Obesity and bariatric surgery with Dr. Kimberly Yane

Hello, I'm Julian. Hello, I'm Julianne Good and this is Psych One-on-One. Welcome. We are here to make psychology understandable with tips for you, your family and friends to make your life easier. Tonight my special guest is Dr. Kimberly Yane and we are going to be discussing obesity and bariatric surgery. Hi, Dr. Yane. How are you? Fine. Thank you for having me on the show. Well, thank you for joining us. Joining me from Palm Springs, correct? Yes. Beautiful, sunny, warm Palm Springs. Very warm. Very, very warm. Well, thank you. Can you tell the listeners a little bit about your background? Yes. I am a MFT, marriage family therapist intern that specializes in bariatric surgery clearances. I actually, this is my second vocation, like most therapists for some reason. I am on theımız on theımız on theımız on theımız on theımız on theımız on theımız on theımız on theımız on theımız on theımız on theımız on theımız on theımız on theımız on theımız on theımız on theımız now. So I would like to start off, I pulled up some statistics before I left my house this evening about obesity statistics in the U.S., Canada, and the world. And I was really quite shocked. They figure that the obesity worldwide in 2012 was 520 million people. And of that 520 million, 92 million were Americans. We are on the top of the list. Very shocking. There's something to be said about that. And part of it is we have a lot of processed food. We have mass quantities of foods such as Costco, fast food, drive-thru. But there's also something that I think a lot of people don't realize is that there's a high level of trauma that's going on in the U.S. and in the world. And that's the fact that we have a lot of people in this country that's directly related to being morbidly obese. We'll have to definitely get into that because the psychological impact, along with the physical impact, is just, it's very complex. Yeah. And I was also looking here too at the numbers for people that are overweight worldwide. It was 1.5 billion people. And the U.S. has 154 million for overweight. Uh-huh. That's about right. Yeah. So can you go into some of the factors that you think are contributing to this epidemic in this country? Well, you know, a lot of it, as I'd mentioned before, there is a lot of processed food. There's a lot of fast food. There's also a lot of the family structure where, you know, most of us that were born from a certain generation have what we call the three meals, a stay-at-home mom cooking, um, more, um, just more homemade meals. But I think a lot of it has to do with the breakdown of the, of the family culture, the, um, structuredness where you have a lot of single moms or single dads and people are on the go. I mean, if you think about it, you know, we have drive-thrus where they serve three meals a day. Right. Yeah. And I think one of the huge culprits is soda. Yeah. Soda is a killer. Soda is one of the things that people, are no longer allowed to drink after they have the surgery. Wow. That's, I'm, I'm sure for a lot of people that would be very difficult because it seems that a lot of people are addicted to drinking soda. You know, there's a belief, um, depending on who you talk to, I'm a great believer of this, that a lot of the food additives are made to have people, um, become addicted to their, to the products like soda, um, fast food, fat, sugar. They all have an addiction. There's an addictive mechanism to them. And what do you think is, uh, another, uh, highly addictive food or liquid? Oh, um, these, uh, energy drinks, um, you know, alcohol is one, it's empty calories. There's all kinds of things out there, um, that really add what we call empty calories to people's bodies. Yeah. And it's, um, maybe you can go a little bit into the, the, um, the component of, of how the body breaks down these empty calories. Well, you know, most humans don't need, you know, we really need no more than 1200 calories a day because, you know, when people become overweight, they're consuming more calories than they can, than they can burn off. And what happens is, um, when people become morbidly obese, it's because they're usually eating triple, um, if not quadruple the number of calories, um, that they're consuming. Um, so, um, so, um, so, um, so, um, so, um, so, um, so, um, so, um, so, um, so, um, so, um, so, Think about it. If you have a Big Mac meal, the super size, you've already consumed about 2,500 calories right there. Yeah, that's amazing. And a lot of these restaurants do not have calorie breakdowns. I know they're getting a little bit better in Southern California where they will list them. It is the law now. It's the law. Just in California or countrywide? I think they're really moving it countrywide where a lot of people are, well, a lot of the organizations, if you look at the little food labels, it is required now that they have like the calories and the salt and all those things that are required to be on it. But I think a lot of it is we don't have nutritional literacy in this country. Yeah, and I was going to ask you how many people really do read those labels when they're out shopping? Just a few. I think the people that are more health conscious, but the average person just really doesn't. I mean, you know, the majority of my patients are really people that are on the go, people that are, you know, very busy, single moms, people that have night shift jobs. They're overwhelmed. Even if they know they shouldn't eat it, they'll eat it just to have that energy boost or to have that comfort that they feel they need. Yeah, it's definitely that component of I need to fill up and I need to do it quick. And what's going to be the easiest thing for me? I need to go and get. Mm-hmm. Right. So what do you think is one of the emotional components to being obese? Let me give, well, one of the emotional components that has become an over underlying theme in the two and a half years that I've only specifically focused on morbidly obese patients is childhood. And that's molestation. Interesting enough. And that seems to be 70, 77% of the people that come through my door have indicated they've had at least one traumatic experience of that sort. Another component is previous drug addiction, drug alcohol addiction, domestic violence, and just childhood unrest, like moving around, childhood divorce from a certain generation. And now you said 77%. 