2522. Bariatric Surgery for Extreme Obesity: What Can Be Leaned about Human Body

By Gina Kolata, The New York Times, December 27, 2016

Jessica Shapiro, second from left, talking to Keith Oleszkowicz at their doctor’s office the month before their surgeries, Credit Michael F. McElroy for The New York Times. 

Editor's Note:  This article is an excellent example of medical journalism for its case study design.  If anyone is interested in bariatric surgery this article should be among her/his required readings.  But I post it here for an additional contribution it makes--to document through case study of two patients how a gastrointestinal surgery can change the body's make up on the most fundamental levels resulting in a change in who the patients are and how their behavior change.  In the late 1980s and early 1990s, in my political economy seminars for first year and second year medical students at the State University of New York-Health Science Center at Brooklyn (SUNY-HSCB), I often spent a two-hour seminar session on the discussion of conceptions of health and various theories of illness.   My hope was to encourage the students to consider the multidimensional determinant of them.  A central conclusion was that the body is an integral bio-social organism and not a sum total of it anatomical parts. The more we learn about the human body and its functions the more that discussion seems important to have not only for medical students and professionals but also for the rest of us.  This is the part of what follows that I urge the reader to focus on.  There are many more recent example.  In the previous post we learn from new research that the brain changes as the result of pregnancy.   KN

*     *     *

It was Oct. 11, 2015, and a middle-aged man and a young woman, both severely obese, were struggling with the same lump-in-the-throat feeling. The next day they were going to have an irreversible operation. Were they on the threshold of a new beginning or a terrible mistake?

They were strangers, scheduled for back-to-back bariatric surgery at the University of Michigan with the same doctor. He would cut away most of their stomachs and reroute their small intestines. They were almost certain to lose much of their excess weight. But despite the drastic surgery, their doctor told them it was unlikely that they would ever be thin.

Nearly 200,000 Americans have bariatric surgery each year. Yet far more — an estimated 24 million — are heavy enough to qualify for the operation, and many of them are struggling with whether to have such a radical treatment, the only one that leads to profound and lasting weight loss for virtually everyone who has it.

Most people believe that the operation simply forces people to eat less by making their stomachs smaller, but scientists have discovered that it actually causes profound changes in patients’ physiology, altering the activity of thousands of genes in the human body as well as the complex hormonal signaling from the gut to the brain.

Over the last year, I followed Keith Oleszkowicz and Jessica Shapiro — a computer programmer and a college student — from their surgeries through the transformations that followed. The operation, increasingly common as obesity threatens the health of millions of Americans, changes not just the bodies of those who have it, but also their lives: how they see themselves and how they relate to their romantic partners, co-workers and families.

As the pounds fell away in a society that harshly judges fat people, Keith and Jessica, two ordinary Americans, would go through an extraordinary experience, one that brought both joys and disappointments.

Jessica, 22, lived with her mother and grandmother in Ann Arbor, Mich., and worked at Panera Bread preparing food. At 5-foot-3 and 295 pounds, she had a difficult life. She needed a seatbelt extender on airplanes. She was unable to cross her legs. She had acid reflux and mild sleep apnea, which meant she woke up at night about seven times an hour.

A doctor told her something that shook her: “You are only 22, but your body is much older than you are.”

Even worse were the constant struggles of being fat in today’s society. She never had a date and no man ever seemed interested in her. Total strangers lectured her on how to eat. And she suffered unexpected humiliations, like when she went to an amusement park with friends and the ride attendant pulled her aside and asked her to try pulling the safety bar over her stomach. It didn’t fit, and he turned her away.

“Every day of my life, I’m just aware of how overweight I am,” she told me as she sipped a cup of water at a Starbucks near her home.

She tried programs like Weight Watchers, but her urge to eat, as powerful as the urge to breathe when holding your breath, defeated her. It is a drive, obesity researchers say, that people who have never felt it find hard to fathom.

“It’s like a physical need,” Jessica said. “It’s not just a longing or just a passing urge.” It is, she said, “like a kind of hunger that like kind of claws at you from the inside out.”

The surgery, she said, “is a last resort for me.”

Keith’s circumstances were a bit different. He was 40, married with a teenage son, and worked as a programmer at a big automaker. His wife, Christa, had had the operation two years before, after pondering it for nine years. She lost 143 pounds and felt that her life had been transformed.

