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Yesterday, I had a full day of pre-operative appointments consisting of the psychologist, nurse practitioner, physical therapist and nutritionist. It was an eye opening day!  

Psychologist
Well, my MMPI must have come out okay because they didn’t haul me away in a straight jacket. Dale is a great psychologist to talk about issues both in what past experiences got me here and how to prepare for the upcoming change. Blogging helped me pinpoint some events and issues, but there were some small a-ha’s that went on which created some additional awareness. It was very beneficial. I believe it is critical to be with a psychologist specializing in weight management as they have encountered many stories and have greater experience. He wanted me to identify “what is good enough”, set some goal not surrounding the number on the scale and start attending support group.   

Medical Exam  
The session with the nurse practitioner was straightforward.   We talked over my medical history and family’s medical history. We went over my blood tests. I’m much healthier than most patients they see, but there were a few things. My glucose was 95. This is below the diabetic range, but Claudia felt 95 was creeping up there and could be deemed pre-diabetic. My Vitamin D levels were low, but she said that is common among anyone living in the Pacific Northwest. Most Oregonians (at least in the valley and coast) should be taking 2000 mg of Vitamin D per day. She wants me to double that pre-operatively to get it back up.   Though my cholesterol levels were fine, my LDL was a tad on the high end. Claudia said none of these are huge issues and surgery will definitely resolve them all as well as mitigate the future exposure of health issues that run in my family.   
Physical Therapist 
Well, I wasn’t characteristic of what the PT generally sees either. I’m much more active, stronger and flexible than a typical WLS patient. My body comp of fat to muscle wasn’t horrible. We chatted about a number of things, but she was the one who presented the most eye-opening and validating news of the day.   

Remember that little resting energy expenditure (REE) fasting test I had to take last week? It only took about 15 minutes and seemed a little frivolous. Boy, I’ll never doubt the value of that test again. In fact I’d like to have another one about six months post-op. The test measures metabolism. I know, I know. A lot of overweight people like to rationalize they have a slow metabolism and everyone else thinks, “Yeah, right.” Well, there may be some truth to it….at least in my case. Apparently, I have completely screwed up my metabolism with endless dieting and sporadic exercise. I can joke and say my drive for efficiency in every aspect of my life has carried over to my body being very efficient at fat storage. However, it’s not efficient for trying to reach a normal weight. It was emphasized on my chart I have low metabolism. How low? Well, I run a 600 calorie deficit daily compared to a normal person. So, my body is penalizing any efforts with those 600 calories every day. That’s well over a pound per week. This explains so much. 

To remedy this, I must get moderate exercise consistently each day and build muscle. Surgery will also help get this back on track. Geez! It was validating I wasn’t crazy afterall, but frustrating that it got so skewed.    So, my marching orders were 30 minutes of moderate exercise 7 days per week and weight-lifting 2-3 days per week. I had already started exercising again, but now I know I need to ensure it’s done every day. I also know how critical it is given the rehab required for my metabolism.  

Nutritionist 
This was a good meeting and where I had the most questions. I got them all answered. She had few recommendations other than for me to continue with the transition changes I have been making in preparation, get my vitamins in order and switch my protein supplement.   

So, I came through the exams with flying colors and some specific recommendations. However, none of it’s overwhelming and nothing will hold up moving forward. The next step is meeting with the surgeon and then taking the pre-op class. They said they would have the complete pre-op work-up packet to the surgeon’s office by tomorrow. However, they are waiting on that sleep study doctor to get the dictation to them. He may be the one that holds things up, but I’ve already contacted them a couple times.  It's getting closer!! 

I’ve been taking baby steps on telling family and friends about my plans. Thus far, everyone has been very supportive. However, I really haven’t told many people. More friends know than family.    Before all this recent WLS activity, I had talked about the idea with a coworker who underwent lap band surgery. She was a wealth of information about options in our area. Her pod mates were very supportive of her decision and were privy to my interest given I was over there talking with her. So, they have known from the beginning and have kept it in confidence. I’m grateful to them as discretion can be a challenge in an office environment. 



I’ve devoured any post on the forums pertaining to sharing WLS plans with coworkers. It seems most don’t say anything, but eventually it comes out. I did tell my supervisor as he needs to know for FMLA and my plans to be off three weeks. I suppose I didn’t need to tell him what surgery I was having, but it’s hard for me to not be forthcoming with the truth. His reaction was typical for being in management and consistent with his personality. Though he didn’t express any opinion (and I’m glad), he’s been kind, understanding, discreet and accommodating. I needed that from him and appreciate his handling.



