Doing the Head Work of Bariatric Surgery: A Deep Dive with Expert Lora Grabow, LMSW

Music. Welcome to the Former Fat Friend Podcast. I'm Kasey. I'm Lisa.

I'm Allie. And together, we've lost over 370 pounds. We all know what it's like to be the fat friend. And now we are sharing the ins and outs of our weight loss journeys. Welcome back. You've got Kasey and Lisa here today. And today we have a very, very special guest. I am particularly excited about this guest because I never shut up about what this guest is an expert in. And I am so excited.

Just to give a little introduction, she is a bariatric therapist, coach, and professional speaker with over 20 years of experience working with bariatric patients. She helps patients discover the missing piece of bariatric treatment and the piece she calls head work. Her expertise includes providing individual therapy and one-on-one coaching, facilitating bariatric support groups, and engaging patients in her online course, Foundations in Head Work for Healthy Weight Loss.

She's an active leader in the American Society for Metabolic and Bariatric Surgery. And she is a sought-out podcast guest and speaker at National Provider and Patient Bariatric Conferences. And tonight, we are so lucky to have her on our podcast. It is Laura Grabo. Hi, Laura. Hi, Laura. Welcome. Thank you so much for having me. You know what's so funny? I'm so happy to be here. I always try to like, I think I'm like keeping some secret.

Like I try to be mysterious about who it is in the bio and not reveal you until the end. And then I always realize like, well, they're going to see in the title. It's going to say.

Secrets out. I always forget that. It's always weird for me to hear my bio read too, but thank you. It's very impressive. And we are really honored to have you on the podcast today. You were on like top of our list of guests that we wanted. And so we were so glad we could make this work. And we just appreciate you taking the time to be here. I'm really excited.

Yeah, I'm really excited. This is a conversation that I think Casey and I have had a fair amount of like, This thought of like, oh, bariatric surgery is the hardest thing I've ever done versus people saying it's the easy way out. And I'm like, well, it is the hardest thing I've ever done, but not physically, mentally. I'm like, the mental stuff is what has gotten me. And yeah, that is like the key piece for me and my journey.

And as a journey, I wish I had started sooner. So I am like, I'm geeking out. I'm excited. Great. I'm excited too. Laura, I think one thing I think is so interesting is in the bariatric community on social media, there is this term head work that we hear a lot. And I suspect that you are responsible for that word being used so frequently. Can you define for us what you mean by head work? Yes. And yeah, I use it so much that I finally decided to trademark it.

So that's, that's exciting. I feel like it's getting around. I, you know, it's exactly what, you know, Lisa just said, right? Like, bariatric surgery is definitely not the easy way out. And the hardest part is the mental piece. And what I say to patients and have been saying to patients for years is all of you have picked the best tool, hands down, to treat your disease of obesity, which answers the how question. How can I treat my disease of obesity from a surgical perspective?

What's the best thing we have in obesity medicine right now? Hands down, bariatric surgery. But there's a more important question, or equally important or more. I'd love to hear what you two think as patients. You also have to answer why you eat. Why do I eat? And that's where head work comes in, where we start talking about the mental aspects of bariatric surgery and the work that you need to do in your head.

And where I got, in a way, I listened to my patients through the years always say, you know what, I had surgery on my stomach, not my head. I had surgery on my stomach, not my head. And what I've learned in the 21 years I've been doing this is it's still the missing piece of the bariatric treatment plan. I would hope someday I could take missing out of my tagline, if you will, but patients are getting a lot of information, of course, on their surgical tool.

They're getting a lot of information on movement and nutrition, but who's teaching them things like, Like, how do I exit my emotional eating roller coaster? How do I build and use a support team? Wait, what's this thing called bariatric grief? And why am I grieving on this journey? And, oh, let's not even talk about all the thoughts that are still in my head. Like, man, surgery may have changed my stomach, but it didn't do anything to take out my habits.

Right? And so that's my passion. That's head work is to help you jump into why you eat and address some of those areas. Yeah, I think that's so important. And it's so important for long term success.

I want to take a step back, though. And I want to understand a little bit about your background. And how did you come to specialize in bariatric therapy? Yeah, right. Never thought that's what I'd be doing. So I graduated grad school. Oh, it's been a long time now. 1997. You guys probably weren't even born. Yes, we were. Okay. All right. All right. And I always wanted to work in adolescent psych, adolescent girls, adolescent psych. That was my jam. I was going to do therapy.

First job out of grad school with teen moms who were homeless. Absolutely loved it. Then I moved into locked residential psych settings, working with a lot of girls with trauma and was certified in trauma therapy as well.

And then I had my own kids and I knew I wanted to work less but more importantly I realized I can't do this trauma work anymore I can't it's intense and as I was lasting my hours I had a new baby at home I had a colleague call me and say hey Laura we're looking for someone to do group in medical and surgical weight loss it was here in Grand Rapids Michigan and I said oh that's great I love groups, but I don't know anything about medical and surgical weight loss.

And he's like, I know, but you know how to do groups. So why don't you check it out? And I know you're looking for evening hours and less hours. So we'd love to have you. So come check it out. So I interviewed, and guys, this was in 2003, right? So they had a medical weight loss program. Surgeries had just gone from open to laparoscopic, right? The sleeve was not even being done. Everything was a ruin Y. And... Here I am popping in with my adolescent psych experience to do groups.

And I love to do interactive groups. And I had to do one for my interview, got hired, and I never looked back. Why? Because I got to work with adults who wanted to be there. That is quite a different population. Than working with my adolescent girls and, you know, long-term treatment. I was like, wanted to be there and they were so engaged. And no, I just fell in love with it. I fell in love with understanding obesity as a disease and not a decision.

I just have a passion for helping people with chronic illness and giving them tools to have success. And obesity is like that. And I never looked back. So that's how I got started.

