Family Magazine
The facts
The American waistline is ballooning. The World Health Organization estimated that in 2005, 39 percent of adults were obese, which is generally defined as a body mass index (BMI) of 30 or greater. In 2015, just 10 years later, it projects that more than half of the nation will be obese. Morbid obesity, defined as a BMI of 40 or greater, or more than 100 pounds overweight, currently afflicts about one in 50 adults. The repercussions are dangerous and potentially deadly.
“It’s estimated that the life expectancy is 15 years less in someone that is morbidly obese,” said Dr. Timothy Monson, a bariatric surgeon with MeritCare Health System in Fargo. “There’s also a higher risk of developing diabetes, high blood pressure, premature heart disease, and joint problems.” A recent report has even suggested about six malignancies that are linked to obesity, he said.
The list gets longer. According to the Centers for Disease Control (CDC), the risk of osteoarthritis, gall bladder disease, sleep apnea, and other respiratory problems is also increased with excess weight. Type 2 diabetes, in particular, has long been associated with obesity. Type 2 diabetes accounts for 90 to 95 percent of all diabetes cases, and 80 percent of people with Type 2 are also overweight.
The faces
As a young child, Julie of West Fargo found comfort in food. It gave her the acceptance and security she hadn’t found elsewhere. Food wasn’t mean to me, she said, and it was always there for me. It became her “soul mate,” but the friendship exacted a painful toll—382 pounds.
Julie considers herself fortunate she never developed high blood pressure or diabetes, but plenty of other problems plagued her severely obese frame. She had shortness of breath and trouble swallowing, constantly swollen eyelids due to excess fluid, and weakness in her knees that caused them to buckle. For years, Julie said, her skin chafed and blistered as skin rubbed on skin. The most devastating effect, though, was emotional. It was impossible to ignore the negative reactions to her weight and the resulting difference in how she was treated.
Carla Jenson of Fargo empathizes. She constantly feared not fitting in with the rest of society. “You’ll never know what it’s like to worry about restaurant seats or to be afraid of going to a movie theater,” she said. “Not fitting in is all you think about, and then, of course, what do you resort to? Food.” There were other frustrations. Her two-year-old daughter wanted playtime with Mommy, but at 283 pounds, Jenson had trouble rising from the floor. And she had zero energy to keep up with the effervescent toddler.
Both women needed a viable weight-loss solution. Unfortunately, non-surgical options for weight-loss seldom produce the desired long-term results. “Patients are inundated day in and day out on the television and the news print with weight-loss programs that purport long-term success, and that just hasn’t been born out by studies,” said Monson. “Dieting is only proven to be effective as a long-term weight-loss strategy in three percent of [morbidly obese] patients.” He calls those results “dismal.”
Jenson, who has battled her weight throughout her life, wasn’t one of those lucky three percent. Over the years, she’d joined NutriSystem and Weight Watchers, tried the prescription diet pill fen-phen, and over-the-counter diet pills. “I tried any type of diet that looked like a good idea,” she said.
None of it worked. Dieting failed. Exercise programs failed. Nothing helped her keep the weight off long-term. It wasn’t until she watched a Dateline NBC episode about Al Roker in November of 2002, that she discovered what she hoped was the answer: gastric bypass.
Long-term hope
Bariatric surgery, of which gastric bypass is one form, surgically alters the stomach, reducing the volume of food it can hold to mere ounces. Some surgeries limit not only food intake, but also reroute the digestive process to restrict the absorption of calories and nutrients. It’s an option reserved for the morbidly obese, or those with a BMI of 35 or more in combination with a weight-related disease. And it’s not without risk and the possibility of complications, said Monson, but “compared to operations such as hip or colon surgery, the risk of death with obesity surgery is extremely low, and it is extremely safe.”
The lifestyle changes are dramatic and immediate. Exercise and eating habits, in particular, must undergo radical transformations. Patients relearn how to eat, as strategies such as eating slowly and in small amounts, chewing food well, and avoiding food that could produce desperate dashes to the bathroom, become necessities instead of choices.
