I've always been obese; I was overweight before I had teeth. But when I entered menopause about two years ago, the problem escalated. By January 2011, my weight had ballooned to a high of 319 pounds, 50 more than I weighed just 18 months before.
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Is obesity itself a disability? Probably not, but it can cause or contribute to some disabling health problems. Obesity is comorbid with a staggering number of conditions: Type II diabetes, several kinds of cancer, cardiovascular disease, asthma, osteoarthritis, chronic back pain - all are dramatically more common among obese folks. Obese women are 12x more likely to have type II diabetes, 3x more likely to have coronary artery disease, almost 3x more likely to have chronic back pain than normal weight peers.
So as I hit menopause and my already obese figure started to balloon, it was real cause for concern. I’ve always been active, but constant joint pain began to slow me almost to a stop. I had developed high blood pressure, high cholesterol, sleep apnea and was headed toward what looked like inevitable type II diabetes. In other words, I was headed for either an early death or a miserable old age.
What to do about it? Well it's a puzzle. It's terribly hard to lose weight and even harder to keep it off. Here's an article "The Fat Trap" from The New York Times that recaps some research on weight loss and maintenance. The bottom line: If you've been significantly overweight and then lose, your body fights you.
From "The Fat Trap":
From a study at the University of Melbourne: While researchers have known for decades that the body undergoes various metabolic and hormonal changes while it’s losing weight, the Australian team detected something new. A full year after significant weight loss, these men and women remained in what could be described as a biologically altered state. Their still-plump bodies were acting as if they were starving and were working overtime to regain the pounds they lost. For instance, a gastric hormone called ghrelin, often dubbed the “hunger hormone,” was about 20 percent higher than at the start of the study. Another hormone associated with suppressing hunger, peptide YY, was also abnormally low. Levels of leptin, a hormone that suppresses hunger and increases metabolism, also remained lower than expected. A cocktail of other hormones associated with hunger and metabolism all remained significantly changed compared to pre-dieting levels. It was almost as if weight loss had put their bodies into a unique metabolic state, a sort of post-dieting syndrome that set them apart from people who hadn’t tried to lose weight in the first place.
Another: The National Weight Control Registry tracks 10,000 people who have lost weight and have kept it off...snip...There is no consistent pattern to how people in the registry lost weight...But their eating and exercise habits appear to reflect what researchers find in the lab: to lose weight and keep it off, a person must eat fewer calories and exercise far more than a person who maintains the same weight naturally.
I’ve lost some of the weight at least a dozen times over my life; my first major diet was when I was 14 and I’ve made a push at it every few years since. I’ve often lost down substantially, but never enough to make it out of the obese category much less approach a normal weight. And I never maintained the loss for long. Now, after decades of failure and determination to do it the “hard way” I decided I needed help.
In January 2011, I began exploring the possibility of weight loss surgery. I’d always looked at it as “the easy way out”, but now I began to look at it as “the possible way out”. I decided on a surgery called Vertical Sleeve Gastrectomy, where the surgeon removes around 85% of the stomach, leaving a fully functioning but much smaller organ. This surgery has a couple of advantages for me compared to the traditional Gastric Bypass. First, because it maintains the pyloric valve and the normal plumbing, food is released slowly into the intestines. That prevents sudden spikes and then drops in blood sugar. Second, the part of the stomach that’s removed produces the majority of the body’s grehlin (remember grehlin from the NYT article, the hunger hormone that spikes in people who’ve lost weight and is associated with problems of regain? Significantly reduced forever.)
Once I decided on surgery, the process moved pretty quickly. I had a bunch of pre-op testing. Six weeks pre-op I started first on a very reduced calorie, then a liquid diet. By the day of surgery, April 18, I had lost 35 pounds and weighed 284 pounds.
This photo was taken on my wedding day in
2010. In it I weighed just a little more than I did
on the day of surgery. Since then I had ballooned
over 30 pounds.
I was in the hospital two days post-op and had no problems, no complications and very little pain. In fact I was doing so well and up/moving so much that the exercise therapist who wanted to give me discharge instructions finally had to go searching the halls for me after several visits to an empty room. The only problem I had during recovery was back spasms. My back muscles were so weak they refused to pick up the slack for the abdominal muscles weakened by surgery. Wimps. That cleared up as the abdominal muscles healed.
The goal of the vertical sleeve gastrectomy is for the fully-healed stomach to have significantly reduced capacity. The swollen post-op stomach, therefore, can hold very little at all. At first, it was difficult to even drink; I’d take an hour to drink 8 ounces. When I was first able to eat solid foods 4 weeks post-op, I could only eat a few bites. At 10 1/2 months post-op, my capacity remains about 2 ounces of dense food, up to 4 ounces of softer foods. Because I still have my pyloric valve at the bottom of the stomach, I stay full as long as I used to with an enormous meal.
Reality check #1: While I have great restriction with proteins and fibrous foods, not all foods will keep a sleeve satisfied. There’s a term we use – sliders – to describe foods that will slide quickly through the sleeve and leave room for more. They vary from person to person but typically include simple carbs (sugars and starches; complex carbs are generally fine). Keeping the weight off means making a life-long commitment to stay away from these foods. I only allow myself occasionally treats like that outside the house – never at home because that would be a slippery slope for me.
My life is now five or six small feedings a day. I choose to drink high protein meal replacements for two of those feedings to help meet my nutritional needs. The others I eat generally 2-3 ounces of food, 4 ounces of yogurt, or an ounce of nuts/seeds.
