Fat Wars E-Book

Ellen Ruppel Shell

• Herausgeber: Atlantic Books
• Kategorie: Ratgeber
• Sprache: Englisch
• Veröffentlichungsjahr: 2015

Beschreibung

We are facing a gathering health crisis of epic proportions. The crisis is obesity and the diseases linked to it - hypertension, diabetes, cancer and heart disease. While multinational drug companies race to find a cure, the problem only worsens, with experts declaring thatthe UK is the second most obese nation on the planet and that 31,000 death a year in Britain are obesity-related. In a rare blend of cutting-edge science, history and personal stories, Shell builds a compelling narrative culminating in a thought-provoking - and radical - call to arms. This is the definitive account of how the western world got fat - and what we can do about it. 'A fascinating book... Shell has a droll manner and narrative gift that transforms the most unpromising chapters of obesity R&D into observant little dramas... An illuminating history of overweight' -- Catherine Bennett, Guardian 'A real steel magnolia of a book. A political fist clenched inside a scientific glove. Charmingly written with plenty of human interest and colour, its underlying message is nonetheless clear and radical.' -- Jerome Burne, Financial Times

Leseprobe

About the Author

Ellen Ruppel Shell is a correspondent for the Atlantic Monthly and writes for Discover and the New York Times Magazine, among other publications. She is associate professor and co-director of the Program in Science Journalism at Boston University.

‘Revelatory’ Observer

‘Shell gives us the history of obesity and efforts to cure it, showing how the leading theories have changed over time … The evidence is now over-whelming that obesity has nothing to do with failed willpower, unconscious dynamics, psychological problems or bad habits’ Carol Tavris, Times Literary Supplement

‘A provocative and erudite book’ Irish Examiner

‘Enthralling … Shell’s advice and what we can do about getting fat – and not getting fat – is well written and convincing’ New Scientist

‘Ellen Ruppel Shell brings the book alive with her investigative docu-journal style’ Nature

‘A witty and thought-provoking book … Shell tells the story of the search for “obesity genes” set against a background of the societal changes that have done so much to generate the current epidemic of obesity … An excellent piece of scientific journalism’ Sir David Weatherall, Times Higher Educational Supplement

Fat Wars

The Inside Story of the Obesity Industry

Ellen Ruppel Shell

ATLANTIC BOOKS

London

Copyright page

Originally published in Great Britain as The Hungry Gene in 2002 by Atlantic Books, an imprint of Grove Atlantic Ltd

Revised and updated edition published in 2003

First published in the USA by Atlantic Monthly Press, an imprint of Grove/Atlantic, Inc., 841 Broadway, New York, NY 10003–4793

Copyright © Ellen Ruppel Shell 2002

The moral right of Ellen Ruppel Shell to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act of 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of both the copyright owner and the above publisher of this book.

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A CIP catalogue record for this book is available from the British Library.

Paperback ISBN 978 1 84354 142 4

E-book ISBN 978 1 78239 653 6

Printed in Great Britain by Mackays of Chatham Ltd, Chatham, Kent

Atlantic Books

An imprint of Grove Atlantic Ltd

Ormond House

26–27 Boswell Street

London WC1N 3JZ

www.atlantic-books.co.uk

Dedication

For Opa

Contents

Epigraph

Preface

One: A Weariness of Eating

Two: Walking Naked

Three: Natural Born Freaks

Four: On the Cutting Edge

Five: Hunger

Six: The Clinical Exception

Seven: Collateral Damage

Eight: Spammed

Nine: The Child is Father of the Man

Ten: An Arm’s Reach from Desire

Eleven: The Right Choice

Notes

Acknowledgments

Index

Epigraph

No fear can stand up to hunger, no patience can wear it out, disgust simply does not exist where hunger is; and as to superstition, beliefs, and what you may call principles, they are less than chaff in a breeze. It’s really easier to face bereavement, dishonour, and the perdition of one’s soul than this kind of prolonged hunger.

—Joseph Conrad, Heart of Darkness

Preface

TO THE PAPERBACK EDITION

While writing this book, I had no idea that obesity was on the cusp of becoming one of the most debated and discussed controversies of the early twenty-first century. Nor had I any idea that I was touching upon an American—and international—obsession. But I’ve since learned that obesity represents for millions the physical manifestation of a deep and abiding fear. So many of us have tried to control our appetites, and our weights, and so many of us have in the long run failed to do so. And the disappointment in this failure runs deep, far deeper than I had previously imagined.

