Saturday, June 16, 2012

Another Precedent Falls

This post marks the official lifting of my long-standing ban on this blog about discussing weight-related matters. It hasn't been an absolute ban; I wrote a year ago about insulin resistance. But I've always tried to steer clear of the topic exactly because it seems so self-absorbed, and because so many people can write the exact same posts. Plus, it seems hopeless and intractable to expect others to live in the head of someone whose interface with food is fundamentally out of whack; it's like, I suspect, the non-addict reading a day-to-day account of the addict's mindset: alien and depressing and rather hopeless, for the addict himself, certainly, but also for the reader who would have no reason to opt into a situation they could otherwise avoid. And to what end? I could see myself doing the Oprah: writing about my struggles, vowing to follow a new path, losing weight in triumph, basking in the glow. And then slowly (or rapidly) putting it all back on again. I could see this because I *have* seen it, several times.

I'm lifting my ban now because I have decided to undergo bariatric surgery to get my weight under control. This therapeutic approach--medicalizing my weight problem--perhaps takes a garden-variety topic into less-familiar waters; and so if there are fewer people who might relate to the whole business, it might also be interesting for its comparative rarity. The blog is slow these days, and I've come to rely on writing things out as a means of making sense of them.  So here we are.


I'm scheduled on 7/16 for a procedure called the VSG for Vertical Sleeve Gastrectomy (sometimes called a Vertical Sleeve or  Gastric Sleeve). This decision took me the better part of a year to make, and this post is an attempt to put my deliberations down on paper. It will help everything that follows make more sense (assuming there's anything to talk about after the fact). 

My introduction to bariatric surgery, and the VSG specifically, came a year ago when I flew a couple long international legs with a pilot who, a year prior, had undergone the procedure. We talked about the procedure and its aftermath in exhaustive detail for several hours. He had been encouraged in his procedure by another pilot at our company--we'll call him "the Godfather," since he has advised a bunch of people at my company who have gone on to have the procedure. The Godfather had undergone the same procedure several years before, and I realized as we discussed it that I had heard of him. Anyway, this lengthy discussion started me chewing on the idea of bariatrics, and I spent the next several months thinking about it, off and on. My wife was mortified at the very idea, and so I did most of my deliberation internally.

By way of background (most of which is on that previous post): I've been overweight my whole life. I remember seeing with horror 202# on the scale when I was in eighth grade, and by high school I was in the 220# range. By college I had moved up to 240# or so, and have gradually edged up from there to my current 275-280#. Along the way I have lost substantial amounts of weight on half a dozen occasions, each weight loss followed with sunrise certainty by a regain of the lost weight and another 10# in penalties. In between these half dozen short-term successes, I have undertaken literally a thousand diets. I have gone to bed feeling disgusted at the day's eating an uncountable number of times and awakened with a vow to do better in the new day only to scuttle my plans by the first hour or two of the day. This has been going on for decades. The person who struggles with their weight--particularly the obese person--will no doubt find a painful resonance here; for those with a more normal interface with food, this will be foreign territory.

Like all fat people, I have spent countless hours contemplating issues of will power and psychology and craving and addiction, all of which have gained me exactly nothing. I'm not 600#; I do not order 4 porterhouse steaks at a sitting. I do have a mechanism that tells me when to eat and when to stop like any other person. But that mechanism seems to shut off about 20% later than it should, and the result sits at the keyboard now.