That's fantastic. So were you, at the time, were you working with pre-surgery patients or were they all post-surgery? Both. Okay. So I did the pre-op PsycheVale, did a lot of those, and then also did support groups for surgery patients. And then what I loved is we did behavioral education groups. It was a very integrative center. Like I thought every patient had that. Like there was four of me on staff. We were called behaviorists. There's four of us. Wow.

That's unheard of. Most surgical centers don't even have one. Yeah, especially. Outsourced. Yeah. And we had a really large medical program, too. This was even before GLP-1s. We had a medical weight loss program. And back to my job, right? The patient gets to pick the tool. How am I going to treat the disease of obesity? Mm-hmm. My job's the same with why you eat. And so we would combine surgical and medical weight loss patients in these behavioral edification classes.

And I did a lot of that. And that's where I really got my love for doing the postdoc work with patients. It's interesting, you know, you talk about it being this missing piece. And I totally agree with you. I think, you know, one of my big frustrations with bariatric surgery is when people say like, oh, you know, my aunt's brother's cousin had that surgery and they gained all the weight back. And my response every single time is, did they go to therapy?

Like they didn't do the head work. Like they just, I firmly believe it. I'm like, if you, I mean, of course, regain is real and we experienced it and there ebbs and flows of life. I don't, I'm not here. I'm not speaking to that at all, but I'm like, you have to, you have to do both. And I was very lucky because my surgeon would not do my surgery until she knew who my therapist was and knew when my first appointment was.

She gave me here some I work with. You don't have to pick one, but I need to know that you're in therapy and I need to know that you're doing this. And that's not the norm. That is not what the majority of surgery centers are out there doing. That's not a requirement. And I am so grateful for that.

And I wish I had started that journey sooner because I think the biggest when we talk about what regrets do you have or your biggest hurdle, for me, it was I realized I didn't have a trusting relationship with my own self, with my own body, with my own mind. And I wish I had started working on healing that relationship sooner because it's been so you have there has to be trust. Anyway, I say all that to say, I'm curious in your experience when like for someone who's.

Considering bariatric surgery, when do you think that process should start in terms of the emotional, the mental side of it, and how important is that, you know, in that journey? So, of course, I'm going to say pre-surgery. I believe in what I do. I think everyone should be in therapy. I'm not a bariatric patient, but I've been in and out of therapy. Every good therapist should be in therapy, and I practice what I preach. What I've learned is the, And kudos to your surgeon, Lisa.

We kind of had the same model where I worked here in Grand Rapids, Michigan before I went into private practice. I was at that surgical center 18 years. And then in 2021, I stepped out into private practice because I wanted to do things like this. I wanted to reach more people outside of Grand Rapids, Michigan with head work. And we would assess our patients. And I always said we had like a green, yellow, red light, kind of like, yep, green, we don't see any issues.

Yellow is like, you know what, I really think you could benefit from some counseling. And we did exactly what your surgical center did, Lisa. We gave them a list and surgery did not get scheduled until we had confirmation that they had started therapy. And then red, which was very rare, was like, whoa, we need to put your surgery on hold until you're connected with a therapist and they say you're psychologically ready to have surgery. Now, that's an ideal world.

And I would love to hear, Casey and Lisa, what you think of this. What I found in my experience is, you know, something what you just said, Lisa, it's like, I didn't trust myself. I didn't know how to have a relationship with my body. Or I'll hear from patients, like, I didn't know I was an emotional eater or how much I was an emotional eater until after bariatric surgery. And so even though I'd love for patients to get into therapy before, how do they know what they don't know?

I can tell them that they have had work to do. I could tell them that they have mental health work to do. But until they experience it, until after surgery, they're like, oh my gosh, what did I do? Like, this is so much more than just changing my anatomy. Then our patients are open to say, oh yeah, I probably need to do some work with my head because I had surgery on my stomach, not my head.

And so it's usually after, right, that patients start therapy. And it's often they wait till they are struggling. And I would love for them to start sooner. So they have tools to prevent that struggle with weight recurrence, but are also at least limited. Like, let's catch it in the beginning and you can have all your resources there. Yeah. Well, I think after surgery, it's very confronting. So there's a lot of things that you can convince yourself, like, I'm fine.

I'm, you know, I'm just going about my life. I'm not an emotional eater. I'm not a binge eater.

I'm, you know, I'm doing fine. And then you have surgery and you're forced to confront like you cannot eat food you can't eat you're on liquids right and that's hard for anybody but when you physically can't do those things anymore it is really confronting of like oh man okay maybe I have some issues that I should have probably worked through beforehand and I think that's that is definitely a challenging place to be and I say that

as a person who did not do therapy before surgery and also haven't done it really after so So I I'm probably not the poster child for that. But I do think it makes sense why having that before surgery would be so much more beneficial just in terms of kind of setting yourself up for success. But you know what? I do think I think you're right, Laura. I was in therapy already just because I think therapy is helpful. Yeah.

And it didn't matter. It didn't matter that I was already in therapy. Number one, I wasn't working with a therapist who specialized in bariatrics. And I thought that would be fine. And then I had, I think I was like eight days post-op, 10 days, something like that. And I was like, oh my God, I need a bariatric therapist. I don't care how much it costs. I don't care. I'm literally, because my surgeon, the one she had recommended to me,

didn't take insurance and was very expensive. And I was like, I just can't afford that. And then I ultimately was like, I don't care. I am literally, I don't know what I've just done. I don't know what's happening to my head. So even if you start it sooner, it doesn't necessarily, like you said, I didn't know what I didn't know.

I hadn't experienced those things yet. And I think something, too, that I believe is that even if you don't, like Casey, you said, when you're newly post-op, you're forced to not do those habits. But they don't go away. In my mind, they just get suppressed. So your restriction might stop you from those habits for a certain period of time.

