Fat, and Happy About It

The newspaper ad inviting fat people to learn about El Camino Hospital’s new weight-loss surgery program held out the opportunity to be not just a thinner person, but a better one.

“It’s not what you have to lose,” the Mountain View, Calif., hospital ad said. “It’s what you have to gain. Pride. Dignity. And Better Health.”

Marilyn Wann, 5-feet-5, 270 pounds and darn proud of it, scanned the ad and fumed: How dare they imply that fat people are not proud, or that dignity is reserved for the thin? Wann threw down the newspaper. Then she smiled and began to e-mail her friends.

At the hospital’s weight-loss surgery workshop in October, Wann and a handful of others blended into the crowd, most of them at least 100 pounds heavier than doctors say they should be. They listened to the surgeons -- then Wann blew a whistle.

The infiltrators jumped up, whipped off their clothes and, clad only in bathing suits (Wann in a pink two-piece), danced through the stunned audience with the words “Fat+Pride” and “Fat+Dignity” marked on their stomachs.

The pro-fat parade may not have swayed many at the workshop. But it was an ample demonstration that activists in the fat acceptance movement, as it is sometimes known, were galvanizing against a medical procedure they consider dangerous and demeaning.

Doctors agree that weight-loss -- or bariatric -- surgeries involve risks, but also argue that for now they are the most effective way for extremely obese people to shed pounds over the long term. The most common type of bariatric surgery is the gastric bypass, in which the stomach is sectioned off, leaving a small pouch at the top that severely limits food intake.

The American Society of Bariatric Surgeons estimates that 103,200 weight-loss surgeries were performed in 2003 and that the number will swell to 144,000 this year.

The surgery is recommended only for people who are at least 100 pounds overweight. Afterward, patients are warned to limit their food intake and to exercise regularly for the rest of their lives.

Many patients are lured to the surgical solution by celebrity success stories, dramatic before-and-after pictures, and promises of small scars -- instead of the Frankenstein weals of the 1970s and ‘80s. Demand is so great that the wait at some hospitals is a year or more.

General surgeons are diving into the business of weight loss: The bariatric surgeons association grew 39% from 2001 to 2002 and 43% from 2002 to 2003.

The society, which provides guidelines but not credentials to surgeons, now has about 1,200 members.

Against this trend stand a handful of organizations such as the National Assn. to Advance Fat Acceptance, the Council on Size and Weight Discrimination, and the International Society for Size Acceptance. More obscure fat pride groups include SeaFattle in Seattle; Pretty, Porky and Pissed Off in Toronto, and the Bod Squad in San Francisco -- a radical cheerleading group.

The stalwarts -- those who dive into discrimination lawsuits, attend obscure medical conferences on obesity or make talk show appearances -- know one another.

Thousands of others have found each other through Internet chat rooms, e-mail lists and conventions. Many take solace in solidarity after years of dieting debacles, humiliation and loneliness.

“It [stinks] to be fat,” said Wann, 37. “Nobody would do it if they didn’t have to -- except for maybe me.”

Demonstrations locally and nationally often have their genesis in an e-mail from Wann.

“I’m accustomed [to] getting e-mail from Marilyn that requires me to get in costume,” said Sondra Solvay, an attorney specializing in fat discrimination cases.

The activists point to some successes. Three cities -- San Francisco, Santa Cruz and Washington, D.C. -- and one state -- Michigan -- have outlawed discrimination based on size.

But their central belief -- that the only problem with being fat is existing in a “fat-hating society” -- puts them at odds with virtually the entire medical establishment.

The National Institutes of Health, the Centers for Disease Control and Prevention, the U.S. surgeon general, the American Diabetes Assn. -- and, of course, the American Society of Bariatric Surgeons -- all maintain that obesity is dangerous.

Numerous studies show that obese people are at high risk for diabetes, hypertension, sleep apnea, some cancers and a range of other life-threatening conditions.

“Someone who is 40 years old and 100 pounds overweight will get diabetes,” said Roland Sturm, a health economist at the Rand Corp. in Santa Monica. “I know there are people who don’t like it when I say that. I’ve had threats from some of those activists. But it’s the truth.”

Health officials estimate that more than 60% of Americans are overweight, and half of those are obese.

Body Mass Index

Obesity is defined by body mass index -- a number reflecting weight in relationship to height. A 5-foot-5 woman weighing 180 pounds, for instance, would have a body mass index of 30, which is considered obese. Most doctors would require that she have an index of about 40 to consider performing weight-loss surgery. Her weight in that case would be at least 240 pounds.

Fighting the obesity epidemic, health officials argue, is not just a matter of health, but economics.

A joint study by the CDC and the North Carolina research group RTI published last month in Obesity Research found that Medicaid and Medicare spent $75 billion last year on obesity-related illnesses. In a report issued last year, U.S. Surgeon Gen. Richard Carmona announced that the nation spent $177 billion on obesity-related health costs in 2000.

