Moving Towards a Decision

At first, my research on private bariatric clinics focused on Montreal. Healthcare in Quebec is more privatized than BC -- probably more than any other province. 

In BC, private clinics cannot offer services that are available through the public health system.* This is a good thing, and I don't want it to change -- but since the province has capped the number of bariatric surgeries, BC residents are left without other in-province options.

Quebec, the leader in privatization (not good) is also the leader in bariatric surgery (good). There are clinics with exceptional experience and results, for people who can afford it. Gastric sleeve surgery is $18,000; gastric bypass starts at $23,000. That's without airfare and other incidental costs. 

And I was actually considering this. Which shows you how badly I want this surgery. We are financially comfortable, but we don't have $20,000 sitting around.

Financing is available, and I started looking into and rationalizing the expense. I can rationalize anything, and I was well on my way to talking myself intothis.

Then I did more research, and started looking into Mexico.

I know: it sounds alarming. Many Canadians and Americans think of Mexico as a place where everyone lives in shacks and walks barefoot, like one giant slum. That's just bias. I'm not saying that there isn't poverty in Mexico, but there's poverty in the US and Canada, too.

There is no shortage of sensational newspaper stories about people who had botched procedures in Mexico. It's a perennial of American journalism, and make good episodes on "House". We have no idea how prevalent those stories are, or how many botched procedures are performed in the good old U S of A. 

When it comes to reporting on health care, the American media has very low credibility. Everything Americans see and read about health care in Canada and the UK is wrong. Lies. Why would this be any different? Especially since many Americans think anyone who speaks Spanish is poor, ignorant, and untrustworthy.

Thousands of Americans travel to Mexico for treatments every year, especially from Texas, Arizona, and California. There are shiny, clean, modern hospitals, frequented by Americans who have been denied coverage by their insurance companies or who have no coverage. 

People also travel to Mexico for alternative cancer treatments that are not legal in the US. A former co-worker of mine had Stage IV breast cancer, went to Mexico, and was put into remission without surgery. Yes, I know that is merely one anecdote and not a scientific study. But she went to this clinic because of a preponderance of these stories. And she's still alive, with her body intact. A treatment that is unproven may still be effective.

In any case, one of the largest cancer facilities in Mexico is also a hub for bariatric surgery. At about $5,000 including airfare, the price tag is a lot more palatable.

It's not easy to find independent assessments of the Mexican clinics. I did find one study that looked at complications and outcomes in Mexico, based on 500 surgeries performed at one hospital over a period of 4.5 years.

The study found that in the well-established, high-volume Mexican bariatric clinics, the outcomes and rates of complications were comparable to similar hospitals in the US. There was no statistical difference.

This article looks at the cost to Canadian health care from complications from medical tourism. It profiles four cases of people who had bariatric surgery abroad, then had complications, and what the implications were for their provincial health systems. It doesn't compare complication rates from surgeries between countries. 

In the conclusion, it states:

Our limited, anecdotal impressions are that obese patients are poorly informed when they seek bariatric surgery as medical tourists. They do not consider the far-reaching implications of having complex gastrointestinal surgery for morbid obesity (a chronic disease) in a foreign country and they have made no plans whatsoever for appropriate, informed follow-up care.

I will not fall into that category. If I do this, I will be well informed, and I will absolutely have plans for follow-up care.

The article also includes this:

In terms of quality of care, there is certainly data to suggest that some overseas centers have equal, if not superior, results for certain procedures. The peri-operative mortality rate after coronary artery bypass surgery at the Escorts Heart Institute and Research Center in India is .8%, less than half the rate of most hospitals in the United States.

I'm sure many people would find that statistic surprising.

I would like to read more unbiased comparisons of safety, but so far I've only found the one. Most information is written by clinics -- either Mexican clinics saying how great they are (worthless) or American, for-profit clinics scaring potential customers away from Mexico (also worthless). A clinic in Dallas claims "Our doctors are highly educated and regulated, with national and state licensing boards ensuring everyone on the medical team is qualified for practice. Other countries might not have as stringent educational standards or be as thorough with regulations." That's just an unsubstantiated claim. Anyone "might" have anything.

I'm not sold on Mexico, but I'm leaning towards it.

* A decade-long lawsuit challenging this came to a close in February 2020. A Supreme Court decision is pending.

I Am Considering Having the Surgery Done at a Private Clinic

I've been researching the options for having bariatric surgery done privately, outside of our public health care system. The big consideration -- actually, the only consideration -- is money. It is very expensive, far more than I should even be thinking about. 