But if you don't deal with the underlying reasons of why you do the things you do, that three, four years down the line, when your restriction is not what it used to be, you may see those things rearing their head again.

And Laura, I'd love for you to talk about some of the things that do come up for bariatric patients in terms of like body dysmorphia and the brain, you know, catching up to how fast things are happening and the potential for, I know for me, like I didn't have, I developed a new eating disorder. I started I started throwing out my food, which is something I had never done before in my life. And it it became a problem because it became a pattern and it became a punishment

of like, oh, you this is uncomfortable. You ate too much. You ate too fast. You're too full. And it became like you did a bad thing and now you have to throw it up. And I had to like that was a thing that I never expected. And I just would love for you to talk about that a little bit, about those other things that can come up that, you know... Are perfect examples of where if someone like you comes into play.

So certainly you mentioned some of the body image issues and you mentioned eating disorders. I'll get to those in a minute. I want to talk about more of like the general head work that I think all bariatric surgery patients struggle with because not all of our patients will struggle with eating disorders or body dysmorphic disorder. That was me being selfish. So I'm going to get to that. I'm going to get to that and bring me back if I forget.

Okay. I think the number one issue I probably talk about the most with bariatric patients from a head work perspective is emotional eating. And what you said, Lisa, exactly, like you have to get to the why. And I often say this when I was trained to be a therapist, therapy 101 is you do not remove a client's unhealthy coping skill. One, until they realize it's unhealthy. I may think it's unhealthy, but they have to come to that realization that, oh, this isn't really working for me anymore.

Two, and you spend time talking about, well, what else would you like to try? And you have the client come up with things. What are some alternatives? You provide some education. And then the client gets to go practice it. And then you come back and you talk about it. How did it go? What went well? You know, do you want to try another? Okay. It's a whole thing. That doesn't happen with bariatric surgery, right? You have bariatric surgery and that coping skill is severed.

Yeah. If you were using food to cope, it is gone when they changed your anatomy. And there's, you know, there's a reason for that. Obesity is a serious disease and there's comorbidities that need to be treated with the surgical tool. But again, I don't think our patients are getting educated about this. And that first week, that second week, they're on liquids, and they are feeling these big feelings, and they can't turn to food, right?

So, so much of my work is helping our patients, first of all, name their feelings. Before surgery, it was always just, I'm hungry. And then now they're realizing that first year, well, I'm not physically hungry. I can't be. So, this must be head hunger. It must be emotional hunger. And then we work on, well, what are you really hungering after? Right? Are you hungering after you just want to decompress and unwind after a long day?

Hey, that's a healthy need. But we need to figure out how to do it without food. Right? So, that's a big piece of the head work that I do with every patient is, and we call it affect regulation, in terms of being able to name your feeling and then regulate it and get through those waves of emotion without food. Another big head work piece I mentioned is the thinking, right? So, surgery changed your stomach, not your thoughts.

So, you are still going to have thoughts like just one won't hurt. I'll start tomorrow. If nobody sees me eat it, it doesn't count. I deserve this. It's not fair. You know, those thoughts don't go away. And a lot of my work is using what I call CBT, cognitive behavioral therapy strategies, to help our patients, what I call the three C's of CBT, catch it, check it, change it. Catch that thought, check it. Is it a helpful thought? And then change it.

And again, you know, are these things in your surgical binders? No.

But they're things you have to deal with. And then I'd have to think, you know, if there's this top three of the head work, and then I'm going to get to the eating disorders and body dysmorphia, is setting boundaries. Interesting. Right? And so, obviously, you're learning how to set boundaries with food. But what I have learned from my patients, and Lisa and Casey, you can tell me if you relate to this, is they are yes people. They are everything to everyone.

They're like, I'll do it. call Lisa. You can count on her. Casey will say yes. And they want to make everybody happy. And they're yes, yes, yes. And there are no muscles are paralyzed. Okay. And actually, I have an online course. And one of the sessions is called, Could Your Yes Be Sabotaging Your Weight Loss? And it's helping our patients, our bariatric patients, realize you are essential.

When you made the decision to have bariatric surgery, that was the first, maybe one of the first times that you said, I matter, and I'm going to do this for me, but you have to continue to do it for you. And then tied with that is, well, why? Why are people yes people? And are they basing their self-esteem and worth on making other people happy? And, you know, that's a lot of my job as well.

And with that, oh my goodness, this could be a whole nother episode, but breaking free from perfectionism right so that's an issue that i think is across the board laura i feel so attacked right now i i feel so attacked this is uh i hope you feel seen yeah you're right that's the that's the better reframe i feel so seen so i i literally my therapist just yesterday was telling me that that i'm dealing with some stuff and she's like it's your perfectionism It's your perfectionism.

It's the underlying perfectionism that's there. Yeah, I can't speak for Casey, but yeah, absolutely. Always say yes. Always want to make other people happy. And I think something I learned... Was that as a chronically obese person, I felt like I had to do more to be valued and accepted. I had to be twice as funny, twice as friendly, twice as whatever, because just looking at me, you wouldn't want to be friends with me because I was fat.

So how can I win people over? And I think that that's how a lot of us become those yes people is because we're just trying to feel accepted and fit in. Yeah, absolutely. I think for me, I didn't realize until I had surgery how much I wasn't putting myself first. And in that kind of, especially that first year after surgery, it was all about me. Like I had to focus on myself and I had to put myself first and it was all about my health and my nutrition and fitness.

And that was the number one goal. And that changed a lot of dynamics in my life with relationships in ways that were surprising to me. Because if you had asked me before, if I was a yes person or a people pleaser, I don't think I would have said that. But it wasn't until I did say like, I matter.

And right now in my life, in this season of my life, I matter more than anything else, that I realized how much I was, you know, kind of minimizing myself before and going with everyone else's, you know, wants and needs and desires and making them happy even at the expense of myself. Yeah. And there's another reason why you need some good therapy is that you start valuing yourself, you start setting healthy boundaries and making yourself first and taking care of yourself.