I work closely with a few people and we have worked well together so I didn’t think it would be much of an issue sharing my news with them. They know my other coworker who underwent WLS. However, I did wait until last week to tell them. A conversation was occurring and it seemed the right time to mention it to them. I’ve been a little surprised with the reaction or lack of reaction. The one female coworker whom I’m the least close to was supportive in a “who cares what anyone chooses to do” style. That works for me. My two male coworkers who I do feel a higher level of camaraderie with had nothing to say. I’m getting that feeling now they want to make sure they don’t say anything wrong. Do I really give off that kind of vibe? They know me better than that.  Needless to say, I’m feeling a little punched in the gut and I regret saying anything. 



There is a little more to the context though. The type of work we do involves health care and injuries. Our ability to do our work is hampered by clients with obesity issues. Thus, conversations often occur regarding how to handle a situation where obesity is an issue. Sometimes, the conversations are not entirely constructive. This is one of the reasons I sometimes want to crawl under a desk. However, I’ve become quite skilled at keeping a straight face and talking about it objectively. So, for anyone in our industry to pursue WLS, there may be a certain hush or subdued reaction at the topic. This is that silent stigma and discrimination that obese individuals are always aware of, but still seems accepted in today’s world. This is why I admire my coworker for paving the way and being open about her journey. I’m probably being way more sensitive and read more into individual reactions, but I don’t think I’ll be sharing my news with anyone else at work anytime soon. So much for my initial lofty intentions of sharing my story to raise the awareness of others. 



If I’m sensitive now, wait until those hormones get released from the fat cells into the blood stream post-operatively. I will have to keep my head down and my mouth shut.



UPDATE:  One of my coworkers and I talked this morning when we were by ourselves.  He's happy for me, but just concerned about the potential complications.  I feel better now.  Thx RW!  My husband also pointed out last night that decent guys just don't always know what to say and I should cut them some slack. 

Today was my third pre-operative appointment in the journey towards the big event. I haven’t heard others in the forum talk about a Resting Energy Expenditure (REE) test, but it’s a routine requirement at my surgeon’s office. An REE is a metabolic test to determine how much energy you expend at rest to provide a baseline. Apparently, the physical therapist and other physicians use this to determine how one’s metabolism is functioning. In other words, how bad has metabolism been screwed up by on/off dieting and weight fluctuations.   

It was another event requiring an 8-hour fast and an early morning drive to Portland without coffee or breakfast. I picked up Starbucks before the appointment and just left it in the car so it was ready when I left. They didn’t want you to exert much so I they had me use the valet parking, sit quietly for 15 minutes and then took me back for the test. I had to lie down on a bed and then they put this space helmet thing over my face to contain the air. All I had to do was breathe normally for awhile until they got seven minutes of consistent recording of data. I didn’t think I’d have a problem, but once she put that helmet on, I got claustrophic. I just closed my eyes and had my mind wander somewhere else. That was it and I was out of there. It was a lot of work-up for a short visit. Interesting what they can do with technology. 

I think the sleep study requirement has been the most vexing of pre-operative preparations. Since I’m a self-pay patient, I have looked for things I can ask my insurance to cover. My Kaiser PCP evaluated me for sleep apnea and made the referral for the study. I was under the impression my PCP made those decisions. However, after waiting 10 days to hear from them for scheduling, I found out I would have to see a Kaiser pulmonologist to determine whether I really needed the sleep study or not. And, the appointment wouldn’t be available for six weeks. So, I was looking at waiting six weeks to find out whether a second doctor would authorize the sleep study which I needed regardless for the WLS. It was a gamble with my time I didn’t want to take.   

My surgeon’s office made a referral to a non-Kaiser physician who provided the home sleep study test. So, I met with him yesterday which was an experience in and of itself. He was an old rambler who digressed a great deal and was already assuming I had sleep apnea. I pointed out to him the purpose of the take home test was to determine this.   



Last night I hooked myself up to this little device which was not nearly as intrusive as I thought it might be. It’s amazing how it could record my breathing and pulse all night. Though everything remained intact, it took me longer to disentangle myself than it did to put it on. I drove back to Portland and they downloaded the information from the device. I eagerly awaited the result because the next huge dilemma could be getting a CPAP from Kaiser. It turns out I’m borderline. For someone with a straightforward personality, I don’t seem to have straightforward situations. I learned there is an apnea-hvpopnic index (AHI) scale of sleep apnea based on the number of obstructive events per hour.   

Mild OSA = 5-15
Moderate OSA = 15-30
Severe >30  

An index of 5 provides some justification for considering therapy. I’m a six so I have it, but it’s very mild. I don’t know if my WLS surgeon will require me to have a CPAP or not. I would think not. I did fine with my fibula fracture surgery in 2005. I E-mailed my surgeon’s hand-holder who said my surgeon would make a decision when I meet with her. So, I guess I’ll wait for that. I did keep that Kaiser appointment as a back-up. I’ll get the documentation from my recent sleep study and provide it to him to see if he can just use that for assessing a treatment plan versus going through a formal sleep study. I’m saving Kaiser money!  

