Jean McMillan

To tell, or not to tell? That is the question on the lips of many WLS patients. Once again, there’s no one-size-fits-most answer to this question. The decision to tell (and how much to tell) or not to tell is unique to each patients’ unique personality and circumstances. IN & OUT OF THE WLS CLOSET I was happy about my decision to have WLS and thrilled when my insurance company finally approved it. I shared this happy news with many friends, acquaintances, family members, and coworkers. I don’t know but I assume that they discussed it amongst themselves to some extent, expressed opinions or concerns, and perhaps worried about my decision, but none of them gave me frankly negative feedback. They might have been thinking it, but they didn’t say it. I very much doubt I would have reversed my decision if someone had said, “That’s too risky/it’s a bad idea/I don’t want you to/you’re crazy/or whatever.” I’m going to assume that you, the reader of this article, are an adult over the age of 18, with the right to vote, the obligation to serve in the military, and (at some point, depending on your location) the right to purchase and use tobacco and liquor. Unless a judge has declared you mentally incompetent (and that’s harder to accomplish than you’d think), you are the one who’s responsible for your body – for its care and nourishment and any medical treatments or procedures that affect it. So if you’re in the early stages of considering WLS, whose input are you going to trust to inform your final decision? A bariatric surgeon, or your dad? Your primary care physician, or your sister? Your therapist, or your hairdresser? And hey, I’m not slamming hairdressers. Mine could do very well indeed as a therapist, but she has a cosmetology license, not a mental health practitioner license. Last summer I was startled to hear a 50-something bandster state that she had gotten her husband’s permission to have plastic surgery. His permission? Huh? Does that mean he’s the only adult in that relationship, or what? I’m not against asking permission, mind you. I ask my boss’s permission to undertake certain tasks or projects at work; I ask the State of Tennessee for permission (i.e., a driving license) to drive a car; if I still lived in a suburban development, I might ask the zoning board for permission to add a room to my house; I ask the government of China for permission (i.e., a visa) to travel in that country. I’m an extremely independent person in many ways, so I have to stop and think carefully about what I might ask my husband permission to do. We have our own separate checking accounts as well as a joint account, so I might ask him for “permission” to spend a chunk of that joint account on a big purchase like a computer or a car. Everything else gets negotiated. I have a lot of experience in negotiation because of my business career. I negotiated things with everyone from my coworkers to my suppliers. But people who do that kind of thing for a living aren’t the only ones who negotiate, and negotiators aren’t necessarily politicians or manipulators trying to advance some evil cause. My own career as a negotiator probably started when I was a child who realized that good behavior often yielded a treat. My negotiations with my mother went something like this: It’s 7:00 o’clock on Thursday morning. Mom is brushing the tangled cobweb of my hair in preparation for braiding it. I am sniveling because the untangling hurts. The negotiation begins. Mom says: “Jeannie, if you stop whining right this minute, you can have Cocoa Puffs for breakfast.” Jeannie sees an opportunity and negotiates this agreement by asking, “Can I have chocolate milk on my Cocoa Puffs?” Mom sighs and yanks at a hank of hair. Jeannie snivels a little bit more. Finally Mom says, “Yes, you can have chocolate milk on your Cocoa Puffs.” Jeannie instantly shuts up. Negotiation over. It’s a win-win situation. Everybody’s happy… for maybe 15 minutes. In 15 minutes, Jeannie’s hair is finally tamed into two narrow braids and it’s time to choose an outfit for school. This time Jeannie begins the negotiation. “Can I wear my pink dress to school?” Mom says: “That dress is brand new. We’re going to save it for church.” Jeannie says: “I promise not to get it dirty.” And so on and so forth. Well, that’s enough time spent traipsing along Memory Lane. My point (and, like Ellen Degeneres, I do have one) is that the “yes or no” WLS decision is yours. Everything else (how to make it work best; what your family can do to help you; how much to tell your nosy coworker) needs to be negotiated with (or modulated by) the people who will be involved in your WLS journey on a daily basis and possibly renegotiated as time goes on and your needs change. The negotiation may be simple (“Will you take the kids to McDonald’s for lunch if I pick up your dry cleaning?”) or complex (“Let’s talk about how we’ll handle Thanksgiving Dinner this year”) or downright messy (“I feel like you’re trying to sabotage my weight loss.”). That’s life, isn’t it? BE CAREFUL WHAT YOU ASK FOR Getting feedback from others is usually a mixed bag experience. It’s wonderful to get the positive stuff and uncomfortable to get the negative stuff. It’s also very frustrating when your announcement elicits no response at all. What if you tell your sister, “I’ve decided to have weight loss surgery,” and all she says is “Oh.” What’s that all about? She’s shared her thoughts about your hairstyle, your boss, your kid’s struggles with math, your parents’ new car, your high blood pressure and now she has nothing to say about something as momentous as weight loss surgery? If you’re like me, your mind gets busy filling in all the empty spaces with scenarios and speculation. My own little mind is always full of running commentary (most of it – well, some of it – never uttered aloud). When I’m exercising, I’m planning what to wear to work that day. When I’m driving to work, I’m considering the best way to write the first or fifth or fifteenth sentence of my next article. When I’m driving home at the end of that day, I’m replaying a conversation I had with a coworker and fiddling with what I could have said better. So when I encounter my complete opposite (someone who has nothing to say on a matter that’s important to me), I cast my fishing net into my teeming mental pond, scoop up a dozen squirming fish, and off I go into Wonderland. “Wonderland” as in the land where I wonder, and wander, on an endless circular track. Around and around Jean goes, and where she stops, nobody knows, least of all Jean. The official term for that is “projection”. You project your own internal drama onto someone else’s blank white movie screen without having the first clue about what’s really going on behind that blank screen. You’ve known your sister all her life, ever since she supplanted you as the baby of the family. That’s what, 35 long years? After 35 years together, you might think you could predict her reaction to almost anything, but it’s also quite possible that you cannot correctly read her mind. Your suspicions about her reaction to your weight loss surgery announcement may be accurate, but you’ll never know that unless you specifically ask her. That’s more or less what happened to me when I first began discussing weight loss surgery with my husband. We had been married for 20 years, so he had two long decades of experience with his wife launching herself into risky situations (be it a new job, an overseas trip, adopting a pet, redecorating a house, taking fen-phen). He had been amazingly patient through all of that, not just because he loves and supports me but also because he knows that hell hath no fury like Jean with an obstacle in her path. So when I said, “Today I made an appointment to go to a bariatric surgery seminar,” and he said nothing in response, a dozen things ran through my mind. He thinks I should be able to lose weight by dieting. He doesn’t want me to lose weight because he likes fat girls. He thinks this is another of Jean’s wild goose chases and if he leaves it alone, she’ll get over it and move on to some other project…and so on and so forth. What was actually going on in his head was probably more like, “I wonder if there’s more rice in that saucepan, but if Jean forgot to buy soy sauce again, I won’t have another helping because I can’t eat rice without soy sauce. If Jean has weight loss surgery, will we ever get to eat rice with soy sauce again? Will we be living on warm water and melba toast? Did I remember to fill the cat’s water dish before I came in the house? We really need to get the cat fixed but I don’t want another argument about whose turn it is to take a critter to the vet. Oh no, Georgie’s puking in the living room again. If I ignore it, can I get Jean to clean it up? I’m going to write SOY SAUCE on the grocery list in big letters so Jean won’t forget to buy it. Maybe if I ignore the weight loss surgery thing, it’ll disappear, like Georgie’s puke”…and so on and so forth. I’m not trying to make my husband’s thought processes sound asinine (for a taste of truly asinine thinking, you really need to listen to a few minutes of my own stream of consciousness). I’m just making the point that our minds are full of stuff that may be worthwhile or interesting to us but doesn’t necessarily have to be shared in detail with everyone around us, and that nobody but the Amazing Kreskin can hear someone else’s thoughts. When my husband finished his dinner (without a second helping of rice) that night without making any response to my bariatric ambitions, I asked him, “So what do you think of the idea of me having weight loss surgery?” And he said, “I’m not crazy about it, but if you really believe it will help you, I’ll do my best to support you.” And what did I say to that? All I said was, “Thank you.” I could have said a lot of other things. I could have said, “Why aren’t you crazy about the idea?” I could have quizzed his knowledge about weight loss and weight loss surgery. I could have asked him if he would still love me and desire me when I was thin. I could have gone on and on for hours, while adding to my own anxiety and creating a host of brand new anxieties in his poor head. But instead I said, “Thank you,” because his promise of support was all I needed to hear at that time, and we had a lifetime of conversations ahead of us. And I said “Thank you” because when I’m in the planning stages of something big that will require a group effort, I try not to invite discussion that will derail the whole project even before its engine starts. You may have a different style, and you may think I was postponing a discussion that should be tackled immediately, but my approach is: one step at a time. I don’t try to build Rome in one day. I pick up one brick, walk it over to where I want the wall, put it down, and go back for another brick. Eventually the wall (or Rome) gets built. IN & OUT OF THE BAND CLOSET My feelings about sharing my WLS journey with other people have changed as time has gone on. For three months before and about 18 months after my band surgery, bariatrics was the #1 subject in my mind at least 75% of the time. I had to exert effort to not talk about it constantly. If I hadn’t discovered online WLS forums, where I could talk about it constantly with other people who talked about it constantly, I think my head may have exploded. I didn’t talk about WLS with every single person in my everyday circle of friends and acquaintances (for example, I decided not to tell my church friends about it, mostly out of laziness), but most of the people who knew me as obese also knew about my surgery. When I had lost my excess weight, the focus of my life began to shift to other things. Yes, bariatric surgery was still important to me, and so fascinating that I wrote a 500+ page book about it, but as my interests and activities grew and changed, I acquired a whole new set of friends, acquaintances, and coworkers who had never known Fat Jean. It didn’t occur to me to tell them I’d had WLS any more that it occurred to me to tell them I’d had a hysterectomy or hemorrhoids. If the subject of weight loss or dieting or exercise came up, I was willing to talk about those topics, but not necessarily in the context of weight loss surgery. I guess you could say I was in the band closet then, though I won’t admit to hiding in there. I still wanted to talk about bariatric topics, but not with the general public. I made two new friends during that time who know about my band surgery. One of them had heard about it from her mother (a former coworker of mine) and the other heard about it from me. Otherwise I was kind of enjoying being perceived as a “normal” woman by people who couldn’t even imagine me as a fat woman. But one day my feelings changed. I opened the door of my band closet and peered out. It was time to get out of there. Here’s what happened. During an exercise class at my fitness studio, another (naturally slender) student began making fun of fat people, and a few more people there chimed in. They just couldn’t imagine how someone could “let themselves go” like that. It sounded to me like these well-meaning people were saying that obesity is a choice – that the fat people had made a conscious decision to overeat, under-exercise, and gain an unhealthy amount of weight. It sounded to me like these well-meaning people were saying that fat people don’t have the willpower or intelligence to maintain a healthy weight. And suddenly I heard myself say out loud, “Those people aren’t proud of their fat. Don’t be making fun of them.” After a minute or two of mumbled objections, those well-meaning people fell silent, and soon the conversation took a new direction. Months later, when I was about to publish Bandwagon Cookery, my friend, instructor and personal trainer, Caroline, suggested holding a book-signing event at the fitness studio. At first I was wary of the idea. It would require me to step out of the band closet and expose my bariatric secret to a community of people who had never known Fat Jean. It would require me to step out of my comfort zone and into the limelight. I’m not afraid of public speaking – I actually enjoy it in most circumstances – and I’ve told my WLS journey story plenty of times, but mostly to bariatric patients and professionals. At Caroline’s loving insistence, we hosted the book signing, which was well-attended by women for whom weight management was an interest but for whom obesity was not an issue. One of them had a sister who was banded, but the rest of the guests were blank slates when it came to bariatrics. I want to share with you what I told this audience after announcing that I had weight loss surgery, something that I felt they needed to hear before I could tell my nitty-gritty obesity story: “I need to talk about the elephants in the room. The elephants are the beliefs that many people have, that obesity is a moral failing and that weight loss surgery is taking the easy way out. Obesity is not a choice, nor is it evidence of inadequate willpower. It’s a chronic and incurable disease caused by a combination of genetics, environment, and behavior. Weight loss surgery is the only effective long term treatment for obesity available in the United States today. And weight loss surgery is by no means the easy way out. Weight loss is hard work with or without the help of surgery. Has my weight loss been easier because I had bariatric surgery? Of course it has. That’s one of the reasons I chose surgery – because without it, my previous weight loss attempts had been so difficult and so ineffective. “I’m glad to have my Lap-Band, but it’s just a little piece of plastic, a tool that reduces my appetite. When I stick my hand in a bag of potato chips, my band doesn’t yank it out again. When my alarm goes off in the morning and I want to roll over and go back to sleep, my band isn’t what gets me out of bed, into workout clothes, and into this fitness studio. When I’m thinking that I need a 2nd helping of mashed potatoes, my band doesn’t shout, “Don’t do it, Jean!” When I’m sad and thinking that buying and eating a gallon of ice cream would make me feel so much better, my band doesn’t hide my car keys on me. “I am the one who makes decisions about what I eat and how I exercise. I am the one who’s responsible for making good food choices and changing my eating and exercise behavior. So I get the credit for my weight loss, and I’m the one who has committed to maintaining that weight loss for the rest of my life.” Looking back, I’m not sure how much of an impact that speech had on any of my listeners, but it had an impact on me. Hearing myself say those words affirmed my important and life-changing decision to have bariatric surgery. Whatever you do as you go forward on your weight loss journey, be proud of what you’re doing. It’s a courageous thing. If no one else congratulates you for the undertaking, you should still pat yourself on the back for it.

