QOTW=Cognitive Behavioral Therapy for Weight Issues; Study on Sleeve shows it comparable to RNY

Well, first off, my research and topic exploration of the week for me is the use and role of Cognitive Behavioral Therapy to assist in changing behavior around eating and exercise to help in achieving a normal weight.  I’m very familiar with the concepts of Cognitive Behavioral Therapy, due to some of my past projects at a past employer.  I have the intellectual concepts down pretty cold.  However, I have a hard time putting it into practice.  I’ll be looking at this week how therapists might be working with wls patients using cognitive behavioral therapy to learn new ways to respond to the typical negative tapes and stressors that come up in our lives, and seeing if there are any cool tools for CBT for weight loss out there.  To the crickets out there reading this, if you have great suggestions for resources, I’m all ears and will include your suggestions in my summary post at the end of the week.

For now, if you want to play along at home….*

Think of a typical situation that might make you feel bad about your weight loss efforts.  Take a moment to write out that situation right now. What happened to make you feel badly? What was your reaction?  What did you do?  How did it affect your weight loss progress?

Now, ask yourself whether your thoughts about the situation were completely true and accurate.  how else might you think about/frame what happened?

Finally, rescript the situation.  What could you have told yourself that would have been more supportive and accurate, when the bad situation occurred?  Try it now, how does this new response make you feel about your weight loss progress?

Ok, now a quick poll regarding head hunger and how you approach it.

Okay, topic #2.  I am very interested in this study that WLSHelp has on their site about a 3 year study comparing vertical sleeve gastrectomy with roux-n-y bypass.  I have been flopping back and forth on which procedure to choose, and have been lacking the evidence-based data my mind desires to spell out some of the outcomes.  What is still missing is long term outcomes.  As in, does something creepy happen 10 years out to sleeve patients that no one expected? How long have sleeves been done in other countries, and what are the outcomes there?  This is the knowledge my brain seeks.  Ultimately, I think I would like the sleeve first, in the hopes that I can reprogram myself in portion size and feelings about eating effectively, but still occasionally be able to have a tiny portion of something without worrying about dumping.  I know many feel dumping is overrated, but I think about the little things, being able to have a little tiny piece of cake at a birthday party.  I know its a slippery slope though, so that is where I wrestle.  Do i need the RNY to keep me honest?  Surgeon said I could always revise to RNY later, but I’d just as soon only have to do this once.  And I would like my life after the initial weight loss to have the opportunity to be normal relative to other normal people.  I also think the appeal of losing all the grehlin production is awesome to me. if it would long term eliminate hunger signals, how awesome is that?

* I am not a doctor nor do I play one on twitter.  Check with your therapist for the best interpretation of CBT.

Surgery Consult and Next Steps

Boy, the consult was quick.  You kind of think about such a momentous decision maybe deserving a few more moments.  They took me in, took my weight which in the office was 270.1. Certainly a lot lower than it would have been if I had had an appt a couple of weeks ago, but still clocks me in with a rounded up BMI of 42, according to them. 

Met Dr. Doe, and he asked me some questions about my typical eating behaviors, and then he started talking about the pros and cons of my two favored options — Sleeve Gastrectomy and Gastric Bypass (RnY).  Reinforced much of what I’ve already learned about the two options. The points of note:

• Sleeve gastrectromy is showing a similar initial weight loss trend as bypass in his practice, but doesn’t have long term results.
• With sleeve, he says that typically patients on the lower end of the MO scale lose weight faster than patients with higher BMIs.  he didn’t say why.
• While gastric bypass patients show an amazing reduction in appetite initially, it starts to climb back up as the stomach figures out how to restart grehlin production, however, malabsorption keeps intake in check somewhat.
• In sleeve, because the stomach is mostly gone, while appetite suppression is not as marked initially, it stays consistent forever, because the stomach is gone and can’t produce grehlin anymore.  My question that I need to look up — is leptin produced in the stomach, too, and how is that impacted?
• Sleeve doesn’t have the negative consequences of dumping and malabsorption, which is both good and bad.   Sleeve allows you to eat more like a normal person, just less of it, so it is easier to cheat, ultimately, but might be easier to manage in a normal busy lifestyle. 
• Gastric bypass patients often do experience dumping, and dumping causes a definite negative consequence to keep you on the right path of staying away from sugars and fats. Gastric bypass, for some reason because of the bypass of part of the intestines, seems to have better outcomes for people with fairly entrenched diabetes. In my case, my diabetes is quite early in stages so sleeve would probably be just as reasonable.

My impression of Dr. Doe.  Nice enough, intelligent enough. Didn’t get any warm fuzzies, for sure.  He whipped through quickly with his pitch and questions and got up and started walking out to ask the admin staff about whether my insurance covers sleeve (which we learned it does) and kind of threw back over his shoulder if I had any questions.  not the ideal way to cover my questions.  Boo.  But I did ask him about his experience and mortality.  The website didn’t reference his experience.  He has done over 700 gastric bypass surgeries, 40 sleeves and about 60 bands.  What is typical? 

With the admin staff I covered next steps, and I have my first medical diet supervision appt next monday already, which is great.  We talked about my ideal timing, which would be somewhere around the 21st of December.  I know that sounds crazy, given holidays, but between forced vacation between christmas and new years, I can get a straight two weeks off and then some with minimal additional time off and need to discuss at work.  She said that my insurance is quite quick about processing the approvals, and that after my last diet supervision appt is complete around November 14th, they can submit.  She said Dr. Doe is scheduling about 3 weeks out, so its cutting it, and depending on his holiday schedule, maybe not, but there is a chance I could have it done in the timeframe I am hoping for.  Crossing fingers!

