The following is extracted from a pamphlet given me by Doctor Rumbaut.  Except for minor spelling errors, all the material is original.  Thank you Dr Rumbaut.


MORBID OBESITY


When you are so fat that  it causes major problems with your life and health, you are morbidly obese.  It is not simple to provide a single measure of your weight, which tells if you are morbidly obese.  The best that we have at the moment is a measure called the Body mass Index or BMI.  This index is obtained by calculations using your weight and your height.

Normal people have a body mass index of 20-25, overweight people have a body mass index of 30-40, and morbidly obese people have a body mass index greater than 50.  If the body mass index is greater than 50 some refer to this as super obese.

If your body mass index is greater than 40, it is likely that you are suffering major physical, medical or social problems because of your weight.  Some will be suffering these problems even at body mass index values between 35-40; some don’t seem to have a major problem even above a BMI of 40.  However, it is around this BMI value of 40 that we generally start to see the major problems caused by obesity.

If the concept of the body mass index is confusing to you, a rough approximation of a BMI of 40 is to be 80% above your ideal weight or to be 45 kegs above your ideal weight.
 

WHAT ARE THE PROBLEMS OF MORBID OBESITY?
 

The first problem to stress is the one that most obese people focus on the least – you are less likely to live a long life if you are too fat.  The life insurance companies have known this for a long time.  They know that for life insurance purposes, the fatter you are the worse the risk you are to them.

The following graph shows the risk of dying in large group of American men and women who were followed for many years.  If you have normal weight the relative risk of dying is set at 1.
 
 
 

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MEDICAL DISEASES
 
 

The next major group of problems caused by morbid obesity is medical diseases.  There is a long list of illnesses that are either caused by obesity or are made worse by obesity.  There are too many for you to focus upon so we will shorten it to the more important and frequent problems.
 
 
 

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These include diabetes, high blood pressure, asthma, arteriosclerosis which leads to heart disease and stroke and other blood vessel diseases, sleep apneas where you stop breathing during sleep, and wearing out of the joints – especially in those areas which have to carry the extra weight such as the lower back, the hips, the knees and ankles.  Also, obese people are more at risk of accidents at work or at home or on the road and of sudden explained death
 
PHYSICAL LIMITATIONS
 

Morbidly obese people often cannot do the thing that others can do.  Sporting activities are generally out, which excluded them from many family activities.

Physical, activity of any sort can be quite difficult due to shortness of breath or just plain tiredness, so that even housework or standard employment is a challenge.

Most cannot buy clothes easily and some have difficulty getting into and out of cars, into seats on the bus or the theatre, or even getting through the turnstile at the supermarket.
 
 
 
 

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SOCIAL ISOLATION
 
 

Not surpassingly most who are morbidly obese feel embarrassed in public.  It is common to sense that people are looking at them and commenting on their weight and the difficulties it produces in dressing well and moving easily.  They prefer to withdraw – to live within the family circle at home rarely venturing into the public gaze.  This may help them cope with the embarrassment but equally it deprives them of the chance to work the chance to join the family in outside activities and to join friends socially.  It is not too surprisingly therefore to find that morbidly obese have a low lever of self-esteem, a feeling of worthlessness and uselessness and it is common for them to suffer depression.
 
 
 
 
 
 

SO THAT’S THE PROBLEM. .
. . WHAT ABOUT A SOLUTION

First we must ask why it is that some people become morbidly obese.  The answer is simple – they have eaten more than they have needed.  The calorie intake has exceeded the calorie use.  No matter how much we might argue about the detail, it is fundamental truth that if we take in more calories than we use up, we will store them and put on weight.  Therefore the solution also is simple – obesity can be cured by taking in fewer calories and/or by increasing the energy used.

This is all very true, it is very simple and it is very hard to achieve.  The traditional method for weight reduction always has been and still remains the same – we must take in less energy and we must use up more energy – diet and exercise.  Gastric restriction does not change this process at all, it just makes the process of dieting easier to achieve and then as the weight comes down the process of exercise also becomes easier.

