The end of 2012 resulted in an uptick in patients of mine requesting gastric bypass surgery.
A group of extremely well-intentioned, highly motivated individuals for whom attempts at weight loss were met with constant trepidation.
Every nutritional and health podcast on iTunes will have you believe that with just the right gut flora, just the right PAGG, just the right amount of carbohydrate restriction, just the right amount of interval or HIIT training, just the right DVD set, just the right calorie counting web site, or gym membership, or support group…. AHHHHH!!!
I feel my patients pain, I really do.
I wish I could take their hand and lead them down the road of healthy feelings and much well beings. But sometimes we fail to reach this goal together. I may still be willing to walk up that mountain. But at times it is no longer in my hands, and often a patient of mine decides they want to take the drastic step toward bariatric surgery: The final frontier on an intercontinental dietary space odyssey.
So I offer support. Because maybe they are right, maybe there is no other way.
The Bariatric Blues
When I was a PA student I spent 2 months completing my surgical rotation in a very busy hospital just outside NY City. I spent six of my eight weeks as a grunt on a “general” surgery team, and to my surprise, I assisted with a large number of Roux-en-Y gastric bypass surgeries.
The doctor I was working with was animately opposed to laparoscopic surgery. Hence, these were extremely long 6-8 hour procedures, a large portion of this time was spent closing the new stomach pouch with an intricate web of sutures. It was impressive, and also mind blowing to be a part of this dramatic weight loss procedure.
About 2 weeks into my rotation we received a young and ambitious couple on our service. They were best friends and had decided to undergo the Roux-en-Y gastric bypass procedure at the same time. One was morbidly obese and had many associated health problems, including type 2 diabetes that was poorly controlled. Her friend, Jenny was just borderline to meeting the requirements necessary for the procedure. She was obese but not extremely, she was bright-eyed and full of life. They were both in their early 30’s and extremely kind, funny and generous. I did not scrub into their surgery, but I was there the day they pronounced Jenny dead. She died from an intra-abdominal infection that was a complication of the surgical procedure.
Later that month I wrote a paper on gastric bypass surgery and presented it during our surgical grand rounds. I think about Jenny often, I think about Jenny whenever I hear the word surgery. I think about Jenny when my patients ask me for the referral slip for gastric bypass. I debate weather or not I should tell them about Jenny.
The Other “Jenny”
Three years ago my sister, Jennifer, developed a nagging pain in her right mid-foot. She was 34 and diagnosed with osteonecrosis of her Navicualar bone. Once they ruled out the bad stuff, the doctors all agreed that Jennifer needed to lose weight.
No one wanted this more than Jennifer. But up to this point, her life had been a buffet of failed and frustrated diet attempts. You may assume then that my sister is week minded but you would be wrong, this word is not part of her vocabulary. This battle was one she had struggled with her whole life. Not the least bolstered by myself who used to call her names (in spite of my own struggles with weight) as a way to attack her when we would fight as children.
We all have our “hot spots”, and like most families she knew mine and I knew hers. There were times as we grew older when I would see people treat her poorly. Once we were outside of a pool hall on summer break from college with friends and a group of young guys pulled up in a truck and laughed at my sister and called her fat. I wanted to beat those guys to a pulp! It was at that moment (and even before) when I became fully aware of the intense degree of pain that accompanied her with regard to her weight, her helplessness to overcome the situation, my love for her and my angst against a society that felt entitled to judge and ridicule.
When my sister walked out of the doctors office that day with her diagnosis the doctor told her she needed gastric bypass surgery. She quietly gave them the hidden middle finger, walked out that door and went on to lose (and maintain) a 120 pound weight loss, using healthy diet modification, a change in mental attitude and moderate exercise.
You go girl! And now I watch the same group of guys pull up in their truck and whistle… Go screw yourselves I think.
Roux-en-Y Gastric Bypass and the Slow Carb Diet
As I mentioned earlier, 2012 had been a year of increased requests for bariatric surgery. And an increased amount of patients undergoing the procedure. Did I tell them about Jenny number one? No I did not. I did reiterate the fact that there were significant risks that go along with bariatric surgery, not the least of which is serious infection or even death. But, as you may know, this is a risk/benefit analysis each person must make for themselves.
Every patient that opted to undergo gastric bypass had at a minimum 2 years of intense lifestyle and dietary modification with unsatisfactory results. You must keep in mind that intense dietary and lifestyle modification is a general term and means different things to different people. Not everyone exists in the world of Robb Wolf, Loren Cordain, Tim Ferriss or Chris Kresser. We are talking about rural central California here (where I practice), where most live underneath the federal poverty line and many speak English as a second language. How many people have gone on to read The Paleo Diet even after I have given them a free copy? One (she also lost 125 pounds by the way)!
I am going to talk about one patient today: Patient A.
