“Bob. Single, professional, 42 y.o., 5’9”, 227 pounds (down from 320 pounds since my VSG last year!), likes long walks on the beach and golden retrievers.”
Would you swipe yes or no? I suppose it depends on the circumstances.
Many of my patients have asked me when they should start dating after bariatric surgery. A subset of those patients have asked how and when to tell others that they have undergone a weight loss procedure. The answer is highly personal, and demands an in-depth discussion of the various approaches.
“Did you stop working out?” a co-worker asked me last week in the hospital cafeteria. “You look way too skinny,” said a colleague in the O.R. to me a few months ago. “You used to look a lot stronger,” a former co-resident said to me at a national meeting of Bariatric surgeons.
Sound familiar? Anyone ever come up to you at work and remark on your weight going up or down? Since when did our weight become an appropriate point of discussion with acquaintances? Okay, so I used to be a lot heavier, and my weight has fluctuated over the years, just like everyone else’s, but what the heck?
I saw a patient in the office for a weight loss consultation the other day. For the sake of discussion, let’s call her “Kate.” Kate meets all of the criteria for bariatric surgery, being just over five feet tall, with a weight in the low 200 lb range. She also has a fairly large hiatal hernia and severe acid reflux, in addition to some other medical problems that put her at high risk for sleeve gastrectomy. On the other hand, she is a great candidate for a gastric bypass with hiatal hernia repair, a larger, more extensive operation, but one which I perform quite frequently.
Unfortunately, Kate’s insurance does not cover bariatric surgery.
I explained the self-pay system that we have built into our program, which includes contingencies for unforeseen complications, but this very well-educated, financially stable patient stated, “That’s okay, I’m going to go have it done in Mexico.”
Please don’t get me wrong, Mexico has some outstanding Bariatric Programs, with excellent surgeons. The problem is the lack of follow-up for American patients, and the need to return to Mexico should anything go awry. When I raised the aforementioned issues to Kate, she replied, “You can take care of me if anything happens.” Unfortunately, Kate, that puts me in a very difficult situation. Fixing another surgeon’s complications is fraught with danger. Each surgeon has a different way of doing a procedure; and suture material, stapling devices, and hernia mesh used in other countries may not meet the guidelines of the FDA, which can end up creating a huge and complicated mess inside the abdomen.
I have now repaired, revised, or performed what we refer to as “damage control” on over 40 cases that were performed in Mexico and other countries, and I was featured in a newspaper article about some of the problems from other countries that I have had to correct. Medical tourism is a prolific and lucrative industry, but it should be discouraged in the setting of procedures that can be performed safely and effectively by surgeons that have a vested interest in following their respective patients.
The Hippocratic Oath of “Do no harm,” is not a universally applied principle. Developing and maintaining a long-term relationship with patients is one of the reasons I chose bariatrics as my specialty. Weight loss surgery is one of the few surgical disciplines that enables a surgeon to follow patients forever after surgery. In fact, the Center of Excellence designation requires us to follow our patients long-term after surgery, and we are held accountable for lack of follow up and/or complications. Our data demonstrate that the more points of contact a patient has with a bariatric program (surgeon, dietitians, mental health, support group, nurse practitioners, physician assistants), the better he or she will do long term.
Going to another country to save some money might make sense if having a minor procedure, but a laparoscopic roux-en-y gastric bypass, with a simultaneous hiatal hernia repair, does not qualify as a minor procedure. Please folks, and especially “Kate”, think about the reasons you or your loved one is considering bariatric surgery. You want to get healthy. You want to be around for your family. You want to enjoy life, and get rid of a bunch of medications. Don’t throw everything away to save a few bucks, and then hope that someone back home can fix an unnecessary surgical disaster. Find a local, board certified, Center of Excellence Bariatric Program to take care of you. Do it right the first time, and let’s get healthy together.
Let’s get healthy together!
Dr. Matt Metz, MD, FACS
Bariatric and Aesthetic Surgery Associates
I was in the Personal Trainers’ office at a local gym recently, and saw the following caption attached to some popular cartoon characters:
“I’m fat because obesity runs in my family.”
“No, you’re fat because no one runs in your family.”
One of the cartoon characters was laughing hysterically, the other was not.
I will reiterate where I found the aforementioned cartoon—in the Personal Trainers’ Office at the gym. These are the very people to whom we entrust our feelings of physical inadequacy or unattractiveness. These are the experts to whom we look for guidance in our fitness routines, diets, and, in some cases, relationships. How could they be so crass? So arrogant?
Perhaps I’m being overly sensitive, but I have had several encounters with personal trainers who claim that overweight patrons are just lazy. As I mentioned in a blog several years ago, when I offered bariatric information and seminars to the clients of the Chief Personal Trainer at a major gym, he responded with, “I don’t see the problem. They just need to diet and exercise—calories in, calories out.”
Much to my utmost dismay, I have had numerous patients tell me their Personal Trainers are abusive, discriminatory, and have even fat-shamed them in their efforts to lose weight. I even heard of a Physician Assistant who specializes in weight loss, send two women crying from her office, after she accused them of drug-seeking, when they asked for a trial of appetite suppressants to help in their stalled weight loss efforts.
People who have never struggled with their weight will never understand why one person can eat a small serving of ice cream and gain 3 pounds, while another can go on a weekend pizza and fast food binge and not gain an ounce. Our genetics, hormones, medical conditions, and metabolism are all different from one another’s. It seems as if some people can talk on the phone to their mother for 10 minutes and gain 5 pounds (ahem, no hard feelings, Mom), while others can graze all day in front of the television without any weight effect whatsoever.