“Obesity,” he said, “is the terror within.”

“Great,” Wann deadpanned. “Now we’re worse than Saddam Hussein or Al Qaeda.”

She said fat people are put in an impossible position.

“It’s what I call a gun to the head,” she said. “They tell you that only surgery works, and oh yes, you’ll die if you don’t do something now. But are they crazy? I wouldn’t risk my life to mutilate a perfectly healthy organ for the odds that they give.”

The death rate for weight-loss surgery, quoted by the bariatric surgeons society and some fat activists, is one in 200. Serious complications include blood clots, hemorrhages and infections from leaks; follow-up surgeries are common.

Even measuring mortality, however, is a point of contention between the medical establishment and activists. Many surgeons only count deaths that occur within 30 days of surgery. But activists say that adverse consequences are progressive and that degenerative conditions can occur as long as 15 years after surgery. Many cite long lists of friends they believe died from surgery or its complications.

One of the most recent studies of patient mortality, reported in a paper presented to the American College of Surgeons in October, found that the surgery or its complications led to death in 2% of patients who had undergone the operation in the past 15 years.

But the study also found that the likelihood of survival depended on the experience of the surgeon, said Dr. David Flum of the University of Washington. Patients of surgeons who had performed fewer than 20 operations were 4.7 times more likely to die than others -- a finding that underscores activists’ concerns about the number of doctors entering the field.

The National Institutes of Health only began to look at the long-term risks of the surgery last year.

Clinical trials should have been done 30 years ago, said Flum. He said more needed to be known about “the price we pay for getting that significant weight loss.” Nevertheless, the benefits of bariatric surgeries are clear, he said.

“We’ve found a couple of amazing things,” he said. “The hunger drive is almost completely lost. Also, hypertension and problems related to joints improve dramatically, and 85% of people who had diabetes before surgery” see their blood sugar levels return to normal.

Many of those who have undergone the procedure credit it with saving their lives.

Walter Lindstrom, a San Diego attorney specializing in obesity issues, insisted that it saved his, and that of many of his clients. He called the activists’ opposition to the surgery “antiquated.”

“I’m in lock-step with them on some things, like discrimination, but now you really do have to accept this is no longer voodoo medicine and treat it with the respect of any other medically necessary procedure.”

Raising Awareness

Many advocates for weight-loss surgery seem only vaguely aware that fat activists exist.

Some activists’ low-budget stunts, however, are meant to change that.

“One of the problems with activism is it becomes so morose and so serious,” Solvay said.

People lose their jobs, are refused housing and even have their children taken away because they are fat, she said. For her, the antidote is to do something absurd -- in public.

So Solvay, a member of the Bod Squad of San Francisco, jumps, kicks and does splits in a silver-sequined black miniskirt with pink ruffled panties underneath.

Wann, Solvay and others make tactical strikes, displaying their fat with pride.

The goal is to warn “fat brothers and sisters” about the dangers of “stomach amputation” and “self-mutilation,” as Wann calls the surgery. Almost as bad as the health risks involved, she adds, is the psychological kowtowing that comes with a stapled stomach.

Some medical centers and doctors are nonplused.

El Camino Hospital officials said they were surprised to learn that some people were offended by its newspaper ad linking pride and dignity to losing weight. It pulled the ad, however, after Wann and others called the hospital to complain.

“The last thing we wanted to do was to offend anybody,” said Ann Fyfe, vice president of business development for the hospital.

Fyfe saw Wann’s group, called the Bypass the Bypass Brigade, disrobe. “It was shocking” and upsetting for the 62 people who came to confront their weight problem.

She likened their attendance to a first meeting of Alcoholics Anonymous. “For people to decide they want to do something about it, to actually show up somewhere ... to say, ‘I am obese, and I want to explore options for me’ -- well, I think it takes courage,” she said.

Likewise, when Bryan Woodward organized a national fundraiser for the bariatric surgeons society, “Walk From Obesity,” he was stunned to learn anyone could be opposed to such an idea.

“It really hurt at first, because I wanted to do something good. We have walks for heart disease and we have walks for cancer, and the biggest killer for all of us -- besides smoking -- is obesity,” he said. “So why not have a walk to educate people about that disease?”

Woodward is as earnest as Wann is angry. People do not have gastric bypass surgery because of advertising campaigns, he said. They have it because they can no longer play with their children, walk up the stairs or bathe without help.

The walks, in 39 cities around the country, he said, were a success, raising almost $300,000 to increase awareness about obesity.

Activists thought they were a success too. In New York, San Diego and San Francisco, they faced off against the bariatric walkers.

At Chrissy Field in San Francisco, as the walkers paraded by, Bod Squad cheerleaders in pink, silver and black pleated skirts jumped and cheered.

Waving pompoms, they chanted: “Two! Four! Six! Eight! We do not regurgitate! Three! Five! Seven! Nine! Love your body, it’s just fine!”