Patient A is a 36 year old female who has struggled with weight her whole life. She was also struggling in a relationship with here husband. She has 3 wonderful children, a sparkling personality and a killer work ethic. She had “tried every diet possible” and in 2011 developed pre-diabetes… for her, this would prove to be the final straw. We worked for 1 year on implementing a slow carb diet. She did well at first, losing about 6 pounds in the first month. This turned into 10 lbs. after 3 months and then a gain of 3 lbs. and then a loss of 1 lb., and you may know the story from this point on. She began a moderate exercise and walking program, but continued to have a significant amount of stress at home with her husband. She was working on this as well. Her insulin resistance became worse, her weight rebounded and she was miserable.
A good friend of hers had amazing results with bypass and she was “sick of living like this”. I have known her and her family for over 9 years. She is a wonderful mom, hard worker and motivated individual. I felt she suffered from “superstress”, none of which I could “counsel away” but we worked on it. Who cares what her cortisol levels were (although they were normal), her insulin levels were a a bit elevated, although this improved on the slow carb diet as did her fasting glucose to some degree. But, it wasn’t enough. Hormones, it’s all hormones right? We just need to modulate and control the hormones… Then we will get what we want!
It is not this easy. Anyone who has worked with patients for as long as I have can tell you that it is often not this easy. And you probably know this. Just to get to the point where many of the diet book gurus have made it requires intense discipline, time, research and motivation. It also requires a certain control over stress in your life. We all need a 4 Hour Workweek and passive income stream and I am sure this would solve a lot of problems. But it is not this straight foreword, and the human condition comes in many shapes and sizes.
Therefore, when she asked me for the referral to the bariatric surgeon I agreed to her request.
One Year later
Patient A is 120 lbs lighter, but (and there is always a but) she developed Nesidioblastosis after Roux-en-Y gastric bypass surgery. In other words she came to me extremely fatigued one day, tired and again miserable. Another doctor had ordered a fasting glucose which came back at a respectable 85. Yet after eating she felt horrible. I ordered a two hour glucose tolerance test and her two hour postprandial glucose was 30! If you don’t know, that is close to dead.
And like a viscous circle it all comes back to insulin. Her pre-diabetes was now resolved, but now if she ate carbs her pancreas overcompensated and she developed severe hypoglycemia. Guess what, she was about to be placed again on the slow carb diet. Something she had never really stopped in the first place.
The last 3 months have been a battle. Her deadbeat husband left, which was good but she has incurred a huge financial strain. Her weight has gone from 260 to 153, and she looks amazing. But she feels like crap, we placed her on a medication called Acarbose, which helped some. She became severely hypothyroid, depressed and anemic, despite high doses of vitamin and nutritional support. Every day she tells me she regrets her decision. Although I assure her that she will be happy about it once we get things under control, and I believe this. I am still left wondering if it is worth it.
I have admitted 2 patients in the past year to the hospital for blood transfusions and monthly iron infusions after becoming severely anemic several years post gastric bypass.
Many have had significant weight loss much of which came back. For some of these patients going from nearly 400 lbs. to 250 lbs. is obviously a huge improvement. But something is still lacking here. Many have chronic stress and a difficult home life. I wonder why they would stop taking their vitamins. For some it is a yearly occurrence, they come to me and say “Steve I think I need to go the hospital.” This is curious I think, and as I am admitting them I am lecturing them on their need to care for their health. Some things never change!
Slow Carb vs. Bariatric Surgery
I have had many patients make significant improvements in 2012 using a slow carb approach. I am sure (although I have lost count) that we have had well over 1000 pounds lost in 2012 from within my clinic population.
We have thrown meds out of patient formularies. We have laughed, we have cried, I have held hands through the trepidations of surgery, of dietary frustration and the many, many roadblocks that exist on ones path to better health.
I don’t particularly like bariatric surgery and I don’t think my opinion on this is likely to change in 2013. My patients who have lost weight through dietary modification are happier, healthier and appear better off. I know of some success stories that involve bariatric surgery, and I even have patients who swear by it, and maybe you are reading this and you have had the surgery, but I haven’t been sold.
Depression, digestion problems, anemia, fatigue among many other complications all for what? The problem may not be just in the procedure but the lack of good follow up from specialists and bariatric surgeons who provide little post-operative support after the check has been cashed. Instead they often leave patients to follow up with a totally unprepared family practice community that is mostly unaware of the consequences. The extreme caloric deficit that follows bypass is the subject for a good research article, my thoughts on dopamine deficiency and the benefits I have noticed with the addition of medications such as Bupropion may be something I will discuss later.
We are chipping away at the solution to this all encompassing problem. It may lay in the ancestral health movement, or maybe Dr. Oz has the cure? I don’t know, maybe we all just need less carbs and more herbs, or maybe we all suffer from “superstress.” Or maybe, none of it matters, maybe we don’t need anything external at all. Maybe what we suffer from, maybe the root cause of the problem lies way beyond the reach of Tim Ferriss. It could be a mindset, the very mindset my sister developed when they told her it was either lose weight or lose the ability to walk without pain.
Maybe it is as simple as sending oneself up “the mountain” without a rope, per say. We all would have a better chance of making it to the top if we knew the only alternative was a long, likely detrimental fall to the bottom.
I woke up midway on that climb several years ago, and trust me once you cut the rope the ascent becomes the only reasonable option.
My advice: Cut the rope and climb the mountain, and be extremely careful of shortcuts along the way!