Three sisters sit at a table in a sleepy, intimate restaurant outside Allentown, PA. They study the menu with intensity, as if a test is coming. In a way, it is: What can they choose that won’t make them sick, that will be easy to chew and swallow, that won’t give them heart palpitations or sudden sweats? An insignificant error for anyone else-swallowing an overlarge piece of food, say-can incur a 2-hour penalty of gut-busting pain for these women.
The sisters look strikingly healthy—partly because they are now roughly half their former sizes. Lee Ann McAndrew (on the left in the photo above), is the youngest at 48. She’s tiny, with a flat stomach, a broad smile, and sparkling eyes. Pam Marks (right), 49, is rangy, lanky in a way that fits her former life on a sheep farm. Cindy Ratzlaff (in the middle), 52, is introspective, thoughtful, and the most talkative. Though she “felt like crap” when she was fat, she also always felt beautiful inside—like Susan Lucci. She’s lovely now, with squared-back shoulders and a soft figure in feminine, bright clothes. “For 20 years, I wore black,” she says. “It was like trying to hide an elephant.”
In the world of dieting and slimming down, their transformation was sudden and extreme. It has provoked some bizarre reactions. When one overweight friend saw Lee Ann, she said: “Oh my God, you skinny bitch.” Another called Pam an “anorexic whore.”
The menu pages flip back and forth as the sisters discuss their new lack of interest in food. Hunger, says Lee Ann, is more like a small tap on the shoulder. Explains Cindy, “Now we’re just eating like everyone else.” But they don’t eat like everyone else. Not really. If Cindy eats more than two chocolate malt balls—which she still craves—she gets heart palpitations, a symptom known as “dumping.” Pam couldn’t drink coffee for 6 months after she began losing the weight—the taste and smell made her sick. “And noodles make me feel like someone’s hit me in the stomach,” she says. “All I want is a good greasy piece of garlic bread, but I know that afterward I’d have to lie down and throw up.”
What has created this miraculous yet nightmarish existence for the sisters? Gastric bypass surgery—a 40-year-old operation with a surging new popularity. That the technique is in demand is no surprise: Of the 6 million Americans who are morbidly obese (more than 100 pounds overweight), nearly all are candidates, and more than 200,000 have already had the procedure. The benefits are substantial, but so are the dangers it poses and the compromises it forces. As the sisters have discovered, the surgery has radically changed not only the way they eat—and even think about eating—but every aspect of their lives, from their health to their relationships.
Then again, weight has always been front and centre in the sisters’ lives. By the time Cindy was 15; she was 5-foot-2 and weighed 145 pounds. “What filled everybody else didn’t fill me,” says the former vice president and associate publisher of Rodale Trade Books in Emmaus, PA. (Rodale publishes Prevention.) Her doctor put her on diet pills, the first of many regimens she tried, including fasting, purging, Overeaters Anonymous, macrobiotics, exercise, drugs such as Fen-Phen and Redux, and—as her sister Pam says—”every diet known to man.” Any weight she lost would simply pile back on, and Cindy would reach a new high. By age 50, she tipped the scale at 267.
Her sisters soon caught up. Both gained weight in their 20s during pregnancies, and every year they got heavier. At 255 pounds, 5-foot-4 Pam—who lives 5 minutes away from Cindy in Allentown—dreaded walking by the close-set tables at Saturday-night auctions, her wide body knocking things to the floor as she passed.
Lee Ann, the last to really pile on the pounds, could see in her two sisters the fate that would soon be hers. Her free-falling self-regard worsened the problem. “I absolutely used food emotionally,” says the 5-foot-2 former Federal Emergency Management Agency employee in Phoenix, Arizona “I ate when I was lonely or bored. I ate all the time. Food was my buddy.” And like her sisters, she tried anything and everything to get thin—ephedra, Metabolife, Fen-Phen. But each time she quit a diet, she gained back more than she had lost, until she reached her high of 230 pounds.