In theory we shouldn’t need gastric restriction at all – eat less and do more and the weight will come down – continue to eat less and do more and the weight will stay down.  Sadly, for most, it just does not happen.  The majority of morbidly obese who seriously tries to diet do not lose a significant amount of weight.  For those few who do lose a useful amount of weight, most will put it back on again within a year.  Something more is needed and this is where operation for restricting the food intake comes in.

All operations on the stomach to reduce weight do two things – they limit the amount of food that the stomach will hold at any time and they slow down the emptying of all small stomach.  In this way, if you eat about the amount of fool that you can get into half a glass, you will feel comfortable full and because of the slow emptying the feeling of fullness will stay with you for several hours so that you won’t have the urge to eat between meals.
 To achieve the full benefits of gastric restriction you must establish good eating habits.  Take only three regular small meals a day with no snacks in between.
 
 
 

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Each meal has to be solid food.  The procedure does not work for liquid calories, so all liquids taken have to be insignificant calorie content – such as water, mineral water, tea, coffee, and low calorie soft drinks.  As you cannot eat much food the food you eat must be nutritionally good, high in protein and high in complex carbohydrates or fiber.  IT must include vitamins and minerals.

You cannot waste your eating capacity on empty calorie food.  The main foods to be encouraged are vegetables, meats, and bread, egg dishes and such like.  We will come back to the eating rules in detail later in the booklet.
 
 
 

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THE LAP-BAND
 
 

There are many variations of operations on the stomach to achieve weight loss and I believe that the most suitable of the various procedures currently available in the Lap-Band, which is an adjustable silicone gastric banding procedure.  I say this for the following reasons.

Firstly:

It appears to be as effective as the best of the others in achieving weight loss.  On average I expect people to lose about two thirds of their excess weight.
 
 
 

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For example if your current weight in 114 kgs and your ideal weight is 60 kgs, then you have a total of 54 kgs of excess weight.  Two-thirds of this is 36 kegs.  Therefore, if you lose two-thirds of your excess weight you will come down to 78 kegs.

This is the average.  Some will have more weight loss than this, some will have less, but on average this is how it will turn out.
 Secondly:

It is a less invasive procedure than all other forms of gastric reduction.  For most people the band can be placed laproscopically by passing some tubes through the skin doing the operation through those tubes.  This avoids any large incision in the tummy, it avoids a lot of the handling of the gut inside and it avoids much of the pain that goes with an operation.  It enables you to get back to your normal activities more rapidly than would occur with other procedures.  For various reasons some people wills to have to have an operation but because the placing of the band doesn’t involve many traumas to the tissues the recovery is still quite rapid.
 
 

Thirdly:

It is adjustable.  This is perhaps the most attractive aspect of the band.  The tightness of the band around the stomach is set very carefully at the time of the operation.  However, we cannot expect that this will be exactly correct for all people for all time.  This particular band can be adjusted by injecting some fluid through the skin into a special reservoir tucked away under fat.  If the band is too tight and there is a problem with vomiting we can release it \a little by taking out some of the fluid which opens the band a little if it is too loose and the rate of weight loss is too slow, we can tighten the band by adding some fluid.

The Lap-Band is the only one of the current available procedures, which can be readily performed without need for large incision.  It is also the only one, which is adjustable.
 
 
 
 
 
 
 
 
 
 
 
 
 
 

This is the Lap-Band, which consists of a silicone ring, which passes around the stomach.  The ring has an inner balloon, which is connected, to the tubing, which joins to a reservoir.
 
 
 

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The reservoir is placed under the skin.  We can place a needle through the skin into The reservoir and by injecting some fluid can cause the balloon to expand
 
 
 

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This shows a close up of the ring of silicone.  The inner balloon is not flat at all and is just visible.
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Now some fluid has been added to the inner balloon and you can see how the space has been reduced.  This will narrow the opening from the upper stomach pouch into the rest of the stomach and thus makes it more difficult to eat.  By adjusting the amount of fluid in the balloon, we can set the limits of food intake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

NOW WHAT ABOUT THE BAD NEWS


It can’t all be good news.  There must be dangers; there must be problems.  What is the worst that can happen?

