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Surgery - and then the hard part

Weight-loss surgery is "just a tool": As Chris Christie and other patients learn, "eat less" remains the imperative.

Debbi Cook decided to have weight-loss surgery when her doctor told her she needed five shots a day for her diabetes instead of four.

She was 5-foot-8 and 349 pounds, and she'd already had diabetes for 37 years. She just couldn't face one more shot. "I really honestly would have rather died," the Norristown woman said.

Cook, 57, chose to have gastric bypass surgery at Mercy Suburban Hospital 11 months ago. The most complex of the three common weight-loss procedures, it also has the best record of alleviating or even reversing diabetes.

Cook knew, though, that she'd have to drastically change her behavior. Worried that she'd blow it later if she couldn't eat right, she began the restrictive postsurgery diet before her doctor reduced the size of her stomach and bypassed part of her intestine.

One by one, she had a last meal with her favorite foods - fish and chips, Coca-Cola, ice cream, mac and cheese, homemade carrot cake, Yorkshire pudding, a Bloomin' Onion - as if they were dying, beloved relatives.

"This was the funeral for that food," she said.

She lost 40 pounds before surgery and 150 more afterward. She's still losing.

New Jersey Gov. Christie's decision to have the laparoscopic adjustable gastric band or lap band has focused attention on weight-loss procedures. But experts and surgery veterans said patients still must change their ways.

"A lot of times people don't focus on this and it's probably the most important part," said David Tichansky, director of minimally invasive and bariatric surgery at Thomas Jefferson University Hospital. "The surgery's just a tool to help people stay on a diet, but it's still a diet."

The really successful patients also exercise intensely.

About 20 percent lose less than expected or regain weight, said David Sarwer, a University of Pennsylvania psychologist who counsels weight-loss surgery patients. "Most of the time, it's more behavioral in nature," he said. People return to the "eating behaviors that got them in trouble in the first place."

In the lap-band procedure, a band filled with saline is wrapped around the upper part of the stomach. This forms a small pouch and restricts entry of food into the rest of the stomach, but doesn't change digestion. Patients can "cheat" by eating soft, high-calorie foods.

It is becoming less popular, while sleeve gastrectomy is in ascendancy; surgeons staple the stomach vertically, reducing its size by 85 percent.

In gastric bypass, the size of the stomach is greatly reduced and it's attached to the middle of the small intestine. This limits calorie absorption.

The duodenal switch, which is done less often, combines gastrectomy with a longer bypass.

All the procedures make patients feel full quickly. All but the lap band also reduce the release of hormones that signal hunger.

On average, patients lose the most with the bypasses and the least with the lap band. The band is reputed to have the most weight regain, but Sarwer said studies had been equivocal. It also produces the slowest weight loss.

Patients can undermine any of the operations by eating too much of the wrong foods.

Michelle Porter, a registered dietitian who works with weight-loss surgery patients at Jefferson, said patients' diets are similar regardless of the procedure. They are to eat three small meals a day. By small, she means that each mea totals about 4 ounces or 1/2 cup. Three ounces of that should be lean protein. Many use protein supplements to meet daily requirements, and take vitamins.

They don't drink fluids with meals and aren't supposed to drink alcohol. It's wasted calories, and the tiny meals make its effect more potent.

Jaime Ponce, president of the American Society for Metabolic and Bariatric Surgery, gives patients the rule of 20s: Chew each bite 20 times. Put the fork down for 20 seconds. Stop eating in 20 minutes.

Patients eat about 1,000 calories a day at one year after surgery, and a few hundred more daily after that.

Overeating can cause vomiting. Bypass patients who overeat or eat sugar risk "dumping syndrome," which can give patients nausea and diarrhea.

The new way of eating changes patients' relationship with food, and with friends and family. "It does kind of take their world and flip it upside down," Porter said. "It's not just a diet. It's changing their life."

Surgery patients said that over time, they'd gotten a little more relaxed about the rules. They felt they could eat whatever they wanted in very small quantities and didn't deny themselves an occasional glass of wine. They'd learned to substitute walks or exercise classes for socializing over meals.

Kenya Boyle of Upper Darby chose the lap band at Mercy Fitzgerald Hospital in 2007 because it was the least scary. She was 5-foot-5 and 285 pounds. She dropped to a low of 128, thought that was too thin, and she's now 146.

Boyle, 37, still exercises three days a week and watches what she eats. At a recent dinner, she ate the same food as her three daughters, but they got big plates and she ate on a saucer. She had two baked chicken wings, a couple of level tablespoons of potato salad, and some collard greens. She has to be disciplined, but the band helps. "I don't feel hungry all the time," she said.

Kelly Niszczak, 44, of Lansdale, who had a sleeve gastrectomy at Abington Memorial Hospital in November 2011, often shares restaurant meals with her 6-year-old and still takes food home. "I'm like the queen of to-go containers wherever I go," she said.

Now that she has lost 90 pounds, she has a new perspective on restaurant portions. "It's overwhelming to me how much I'm overserved food," she said.

Ellen Garfield, 41, of Bensalem, who had the duodenal switch at Abington in 2010, always takes powdered protein with her when she goes out so she can make a protein shake if she needs to eat.

"I have friends that laugh at me," said Garfield, who has lost 200 pounds. "I put protein in my purse. You never know when you're going to need some protein."

She has also taken up running.

The patients and the pros think Christie has a shot at doing well - if he follows the rules. His job will make things challenging, but Tichansky said the governor's power will help. If he asks for a smaller portion, he'll probably get one. Even then, it will be too much food.

"Every restaurant in the country is going to give you a bigger portion than you're supposed to eat," he said.