77% have been molested. Is that male and female? Male and female. And all under the age of 18. So for them, did they start gaining the weight then after the molestation? You know, one of the things in my evaluation, I always ask, when did they first notice their weight gain? And it always seems to correlate. Right after that incident. So usually people say, I started getting really heavy when I was 12. And then I would ask, were you ever violated as a child? And they'll say, like, around the time I was 11. So it sort of correlates. And it seems to be after a traumatic event, it seems to be that the weight seems to come on. So is it a mechanism then possibly of stuffing down the trauma and trying to fight? Or is it just a way to find some way to have a coping mechanism? Absolutely. You know, a lot of it is people always often ask me how I got into this field particularly. There really isn't any specific training for it. I did a lot of study on my own work with bariatric surgeons and nutritionists. A lot of it is related to addiction theory because of the fact that food is a legal addiction. When people are eating two gallons of ice cream a day or eating a whole. Tub of Twizzlers, that's an addiction. Or I have people that are drinking those two big two liter bottles of soda per day. Yeah, so it just becomes an automatic habit then. Is it something that that is built up to that point or? You know, becoming morbidly obese is not an overnight sensation. It's a gradual build up. And usually it takes about I've had people they put on the weight within one calendar year. I've had people that have had the build up. Um. Over a 20 year span. And these are people that are 250 pounds up to 550 pounds. So at any point when they were going through that process, were they having any kind of self-talk? Like, you know, what are you doing? Look in the mirror, you know, kind of a body concept. What happens with along those lines? You know, most of the patients that I've come across, usually they become very socially. Isolated. And so they're really not interacting with a lot of people. They know something's going on, but usually it's when they've had enough of enough sort of oftentimes I hear they're just sick and tired being heavy. The men in general, usually they've been told you basically have six months to live. If you don't lose this weight, you'll die. And so they do have these conversations with themselves. Oftentimes they realize they're missing out on life. They're missing out on their children's lives. They're being passed up. For. Social and professional opportunities. So they do have these conversations. But to make that fundamental change and especially to lose over 80 pounds becomes a whole nother task of its own. Well, I would imagine because it is it's some sort of. Of protection. Having. That much weight on. Yeah, it is because I've often had women say after I was violated by an uncle. I just felt that if I became fat, no one would bother me. So that's a pretty typical story then, correct? Very typical or oftentimes it just becomes a comfort where the eating fills a void in their emotional life. Often with kids, I've had childhood neglect and abandonment. So it all depends. The thing about it, the stories are also individual. They're common underlying themes, but every person comes in with their own story. So what is like a common theme in your office? A common theme usually is someone that is about 35 to 40 years old. That is a single parent that works a night shift that had early childhood violation and then probably most likely a a bad marriage that might have involved domestic violence and then a remarriage that involves dissatisfaction. And I. Often. Get a lot of people that are just trying to see if this weight loss will change their lives, turn their lives around. So what about people who are former addicts, drug addicts, alcoholics? Is it like switching one addiction for another cross addiction? Can you can you tell us a little bit about that? Well, you know, those of us in the psychology world, we know that one. Addiction addiction can lead to another. So oftentimes people people go from alcohol to drugs. And oftentimes when people go through drug rehab, they will unless they work on their addictive personality, they'll find another addiction. And the food then takes place of the drugs or the alcohol. But it's legal. And you'll often see that I have a good number of people that were previously incarcerated. When they come out, they lose the structure. They overeat. So that that's their new form of structure then is just going to the refrigerator in the cupboards. Interesting. Very interesting. And. What would you say. To somebody that's going from one addiction to another, how how would you present that to them? Oftentimes I can tell right away. My suggestion to them is to really look. At the underlying factors. And, you