From obese to unchained – “a citizen of the world instead of someone hiding on the sidelines” – Alison Smith charts her weight-loss surgery journey.
At my fattest, I was 114kg – about 50kg over my “ideal” weight, which is probably the weight at which Spiderman would be able to winch me up the side of a building without mishap.
Even then, my friends would say to me, “You’re not that big!” and that it didn’t matter what size I was, because I was still Alison, someone quite unique, no matter how overweight. That was a trifling comfort to me, because it was still an admission that I was obese, and a ploy to divert attention elsewhere.
There, I’ve said it. That word that so many overweight people hate to hear. To be formally classified as obese, your BMI must be over 30. Anyone reading this who carries some extra weight will know BMI is body mass index. It is calculated by dividing your weight in kilos over the square of your height in metres. My BMI was 44, so I was well into the long grass of obesity.
I had not reached a BMI in the 50s or 60s, which characterises those who are “morbidly obese” – the people whose hearts, lungs and kidneys work much harder just to keep them alive. They have hundreds of miles of capillaries taking blood to the deposits of fat, to maintain those precious stores, which evolution tells the body is like money in the bank.
It’s hard for them to get up from chairs, to bend over without letting their breath out, and to move from one place to another. I find it useful to imagine an obese person as someone carrying suitcases round an airport. I used to carry two 20kg bags (without wheels) and a 10kg carry-on. I know people who carry four or five 20-kilo suitcases strapped to their bodies every time they take a step. They are trapped inside their own body. This is heartbreaking.
Obese people don’t like to talk about their weight, or the struggles they have just trying to live normally, or their fear for the future if they cannot lose the weight. Just to be clear, they know full well they are obese – they don’t need anyone around them stating the obvious, saying things like “You could do with the exercise”, “I go to a great Zumba class – you should come” or “I love summer, you can just eat salads every day!”
Dragging multiple suitcases around with you all day long has a way of focusing the mind. At least someone with bad teeth can forget about it sometimes, until they look in the mirror. People don’t generally say, “You could do with brushing your teeth more often, mate” or “I use a great toothpaste – you should try it!”
We see both bad teeth and being fat as a sign of weakness, but fatness is the last frontier for those full of righteous indignation who repeat the endless mantra, “calories in, calories out”.
I was convinced by these people that I was mainly to blame for my size. After my son was born, I’d become a little more reluctant to take exercise and eaten a little more each year, in a pattern that led to incremental gains in weight of two or three kilos per year.
I have a lifetime membership to Jenny Craig, and started on their plan three or four times. Each time, I lost lots of weight, felt like I could go it alone, and eventually put all the weight back on. I’d tried more fad diets than you could shake a stick at, including fasting and hypnotism, but the weight always came back. I’d even tried Xenical, which sops up from the intestine all the extra fat you’ve eaten, and excretes it in an oily orange discharge that can permeate many layers of clothing. It was revolting.
However, this is not the place to debate whether weight gain is “nature or nurture”, or whether, with a little bit of willpower, I could have stemmed the tide by changing my eating and exercise habits 20 years ago, and been thin now. To employ two trite phrases, “it is what it is” and “the past is another country”.
So, I continued with my life. Recently diagnosed with type 2 diabetes, I’d read the scary pamphlet telling me I was at risk of losing feeling in my face, my limbs and even of losing my life, if I didn’t change my ways. I was exhorted to check the feeling in my feet every day! It gave me a real scare, and I changed my diet almost overnight. I went for lots more walks with the dogs, my eyesight improved, I felt physically much better and over six months, the diabetes stabilised. But I didn’t lose any weight.
My decision to have weight-loss surgery happened over many months, mainly spent wondering how I would find the money. Operations which alter one’s stomach and/or intestinal structure start at about $19,500 and go above $25,000. I had to accept my situation as it was – no amount of wishing it away or pretending a strict diet and strenuous exercise was my way to success would change matters. I was not one of those very rare people who get their “before” and “after” photographs published in magazines to celebrate their superhuman weight loss.
I decided to change my life drastically. I rang a well-known weight-loss centre and inquired in detail about having a gastric sleeve operation, to reduce the size of my stomach. This article is about my journey through this surgery, out of the wilderness, to the other side.