And we say kids act out, adults act out. People will start acting out in your life. And the people who don't like your boundaries the most are the ones that benefited from you having them. I'm going to say that again, right? People who do not like your boundaries, don't want to respect your boundaries, are the ones that benefited from you not having any. And so I will always tell my patients, you know you're doing it right if you're receiving a guilt trip.

So it's back to how Lisa started this podcast. The hard work is the mental work. It's hard to set boundaries. It's hard to see people not respect your boundaries. It's another thing I work on with patients is, you know, relationships change after bariatric surgery. And my patients tell me, you know, people I thought were going to be my biggest supporters were not. But then I was really surprised of the people who did show up and were on my team. But that's hard.

I promised I'd get back to other issues with our patients. Lisa, you mentioned that you struggled with an eating disorder after post-surgery. I don't know if you felt like you struggled with an eating disorder pre-surgery, but many of our patients struggle with an eating disorder called binge eating disorder and bariatric surgery before surgery.

And binge, and it's not, and we don't say no, that you can't have bariatric surgery if you have binge eating disorder. We certainly, that would be one of those yellow lights, right? We want you in therapy, working on things. And it has to be somewhat controlled, right? If it's severe and not controlled, we're not going to approve you for bariatric surgery. I have to get that out there. But all my colleagues who do the pre-op are going to be like, Laura, what are you talking about?

And that's for patient safety and success, I would imagine. Absolutely. Absolutely. Bariatric surgery does not cure binge eating disorder. It just looks different after surgery. And so what we call it in the bariatric world is we call it loss of control eating. So you can't get the volume in that you got in before surgery, but you certainly have a lot of the other dynamics of this loss of control eating, food controlling you instead of you controlling it, eating in secret, a lot of shame.

And then sometimes as Lisa said, you know, maybe some purging. I mean, so that is part of our patient population, and therapy is a good thing for that. I have had, again, I've seen a lot of patients in the 20 years I've been in this work, and I've had a few, not many, a few, I wouldn't say it's the norm, develop atypical anorexia post-bariatric surgery. That's not my specialty, so I immediately refer out.

But again what is so interesting about eating disorders is they're not about food they're about control right eating disorders aren't about food they're about control and this is where, my work with the teenage girls came in is I did work with girls who had anorexia back right out of grad school and they would that's where I learned that it had nothing to do with food they would say to me, do you know how much power I feel? Like no one can make me eat.

It's the one thing I have control over in my life. Like nobody can make me eat and that feels good. And I also can count on my eating disorder. My eating disorder is my friend. It's always there for me. Deep stuff, right? Yeah. So then I come start working with people, adults with a disease of obesity. And I start seeing some of the same dynamics, but flipped.

There's so much out of control in my life but at least at the end of the night I got me and my chips I got me and my ice cream like I can count on that like I know what that's going to give me it's always there for me I can count on it food's my friend and then Laura will say they'll say but Laura you just said it was about control like I'm out of control with my eating and I'm like yeah but you get to be out of control so no one can this is my teenage

girl so no one can make me eat no one can make you stop eating. So a big part of the eating disorder treatment is where are some healthy ways I can take control. And what we also know, especially with binge eating disorders, there's that affect regulation piece. You have to, a big part of people who struggle with binge eating disorders, they don't know how to feel their feelings, but they do know how to feel physical pain. Like you need a release and how do you get physical pain?

You overeat, especially post-surgery, Lisa, like you said. You know, it's complicated. You mentioned dysmorphia. I will say, and I've heard other therapists in the bariatric field talk on this, I do think the term body dysmorphia gets overused in the bariatric population. I would encourage all your listeners to Google body dysmorphic disorder, BDD, body dysmorphic disorder.

It is a severe mental health disorder, meaning you're completely obsessed with a flaw in your body that you perceive that's either real or imaginary, usually much more severe in your head than what we see. And to be a clinical disorder, body dysmorphic disorder, it has to be affecting other areas of your life. It's affecting your relationships. It's affecting your job. It could be affecting your sleep. There's usually some co-mental health disorders with it, depression, anxiety.

There are people, but again, in my 20 years, it's only been a handful of body dysmorphic disorder. I mean, I have some patients, they weren't leaving the house because of their perceived flaws. Now, we do have bariatric patients who struggle with what I call phantom fat or what we call phantom fat. I feel so validated. I think I've talked about this on this podcast where I had skin removal surgery and I still have like, it's like my phantom limb.

I swear I'll like go to like grab the roll of my stomach. Like just instinctively, I like feel that it's there and it's not, it's the most bizarre thing. So have you heard the term phantom fat? No, I had never heard that before. Well, you're describing it perfectly. And, um, you know, you're exactly right. And when I first start again, back in 2003, this is what I hear from my patients. And I've heard every year since.

Why can't my mind catch up? Like, I know that I've lost weight, but I just don't see myself that way. And that's where I think it's just a lack of education. It's like, oh, I have body dysmorphic disorder, where it's more, you're struggling with body image distortion or phantom fat. And I would hear that over and over and over again. And I'm like, this has to be a thing.

Like exactly what you said, Casey, like, like I had patients like turn sideways because they didn't think they would fit through certain areas. Or I had one who had a panic attack in the airport because she didn't think she would fit through the turnstile. But she could, right? It's again, experiencing yourself much bigger than you really are, this distortion.

And I went to a conference and I heard a speaker. I wish I could remember his name because I talk about it all the time. He introduced the concept of phantom fat. I'm like, That's it. Yeah. That's what my patients struggle with. Do you think that that does does that just take time to kind of get used to living in a different size body and kind of understanding what you look like now? Mm hmm.