It interests me when a member posts something potentially controversial or inflammatory and then states that he/she "won't be reading the negatives anyway." This is like setting a pot of Soup on a stove burner on a high setting, then leaving the pot to boil over and burn someone, while announcing that "It's too hot in the kitchen so I'm getting out of it." Although the OP (original poster) states that this thread is directed at "many who seek accurate information", 99.9% of the thread appears to be directed at a single, unnamed individual. If the OP has a problem with that individual, I believe it should be dealt with in a private conversation with that individual. In my own not-so-humble opinion, making a personal problem the topic of a public discussion that invites the victim to defend him/herself, and others to join the mob mentality the thread fosters, is the passive-aggressive antithesis of the "best wishes" the OP expresses at the close of the thread. I will now close the kitchen door and depart this thread with the hope that the fire burns itself out so we can all go back to helping and supporting other. Jean

You weigh and measure yourself, don’t you? It can be such a gratifying way to see your progress towards your weight goal. But do you weigh and measure your food as well? No? Despite the potential for that practice to help you lose weight? Tell me why you don’t weigh and measure you food before putting it on your plate. Is it painful? Surely not. Is it impossibly difficult? No, I can’t believe that either. Or do your cups, spoons, and scale gather dust simply because they remind you too much of…gasp!!...dieting? Dieting…one of the most hated words in the vocabulary of every obese person who hated dieting, and failed at it so often, that she or he finally got fat enough to qualify for weight loss surgery. I completely understand. I’ve been there, done that, and got the size 3X tee-shirt. Yet still I’m going to insist that you give the practice of weighing and measuring food a try, because it’s one of the things that has made me a WLS success and because I can think of 9 (count 'em - NINE) excellent reasons for you to do it too. 1. It will prevent you from consuming more calories than you can burn each day, thereby helping you lose weight. Me, I’m terrible at eye-balling food amounts, even after years of practice. I cut myself a piece of chicken that I think weighs 2 ounces, and find to my surprise that it weighs 4 ounces. I spoon myself a modest mound of veggies that I think measures ¼ cup, and discover that it actually measures ½ cup. 2. It will make the data you enter in your food log more accurate so you’ll know how much you’re really consuming and whether you’re eating appropriate amounts of proteins, carbs, and fats each day, not just for weight loss but for good nutrition. You do keep a food log, don’t you? Did you know that scientific studies have shown that people who keep a food log lose more weight than people who don’t? 3. It will help give you a sense of control and mastery over food and eating, which will be very welcome and empowering after years of feeling that food and eating controlled you. 4. Weighing, measuring, or counting out 10 potato chips or 14 M&M’s will give you a chance to think one last time about whether that stuff will meet your nutritional and health goals as well as temporarily scratching the itch of a food craving. 5. It will slow your progress from stove to table, thereby reducing your risk of inhaling your food without even tasting it. You do sit at the table to eat, don’t you? It’s not true that calories eaten while standing up at the counter (or in your car or at your desk) don’t count! 6. The ceremony of weighing and measuring will help you appreciate the sensual delight of food, and that will increase your satiety (the sensation of having eaten enough food, which by the way is quite different from feeling “full”). 7. Until you learn what your satiety or “stop eating” signals are, you’ll have no way of knowing if you’ve eaten too much until it’s too late. And stopping eating too late can translate not only into disappointing weight loss but into unpleasant side effects like PB’s (regurgitation), sliming, foaming, and stuck episodes. 8. It will prevent you from consistently overeating, thereby preventing you from experiencing not just the side effects mentioned above but also some unwanted and potentially irreversible medical complications, like a band slip, a dilated esophagus, and/or a dilated stomach pouch. 9. If you give it an honest try for at least one week – just 7 days – and it doesn’t help, you’ll have the pleasure of saying that you proved me wrong. That’s highly unlikely, but hey, give it a shot! Oh, one last thing (for now). I know some highly successful bandsters who never weighed and measured a single morsel of food. They ate small amounts of foods they liked, lost weight, and maintained that weight loss. But they’re in the minority. And I, the World’s Greatest Living Expert on Everything, who slacked off on food vigilance after I reached my goal weight, have found that one of the quickest and easiest ways to get my eating back on track and nip weight regain in the bud is to go back to weighing and measuring. At the same time, I’m able to eat small amounts of foods that I like – just like the ones who don’t weigh and measure. The fact that my food has been weighed and measured doesn't make it any less delicious! If it makes the practice easier for you to bend your stubborn mind around, tell yourself you’ll just do it just for this one week, or one day, or one meal. Sometimes the WLS journey has to be taken one tiny baby step at a time. And that’s perfectly okay, because hundreds of baby steps can add up to hundreds of pounds and inches lost, and a lifetime of weight maintenance. Isn’t that what you want, in the end? Yeah, me too.

This exchange is an excellent illustration of why combining different WLS forums into a single site was not a good idea...IMHO. Sojourner, I don't disagree with what you've said here, but I do want to comment on the above statement, which I do understand is your personal opinion. For 6.5 years, I've belonged to another WLS site that includes forums for different WLS procedures, where heated exchanges like the one on this thread happen from time to time, but I don't think combining all the various forums on Bariatricpal will significantly increase the frequency of online arguments, because I've also observed quite a few people who hop from one site to another, and one forum to another and back again, waving whatever banner is important to the at the moment. Tis the nature of the beast. I'm almost a techno-phobe, so if it's easy for me to navigate the Internet, surely it's even easier for the rest of the online world?

If nothing else on this thread is certain, it's clear that you didn't intend to start a bonfire. Unfortunately, that kind of thing happens in online forums from time to time - not just on bariatric sites, but on sites devoted to topics as varied as books, cooking, and exercise. You've gotten some useful, supportive replies to this thread, so it was worth posting it. I hope your future bariatricpal conversations are less contentious!

It sure sounds like your body is trying to get rid of your port, and if it also goes to work on your band, your complications will get even worse. Like Carolinagirl, my life is more important than my weight loss surgery, and I'd go to the emergency room and call my bariatric surgeon immediately. Please don't think that your only choices are to live skinny with open abdominal wounds or live fat without your port and/or band. Once the port complications are dealt with, you may be able to revise to a different bariatric surgery procedure that doesn't involve implants. Good luck! Jean

It is confusing, isn't it? And very hard to study and analyze in a scientific manner, so we may never have an answer to the eternal question of: is it me or my WLS? Your ability to eat less even of "bad" foods is probably due to a combination of your band's effects on your appetite and satiety and new eating habits developed over time following your band surgery. I think some of the eating habits I acquired in 5 years with my band did survive, but since my sleeve surgery, my conscious behavior while eating seems to have changed. For example, with my band, I would suddenly lose interest in finishing whatever food I'd been eating (even a "bad" one). In fact, that food would often seem repulsive when I'd been enjoying it just moments before. And on the whole, food was less appealing to me, so I thought about it, anticipated, and enjoyed it less. That's all history for me now. WLS of various types has been done for decades now, but even the best bariatric medical professionals are still learning how each procedure works. The human body is very complicated and as I understand it, nothing in the body works entirely independently. Conscious and/or exterior actions affect unconscious, interior, autonomic functions, and vice versa. The nervous system, immune system, digestive system, circulatory system, endocrine system and so on may be able to function independently in some ways, but that doesn't mean each system receives no messages, input or effects at all from the other systems. Then a surgeon opens up that complicated human body, fiddles with the innards, closes up it up (perhaps even leaving a "foreign object" like a gastric band behind), and as a result, all of the bodily processes we take for granted are thrown into a tizzy. Some of the tizzy is beneficial, some is not, some is neutral. And since every human being is unique, it's impossible to predict how that surgery (be it dental, bariatric, cardiac, etc.) will affect the patient in the short or long term. I don't think it's a bad thing to have both WLS and conscious behavior helping to manage our weight, and after 5+ years on WLS forums, it's my opinion that believing that WLS can and will do all the work in weight loss and management is all too likely to lead to frustration and failure.

I've had 2 WLS procedures (the band and the sleeve) and neither of them have cured my obesity or any of the emotional stuff that contributed to my obesity. I'm 18 pounds below my goal weight thanks to WLS, but I still experience stress and temptation during the holidays - in fact, all year 'round - because unlike B52, I'm a human being.

While it's true that the sleeve is easier for some because it doesn't require adjustments (fills and unfills, I don't agree that it provides a better quality of life post-op. I revised from band to sleeve in August 2012 and in the 16 months since then have experienced complications that required more tests, procedures, treatments, time off work, and general misery than I ever experienced in 5 years with my band or even for decades before that. I'm happy with my weight loss, of course, but nothing else about my sleeve is easy to live with on a daily basis. I wrote in some detail about my band-sleeve experience in a blog post here: http://jean-onthebandwagon.blogspot.com/2013/03/a-lot-of-people-especially-those.html One of the unexpected (to me) aspects of sleeve gastrectomy is that, contrary to popular opinion, it does indeed cause the micro- and macro-nutrient malabsorption that made me decide against RNY. So I'm dealing with a variety of Vitamin and mineral deficiencies, supplements to compensate for all that, and unintentional weight loss. I'm 18 pounds below my goal weight and still losing. I don't dwell on my dissatisfaction with my sleeve because there's really nothing I can do about it. Most of my stomach is gone forever, so all I can do for the rest of my life is make the best of the situation. Quality of life is a very individual thing, hard to quantify, and unless the members of whatever committee you met with have had weight loss surgery, I doubt they're able to give you any accurate reasoning, data or scientific evidence to back up their claim that the sleeve offers a better quality of life. If you want anecdotal evidence about that, I suggest that you visit the sleeve forum. And keep in mind that band-to-sleeve revision members who post there may be delighted with their improved quality of life because their band side effects and complications were so awful that just removing their bands was a relief, not because the sleeve is superior to the band. The bottom line is that there is no such thing as a perfect, risk-free, easy success weight loss surgery. All you can do is do your research, pick the procedure that feels right to you, and move on. I'll close this message now because I'm tired, don't feel well, and have too much to do today, including picking up a prescription for injectable B12 and syringes and making an appointment with my gastro-enterologist about starting Iron infusions to deal with my post-sleeve anemia. Jean

The idea for this article came to me in a dream. It was what I call an anxiety dream, in which I’m trying to accomplish something important but encounter obstacles everywhere I turn. That’s kind of a parable of life itself, isn’t it? When I wake from a dream like that, I feel frustrated because I didn’t get to finish my dream task, but at the same time I’m relieved to be released from the endless struggle. So in this particular dream, I was moving into a new, multi-story house, kind of like the old tenement buildings you see in dying New England mill towns. It was essential that I quickly locate and organize all my belongings so that I could use them to start an urgent and important project. Every time I carried something into another room to put it away, I would find other people there, already moving my stuff, wreaking havoc on my carefully ordered household. When I went back outside for another load of stuff, more people would be poking through it as if it was so much garbage left out to be collected and buried at the dump. These interfering people ignored my pleas to leave my things alone. For every armful I took into the house, they carried out ten. Then my husband started a load of wash in the laundry room a few feet away from the bedroom, and the sound of the washer’s spin cycle woke me up. Thank God. I trudged off to the bathroom, pondering the meaning of the dream. I haven’t moved into a house for 14 years, so why was I having a dream about moving house? As I made the bed and thought more about the dream (which didn’t want to leave my head just then), I suddenly knew what it was about. My big moving project for the past 6 years hasn’t involved moving into a new house. It’s involved moving into a new body. Like any move into the unknown, it’s been both exciting and scary. I no longer have a jumbo, custom-built pantry to hold 50+ years’ worth of bad habits and warped beliefs about myself. I keep forgetting where I’ve put things, and have sabotaged my own efforts numerous times. At times, circumstances beyond my control have put my new “home” into disarray, but I’ve kept working at it, carrying things in, bringing things out, rearranging things…a seemingly endless task. I think I’m pretty much settled now. I watch elderly people who have to work so hard to accomplish the simplest tasks – sit down, get up, button a shirt, open a jar – and remember my mom talking about the way her body had betrayed her as she aged. I suppose that could happen to me sooner or later. But for right now, I’m in a good place: my new body - the home I carry with me everywhere. As you continue on your weight loss journey, please take good care of your body. You may not like it much now, but it’s your home. Your very own home. As it changes, you will have to learn its new floor plan. When you go to a closet to fetch a size 16 dress and find only size 18’s, you may feel so disoriented that you forget the size 20, 22 & 24’s you took to the Goodwill Store last week. As you pass through the front hallway of this new home and see yourself in the mirror, the person you see might look like a complete stranger. What’s she doing there? She’s fat, I’m not, so why is her reflection all I can see? Where did this mirror come from, anyway, the funhouse at a circus? Don’t give up. One day you’ll have all the curtains hung, the walls painted, the furniture arranged, a fire burning in the fireplace, and you’ll think, “I’m so glad to be home.”