The Vertical Sleeve Gastrectomy (VSG) was developed about 15 years ago as the first part of a two-part procedure (the second part is called a Duodenal Switch). The idea was for the VSG to help super-obese patients lose weight preparatory to having the more extensive part of the procedure. But it was discovered that many people--especially those not super-obese--had good enough results from the VSG alone that the second part was not required. While most bariatric procedures--including the Duodenal Switch--involve some kind of re-plumbing of the intestinal tract, the VSG avoids this. With the VSG, about 80% of the stomach is carefully removed while leaving everything else exactly intact. The radically smaller stomach restricts the amount of food that a person can eat in a sitting. That's it. The stomach and the pyloric valve remain, their functions unchanged. The rest of the digestive tract is untouched. Where other bariatric procedures may impose post-operative nutritional requirements because of physical changes in one's digestive tract, with the VSG one can eat pretty much anything, though in greatly reduced quantities. (There are a few nutritional requirements: one is encouraged to concentrate on protein, both to help prevent muscle loss during the initial, rapid weight loss after the procedure and as a means of filling the small stomach with innocuous foodstuffs, leaving little space for the bad stuff; and one is encouraged to take several supplements because there is simply less food coming in to satisfy the body's nutritional requirements. Also, carbonated beverages are generally off limits, as the gas contributes to acid reflux and can stretch out the newly-shrunk stomach.)

As I said, after flying the trip with my new bariatric surgery contact I chewed on his procedure and his results for a number of months. He had lost about 120 lbs. without exercise, and (a refrain I was to hear again and again) he said it was the single best thing he had ever done for himself--he was sorry he hadn't done it a decade ago. His life now seemed entirely normal to him; he had merely switched his expectation about how much food constituted a meal, and everything else was unchanged. He said he still eats out most of his meals, ordering from the appetizer menu and bringing half of that home. While exercise is strongly encouraged, he lost his weight without exercising. My later discussions with the Godfather only amplified all of these impressions. He had gone from about 375# (as I recall) to about 170# now and has taken to running triathlons. He said it was like being given a new life (another refrain I've heard numerous times).

As I said, my beloved wife was frankly horrified at the whole idea. Removing a majority of a perfectly functioning major organ--which was not in itself defective nor responsible for my problems--just didn't make sense to her. I was contemplating something drastic and *permanent.*  And at first I tended to agree with her, though I admit to being secretly intrigued: whatever I thought about the matter, it was hard to argue with the results, especially when none of my contacts had had their lives turned upside down in any way by the procedure. On the contrary. I remained in this contemplative state for several months until, a couple months back, I ran across an article online (at NPR, I think) with the headline that bariatric surgery worked better than diet and exercise. The article said that stats showed that bariatric surgery was simply much more effective at helping obese people take their weight off and keep it off than were diet and exercise, which basically had a dismal track record. And whatever else I did or did not know, I could attest firsthand that diet and exercise were not working for me. It's not that dieting did not take the weight off: if I dieted, I lost weight; it's that I could not succeed in starting a diet in most cases, and in staying on that diet in every case. My gradually-rising weight over the years was a testament to my inability to control the situation, whatever tools and resources one may think were available to me.

And so I began a more earnest investigation of bariatric surgery.

One of the first things that jumped out at me was the realization that I had been living under a kind of reverse-anorexia. My weight has been an issue for all of my adult life, and I don't think I've ever been in denial about it. Or not exactly. But I also don't think I live my daily life with an awareness that I am over 100 pounds overweight. This places me firmly in the category of morbid obesity, the highest category of overweight available (Category 3 Obesity, technically). I have long been concerned in a general way with my risk of heart attack and stroke, but there's a denial in living every day pretending there's not a noose around my neck. So Step One was to face this: as a general category, I'm as overweight as they come, and I must face that I'm in the highest possible risk category for a bunch of bad shit that I need to take seriously. And further enforcing that I'm not an exception to the rule, my weight is responsible for my taking medicine for blood pressure and cholesterol, and my blood sugar has slowly been rising over time. I will eventually be facing Type 2 diabetes, and at age 50 probably sooner than later. The denial comes from not acknowledging the huge risks these factors represent.

Researching bariatric surgery, I find I'm exactly the person for whom the procedures are intended. With a BMI of 41, my issues are exactly those for which these procedures have been developed.

So I got in touch again with the people I knew who had undergone the procedure and began to amass some data. I also, at my wife's very sensible insistence, went to my local doctor and discussed the subject with him. My wife, still repelled by the idea of bariatric surgery, was sure he would send me home with a scolding and tell me it was a terrible idea and what I really needed was to go on a diet. But he did not; indeed, he was quite supportive. Even before talking to him, I chatted with his nurse, who had undergone bariatric surgery some 25 years before (and had then needed to have it altered after there were complications); and she was still 100% happy she had done it and was THRILLED to learn that there were newer, laparascopic procedures available. The doctor insisted that bariatrics were not extreme or fringe procedures; this was sensible, mainstream medicine, he said, and he was confident these are relatively low-risk procedures which are almost certain to lower the very real risks I'm laboring under now.

