stomach

Bariatric surgery is often the most effective treatment for the morbidly obese and with a mortality rate of around one percent it isn’t terribly risky by Bennet Omalu et al. (abstract only without subscription). The highest risk is faced by patients who undergo the procedure at the hands of an inexperienced surgeon. This by David R. Flum and E. Patchen Dellinger shows a strong correlation between survival rates and surgeon experience (abstract only without subscription). Annual gym memberships are another purchase on the commitment device shopping list for those trying to lose weight. Except that people overestimate by 70 percent how much they will use them as Dubner and Levitt wrote in their Jan. 7. 2007 column. “.” The column references Stefano DellaVigna and Ulrike Malmendier’s paper. The popular new weight-loss pill Alli which partially blocks the body’s absorption of fat is a commitment device with real consequences: a person who takes Alli and then eats too much may experience a bout of oily diarrhea. (Among the initiated. .) “We also estimated the long-term mortality for individuals who had undergone surgery many years ago. For the 1995 cohort who had at least 9 years of follow-up. 13.0% had died. From the 1996 cohort with 8 years of follow-up. 15.8% had died and from the 1997 cohort with 7 years of follow-up. 10.5% had died. For the 1998-1999 cohorts with 5 to 6 years of follow-up the total mortality was 7.0% to 2004.” That’s from a very comprehensive study of all patients in Pennsylvania they can’t all have been worked on by hacks can they? Doing it is impossible for obese people. They have different hormone levels of several hormones including leptin and ghrelin that regulate appetite. I suspect that for them not to eat an entire cake takes more will power than for a thin person to avoid nibbling on a cookie. Sure years of overeating has probably caused this disregulation. But some people are more susceptible than others. Why blame the individual who will fast starve and diet or even commit suicide to end the misery of obesity? I blame the screwed up junk food environment and the culture of fast food that has been created by industry and advertising. Why should a three year old be subjected to ads beckoning them to ignore their parents and eat crap? We didn’t evolve for this and many people CAN’T deal with it. I would like to point out that in your excellent article about bariatric surgery you mention that the procedure “often produces complications — physiologic ones to be sure but also perhaps psychological ones.” I think you may have reversed the vector of causality here and in my humble opinion the use of “perhaps” was also superfluous. As a psychiatrist there is no doubt in my mind that a morbidly obese patient without other medical cause for obesity (ie thyroid disease) already has a severe psychiatric problem that has produced the complication known as obesity. Such a person overeats when they know it makes them unhappy to say the least as well prone to other life threatening diseases but it literally unable to stop. Without treating the psychiatric compulsion to harm oneself that underlies such behavior it is no wonder that patients who have surgery but no psychiatric treatment develop “new” psychiatric symptoms like gambling compulsive shopping and alcoholism as you’ve mentioned. All patients considering bariatric surgery and all physicians recommending it should consider psychiatric consultation for those patients who are open to it so that they can maintain the health benefits that they achieve through sugerry without acquiring a potentially more dangerous psychiatric ailments. In a way there is a simple economics to it. The patient who undergoes surgery perhaps even covered by insurance does not pay the psychological price never mind the opportunity cost of couch time and the true cost of paying for therapy that would be required to come to understand why he thwarts himself so. And so the psychological problem having not received it’s due sum returns in a new form. While the actual procedure deaths are fairly low deaths afterwards from later complications malnutrition and even suicide are far higher than in comparable morbidly obese patients who do not lose the weight. Even the weight loss of bariatric surgery is not always permanent Gastric bypass does not force one to eat a healthy diet or else. It forces one to eat an unhealthily small amount of food and supplement that rigorously as the body is no longer capable of absorbing certain nutrients. As for the diabetes reduction that happens almost immediately within the first few days following surgery. It has nothing to do with the weight loss but something to do with the digestive mechanisms that have been altered. While this is encouraging knowledge as far as diabetes treatment is concerned it bears more investigation of what exactly has changed and if there are ways to do this for diabetic patients short of a risky and life-altering surgical procedure. For those who say stop eating? Research has shown that in those who have been very overweight for a long period of time this is FAR easier said than done. Many of them already eat far less than one imagines. Whether or not that is the case a calorie restriction leads to a starvation response. In order for most obese people to take weight off and leave it off it requires living in a state of starvation for the rest of one’s life. Perhaps there are ways to prevent obesity. I do not think dieting - forcing one’s body into a state of starvation and lowering one’s metabolism - is one of them. After all this increase in obesity has occurred concurrently with the rise of the diet industry and how many overweight people have not already tried several diets? It is not willpower in resisting eating a whole cake we are talking about. It is pushing aside hunger a basic physiological urge more akin to deciding one is only going to go to the bathroom once a day or only breathe every thirty seconds. Do I know the answer? No. I am lucky enough to have thin and fit parents and have eaten healthfully (neither overeating nor dieting) my entire life. But it horrifies me when we as a society focus on beating down those who have not been so lucky encouraging them to mutilate their stomachs and hurt themselves. The truth is we don’t know much at all about human weight regulation and turning people into pariahs for a state most can no longer permanently control is certainly not the answer. Alli is the equivalent of Antabuse for alcohol. You pay a (nasty) price for a bad decision. Gastric bypass makes you abide by portion control whether or not you want too. As medical insurance will not reimburse for therapy that focuses on that coping skill so too a refusal to fund the treatment needed to change those automatic choices (unlike the advertisement your baby isnt going to slap you when you choose the french fries). The studies that demonstrated the efficacy of “lifestyle modification” in weight loss diabetes prevention heart disease usually included intense intervention - weekly then gradually decreasing frequency over a 3-4 month period. This usually includes work with a nutritionist and a physical therapist or trainer. Instead insurance would rather pay a single larger sum for a single “procedure” with its “universal reproducible” effect. More importantly how many choose this option for cosmetic reasons rather than for future health status? What is the perceived “value?” The people you describe in this article are compulsive overeaters. Addicted to overeating the same as an alcoholic is addicted to alcohol. Would you suggest that an alcoholic where a stinky scarf to cure their disease? Just as I can never trully understand the urge to drink excessively. I cannot expect non-compulsive overeaters to understand my urge to overeat. But I have found a solution in the twelve-step program of recovery — Overeaters Anonymous. By working this program daily. I have been free from the compulsion to overeat for over three years. I hope that you’ll at least mention this program when you write about the hopelessness of the obesity epidemic. There is hope. If just one person experiences the recovery I have received you’ll have done a great service. While there are some statistics and quotes published in this article it is an opinion - plain and simple. The authors like in most of society wrote this piece under the presumption being fat is bad unhealthy and unacceptable. But moreover the generalizations are being made that fat people themselves are bad unhealthy and unacceptable - as well as lacking any knowledge or discipline. As usual there is a judgment upon those of us who are fat about our choices what our lifestyles might be like. I particularly enjoyed the part about how thanks to these surgeries fat people can. “Now people can eat all they want for years and years and then at the hands of a talented surgeon suddenly bid farewell to all their fat”. What an ignorant statement - and one that indicates a sad truth about our culture. This is SURGERY that seriously alters a MAJOR ORGAN of one’s body. I know people who have opted to have this surgery and I respect their decision to do so. However it should be said that such a thing is not an easy decision - never mind the expense the recovery - there are a lot of risks involved during the procedure after and then in the long term. I want to call attention to a statement in this article a quote by Marc Bessler who talked about his father being fat and developing colon cancer. Marc says: “…He died at age 54 from colon cancer. It may have been picked up late because of his obesity.” With respect to Mr. Bessler and his father (whom clearly I do not know the specifics of his case). I must reject the last part of this quotation - that because of his obesity the colon cancer was not found. Fat people often have mis-diagnosis given to them by Doctors who simply dismiss their symptoms because they are fat. I recall an acquaintance who at 35 was finally diagnosed with ovarian cancer after longstanding symptoms - which had been dismissed because she was fat. By the time she was diagnosed she had stage 4 cancer and a very low survival prognosis. I reject that fat is the lone reason for these mis-diagnoses. It is the assumption on the part of many doctors that whatever the problem is is simply because the person is fat they need to lose weight - case closed. I say this understanding that sometimes losing some weight may help depending on the medical situation but I am speaking specifically about the dismissal of another possible diagnosis other than “fat” or “morbidly obese”. I wish for there to be more understanding about the assumptions made and are encouraged to be made about fat people. It is contrary to general belief very possible to be fat and healthy. I wish there to be more questioning of our assumptions that thin = healthy. Our culture produces more processed foods than ever before not to mention all of the engineering that goes into low-fat and non-fat foods. How about questioning what those foods do to prevent the absorption of nutrients into our bodies - and so perhaps they are not really “healthy” after all? Asking more questions to get better answers that is what I hope for. I encourage anyone who read this article to also read the following article which talks about the largest and longest study about food nutrition weight loss which was conducted and it’s surprising results. These results weren’t widely published because it did not support the agendas of the larger medical establishment. This article is written by Sandy Szwarc. BSN. RN. CCP on 10/15/07 and is on her blog. Junkfood Science: When I lived in Switzerland going to the farmers market meant losing 120m in elevation. That means that whatever I bought. I had to haul back up the 120m of elevation that I lost to get to the food. And going to the supermarket meant losing an additional 80m or so in elevation. So see the “economics of food gathering” prevented me from gaining any weight at all. In fact transferring there from the US always made me lose 15-20 pounds without even trying. Unfortunately in most of the US nowadays one has to drive everywhere since we are stuck in our islands of subdivisions. Perhaps this can be thought of as a long-term failure of city planning and policy a very INELASTIC infrastructure. What a crock. Weight loss isn’t successful if it isn’t permanent and maintainable. How do you define permanent? I’d define it to be over the course of a lifetime. But we don’t really have any studies for that. How about 5 years out from the diet or surgery? How about 10 years out from the diet or surgery? To the person who commented that 5 to 9 years out you have a chance of dying from lots of other things not related to a “successful” weight loss surgery. That’s true but studies have shown that people who have WLS die much more often than people who didn’t have WLS. Even fat people who didn’t have WLS don’t die as often. Look at bariatric surgeries 10 years out. Spell out how we are defining success. Is it a 