Obesity bias. We all hear about, and some of us experience it, in the workplace and in social situations. But obesity bias lurks elsewhere, in places where you’d least expect it because the people involved are so well-educated. It lurks in what I call the “helping professions”. Teachers, ministers, people who ought to know better. Because of that, I addressed the last chapter of Bandwagon to medical professionals. Telling them how I feel about obesity bias is important to me personally, and awareness of the issue is important to us all, fat or thin, young or old. Politicians, educators, and the media can help (if they can just get their heads screwed on straight), but those of us who suffer from obesity can help by refusing to tolerate it. That’s why I’m reprinting my obesity bias chapter here: I want to put the fire in your belly. Curious? Read on. AN OPEN LETTER TO MEDICAL PROFESSIONALS You wouldn’t guess it to look at me now, but I was once obese enough to qualify for and have bariatric surgery. I was so fat that I got stuck in turnstiles, had to use handicapped stalls in public restrooms, and dressed in drab garments that looked like they were made by Omar the Tentmaker. I was so fat that children would point at me and giggle. So fat that I couldn’t fit in a booth in nice restaurants. So fat that fellow airline passengers groaned when I sat down in the seat beside them. Despite all that, I think I've been pretty lucky. I haven't suffered as much of the obesity prejudice that others like me have faced. My career might have been more successful if I was thin, but I was never aware of obesity bias in a workplace and I advanced further in my career than I ever could have dreamed possible. But I have experienced obesity prejudice, and some of that has come from you: the health care professionals with whom I've entrusted my physical and mental health, and that's a special kind of betrayal. I’m not a doctor; nurse; nutritionist; dietician; surgeon; exercise physiologist; physical or occupational therapist; medical, laboratory, radiology or surgical technician; or psychiatrist, psychologist or social worker, so I can only make assumptions about what motivates you in the practice of your profession. It’s probably a mix of things: the need for a paycheck; love of science; the expectations of your families, teachers and employers; laws and ethics (both written and unwritten); the desire to relieve suffering; and compassion for your patients. In reality, compassion seems to be undervalued in both the medical community and society at large. I'm told that medical students undergo training so grueling that it would be considered inhumane in any other environment. Then they leap into a practice that requires them to balance patient care with business, financial, insurance, legal and ethical issues that their formal education did not fully address (if at all). Americans of any profession live in a paradoxical society. We praise the athlete who finishes out a game despite a serious injury while we pop pain pills for the aches in our own inactive bodies. We give our children television sets, video games, cell phones and junk food, but don't have time to play with them or encourage them to exercise. Our government mandates the publication of nutrition information on food packages that we are unable or unwilling to understand. We admire the underweight women pictured in celebrity magazines while we wait in line at the supermarket to purchase a cartful of super-processed, calorie-rich, nutrition-poor food. During our daily trip to McDonald's, we recoil when we see an obese person enjoying the same meal that's on our own tray. We think, "What a pig! I would never let myself get that fat. Why doesn't she go on a diet? She must be too lazy or too stupid." Then we stuff another fistful of French fries in our mouths, take a big swig of Coke, and secretly loosen the button on our own straining waistband. The meal we have just eaten could feed a third-world family for a week, but neither our greediness nor their neediness concerns us. Somehow the careless eating habits of a normal weight person, the anorexic eating of an underweight actress, and the starvation of an impoverished child are all okay, but the overeating of an obese person is reviled. Despite the societal stigma associated with it, obesity isn't the shameful plight of "other" people — lazy, unlucky, immoral people. It can happen to anyone. It happened to me, and it can happen even to well-educated medical professionals like you. I am by no means lazy. God has given me many blessings, and I do my best to live in a moral fashion, but through a mysterious combination of nature and nurture, I suffer from the chronic disease of obesity. It is no easier for me to cure myself of this disease than it is for someone to cure herself of asthma, epilepsy or diabetes. I find it ironic that the only current "cure" for diabetes - gastric bypass surgery - is so often considered to be unnecessary “cosmetic” surgery when an obese person seeks it as treatment for their disease. When I asked him for a referral to a bariatric surgeon, the physician who diagnosed my Type 2 diabetes (who happens to be morbidly obese himself) told me, "You don't need something that drastic. You just need to try harder." Telling me that was as helpful as telling a patient with a broken leg, "Let's just wait and see if this gets better on its own. If you concentrate hard enough, that bone will mend itself." That same doctor told me many times to exercise more and eat less. We live in a small town and I see him and his family in local restaurants and stores, but never at the health club owned by the hospital with which he is affiliated. The most strenuous exercise I've seen him do is to repeatedly lift a fork to his face as he plows through a plate of Mexican food. Do I sound bitter? I suppose I am, and you would be too if you had been treated by your fellow human beings, including medical professionals, the way I have been treated. To hear me talk, you might think I'm nursing a grudge against my doc, but I'm not. My obese doctor is a really nice guy, and I have genuine respect for the talented, hard-working people who practice the "helping professions". But not for one minute do I believe that any of them are qualified to judge me. That privilege is reserved for God. Sometimes it's the most kind and well-intentioned people who inflict the most hurt and humiliation on an obese person. To suffer that at the hands of professionals who ought to know better has been especially hurtful and disappointing. When I first moved to Tennessee, I went to see Dr. X, the family physician recommended to me by a local friend. He gave me a prescription for my high cholesterol (essential, he said), refused me medication for depression (not necessary, he claimed), and told me I must lose weight (also essential). I asked him how I should do that. His response was, "It's simple. Put the fork down. Eat less and exercise more." When I said, "That's easier said than done," he answered, "You don't need to talk about it. Just do it." (He also inexplicably refused to give me a referral to a nutritionist, psychotherapist or weight loss support group.) From this experience I could only conclude that my obesity was due to a fatal lack of willpower. I reported that conversation to my friend, who said, "That's probably because Dr. X used to be very heavy himself, and he thinks if he can lose weight, anybody can." The fascinating thing about that factoid was that although Dr. X was specially equipped by his own experience with obesity to give advice, support, and compassion to an obese patient, he was unable or unwilling to offer me any of those things. I don't know what his problem was, because I never got to know him better. I found another family doctor (the obese one) and never returned to Dr. X for medical care. I've also experienced obesity prejudice in a mental health setting. For a year or so I attended a support group meeting for behavioral health patients at our local hospital. The woman who facilitated the group was an addiction specialist - entirely appropriate considering the high proportion of drug and alcohol addicts in the group, but even she laughed when I told the group, "It's all very well for you to talk about abstinence. You can completely give up drugs or alcohol and survive just fine, but if I completely give up food, I'll die." I'll admit I often say funny things with a serious expression on my face, but how was that statement funny when tears were running down my face? I've even experienced a subtle form of obesity prejudice in a bariatric medical practice. In the past five years, I've used the services of two different hospitals with well-established, well-respected bariatric surgery programs. I won't name them because medically I have no bone to pick with them, but I will describe them because they reveal a lot about themselves in their bariatric facilities' design. One facility is supplied with plus-size patient gowns; wide benches and chairs; wide hallways and doorways; big exam tables with sturdy step stools beside them; large, easy-access restrooms; specially-equipped operating rooms; large-size blood-pressure cuffs; and many other accommodations for large-sized patients. The other facility has none of that, and if a patient is too large to fit through the door that leads to the exam rooms, his or her consult may take place in the waiting room, in the sight and hearing of other patients. So much for patient confidentiality, huh? Both of these facilities have given me excellent and considerate care, but only one of them gives the impression of having thought deeply about what its patients really need. And speaking of what bariatric patients really need, I also have a word for the general surgeons who are jumping onto the bariatric bandwagon in hopes of increasing revenue: please, please don't lift that scalpel until you've established a complete patient education and aftercare program, employing the services of the experienced nurses, nutritionists, psychologists, exercise physiologists and other bariatric professionals who can make or break your patients' success. When you have your team assembled, please make sure they're all singing from the same sheet of music. One of the most common complaints I hear is that staff members in a single bariatric practice issue conflicting instructions - for example, the surgeon says you should eat 1/2 cup of food per meal, but the nutritionist says you should eat 1 cup. My response to this is always: follow the surgeon's advice until you're able to clarify the issue. But bariatric surgery patients, especially new ones who are trying to learn dozens of new facts and behaviors, do not need their bariatric team adding to their confusion. Just as you should not underestimate your patients' need for education and support, nor should you underestimate their intelligence. Surely as a scientist you can acknowledge that human intelligence is not inversely proportionate to body size, any more than it's related to skin color, ethnicity or religious belief, but I must remind you that mental faculties do not decrease as body size increases. While I appreciate any efforts you make to communicate clearly, it is not necessary to talk down to me. And baby talk is out of the question. I will never forget the doctor (about 15 years my junior) who explained to me that while I (age 50) was catheterized for surgery, I would "go pee pee" into a bag. I am not a child, and I will thank you to treat me as an adult. If you want me to call you "Doctor Smith", please address me as "Ms. McMillan" (or, if you are of a southern persuasion, "Miss Jean"). By now you may be thinking, "I don't have time for any more of this nit-picking," or, as a nurse practitioner once said to me, "I don't have any more time for you today. I have sick people to see." But before you run off, I also want to say this: Thank you for all that you do, for your arduous studies, hard work, and long hours; for the risks you take, your research, your continuing education; for being willing to treat a complicated and chronic disease like obesity with an expensive medical gadget that's being refined and improved even as I write this, even as you walk through the operating room doors to perform weight loss surgery on another patient. Keep up the good work, partner. None of us would get very far on the bariatric bandwagon without you!

I’m a control freak, so this is hard for me to say, but say it I must. Life is full of unexpected events. Events that are good or bad, that you can or can’t explain, with effects that you may or may not be able to control. As much as I wish you (and myself) continued success on your weight loss journey, chances are that at some point, something’s going to go wrong. The fickle finger of fate is going to zap you with a surprise, a disappointment, a side effect, or a complication. It’s going to confuse, upset, frustrate, or infuriate you. What are you going to do when that happens? Who are you going to blame? Your surgeon, your spouse, your sister, or the girl who won the spelling bee in 6th grade when you were the far better speller? And when the blame is firmly placed (preferably at a considerable distance from you), then what are you going to do? Wait for your fairy bandmother (that would be me, Jean) to wave her magic wand over you and make it all better again? You might not want to wait for me and my magic wand, because we’re fully booked until March of 2044. That means that you may have to find your way out of the problem all by yourself, because even if you can get someone else to accept the blame for your stuck episode or band slip or weight regain, you are the one who’s going to have to either live with it or fix it. Oh, sure, you can take your surgeon to court over his purportedly inept placement of your band or port, once you convince an attorney that the case is worth at least (say) $100,000 in medical expenses, lifetime nursing care, lost wages, pain, suffering, and hangnails. And some ten or eleven years later, after dozens of postponements and motions and hearings, as well as thousands of $$ in court costs (all at your expense), you may or may not be granted an award or settlement that you may or may not be able to collect before March of 2044. And meanwhile, you’ll still be obese, confused, upset, frustrated and infuriated. You’ll be divorced because your husband’s pizza habit ruined your diet. You’ll be lonely because your sister lied about how easy WLS is. You’ll be doctorless because your surgeon flagged your name with the infamous Difficult Patient tag. And did I mention you’ll still be obese? Wow, this story doesn’t have a very happy ending, does it? I think we’d better start over. So take a deep breath and click here to find out how taking personal responsibility for your weight loss will give your WLS story a happy ending.