Weight Loss Surgery Consult is tomorrow!

I am excited and curious — tomorrow is my first consult with Dr. Doe*.

 I didn’t know really, who to pick from the group.  There are three doctors in the Bariatric Center of Excellence I will be working with.  Dr. Smith is the big shot, who has the most surgeries under his belt and a great reputation.  Dr. Doolittle is who did the seminar I attended in August 2011.  He has a reputation of meticulous and a good surgeon, but I didn’t click with him at all. 

Dr. Doe is the one with the least experience, but still lots of surgeries under his belt. So why, you ask, did I pick him out of the three?  Well, in talking with the nurse/patient advocate,  she said I could switch at any time with no worries, happens all the time.  Based on what I’ve heard about  Dr. Smith, he is likely to be a great personality fit for me, but he is so backloggeddue to his popularity that I could be waiting an exceedingly long time to get in with him.  Dr. Doolittle, I have a feeling I would continue to not appreciate his fairly paternalistic approach to medicine, given my background and education, it will rub me the wrong way.  So, I’m going to start with Dr. Doe, he still has a lot of surgeries under his belt, he’s practicing in a COE, so there are standards he has to meet, etc, and I think he may be slightly more compatible in terms of attitude.  If he isn’t a match, I’ll flip over to one of the other two, but I’ll already have the initial consult under my belt so hopefully it won’t be too much of a hassle. 

I’ve spent the weeks since the seminar thinking a lot about weight loss surgery, and trying to learn as much as I can.  Using my obsessive nature to my benefit, I’ve been able to consume an ungodly amount of information about the procedures, what to expect and how to succeed in a few weeks.  (The one benefit of a mildly obsessive/compulsive personality…LOL) 

Which procedure am I leaning toward?  For years when thinking about this, I always thought Lap-Band would be the way to go, but looking at the actual stats of the procedure, I’m not so sure about that now.  In Lap band, as I think most people know, they stick a ring around the top part of your stomach, creating a little tiny restricted stomach that you feel fuller faster with because they fill up the ring to manage the restriction of the stomach.  Its a restrictive procedure that is reversible, and requires regular checks and fills to be sure the band is restricted the appropriate level.  It is the cheapest procedure and certainly the one that gets the most press. 

The statistics regarding averages for Excess Weight Loss (EWL) with Lap-band are not nearly as good as the other procedures.  A lot of variation in what is reported and by whom, but all agree it has a lower and slower weight loss rate, averaging generally somewhere between 30-50% excess weight lost, and that the variations in individual experience are wide, so the ranges go pretty solidly from 20% to 80%.  So if you have 100 lbs to lose, the chances that you could be a person who only loses 20-30 lbs from the procedure are fairly decent, and that seems like a big surgery to have for potentially crappy results.  I was also surprised by the foods that were on the ‘never’ list, even after surgery recovery, for lap-band, such as breads, pastas, rice, popcorn, pizza, etc.  I know my diet is going to change, and that if i go RnY, I will have dumping to content with on high sugar/high fat foods, and if I go lapband, I’ll have significant restrictions because of fears of blockage.  So I know I’ll have something crappy to accept long term either way.  With lap band, since they aren’t rearranging intestines, food absorption is normal, and you don’t end up with things like dumping syndrome or worries about leaks.

Gastric sleeve is quite interesting.  They have not been doing it as long, but it has been having really promising results, similar in excess weight loss to gastric bypass. In this procedure they take off most of your stomach, leaving you a smaller stomach about the size of a banana.  Its still a restrictive procedure, as they don’t rearrange your guts, so there is no adjustment to absorption.   They are seeing really good results with it, but they don’t  have a long track record with it to know if the results will hold as well long term.  It appeals to me because it doesn’t mess with absorption, so seems more forgiving, but still has the benefits of reduced grehlin production, because so much of the stomach is removed.  Of course, that is a key fact, because they actually REMOVE the stomach, it is not a reversible procedure.  So once it is done, it is done.  I have a friend in an online mom’s group that had this procedure done recently, and I am hoping to talk to her soon about her satisfaction with the procedure.  I have heard that not all insurance plans cover it, however, so not sure if its even an option for me.  If it IS covered for me, I think its a contender, depending on what I hear from the doctor tomorrow.

Ultimately, barring confirmation that my insurance will cover sleeve,  it seems I’m leaning towards gastric bypass (RNY).  In this procedure they make a new tiny stomach at the top of your stomach called a pouch, and staple off the rest and the old stomach just kinda hangs out.  Then they reroute your intestines to bypass part of them so that you can absorb less from your foods.  Its the procedure that has the longest track record and stats. And unlike lap band which seems to have a decent average of EWL, I guess, the average amount of EWL is higher with gastric bypass typically 50-75% EWL, and the results plot more like a bellcurve than a scatter chart, which most people seeming to see about 60% EWL.  So that means if a person has 100 lbs to lose, you are quite likely to lose 60 lbs and so so many people do much better if they follow the guidelines for eating.  Dumping syndrome really scares me, but it might be just the tool I need to break my addiction to high sugar and high fat foods. 

My favorite resources so far are:

Renewed Reflections

Weight Loss Surgery for Dummies book

 * I will not be referring to my doctors by their real names in order to be able to talk freely.