Thursday, January 17, 2013

The chance to cut is the chance to cure

Pressing the Reset Button


      I've been doing weight loss surgery since 2008.  When I first started, I actually didn't intend to do weight loss surgery.  I wanted to do additional training in laparoscopy and most laparoscopic fellowships included some (or LOTS of) Bariatric surgery.  I found a program that looked like it didn't have too much, applied and was accepted.  Once I started training, I realized that a good Bariatric surgeon is like a magnet.  Once word gets out, the inflow of patients is almost non-stop.  So, for better or worse, I did a LOT of bariatrics that year.

    It turns out that it was for better.  I discovered that, despite my inclination going into it, that I really liked bariatric surgery.  I've been varying degrees of fat for most of my life (100 in the 4th grade, 180 in the 8th grade, 170 in college) and it was so rewarding to see people regain their life after losing their weight.  What I hadn't realized prior to fellowship was that the pre-conceived notions that made me think it wasn't a worthy pursuit as a career are the same ones that keep people who need the surgery from getting it.  They are also the same notions that make the nay-sayers say "Nay". 

    We've all heard it:
"You're just taking the easy way out."
"You just need to eat better and exercise more"
"Well, if you ate this way before you had the surgery, you wouldn't have had to have the surgery."

    None of these are even close to the mark.  Anyone who has ever had bariatric surgery can tell you that there is nothing "easy" about it.  It's usually a 6 month or greater slog through nutritionist, psychologist, medical "weight loss" and insurance purgatory  before you can even be considered.  This is followed by preoperative evaluations, weeks of nothing but proteins shakes, moderately painful major abdominal surgery and lets not forget, more weeks of protein shakes.  The culmination of this process is carefully tracking everything you eat for at least the next few months, relearning how to eat (or rather unlearning all the terrible habits you have) and finally getting an organized exercise habit in place.  If you are vigilant, during the first 12 months, you lose about 75% of your excess weight. 
   
    Then, the real work begins.  From year 1 to year five, you have to prove that you actually made the changes and can sustain the new habits and lifestyle.  If you didn't/can't, you regain the weight.  I have seen many patients who have had bariatric surgery 3, 5, or 10 years ago who are now the same weight they were before they started or more.  There is a 25% failure rate and I assure you it has nothing to do with what I did while I was in there, and EVERYTHING to do with what the patient did with it after the fact.

  Speaking of failure rates, the failure rate of traditional treatment - diet and exercise - is 95%.  No, that's not a typo.  Only 5 % of people can lose significant weight and successfully keep it off.  So, while it's a noble idea that moving more and eating less can have the same effect as me and my knife, reality shows this not to be the case.  I'll take the 25% failure rate over the 95% one any day.

    We've all dieted.  It sucks.  It's slow.  It's aggravating.  And, as I showed in the math post, the metabolic numbers do not work in our favor.  Most of us have no real trouble maintaining our weight (be it normal or elevated) because living on 2100 calories a day is not really too bad.  To expect people to eat like they've had bariatric surgery when they haven't is just cruel.  The trick is to not get overweight/obese in the first place.  Only, we figure that out when it's too late. 

    So here's where bariatric surgery comes in.  It's like hitting a reset button.  You have your surgery, you have one year to make the behavioral and psychological changes needed to live a healthier life.  You have one year relatively free of your grehlin and leptin monsters to relearn what real hunger feels like.  You have one year to find something fun to do that involves moving your body again.  You have one year to shed your 100 lb backpack and remember what it feels like (or maybe learn for the first time) to not be carrying around that baggage.  And at the end of the year, if you've done all that, you get a chance to try to eat like a normal human being, and maintain your new healthier weight.  2100 calories a day, just like all your skinny friends always did while you were dieting all those years.

  Data right now says that only 1% of Americans eligible (based on obesity criteria) have actually had bariatric surgery.  That means there are a lot of people out there who may benefit from pressing the reset button.  Food for thought...


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