Well, there are many negative aspects to operations for obesity in general and to the adjustable gastric band in particular, and it is essential that you are aware of these.  Any gastric operation for obesity is major surgery and carries with it the risks that would go with any complex operation.  People have died from having operation for morbid obesity – it happens rarely but we can never take away the risk completely.  If you are older and if you already have certain diseases due to your obesity, or if you are otherwise unwell you will be at greater risk.

Deaths associated with obesity surgery occur mostly because of heart attach after the operation, clots passing to the lungs or infection due to breakdown of some part of the stomach wall.  There are reasons why we might expect the Lap Band to have a lower risk of death than the earlier operation, but still death might occur in 1-2 of every 1,000 who have the procedure.

There is probably of about one chance in ten that complications may occur at the time of the operation.  Some of these are of minor significance and do not slow your recovery significantly.  Others may be of major significance and can be associated with a much longer hospital stay and a much longer recovery period.  The sorts of problems that are relatively common are infections, which may occur in the lung, in the stomach in the area of the band, or at the sites where the ports are placed through the skin.
 Clots can form in the legs and some of these may pass to the lung-giving rise to a potentially dangerous situation.  The stomach can be damaged as the band is placed and perforation of the stomach can follow.  Pre-existing illnesses such as diabetes and asthma may become more difficult to manage around the time of the operation.  We take a range of measures to reduce the likelihood of problems occurring but in spite of our best efforts, we are unable to prevent them completely.

After the operation there is a period where a new eating pattern must be established during this learning phase it is likely that you will have episodes of vomiting.  During the first monthly after operation we could expect that an average you would have vomiting three times per week.  As you become more aware of what the limits of the new stomach are, this frequency will normally reduce so that vomiting is not usually a problem after several months.

It is most important therefore that you see the decision to go ahead with operation as a most serious one and it can only be justified if the problems associated with your obesity clearly exceed the problems that may be associated with the operation.  It is not a decision to be taking lightly; it is not like going on another diet – you can always give up on a diet.

The placement of the Lap Band is an event, which occurs, and there is no easy going back.  We place the band with no fixed intention of ever removing it.

The band is made of cured silicone and there is no known side effects from having this material within the body.  If the band was removed we would normally expect that you weight would go back to the level it was before the procedure was done.
However, although we place the band without any planned intention of removing it, there are three points that you need to bear in minds.
 
 
 
 
 
 
 
 
 

First we must be able to maintain follow-up with you permanently.  This may mean a visit only once a year to look at progress, look for any problems, and discuss any other matters.  If you move telephone or mail as an absolute minimum must maintain interstate or overseas contact.  If you are prepared to make this commitment we shouldn’t proceed further.

Second, the band can be removed if necessary.  Id it is placed laproscopically then generally it can be removed laproscopically.  By the nature of the material, it does not stick to other tissues and therefore if some reason develops which make its removal appropriate, this can be done.

Third, it could be in the future that reasons will develop, either for you as an individual or for all people who have had the band which make it appropriate that it cube removed.  We will continue to monitor each person and the information about the procedure itself and as long as we maintain contact with you we can always advise you of this.

Although I have no reason at all at this stage to expect that we would wish to remove the band we must recognize that depending on your current age, you further life expectancy may be up to 60 or more years and it is simply not appropriate to be locked into a situation which has to hold for all of that time.  It is indeed one of the attractions of this procedure that it can be reversed if necessary.
 WHAT HAPPENS AT OPERATION?

After we jointly make the decision to go ahead with the procedure we will do some preliminary tests that we need to document your general state of health, some specific measures regarding your problems, and some checks that will minimize any risk associated with the anesthetic.  You will generally come into hospital either the afternoon before the procedure or on the morning of the procedure.  The operation is performed under a general anesthetic and takes about two hours.

