WEIGHT PROBLEM

Originally published in Boston Magazine.

By Jake Halpern

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At first glance, the scene looks like a 30th high schoolreunion—balding men in golf shirts mixing with middle-aged women ineveningwear sipping drinks and chatting amiably in a garish banquetroom in Braintree—but then someone turns on a microphone. “My name isJody,” announces a short woman with spiky black hair and heavyeyeliner, “and I have lost 250 pounds.” There is polite applause andJody passes the microphone to Linda, who declares that she has lost 165pounds. Next comes Dave, who announces that he has lost 280 pounds,which is roughly equal to the weight of two tractor-trailer tires.

Gradually the microphone makes it around the room, as all the gueststake turns announcing their names and the amount of weight they'veshed. When this is done, the master of ceremonies—a woman in her 30snamed Marie Desjardin who has lost 142 pounds—explains that there willbe a contest in which everyone has to guess the total number of poundsthat have been lost. An excited murmur ripples through the crowd. Afterall the guesses are submitted, Marie clears her throat and announcesinto the microphone: “We have lost a grand total of 9,201 pounds.” Morethan four and a half tons.

“Holy shit!” gasps an elderly woman at the far end of the room.

“Yes,” replies Marie. “And the winner is . . . “—there is a dramatic pause—”. . . Evan, who guessed 8,437 pounds.”

The crowd breaks into a boisterous round of applause.

As it turns out, these 9,201 pounds were lost not through Atkins orSouth Beach, or even good old-fashioned exercise, but through surgery,which virtually everyone in the room has undergone. Boston has becomean international capital of weight-loss surgery, bringing in a steadyflow of cash to many of the area's financially ailing hospitals.Although surgeons have been stapling stomachs since the 1960s, theprocedure has become exponentially more popular within the past fewyears, and many patients who've been through it are finding their wayto support groups like this one.

Tonight's event is sponsored by the Friends of Weight-Loss Surgery,or FWLS, a Boston-based group that gathers once or twice a year for aretreat. Typically, FWLS retreats include a big Saturday night gala.Before the hard partying begins, however, there is usually a speakerwho talks about the psychological challenges of the surgery or themedical complications it can cause. Tonight's speaker is Kymber Estes.

Kymber's story is, from start to finish, a worst-case scenario, andas she begins to tell it, the giddy excitement in the banquet roomrecedes into silence. “After my surgery, I was in a coma for 17 days,”Kymber says almost casually. “I had major complications includingsepsis, peritonitis, pneumonia, two blood clots in my neck, and an openincision for a year because it was infected and they couldn't seal itup.” As if all this weren't bad enough, the staples in Kymber's stomachhad given way and she was now scheduled for a nine-hour “re-do”operation that her doctors told her would be very dangerous. “When I goin for surgery on Wednesday, the doctor is trying to save my life,”Kymber says. “I've done my living will and, if you don't have one, youall need to do it.” Kymber pauses to regain her composure. “Anyway . .. ,” she stammers, “this is the time for us to be the divas that weare—no matter who laughed at us or made fun of us in the past.”

If Kymber's experience were a freak occurrence, her story might beeasily dismissed. It's not. A University of Washington study, the firstto look at gastric-bypass survival beyond hospitalization, reports that1.9 percent of patients die within 30 days of the procedure. As many as20 percent experience complications, and some of them require secondoperations, which are typically much more risky. Nonetheless, for manyprospective patients, the desire to be thin is so dire that it trumpsany concerns about the dangers.

Midway through the FWLS dinner, I get to talking with 21-year-oldSarah Roberge from Manchester, New Hampshire, one of the very few“pre-ops” in attendance. In the world of weight-loss surgery, thepre-ops are the newbies, the people who haven't had their operationsyet. Sarah weighs 342 pounds. “I hope to lose about 170 pounds, andthat would put me at a normal weight for someone my age and height.Anything would be better than now,” Sarah says.

