People grow through experience if they meet life honestly and courageously. This is how character is built.
-Eleanor Roosevelt, My Day
When we look back on our lives each of us can identify certain major milestones. Some were the result of events that we couldn't control. Others were things that we specifically caused to happen by virtue of our own actions. Making major decisions of this nature takes courage, whether they be buying a home, changing jobs, or deciding to do something definitive about chronic obesity.
Every patient I see has a different story to tell about how they came to their decision to get an AGB. However, what is common to each story is an underlying awareness that they've tried everything and nothing seems to work. Ultimately, the majority of my patients tell me that their decision was in fact one of those life-altering milestones.
Coming to a CrossroadsTreating Obesity as a Disease
For many people the decision to have surgery to help them lose weight comes only after extensive research. For others it may be the result of having personally observed the success of a close friend or family member. Regardless of what triggers that decision, it makes sense only if you have come to the realization that you aren't able get control over your weight by yourself. This is tough, because we invariably feel like a failure whenever we have to admit we can't do something on our own.
Prospective patients frequently start out trying to explain to me all the reasons why they haven't been successful losing weight on their own. Before they get too far into their list I stop them and ask, "Do you think you could treat your own heart attack?" Obesity is a disease, and like any other disease it requires professional treatment. Once you learn to view it as such and recognize that being involved in a weight-management program is in fact a medical treatment designed to control that disease, your success will come much easier. The true crossroads isn't the decision to get a band; it's the decision to change the way you look at your obesity.
The Minimum Criteria
While your actual weight in pounds and your specific EMI are important, I think it is of greater importance to look at individuals and how their weight affects their health, both now and in the future. But everyone is obsessed with numbers, so what follows are "the numbers."
Back in Chapter 1 we talked about Body Mass Index (BMI) and how it is used to create the categories of obesity. A EMI of 25 to 30 kg/m2 is classified as "overweight." A BMI of 30 to 40 kg/m2 is classified as "obese." A EMI above 40 kg/m2 is classified as "morbidly obese," and one over 80 kg/m2 falls into the "super obese" category. Anyone can calculate their own BMI using the formula BMI = body weight in kilograms divided by height in meters squared. Generally it is easier to determine your BMI using a chart like the one provided in the Resources section of this book (page 261).
Most surgeons agree that patients should meet some minimum criteria before even considering bariatric surgery. This is not something that should be done for someone who needs to lose just 20 or 30 pounds. A number of years ago, the American Society of Bariatric Surgeons (ASBS) developed some general guidelines for its members to use when evaluating patients for weight-loss surgery. Under those guidelines, for a patient to be considered for any type of bariatric surgery, including the AGB, they should have a BMI greater than 40 kg/m2, or a EMI greater than 35 kg/m2with at least one significant medical comorbidity, such as Type 2 diabetes, hypertension, sleep apnea, major arthritic changes, or gastroesophageal reflux disease. The patient's obesity should also be a chronic problem, generally of five years' duration or longer, and during that time the patient should have made a reasonable effort to lose weight through dieting and exercise.
Checklist: General Criteria for Weight-loss Surgery Patients
(Established by the American Society of Bariatric Surgeons)
✓ BMI greater than 40 without a medical co-morbidity
✓ BMI greater than 35 with a medical co-morbidity'
✓ Obesity chronic for five years or longer
✓ Reasonable efforts made to lose weight through dieting and exercise
Clearly, insurance coverage is a huge issue for most prospective patients. But the fact is that each and every policy is different, creating an extraordinarily challenging set of problems. However, virtually all policies that offer coverage for bariatric surgery have adopted the ASBS guidelines as criteria, which must be met before the patient can be approved for any weight-loss procedure. These guidelines were never meant as absolute rules for performing bariatric surgery, but, with the dramatic increase in demand, the insurance industry has elected to adopt them as rigid criteria for paying weight-loss surgery claims. That can be a major source of conflict, because the "criteria" are not always followed in determining whether a claim is paid. And, as I eluded to, many policies have specific language in them that excludes coverage for any bariatric surgery. It is also important to realize that insurance coverage for bariatric surgery, and the AGB in particular, can be added to the list of excluded procedures by the insurer without notification at the annual renewal of the policy. Such exclusions for bariatric surgery take effect immediately, so just because a policy covered the band operation one year, doesn't mean it will cover it the next.
While it is relatively easy to measure your BMI, the presence of co-morbidities can be and often is disputed by insurance companies. Despite the presence of "written criteria," arguments frequently arise when attempting to define the "medical necessity" for bariatric surgery. Even after getting letters from physicians and documenting medical conditions, many patients are also required to document their weight-loss efforts. As you might expect, those efforts are then subject to interpretation. Some policies require that specific dieting efforts be under the direct guidance and supervision of a physician, but even then the level of supervision can come into question.
