Eating Ice Cream With My Dog (31 page)

“I want a meeting with you, Dr. Franks. and Dr. Lefkowitz,” Katie said, in that whisper that masks tears. “Kaiser’s supposed to be a team. I want my team.”

She got the meeting, but only after she’d slung every invective imaginable against her therapist and insurer on her blog. My personal favorite was calling Dr. Sneak an “ass-hat.” Readers were sympathetic to her cry in the wilderness of fat—that she couldn’t live this way anymore. They told her she had so much going for her, that fat or thin she was a wonderful person, that her shrink was a bastard.

I took a more nuts-and-bolts approach. “Get very calm. Make a list of how Kaiser has infringed upon your privacy. Explain how your blog reflects a bad day or a bad hour, not your general state of mind, and remind them of the statistics that show obese people are twenty-five percent more likely to be depressed. Also remind them of how many years of weighed-and-measured, restricted eating you’ve done, that you’re perfectly capable of following a nutrition plan. Tell them how you’re selling pet-sitting franchises and how well you’re doing in a self-starter business, that you’re a hard worker and show up for your life no matter how you’re feeling. Go in there like a lawyer, not a beggar.”

She thanked me for the advice although I don’t know if or how capable she was of following it in her rage and, mostly, shame that she’d screwed up once again.

Compounding what had now become her notorious and permanent psychological profile, the surgeon stated that he was reluctant to put her on the operating table unless she lost weight.
⁸⁹

“Why?” she demanded. “I’m fat, but I don’t have high blood pressure or diabetes. Lots of people who are fatter than I am have surgery.”

“Anesthesia would be extremely risky,” he said.

He tabled further discussion until she took Laura’s class.

Mindful eating? we scoffed later. “I don’t mind eating,” she said.

“I don’t mind it at all,” I answered. “Would you mind passing the cake?”

“Sure, if you wouldn’t mind ordering pizza.”

Somehow, when disaster strikes Katie, it does so exponentially. Within a week of the Kaiser debacle, her landlord discovered Apple and Orange, and gave her two weeks to move out. It was lucky that the procedure had been put off.

“Who will rent to a four-hundred-poundy?” she wailed. “How can I possibly pack up my apartment when I can’t stand for more than twenty minutes?”

Katie was due for a lesson in serendipity. She found a small apartment in Alamo that had a cocktail napkin–sized atrium. Her new proximity to Oakland revived old ideas of the way she wanted to live. College Avenue was Mecca for her, and the lights around Lake Merritt could keep a desperate woman hopeful. She decided Alamo was a step toward a bigger destiny. A few days later, when she placed an ad offering to give the rest of her thin clothes away so she wouldn’t have to pack them, the respondent who swept up the pile of bags wept with gratitude because it would make her job search possible. In return, she recruited her brother and boyfriend with their trucks and they arrived on the Saturday of the move to do the whole job.

Could Katie have handled the gamut of weight-loss surgery? It is emphatically not for sissies, that’s for damn sure.

A number of articulate and frank women responded to the note I put on the home page of my website asking for interviews with bariatric patients. One of them was Em. At five foot one, weighing 365 pounds, her life was on the line. Two years before having gastric bypass, she had her tonsils removed. The anesthesiologist arrived and gave her two injections in her neck, apologizing for the pain but explaining that it would take so much sodium pentothal to put her to sleep that he couldn’t promise she’d wake up. She was awake for her tonsillectomy. Her evaluation for bypass surgery included an endoscopic examination of her upper gastrointestinal tract, and she was too heavy for sedation.

Sissies, indeed.

There are essentially three commonly used forms of weight-loss surgery that work through creating a small pouch at the top of the small intestine and bypassing the duodenum and upper portion of the jejunum where much of digestion takes place. The patient is restricted in the amount of food she can eat and cannot absorb many of the calories of the food she eats. These procedures are the vertical gastrectomy with duodenal switch (commonly referred to as the duodenal switch, or DS), the Roux-en-Y (the procedure referred to when using the phrase “gastric bypass” and often called RYGB—with about 140,000 such surgeries performed in the United States in 2005, it is the most popular form of WLS), and laparoscopic adjustable gastric banding (referred to as Lap-Banding).