Keith’s older brother had had the surgery, too, 16 years earlier, at a time when many doctors were splitting patients open instead of doing the surgery laparoscopically as they do today. The complication rate was much higher at that time, and the death rate at one year after surgery was 4.6 percent, verging on unacceptable.

“We were not in a good place then,” Dr. Amir Ghaferi, a bariatric surgeon at the University of Michigan, told me. The one-year mortality rate today is 0.1 percent, safer than gallbladder surgery or a joint replacement.

Keith, at 5-foot-9 and 377 pounds, was not as fat as his brother had been, but he was having physical and medical problems. He somewhat hesitantly listed some of them: His joints hurt; moving around was an effort; he could not bend down to tie his shoes; he had sleep apnea and had to use a continuous positive airway pressure machine to push air into his lungs when he slept; he had high blood pressure.

He had lost 10, 20, 30, even 40 pounds at a time over the years with various diets, but he was plagued with insatiable urges to eat. The weight always came back.

“I’ve tried everything I can,” Keith said.

But, he stressed, it is not as hard for a guy to be fat as it is for a woman. And he’s right. Researchers have found that there is more prejudice against fat women than against fat men. Still, Keith suffered many indignities.

As a child, he was teased and became so ashamed of his body that he could not bring himself to undress for gym class. So he wore his shorts and T-shirt under his school clothes and spent the rest of the day with those sweaty clothes underneath. He even had his own amusement park moment, at the same place, Cedar Point in Ohio, where Jessica had been embarrassed.

Yet he had a hard time committing to the surgery. It was such a big step, and once it was done, there was no going back.

In the end, it was Keith’s son who tipped the balance. “I don’t want you to die, Dad,” he told him one day when the two were playing video games. He looked up at Keith, saying, “Dad, we need to do something.”

The Operation

By the day of their surgeries, Oct. 12, 2015, Jessica and Keith had spent months preparing.

They had had medical and psychological tests. They went to counseling and mandatory sessions explaining what was going to happen, and what to expect and how to eat afterward.

They learned that the gastric bypass operation both had chosen (it and a procedure called the gastric sleeve are the two main options) leaves patients unable to absorb some vitamins and minerals. They would need to take supplements daily for the rest of their lives. And because the rearranged digestive tracts can dump sugar into the bloodstream too quickly, they would have to be careful about sugar intake or risk “dumping syndrome,” which can cause vomiting, sweating and shakiness.

For two weeks before the surgery, Jessica and Keith followed a high-protein liquid diet to shrink their livers. People with obesity often have large, fatty livers that can get in the way during the operation.

The day before, Jessica stood at her kitchen counter preparing a mango protein shake with mango flavored Crystal Light and protein powder. It smelled foul. She forced herself to swallow it.

“I am excited,” she said.

At 6:30 the next morning, a nurse and a surgical resident wheeled Jessica into an operating room on a special wide gurney. They slid her onto an operating table that was set as low as it could go because bariatric patients’ abdomens rise high, as if they were domes.

The surgeon, Dr. Oliver Varban, started by inflating Jessica’s abdomen with carbon dioxide to give him more room to work. Then he made seven small holes in her skin and inserted his equipment, including a cylindrical tube containing a tiny light to illuminate her abdominal cavity, lenses, mirrors and a tiny camera to project the scene on a computer monitor above Jessica’s head. The screen showed gleaming golden bubbles of fat that were surprisingly beautiful.

Dr. Varban used what looked like a miniature table tennis paddle to push Jessica’s liver aside and give him a clear view of her stomach. Her intestines were obscured by fat, so he used a special surgical grasper to gently push the fat aside.

It might seem reasonable for Dr. Varban to simply remove some of the fat from Jessica’s abdomen, but doing that, he said, would result in a bloody, hemorrhaging mess. He explained that there is a mile of blood vessels in every pound of fat.

Dr. Varban cut off most of Jessica’s pink and healthy stomach, leaving a pouch the size of an egg. He stapled and sealed the pouch with a device that looked like a saw-toothed pair of shears, leaving a shiny metallic edge of staples. Then he grabbed the top of her small intestine and attached it to the stomach pouch.

A couple of hours later, he was done and it was Keith’s turn. The operation was the same, but Keith’s fat looked different, more yellow than golden, and lumpy. And there was much more of it — his organs were buried in it. Men tend to have thicker abdominal fat, Dr. Varban said, and it is slipperier, harder to grasp with the laparoscopic instruments.

