Life = good

Today I’ve noticed a lot of good things are happening for me, healthwise!

• I now have a bunch of clothes that are too big for me. Pants, shirts, belts. Yay!
• The incisions are healing faster than expected. (Pic coming soon.)
• I am getting a good seal on my new CPAP mask… last night I had one of the lowest leak rates yet.
• My energy level is climbing, slowly but surely.
• My feet always used to be kinda puffy. They’re not anymore.
• My left eye used to twitch a lot. The doctor says it was a side effect of the Provigil. I’m not taking it anymore, and the twitch is gone.
• Several folks have commented that my eyes don’t look as baggy anymore.
• I’ve been 100% compliant with my daily supplements, in attending the nutrition support group, and in getting 30 minutes of activity every single day. (Mostly walking, some biking.)
• Remember that sinus surgery I had last year? I actually have been reaping the benefits (finally!) over the last several months. I can breathe freely through my nose now. Not just sometimes, but every single day, and every single night. Which is making the CPAP therapy more effective.

I still have a long way to go, but things are improving even faster than I expected. Yay!

You may have noticed that I’ve not been focusing on my weight (as a number). I don’t think the number is a good way to measure one’s health. However, I suppose it would be good to give a rough idea of how much progress I’ve made; let’s just say I’ll easily surpass the 50lb mark by mid-June.

And I haven’t felt like I’ve been depriving myself of food at all. A small serving of food tames my tummy with no problem.

By the way, I finally did receive a letter from the insurance company, in which they let me know the denial was upheld. I’m not really surprised, and, as I’ve mentioned previously, I don’t blame them. (It was never a question as to whether the procedure was medically necessary; the fact is, the procedure is simply not available through my particular coverage plan.) Ah well, it was worth a shot.

Life = good.

The Vicious Cycle of Weight Loss

OK… last chart for awhile. (God I’m such a geek.)

This is the vicious cycle that I was caught-up in. I firmly believe the weight-loss surgery is going to help me escape it.

I made this chart. Maybe it will be useful to someone who’s been caught in the same cycle.

Learn, manage, share, track your health for free with SparkPeople.com

I’d like to introduce you to a totally rad website called SparkPeople.com. I learned about it from my sister Suzanne awhile back.

SparkPeople helps you live a healthy lifestyle, even if your goal isn’t necessarily to lose weight. You can:

• Set health-related goals and track your progress.
• Use an instant search to get nutrition statistics about thousands of different foods, including fast food.
• Explore tips about nutrition and physical activity.
• Find, contribute, and rate food recipes.

You already know my beliefs about the rebound weight re-gain when you reduce food intake to lose weight. So I really like SparkPeople because the emphasis is placed on healthy living. You don’t need to focus on weight if you don’t want to.

Say for example, you just want to concentrate on your sodium consumption, or fiber, or you want to drink 8 glasses of water per day. Perhaps you want to reduce (or eliminate) alcohol or caffeine. Reduce your triglycerides. Eliminate high-fructose corn syrup. Maybe you want a way to track how much physical activity you’re getting every week. Whatever your goal, SparkPeople will help you track it. Here are some of my goals, for example:

(NOTE: The items listed above are based-on my doctor’s recommendation for lap-band patients. Your actual goals and numbers may be much different.)

What else do I like about SparkPeople?

• It’s totally and completely free.
• No junk mail, no obligations, and NO CATCH. Unsubscribe at any time.
• Well-designed, easy to navigate, useful.

I like receiving the “SparkPeople Food Showdown” e-mail newsletter. Every day they pit two foods against each other, then tell you which one is better for you. What’s great is that they pick foods that you’d probably actually eat… the Whopper vs. Big Mac, for example. Sometimes the results are obvious, and sometimes they’re surprising. And often they’ll throw in useful tidbits… like “hold the mayo and save another 120 calories.”

There are a number of other features, some of which are useful, others not. You might find the community features helpful, and you might even create your own SparkPage or gather friends into a SparkTeam. Or you may just want to join to get the e-mail newsletters and do nothing else. You can pretty much decide what level you want to participate at, then go with it.

No matter how big or small you are. No matter if you’ve had weight surgery or not. SparkPeople has something for everyone, and I highly recommend it.