The results are impressive. According to the American Society for Metabolic and Bariatric Surgery (ASMBS), individuals may lose between 30 and 50 percent of excess weight in the first six months following surgery. After one year, 77 percent of excess weight may be shed.
But the physical weight loss is proving to be only one of the benefits. Numerous studies report that bariatric surgery patients show improvements in many weight-related diseases. A study published in the Journal of the American Medical Association (JAMA) found that the patients, whose average weight loss was 61 percent, saw Type 2 diabetes eliminated in almost 77 percent of cases, high blood pressure eliminated in 62 percent, and sleep apnea eliminated in 86 percent. Asthma, high cholesterol, and joint disease also significantly improved. Other research found a 92 percent decrease in long-term mortality following obesity surgery.
Jenson was hopeful, but cautious. To learn more, she, along with her husband and mother, attended a gastric bypass support group. People from around the region shared emotional support, encouragement, and practical tips, she said, and they were all at different stages. The breadth of experience gave her a good picture, she felt, of life after surgery. And when she saw how happy they were, she made her decision. “I was gung-ho to get it done.”
Jenson chose laparoscopic gastric bypass surgery primarily because, as a less intrusive surgery, recovery would be faster. “I didn’t want to be out of commission for too long,” she said. “And the healing [for laparoscopic] is just awesome.” In two days, she said, she was out walking. She eased back into her work routine, and at the end of three weeks, she was working full-time again.
Julie’s recovery was more difficult. Because of her BMI of 65, she had to have open gastric bypass surgery. For a while, the pain was unbearable, and she didn’t believe she’d ever feel better. After four days in the hospital to monitor for infection, suture leaks, and breathing problems, she returned home but with continued restrictions to her mobility that sometimes proved hard to follow. On one occasion, she lifted her grandson too soon, tearing sutures open and prolonging her recovery.
But both women saw rapid results. Julie lost 200 pounds, half of that in the first year following surgery, and Jenson remembers that during one of her personal weekly weigh-ins, she was amazed to discover that she had lost 12 pounds, going from 251 pounds to 239 pounds. “I skipped all the 40s,” she said, laughing. “It was exhilarating.” But losing the weight often proves easier than losing the attitudes toward food that helped contribute to obesity.
Lifetime change
For Julie, the hardest part has been not falling back into her previous relationship with food. “This may be a quick way to lose weight in the beginning, but without the lifetime change of your eating habits and the way you think, it will not work for you,” she said.
Jenson agrees. “You lose your weight a lot faster, but you still have to deal with life’s everyday challenges.”
“We depend on eating to soothe our emotions,” said Jennifer Ross Sawyer, a licensed professional counselor with Ballantyne Counseling in Charlotte, North Carolina, and a weight loss surgery patient herself. “So the biggest factor in long-term success is changing your view of food to fuel.”
Jenson, who attended a support group for six months following her surgery, said she had good and bad days trying to reconfigure her life to get by on a day-to-day basis. “It’s a scary thing, because it’s all experimental,” she said. “The joke at the support group was that weekends were the trial period. You didn’t dare try and eat something at work because, my goodness, you didn’t want to go to the bathroom.” For her, that camaraderie with other people experiencing the same challenges was very helpful.
Research validates the benefits of support groups. A study published in September of 2007 found support groups positively influence weight loss, even going so far as to say that they were the best chance for achieving maximum weight loss.
Sometimes when an unhealthy coping strategy is no longer available, individuals may attempt to find a new way to fill an inner emptiness. After three major surgeries in three years—gastric bypass, gall bladder removal, and a tummy tuck that removed 11 pounds of loose skin—Julie sometimes didn’t know whether she was coming or going. Although she is reticent to elaborate, she said that she started using other things to fill the void once occupied by food. They took control of me for a while, she said, but my faith in the Lord and a lot of support from co-workers, friends, and family members helped me regain it.