Jessica and Keith spent two nights in the hospital and then were discharged, with instructions to follow a liquid diet for a couple of weeks and then gradually add solid foods.

Jessica was surprised by the pain. When she was home, recuperating, she started to have second thoughts about the surgery. One day, she sat down and cried.

“I had like this awful buyer’s remorse,” she said. “I was like, ‘What did I do to my body?’ This is not reversible, there is no going back.”

Improving the Technique

For years, surgeons thought weight-loss operations worked because they made the stomach so small that it hardly held any food. And with the bypass operation, they made it even harder for food to be digested. Of course patients lost weight.

But some things just did not add up.

A simple surgical treatment, the gastric band, which constricts the stomach, was widely used when it was first approved in 2011 but fell out of favor because its effects on weight were variable and almost always smaller than those of the other operations. It still is used (New Jersey’s governor, Chris Christie, had one), but it now accounts for just 5.7 percent of weight-loss surgeries.

At a recent meeting of Michigan bariatric surgeons, one doctor asked for a show of hands. Who in the room would refuse to do a gastric band procedure even if a patient asked for it? Just about every hand in the room went up.

“The most common operation with the band now is an operation to remove it,” Dr. Varban said.

Even leaving aside the gastric band issue, the idea that the bypass and sleeve surgeries were a mechanical fix, by limiting the amount of food a patient could eat, did not seem right.

Wiring people’s jaws shut would keep them from eating, noted Randy Seeley, who holds a doctorate in psychology and is a professor of surgery at the University of Michigan. But, he asked rhetorically, “If I wired your jaw shut, would you be more hungry or less hungry?”

In contrast, patients who had bypass and sleeve operations reported that they were not particularly hungry afterward, and that their incessant urges to eat vanished. Even more surprising, their taste for food often changed.

Dr. Lee Kaplan, an obesity researcher at Massachusetts General Hospital, recalled a patient who asked him: “Are you sure they didn’t operate on my brain? Food does not call out to me anymore.”

Another, who used to seek fatty and sugary foods, said, “I crave salads now.”

Dr. Justin Dimick, a bariatric surgeon at the University of Michigan, said a woman who lost 200 pounds told him that before the operation, a Reese’s peanut butter cup gave her such a rush that it was, she said, “like an orgasm of pleasure in my brain.” Now, she said: “It’s just peanut butter and chocolate. What’s the big deal?”

Experimental data support these reports. Both patients and rodents who had surgery are actually more sensitive to the taste of sweets: Receptors on their tongues detect smaller amounts of sucrose.

The data, the patients’ stories, made no sense if all surgery did was make it harder to eat, Dr. Kaplan said. Both the bypass and sleeve operations, he added, “drive the body to want to eat less.”

But why?

Some, including Dr. Seeley and Dr. Kaplan, looked for answers by studying the surgeries in fat rats and mice.

“What you find very quickly is that rats and mice lose weight just the way you see in humans,” Dr. Seeley said. “It’s remarkable.” Surgery changed the weight the animals’ bodies settled into. And, as with patients, their tastes in food changed.

For example, Dr. Seeley gave some rodents the exact bariatric surgery operation that humans get while he gave others, which served as controls, sham surgery: Researchers opened the animals’ abdomens and then sewed them shut. The bariatric surgery animals lost most of their excess weight and then stabilized at a lower weight.

Then the researchers put all the rodents on a diet. All lost weight.

Three weeks later, the animals were given as much food as they wanted. Those that had had the sham operation ate until they were back to their original weights. Those that had had the real bariatric surgery ate until they reached their post-surgery weight.

“Surgeons often talk about bariatric surgery as a tool. You have to follow all these instructions,” Dr. Seeley said. It only works, they tell patients, if they follow a diet and exercise program.

“My message is that the rats don’t appear to do it that way. They don’t know it’s a tool. They just naturally change lots of things in the way they relate to food.”

Three Months Later

After plummeting soon after the operation, Jessica’s weight began to fall more slowly. By January she had lost 65 pounds.

It showed. She moved more briskly and met me wearing a black elastic belt over a loose top. “I have a waist!” she exclaimed.

Her predicted final weight is 180 pounds, based on a statewide database of nearly 70,000 bariatric operations by 80 surgeons in Michigan. Doctors use it to calculate what a person Jessica’s age and starting weight can expect to weigh a year after the operation, when nearly all the weight loss will have occurred.