I recently had a small surgical procedure done, and I had to be weighed for the anesthesia. I was both shocked and not at all surprised to see I have gained yet more weight. 

Shocked, because I haven't been on a scale in more than two years, so seeing the number was a shock. 

Not surprised, because this is what my body does. Despite any steps I have taken or will take, I gain weight.

At this point I feel that my weight is diminishing my quality of life. I am becoming increasingly less mobile. More and more health issues are popping up. I'm sure that surgery is my only option. But surgery in this province is easily two years away -- or more.

I could have the surgery done in another province (on the other side of the country), right away, no waiting, if I'm willing to spend an extremely large amount of money. I would have to finance it, so I'd have yet another bill to pay. We are currently paying off a short-term (no interest) loan that ends in December 2021. Financing part of the surgery would make next year's finances even tighter. Although not impossible. 

The private clinic sees people from all over Canada, and they can arrange it so there is only one trip, for the surgery itself. Tests and whatever medical prep is needed can happen locally, and consultations can be done by videoconference.

What if I have the surgery done privately, incur all that expense and debt, then the Province announces a new policy, and they clear the bariatric surgery waitlist? That would suck!

I already know I want the surgery. I don't know if I should do it financially.

I also know this is not a question anyone else can answer for me. 

Bye For Now, Until There's News To Report

I don't want this blog to turn into a diet-and-exercise blog without the surgery. So I'll put this space on hold until I get some news on the surgery. You might want to subscribe by email, so you'll receive a notice when I'm back.

Thank you for your support and encouragement. I really appreciate it!

After That Shock, Next Steps

It's taken me a few days to get past the shock and disappointment of learning that bariatric surgery is years away. Now I'm left with serious concerns about my health.

The RD in our local health centre showed me that the best way to reduce my blood sugar levels is to increase my exercise. And of course increasing exercise is good for so many other reasons. I'm 58 years old, overweight, and there's cardiovascular disease in my family. Enough said.

The habit itself is not the issue. An exercise routine had always been part of my life, until about 10 years ago. I'm motivated and ready to change that.

The issue is what and how.

One of my goals or desires has been to spend more time outdoors, which is not always easy when you're a bookworm and completely non-athletic like me. I love to walk and hike, and I've been trying to maximize that.

But walking is so weather dependent! I thought I would buy good rain gear and walk in all weather, but that just hasn't worked out. I just really don't like being out in the rain. Plus, for a good portion of the year, at my preferred time to exercise, it's dark outside.

I'm swimming again, but until/unless the pool in our tiny town opens early in the morning, that's only once or twice a week, at best -- and many weeks, not at all.

There is a gym in town, so that's an option.

Right now I think getting some exercise equipment for our own home is the best option. In the past, at different times we've had a cross-country machine, and a manual treadmill, which I used to rotate with swimming. I'm going to start investigating.

As far as writing this blog... I'm not sure what I'll do.

Why Are Wait Times for Bariatric Surgery So Long? Bias.

I saw this article when I was first researching weight-loss surgery, so I knew there had been a 24-month wait list.

But when I looked deeper, I saw Health BC showed very low wait times. The local RD confirmed that. A few times, my partner and I said to each other, so what happened to that long waiting list? .... It seemed to have disappeared.

But no.

The story criticizes BC Health's decision to cap the surgery at 400 per year.

Sheila Vataiki was struggling with obesity, sleep apnea, atrial fibrillation and high blood pressure, plus taking four medications to control her diabetes.

Her children were convinced she didn’t have long to live, but Vataiki’s problems were beyond her ability to fix.

She got progressively sicker for 10 years before she was finally offered a radical, but life-altering, solution: Bariatric surgery to reduce the capacity of her stomach.

“I had to be really, literally on the verge of death before I could get offered this as an option,” she said.

Since the surgery earlier this year, she has lost more than 100 pounds and every one of her related health problems has vanished.

“This literally changed my life, it gave me back my life,” she said.

Vataiki, now 62, only wishes she could have had the procedure years earlier.

More than 2,500 people in B.C. are waiting to enter bariatric surgery programs to address severe obesity and related health issues, but only 400 will get the procedure this year due to a cap imposed by the Ministry of Health.

“My endocrinologist, who is in the business of treating people with diabetes, can only get two or three people a year into the program (for bariatric surgery),” she said. “Imagine how many people he has that could benefit from this. It’s an incredibly effective treatment.”