Updates, status, catch-up, the latest and stuff

Some quick updates…

• Stopped taking my Provigil for now. Though it’s a little harder to focus in the afternoons, hopefully it’ll be easier to stay asleep all night.
• After a full week of only pre-op eating (3 protein shakes + 400 calories per day) I am feeling verrry… um. Regular.
• Been getting my 30 minutes of activity every day. Mostly biking and walking so far.
• Henry made me an awesome salad on Saturday with fresher-than-fresh veggies, a simple but tasty dressing and strawberries and whipped cream for dessert. (I love me some strawberries…) Spent the afternoon with Henry catching-up, playing XBox 360, sitting on the balcony, hittin’ the grocery store, etc. Also learned a thing or two about food and produce and such. It was a very a nice afternoon, Henry!
• Went to my first bariatric surgery support group last night. The group was a mixture of people both post- and pre-op, with the majority being post-op. About half of them had gastric bypass, while the other half had lap-band. It was useful to talk to other people about what works, and what doesn’t. The point was reiterated that there is still a lot of hard work ahead.
• Tomorrow is the big class. This is where we learn all the details about everything… surgery scheduling, eating plans, etc. Matt’s going with me and I am lucky to have him by my side.
• Today I go in for one final blood test.
• Still haven’t heard back from the insurance about my appeal. But moving forward regardless. (I did call them to confirm they had received the letter and it is currently being reviewed.)
• Surgery is 7 days away. I’m ready.
• The doc assured me that I’ll be able to ride roller-coasters (once I heal. Yay!) In fact, he said you can do just about any kind of sport, etc. once things have healed. In the meantime, the next few weeks are going to include walking every single day, even the same day of the surgery.
• My sleep has been up and down, as usual. Last week was particularly rough; Friday I was practically a zombie. Since then I’ve had perhaps three nights of sleep that didn’t totally completely suck… I slept perhaps four or five hours for three nights in a row, so that was welcome.
• Sunday I biked to The Hole (San Diego’s “world-famous dive” bar) with the uber-awesome Tim. We had a nice, six-mile ride through the neighborhoods of University Heights, Hillcrest, Mission Hills and Old Town. Hope to do that again sometime!

More soon.

Updates

Some quick updates.

• Surgery still on schedule.
• Stopped taking Claritin and Nasonex. Gonna see how I do without them.
• I’m on Day 3 of pre-op eating plan. I want pizza. (Don’t worry, I’m not going to.) Just tried cottage cheese for the first time. It’s gross. Gonna try a few suggestions to make it edible though.
• Still sleeping really poorly (not that I expected anything to change yet. It’s gonna be a couple months before I’m sleeping soundly, methinks.)
• Haven’t heard back whether the insurance will cover the procedure. But continuing as planned, regardless.

By the way, regarding that insurance appeal letter I posted last week. I did not intend to demonize the insurance company. They actually do offer a medical insurance package that includes coverage for weight loss surgery; but last year, my employer (who admittedly has a lot of other employees to consider, as well as other operating expenses associated with being a small business) had not selected that package.

I really don’t blame anyone for the situation. It is what it is. Hopefully the insurance company will come through. But I’m going to proceed regardless.

So why did I post the appeal letter? I felt it conveyed my situation well… and I don’t think I’d been communicating it clearly up until then. I also thought perhaps the appeal letter might be useful for others who might need to write their own.

The Eating Plan

When my doctor first recommended having gastric surgery in 2005, it seemed like a magic bullet. Other than recovery from the surgery itself, I thought perhaps it would be an easy way to force me to eat less.

Since then, through research and after talking to doctors, I’ve learned that it’s actually a lot more work than that… otherwise you risk regaining the weight.

From a 2004 article in the Wall Street Journal:

Despite anatomical changes that make it impossible to binge or eat large quantities of food, some patients learn to “outeat” the surgery, grazing on small portions of high-calorie foods throughout the day.

I’m getting ready to start a strict eating plan this week in preparation for the surgery. Following the well-defined eating plan will be critical to long-term success.

There are a few things that I will have to give-up entirely:

• Caffeine and any carbonated beverages (yup, no more Diet Cokes.)

There are a few things you have to give up temporarily:

• Alcohol (several months)
• Solid food (6 weeks or so)

There are things which must be reduced:

• Refined sugar
• Fried and fatty foods
• Carbs
• Almost zero bread (and similar foods like pizza, pretzels, etc., because they expand in the stomach; this was the hardest part for me to accept. I love bread!)

