The Weighting Game- Part One

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Losing excess weight is very hard. People who have struggled with their weight know this. Some doctors know. The community does not, which in part is why there are negative stereotypes and assumptions out there regarding the overweight and obese. ‘They are obviously too lazy’, ‘they just won’t make an effort’, ‘it’s their own fault’ are some of the comments thrown around. The people they are accusing of willfully endangering their own health are the very people that would have outlived us all in times of famine. However, here in Australia, food is plentiful. Energy dense foods are abundant. It is all too easy to stack on weight.

Scientists are learning that it is not a simple matter of energy in minus energy out that determines our weight. Conversely, how much we weigh determines how much we eat and move.

Why is it so hard to lose weight?

Even with a little bit of weight loss, the body fights back tooth and nail. This happens especially if the weight loss is rapid. The complex human organism goes into starvation mode. Hunger surges. Lethargy sets in. The person is inclined to move less and eat more. Metabolism slows. The weight that was lost jumps back on, plus often a little more.

This is why ‘diets’ don’t work, in general and in the long term. In fact the best ‘diet’ I have come across is a non-diet. Interested readers are advised to read ‘The ‘Don’t Go Hungry Diet’, by Amanda Sainsbury-Salis.

The only solution is a permanent change to good eating habits and an active lifestyle. Attention must be paid to portion sizes and the types of foods consumed. Liquid calories are to be avoided. Mindful eating is a must, with attention to bodily cues and eating to the point of satisfaction rather than bursting fullness. Such a lifestyle will result in better health and wellbeing. It will likely result in the loss of some of the excess weight. This can be frustratingly slow, but tends to be more sustainable as it doesn’t send the body into a panic.

People prefer fast results, however. This is why the quick fix diets are so appealing, even though in the long term they usually result in weight gain. Fighting our ingrained physiology is difficult and counterproductive, which comes as a surprise to patients who have come to expect miracles from modern medicine.

I have been working with gastric band patients for over six months now and I am a fan. Of the procedure and the patients.

How the band works is by altering hunger signals. A well-adjusted band means you rarely get hungry. You also feel satisfied after a small portion. It promotes mindful eating, in that you must eat small mouthfuls, chew them thoroughly and pause between mouthfuls- the way we all should eat. If you eat too quickly or eat something too tough, it will get caught and come back up.

I get frustrated when patients persist in thinking this latter feature is how the band works. ‘My band’s working,’ they say. ‘If I eat something I shouldn’t it just comes straight back up.’ I despair for their poor oesophagus, which is in danger of dilating if they persist in overloading their band.

The average band patient will lose 20% of their starting weight. For some patients this means they will still be obese and often haven’t lost that much weight. However, their natural trajectory (we all tend to put on weight as we age) would have meant they’d be above their starting weight if they hadn’t had their operation. I have had to learn to be content with an average result. For example I have one patient, a man, who is still 145kg. However, his starting weight was 180kg, so he is actually much better off. I have learnt that it is the rare band patient who will reach a ‘healthy’ range BMI. The majority of them seem to do well though.

I like the band because it is completely reversible and it can be adjusted- made looser or tighter depending on the patient’s progress and symptoms. It is the procedure I would have done if I struggled with obesity.

Although everyone seems to know someone for whom the band ‘didn’t work’, the majority of band patients I have seen have had a good result. Certainly, I have seen patients ‘beat their band’ and put on weight. This is because the band doesn’t change you. It is a tool you can use, or not use. It doesn’t work in people who lack understanding of how the band works and how they should be eating, despite hours of education and follow up. It works less well if the patient has completely lost their motivation. The band doesn’t stop you eating rubbish and if you persist in eating for hour-long sessions, you can get almost anything down.

The sleeve gastrectomy, where part of the stomach is removed, results in quite rapid weight loss at first. However if the weight loss slows or stops, or there is some weight regain, not much can be done to enhance it. The reflux can be horrible.

The bypass is quite effective but more invasive, and can result in some nutritional deficiencies. It is a good operation in terms of reflux.

Even with a bariatric procedure the majority of the work the patient must do is psychological. There is no operation that can stop you eating when you are not hungry (out of boredom, stress or for comfort) or eating past the point of satisfaction. No operation can force you to choose fresh, whole foods over processed crap.

I love working with such a motivated, appreciative group of patients. The work combines my love of mental health and procedural skills. These people put their life on the line (as anyone does undergoing an elective procedure under general anaesthetic) to achieve better health, but it really is a life-saving procedure.

Where I work, bariatric surgery is a privately funded undertaking, as the local health service won’t fund it. Patients not covered by their health fund either save up themselves, or apply to have some of their superannuation released.  I wish the local hospital bureaucrats could see how cost saving it would be for them in the long term to fund some of these operations. I have patients who have been able to come off their medications for hypertension, diabetes and high cholesterol due to the sustained weight loss they have achieved. I am sure that in the rest of their life they will have less hospital visits, require less ICU bed-time and less procedures done to address diabetic complications, renal problems, heart disease and peripheral vascular disease, as a result of their weight loss.

In this post, what I say is the result of knowledge accumulated during my training in bariatrics rather than from specific references. However I can certainly direct readers to useful references on request.

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