10% loss? More? Less? So if a study defines a successful bariatric surgery as an overall weight loss of 20% of body weight over 5 years and the patient weighed 300 pounds at the time of surgery what does success look like? And I guarantee that if you actually do your homework and read the studies checking carefully to determine how they define success what cases they are excluding from the final results and why and look at the long term picture you will find that the surgery is a disaster for a very large portion of the people who do it. Especially note the number of people who are “lost to follow up” in these studies. Do you really think that all of those people are now living in a size six? Aside from the debate about the merits of bariatric surgery. I do think the idea of a commitment device is an interesting concept in terms of incentives. Weight loss however is a particularly difficult realm to discuss it in. On one hand it’s personable and something many people can relate to. But on the other it’s a combination of psychological and physiological factors and much more complicated than simply not gambling or not running up a huge credit card bill. One CAN simply throw out the credit cards or stop going to casinos. One cannot stop eating altogether. Though as another aside. I’m kind of horrified by the blobs of fat as a deterrent. Some degree of fat cells are required simply to live. I believe it’s 4-6% of body weight for men and 12-14% for women. Having something in my kitchen meant to elicit feelings of disgust towards a not insignificant part of my physical self? I’m kind of horrified. But commitment devices for less physiological issues? Very interesting. The best I can come up with was setting a test date for an exam I had to take. Once it went from “within the next few months” to “a week from wednesday or else” I was much more motivated to study. You have a poor understanding of why people become obese (and there isn’t just one reason). To simply decry people for “eating too much” doesn’t help. Many obese people have displayed extraordinary discline time and again with only to ultimately succumb and fail. Prior to having children. I was always thin and disparaged the obese having seen my grandmother and mother struggle with obesesity. After my first child. I gained a great deal of weight. Fortunately. I had never used food as an emotional comfort and do not have an addictive personality. I have gradually lost some of the weight but it is a struggle. This experience gave me a real insight into how people become grossly obese. Yes some people will have bariatric surgery because they want “the easy way out,” but do not think that at least at present all bariatric surgery patients blithely opt for surgery. Your statement is simply absurd. As the author pointed out just 30 years ago there were far fewer obese people. So how come people who had no problem eating less 30 years ago all of a sudden find it “impossible” to eat less now? You can blame genetics or “the society” all you want. But let’s face it - obese people eat more because they *choose* to do so. Other countries have far fewer obese people as a % of their general popukation. Why is it that people in other countries can eat less but doing the same thing is deemed “impossible” by americans? People will go to any extreme to lose weight because to be fat is to be constantly vilified. We have two types of commercials on television in this country food and weightloss. There is also an attempt(successful)in this coutry to link every medical disorder to obesity. Most of this is not evidenced based research but it allows health care providers,the insurance industry and any company with a stake in the shrinking health care pie with an actual visual cue of the “potential” problem children who may cause a spike in their longterm healthcare costs. Please note this includes you the pleasingly plump and will eventually touch you yes the forgotten underweight. This will morph into which body types tend to be healthier (sorry endo’s) and run right into who has a healthy genetic profile. We have already have a fantastic amount of the ground work completed as it is acceptable to call anyone who is fat any name,ascribe any attribute and openly discriminate with immunity. I don’t think you have to walk around in a fat suit in NYC to see why someone would risk their life to lose weight. Again we are not talking about a healthy normal weight…you now need a body weight that is deemed aceptable to at least 75 percent of the population to be consideredslim ( please make sure your proportions are correct). Do you actually think this is about caring if people are healthy? With money and a handy their personal responsibily logic card safely on the table… As a certified fatso (365 lbs.) I find that the only thing that controls my appetite is to keep my glucose level low by eating complex carbohydrates like brown rice. My glucose level becomes high whenever I break my diet by pigging out on simple carbohydrates like pastries or pasta. High glucose causes me to crave more food. Eating whole grains helps me break the viscous cycle. Exercise helps too. Yet it’s very easy to “fall out of the saddle” because temptation is everywhere and old habits die hard. Actually the obese and overweight don’t eat more than the non-obese/overweight; it’s myth. Take a look at studies on weight balance and you won’t find any that say caloric intake dictates weight gain/lose. Impaired glucose metabolism is almost solely to blame for the diabesity epidemic and the overwhelming majority of overweight/obese have problems with insulin (the fat-storing hormone). So telling fat people not to eat so much is ridiculous; the problem is not lack of will power or exercise it’s lack of insulin control. Alli (or Orlistat) has been used for the treatment of obesity for a long time and with the experience gained from this time. 2 points can be made: 1: Weight loss will be modest(average 2.9 kg more than placebo with a follow-up of 1-4 yrs (Rucker et al. BMJ 15 Nov 2007 )) and 2: using orlistat has a lot of adverse events which will affect compliance negatively. A recent review demonstrated that the long-term effects of behavioral therapy for obesity are disappointing (Psychother psycomed med psychol 2007 Nov;57(11):420-7) The focus on bariatric sugery from a medical point-of-view makes sense two studies published in the new england journal of medicine had demonstrated that bariatric surgery reduces mortality rates significantly (Sjostrom et al. N Engl J Med 357:741. August 23. 2007; Adams et al. N Engl J Med 357:753. August 23. 2007 (http://search nejm org/search?w=bariatric)). When people present themselves at the outpatient clinic with being overweight or suffering from type 2 diabetes,bariatric surgery (especially bypass) is the best treatment that can be prescribed! An interesting other theory to explain the óbesity epidemic’ is based on a paper in the Annals of inernal medicine. Epidemiologic studes demonstrated that as the prevalence ofobesity increased the average amount of sleep (in hours/night) decreased. In the paper the authors demonstrate that sleep curtailment increases hunger and appetite and alters certain hormone levels in a way that would increase food intake (Spiegel et al. An Int Med. 2004;141:846 (http://www annals org/cgi/content/abstract/141/11/846? ijkey=9bd315cc48be60331472c94964e1e620107584c7&keytdype 2=tf_ipsecsha)). Although it would be absurd to point to sleep reduction as the sole reason for the ‘obesity epidemic’ just stating that ‘people just eat to much’ is too. Dubner and Levitt first ask why many obese people chose the “drastic” option of bariatric surgery. Well consider this: for the extremely overweight - heck even for people with just 10 pounds to lose - losing the weight is only the first really difficult hurdle to deal with; *keeping it off* is even more difficult. Regain is extremely common particularly when you demand of the body a loss of 100+ pounds. And so with each weight-cycling of loss/gain/loss/gain the body becomes less adept at losing weight and very inclined to cling to it instead. Desperation (and hatred - which is both self and other - generated) is why obese people often feel driven to risk their lives through bariatric surgery. This view of the problem backed up by science still seems to let fat people off the hook too much for many. Could this be why Levitt and Dubner decide from *their* “vast cerebral storage network” that it’s really because surgery is just an easy way out after all. Yup it’s just like a dumbed-down game-show (an oxymoron if ever there is one). To quote L & D on the latest trend in game shows: ““Deal or No Deal,” which requires no talent whatsoever beyond the ability to randomly pick a number on a briefcase.”Fat people just want the “easy” way out. Listen please: Obesity is almost a crime these days and thinness is the only reprieve. It doesn’t really matter how you get “pardoned” either as People Won’t accept health improvements even if you don’t lose much weight. You can exercise and moderate your eating but only massive weight loss matters when you are obese. It’s be thin or die. And so: people get their innards switched around. Some would even say they get them butchered. Desperation to be thin not stupidity and not the “easy way out” is what drives people who are obese. Obese people most definitely eat more than their bodies need. That is no myth. It’s how they got to be obese in the first place. It’s called the First Law of Thermodynamics - one of the most fundamental law of physics in this universe. If you eat more than your body burns all those extra energy has to go somewhere. Guess what? They got stored as fat. Hence you gain weight. If you *consistently* eat less than your body burns you *will* lose weight. Again that’s the First Law of Thermodynamics. If you believe “insulin control” or some other pseudoscience can circumvent the First Law of Thermodynamics you might as well start building a perpetual motion machine… Actually there is at least one nonsurgical solution for weight loss (Stephen J. Dubner and Steven D. Levitt Nov. 18) that has been extremely effective for food addiction. Compulsive Eaters Anonymous a 12-step program for food operates on the same principles of Alcoholics Anonymous. Like alcoholics many compulsive overeaters battle a physical allergy coupled with an obsession of the mind. In the 12-step rooms addiction whether to alcohol food debting gambling sex narcotics and so on is treated as a disease which may explain why other addictions pop up after patients undergo bariatric surgery. This procedure seems like yet another opportunity for the medical industry to make a profit on the illusion of the quick fix. Isn’t that what this is about anyway? The quick fix. How many people are out there taking antidepressants prescribed by their gynecologists? Do these medical professionals ever bother to suggest psychotherapy first and/or inquire to the amounts of alcohol and marijuana their patients are consuming? On another note does filing for bankruptcy alleviate the problem of debting for the compulsive debtor? There are many people in Compulsive Eaters Anonymous who have lost well over 150 pounds and have kept the weight off without drugs and dieting while gaining the gift of serenity in the process. Furthermore for those who have found themselves continuing to gain weight after having had bariatric surgery this program has been “their last house on the block.” There are no dues or fees to be a member only a desire to stop eating compulsively one day at a time. Clearly this is not a program for people who need it. It is a program for people who want it. To john,You say that obese people eat more than their bodies need? But why is it that when I eat more than I “need” (~4000kcal/day) my weight (~75kg) never increases (and in fact has decreased in the last year) but many obese people continue to gain weight on much fewer calories? Is it genetics? Do I have some genetic predisposition to burn more calories than the obese? I don’t think so. You see on a low-fat high-carb diet. I was gaining weight eating fewer than 2000kcal/day. How does that fit into your first law of thermodynamics? Don’t forget there’s a second law of thermodynamics! How do you know you need 4000kcal/day? Just because some website you found on the Internet spits out that number doesn’t make it a scientific truth. And why does it surprise you at all that you lose weight on 4k calories a day while others gain weight on fewer calories. So *different* people need *different* amount of calories to maintain their weight - is that really such a shocker? I mean we’re talking about different people here right? And there’s also nothing surprising that you were gaining weight on 2K calories per day. After all we’re talking about different periods of your life here. The amount of calories your body needed could very well have changed. Also when you changed your diet the % of calories your body absorbed could also have changed. But just remember you can never absorbed more calories than you eat. So if you were eating 2000 calories a day you could never absorb more than that. And if you were gaining weight on that diet it means your body needed less than 2000 calories a day during that period of your life. None of the above violates the 1st law of thermodynamics. And yes there is a 2nd law but your body weight really has nothing to do with entropy… Some people have brought up Overeater’s Anonymous as a possible solution. Although it works for some there are also many *very* valid criticisms of OA such as: “OA has been the target of feminist criticism for encouraging bulimic and binge eating women to accept powerlessness over food. Feminists criticize that the perception of powerlessness adversely affects women’s ongoing struggle for empowerment. Similarly teaching people they are powerless is liable to encourage passivity and prevent binge eaters and bulimics from developing coping skills. These effects would be most devastating for women who have suffered oppression distress and self-hatred.” “Opponents of Twelve Step programs argue that members become cult-like in their adherence to the program which can have a destructive influence isolating those in the programs. Moreover this kind of fanaticism may lead to perception that other treatment modalities are unnecessary. Surveys of OA members has found that they exercise regularly attend religious services engage in individual psychotherapy and are being prescribed antidepressants. This is evidence that participants do not avoid other useful therapeutic interventions outside of Twelve Step programs.” “The concept of abstinence in OA has beencriticized for its inherent ambiguity. While in AA abstinence means not drinking alcohol there is no direct analogy for compulsive eaters.”