Some psychologists label the swapping of one compulsive behavior for another “addiction transfer.” And while most would agree that alcoholism and other behaviors such as excessive shopping and gambling addiction are maladaptive because they are counter-productive or interfere with daily life, not everyone is convinced that their occurrence following weight-loss surgery is the result of “transfer.”
Monson estimates that five to 10 percent of bariatric patients will begin to see some maladaptive behaviors develop or become more prominent after surgery. But he doesn’t know, and isn’t sure anyone else does either, whether that maladaptive behavior is an addiction transfer or whether it’s a psychological stressor because of the radical changes they’ve experienced going from being a morbidly obese person to a non-morbidly obese person. “What is important to recognize is that a certain percentage of patients will get into maladaptive behaviors after their operation and weight loss, and that has to be addressed,” he said.
The pre-operative psychological evaluation is useful for identifying individuals who have issues, such as depression or a binge eating disorder, that should be addressed prior to surgery, said Monson. It can also pinpoint psychosocial stressors—a bad marriage, troubles with children, job issues—that could prove problematic during weight loss. “The operation produces a profound change in people, and things are not the same after the operation as they were before. That’s a significant stressor in and of itself, so it’s nice to have as many things under control as possible before the operation.”
Sawyer finds that many people have unrealistic expectations about how the surgery will change their life. “Sometimes they think that if they lose the weight, everything in their life is going to be okay,” she said. “They’re hoping that there’s going to be a miraculous change.” Sawyer knows that isn’t always true. In 2003, she underwent gastric bypass surgery and dropped from a size 22 to an 8. She felt as if she could conquer the world, but her husband felt like she was a different person. One year later, she underwent a double mastectomy, and that, she thinks, was too much for him. “He said, ‘I don’t feel the same way about you that I used to.’” Sawyer doesn’t attribute her divorce to the weight-loss surgery, but she does think it contributed to it. “Certainly I changed so much that my husband was not comfortable with me. I think that happens a lot.”
Because of the jolt to family dynamics, Sawyer, who is also a certified weight-loss support group leader, recommends that individuals in the patient’s support system attend support groups. Patients can talk to patients, and support people can talk to support people, she said.
Despite the validation from researchers and the discouraging results of non-surgical methods, the ASMBS reports that only about one percent of individuals who meet the criteria for bariatric surgery actually have the procedure. Monson cites three reasons for this. First, the operation is expensive and if patients aren’t insured, most don’t have access to the $14,000 to $28,000 required. Second, there aren’t enough surgeons to serve the number of obese patients in the United States. His third reason, however, may be more difficult to change than the insurance industry or the lack of surgeons.
There is tremendous prejudice against obese people, he said. Many doctors are not referring their patients for these operations because they believe it’s an issue of willpower, just eat less and exercise more. “It’s not about willpower. I think it’s supported by research that the brain is not wired correctly to stop eating when they’re gaining weight,” said Monson, who calls this faulty wiring a “disconnect.”
But society judges obese people based on appearance and concludes that they are lazy, ignorant, and slovenly. In a culture that worships Barbie doll dimensions, obesity equals failure. Monson knows this view is untrue. “They are very hard-working people and active members of society,” he said. “They are not slovenly. They are very interested in losing weight.”
Monson is hopeful that the next two decades will yield a pharmaceutical solution to obesity. But “until we have a medication that can intercept that disconnect, what we do have to offer are operations that are pretty effective.”
Long-term results
So how effective is bariatric surgery? Does the initial short-term weight loss translate to successful long-term weight maintenance? Once weight loss is achieved, weight maintenance requires vigilance, but research indicates 50 to 60 percent of the excess weight lost can be maintained up to 14 years after surgery.
For Jenson, who celebrated the five-year anniversary of her surgery in April, and Julie, a three-year veteran, this journey has offered the best chance of long-term success.