When patients find out that their insurance doesn't cover the cost of bariatric surgery, or the band in particular, the most common response I hear is, "Don't they understand that I am going to cost them less in the future when I no longer need medications for diabetes and high blood pressure?" While this sounds like a reasonable argument, the fact is that insurance companies are not in the business of investing in your future health. The economic benefits of weight loss are obvious, but they are realized over a number of years. The insurance company has no assurance that you will remain insured by them beyond the current contract year, so they have little incentive to provide coverage based on future savings.
Another insurance issue is somewhat unique to the AGB. Following the procedure, the band must be adjusted, often several times over a period of months. These adjustments are not part of the procedure, and therefore the insurer may not pay for adjustments even if the operation was covered. Likewise, most policies don't even recognize a comprehensive weight-management program, but instead place all of the emphases on the surgery. This inappropriately discounts the other elements critical to the patient's success.
Without question, insurance coverage makes it possible for some people to access healthcare who might not otherwise have the means to pay for it. But at the same time there are many others who are denied bariatric care through this system. The system has evolved to the point where many, if not most, people perceive that healthcare is available only through their insurance. Therefore, if they are denied coverage for obesity surgery they feel they have no other choice. To address this problem, many surgical practices offer a number of financing options for those without insurance coverage. That allows patients to choose for themselves how they wish to deal with this lifelong condition.
The Initial Evaluation
Many surgical programs offer free seminars for prospective patients as a means of providing information in an efficient manner. These seminars can range anywhere from a 20-minute presentation by a nurse or other staff member to a two-hour comprehensive explanation by the surgeon and his or her entire staff. While the seminar can be quite informative, it is not designed to provide individual recommendations. If the seminar is followed by an on-the-spot attempt to get you signed up for surgery, you may want to consider looking elsewhere. The decision to change your life by getting an AGB is one that is very personal and should be made only after careful consideration. Don't let anyone pressure you into making this important decision on the spur of the moment.
It may be a good idea to go to more than one seminar, just to see for yourself what the differences are in the various programs. Once you have made up your mind to move ahead, you will need to make an initial appointment with the surgeon. During this initial appointment the surgeon or a staff member will take a detailed look at your particular situation and let you know about their screening process for prospective patients.
Different programs have different processes for screening prospective patients prior to approving them for surgery. Sometimes this screening includes insurance preapproval before an appointment is even made to see the doctor or a member of the staff. Personally, I believe that excludes many patients who not only would benefit from the program but who also might well be inclined to find a way to obtain financing despite being denied insurance coverage.
At a minimum, each patient should be evaluated by the surgeon to determine whether an AGB is an appropriate option. Subsequent visits with a clinical psychologist and a registered dietitian should also be considered mandatory as part of the presurgical assessment process. Having an exercise physiologist perform an initial exercise tolerance test and a series of body measurements is also a routine part of many programs.
The Surgical Assessment
The first assessment should be by the surgeon. During your initial visit he or she will gather all the necessary medical information, which allows them to provide you with appropriate medical advice regarding the band. They will likely have you fill out a medical information form similar to ones other doctors use. However, for patients with the diagnosis of morbid obesity there are several areas of the medical history that deserve special emphasis. Problems such as diabetes, high blood pressure, heart problems, respiratory problems, sleep apnea, liver disease, or gastric reflux are among the most common conditions associated with obesity. Any one of those conditions can significantly influence your overall risks and benefits in terms of the AGB. Even if you have written down everything on the information form, be sure to make a point of telling the surgeon about these problems yourself. Don't assume, if he or she doesn't bring it up, that it isn't important.
Checklist: Conditions You Would Be Wise to Bring Up When Talking to Your Surgeon about the AGB
(Hint: Don't assume that, because you wrote them on the patient questionnaire, your surgeon knows about these conditions.)
✓ Diabetes
✓ High blood pressure
✓ Heart problems
✓ Respiratory problems
✓ Sleep apnea
✓ Liver disease
✓ Gastric reflux or gastroesophageal reflux disease (GERD)
✓ Hiatal hernia
Potential Road Blocks
There are a number of conditions that can have a direct bearing on AGB surgery. One of the most common is gastroesophageal reflux disease, or GERD. This condition involves the abnormal movement of stomach contents, usually acid, up into the esophagus, causing heartburn, chest pain, regurgitation of food, and other related symptoms. Many of my patients have been on medications for years to reduce the amount of acid produced by the stomach. Not surprisingly, they have also been told repeatedly that losing weight would improve their reflux. Some patients are actually referred for the AGB for weight loss because their reflux has become unmanageable. While the AGB can offer significant relief from GERD symptoms, it is important to recognize that reflux can also be associated with a hiatal hernia, a medical condition involving the stomach and the diaphragm.
