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.

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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.

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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.

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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.