REWARD & PUNISHMENT Yummy food rewards for good behavior, and severe punishment or deprivation for bad behavior, go back a long way in my psyche. With every good intention, my mom trained me using the classic reward-punishment technique from the time I was a very small girl. As soon as I was old enough to think for myself – at age 40 or so (just kidding!) – I applied the same technique to managing (or should I say mismanaging) my weight. Even a tiny infraction of whatever diet plan I was following at the moment was punished severely with hours, days, or weeks of self-loathing and recrimination which would be followed by much bigger eating crimes (I’m a hopeless screw-up because I ate a donut yesterday, so I’m going to eat a dozen donuts today) or by extreme deprivation (I ate a donut yesterday, so I’m going to eat nothing at all today, and if I’m a very, very good girl, I’ll earn half a carrot stick as my reward tomorrow). I learned a bit about behavioral science in college, and goodness knows I’ve read enough self-help books and articles to have picked up a thin smattering of knowledge about it, but none of it meant very much to me until the past five or six years. As I moved towards my weight loss surgery decision, I had to admit that the good girl, bad girl system had not been working very well for me. I just couldn’t seem to responsibly give myself one “cheat” a week as recommended in women’s magazines. The authors of these magazine articles claimed that one serving of cheesecake on Sunday would keep me from bingeing out of desperate deprivation for the rest of the week, but one serving was never enough for me. I guess I’m an all-or-nothing kind of gal, and for me, the only alternative to eating an entire cheesecake was to (mentally) beat myself with heavy chains and a medicine ball covered with spikes. Neither approach yielded the results I wanted, but what other way is there to live as a responsible, law-abiding adult? Without laws and law enforcement, don’t we suffer the chaos and degradation of anarchy? POSITIVE & NEGATIVE REINFORCEMENT Sad to say, I’ve learned more about reward and punishment from living with dogs than from living with myself. I can plainly see that screeching at them for bad behavior is more likely to get them cranked up than to get them to behave. They have taught me that a positive or negative response to a behavior, be it good or bad, reinforces the behavior. We humans are not doing ourselves any favors by punishing our own “bad”, negative, or counter-productive behavior with more negative behavior. All that does is reinforce the bad stuff and use up all the extra energy we really need for the good stuff. When all we hear is an internal voice crying, “bad girl!” (or “bad boy!”), eventually we become resigned to being a bad girl (or boy, as the case may be), and the bad stuff goes on and on. Nor are we doing ourselves any favors by molly-coddling ourselves after an eating infraction. You say you don’t do that? Well, I sure do. I eat five cookies off the plate on the break room table at work, sigh, and grab a sixth cookie while thinking, “It’s just too hard to resist those cookies, you’ve had such a trying day, you deserve a treat, you poor thing.” That kind of response also reinforces the very behavior that’s can keep me from maintaining my hard-won weight loss goal. The reward-punishment cycle is hard to stop when it’s so deeply ingrained in us, but it is possible to end or at least reduce the occurrence of the negative stuff. One of the things that’s helped me regain control over my eating behavior (on many levels) is keeping a food log. Entering my food intake (including time of day, amounts, the eating environment, my physical hunger, any eating problems, and how I felt emotionally before, during, and after eating) has forced me to put on my scientist hat. I’ve always thought of myself as an intuitive, creative person, not a scientific one, but sometimes when I act a part, I become a part. When I’ve written down all this data about my eating, it’s easier for me to see it with an objective eye. Patterns that are invisible to me when I’m in the middle of a situation become clear when I’ve backed far enough away from it. Things that I didn’t understand when they happened to me yesterday have new meaning when I study them today. Things that I don’t really want to understand also become clearer to me when I see them in my food log. For example, after my weight loss surgery it became increasingly difficult for me to eat when sharing a meal with my elderly mother. Twenty years earlier, eating with her was a joy because we both loved food and the conversation that surrounds a meal. As she grew older, fussier, more confused, more demanding, the joy drained away and I found myself in the middle of painful stuck episodes every single time we ate together. A few hours after each incident, I would find myself seeking comfort in food, like stopping at Baskin-Robbin’s for a 670-calorie Cappuccino Blast after leaving Mom in the capable hands of her assisted living facility staff. I loved my mom, I loved our old ritual of enjoying meals together, but it just wasn’t working any more. Time to make a change, Jean! After that realization, when it was time for a family meal, I spent the time fussing over Mom instead of trying to eat my own meal. I ate my meal later, when Mom was safely tucked in bed. The take-home message here is this. Try to avoid the extremes of “good girl, bad girl” thinking, not just in your eating but in your exercise, work, parenting, and anything else you undertake. Sometimes a little bit good can be good enough, and a little bit bad doesn’t necessarily signify the collapse of western civilization. Try to be a kind, tolerant, but firm parent to yourself. Instead of screaming, “Bad girl!” when you fall off the bandwagon, give yourself a boost back up onto the wagon by saying, “That wasn’t good, but I know you can do better, so go prove it.”

If you’ve been married as long as I have (we just celebrated our 25th wedding anniversary), you’ll probably know what I mean when I say that at times, my relationship with my husband is a love-hate thing. The hate is provoked by stupid little things, like: why must an adult male in good health and in possession of all his faculties spit toothpaste on the bathroom mirror every single day of his life? Ten minutes after wanting to throttle him for that, I catch a glimpse of him cuddling a tiny kitten and my heart melts. He has truly been there for me through thick and thin (more thick than thin) and I can’t imagine life without him, but the next time I walk into the bathroom and see the Colgate version of a Jackson Pollock painting on the mirror, my husband’s life will hang by a thread, at least for a few moments. I also have a love-hate relationship with my band at times. I resent it because it prevents me from eating mindlessly. I love it for the very same reason, but when I’m tired or hurried or distracted, the effort to eat carefully seems enormous. Why can’t my band just do its job and leave me the heck alone? I’m by no means a lazy person but there are days when living with an adjustable gastric band is a lot of work. It’s certainly not a spectator sport – to win this game, you have to jump right in and get busy, and it’s not over when the cheers fade away…it starts all over again the next day, and the next day, for the rest of your life. Like me and the stupid bathroom mirror. Happily Ever After? I think that many people have bariatric surgery believing or hoping that it will solve everything, that they’ll never have to struggle with their food or eating again. Most of the time, that’s not the happy ending to their story. Their story has a different ending that could be happier if they adjust their thinking to it. Is the burden of good eating choices too heavy? If surgery helps you lose all the excess weight, shouldn’t it help you maintain that weight loss without another thought for the rest of your life? Dream on. I’ve seen a lot of bandsters (including the short blonde one in that bathroom mirror) crash into the Forever Wall, kind of like hitting the “seven-year itch” in a marriage. We prepare for band surgery with all the hope and care of a bride and groom planning a wedding – what we’ll wear, what we’ll eat, what music we’ll dance to. We enjoy a romantic honeymoon with the band, things go great for a while, and then things get harder and harder. At that point, you can fall in love with another bariatric procedure, believing that a revision to gastric bypass or whatever will hand you the key to happily-ever-after. Or you can stick with the partner you’ve already got, survive some tough times, and come out of it all the stronger. My friend Tami send me these wise comments: “Your comparison of WLS to marriage made me chuckle. One time my daughter asked me whether I’d ever divorce her dad (sometimes he can be such an ass!). I said, “Absolutely not. He’s family. You sometimes can’t stand your brother, but you can’t divorce him.” Now, if there was a serious “complication” in my marriage, like abuse, I’d have to reconsider my options. And that’s exactly how I feel about my band. It’s part of me, and as long as it doesn’t abuse me with serious complications, we’ll stick together. And just like my husband, I have to respect my band, take care of it, and learn from mistakes.” To Have & To Hold – til it’s no fun any more? I’ve survived some complications with my band that I suppose you could classify as on the low side of serious: a band slip, and a flipped port. Since the actions my surgeon and I took in response to these complications were swift (in the case of the slip) and sensible (in the case of the port flip), neither one of them ever endangered me – not in terms of my health, and not in terms of my quality of life. In fact, they seemed quite minor to me compared to other problems that my fellow humans face every day – a terminal cancer diagnosis; a fatal automobile accident; a crippling disease; the loss of a partner; parent or child – that except for the occasional moment of frustration or angry, “Why me, God?”, I just kept trudging onward. Perhaps another person with a different world-view and/or different expectations would consider a band slip grounds for divorce. I can’t criticize people who choose divorce, whether it involves their spouse or their band. Only I can decide what’s acceptable and tolerable for me, and others must decide that for themselves. But if you walk down the church aisle three minutes before your wedding begins thinking, “If I don’t like marriage, I can always get a divorce,” perhaps you don’t belong in the church in that fancy get-up in front of all your family and friends after all. At this (fairly advanced) stage of my life, I’m convinced that God or the universe throws nails on the road before me as a way to get my attention, make me stop and get my bearings, make me enjoy the scenery and make me appreciate how far I’ve traveled so far. So I do my best to learn what I can from each challenging situation with the gastric band that’s complaining or my husband who’s vigorously brushing his teeth or the dog who’s chewing on a chair leg. For all I know, my greatest goal in life is to be a champion cleaner of bathroom mirrors!

And other things you need to know about WLS but are afraid to ask... I wonder sometimes if bariatric professionals forget to emphasize the importance of good band eating skills because they they've never had to live with a gastric band. Of course, a few bariatric professionals are also bariatric patients, and thank goodness for that. I also wonder if bandsters are unaware of the importance of good band eating skills because their brains slipped into neutral during that part of their pre-op education. You'll have a hard time convincing me that's never happened to you, because I am the Queen of Lists and Note Taking. In high school and college, classmates would pay me for copies of my class notes. (Not only were they thorough, they were neatly penned in my prize-winning handwriting and decorated with cunning cartoons depicting my teachers and professors in embarrassing situations.) I take a notebook and a list of questions to every medical appointment, I ask questions, I re-read my notes, but despite all of that, my brain tends to shift gears when I see or hear something that strikes me as unimportant or irrelevant. And aside from being The World's Greatest Living Expert on Everything, what exactly qualifies me to make the unimportant or irrelevant judgment? Nothing. Nada. Nichts. Niente. During my pre- and post-op patient education, which was tailored exclusively to bandsters and administered by well-prepared bariatric dietitians, nurses, physician's assistants, and so on, I must have heard the eating skills lecture a dozen times. I was told that if I didn't eat carefully, I would end up in pain or with my meal in my lap. I nodded my understanding each time I heard that and could repeat the lecture verbatim, but it wasn't until I took a huge bite of a grilled cheese sandwich 24 hours after my first fill that I truly understood what all those folks had been telling me. And that’s not an experience I’m likely to forget. Take Tiny Bites I talk about good eating skills a lot. Why do I go on and on about that? Is it because I like the sound of my own (editorial) voice? Well, sure - that's no secret. But for what reason besides that? Important information bears repeating, and repetition is one of the ways that we acquire new information and learn new habits. If you doubt that, pay attention to how many times the Geico lizard appears on your television screen each day. Good band eating skills must become a habit if you're going to succeed with your band and avoid side effects and complications. Those eating skills must be your habit every hour of every day, not just as a new post-op or after each fill, but every day for the rest of your life. That sounds like a pretty tall order, doesn't it? Don't panic, though. A well-ingrained habit doesn't take as much conscious thought as a brand-new one. Your own behavior has already proven that if you've ever found yourself with a half-finished Twinkie or a cigarette or a beer in your hand and couldn't remember how it got there. It works the other way too. Your healthy new habits will eventually dig themselves into your life and using them will get easier as you go along. When you forget your band eating skills, your band will give you a loud reminder in the form of side effects like PB's, sliming, or stuck episodes, but I beg you not to rely on your band's built-in warning system on a regular basis, because doing so will send your bandwagon skittering down the road to complications like esophageal dilation, stomach dilation, band slips and even band erosion. One of the problems with the band's alarm system is that the truly destructive behaviors it reacts to may trigger relatively mild warnings so long before the damage is done that it's easy to shrug them off. For example, let's say that you often take big bites, don't chew very well, eat quickly, and/or eat beyond your soft stops (soft stops are gentle stop-eating signals, like hiccups). Each time you do those things, you experience mild discomfort. Nothing horrific. It happens, you think, "Oops," and you go back to whatever you were doing before the discomfort happened. Eventually this mild discomfort becomes just a part of your post-op life - the same as the way you sneeze when you pet a cat, pass gas when you eat beans, or get a headache when you don't wear your eyeglasses. Hey, that's just the way it is, right? But one bad day after dozens of ordinary days you can't even swallow your own saliva. You rush to the doctor, who does an upper GI x-ray and tells you your band has slipped. "How can that be?" you cry, "Everything's been fine until now!" In fact, everything has not been fine, because your careless eating has been pushing, pushing, pushing at your band's limits, until finally it pushed your band up your esophagus or down your stomach. I don't like finger-pointing any better than you do, but whose responsibility is that band slip? Is it your surgeon's, for not stitching it on there well enough? Is it the band manufacturer's, for not making your band slip-proof? Or is it yours? There can be a happy ending to your story, though. Even if the band slip is clearly your fault, you won't get sent to prison to sip brackish water and gnaw on stale bread for the rest of your days. Your surgeon can unfill your band (or, less likely, re-operate to reposition your band), and you can revamp your eating skills, lose weight, and live happily ever after. Or better yet, you can avoid the pain, inconvenience, financial and emotional costs, and pay attention to your eating from now on. I ain't gonna lie to you...acquiring and practicing this new habit won't be easy, but I can think of a lot of things that could be worse. A lot worse. The official Bandwagon® Eating Skills are: 1. Don't drink while you eat or for 30 to 60 minutes afterwards. 2. Take tiny bites. 3. Chew, chew chew. 4. Eat slowly. 5. Eat the protein first. 6. Learn your stop signals. 7. Pay attention to problem foods. 8. Eat only when you're hungry. 9. Avoid liquid calories and slider foods. 10. Use a small plate. 11. Plan your food in advance. 12. Don't watch TV or read while you eat. 13. Don't put serving dishes on the dining table. 14. Eat sitting down at the dining table. 15. Follow the HALT rule (don't eat when you're too hungry, angry, lonely or tired). You’ll find full explanations of each skill in Chapter 12 of Bandwagon, Strategies for Success with the Adjustable Gastric Band, by yours truly.