The diaphragm is a broad, flat muscle that separates the chest cavity from the abdominal cavity. There is a natural opening in the diaphragm, called the esophageal hiatus, which allows the esophagus to pass through it before emptying into the stomach. The natural resting pressure in the abdomen is significantly greater than the pressure that exists in the chest. The negative pressure in the chest is what allows us to breathe air into our lungs. By contrast, the pressure in the abdomen is positive. In obese patients, their excess weight presses down on the abdomen, further increasing the pressure gradient between the chest and abdomen. That is part of the reason why many overweight people experience shortness of breath.
Over time, the pressure in the abdomen can stretch the hiatal opening in the diaphragm, pushing the stomach through this enlarged opening and up into the chest. This condition is known as hiatal hernia. Since the band is designed to be placed around the top of the stomach, a significant hiatal hernia creates a potential problem because the band needs to be on the abdominal side of the diaphragm to work properly. A small hiatal hernia can usually be repaired at the time the AGB is placed, but for patients with a hiatal hernia larger than a couple of inches in size, the band is generally not a good choice.
For anyone with a history of hiatal hernia, or significant reflux symptoms, it is important to document the presence and size of the hernia. The easiest way to make this determination is with an upper GI X-ray series. The patient is asked to swallow a liquid solution containing barium that shows up on an Xray. This test will generally demonstrate whether there is a hiatal hernia, its location, and its approximate size. The presence of a hiatal hernia can also be determined using an endoscopic examination of the esophagus and stomach. A flexible, lighted tube is passed through the mouth, down the esophagus, and into the stomach. During this examination the location of the junction between the esophagus and stomach, as well as the position of the diaphragm, is evaluated.
An unsuspected hiatal hernia that is not identified until the time of surgery can create a real problem for the surgeon. While repairing a small hernia as part of a band procedure can be done, it requires more dissection and may also increase the surgical risk. There is also a possibility that later on the hernia repair could come loose and allow the stomach and the band to slip up above the diaphragm and into the chest. It could even result in the surgeon's having to abort the band procedure altogether. So it is far better to know about a hiatal hernia beforehand. If there is any question about the presence of a hiatal hernia, the surgeon will likely order either an upper GI X-ray or an endoscopy before recommending the band. You will certainly want to discuss your situation with the surgeon before deciding whether the band is right for you.
Another medical condition that is common in obese patients is gallbladder disease. If you have known gallstones or have been diagnosed with gallbladder disease, the surgeon is likely to recommend your gallbladder be removed at the same time you have your band operation. That decision will be based on confirmation of gallbladder problems, which will require a gallbladder sonogram or a gallbladder function test called an HIDA scan. It is usually not a problem to combine the elective removal of the gallbladder with the AGB procedure, but if the gallbladder is acutely inflamed or infected, it is generally better to remove it during a separate procedure rather than risking infection of the band.
Chronic conditions that involve the stomach or intestinal tract may also influence whether you are a candidate for the AGB. A diagnosis of inflammatory bowel disease, also known as Crohn's disease, can influence the surgeon's decision regarding whether a band is an appropriate choice for you. Likewise, chronic liver disease, especially when complicated by cirrhosis and dilated veins in the esophagus, known as esophageal varicies, will certainly influence the surgeon's judgment regarding the AGB.
Checklist: These Conditions May Need to Be Addressed Before You Have AGB Surgery
✓ A hiatal hernia (even if you haven't been diagnosed with one, the presence of gastric reflux or gastroesophageal reflux disease is a symptom, and you should be checked for this condition prior to band surgery)
✓ Gallbladder disease
✓ Crohn's disease
✓ Chronic liver disease
✓ Hepatic cirrhosis and dilated veins in the esophagus, known as esophageal varicies.
If after your initial assessment the surgeon tells you that he or she doesn't think the band is a good choice, you may want to get another opinion. If you get the same recommendation from a second surgeon, then you should probably heed that advice, even if you ultimately find someone willing to do the AGB surgery.
During your evaluation by the surgeon, he or she will also explain in detail how the procedure is performed. The surgeon should also go over the potential complications and problems that can occur both during and after the procedure. Sometimes patients are so excited about the prospect of getting a band and starting to lose weight that they fail to pay attention to the surgeon's discussion about the procedure, the downside, or the risks. It's important to pay attention to these explanations and know precisely what you're getting into.
During the surgical assessment your surgeon should also help you establish some realistic expectations about where you are likely to end up and how quickly you'll get there. Virtually every patient has seen the "before and after" photos of individuals who have been extremely successful with the band. You will even see some in this book. In many instances it is those images and the success stories that convinced patients to pursue getting a band for themselves. Obviously, the procedure can be, and is, marketed using those particular patients because they illustrate the optimal results. Not everyone, however, achieves optimal results. So before you assume anything, you should get an idea what the surgeon considers average results. It is important to understand what constitutes poor results as well, and what produces poor results.