So absolutely, I'm so glad you asked that. I was going to give a couple of reasons of why you experience it, and then we could talk a little bit about what you do. Like, I'm having phantom fat. What do I do? So the first one is the rapid weight loss, right? So we know those having bariatric surgery lose weight fast. And we do know that it honestly does take time for your brain to catch up with your body.

The second reason we know our patients struggle with phantom fat is what I call unrealistic expectations, which goes with what do I do as a now? So we're going to have realistic expectations. But patients had an idea in their head what they were going to look like when they lost 100 pounds. Or I'm going to look like this in a little black dress when I lose 100 pounds. Or I'm going to look like this in my bathing suit when I lose 100 pounds or 50 pounds.

You put in your number. And then what happens? You don't look like that. Because there's things like hanging skin, right? And it's not normal for us to go back to our high school bodies, you know, if we're 55 years old. So, you know, it's just, there's these unrealistic expectations. Totally. And then I found this one really interesting that, and I believe it's subconscious, but as I say it now, you might be like, oh yeah, that's me, or I was there.

Patients don't believe the success is going to last. And that is real because they've had so much experience with losing weight, gaining it back, losing weight, gaining it back. So one of the reasons for phantom fat is they're waiting for the other shoe to drop. I don't want to embrace this smaller body. And again, it's not like you're just sitting around talking about this at the lunchroom table, like a therapy and you're interviewing a therapist right now.

I don't want to embrace this new body image or what I really look like because I don't really think it's going to last. And so what do you do? So Casey, absolutely time, time, time, time, time.

Two pictures I know you hated getting your pictures taken um before uh bariatric surgery please start taking them afterwards yeah um do your inches right so you have data so you have facts um I know a lot of us you know gone are the days we're trying on things in dressing rooms right but you know maybe now it's we order a bazillion sizes online um and it's frustrating because okay I tried I thought that one was gonna fit but it was too big and now I gotta do this one know, that one's too big.

And that's actually helping you with the phantom fat. It's helping you cement, okay, here's what I think I look like, but here's the reality. And then obviously getting into some therapy to talk about some of those issues of what are realistic expectations. I know that I've worked in obesity medicine for 21 years because I want your life to be longer. I want you to prevent 13 types of cancer. I want you to decrease your risk of cardiovascular disease.

I want you to be able to have mobility and to be active with your family. And let's start celebrating that part of bariatric surgery and having realistic expectations. Like, yes, your scale goes down.

And yes, you may look different in your clothes. But our body image needs to be so much more than how we look in our skin. Yeah, absolutely. I think I've been learning this a lot over the last couple of years because I lost 100 pounds, and then I had skin removal surgery. And while I feel like I look great, I think I've had to come to the realization that my body is never going to look like a person who didn't lose 100 pounds.

Like, it's just not. I'm either going to have skin. I'm going to have scars. It's never going to be the same. And I think it's interesting what you said about photos really helping because I think I kind of went through this process where I started at first it was like you can't you can't see it at all. Right. You lose a lot of weight and you just don't even like notice it in the mirror. And then I started to as I was buying clothes, I noticed I could gauge what

size I was going to wear in the store. Right. But my brain didn't quite compute. Like I remember picking up like a size four pants and being like, I think these are going to fit just looking at them, looking at the pants. But like my brain couldn't comprehend that. I was like, I don't look like I wear a size four. Like I can see these physical objects. I know this is going to fit on my body, but I don't actually look like that. You know what, you know what I did recently?

I think it was something similar where something smaller for me, I think it was a size small. And I was like, okay, well this fits, but I know that I'm not a size small. So what are the real size smalls wearing? Like that was a real thought in my head. I was like, what are they wearing? They're making everything so oversized these days. If I can fit into this, what are the tiny people wearing?

Oh, I had, yeah, I've thought that too. Or like I've been in a dressing room and had to ask for a smaller size. And I feel like I need to like almost tell the sales associate like, oh, I know I don't look like a size two, but like this one just must run big or something. Like I need to qualify the statement or something.

But what I was gonna say about the photos is so I obviously share a lot on social media and I think in some ways that has helped me so much because I'm like constantly seeing and taking photos of myself so I've just had to get used to seeing myself all the time and I actually think that's been incredibly beneficial to like like helping with my body image in a way the photos are so helpful you're that's been one of my biggest,

I remember putting on an outfit that I had taken a picture of like a before picture and not feeling like it looked any different and feeling so frustrated and so discouraged. And like, I've lost all this weight. I did all this. Why doesn't this look any different? And then I remembered that I had taken that picture. So I took another one and I put them side by side and there was a pretty darn big difference between the two pictures. I just couldn't see it in the mirror.

So I completely agree with you. Like take everyone, and take all of the pictures, even when you don't think you want to take the ugly ones, take the naked ones, take that like you one day you will want them. And you'll be glad you have them because that's I think one of the biggest anytime I'm struggling and having negative self talk or negative thoughts, I do a side by side. And I'm like, let's, let's check the facts here. Let's like pull some data and see what we're really working with.

Bingo, facts and data, because body image is subjective and ever-changing, and it's not based on fact, right? So pictures and sizes are facts and data. And this body image distortion is also, it's just not unique to post-op patients. My patients will tell me they struggled with body image distortion pre-surgery and that they didn't see themselves as big as they were. Yes, yes, yes, 100%. There's not that study all the time now. Yeah. And then oftentimes it was a picture. Yeah.

Right. And so it's a struggle pre-op and then it flips to a different way post-op. But again, it's something we can work on. But again, it's not what you're getting in your surgical binder. Right. Where's the chapter on body image distortion? And what's the difference between body image distortion and body dysmorphic disorder? And what's this thing called phantom fat? And how do I deal with it? Right. I want my patients to know this, which is why I take every opportunity to come

on podcasts like this to educate. Yeah, it's so important. So I want to actually go back to something that you had talked about before. You had mentioned this idea around emotional eating where people find comfort in food or they say food is my friend. I have found myself over the last three years since I had surgery often wondering what is it like to be normal with food or what's a normal relationship with food?