know, those of us in the therapy world, a lot of therapy is re parenting. And oftentimes when people haven't been taught how to cope correctly, they find ways to cope. And often that's like drugs, alcohol, food or gambling addiction of some sort. So I really try to work with them to see the underlying issues that are bothering them. That's, you know, driving them to find find some source of some some source of comfort either through food. And usually it's because. They were on drugs or alcohol and then they moved over to food. Does that make the therapy sessions more complex because you're almost working with a one standing addictive pattern? Yes and no. I think often again, it's it's based on the individual. For some people, they're ready to break the pattern because they're fully aware of what's going on. The hardest ones are the ones that really are not quite aware of their own actions and oftentimes. One. They're not to use it as an excuse because they're too busy or like they need this or like they, you know, they really can't quite pinpoint or they're in denial of what's really going on in their life. So it's getting them to stop and think about what they're doing before they open their mouth and start just, you know, shoving the food in without thinking about it. Do you work with any kind of mindfulness techniques for that? Absolutely. Absolutely. It's all about mindfulness. It's about self-awareness. You know, oftentimes I work with them on the psychodynamic part of it, like really delving into their childhood development. I like to see myself as an Adlerian therapist. I really think the childhood development part is very important. It is. And and then what I do is we then work, move on to the cognitive behavioral because they often work with a nutritionist and the nutritionist teaches them the right food to eat. And then my job is to reinforce that. So how much resistance do you deal with in session and out of session? There is a good amount. There is a high failure rate in this surgery. There's about a 35 percent failure rate. They may tell you one thing, but when they go outside that outside the therapy session, there are people they cheat on their their eating. The people that use lap bands. I've had people admit. They mess with their lap band so they can put more food in. There is a category of people and I've been meeting more of them where they went from the lap band to the ruin. Why to the sleeve surgery? Because there are three forms of surgery for morbidly obese people looking to lose weight. And we will definitely talk about that after we take a commercial break. OK, Dr. Yang. OK, thank you. Great. Thank you. Are you searching for answers and insight? To life issues? Is the behavior of family or friends questionable or concerning? Find tips and possible solutions from the convenience of your own PC, cell phone or tablet at therapycable.com. Therapy Cable has the most comprehensive library of contemporary therapy videos online. Help may be as easy as a few clicks away. Therapy Cable offers comprehensive therapy videos ranging from addiction to self care and contact information for qualified providers. Find the answers to your life challenge. Watches at therapycable.com. And thank you for joining us on Psych One-on-One. I'm Julianne Good and I'm with Dr. Kimberly Yang this evening. We're talking about obesity and bariatric surgery, which Dr. Yang specializes in counseling. Can you tell the audience a little bit about what bariatric surgery is? Yes, bariatric surgery is a surgical procedure. There are three kinds to help people. One. It's a surgery that allows people to lose more than 80 pounds of weight. And it's been around since the 60s, but it's been fine-tuned. Back in the day, people would say you're getting your stomach stapled. And literally, that's what they do. The most invasive one and the oldest one is called Ruin Y, where they basically reroute your digestive system. Then the one that came after it is the lap band, which is a foreign body that's put on the top of your... They insert it in the top of your digestive system. And it's a very effective area of your stomach, so less food can go in. And the newest and probably the most effective is called the sleeve gastrectomy, where they go in laparoscopically with a microscope. And they cut part of the stomach and sew it up, so less food is able to be held in the stomach. And you said that that was the most effective out of the three at this point, correct? It's the least invasive, and it doesn't involve a foreign body. And it seems to be the most effective and less invasive. Yeah, and I know I used to be a medical transcriptionist and typed up some of those bariatric surgery reports. And they can be really radical, at least when the band was out, for just prepping up for the surgery and then post-surgery. So if a person undergoes one of those procedures... Approximately how long is the pre-, the peri-, and the post-operative appointments and recovery? Okay, so it really is dependent on your insurance policy. This is usually the routine. Most people will get a referral from their primary care doctor, or they just see an ad and they decide to call the doctor. And so they have to go through cardiac and digestive and blood... And they have to have a nutritional counseling and a psychological clearance. So usually what I do, what they do is, let's say they call on week one to the bariatric surgeon. The bariatric surgeon will give them the consult, and then I get the referral. And usually I'll schedule them the week following week, and then they have to do all this. So I'd say all said and done before surgery, depending on the insurance policy, maybe 90 days to 120 days out. And then what is your part in it for the psychological evaluation? Why is that necessary? Well, the insurance companies and the physicians want one of two things. They really want to see if the individual is drug alcohol-free and free of any severe mental illness like schizophrenia or bipolarism. Not to say that people that have those diagnoses don't get the surgery. It just has to be well-maintained. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. it gets them to understand how much self-responsibility they have to take post-surgery to keep that weight, you know, to start melting off the pounds and keep the weight off. Yeah, oftentimes the patients come in with sort of a, not all, but there's a good number that have this unrealistic expectation that, you know, I can go back to eating the way I eat, my fast food, and eat whatever I want, do whatever I want until it's really discussed with them. And part of my job, and I think my effectiveness is just being straight up with them, reminding them it is still surgery, that there are things can happen. People have obstructed where their stomach breaks apart and they get infection. There's something called dumping syndrome where you can't stop having diarrhea. You can have, like, just all kinds of complications. So it's a friendly reminder that this is not a quick fix. I personally find it very, very hard post-surgical life. Yeah, it's a whole lifestyle change. And pre-surgery, they have to go for two weeks on a straight liquid diet. Wow. So how many people drop out at that point can't do that? Well, it's very interesting. So out of, let's say out of 10 referrals, only five people will go through with the surgery. So about 50% then. 50%. Yeah. And oftentimes there are people, after talking to me, they decide it's not for them. They want to give a good college try of doing Weight Watchers again or trying some fad diet. It's usually when they really have tried everything. Or there's a group of people that really feel like, you know, if this happens for me, maybe. My life will get better. I can finally divorce my spouse, get a better job. My life will turn around. I'll get the job promotion I always dreamed of. So as you said before, the huge expectations about what's going to happen post-surgery. And that's got to make it more difficult when... Now, do you work with the patient also post-surgery and for how long? Yes, I do. Here's the part that's very interesting. It's optional. It's optional. And I would say only 10% choose to go with it. The insurance companies cannot force them to do it and nor do they pay for it. So only 10% of people will take out their own money to work with it. And I notice the people that do work with me post-surgically do much better. Well, I would imagine. I mean, you're the extra support system that they need. Yeah. And also a reminder that... This is a personal choice they made and that it's not going to happen overnight. And for many people, they're not just working about losing weight. It's all the issues that cause them to gain weight. Oftentimes, it's self-image, lack of self-worth. This is a small town. Palm Springs, if you've ever been out here, is a very small town. Even though it's a whole valley, it tends to be a certain group of people only do certain things. And so you run into a lot of people. And I have people, they say, I'll notice them or they'll say hello to me and they'll have to flash me their before picture. And I'll ask them, how are you doing? They go, oh, okay. I just wish it were better. And oftentimes, it's not what they thought it would be. The weight's gone, but their issues are still there. So it's just not that straightforward. And I think oftentimes, the people that do the extra counseling really come to terms with issues of childhood abandonment. Childhood violation, bad self-esteem, lack of self-control, all those things that have caused them to become morbidly obese. So anybody that undergoes this process really has to make the commitment to themselves and to you and the medical team that they're going to follow through on what is recommended. Absolutely. It's not an easy... You know, I often run the support groups afterwards. And it's interesting. There's what we call plateau at about between 50 to 80 pounds, depending on the individual, they'll plateau. And they just all of a sudden stop losing weight. And that's when the frustration kicks in. And oftentimes, there's a good number of people that just, like, give up completely. So why is that? They plateau at that point. Your physiology is trying to catch up. And does it ever go back to, like, at a certain point, you plateau, you kind of stay along that path, and then you can go back and lose more weight? Or what happens after that? Oh, it does. Okay. Yeah, it does. Because, you know, when you think about the surgery, it's pretty traumatic. Because all of a sudden, let's say you're a person that's 250 pounds. You lose the first 80 pounds. That's, you know, for some people, that's a very... A small-bodied person. Almost a whole person. And so then you're going down. So let's say someone that's 250 pounds is looking to lose 125 pounds. That's a lot of weight. Your body's trying to readjust to everything. Yeah. And then isn't there surgery for some people after that, too, that they undergo cutting off the skin and excess tissue? This is the part that's very disappointing. It's very disappointing for a good number of people. The demographics for this kind of surgery tend to be lower socioeconomic. And so a lot of this is what we call... What they call fee-for-service. So the plastic surgery