“Being just 21 years old, it is hard to think that guys—it's hard tosay this—guys don't look at me,” Sarah says, swallowing hard. “And Ifeel like I am missing out on that companionship. I have also had toput other dreams on hold. I wanted to be an ichthyologist and studyfish, but because of my size I could never scuba-dive.”

When I ask Sarah how long she has been struggling with losingweight, she replies that it has been an issue since the second grade.“It was tough as a kid,” says Sarah. “I remember being picked onhorribly—like, I had a red winter jacket and the kids used to call me'Mrs. Claus.' So I tried to watch the calories, I tried Slim-Fast, Itried Sweatin' to the Oldies, but it didn't happen. And ifyou are overweight it's harder to exercise. I get hot much more easily.I have terrible joint problems in my ankles, knees, and hips. Evenwalking half a block to work would give me terrible muscle pains in mythighs.”

Sarah stares longingly out toward the center of the room, where someof the post-ops have begun to dance to a Van Morrison song. “Could youever see yourself out there?” I ask her finally.

“I'm not very coordinated,” Sarah says softly, almost inaudibly. “But I could see myself giving it a try.”

“Are you worried about the surgery?”

“Kymber's speech scares me,” she replies with a slight nod. “Itmakes me realize that I want to tell everybody who means something tome that they do, because I might not get a chance to later on.” Sarahpauses and then concedes—rather uneasily—that this surgery could endvery badly. “But that doesn't scare me to the point where I don't wantto do it,” she adds quickly. “This surgery is kind of the last chancefor me to have a life.”

Not long after m y e vening in Braintree, I pay avisit to Dr. Edward Mun, a bariatric surgeon at Faulkner Hospital andan assistant professor at Harvard Medical School who has performedweight-loss surgery on hundreds of patients, including one of thepeople I had met at the FWLS dinner. According to Dr. Mun, weight-losssurgery is quickly gaining popularity, not just with patients but withsurgeons. “If you are going to be a surgeon, you want to make sure youhave enough cases, which is how surgeons make money,” he saysmatter-of-factly. “Many surgeons who are in stiff competition for colonor hernia operations may find that this is a field with an unlimitednumber of patients.” Why unlimited? Because, as Dr. Mun is quick topoint out, with America in the midst of an obesity epidemic, there is aseemingly inexhaustible supply of grossly overweight people.

Dr. Mun leads me down the hallway to the surgical ward, where wemeet one of these patients: a plainly obese, middle-aged woman namedTina, who is sitting by herself in a formless blue gown, waiting forher operation. When I ask how she feels about her imminent procedure,she forces a meager smile and responds that she is looking forward to anew life, one in which she can walk around, play with her kids, and getinto her clothing without a major ordeal. “I don't expect miracles,”Tina adds softly. “I am not going to be Cindy Crawford.”

Half an hour later, I get into scrubs and join Dr. Mun in theoperating room as he cuts into Tina's flesh and inserts a device calleda harmonic scalpel into her body cavity. Standing nearby is a wide-eyedmedical student, who has thrust a small surgical camera into anotherincision in Tina's belly. This camera is connected to two televisionmonitors that are now displaying Tina's intestines, which, when viewedclosely, resemble a slopping pile of uncooked chicken tenders. Usingthe harmonic scalpel, Dr. Mun presses into the thick of this and startscutting away. A nurse appears to yawn. Someone else flicks on a boombox, which is soon playing Ray Charles's Georgia on My Mind. It's another day in weight-loss-surgery land.

If the atmosphere in the operating room seems humdrum, it might bebecause Dr. Mun typically does three to four weight-loss surgeries aday. And he isn't the only Boston doctor staying so busy. The number ofweight-loss surgeries has increased nearly 500 percent in the past fiveyears, according to the American Society for Bariatric Surgery. InMassachusetts the number has jumped from 630 such surgeries in 1999 to3,036 last year. This means there are now about 60 people undergoingthis surgery every week in this state.

