I don't want any yes-men around me. I want everybody to tell me the truth even if it costs them their jobs.
-Samuel Goldwyn, movie producer
Someone asked me the other day about getting a band. The first thing I said was, "You realize it isn't really about surgery, right?" The look I got back was one of total surprise. After all, they had read about "the surgery" on the Internet, they knew someone who had actually had "the surgery," and they saw an ad in the newspaper about how much weight some guy had lost after "the surgery." The procedure certainly sounds safe enough. After years of struggling with weight, it seems like a miracle cure. So, of course, "I want one, too." Armed with this certainty, some people are even willing to fly off to a foreign country to have someone they have never even met before, and will probably never see again, put a band around their stomach. Simple-right? Well ... no!
People are drawn to having bariatric surgery for a variety of reasons but nearly always with a sense of finality. In many respects it represents a last resort approach to losing weight. I've heard many patients say, "I've tried everything else, so this just has to work." There is clearly a sense of desperation, which in many cases is accompanied by a transfer of responsibility for success, or failure, directly to the surgery. But surgery alone, no matter what kind of operation, cannot solve the problem by itself. Let me give you an example.
A woman approached me after a seminar a few years back, inquiring about whether she would be a candidate for the band procedure. She weighed about 350 pounds, so I thought she would surely meet our criteria. However, she went on to tell me that 25 years earlier she'd had a gastric bypass operation and had lost 175 pounds. Over the next several years she gained all her weight back again. What that meant to me is that through consistent overeating she had stretched out the stomach pouch that had been created by the bypass, and was able to overeat the way she had before her surgery. She went on to say that 10 years ago she had another operation to revise her stomach pouch, meaning that the surgeon had essentially redone the gastric bypass. Again she lost 175 pounds, only to regain it all yet again over the next few years. Now she was looking to the AGB. I'd like to say that was the only time I'd heard such a story, but it's not. For me, stories like this woman's are extreme examples of how surgery alone doesn't solve the problem.
Do I Really Need a Weight
Management Program?
Getting a band should be viewed as merely the first step toward making major and permanent changes in your lifestyle. Changing the way you eat, what you eat, the role that food plays in your life, how and when you exercise, even how you view yourself are all part of the road to success. The fact is that all of these things and more must change. One of my favorite quotes is from Albert Einstein: "Insanity is doing the same thing over and over and expecting different results."
You have to change the way you behave, not just go get an operation. The question is, Can you make those changes alone? It has been my experience that very few people are capable of the degree of self-analysis, self-direction, and self-motivation required to make lifestyle changes without some help.
As we discussed in a previous chapter, the band is a tool, but like any tool it requires proper instruction in its use. No virtuoso pianist just sat down one day and began playing a Chopin concerto. To get the most out of any tool requires not only instruction and practice but also oversight and continued guidance. Call it coaching, if you will. The band is a tremendous device, capable of producing wonderful results when used appropriately by a well-motivated patient, but to obtain consistent and long-lasting success requires a team approach, and even then the battle is not easily won. Conquering a lifetime of obesity is a formidable task that requires both your personal commitment and a team of professionals dedicated to helping you achieve your goal. It is critical that you and your team have a coordinated plan that you understand and agree to follow. This is what I mean byA PROGRAM. The surgeon, dietitian, an exercise physiologist, and psychologists each play their separate but equally important parts within a comprehensive weight-loss program.
The Surgeon
In the last chapter, we discussed appropriate criteria for patients seeking the adjustable gastric band. Assuming that those criteria are met, the next step is finding a surgeon and a comprehensive program. Whether you find the program first and work with a surgeon they recommend, or find a surgeon who has developed a program-it doesn't really matter. What does matter is that you have both, a reputable surgeon and a comprehensive program.