to tighten up the skin is often not covered by insurance unless it can be documented that it's causing a hindrance in a person's life. So the majority of people don't get it. So oftentimes with the older crowd, usually women, their biggest complaint is, I lost the weight, but I have all this hanging skin. Yeah. So what do you do with that afterwards if you cannot afford to have the plastic surgery? They just live with it? They live with it. If they're not careful, they can develop infections underneath. Oftentimes there is a high level of dissatisfaction with that surgery, with the bariatric surgery, if they can't go along with losing that skin. Men do respond to it. A little better because they tend to have less body fat. And so oftentimes people just have to live with it unless they can raise the funds to go get the surgery. Right. And then, yeah, that would make it an interesting new body to be living with. I would imagine it's a whole different paradigm shift. Yeah. I often use a phrase when I talk to some folks. I go, do you think you can swing it like a skinny person? And sometimes... Some folks understand what I mean is that they feel the confidence of a normal-sized person where they don't... Oftentimes they're people that have been heavyset for such a long time that even though they lost the weight, they still see a heavyset person in the mirror. How do you work with that? You know, oftentimes it's breaking down barriers. I often have patients say, you know, I was the fat one in the family or I was always the fattest kid. And so it's reframing. It's reframing their viewpoint of who they are, the kinds of people they want to be, who they've been wanting to be, and really helping them dig deep inside to realize that their weight is not their only identity. I've had people that regret losing the weight because they were getting so much attention with the weight. I had a woman that was getting a lot of attention from smaller-sized men, regular-sized, normal-weight sized men. And when she lost her weight, that all stopped. And it became... It became very disappointing for her. So then she... That's interesting. Yeah. It's a whole different perception from the outside world once you lose the weight. It's very complicated. Mm-hmm. Yeah. I would imagine. And sometimes, too, if you don't go deep enough with the therapy of the childhood abuse issues or they get to a certain point and they stop and then all of a sudden they go through the surgery, they lose the weight. And now they're starting to get the attention again that they were trying to get away from in the first place. Yeah. And it's very interesting. There's a high number of divorce after the surgery, a lot of extramarital affairs sometimes. And one of the questions I ask in my evaluation is, is there anyone that opposes you having the surgery? And oftentimes, there's spouses, partners that fear that if their spouse or partner loses the weight, they'll leave them. And it's not unheard of. It's actually a common... It's a common phenomena. So they're afraid initially that if my partner goes through the surgery and they change, then I need to change, too, somehow. Or, you know, often not even that. They're afraid that the comfort zone they've been in is going to shift. It's sort of like when somebody in a family stops drinking and has sobriety where the roles change. And so in a relationship where someone's heavyset, they may be the one that's kowtowing to the normal-sized person or, you know, doing what the normal-sized person wants or the normal-sized person likes having a heavyset person that they can control. So it all depends on the relationship. Oh, that sounds complicated. It's very complicated. And it's actually not like a one-show shot. I've done a lot of local radio. I've done a lot of radio on this. And it's just... There's always something new that comes up. So do you do couples counseling also or do you only counsel the patient? Oh, I do couples counseling. Oftentimes, many people come in with marriages that are really barely hanging in there. And it has nothing to do with being heavyset. It's just the general dissatisfaction of their marriage and life. It just happens to be that somebody in that relationship or even both of them... are heavyset. So they're eating instead of communicating. Mm-hmm. Or they're just very... This is a typical scenario where it's usually the wife that is working night shift and the spouse is taking care of the kids, the husband's taking care of the kids, and there's a complete lack of communication because everyone is just so tired. Yeah. They've given up. Is that... Is that... Is that the case? They're existing. You know, a lot of it is... It really comes down to a societal change where we have a lot of these night shift jobs. I often have a lot of my patients, they are working these night shifts at the local casinos, at the local hospital, all kinds of... At the... What you call AM, PM mark. And what happens is that people are trying to make it and they're trying to make a living. And for whatever reason, that has just taken over their lives. And they're just doing it to pay the bills and the kids and the spouses. And they themselves are being put on... Are being put on hold. Yeah. I... Yeah. I can attest to that one. I've... You know, when my son was little, my husband at the time and myself were doing that. He was working first shift. I could be at home with my son. And then I was working second shift. And yeah, it throws off the whole dynamic. Yeah. Yeah. Yeah. It's the whole dynamic of a household because you're trying to save the money and not take the kids to daycare because it gets