There are numerous steps to getting to the point of actually having surgery. All of these cost quite a lot of money, so there is no point budgeting for $20,000.
Weight-loss surgeons and their associates (at least in Auckland) have some very creative ways of taking your money. Nearly everything is an “extra”. First, as someone from a small provincial town with no weight-loss surgeons within 300km, I had to fly to Auckland to meet with a dietitian ($120) and the surgeon ($280). Allowances were made for me to have an extended phone call with a psychologist (another $210), and a gastric surgeon only 50km away agreed to take on my long-term check-ups ($140), so I wouldn’t have to fly to Auckland every three months following the surgery.
The dietitian was obviously used to dealing with people who made excuses and allowances for themselves – she was straight as a die and it was her way or the highway. There was one way of preparing for the operation, one regime, and woe betide anyone who strayed from the path of low-calorie eating.
To prepare for the operation, it was necessary to lose at least 6kg, following a diet of special shakes, puddings, soups and protein bars from a company called Optifast. In New Zealand, there doesn’t seem to be another firm that offers the same ultra-low-calorie blend of high protein and every single vitamin and mineral necessary for people who have abandoned a normal diet in order to have surgery. Optifast is also very expensive, costing between five and 10 times what ordinary food would cost, but it is currently the only comprehensive alternative in New Zealand for the purpose.
At first, I thought it was ridiculous and didn’t take it seriously – why would you go on a crash diet to prepare for weight-loss surgery? But because Optifast has been devised with many years of research and input from clinicians, and was making a real difference after the first week, I began to sit up and take notice.
The main thing about the diet is that it reduces the size of the liver, which in obese people is usually too large. It is extremely important for the liver to shrink somewhat, as it sits in front of the stomach, and it is much more difficult for a surgeon to operate on one’s stomach if there is a dirty great essential organ in the way that you just can’t pin back or move to one side.
The other reason, I suspect, for this dieting is it stops people bingeing. Imagine you’re a really fat person and you love food, and someone has just told you they will perform a gastric procedure and you will lose all the weight you’ve ever wanted to. What would you do? Well, you’d probably think, “It doesn’t matter if I overeat now, because my problem will be solved very soon, when I go under the knife.”
The last thing surgeons want is to operate on someone whose weight has increased a good deal since the last time they saw them. It’s already pretty risky to cut into a person who has many layers of fat, and keep them stable on an anaesthetic, as well as poking around in the dark behind their liver. I wouldn’t do it for any money.
Absolutely everything possible is done to ensure the operation and the post-op recovery goes as smoothly as it can. Far more effort is put into this when compared with the operations I’ve had under the state health system, but they were emergencies so it wasn’t possible to prepare over weeks or even days.
Anyway, back to Optifast. If you can imagine that someone has taken a bowl and mixed in all the essential elements needed by a human body every day, added heaps of manufactured protein and then decided it should also be palatable, that is what you have.
It comes in at least six different flavours, is usually sweet, and tasted to me the way something tastes when it’s too full of “goodness” to taste like real food. The dietitian got it right when she said, “Most people either love it or they hate it.” Ain’t that the truth! There was temporary respite each day in the form of two servings of actual low-calorie vegetables or fruit – real food.
I was to be on this diet for four weeks, which by week two seemed like an eternity, but there are people who are routinely put on this diet for two or three months. For those whose worst failing is lack of willpower, this is torture, but if they can’t lose enough weight, they cannot have the surgery. And yes, I did cheat a bit – I had quite a few boiled eggs and a little cheese with my green beans every now and then, instead of a shake or protein bar. This came back to bite me later on.
When I sat in the lobby, waiting for my turn to see the surgeon, I met some interesting people, most of whom had already been through the operation.
One was a girl who could only have been in her early 20s but was about four sizes larger than me. Her mother had had the surgery, so recommended it for her daughter, who’d lost 16kg since the operation about four months before. Another (thin) woman sat with her (fat) sister giving her a half-hearted pep talk as she waited to see her own surgeon.
My surgeon was a really nice man who would have been a friend if I’d met him socially. He was laidback and pragmatic and just a little podgy, which was a huge relief. He had a set script to go through, in particular asking questions about my mental state, why I wanted the surgery and what preparations I’d made for life after the operation.