Finding someone capable and willing to do band surgery was a problem in the early days of the AGB in the United States. Today there are many more surgeons performing these operations, and advertisements for the procedure can be found almost everywhere. So how do you know who to go to? Is it enough to go to a doctor just because your friend went there? Should you assume they did their homework and found the best surgeon and the best program? The answer to these questions should be obvious. For something as important as this, you should do your own research, even to the point of interviewing several surgeons before you decide.
The first question you should ask the surgeon or the office staff is, Are you part of a comprehensive program? If you call a surgeon's office and ask about their program, and they act as if they don't know what you are talking about, then the answer is clearly no. If their answer is "Yes, we have a support group that meets once a month," you should probe further. What you are looking for is a clearly defined program that offers nutritional, exercise, and psychological support and guidance from true professionals. Don't hesitate to ask plenty of questions. Find out how adjustments are done and who performs them, what kind of nutritional counseling they offer, what psychological support is available, whether they provide exercise guidance, and what the follow-up process is. Even if the surgeon doesn't have a formal program, he or she should still have made some arrangement for patients to receive all of these necessary services.
Checklist: Questions to Ask before Choosing a Surgeon and a Program
✓ Is the surgeon part of a comprehensive program? (If they don't know what that means, you have your answer.)
✓ Does the surgeon have a patient support group?
✓ How are adjustments done, and who does them?
✓ What kind of nutritional counseling is available?
✓ What psychological support is available?
✓ Does the surgeon provide exercise guidance, and what is the follow-up process?
✓ Are these services provided by trained professionals? (You're looking for licensed dietitians, exercise physiologists, and psychologists.)
✓ Ask about your surgeon's experience with laparoscopic techniques. Is the surgeon experienced with laparoscopic suturing? Is the surgeon certified through the American Society of General Surgeons PALSS program?
✓ What about patients who haven't done well or who are failing to lose weight? What percentage of patients are struggling, and what's been done to help them succeed?
✓ What kind of complications have there been? (You're looking for infections, slippage, and band erosion as the most common complications.)
✓ Ask the surgeon to explain the common complications, what he or she does to help prevent them, and how they are handled when they occur.
✓ Ask yourself, How comfortable do I feel?
Provided the surgeon has or is affiliated with an adequate program, your next questions should be about training, experience, and results. In 1988 the world of surgery changed forever. That was the year that laparoscopic surgery in the United States really got started. Since then many different operations have been performed using this revolutionary technique; however, it is important to recognize that not all surgeons have embraced this technique for doing abdominal surgery. Many have little experience beyond the removal of the gallbladder or the appendix. It is only in the last few years that laparoscopic surgery has been taught to any extent in surgical training programs, and many of those who are "teaching" these techniques have only limited experience themselves.
There is a new laparoscopic skills certification process offered by the American Society of General Surgeons called PALSS, which stands for Proficiency Assessment of Laparoscopic Surgical Skills. This certification is a peer review evaluation of laparoscopic skills, and it may offer patients some level of assurance that their surgeon has demonstrated his or her technical ability to a panel of experts. The program is still in its early development and as such is not yet considered a benchmark in the surgical community. Only a few surgeons have actually participated in the PALSS program so far, but it is a start.
The American Society of Bariatric Surgeons has also put together a process for designating facilities as "Centers of Excellence" in bariatric surgery. Typically these are hospitals or surgical centers that do a large number of bariatric procedures. Such a designation is more a reflection of the number of procedures done in that facility than it is the individual experience of a specific surgeon. While having an experienced staff with all the necessary equipment and services available at the facility is an important aspect of your care, the surgeon is the most important part of the equation. Just because a facility or even the individual surgeon does a huge volume of business is no assurance of the quality of the service you are likely to receive.
The laparoscopic placement of an adjustable gastric band is generally considered to be a fairly advanced procedure that requires significant laparoscopic skills-in particular, the ability to place sutures. You should not hesitate to ask the surgeon about their training and experience with laparoscopic suturing. Even if he or she hasn't performed thousands of banding procedures, the surgeon may possess the necessary skills, provided they have experience with other advanced laparoscopic operations. You may want to ask the surgeon about his or her experience with hiatal hernia repairs, antireflux operations, colon resections, and other procedures that they perform using the laparoscopic technique. Any reputable surgeon will be happy to share their experience with you. If the answer you get indicates that sutures are either unnecessary or unimportant, that should tell you everything you need to know.