From time to time, a bandster will comment (sometimes in the context of a complaint, sometimes just in surprise or confusion) that weight loss with the band is basically the same as weight loss with a diet. They’re disappointed by this. They expected WLS to make weight loss easier than it is with dieting, and while that's true, it's only part of weight loss success. They may hold the mistaken belief that the band itself is what causes weight loss, but that’s not true either. The band is just a piece of plastic. Although it’s inside the patient’s body, it does not directly affect the way nutrients from food are ingested or metabolized. It releases no weight loss instructions into the patient’s bloodstream, nervous system, or endocrine system. It doesn’t directly affect the patient’s eating behavior or exercise habits. It doesn’t compel the patient to make good food choices, limit portion sizes, eat slowly, or resist the urge to graze or binge because of boredom, stress, cravings, etc. After reading that long list of what the band doesn’t do, you may be thinking that it’s a mighty expensive and not very helpful weight loss tool. Why go through the risk, trouble and expense of WLS when you could achieve the same results with plain old dieting? HALF EMPTY OR HALF FULL? Here’s some news that may shock you: I lost 100% of my excess weight by dieting after my band surgery. My dietitian gave me a food plan to follow, and I followed it. It never occurred to me to do otherwise or to complain about that because my bariatric team had made it clear that I, not my band, was going to have to make some significant lifestyle changes in order to succeed. It wasn’t until after the excess weight was gone, after a big unfill to treat an irritated esophagus and stoma (after swallowing a large, corrosive antibiotic capsule), that I realized how much my band had been helping me by reducing my appetite and giving me early (if not always prolonged) satiety. I had been taking my band for granted – out of sight, out of mind. I suppose it’s possible that I had been experiencing a placebo effect; that my band worked for me simply because I believed it would. If so, it was a remarkable and long-lived placebo effect. It wasn’t until my band was being refilled after a complete unfill (to treat a band slip) when I was 3 years post-op that I experienced a stunning, “Oh, so this is what it’s all about!” aha moment. My experience of restriction then was quite different than it had been the first time around, because I understood more about my band’s effects and how to optimize those effects, and because my body had changed so drastically since my surgery. Whether your 8-ounce water glass is half empty or half full, it still contains 4 ounces. Getting the most out of those 4 ounces is largely a matter of attitude adjustment. You can accept that you have 4 ounces, then make the best of it, or you can give up all together and spend your life in wistful regret. You can find another way to fill your WLS glass – complain to your surgeon, or the band manufacturer, revise to a different WLS procedure – or give up altogether and spend your life in angry regret. Taking the “half full” viewpoint may be easier for me than for others because I’m an opportunist who actually enjoys making a silk purse out of a sow’s ear. Webster defines “opportunist” as one who uses the art, policy, or practice of taking advantage of opportunities or circumstances, often with little regard for principles or consequences. Since I do have immense regard for principles and consequences, perhaps I’m not a classic opportunist. But I see nothing wrong with taking advantage of opportunities and circumstances when my own careful plans aren’t working or have led me into unknown territory. Resourcefulness has been a handy life skill for me. BUT I WANT IT TO BE RIGHT THE FIRST TIME I do know what it’s like to be disappointed with a purchase, though, be it a band, a blouse, or a bicycle. I want the item I purchase to be suitable, if not perfect, for its intended use. During a shift at my retail “day job” the other day, I helped a customer whose garment size wasn’t in stock. She didn’t want to order that garment – she wanted it now, so much so that she considered buying the wrong size and having it altered to fit her. Before I could volunteer an opinion, this woman uttered the very words I was thinking: “I hate to pay good money for something new and have to alter it. I just want to buy it and wear it.” If I were a better (or pushier) salesperson, she might have bought that garment, but I’m not and she didn’t. If your adjustable gastric band hasn’t (yet) lived up to your expectations, you do have my sympathy. It’s not easy – if even possible – to return a disappointing medical implant, and it’s maddening to have to “alter” it (by dieting, for example) to make it work for you. I could tell you (unhelpfully) that your expectations were not realistic, but it’s also possible that your surgeon educated you well, you’re a “compliant” patient, and yet your band just isn’t up to snuff. According to Doctors Jerome Groopman and Pamela Hartzband, authors of Your Medical Mind, “Medicine is an uncertain science.” No one, not even your doctor, can say with certainty what impact a condition “will have on an individual’s life or how someone will experience the side effects from a particular treatment. Each of us is unique in the interplay of genetic makeup and environment. The path to maintaining or regaining health is not the same for everyone.” Doctors Groopman and Hartzband go on to describe what they call the ‘focusing illusion’. “In trying to forecast the future, all of us tend to focus on a particular aspect of our lives that would be negatively affected by a proposed treatment. This then becomes the overriding element in decision making. The focusing illusion neglects our extraordinary capacity to adapt, to enjoy life with less than ‘perfect’ health. Imagining life with a colostomy, after a mastectomy, or following prostate surgery can all be skewed by the focusing illusion. We cannot see how the remaining parts of our lives expand to fill the gaps created by the illness and its treatment.” Despite carefully-devised formulas and scoring systems (intended to direct resources and money to those most likely to survive) for calculating a patient’s chances of surviving a treatment or illness, doctors are lousy at predicting outcomes. A study in England found that one out of 20 ICU patients who doctors predicted would die actually lived, and most of those who survived had a good quality of life. I don’t think that’s a sign of medical incompetence. I think it’s a sign of the unquenchable human spirit and its enduring will to survive and even thrive against all odds. One of my life goals is to survive and thrive, no matter what. That’s an ambition you can’t get from a medical device or bottle of medicine. It comes from within you, and if you think you don’t have it, or not enough of it, I suggest that you look again. You might be pleasantly surprised.

No, I haven’t lost my mind. I still think the band is grand and I still wish I still had mine, but because I want everybody to succeed at weight loss, I feel duty-bound to tell you some reasons not to have adjustable gastric band surgery. So here goes, in no particular order. Don’t have band surgery if… You’re phobic about needles. Right now, a needle is the only way to get fluid into the band. The fill needle is not a big, scary one, and you don’t have to look at it at all if you prefer, but it’s still a needle. You believe that band surgery cures obesity. Obesity is an incurable, chronic disease with the very real potential for recurrence. Weight regain can happen to anyone. You think that once you get to your goal weight, your weight loss journey stops. Nope. It’s only just begun. Next you’ll have to maintain that weight loss for the rest of your life, and that takes vigilance and hard work. You’re a self-pay planning on having surgery in Mexico or elsewhere out of country. What are you going to do if you have a problem or complication or just need another fill or unfill? Travel back to the Mexican clinic? Try to get help locally? Finding a US-based bariatric clinic that will accept patients who had surgery overseas is not easy, and once you do find one, you’re probably going to have to pay a non-refundable program fee, from $200 to $2000. You can’t afford the time and expense for frequent follow up visits for fills, unfills, and other medical care. Even if your insurance covers those visits, you’ll have to take time off work, arrange for child care or pet care, fill your car’s gas tank, and shell out a co-pay. You're a self-pay and don't have money or plans for dealing with fills, unfills, and possible complications. See above. You hope to lose weight without getting any fills. Sorry, but it probably won’t work that way. See above. You expect to lose a pound+ a day. Average weight loss with the band is 1-2 pounds/week. That average includes people who lost weight faster as well as people who lost no weight at all. Rapid initial weight loss is usually related to fluid retention, not fat loss. You believe that slow weight loss with the band will prevent sagging skin. According to several plastic surgeons I’ve asked about this, your age and genetics have the most influence on how your skin will respond to massive weight loss. The rate of weight loss has little or anything to do with it. You expect to experience restriction and lose weight steadily from the moment you wake up after surgery. Most band patients need several fills to achieve optimal restriction, plus more fills and unfills (or adjustments) to maintain that restriction, and virtually no one loses weight at a steady rate. My weight loss was extremely uneven – down 1#, down .5#, up .75#, down 1.75#, down 0/up 0, down .25#, and so on. You believe in the sweet spot or perfect restriction. Restriction is constantly changing, just like our bodies, because of dozens of quite ordinary factors (food choices, eating and drinking habits, weight loss, time of day or month, illness, medications, stress, etc.). If you think you’ll lose weight only at the mythical sweet spot, you’re going to spend energy on frustration that could be better applied to changing your eating behavior. You’re not willing to follow pre- and post-op liquid and puree diets. No, liquid and puree diets are not fun, but they’re short-term. When I was banded, I had 36 years ahead of me, assuming that I live as long as my mother did. That’s 12,672 days. My pre- and post-op liquid diets used up a whopping 17 days. Do the math. Even if you add in post-fill liquids and purees, those liquid and puree days represent a teeny, tiny fraction of my life. You believe you’ll never be hungry again. Maybe, maybe not. The fact that you feel hungry 5 hours after a meal doesn’t mean your band isn’t working. It just means that your body needs fuel. And part of your ongoing work as a bandster is going to be figuring out whether you’re feeling physical hunger or “head” hunger. You think the band is going to do all the work for you. The band has no magic ingredient that triggers weight loss once it’s wrapped around your stomach. All it does is affect your hunger and appetite. The band is not going to make good food choices, practice portion control or banish the demons who make you eat when you’re stressed or bored. Nor is it going to exercise for you. Success with the band is the result of a joint effort between you, your band, your surgeon and dietitian. Have a don't-have-band-surgery reason to add to this list? Post it in the comment section!

ADJUSTING TO BANDED LIFE Having weight loss surgery is a huge project. You spent months, even years, in research, education, preparation, recovery and adjustment. No wonder you're obsessed with it. But it is not the only thing going on in your body and your life. It is not the cause of every adverse - or favorable - event. When I buy a new car, I go through phases similar to the ones I experienced as a new bandster. I look around, do research, study and compare before I buy. With all of that foremost in my limited-capacity brain, I cherish my new possession, and suddenly I see that same vehicle everywhere. Like magic, the same make, model, and even color is on every road, in every parking lot. It’s as if the 2011 Toyota Camry has become my world. Gradually the novelty wears off, things shift back into position, and the Camry becomes transportation again – at least until it suffers its first scratch or dent. Adjusting to life with a new band can be a lot like life with a new car, or even more so, because an adjustable gastric band isn’t something (I hope) you’re going to tire of and trade in one day. It’s a lifetime commitment, and even if your insurance pays for all or part of it, a band is a huge investment in terms of time and energy. It’s not surprising that everything that happens to you as a new post-op gets filtered through the AGB lens. We suddenly tune in to every little whisper of AGB stories, especially scary ones. As we move forward in the shiny new vehicle that we hope will take us far from the land of obesity, we listen carefully for any suspicious creaks, squeaks or whines, while cringing at every little bump in the road. After months of preparation and anticipation, we’re now in a hyper-vigilant mode that rings an alarm bell every time something even mildly unfamiliar happens in our bodies. We’re so alert that even a sore toe could be a sign of something insidious happening to our bands. We analyze every sneeze, every burp, asking, “Is this normal? Is something wrong with me or my band?” The answer to that is almost always, “Completely normal, and nothing wrong.” Although there's a tendency to interpret every post-op experience (especially physical ones) as band-related, chances are that the pain in your big toe has nothing to do with your band. It's easy to "awfulize" things when you have a pain, symptom or experience you didn't expect and can't explain. You're sure that's something's wrong. You haven't lost weight in three days, or you found hair clogging your shower drain, or you puked up your spaghetti dinner. You’ve probably had more practice at dealing with this kind of worry than you give yourself credit for, because it applies to many other aspects of your life. It's extremely difficult to make a good decision when you're in a panic. Your vomiting might be band-related, but it could also be the result of a garden-variety intestinal bug. Your teenaged daughter's failure to return your phone call could be because she was in a terrible accident, or it could be because her cell-phone battery died. WHEN SOMETHING GOES WRONG First, take a deep breath. Panic will not solve the problem, and it might make it worse. First, have a look at any discharge instructions or other written post-op information you were given before or after your surgery (if your surgeon or the hospital doesn’t give you anything like that, ask for it!). Then ask yourself: Is this an emergency? Is it life-threatening, disabling, or just inconvenient? What will happen if I don't do something about it right now? Can I deal with this myself, or do I need help? What kind of help (medical, emotional, spiritual, financial)? Who can help me (my surgeon, therapist, best friend, minister)? Be careful how you choose your helper(s). I know you love your sister, who might tell you that everyone in her family has been sick with a bug since you saw them (and their germs) on Sunday, but she cannot tell you whether or not your band slipped. So please don’t ask her, me, your hairdresser, neighbor, personal trainer, or a casual Internet acquaintance for medical advice. We may be well qualified to sympathize, but we’re not qualified to give you medical treatment, so call your surgeon instead. But first, make a list. I like list-making because it gives me the illusion of control and because it helps jog my memory when I finally get a doctor, nurse or dietitian on the line. If nothing serious (a temperature over 101°F, you can’t drink clear liquids, you can’t stop vomiting) or life-threatening (you can’t breathe, can’t move, can’t speak, are bleeding profusely, etc.) is on the list, consider waiting to call your surgeon for an hour or two, or until you have a list of at least three questions. Use that time to think of the answers to some basic questions your surgeon is sure to ask: how long the problem has been going on, whether it’s constant or intermittent, and whether it seems related to a particular behavior, time of day, or other event. If your list includes something life-threatening (see above), leave a brief message like “This is Jane Doe. I’m on my way to the ER at Hometown Hospital because I’m having severe chest pain” and don’t wait for your surgeon to call you back. Call 911 or have someone take you to the emergency room. But once you’re there, remember that you can’t expect the average ER doctor to know how to treat a problem related to bariatric surgery. The ER will rule out and treat things like cardiac arrest, infection, pneumonia, stroke, and the like, and will give you palliative care to make you more comfortable until your surgeon arrives or tells them what to do next. While it’s always okay to ask your surgeon or his/her staff about your worries, it’s important to remember that you are not the only patient under their care. If you don’t get a return call within a few hours of leaving a message, it may be because they’re overwhelmed with other patients’ problems and/or because they didn't understand the nature of your problem. Leave a clear, simple, but specific message. If you’re running a temperature and have a bad headache, say, “This is Jane Doe. I’ve had a temperature of 103°F and a bad headache for 5 hours. Please call me back as soon as possible at 123-456-7890.” NOT EVERYTHING IS RELATED TO YOUR BAND Now that you’re at least somewhat prepared to deal with medical emergencies that might arise, you need to hear this: not everything is related to your band. While it’s appropriate to be concerned and alert after any surgery and in adjusting to life with an implanted medical device like a band, don't let fear cloud your thinking. You will wear yourself to a frazzle if every event becomes a crisis, and you don’t want to neglect other important things in your life (like family, job, etc.) because your band has somehow taken over every waking thought.. I may sound unsympathetic, but I'm really not. I can whine with the best of 'em. I’m not saying that your confusion and struggles as a new bandster aren't important. They are. But it will be easier for you to handle them if you do it with a clear mind and a calm heart. I know from personal experience that worry and self-pity are deadly traps because they tend to paralyze you. So while it's good to keep your little buddy in the back of your mind when trying to figure out what's going on, remember that you are still vulnerable to the bacteria, viruses, accidents, exhaustion, bad habits, and dumb luck that ambushed you before your band surgery. Try not to let a three-inch ring of plastic hold you hostage. Your post-op life includes much, much more than just your band, eating, and weight loss efforts!