Losing stacks of weight when you’ve been very overweight for a long time is mentally taxing, even if you wouldn’t immediately think so. Having someone make five incisions into your tummy and shrink your stomach is a conscious decision; so is deciding how to deal with a new body that doesn’t behave anything like the old one. Will one continue in one’s old habits, just eating less junk? Or will the decision be to change every aspect of one’s health and nutrition as the weight tumbles off and things like exercising and eating tiny portions become a pleasure?
My surgeon had done dozens of these operations and seen the whole spectrum of human reactions. He was very encouraging about my main motivation for having the surgery: to get my life back, pure and simple.
The last (phone) appointment was with the psychologist. She went over the mental-health ramifications of the decision once again. In particular, I think she wanted to know I had reached this decision on my own, and that my reasons for having the surgery were not purely cosmetic.
I suspect her main role as part of the team is to ensure people wanting the operation actually understand what they’re asking for, and are under no illusions about what can and can’t be achieved. For me, she was of most value when she rang during my dieting period, and gave me a pep talk at a time when I felt the Optifast regime was going to defeat me.
After she’d been in touch, I got into the habit of asking anyone who phoned from the clinic if I was going to be billed for the call, before we got under way. I only continued if the answer was no.
I arrived in Auckland the day before the operation and checked into an Airbnb for the night, after stopping at the hospital to have a blood test. After that, I went to the cashier and together we did some difficult sums based on how much I had already paid, how much was covered by health insurance, and how much was outstanding. As a long-term member of Southern Cross, the cover for weight-loss surgery was a loyalty bonus. But because my policy was for surgical and hospital care, it only covered about a third, after I’d paid an excess of $1000. Fees for the surgeon ($4000) and anaesthetist ($1500), and an estimated two-night hospital stay ($14,000) had to be paid upfront. Specialists’ appointments ($1500), plus travel and accommodation ($800), brought the total cost to almost $22,000. A pre-approval from the insurer took some pressure off, but it seemed apparent people did not normally quibble about the price.
The whole process was exquisitely stage-managed from start to finish, and each part of the admission process, surgery and post-op took place with military precision. I checked in, having not eaten anything since the night before, and was collected from reception five minutes later by a nurse, who took me to the pre-op suite. There, I was weighed (I’d lost a whopping 8kg), given a surgical gown and a pair of compression tights, which were put on by a special contraption that precluded the need for hauling them up my legs (they were pretty tight, what with having “compression” in the name).
I was then asked a series of detailed questions about my general health, bodily functions and weight-loss journey to date. All the medications I’d brought with me, including vitamin pills, were removed and put in a plastic bag with my name on it. I surrendered any autonomy whatsoever, and simply let events take their course. I did take covert sips of water when no one was looking, as waiting is thirsty work. I was “nil by mouth” and hadn’t had a proper drink for hours.
Presently, another nurse came to put me onto a bed and take an ECG – yes, my heart was still in the right place! At this stage, I was covered with a warming blanket to bring my blood vessels closer to the surface of my skin, so it would be as easy as possible to find a vein for a cannula to be put in.
Before long, I was sweating (as women of a certain age tend to do), so the blanket was removed. This made life more difficult for the anaesthetist, who was an absolute darling, to find a vein. The presence of a good vein to deliver all medications is essential, so I had the cannula placed on the back of my forearm, which was not ideal. However, the anaesthetist promised he would move it to the inside of my arm after surgery and he was true to his word. If you’ve ever had a cannula put into the back of your hand, so you hit it painfully on something every time you move, you will appreciate its location on your body can either contribute to or detract from your comfort in a big way.
The surgeon also came to see me, and apologised for running late. The operation before mine had been unexpectedly complicated, mainly because of the patient’s inability to diet effectively, as well as a propensity to lie when answering some of the questions that were asked. I can only assume someone would do something so stupid out of the most acute embarrassment (or fear of the dietitian).
I was wheeled into theatre and everyone said “Hello” and “How are you?” (a fairly ironic question, given the circumstances), introducing themselves in a very relaxed sort of way as I counted down to oblivion.
There seemed to be an awful lot of people in there. The operation was laparoscopic, or keyhole surgery, so five small horizontal cuts 1-3cm long were made across my upper abdomen, then carbon dioxide gas was pumped through the holes to expand the space, giving extra room for the surgeon to work with his tiny instruments.
