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This is very much a joint decision. You will know if you are still hungry, if you are eating too easily and maybe too big a volume, and you will sense that you are not losing weight fast enough. We will be asking you about hunger, appetite, volume and type of food and presence of symptoms such a vomiting or heart-burn which could indicate that you are in the yellow or red zones rather than the green zone. We will measure your weight and look at how much you have lost since the last visit. We will also be looking at your overall rate of weight loss.

It can happen that you do not lose much weight over a 2- or even 4-week period yet we are happy with your overall progress because you had lost more weight than expected at an earlier time and you are on track to achieving our target for weight loss. We see your progress toward our targets very readily on 'LapBase,' our computer record for your baseline and follow-up details, and can show you whether you are on track to your target or not. This is a great help on deciding whether you need further adjustments and of reassuring you after a slow month. It also shows clearly if we are going too slowly, in which case we will review your eating and exercise patterns, and consider adding more fluid to the band.

If we both agree that you are not in the green zone, we are keen to adjust the band so that you get there as soon as possible. The actual volume of fluid that is in the band is important to us and we document it in LapBase. However, we do not want you to focus on it unduly. There is nothing magical about any particular volume. The best volume is the one that gets you right in the green zone. It depends on you and the type of band you have. It has no relation to anyone else. The fact that your friend or someone in a chat room on the Internet has a different volume is not relevant.

Your first adjustment after the placement of the LAP-BAND is usually at 4 weeks for two reasons, as stated above. Firstly, 4 weeks is expected to be enough time to allow the band to settle into position. Secondly, you are usually starting to get hungry by then.

During the first week of the operation you would normally find that you don't feel hungry at all. You have no interest in food and couldn't care whether you eat anything or not. We want you to recognize that feeling and remember it. That is the feeling of satiety that we will be seeking to restore with the adjustments. If you can remember what it feels like, you can tell us when you have reached that point again during the later adjustments. By the second or third weeks after operation you will be losing that feeling of satiety and the good initial weight loss will have slowed. By the fourth week, when you are usually getting hungry and not losing any more weight, it is time to step in and start the adjustment process.

From the first adjustment at 4 weeks, visits should occur at 2-weekly intervals until you feel that you are in the green zone. This may require two to four more visits. After each adjustment you are likely to feel an exaggerated effect for the first 2-3 days before settling into a new level of satiety restriction. By the end of the week after an adjustment you are usually able to recognize if you are sufficiently restricted. We could arrange to see you and do further adjustment at that time but usually we prefer to wait an extra week to allow you to be sure of the effects on appetite and eating and to allow us enough time to check your weight loss over a longer period.

As we get nearer to the green zone we can stretch out the interval between visits to 4 weeks, 6 weeks, 3 months and eventually to 6 months. We do not want to ever have a gap more than 6 months between visits.

Remember the eighth of our golden rules is 'Always keep in contact.' You must always be coming back for check-ups, with 6 months the longest duration between check-ups that we would like to happen. At all visits, doing adjustments is just one of the tasks we want to do. We also want to discuss your eating practices and your exercise program. We want to check whether you are taking supplements of vitamins and minerals. We want to inquire about symptoms that could indicate the band is too tight or misplaced, and we want to be checking on the activity of your other health problems and their treatments. Please do not see these visits as solely for 'a fill.' They should always be proper medical consultations and adding fluid to the band is just one of the many important task! s to be completed.

Nevertheless, keeping the volume of fluid id the band is one of the most important tasks and it will remain so even years after the band has been placed. You should always expect that there will be an ongoing need for further adjustments for two reasons. Firstly, there is a continuing process of adaption or molding if the band and the stomach. What was tight enough at one time may be too loose 6 months later. Secondly, there is a slight loss of fluid from the band over time. If you had 7.0 mL placed at an adjustment, you could expect that 6 months later that volume may have dropped to 6.7 mL. That small loss of fluid is enough to lead to overeating. If you were unaware of this small fluid loss, you may think that you are failing and blame yourself. In reality, you just need a top up. That gets you back into the green zone.

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