Next appointment is Friday for REE (resting energy expenditure) test.

I’ve found a way to further justify WLS when looking at the political world. This is a bit tongue in cheek so no one should freak out on me. For now, we still have freedom of speech so I’m allowed commentary.  

By having WLS (paid for by my father & myself without insurance), I am mitigating the likelihood of having to depend on medical care and insurance companies in the future for benefits related to such conditions such as diabetes, heart disease and cancer. Thus, I will hopefully be able to have few interactions and headaches with private insurance companies or socialized government medicine, be it Obamacare or Medicare. I am also saving my company and taxpayers money in the long run. 

Rationalize, rationalize, rationalize! 

Today was my first series of appointments in preparation for WLS so I was excited to finally get things going.  Because I live about an hour away from my surgeon, they were really great about grouping appointments together so I make fewer trips.  I got up about 4:45 am to make the drive for 7:00 fasting blood draw.  There were about 10 people ahead of me, but it went pretty quickly.  After that, I could finally have my coffee that I had brought with me along with yogurt. 

As soon as labs were done, I booked over to the physician's office to check-in for the Welcom Group session.  There were four other ladies attending as well.  Filled out some more paperwork before being taken back with the others for discussion by the nutritionist, physical therapist and psychologist.  It was a great presentation.  After a break, it was time for the psych questionnaire, eating profile questionnare, height/weight, EKG & pictures.  I got done about 12:30 and headed home. 

Monday, is sleep study appointment with a take home test which I have to drive back the next day.  Things are moving!!! 

One side effect of WLS I have to prepare and save for is S-K-I-N. Loose and excess skin is one of the side effects of WLS. Imagine what a deflated balloon looks like! Stretched out and puckered!   Saggy skin can vary among patients depending on their age, smoking history, size, elasticity and speed of weight loss. Exercise helps mitigate the appearance and significance of excess skin. I’d love to turn out to be one of the ones who don’t have much of an issue, but I’m not counting my chickens on this! Some people live with the skin and others undergo surgery to get rid of it. I’ve seen posts where a patient loses an additional 20 lbs after having the excess skin cut off or they go down an additional pant size. That’s quite something. I’ll be lifting weights and exercising to minimize the effects.   

Cosmetic surgery for the skin issue occurs once weight loss has maximized and stabilized. Insurance rarely covers this unless there are health issues associated with excess skin, but even then they can by choosy. The most common procedures are tummy tucks, pannilectomies (imagine pulling trousers up at the waist and cutting off the excess skin), total body lifts, skin removal of the flabby arms and breast lifts/implants. I won’t know what I’ll need until I see how I deflate. Even with the possibility of excess skin, I’ll still be healthier and look better….at least with clothes on. Sorry honey!

 

 I love my iPhone! So many people say that, but it has been a life-changing device. I used to be one of those Type A’s that hauled around a little briefcase daytimer filled with a weekly/monthly calendar, daily todo’s, lists of various topics, addresses, everyone’s birthday, etc. It weighed 5-10 lbs and was in addition to my purse. Coworkers and friends made cracks, but I was never willing to give it up. Well, not until I saw what the iPhone could do. I’ve held onto that daytimer just in case I wanted to go back. It’s been sitting next to my desk for two years now. My iPhone goes EVERYWHERE with me and I mean everywhere, sometimes even the bathroom. It’s the ultimate for multi-tasking. 

So, what does this have to do with weight-loss. OMG! There are umpteen different apps for tracking eating and exercise. There are even a few apps regarding lap band fills. I used the Weight Watcher app for awhile. I’ve switched now to My Net Diary as I know my nutritionist will likely be going by calories pre- and post-operatively. I also like this app more because it not only tracks calories (finds the foods for you with internet search), it tracks nutrients which is great for WLS patients who need to track protein, iron, sugars, fats and other nutrients. It also helps you track exercise, water intake, vitamins, weight and measurements. It provides a plan, analysis and before/after pictures. I believe I’ll even be able to E-mail a report to myself with the history of entries so I can print it out for the nutritionist. Not sure on that, but need to check. This app is my new favorite. There are lots of apps that do all this, but this is a one-app stop for all this and my new favorite aside from my TODO application.

