Weighty decisions

At 235 pounds and 5 feet 10 inches, Jim La Fountain is hardly petite. But for the first time in years he’s stopped hearing hurtful comments like the one he overheard a woman telling her daughter: “If I were that fat, I wouldn’t leave the house.”

Just eight months ago, the Chico man, who’s 54, was 82 pounds heavier, weighing an immense 317 pounds. He was considered “morbidly” obese, a condition that gave him diabetes, rising blood pressure, severe heartburn and sleep apnea, which caused him to stop breathing periodically during sleep.

It wasn’t that he didn’t try to lose weight. “I once fasted for two weeks and gained nine pounds. I tried all the diets, and nothing.”

Doctors didn’t help. A physician at a veterans’ clinic suggested La Fountain try going out in a rowboat with a toothbrush and toothpaste, he recalls. “If you’re still alive, come back and see me in two weeks. You’ll never get the weight off before you die.”

On top of that he suffered disabling pain from an industrial accident eight years ago in which he was “crunched by a forklift.” He had 12 operations for the injuries, which left him down for six to 12 weeks at a time. He picked up a lot of extra weight as he recovered from the surgeries, and the incident cost him and his wife Cathy their home and the savings they’d built up for 27 years.

But the worst thing was the constant depression, he says.

“If I was depressed and down, I would go raid the fridge.” Though it may have been a momentary comfort, the binging only made his weight problem worse.

“I had resolved that I would die early and die fat,” he says. “I felt my own mortality. I knew I was not going to be here much longer. I couldn’t get around. The depression was too much to handle; the lack of sleep, the continuous pain, tons of medicine. The depression was all-consuming sometimes.”

It was also the last straw.

In the depths of his despair, when he’d hit rock bottom, Jim La Fountain decided to risk his life in order to save it. In May 2003 he underwent a major surgery called gastric bypass.

“In the last eight years, since losing my job, our home and having to start from scratch and seeing my own mortality, and [if I died] leaving Cathy, who spent a lifetime with me—that’s what pushed me to research this,” he said.

He is one of a growing number of severely overweight Americans who have given up on traditional weight-loss efforts and decided to go down this potentially dangerous path.

The premise behind gastric bypass, otherwise known as bariatric surgery, is simple enough: Make the digestive system smaller so the patient has no choice but to eat less food. But making dramatic changes in the digestive system—stapling or suturing the stomach to turn it into a small pouch and shortening and rerouting the small intestine and attaching it to the pouch—requires major surgery and, of course, total anesthesia.

About 7 percent of patients have complications from the surgery, including bleeding, internal injuries, leaks or blockage at the staple or suture site, pneumonia or breathing problems, infection, blood clot in the legs or lungs, irregular heartbeat, vomiting, diarrhea and psychiatric changes, according to the International Bariatric Surgery Registry.

And then there is the severest of complications: death. About 2 percent of patients do not survive the surgery.

La Fountain, who saw death nearing anyway if he stayed obese, figured “2 percent was an acceptable risk.”

La Fountain is one of just a handful of Northern Californians who have opted for this surgery, but more and more are choosing it. “It’s becoming extremely popular,” says C. Gary Cooper, the only doctor in Chico doing the operation.

A patient calling his office today would have to wait about a month to see him. Then, assuming all went well, a surgery could be booked in April.

“I’m tremendously busy,” said Cooper, who has been on the Enloe Medical Center staff since 1973 and operates on people from all over Northern California and occasionally from Oregon. “The demand is far greater than the supply.”

Cooper is a general surgeon, but he has been doing only gastric-bypass surgeries for the past 15 to 20 years. He remembers a time when he was the only doctor north of Sacramento offering any type of bariatric, or obesity, surgery.

Now bariatric surgeons are springing up all over Northern California, including Roseville and Redding. Neighboring states are drawing Californians, as well. Jim La Fountain went to Carson City, Nev., to have his operation done, and others have made the trip to southern Oregon.

About 10 percent of all bariatric surgeons in the country practice in California, reports Georgeann Mallory, executive director of the American Society for Bariatric Surgery. That totals 113 surgeons, with most located in Southern California.

Nationwide, bariatric surgeries increased 43 percent, to 103,200, from 2002 to 2003, and they have jumped from 16,800 since 1993, Mallory said. The estimates are based on the ASBS’s data from its member surgeons, and since not all doctors who do the surgeries are members, the actual number of surgeries is likely higher.

The organization predicts that up to 145,000 bariatric surgeries will be performed this year.

