Do I really need surgery

In order to fully examine the question of whether or not Bariatric Surgery is necessary for you to achieve your weight loss and health goals, we must rephrase the question.  The actual question that you should ask yourself is: Can I lower my set point by modifying my diet and increasing my exercise, or is Bariatric Surgery the only treatment that will work?  When we examine this question, we are able to abandon the unhelpful, self esteem depleting view of surgery as “the easy way out,” or “cheating.”  Most patients have convinced themselves that if they could just improve their willpower, they would meet with success.  In my mind, the willpower argument is a useless one that only results in shame, guilt and depression.  Willpower is rarely the missing ingredient in achieving success.  What is missing is an accurate understanding of obesity and how the surgery works.  Once we develop an understanding of our metabolic thermostat and the role of surgery, nutrition and exercise in adjusting our thermostat, we are able to make sensible decisions about our options for weight loss that are based on physiology and devoid of useless, self defeating, emotional condemnations.

In my practice, I offer assistance to all patients who suffer from obesity, not just those who have chosen to undergo bariatric surgery.  For this reason, I see patients at all points in the decision making process, from those who have no interest in having surgery all the way to those who are eager to schedule their surgery as soon as possible.  Often times, I find that my assessment of whether or not a patient truly needs bariatric surgery in order to lose weight differs from their own opinions and I will work with these patients for several months before we come to a joint decision.  Often times, I find that I’m able to show the eager surgical patient that by implementing my Pound of Cure nutritional program, they can meet their weight loss and health goals without surgery.  Just as often, I work with patients who are not interested in surgery initially, but after months of good compliance with the Pound of Cure program recognize that their set point is tightly fixed and their weight loss and health goals can only be achieved through surgery.  Again, Bariatric Surgery should be used for the patient who is unable to lose weight despite making significant nutritional changes, not the patient who is unable to make these changes in the first place.

Every patient is different and there are no hard and fast rules that allow me to determine whether surgery is necessary at their first appointment.  Instead, I find that after 3-6 months of working together, we are usually able to come to the same conclusion about whether or not we should move forward with surgery.  Despite our extremely low complication rate and high success rate with surgery, it’s important to recognize that meeting  your goals without a trip to the operating room is the best possible outcome.  Just as importantly, it’s critical that we recognize that not everyone is capable of achieving weight loss through nutritional modification and exercise alone.  Just like all other medical treatments, dieting does not trigger long term, sustained weight loss in every patient.  I have worked with hundreds of patients who are only able to lose a few pounds despite making significant improvements in their diet.

Most people have been convinced by the media, their physicians and their skinny friends that if they just managed to get their eating under control, their weight problem would disappear.  Unfortunately, for a large group of people, the physiology of our metabolic thermostat makes sustained, permanent weight loss through dieting alone impossible.  The cumulative effects of their genetics, past life experiences and current health all conspire to maintain a tightly fixed set point that will not respond to changes in their diet or increases in their level of exercise.

In order to determine whether or not a patient truly needs surgery, I ease my patients into our Pound of Cure nutritional program over a period of a few months and look for two results.  First, I want to see if you lose weight easily and steadily, month to month.  I look for a minimum weight loss of 2% of your total body weight each month, however 3-4% per month is ideal.  I also like to see the patient move steadily past the 10% total body weight loss mark without slowing down.  If you are not moving your set point and only losing weight because of decreased calorie consumption, you will typically plateau after losing 10% of your total body weight.  Younger people can lose more while older individuals often plateau after even less total weight loss.  But for the majority of us, weight loss stops very close to the 10% mark.  It is at this point that your hunger increases and your metabolism slows down to the point where further weight loss becomes nearly impossible.  When I see patients losing beyond the 10% mark and not reporting significant hunger or food cravings on the Pound of Cure program, I look at this as the result of a lowering set point, making me question the necessity of surgery to achieve the same goal.  

The second factor that I look for in patients who I believe will be able to succeed without surgery is that they enjoy following our Pound of Cure program that is rich in fruits, vegetables, nuts, seeds and beans and find it easy to fit this new way of eating into their lifestyle.  Long term weight loss success requires long term dietary change and if you are miserable on the Pound of Cure diet, then the chances that you will continue to adhere to it for the rest of your life are exceedingly small.  The patients who are likely to avoid the need for surgery are those who enjoy eating large portions of fruits and vegetables.  I also use your ability to comply with the Pound of Cure program when I discuss procedure choice with patients, but we’ll leave the details of this discussion for later.

As important as your enjoyment of your new, healthier diet is the absence of hunger.  When you switch from a diet of largely processed foods as most Americans eat to one that primarily consists of plants, your total, daily calorie consumption usually decreases (but not always).  If you find that your cravings for processed foods do not decrease after a few months on the program and you are constantly hungry, then it is likely that we’re not seeing weight loss from your set point movement.  We are likely seeing the same type of weight loss you experience on a reduced calorie diet that focuses on low calorie packaged foods or protein shakes.  Your set point remains fixed despite your increased consumption of set point lowering foods. so each pound that you lose triggers an increase in your hunger.  Your hunger and happiness are very tightly linked as most hungry patients do not enjoy being hungry while those who are losing weight without experiencing increased hunger are typically a very happy crowd.

While a trial of our Pound of Cure program is my ultimate litmus test to determine whether or not a patient truly requires bariatric surgery to meet with success, there are several other factors that I take into consideration when I counsel patients.

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