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Imaginary gastric banding; losing weight without surgery.

INTRODUCTION

A recent study by Livingston EH1 reports that laparoscopic gastric banding is performed in 37% of all bariatric surgery cases (the 2006 National US Hospital Discharge Survey, National Inpatient Sample, and National Survey of Ambulatory Surgery were assessed for bariatric surgery procedures and data were compared with inpatient data from 1993 to 2007). Laparoscopic adjustable gastric banding (LAGB) has become an accepted procedure for weight loss surgery, particularly due to fewer early complications and decreased mortality in comparison to other bariatric procedures.

Obesity is a rapidly increasing worldwide epidemic and surgery seems to be the only treatment effective in achieving weight loss without relapse. Treating obesity effectively means to design and perform a number of health strategies that cover the metabolic complications, mental disorders and disabilities that are connected with obesity.

Daily calorie restriction is the driver of all intervention and non intervention strategies developed for the treatment of obesity. However, other variables, as the meal size have been proved to be important for weight loss, as it has been succeeded by gastric bariatric surgery. The laparoscopic adjustable gastric band is a useful tool in the treatment of severe obesity. It is a safe and durably effective procedure; however, optimal results depend upon the patient participating in a process of lifelong care. This means that if the patient does not participate with his/her will power to maintain a healthy eating behavior for a lifetime, the surgical operation will not be enough.

PRESENTATION OF THE IMAGINARY GASTRIC BANDING

Imaginary gastric banding (IMGB) is not an operation. It is a dietetic concept which simulates the eating behavior of a patient operated with the technique of gastric banding. It is based on the reduction of the meal size to the half of the volume received in the past. In IMGB the meal size is not very limited as it happens with surgical gastric banding. But the meal size is fixed during the day, and the volume per meal should always be half than the usual meal volume received in the past.

For example, we ask the patient to divide into two smaller meals all the meals he usually receives daily. The first half of the meal can be received in the usual time. The second half of the meal should be received after one hour or later (if the patient does not feel hungry after one hour, he may eat later). In this way, in the end of the day, some food will stay on the table untouched. Thus, the patient will not only shrink the volume per meal and per hour but also will reduce the daily energy intake.

The duration of the weight loss with IMGB is not as rapid as it happens with gastric banding because the volume is half of the usual and not too limited. But it is absolutely easy for someone to wait for only one hour until he eats the rest of his food. "Stealing of time" by postponing the second half of the meal for one hour is very important for eating less per day and per hour. Weight loss is based on the surgical procedure of the gastric banding but there is the difference that if the obese eat more, they will not vomit and the diet will fail. This means that in order to perform this diet scheme the obese should be self-confident, should have will power and should believe in this method.

Advantages of the Imaginary Gastric Banding

1. The patient is saved by an operation and the perioperative and long-term complications (symptoms of volume reflux, nocturnal aspiration, dysphagia, regular regurgitation and vomiting, abdominal pain, acute complications).

2. The results of the surgical gastric banding do not last a lifetime if the patient is not armed with personal will power. This means that he will have in the end to perform the IMGB if he wants to maintain healthy weight. So, why not perform it before the operation?

3. The quality of life is better with IMGB because the volume of the meal is not very small. In the long term, the meal size will be reduced again until an ideal or satisfactory weight loss is succeeded. The overall weight loss procedure will be slower and healthier.

4. The obese can perform this protocol even for some days during a week (e.g. due to their job needs); they will definitely see changes in their weight and decide to perform the protocol with attention after this observation. Surgery on the other hand, with the complication of constant vomiting, prohibits them to eat at work or go to a restaurant, to a party etc. because everyone will understand they have a problem with eating; sometimes they will vomit in front of their friends and colleagues. IMGB allows the obese to stop the program for some days during the week and get rest.

5. Patients should not be offered surgery unless a process for continuing care is in place. This is the area that IMGB can be implicated.

Dis-advantages of the Imaginary Gastric Banding

1. This method needs a personal trainer for 3-4 weeks or longer (especially for difficult patients). This may cost the same with surgery, but it will be a solution in cases that the operation is not recommended.

2. Patients eligible for IMGB are obese with normal or higher IQ and will power; disciplined personalities may perform this method without a personal trainer, but this description would rarely correspond to obese people! However, if the obese can perform this protocol even for some days weekly even if they lose some days due to overeating crises, an overall benefit will appear.