All went well, except that the cheating I’d done on my diet had made a difference, and my liver had not contracted as much as would have been expected, given my accompanying weight loss. This meant another procedure I might have needed could not have been done while I was opened up.
One of the things my surgeon often does during these operations is to look for a hiatus hernia (when the stomach pokes through the upper diaphragm wall) and, if he finds one, he repairs it at the same time. Because my liver hadn’t shrunk to the anticipated size, he couldn’t see further up to the oesophagus – so couldn’t have repaired such a hernia, if I’d had one. Fortunately, I didn’t, but many people do without even knowing it. This was a sobering lesson about doing exactly what one’s medics tell one to do.
I woke up in recovery without the heavy wooziness I expected after being under a general anaesthetic, and within a couple of hours I felt surprisingly “normal”. My small wounds were taped together and dressed, but I had no stitches, thankfully. All in all, my abdominal region looked fairly tidy, and I had no pain.
As the evening progressed, I sipped water and took all my prescribed medications, handed to me by my nurse. The nursing staff were uniformly efficient, polite and kind. From the very first one who actually introduced herself to me, they listened, took plenty of time to help me with whatever I needed, and came up with little extras to make me more comfortable. They were punctual with checks and medications, answered all call bells promptly and even had enough time just to talk for a few minutes. This experience was quite a contrast with previous surgeries I’d had in the public system, where staff are so busy they’re rushed off their feet, and don’t have time for the niceties.
No matter what is happening in any hospital, all routine action is suspended when surgeons come around to check their patients. If a surgeon is expected, meals stop, physiotherapists change appointments, bathing is discouraged and scheduled checking of dressings or vital signs may also be delayed. Medication is usually given at the right time, but if the surgeon is late (and this is far more the norm than otherwise) it seems as if a “subsistence” schedule kicks in, and no extras are offered. After my gastric sleeve procedure, my surgeon came round pretty much at the times he said he would, but this seemed to be very much the exception. During my last public hospital stay, I never saw my surgeon at all – only his registrar, who was usually several hours late and surrounded by students.
After this operation I did not feel like eating anything, or indeed, feel the sensation of hunger for some months, but it was important to keep my fluids up from the very start, with little sips of water. On the second day, a physiotherapist came to see me with some difficult and slightly painful deep-breathing exercises that were necessary to get my blood moving, in case it had become sluggish from being under anaesthetic. She wanted me to walk around the ward, which was circular (handy), as many times as I could, still in my compression stockings, to minimise the tiny but still-possible likelihood of deep vein thrombosis.
Recovery was swift. When all the professionals had assured me I’d be eating a purée by the second day, having graduated from sips of water, I’d considered that only a possibility. The very first rule was not to drink anything while eating, or within half an hour on either side. Over 24 hours, I was able to manage a couple of tablespoonsful of soup, some stewed fruit and a thicker chicken broth. Everything tasted delicious!
I slept and walked the ward, showered and did deep breaths for the physiotherapist. I was not allowed to lift anything heavier than 2kg, but there was no pain at all until I started the deep inhaling and exhaling, and then there was an uncomfortable pinching deep in my solar plexus. Apart from feeling a little stiff, and getting tired after walking for a short time, I felt like a box of birds!
By day three, when I was due to leave, I’d been transferred onto paracetamol and codeine tablets, as I no longer needed the morphine I’d started with. I was ready to leave by 10.30am, once all my medications had been retrieved. The dietitian had been to see me again and I was on the right track. I would be looking forward to about 10 days or so of eating purées, mousses and Optifast shakes, while my poor stomach healed and became the daintier organ it would be for the rest of my lifetime.
I went back to my Airbnb digs in Auckland and stayed there for another two days, in case of misadventure, but all was well. The first meal I felt like eating after leaving hospital was ordered in, and was fettucine carbonara. This I faithfully puréed, and enjoyed the one takeaway packet for the rest of my stay. When I forgot to eat over the following few weeks – which is surprisingly easy to do when your stomach is stitched and swollen like a change purse full of air – I sometimes felt a little dizzy and quickly had some milk or soup.