Other apps that may be of interest include the Couch to 5k, Couch to 10k and Couch to 25k. I also have iPeriod which is a running joke with my family, but since I’m no longer on the pill, I need something to give me a heads up as to when to expect Aunt Flo! For awhile I thought I might be starting early menopause so it tracks symptoms as well. It also helps with family planning. I can see it being helpful to WLS patients who are ready to start tracking fertility or for those who have gotten out of having periods when they were overweight and now are getting them again post-operative. Ha, ha!   

If you’re already an iPhone user, you understand. If you’re not an iPhone user, check them out when your current contract is up. No, I don't work for Apple, but I believe in this product! 

I have watched The Biggest Loser on NBC pretty regularly since it has come on, probably subconsciously thinking that somehow watching it will make me lose weight. It’s very inspiring and the results are dramatic. I enjoy watching their success, but can’t stand the drama of the “game”. The show is doing a service in educating those who don’t have the knowledge about nutrition, counting calories, exercise and breaking through psychological barriers. I do have concerns about whether the habits are sustainable long-term for such obese contestants. I’ve heard them talk that they are in the gym all day and calories are severely restricted. That works for awhile and teaches the skills. However, then they go home and are faced with going back to work, spouses, children, stressors and a schedule. Going from working out all day everyday to trying to fit in a two-hour workout 6-7 days a week appears to be an unrealistic expectation. That’s just the working out. Imagine how these individuals are dealing with hunger from their enlarged stomachs. Some have been able to keep it off (but I question if they have real jobs), some have gained back a little and a few have gained quite a bit back. I’ve heard one even went onto have WLS. I do enjoy the show and am proud of contestant efforts and their success. I had to turn the channel the other night when this season premiered as I didn’t care for how they were deciding who got on the show. There were a lot of tears, excuses and drama. No drama for me thank you.   

I do think they help contestants identify their psychological barriers. Maybe if I let Jillian beat up on me for a few weeks, I’d figure it out. Dr. Phil says you continue self-destructive behaviors because there is some sort of payoff. I have wracked my brains trying to figure out how I’m benefitting from extra weight or why I never seem to be able to get past a certain weight. I know my size keeps other people at bay in a number of ways. I tend to be claustrophobic so I don’t like crowded events, crowded stores, crowded streets, cities (I live in the country), etc. So, my definition of personal space is larger than others and my wide pear hips keep people out of my face. It also takes awhile for me to get comfortable with others and trust them so maybe there is a psychological space involved as well. My weight also tends to keep men from getting googley around me though it doesn’t stop others – particularly at Jimmy Buffett concerts. I didn’t like dealing with oggling when I was younger, but now I feel better equipped to handle it in my wiser 40’s. So, perhaps my eating behaviors have worked with me on my personal space preferences. That would make sense though it’s not nearly as dramatic as Dr. Phil would need for his TV show.  

There is also the anxiety element where food works for me. In blogging and focusing on getting ready for WLS, anxious feelings often trigger my poor eating choices. Looking back at the summer I was 10 years old, I thought it might be loneliness, but I suspect it was because I wanted to be left alone by my cousin. I’m thinking the anxiety eating gives me something to focus on when I’m wound-up, obsessing on an issue, irritated, worried, etc. I get where I’m shaking my hands like a kid having a hissy-fit trying to figure out what to do with the feelings. No wonder I’m on drugs for this! Food gives the hands something to do, the mouth something to shut up on and the brain something to focus on. No wonder I crocheted so many scarves last fall when I was trying to curtail habits. There is really little for me to be anxious about as I have a wonderful family, job and life. I just seem to find something be it work-related, family-related or project-related. They say recognition is half the battle so maybe I’m getting a better grip on how to manage this. It’s a journey they say. 

In one sense I would so like to be able to share this journey more of my family, friends, coworkers and Facebook crowd. I think it’s critical to generating understanding and acceptance of obese individuals and the decision to pursue WLS. On the other hand, I hesitate to share because this is so personal and creates a feeling of vulnerability when I prefer to be in control. It’s much easier to share these thoughts with the obese community whom we may or may not know personally. That’s why I think the Obesity Help (OH) forum is so popular.     

Eventually, everyone will find out because no one goes from being morbidly obese for nearly 20 years to normal weight in 18 months without some eyebrows being raised and whispered questions. I tend to like to lay things on the line and get things out in the open. I see it as an opportunity to educate, address questions and resolve conflicts. If the conflicts can’t be resolved, then at least we know where everyone stands. However, sometimes laying it out creates drama and I hate drama.    

I’ve thought maybe I’ll wait until I’ve had the surgery to share this blog. However, then they lose the benefit of understanding what led me here unless they go back and read the prior blog entries. If I tell them now, someone is bound to try to change my mind. It’s probably someone who doesn’t know my tenacious side. I’m rambling I know. I guess I’ll know when I’m ready to come out of the bariatric closet.