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Bariatric surgery: Fighting the flab with multi-layered weapon

Weight loss surgical team offers new beginnings for obese Richmond patients

Mark Krier knows he'll never again get his money's worth at a Las Vegas buffet, and it doesn't bother him in the least.

He's just glad he can comfortably order a plane ticket to the sparkling city in the Nevada desert and not have to worry about fitting in one of the seats.

It was a different story a couple of years ago.

Krier, who works as director of operations at East Richmond trucking firm CF Dedicated Services, once tipped the scales at 428 pounds.

He was suffering from diabetes and felt like his six-foot-three-inch frame was continually sapped of energy.

His living room couch was his landing pad to collapse on after work. He'd tried becoming more active to slim down and break out of his funk, but found the efforts left him feeling even more drained.

Shareane Heuring found herself in a somewhat different situation with her weight. A former top athlete while in high school, she had seen the numbers on the scales yo-yo as she turned to diet pills to address the 360 pounds she had packed on.

While the pills were good for losing close to a third of that, the rebound once she stopped taking them added even more to her total and came as a crushing blow.

Work stress was a factor for Brandi Lee, who at one point weighed 450 pounds. Salty snacks were her escape from the pressures of the office, and she gradually saw the numbers on the scales rise.

For Dave Chin, he didn't fully realize just how much regularly entertaining business clients with dim sum meals was adding to his waistline. The two or three times a week trek to local restaurants left him at 330 pounds.

While their circumstances are all unique, each of the four who struggled with their weight have managed to find a common denominator to help shed the excess.

They turned to Westcoast Bariatric Surgery, a publically-funded program operating out of Richmond Hospital. Started in 2011, the staff at Westcoast stress that surgery is just one point along the journey towards new, healthier lives.

One of the guides is Dr. Sharadh Sampath, who along with Dr. Nam Nguyen, form the surgical team performing the three different procedures that all have the same goal - reducing the size of a person's stomach.

But as Sampath is quick to point out, what goes on in the operating room is just one factor in achieving long-term weight loss.

"This program, the only one of its kind in B.C., is a multi-disciplinary one," he said. "It's like a house with three pillars. Pillar number one, the most important pillar, is the patient. And they need to come with insight to the causes of their problems and motivation to make the lifestyle changes that are necessary and accompany surgery in order to have long-term success."

The second pillar is the healthcare team. "(Obesity) is a hard thing to tackle by yourself without a team to counsel you, support you and get you through both pre and post surgery," Sampath said, adding the third pillar is the surgeons. "We need all three to really make things work."

The demand for intervention is apparent as obesity - now classified as a disease - has reached epidemic proportions over the past 20 years in Canada. World-wide it is the second leading health-related cause of mortality and is linked to other ailments including diabetes, high blood pressure, sleep apnea, heart disease and cancer, and is associated with a shortened life expectancy of a startling 20 years in men, and five in women.

An insight to just how widespread the issue is can be emphasized by the Public Health Agency of Canada which estimates a quarter of the population is now considered obese. And with a multitude of contributing factors, it's not a problem that can be easily unraveled.

"There's no one cause - there's genetics, metabolism. There's psycho-social factors. There's a lot that goes into creating the disease and a lot that goes into managing it," Sampath said. "There's no, one quick fix. And surgery is by no means a quick fix."

Many try that route, and sometimes Sampath and his team are left tending to the complications when a patient, who has gone elsewhere for their surgery, needs help to get back on track.

"A lot of patients will go to Mexico or the states and essentially just buy it (surgery). The problem with that is surgery by itself does not tackle the other underlying causes of this disease," Sampath said. "They are not going into it with appropriate counselling on what this will do to change their lives. So, your long-term success rates are fairly poor.

"With a multi-disciplinary approach, with our allied health colleagues, our long-term success is much better. Patient satisfaction is much better. Management of both obesity and things like diabetes, hypertension, sleep apnea, cholesterol problems, all are substantially improved."

Part of that success rests with the lead up to surgery which can take some patients upwards of a year to complete, plus, post-surgical support as patients enter a new and very different phase of their lives.

"Patients with this disease are quite educated about their options. They've tried a lot of things by the time they come to us. And typically, they realize they need a bit more of a powerful, multi-modal approach," Sampath said. "The ones who come here are, to a certain extent, self selected."

The vast majority, greater than 70 per cent, are able to complete the pre-conditioning process, pre-screening process and proceed to surgery.

With long-term tracking of patient outcomes just starting to be collected, Sampath said more than 80 per cent of patients going through the system experience successful weight loss.

Plus, diabetes remission figures are greater than 70 per cent. And those still considered to be diabetic have shown dramatic decreases in the need for medication to control their conditions.

