Dr Rob Cable, who owns Tauranga Obesity Surgery Centre, is a private bariatric surgeon, and has attracted obese patients from all over the country. Photo / Andrew Warner
Dr Rob Cable is one of the country's specialist obesity surgeons, and is in demand. As Kiwis continue to get fatter, the number of weight-loss surgeries performed is only scratching the surface.
He was a "fat bastard".
A big bloke who turned heads when he walked past, but not in an approving way.
He was a former patient of Cable's, and wrote a book on the perils of being pudgy.
The implications were far beyond the day-to-day struggles of moving around and breathing normally.
He told his doctor that a "fat bastard" was how he felt slim people saw him.
"He'd walk down the street, and people would think: 'There goes a fat bastard'. I think that really encapsulates the feelings [of many patients]," Cable says, from behind his desk.
"They feel unattractive."
Cable, who owns Tauranga Obesity Surgery Centre, is a private bariatric surgeon, and has attracted obese patients from all over the country.
He's in high demand and there's initially likely to be a "hiatus" in Tauranga when he finally hangs up his scrubs.
At age 73, he performs the highest number of bariatric surgeries in the private sector in the Bay of Plenty, and recently put on an extra clinic to cope with demand.
The costs for this type of surgery are high (roughly $20,000, which includes surgery, hospital equipment and anaesthetic costs) and out of reach for many ordinary Kiwis who desperately need it.
District health boards offer a limited number of weight-loss surgeries to patients with severe comorbidities.
Cable, who operates at Grace Hospital, has been performing sleeve gastrectomies for more than 10 years, and less commonly nowadays, lap-bands since the mid-1990s.
Before that, banded gastroplasties. He's operated on more than one person from several families.
"It's really scratching the surface," he says. "You could have surgeons and theatres only doing obesity surgeries, and maybe even that, wouldn't be enough."
It's really scratching the surface," he says. You could have surgeons and theatres only doing obesity surgeries, and maybe even that, wouldn't be enough.
Bariatric surgery struggled for a long time to be recognised as a sub-specialty, but now is the most rapidly growing division of surgery.
Kiwis are getting fatter (32 per cent of adults are obese according to the Ministry of Health), and the heaviest of us are suffering exponentially.
"Some are very large and heavy, and many of them have sore joints. They tell me they can almost hear their joints giving a sigh of relief when they get their weight down," Cable says.
Some are very large and heavy, and many of them have sore joints. They tell me they can almost hear their joints giving a sigh of relief when they get their weight down.
To be formally classified as obese, your BMI (Body Mass Index) must be over 30. It is calculated by dividing your weight in kilos over the square of your height in metres.
Cable can safely operate on patients up to 180kg, and says patients with a BMI over 35 with comorbidities like arthritis and diabetes, or a BMI over 40, are likely good candidates for obesity surgery.
He has had patients who have reached a BMI of over 70, but adults aren't the only ones tipping the scales. Some children are seeing their first dietician from age 4.
"I've seen kids who have adult weights as young children, so it's really concerning. This is the first generation where the kids potentially aren't going to live as long as their parents."
I've seen kids who have adult weights as young children, so it's really concerning. This is the first generation where the kids potentially aren't going to live as long as their parents.
Both genetics and lifestyle are to blame. Nowadays the horizon that kids can travel, safely, has gotten smaller.
And while kids are into exercise and sport, Cable says it's not enough.
Cable himself, is a runner, trekker and "berries and yoghurt man" for breakfast.
"I do practise what I preach."
He's never been overweight ("my genes are good"), but he certainly is sympathetic, and like most of us, wouldn't turn down a piece of mud cake.
Helping patients get their weight down is satisfying.
"They just hate being heavy, and you feel so sorry for them," he says. "These lovely people, trapped inside big bodies."
Cable has been involved in obesity surgery since the 1980s.
Kiwis with the biggest waistlines tend to be Maori and Pacific Islanders, especially from lower-socioeconomic backgrounds, but no one is unaffected.
Obesity surgery is everyone's last resort.
"All the patients I've seen have been to all the main weight watch programmes and sometimes been to them many times.
"I have lots of patients who say: 'I've tried everything'. And yes, they will have had success, and some will have had quite spectacular successes, but the fact is, it often goes back on again. It's very hard to maintain the required willpower, which is sad."
I have lots of patients who say: "I've tried everything". And yes, they will have had success, and some will have had quite spectacular successes, but the fact is, it often goes back on again. It's very hard to maintain the required willpower, which is sad.
There are several surgical options to lose weight, but the most common nowadays is a gastric sleeve operation (sleeve gastrectomy), which has superseded gastric bypass and lap-band operations in popularity.
In gastric sleeve surgery, Cable creates a small stomach "sleeve" using a stapling device, and the rest of the stomach is permanently removed.
It started as an operation for super obese patients, as a first-stage to other weight-loss operations.
It soon emerged results were substantial with the sleeve alone. Patients may also be left with less excess skin than other procedures.