Weight is widely considered a matter of personal responsibility, and on radio chat shows I’ve been chastised—sometimes bitterly—for suggesting otherwise. People call in to crow over how much weight they’ve lost on the latest diet—low-fat, high-fat, low-carbohydrate, whatever—and to add that if others are too stupid or too lazy or too gluttonous to do the same, why should any of us care? After all, they say, this is a free society, in which we make our own bloody choices, and if everyone would make the same choices as they’ve made, the world would be a thinner place. Rather than resorting to the obvious retort (“just wait: taking off weight is easy, keeping it off is not,”), I often tell the story of a young man I met in the course of researching this book, a boy who looked far older than his thirteen years. We were introduced in a hospital clinic, where he was being treated for Type II diabetes, an obesity-linked disorder once seen only in adults, but now increasingly common in children. I watched from the sidelines while he mounted the scale—carefully, one lumbering foot after the other—and the attendant slid the pointer just beyond the 300-pound mark. The boy looked impassive, resigned, and a little shamefaced as a nurse blitzed him with questions about his lifestyle: what did he eat, how much did he exercise, which I interpreted as code for: how did you manage to gain still more weight since your last appointment? Meanwhile, I spoke with his mother, a small woman, perhaps one third the weight of her son. She told me her boy ate only one meal a day, usually healthy food, like beans and rice. His weight problem, she said, was an absolute mystery; in particular given that his brothers were as slim as she. I asked her whether I might meet with her son privately, and she agreed. I waited while the boy plodded off to a nutritionist who lectured him once again on the importance of moderate portion size and regular exercise, and then we left, taking the elevator one floor down to the hospital lobby, where we all but fell into a fast food restaurant.

I now know that nearly forty percent of American hospitals have similar eating places, but at the time, the sight of such a place in the lobby of a hospital that specialized in treating children perplexed me. But I was desperate for a cup of coffee, and it was convenient, so I suggested we step inside. The boy lost his suspicious look, slouched through the doors, and up to the counter to order an early lunch. When the server asked the inevitable question, the boy didn’t hesitate. Of course he wanted his burger, fries and soda “super-sized.” Later he told me what he apparently hadn’t told his mother—that fast food restaurants were a second home to him, a place he went before and after school, and with friends on weekends. He loved everything they had on offer, and especially the feeling of freedom it gave him, to make his own choices, to have it his way.

Television carries hourly reminders that having it “our way” is not a merely a privilege, but a right, whenever and wherever we want it, even in the lobby of a clinic for treating child obesity. It is increasingly difficult to resist, and indeed most of us don’t, at least not for long. The odds of becoming overweight in much of the industrialized world today are remarkably high—about three to one in favor of corpulence in the United States, two to one in the United Kingdom. The argument of personal responsibility weakens when one considers the consequences, which are enormous and borne by all of us. Industry is now beginning to recognize this: earlier this year a consortium of multinational corporations formed the Institute on the Costs and Health Effects of Obesity, focused on reducing obesity in the workplace and lowering the associated healthcare costs. To take but one example, Quebecor, a Canadian printing company, has calculated that fully 18 percent of the company’s health benefits costs in 2003 will go towards employees with weight-related problems. Currently, about 9.4 percent of the national health care expenditures in the United States are directly related to obesity, but by the time you read this, that figure will almost certainly have edged upwards. The obesity pandemic is by far the fastest growing public health crisis in the industrialized world.

Naturally, the cost in human lives and health is horrifying, but what is motivating the industry to change is fear of litigation and backlash, the threat to the bottom line. UBS, the international financial firm, recently warned of a “clear long-term risk to producers of fast foods, soft drinks, confectionery and snacks that anti-obesity measures will curb their ability to grow revenues in the future.” In the United States, a trial lawyer threatened to sue Kraft Foods for stuffing its products with unhealthy fat, and though he dropped the action, Kraft nonetheless surprised the world by promising to stop marketing its products in schools. Another legal action charging McDonalds with contributing to the obesity of children, though mocked by observers on both sides of the Atlantic, may in fact result in similar defensive actions.

Tackling this issue has not been easy, or comfortable. I’ve been put on industry “hit lists,” and blasted by columnists in the business press. If anything, this has strengthened my resolve, encouraged me to move forward. Vested interests are resistant to change, but they must, and they will. Indeed, it has already begun: in the course of just a few years, corporate involvement and concern over obesity has blossomed. Public awareness is greater than ever before. This is all to the good, of course, but it is only the start of what is almost certain to become a serious and perhaps global movement. Such is the power of humans to change even the most entrenched institutions, and to challenge even the most firmly held assumptions. It is to this end that I hope this book will continue to contribute.

Boston

July 2003

One

A WEARINESS OF EATING

If you examine a man who suffers from his stomach. All his limbs are heavy. You find his stomach is dragging. It goes and comes under your fingers. Then you shall say concerning him: this is a weariness of eating.