expensive, especially if you have more than one child. So I would imagine that this is going to be a trend that's going to be continuing over the years. And it's not just about the money. It's also the idea that oftentimes the kids aren't really being watched. And then the kids often have issues with, you know, learning disorders, all kinds of stuff that comes up. Yeah. So it's one problem on top of another or just, you know, people are just... I often have a lot of parents, mothers that often are trying to spread themselves thin between the kids, their job, caretaking for their elderly parents. It's just a whole... It's just a whole way of living. Yeah. It's definitely super women's syndrome. You know, you have to do it all because who else is going to do it? It's very difficult. It's very difficult. So Dr. Yang, we're going to take a music break for a few minutes and we're going to come back, wrap it up and yeah, give us your insight on what to do about weight problems. Okay? Wonderful. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. What would you recommend for a person if they feel like they're starting to put on the weight? Well, first of all, the first thing I always remind people is that they really need to be aware of what they're eating. I work with a nutritionist, and we actually encourage people to start a food journal. Basically, everything you put into your mouth for a whole entire week, down to, you know, no cheating on writing this down, if it means that you had a frappuccino, you had the Trenta-sized frappuccino, you better write that down and start writing all the food down and counting the calories. And it's being honest with yourself, most definitely, and then being honest with you. It's like, again, you were talking about getting the conscientious part of the puzzle into this and saying, okay, this is exactly what I want. I'm eating. And I didn't even realize that I'm eating, you know, something that has this many calories. Do you recommend that they put down the calorie count also if they have that? If they have that, yes. It's really just being honest and transparent. I've had patients write. I specifically remember one person writing me an apology letter for lying to me about what she ate. Wow, that's honest. I think she was ready because she knew I saw through it. And oftentimes, as a therapist, it's not our job. It's not our job to make them feel bad about it. They know what they're telling you and what they're not telling you. And oftentimes, it's lying by omission. And this is often with the eating part. People say, no, I really didn't eat that much. And then you really go, well, how many times did you go back to that buffet? How many, you know, out of a bag of saltwater taffy, how many pieces did you really have? Right. And then all of a sudden, they, you know, go, wow. I didn't realize that. But this is what I'm doing. Do you also have them write down what emotional state that they're in while they're doing this eating? Absolutely. And one of my questions in my evaluation is, are you an emotional eater? And can you point out when you're triggered? And it's very, what's part of it is the CBT part is very big with morbidly obese people is because they're often, when people overeat, it's a trigger. There's a show called The 600-lb Life, and they often portray the folks that are morbidly obese, and they'll actually film them. I don't know, you know, how scripted it is, what they're eating when they're under distress. Yes, I have seen parts of that program, and it's fascinating. It's sad. It's really, it's painful. It is. It is. It is. So after you have your clients. Yes. Do the journal process. What's the next step? Making a decision as to where they want to start working on themselves. Oftentimes, you know, people come in with five to six different issues aside from being morbidly obese. And it's really deciding, are you ready for the challenge to take care of yourself first? And the average client coming in has neglected him or herself. And the average client coming in has neglected him or herself for the longest time due to being overly conscientious with different things or just totally being mindless with themselves. And that's what happens is, are you ready for this challenge to focus on yourself? What have you not been doing for yourself aside from rewarding yourself with food? And oftentimes, it's the only thing they feel they can reward themselves with. And that's just, that's what we call safe reward. So what do you have them opt out? What do you have them opt out with for a reward? Opt out with things they've always wanted to do. Hobbies or maybe a new challenge in their life. I often have people say that, you know, for the first time, they want to be able to get on an airplane seat without any embarrassment. To be able to run with their kids. To go to Disneyland without feeling embarrassed they're going to get stuck in a ride. Not having to go to a plus-size clothing store. So these are personal challenges to them. They're often. I never tell them what it is that they need to achieve. They actually already know what they want. Or for some people to have the, what you call, the enough of courage to go and date again. Or to find a new job because they're unhappy with what they're doing right now in their life. That sounds like a definite multi-step process then. Yes, long and complicated. And then what percentage of clients that you work with stick with this program? I would have to say the initial consult. So if I had 100 people come in, in terms of sticking with it and really being vigilant, I would say about 70%. And in that 70%, it's not a great day every