(from:http://en wikipedia org/wiki/Overeaters_Anonymous #Fanaticism) There are more problems than space enough here to list them all. OA is not a good solution for many people but if one critiques it people in OA freeze you out. Many people in OA can’t seem to bear that other people can and do chose other paths that *work for them* when OA *does not work*. OK. I’m not even going to justify the stinky-ziploc-under-the-nose remedy with a comment as I’m sure any statement that stupid could only have the purpose of provoking controversy. The misconception that overweight people simply lack willpower continues to baffle me. All told. I’m sure I have lost and gained well over 100 pounds throughout my life. I have come to suspect that the gaining required just as much willpower as the losing. People who are overweight often suffer from self-destructuve behavior very low self-esteem and a poor body image. They are pretty good at telling themselves that they are utter failures for not being able to lose weight so really there’s no reason to remind them. My experience has been that 400 hours of psychological therapy has had only limited success at changing these underlying causes. What I have found to be the best remedy has been the discovery that it’s just really fun to have a body no matter how I feel about how it looks or about the person it contains. This has occurred incidentally and incrementally since moving to Europe eight years ago. I started out riding my bike most places. Gradually without really noticing it. I have ended up riding my bike everywhere no matter what the weather or how far. About twice a year I get on a bus to go to the airport when I fly to the US. At some point that wasn’t enough especially in the dark Nordic Winter so recently I joined a gym. Four or five days a week I spend two or three hours working out. I now have more strength endurance and flexibility than many women who are much younger and slimmer than I am and I have seen some very attractive bodies in pretty poor shape. Now I’ve gotten to the point where I lose weight sometimes and when I don’t it would take more than even I can eat to gain it back. Not everyone who is overweight is unhealthy but those who are pay a terrible price in quality of life and self-image. They feel trapped in their bodies. So maybe the best way to help them is not to remind them of all the things that are wrong with them. They are better at that game than you are. Help them remember what a joy it is just to have a body no matter how inadequate it might seem to be. Take them for a walk down the street. Next week you might get them around the block and next year you might not be able to keep up with them anymore. PS I think a more interesting column might be about why it is that a smoker who wants to quit smoking and knows that a piece of nicotine gum will quench his desire for a cigarette decides to light a cigarette instead of putting a piece of gum in his mouth. Or how someone who wants to lose weight and knows that he will buy healthier foods if he is not hungry when he goes to the supermarket goes to the store on an empty stomach. Somehow it seems to me there must be an economic correlation for the fact that someone who wants a cigarette or a cookie doesn’t really want to not want one when he wants one. Much criticism of OA has been posted here. I’m not going to respond except to say the program has saved my life and I’ve heard the personal testimonies of many who feel the same. The program is not for everyone. You do have to be willing to change. The 12-steps will help you do that but you must be willing to use them. For me that willingness only came after trying everything short of bariatric surgery. For those who are wondering if it might work for them. I encourage you to check into it (no fees or commitments). What have you to lose except a lifetime of struggle? And I have received so many benefits in addition to maintained weight loss. I’m including the OA website link. For those of you who are sure it will not work for you best wishes in the path you choose. If you change your mind you are always welcome to OA. Actually. OA has received many accolades here so I wanted to present an alternative view one that honors the fact that OA is NOT right for everyone (and as I said. OA not working does not have to do necessarily with being “unwilling” to change). I *did* say that OA has helped many. However many also find their own way out of the binge mentality *without* it. OA can be cultish repressive and controlling. People should know about the downside of OA too. To the idea that: “it only works if you work it”. I would say: “it only works if it’s right for the person who works it”. If not say goodbye without guilt and move on.

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Bariatric surgery is often the most effective treatment for the morbidly obese and with a mortality rate of around one percent it isn’t terribly risky by Bennet Omalu et al. (abstract only without subscription). The highest risk is faced by patients who undergo the procedure at the hands of an inexperienced surgeon. This by David R. Flum and E. Patchen Dellinger shows a strong correlation between survival rates and surgeon experience (abstract only without subscription). Annual gym memberships are another purchase on the commitment device shopping list for those trying to lose weight. Except that people overestimate by 70 percent how much they will use them as Dubner and Levitt wrote in their Jan. 7. 2007 column. “.” The column references Stefano DellaVigna and Ulrike Malmendier’s paper. The popular new weight-loss pill Alli which partially blocks the body’s absorption of fat is a commitment device with real consequences: a person who takes Alli and then eats too much may experience a bout of oily diarrhea. (Among the initiated. .) “We also estimated the long-term mortality for individuals who had undergone surgery many years ago. For the 1995 cohort who had at least 9 years of follow-up. 13.0% had died. From the 1996 cohort with 8 years of follow-up. 15.8% had died and from the 1997 cohort with 7 years of follow-up. 10.5% had died. For the 1998-1999 cohorts with 5 to 6 years of follow-up the total mortality was 7.0% to 2004.” That’s from a very comprehensive study of all patients in Pennsylvania they can’t all have been worked on by hacks can they? Doing it is impossible for obese people. They have different hormone levels of several hormones including leptin and ghrelin that regulate appetite. I suspect that for them not to eat an entire cake takes more will power than for a thin person to avoid nibbling on a cookie. Sure years of overeating has probably caused this disregulation. But some people are more susceptible than others. Why blame the individual who will fast starve and diet or even commit suicide to end the misery of obesity? I blame the screwed up junk food environment and the culture of fast food that has been created by industry and advertising. Why should a three year old be subjected to ads beckoning them to ignore their parents and eat crap? We didn’t evolve for this and many people CAN’T deal with it. I would like to point out that in your excellent article about bariatric surgery you mention that the procedure “often produces complications — physiologic ones to be sure but also perhaps psychological ones.” I think you may have reversed the vector of causality here and in my humble opinion the use of “perhaps” was also superfluous. As a psychiatrist there is no doubt in my mind that a morbidly obese patient without other medical cause for obesity (ie thyroid disease) already has a severe psychiatric problem that has produced the complication known as obesity. Such a person overeats when they know it makes them unhappy to say the least as well prone to other life threatening diseases but it literally unable to stop. Without treating the psychiatric compulsion to harm oneself that underlies such behavior it is no wonder that patients who have surgery but no psychiatric treatment develop “new” psychiatric symptoms like gambling compulsive shopping and alcoholism as you’ve mentioned. All patients considering bariatric surgery and all physicians recommending it should consider psychiatric consultation for those patients who are open to it so that they can maintain the health benefits that they achieve through sugerry without acquiring a potentially more dangerous psychiatric ailments. In a way there is a simple economics to it. The patient who undergoes surgery perhaps even covered by insurance does not pay the psychological price never mind the opportunity cost of couch time and the true cost of paying for therapy that would be required to come to understand why he thwarts himself so. And so the psychological problem having not received it’s due sum returns in a new form. While the actual procedure deaths are fairly low deaths afterwards from later complications malnutrition and even suicide are far higher than in comparable morbidly obese patients who do not lose the weight. Even the weight loss of bariatric surgery is not always permanent Gastric bypass does not force one to eat a healthy diet or else. It forces one to eat an unhealthily small amount of food and supplement that rigorously as the body is no longer capable of absorbing certain nutrients. As for the diabetes reduction that happens almost immediately within the first few days following surgery. It has nothing to do with the weight loss but something to do with the digestive mechanisms that have been altered. While this is encouraging knowledge as far as diabetes treatment is concerned it bears more investigation of what exactly has changed and if there are ways to do this for diabetic patients short of a risky and life-altering surgical procedure. For those who say stop eating? Research has shown that in those who have been very overweight for a long period of time this is FAR easier said than done. Many of them already eat far less than one imagines. Whether or not that is the case a calorie restriction leads to a starvation response. In order for most obese people to take weight off and leave it off it requires living in a state of starvation for the rest of one’s life. Perhaps there are ways to prevent obesity. I do not think dieting - forcing one’s body into a state of starvation and lowering one’s metabolism - is one of them. After all this increase in obesity has occurred concurrently with the rise of the diet industry and how many overweight people have not already tried several diets? It is not willpower in resisting eating a whole cake we are talking about. It is pushing aside hunger a basic physiological urge more akin to deciding one is only going to go to the bathroom once a day or only breathe every thirty seconds. Do I know the answer? No. I am lucky enough to have thin and fit parents and have eaten healthfully (neither overeating nor dieting) my entire life. But it horrifies me when we as a society focus on beating down those who have not been so lucky encouraging them to mutilate their stomachs and hurt themselves. The truth is we don’t know much at all about human weight regulation and turning people into pariahs for a state most can no longer permanently control is certainly not the answer. Alli is the equivalent of Antabuse for