It is generally done laproscopically.  That means that we do not make any large incision but pass instruments through ports, which are placed through the skin into the abdomen.  A special telescope is placed through one of these ports.  It has a camera attached to so that we can look inside the abdomen on a television screen.  We pass instruments through other ports and we watch what we are doing on the TV screen
 
 
 
 

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The Lap-Band is placed around the upper part of the stomach to create very small stomach above the band and the rest of the stomach lying as normal below. All the food that you eat initially will go into this small stomach and then will empty slowly through the space left within the band.

The reservoir is placed in the abdominal wall, usually on the left side of the midline.  To do this we need to make a small cut in the skin, which measures about 4 CMS in length.  Therefore at the end of the operation you will note this small cut and also the sites where the ports passed through the skin.  These are usually only about 1 cm long.

When you wake up from the operation you will have some discomfort.  The procedure is not totally painless but is not nearly as painful as if we had made a large incision.  We will give you whatever treatment you need for paid relief at that stage.

You will also have an intravenous drip in one area to give you fluid overnight.  We will be encouraging you to get up out of bed and move around, usually later on the day of the operation itself, or certainly by the next day.  We will usually do a special X-ray of the stomach on the day after operation and then start you taking fluids orally.

Occasionally the procedure can’t be performed laproscopically.  This may be because there has been previous surgery in the area and there are too m an y adhesions.  Sometimes although we start to do the procedure laproscopically, something happens which makes it more appropriate to change over to an open operation.

This may occur is a significant amount of bleeding happens or if there are difficulties in passing the band around the stomach.  You won’t know that we have had to do this until after the completion of the operation and you have to go into the operation recognizing that this may happen.  However, we expect that it should occur with less than 1 to 20 operations.
 If we need to do an open operation generally you will have more discomfort after the operation, you will need to stay in hospital longer and it will be a long period before you are able to return to your normal activities.  However the procedure itself is done is essentially the same way and the end result is the same.

Assuming that the operation is completed laproscopically, you would normally stay in hospital for four to five days during this time you would begin the process of learning the new rules of eating.

After you go home we would normally expect you to take about two weeks to get back to your normal activities.  Even at this time, however you will be feeling more tired by the end of the day and you still be trying to identify the best practices regarding eating.  Nevertheless, by then you clearly see that you are almost fully recovered from the procedure and will already be seeing some weight reduction.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

WHO IS CONSIDERED SUITABLE FOR  GASTRIC BANDING
 
 

There are three central factors, which we take into account in determining if this might be an appropriate procedure for you.  These are the current levels of your weight, the problems that this of obesity generates, and the confirmation that you have made significant effort at weight loss by other means.  Let me discuss these in a little bit more detail.

Generally we would not wish to proceed with this procedure if the body mass index was less than 35.  We find that at 35 or greater there is a clear risk to a long healthy life, there are generally significant problems associated with obesity and there is generally as poor outcome from any alternative therapy.  Occasionally though, in those who have major medical problems associated with obesity, we will give consideration to those whose weight is of a body mass index below 35.

If there is not a problem then we don’t need to look for a solution.  Even if you were truly morbidly obese by our definitions, we would not wish to proceed with any treatment unless you perceived a significant problem with your obesity.  This might include the physical limitations, social isolation and the medical diseases that go along with morbid obesity.

It must be the solution that you are seeking in answer to your problems.

It is not something for us to encourage just because we perceive that you have a problem.

It is important that all other efforts to reduce your weight has been reasonably tried.

This will include supervised dietary and exercise programs and we find that almost all of our patients have spent much time and money with the commercial dietary groups.
 We make this stipulation, not because we believe that these alternative lines of therapy are generally effective, in fact that they are almost always ineffective in the long term.  We make the requirement because it is an expression of your commitment to lose weight and without that commitment we cannot be confident that you will follow your part of the deal.

Your weight status, the problems associated with your weight and your efforts to reduce your weight in the past are three specific measures, which we will also take.  On top of that we will only proceed if we believe that you are able to understand what the problem with your weight is, what the procedure consists of and what the procedure aims to do, and that you are able to fulfill your part of the process.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

WHAT ARE YOUR RESPONSIBILITIES FOR  THE SUCCESS OF THE OPERATION
 
 

Although the operation of gastric banding limits the quantity of food you can eat at any time.  It will be your responsibility to correct food habits.  You must not only control the amount of food but also The type of food eaten if you are to be successful at long-term weight reduction.
 