In the next chapter we'll discuss how optimal results are related to a comprehensive program offering dietary, exercise, and psychological support in addition to the band. However, it is your willingness and commitment to participate in such a program that will determine just how successful you are. Patients who avail themselves of all aspects of the program will typically lose between 50 and 75 percent of their excess body weight and keep it off. In other words, if you are 100 pounds overweight, you should realistically anticipate losing between 50 and 75 pounds over a period of 12 to 24 months, at the rate of 1 to 2 pounds a week. If you are 150 pounds overweight, the loss should be more like 75 to 115 pounds at the same rate over the same period. Remember, these are average results; some people do better, others not as well.
I have had many patients look at these numbers and suggest that they can and will do much better. In some cases they do. However, the realities are that (1) people who have been overweight for many years are generally unable ever to achieve their ideal body weight, and (2) the objective of the AGB or any weight-loss program is to return the individual to a healthier weight that they can maintain long term. For most patients the loss of at least half of their excess weight represents a significant improvement in their overall health. That is not to say everyone is always satisfied with that result, and perhaps they shouldn't be. The important thing is to establish a realistic target and understand that it is normal to lose between 1 and 2 pounds per week.
You owe it to yourself to be fully informed about all aspects of the surgery This includes the qualifications of the surgeon, the experience of the anesthesiologist, the capability of facility and support staff, as well as the risks of the procedure and the anticipated results. These are all part of the Comprehensive Weight Management Program, and the time to find out these things is before you proceed.
Once you have been told you are a potential candidate for the AGB, the next steps involve assessments by the other members of the team. Ideally you should be evaluated and advised by a psychologist and a licensed and registered dietitian, along with an exercise physiologist. The purpose of these assessments is to ensure your success by outlining all aspects of the program. Likewise, it will help you to avoid spending time and effort on the AGB if it clearly isn't likely to work for you.
While all of these assessments may make you feel as if you are being placed under a microscope, they also offer you an important opportunity to assess the team that you will be working with in the months and even years to come. Since you are going to be meeting with these people over and over again, you need to feel comfortable with them and believe that they hold your interests paramount. You may want to ask them some questions about their goals and expectations for you, as well as for other patients. It is important that everyone is "on the same page of the program" before getting started.
The Road to Success Is a Change in Thinking
G. Dick Miller, Psychologist
I see the band as a beginning, a start. A lot of people will get a band, but the ones who succeed will be the ones who change their thinking. These patients move away from the concept that someone is going to do something to "fix" them. They adopt an internal locus of control instead of looking outward.
Many band patients have been out of control for some time, and not only with their weight. Their social and emotional lives have been out of control, too. I see it when I walk into a store. If I'm waiting for a clerk and an obese person is also waiting, I'll get the attention. It's clear to me, when I watch the way heavy people are treated, that they are perceived as being less-than. And it's my opinion that those perceptions lead to an attitude on the part of a heavy person of waiting for someone to give them something that will make them okay.
The successful band person is not waiting for someone or something outside them to change their situation, or give them permission to be all right with themselves. They take responsibility for developing new habits physically, emotionally, and socially. Those who adopt a "wait and see" attitude are on their way to sabotaging themselves. This isn't gallbladder surgery. You cannot just wait for your body to heal and then go about your life the way you did before surgery. It's an ongoing process that begins and centers around change.
And band patients are not the only ones facing a change in their belief system. This requires an adjustment on the part of the surgeon, too, whose training is in cutting and "fixing" the problem once and for all. Many people are waiting for the surgeon to fix them, and the surgeons get angry-sometimes at the patient-if they can't. The gastric bypass fits this "quick fix" description. The band is gradual, which is much safer, but not quick. And it requires ongoing interaction between the medical staff and the patient for adjustments.
My experience is that many people want to believe the hype-that they can just have surgery and it will all be taken care of. But long term it will be the person's belief systems that determine their emotional well-being. "As a man thinketh, so is he," not as the band "worketh or not worketh." A lot of people will get a band, but some will change the way they think. These patients will recognize the band is a tool, but the real victory, the road to success, is in changing their thought process.
The Psychological Assessment
For some, the thought of having a face-to-face meeting with a psychologist can be more frightening than the surgery. "Is this guy going to find out that I really am a little crazy? What if I don't answer all the questions right? Does that mean I won't be a candidate for the surgery?" Nearly everyone has the same concerns, and they are almost always unfounded.
The reason for the psychological evaluation is to help determine the best way to help you achieve success. It is very evident that obesity is closely tied to how we perceive ourselves and our surroundings. There are certainly some causes of obesity that have their very roots in our psyche, and conversely, the presence of obesity often has profound effects on our psychological well-being. The objective of the psychological assessment is to determine within reasonable probability whether you are appropriately motivated and capable of making the behavioral changes needed to be successful. The only way to answer these questions is through an assessment by a trained psychologist.
The evaluation is typically in the form of a personal interview, during which you will be asked a number of questions that will probe into who you are and what motivates you to do what you do. Despite what you may think, there are no trick questions. If you simply answer all of the questions as honestly as possible you will sail through without any trouble. The objective is to find out who you are, not who you think you are or who you would like to be. Psychologists are taught to spot incomplete answers, half-truths, and nontruths, so there is no point in trying to tell them what you think they want to hear. Even if you are successful in disguising your true self, the only person that is potentially harmed is you.