During your interview, you should also ask the surgeon about results. Don't accept an answer that simply quotes the latest medical literature. You need to know what kind of results your surgeon is getting. Every surgeon will have some patients who are doing extremely well, and naturally those are the ones that you are likely to hear about first. Make sure to inquire about those whose results have been less than satisfactory. If the surgeon has been doing the AGB procedure for any length of time, he or she will have some failures. Find out why the surgeon thinks those particular patients failed to achieve their objective and what has been done to help improve their results.
You should also ask about complications, such as infections, band slippage, and erosions. The surgeon will likely provide you with information about potential risks even before you ask, but don't hesitate to inquire further if you are not satisfied with the information you get. This subject is covered more thoroughly later in the chapter on complications, but make sure you understand them directly from your surgeon.
Personally, I think that one of the most important criteria when deciding on a surgeon is how comfortable you feel. All the credentials in the world or affiliations with the most prestigious medical centers are no substitute for the feeling of confidence you get following a face-to-face meeting. Some bariatric practices are so busy and so automated that the surgeon doesn't actually see the patient until just before the operation. This time-saving process may be fine for the surgeon, but it is rather impersonal. You should insist on a personal meeting before you commit to anything, and you should specifically discuss the procedure, and all the other issues mentioned earlier, directly with the surgeon. If you are told that is not possible, or if the meeting is only a brief "Hi, how are you?" then you should probably go elsewhere.
Nutritional Support
The whole idea of having a band around your stomach is to alter the amount of food you can eat. But with that kind of restriction, there is a need to ensure that the food you eat has adequate nutritional value. Getting enough protein, vitamins, and minerals can be a real challenge. Somewhat surprisingly, it can also be difficult to drink enough water. Failure to take in the right things in the right amounts can lead to a variety of problems, so the assistance of a professional dietitian throughout the process is essential.
Any bariatric program will likely have some form of nutritional counseling after the procedure, but it is important that this individual, or group of individuals, also be part of the initial screening process before surgery. Prospective patients need to hear ahead of time precisely what they can expect to eat and what changes they will need to make in the way they eat.
For the band patient it isn't just a matter of eating the "right stuff." Having a band requires you to eat differently, and many patients find changing their eating habits to be the most difficult part of the program. If you are unwilling or unable to change the way you eat, your results will be disappointing to say the least. There can be no substitute for proper instruction by someone who understands the way the band works, followed by positive feedback when these changes are actually achieved.
This difficult task of instructing, challenging, and encouraging the patient is done largely by the dietitian. The need for professional guidance is especially critical for patients with Type 2 diabetes, because their blood sugars and subsequent medication requirements can, and frequently do, change even more rapidly than their weight.
Finally, the dietitian also needs to be involved in the process of deciding when and to what degree adjustments are made to the tightness of the band. Having the dietitian's input is very important. A well-trained professional can usually see through the protests of the patient, and help the patient recognize that it may not be the tightness of the band that is creating problems as much as it is their own reluctance to change the way they eat. For the band patient, the dietitian must be part psychologist, part nutritionist, part drill sergeant, part den mother, and part coach. But most of all the dietitian must stay involved, especially during the first year, when those new eating habits are being created.
Sue's Story
(Left) Sue, pre-op, 312 pounds.
(Right) Sue, four years post-op, 185 pounds, holding jeans that used to fit tightly.
I was 53 years old, 312 pounds at 5 feet, 8 inches, and my quality of life was lousy. In fact, I was pretty sure I wasn't going to live much longer. What made it worse was I taught preschool and felt the principal was prejudiced against overweight people. Plus I had sleep apnea and was on a Cpap machine, and I had knee and hip pain.