 

In Hospital:

For up to 2-3 days after the operation only small amounts of fluid can be taken (about 30 to 50 mls) at a time.

The progression from fluids to vitamins to soft foods will vary from person to person.  Usually at the time of leaving hospital you will be managing liquid food.

Remember to take small amounts of food, initially about 8 teaspoons, and stop eating when you are full.

At Home:

At home you will continue to progress from foods of a soft consistency to all types of foods.  It is important that you do not restrict your intake to a small range of foods.  No individual food will supply your body with all the nutrients required.  If a particular food is not tolerated try again several days later.


 COMMENCING DRINKING AND EATING AFTER LAP-BAND
 

The correct introduction of fluids and then food during the first few days and weeks after placement of the Lap Band is vitally important in preserving the structure which has been created at operation.  It is essential that we do not unduly stretch the new small stomach at this early stage, but allow it to settle in position and develop some adhesions around it, which will stabilize it for the future.  It takes at least a month for this to occur and therefore during the first month after the operation you must be very careful about the volume of fluid taken and to avoid taking any solid food during this time.

Normally you will not start drinking until the second or third day after the operation.  At first, you will have only clear fluids such as water, tea, coffee, or fruit juice.  You must take only small amounts (normally 30-50 malls) of fluid at any one time.  You must then wait and confirm that you are quite comfortable and don’t feel at all full with this fluid before you take anymore.

The fluid may go through quite rapidly and therefore you don’t need to expect to feel full.  If however you do feel uncomfortable full after taking a small amount of fluid you must not take any more until that feeling has passed.

Once you are coping with clear fluids without difficulty we will slowly introduce liquid food and very soft foods such as soups, yogurt, vitamin foods, stewed fruit and eggnog.

On each occasion you again must take a small amount, wait to see if it leads to any discomfort and if not then proceed with more.  Notice that at this stage you will be encouraged to take liquid calories.  Later on these will not be allowed but they are important during this phase the same time not puttingansition phase to enable you to maintain some nutritional intake while at the same time not putting any stress on the system as the band settles into position.  We will encourage you to continue with this pattern for at least the first four weeks.

During this time you should take no solid food at all as this could block the pathway through the band and then lead to enlargement of the stomach above the band.  This is a most undesirable outcome and needs to be avoided by staying on the fluids.

After one month we will begin introducing soft foods into the diet and as soon as you find you can cope with these and not feel uncomfortable, it is them time to start introducing solid food.  These will be some of the foods, which even at two or three months after operation may still generate some difficulty.  This occurs parti9cularly with red meat.  It is best to avoid those foods, which have a tendency to make you feel uncomfortable and particularly those which lead to vomiting.  Vomiting will occur with most peopled at some time but generally will occur if you have wither eaten too much or too quickly.  As neither practice is recommended you should be striving to identify what has provided the vomiting and seed to avoid it in the future.

Once you get a full diet of solid food you must avoid taking liquid calories as indicated in the rules.  The operation is designed to achieve best results if food is only in the solid form and those liquids have no significant calorie content.
 YOUR FOOD GUIDE

An attempt should be made to choose at least one food from the variety within each of the following food groups each day.

1. Fruit and Vegetables

Aim for 2-3 types of vegetables.  1-2 pieces of fresh fruit, stewed or canned (with no added sugar) every day

Ensure that you have some of a dark green or orange vegetable daily.

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2. Breads and Cereals:

Aim for:
1 small bowl of cereal
1-2 slices of bread a day
 

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Use whole grain, whole meal or rye breads

Initially begin with toast rather than bread.  Remember to thinly scrape on the margarine or butter.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Choose whole meal breakfast cereals, e.g., Wheaties, vitamin, rolled oats.
 