Many psychologist use a written test in addition to a personal interview to determine more precisely the personality traits of the patient. This is still somewhat of an inexact science, but there are some clear patterns of thought and basic beliefs that can be accurately identified through this type of evaluation. While a lot of information can be obtained through testing, the first question that the psychologist is trying to answer is this: Does the individual have sufficient personal insight to accept the fact that their past behavior is what led to their weight problem? If so, do they recognize the need to change their behavior patterns and are they capable of making the necessary changes?
These sound like pretty simple questions, right? Unfortunately, there is no single test or series of questions that can ensure an accurate assessment. In large part that is because many people tend to be less than honest with themselves when it comes to evaluating their own behavior. Getting the most accurate answers often means asking questions in a variety of ways, so don't be surprised if it seems like the questions are repetitive. The objective is to get as clear a psychological picture as possible in an effort to determine whether the adjustable gastric band program is likely to yield the best results for you.
What We Look for in Psychological Testing of AGB Patients
Steven Greer, Ph.D.
When I was brought in initially to run psychological testing on potential band patients for Dr. Sewell, our only source for information was Scandinavian healthcare data. One thing we didn't take into account is how different those systems are. There's no one in Scandinavia who isn't eligible for coverage, although people may have an extremely long wait for care. As a consequence, the Scandinavians used their experience to predict who would fail with the band.
We were warned about certain problems to watch out for, such as severe mental illness, major depression, compulsive people, drug or alcohol dependency, and less self-directed persons. Oddly enough, they said nothing about eating disorders.
So we got a "cannon" of a testing instrument, the MMPI-2, a test that takes on the average an hour and a half to complete, in order to screen for a wide array of psychological problems. We wanted to be very careful about screening.
What we didn't take into account was that in Scandinavia, people aren't paying for any part of their band treatment, so the doctors get absolutely anyone and everyone. We, on the other hand, had to charge several hundred dollars for the testing, which is usually not covered by insurance. What we found is that we didn't see the types of psychological disorders the Scandinavians were describing.
We were given numbers that one out of six people would fail our psychological screening. But what we found was that only 3 percent of the first 100 people we tested ended up having any of the problems we were screening for. People who are seriously depressed or addicted knew it, and they weren't about to pay several hundred dollars to be tested just to be turned down. So, inadvertently, we developed our own screening.
A full 50 percent of the patients coming in to be tested didn't have insurance that covered bariatric surgery. And what we know from other research on self-pay medical patients is that people who pay a significant amount for any kind of medical procedure tend to do better than people who pay nothing. The literature suggests that people are more motivated and more involved when they have a significant financial investment. That's what we were seeing consistently: highly motivated, sophisticated people.
We also know that people who have a religious or spiritual faith, who feel they have an internal source of strength and health, do better in any health category, from cancer to dealing with death. And that also came out in the testing.
The bottom line was that we were seeing hardly any of the things we were warned about. And it came out that some of the things, such as major depression, weren't as much of an issue with the band as we'd been told. Later research in Australia among people who were given a band even though they suffered from major depression, showed they did fine. The depressed people lagged behind others a little in their weight loss, but they didn't show up significantly different than people who weren't depressed.
We were still concerned. One of our biggest concerns was alcoholism and eating disorders, both of which we identified as big league problems for potential patients because those issues put the band at risk. Damage to the esophagus can be a result of either of those addictive disorders, but is especially likely with an eating disorder. With the band, we want people to avoid vomiting because that can throw the band out of place and create problems such as band slippage and erosion, most of which have to be corrected surgically by either repositioning or removing the band.
After the first couple of years, we realized that we didn't need such a comprehensive psychological test. So we switched to tests that take 15 to 20 minutes to complete, including how patients manage their health and a very basic profile of distress.
What we found is that the vast majority of patients who had a weight problem serious enough for them to consider band surgery fell into two categories. One group had a high degree of sociability and gregariousness. They are outgoing and engaging. Since a lot of socializing is done around food, that made sense. These people generally feel confident, some were a little overconfident, and most were independent. The combination of sociability and overconfidence tends to lend itself toward being overweight. These people tend to over-ride their own internal controls because they feel they can take life by the horns and fix things later. They're the kinds of people who will overeat now, thinking they'll eat less either later in the day or maybe on another day.
The second group were very rule-governed, responsible people who want to do all the right things. These people tend to hide their emotions from themselves and from others, are overcontrolled, and sacrifice their own personal interests for those around them. We often refer to these folks as "pleasers." Of this group, the majority were women by nearly three to one. This kind of personality makes for a lot of quiet, "subterranean" needs that food is a handy way to satisfy.