There are several types of bariatric surgeries, but the most popular is the type La Fountain chose, the gastric bypass. About 85 to 90 percent of all obesity surgeries are of this type, Mallory estimates.

Traditionally, surgeons have used an “open” technique, making one large incision, usually from the breastbone to the belly button. With a newer laparoscopic option, the surgeon can make several smaller incisions, poking instruments through them and watching his or her work on a video screen.

Cooper does not do laparoscopic procedures and says he never will. These have a higher rate of serious complications until a surgeon becomes proficient at it, and that can take as many as 50 operations, he explains. “I’m not willing to accept an increase in the amount of complications as I am learning it.”

The ASBS, of which Cooper is a member, believes that the newer technique is “equally as good” when a surgeon has laparoscopic experience, Mallory said. This technique actually comes with less chance of wound infection than the “open” procedure because of the smaller incisions, but leaks at the surgical site—a more worrisome complication than infection—are more common in patients of doctors new to laparoscopic surgeries.

Whichever type, the so-called weight-loss surgery has become prevalent enough that there’s at least one magazine, called WLS Lifestyles, dedicated to pre- and post-operative patients.

Karol Billingsley, a 62-year-old Chico mother of six and grandmother of 11, is another formerly obese person who decided that surgery was her best chance to live a normal life. “They say the surgery is life-threatening,” she explains, “but so are diabetes, high blood pressure, heart attack.”

As a borderline diabetic with high blood pressure and high cholesterol, the 5-foot-6-inch assistant nutritionist for Head Start weighed 259 pounds before the surgery. She was obese enough to qualify for the surgery, but for her the determining factor was the bad health of her husband, who had terminal cancer. “I knew I’d be responsible for everything. I didn’t want to be a burden on my children.”

She also didn’t think she would have been able to go through with the surgery without her husband. She asked for his support, and though he was worried at first, he eventually consented. “He went through it with me, and he died about one year afterwards.”

Debbie Tosi, of Mt. Shasta City, was already a widow when she underwent bariatric surgery. Her husband had died in 1992, leaving her to finish rearing her children, who are now 16 and 21 years old. Her biggest concern before doing the surgery was the possibility that she might not survive it, leaving her children as orphans.

At the same time, she says, her children knew how miserable she had become. She weighed 340 pounds before her surgery in April 2003. “I just wanted to be comfortable and not be a spectacle,” she explains. She longed for things that others take for granted: to fit in a chair at the theater or on a plane, to cross her legs again.

“They’re the simple things in life, but they’re so important,” said the 48-year-old, who works as a staffing placement person.

Just as gastric bypasses are on the rise, so is obesity. About 16 million Americans are morbidly obese, meaning they’re at least 100 pounds overweight, according to the ASBS. About 64 percent of adults, or more than 120 million, are overweight or obese, according to a 1999-2000 survey by the Centers for Disease Control and Prevention. By any measure, Americans are the fattest people on Earth.

All this excessive weight is hazardous to our health. It can lead to such life-threatening conditions as high blood pressure, sleep apnea, coronary-artery disease, diabetes and cancer. Other common health problems include acid reflux, arthritis and joint pain.

Obesity is the second-leading contributor to illness and death in the United States, behind only smoking, according to Obesity-Online. About 300,000 people die each year in the United States from problems associated with obesity.

Obesity is also expensive. A new study shows that medical costs related to obesity totaled $75 billion last year. Taxpayers paid for about $39 billion of that, which comes to about $175 per person, according to a study done by RTI International and the Centers for Disease Control and Prevention.

For a morbidly obese person, the usual remedies, diet and exercise, almost invariably don’t work, Cooper says. He is convinced that gastric-bypass surgery is a morbidly obese person’s “only chance of success” for permanent weight loss and improved health.

Surgery works 80 to 90 percent of the time, whereas diet and exercise work only 3 percent of the time, he said.

After surgery, as the pounds disappear, so do many of the illnesses brought on by the excess weight.

La Fountain attests to this 100 percent. He had the surgery at Aspen Weight Loss Surgery LLC in Carson City, done by Dr. Kent Skogerson. Before the operation, he says, he suffered from arthritis, acid reflux and adult type II diabetes; high-blood pressure was “on the way,” his mobility was decreasing, and his sleep apnea was so bad that it was like “I was running a marathon every time I slept.”