You must take daily supplements, otherwise risk problems down the road (including some potentially serious neurological issues):

• Daily multi-vitamin
• Vitamin B-12 (sublingual)
• Calcium
• Iron

You must get regular physical activity:

• They have you walking within 4 hours after surgery
• Walking and/or other physical activity every day

You can’t just have the surgery and walk away. You must come back regularly, including:

• “Fills” for the lap band
• Weekly support groups (important for long-term success)
• Lab tests
• Follow-up visits with the surgeon and a nutritionist (4 to 5 appointments over the course of a year afterwards)

There are other things which must be done as well:

• You have to chew your food very, very thoroughly.
• Drink zero-calorie beverages (obviously not soda).
• Get lots of protein.
• Don’t drink liquids for 30 minutes before, and 30 minutes after a meal (because liquids wash the food down too quickly.)

A typical meal will be less than 10 bites of food.

If you’re considering bariatric surgery, many doctors will want you to quit smoking 6-8 weeks beforehand, and some won’t allow you to have the surgery unless you’re committed to quitting forever.

There are more guidelines; my doctor made it clear that work will be involved, and there will be things that will require some getting-used to. He said it like this: weight surgery is only a tool, not a cure, for obesity.

After all this, you might be saying… can’t all of this be done without having surgery? Couldn’t you just follow the above-mentioned eating plan and lose weight? The important distinction is this: the surgery creates a smaller pouch for the stomach. Not only do you get full faster, but the chemical signal is sent to the brain saying “FULL!” This notion of being full, or “satiety” as it’s called, is not just psychological, but actually affects your body chemistry and the way it processes food.

Updated schedule:

• April 28 (today) – Go shopping to stock-up the kitchen with required foods, supplements and supplies.
• April 28 – A “last meal” (and one last icy Diet Coke from the fountain)
• April 29 – Start the pre-operation eating plan (lots of protein shakes)
• May 7 – Attend pre-operation class.
• May 9 – Should have an answer from insurance whether they’ll cover the procedure.
• May 12 – Nothing to eat or drink after 11pm.
• May 13 – Surgery.
• May 14 – Come home. Subsist on Jello, broth, liquids and supplements for awhile.

About that lap band thing..

Just to pre-empt a few comments:

• This may seem out-of-the-blue, but it’s something I’ve been considering for a very long time.
• If the insurance won’t cover the procedure, I’m going to finance it personally.
• I’m fully aware of the risks of the surgery. I’m fully aware that there is the possibility of some weight re-gain. I know that the eating regimen is strict. I know this is not an easy way out. I know that it will still require discipline, support, and determination. I do not see this as a magic bullet. Instead, I see it as something that greatly increases the viability of getting to a healthy weight.
• I know that physical activity is going to be required for long-term success. I’ve been drawing-up plans for awhile, and am getting ready to execute.
• I’m aware of the various types of gastric surgery. I’ve reviewed the pro’s and con’s of each with the surgeon, and we decided on the lap band. (I’ll try to post more about this later.)

The Appeal

To whom it may concern:

I am writing to appeal your decision to deny authorization for laparoscopic adjustable gastric band surgery, a decision which was made in February 2008. It is acknowledged that weight-loss surgeries are currently excluded under my insurance plan. However, this surgery is medically necessary to treat my case of Obstructive Sleep Apnea (OSA). I implore you to reconsider coverage for the reasons below.

I have been fighting OSA for nearly my entire adult life. Over the last 12 years I’ve endured excessive daytime sleepiness, fallen into deep depression, nearly died one night when I stopped breathing for an extended period of time during sleep, missed countless hours of work, and suffered through relentless side effects. These include depression, memory loss, mental dullness, sleep paralysis, general fatigue, restlessness, dizziness, numbness in my upper body, morning headaches, mood swings, panic attacks and general lack of motivation.