Gastric Banding: A cognitive- surgical method based on Pavlof reflex

Gastric banding helps obese people to avoid eating large meals even if they are very hungry and they feel weak to control themselves (e.g. when they are tired, sad, and they have a tension for emotional eating). Due to the surgical reduction in the functional volume of the stomach, the meal should always be very small and if the obese eats more he/she will vomit. Obese who are accustomed to eating large meals will continue to eat like this and will be vomiting every day. This constant vomiting is so shocking that the obese develop a conditioned reflex and start eating less, until post meal vomiting stops or at least appears very rarely. It is a cognitive method in fact, which educates the obese to eat small meals via the punishment of vomiting.

Some of the obese who are operated with gastric banding will regain the lost weight and some more kilos until their doctor meets them again. Some others are influenced so much from this change in their lives that they manage to keep a normal or at least a tolerable weight for many years. This happens with the power of their mind and their will and is based and empowered by the good life they acquire with weight loss.

Imaginary Gastric Banding: A cognitive but non-surgical method based on Pavlof syndrome

How could we intervene without surgery to a person who eats all the time? Often we have to cheat ourselves to succeed a goal. If we imagine that we do have a banding in our stomach then we should lower very much the volume of our meals. How will we succeed this, if we feel very hungry? And if we eat very much as always and vomiting will not come to punish us?

Let's see the plan. We tell the obese trainee to put all the usual dishes he eats for noon on a table. Let us suppose that this was a rich meal of a total volume 1 litre or 1.5 litre in volume, and had a total calorie value of 1000 or 1500 kcal. We ask the obese to divide all the dishes (salads, meat, potatoes, deserts) into two equal parts. So, he will have for example 2 meals with a volume of 750 ml and 750 Kcal each. We let him to eat the one of the 2 parts and we ask him to wait for one hour before he eats the second part. He should feel calm because he is not losing his food (which he adores and needs very much) but he only accepts to postpone eating. This should be done for all his meals. So, instead of having one meal with a duration of eating 10 minutes, we have 2 meals with duration of eating 10 + 10 minutes and an interval commencing between those meals.

Of course this one hour's waiting time will be very difficult for some obese people. But it is only one hour, and it is possible to happen. For this goal to be succeeded, the obese should have the IQ, the disciplined personality and the will power to wait one hour until he eats the second half of his meal. Otherwise, if a person should perform IMGB and cannot keep the intervals, he should not be able to reach the food for this one hour and be forced to wait. This can happen if he is admitted in a Hospital and the food is restricted for him and served by others.

With this method it is sure that there will be loss of weight. Because the stomach will be having half the volume than before repeatedly, a new eating habit will be adopted. Also, it is sure that the obese will stop eating more and more, as it was happening until the day they came to the doctor (the volume of food is gradually increasing in obese while they think they eat the same quantities every day- it happens unconsciously). (2)

What happens with this method:

1. Stop gaining weight

We stop eating increasing quantities of food every day. So we stop the process of gaining weight which is something that obese are not aware. Their first goal should be "not to gain more weight". This will happen by taking into account the size of their meals except the daily calorie intake. Many are the obese who stop successful and well-performed diets because they do not lose weight from the first days or weight loss is too slow. Their fear of failure is a very big mistake. Because if you are gaining weight for years, the immediate reverse to weight loss is impossible. Which means that the anabolic phase which they experience before they visit the doctor cannot become catabolic before some critical time passes. (3)

What obese are characterized from is greed. (4) Greed for eating becomes greed for losing weight at the period of dieting! Obese cannot wait for the time needed in order to lose their kilos because they are greed; they want to lose many kilos in very short time. That is why they go to bariatric surgeons, in order to have fast results. They suffer by constant vomiting after the operation, they usually lose 20 kilos in the first period, and after taking off the gastric banding they regain the kilos they lost--why? Because they are greedy and greed was not treated. So, surgical gastric banding may not treat greed in many obese people. Because they think that an operation can make magic and treat their obesity in 2 months and after that they will continue to eat the huge meals they used to eat. The obese should understand that healthy diet should last a lifetime and their greed for eating should be treated. This is what IMGB suggests.

First of all, when we stop gaining weight we should be happy that we stopped to gain weight. This is opposite to the philosophy of the greed person, who thinks that he should always be receiving things without being happy for the things he already has. So, the treatment of greed should first focus on feeling happy when we stop gaining weight. For example, when a car has a driving direction towards North, and suddenly the driver decides to return to the South, a critical duration is needed for this change to happen. The same is needed during a diet, too.

2. Satiation will come

With the reduction of the meal volume, satiation will come while waiting, even with the half of the meal. (5) Hunger cannot last for one hour after the obese ends with the first half-meal. (5) So, when the obese starts to eat the second half-meal he does not feel the same hunger but he will eat the food because he is greed and he wants to eat it. This will happen during the first period of the protocol. But later, more experiences will come.