I tried the usual diets, including Jenny Craig® and Weight Watchers®. When those didn't work I did a ton of research on surgery. My insurance would cover the bypass but not the band. But the mortality rates for the gastric bypass really scared me. I felt I'd be crippled or die before I had the time to save the money to have the surgery in the States, and back then there was a much bigger difference. So I had the surgery in Mexico.
I had a huge case of buyer's regret afterward. My experience in Mexico was fine, and I was supposed to go to a hotel after a few hours. But I had some residual esophageal swelling, so they kept me overnight. After they released me I went home, but the swelling didn't go down enough and I was getting really dehydrated. After a couple of days, I even stopped producing saliva. It was hot. I live in California. I was sweating. I had to carry a cup around to spit into because my own spit wouldn't stay down and I couldn't sleep. I called the doctor in Mexico and he suggested I come back, but I didn't want to. I didn't think I could make it back to Mexico. I wasn't even peeing anymore at that point.
So the Mexico doctor found a U.S. doctor near me and got me admitted to their ER. I spent four days in the hospital on IVs. They checked the band to see if it had slipped, but I was fine. I think that would have happened no matter where I got the band. I didn't have a fill for almost a year. I didn't need one. And I lost a lot of weight. Now I'm at 185.
When I did get a fill, I found a U.S. doctor and got a very small one to start with. I'm not real thrilled with driving around on the other side of the border. My husband is a police officer, and he's really cautious. It's just too much of a pain to go back.
I don't feel hungry anymore. I have to remind myself to eat. At midday I have to eat some lunch so I don't eat too much at dinner. I remember having my stomach growl and the feeling I would eat anything that doesn't move.
There are some things I'll never eat again, such as pizza crust or toast. But if I start feeling deprived I go to my closet and say, Is the toast worth being where I was? No way. I remember I used to lie down on the bed and suck my stomach in to zip and button the pants I'm holding in the "after" photo.
There are other things. I flew to see my daughter on the East Coast right after 9-11, and I had no room. I could barely wedge myself into the airline seat. It was torture. Two years later I got on the plane to see her again, and I put the tray table down. I could cross my legs. I thought, This is heaven. I go to amusement parks now and I ride the rides. I used to have to stand and watch. Some rides I don't do because they're scary, but I can if I want to. Last summer I went to Colorado and climbed up Pikes Peak. I also went to New Mexico and climbed up some ruins. I can do more now than I could when I was in my late forties.
I look in the mirror and think I need plastic surgery. But I'm not doing that. My arms are real hangy, but so what? I'd like to have the roll around my stomach gone, but I don't know that I will. No one sees it. I don't run around in shorts or bathing suits. And now that I'm retired, I don't think it matters.
My only regret now is that I didn't do this years ago. I lost so much of my life. I wish it had been more widely available in the United States. And I like it that the band is reversible. I could go back because my anatomy hasn't changed, although I wouldn't want to now.
An Exercise Program
Joining a health club or getting a personal trainer may be precisely what some people need to develop an exercise program and remain committed to it. But if that's all it took to be successful in losing weight, you would not be reading this book. To some extent the failure of exercise programs alone in dealing with obesity may be related to the fact that many personal trainers have little training and experience with obesity and the physical limitations that go along with it. Morbidly obese individuals are frequently unable to do the kind of exercises that the typical personal trainer expects. Another aspect that can lead to failure is the psychological impact of "going to the gym." It often seems that everyone else who is there is trying to get "buff," while you are just trying to survive. "Is it my imagination, or is everybody really here just to watch me struggle?" Not surprisingly, some obese people decide they are just not going back because of the humiliation factor.