My sleep apnea has been maddeningly resistant to a myriad of treatments. I’ve had 12 overnight sleep studies since 1996. Each time, doctors have prescribed treatment, which I have followed carefully, but in the end have been ineffective. I have undergone four surgeries in attempt to open my airways:

• Tonsillectomy/Adenoidectomy in 1996
• Uvulapalatopharyngoplasty (UPPP) in 1997
• (Repeat) Adenoidectomy in 2003
• Sinus surgery in 2007 (cauterization of turbinates, removal of scar tissue and clearing of sinuses)

In addition, I’ve tried four different CPAP and BiPAP devices; tried 15 different CPAP masks; tried countless combinations of CPAP air pressures, both heated and non-heated humidifiers; chin straps; embarked on exercise and eating regimens; gone through repeated CPAP mask desensitizations; tried three different adjustable mandibular advancement devices; tried two different tongue restraint devices; and taken two years of allergy shots in attempt to improve my breathing. With my current BiPAP device, I’m using the maximum air pressure available (25 cm H2O, which is extremely high) and still have not had relief. I’ve taken various prescriptions in attempt to mitigate the effects of sleep apnea and improve my breathing. (Currently I am taking Provigil, Paxil, Nasonex and Claritin daily; and Albuterol as needed.)

I have family history of stroke. As you know, OSA dramatically increases the chances of having a heart attack or stroke. On several occasions this year, I have felt as if blood was not circulating properly to my head. On one occasion I nearly passed-out. On another occasion, I fell asleep on my keyboard at work. In 2007 I had five episodes of sleep paralysis, during which I was alert to my surroundings, but unable to move my body.

In the space of just 6 years I gained 100 pounds. I’ve made repeated attempts to lose weight, including two periods supervised by medical professionals. Each time, I lost some weight, but it rebounded within months, and I gained more.

Over the same period of time I have missed approximately 500 hours of work, and spent approximately $30,000 on various treatments, devices, medications and copays. (Similarly, my medical insurers have already paid-out over $150,000 in sleep apnea-related medical bills for me; a large portion of those were paid by your company.) It’s become agonizingly clear to me that devices, prescriptions and diets are wholly insufficient to treat my severe OSA.

Obstructive Sleep Apnea is defined as five or more episodes of apnea or hypopnea per hour of sleep in individuals who have excessive daytime sleepiness. According to my most recent sleep study a few months ago, I have 120 apnea/hypopnea episodes per hour; quite literally I can’t even sleep for 30 seconds without stopping breathing. (After my last surgery, the doctor insisted I stay in the hospital overnight because my apnea was so bad.) I am over 100 pounds overweight, I have a BMI of 45, and I score 14 on the Epworth Sleepiness Scale, which is considered dangerous. As you can imagine, I’m at extremely high risk for some very big health problems.

As my condition has grown worse, I have had several episodes where I wake-up choking. My significant-other has witnessed events where I stop breathing for long periods of time. When I lay down to go to sleep, I sometimes really do wonder if it will be for the last time.

My doctors have advised me that I should have weight loss surgery, since we’ve exhausted all other possible treatments (other than tracheotomy). These doctors include Dr. xxxxx, MD (my family doctor), Dr. xxxxx, MD (ENT specialist and surgeon), Dr. xxxxx, MD (sleep specialist), Dr. xxxxx, DMD (sleep dentist) and Dr. xxxxx, MD (gastric surgeon), and they consider the surgery medically necessary to treat my condition. Over the long term, weight loss surgery has a significantly higher success rate than eating/exercise regimens alone. By losing the weight, the layers of fat in my throat will shrink, thereby clearing my airways. This is my only hope of escaping the stranglehold that OSA has had on my life.

I fully understand that under my policy, gastric surgeries are normally not covered as treatment… at least, not for morbid obesity. However I would respectfully ask you to please consider it as treatment for severe and otherwise un-treatable Obstructive Sleep Apnea. We’ve exhausted all other options, and I’m barely able to function. Without the surgery, I fear I will be stuck in an endless cycle of failed attempts to lose weight, risking stroke, losing more work, taking endless prescriptions and aimlessly trying variations on treatments that just don’t work for me.

I am certain that by covering the cost of the Lap Band procedure, your company would save a lot more money down the road. If left untreated, my condition may require even more complex and costly treatment in the future.

I have included a few documents with this letter, notably a letter from my first diagnosis in 1996, as well as the current surgery authorization request from Dr. xxxxx. I am happy to furnish any additional documentation that you may require, including medical records, doctor letters, sleep studies, weight histories, receipts, etc. Please let me know if any additional information will be helpful to my request. I can be reached any time at (xxx) xxx-xxxx (cell/home/work).

