A Last Resort for the Obese

The drastic surgical procedure with the unnerving nickname, “stomach stapling,” was Nan Coulter’s last best hope. She was too desperate to feel nervous about it.

At 5 feet, 8 inches tall and nearly 400 pounds, Coulter’s weight was closing in on 400 pounds. Her body mass index, a measurement of height and weight, was 61, nearly double the number considered morbidly obese.

The 37-year-old telecommunications executive was so exhausted from lugging around hundreds of extra pounds that she fell asleep at her desk twice a day and spent most weekends in bed. At night she wore a special apnea mask to prevent her from dying in her sleep when she stopped breathing. Her weight also was a cause of her asthma, dangerously high blood pressure, incipient diabetes and years without a period.

Coulter was so fat she couldn’t fit into a nonhandicapped stall in a public bathroom, a coach seat on an airplane or a booth in a restaurant. She drove with difficulty, her chest mashed against the steering wheel. People stared at her and pointed, or acted as though she were invisible. Her family was embarrassed to be seen with her; on infrequent visits home, her parents monitored her every bite.

“I figured I had nothing to lose and I was going to die unless I did something,” recalled Coulter, a veteran of innumerable failed diets and weight-loss regimens.

Spurred by a friend’s experience, in December 1998 Coulter flew from Portland, Ore., where she was then living, to her native North Carolina for surgery to permanently reduce the size of her stomach.

Coulter was supposed to spend three days in a Durham hospital recuperating from the operation that was supposed to cost about $20,000. Instead, she was hospitalized for a month, much of it in intensive care, battling internal hemorrhaging followed by a massive infection, both of which nearly killed her. Her medical bills totaled $100,000.

Now, 14 months after surgery, Coulter has lost 115 pounds and dropped 12 clothing sizes. She no longer needs the apnea mask or her asthma inhaler. Her blood pressure, blood sugar and menstrual cycle are completely normal. She has so much energy that she regularly wakes up at 5:30 a.m. Her life no longer revolves around food.

“Surgery was the best decision I ever made,” said Coulter, who weighs 270 pounds, ticking off the myriad triumphs of her new life, including her new-found ability to cross her legs. “It has permanently changed my life. Even if I don’t lose any more weight, I’d be very happy.”

Ranks of Morbidly Obese Doubled in a Decade

It’s not surprising that surgery for obesity, known as bariatric surgery, has become increasingly popular. Even though weight loss is a $33-billion-a-year industry, Americans have never been fatter: One in five is obese, defined as being 30 or more pounds overweight. The ranks of the fattest, those who are morbidly or severely obese (the terms are used interchangeably) because they are at least 100 pounds overweight, have doubled in the last 10 years. Many have been fat all their lives and come from families in which obesity is common.

Being fat is not only a source of enormous emotional pain and stigma, but also one of the leading causes of premature death. Being overweight or obese is linked to a staggering array of disabling and expensive diseases: several kinds of cancer, heart problems, high blood pressure, arthritis, asthma, diabetes, stroke and infertility among them. Scientists know that many, but not all, of these conditions can be ameliorated by losing weight.

But as anyone who has tried to banish as little as 5 pounds knows, losing weight is hard--and weight loss usually doesn’t last. It is estimated that 95% of diets fail, largely because maintaining weight loss involves changing a lifetime of bad habits.

That’s particularly true for the morbidly obese, who have dozens, if not hundreds, of pounds to lose. Many people who are severely obese, Nan Coulter among them, can recount a litany of diets, drugs, therapies and bizarre and even dangerous remedies to which they’ve resorted. Most are yo-yo dieters, some of whom lose huge amounts of weight--sometimes 100 pounds or more--only to regain it all. Others have simply given up and gotten progressively fatter.

In the last decade, as science has searched mostly in vain for new drugs and other ways of treating obesity, doctors have begun turning to another remedy: gastric bypass surgery. Although there are several dozen variations of the gastric bypass, all obesity operations are designed to shrink the size of the stomach, which stores and processes food, from a capacity of 30 to 50 ounces to 1 to 2 ounces, the equivalent of five bites. The surgeon then reroutes a portion of the small intestine, attaching a Y-shaped piece to the new, smaller stomach. This allows food to bypass the duodenum and part of the jejunum, reducing the absorption of calories as well as vital nutrients, including calcium and B vitamins, by shortening the length of the small intestine through which food travels.

In many patients the bypass causes “dumping,” a sick feeling characterized by nausea, sweating, faintness, diarrhea and dizziness, when patients eat one bite too much or consume sweets.

While surgery is too drastic, expensive and permanent a solution ever to attract the legions of desperate dieters who snapped up the hugely popular weight-loss drug combination fen-phen or the multitudes who have flocked to high-fat, low carbohydrate fad diets, the procedure is generating considerable interest. Some of that interest is fueled by the Web, home to dozens of obesity surgery sites and chat groups. And some of the buzz has been created by the experiences of such celebrities as Roseanne Barr, who underwent surgery in 1998 and has credited the operation with “changing my life.”

40,000 Operations Estimated Annually

Because surgery is bound by few regulations and because obesity operations are the subject of little rigorous research, no one knows how many gastric bypass operations are performed each year or how most patients who undergo them fare.

Georgeann Mallory, executive director of the 520-member American Society for Bariatric Surgery, estimates that about 40,000 patients, most of them women, undergo obesity surgery annually, an increase of about 20% from two years ago.