alcohol. You pay a (nasty) price for a bad decision. Gastric bypass makes you abide by portion control whether or not you want too. As medical insurance will not reimburse for therapy that focuses on that coping skill so too a refusal to fund the treatment needed to change those automatic choices (unlike the advertisement your baby isnt going to slap you when you choose the french fries). The studies that demonstrated the efficacy of “lifestyle modification” in weight loss diabetes prevention heart disease usually included intense intervention - weekly then gradually decreasing frequency over a 3-4 month period. This usually includes work with a nutritionist and a physical therapist or trainer. Instead insurance would rather pay a single larger sum for a single “procedure” with its “universal reproducible” effect. More importantly how many choose this option for cosmetic reasons rather than for future health status? What is the perceived “value?” The people you describe in this article are compulsive overeaters. Addicted to overeating the same as an alcoholic is addicted to alcohol. Would you suggest that an alcoholic where a stinky scarf to cure their disease? Just as I can never trully understand the urge to drink excessively. I cannot expect non-compulsive overeaters to understand my urge to overeat. But I have found a solution in the twelve-step program of recovery — Overeaters Anonymous. By working this program daily. I have been free from the compulsion to overeat for over three years. I hope that you’ll at least mention this program when you write about the hopelessness of the obesity epidemic. There is hope. If just one person experiences the recovery I have received you’ll have done a great service. While there are some statistics and quotes published in this article it is an opinion - plain and simple. The authors like in most of society wrote this piece under the presumption being fat is bad unhealthy and unacceptable. But moreover the generalizations are being made that fat people themselves are bad unhealthy and unacceptable - as well as lacking any knowledge or discipline. As usual there is a judgment upon those of us who are fat about our choices what our lifestyles might be like. I particularly enjoyed the part about how thanks to these surgeries fat people can. “Now people can eat all they want for years and years and then at the hands of a talented surgeon suddenly bid farewell to all their fat”. What an ignorant statement - and one that indicates a sad truth about our culture. This is SURGERY that seriously alters a MAJOR ORGAN of one’s body. I know people who have opted to have this surgery and I respect their decision to do so. However it should be said that such a thing is not an easy decision - never mind the expense the recovery - there are a lot of risks involved during the procedure after and then in the long term. I want to call attention to a statement in this article a quote by Marc Bessler who talked about his father being fat and developing colon cancer. Marc says: “…He died at age 54 from colon cancer. It may have been picked up late because of his obesity.” With respect to Mr. Bessler and his father (whom clearly I do not know the specifics of his case). I must reject the last part of this quotation - that because of his obesity the colon cancer was not found. Fat people often have mis-diagnosis given to them by Doctors who simply dismiss their symptoms because they are fat. I recall an acquaintance who at 35 was finally diagnosed with ovarian cancer after longstanding symptoms - which had been dismissed because she was fat. By the time she was diagnosed she had stage 4 cancer and a very low survival prognosis. I reject that fat is the lone reason for these mis-diagnoses. It is the assumption on the part of many doctors that whatever the problem is is simply because the person is fat they need to lose weight - case closed. I say this understanding that sometimes losing some weight may help depending on the medical situation but I am speaking specifically about the dismissal of another possible diagnosis other than “fat” or “morbidly obese”. I wish for there to be more understanding about the assumptions made and are encouraged to be made about fat people. It is contrary to general belief very possible to be fat and healthy. I wish there to be more questioning of our assumptions that thin = healthy. Our culture produces more processed foods than ever before not to mention all of the engineering that goes into low-fat and non-fat foods. How about questioning what those foods do to prevent the absorption of nutrients into our bodies - and so perhaps they are not really “healthy” after all? Asking more questions to get better answers that is what I hope for. I encourage anyone who read this article to also read the following article which talks about the largest and longest study about food nutrition weight loss which was conducted and it’s surprising results. These results weren’t widely published because it did not support the agendas of the larger medical establishment. This article is written by Sandy Szwarc. BSN. RN. CCP on 10/15/07 and is on her blog. Junkfood Science: When I lived in Switzerland going to the farmers market meant losing 120m in elevation. That means that whatever I bought. I had to haul back up the 120m of elevation that I lost to get to the food. And going to the supermarket meant losing an additional 80m or so in elevation. So see the “economics of food gathering” prevented me from gaining any weight at all. In fact transferring there from the US always made me lose 15-20 pounds without even trying. Unfortunately in most of the US nowadays one has to drive everywhere since we are stuck in our islands of subdivisions. Perhaps this can be thought of as a long-term failure of city planning and policy a very INELASTIC infrastructure. What a crock. Weight loss isn’t successful if it isn’t permanent and maintainable. How do you define permanent? I’d define it to be over the course of a lifetime. But we don’t really have any studies for that. How about 5 years out from the diet or surgery? How about 10 years out from the diet or surgery? To the person who commented that 5 to 9 years out you have a chance of dying from lots of other things not related to a “successful” weight loss surgery. That’s true but studies have shown that people who have WLS die much more often than people who didn’t have WLS. Even fat people who didn’t have WLS don’t die as often. Look at bariatric surgeries 10 years out. Spell out how we are defining success. Is it a 10% loss? More? Less? So if a study defines a successful bariatric surgery as an overall weight loss of 20% of body weight over 5 years and the patient weighed 300 pounds at the time of surgery what does success look like? And I guarantee that if you actually do your homework and read the studies checking carefully to determine how they define success what cases they are excluding from the final results and why and look at the long term picture you will find that the surgery is a disaster for a very large portion of the people who do it. Especially note the number of people who are “lost to follow up” in these studies. Do you really think that all of those people are now living in a size six? Aside from the debate about the merits of bariatric surgery. I do think the idea of a commitment device is an interesting concept in terms of incentives. Weight loss however is a particularly difficult realm to discuss it in. On one hand it’s personable and something many people can relate to. But on the other it’s a combination of psychological and physiological factors and much more complicated than simply not gambling or not running up a huge credit card bill. One CAN simply throw out the credit cards or stop going to casinos. One cannot stop eating altogether. Though as another aside. I’m kind of horrified by the blobs of fat as a deterrent. Some degree of fat cells are required simply to live. I believe it’s 4-6% of body weight for men and 12-14% for women. Having something in my kitchen meant to elicit feelings of disgust towards a not insignificant part of my physical self? I’m kind of horrified. But commitment devices for less physiological issues? Very interesting. The best I can come up with was setting a test date for an exam I had to take. Once it went from “within the next few months” to “a week from wednesday or else” I was much more motivated to study. You have a poor understanding of why people become obese (and there isn’t just one reason). To simply decry people for “eating too much” doesn’t help. Many obese people have displayed extraordinary discline time and again with only to ultimately succumb and fail. Prior to having children. I was always thin and disparaged the obese having seen my grandmother and mother struggle with obesesity. After my first child. I gained a great deal of weight. Fortunately. I had never used food as an emotional comfort and do not have an addictive personality. I have gradually lost some of the weight but it is a struggle. This experience gave me a real insight into how people become grossly obese. Yes some people will have bariatric surgery because they want “the easy way out,” but do not think that at least at present all bariatric surgery patients blithely opt for surgery. Your statement is simply absurd. As the author pointed out just 30 years ago there were far fewer obese people. So how come people who had no problem eating less 30 years ago all of a sudden find it “impossible” to eat less now? You can blame genetics or “the society” all you want. But let’s face it - obese people eat more because they *choose* to do so. Other countries have far fewer obese people as a % of their general popukation. Why is it that people in other countries can eat less but doing the same thing is deemed “impossible” by americans? People will go to any extreme to lose weight because to be fat is to be constantly vilified. We have two types of commercials on television in this country food and weightloss. There is also an attempt(successful)in this coutry to link every medical disorder to obesity. Most of this is not evidenced based research but it allows health care providers,the insurance industry and any company with a stake in the shrinking health care pie with an actual visual cue of the “potential” problem children who may cause a spike in their longterm healthcare costs. Please note this includes you the pleasingly plump and will eventually touch you yes the forgotten underweight. This will morph into which body types tend to be healthier (sorry endo’s) and run right into who has a healthy genetic profile. We have already have a fantastic amount of the ground work completed as it is acceptable to call anyone who is fat any name,ascribe any attribute and openly discriminate with immunity. I don’t think you have to walk around in a fat suit in NYC to see why someone would risk their life to lose weight. Again we are not talking about a healthy normal weight…you now need a body weight that is deemed aceptable to at least 75 percent of the population to be consideredslim ( please make sure your proportions are correct). Do you actually think this is about caring if people are healthy? With money and a handy their personal responsibily logic card safely on the table… As a certified fatso (365 lbs.) I find that the only thing that controls my appetite is to keep my glucose level low by eating complex carbohydrates like brown rice. My glucose level becomes high whenever I break my diet by pigging out on simple carbohydrates like pastries or pasta. High glucose causes me to crave more food. Eating whole grains helps me break the viscous cycle. Exercise helps too. Yet it’s very easy to “fall out of the saddle” because temptation is everywhere and old habits die hard. Actually the obese and overweight don’t eat more than the non-obese/overweight; it’s myth. Take a look at studies on weight balance and you won’t find any that say caloric intake dictates weight gain/lose. Impaired glucose metabolism is almost solely to blame for the diabesity epidemic and the overwhelming majority of overweight/obese have problems with insulin (the fat-storing hormone). So telling fat people not to eat so much is ridiculous; the problem is not lack of will power or exercise it’s lack of insulin control. Alli (or Orlistat) has been used for the treatment of obesity for a long time and with the experience gained from this time. 2 points can be made: 1: Weight loss will be modest(average 2.9 kg more than placebo with a follow-up of 1-4 yrs (Rucker et al. BMJ 15 Nov 2007 )) and 2: using orlistat has a lot of adverse events which will affect compliance negatively. A recent review demonstrated that the long-term effects of behavioral therapy for obesity are disappointing (Psychother psycomed med psychol 2007 Nov;57(11):420-7) The focus on bariatric sugery from a medical point-of-view makes sense two studies published in the new england journal of medicine had demonstrated that bariatric surgery reduces mortality rates significantly (Sjostrom et al. N Engl J Med 357:741. August 23. 