Thank you for your immediate attention to this matter.

Sincerely,

Michael _____,
Subscriber # __________

A little dramatic? Yes, but it’s all true.

My intention here is not to demonize the insurance company. They actually offer packages that cover the surgery, but last year my employer elected not to spend the additional funds required. In any case, I’m still waiting to hear back if they’ll cover the procedure. But I’m going to have the surgery done, no matter what.

Why weight?

Why am I so focused on the weight? And why am I bringing it up again now?

It has nothing to do with vanity, and everything to do with my health.

My sleep apnea is out of control. My CPAP (technically it’s a BiPAP) is not enough, even though I’m at maximum pressure. I can’t stay awake long enough to do much work; when I don’t work, I don’t get paid. I’ve probably lost about $7,000 since November because I’ve missed work. I’ve already missed three days this week. (For the record: my boss knows what’s up. He’s been completely supportive, but acknowledges my performance at work has suffered greatly.)

I’m drained. I’m not motivated. I’m sleepy. My head is fuzzy. I’m moody. I can’t get anything done.

I’ve managed to keep it somewhat hidden from the view of my friends… usually I accomplish this by staying in my cave when it’s really bad. And I’m usually pretty good at putting-on the brave face.

I’ve also been using prescription medications to help, notably Provigil, a stimulant that is also used by narcoleptics to keep from falling asleep. It’s been helpful, and keeps me alert in certain situations. But I know it’s a crutch, and it can never replace the lost sleep, the lost oxygen, the lost productivity.

The only person who has seen the whole, unfettered drama is Matt. He’s been wonderful and supportive and understanding. But still, my health has put a heavy strain on our relationship and our friendship.

Why is weight so important with apnea? It has very little to do with the beer belly. Instead, my airway is constricted by layers of fat (in my throat, near my soft palate, etc.)

After a myriad of treatments, surgeries, prescriptions, devices and therapies, my doctors have left me with some options:

• Get a jaw restructuring surgery. They break the jaw and reposition it forward, then re-fuse it. 15 weeks recovery time, during which my jaw would be wired-shut. The most common side-effect afterwards, is feeling numbness on the face.
• Get a tracheotomy. (I’m not kidding.)
• Have weight loss surgery (gastric bypass or Lap Band.)
• Continue fumbling, as I have been for the last few years, with other treatments, try different CPAP masks, and try to lose weight myself. (The charts say I’m 176 pounds overweight, but my doctor thinks it’s more like 100 pounds.)

These options are not new. I’ve known about most of them for several years.

The weight loss surgery, in particular, I’ve been considering for a long time; I first began researching it in 2005.

I’ve decided to do it.

I’ll be posting a lot more on the topic very soon.

Weight loss: Please bang your head against this brick wall repeatedly

Last year, UCLA researchers published a report about long term weight loss.

News headlines quickly appeared: “Diet’s Don’t Work!”

To be clearer, they should’ve said (though maybe it wouldn’t have made as interesting a headline) is “Restricting calorie intake in order to lose weight does not result in sustained weight loss.”

From UCLA’s news release:

Will you lose weight and keep it off if you diet? No, probably not, UCLA researchers report in the April issue of American Psychologist, the journal of the American Psychological Association.

“You can initially lose 5 to 10 percent of your weight on any number of diets, but then the weight comes back,” said Traci Mann, UCLA associate professor of psychology and lead author of the study. “We found that the majority of people regained all the weight, plus more. Sustained weight loss was found only in a small minority of participants, while complete weight regain was found in the majority. Diets do not lead to sustained weight loss or health benefits for the majority of people.”

Mann and her co-authors conducted the most comprehensive and rigorous analysis of diet studies, analyzing 31 long-term studies.

“What happens to people on diets in the long run?” Mann asked. “Would they have been better off to not go on a diet at all? We decided to dig up and analyze every study that followed people on diets for two to five years. We concluded most of them would have been better off not going on the diet at all. Their weight would be pretty much the same, and their bodies would not suffer the wear and tear from losing weight and gaining it all back.”

People on diets typically lose 5 to 10 percent of their starting weight in the first six months, the researchers found. However, at least one-third to two-thirds of people on diets regain more weight than they lost within four or five years, and the true number may well be significantly higher, they said.