And of the four guys from work I talked to who had undergone the procedure, three had spouses or other family members who joined them in the procedure, including two medical professionals who were at first very skeptical. I could not find a single discouraging word from firsthand sources, and even those rare cases I read about on the internet where difficulties had been encountered, the difficulties were relatively minor and no one regretted their decision or would not undergo it again. And the rest--the rule--were strong advocates of the procedure.

So this is all very encouraging.

But I wanted not to make such a far-reaching decision on a wave of euphoria, and my wife was still very much a hard-sell. So I tried to focus on her objections, both to honor her anxiety and to see if I were overlooking something. Her chief complaint is that the procedure doesn't fix what ails me, which is true enough so far as it goes. If I'm food-obsessed and in love with all the stuff I'm not supposed to eat; if for whatever reason I fail to eat as I should, this procedure doesn't fix that--it doesn't change what's wrong with my brain and my interface with food. But that leads inexorably to the question of whether ANYTHING can fix what is wrong with me? Ideally that would be the goal--"fixing" me--but that's maybe setting the bar to a height that no one could get over it. My experience suggests this in my case, and regardless we must deal with what can be made to happen. Bariatric surgery doesn't work by revising our mis-wired brains, but by circumventing the negative effects of that mis-wiring. Given the odds of anything else on the table, I think we have to be OK with this. If we are unable to re-wire the brain--and I have zero confidence that anything will make my interface with food a healthy one--then I think we need to focus on what will alleviate the negative symptoms of that mis-wiring.

The field of bariatric medicine has arisen exactly because people like me are becoming an epidemic problem. I agree that the long-term solution to society's problem cannot be surgery for everyone. But fixing the world's food supply and fixing my food brain are quite separate challenges, I think. I suspect that my mis-wiring is the outcome of decades lived in a bad food environment and my tastes and preferences cannot be re-decided. Maybe not forever, but for now; maybe medicine will eventually get a handle on this. Anyway, I've come to believe that alleviating the symptoms is probably the best possible outcome for me.

And so that leads me up to the present day. I'm on the clinic's schedule for mid-July, a couple weeks after another (non-pilot) friend is undergoing the same procedure at the same clinic. We've become "sleeve buddies," and have been exchanging information.

More to come.


PS: In the long term, I suspect we're going to have to get the vast amount of processed carbs--sugar and HFCS and white flour--greatly reduced in our diet. It's probably my particular paranoia, but I think we're in this epidemic because crappy food is more profitable: highly processed foods are cheaper to make, and more and more of our food comes from corporate sources. Their low nutritional content means that people eat more, and the resulting insulin-resistance makes for an addicted society--which means huge profits for big corporate food companies.


Jeff said...

I agree with both you and your dear wife - this seems like a drastic measure when you can get the same results simply by eating differently, but unfortunately it is not simple to eat differently. It is extremely difficult to eat differently. As you say, this is because of what we have been trained to eat and because of what is available for us to eat.

I only know of one other person who has undergone bariatric surgery, and I think it has been a generally positive thing for her. I don't think it was as effective as she would have liked, but I think it has helped her quite a bit. It is good to hear that it is not considered an extreme measure - but it will certainly be a major undertaking for you. I think it is a fair bit of work to make sure that you get a good diet, so you will still need to pay pretty close attention to what you are eating, you just won't be trying to avoid things and feeling guilty when you don't succeed (although as you say there are some items on the do-not-eat list, including some that you currently consume by the gallon jug ;-).

I also think that you are right that a big part of the reason so many people are overweight is because of the artificial food environment that has evolved around us. I don't think that it is a result of any sort of wicked plan, I think it is just an unfortunate result of the commercialization of our food supply. We no longer eat predominantly fresh foods that were grown close by to where we live, we now eat factory-processed foods that were manufactured far away and a relatively long time ago. Because of that we are eating foods that can be produced in bulk, easily shipped, stored for later, and all done quite inexpensively.