But her goal is to weigh 130 or 140, and she plans to diet to get there if the surgery does not do it for her.

Almost all patients have such vows, her surgeon, Dr. Varban, says. But they rarely succeed in losing more weight and keeping it off. The surgery resets their weight at a lower level, but it is just as hard to lose more than that as it was to lose weight before the surgery.

Still, Jessica did not crave food like she used to; some days she actually forgot to eat, she said. She was not counting calories or consciously trying to diet, but the weight came off. She still got hungry but was quickly satiated.

Yet surprisingly little had changed in her life. She had returned to community college after taking a semester off and her typical day was “the same as before,” she said. “I go to school or do homework. On days I don’t have school, I sleep or stay up late and watch shows or read into the night, from midnight until 5 a.m.”

She knew she was thinner, but she said: “I feel like the change isn’t dramatic enough. I look at myself and still see fat.”

Keith had lost 80 pounds by the time I visited in January. His sleep apnea was gone; he didn’t even snore anymore. His blood pressure dropped to normal before he left the hospital and stayed normal; before surgery he had been taking two drugs to control it.

He dropped 10 pants sizes — from 58 to 48. Even his shoe size shrank. His legs and knees did not hurt anymore.

And his eating habits were transformed.

“I used to crave pizza like crazy,” he said. He doesn’t like it anymore. It’s too heavy, too greasy.

Same with White Castle hamburgers, which he used to lust after. One day, on his way home from work, he bought a bag. Somehow, they didn’t smell appetizing. He took a bite. He did not like the taste.

“I don’t have to worry about White Castle hamburgers anymore,” Keith said.

But he, too, still thinks of himself as fat.

Keith knew he should exercise, although he never liked it. On a bright winter Saturday, I went with him to the gym. He stepped onto a treadmill and started to walk, going two miles at a pace of three miles an hour, sweating at the end, breathing a bit hard. Before surgery, walking on a treadmill for one mile at a pace of two miles an hour was a huge effort. We followed the treadmill with a one-mile walk on the gym’s indoor track.

Keith did not change into workout clothes at the gym, remaining in jeans (that were now loose) and a polo shirt. When I asked him why, as we drove away, he told me it must be a remnant of his school days when he did not change for gym class. Being fat stays with him.

“I have a fat brain,” he said.

Eight Months Later

One day in June, Jessica walked into the Ann Arbor Panera Bread where she had worked before her surgery, 90 pounds thinner than her peak weight of 295 pounds. She had cut her hair short and wore a glittery black scarf as a headband.

She ordered a turkey and cheese sandwich, a kids’ yogurt and a bottle of water. She ate slowly, as though hunger were an afterthought.

As the pounds dropped, she had become a bit more daring.

She even ventured onto OkCupid, an online matchmaking site, posting a couple of selfies. She got 30 likes and a few messages. But after six hours, she deleted her account.

“It was weird and it wasn’t me,” she said. She worried when one guy wrote, “Hey, want to have fun?” Another guy, she said, “seemed all right but then he started asking about sex and things.”

Still, she said, the experience “was definitely a confidence booster.”

When I visited Keith the same weekend, he had lost 93 pounds and was down to 277. But his weight loss had stalled, and he worried because his goal was to weigh 210. He wondered if he would even reach his projected weight of 230.

But he, too, had noticed some big changes. He mulched his front yard in a day. Before surgery, he said, it would have taken a couple of weeks. His back did not ache; his knees were not sore.

Keith’s weight loss, Christa said, “has definitely changed our relationship, in a good way.” He used to slouch on the sofa when he was off from work, too tired to accompany Christa on errands. Now, she said, “if I need to go to the store, Keith says, ‘Want me to come with you?’”

On that sunny June Saturday, I accompanied Keith, Christa and their son on a trip to Zingerman’s, a famous Ann Arbor deli. Keith’s jeans, size 44, had fit when he bought them a month earlier, but they were already loose. Christa and I watched as he tried samples of soft cheeses, seeking one with just the right tang. The other customers paid no attention, a big change from the presurgery days when people could not help staring at the fat man.

Resetting the ‘Set Point’

For obesity experts, bariatric surgery is at best a compromise. What they really want is a medical treatment with the same effect — lowering the body’s set point, the weight it naturally settles into — without drastically altering the person’s digestive tract.

Ten years ago, it seemed as if it could be simple.