day. There are days where they will call me or email me or text me and say they think they're going to fall apart. Or their boss just said something to them. Or they just got hit with something. Their child did something. Or their husband did something. Or their wife did something. And they think they're going to, they need to go grab a donut or something. And my reminder is you work so hard. Is there something else you can look toward to, you know, vent the stress? So it's teaching them self-empowerment techniques. Having them come up with a substitution list. Absolutely. Absolutely. Absolutely. Absolutely. Absolutely. Absolutely. Absolutely. Because it's about them. It's not about anybody else but themselves. It's about what they feel they need and what they want and how they're going to best negotiate it. Because I'm not living in their body. And they've lived in their bodies longer than anybody else, of course. Yeah. They're with themselves 24-7. What about the exercise component of weight loss? It depends. One of the things I always remind these folks is don't expect to be doing marathons. Or, you know, doing triathlons of any sort. The expectation is they have 30 minutes of some kind of cardio exercise every single day. And for many of these folks, they are not, they never like PES kids. They were the kids that were the last to be picked for the softball team or what have you. So the big thing is always encouraging them to find something they enjoy. And oftentimes they'll be like walking Zumba, walking their dog, swimming. Whatever it is that they enjoy as long as it's 30 minutes of a little sweating and a little cardio. And what with the clients that are morbidly obese that are having problems just even walking? What would you recommend? It all depends on the person. You know, some folks already have had knee replacement surgeries. They've had bone spurs in there. It's not just they're being morbidly obese. Most people come in with at least a minimum 5 to 10 comorbidities. Either backache, knee replacements, diabetes, high blood pressure, you name it. Joint issues, arthritis. So it all depends on the person. One size doesn't fit all. Yeah. And that's another complex issue too. If walking is even difficult and they're short of breath. If they're walking like a block or two and it takes them a long time. And, you know, I've known some overweight people. I could just. I've seen them. I've seen them. I've seen them. I've seen them. And their face, it's just almost excruciating to go from point A to point B. Well, you know, once they lose the weight, they become more encouraged. And as I always remind them, you know, three weeks out of the surgery, don't expect more than. If you can only do 10 minutes of exercise, then that's 10 minutes more than you did before. And build it up. And a lot of it is just encouragement of sticking to it. There have been people that, you know, previously they were not even able. They walked from one end of their office building to another. They're running 5Ks, 10Ks. There was someone that ran a marathon. So it's all about just sticking with it and sticking to a dream and a goal that they've set for themselves. For some people, they are just finally able to just walk their whole entire neighborhood. And or run after their little kids and not be completely out of breath right away. Yeah. And what an incredible transformation to be able to do that. I mean, it expands your social horizons. It opens so much to be able to do what you couldn't do previously. It just opens up so many doors. I that would be an astounding process to go through. It is. And people become different afterwards if they really, really decide to make a fundamental change. The hardest thing to see people that have lost the weight, but they still feel the same in terms of their own self-esteem or motivation. And those are the people that oftentimes gain the weight back within themselves. Yeah. Yeah. Yeah. Yeah. I mean, I feel that's part of the challenge to maintain that self-esteem. Yeah, so they have to kind of keep outside motivators around them. Is that correct? Yes. One of the important questions I ask is their social support. If they are living in a family where everybody else is eating hamburgers and hot dogs and, you know, eating Haagen-Dazs and they're no longer allowed to, it may not be as easy. So oftentimes we have to have the family buy-in and we have to have everyone on board. I often get a lot of mothers that say, all my kids are obese, so I want to learn how not to turn my kids into obese adults. And so it's a whole family project. Yeah, that's wonderful that a parent can stop that process and go, okay, I want to be a good role model for my children. I don't want them to be obese also. And then watch them suffer through obesity. All of the different health sequelae because of the weight. Yeah, not just the health, but the social isolation, the bullying. That's another one of my questions I often ask is, you know, have you experienced negativity due to your weight? And, you know, I would have to say 79% of the people that come in say yes, they've either been passed up for a promotion or they've lost social opportunities. Or, you know, when they go places, people make nasty comments about their weight. Or total strangers will call them nasty names without them, you know, unprovoked. Or their coworkers will give them more work to do or just treat them less than competent. Yeah, that's so difficult to have to put up with all of the social consequences of having too much weight. It's really, really crazy. What tips would you recommend to just the general public on either shaving down the