TIME FOR SOME TOUGH LOVE? Genuine Jean Tuff Luv™? What’s that? It’s my version of the kind of love that hurts so good, because it gets you going in the direction you want to go. Stern but caring parents, teachers and coaches who maintain strict rules and demanding training regimens are said to practice tough love. Those rules and regimens may not be fun, but they can turn around kids, students or athletes who’ve gotten off track or are underachieving. Tough love may seem too severe, too tough. It works best when the parent, teacher or coach believes in, proclaims, and respects the inherent value and purpose of the person they’re trying to help. Sometimes all we need is a wakeup call to shake us out of our stupor and pull us out of a rut. The drills and discipline of tough love can help (even as they hurt) when our bandwagons have gotten lost or stalled somewhere along the way to success. A bandster once said of me, “Jean tells people the things they don’t want to hear.” I chose to take that as a compliment. Many times in my life, I’ve benefited from a slap upside the head by a concerned friend. When I do the slapping, I try to do it with just enough emphasis to get a friend’s attention long enough to deliver an important message, followed by a gentle and loving kick in the butt. So here’s my top 10 list of things you need to know about adjustable gastric band surgery. Consider yourself kicked! THE GJTL TOP TEN LIST 1. You will not wake up in the recovery room at your goal weight. Average weight loss with the band is 1-2 pounds per week, and virtually no one loses weight at a nice steady pace of (say) 1.75 pounds per week. Some weeks you’ll lose, some weeks you’ll stall and some weeks you’ll gain, but as long as the overall trend is downward, you’re doing great! 2. Slower weight loss with the band does not prevent sagging or excess skin. How your skin reacts to massive weight loss depends mostly on your genetics and your age. As we age, our skin loses elasticity. If the possibility of sagging or excess skin worries you, start tossing your change into a plastic surgery piggy bank. 3. Weight loss surgery (of any type) does NOT cure obesity. Obesity is a chronic and incurable disease characterized by relapse and recurrence. Although bariatric surgery is currently the most effective way of treating obesity, obesity is something you’re going to have to manage for the rest of your life, with or without surgery. For most of us, a tool like the adjustable gastric band makes that a lot easier, but it’s not effortless, either. 4. Most eating problems after band surgery are due to user error, and can be prevented by using good band eating skills. Read an article about those skills by clicking here: How to Eat Like a Bandster. 5. In order to decrease your weight and increase your health, you must decrease your food intake and increase the quality of your food choices and the time you spend exercising. While you may be able to lose weight for a while by just eating much smaller portions of Chicken McNuggets, potato chips, and candy bars, eventually that approach will stop working, and at the same time it will start biting your health in the butt. And though it may be difficult for you to exercise at first, each pound you lose will make it easier, and each additional hour you spend exercising will not only burn calories but improve your physical and mental health. 6. No weight loss surgery procedure will cure eating disorders, eating demons, emotional eating, boredom eating, stress eating, celebratory eating or food addiction. Changing those behaviors is your job. If it’s too hard to tackle yourself, consider getting some counseling with a therapist experienced with eating disorder and WLS patients, and/or joining a 12-step group like Overeater’s Anonymous. 7. The band rarely works without fills. Even if you initially lose weight with one or no fills, sooner or later, you’re going to have to face the fill needle. And if you’re too needle-phobic to tolerate a fill needle, why did you choose band surgery in the first place? 8. The restriction “sweet spot” is a myth. There is no such thing as “perfect” restriction, or if there is, you can’t count on it to last more than one hour, one day or one week. This is because the band is an inert silicone object implanted in a living, breathing human body that changes constantly in reaction to the time of day, time of month, time of year, hydration, illness, medication, stress, you name it. Restriction variability is part of the gastric band package. 9. There is nothing magic in the band that makes you lose weight. Changing your eating and exercise behavior is what makes you lose weight. All the band does is make that work easier for you by reducing your physical hunger and increasing your satiety. 10. YOU are responsible for your weight loss. Not your band, not your surgeon, and not the server at McDonald’s who invariably asks you, “Want to supersize that?”

TIME TO THROW OUT SOME OLD MYTHS It’s time to throw out some old myths about the adjustable gastric band, but before we start flinging those myths around, let’s all agree on what a myth is. The traditional definition is that a myth is an ancient story of unverifiable, supposedly historical events. A myth expresses the world view of a people or explains a practice, belief, or natural phenomenon. For example, the Greek god Zeus had powers over lightning and storms, and could make a storm to show his anger. If you think myths are dry stuff found only in schoolbooks, think again. They surround just about every aspect of our lives, and travel much faster now, in the age of technology, than they did in the dusty old days of ancient Greece and Rome. They’re a way for us to make sense of a chaotic world, both past, present and future. They affect thoughts, beliefs, emotions and assumptions in our everyday lives, coming alive in our minds as we, and the people around us, seem to act them out. Some myths are helpful because they give us a shared sense of security and express our fundamental values and beliefs, but some myths are just plain wrong and can be harmful to us and to others. A good example is the myth that having weight loss surgery is taking the easy way out. Every time I hear that one repeated, I want to laugh and scream at the same time. If you’re a post-op, you know why. Weight loss is hard no matter how you do it (surgery, diet pills, prayer, magic cleanses, and so on). On the other hand, WLS is supposed to be easy, compared to the dozens or hundreds of weight loss attempts in our past. Why on earth would I put myself through a major surgery if it wasn’t going to help me lose weight and keep it off? Now that we’ve shared a little laugh (or scream) over a WLS myth we can all agree upon, let’s test out some band myths whose validity may not be as clear. This kind of examination can be uncomfortable, but believing in a falsehood is almost guaranteed to make your WLS journey bumpier than it needs to be. Let’s start with the myths that are easiest to digest and end with the ones that can be tougher for a bandster to swallow. #1 – THE BAND IS THE LEAST INVASIVE WLS PROCEDURE I believed this one at first, mainly because I knew little about the other WLS procedures back in 2007. It’s still a widely-circulated myth, one that even my surgeon’s well-intentioned dietitian endorses. So, what’s the truth according to Jean? Face it: any surgery done on an anesthetized patient, during which a surgeon cuts into the belly in several places, does some dissection (more cutting) and suturing (stitching) of the internal anatomy, and implants a medical device (the dreaded “foreign object”), is invasive. It is true that band placement generally involves less internal dissection and suturing than other weight loss surgeries, but neither is it on the same level medically as having your teeth cleaned. So while the invasiveness of a surgery is worth considering, you do yourself a disservice if you let that override other considerations. A bariatric surgery might last 45-60 minutes, with recovery lasting a week or so, but its effect on your health and lifestyle last a lifetime. Or I sure hope it does. Some people associate invasiveness with irreversibility. Although the band is meant to stay put once clamped to your stomach, it can indeed be removed if medically necessary. Gastric bypass (RNY) surgery can also be reversed, while the sleeve (VSG) cannot and only the “switch” (malabsorptive feature) of the duodenal switch (DS) can be reversed. Removal or reversal is not as easy as operating on a “virgin belly” (as my surgeon so colorfully puts it), so it’s important to weigh the benefits against the risks of reversal or revision surgery. #2 – BAND WEIGHT LOSS TAKES TOO MUCH WORK Aside from the desire for instant and effortless weight loss (which is a fairy tale if I ever heard one) that so many obese people share (me among them), this is a myth that often turns people away from the band and towards other WLS procedures. While this myth may be true in the first 12-18 months after surgery, eventually everyone ends up in the same boat, rowing hard against the powerful tide of obesity. Weight loss and weight maintenance is hard no matter how you achieve it. A dietitian who spoke at a band support group meeting I attended a few years ago said that while band patients must change their lifestyle immediately in order to succeed, every WLS patient must do that sooner or later. It’s a pay-me-now or pay-me-later deal. You can slice it, dice it, sauté it and serve it on your grandmother’s best china. However you serve it, weight loss and maintenance is a lifetime project because obesity is a chronic disease with no cure. No matter how successful we are as new post-ops, all of us must face the possibility of regain. That’s why I cringe when someone proudly crows, “XXX pounds gone forever!” #3 – THE BAND’S SLOWER WEIGHT LOSS PREVENTS SAGGING SKIN This is a fairy tale. According to several plastic surgeons I’ve heard speak on the subject. The effect of weight loss on skin depends mostly on your genetics and your age (because skin loses elasticity as we age). Other factors can be how obese you were, how long you were obese, how you carried your weight, and how much (and how) you exercise as you lose weight. I’ve heard women say that they’d rather be obese than have sagging or excess skin. To my mind, that’s a sad statement, because I’d rather have sagging or excess skin (as long as it didn’t interfere with my ambulation or activities) than excess weight. Don’t get me wrong: I loathe the excess flab on my midsection (whose nickname is “The Danish Pastry”) and I’m not thrilled about my batwings, throat wattles, or anything else that’s happened to my skin in the past few years (during which I’ve undergone the double-whammy of weight loss and the fast approach of my 60’s). On the other hand, I think I look pretty good for a woman my age, especially when I conceal my figure flaws in flattering clothing which, I might add, no longer needs to be purchased at Lane Giant. #4 – TO LOSE WEIGHT, YOU HAVE TO FIND YOUR SWEET SPOT I used to wonder how the Sweet Spot Myth could survive in the face of so much clinical evidence against it, but last year I heard the “you gotta find your sweet spot” claim uttered by a bariatric dietitian, so apparently this is a myth being validated by medical professionals who ought to know better. Instead of the sweet spot, Allergan (the first to introduce the band in the USA) uses a zone chart to illustrate band restriction, with not enough restriction in the yellow zone, good restriction in the green zone, and too much restriction in the red zone. In other words, restriction happens in a range of experience, not at a single static point. That experience changes over time as we lose weight, deal with ordinary processes such as hormonal fluctuations, hydration changes, stress, medications, time of day, and so on. It’s also affected by our food choices (solid vs soft/liquid food). In my banded days, I traveled through and around a sweet spot many times. It might last for 30 minutes, 3 days, 3 weeks, but it never stayed exactly the same, and yet I still lost weight! I don’t actually want to stay exactly the same for the rest of my life (throat wattles notwithstanding). As any Parkinson’s disease patient will tell you (if they’re able to speak), a body that gets stuck in time is a very big problem (and with my luck, I’d get stuck in the worst sinus infection or case of the flu of my life). Some people who are very sensitive to their band and its fills find sudden or unexpected changes in restriction to be very, very frustrating, and I wouldn’t wish that on anyone, either. To read more about the sweet spot, click here to go to an article, The Elusive Sweet Spot. http://www.lapbandtalk.com/page/index.html/_/support/post-op-support/the-elusive-sweet-spot-r59 #5 – NO SIDE EFFECTS MEAN MY BAND ISN’T WORKING Equating side effects with a properly working band is very common, and potentially very harmful. The two most significant signs of the band’s proper functioning are (1) early satiety and (2) prolonged satiety. Those signs are rarely expressed in large, bold, uppercase letters, such as STOP EATING NOW! Those signs won’t be accompanied by clanging bells or flashing lights, either. In fact, the less noise and distraction (such as “Why don’t I have stuck episodes?”), the more likely you are to be able to recognize early and prolonged satiety. Before I tell you why the no side effects = broken band worry is a sign of mythical thinking, let’s make sure we agree on the definition of a side effect, and how that relates to complications. A side effect is an unintentional or unwanted effect of a medical treatment, and it’s usually exceeded (or at least balanced) by the benefits (the intentional, wanted effects) of that treatment. For example, antibiotics can cause diarrhea. That’s an unpleasant side effect, but an untreated infection can have far worse consequences for the patient. Side effects can often be managed by tweaking or changing the treatment, and they are rarely worse than the original condition. A complication, on the other hand, is a more acute, serious consequence of a medical treatment, and usually needs a more aggressive approach, including surgery to fix the problem. Now let’s go back to the antibiotic example. An allergic, anaphylactic reaction to the antibiotic can be fatal without prompt medical treatment. That’s a complication, and it’s far worse than the original condition. So in the context of all that, it seems strange to me when bandsters long for side effects like regurgitation (PB’s), stuck episodes, and sliming. Instead of looking for more subtle clues from their bodies (like early and prolonged satiety), they go looking for problems, and worse than that, they tend to “test” their band with foolish eating and/or overeating, hoping to provoke a side effect that will signal to them that they really do have a band in there. One of the many problems with that approach is that it can also provoke a complication. And that brings us to the final myth in today’s article: #6 – THE MORE FILL, THE BETTER I’ve heard bariatric surgeons comment that some band patients seem to be addicted to fills. I can identify with that because I had a good relationship with my band surgeon who not only administered my fills but gave me a lot of encouragement as well as answers to my many questions. I left each fill appointment with a renewed sense of commitment and hope. How can you not get hooked on something good like that? The problem with equating fills with weight loss success is that more fill is not always better. In fact, too much fill (which varies from one patient to the next, and also varies in a single patient as time goes on and the patient’s body keeps changing) can be downright dangerous. An overfilled band, and the side effects it causes (see #5 above), can lead to a complication like a band slip, esophageal dilation, or stomach dilation. While complications can come out of nowhere, most bariatric surgeons agree that too much saline in the band puts too much pressure on the stomach. Eventually something’s got to give. That’s often hastened by the patient’s efforts to eat around the problem, and it is absolutely not a guarantee of weight loss. I gained weight several times because of what’s called Soft Calorie Syndrome. My band was too tight and I was dealing with it by consuming mostly soft and liquid calories that offered little or no satiety. The human body is an incredible organism, capable of amazing feats of growth and healing that we take mostly for granted, but it’s not endlessly forgiving. Too much fill in your band, too many eating problems, too much inflammation and irritation in the upper GI tract, can compromise your body’s ability to recover from a complication like a band slip. Sometimes a complication can be treated conservatively, with an unfill and rest period, but sometimes it requires a surgical fix, including removal of the band. And after all you’ve gone through to get that band wrapped around your stomach, shouldn’t you be doing your utmost to treat it (and your body) with respect? Finally, the fill myth can cause us to overlook a very important guest at your WLS party….you. If you are going to succeed with your band, lose weight and keep it off and keep that band safe and sound inside you, sooner or later you will have to take personal responsibility for your success. Expecting your band alone to carry you to your goal weight is like expecting your car to safely deliver your child to school without anybody in the driver’s seat. And I sure hope that you are a very important person in your life!