2007; Adams et al. N Engl J Med 357:753. August 23. 2007 (http://search nejm org/search?w=bariatric)). When people present themselves at the outpatient clinic with being overweight or suffering from type 2 diabetes,bariatric surgery (especially bypass) is the best treatment that can be prescribed! An interesting other theory to explain the óbesity epidemic’ is based on a paper in the Annals of inernal medicine. Epidemiologic studes demonstrated that as the prevalence ofobesity increased the average amount of sleep (in hours/night) decreased. In the paper the authors demonstrate that sleep curtailment increases hunger and appetite and alters certain hormone levels in a way that would increase food intake (Spiegel et al. An Int Med. 2004;141:846 (http://www annals org/cgi/content/abstract/141/11/846? ijkey=9bd315cc48be60331472c94964e1e620107584c7&keytdype 2=tf_ipsecsha)). Although it would be absurd to point to sleep reduction as the sole reason for the ‘obesity epidemic’ just stating that ‘people just eat to much’ is too. Dubner and Levitt first ask why many obese people chose the “drastic” option of bariatric surgery. Well consider this: for the extremely overweight - heck even for people with just 10 pounds to lose - losing the weight is only the first really difficult hurdle to deal with; *keeping it off* is even more difficult. Regain is extremely common particularly when you demand of the body a loss of 100+ pounds. And so with each weight-cycling of loss/gain/loss/gain the body becomes less adept at losing weight and very inclined to cling to it instead. Desperation (and hatred - which is both self and other - generated) is why obese people often feel driven to risk their lives through bariatric surgery. This view of the problem backed up by science still seems to let fat people off the hook too much for many. Could this be why Levitt and Dubner decide from *their* “vast cerebral storage network” that it’s really because surgery is just an easy way out after all. Yup it’s just like a dumbed-down game-show (an oxymoron if ever there is one). To quote L & D on the latest trend in game shows: ““Deal or No Deal,” which requires no talent whatsoever beyond the ability to randomly pick a number on a briefcase.”Fat people just want the “easy” way out. Listen please: Obesity is almost a crime these days and thinness is the only reprieve. It doesn’t really matter how you get “pardoned” either as People Won’t accept health improvements even if you don’t lose much weight. You can exercise and moderate your eating but only massive weight loss matters when you are obese. It’s be thin or die. And so: people get their innards switched around. Some would even say they get them butchered. Desperation to be thin not stupidity and not the “easy way out” is what drives people who are obese. Obese people most definitely eat more than their bodies need. That is no myth. It’s how they got to be obese in the first place. It’s called the First Law of Thermodynamics - one of the most fundamental law of physics in this universe. If you eat more than your body burns all those extra energy has to go somewhere. Guess what? They got stored as fat. Hence you gain weight. If you *consistently* eat less than your body burns you *will* lose weight. Again that’s the First Law of Thermodynamics. If you believe “insulin control” or some other pseudoscience can circumvent the First Law of Thermodynamics you might as well start building a perpetual motion machine… Actually there is at least one nonsurgical solution for weight loss (Stephen J. Dubner and Steven D. Levitt Nov. 18) that has been extremely effective for food addiction. Compulsive Eaters Anonymous a 12-step program for food operates on the same principles of Alcoholics Anonymous. Like alcoholics many compulsive overeaters battle a physical allergy coupled with an obsession of the mind. In the 12-step rooms addiction whether to alcohol food debting gambling sex narcotics and so on is treated as a disease which may explain why other addictions pop up after patients undergo bariatric surgery. This procedure seems like yet another opportunity for the medical industry to make a profit on the illusion of the quick fix. Isn’t that what this is about anyway? The quick fix. How many people are out there taking antidepressants prescribed by their gynecologists? Do these medical professionals ever bother to suggest psychotherapy first and/or inquire to the amounts of alcohol and marijuana their patients are consuming? On another note does filing for bankruptcy alleviate the problem of debting for the compulsive debtor? There are many people in Compulsive Eaters Anonymous who have lost well over 150 pounds and have kept the weight off without drugs and dieting while gaining the gift of serenity in the process. Furthermore for those who have found themselves continuing to gain weight after having had bariatric surgery this program has been “their last house on the block.” There are no dues or fees to be a member only a desire to stop eating compulsively one day at a time. Clearly this is not a program for people who need it. It is a program for people who want it. To john,You say that obese people eat more than their bodies need? But why is it that when I eat more than I “need” (~4000kcal/day) my weight (~75kg) never increases (and in fact has decreased in the last year) but many obese people continue to gain weight on much fewer calories? Is it genetics? Do I have some genetic predisposition to burn more calories than the obese? I don’t think so. You see on a low-fat high-carb diet. I was gaining weight eating fewer than 2000kcal/day. How does that fit into your first law of thermodynamics? Don’t forget there’s a second law of thermodynamics! How do you know you need 4000kcal/day? Just because some website you found on the Internet spits out that number doesn’t make it a scientific truth. And why does it surprise you at all that you lose weight on 4k calories a day while others gain weight on fewer calories. So *different* people need *different* amount of calories to maintain their weight - is that really such a shocker? I mean we’re talking about different people here right? And there’s also nothing surprising that you were gaining weight on 2K calories per day. After all we’re talking about different periods of your life here. The amount of calories your body needed could very well have changed. Also when you changed your diet the % of calories your body absorbed could also have changed. But just remember you can never absorbed more calories than you eat. So if you were eating 2000 calories a day you could never absorb more than that. And if you were gaining weight on that diet it means your body needed less than 2000 calories a day during that period of your life. None of the above violates the 1st law of thermodynamics. And yes there is a 2nd law but your body weight really has nothing to do with entropy… Some people have brought up Overeater’s Anonymous as a possible solution. Although it works for some there are also many *very* valid criticisms of OA such as: “OA has been the target of feminist criticism for encouraging bulimic and binge eating women to accept powerlessness over food. Feminists criticize that the perception of powerlessness adversely affects women’s ongoing struggle for empowerment. Similarly teaching people they are powerless is liable to encourage passivity and prevent binge eaters and bulimics from developing coping skills. These effects would be most devastating for women who have suffered oppression distress and self-hatred.” “Opponents of Twelve Step programs argue that members become cult-like in their adherence to the program which can have a destructive influence isolating those in the programs. Moreover this kind of fanaticism may lead to perception that other treatment modalities are unnecessary. Surveys of OA members has found that they exercise regularly attend religious services engage in individual psychotherapy and are being prescribed antidepressants. This is evidence that participants do not avoid other useful therapeutic interventions outside of Twelve Step programs.” “The concept of abstinence in OA has beencriticized for its inherent ambiguity. While in AA abstinence means not drinking alcohol there is no direct analogy for compulsive eaters.”(from:http://en wikipedia org/wiki/Overeaters_Anonymous #Fanaticism) There are more problems than space enough here to list them all. OA is not a good solution for many people but if one critiques it people in OA freeze you out. Many people in OA can’t seem to bear that other people can and do chose other paths that *work for them* when OA *does not work*. OK. I’m not even going to justify the stinky-ziploc-under-the-nose remedy with a comment as I’m sure any statement that stupid could only have the purpose of provoking controversy. The misconception that overweight people simply lack willpower continues to baffle me. All told. I’m sure I have lost and gained well over 100 pounds throughout my life. I have come to suspect that the gaining required just as much willpower as the losing. People who are overweight often suffer from self-destructuve behavior very low self-esteem and a poor body image. They are pretty good at telling themselves that they are utter failures for not being able to lose weight so really there’s no reason to remind them. My experience has been that 400 hours of psychological therapy has had only limited success at changing these underlying causes. What I have found to be the best remedy has been the discovery that it’s just really fun to have a body no matter how I feel about how it looks or about the person it contains. This has occurred incidentally and incrementally since moving to Europe eight years ago. I started out riding my bike most places. Gradually without really noticing it. I have ended up riding my bike everywhere no matter what the weather or how far. About twice a year I get on a bus to go to the airport when I fly to the US. At some point that wasn’t enough especially in the dark Nordic Winter so recently I joined a gym. Four or five days a week I spend two or three hours working out. I now have more strength endurance and flexibility than many women who are much younger and slimmer than I am and I have seen some very attractive bodies in pretty poor shape. Now I’ve gotten to the point where I lose weight sometimes and when I don’t it would take more than even I can eat to gain it back. Not everyone who is overweight is unhealthy but those who are pay a terrible price in quality of life and self-image. They feel trapped in their bodies. So maybe the best way to help them is not to remind them of all the things that are wrong with them. They are better at that game than you are. Help them remember what a joy it is just to have a body no matter how inadequate it might seem to be. Take them for a walk down the street. Next week you might get them around the block and next year you might not be able to keep up with them anymore. PS I think a more interesting column might be about why it is that a smoker who wants to quit smoking and knows that a piece of nicotine gum will quench his desire for a cigarette decides to light a cigarette instead of putting a piece of gum in his mouth. Or how someone who wants to lose weight and knows that he will buy healthier foods if he is not hungry when he goes to the supermarket goes to the store on an empty stomach. Somehow it seems to me there must be an economic correlation for the fact that someone who wants a cigarette or a cookie doesn’t really want to not want one when he wants one. Much criticism of OA has been posted here. I’m not going to respond except to say the program has saved my life and I’ve heard the personal testimonies of many who feel the same. The program is not for everyone. You do have to be willing to change. The 12-steps will help you do that but you must be willing to use them. For me that willingness only came after trying everything short of bariatric surgery. For those who are wondering if it might work for them. I encourage you to check into it (no fees or commitments). What have you to lose except a lifetime of struggle? And I have received so many benefits in addition to maintained weight loss. I’m including the OA website link. For those of you who are sure it will not work for you best wishes in the path you choose. If you change your mind you are always welcome to OA. Actually. OA has received many accolades here so I wanted to present an alternative view one that honors the fact that OA is NOT right for everyone (and as I said. OA not working does not have to do necessarily with being “unwilling” to change). I *did* say that OA has helped many. However many also find their own way out of the binge mentality *without* it. OA can be cultish repressive and controlling. People should know about the downside of OA too. To the idea that: “it only works if you work it”. I would say: “it only works if it’s right for the person who works it”. If not say goodbye without guilt and move on.

