. However, for others change represents significant stress, the consequences of which are emotional numbing, flattening of affect, hyper arousal and sensitivity, sleep disturbance and mood lability. These symptoms of stress place undue pressure on the body's coping mechanisms which in turn stretches the individual's capacity to integrate the change and see it as ally rather than foe. For those individuals who are susceptible to stress it is imperative that stress levels are monitored carefully after bariatric surgery. Good coping mechanisms, such as support from family and friends, therapeutic intervention and in some cases medical support need to be accessed.

Emotional resilience is the ability to weather the storm without undue emotional distress. While it is subject to genetics, gender, age and exposure to difficult situations, it can also be a learned skill. Those with emotional resilience usually have a good emotional awareness, an internal locus of control, are optimistic and know the value of social supports. In addition, emotionally resilient people cultivate an ability to see the humorous side of life, they learn from their mistakes and see obstacles as challenges. Developing these characteristics will take time but the rewards will be immeasurable.

A cautious responsiveness to the opinions of others puts the individual in a position where their actions are a result of intrinsic or internal motivation rather than extrinsic or external motivation. Unfortunately, while it is valuable to be open to other opinions and perspectives it can also be damaging when those opinions go unquestioned. This can be related to comments about food intake, clothing, activities and even parenting and relationship issues. A healthy consideration of other perspectives in the presence of reason is advised. This is particularly important after bariatric surgery when behaviour patterns change and are frequently commented on by others.

A healthy self-esteem is a function of a number of factors. One of the primary ones is a refusal of the individual to be in an adversarial relationship with themselves. This is a key ingredient to being able to respect and love the self. The difficulty with obese clients is that their eating difficulties have frequently impacted on a state of self loathing. Over time this becomes an entrenched pattern and is hard to shake. Thus the challenge of any potential bariatric surgery patient is to be able to love themselves and focus on strengths rather than weaknesses. This is not a denial of the eating difficulties but a simple realization that one's value is more than, and way beyond, eating issues.

 

 


 

PRACTICAL IDEAS

by Shamala Govender

 

  1. Basmati rice can be too hard. Other rice tends to give a softer cooked product e.g. Tastic or Aunt Caroline.
  2. More "watery" fruits (less fibrous), tend to be better tolerated e.g. melon, mango, nectarine, instead of apple. Eat the orange so you get the "juices", without the pith / cell parts.
  3. When feeling ill, have the tea without milk (as the milk in it can make you feel more nauseous).
  4. When the family wants to order KFC, get the mash and gravy for yourself.
  5. A slice of bread rolled up, with filling, and cut into 3, can be used for 3 meals.
  6. When eating chicken, the thigh portion seems a better option as breast tends to be stringy and dry.
  7. To bulk up a cup a soup, add 2 minute noodles to it, as these noodles are easier to eat.
  8. You can consume liquid dhal as a soup.

 

Don't restrict yourself by saying "I don't like..." or "I don't eat..."
Try new recipes or new ways of making things. You will be surprised with how nice things can taste, that you thought you would never eat (and it will give you a wider meal variety)

RECIPE FOR TUNA

Tuna

Black Pepper

Low fat Mayonnaise

Chilli - chopped

Diced onion

Eat on its own with dry crackers.

You can substitute the tuna with chicken.

 


 

THE PROCESS OF CHANGE AND THE ROLE OF THE PSYCHOLOGIST

(Sarah van Niekerk, Clinical Psychologist)

 

Anyone who has ever made and broken a New Year's resolution (and yes, that includes all of us!) will be able to appreciate the real difficulty of behaviour change. Making a lasting, meaningful change in behaviour is rarely a simple process, and usually involves a substantial commitment of time, effort, sometimes money, and always emotion. People tend to progress through different stages on their way to successful change, with each of us progressing at our own rate, and making use of different means and support structures along the way. Researchers in the human and behavioural sciences maintain that the process of achieving one's goals and sustaining the gains made is perhaps best supported by an attitude of flexibility (well, this technique hasn't worked so let's try something else) and finding positive ways to stay motivated and focused.