Bariatric surgery has a long history in Boston. Dr. GeorgeBlackburn, who began his career as a bariatric surgeon at DeaconessHospital more than 30 years ago, is considered one of the grandfathersof the field. The reason you may not know this—the reason many peopledon't know this—is that the field itself has not been particularly wellrespected within medical circles. “Unfortunately people have theimpression of weight-loss surgery being merely cosmetic,” says Dr.Malcolm Robinson, who runs Brigham and Women's Hospital's Program forWeight Management. “Then you have celebrities like Al Roker who've hadthe surgery and are embarrassed about it. I had a patient justyesterday who has still not told her family anything about thesurgery—she didn't even want me to call them—because she is ashamed.Society still has a significant bias against obese people. Even 10years ago people would make very derogatory remarks, not just about thepatients, but about the surgeons.” But times are changing. Nowadays,says Dr. Robinson, the stigma is waning and his is quickly becoming“one of the hottest fields in surgery.”

One reason the industry is taking off is that insurance companiesare starting to pay for the surgeries. Blue Cross Blue Shield ofMassachusetts will typically shell out $12,000 to $18,000 to a hospitalto cover the cost of one gastric-bypass surgery. Exactly how much ofthis is profit depends on how efficient the doctors are. If they use aminimum of staples and nail the procedure on the first try, it can beextremely lucrative.

For insurers, the business advantages are clear. The average annualcost of treating an obese person in 2002 was $1,244 more than the costof treating a person of healthy weight. This means that within the spanof 10 or 15 years an insurer would theoretically make back its“investment” and possibly then some.

All of this is good news for struggling hospitals. To begin with,the procedures themselves are elective, which allows the hospitals towait and verify a patient's insurance coverage, cash a personal check,or line up some other means of financing. On top of this, many patientsalso require plastic surgery to remove their excess skin, and this,too, can be quite profitable for hospitals. “Bariatric surgery is thecurrent gold rush in medicine,” says Roland Sturm, a senior economistat the RAND Corporation, who has been studying obesity in America. “Andno hospital or doctor wants to be left behind.”

Weight-loss surgery has actually saved at least one hospital fromfinancial ruin. Durham Regional Hospital in North Carolina, which lostmore than $26 million between 1999 and 2002, reportedly turned itselfaround by building up a highly profitable weight-loss surgery programthat helped generate a net operating income of more than $8 millionlast year. In the healthcare business, this kind of rags-to-richesstory doesn't go unnoticed. At Boston's Brigham and Women's, the DurhamRegional turnaround raised eyebrows. Dr. Robinson was among those whotook notice. “I hate to turn a critical health issue into a businessplan,” he says, “but there is a chance for this to be a moneymaker ifthe doctors are providing quality care.”

It would be an especially attractive proposition for many communityhospitals that are financially on the ropes. Dr. Scott Shikora, whoruns the New England Medical Center's surgical weight-loss program,says he has been approached by other hospitals that are looking to getin on the boom. “I often hear hospital administrators talk aboutservices as product lines, and bariatrics, where there is a largepotential for patients, is a very hot product line right now,” Shikorasays.

One problem is that some of these community hospitals are illequipped to run safe weight-loss surgery programs. Last year, forexample, a 38-year-old woman named Dawnmarie Fernandes died just 11days after undergoing gastric-bypass surgery at Saint Anne's Hospitalin Fall River. According to relatives, Fernandes's primary-carephysician warned her that her failing health made her a poor candidatefor the surgery. She underwent the procedure anyway at Saint Anne's,and soon after met her death. Stories like this one prompted theMassachusetts Board of Registration in Medicine to conduct a study,which found, among other things, that there had been 16weight-loss-surgery-related deaths in the state between March 2003 andOctober 2004.