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Bariatric surgery is often the most effective treatment for the morbidly obese and with a mortality rate of around one percent it isn’t terribly risky by Bennet Omalu et al. (abstract only without subscription). The highest risk is faced by patients who undergo the procedure at the hands of an inexperienced surgeon. This by David R. Flum and E. Patchen Dellinger shows a strong correlation between survival rates and surgeon experience (abstract only without subscription). Annual gym memberships are another purchase on the commitment device shopping list for those trying to lose weight. Except that people overestimate by 70 percent how much they will use them as Dubner and Levitt wrote in their Jan. 7. 2007 column. “.” The column references Stefano DellaVigna and Ulrike Malmendier’s paper. The popular new weight-loss pill Alli which partially blocks the body’s absorption of fat is a commitment device with real consequences: a person who takes Alli and then eats too much may experience a bout of oily diarrhea. (Among the initiated. .) “We also estimated the long-term mortality for individuals who had undergone surgery many years ago. For the 1995 cohort who had at least 9 years of follow-up. 13.0% had died. From the 1996 cohort with 8 years of follow-up. 15.8% had died and from the 1997 cohort with 7 years of follow-up. 10.5% had died. For the 1998-1999 cohorts with 5 to 6 years of follow-up the total mortality was 7.0% to 2004.” That’s from a very comprehensive study of all patients in Pennsylvania they can’t all have been worked on by hacks can they? Doing it is impossible for obese people. They have different hormone levels of several hormones including leptin and ghrelin that regulate appetite. I suspect that for them not to eat an entire cake takes more will power than for a thin person to avoid nibbling on a cookie. Sure years of overeating has probably caused this disregulation. But some people are more susceptible than others. Why blame the individual who will fast starve and diet or even commit suicide to end the misery of obesity? I blame the screwed up junk food environment and the culture of fast food that has been created by industry and advertising. Why should a three year old be subjected to ads beckoning them to ignore their parents and eat crap? We didn’t evolve for this and many people CAN’T deal with it. I would like to point out that in your excellent article about bariatric surgery you mention that the procedure “often produces complications — physiologic ones to be sure but also perhaps psychological ones.” I think you may have reversed the vector of causality here and in my humble opinion the use of “perhaps” was also superfluous. As a psychiatrist there is no doubt in my mind that a morbidly obese patient without other medical cause for obesity (ie thyroid disease) already has a severe psychiatric problem that has produced the complication known as obesity. Such a person overeats when they know it makes them unhappy to say the least as well prone to other life threatening diseases but it literally unable to stop. Without treating the psychiatric compulsion to harm oneself that underlies such behavior it is no wonder that patients who have surgery but no psychiatric treatment develop “new” psychiatric symptoms like gambling compulsive shopping and alcoholism as you’ve mentioned. All patients considering bariatric surgery and all physicians recommending it should consider psychiatric consultation for those patients who are open to it so that they can maintain the health benefits that they achieve through sugerry without acquiring a potentially more dangerous psychiatric ailments. In a way there is a simple economics to it. The patient who undergoes surgery perhaps even covered by insurance does not pay the psychological price never mind the opportunity cost of couch time and the true cost of paying for therapy that would be required to come to understand why he thwarts himself so. And so the psychological problem having not received it’s due sum returns in a new form. While the actual procedure deaths are fairly low deaths afterwards from later complications malnutrition and even suicide are far higher than in comparable morbidly obese patients who do not lose the weight. Even the weight loss of bariatric surgery is not always permanent Gastric bypass does not force one to eat a healthy diet or else. It forces one to eat an unhealthily small amount of food and supplement that rigorously as the body is no longer capable of absorbing certain nutrients. As for the diabetes reduction that happens almost immediately within the first few days following surgery. It has nothing to do with the weight loss but something to do with the digestive mechanisms that have been altered. While this is encouraging knowledge as far as diabetes treatment is concerned it bears more investigation of what exactly has changed and if there are ways to do this for diabetic patients short of a risky and life-altering surgical procedure. For those who say stop eating? Research has shown that in those who have been very overweight for a long period of time this is FAR easier said than done. Many of them already eat far less than one imagines. Whether or not that is the case a calorie restriction leads to a starvation response. In order for most obese people to take weight off and leave it off it requires living in a state of starvation for the rest of one’s life. Perhaps there are ways to prevent obesity. I do not think dieting - forcing one’s body into a state of starvation and lowering one’s metabolism - is one of them. After all this increase in obesity has occurred concurrently with the rise of the diet industry and how many overweight people have not already tried several diets? It is not willpower in resisting eating a whole cake we are talking about. It is pushing aside hunger a basic physiological urge more akin to deciding one is only going to go to the bathroom once a day or only breathe every thirty seconds. Do I know the answer? No. I am lucky enough to have thin and fit parents and have eaten healthfully (neither overeating nor dieting) my entire life. But it horrifies me when we as a society focus on beating down those who have not been so lucky encouraging them to mutilate their stomachs and hurt themselves. The truth is we don’t know much at all about human weight regulation and turning people into pariahs for a state most can no longer permanently control is certainly not the answer. Alli is the equivalent of Antabuse for alcohol. You pay a (nasty) price for a bad decision. Gastric bypass makes you abide by portion control whether or not you want too. As medical insurance will not reimburse for therapy that focuses on that coping skill so too a refusal to fund the treatment needed to change those automatic choices (unlike the advertisement your baby isnt going to slap you when you choose the french fries). The studies that demonstrated the efficacy of “lifestyle modification” in weight loss diabetes prevention heart disease usually included intense intervention - weekly then gradually decreasing frequency over a 3-4 month period. This usually includes work with a nutritionist and a physical therapist or trainer. Instead insurance would rather pay a single larger sum for a single “procedure” with its “universal reproducible” effect. More importantly how many choose this option for cosmetic reasons rather than for future health status? What is the perceived “value?” The people you describe in this article are compulsive overeaters. Addicted to overeating the same as an alcoholic is addicted to alcohol. Would you suggest that an alcoholic where a stinky scarf to cure their disease? Just as I can never trully understand the urge to drink excessively. I cannot expect non-compulsive overeaters to understand my urge to overeat. But I have found a solution in the twelve-step program of recovery — Overeaters Anonymous. By working this program daily. I have been free from the compulsion to overeat for over three years. I hope that you’ll at least mention this program when you write about the hopelessness of the obesity epidemic. There is hope. If just one person experiences the recovery I have received you’ll have done a great service. While there are some statistics and quotes published in this article it is an opinion - plain and simple. The authors like in most of society wrote this piece under the presumption being fat is bad unhealthy and unacceptable. But moreover the generalizations are being made that fat people themselves are bad unhealthy and unacceptable - as well as lacking any knowledge or discipline. As usual there is a judgment upon those of us who are fat about our choices what our lifestyles might be like. I particularly enjoyed the part about how thanks to these surgeries fat people can. “Now people can eat all they want for years and years and then at the hands of a talented surgeon suddenly bid farewell to all their fat”. What an ignorant statement - and one that indicates a sad truth about our culture. This is SURGERY that seriously alters a MAJOR ORGAN of one’s body. I know people who have opted to have this surgery and I respect their decision to do so. However it should be said that such a thing is not an easy decision - never mind the expense the recovery - there are a lot of risks involved during the procedure after and then in the long term. I want to call attention to a statement in this article a quote by Marc Bessler who talked about his father being fat and developing colon cancer. Marc says: “…He died at age 54 from colon cancer. It may have been picked up late because of his obesity.” With respect to Mr. Bessler and his father (whom clearly I do not know the specifics of his case). I must reject the last part of this quotation - that because of his obesity the colon cancer was not found. Fat people often have mis-diagnosis given to them by Doctors who simply dismiss their symptoms because they are fat. I recall an acquaintance who at 35 was finally diagnosed with ovarian cancer after longstanding symptoms - which had been dismissed because she was fat. By the time she was diagnosed she had stage 4 cancer and a very low survival prognosis. I reject that fat is the lone reason for these mis-diagnoses. It is the assumption on the part of many doctors that whatever the problem is is simply because the person is fat they need to lose weight - case closed. I say this understanding that sometimes losing some weight may help depending on the medical situation but I am speaking specifically about the dismissal of another possible diagnosis other than “fat” or “morbidly obese”. I wish for there to be more understanding about the assumptions made and are encouraged to be made about fat people. It is contrary to general belief very possible to be fat and healthy. I wish there to be more questioning of our assumptions that thin = healthy. Our culture produces more processed foods than ever before not to mention all of the engineering that goes into low-fat and non-fat foods. How about questioning what those foods do to prevent the absorption of nutrients into our bodies - and so perhaps they are not really “healthy” after all? Asking more questions to get better answers that is what I hope for. I encourage anyone who read this article to also read the following article which talks about the largest and longest study about food nutrition weight loss which was conducted and it’s surprising results. These results weren’t widely published because it did not support the agendas of the larger medical establishment. This article is written by Sandy Szwarc. BSN. RN. CCP on 10/15/07 and is on her blog. Junkfood Science: When I lived in Switzerland going to the farmers market meant losing 120m in elevation. That means that whatever I bought. I had to haul back up the 120m of elevation that I lost to get to the food. And going to the supermarket meant losing an additional 80m or so in elevation. So see the “economics of food gathering” prevented me from gaining any weight at all. In fact transferring there from the US always made me lose 15-20 pounds without even trying. Unfortunately in most of the US nowadays one has to drive everywhere since we are stuck in our islands of subdivisions. Perhaps this can be thought of as a long-term failure of city planning and policy a very INELASTIC infrastructure. What a crock. Weight loss isn’t successful if it isn’t permanent and maintainable. How do you define permanent? I’d define it to be over the course of a lifetime. But we don’t really have any studies for that. How about 5 years out from the diet or surgery? How about 10 years out from the diet or surgery? To the person who commented that 5 to 9 years out you have a chance of dying from lots of other things not related to a “successful” weight loss surgery. That’s true but studies have shown that people who have WLS die much more often than people who didn’t have WLS. Even fat people who didn’t have WLS don’t die as often. Look at bariatric surgeries 10 years out. Spell out how we are defining success. Is it a 10% loss? More? Less? So if a study defines a successful bariatric surgery as an overall weight loss