Thoughts On The Eve

Tomorrow I'm off for my bariatric procedure. Tomorrow is just a few tests and a travel day, and the procedure itself--all 45 minutes of it--occurs Monday morning. I'm quite excited for it, and, truth be told, I'm a bit sick of waiting. As luck would have it, I spent the last eight days here in Louisville waiting for a phone call that never came. This is normally not such a terrible thing--to be paid to NOT work--but in this case my mind naturally kept busy with the impending event and I'm sick of living inside my own head on this topic. I'm eager get past the thing and for life to resume.

All this chewing is not for naught, however. I begin to see more clearly why this procedure--the Vertical Sleeve Gastrectomy--works and why it's a good fit for someone with my psychological makeup. It works, of course, because it restricts a person's intake of food--that's simple enough. But HOW it does that, and the logistics and timing of things seem felicitous. The period of greatest restriction from the procedure is immediately after having the procedure done. Not only is the new stomach pouch the smallest at this time (due to swelling from the procedure itself) but it's also less pliable--that is, stretchable--than it will become over time. But our diet is most restricted at this point as well, a function of the new stomach needing to heal. So for a month afterward we are confined to a liquid diet with very few calories. (This is tolerable because the portion of the stomach which secretes the hunger hormone Ghrelin is removed in the procedure, so most people experience little or no hunger. Sensations of hunger do return with time, but they are typically much less insistent.) After a month we are back to normal foods, but in greatly reduced quantities.

This whole time we are losing weight like a swimming pool with a wall removed, so the incentive to honor the program to the letter is very high; for an obese person, to be freed from this ever-present, all-encompassing cage of fat is the stuff dreams are made of, as Bogie would say. Most of our weight is lost in the first three months, though most people will continue to lose for up to a year before their weight finds its new set point.

It's what happens afterward that I've been chewing on. I have little uncertainty and no anxiety about what will happen in this first phase; everybody loses a boatload of weight in the months following the procedure. But what happens down the road is kind of the whole banana, since weight lost that is not kept off is as bad--no, it's worse--than weight never lost in the first place. There is no diet or bariatric procedure that cannot be beaten or overwhelmed, and my overriding concern is that I not fail to take all the appropriate steps to make good on the changes I'm about to undergo.

There's a fair amount of information about this. My doctor has a number of handouts, plus they spend some time before and after the procedure itself talking about dietary matters. Other specialists in bariatric procedures have their own protocols, and of course there's a wealth of information from those having already gone thru the procedure and who are living with the aftermath.

So many questions: Do we track our food intake scrupulously? Do we develop certain key rules which we abide by and leave the details to circumstance? Should one measure and weigh things? And for how long? Forever? And if so, how much of the long-term success of the procedure depends on that?

One universal I've seen is the focus on protein. Initially, getting enough protein is vital to keep the body from consuming its own muscle during the early months. But down the road it seems like the emphasis on protein continues. Near as I can tell, this is for a couple of reasons: 1) protein is the most innocuous of food sources (compared to carbohydrates and fats), and 2) the protein signals the pyloric valve in the stomach to close, thus enabling the quickest sensation of satiety at mealtime. This is one of the reasons that we do not eat and drink at the same time after getting the sleeve. Liquids tend to move quickly through the system, and will flush the small quantity of food out of the stomach before it can register "full" to our brains (another reason is because the small stomach needs the food that will supply nutrients to the body, and the room taken by liquid can be better used by solids). My own doctor's instructions say that failure to get enough protein will slow weight loss and can cause hair loss and cracked nails, etc.

So protein's the thing. But after getting a small amount of protein at each meal, the trail becomes harder to track. Some plans say to get veggies, others just emphasize percentages of protein vs. carbs vs. fats. Most recommend exercise, and all suggest avoiding sugary foods, both because they may not sit well with the new stomach and because they will slow or sabotage weight loss.

I've made a point to ask the people I know who have had the procedure how they are eating now. Their response is universal: "I eat whatever I want; I just don't eat very much of it." Other "sleevers" have echoed a similar theme: start with your protein, and then finish up with whatever you want--with the understanding that after a couple ounces of protein there's little room left for "whatever you want." My work contacts say, "I still eat dessert, but it's generally a bite or two. And that is quite satisfying."

One key thing my doctor talks about is not relying on feeling FULL as an indicator of when you've had enough to eat. The nerves of satiety, he says, are "slow" nerves, and it takes several minutes to register that we've had enough to eat. The better thing, he says, is to gain a visual and mental sense of what constitutes a proper amount of food--based on careful observation of what works and doesn't work early on post-procedure as we're learning a new way of eating--and go strictly by THAT sense rather than relying on a feeling of fullness. Over time, as the stomach becomes more pliable and we are able to tolerate more food, our reliance on this new sense of what constitutes a meal--rather than a feeling of fullness--ensures that we retain the sleeve's restrictive properties (this restriction is the keystone of the procedure's effectiveness).

I'm also concerned with my historic penchant for chocolate and such. It seems unrealistic to think I'm going to live the rest of my life without eating another M&M (though I'll do my best if this seems necessary). And during the weight loss phase of 6-12 months I expect to avoid desserts with great care. But I also don't want to turn the occasional pleasure carbs into an unattainable fetish. It would seem wise to introduce the occasional bite of chocolate cake or apple pie into my diet in a controlled fashion so that the tendency to fall off the wagon in a meltdown of slobbering weakness does not loom so large. (One of my contacts says that one of his favorite food groups--starches; breads and pastries and potatoes, etc.--just lost their allure after getting the sleeve. "They fill me up immediately and I feel like I've been cheated out of the (admittedly small) meal I was looking forward to." I'm interested to see what becomes of my own cravings over time.)

The sleeve will not solve my problems magically by itself. It is a tool to be used to help make better choices and avoid some of the more destructive paths. My regular practice of eating two huge triple-chocolate donuts every morning or of eating a whole pack of of Double Stuff Oreos in a single day (and then enduring several days of self-loathing because of it) are options that are precluded by the sleeve. And good riddance to them. It remains to be seen whether Oreos and I can be friends at vastly lower dosages or whether we need to part company permanently. Stay tuned for this.

Many obese people--myself certainly--are obsessed with food (more or less). It's not uncommon for me to be planning a meal as I'm eating the previous one, or even before. I think about food a lot, and I strategize my beverages so that I'm never without one. For a mentality like mine, the sleeve's requirement to minutely strategize the day's eating is not an unwelcome thing; it meshes nicely with my already-existing food interface. And since each meal is relatively small, the consequences of not eating what you like or not liking what you eat are diminished, because another meal is just up around the next bend.

We'll see if I'm singing the same tune a year or two from now.