3. Meat/Fish/Poultry/Eggs

Aim for 2 oz. of meat, fish, or poultry or an egg twice a day.  Remember to always:
· Remove all visible fat from meat
· Remove skin from poultry
· Use low fat cooking methods such as grilling, steaming, microwave or boiling (avoid frying).
 
 

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4. Dairy Products

Although low fat milk and yogurt are nutritious; they are not allowed, as they are liquid forms of calorie.  However, small quantities of low fat milk may be taken in tea and coffee.
 
 

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 5. Fats

Limit your intake to 3-4 teaspoons

Of margarine, butter or oil each day.  Low fat salad dressings and mayonnaise is allowable in moderation.
 

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6. Fluid

Drink at least 8 glasses of fluid each day.
 

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Tea and Coffee  Clear Soup

Plain Water  Mineral Water

Low Calorie Cordials Low Calorie
   Soft Drinks
 
 

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Foods such as sugar and those foods and beverages containing large amounts of sugar, e.g., soft drinks, cordials, rich cakes and biscuits, jam, marmalade, honey, contain very little food value.

These foods are called "empty calorie" foods from the diet.

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If you are considering using special dietary food products (e.g., sugar or carbohydrate reduced, fat reduced, etc.) it necessary to know whether these are suitable for you.  You may use low calorie soft drinks, low calorie cordial, unsweetened or artificially sweetened canned fruits, artificial sweeteners.  However, some specially labeled food products suitable for diabetics are not suitable for weight reduction diets.

Milk and milk products are basically nutritious foods but contribute concentrated sources of energy (calories) to the diet because of their high fat content.  For this reason it is important to use skim and low fat mild and milk products which have had the fat removed but the nutrients are retained.

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Alcoholic beverages, including beer, wine, spirits, diet beer, liqueurs, port, sherry, cocktails, champagne and diabetic wine contribute a concentrated source of energy to the diet but with no other nutritional benefit, therefore we recommend that you avoid these beverages.
 
 

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 THE GOLDEN RULES OF EATING AND EXERCISE

There are Seven Golden Rules, which summarize all that I want you to focus on in getting the best result from the procedure.  It is of absolute importance that you are able to follow these rules.  The success of the procedure requires us to place the band correctly but it equally requires that you follow these rules.  I will list them and then discuss each in more detail and then list the again.
 
 
 

THE SEVEN GOLDEN RULES

1. Eat three small meals per day.
 

2. Eat only good solid food.
 

3. Eat slowly, sense fullness and
then stop.
 

4. There must be no eating
between meals
 

5. Take no liquids with the meal.
 

6. All liquids must be of zero
calorie content.
 

7. Exercise for at least 30 minutes
each day.
 
 
 
 

1. Eat three small meals per day.

The upper stomach is made to hold about the amount of food you can fit into half a glass. If you try to get more than that in on a single occasion it is likely that you will feel sick and vomit.  If you repeatedly try to get more than that in you will eventually stretch the stomach and lose the effectiveness of the operation.  You must therefore learn just how much your stomach can accept at any one time and not ever go beyond that.

2. Eat only good solid food.

You can’t eat very much and therefore you must eat the right foods and not waste your capacity on nutritionally poor fool.

Foods that are high in protein and foods that are high in complex carbohydrates are best.  Foods that are high in fats and that are high in simple sugars are worse.

As far as possible restrict your range to the good foods.  This will include vegetables, fruits, meats, eggs, cereals, and breads.

It is important that the food you take is solid food.  The operation does not work for liquid calories.  They will simply run through without any particular resistance and no feeling of fullness will be obtained.

As far as possible then the foods should be as solid and as dry as possible, and liquid calories regardless of how healthy they may seem to be should be avoided.  Eat apples and oranges; don’t drink apple juice and orange juice.

3. Eat slowly, sense fullness and then stop.

When the stomach is full, signals will tell you that you have had enough.  You have to give time for these signals to be generated.  If you eat rapidly you will already have had too much before you perceive that you have had enough.
 
 
 

 


 


 


NOTICE:  All opinions expressed herein are the author's own.  None of this is to be construed as to being medical advice.


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