“Our members tell us that it’s definitely on the increase,” she said.

Many bariatric surgeons--and a growing number of physicians who treat weight loss with less invasive methods--contend that surgery is the only way many morbidly obese patients can lose weight and keep it off. But surgery should be considered a last resort, they say, and the risks of the operation must be balanced against the consequences of obesity and its attendant diseases.

“For people who really need surgery, the people who are 200 and 300 pounds overweight, it’s not a question of diets or willpower,” said Edward H. Livingston, director of bariatric surgery and vice chairman of the department of surgery at UCLA Medical Center. “Nothing else works for them.”

“As little as five years ago at most professional obesity meetings, surgery wasn’t taken seriously, but that’s changing,” said Kelly Brownell, director of the Yale University Center for Eating and Weight Disorders.

The change has been spurred in part by the findings of a large, long-term Swedish study involving more than 1,600 patients that American obesity researchers are watching with interest. Launched in 1992, the Swedish Obese Subjects study has found that patients who underwent gastric bypass lost considerably more weight and had greater improvements in their physical and mental health than those treated in a conventional obesity program emphasizing diet and exercise.

“We know that eating is a habit, a behavior,” said Joseph D. Afram, chief of surgery at Columbia Hospital for Women in Washington, D.C., who recently operated on an entire family. “The only factor that can control your overeating is a smaller stomach. But after surgery, patients have to change their behavior. They have to eat very slowly, taking about five bites in 10 minutes. They can’t eat and drink at the same time. And they’ll find if they eat one bite too much or they eat certain foods such as sweets, they’ll get sick.”

“It’s aversive, sort of like an alcoholic and Antabuse,” said psychologist Maria Z. Cohn, referring to the prescription drug that makes alcoholics physically ill if they drink. “I tell people that surgery is a tool,” said Cohn, who counsels Afram’s patients before and after surgery. “It enables them to create new lifelong habits for themselves, but many of them continue to struggle” with food.

Modern gastric bypass surgery was developed 40 years ago by Edward E. Mason, a surgeon at the University of Iowa and the founding president of the bariatric surgeons society. Mason observed that patients who underwent irreversible operations to remove large parts of their stomachs or intestines to treat cancer or severe ulcers lost a lot of weight and remained underweight regardless of what or how much they ate. They also suffered from severe “dumping” every time they ate.

After several modifications of the procedure--and a period when obesity surgery fell out of favor because of deaths from a different, dangerous operation confusingly called the intestinal bypass--doctors in the early 1990s began performing a modern version of the gastric bypass.

In 1991, obesity surgery acquired respectability when a consensus conference sponsored by the National Institutes of Health endorsed it as one option for treating carefully selected patients.

The imprimatur of the NIH proved to be a major boost for the nascent field.

Obesity Once Seen as a Moral Failing

“It used to be that bariatric surgeons were considered to be the pariahs of the profession,” Livingston said. Most surgeons have traditionally regarded morbid obesity as a moral failing, not a disease, and have been loath to operate on patients who are inherently high-risk and notoriously difficult to care for.

Gertrude Brummitt, 50, of Mount Rainier, Md., is all too familiar with the humiliations faced by super-obese patients who need medical attention. Several years ago when she fell and hurt her arm, paramedics had to summon a firetruck to round up the nine people necessary to hoist her 500-pound body into the ambulance.

“I heard all the fat jokes,” recalled Brummitt, who underwent gastric bypass in March 1998.

Since then Brummitt has lost 250 pounds and hopes to return to work later this year after three years on disability.

“Now I can sit in a chair, get into bed by myself and cook and clean and hold a baby in my lap,” said Brummitt, who was bedridden before her surgery. She no longer suffers from cellulitis, a spreading bacterial infection beneath the skin, or asthma or blood clots.

In the last five years, the growth in obesity surgery has been fueled by the economic changes wrought by managed care and the advent of the Internet. The Web has enabled doctors to reach many thousands of people through their Web sites, a relatively inexpensive form of advertising, and has allowed patients to communicate with each other, swapping personal stories, tips and recommendations. An obesity subculture thrives on the Internet, which for the most isolated and obese may provide the dual functions of social life and safety net.

“It’s perfect for very fat people like me because we don’t like to go out in public,” one bypass patient noted. “You can talk to people who know what you’re going through and know what it’s like.” Interested patients also can watch actual bypass surgeries in streaming video. Managed care, with its emphasis on cost controls and decreased reimbursement, has made bariatric surgery much more attractive to surgeons and revenue-hungry hospitals. Until recently, most insurance plans did not cover gastric bypass, which meant that surgery--which can cost between $6,000 and $10,000 in surgical fees alone--was paid for in full and upfront by desperate patients.

Obesity surgery also became more desirable to hospitals seeking to fill beds and lure patients. Some institutions have launched bariatric-surgery programs in recent years.

But some obesity specialists say they worry that the growing acceptance may feed a dangerous misconception: that gastric bypass is an easy solution that will solve a multitude of problems.

“I think it’s represented often that surgery is going to do all the work, and it doesn’t,” said Jean Hardesty, a psychologist specializing in weight-loss counseling who’s affiliated with UCLA. Years ago Hardesty lost 80 pounds the old-fashioned way. “A year or two later, people are working as hard” as those who lost weight and kept it off through diet and exercise.