We are fortunate to have resources available to us that have examined the effects of specific exercises and structured diet plans on various body types. We can now tailor unique programs to patients that are struggling with more than 30 pounds of excess weight, without hurting them physically, emotionally, mentally, and spiritually. The often utilized, one-size-fits-all model of personal training does not necessarily apply to clients with a higher BMI. Coaches take previous injuries into account when designing diet and exercise plans, why don’t more Trainers design programs for clients with different weights? More importantly, why aren’t more Personal Trainers sensitive to weight as a disease process, rather than labelling it a symptom of laziness.
For example, most people are aware that the “Biggest Loser” philosophy of working out all day until you drop is not a viable option for people with jobs, school, families, limited finances, and preexisting medical conditions; however that model is often touted as the path to fitness. But not everyone knows of the struggles, injuries (physical and mental) and pain that the contestants of a show like that must endure. Case in point, calling the contestants, “Losers,” in and of itself, creates a culture of shaming—which has proven to be harmful, not helpful. Additionally, people that have 100 pounds of excess weight should not be thrown into grueling workouts that beat up joints, cause shin splints, and tear muscles. And they should certainly not be undertaking horrendous 4-hour workouts with only 500 calories per day of fuel (see HCG-type diets).
While I have had the pleasure of interacting with some extremely bright trainers, who dedicate themselves to working with the bariatric population, they have been the exception, not the rule. It behooves us to integrate the needs of our heavier patients in the Personal Trainer certification process.
Case in point: A patient that struggles with severe joint pain and obesity is in a vicious cycle. The orthopedic surgeon informs the patient that he or she cannot undergo a joint replacement until the patient loses weight. That surgeon then typically prescribes an exercise routine. Unfortunately, that patient is unable to perform those exercises because he or she has joint disease prohibiting the very activities that are being prescribed (“You’ve got to have a membership card to get inside”).
After a heart attack, patients undergo something called cardiac rehabilitation, a gradual increase in exercise to help strengthen a heart that has limited functional capacity. Cardiac rehab specialists do not throw recent heart attack patients into a hellacious regime of burpees and jump squats, because that would be harmful. Do those cardiac rehab specialists have cartoons in their offices making fun of patients with heart disease? Probably not.
The day after a total knee replacement for severe joint disease, the orthopedic surgeon and physical therapist do not tell the patient to go out and run a marathon, because that would be harmful! Does the Physical Therapist have posters in his or her office making fun of people learning how to walk after a car accident?
According to the American Medical Association, obesity is a disease. In the same manner as in the aforementioned examples, a patient that struggles with 100 pounds of excess weight is also suffering from a disease. That patient should not be told to run on the treadmill for an hour and perform 5 sets of weighted pullups, the first time they show up for a personal training session. And they certainly should not be ridiculed (overtly or behind closed doors) for not being able to get rid of their disease. Where is the disconnect? Why is it acceptable to shame the patients trying to improve his or her weight, when no one is making fun of the stroke victim, or breast cancer patient. Almost every major health problem we face in the Western World, other than trauma and infectious disease, is associated with obesity. The incidence of cancer, heart disease, stroke, diabetes, and high blood pressure are all increased as our weight increases. Yet, while no one is making fun of the cancer victims, many people continue to mock and discriminate against patients struggling with obesity. By the way, Personal Trainers of the world, those clients who you mock are paying your salaries!
I would like to see more collaboration between Bariatric Programs and Coaches to tailor workouts and diet plans to our specific patient population. My Practice collaborates with a number of Coaches that have undergone sensitivity training, education about the various bariatric procedures (It drives me up the wall when a Trainer tells a bypass patient to guzzle 20 ounces of water between cardio and weight lifting), and have exercise programs that are designed for patients that struggle with more than 30 pounds of excess weight.
Above all, we need to increase the awareness that being overweight does not equate to being lazy. Weight remains one of the last characteristics for which it is still socially acceptable to discriminate. As our obesity rates climb beyond 30% in many countries, skinny discriminators had best wake up, lest they be overtaken by the new majority! And do me a favor, Personal Trainers, take down that dang cartoon!
Let’s get healthy together!
Dr. Matt Metz, MD, FACS
Bariatric and Aesthetic Surgery Associates
“I heard my body is a topic of conversation so I wanted to say, I’m proud of my body and you should be proud of yours too, no matter who you are or what you do.” –Lady Gaga, 2017.
I have to ask, what has become of us? Do mature adults routinely ridicule individuals for “pot bellies,” and make fun of tummy “rolls?” Have we regressed to the fifth grade playground?
Lady Gaga gave the world a truly impressive half-time show at Super Bowl LI, then was criticized for her body in the comments thereafter. I wonder how many of her critics could even approach her level of fitness, endurance and athleticism; yet many outspoken individuals on social media and elsewhere resorted to schoolyard bully tactics in order to cast a shadow on her great performance.
While I’m thankful to have such a high profile example to illustrate “fat shaming,” I’m pained by the continued pressure of media (social and otherwise) to conform to a certain ideal weight and appearance. The past president of the IFSO (International Federation for the Surgery of Obesity and Metabolic Disorders) once said, “We’re trying to make a patient a certain weight, where G-d and the genes say otherwise.”
People come in many shapes and sizes. We have the opportunity to influence those shapes and sizes, to some degree, as individuals and as physicians. Shaming someone for not conforming to a physique that represents an extremely small portion of the human species is not appropriate – especially when that someone totally rocked the Super Bowl half-time show.
Let’s get healthy together, and let’s grow up a bit.
Matt Metz, M.D., F.A.C.S.