of 20% of body weight over 5 years and the patient weighed 300 pounds at the time of surgery what does success look like? And I guarantee that if you actually do your homework and read the studies checking carefully to determine how they define success what cases they are excluding from the final results and why and look at the long term picture you will find that the surgery is a disaster for a very large portion of the people who do it. Especially note the number of people who are “lost to follow up” in these studies. Do you really think that all of those people are now living in a size six? Aside from the debate about the merits of bariatric surgery. I do think the idea of a commitment device is an interesting concept in terms of incentives. Weight loss however is a particularly difficult realm to discuss it in. On one hand it’s personable and something many people can relate to. But on the other it’s a combination of psychological and physiological factors and much more complicated than simply not gambling or not running up a huge credit card bill. One CAN simply throw out the credit cards or stop going to casinos. One cannot stop eating altogether. Though as another aside. I’m kind of horrified by the blobs of fat as a deterrent. Some degree of fat cells are required simply to live. I believe it’s 4-6% of body weight for men and 12-14% for women. Having something in my kitchen meant to elicit feelings of disgust towards a not insignificant part of my physical self? I’m kind of horrified. But commitment devices for less physiological issues? Very interesting. The best I can come up with was setting a test date for an exam I had to take. Once it went from “within the next few months” to “a week from wednesday or else” I was much more motivated to study. You have a poor understanding of why people become obese (and there isn’t just one reason). To simply decry people for “eating too much” doesn’t help. Many obese people have displayed extraordinary discline time and again with only to ultimately succumb and fail. Prior to having children. I was always thin and disparaged the obese having seen my grandmother and mother struggle with obesesity. After my first child. I gained a great deal of weight. Fortunately. I had never used food as an emotional comfort and do not have an addictive personality. I have gradually lost some of the weight but it is a struggle. This experience gave me a real insight into how people become grossly obese. Yes some people will have bariatric surgery because they want “the easy way out,” but do not think that at least at present all bariatric surgery patients blithely opt for surgery. Your statement is simply absurd. As the author pointed out just 30 years ago there were far fewer obese people. So how come people who had no problem eating less 30 years ago all of a sudden find it “impossible” to eat less now? You can blame genetics or “the society” all you want. But let’s face it - obese people eat more because they *choose* to do so. Other countries have far fewer obese people as a % of their general popukation. Why is it that people in other countries can eat less but doing the same thing is deemed “impossible” by americans? People will go to any extreme to lose weight because to be fat is to be constantly vilified. We have two types of commercials on television in this country food and weightloss. There is also an attempt(successful)in this coutry to link every medical disorder to obesity. Most of this is not evidenced based research but it allows health care providers,the insurance industry and any company with a stake in the shrinking health care pie with an actual visual cue of the “potential” problem children who may cause a spike in their longterm healthcare costs. Please note this includes you the pleasingly plump and will eventually touch you yes the forgotten underweight. This will morph into which body types tend to be healthier (sorry endo’s) and run right into who has a healthy genetic profile. We have already have a fantastic amount of the ground work completed as it is acceptable to call anyone who is fat any name,ascribe any attribute and openly discriminate with immunity. I don’t think you have to walk around in a fat suit in NYC to see why someone would risk their life to lose weight. Again we are not talking about a healthy normal weight…you now need a body weight that is deemed aceptable to at least 75 percent of the population to be consideredslim ( please make sure your proportions are correct). Do you actually think this is about caring if people are healthy? With money and a handy their personal responsibily logic card safely on the table… As a certified fatso (365 lbs.) I find that the only thing that controls my appetite is to keep my glucose level low by eating complex carbohydrates like brown rice. My glucose level becomes high whenever I break my diet by pigging out on simple carbohydrates like pastries or pasta. High glucose causes me to crave more food. Eating whole grains helps me break the viscous cycle. Exercise helps too. Yet it’s very easy to “fall out of the saddle” because temptation is everywhere and old habits die hard. Actually the obese and overweight don’t eat more than the non-obese/overweight; it’s myth. Take a look at studies on weight balance and you won’t find any that say caloric intake dictates weight gain/lose. Impaired glucose metabolism is almost solely to blame for the diabesity epidemic and the overwhelming majority of overweight/obese have problems with insulin (the fat-storing hormone). So telling fat people not to eat so much is ridiculous; the problem is not lack of will power or exercise it’s lack of insulin control. Alli (or Orlistat) has been used for the treatment of obesity for a long time and with the experience gained from this time. 2 points can be made: 1: Weight loss will be modest(average 2.9 kg more than placebo with a follow-up of 1-4 yrs (Rucker et al. BMJ 15 Nov 2007 )) and 2: using orlistat has a lot of adverse events which will affect compliance negatively. A recent review demonstrated that the long-term effects of behavioral therapy for obesity are disappointing (Psychother psycomed med psychol 2007 Nov;57(11):420-7) The focus on bariatric sugery from a medical point-of-view makes sense two studies published in the new england journal of medicine had demonstrated that bariatric surgery reduces mortality rates significantly (Sjostrom et al. N Engl J Med 357:741. August 23. 2007; Adams et al. N Engl J Med 357:753. August 23. 2007 (http://search nejm org/search?w=bariatric)). When people present themselves at the outpatient clinic with being overweight or suffering from type 2 diabetes,bariatric surgery (especially bypass) is the best treatment that can be prescribed! An interesting other theory to explain the óbesity epidemic’ is based on a paper in the Annals of inernal medicine. Epidemiologic studes demonstrated that as the prevalence ofobesity increased the average amount of sleep (in hours/night) decreased. In the paper the authors demonstrate that sleep curtailment increases hunger and appetite and alters certain hormone levels in a way that would increase food intake (Spiegel et al. An Int Med. 2004;141:846 (http://www annals org/cgi/content/abstract/141/11/846? ijkey=9bd315cc48be60331472c94964e1e620107584c7&keytdype 2=tf_ipsecsha)). Although it would be absurd to point to sleep reduction as the sole reason for the ‘obesity epidemic’ just stating that ‘people just eat to much’ is too. Dubner and Levitt first ask why many obese people chose the “drastic” option of bariatric surgery. Well consider this: for the extremely overweight - heck even for people with just 10 pounds to lose - losing the weight is only the first really difficult hurdle to deal with; *keeping it off* is even more difficult. Regain is extremely common particularly when you demand of the body a loss of 100+ pounds. And so with each weight-cycling of loss/gain/loss/gain the body becomes less adept at losing weight and very inclined to cling to it instead. Desperation (and hatred - which is both self and other - generated) is why obese people often feel driven to risk their lives through bariatric surgery. This view of the problem backed up by science still seems to let fat people off the hook too much for many. Could this be why Levitt and Dubner decide from *their* “vast cerebral storage network” that it’s really because surgery is just an easy way out after all. Yup it’s just like a dumbed-down game-show (an oxymoron if ever there is one). To quote L & D on the latest trend in game shows: ““Deal or No Deal,” which requires no talent whatsoever beyond the ability to randomly pick a number on a briefcase.”Fat people just want the “easy” way out. Listen please: Obesity is almost a crime these days and thinness is the only reprieve. It doesn’t really matter how you get “pardoned” either as People Won’t accept health improvements even if you don’t lose much weight. You can exercise and moderate your eating but only massive weight loss matters when you are obese. It’s be thin or die. And so: people get their innards switched around. Some would even say they get them butchered. Desperation to be thin not stupidity and not the “easy way out” is what drives people who are obese. Obese people most definitely eat more than their bodies need. That is no myth. It’s how they got to be obese in the first place. It’s called the First Law of Thermodynamics - one of the most fundamental law of physics in this universe. If you eat more than your body burns all those extra energy has to go somewhere. Guess what? They got stored as fat. Hence you gain weight. If you *consistently* eat less than your body burns you *will* lose weight. Again that’s the First Law of Thermodynamics. If you believe “insulin control” or some other pseudoscience can circumvent the First Law of Thermodynamics you might as well start building a perpetual motion machine… Actually there is at least one nonsurgical solution for weight loss (Stephen J. Dubner and Steven D. Levitt Nov. 18) that has been extremely effective for food addiction. Compulsive Eaters Anonymous a 12-step program for food operates on the same principles of Alcoholics Anonymous. Like alcoholics many compulsive overeaters battle a physical allergy coupled with an obsession of the mind. In the 12-step rooms addiction whether to alcohol food debting gambling sex narcotics and so on is treated as a disease which may explain why other addictions pop up after patients undergo bariatric surgery. This procedure seems like yet another opportunity for the medical industry to make a profit on the illusion of the quick fix. Isn’t that what this is about anyway? The quick fix. How many people are out there taking antidepressants prescribed by their gynecologists? Do these medical professionals ever bother to suggest psychotherapy first and/or inquire to the amounts of alcohol and marijuana their patients are consuming? On another note does filing for bankruptcy alleviate the problem of debting for the compulsive debtor? There are many people in Compulsive Eaters Anonymous who have lost well over 150 pounds and have kept the weight off without drugs and dieting while gaining the gift of serenity in the process. Furthermore for those who have found themselves continuing to gain weight after having had bariatric surgery this program has been “their last house on the block.” There are no dues or fees to be a member only a desire to stop eating compulsively one day at a time. Clearly this is not a program for people who need it. It is a program for people who want it. To john,You say that obese people eat more than their bodies need? But why is it that when I eat more than I “need” (~4000kcal/day) my weight (~75kg) never increases (and in fact has decreased in the last year) but many obese people continue to gain weight on much fewer calories? Is it genetics? Do I have some genetic predisposition to burn more calories than the obese? I don’t think so. You see on a low-fat high-carb diet. I was gaining weight eating fewer than 2000kcal/day. How does that fit into your first law of thermodynamics? Don’t forget there’s a second law of thermodynamics! How do you know you need 4000kcal/day? Just because some website you found on the Internet spits out that number doesn’t make it a scientific truth. And why does it surprise you at all that you lose weight on 4k calories a day while others gain weight on fewer calories. So *different* people need *different* amount of calories to maintain their weight - is that really such a shocker? I mean we’re talking about different people here right? And there’s also nothing surprising that you were gaining weight on 2K calories per day. After all we’re talking about different periods of your life here. The amount of calories your body needed could very well have changed. Also when you changed your diet the % of calories your body absorbed could also have changed. But just remember you can never absorbed more calories than you eat. So if you were eating 2000 calories a day you could never absorb more than that. And if you were gaining weight on that diet it means your body needed less than 2000 calories a day during that period of your life. None of the above violates the 1st law of thermodynamics. And yes there is a 2nd law but your body weight really has nothing to do with entropy… Some people have brought up Overeater’s Anonymous as a possible solution. Although it works for some there are also many *very* valid criticisms of OA such as: “OA has been the target of feminist criticism for encouraging bulimic and binge eating women to accept powerlessness over food. Feminists criticize that the perception of powerlessness adversely affects women’s ongoing struggle for empowerment. Similarly teaching people they are powerless is liable to encourage passivity and prevent binge eaters and bulimics from developing coping skills. These effects would be most devastating for women who have suffered oppression distress and self-hatred.” “Opponents of Twelve Step programs argue that members become cult-like in their adherence to the program which can have a destructive influence isolating those in the programs. Moreover this kind of fanaticism may lead to perception that other treatment modalities are unnecessary. Surveys of OA members has found that they exercise regularly attend religious services engage in individual psychotherapy and are being prescribed antidepressants. This is evidence that participants do not avoid other useful therapeutic interventions outside of Twelve Step programs.” “The concept of abstinence in OA has beencriticized for its inherent ambiguity. While in AA abstinence means not drinking alcohol there is no direct analogy for compulsive eaters.”