It's a familiar route for Krier who had his surgery this spring and had dropped about 117 pounds by the end of summer. Just as significant was dropping the need for 160 units of insulin a day to combat the diabetes he was suffering from for the past 20 years.

"That was in the neighbourhood of $1,000 a month in drugs," Krier said. "It (diabetes) was like a vicious cycle. The more I tried to do things, the more tired I became, and the more I slept.

"I was definitely a ticking time bomb." Plagued by rarely feeling satiated after a meal, Krier's weight gain coincided with personal strife - a divorce and diabetes diagnosis.

"I'm a relatively tall guy - I'm six-footthree - and can carry 400 pounds," he said. "But when you walk into a restaurant, right away you say, 'No booths, please.' Those are the first words out of your mouth."

Travel was another concern. "You get to a point in your life when you say, 'let's fly to Las Vegas for the weekend.' And you start asking things like what kind of plane would you be taking, how big are the seats? "It's not that you can't fit, but if there are two other guys my size in the other two seats, it's going to be a very uncomfortable flight."

Krier tried exercising, but with diabetes he just ended up feeling even more fatigued.

"There came a point that all I did was work, eat and sleep, and with no energy to do

For computer animated video of the surgery. anything else." That's when he felt a more aggressive approach was needed.

For Heuring, she didn't realize she had a weight issue until she became pregnant with her daughter at age 18.

"I put on about 100 pounds when I was pregnant with my daughter, just with stress. I was just so focused on her, I never realized I was getting bigger and bigger." she said.

At five-foot-ten, she had been a forward on Thomas Haney secondary's basketball team that won a provincial championship. She also excelled on the soccer field and baseball diamond.

But after entering the workforce to support herself and her new daughter she experienced the discrimination many overweight people encounter.

Working as a receptionist in a dental office, she had patients approach her and tell her "what a big girl she was."

"I had people tell me how ugly I was and didn't want to deal with me at the counter," she said.

Already using food as a coping mechanism, Heuring said encountering that type of adversity made her situation worse.

"Pizza was definitely my food drug of choice. Soon as I had one I couldn't stop eating it," she said.

That's when she tried the diet pill route with little success.

Weight became an issue for Lee, 34, when she was in her late teens. Later with mounting work demands, she turned to food for comfort.

"I just let the outside factors control my life," said Lee whose weight grew to 450 pounds at its height. "If I was really stressed I would go eat. You can easily eat a bag of chips and not realize how many calories are in there."

Knowing she had to do something to change her life, Lee modified her diet, exercised and lost 150 pounds, but then gained 70 of it back.

Undeterred, she hit the gym again, harder this time, hiring a personal trainer, but could not get her weight to drop below the 350-pound mark.

Worried there might be an underlying medical issue to explain her inability to lose the weight, Lee asked her doctor for a comprehensive blood test.

"I was 32, and if I didn't get control of my health I was going to die at a young age," said Lee.

"Both my grandparents had a history of heart problems. I also had high blood pressure and diabetes in my family. I didn't want to develop other health issues because I wasn't able to take care of myself." For Chin, 36, weight was always an issue.

The Richmond resident considered himself to be pudgy all through his childhood, school years and adulthood. But what really twigged his concern was the 100 pounds he tacked on after he stopped smoking five years ago.

"My metabolism really got affected when I quit," he said. "I had always believed that I didn't eat a lot."

But when he started to look at the pattern of taking clients out for lavish meals, it added up.

"When I used to go to dim sum, in the Chinese mentality, if everything is finished at the table, you're not a good host. So, you have to order in excess," Chin said. "My normal lunch was 500 to 600 calories. I would easily triple that when I went out."

The response was to try to exercise with a personal trainer, but found the efforts unsustainable with his busy lifestyle.

Then there was a multitude of diet schemes. "You name it, I tried it," Chin said.

And while he didn't as yet have diseases related to obesity, family history showed where he was likely heading.

"My whole family has cholesterol and diabetic problems, it's all written on the walls."

That's when Chin learned about the possibility of surgery.

When patients like Krier, Heuring, Lee and Chin arrive at the door of Westcoast Bariatric Surgery the pre-op counselling begins almost immediately.

"We re-teach them a lot of things - how to shop, how to cook, how to eat, what to eat, when to eat, and how to cook for their families," Sampath said. "Often there's a lot of emotional eating and eating out of boredom.

"But the emotional component is very strong. And we tackle that also in a multi-modal fashion. One of the programs that our occupational therapists use is called the Change Ways Program - it's a cognitive behavioural therapy group that teaches patients some coping mechanisms that are more positive than simply turning to food. And our dieticians also work with them to make alternative choices."

For patients with more serious concerns, there is psychological and psychiatric counselling available long-term.

