From the outside, weight loss surgery appears to be a cure-all for obesity and related diseases - the easy way to drop a lot of weight and keep it off for good. Rebecca Blithe speaks to four Kiwi women about the varying successes of this purported marvel of modern medicine.
Maree* never took much notice of the food on café menus. It was the chairs she paid attention to. "When you go out, you don't give a s*** about what's on the menu," Maree tells the Herald from her home in the Bay of Plenty. "You care about if the chairs are going to cope with your fat a***. I remember my mum getting stuck in a café. My whole family is obese."
And her whole adult life, Maree had been that way too.
Every morning, she woke up in agony. All 146kg of her. "Every bone in my body hurt. It was horrible, I was pre-diabetic. I was on a sleep-ap machine. I couldn't breathe properly because the fat was up around my throat. I couldn't get more than five steps before I didn't want to go any further."
For years Maree had tried to lose weight: "I went to Weight Watchers then Jenny Craig. I tried the blood one, fasting, you name it, I've tried it. But because I'm an addict, I came back to food."
Maree shares that she was also an alcoholic and suffered from depression.
"I was going to die. I really wanted to die. Seriously. I was smoking and drinking a lot. And I was so overweight."
Then, something in Maree changed. "I decided I wanted to live. I got sober and I went to Tijuana and got bariatric surgery. I just made up my mind and four weeks later I was under the knife in Mexico.
"It cost me under $6500 including flights."
Her options in New Zealand were to go through the public system, which manages about 300 weight loss or bariatric surgeries a year, or pay up to $25,000 to have surgery privately.
Whangarei mum of six, Jo Kaipo, paid to go private - twice. During the occupational therapist's first surgery, a tumour was discovered on her intestines and was removed then and there. Her gastric bypass could not be completed at the same time.
"I had to pay another $15k. Such is life," says Kaipo, who notes her surgeon and anaesthetist decided to donate the cost of their time to her first surgery.
That was 10 months ago. Since then, Kaipo has lost 54kg. But, contrary to what many may assume with weight loss surgery, dropping those kilograms from her almost 140kg frame has not been easy.
"I've worked really hard for that," shares Kaipo, who after years of yo-yo dieting has found success through surgery. "I still have an Optifast diet drink, every day. I have to do lots of walking, lots of exercise, I have to have little mantras in my head like, 'protein first'."
She explains that by eating protein before anything else, "you can't fit much in. Whereas if you eat what they call 'slider foods', like chips or Cruskits or biscuits, you can fit more in. Your body doesn't get as full as quickly. You've got to constantly hold yourself accountable and keep looking at what you're doing."
While she says she doesn't regret having surgery "for a minute", seeing positive changes to her sleep, energy levels and mood, people wrongly assume it's the "easy option".
"It's not," says Kaipo. "There are lots of things I wish I'd known."
"Everyone's story's really different. There are misconceptions out there. I was under the impression that I wouldn't be able to eat the foods that make you fat. That if I ate sugar or fat, my body would reject it. That I wouldn't feel hungry all the time and the weight would just fall off. That I wouldn't have to put much effort in and my brain would reset to stop me craving those foods that I crave.
"I'm an intelligent person with a degree in science-based stuff, but none of what I'd thought is true. I can eat anything and everything, the only thing I don't tolerate is cream. I can have a piece of chocolate. I can have ice cream."
She discovered that while she can only eat a small amount at once, in two hours' time her body is ready to eat that same portion again.
Maree's post-surgery diet experience has been similar to Kaipo's: "I eat less and I take longer to eat. But I could eat anything I want - that sucks. It creeps up on you."
While Maree's diet support in Mexico consisted of two pages of "what to eat", Kaipo was given access to a dietician. But she says they weren't particularly helpful. "I felt I knew more than them. I'd done a lot of research."
Kaipo has since engaged with a bariatric nurse for ongoing support and advice. She's learned that weight loss surgery should be seen as "a tool" to help you on your way.