An additional procedure, the vertical gastrectomy (known as VG), does not utilize malabsorption in weight loss. No portion of the intestines is bypassed but 90 percent of the small intestine is removed, reducing the amount the patient can initially eat to about two ounces, expanding as time goes on to about six ounces. There are only fifteen certified surgeons in the world performing this procedure.

All of this is big business. The cost of gastric bypass runs between eighteen and twenty-two thousand dollars for hospitalization, surgeon, and anesthesiologist’s fees. Insurance companies are loath to hand out weight-loss surgeries but are persuadable if the surgeon documents the patient’s medical need for it. Reconstructive surgery, nutrition counseling, and supplements,
⁹⁰
psychotherapy, and exercise costs load on more expense, much of it not covered by insurers. A typical, high-end tummy tuck, for instance, can amount to more than fifteen thousand dollars, and may be combined with a body lift that ranges from twelve to fifty thousand. She may also need or want face (six to fifteen thousand) and breast lifts (three to six thousand), and liposuction.
⁹¹
An RYGB patient can spend up to sixty-six thousand dollars in surgical procedures when these fees are averaged. That’s over nine million dollars a year in Roux-en-Y and skin reduction costs alone.

Bariatric surgery is a boomtown for surgeons, “the only general surgical procedure…for which practitioners actively advertise.”
⁹²
With stakes like that, the medical community promotes WLS as almost foolproof. It’s not surprising, then, that finding hard data on the risks of surgery is not an easy task.

One such study was conducted by a team from the University of Massachusetts Medical School on a pool of 188 RYGB patients. In the year following their surgeries, fifty of them had complications severe enough that a second surgery was required. Two patients died. The study concluded that sleep apnea, hypertension, and surgical inexperience were predictors of future complications.
⁹³

There is also ample evidence of nutritionally compromised spinal cords, peripheral nerve damage, and brain complications that can set in from two weeks to several years after surgery. These neurologic complications seem to result from the lack of thiamine, copper, and vitamin B12 absorption from food.
⁹⁴
Complications, running from leaks to hernias, various infections, and increased chances of developing kidney stones, add yet more expense.

For all surgeries, weight loss peaks at twelve to eighteen months, at which time there is usually a ten-to fifteen-pound weight gain because that palm-sized pouch has stretched to the size of two cupped hands. A significant portion of WLS patients manage to stretch their pouch, despite dumping,
⁹⁵
enough that as many as 10 percent of WLS patients return to their original weight after two years, and almost 30 percent of some WLS procedures produce no maintained weight loss at all.
⁹⁶
Gina Kolata notes that despite large losses, most patients remain above the demarcation line of obesity, a BMI of 30.
⁹⁷

Part of insurers’ criteria for the surgery is proof that no other weight management program will work for the individual. All WLS patients are many-times-over failures before they meet their anesthesiologist. The women I spoke to for this book take their past failures as serious warnings of what could begin at any moment, and all of them have witnessed failures from their surgical groups. Even with weight-loss surgery, they worry that they’ll fail. Bariatric surgery is no guarantee of permanent weight loss. I met two women, Cynthia and Karen, for whom their Lap-Bands ultimately failed.

The introductory literature WLS candidates receive must state that the contemplated procedure is a tool, not a cure, because Karen, Cynthia, and Katie have all used the phrase.

Seven years ago, at the age of twenty-four, Karen dropped a hundred pounds to 145 on a low-carbohydrate diet. The change was so dramatic that her law school classmates thought she was a transfer student when she returned for their second year. A terrible first boss sent her back to chocolate, and her weight skyrocketed to 274 pounds. Karen met her husband at 145 pounds and he proposed to her 130 pounds later but she worried that he loved her
despite
her weight.

