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Questioning Need for Surgery

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Dr. Callery,

I know this issue is mentioned a lot, but I have a concern regarding surgery.  Namely, the need for it.  When I started this journey, I initially went into a visit with my PCP (first time with new doctor).  The doctor, personality wise, was excellent and meets my needs.  He's honest, he can be a coach instead of a guide (advised he would absolutely hold me responsible for things that I say I'll do), and he was very even tempered and didn't brow-beat me to death (this has been my usual experience).  I told him that I was interested in quitting smoking, losing weight and that I had started down this path with my old PCP but could no longer go to him due to a switch in insurance.  My last PCP had assisted me with severe sleep apnea and working together I was able to get treated and now have a BiPAP that I use religiously.

So, to cut to the chase, Doctor prescribed Welbutrin XL for the smoking.  Gave me some basic instructions and voila, I've been smoke free for going on two months.  The Welbutrin plus knowing I couldn't continue my journey really got me in gear and helped me get through the rough days where I craved constantly.  Now I barely crave them. 

However, when I had mentioned interest in anorexants (sp?) to my doctor, he seemed to dismiss them.  I told my doctor that I seldom feel full, that I mindlessly eat, and that I sabotage eat (you ate two slices of pizza, might as well eat two more, etc.)  Either way, I thought that I would like to try medically resolving the issue and, worse case scenario, if I wasn't able to lose, then I could at least say that I've exhausted all options prior to having surgery.  My doctor AND my surgeon both advised that because of my BMI being 50 at the time and because of my comorbidity (sleep apnea) that I should skip the medicine and go straight to surgery.

I know I'm second guessing Doctors who have years of instruction and experience, but this seems a bit forced to me.  Especially with asking about anorexants point blank to both my PCP and my Surgeon.  I understand that documented losses are minimal, and that long term losses are smaller still.  However, I've been able to lose weight before, and I feel like I'm motivated this time to make a permanent life change.  If I can get the weight off this time, I won't allow myself to fall into old habits.  I'm more educated and focused about things now, especially knowing that I quit smoking.  Quitting smoking has really helped my confidence; it was something I never thought I'd do.

To add some tertiary information, I've stopped drinking all soda, I've followed the 'Portioned Plate' advice from my nutritionist.  I've been creating weekly menus for the entire day, and holding fast to them, keeping myself accountable.  I've been eating lean protein, non-starchy vegetables and healthy whole wheat grains (when necessary), taking my vitamins and loading up on water.  I've went from zero exercise in a sedentary office environment to standing while I work, and walking on my lunches and breaks (at least 2.5 miles/day). My weight is falling off of me and I can already tell a difference in my body.  HOWEVER, I still have those afternoon/pre-dinner cravings where I know I'm not really hungry yet, and if I eat now I'm just going to ruin my appetite for dinner.  THIS SPECIFIC TIME is when I wish I insisted that I had an anorexant.  If I had that, and hadn't snacked before dinner unnecessarily, how much extra could I have lost? 

Sorry for this monolith of text, but I wanted to be thorough.  I like my PCP very much and feel he wouldn't lead me astray, I like my surgeon and my nutritionist.  I just feel like if I go along with this surgery and I don't at least try the anorexants, that I'm going to wonder the rest of my life.  Curiosity killing the cat, here? 

Of note, I am not diagnosed with hypertension but I was notified that I have elevated blood pressure (probably should have mentioned this earlier but I seriously just remembered...).  I think this was one of the reasons my PCP gave pause.  I know that my blood pressure will be under control at my next visit.  I've lost weight and quit smoking, and I had chain smoked before I went in to see my PCP, and I had severe reservations about going to the doctor (I have an irrational fear of Doctors, nothing personal).  I'm feeling great!  Loving the exercise!  My blood pressure is 'normal' enough for me to give platelets again (something I couldn't do because of BP before). If that is the case and my blood pressure is stable and normal, should I push the issue with the medicine route or should I give up on suggesting it and continue with the surgery?  I know surgery will alter my set-point and I'm honestly EXCITED about the surgery and the tool of a smaller stomach. I'd just hate to jump straight to 'the end' for expedience and risk skipping a crucial chapter.

Thanks for you time and consideration and if you need to bill me for an hour, I understand.  :)

Highest Weight: ~360
Beginning Weight: 355
Current Weight: 338

Edited by Obsidian

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Dear Obsidian,

1. You should only go to surgery if and when you are ready. No one should push you into it. And you shouldn't push yourself. There certainly are risks to surgery as well as benefits, and there are heavy patients who clean up their diet, exercise regularly, and lead very satisfying lives. They have the latitude to eat and celebrate as they wish. They may shorten their life expectancy and incur accelerated health problems, but it's a trade off. They have more freedom and no short term or long term surgical risks or side effects.

2. Oral anti-appetite drugs help people lose 5 - 10 % of their body weight over the short run. They are costly (up to $200 per month). They do not have proven long term (5-year) efficacy. Perhaps they can be used to help sustain weight loss if a patient who has lost weight goes through an emotional rough patch. They may help a person jump start or augment weight loss.

3. There are 3 brands of gastric balloons available that help provide similar short term weight loss. They may help patients lose up to 20% of their weight. They are expensive ($8-10,000)and cary some risk and discomfort. When the balloons are removed, eventual weight regain seems almost inevitable. 

4. 90-95% of patients who lose weight by calorie restriction regain it. However some do keep it off. Perhaps through real dedication you can be one who does.

So, if  you have really cleaned up your diet, your activity, your sleep, and your stress levels, you might try an oral agent as an adjunct to weight loss. Know that you can't take the drugs forever, and that at some point you're going to have to stop and keep a very close eye on the scale. Only when your are truly satisfied that you have made a maximum effort and believe that the long term benefits outweigh the risks of surgery should you move forward.

Disclaimer: These points reflect fairly well informed personal opinion. Other physicians or surgeons will have a spectrum of thoughts on the matter.

Dr. Callery


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