B.C. has had some success speeding patients through to surgery once they qualify. There are 75 people on the surgery waiting list, compared with 488 in 2010/11. The median wait time has dropped from 126 weeks to just 4.9 weeks today.

To qualify for the bariatric surgery program headquartered at Richmond Hospital, patients typically must have a Body Mass Index above 35 and a host of obesity-related illnesses, such as diabetes, high cholesterol and high blood pressure, according to surgeon Dr. Sharadh Sampath, president of the B.C. Obesity Society.

All three bariatric procedures — the sleeve, gastric bypass, and duodenal switch — are covered by MSP, if you can get admitted to the program. Sampath’s waiting list is about 1,400 patients, and a similar number are waiting to be admitted to the program at Victoria’s Royal Jubilee Hospital.

Any increase in the cap on surgeries would help manage heavy demand, he said.

Further increases could help patients get the procedure before they are critically ill, in particular diabetics with a BMI above 30, who can benefit, said Sampath.

Per capita, Alberta funds twice as many procedures as B.C., Ontario three times, and Quebec five times as many.

“The disease processes get worse to the point that they can’t be cured by bariatric surgery, or patients are too sick to even have the surgery,” said Sampath.

Diabetics can develop end-stage symptoms such as heart disease or renal failure that could disqualify them for surgery.

“If you are too sick for the surgery, we have missed our window of opportunity,” he said.

There is a compelling business case to be made for raising the cap.

Bariatric surgery and post-operative care costs about $13,000. Vataiki’s medications alone cost $15,924 a year, not to mention all the visits to specialists and a period of hospitalization.

Patients who miss their window of opportunity can end up in our hospitals for months, costing the system millions of dollars, said Sampath.

From the Globe and Mail, May 2018. After a description of the surgery, how much weight the patient is expected to lose, and how his health outcomes will improve...

It’s time to admit what is patently obvious: The western world’s approach to reducing the ever-burgeoning size of its citizens has been a colossal failure. With its emphasis on diet and exercise, this approach has been utterly ineffective in controlling our expanding waists.

Worse, it has essentially shamed the hundreds of thousands of people who are unable to lose weight or fail to maintain weight loss. And fail they do: According to a 2015 study in the Lancet medical journal, up to 90 per cent of patients on a diet-and-exercise regime regain any weight they lost within five years. Yet we continue to offer trite advice and ineffectual platitudes, along with a stern wag of our collective finger at the obese.

This notion is quietly being put to rest in Quebec, home to the largest per-capita number of bariatric surgeries in the country. One in 90 obese people get bariatric surgery in the province, more than double the national average. As home to some of the skinniest people on the continent, and among the lowest per-person health spending in the country, Quebec might seem an odd place to be at the forefront of bariatric surgery research and practice.

Two surgeons, Rae Brown and Lloyd MacLean, were among the first to perform earlier, far more invasive versions of bariatric surgery, at McGill University in the 1970s and 1980s. Most of the advancements in the surgery, including the sleeve gastrectomy and the laparoscopic duodenal switch, were developed in Quebec. Dr. Gagner was the first to do both.

Today, the vast majority of bariatric surgery procedures in Quebec are performed in the private sector, in large part because the stigma against the overweight has become institutionalized within the province’s health bureaucracy.

Quebec is the only province that has paid for all types of bariatric surgeries. Yet, even now, bariatric surgeons have difficulty getting operating time for their patients. “They’ll give a liver transplant to an alcoholic before they let me operate on an obese person,” Nicolas Christou, one of the world’s leading bariatric surgeons, told me recently.

Past health crises have spurred government action. Cancer, among other diseases, has its own society and myriad hospital and governmental research facilities dedicated to its treatment and avoidance. Yet there are no such initiatives with obesity, even though the condition will affect some 34 per cent of Canadians over the age of 18 by 2025, according a 2018 World Obesity Federation report. Instead, we stubbornly believe that the obese are such because of their own failings and overindulgence.

A Big Disappointment

It seems that I started this blog way too early!

I've just had a major disappointment about the surgery.

Looking at surgical wait times online, the wait for bariatric surgery is minimal -- anywhere from 5 to 12 weeks. As it turns out, that is after you've been accepted into the program. Wait time to get into the program: 30 months. 2.5 years.

I'm so disappointed!

Yes, yes, I know I can eat less and exercise more in the meantime. But I also know that will have minimal effect. I will continue to be hungry almost all the time, and continue to be limited in how much exercise I can get, because of other health issues.