Because when you talk about, you know, enjoying food like that, I have to imagine most people in the world enjoy food. Like so much of society revolves around food. There's enjoyment in food that feels like it should be normal. So, like, is there a normal way to have emotion tied to food that's not emotional eating in a way that's harmful? Absolutely. First of all, Casey, I want to let you know, we all emotionally eat, not just our patients affected by the disease of obesity.

Everyone emotionally eats. And by the way, we will never cure you from emotional eating. So I get very concerned when I see people out there say, I'm going to eliminate your emotional eating, stop emotional eating forever. No, right? And then, okay, so maybe you're making progress and you're decreasing the power of it in your life. And then you do it again. You're like, what's wrong with me? I'm a failure. why is this not gone from my life?

But yes, food is emotional, right? And, you know, we have the holidays coming up and the food is very attached to holidays. And I would say hungry for nostalgia and hungry for tradition. And many of that, you know, much of that is connected to food and that is okay. Like that's like a healthy emotional eating, if you will, okay? Celebrating on your birthday, you know, healthy emotional eating.

When is emotional eating not healthy? When it gets control of you instead of you feeling in control of it. And it really, I guess the difference is, is when it becomes a coping skill. When you're using it to numb, avoid, or escape. Like those situations I just described, you're not numbing. You're not avoiding. You're not escaping. You're most likely celebrating. Right. Right. You're most likely engaging in a family tradition that is connected with food. I don't want those to stop.

But I certainly want to teach you healthier coping skills. Yeah, that makes sense. And I think too, Laura, would you say, at least in my experience, that's not always obvious. It's not always obvious that you're using it to cope. It is that work and being able to have that awareness and taking a step back and asking yourself, why am I going for this right now? Am I actually hungry or what's happening in my world right now? Am I stressed? Am I upset? Am I this? Am I that?

Am I truly hungry? Or like you said, am I hungering for something else? And that's not always obvious.

No. And you're not getting it in your surgical binder. And one of the first ways you experience it is that first or second week after surgery where you're like, why am I so angry? Why am I so sad? Why have these big feelings? Because what I've learned, especially the uncomfortable feelings like sadness and anger and loneliness and shame, which again, many of our patients don't even have a vocabulary. for that.

But on a scale of 1 to 10, with 10 being like feeling it the most intensely, our patients maybe pre-surgery would feel their uncomfortable feelings at a 2 or 3. And then they would eat to take the edge off, right? It's really your eating to stuff it. And then you can't do that anymore, right? So now you're walking around feeling these feelings at an eight and a nine. What is going on? What did I do? I miss being able to order Chinese when I'm stressed.

And that's where I hope you reach the point where you say, you know what, maybe I should talk to a professional. Maybe I should go to a group. I don't want to do this by myself. Yeah. Laura, I'm curious to hear your thoughts on intuitive eating and how that kind of comes into play with emotional eating and also for bariatric patients post-surgery. Are you trying to open a can of worms? What are your thoughts on intuitive eating as a bariatric patient?

Well, I think I have, I feel like I have learned to eat what I would consider pretty intuitively. Now, at this point, I'm almost three years out and I don't have to track my food anymore. I kind of eat when I'm hungry and eat what sounds good and what, you know, what I think I want.

And in talking with Kim Tirapelli, she's a bariatric sports dietitian, I asked her about this and she had some interesting thoughts where she said, you know, I don't think intuitive eating just like happens by chance. I think it happens from a very long period of habits being put into place. And so what my brain now perceives as like being intuitive is actually because I laid a lot of groundwork in those early months and years post-surgery that now it just sort of feels natural.

So I've just been curious about this whole concept because it's so foreign to me before surgery. I never felt like I couldn't have even fathomed the idea of eating intuitively. And now it seems like I kind of just do it. And I'm just so curious how it all works. I think it depends on, you're right, it is a bit of a can of worms because I think there's a difference in what you're defining intuitive eating.

If you're saying intuitive eating means I can eat whatever I want when I want, if I'm craving it, I get to have it. That to me is not intuitive eating. And that's where I think it gets dangerous, especially for bariatric patients and people with a history of disordered eating.

For me it's I told a story on the podcast recently that I have a gluten allergy and I went to a restaurant where they could make almost anything gluten-free and it was like oh my god the sky's the limit this never happens I want to order something that I could not normally get but there was this like brussel sprouts grain bowl that just was like that sounds that's what that's what I'm craving right now like I want something green I was on vacation I hadn't been eating the greatest.

And I was like, previously before surgery, I would have been like, no, I got to get the fish and chips because I can't ever get fish and chips. That's never gluten-free. And I got the veggie grain bowl. The waitress was like, really? That's what you're going to pick? That to me seems more intuitive eating. I listened to my body.

I can tell now when I'm craving a, green when I'm craving a vegetable when I'm craving I can just I am because like Casey said I did I laid that groundwork I laid that foundation and I feel in tune with my body in a way that I never have in my entire life and I have so much more awareness about like when I eat these things it this is how it affects my body this is how it impacts me and I'm able to identify when I eat this,

I feel better and not mentally better physically, but like I feel more well. And that to me, that's where I think that to me, that's what intuitive eating is to me. And at least that's where I think like I have had, I think I eat intuitively as well. I kind of, I laid the groundwork. I tracked, I weighed for months and months and months. I weighed all of my food. I measured it all out. I know what a serving size looks like.