3. Satiation will be "discovered"

When the obese gets aware of the fact that he can feel satiated with the half of his meal, then he starts to think that perhaps he exaggerated with eating so far. This is like how consumers in super markets--who feel insecure to buy unknown and cheap products for the first time- get accustomed to new consuming trends. When some of those products prove to be "a good value for the money" then the consumer never buys overestimated products again, because he knows now "what is happening". In the same way, the obese is educated to eat less because he knows now that he can satiate his hunger with less food. And this knowledge can be useful for a lifetime. So, the knowledge and awareness of how satiation comes is very important to be understood by obese people. The cognitive skills of the patient are important for new habits to be developed. (6)

4. Gaining time induces lower daily energy intake Gaining time is a very important outcome when performing IMGB. At the time of consuming the 2nd half of each meal, the most probable is that the obese would eat a bar or chocolate or some biscuits and orange juice (he would have a post-meal hypoglycemia after a large meal). These snacks will not be consumed now, because he will eat the half of his meal. So at the end of the day he will have to leave some meals on the table untouched, because the hours of the day will not be enough for all meals to be consumed.

5. One hour is short waiting time

Only one hour between the two half-meals is great consolation for the "drama" of the obese. Because in this way he manages to succeed his goal and overcome his greed and he is also satisfied because he will not lose his food but will only postpone the second part of his meal. With this method we manage to treat greed except obesity.

6. Hormonal ups and downs and wild hunger are avoided

Post-meal hypoglycemia after a smaller meal is definitely less intense. (7) So, the obese feels hunger one hour after the first meal which is less "wild" than the hunger he would feel one hour after the large meal received in the past. So he avoids this way the development of uncontrolled hunger and overeating. Insulin levels and glucose levels are better. (7)

7. The salt meal index is lower & the blood pressure is protected

The salt received during the small meal becomes half than the salt received in the large meal. This change is expected to exert positive effects on blood pressure, which is a benefit for the heart and vessels. (8)

8. Not vomiting involved in IMGB

You have all the good impact of surgery without vomiting. Of course, in this way, there is not a punishment, and it might be expected that a person with greed, weak will and low IQ will not be punished repeatedly and may, at some inevitable moment, eat large meals and interrupt the protocol. However, IMGB is recommended for people with a normal or higher IQ and a will power and want to lose weight with a healthy and tested method, as it is gastric banding. Which clears out that IMGB is one more challenging diet with the difference that it should last for long and that it will have successful results because its "surgical simulation clone" has been tested in thousands of people. Also, IMGB can be performed with the support of a personal trainer to people inside Hospitals, who cannot be operated due to advanced age or concomitant diseases.

9. Long term care with IMGB

After surgery and the consequent weight loss phase, many greed obese regain all the weight they lost along with 1020 kilos more. Some others recognize the benefits of a new life and get aware of how they should make progress and succeed in having a tolerable weight in the long term. Good life after the loss of weight is a very strong motivation for a healthy diet in the long term. IMGB omits the phase of surgery and performs what should be done from the very starting point. It is a realistic solution for realistic people who feel ready for making changes to their eating behavior. Moreover, the changes suggested by IMGB are less violent than the very small meal size recommended after gastric bariatric surgery procedures. In the long term, the meal size will be reduced again until an ideal or satisfactory weight loss is succeeded.

10. Treating the greed of people

Bariatric surgery is limited in the physiology of the gastrointestinal tract only. IMGB uses the concept of the classic gastric banding but mainly performs the treatment of the greed of obese people. It is like "mental surgery" or "surgery of the soul". One billion people are hungry today and one billion people are overweight. Many of them are greedy and their greed is so wild that is rather a psychiatric problem than a personality characteristic; if greed is treated, this will help people to improve their behavior and their personality imperfections except having a better somatic icon and a healthier metabolic profile. Hunger is getting bigger as obesity gets worse and at some point obese are willing to eat constantly. (9) If greed is the cause of eating, and greed with hunger in obese are connected via a cumulative causation relationship, then eating becomes a crucial point for the mental health of the obese.

11. Calorie restriction policy in IMGB

Energy-dense foods and beverages such as fat spreads, packaged snacks, biscuits and fruit/cordial drinks make a greater contribution to energy intake and should be avoided for better results.