That was why she decided to have surgery, and she has regretted it ever since. After Lap-Band, she’s gone from 274 (BMI 44) pounds to 171 (BMI 27.4) then up to 230 and down to 170. With the band too tight for the salads and proteins she considered proper weight-loss food, she woke up choking with reflux in the middle of the night and had stuck to “squishy” foods since. In her third upswing in as many years, she weighed 224 pounds. “I wasn’t aware of the complications of eating,” she said. Karen eventually joined Overeaters Anonymous, giving up sugar and white flour. Her Lap-Band slipped and she had to have it removed.

“People can use [the surgery] and lose weight or go back to their old lifestyle and try later,” Cynthia observed. She knows this from her own experience.

Failure is easy with the move, after a couple of weeks, from protein shakes to soft foods such as milk shakes or mashed potatoes and gravy. Because of the interim soft-food diet, Cynthia didn’t change the method of how she ate. The move to whole food, which she wolfed in her customary manner, made her violently ill. “I’d be out at a restaurant and have two or three bites, get up, and vomit. Mom called the band my choke chain around my stomach. If it was liquid, I could eat a gallon, but after a bite or two of substance, I was done. And it would hurt.” And so she ate the gallon of liquid, and her initial weight of 280 pounds dropped to 230 in the first six postoperative months and stayed there.

Frustrated with her Lap-Band failure, a year and a half later, she underwent vertical gastrectomy and had 90 percent of her stomach removed, including the portion that produces gherlin, one of the hormones that tells the brain we’re hungry. (This is perhaps the only aspect of any of the surgeries I personally envy. Oh, to be released from hunger!) Unlike the other surgeries, the VG doesn’t rearrange the stomach, so there is less propensity to dumping and nausea. This aspect of the surgery, Cynthia said, “puts the responsibility squarely on the patient’s shoulders. Your body isn’t going to punish you for what or the way you eat.” In the eighteen months since the surgery, she has dropped from 230 to 140 pounds and is working toward a goal of 125 pounds.

The costs are enormous. Cynthia had two surgeries and body-lift surgery,
⁹⁸
which she wanted in order to better unite the thin girl walking down the street with the girl on the beach or in the bedroom. No matter how great she looked clothed, the apron of excess skin on her stomach and sagging breasts made her reluctant to show herself beyond a certain stage of undress. Her marriage was also part of the price of the surgeries. “My husband married a morbidly obese girl, and that’s what made sense in his world.” Add in the cost of a divorce.

Vertical gastrectomy sounds infallible, but it’s had its failures. Worried after her failure with her Lap-Band, Cynthia asked her doctor if anyone ever bombed out on the new procedure. He told her he’d had two patients who never lost a pound. “It is possible to sabotage any surgery if you are determined, I guess,” she said ruefully.

But there are far more success stories than failures. Betsy’s bottom came when she could no longer look at herself in the mirror, even from the neck up. “I was so unhealthy, on so many medications for high blood pressure and high cholesterol. I couldn’t get out of bed in the morning. I hated life, hated myself. I couldn’t white-knuckle through Weight Watchers one more time. Surgery was my last chance in life.” The cost for her was mortgaging her house when, as a single parent, she had two kids in college.

The mortgage was her weapon in making her Lap-Band surgery work. “I went in with the attitude that it was sixteen thousand dollars out of my pocket—I make a penny scream, I pinch it so hard. Maybe people who don’t have to mortgage their house don’t have to commit to the process.”

Lap-Band is the least invasive procedure, but it often requires several follow-ups to get the right “fit” of the Silastic Ring around the newly created stomach pouch. Betsy had three saline “fills” through the port to get the correct feeling of restriction.

One of the ironies of most of the weight-loss surgeries is that what we think of as “diet” food is nearly impossible to eat. Raw vegetables, salads, dense proteins such as meat, sugar-free soda, and caffeine all cause a suffocating panic from the food getting stuck. Betsy said she either vomited or the food would eventually go down, but the experience was terrifying.

One of the reasons that Em, Karen, Cynthia, and Betsy were willing to discuss the reality of their experiences is that it was, simply, a chance to talk. Most bariatric surgery centers have patient groups, but they were, according to Betsy and Cynthia, so full of newbies that it was tough to talk about raw versus baked apples or being with a new friend who made a nasty comment about a fatso walking down the street.