I know how to kind of eyeball my protein and monitor it in the back of my mind and know that I'm hitting it. And I don't think it's a one size fits all for everybody. What works for one person isn't going to work for anyone else. And I still have to check in with myself and ask myself, like, just because it comes gluten free doesn't mean you need to eat it every single time. But yeah, I think that's a, I don't know, how does that impact Laura,

what you, you wanted to know what we thought first? Well, you said an important thing, a couple of important things. One and two to be learned. Two, it's not one size fits all. And when I say it's a can of worms, right? So there are a lot of therapists in the eating disorder field that would not respect me at all. One, because I believe obesity is a disease, because I believe in bariatric surgery, because I support GLP-1 medication. And there is...

What do I want to call it out there, a paradigm? There's just a way of looking at things out there that, well, if you just teach your patients intuitive eating, they wouldn't struggle, right? Like, let's just teach intuitive eating and mindful eating. And as patients that were affected by obesity, I mean, do you really think that was the answer?

Right. Yeah. No, no. Because if it was the answer, we wouldn't be going on to 60% of America is struggling with excess weight or has the disease of obesity. And that's what I learned about the physiological component, right? So your hormones are whacked out, right? I'm not the doctor, I'm the therapist. So you're going to hear like Lord Grabo's terms, like whacked out. I like that medical term. Their ghrelin hormone pre-surgery is in overdrive. So they're hungry all the time.

And their leptin hormone, which kicks in satiety isn't working. So how am I supposed to teach a patient to stop eating when they feel full, when the hormones that are cuing hunger and satiety aren't working? That has nothing to do with willpower. That has nothing to do with paying attention to your body cues. So that's where I say it's a can of worms. And you said you have to treat the obesity. And there are people, So, there are some eating disorder therapists who said,

no, don't measure your food. No counting. No restriction. So, it's just a very, very complex. But I value intuitive eating after surgery and what both of you have said in laying the groundwork and being able to become more in tune. For the first time, patients say to me after bariatric surgery, Laura, I'm not hungry. I've never felt this in my life. I am not hungry. And, or as we're hearing now with people who are on the GLP ones, like, my food noise is gone.

It's gone. Right? So there is something physiologically that has nothing to do with people practicing to be mindful in their eating practices. Right? This is a complex disease. Right? But part of treating it is afterwards, how can I teach you to be fully present with your food? How can I teach you to start relying on food for fuel and not as a coping skill and being fully present in those moments and enjoying it and not eating mindlessly, right?

And also, you know, again, back to food is fuel and food isn't fun, right? We want you to meet your fun needs and more on waste than food. And it's complex, but I'm not against intuitive eating. Of course, I think it's a very, very healthy way for all of us to eat. I just struggle when they say it's the answer. Yeah, it can't be. And I'm so glad that you said that about your hormones and leptin and ghrelin because I hadn't thought about that.

And I think that's why it's such a personalized thing. I I had VSG, and I never lost them. I've been hungry since day one, and I was panicked. I was like, it didn't work. Like, why am I hungry? Why do I feel? And my dietitian was like, this is good. Like, it's okay. But I just remember being like, I have to do more work. Like, this is going to be harder for me. Like, what? I thought that was going to go away. So I was able to work on that because I feel my hunger and my fullness cues.

But if I couldn't, I can't, you know, I wouldn't, it wouldn't have had the same outcome. So it is just such a, such a personalized experience for sure. Yeah. Laura, I have a question for you. So you had mentioned that it's important to understand, you know, you, for someone who's obese, understanding why you eat is important so that you can understand how to kind of fix that post-surgery. Is there... Have you ever had patients or have you ever encountered bariatric patients who

like don't have any underlying issues with food? They don't have binge eating disorder. They don't have emotional, well, emotional eating to a what would, you know, I don't know what the terminology is, but reach a level of like, you know, disordered causing problems. I guess what I'm asking is, do you think every bariatric patient needs therapy or is there a patient who is like, you have surgery and like, yeah, then you're good?

Ooh, that's a hard question. Hypothetically, of course, I'm not talking about myself. Couldn't possibly be. No. I don't think every bariatric therapy patient needs therapy. And that's like thinking like, oh my gosh, like I have a serious problem. I need therapy. You need to know how I view therapy because I'm in therapy. It's a way to self-care, right? It's a way to make yourself essential.

It's a way to say yes to you and say, you know, I matter and I want to go to a place where it's all about me. For me, I'll talk about my own life. I don't have to be mom.

I don't have to be therapist. I don't have to be wife. I get to just be Laura and talk about my happy and talk about my heart and process through it. So I think all of us can, I think every single human can benefit from that. Now, bariatric surgery patients. You know, I do. I think there's some people who just, they don't, they're fine. Like they have coping skills and they're not using food to cope.

They don't have an eating disorder. I mean, it's really just that physiological disease of obesity. But you have to know I'm skewed, right? Because who's coming to see me? The ones with the struggles, right? Or if I'm in a support group, because a lot of this work can happen in group as well, at least some of the groups I do. And I know I'm going to be talking about that. Maybe not the groups at your surgical center. But, you know, you start realizing like, oh, I do have some issues,

right? Like I was using food to, when I was angry, you know, I didn't realize I had that, but I did. And so what are some other ways? Well, what am I really hungering for? How do I tell the difference between physical and emotional hunger? I would say people who haven't had bariatric surgery need to learn that. Yeah. Yeah. So, but yes, not everyone, you know, but. There are some people who do have disordered eating or have full-blown eating

disorders, but not all of our patients. Did that answer the question? It does. I often get asked, like, why do you think you gained so much weight? How did you get to be so obese? And I have no idea. I really genuinely can't answer that question because I don't know. I just was. And I think my worry now is, like, I feel like I'm doing very well. Like, I've lost weight. I've kept it off for two years, two-plus years now at this point. feel pretty solid in my habits and solid in my routines.