After the gastric bypass, the digestive problems and diabetes went away and La Fountain’s blood pressure returned to normal. Whereas before he had difficulty getting through a store, he now takes six-mile walks with his wife, Cathy, once or twice a week. He also takes daily one-mile walks, often to check locks at the self-storage business he and his wife manage. Before the surgery he used a golf cart to get around the lot.

“My mobility has improved tenfold,” he says.

His sleep apnea is also gone, and he says his lungs are working better. “I get quality sleep.” Though he still needs oxygen treatments for the sleep apnea, his doctor believes in early March he’ll be able to stop those, too.

Cathy La Fountain says she’s relieved that her husband’s severe heartburn has disappeared. “Before surgery he lived on Alka-Seltzer. Sometimes I’d be in tears because I couldn’t find anything that he could eat and that didn’t cause the acid.”

Karol Billingsley feels similarly happy about the results of her surgery. A patient of Cooper’s, she bubbles over with joy when she talks about her experience. Before the surgery nearly eight years ago, she was borderline diabetic, had high cholesterol and high blood pressure. But all these problems melted away with the weight after the gastric bypass. Now her cholesterol is actually too low, and she’s been told she might have to start eating milk- and egg-rich pudding to bring it up.

These dramatic health changes could explain why some insurance companies find it worthwhile to cover the surgeries. Medicare and Medicaid programs sometimes pay for it as well. Of course, none of these organizations will allow just anyone to have it done. The general requirements, which surgeons also tend to adhere to, come from guidelines set by the National Institutes of Health, said Mallory of the ASBS.

These say that to qualify a person should have a body mass index, or BMI, of 40 or higher, or a BMI of 35 or more plus a major health problem, like one of the four life-threatening conditions of obesity: high blood pressure, sleep apnea, coronary-artery disease and diabetes. Body mass index is a mathematical formula based on height and weight. Jim’s BMI, for example, was 63, whereas the BMI for a “normal"-weight person of his height is between 18.5 and 24.9; 30 is considered obese.

Though many doctors follow these guidelines, “it’s a medical and ethical issue, not a legal one,” Mallory says.

Some doctors and insurers also want to know what weight-loss programs patients have tried and require a multitude of tests, including a psychological evaluation. La Fountain’s physician, Skogerson, requires “a multi-disciplined evaluation process completed by a number of experts,” including medical doctors, physical therapists, sleep specialists and endocrinologists. He wants to know what health problems he could be dealing with before surgery.

“It’s very risky surgery for these people because they are not healthy,” Skogerson explains. “They run the risk of dying. That message needs to come across to everyone. Yes, it’s tragic. [However,] most people accept the fact that they might die with the surgery.”

Anyone thinking of having the surgery for cosmetic reasons, which is generally ill-advised in the medical community, would need to be either wealthy or able to deceive an insurance company or government health care program. Gastric-bypass surgery costs $25,000 on average, Mallory says.

La Fountain said his costs have added up to $40,000, and “we’re still getting bills.” His wife’s insurance paid for some of it, but the La Fountains doled out about $10,000 of their own money.

That doesn’t bother Jim, who once wore a triple-x shirt and now fits nicely in the size-large leather jacket his wife gave him for Christmas. He’s also pleased that he’s traded in his 50-waist pants for 38s, which should stay like new since he thinks he’ll be ready for 36s sometime soon.

“I feel that with the medical problems that I had, that this surgery—the reassurance that there was going to be rapid weight loss—even though there are risks, this outweighed the risks. … I’d pay 80 [thousand dollars]. You know I’d sell my car and start riding my bike if I had to.”

La Fountain doesn’t actually own a bike, but Karol Billingsley does, and she’s taken up riding it with her grandkids.

“Oh my gosh, I just love the world so much better,” she says.

Before her May 1996 operation, she explains, “I was so fat I couldn’t sit down on the floor to play with my grandkids. I couldn’t hold them on my lap.” And exercise? Forget it. “No, I wouldn’t go for a walk. The insides of my legs would rub together.”

But nowadays Billingsley and her grandchildren do all sorts of activities, like biking, bowling and baking. (For the record, she keeps only one piece of any baked goodies, sending the rest home with the children or giving them away.)

“Whether it’s raining or not, I still see the sunshine. Before the surgery, I’d say, ‘It looks like a sweats day,’ “ she remembers. “Now I don’t wear sweats because there’s too much room to hide.”

For La Fountain, one of the most freeing things has been the end of nasty remarks and the evil eye. He would be more comfortable on planes, too, if he hadn’t sworn off them after a particularly bad incident before the surgery.