So the majority of what we see in our psychological testing is two personality groups: one group is self-indulgent, the kind of people who think they'll fix it later. And the other has unmet needs and uses food as a substitute for basic gratification that is missing.
We have certainly seen some minor depression, discouragement, demoralization, and restriction of activity caused by the limitations overweight people have. We've often heard complaints to go with these symptoms, such as they couldn't climb three flights of stairs, couldn't play with their kids or grandkids, and couldn't fit very well into an airplane seat. But we almost never saw severe psychotic issues.
What we have found is that attention deficit hyperactivity disorder (ADHD) is a problem for someone who has a band. ADHD is an impulse control problem, and untreated it can potentially lead to problems adjusting to the band.
Bulimia is another issue that we were concerned about. Bulimia is almost always accompanied by a history of sexual abuse, and statistically one out of every eight women has experienced significant, recurrent sexual abuse. If someone is bingeing and purging a couple of times a week and trying to hide it from others, or if they have ADHD, those difficulties need to be dealt with before they actually get a band.
Another thing we looked for is noncompliant personality types, who are very independent and very autonomous. Those are characteristics that tend to lead to overeating to begin with, but these people can also be medically noncompliant, meaning that they have a tendency to be unwilling to submit themselves to medical authority or follow a program. Self-indulgent people tend to give themselves permission not to follow the guidelines put in place by a medical authority, such as their doctor. So we hope to identify these tendencies so that we can provide extra support. These types tend to hit a bump in the road and not make progress for several months to a year. When that happens, the medical staff can find it very frustrating if they're not prepared to handle someone in this position.
So what we have found in psychological testing of potential band patients is different from what we were warned about by Scandinavian data, perhaps because our healthcare system is different. What we now look for are issues that relate to either poor impulse control, such as ADHD, or addictions, such as alcoholism or bulimia. And when we find evidence of these conditions, which hasn't been often, we encourage the patient to seek treatment for those issues before attempting band surgery.
Checklist: Problem Areas We Look for in Psychological Testing with Potential Band Patients.
✓ Untreated ADHD
✓ Alcoholism
✓ Bulimia
✓ Severe emotional disturbance.
Checklist: Psychological Factors that Are Helpful in Living with a Band.
✓ Some significant financial commitment toward the band procedure. Research shows that patients having a degree of financial responsibility do better in any medical procedure, and the band is no exception.
✓ Religious or spiritual faith. Again, research shows that people who hold these beliefs tend to do better in terms of their health, especially when facing challenging medical situations.
✓ Medical compliance. People who are committed to following their doctor's advice and the band program do better.
The Dietitian's Assessment
Weight loss is the clear objective, but it is equally important that each patient maintain adequate nutrition as they lose. Most of us give little thought to the actual nutritional value of the foods we eat, and even if we do think about nutrition, we are often misinformed as to what our requirements are and which foods are best. Perhaps the most important assessment prior to surgery is the one you will have with a licensed and registered dietitian. It will involve an extensive dietary history, including not only what you eat but also when, where, and why. This information provides important insight as to which eating behaviors have been most responsible for the development of obesity in the first place.
The discussion with the dietitian may be somewhat uncomfortable for some patients. The probing questions asked may make you feel a sense of guilt, or even shame. While admitting certain eating habits to someone may be painful, it is a necessary part of the process of developing new habits. Say, for example, you make a habit of eating a whole box of cookies or a large bag of potato chips at one sitting. You know that habit has contributed to your weight problem, and you have vowed many times to stop. But now, when you are asked specific questions, you are embarrassed to admit it, so you simply withhold the information. After all, you know what to do, and you don't need somebody preaching to you about it, right? Well, don't you think if you really could change your behavior by yourself you would have done it already? The dietitian is trained to help you but will be unable to assist you change your behavior without full information.
During your evaluation by the dietitian, you may be tempted to demonstrate just how good you are at counting calories or how much you know about the basic food groups. A few patients have suggested that they know all about nutrition and don't really see the point of meeting with a dietitian. While your knowledge of nutrition may be considerable, each of us tends to be extraordinarily poor at evaluating our own behavior when it comes to food. So before you blow off this evaluation, recognize this as your opportunity to begin actually getting the help you need to change the food choices and eating habits that helped create and perpetuate your obesity. Just as with the psychological evaluation, you need to make every effort to answer the dietitian's questions as honestly as you can. To do any less is only cheating yourself.
After the dietitian has taken your dietary history, he or she will give you a thorough explanation of what and how you can expect to eat after the band is placed. This is an extremely important part of the dietitian's role. You can expect to eat more slowly, take smaller bites, chew your food thoroughly, and avoid drinking liquids during your meals. We have devoted an entire chapter to the subject, but suffice it to say that your success with the AGB program depends on your willingness to make a major commitment to modify your eating behavior.