But there's always this little piece in the back of my mind of like, how do I make sure this lasts for the rest of my life? And am I missing like the, if I don't, if I can't answer that question of how I got to be so obese, is that going to come back to bite me later on down the line? Because I didn't ever figure that part of it out. And so, and I don't know what the answer to that is. Obesity is a disease. There's the answer. And I'm really going to encourage both of you,

right? So even in the language. There's so much stigma and bias with the disease of obesity that we've even called people their disease. And that's not okay. So I'm going to challenge both of you going forward to never call yourself obese again or that you were obese. You had the disease of obesity. Do you see the difference? We don't call people a cancer. Yeah, no, you're right. Totally. Unless it's their sign. You know, we don't call people a rheumatoid arthritis. Yeah, no, you're right. Yeah.

Right. They, we don't, you know, you're a celiac. No, you have celiac disease. Yeah. Yeah. And, but with obesity, because of stigma and bias, even the medical community, and I still hear it, I still hear it. And I'm like, oh my gosh, what are we doing? It's all about people first language. And it's no, your answer, Casey, is I had the disease of obesity and I see it all the time in terms of, and I don't know if this was your experience, but I had friends who's just like, I have three kids.

I feed them all the same way. Why is one struggling with excess weight? Yeah. And again, I think it's that complex disease of obesity. It's a metabolic disease. It's a chronic disease. There's things going on with your gut microbiome. There's things going, I mean, it's just so complex with your metabolic system, your hormones, your brain. When you eat sugar, fat, and salt, you get more of a light up with people who don't have the disease of obesity.

It's complex and if there was a cure someone would have found it by now but please know that. You're before you had surgery you weren't obese you had the disease of obesity that's how you answer that question how well I had the disease of obesity yeah and then I got treatment and I'm doing better. And it also helps you realize that right now, both of you are controlling your disease of obesity. And Casey, I hear like, I have this fear, am I doing everything right? And that's normal.

But just like other chronic diseases, you can go in and out of remission, if you will. You can have flare-ups. In autoimmune, we call them, I have a flare of my disease, I'm in a flare. We see that in obesity, and the symptom we see is weight recurrence, right? And all that tells us, just like other diseases, right? So, if your blood pressure, your chronic hypertension, if you're getting high blood pressure, you're going to call your team, they're going to give you some more intervention.

If you're in a rheumatoid arthritis flare, you're going to call your team, they're going to give you some more intervention. gas-wide obesity is the same way. But you gotta make that call. And it's hard because our patients shame themselves and they think it's their fault. I think that's so important. And I love that language of saying I had the disease of obesity. That's why.

And it's also really important, I think, in kind of taking away, we know that there's a stigma about obesity, but there's also such a stigma about regain within the bariatric community. And I think reframing that language really just completely changes how you think about regain and weight recurrence. And I think that's so, so important. It's a symptom of a disease. Yeah. Yeah.

Well, Laura, this has been fantastic. I have learned so much. Thank you so much for being on tonight. I know you have quite a few resources for our listeners. Can you share some of that? Yeah. Well, a couple of things. I would love to invite your listeners to purchase my online course. It's kind of my baby. I did several years ago in terms of I knew that I needed to get head work out to the world. And this was actually, I filmed it right before the world shut down in COVID.

I had no idea that everything was going virtual. So it was just like meant to be. Yeah. So you can go to my website, lauragravo.com. And I'm just looking up because I know I did a code for all of your listeners. I believe it's FF30 can get them 30% off of my course. So let me just make sure. Yes. FFF30. FFF30. Former fat friend pocket. So FFF30 gives them a 30% off. So I'd love to welcome them into my course. You own it for life. You go at your own pace.

We address a lot of the topics we talked about today. Squashing, stinking, thinking, exiting, emotional eating, setting healthy boundaries, building and using a support team. Amazing. I also own my own counseling practice. And someone's like, oh, I want to do therapy or coaching with her. Sadly, I'm not accepting new therapy or coaching clients. But because this need is so important, I've just added two phenomenal therapists to my staff.

And they have been working with bariatric patients. They used to work with me at the surgical center. They're still working there. It's their expertise. Again, contact me through my website or just email me, laura at lauragravo.com. Christy and Kate are excellent, and they would love to work with you. Now, if you're thinking about, no, like, is there really, could I work with you live? Is there anything else? I'd like to invite you into two communities where I do groups on a regular basis.

And one is the Berry Nation community. And you can put that in the show notes or, you know, drop the link, whatever you do. You can join. And I'm actually doing four groups a week in Berry Nation, four support groups a week. That's awesome. And yeah, it's awesome. So I would love to invite you to be part of the Berry

Nation community. and another community I would love to invite you to be part of where I also do groups in education is a brand new program that Dr. Dovic and her team have launched called Project Reset. You hear the word reset in the bariatric community. I got to do a pouch reset. I got to do a pouch reset. No, you don't. No pouch resets. Just say no to pouch resets. It's just another diet. It's just another fad. It's horrible. Right. What you really need is a mindset reset.

And so we've developed a, it's Project Reset and it's focused on the forums, mindset, movement, meals, motivation, but the core is mindset. You get to interact with me live with a group of people. Again, from all over the country, you don't have to be a patient of Dr. Dovick's practice in Orlando. And I'll make sure you have that information too. So I would love to walk alongside your listeners in the Berry Nation community, in the Project Reset community,

and of course, in my online course. And please follow me on social. If you haven't, I'm often doing live courses on emotional eating or cognitive behavioral therapy. Last January, I did my first book study, and that was a big hit. So follow along and sign up for my email on my website. I did your book. I did your book club. I loved it.

I loved that book so much. And I really enjoyed the the book club um and i and i'm so glad that you were here today thank you so so so so much um we'll put everything you discussed in the show notes so guys you'll have all those links for you there and if you want more former fat friend you can find us at former fat friend pod on instagram and tiktok you can also watch the video version of this podcast on youtube now uh and for me i am at leaning into lisa i'm at maintaining casey. Music.