Overeating by even one mouthful is swiftly rewarded by a feeling of pressure in the middle of my upper abdomen, as if I have a cork stuck in the bottom of my oesophagus.
After about a week of purées, some of which I’d prepared from previous dinners and frozen, I tried a little of the next step, which was soft food such as scrambled egg, soggy Weet-Bix or creamed potato. The gradual move from one stage to another can take up to three weeks, and the trick is not to be in a hurry. Eating food that was too solid at too early a stage was like landing on “Go to Jail” in Monopoly – not only did it result in terrible indigestion, but it could harm the stomach repairs and send you right back to gruel and Optifast shakes.
It was important to keep protein to a maximum, but meat was the most difficult thing to digest, so I invested in a tub of protein powder to sprinkle on practically everything. If you ever do this, get the one with no flavouring, as chocolate or vanilla protein powder on mash and scrambled egg tastes weird!
The other thing to avoid like the plague is overeating. While it was incredible to experience eating so little and not feeling hungry in the least, at times it seemed too good to be true. Overeating by even one mouthful was swiftly rewarded by a feeling of pressure in the middle of my upper abdomen, as if I had a cork stuck in the bottom of my oesophagus that was pushing up into the base of my lungs.
It was a very tight feeling, verging on pain, and there were two ways of getting rid of it: waiting until the food had started to move through my stomach to my intestines, which took about half an hour, or I could trot to the loo and vomit some of it up, which was very simple, as it was “right at the top” anyway. That sounds pretty gross, but the relief was immediate, and anyway, we are talking about bodily functions here.
Even when one has completely recovered from surgery, there are stern warnings against overburdening the stomach, as it is possible to slowly increase its size by regularly eating a little too much. This, of course, defeats the purpose, and people eventually find they do not lose any more weight, and may actually gain some over the years.
After two-and-a-bit weeks, I was eating soft food pretty much all the time. I had eliminated Optifast as soon as possible; now purées became tedious and tasted watery compared with real food. I got very creative, and invented all kinds of dishes I hadn’t tried before, such as creamed corn with a tiny bit of curry powder, miniscule pieces of pasta with a creamed spinach and bacon sauce, mash with onions and melted cheese, and spaghetti bolognese that had been squashed under a fork. Food that was lightly spicy was not a problem at all. The only thing that really didn’t agree with me in the first few months was rice, possibly because rice expands in one’s stomach.
The other thing happening was that I was feeling gradually better overall as the weight came off. When the first “carry-on bag” of 10kg was gone, I started walking the dogs much further than the perfunctory block or so. As the weeks went on, I got fitter and walked further and faster, as did the dogs. Now that I’ve lost more than my first “suitcase”, I take the dogs out every day for a fairly brisk 40-minute walk, unless it is absolutely pouring with rain, when I try to ignore their penetrating gazes and petulant whining.
Swimming is not advised until about six weeks after the operation, but I’ve started again after many years. The place where I live has the most traditional of facilities, a school pool that’s actually open free to the public over summer. I can walk there from my house, just far enough to work up a glow in the sun. The pool feels cold for the first two minutes, and people make way for me as I do my “old lady” strokes up and down the pool. I’ve increased the number of lengths slowly from 16 to 24, but the trick is not to overdo it. After my swim, I lounge in the sun to get my togs dry so the seat of my jeans doesn’t get wet on the walk home.
I’m now on an improvement trajectory, because the weight loss has continued as I have been able to eat a little of more and more foods. After three-and-a-half months, there is not really anything I cannot eat, although sugar overload results in an extended trip to the loo and a feeling of general malaise.
I previously took two medications for my type 2 diabetes, but now I’m down to one lower-dose tablet of Metformin, and I will be able to cut that out once I have lost about 40kg. I know with certainty that this will happen, as it is impossible not to drop kilos, unless I eat sweet and fatty things all day, which my body just will not allow me to do.
Food has become a precious commodity. Since I can only have a small amount, I make sure it’s something that tastes really good, like smoked salmon or fresh cherry tomatoes that burst with flavour in my mouth. I eat grapes like lollies and a breakfast on the run is a banana.