Grace Ann's Story
I always thought my weight was about the bad habits I was taught as a child. I never could understand why my eating something would keep a baby from starving in another country. But my grandmother said it would. So I ate everything put in front of me. However, when I had my daughter, she totally blew my idea. I thought I could make her thin by never telling her to clean her plate. But it didn't work. My daughter as an adult is 300 pounds. There is no doubt in my mind that this weight problem is at least in part genetic.
My heart surgeon told me that I needed to lose weight. My top weight was 292 at 5-foot, 3/4-inch tall, and that was after my open heart surgery. At that weight, I was miserable. I couldn't move, my legs were so sore from swelling, and I felt like everything was too tight and cutting off my circulation. But really, it was my skin, stretched to the limit, that was cutting off my circulation. It was ugly. It was difficult.
Recently my husband and I joined Weight Watchers and paid our money. Then we had a death in the family and a bunch of other stuff going on. At the end of the Weight Watchers time we'd signed up for, we had each gained 6 pounds.
I ultimately decided I had to do something different. I've been banded for only three months now, and I've lost only 10 pounds. But already, I wouldn't go back. I thought I'd lose faster, but this is so much easier than dieting. With other weight-loss programs, I'd get so sick of what I was eating and I'd ask myself, "Am I supposed to do this all the time?" The biggest thing for me about the band is just knowing I can eat like this for the rest of my life. For example, I've had one hamburger in the last six weeks, something prohibited on other diets. I didn't eat all of it, but I probably could have. Now with food left over on my plate from a meal out, I can either give it away or save it for another meal, and that's okay. Before, if I went out to eat and brought food home, I just brought it home for showI ate it as soon as I got home.
Another change is that I'm exercising and I have a personal trainer. I never felt like doing that before.
I live several hours from my surgeon, so I found a fill doctor only an hour away. My surgeon's office said they'd work with the fill doctor, but there was a misunderstanding about the type of band I had. I've gotten three fills but didn't feel as much restriction as I'd like. Turns out I had a bigger band than the fill doctor knew about. Also, my surgeon turned my post-op care over to another doctor who billed me extra for visiting me in the hospital. Since I'm a self-pay patient, I felt like these issues around my fills and the second doctor cost me additional money that wasn't necessary.
I do love the band. It is always there. I don't fall off the wagon and stay off like I did with diets. If I continue at this rate, I'll have all the weight I want off in a couple of years. But another problem I have encountered is there is not a band support group where I live, and, as I mentioned, my surgeon is several hours away by car. So I'm looking for other band people who can help me.
The Exercise Physiologist's Assessment
Increasing the level of physical activity is vital to success with any weight-loss program. This is particularly true with the AGB. However, it is obvious that getting regular exercise when you are significantly overweight can be a challenge, not only physically but also psychologically.
Virtually every patient we see has been on some type of exercise program in the past. Many have had personal trainers and have joined a local fitness center, often more than one. They have been told repeatedly that if they would just exercise regularly they will eventually lose weight. Personal trainers tend to be exercise fanatics, and many have a difficult time relating to the problems of someone who is morbidly obese. Not surprisingly they promote, and are usually excited to get you started on, the exercise routines that have worked for them. But, despite all the encouragement in the world, the absence of significant weight loss after hours of toiling away on some machine can often have a profoundly negative psychological impact. Many people just give up. It is simply too hard.
There is another group of fitness gurus that are involved in aggressive mass marketing of various products or exercise regimens that are "easy to do." "You too can have the body you've always wanted in as little as 10 minutes a day." Does it sound too good to be true? Obviously, they want you to buy their product. The professional models seem to move through the exercise effortlessly, and they don't even break a sweat. It's interesting that you never see advertisements for any exercise products showing a morbidly obese person actually using the device. In fact, in some cases the equipment may actually have a weight limit that prohibits its use if you weigh more than a certain amount.
As soon as the subject of exercise is brought up, many patients are quick to point out that they just can't do it. Obviously, morbid obesity often severely impairs an individual's physical capabilities. That is especially true with chronic back, hip, knee, ankle, or foot pain. This is why it is so important to work with someone who is experienced in recognizing these various restrictions, and who can develop specific physical activities that will increase metabolism and help burn off fat without aggravating underlying conditions. An exercise physiologist is trained to identify those ailments that restrict physical movement, and can develop an exercise program that you can actually do. Even patients with severe physical limitations that confine them to a wheelchair can be taught exercises they can readily do.
While weight in pounds is the most recognized measurement of obesity, it often does not reflect your true physical situation. Part of the preoperative assessment by an exercise physiologist is to obtain other specific measurements and perform an evaluation of your relative ability to participate in regular exercise. By obtaining a more comprehensive set of body measurements and assessing your exercise tolerance, the exercise physiologist will develop a more complete picture of how obesity is affecting your health. This initial data also provides an important baseline, and the same measurements will be repeated over the coming months and years to measure your success beyond just pounds lost. Many of my patients have gained significant encouragement from the inches they've lost, especially if they've hit a plateau regarding their weight. This initial assessment is part of your preparation for success and encouragement later.