It happens to everyone sooner or later. Your bandwagon stalls. You’ve been going great guns, fired up with enthusiasm, working that tool, doing all the right things, and losing weight. Then one day the weight loss stops. One day, two days, twenty days go by…you’re still stuck, and you’re wondering what happened. And because you’ve spent so many years failing at dieting, and being told that obesity is always the fault of the patient, you start to wonder what you are doing wrong. You even think, “Is my band broken?” Chances are, you’re not doing anything wrong, and neither is your band. What’s happening is that your body is adjusting itself to the many changes that have happened during your weight loss. The human body doesn’t know what you’re going to do next, be it climb a mountain or relax on the couch, so it has to continually adjust and readjust your metabolism to make the best use of the calories you take in. It looks at the history of what you’ve been eating and how much you’ve been burning off through physical activity and comes up with a forecast of what you’ll need to stay alive for the next week or so. THIS MONTH’S WEIGHT LOSS FORECAST IS… At work I’ve had to prepare sales forecasts for various jobs through the years. How many widgets will we sell in the month of April? How many defective widgets will be returned by unhappy customers who want a refund? Will all this income and outgo generate enough cash (in our case, energy) to cover the payroll and the equipment maintenance and the CEO’s country club membership? I once had a boss who joked that we might as well toss a deck of cards down a flight of stairs to come up with a prediction of which new product (represented, say, by the joker card) was going to be the best-seller. That suggestion didn’t go over big with the finance guys. Like us, they were trying to follow the rules, keep everything identified, counted and categorized. And like the bean-counters, we count our calories, carbs, fats, proteins, liquids, solids, income, outgo, with faith that this accounting system will help us win the weight game. Meanwhile, our bodies have a different agenda: survival. When we decrease our food intake and increase our physical activity, the body watches to see what will happen next. As our purposeful “starvation” continues, the body struggles to accommodate the changes we’re making. It makes some withdrawals of funds from our fat cells and fiddles with our metabolism to prevent an energy (calorie) shortage. Gradually it becomes acclimated to the new routine so that it’s making the best possible use of the few calories we’re consuming. It’s keeping us alive, but it’s also putting the brakes on weight loss. Eventually we find ourselves stalled on what seems like an endless weight loss plateau. And unless we change our routine and keep our bodies working hard to burn up the excess fat, we’re going to grow to hate the scenery on that plateau. AND ON THE FLIP SIDE I’ve suffered through countless weight loss plateaus but by varying my exercise, my total caloric intake, my liquid intake, my sleep, and so on, did manage to finally arrive at my goal weight. For the past few years, I’ve felt mighty smug that I finally got promoted to the Senior VP of Weight Management here at Chez Jean. Maintaining my goal weight +/- 5 pounds seemed effortless. But it didn’t last. Turns out it was time for me to learn another lesson about my body’s fuel economy. When I had all the fill removed from my band to deal with some bad reflux, my eating didn’t go berserk. I didn’t pig out at Burger King, didn’t drown my sorrows in a nightly gallon of ice cream. I was definitely eating more because I was so much hungrier than before – perhaps 500 extra calories a day, which would amount to a weight gain of one pound a week. Imagine my dismay when I gained seven pounds in 2 weeks – the equivalent of an extra 1750 calories a day! There was a time when I could have overeaten that much without any effort at all, but as a WLS post-op, I’d have to work hard at eating that much extra food. I was flabbergasted. And frightened. Obesity was a mountain on my horizon again – far in the distance across my weight maintenance plateau - when I thought I’d left it far behind. So at the end of a visit with my gastro-enterologist during that scary time, I asked him if my sudden and substantial weight gain was the equivalent of my body shouting, “Yahoo! We’re not starving anymore! Let’s get ready for the next starvation period by hanging on to every single calorie she takes in! Let’s store those calories in those fat cells that have been hanging around here with nothing to do! C’mon, troops, get to work!” I’m pretty sure that’s not the way Dr. Nuako would have explained it, but he smiled, nodded, and said, “Oh, yes.” I felt like I was facing the flip side of a weight loss plateau: I might be in a weight gain plateau. All I could do is keep on keeping on with exercise and healthy eating, enjoying some of the foods, like raw fruits and veggies, that had been harder for me to eat with a well-adjusted band. PUZZLING OUT THE WEIGHT LOSS PLATEAU So the good news was that my wonky metabolism following that complete unfill wasn’t my fault, but the bad news was that my metabolism wasn’t in a cooperative mood. I was going to have to start playing much closer attention to the details of weight loss and maintenance again. What a pain! But hey! I’d already had a lot of practice at that. I had the tools – a little rusty maybe, but still in usable condition. I ended up regaining 30 pounds between that unfill and my revision to VSG, but I have a suspicion that without those weight tools, it could have been 60 pounds. And that’s one of the reasons that even today, bandless for 14 months now, I don’t regret my band surgery. The band helped me lose 90 pounds and learn a host of useful (if uncomfortable) things about myself, my behavior, my body, my lifestyle. What about you? How can you get your weight loss going again and avoid regain? So many factors can affect your weight that sorting out the reason(s) for your weight loss plateau can make you dizzy even if you’re not a natural blonde like me. To help you assess what’s going on and what might need to be changed, I created a Weight Loss Plateau Checklist. To access the checklist in Google Docs, click here: https://docs.google....emtSYjJLRnVGTFE The checklist includes a long list of questions about you and your behavior, with answers and suggestions for each question. I can’t claim that it will give you the key to escaping that plateau, but it should give you some food for thought and perhaps some ideas to try. Use that to come up with a plan to deal with the plateau, and work that plan for at least a month to give your body a chance to get with the new program.

Growing up, I watched Popeye guzzle cans of spinach to instantly restore and increase his legendary strength as he battled his enemies and courted the thin, homely Olive Oyl. I didn’t identify much with Popeye or Olive Oyl – I was more like the portly J. Wellington Wimpy, who would gladly pay you Thursday for a hamburger today. But like millions of other children, I did get the message that spinach was good for me. Magically good! And if eating spinach could help me prevail in the endless fights I had with my brother, it was worth a try. I never did win a battle with my brother, but I ate my spinach and actually liked it. Not canned spinach like Popeye’s (the very sight of canned spinach is revolting), but frozen chopped spinach, boiled, drained, and covered with melted Velveeta cheese. When asked if he liked spinach, Popeye replied, “I hates it.” He might have liked my favorite cheesy spinach better, but clearly he was taking his spinach like medicine at a time in history when medicine always tasted terrible. The worse the taste, the more potent it was. Spinach didn’t give me bulging Popeye muscles (or, thankfully, his speech impediment), and since I hated gym class and avoided exercise as much as possible, I didn’t develop any more than minimal strength and endurance. When I reached puberty in the 1960’s, women’s liberation and the concept of a strong, independent woman were still quite new. My macho first boyfriend thought women shouldn’t be allowed to drive a car, never mind lift something heavy. As I wrote in Bandwagon, my parents scorned President Kennedy’s physical fitness advocacy and encouraged intellectual rather than physical strength. The exercise programs and studios I tried in the 1970’s and 80’s prescribed exercise for weight loss and toning; the dance classes I took taught me about form, agility and flexibility; but never did I hear any messages about strength. Perhaps I wasn’t listening very well. I thought that weight lifting would turn me into a muscle-bound freak like the ones I occasionally saw on television. As an adult married woman, I’ve had a tall, strong husband to open jars, change flat tires, take out the garbage, and reach things stored on high shelves (he claims that’s why I married him, when in fact it was his dog, not his brawn that captured my heart). That allowed me to reserve all my meager strength for the herculean task of moving my obese body from my arm chair to the kitchen and back. It wasn’t until I had weight loss surgery at age 54 that I learned about the value of muscle during weight loss. That was the first time ever that I heard that muscle burns calories faster, and takes up less room, than fat. The theory sounded good, but for my first post-op year I focused on cardio exercise because an online calculator showed that I could burn almost three times more calories doing an aerobic dance class than the same time spent weight training. I worked out faithfully, walking and doing a variety of cardio classes, and reached my weight goal, but I was still a weakling… a scrawny weakling instead of an obese one, a weakling who could wear a size 10 but struggled to pick up a 10-pound bag of dog kibble. Here at the 9 Dogs Howling ranch, that’s a serious deficit indeed! Eventually I got bored with my workout routine. To add more variety and challenge to my exercise, I began working with a personal trainer when I was 20 months post-op. My trainer taught me lots of moves with free weights and weight machines, some of which I grew to hate, but after about three months of our weekly sessions, I began to notice some muscle definition in my flabby arms. Nothing like Popeye, but there before me was proof, visible to the naked eye, that I actually had some muscles underneath that sagging skin. Even after I stopped working with my personal trainer, I kept working at strength training, hoping to see more and more muscles. All that effort was in the service of my vanity, you understand. I just wanted to look “ripped” and it didn’t occur to me that strongly-defined muscles could be pressed into service at home (lifting dogs as well as dog food bags) and at work (lifting boxes, shifting heavy display fixtures, climbing stock room ladders). Gradually I came to realize that I was getting physically stronger. I could no longer claim to be a “delicate flower of womanhood” like Scarlett O’Hara. That turned out to be no terrible loss. It turned out that being strong(er) was as good for my insides as my outsides. Not only was strength training helping make my bones and muscles stronger, it was making my mind and heart stronger. Instead of being afraid to try something new, I just went ahead and did it, and even if I brought absolutely no skill to the task, I had enough strength of mind and body to tough it out. Early in 2010 I joined a new fitness studio, one with Stott Pilates machines instead of weight machines. At first I worried that I would lose muscle definition without weight machines as part of my workouts, but in fact my muscle definition improved all over my body and especially in my legs. In late summer 2010, I did some personal training with the owner of the studio. Her first step was to give me a fitness evaluation. I had to do push ups, step ups, toe touches, and other moves to evaluate my strength, agility, flexibility and cardio fitness. Much to my (happy) surprise, I scored above average for my age in most of those areas. Just the process of being tested was a revelation, because each time Caroline instructed me to do a new move, I did it without any anxiety or hesitation about whether or not I’d be able to do it. Since then, I’ve thought many times about the importance of fitness and strength to an average, everyday woman like me. Not an Olympic athlete, not a dancer, not a ditch digger, not a materials handler, just Mrs. Middle Aged American. Although I admire my late mother and aspire to be like her in many ways, I don’t want to end up the way she did after a lifetime of avoiding exercise. She was only in her early 70’s when she began to struggle with little tasks that most of us take for granted. Dressing herself, picking a pen off the floor, getting out of a chair, walking from her apartment to the elevator, opening a door, all of that was too hard for her. She had never claimed to be a delicate flower of womanhood, either. She was one of the most capable and energetic people I’ve ever known, but she never took care of her body and in the end, her body failed her. I’ve vowed that I won’t let that happen to me. I’m going to keep this body moving, or die trying, and that’s got to be a better way to go than lying helpless in bed while an attendant maneuvers a straw into my mouth. I hope that in 20 years when I’m 78, I’ll enjoy sitting in a rocking chair beside my husband for a while, and then getting up to kick ass in an exercise class.