In light of all this, Roland Sturm's “gold rush” analogy seems quiteaccurate, but perhaps the community hospitals aren't entirely to blame.We live in a country that loves quick fixes—whether it's get-rich-quickpyramid schemes, get-happy-quick pharmaceuticals, or lose-weight-quicksurgeries. What's more, we're obsessed with being thin. This, Isuspect, creates a certain amount of desperation. For me, this notionreally hits home during a conversation I have with Dr. Mun's patient,Tina. “My husband wanted me to lose weight normally,” Tina tells mejust before she's wheeled off for her surgery. “But it wasn't happeningand now he thinks this is okay because he cannot stand to look at me.”

Even if Tina's surgery is a success and she becomes thinner than sheever dreamed, it might not solve her marital problems. In fact it mightexacerbate them. Divorce rates are very high among patients who havehad significant weight loss. I hear this not just from medical expertsbut from many of the “post-ops” I meet at the FWLS dinner in Braintree.As one woman puts it: “There are several of us who have lostweight—which gets your self-esteem up—and the husbands don't like itbecause suddenly you are not willing to sit back and be a nobodyanymore.”

Post-ops are prone to feeling angry at colleagues or family memberswho treated them poorly when they were obese. Dr. Robinson, at Brighamand Women's, describes many of his patients' mindsets this way: “Theirfeeling is, 'At 300 pounds people treated me like dirt, and now that Iam 150 pounds, instead of treating me like dirt, you are treating melike a person—which you should have done all along!'” This, among otherreasons, is why groups like Friends of Weight-Loss Surgery have begunto sprout up in Boston and elsewhere. In many ways, the real benefit ofthese gatherings—beyond the emotional support they offer—is the chanceto step gingerly into the world of thin people and enjoy the newfoundpleasures of dressing up, dancing, flirting, and generally having agood time.

During the FWLS dinner, I see this for myself when the dance partygets under way. After a dessert of fruit is served, the DJ flicks onhis equipment and the room's speakers rumble to life with the song“Celebration,” whose lyrics exhort everyone to “Celebrate good times,come on!” There's a sudden rustling of dresses, and moments later thedance floor is packed with undulating female bodies. The only lingeringtraces of obesity are the flaps of excess skin hanging from some of thewomen's arms. “We call those 'wings,'” explains Marie Desjardin. “Ilike to say that I could go to Timbuktu and back with mine. But that iswhat is so great about tonight. You will see people take off theirjackets, and six inches of skin hangs off. And I would never do that inpublic.

“We are generally people who did not go to our proms,” Mariecontinues. “I was 300 pounds in high school and I was too large to beasked to my prom. So this is our chance to dress up to the nines,dance, dine, and party.”

For some of the evening's revelers, dressing up goes beyond justgetting a new set of clothes. “I recently got contact lenses, had mytop teeth whitened, and had surgery to remove the excess skin from myabdomen,” says Jerry Cohen, who lost 185 pounds and is one of the fewmen at the dinner. “I'd considered hair transplants, but decidedagainst it.”

According to Jerry, this event is downright tame compared with someof the others he has attended. When I press him for details, hedescribes a rowdy three-day bacchanalia, which included drunkenrevelry, lingerie shopping, adultery, and a night out at a strip club.“You have all of these people who have been kind of repressed andisolated their whole lives, and suddenly they have these new bodies andthey want to try a lot of things they missed out on,” he explains.“They just let it out in one weekend.”

At the Braintree dinner, though it never gets truly out of hand,even I can sense the raw pulse of renewed life surging through theplace as the women dance into the night—smiling, swaying, whooping,hollering, pounding the floor with their shoes, and embracing eachother as their mascara runs with tears and sweat.

Perhaps no one is more struck by this than Sarah Roberge, the21-year-old pre-op. “To me that night was incredible,” Sarah laterrecalls for me. “I was astounded to see how lively these people were.They were living to the fullest.”

Sarah finally had the surgery herself. By her one-month post-opappointment she had lost 16 pounds. She has since lost 74 more. Shesays she already feels more hopeful. One source of her hope is hermother, who had weight-loss surgery herself a few years ago. “Mom saysthat people treat her differently now,” says Sarah. “They don't look ather with pity or disdain. I look forward to that.” “, “

Research assistance by Brian Bowen.