Interacting with the exercise physiologist prior to surgery is also very important from a psychological standpoint. As has been repeatedly stated, some type of regular exercise is vital to your success, and virtually everyone will agree to exercise more provided they can have the AGB surgery. Unfortunately, these commitments are often rather vague and are quickly forgotten. What is required is a defined plan that outlines precisely what your exercise program is going to entail. Then you need to commit to it. This involves still another specific behavior modification, and is one of many lifestyle modifications, all of which involve also changing your thought process.
What about Obesity Surgery for Teens?
In the last few years the subject of bariatric surgery in morbidly obese children and adolescents has been discussed extensively in the media as well as within the medical and surgical community. The problem of childhood obesity is growing at an alarming rate, and all forecasts suggest that the situation is getting worse by the day. The anticipated health costs for dealing with obese kids as they become obese adults is staggering. Likewise, the psychological and social impact of childhood obesity has become a major issue among child psychologists. The obvious question is, Should we treat teenage obesity the same way we treat adult obesity, with surgery? Well, the jury is still out, but more and more pediatric surgeons are at least looking at this option.
When considering treating adolescent obesity with an operation, there are several questions that must be asked. These are the following: Are we sure the child is going to remain obese through and beyond puberty? Are we sure the child is mature enough to understand the ramifications of bariatric surgery and the restrictions it imposes? Is the child capable of dealing emotionally and socially with what may be a newfound "celebrity status" among their peers? And what procedure is appropriate for a person who is still developing physically?
Checklist: Questions to Ask before Surgically Treating Adolescent Obesity
✓ Are we sure the child is going to remain obese through and beyond puberty?
✓ Are we sure the child is mature enough to understand the ramifications of bariatric surgery and the restrictions it imposes?
✓ Is the child capable of dealing emotionally and socially with what may be a newfound "celebrity status" among their peers?
✓ What procedure is appropriate for a person who is still developing physically?
There seems to be little doubt that if a person is obese as a child they are very likely to be obese as an adult. Many of my patients relate that they actually began gaining weight in their preteen years and have struggled with obesity their entire life. Certainly, a case can be made for intervening early in this process, before major medical problems, such as high blood pressure and diabetes, become well established. However, it is hard to know when and if these problems will actually develop, when surgical intervention is warranted, and when it isn't. After all, we aren't dealing with a long medical history, since by definition these are children we are talking about.
Another argument that is frequently made suggests that teens who are morbidly obese suffer from impaired social development, so obviously they should benefit from bariatric surgery as a psychosocial development tool. Unfortunately, most children under the age of 18 have limited insight into their psychosocial situation and are generally most comfortable maintaining the status quo. They are often quite uncomfortable drawing undue attention to themselves, especially if it involves their appearance. Assessing the child's motivations and likely response to a major change in body image is perhaps the most critical part of any adolescent bariatric program. One program I'm familiar with requires one full year of psychological assessment and counseling before any child is considered a candidate for surgery. It is also extremely important to identify the motivations and the role of the parents in this process. The decision to explore weight management through surgery must be shared by both child and parents if there is any hope for success.
We all know how important "image" is, especially to a child around the age of puberty. Assuming that a high school student who is recognized by their peers as the "big man" or "big girl" on campus suddenly begins to lose a large amount of weight, they will undoubtedly become the subject of considerable interest, some positive and some negative. This unusual level of attention can potentially cause a number of problems. They may achieve sudden "star" status, or sudden "freak" status. Either way can lead to a variety of behavioral changes, including juvenile delinquency, poor performance in school, and even drug use. Children who undergo bariatric surgery must be followed very closely by an experienced child psychologist or psychiatrist to help identify such behaviors before they become a serious problem. These kids should also be compelled to be involved in a support group of their peers as well as a supervised exercise program.
If a well-adjusted, emotionally stable, morbidly obese child and their parents make the decision to have weight-loss surgery, it only makes sense to employ the lowest risk procedure possible, and preferably one that is reversible. It is certainly possible that within the next few decades one or more medical treatments will come along in the form of a new diet pill or a genetic re-engineering process that may make bariatric surgery obsolete. Should that occur, it might be advantageous to reverse whatever weight-loss procedure a young man or woman may have had performed when they were an adolescent.
The entire subject of bariatric surgery in children remains very controversial, but it is one that will continue to spark considerable debate in the years to come. At this time, if any parent is considering bariatric surgery for their child, they should first seek the advice of their pediatrician. It is also important to recognize that there are only a handful of centers capable of providing all the special testing and care required to be successful. Remember, children have special needs. They are not just small adults.
Conclusion
Assuming you are a candidate for the AGB, your overall success will depend on many factors, beyond the operation itself. The complexity of obesity as a disease requires more than just an operation. In the next chapter, we'll look into why you need a comprehensive approach to treat your obesity and what you should be looking for in the way of a program.