Me last June at 2 months post-op. I had lost 27
pounds since surgery, 62 pounds overall and
weighed 257 pounds. We rode 11 miles that day.
Reality Check #2: Remember from the NY Times article that folks who have been obese need to eat less calories and exercise more than folks the same weight who never were obese? My surgeon’s office stresses that the most successful patients at keeping weight off long-term are those who become much more active. Those who remain sedentary have much higher odds of regain.
I’ve always liked hiking and we’ll do more of that this summer. On a lovely day recently, my husband (Kossack trs) and I walked about 14.4 miles on the C&O canal towpath. My knee and hip, which had prevented me from doing much walking pre-op, both did great. In the meantime, I do fun exercise DVDs and some step-aerobics at home at least 4 days each week.
Somewhere in month 4 post-op I hit a personal landmark: when I crossed below 240 pounds, I became the lightest I had been in my adult life. By 5 months, I weighed what I had weighed in the 6th grade. I am now down to my earlier elementary school weight. How early I don’t know, but I weigh almost 60 pounds less than I did in 6th grade.
Me at 6 months in October. I had just recently
hit the Century mark, down 108 pounds overall.
I weighed 211 the day this photo was taken. Can
you see that unfamiliar phenomenon I like to call
a “waist”? Also collar bones! Who knew?
Reality Check #3: I will never eat normally again. Since the vertical sleeve gastrectomy doesn’t have any bypass, I absorb every calorie I eat. Instead, it relies on feeling satisfied with small amounts. To do that, there are foods you can’t eat, except as very rare treats. I have a very tiny tummy and I can only put the best quality food in there to remain healthy.
As a side note, it can be a little uncomfortable in restaurants. Sometimes I’ll get something off my husband’s plate. Other times I’ll just order an appetizer. Even then, though, I’ll take home a box and get several more servings out of it. The other day, we went to Carrabba’s Italian Grill. I had a tiny piece of bread (my rule: bread is only allowed in a restaurant and then only a partial piece) and a bowl of minestrone soup. I ate about ¼ of the soup. Of course the waiter, on seeing that, thought something was wrong with it. I get that ALL the time, even when I ask for a box to take the leftovers home. Can’t help it.
Me at almost 8 months. I had lost 128 pounds and
weighed 191. There is something extra special magical
about this photo. Can you pick it out? For the first time
in my entire life, a picture of me in which I am not obese!
Overweight yes, but not obese.
Reality Check #4: Most weight loss surgery patients don’t get to a normal weight. In fact, less than 20% do. The average loss is just under the threshold between overweight and obese; about where I am in the photo above. Obese is defined as having a BMI (body mass index) of 30 or more. My starting BMI was over 47 or morbidly obese – most insurance companies that cover weight loss surgery require a BMI of 40 or more. That said, getting into the overweight category (BMI above 25 but below 30) yields huge health benefits for most morbidly obese folks, and usually means a loss of 100+ pounds.
So month 7 ½ is when I crossed into the overweight category at 197 pounds and began to beat the odds.
Staying healthy during massive weight loss requires a number of things, but two keys are protein and more liquids than you thought possible. Protein because it helps preserve lean mass and keep you from becoming a skinny fat person (the exercise helps this too) and liquids to flush out all the by products of protein synthesis AND the fat you’re burning. It doesn’t just evaporate.
Me at 10 months and goal weight range. I’ve lost
153 pounds to date (6 since this photo was taken). I'm
trying not to lose much more. This may be the only
context in which the word normal can be used to describe
me, but it fits. Barely, I currently weigh 166 and the
threshold of "normal" weight range for my height is 169,
but it fits.
Raising my calories and transitioning into maintenance is not only challenging given my capacity, it’s a little frightening. The reality is that my brain hasn’t caught up with my size. When I look objectively I can see signs that I shouldn’t lose any more, but when I look at myself in the mirror I still see someone fat. The whole thing still feels shaky and insecure. I’ll get there, but it’ll take time. Pictures help. In them, I can see the progress and the reality of how I look.
In 3 days, I’ll be 50. Remember the Bowflex commercial where the bikini-clad woman proclaims “I’m 50 and I’m in the best shape of my life”? Well I am, but there’s no way I’ll ever put on that bikini.
Reality Check #5: I have become a Shar-Pei.
When a body carries 150 pounds of excess weight for decades, it leaves evidence behind. The skin stretches and it doesn’t all bounce back when the weight goes away. Weight-lifting will give muscle to fill some of the skin back in and improve the appearance, but it isn’t a cure.
How much the skin bounces back depends on a variety of factors: genetics, skin type (fair people tend to have more loose skin; I am as fair as it gets), and age (sigh). There is very little you can do about the loose skin short of plastic surgery, which is said to HURT. Many formerly morbidly obese people need (and insurance will sometimes pay for) plastic surgery to remove the apron of drooping skin that used to cover the stomach. I’m lucky – I didn’t carry a lot of weight in my tummy area, so I don’t have much of a pannus. For me any plastics would be optional (and not happening).
I do have droopy loose skin on my belly. I also have loose skin in my upper arms (terrible) and my forearms (mild). I had rolls of fat on my back, and now have loose skin where they aren’t any more. Plus droops where my butt used to be. The worst for me, though, is my legs where I carried so much of my excess weight. I have droopy thighs; when I stand up the skin migrates towards my knees and they become a poochy, lumpy mess.
Bermuda shorts and sleeves for me in the summer, I guess (but at least they're size 8 instead of size 28!). And at I’m healthy and can do whatever I want when I’m wearing them! I wouldn’t trade that for the most gorgeous skin in the world.