Although she had considered stomach stapling (an early form of gastric bypass) as long ago as 1984, she dismissed it as too dangerous. But then, in 1996, a friend had gastric bypass, and her success stung Lee Ann, who by this time feared for her life. She had high blood pressure, borderline diabetes, thyroid problems, and heartburn so painful she had to sleep in a recliner, and gastroparesis, a stomach disorder that made her nauseated, gassy, and bloated. By 2001, when Lee Ann finally had insurance coverage for the operation, her decision was firm: She would sign up for gastric bypass.
The operation involves isolating a portion of the stomach with staples and sometimes bands. This thumb-size pouch becomes the new stomach; usually, surgeons then attach the small intestine to it, thereby skipping most of the football-size stomach and some of the small intestine.
Gastric bypass isn’t a sure-fire cure for obesity. Within the first 2 years of surgery, patients typically lose 75% of the extra weight they were carrying. Five years out, 85% of patients have regained about half of the weight they’ve lost. The other 15% have gained back even more.
To qualify for bariatric surgery, candidates must have a BMI (body mass index, an equation that factors in height and weight) of 40 or above (about 100 pounds overweight), or have a BMI higher than 35 along with a chronic disease such as diabetes, heart disease, or sleep apnea. Lee Ann’s BMI was 42. Like most candidates, she also had to verify through her doctor that she had failed at diet therapies lasting 3 to 6 months or longer. And she had to indicate that she understood how drastically the operation would change her life. Through it all, Lee Ann remained resolute.
For her last full meal before the surgery in April 2002, Lee Ann’s husband, Patrick, made her favourites—steak, potatoes, mushrooms, salad, and ice cream—a sizable meal she knew she would likely never have again. But if Lee Ann was ready, Patrick, a substitute teacher, wasn’t: “I was afraid for her. And I didn’t want to raise our young son by myself.” Lee Ann’s qualms hit as she was being wheeled into surgery. “I thought, why couldn’t I do this myself? Why do I have to do something this extreme?”
Those are questions that bariatric researchers would like to answer. Ninety percent of people who non-surgically lose more than 5% of their body weight regain it within 5 years. “When you diet, every signal in your body says eat,” says David R. Flum, MD, MPH, a gastrointestinal surgeon at the University of Washington who investigates the outcomes of bariatric surgery. “When you exercise, every signal says eat. And a lot of genetic determinants allow some people to pack on weight. Their calories burn more slowly and turn into fat more quickly. Those are Stone Age genes in a modern society. That doesn’t mean that fat people are powerless, but their bodies do handle calories differently than the bodies of thin people do.”
Lee Ann came through the operation beautifully, remaining in the hospital for 3 days. On day 1, a nurse wheeled in Lee Ann’s dinner under a silver dome. She picked up the dome and there, sitting on a doily, was a 2-ounce cup of hot cereal. The nurse handed her a baby spoon and said, “Don’t take bites bigger than this, and eat slowly.” Lee Ann thought, you have got to be kidding me.
But then she began to eat. “I would take a bite, and it felt like a little bubble popped in my stomach, like a signal to stop eating.” Some foods also repulsed her. “Before surgery, I could drink two big glasses of milk. But afterward, just the thought of milk—and sugar, too—made me sick. If someone walked by me with a doughnut, I wanted to gag.” The operation enforces lifestyle changes that dieting alone cannot, short of being locked in a cell. The new pouch can hold only 1 ounce of food at a time, stretching later to hold up to 4 ounces. Eat too much and you throw up—sort of like surgically induced bulimia.
“Some meals will never be acceptable—such as dense sugary milkshakes—and meat may never taste the same,” says Flum. Palatability shifts, researchers think, because of hormonal changes that take place when much of the stomach is out of play. “And patients have to learn to eat small pieces, to chew food better and more slowly, to separate liquids and solids. It’s behaviour modification,” Flum says. “Patients have to reset eating patterns that have become abnormal.” Lee Ann now prefers soft foods like beans to a good steak. “I immediately lost my desire for any beef,” she says. “That lasted a year. I’ll eat it now and it tastes okay, but I would much rather have chicken, seafood, or tofu.”