Look at what a large portion of our calories come from processed grains - cereals, crackers, breads, pasta, cookies, cakes, chips, and so on. All of these are things that were a small part of our diet 200 years ago, but now they constitute a large percent of our caloric intake. They are easy to grow in great quantities, ship and store easily, and provide a large reliable supply of calories for a hungry population. They also happen to be calories that come in a form that is quick to be absorbed by the body, and the body soon demands more. If you want to eat differently, not only is it hard to convince yourself to go against your desires, but it is a lot of work to find food that it better for you, since this is now the food we have. I know people who eat differently, and I know that they spend a LOT of time doing it.

In the end I think you are making the right choice, even if it isn't really a direct solution to your actual problem. As you well know, that problem can not reasonably be fixed. We are built to eat all that we can scrounge up and store any rare extra calories for the inevitable lean times, but we now live in a world that is different than the one we were designed for. For most of us there are no lean times and the food that we can find turns out to not really be what we should be eating (if we even actually know what we should be eating). The real solution would involve a food environment that better matched what we were engineered to live on, and while it may be possible to shut out the 'real' world of food and construct your own private dietary eden, that is not a task that most of us can undertake. I suspect that it will become easier and easier to find people to include in your circle of 'sleeve buddies' as more and more of us get to the point where there is no better option.

wunelle said...

I'm glad you weighed in. This is one of those topics you, perhaps, seem well-situated to contemplate the many ins and outs of (not from any weight issues you have, which are a small fraction of my own, but just because you are adept at chewing on multi-headed beasts!).

The extremity of the therapy tends to take us by surprise, I think, though after a little contemplation it seems maybe not quite so monstrous. And again, I find I must weigh my resistance and the risks of surgery against the present risks of heart attack and stroke and diabetes, which in my case are substantial and ever-present. The idea of being able to fit in a theater / car / airplane seat or of not being winded by a flight of stairs or of not sweating constantly are all fringe benefits.

The Diet Coke things is interesting, and I may put up a separate post about it. I stopped drinking it about two months ago now in preparation, and surprisingly it has been no difficulty whatsoever. Didn't expect that.

My "sleeve buddy," as you may know, is Nancy's Tom. We're using the same clinic, though he's headed there first--late June.

I've long thought about resuming my running, but there are complicating factors. I'll probably post about that.

Anyway. Thanks for piping up!

Vancouver Voyeur said...

One of my best friends had the gastric bypass because she was a few hundred pounds overweight. She was nearing death due to her weight and attendant diseases brought on by her excessive weight. She was so overweight, no doctor would do the surgery. She finally found a doctor who would do it, but only if she lost substantial weight first. It's been a number of years since she had the surgery, she's healthier, more active, happier, and most importantly, still alive. You should do what you need to do to increase your health and increase your chances for a long life. I looked at a chart the other day and it said I was 80-100 ponds overweight. This shocked me. I knew it was bad, but I hadn't really acknowledged it before. I recently lost 16 pounds, slowly, put 5 back on, and then lost them again. I'm aiming for a gradual weight loss brought on by changing my activity levels and food choices. It's a slow process, but I am heading in the right direction on the scales.

wunelle said...

If you can make workable changes that you can live with and get the results then you're on the right track. Like you, I think being overweight and *being 120 lbs. overweight* are pretty seriously disconnected in my brain. It's a little shocking.

I don't mean to abdicate my responsibility for what I've become, but at some point we have to look at this figure--2/3 of Americans overweight or obese; not sure how Canada stacks up--and recognize there's something more at work here than just people making bad choices. As I say, we'll need to so something as a society to reverse this, but that's quite a different matter from what an individual needs to do to re-wire a mis-wired brain. My attempts to make changes in my diet have resulted in my gradually... gaining weight.

Stay tuned! (And thanks for the comment. It's good to have all the input I can find on such a subject.)