I feel free within my own skin – not just comfortable but unchained. It sounds trite, but gastric sleeve surgery has given me back my life. I don’t have to worry whether my thighs are chafing if I wear a skirt, or constantly suck in my tummy as I pass a restaurant window full of people looking out. Bending over has become so easy, and I can walk for 10 minutes up a small hill without being aware that I’m getting puffed.
My confidence has skyrocketed, and I feel like a citizen of the world, instead of someone hiding on the sidelines.
Looking ahead, I anticipate emptying my wardrobe of “fat” clothes. This has already started, as my size 20 and 18 clothes are too loose now. The trousers fall off my hips! Like so many women, I’ve hoarded smaller clothes, particularly the more costly ones, while fantasising for years about one day fitting them again. The bag of old clothes I opened yesterday contains things I was last able to wear in 2003. Fortunately, they haven’t gone out of style.
Because I now eat so little food, I’m actually buying much less. While I still cook for two of us, the amount we need is about 60% of what I used to prepare. I don’t enjoy stodgy foods the way I used to, or fatty meats and pastries, and this has the knock-on effect of improving the food my loved ones eat as well. My limited food intake has all but eliminated my diabetes symptoms, so my eyesight is even better, and so are my reactions and energy levels. I wake up each morning feeling well, and I always look forward to my day now.
Needless to say, my decreasing girth has also resulted in my overall size diminishing, and I look much better. I have not lost enough weight over the past five months to be plagued by capricious flaps of skin on my stomach, thighs, bottom and upper arms, but I have had “wings” up near my armpits for some years now. I suspect my new exercise regime keeps my skin a little firmer, but I have also consciously slowed down my weight loss, so my skin has more time to shrink to my new size.
My legs have taken on a far more attractive shape, and my bottom has flattened pleasingly. My waist has returned and finally I remember what it is to have a differing waist:hip ratio. I don’t mind saying men are noticing this, and I’m starting to get appreciative glances as I walk down the street. Even the vege man at the supermarket stopped to flirt with me yesterday. My confidence has skyrocketed, and I feel like a citizen of the world, instead of someone hiding on the sidelines.
I will likely live at least 10 years longer than previously expected, as I will not be prone to all the illnesses and types of early death the obese may see as inevitable. It is a life worth living fully.
Haves and have nots...
For me, once the full recovery was over, there were no downsides from my decision, except I spent the money I should have kept to fix the roof one day. But it doesn’t need fixing now, and by the time it does, the value of the house will have appreciated to much more than the value of a new roof.
But I should not have had to spend so much money for what, to me, is an essential treatment for the morbidly obese. While district health boards are limiting weight-loss surgery to a tiny number of people really at death’s door (three in Taranaki in 2016), dozens or maybe even hundreds of people in each province are merely existing. Although there are certainly many uses just as laudable for public money, decision-makers need to come clean about the fact that most of us believe fat people are responsible for their own bad fortune. We may be unable to see past this to the extensive benefits of the surgery for individuals and the social structures they support.
For the most part, we no longer vilify smokers for needing heart and lung surgery, once they stop smoking, so why not extend the same compassion to the severely overweight when they need a kickstart to a much healthier life? Ridiculing obesity is the last bastion of accepted discrimination.
The costs for this type of surgery are obscene and out of reach for many ordinary people who urgently need it, and have no choices about how or where it could be done. The surgeons have a package contract with the hospital (except for the ubiquitous “extras”); nothing is itemised for the patient, because then they would see clearly what a rip-off it is. The catch-22 is that the lion’s share of these operations is available only in the private sector at exclusive hospitals, yet even people who have health insurance are either not covered at all or only in part.
This is also true of other “elective” surgery, such as knee or hip replacements or cancer treatment. Something must change, particularly since these hospitals are part-owned by “non-profit” health insurers. The first step would be to audit the value for money private hospitals offer, so the government can strike much fairer deals for weight-loss surgery. Necessity is the mother of economy, or something like that.
A note of caution: This was my experience, but it may not be yours. Mine is an anecdote, whereas the advice of a surgeon and other professional staff has been honed by dealing with all the patients over the course of their careers. From the day of surgery, my experience unfolded the way it was supposed to. But some operations or recoveries do not go exactly according to plan, which is why there are so many precautions and so much preparation. If I jumped off a cliff, would you? At least these days, I wouldn’t fall so hard!
This was published in the April 2018 issue of North & South.