12. The problem of energy imbalance and IMGB

Specific isolated approaches cannot work in obesity. Excessive energy intake and/or inadequate energy expenditure are taken into account in obesity treatments. For this reason, the calorie restriction policy and the physical exercise are parts that can be added in the IMGB program. Also the fat restriction policy is classically a part of the meal selection and preparation, which will be taught to the patient for better results. According to Swinburn et al (4) a reversal of the increase in energy intake of approximately 2000 kJ/d (500 kcal/d) for adults and of 1500 kJ/d (350 kcal/d) for children would be needed for a reversal to the mean body weights of the 1970s. With the method of IMGB the reduction in calories is easy to happen due to the long hours needed to eat all the small size meals.

13. Increased food energy supply and IMGB

The major drivers of the obesity epidemic are much debated and have considerable policy importance for the population-wide prevention of obesity. Swinburn B et al (4) conducted a study in order to determine the relative contributions of increased energy intake and reduced physical activity to the US obesity epidemic. They predicted the changes in weight from the changes in estimated energy intakes in US children and adults between the 1970s and 2000s. The increased US food energy supply (adjusted for wastage and assumed to be proportional to energy intake) was apportioned to children and adults and inserted into equations that relate energy intake to body weight derived from doubly labeled water studies. The weight increases predicted from the equations were compared with weight increases measured in representative US surveys over the same period. According to their results, greed and not laziness was the determining driver of the obesity. Having in mind this important study, IMGB is a method that reduces energy intake and educates the patient to avoid greed which is the most important cause for excessive food intake according to Swinburn et al.

14. The problem of under-reporting of energy intake and IMBG

According to Swinburn et al (2) women, older people and obese people under-report energy intake more than men, younger people and non-obese people. IMBG protects the patients and their doctors from the problem of underreporting of energy intake. Because, as it was shown by Wansink and Chandon, greater underestimation of calories by overweight persons is a consequence of their tendency to consume larger meals. Calorie underestimation is related to meal size, not body size. (10) Also, because obese should divide everything they used to eat into 2 meals and reduce their daily intake, the underreported calories are becoming a shrinking amount per meal and per day.

15. Energy Density and IMBG

La Fontaine et al (11) reported that many foods with reduced-fat (RF) claims are relatively energy-dense and that high-fat (HF) vegetable-based dishes are relatively energy-dilute. In their study, nutrient data were collected from available foods in Melbourne supermarkets that had an RF claim and a full-fat (FF) equivalent. Nutrient analyses were also conducted on recipes for HF vegetable-based dishes that had more than 30% energy from fat but less than 10% from saturated fat. The dietary intake data (beverages removed) from the 1995 National Nutrition Survey of Australia were used for the reference relationships between energy density (ED) and percentage energy as fat and carbohydrate and percentage of water by weight. According to their results, both FF and RF foods were more energy-dense than the Australian diet and the HF vegetable-based dishes were less energy-dense. The Australian diet showed significant relationships with ED, which were positive for percentage energy as fat and negative for percentage energy as carbohydrate. There were no such relationships for the products with RF claims or for the HF vegetable-based dishes. In conclusion, the authors suggested that a reduced-fat diet is relatively energy-dilute and is likely to protect against weight gain, there appear to be two important exceptions. A high intake of products with RF claims could lead to a relatively energy-dense diet and thus promote weight gain. Alternatively, a high intake of vegetable-based foods, even with substantial added fat, could reduce ED and protect against weight gain.

The restricted meal size which is received with gastric surgery causes a consequent reduction in the volume of vegetable based meals which protect us from high ED intake and help weight loss. (11) In IMBG, the volume of vegetable based foods can be larger, according to the patient's needs (personalized diet can be given by the personal dietician of the patient) and in order to help him lose weight and improve his metabolic profile.

IMGB FOR CHILDREN AND ADOLESCENTS

Public health systems aim to build the programs, skills and evidence necessary to attenuate and eventually reverse the obesity epidemic in children and adolescents. However, what mothers do in their homes-which means if parent awareness and attitudes about healthy eating are sufficient- is most important for obesity in the young people. If the smaller size meals were performed as a good habit in young ages, this would reduce the greed which is very common in obese children. (12)

LIFELONG CARE IN IMGB

Lifelong care involves counselling about food choices and eating patterns, as well as adjustment of the program during illness, or special conditions like pregnancy, sports, jobs hours, etc. The delivery of this care should involve a multidisciplinary team.