The reasons I want the surgery are the reasons that eating less and exercising more is not an adequate answer for me.

Wow. Really sad.

Will the Surgery Trigger Destructive Behaviours?

I mentioned that I've struggled with an eating disorder.

I think most women in our society have had eating disorders at some points in their lives, whether they realize it or not. We think our constant dieting, our obsession with our weight and size, is normal. I learned to think about eating disorders as a continuum of behaviours. When thoughts become obsession and behaviours take over your life, there is a problem!

My problem took the form of obsessive dieting and weighing myself. I was addicted to weighing myself. And it took me a very long time to quit. I put the scale in an inaccessible place... and then stood on a chair to reach it. I put myself on a regimen, only allowed to weigh myself once a day, then every other day. I succeeded a bit. I relapsed. I lied to myself. I gave up. I started again. And so on and so on. Everything you know about addictions, I did that.

OK, maybe not everything. I didn't sell the TV to buy a fix, I didn't lose my job, it didn't end my relationship. But trust me, even something seemingly harmless as stepping on a scale can strangle you.

For a time, I tried weighing myself only at the gym. I was swimming. I would leave the pool feeling great -- loose, invigorated, happy. Then I'd get on the scale and ruin my day. Day after day after week after month, robbing myself of all those good feelings.

In the past 15 years, I have tried several times to lose weight in a healthy and non-obsessive way. I lose weight verrrrry slowly, and healthy weight loss is slow anyway. So if I don't weigh myself occasionally, I'm not going to see any progress -- and you need some kind of progress as positive reinforcement.

But that word occasionally... that's the sticking point. Keeping myself off the scale has been very, very challenging, far more difficult than any dietary adjustments. Stepping on the scale is a giant trigger. It opens the floodgates to a rush of self-loathing.

Before and after surgery, there is going to be a lot of weighing. A lot of stepping on the scale. How am I going to handle that?

I don't have an answer to this yet, and I'm okay with that, for now.

But this is one of my greatest concerns about the surgery.

Getting Ready for the Referral

I asked my doctor for a referral for bariatric surgery. I told her I was reading a lot about it online and think it's for me.

She explained that a referral would be not for surgery, but for the bariatric program. Once in the program, it would be decided whether or not I would get the surgery. She also recommended I see the registered dietitian at our health centre, while I take care of other prerequisites.

I had some bloodwork, an electrocardiogram, and an in-home sleep apnea test. And I made an appointment with the RD.

RD was wonderful. Maybe they're all wonderful, I don't know, but I really enjoyed meeting her and working with her. We talked about goal-setting, motivations, how we make change in our lives. She had some great resources that I wouldn't have known about.

RD made a few suggestions on how I might be able to be less hungry, and how to put healthy snacks back in my daily routine -- something I used to do, but fell out of the habit.

I saw her once a month for four meetings. My work with her led to several changes.

• I bought this blender.
• I am drinking green smoothies.
• I bought this awesome container and bring four healthy snacks to work daily.
• I am making these babies which are delicious and so filling.
• I'm no longer eating pre-sweetened fruit yogurt, or eating them only occasionally as a treat. I was relying on them for convenient snacks, but they are very high in sugar. This was not a big deal to give up.

Meeting with the RD also gave me an opportunity to talk about my former eating disorder with someone who understands. But I learned that if I'm accepted into the bariatric program, I'll see a specialist RD who works only with bariatric patients. She's based in the city where the surgery will take place, a seven-hour drive from where I live. I don't know how many of those meetings will be in person and how many can be by videoconference.

Why I'm Choosing Surgery: About My Weight and My Health

Obviously, I'm overweight. Although I'm not shockingly huge, known as "morbidly obese," according to the prevailing wisdom, I am obese.

To qualify for surgery under the public health guidelines, the BMI threshold is 40. My BMI is less than 40. However, you can qualify for surgery if your BMI is over 35 and you also have two or more health conditions that could be improved by the surgery. I do qualify for that.

That's not good, but that alone would not be enough, would not lead me to take this drastic step.

Health Scare

Two years ago, I went for some routine bloodwork, and had a high fasting glucose -- not in the diabetic range, but high enough to raise an alarm. It's sometimes called pre-diabetes. I was completely freaked out. I already have more than one chronic health condition. My life already requires a lot of maintenance. I've adjusted to all of it, but I cannot even think about adding diabetes to that list.