weight or keeping off the weight? Because, I mean, obviously as you start getting older, it's a little more difficult to keep those pounds off just because of the hormone changes and everything else. Well, definitely regular exercise, drink a lot of water, really look at your calorie count. And your protein and your protein and carb intake. Just be, one of the things that I try to be vigilant about is trying to keep under 1600 calories a day. And also at least half an hour of some kind of walking exercise every day. And the other thing is just staying away from processed foods, sodas, anything with high caloric content that can't be burned off. And just cutting down on all the extraneous eating. The one thing I always remind people is try not to eat after 7 o'clock. Late night eating is not good. Eat three meals a day. Breakfast is very important. They say, as they say, you should eat your largest meal in the morning and your lightest meal at dinner. And what if you are not a morning eater? I know I'm not a morning eater. My whole thing is like I have a cup of coffee in the morning and maybe something. I kind of hold a coffee because my stomach isn't quite ready to process food yet. So I probably eat either a kind of a light later breakfast or early lunch at about between 10 and 11 o'clock. So what do you do if you can't really hold a lot of food first thing in the morning? What do you do? Maybe like a yogurt. Usually, you know, the nutritionist I work with, she gave me such great advice. Just work. Working with the patients. We're very integrative in our work. And it's like a yogurt. Coffee actually has been found to actually help lose weight. Just if anything, as we get older, we need to retrain our bodies to eat correctly. And if you're going to have that mid-morning breakfast, you better eat that dinner a little earlier so it doesn't become a late night dinner where you're sleeping on those calories. And also the other thing, if you can, to sleep regularly. Because sleeping is very, very important. When people have these night shift jobs, their circadian cycle is completely messed up and your body is not able to burn your calories off correctly. Yeah, it does throw your whole system off. Absolutely. It's very biological, funny enough, and people often dismiss it. But there's a lot of connection to it. Lowering your stress is a big one. You know, stress really can add on the pounds. Yeah, that's when you become unconscious of what you're eating. Absolutely. Because it just, you know, it feels good, it tastes good. You just want to... It's an adrenaline rush. Yeah, it is. Yeah, and you just want to keep feeding that reward system in your brain and your stomach. And I think also, too, something that helps is learning to... The signals from your stomach to your brain, your stomach says, okay, that's enough. Mm-hmm. And just stopping at that. That's a good point. Absolutely. And also portion control, portion control, portion control. Yes. You know, most of these restaurants, they probably have once, you know, when they serve you, there's about like three servings there when a person only needs one serving. And that's part of the American culture is people overeat because we want to get our money's worth with our food. And, you know, we're also the culture that came up with all-you-can-eat buffets. So really just make sure what you're putting... Just think about what you're putting into your mouth because it does reflect on your body. And at the end of the day, you have only one life to live in your body, and it should be a good one. Yes. That's great advice. Definitely. And then also, too, when you go out to eat, if there's those bigger portions, make sure that, okay, I'm going to eat half of this and then ask for a box. Or maybe ask for a box at the beginning of the meal so you get yourself trained into, okay, I'm only going to eat part of this. And I'm only going to eat when my body says that's enough. Right. You know, the thing that I've noticed a big trend with is the share plates and the small plates. Because oftentimes if you share some plates and appetizers enough for dinner or just, you know, one of the things is if you are a bariatric patient, you can ask for a child's menu. They'll give you a card, and it's legal, actually. Yeah, that's great. Those are nice portions to have. Yeah. Sometimes it's just enough. Honestly, you think about it, McDonald's didn't have supersized when we were growing up. I'm 46 years old. I remember it was just... The regular, the kid's meal was a full adult meal. Yes. Yeah, and then the soda sizes are... The small is actually what used to be a large. I know. Isn't that crazy? Yeah, it is. Oh, my God. That's scary. That's scary. So, Dr. Yang, if anybody would like to contact you, how can they do so? You can call me at 760-861-7299 or check me out on my website, www.kimberlykimberey.com. Thank you. Bye. Bye. Bye. Bye. Bye. Bye. Bye. Bye. Bye. Bye. Bye. Bye. Bye. Bye. Bye. Bye. Bye. Bye. Bye. much great great information this evening dr game thank you so much thank you julianne take care and thank you so much for tuning in to psych one-on-one if you would like to listen to this broadcast again we are on itunes and this show will be archived within 24 to 48 hours at itunes podcast under psych one-on-one and also at skidrowstudios.com i would like to thank my board op this evening scott reyes thank you he did a great job thank you to jeremy hansen our executive executive producer please stay tuned for the coomron report right on after we get done and this has been julianne good for psych one-on-one take care of yourself take care of each other bye now you Thank you.