LIFELONG SELF AWARENESS: THE ANTIDOTE TO GREED

Greed is one common characteristic of people who have the bad habit of overeating. (4) Lifelong self awareness is succeeded with the method of IMGB and it always reminds to people that they should not be greedy. It is an antidote to greed. Birch DW et al (13), report that a number of Canadians who self-refer for bariatric surgery outside of Canada or to private clinics experienced complications that required urgent surgical management at a tertiary care center within Canada. Complications resulted from 3 commonly used procedures: adjustable gastric banding, gastric sleeve resection, and Roux-en-Y gastric bypass. The authors propose that a medical tourism approach to the surgical management of obesity, a chronic disease, is inappropriate and raises clear ethical and moral issues. This behavior, "to buy a slim body" instead of acquiring it by efforts and by long standing discipline to a healthy diet, shows a deficit in the personality of many obese people, which is absolutely compatible with their greed to food. Many of those people are operated every two years until serious health problems eventually stop their "mania" for operations. Naderism, greed and obesity are devastating characteristics of the modern world (14), that is why buyable solutions, like bariatric surgery, have become so popular.

IMAGINARY GASTRIC BANDING: THE PROPER ANTIDOTE TO "OBESOGENIC" ENVIRONMENTS

The "obesogenicity" of modern environments is believed to be fueling the obesity pandemic. ANGELO (analysis grid for environments linked to obesity) is a framework designed by Swinburn B et al (15) which is a conceptual model for understanding the obesogenicity of environments and a practical tool for prioritizing environmental elements for research and intervention. The basic framework is a 2 x 4 grid which dissects the environment into environmental size (micro and macro) by type: physical (what is available), economic (what are the costs), political (what are the "rules"), and sociocultural (what are the attitudes and beliefs). Within this grid, the elements which influence food intake and physical activity are characterized as obesogenic or leptogenic (promoting leanness). Based on the elements that appear in this framework, IMGB may theoretically offer a contribution in both physical and sociocultural as well in economic environmental obesogenic drivers. Because, if greed's dominant impact on obesity was broadly known, then attitudes to eating and consuming in general would be improved.

For example, the serving size of super market foods is important for what we call "obesogenic environment". Because small food packs are more expensive than the economic large ones. This makes consumers buy more food and along with greed makes people eat more. Especially children (12) and old people (2) cannot easily control their meal size due to lack of knowledge, experience and judgement. This is an example of an absolutely obesogenic environment which starts from the greed of the food industry people (greed to sell) and it is coupled with the greed of the consumers (greed to earn by buying economic packs and greed to consume all of what I have bought). Small food packs should be preferred if possible, because when a large food box opens (for example a box of ice-cream) then overeating cannot be avoided! IMGB is something like a wise intra-gastric food deposit, which is installed in our body with the help of our imagination and our will power and not with the use of surgical scalpels. Otherwise, it is a conscious reduction in meal size to the half portion than our beloved large meal, while surgery causes a violent change to a much smaller meal size that is imposed as a necessity under the threat of vomiting.

CONCLUSION

In conclusion, imaginary gastric banding is a selective approach for those patients at increased risk of early postoperative complications and increased age (performed in Hospital under personal quidance only). Also, IMGB is recommended to obese with normal or higher IQ and cognitive skills, as a low cost alternative to gastric surgery. Despite its simplicity, imaginary gastric banding costs the same as gastric surgery due to the constant guidance needed for persons with psychiatric addiction to overeating. There is no cost savings associated with bariatric surgery for addicted to overeating patients; however, there will be much psychic/psychiatric benefit because, as we already know, greed is not treated via surgery for a lifetime.

Conflict of interest: None declared.

REFERENCES

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(10.) Wansink B, Chandon P. Meal size, not body size, explains errors in estimating the calorie content of meals. Ann Intern Med. 2006;145(5):326-32.

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(12.) Fisher JO, Liu Y, Birch LL, Rolls BJ. Effects of portion size and energy density on young children's intake at a meal. Am J Clin Nutr. 2007;86(1):174-9.

(13.) Birch DW, Vu L, Karmali S, Stoklossa CJ, Sharma AM. Am J Surg. Medical tourism in bariatric surgery.2010 Mar (doi:10.1016/j.amjsurg.2010.01.002).

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Irene Christodoulou

Aristotle University of Thessaloniki, Greece & Democritus University, Alexandroupolis, Greece

Corresponding author: Irene Christodoulou, MD, MSc

8 Heronias Street, Sikies, 56626, Thessaloniki, Greece

Tel : 0030 2310613736

e-mail: intermedjournal@yahoo.gr
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Title Annotation:ORIGINAL ARTICLE
Author:Christodoulou, Irene
Publication:Archives: The International Journal of Medicine
Article Type:Report
Geographic Code:4EUGR
Date:Jan 1, 2010
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