"Readiness for change" is a dense concept with roots in personality structure and style; self-awareness and insight, self-concept, self-worth and attitudes towards self-care; motivation; one's profile of adjustment and adaptation; patterns of coping with stress; lifestyle factors; exposure to adequate knowledge and preparation; and the availability of support structures and a milieu of encouragement. Furthermore, stable and long-term change presupposes a process of decision-making that is internally-driven, as opposed to externally imposed.

When we consider that obesity places individuals at risk not just for associated physical and medical conditions, but also for a poorer quality of life and psychosocial complications (such as the risk for isolation, compromised self-esteem and depression), it becomes a physical and mental health imperative that we understand not only the mechanisms of behaviour change, but also those factors that may support and hamper the process of change towards general health and a sense of well being. In relation to the bariatric procedures, it is also noteworthy that the same procedure may yield different outcomes in different patients, hence, highlighting that psychological factors (such as compliance, motivation and adjustment) contribute directly to the outcome of medical intervention and the ongoing management of obesity.

The most important elements in changing a behaviour, and which have relevance to the ongoing management of obesity, include the following:

  • Readiness to change

Do I have the resources (including intra-personal and inter-personal, practical and lifestyle resources) and knowledge to successfully make a lasting change?

  • Barriers to change

Is there anything preventing me from making this change?
(whether it be a personal or relationship factor)

  • Triggers for relapse

What might trigger a return to a former maladaptive behaviour?
(whether it be stress trigger, lifestyle trigger, or relationship trigger)

 

The Role of the Psychologist

Both the mind and body are intricately involved during any process of change we undertake.

The pre-operative psychological/ behavioural health assessment has the goal of identifying both personal resources for coping and positive adaptation, as well as psychosocial risk factors, and to make recommendations aimed at facilitating the best possible outcome and adjustment for the person.

Typically, the person's behavioural style, cognitive/ emotional patterns, developmental history, current life situation and stressors, motivation, and expectations are explored.

The following areas are generally assessed and supported:

  • the person's readiness for change, including assessment of their motivations, expectations, and knowledge around the procedure;
  • the person's eating and dietary styles, including eating behaviours, food preferences, and weight-loss/ gain profiles;
  • the person's lifestyle and activity patterns;
  • screening for patterns of health-related risk-taking behaviours;
  • the person's stress profile and resources for coping and positive adjustment;
  • screening for psychiatric difficulties which may, or may not, affect ultimate health outcomes;
  • the availability of and access to social support;
  • the opinions of significant others and family members are also encouraged, and discussions around potential changes to body-image and self-concept are also facilitated.

 

It is also important to consider that personal change is sometimes not met with the enthusiasm that we may expect from our loved ones and friends. Sometimes, change is met with ambivalence or resistance. It is for this reason that significant others are encouraged to participate in the process of change, and that their views and feelings are acknowledged. It is not uncommon for relationship issues to resurface during times of personal change, and also not uncommon for such issues to find gentle resolution with the correct support.

The process of change in regards to the management of obesity is best supported by the multi-disciplinary professional team, and a collaborative approach to understanding individual readiness for change, enhancing motivation, and developing avenues for social support and hope.

 


 

HEARTBURN GUIDELINES:

Avoid food or large quantities of liquids 3 hours before retiring at night
Elevate top end of bed.
Avoid foods that may aggravate heartburn e.g. coffee, colas, chocolate, black / red pepper, spicy foods, peppermints, chewing gum, citrus juices, tomatoes / tomato juice, vinegar, lemon juice, fried or oily foods.
Avoid temperature extremes in one meal (e.g. very hot and cold served together)
Decrease, or preferably stop smoking.
Contact Doctor for medication, if it doesn't settle.

 

 

You need to change your mind set regarding how much food your body needs. 
It is not about how much you can get into the smaller pouch,
but learning how little you actually need to survive and feel comfortable with.

 

 

 


 

THE TEAM TELEPHONE
Dr GD Brombacher (Specialist Surgeon) (033) 342-3536
Dr D Gounder (Specialist Physician) (033) 345-8440
Dr Redfern & Partners (Anaesthetists) (033) 345- 7720
Anlie Evetts (Dietitian) (033) 897-5000
Shannon Lang (Psychologist) (033) 343-4408
Sarah van Niekerk (Psychologist) (031) 566-3230
Jitesh Gopal (Physiotherapist) (033) 394-4708
   

 

 

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