Once, when flying across the country, he had an aisle seat, but he didn’t quite fit in it, so portions of his body were in the aisle. Whenever the flight attendant went by, she rammed his body with the cart, all the while giving him “a hateful glare like, ‘You fat slob, you’re just pouring out of the seat.’ By the time we got to Atlanta, I couldn’t walk,” says Fountain, who has back and knee trouble. “I swore that I would never fly again.”

Another ride he’s happy to excuse himself from is the horrible cycle of feeling depressed because of the weight, eating for comfort or out of nervousness and gaining more weight, which makes exercise difficult and leads right back to the depression.

His wife Cathy remembers how this affected them both. Part of their job as managers of the self-storage business is to clear away the brush, a chore she could complete in a day. But it took Jim four or five days. “It bothered him that every five minutes he had to take a break. He didn’t want me out there because it made him feel bad that I had to do it. And it pulled me down because he didn’t want me to be out there.”

She sees a real change now. “His attitude and self-worth went up. He’s back how he used to be. … Now he looks forward to doing things. It makes me feel good.”

Debbie Tosi had her surgery one month before La Fountain had his, and she’s lost 145 pounds since then. She tells about one person she knew who recently walked into her work and right past her. “He asked, ‘Is Debbie here?’ He hadn’t seen me in over a year.” And when he finally saw her, “he said, ‘Whoa!’ “

Others have a very different reaction, she adds. “Some people didn’t see the weight. They only saw what was inside.” After the surgery, “they just think your hair is different. I’d think, ‘Well, yeah, my hair is different, but I’ve lost 125 pounds.’ “

Usually, though, she was treated differently when she was heavier. “They think you’re messy and sloppy,” she explains, though her home has always been spotless. “And they think, ‘She eats a bag of cookies. She eats a bag of chips.’ “

She can understand how someone might think this way, but it still upsets her. “You can eat just 1,500 or 1,200 calories a day, but your body wouldn’t burn it. It was like a vicious cycle.

“You have to lose weight, but your body becomes a burden, in a sense. The body has so much weight that you can’t do the exercises. No matter what you do as far as your intake, you couldn’t burn it.” Sure, she could go on diets and lose 60 pounds, but it would always come back. And then she developed a thyroid condition, which pushed her weight up another 50 pounds.

So far, the surgery—which she considers a tool to lose weight—is the one thing that is working for her. “Now I can sit in a chair at the theater and have room on both sides of me.

“You’re dropping weight so fast. It gets you feeling good and inspired,” says Tosi, who exercises four days a week. She has still had to change her way of living and watch her state of mind ("because you still want chocolate"), but “when the body loses that much weight, the mental thing comes into place.

“I can just live. I can be on the go all day long. I can’t believe all the energy I have. … I feel so good and so happy. And that’s the purpose.”

But getting there takes small steps—and very small bites. While the weight comes off quickly after the surgery, it’s not “insta” skinny. It takes about a year and a half to shed most of the pounds a person will lose, Cooper explains. And even then, people may never reach their ideal weight and will likely never be thin.

Eating is never really the same. How can it be when an entire meal can fit on a saucer dish and has to be carefully measured?

There just isn’t much room in the stomach after a weight-loss surgery. As Cooper tells his patients, gastric bypass shrinks the stomach from about the size of your head to the size of your nose.

At first the diminutive stomach will hold only about an ounce of food at a sitting. When it gets as big as it’s going to get, it will allow less than one cup of food, or about four to six ounces. The stomach can actually stretch over time to hold greater amounts, but if that happens, the patient won’t lose as much weight, the surgeon said.

To get an idea of what someone might eat each day, here’s a look at Debbie’s typical menu: a half-cup of cottage cheese topped with fruit for breakfast, a half of a chicken breast with a salad for lunch, and a small piece of steak and a half of a potato for dinner—plus lots of water, 64 ounces, throughout the day.

Patients who eat or drink too much or have sugary treats might find themselves getting sick.

It took La Fountain just one time to discover what “too full” felt like. “We had dinner out, and I had eaten two fried prawns, and it was too much, and I had to go hurl,” he said. Not to get too gross, but it wasn’t just a quick upchuck and on with life. “It took 45 minutes to an hour … dry heaves and trying to throw up.”

The surgery has also apparently extracted his sweet tooth. “I have a dislike for things that are real sweet. It nauseates me.” One bite of a chocolate candy bar, and he feels it may not stay down. Even canned fruit cups and sugar-free gelatin snacks trigger his gag reflex.

