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Shattering One of the Most Dangerous Weight Loss Surgery Fantasies



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A large percent of pre-op weight loss surgery candidates feel that once their waistline changes, so will their thinking, and their dead wrong.




Today, during one of my pre-op psych evaluations, I heard a woman say “I just feel like once I start losing weight and start feeling so much better about my self- I will stop doing all the destructive things that got me here. Don’t you think?”

My response was “no I don’t agree.” I went on to explain that hers was a common assumption, a dangerous “magic-bullet” fantasy about what weight loss surgery can do.

Here’s why: The part of our brain that is responsible for the thought : “wow I look so much better, I better not mess this up,” or “I feel better than I have ever felt in my life, I am a changed person,” is not the same part of the brain that wakes us up in the middle of the night and says: “go on, finish that 1/2 pint of Chunky Monkey in the freezer, there’s only a little bit left anyway, and I have been so good here lately.”

We are dealing with two very different brains; the frontal cortex and the reptilian mid brain. The frontal cortex is the most newly developed (relative to other parts of the brain) part of the brain. It is the component that separates us from animals. It gives us the ability to think about consequences, plan, and execute. It is the “higher” part of ourselves, that often says “why do I keep on doing the same things I keep saying I won’t do anymore?” Or “I feel so out of control. This _______ (eating, smoking, drinking, gambling, pick your poison) is a temporary solution that produces long term pain. I have to find a different way.”

veeterzy-113210.jpgOur reptilian midbrain is the Commodore 64 to our MAC; it is the palm pilot to our iPhone; the horse and buggy to our Prius; the Tommy Lee to our Oprah. Our midbrain is antique equipment, long ago evolved to keep us alive and hence the reason it is still with us today- it keeps us alive. Our midbrain contains the parts of the brain that make us recoil at the site of a snake or a spider in our peripheral vision. It is hardwired to not have to go through superfluous channels of the brain that might otherwise say “hmmm what is that crawling over there? How do I feel about that? Oh its just a spider, my aunt had a collection of spiders, maybe I should collect things, etc etc.” We just jump, and process later.

That very system has helped humans survive for thousands of years. There is an adaptive quality to a brain that proverbially acts and asks forgiveness later. That very old structure once kept us out of harm’s way when a pack of tigers were first seen galloping across a horizon, or when a rivaling tribe could be heard in the far off distance, threatening to pillage our territory.

Our midbrain is associated with learning and reward. Learning what makes us feel bad, what eats us (in the past that would be in a literal sense- like tigers, but presently it might be a mercurial supervisor or unending debt), and even more relevant to this article- what makes us feel good. When our brains come across something that makes us feel good (ex: sex, drugs, food), we are then flooded with an influx of the powerful neurotransmitter- dopamine. Just like not everyone that is exposed to drugs will develop an addiction, not everyone that eats a Nutella crepe will develop a food addiction.

Much of the research on obesity currently, postulates that food addiction, no dissimilar than alcohol or drug addiction- is a reward system dysfunction or dysregulation, born out of genetic predisposition. It’s almost as if some brains think “if one slice of pizza feels good, how would four slices of pizza taste?”

To break these two very different parts up in a different, more basic way; our frontal cortex is the voluntary, while our midbrain is the involuntary.

This very dangerous fantasy, many people carry into weight loss surgery is a myth that I try to dispel quickly. This type of “magic bullet’ thinking is the very thing that gets so many gastric bypass and sleeve patients into trouble years down the road. No one wants to look at triggers. No one wants to sit with a therapist and devise a strategic coping plan. We want a pill, a surgery, a 16 minute solution to a 40 year old problem.

This is not to say that weight loss surgery is not a solution, just that its only part of the solution.

hanna-morris-277323.jpgDespite our best intentions, we are still in some ways animalistic, hedonically-driven to feed our most basic impulses. This is part and parcel of why recidivism is the rule not the exception when it comes to recovery from most addiction. So what does this mean? Are all weight loss surgery patients destined for disappointment and disenchantment when the WLS honeymoon ends? No. But the answer to long term change lies more in two-pronged approach to long term weight loss success; surgery + behavioral change.

Simply thinking ourself slim is a fantasy. Think about your specific triggers for eating. For some it is that golden hour when all the kids are in bed and Narcos is queued up on your Netflix. For others it is that 2-3pm mid day slump. For some - it is when they are alone, the only time they can eat with abandon free from others’ judgement or their own embarrassment.

Whatever your triggers- the key is to identify what need is being met in that moment and to find a non-food alternative to meet each particular need ( many people have multiple triggers for over eating). If it is because its “your time,” after the kids are in bed- maybe you invest in a foot massager, or cultivate a self care space with textures, aromatherapy, candles, and books. If your trigger is that mid day slump, maybe you develop a yoga routine easily done in the office to help re-energize you. If it is the secretive quality to the trigger of being alone and eating, maybe it is finding another thing that is just your own that no one knows (going to a movie in the middle of the day, getting an overly priced facial on your lunch hour, playing hooky with your kid one day, etc).

The rule of the brain is : what fires together, wires together. So over time- if you have paired 8pm, Narcos, and nachos- you have created a neurological super highway. The moment 8pm rolls around, you are likely already getting the chips ready and didn’t even realize the thought pathway that just occurred. The idea is to repair our triggers with alternative behaviors and over time “clip those wires” or create “toll roads” to our superhighways (aka neurosynaptic pruning), so that we no longer experience such strong urges and can call upon the higher structures of our frontal cortex to guide the way again.

When we are in the midst of addiction, it is important to understand that our frontal cortex is not at the wheel. It has been duck taped and tied to a chair in the basement by our hedonic midbrain who is used to getting what it wants when it wants it. The closer we come to accepting this principle, the closer we come to being more mindful of our midbrain’s powerful rationalizations and sick contracts and see them for just that. We are better able to dis-identify from the thought, knowing it is not coming from our best self, but from our most carnal self.