Patients are also required to keep a detailed log of exercise and what they eat in the time leading up to their surgery, and are encouraged to adopt healthier eating habits in an attempt to lose weight and prepare for life after their operation.

The average hospital stay following surgery is two to three days, and a patient’s diet is restricted to fluids for the first month or so. From there, they are allowed to steadily increase the consistency of their meals to the point they are eating solids again — but in much smaller amounts than before.

Usually, that means about a cup of food total per meal, although frequency often rises to five or six times a day.

It’s an adjustment Krier said he has gotten use to. So is learning to share meals when he goes out to a restaurant.

“I am guessing, but I was consuming about 2,500 calories a day prior to joining the bariatric program. I’m consuming about 1,000 a day now, and I have to work hard to do that,” he said.

“I do eat more often than before, but no junk goes in my mouth.”

That has ruled out pretty much all convenience foods, including the Friday night pizza dinners.

And when he does go out for lunch during the week, gone are the days of burgers, and fish and chips.

Now, it’s low on the carbohydrates, and lean protein replaces the heavier items.

Exercise is now also a mainstay in his life.

“I can go crazy. I go full tilt,” he said, adding he rides his bike about five times a week.

“When I started I was at two or three kilometres. Now, 10 kilometres is nothing. It’s effortless,” he said. “I never thought I’d be one of those guys who wore the biking shorts. But I got a pair. I got the gloves, too. I got the whole nine yards.”

With a goal weight of just under 200 pounds, Krier knows he still has a long way to go.

“My dietician thinks I am going to get down to 198 (pounds). I don’t think I am going to be quite there — but anywhere between 240 and 230 would be a pretty happy weight for me,” he said. “My goal is to be healthy.”

A healthy lifestyle is what Lee has accomplished since her surgery when she weighed in at 350 pounds.

She’s now down to 190 pounds.

Lee ran two half marathons in May, did a 14-km run in the fall, and was training for another half marathon in November.

“It’s now part of my life,” she said. “My goal was to run a half marathon in under three hours. I did that in May, so anything from here on in is gravy.

“Weight-wise, I couldn’t care less if I lose another pound. I’m healthy and can get out there and do stuff. I’m happy with myself and am not letting the scales tell me that I’m any less of a person than what I am.”

Lee said she’s noticed people now treat her differently, too.

“People are so much nicer to me now,” she said. “People used to say to me, ‘You have such a pretty face, I don’t understand how could you be so heavy. They felt it was their responsibility to tell me I needed to do something about my size.

“Whether I’m 150 pounds or 450 pounds, I am still a person. And I find that people find me worth talking to now.”

The change has been dramatic for Heuring who underwent surgery in November 2012 and has dropped from 360 to 214 pounds.

Her goal was originally to get down to 199 pounds.

“Now, I don’t have a goal in mind because I am happy where I am. If I lose more, great, but I feel comfortable. I feel good about myself. And that’s all that matters to me now. I’m not worried about a number on a scale.”

One of the big plusses has been regaining the active lifestyle, and social connections, she had in her youth.

“It’s amazing. I get up in the morning and feel good. I am happier for myself, and that means I am happier for my kids.”

She’s completed a couple of five-kilometre fun runs and is training for a 10-km event.

“I wanted to be active again. I grew up as an athlete. I was meant to be active,” she said.

“I haven’t had a day where I have regretted doing this. It’s worth getting your life back. It’s not easy. There are days when it’s tough. But dealing with the emotional part of it, and looking at how healthy a lifestyle you’ll have in the long run is a motivation.”

It may be early days for Chin, but the payoff post surgery is clear in his mind.

His target weight is between 185 and 195 pounds — roughly half of what it was before surgery.

“I don’t want to be in the same situation again. Surgery was life transforming,” he said. “One of the things I want to do is something as simple as skiing, or go to the PNE and not be concerned about fitting on the roller coaster.”

For Sampath, seeing the results of his and his team’s work is satisfying.

“When you talk to the patients pre and post-op, their goals are really heart-breaking sometimes,” he said, “things like being able to get up and play with their grandkids, take their dog for a walk, or go back to work.

“They are not asking for unreasonable things, just a second chance to optimize their potential in life. And if we are able to be part of that, then that’s satisfying.”

From a clinical perspective, the impact of the team’s work is also impressive.

“The results are amazing. You do one surgery and tackle five different disease conditions in a patient, and offering a patient a new lease on life,” he said. “There’s not a lot of things in medicine that you can do to give a patient all of that with one approach. So, for a surgeon, it’s immensely gratifying to see my patients come back in a year or two and see how different their lives are like, see them off their medications, see that they are able to work and enjoy their families, play with their grandkids, and do the simple things they were never able to do before.”