And on such a meagre diet, the weight began to disappear. “That first month, I got on the scale every day, and I had lost 2 or 3 pounds,” Lee Ann says. Of course, she was ingesting only a cup of food a day, 2 ounces at a time, of foods such as cottage cheese or yogurt.
“Feeling full was not at all the same,” she says. As she discovered, patients lose their once raging appetites, sometimes forgetting to eat. Hunger is driven in part by ghrelin, a hormone produced by cells in the stomach. As it turns out, those cells need the regular stimulation of food to flip the ghrelin switch off and on. Because more than two-thirds of the stomach never sees food in people who’ve had the surgery, ghrelin levels plummet, and so does appetite. The sisters understand this shift. Cindy wants a T-shirt that says ghrelin with a slash through it.
When the sisters saw Lee Ann’s success, they, too, began to consider the operation. Cindy called her sister and begged to hear the downsides. She was embarrassed by the idea of having surgery to control her weight. Just considering it meant finally admitting that she was morbidly obese. She also had read about people who died from the operation—a danger that’s very real.
According to a University of Minnesota review of research on 22,000 patients, 1 out of every 200 dies within 30 days of the surgery. And 2 to 3% will suffer a life-threatening complication such as a leak in the intestines, a blood clot, or internal bleeding.
But Lee Ann’s joy overcame all reservations. “When Lee Ann had the operation, she sealed our fate,” says Cindy.
Cindy had her surgery in March 2003. As it had for her sister, the operation went smoothly. By evening, she was walking through the hospital corridors, wheeling her IV pole alongside her. The next day she went home and weeded her garden. Within 2 weeks she’d lost 20 pounds.
“After years of struggling to lose anything, you see the weight melt off,” she says.
Nine months later, Pam followed suit. “I just got tired of having fat run my life,” she says. But this time, things went badly. For 3 days, Pam couldn’t fully wake from the anaesthesia. (Her first thought when she did was, Well, I didn’t die.) Then complications set in: an infected incision, scar tissue blocking the new pouch, and gallstones so severe that she threw up 14 times a day. More surgery followed—to ream out the scar and remove her gallbladder. Finally, 4 months after the initial surgery, she began to remember what a day without vomiting felt like.
There are downsides for all three.
One is what the sisters call “old woman skin.” “As fat women we all had perfect skin,” says Cindy. “But there was a lot of skin over all those pounds.” (One of her neighbours now refers to her as a “flying squirrel.”)A year after her surgery, Lee Ann had a tummy tuck because, as she puts it, “When I put on pants, I didn’t know where to put the hanging skin.” This surgery took longer to recover from than the gastric bypass and left her scarred from hip to hip and from breast to pubic bone. The price tag—nearly $10,000—was covered by Lee Ann’s insurance because she complained of itchiness and discomfort. Generally, unless there are medical complications, cosmetic surgery to solve such problems isn’t covered. Cindy would love to have the same procedure done but her insurance won’t pay. So instead, she’s hitting the gym three times a week, hoping to tone up. The prospect is unlikely: Obesity can permanently damage skin and connective tissue.
Bariatric surgery has also left the women vulnerable to nutritional deficiencies. In the early months, Cindy’s hair thinned out from lack of protein. They work at eating enough of it—at least 60 g per day, the amount in 2 cups of cottage cheese, 2 cups of soybeans, or about ½ pound of ground beef. All three take liquid or dissolvable supplements—C, B12, a multivitamin, and calcium.