"You've got to learn what's head hunger and what's actually your physical signs of hunger – which we've ignored for how many years? It's how we got fat in the first place."
Lauren Peat, 28, is a Whanganui-based bariatric nurse. She's also a busy mum of three who has multiple sclerosis and has undergone weight loss surgery.
"It was the week of my wedding and after weeks and weeks of trying to lose weight, I was going up on the scales, rather than down. I thought, something's got to change," she says of her 124kg peak weight.
She had gastric sleeve surgery privately at a cost of $23,000.
"The lowest I got down to was 70kg and now I'm at a comfortable weight in the mid 70s. It's given me a whole new lease on life," says Peat.
"I had a high possibility of ending up in a wheelchair because of my MS. Obviously, the stress of being obese didn't help that situation."
After bariatric surgery, however, Peat went from enduring approximately four flare ups of her condition a year to one most recently at the beginning of 2020.
While her surgery has been a success, Peat says the limited care and support surrounding the procedure is what inspired her to start her business specialising as a bariatric nurse and developing an intensive support programme.
"In my experience, I spent an hour with a psychologist, pre-op, and a 15-minute phone call with a dietician. So, it wasn't much. The support wasn't there.
"I see so many people really struggling. The first year can be really hard psychologically. Eating gets a lot harder socially. And people will experience stalls. When you're losing weight, whether that's through surgery or a diet, your body will stop losing that weight for a period of time. That happens about three weeks post-surgery and again at about 5 months. Some go through it again at nine months and a year. Stalls can last a week or go on for months. Mentally, it's really, really challenging.
"They call the first six months the honeymoon period, where weight comes off because you physically can't eat the calories you need to sustain the weight you were at. Those first six months are the most important to get that head work done."
When Peat talks about head work, she's referring to "coming to terms with why you were eating the way you were, pre-op. That's going to set you up for long-term success".
It's something Maree, who has dropped to 95kg, has realised she really missed out on in her post-op journey.
"Most of this is all about psychology. Because it hasn't helped my addiction to food. People really need to understand this is a head game. When people say, 'you just need to go on a diet', damn, I just want to slap them. You don't say to someone on drugs or with an alcohol addiction 'just stop'. They are sick and need help."
Peat agrees. "Being obese and having a food addiction is very much a mental illness and I think it's quite overlooked by our healthcare system. I've had clients up to five years post-op. To be fair, the ones I've seen that have come out worse off have been the ones in the public system. They've been really left in the dark. I get a lot of, 'why didn't anybody tell me this?' Some of them have ended up regaining almost everything that they'd lost."
In addition to Maree coming to terms with the psychological barriers to her weight loss, she has experienced physical issues related to her surgery.
"I had no indigestion before surgery but now, if I miss my omeprazole tablets, by 10am I'm a mess. It burns like a – it's horrendous. It continues all day. The tablets are also weakening my muscles, so I can't keep taking them."
Maree is not alone in her experience of going through a surgery that will need to be reviewed.
Jordan Hill, 30, is a solo mum living in Christchurch. Her weight loss journey is complicated and her challenges are ongoing.
After the birth of her daughter 10 years ago, no matter how hard she tried, she could not move her weight from the 130kg she saw every time she stood on the scales.
Through her GP Hill learned she was pre-diabetic and was prescribed medication to help. Hill says she suffered severe reactions and her weight spiralled out of control.
"My gastrointestinal reactions to Metformin were ignored," says Hill, adding it didn't help "control my blood sugars even with a low carb, no sugar diet and exercise".
By the time Hill was 25 her weight had peaked at 142.5kg and her BMI was just shy of 50. She was on two types of diabetes medication plus insulin which she developed a resistance to.
Referred for bariatric surgery, Hill says it was hoped "a gastric bypass would extend my life by putting my Type 2 diabetes into remission. I qualified for public funding, I was living in Dunedin and had my surgery in Invercargill."
However, Hill's surgery didn't go as planned. The surgeon she had been working with was changed on the day of her surgery. Surgeon Mark Grant conducted her procedure instead. When Hill woke up, she was told she suffered an anaphylactic reaction on the operating table and the decision was made to proceed with a gastric sleeve rather than the planned bypass.