I used this scare as a motivation to make smarter food choices and get more exercise. At the time I was very busy, with very little time to myself, and regular exercise had really fallen out of the picture. So I did this for some months, got tested again... and there was no change. Or, there was a change but it was insignificantly small.

Now fast-forward to the present. I'm eating healthfully, I'm getting regular exercise, and I'm taking supplements that are supposed to help with blood sugar levels. My blood sugar readings after eating are normal. But my fasting levels are still in that pre-diabetes range.

Age

I'm 58 years old. I've seen a lot of information about the determinants of a healthy old age, and much can be determined by your health as you head into old age. Being a healthy senior and maintaining my independence as I age is really on my mind. There's so much we can't control. I want to control what I can.

I do eat a very healthy diet. I do get exercise -- not a huge amount, but I aim for that minimum 150 minutes per week. That's all good. But I am never going to lose enough weight, and maintain a lower weight, to significantly lower my BMI and change my health outcomes. The most I could hope for would be to stop gaining weight.

And I'd likely ruin my life while I tried. (I'm not exaggerating.)

My Diet...

I said I eat a very healthy diet. That's both true and not true.

I don't eat fast food, I don't drink soda or anything with sugar in it. I don't eat processed food.

I do eat a lot of fresh fruits, vegetables, and whole grains. I'm an omnivore, which I believe is a healthy way to live.

I don't stress eat, and I don't eat from boredom. I eat only when I'm hungry.

...And My Brain

But. There's the but. I'm always hungry. I eat, and I feel full. Ninety minutes later, I'm hungry again.

And when you're always hungry and have access to food, it's very difficult to always make good choices. I do all the things you're supposed to do. I plan ahead. I have healthy snacks on hand to help with hunger between meals. I'm the queen of healthy snacks. But it doesn't always work.

In the last 10 years, I have gained five pounds per year. And I was about 10 pounds overweight to start with.

Bariatric surgery shrinks your stomach, so that it can only accept small amounts of food. But it does more than that.

Your stomach secretes hormones that tell your brain when you are hungry or sated, and tell your pancreas how much insulin to secrete -- and a lot of other things that medical science doesn't completely understand. After bariatric surgery, those hormones are drastically reduced. It's believed this contributes to both weight loss and the maintenance of a healthy weight.

I've Tried It All... And I Don't Want To Go Back There (Eating Disorders Are More Common Than You Might Think)

When it comes to my weight (size, body image, etc.), I've been there and back. More than once. I gained a lot of weight in my mid-20s, and used one of the many popular diets of the day to lose it quickly. This was the first, and as it would turn out, only time in my life I was actually thin.

As the weight came creeping back, as it inevitably does, I started dieting. And dieting and dieting. I became obsessed with what I ate and with weighing myself. It was a horrible way to live.

I was like this at least 10 years, when, coincidentally, I needed to research eating disorders. I was shocked to recognize my own behaviour.

When many people think eating disorder, they imagine an extremely thin person, probably a young woman -- an anorexic. But there's a huge spectrum of eating disorders, covering a wide range of behaviours. Once I became aware, I would see eating-disorder behaviour everywhere. 

For me it took the form of being addicted to weighing myself, addicted to dieting, and obsessed with restricting my eating. I was probably only 10 pounds overweight at the time, but I was obsessed with trying to lose weight.

After recognizing this in my late 30s, I started seeing a therapist who specialized in eating disorders, and I worked hard to free myself of these obsessions. Eventually, I got there.

I stopped dieting. I stopped strictly policing my eating. I even stopped weighing myself. It took a long time, but it was glorious. It was so liberating! I gained some weight, but I was healthier, and happier. 

I also learned that the link between weight and health is greatly exaggerated. Obesity is a health risk, but those 5 or 10 extra pounds that women become obsessed with are not. They're not even extra.

But keeping people insecure and unhappy is an essential part of our consumer culture -- and the diet industry thrives on it.

So I stopped dieting, started enjoying my life -- and food -- more. I was maintaining a weight that was heavier than most people want to be, but I was healthy and felt good.

Now I've gained quite a bit more than is healthy. But I don't want the demands of bariatric surgery to undo all my hard work and my hard-earned freedom from these obsessions.

I'm afraid the surgery will be a giant trigger that sends me back to weight prison. Pre- and post-surgery, you're supposed to track your eating. And post-surgery, you need to track your weight loss.

How am I going to do that and stay sane?

I'm thinking a lot about this. I want to make it work.