The families’ adjustments have also turned out to be tougher than the sisters anticipated, at least for Cindy and Lee Ann. Lee Ann’s then-obese husband, Patrick, was the cook and grocery shopper in the family, and his inability to adjust portion size and seasonings after Lee Ann’s surgery often brought her to tears. “One night he cooked six steaks, and I cried, ‘Why would you cook that much?’ I would be sitting there with a teaspoon of this and that, and he would sit with a plate mounded with food. It seemed obscene.” Patrick had the surgery himself last summer and now understands his wife’s aversions. And they can share meals again—they split half a pork chop.
Cindy’s 14-year-old daughter, Kathleen, had a tough time with her mother’s new image. “You took the easy way out,” the girl told her. She worried that her mom would be thinner than she is. “I was jealous,” says Kathleen, who is not fat but worries about her weight. “I thought she was escaping a problem I had, that she just got to take care of it, and I couldn’t. But I see she’s healthier and that she and my aunts feel a lot better about themselves. And now we can share clothes.”
The trio bristles at suggestions that they’ve taken the easy way out. “Some of my friends act like I ‘cheated’ to get thin,” says Pam. “But there’s nothing easy about this surgery. I didn’t just wake up one day and say, ‘I’m fat and I think I’ll have surgery.’ I spent 30 years and hundreds of dollars to try to get thin. I had the surgery, but I also knew I had to change the way I ate if I wanted to live.”
“The operation is just a tool,” adds Cindy. “You still have to change years of bad habits.” More to the point: The sisters had little chance of losing the weight by dieting. “My doctor said my health would only continue to go downhill,” says Cindy. “‘You have a 2% chance of reversing obesity through diet,’ he told me.”
Their health problems have melted away with the fat. Gone is the heartburn, the high blood pressure, the incipient diabetes, the incontinence. As Lee Ann puts it, “Now I can sneeze freely.” A 2004 McGill University study underscores the health benefits: Of almost 7,000 obese patients, those who had weight loss surgery reduced their risk of death by 89%, compared with obese people who didn’t have surgery. In the University of Minnesota review, the surgery alleviated diabetes, high blood pressure, sleep apnea, and high cholesterol in 70 to 80% of the 22,000 patients. “That’s powerful,” says lead author Henry Buchwald, MD, PhD, a professor of surgery at the university. “With one operation, you get rid of the primary disease, obesity, and these four other diseases, and you stop the progress toward heart attacks and death.”
Although the sisters would never lightly recommend the surgery, they agree that the upsides far outweigh the downsides. The first time Cindy fit into a pair of size-12 jeans (down from a size 22), she sat in the dressing room and cried. She now wears a petite size 8 and weighs 136, having plummeted from 267. “I lost a 5-foot-2 woman,” she says. Lee Ann dropped to 115, shedding 115 pounds. Pam weighs 134, a 121-pound weight loss—and wears a petite size 6.
Most astonishing is the newfound energy. “People think I’m on drugs because I buzz around so much,” says Pam, who used to sleep until noon and get back in bed by 6. “No one should have this much energy.” She has returned to school to become a pastry chef. Lee Ann goes in-line skating with her son, and she’s been riding along on a UPS truck as a driver’s helper. “I love hopping on and off the truck delivering boxes. I don’t have to go to the gym.” Cindy has time and energy—eating stole a lot of both—for exercise, scrapbooking, even housecleaning, a job she used to leave to her husband. “It’s not like all the problems of life go away,” she says. “It’s all just as complicated as it was before. But I’m not hungry.”
As if to prove the point, she pushes away her potato-leek soup and salad, both half eaten. Her sisters take their leftovers, disguised as foil swans, home to Pam’s husband. Overeating is no longer something they fear. And despite the statistics suggesting that they’re likely to gain
back as much as 50% of their excess weight, they don’t worry. “I’ve weighed 115 for 3 years, so I don’t think I’ll gain much back,” says Lee Ann. “I know what I can comfortably eat, and I just don’t want to eat more than that.” Pam states it more baldly: “We went through too much for this not to work.”