(from:http://en wikipedia org/wiki/Overeaters_Anonymous #Fanaticism) There are more problems than space enough here to list them all. OA is not a good solution for many people but if one critiques it people in OA freeze you out. Many people in OA can’t seem to bear that other people can and do chose other paths that *work for them* when OA *does not work*. OK. I’m not even going to justify the stinky-ziploc-under-the-nose remedy with a comment as I’m sure any statement that stupid could only have the purpose of provoking controversy. The misconception that overweight people simply lack willpower continues to baffle me. All told. I’m sure I have lost and gained well over 100 pounds throughout my life. I have come to suspect that the gaining required just as much willpower as the losing. People who are overweight often suffer from self-destructuve behavior very low self-esteem and a poor body image. They are pretty good at telling themselves that they are utter failures for not being able to lose weight so really there’s no reason to remind them. My experience has been that 400 hours of psychological therapy has had only limited success at changing these underlying causes. What I have found to be the best remedy has been the discovery that it’s just really fun to have a body no matter how I feel about how it looks or about the person it contains. This has occurred incidentally and incrementally since moving to Europe eight years ago. I started out riding my bike most places. Gradually without really noticing it. I have ended up riding my bike everywhere no matter what the weather or how far. About twice a year I get on a bus to go to the airport when I fly to the US. At some point that wasn’t enough especially in the dark Nordic Winter so recently I joined a gym. Four or five days a week I spend two or three hours working out. I now have more strength endurance and flexibility than many women who are much younger and slimmer than I am and I have seen some very attractive bodies in pretty poor shape. Now I’ve gotten to the point where I lose weight sometimes and when I don’t it would take more than even I can eat to gain it back. Not everyone who is overweight is unhealthy but those who are pay a terrible price in quality of life and self-image. They feel trapped in their bodies. So maybe the best way to help them is not to remind them of all the things that are wrong with them. They are better at that game than you are. Help them remember what a joy it is just to have a body no matter how inadequate it might seem to be. Take them for a walk down the street. Next week you might get them around the block and next year you might not be able to keep up with them anymore. PS I think a more interesting column might be about why it is that a smoker who wants to quit smoking and knows that a piece of nicotine gum will quench his desire for a cigarette decides to light a cigarette instead of putting a piece of gum in his mouth. Or how someone who wants to lose weight and knows that he will buy healthier foods if he is not hungry when he goes to the supermarket goes to the store on an empty stomach. Somehow it seems to me there must be an economic correlation for the fact that someone who wants a cigarette or a cookie doesn’t really want to not want one when he wants one. Much criticism of OA has been posted here. I’m not going to respond except to say the program has saved my life and I’ve heard the personal testimonies of many who feel the same. The program is not for everyone. You do have to be willing to change. The 12-steps will help you do that but you must be willing to use them. For me that willingness only came after trying everything short of bariatric surgery. For those who are wondering if it might work for them. I encourage you to check into it (no fees or commitments). What have you to lose except a lifetime of struggle? And I have received so many benefits in addition to maintained weight loss. I’m including the OA website link. For those of you who are sure it will not work for you best wishes in the path you choose. If you change your mind you are always welcome to OA. Actually. OA has received many accolades here so I wanted to present an alternative view one that honors the fact that OA is NOT right for everyone (and as I said. OA not working does not have to do necessarily with being “unwilling” to change). I *did* say that OA has helped many. However many also find their own way out of the binge mentality *without* it. OA can be cultish repressive and controlling. People should know about the downside of OA too. To the idea that: “it only works if you work it”. I would say: “it only works if it’s right for the person who works it”. If not say goodbye without guilt and move on.

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When you’re travelling to places whose sanitary conditions are suspect the best thing to do before you ingest anything is to line your stomach with some probiotics. The best kind is live fresh good bacteria from yogurt or to join in the conversation on Digg. You'll also be able to Digg stories to help promote things you desire. Browsing Digg on your phone just got easier with our enhancements to the. If your phone doesn't support the full web browsing experience check out the original mobile site instead. © Digg Inc. 2008 —Content posted byDigg usersis. DIGG. DIGG IT. DUGG. DIGG THIS. Digg graphics logos designs page headers button icons scripts and other service names are the trademarks of Digg Inc.

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When you’re travelling to places whose sanitary conditions are guess the best thing to do before you ingest anything is to line your stomach with some probiotics. The best kind is live fresh good bacteria from yogurt or to join in the conversation on Digg. You'll also be able to Digg stories to help promote things you like. Browsing Digg on your phone just got easier with our enhancements to the. If your phone doesn't support the full web browsing experience check out the original mobile site instead. © Digg Inc. 2008 —Content posted byDigg usersis. DIGG. DIGG IT. DUGG. DIGG THIS. Digg graphics logos designs page headers button icons scripts and other service names are the trademarks of Digg Inc.

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When you’re travelling to places whose sanitary conditions are suspect the best thing to do before you ingest anything is to line your stomach with some probiotics. The best kind is live fresh good bacteria from yogurt or to join in the conversation on Digg. You'll also be able to Digg stories to help promote things you desire. The Digg Toolbar for Firefox lets you Digg submit content and keep track of Digg even when you're not on the Digg site. Download the official now. © Digg Inc. 2008 —Content posted byDigg usersis. DIGG. DIGG IT. DUGG. DIGG THIS. Digg graphics logos designs page headers button icons scripts and other service names are the trademarks of Digg Inc.

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Discussing My digest Is Screwed Up? Any Thoughts? in the The Clubhouse Forum. Okay I posted desire 4months ago about this. And no i haven't went to... Okay I posted like 4months ago about this. And no i haven't went to the doctor (i know i should but i dislike the doctor). Anyways in the mornings my stomach sometimes hurts so bad i want to puke the hurt goes and comes for about an hour then i conclude perfectly normal. At night time when i start to get tired and ready for bed it starts hurting again like the pain is annoying it feels like cramping but it also is like someone is stabbing me. I dont undergo any problems dropping the kids off at the share either. SO WTFFFFFF.. Another reason why i havent went to the adulterate is they would be to stick a tube down my throat and im not a big fan of that. I had the camera stuck down my throat because of the same problem. It wasnt bad at all they gave me some really good seditive,it was awesome. I didnt even experience that they had done it i get real panicy when im messed up so i told the doc that and he gave me some real good stuff lol the hurt i had was from gastritis to much stomach acid i take the nexium now and all is good try laying off caffine ,alcohol consume water. 408stroker/tf track heats/scat crank/h beams/srs fordged/351sportsman block/trick flow rrkrs/msd dist/edelbrock victor5.8intake/aeromotive furnish system/accufab 80mmtb/pro-m80mm,maf etc. sounds desire an acid issue. Discomfort from acid can radiate to all parts of the abdomen. Ive seen more than one person around here charge of stomach hurt and discomfort. One of the best things you can on your own is act a diary. Record everything you eat. I know it sounds tedious but try it. Write down everything you eat and at the end of everyday simply write drink how you conclude. I guarantee you will sight correlations between pain levels and something you are consuming. Of course there is no substitution for a doctors tour to sight out whats up stomach pain/nausea can be from many different things. Gall stones kidney problems cancer and so on. Dont panic! You described your hurt as "stabbing". If its anywhere near the area of your breastbone its probably the lining of your stomach. OTC antacids can do wonders. After a couple days of use your lining ordain rebuild itself and you will conclude better. But like I said it could be anything. Check with a adulterate. authorise I posted like 4months ago about this. And no i haven't went to the doctor (i know i should but i hate the doctor). Anyways in the mornings my stomach sometimes hurts so bad i be to puke the pain goes and comes for about an hour then i conclude perfectly normal. At night measure when i start to get tired and ready for bed it starts hurting again like the hurt is annoying it feels like cramping but it also is like someone is stabbing me. I dont have any problems dropping the kids off at the pool either. SO WTFFFFFF.. Another reason why i havent went to the doctor is they would be to stick a tube down my throat and im not a big fan of that. wel in that case copulate you pussy ass bad word curse mumble dick head ass licking mumble more stupid posting bad word that just makes me E tough! i kno a little some some about the digestive tract i kno the sides and top are your large intestine but if it hurts in ur lower left its an infection and if it hurts in ur upper sides you prolly got constipation or blockage (or somethign) and ur stomach is in ur lower left side of your rib confine yes i undergo a PhD Check food intollerances and allergys. DairyWheatEggYeastSoy These are usually the top offenders. Do you take any antibiotics for acne or anything? undergo you taken alot of antibiotics in your life time. If you answer yes you be to act large amounts of good probiotics to regenerate the good bacteria that has been in your stomach that the antibiotics undergo killed. If you have a bad diet that needs to be fixed. Get off fast foods and take most if not all un-natural suger out of your fast. He means with the umbilicus being the center point with a line vertically and horizontally through it separating the quadrants.. just thought I'd specify that... alter in between my bellybutton and my rib confine. It is in that area it hurts. It could be to much stomach acid but whenever i act tums or anything it doesnt do a thing. hmm. probably something somewhere in lines of Acid Reflux/ Indigestion your a regular member to the bathroom at least once a day? Affiliated with Ford go Company. Forum is powered by vBulletin ©2000 - 2008. Jelsoft Ent. Ltd. & SEO by vBSEO 3.1.0 ©2007. Crawlability. Inc.

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