That nausea comes from what’s called sugar dumping. Basically, sugar is absorbed into the bloodstream more rapidly by gastric-bypass patients, which causes the blood sugar to rise and triggers the body to fight it by producing more insulin. All of this can make a person feel lousy, but Cooper said that’s actually a good thing: “If sugar makes them sick, then that’s considered a plus … because then they don’t eat sugar and they lose more weight.”

Karol Billingsley isn’t among the “lucky” people with an aversion to sweets. She says, “You can eat half a donut, but you want to eat the right foods because so there’s so little room.”

This is a real concern. A daily vitamin and mineral supplements is strongly suggested in case the small amount of food does not provide enough nutrients.

But the trickiest thing about eating after gastric bypass might be the recommended diets during the first several weeks. It starts with various liquid diets that require patients to sip slowly—one ounce over a period of five to 15 minutes, in the beginning—and to stop when feeling full. Pureed foods are next, and patients must not drink for 30 minutes before and 45 minutes after eating because this can overfill the stomach. When patients finally move on to solid foods, they are told to “chew each bite 20 to 30 times until the food is of pureed consistency.” Swelling around the incision area can cause food that isn’t well mashed to block it off.

“The first eight weeks were the hardest I could ever imagine,” says Debbie Tosi, who remembers having to measure everything she ate and drank.

After those first weeks, people must still be careful. A lifetime of sensible eating and exercise is necessary to keep healthy and trim. The gastric-bypass surgery is considered a tool to limit the amount of food a person can eat, not a magic wand that will do all of the hard work.

And there are ways around that “tool.” Continuously eating small amounts or drinking fattening beverages throughout the day, for example, can actually cause someone to gain back the weight.

There seems to be something about gastric-bypass surgery, however, that enables people—at least those interviewed for this article—to do what they couldn’t do before it, such as exercise and eat the right foods.

Billingsley, for example, says sure, she might splurge and have French fries, but as she puts it: “Five fries and you’re done. A half hamburger on a child’s menu, and that’s it. Oh no, I am a cheap date,” she jokes.

“I still put too much food on my plate,” she continues, but she doesn’t eat it all, and since there’s not much room for the food to fit, she actually doesn’t eat much fast food. She also takes vitamins and does Pilates and stretching for exercise—which she says is to stay strong, not lose weight.

Surgery is not the easy way out, Debbie Tosi says. “It’s a life change. You have to be ready to make it. … Truly it’s not for everybody. If you’re not mentally ready, it can hurt you.”

Another part of being ready, stresses Dr. Cooper, is to check out any doctors before agreeing to have the surgery.

“They should ask doctors, ‘How many operations have you done? How many of your patients have died?’ And they should ask about the main complication, which is leakage: ‘How many patients out of 100 have had leakage?’ Never let someone do it unless they have done at least 100 surgeries. The death rate should be less than 2 percent, and the leak rate should also be well under 2 percent.”

These are questions people almost never ask, he said, because they think doctors are always right, or they do not want to insult them.

“You wouldn’t have someone build a house if they weren’t qualified.”

Jim La Fountain shared this belief and did extensive research, but something important managed to slip by him.

When his eyes opened after the surgery, he found something unexpected attached to his body—drainage bags.

“That was the hardest thing, to wake up from the surgery and see these two bags hanging from me. I thought, ‘Oh my god, what did I get myself into?’ “ He doesn’t think he could have managed these bags, which he said had to be changed up to three times per day for four to six weeks, without his wife’s help.

Billingsley and Tosi, who had the surgery done by Gary Cooper, did not have these drainage bags, but Cooper said that some doctors do like to use them.

La Fountain has made it past the initial shock, but now he’s dealing with another post-surgery surprise. “It’s a kind of bizarre sensation that I’ve been going through lately. When I look in the mirror I still see a fat person. … I’m surprised every morning that I fit into my trousers. I just don’t feel like I’ve lost the weight.”

He does not act on the feeling, he says; he’s not binging and purging or starving himself. But the only way he can believe his weight loss is to look at his old photos.

Debbie Tosi had the same sensation, but says, "Now I do see myself as thinner." By listening to the Bypass Buddies, an online support group, she says she’s discovered that some people are never satisfied. "Our mind is always fat." But she’s OK with where she is now. "I feel so healthy. I’m content. If I stayed like this today, I’d be happy. I see myself as the same because I’m the same on the inside."