Think of that distant cousin that only shows up when they need something, the Uncle Eddy that tells you he’ll move the RV when he leaves next month, indifferent to how it makes you feel. Except in addiction- that distant cousin has taken over, pretending its you until you can no longer tell the difference.

References

http://brainspotting-switzerland.ch/4_artikel/Corrigan & Grand 2013 Med Hyp paper (proofs).pdf

Blum K, Chen AL, Giordano J, Borsten J, Chen TJ, et al. The addictive brain: all roads lead to dopamine. J Psychoactive Drugs. 2012;44:134–143. [PubMed]

Avena NM, Gold JA, Kroll C, Gold MS. Further developments in the neurobiology of food and addiction: update on the state of the science. Nutrition. 2012;28:341–343. [PMC free article] [PubMed]

Gearhardt AN, Yokum S, Orr PT, Stice E, Corbin WR, et al. Neural correlates of food addiction. Arch Gen Psychiatry. 2011;68:808–816. [PMC free article] [PubMed]

Saper CB, Chou TC, Elmquist JK. The need to feed: homeostatic and hedonic control of eating. Neuron. 2002;36:199–211. [PubMed]

Stice E, Yokum S, Zald D, Dagher A. Dopamine-based reward circuitry responsivity, genetics, and overeating. Curr Top Behav Neurosci. 2011;6:81–93. [PubMed]

Blum K, Sheridan PJ, Wood RC, Braverman ER, Chen TJ, et al. The D2 dopamine receptor gene as a determinant of reward deficiency syndrome. J R Soc Med. 1996;89:396–400. [PMC free article] [PubMed]

Comings DE, Flanagan SD, Dietz G, Muhleman D, Knell E, et al. The dopamine D2 receptor (DRD2) as a major gene in obesity and height. Biochem Med Metab Biol. 1993;50:176–185. [PubMed]

Noble EP, Noble RE, Ritchie T, Syndulko K, Bohlman MC, et al. D2 dopamine receptor gene and obesity. Int J Eat Disord. 1994;15:205–217. [PubMed]

Blumenthal DM, Gold MS. Neurobiology of food addiction. Curr Opin Clin Nutr Metab Care. 2010;13:359–365. [PubMed]

Volkow ND, Wang GJ, Fowler JS, Telang F. Overlapping neuronal circuits in addiction and obesity: evidence of systems pathology. Philos Trans R Soc Lond B Biol Sci. 2008;363:3191–3200. [PMC free article] [PubMed]

Volkow ND, Wang GJ, Baler RD. Reward, dopamine and the control of food intake: implications for obesity. Trends Cogn Sci. 2011;15:37–46. [PMC free article] [PubMed]

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This is an amazing article! Pretty much everything you have laid out is new to me... or at least presented in a new way.

Fabulous!

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Love this! It explains so much why I'm such a contradiction at times. It's worth reading again.

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Excellent article Dr Long. Thank you. I'm 4 years out and while I've lost quite a bit of the weight I wanted to lose I have more to go. And this is where the triggers come into play. It's so easy to slip back into bad habits, to allow those things that led to my obesity to overwhelm my self-control and try to re-establish themselves as ruler of my life. For me it's when I'm bored. I've identified most of the triggers but now comes the real hard part - overcoming them and starting new, healthier habits. Thanks again!

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Great article that explains how our brains work both with and against us. I know for myself that it does take a long time to form new habits and ways of thinking (especially when it comes to food), but I've had successes with it both pre- and post-surgery. I do slip up on occasion though, but luckily my sleeve prevents me from falling off the rails too much before I can right myself again. Now I'm trying to work on my triggers (which is mostly not being prepared, food-wise, during and after long days at work) to really get me to good place that will help me to continue to lose weight and then maintain once I'm at goal.

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Thank you for the thoughtful article. It is nice to see a mental health article about WLS patients that is not focused on alcoholism.

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On 10/11/2017 at 6:04 AM, Dr. Colleen Long said:

long term weight loss success; surgery + behavioral change.

Yes!! The hardest part about all of this is the behavioral change. I’ve found some habits wanting to sneak back in, why? Cause I haven’t either fully let go and change or in the process of changing my behaviors still. The sleeve helps, but only so much. I’ve still got work to do...and know it. Thanks for this great article!

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I think for me the new habits I am working on establishing have to be something I really want to do and then it takes time. I think it takes longer than the three weeks that you hear everyone repeat.

Great article.

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On 13. Oktober 2017 at 5:54 PM, Apple1 said:

I think for me the new habits I am working on establishing have to be something I really want to do and then it takes time. I think it takes longer than the three weeks that you hear everyone repeat.

Maybe three weeks are enough to form new habits that are easy to form and as long as we actually like the new stuff we're doing or at least don't minding the stuff we're doing. It's a difference if you're trying to form the habit of cleaning your coffee cup in the morning instead of letting it sit around dirty or it you're trying to form the habit of going to the gym five days a week. One takes a minute, the other takes a giant amount of your leisure time.

Also I don't think the really hard part is forming new habits (though it can be hard enough). IMO the really hard part is giving up the old habits we love.

And I think this is where the real problem and challenge is: too many people are trying to replace an old habit they love with a new habit they hate. On top of it they're trying to convince themselves that they're loving the new habit the hate, fooling themselves.

Robbing yourself of something you love to replace it with something you hate won't work in the long run.

Edited by summerset

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And I am very glad I read,this article, with me Eternal Vigilence will be my helping hand. Down Pesky Midbrain ---it's time for,my higher centers to shine! I feel I still can so,the but the uphill grade just got steeper.😪

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