Despite the pain, and the embarrassment, getting some form of exercise is critical to your success. Exercise increases your metabolism and burns off fat stores that would otherwise remain despite dieting. A comprehensive program needs to have someone who is experienced in both the physiology of exercise and the special needs of obese patients. It is important to develop an exercise routine that is not only effective at increasing your metabolic rate but also safe, given the physical limitations that obesity may impose. This role is very different from that of a personal trainer, and is one that is more appropriately filled by an experienced exercise physiologist or physical therapist. It also doesn't require daily or even weekly instruction. This type of exercise specialist can provide patients with directions for developing a gradually evolving exercise regimen using only periodic encounters.
Part of the preoperative evaluation process should be an interview with the exercise physiologist or physical therapist that will help establish their role as part of the program. This includes a formal assessment of the patient's physical condition and limitations, as well as an evaluation of the patient's preoperative exercise tolerance. Recommendations are made as to what kinds of exercise are appropriate and safe.
A complete set of body measurements, such as chest, waist, hips, arms, legs, and neck, should also be performed as part of the general physical assessment. Despite the fact that some patients find these measurements embarrassing, they actually provide one of the most important motivations and feedback mechanisms in the whole program. Once every three months these same measurements are repeated, and patients can see just how many inches they have lost around their waist, hips, thighs, and every other area measured. It is a universal source of delight and inspiration, often even more so than the number of pounds lost. I've seen many patients proudly carrying their measurements around like a "straight A report card." They are eager to show everyone just how successful they are. Armed with their documented success, they become even more excited about the prospect of expanding their exercise routine so that by the next time they are measured the results will be even greater.
Changing How You Think
It seems as though individual success in our society is often measured by our ability to be self-sufficient, self-motivated, and able to "pull ourselves up by the boot straps." We place great emphasis on "the will to win" and the power of that will. We are made to believe that the difference between failure and success is a strong mind, capable of controlling behavior in every situation. Conversely, we conclude that anyone who would allow their weight to get out of control is weak-minded and undisciplined or just plain lazy. Clearly these assumptions and conclusions are wrong.
If you ask anyone who has been involved in bariatric surgery for any length of time, they will tell you that the psychological aspects of obesity are perhaps the most important and certainly the most challenging. A big part of the challenge comes from the social and psychological stigma that seems to go along with obesity. The mere suggestion that a psychological assessment needs to be done before undergoing bariatric surgery can solicit a defensive response, such as "I'm not crazy!" or, "I certainly don't think I need a shrink!" Along that same line, I've even seen professionals who anticipate a negative reaction from the patient and start by making excuses for the request for a psychological evaluation even before the patient has had an opportunity to raise any objections.
The real reason for our reluctance to submit to an analysis of our thoughts and our behaviors is often fear. There is nothing more personal or more private than our thoughts, especially as they relate to how we perceive ourselves. To have someone probing into our thoughts and perceptions naturally makes us feel uncomfortable, vulnerable, and exposed. But to be successful at changing a lifetime of self-destructive behavior, we must first change the way we think. We have to identify self-defeating, negative thoughts before we can replace them with the positive thoughts that will lead to changes in our behavior. This requires professional help.
A comprehensive weight management program should include an initial assessment by a clinical psychologist or psychiatrist trained in the science of human behavior. This evaluation may be in the form of a standardized test or a personal interview, or preferably both. The objective of this assessment is to determine whether the patient is capable of participating in the program and the patient's receptiveness to change. Occasionally this evaluation will uncover specific personality traits that make the patient destined to struggle with changing behavior, and it is far better to find this out before any surgical procedure is done. In addition, as covered in Chapter 6, insurance programs often require patients to receive a psychological evaluation before weight-loss surgery.
But the psychological components of a comprehensive program go far beyond the initial evaluation. They encompass a whole group of behavior modification tools, not all of which are provided by the psychologist. The elements of a psychological support system range from something as simple as a regular newsletter that provides specific direction and positive testimonials, to a series of formal behavior modification sessions conducted by a clinical psychologist. Actually, every member of the team plays a critical role in supporting patients during their struggle to regain control over their lives. Routine office visits with the dietitian, the surgeon, and even the exercise physiologist should include positive reinforcement of the patient's evolving behaviors. As Steven Greer, Ph.D., mentioned in Chapter 6, under What We Look for in Psychological Testing of AGB Patients, the psychological evaluation can help the team by supplying them with information critical to helping the patient succeed.