From separate articles, on the same study:

Diet studies of less than two years are too short to show whether dieters have regained the weight they lost, Mann said.

“Even when you follow dieters four years, they’re still regaining weight,” she said.

“It appears that dieters who manage to sustain a weight loss are the rare exception, rather than the rule. Dieters who gain back more weight than they lost may very well be the norm, rather than an unlucky minority.”

Read the Reuters article here, or read the full report here (PDF), or read more about the UCLA researchers here.

(Before anyone plays it… “don’t diet, instead change your lifestyle…” means SHIT. The study examined an array of different weight loss programs. I don’t care what you call it. I don’t care how positive you are, how much family support you have, how motivated you are, how disciplined you are. Eventually your body is going to retaliate.)

Even weight-loss experts admit that initial weight loss is mostly a loss of water.

Furthermore, as I recently read in an article titled The Failure of Diets:

Despite a $50 billion diet industry promoting countless weight loss methods, approximately 95–98% of all diets fail. The enormous failure rate is due to the inherent nature of diets themselves, although it is the dieter who is blamed for a lack of willpower or commitment.

When people turn to diets as a means of weight loss, they are met with the strong opposing forces of both genetics and evolution. The body cannot distinguish intentional weight loss from starvation and becomes even more efficient at storing fat for survival purposes, frequently leading to higher than pre-diet weights.

In spite of extremely high rates of failure, dieting is seen as a positive behavior in our society. In a prospective study of high school girls, those who engaged in dieting behaviors were more likely to gain weight during this 4- year period than their non-dieting counterparts. In fact, Glen Gaesser, author of Big Fat Lies, concludes, “A number of studies have shown the inescapable consequence of repetitious cycles of weight loss and gain appear to be even greater accumulations of fat.”

If body size is largely determined by factors beyond the individual’s control, and the culturally-sanctioned route of dieting for weight loss fails 95% of the time and often leads to weight gain, then how can we… continue to sanction dieting as a positive behavior?

Says Gary Foster, Ph.D., clinical director of the Weight and Eating Disorders Program at the University of Pennsylvania:

Even in the best medically supervised programs, nearly two-thirds of participants are back where they started within three years and 80 to 90 percent within five years.

Now listen to this:

Blood Test May Predict Rebound Weight Gain

Plasma levels of norepinephrine, insulin, and leptin can help to predict which patients will rebound after a successful weight loss program, a new study suggests.

“It is important to note, Dr. Masuo said, that the rebound rate is high even if dieters adhere to their weight loss regimens.”

“The results suggest that sympathetic overactivity and insulin resistance contribute to rebound after weight loss, she said.”

Dr. William Dietz of the Centers for Disease Control and Prevention (CDC) adds:

There is something going on during adolescence that makes an individual more susceptible to the complications of obesity as an adult. One potential candidate is the disposition of visceral fat. We know that adolescence is a time when the sex-linked fat distribution develops. Adolescent boys develop central body fat; girls develop gluteal fat. One possibility is that adult morbidity and mortality is mediated by those differences in fat distribution, which are accentuated by obesity present in adolescence.

Why do we keep banging our heads? What good is it to lose weight if most of us are just going to gain it back again?

Am I saying it’s OK to eat poorly? No.

Am I saying we shouldn’t exercise. Hell no.

Am I saying we are helpless victims and should just accept our weight? No.

Am I saying there aren’t a lucky few people who have been successful at keeping weight off long-term? No. I know they exist. I’ve spoken to some of them. I can count them on one hand. I applaud them and hope they continue to be successful.

What I’m saying is traditional methods of losing weight don’t work in the long-term and it’s harmful to keep believing that they will.

“Eating less” may help you lose weight in the short-term, but this weight loss is not sustainable.

Update: I don’t want to hear any anecdotal stories about successful weight loss regimens unless you can say “kept it off for over 4 years.”

I also don’t want ANY advice on how to eat. Been there and done it so many times I could write my own fucking book.

Also, this post is not about losing 10 pounds “here and there.” This is about losing a lot of weight, and keeping it off.

More posts on this topic forthcoming.

Before you reply to this: if you missed my post on the topic last summer, please read it (and the responses) first.