"It's relatively straightforward and the results are great. But easy for the patient? No."
Diet and food intake are changed for life.
"Even though your brain may tell you want something excessive, you can't. And if you do exceed it, you may be in trouble," Cable warns.
"So we make sure patients really understand they really must not, and they learn to adjust to it."
There are numerous steps to getting to the point of having weight-loss surgery.
"We liken it to a student studying for an exam, and athlete training for an event," Cable explains.
"You don't just roll up on exam day with no work, or no training. Obesity surgery is not a quick fix. The expression 'the easy way out' is far from it."
The path to the operating table includes pre-consults with your surgeon, a meeting with a dietician, a meeting with a psychologist (if needed), and the patient needs to lose some weight before the operation by going on an Optifast diet, which helps reduce the size of the liver which sits above the stomach.
It's laparoscopic or keyhole surgery, so it's less invasive, and recovery time is much quicker than for open surgery.
As a side note, laparoscopic surgery has transformed surgery. Its inception was like "science fiction coming true", Cable says.
"And it's become so much better. The detail on the screen is almost perfect. You can slide the scope right in close, like seeing a movie star's face occupying a whole screen."
He is a passionate-talking surgeon.
Before laparoscopic surgery, patients used to sport huge wounds.
"We had these enormous retractors keeping the wound open. The patient is tipped so steeply down, so everything could fall away, so you can get in.
"Now we just go through these very thick abdominal walls, with a 5 or 10mm scope. Many of the instruments we use are just 5mm; others 12.5mm. One wound has to be extended to about 4cm, to allow extraction of the detached portion of the stomach. Smaller wounds means healing is much quicker and less painful."
In saying that, Cable concedes: "There is no operation, unfortunately, that a determined patient cannot undermine and overcome."
While it becomes impossible to eat three full meals a day following obesity surgery, the risk is that some patients will snack continuously, undermining the work done. For this reason, follow-up consults are crucial.
Surgery is ultimately not the answer, he believes. Lifestyle changes, diet and exercise are. Any miracle pill to suppress appetite won't fix obesity either, he reckons. It's just not that easy.
Being fat has a myriad of unfortunate health spin-offs, from diabetes to infertility, to heart disease, but with surgery, it is possible to lose 1kg of fat, sometimes more, per week over prolonged periods.
"If you can get their weight down, it's amazing how their confidence improves. They see themselves in shop windows (and) women notice clothing sizes. For some of them, it's absolutely transforming," Cable says.
"A lot of heavy women feel very unattractive, but the interesting thing is, a lot of the husbands don't think they're unattractive. They like them for more than just their size.
"They like them as the person they married, but they don't feel attractive, and that's a really hard thing. Often, when you get them looking slimmer they kind of rediscover what they were when they were younger."
A lot of heavy women feel very unattractive, but the interesting thing is, a lot of the husbands don't think they're unattractive. They like them for more than just their size. They like them as the person they married, but they don't feel attractive, and that's a really hard thing.
Cable was born in Scotland and came to New Zealand as a baby. He grew up in Wellington and attended Victoria University, and Otago Medical School, before going overseas for surgical training.
He obtained fellowships with the Royal College of Surgeons and Royal Australasian College of Surgeons.
He spent two years as a surgical registrar in Auckland, before coming to Tauranga, and then returned to London to study at the National Heart Hospital.
On his way back to New Zealand, he worked in rural South Australia, before returning to Tauranga Hospital as a specialist general surgeon; initially choosing sub-specialisation in vascular surgery, later changing to obesity surgery. He also sees patients with gallbladder problems, acid reflux and hernias.
He was at Tauranga Hospital for 25 years, before switching to private 15 years ago.
He met second wife, Subha, a former San Diego Certified Public Accountant (CPA), while travelling in India.
The moment he met Subha, who speaks five languages, he knew she was the person he wanted to spend the rest of his life with. "It was amazing," he says.
The couple, and their youngest children, ski in North America every year. Cable "tries" to play golf: "Progress is slower than I like."
He studied classical guitar for years, and always wanted to be a doctor, but initially wasn't particularly studious or directed.
He tells the emotional story of the day his number (91) was called out at the Royal College of Surgeons building in London, indicating he had passed.
"I didn't hear anything after that," he says with a whimsical smile. Years later, he took his family back to the exact spot his life changed.
"It was the most amazing experience. I was surprised how much it affected me."
Cable did 13 years of training, most of it on-the-job, to get where he is. "Hours are unbelievable, and you need enormous energy."
He operates with no music playing, and minimal chatter. He cannot focus with distraction.
For Cable, weight loss is serious business, and involves teamwork, he says.
Absolutely everything possible is done to ensure his patients get the normal life they deserve.
Whether weight gain is a case of "nature or nurture", he is sympathetic, and humorous where appropriate.
As his photo is snapped for this story, our photographer coaxes: "This won't hurt a bit, I promise." To which a grinning Cable, replies: "That's my line."
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