Five Steps to Changing Your Thinking
G. Dick Miller, Psychologist
There are five steps to changing your thinking. The first step is to become an observer of yourself. One good way to do this is simply to write down what is in your head for a week or so. Don't judge it. Just record your inner dialogue. Personal honesty is the key-an honest look at what your beliefs are now. What is really happening in your own head? There's no need to beat yourself up. Just take a look.
The second step is to look to see if your thinking makes sense or if it's nonsense. The trick is to identify the thinking that isn't working. Everyone at one time or another has struggled with this. But it makes sense to check your beliefs. There are five simple rules you can compare your thinking with to see if you're beliefs are rational. They are: Is it literally true? Is it good for my physical health? Is the way I'm thinking now consistent with my short- and long-term goals? Does it prevent significant conflict with others? Does it help me feel the way I want to feel? "The Tests for Rational Beliefs" in Chapter 8 cover these five questions in more detail.
The third step is to come up with a new way of thinking that is rational. This is where you challenge your current mindset. For example, if you've been telling yourself that two cookies won't make a difference in your diet, then it's time to challenge that idea. Will two cookies make a difference? A "no" answer is not rational. Of course they do. They make a difference in your intake for the day, they can lead to permission to have more (after all, I already blew it), they affect your blood sugar, which can lead to ups and downs emotionally and physically, and they can lead to other problems as well; so two cookies do make a difference.
The fourth step is to practice. Start telling yourself what is rational. Use the new rational statement you've come up with to replace the old. So when the thought comes that two cookies don't make a difference, replace it with the thought that two cookies do make a difference. You can also add that you'd rather wake up tomorrow morning feeling good about yourself because you did what is in your own best interest.
The fifth step is learning to tolerate being uncomfortable. Whenever you do something new a pattern gets generated in your brain called "cognitive dissonance." What that means is that your brain is going to generate convictions like these: "This is weird," "It doesn't feel right," "I feel awkward," "I wonder if someone else thinks I'm stupid," and so on. In fact, cognitive dissonance occurs anytime you learn something new, from a golf swing to cooking a new recipe. I'd go as far as to say that if you don't feel uncomfortable, you're not doing something new at all, which means you're not making the necessary changes. The challenge is learning to tolerate discomfort-to give yourself time as you adjust to the change you're introducing in your life. Knowing you're going to experience this can be encouraging. You may actually begin to look forward to being uncomfortable because it's a sign you're making progress.
Checklist: Five Steps to Change
1. Observe your thinking-practice personal honesty.
2. Check your thinking against the five rules for rational thinking.
3. Challenge your beliefs-come up with a new way of thinking that is rational.
4. Practice the new thinking.
5. Tolerate being uncomfortable.
These five steps to change are your steps to success. And they can become a habit, one you can use to ensure your weight-loss using the band.
Summary of a Comprehensive Program
While losing a large amount of weight using only your own willpower can be done, it is pretty rare. Unfortunately, for the majority of people who struggle with obesity the problem and the solution are anything but simple. So being successful in losing weight, and in keeping it off, requires more than just a diet, or an exercise plan, or surgery, or even creating a positive mental image. It actually requires all of those components working together in a coordinated program, and more. The "more" is the dedication and hard work of the patient. No matter what anyone tells you, it isn't easy, even with a team of experts helping you. But the rewards can be generous. When asked about the program a year or two after surgery, many patients relate, "It's the best thing I have ever done for myself."
Once you have found a comprehensive program, the next step is often the hardest. It takes a great deal of courage to call for a doctor's appointment when the problem you are calling about is obesity. But, as is frequently said, "Every great journey begins with the first step." Making that step is up to you.