The difference between a gastric sleeve and a bypass is that a sleeve removes part of the stomach while a bypass involves "bypassing" the stomach and part of the small intestine. Both can achieve around 65 per cent weight loss. However, bypass tends to be better for people with a BMI over 45 and may result in an extra 5 to 10 per cent weight loss.
When it comes to diabetes remission, both sleeve and bypass are effective but bypass tends towards better glucose control.
While Hill says she is disappointed the bypass she consented to wasn't carried out, Grant told the Herald his standard practice as part of the consent process is to "always discuss the possibility of changes in planned procedures as we cannot predict all intraoperative events."
He notes "bariatric patients operated on in the public sector are often very co-morbid [having two or more disorders] and the longer they have Class 2 or 3 obesity the more unfit they get for surgery".
Hill says she remains disappointed because she was told by her original surgeon that a bypass was the best option for putting her diabetes into remission.
Hill's initial results were pleasing and she is in remission: "I did lose 55kg total, reaching 87.5kg, but as I approached a year post-op, I regained 20 to 30kg in the space of three months.
"I discovered that my antidepressants should never have been prescribed to me as they are an appetite stimulant, intentionally prescribed to people suffering from anorexia."
Grant told the Herald: "If a sleeve is performed incorrectly patients tend not to lose much weight post-surgery. Ideally at three months they should have lost a third of their excess weight and at six months, 50 per cent. Sadly it is well documented that if patients over eat, they can dilate and they can regain weight."
Since moving to Christchurch, Hill has come under the care of Richard Flint, a general surgeon and endoscopist. Flint trained in Christchurch, at Harvard University in Boston and in New York. He is now based in Christchurch and performs a variety of bariatric surgeries in the public and private system.
Hill says results from a test known as a barium swallow have shown "that my stomach is not the right size or shape".
While Flint declined to comment on Hill's case, he did share that weight loss surgery is increasingly popular, the results can be tremendously rewarding and if there are issues with a procedure, "all of these things can be sorted out".
"The reality is it's a mainstream operation now. People know it works. It's not an outrageous option anymore. My patients are successful in every other part of their lives. For some of them, they have been battling this [weight challenges] for 20 years - it's not a fight they have to fight anymore."
Flint says data from weight loss surgeries conducted in the 90s shows "on average a person can get an extra 13 years of life. It's very rewarding – over the last two years I've seen more demand. It works. I think people realise that nothing else works."
With regard to varying results for patients, Flint says an individual's physiology is a big component.
"Often the results are down to physiology. With young guys, the weight just melts away. But if you get a woman who has had children or been through menopause, it can be very different. I've had husband and wife teams and they do everything the same, supporting each other through, but there may be big difference in their results.
"There are some who don't do as well as you'd hoped. That's healthcare: not everyone will do as well as your best patient."
Flint says those who experience weight regain often do so around two years post-surgery.
"At that point we investigate to ensure the surgery is as optimal as we expected. If that looks okay then we get them in touch with a dietician and psychologists."
Hill is now waiting for a surgery date for a revision from gastric sleeve to bypass. She says because she has regained weight, she has felt judged by others in the bariatric community when she has shared her story.
"I am still in remission, but I live in constant fear that [diabetes] will return and my quality of life will return to what it once was. It affects my mental health, mostly. I am very open about [my surgery] and feel judged because it's easy to see I'm overweight today. But seeing me doesn't reveal the battle I have fought and the complications I have dealt with."
Kaipo says she has witnessed commentary in online forums where people are told "they are the failures, not the surgeries. So that can be a real trigger for people".
Both Kaipo and Peat stress education is key.
"It's about educating people about what to expect," says Peat. "We give them the tools to keep the weight off long term, rather than it being a quick fix. The biggest thing I can stress is that surgery is a tool. It's not the solution."
*Maree asked to be referred to by her first name only.
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