“We had the idea that probably surgery did several distinct things that you could figure out,” Dr. Kaplan said. “If there were 10 different mechanisms, we could find 10 drugs that could hit them.”

If only.

It has become clear that bariatric surgery changes the entire setting of a complex, interlocking system. There is no one place to tweak it. To show what is involved, Dr. Kaplan reports that surgery immediately alters the activity of more than 5,000 of the 22,000 genes in the human body.

“You have to think of it as a whole network of activity,” Dr. Kaplan said. It’s a network that responds to the environment as well as to genes, he added. Today’s environment probably pushed that network into a state that increased the set point for many people: Their brains insist on a certain amount of body fat and resist diets meant to bring them to a lower weight and keep them there.

“Surgery moves the network back,” Dr. Kaplan said.

But surgery only alters the intestinal tract. That tells you, Dr. Kaplan says, that there are whole classes of signals coming from the gut and going to the brain and that they interact to control hunger, satiety, how quickly calories are burned and how much fat is on the body.

One major hormonal change is in bile acids. There are more than 100 varieties of these hormones, which help regulate metabolism and digest foods. They send out broad signals, like television signals, to any cells in the body with the capability to respond. And the relative proportions of the different bile acids change immediately with surgery.

That simplistic notion — that there may be just a few key places to intervene in the tangled web of controls that sets a person’s weight — seems just that: simplistic.

But some nodes of the network may be more important than others. They may be the drivers.

“What we need to do is find these mechanisms,” Dr. Kaplan said.

One Year Later

This fall, Michigan surgeons gathered about 100 bariatric surgery patients into small focus groups roughly a year after their operations and asked about their new lives, expecting mostly enthusiastic reports. Yet responses were muted.

“From an outsider’s perspective — as someone who hasn’t had the operation — it is confusing,” Dr. Ghaferi said. “Why on earth wouldn’t you be ecstatic?”

There was a lot of talk about changed relationships. Some patients had divorced or separated from a spouse. Some said that a partner did not like the way they looked, or that their partner was still obese and jealous, or that the partner complained, “You’re not the person I married.”

Some believed that people would judge them for having had the surgery, so they kept the operation a secret.

Some did not like the way they looked. It was not enough weight loss, or they were not aware — although it had been part of their presurgery education sessions — that they would end up with big flaps of loose skin that could be gotten rid of only with extensive and expensive plastic surgery.

On the other side of the equation, patients raved about newfound energy and stamina, and the way joint and back pain disappeared. They loved tossing away medications for diabetes or high blood pressure.

Jessica and Keith, too, had mixed reactions.

A year after his surgery, Keith weighed 284 pounds, down from his starting weight of 377, but not at his projected weight of 230. It is increasingly unlikely that he will get there.

But he looked and felt transformed.

“Some people I haven’t seen in years don’t recognize me,” Keith said.

“And I do have more energy,” he added. “It is a huge difference.”

Yet he is still fat, and still feels big. “I expected all my weight to be gone,” Keith confessed over lunch at a sushi restaurant near his work. “I wanted to be 230. I was hoping.”

And he misses his former lust for food. “I just liked eating before. I liked to eat.”

Jessica lost 112 pounds, just about exactly what was predicted.

“I expected myself to grieve a lot more for my loss of my old relationship with food, and I didn’t,” she said.

She began classes at Eastern Michigan University in the fall but dropped out in October, explaining that she did not like the courses and had a lot of anxiety. While she waits to apply to another college, she is working at coffee shop near her home. She still lives at home.

Before her operation, she could blame her stalled life on her obesity. Now, she says, “I don’t have an excuse anymore.”

“I’m smaller,” she said. “But it’s been gradual enough that I still feel like I’m the biggest person in the room wherever I go.”

On the other hand, her acid reflux is gone and she had the confidence to buy a bike.

She wants to lose another 40 pounds. Her plan is to start with that awful liquid diet she was on for two weeks before her surgery. In the meantime, she has not bought new clothes, holding off until she loses more weight. She says she will consider having plastic surgery to remove loose skin after she loses more pounds.

Yet, Jessica says, although she has mixed feelings about the results of the surgery and although she is disappointed that her life has not changed as much as she hoped, she does not regret having the operation.

And she had some triumphs.

She went back to the amusement park where she had been so humiliated when she was turned away from a ride, too big for the safety bar to go over her.

Now she fit.