A WLS friend of mine, Tom B., posted a great article on his blog yesterday: 10 Cold Hard Facts about Weight Loss Surgery. I highly recommend reading the article no matter where you are in your WLS journey. Tom states those 10 facts quite plainly, but not in an accusatory manner - more like a good friend who's answering you honestly when you've asked, "What's it really like?" Here's a link to the article: http://beariatric.com/2013/12/16/10-cold-hard-facts-about-weight-loss-surgery/ Jean

Kiwiladydee, I have fibro also. When researching the Obesity-Fibro article, I spoke to a doctor who told me (in exact terms that I don't remember now) that weight loss releases toxins into your system - plus goodness knows what other toxins we're exposed to every single day in the modern world. Is the rash on your face bilateral (both sides) and shaped something like a large butterfly? That could be a sign of lupus erythematosus, along with your fatigue, pain, etc. Since lupus is an autoimmune disorder, it seems like it could be a first cousin to fibro. I was diagnosed with discoid lupus some 20 years ago. It rarely bothers me now, but I have to wonder if and how my obesity, fibro, and lupus are interconnected. Jean

Bariatric surgery can fail. No one wants to talk about that, especially when we’re filled with hope about what bariatric surgery can do for us. Why does weight loss surgery fail, and what does that mean for each of us? WHY DOES WEIGHT LOSS SURGERY FAIL? In the bariatric community, we spend a lot of time debating about which WLS is the best – that is, which one yields the best outcome (my own definition of that is optimal weight loss with minimal complications). I think we can all agree that there’s no such thing as a perfect or one-size-fits-all bariatric surgery. If we’ve all fought weight battles long and hard enough to need or choose WLS, we can surely agree that obesity is tough to overcome. And that is, I think, the grounds for further agreement, about why WLS fails. Here’s my premise: weight loss surgery fails because of obesity. If you’re thinking you need not read further because you already knew that, please wait until I explain a bit more. And those of you snickering in the back of the room, simmer down. I’m a natural blonde (duh) as well as an old fogey who needs time to make her point, but like Ellen DeGeneres, I do have a point. OK, let’s continue. Some disappointment or failure can be attributed to the inadequacy of a bariatric medical device or surgical procedure or surgeon or patient, but underlying all that is the basic reality of obesity: it’s a chronic and currently incurable disease, caused by a mixture (unique to each patient) of genetics, behavior, environment and biology. Weight loss surgery may address some aspects of those factors, but not enough to cure obesity. So it fails because of obesity. In the past, I’ve given a lot of thought to how genetics, behavior, and environment have contributed to my own case, but no more than a passing glance at the biology of it. I’m the daughter of a gifted scientist who passed on not one single gene of scientific aptitude to me (instead, I got his nose and the name McMillan). I realize that saying that WLS fails because of obesity is like saying the ocean is wet because it contains water, but as with many obvious facts of life, it’s easily overlooked. We go into WLS believing or at least hoping that surgery will fix enough of what’s wrong in us to help us lose weight and maintain that weight loss, but we need to remember that no WLS will cure our obesity. We need to remember that our obesity is at least partly caused by factors that are invisible to us. Those factors were invisible to me until a few months ago, when I was asked to write a magazine article about some recent research studies that found a link between obesity and fibromyalgia. I’m uniquely qualified to write that article because I’m a veteran of both wars. When I began researching the article, I was astounded by the dense mountain of information: scientific data, theories, probabilities and conjectures that I’d heard little or nothing of before despite my exalted status as the World’s Greatest Living Expert on the Adjustable Gastric Band. I’ve had WLS, talked to dozens of bariatric medical professionals, attended three bariatric conferences, read countless books, articles, blogs and reports, but suddenly I felt like a babe in the bariatric woods. Why hadn’t either of my bariatric surgeons (never mind my primary care physician) mentioned any of this to me? Are they unaware of it? Are they hiding it from me and the rest of their patients? Is there a conspiracy afoot? This information is of enormous importance if only because it knocks a big hole in the old-school blame-the-patient approach. The paranoid in me wonders if the information is hidden to protect an industry or to further a political cause, but I put those thoughts aside and instead considered the very real possibility that bariatric surgeons are well aware of the obesity mountain but are practicing a form of medicine that circumvents it. They don’t climb the mountain and they don’t hike around it. They cut right through the middle of it. THE OBESITY OCTOPUS To explain myself now, I’ll have to resort to another simile. In a sense, bariatric surgeons treat obesity by stuffing a many-armed octopus in a sack and bludgeoning it with an axe. I’m not criticizing the surgeons. Surgery of any kind requires a breathtaking degree of confidence, skill, and audacity. Although surgery doesn’t address every waving octopus arm, it is the only effective long-term treatment for obesity available in the United States today, and I’m very grateful that I was able to have WLS and lose my excess weight as a result of it. At the same time, I sometimes worry about the future. This spring, treatment of a medical problem required removal of my band. I’ll soon have vertical sleeve gastrectomy surgery, but what if obesity takes over my life again in spite of my band and all my hard-won lifestyle changes? Are researchers working on an obesity cure now that can help me with that in the future? WHAT CAUSES OBESITY? It turns out that researchers have indeed been busy searching out the causes of obesity in the hope of finding a better way (or ways) to treat it, prevent it, and/or cure it. As I mentioned above, several studies have reported a link between obesity and fibromyalgia. It’s easy to get caught up in a chicken & egg debate about that – does one disease cause the other? I don’t want to go down that road right now. Instead I want to talk about some factors that are associated with (and may be contributing to) both conditions. They are: Non-restorative sleep – Sleep affects the production of hormones (leptin, grehlin, cortisol) that are key to the experience of hunger, appetite, and satiety. Poor sleep tends to decrease leptin (satiety hormone) production and increase grehlin (hunger hormone) production. It also seems to increase sensitivity to pain. If you have sleep apnea or another type of sleep disorder, or even subclinical sleep disturbance, it’s likely that your physical hunger is increased and your sense of satiety is decreased. The adjustable gastric band can intervene on your behalf, but it doesn’t correct the hormone production problem. Neuroendocrine dysfunction – the nervous system (neuro) and endocrine system (glands) control all physiologic processes in the human body. The nervous system works by sending messages through nerves, as if it’s a hard-wired telephone system. Nervous control is electrochemical in nature and is rapid. The endocrine system sends messages by the secretion of hormones into the blood and extracellular fluids. Like a radio broadcast, it requires a receiver to get the message. To receive endocrine messages, a cell must bear a receptor (a receiver) for the hormone being sent in order to respond to it. If the cell doesn’t have a receptor, it doesn’t “hear” or react to the message. Researchers studying neuroendocrine interactions discovered (among other things) that in fibromyalgia and obesity patients, certain cells have damaged or malfunctioning receptors for the leptin, the satiety hormone. It’s the one that tells your brain you’ve had enough to eat. So one of the reasons you rarely feel satisfied by a reasonable amount of food (or in my case, an infinite amount of food) may be that satiety messages are going astray because your cells’ in-boxes are locked or absent. Dysregulated HPA is a factor contributing to both obesity and fibromyalgia. HPA stands for hypothalamus-pituitary-adrenal, three glands (part of the endocrine system) that are crucial to healthy functioning of many bodily processes. The HPA axis is a grouping of responses to stress. When you experience stress (whether it’s physical, like an injury or illness, or mental, like a fight with your spouse), your body produces a biomarker (messenger cell) that stimulates your HPA axis. Your hypothalamus (in your brain) then sends a message to your pituitary gland (also in your brain), where it triggers the release of ACTH (adrenocorticotrophic hormone) into your bloodstream and causes the adrenal glands (on your kidneys) to release the stress hormones, particularly cortisol. Cortisol increases the availability of the body's fuel supply (carbohydrate, fat, and glucose), which is needed to respond to stress. However, prolonged elevation of cortisol levels can cause havoc: muscle breaks down, your body’s inflammatory response is compromised, and your immune system is suppressed. If you’ve ever taken a corticosteroids medication like Prednisone to treat an inflammatory problem (like an allergic reaction) or disease (like lupus), you’ve probably learned the hard that it can turn you into a bad-tempered eating machine. Inflammation, as mentioned above, is another culprit in both chronic pain and obesity. A European study of showed that obese rats have chronic low-grade systemic inflammation that sensitizes them to pain. Immunological vulnerability is common to obese and chronic pain patients and contributes to pain, fatigue, sleep disturbance, and depression. All of those are factors that can prevent us from exercising and are associated with the neuroendocrine dysfunction described above. Mitchondrial dysfunction may also play a role in both chronic pain and obesity. According to Karl Krantz, D.C., “mitochondria are the power house of the cell. If energy is not being produced, logically it can lead to or contribute to chronic fatigue and pain.” A Finnish study of identical twins (each pair including a normal weight and an obese twin) found that the fat cells of the obese twins contained fewer copies of the DNA that’s located in mitochondria. This DNA contains instructions for energy use by the cell. The lead researcher of the study says, “If one were to compare this cellular power plant with a car engine, it could be said that the engine of the fat individual is less efficient.” So it’s no wonder that obese people are not able to burn or use all the calories they consume. Some medical professionals believe that chemical toxins (such as the preservative sodium benzoate, used in many soft drinks) and biotoxins (such as mold) can damage the mitochondria, increase inflammation, and aggravate both obesity and chronic pain. WHERE DO WE GO FROM HERE? Your own brain may in overload now after working its way through all the biological business I’ve ineptly but earnestly tried to explain. Even if nothing else is clear, I hope you’ve grasped the message that the causes of and factors in obesity are extremely complicated and well beyond the means of any currently existing medical device or surgical procedure to cure. I also hope you can see that blaming yourself for your obesity doesn’t go very far in treating it. You are not in conscious control of your neuroendocrine system. But neither are you entirely helpless. You have, or will soon have, a bariatric tool that when carefully used, can bring your appetite under better control and increase your sense of satiety. You can learn as much as possible about the factors that can improve your overall health and counteract the misbehavior of your nerves, hormones, and immune system. For example, I know for a fact that regular exercise helps me manage not just my weight but my depression and pain. You may feel defeated by the very idea of that, but according to an article in the July-August 2011 issue of IDEA Fitness Journal, as little as 5 to 15 minutes of exercise a day can yield health benefits and also increase your self-control when it comes to food choices. At the end of the day, I still suffer from obesity and fibromyalgia, both puzzling and difficult to treat, but I try not to think of myself as a victim of those diseases. I can curl up in a chair with a box of chocolates and weep about my situation, or I can go on learning about my medical conditions and experimenting with ways to improve my health and quality of life. The author of one of the obesity-fibromyalgia studies, Akiko Okifuji, recommends that patients adopt healthier lifestyles and take more positive attitudes toward symptom management. That may sound condescending, but as Dr. Krantz wryly pointed out, “every person in America would benefit from that approach.” I know that’s easier said than done, but I’m willing to try it…are you?