—The Egyptian Book of the Stomach

The first time I set eyes on Nancy Wright, she is flat on her back and cruciate. She is vaguely pretty, her eyes frightened but oddly beguiling. Her thick hair is loose and wavy, auburn with a sly touch of gray at the temples. You can see what some men see in her, and also, perhaps, why two husbands have come and gone. Even as she lies splayed and sedated on a gurney in Operating Room 17 at Beth Israel Deaconess Medical Center in Boston, you can sense that Nancy Wright is possessed of an immutable will.

Nancy once told me that she’d started out life large and kept on going. She didn’t mean it as a joke. She weighed ten pounds, four ounces when she came into this world, and through childhood ate herself so big that her father thought she had psychological problems. Nancy didn’t see it that way, but she did know that her relationship with food was tempestuous, like a doomed love affair. “Food has always been my best friend and worst enemy rolled into one,” she told me. Now, in middle age, this dysfunctional relationship has made even simple pleasures difficult. It is getting harder for her to work in her flower garden, harder to play with her five grandchildren. And she keeps getting sick. She has hypertension, high blood cholesterol, and sleep apnea. She hates being so tired all the time, and so feeble, and she has done everything she can think of to fight it. She has tried Weight Watchers, Jenny Craig, and diet pills. All of these worked, for a while. The pounds melted away, and Nancy thought she’d found salvation. She’d buy new clothes and start making plans for a new life. But then, without knowing why, she’d fall off the wagon, and her old life would rush back. It was like waking up to a nightmare.

People tell Nancy she lacks willpower, but they are wrong. She has plenty. She stayed with the same thankless social services job for twenty years. She stayed with the same thankless husband for nineteen. And as a fiftieth birthday present to herself, she quit smoking. She hasn’t touched a cigarette in four years, and doesn’t plan to touch one ever again. But food is another matter. “You can live without cigarettes,” she said, “but you have to eat.”

It all comes down to a balance of power—or, rather, to an imbalance. Nancy can no more tame her compulsion to eat than a marooned sailor can tame his thirst. For Nancy, food is more than an addiction, it is like breathing—a constant, throbbing need.

Dr. Edward Mun understands all this perfectly. Mun is an assistant professor of surgery at Harvard Medical School, and an attending surgeon at Beth Israel Deaconess Medical Center. At thirty-eight he has the self-assured manner and polished good looks of a man born to take charge. But beneath the Ivy League veneer and the designer suit lie hints of a nerdy immigrant boy, a gawky overeager kid who spent his summers squinting through a microscope at science camp rather than hanging out at Little League with his pals. Like Nancy, Ed Mun hasn’t always fit in. He was born in Korea and grew up in Gardena, California, the son of restaurant owners who expected much more of their boy than they themselves had managed to achieve. Young Ed did not disappoint; he was the model of the good Asian son. He aced high school, enrolled in Yale University, and graduated in four years with both bachelor’s and master’s degrees in biochemistry. He further distinguished himself at Harvard Medical School, and nabbed a coveted surgical residency in sunny San Diego. Surgery offered the most money, the most prestige, and the greatest opportunity to perform technically interesting procedures. But Mun wanted more.

“I wanted neurosurgery because I thought it was only for the talented few,” he said. “But the truth is that there aren’t that many brain operations. Neurosurgeons do herniated disks and trauma cases. Mostly, it’s boring.”

So Mun returned to Boston, to Harvard, and to Beth Israel Deaconess Hospital, to apprentice in general surgery. He removed breast cancers and performed stomach surgery. To his great relief, he didn’t find this boring at all. But he did find it frustrating. Breast cancer patients had the habit of scrutinizing the Internet for facts about their disease and hauling reams of downloaded information to his office for review. Mun didn’t like the messiness of that, the presumptuousness. Breast cancer, he says, is usually a matter of small incisions and quick recoveries. Yet the patients would piss and moan and demand second opinions. He didn’t mind the second opinions, of course, but he did mind being put through the third degree. And he blanched at their sense of entitlement. These women were hot reactors, the sort of patients who required more assurance than he had to offer.

But the stomach was something else altogether. He liked the feel of it, the hard muscularity of the thing. And he liked that stomach patients trusted him, put themselves in his hands. They didn’t ask a lot of extraneous questions, didn’t expect miracles. He found stomach surgery enthralling, so much so that one would think he had some sort of a belly fetish. But it was nothing like that.

“In Japan and in Korea, tens of thousands of people die from stomach cancer every year,” he said. “I also lost several relatives to this disease.”

In Korea stomach surgeons are held in the highest esteem. Among these masters was Mun’s paternal grandfather, the man in whose steps young Ed was meant to follow. Mun very much wanted to be like his grandfather, and to earn the respect of his demanding parents. So he studied and worked until he became one of the best stomach surgeons at Beth Israel Deaconess Medical Center, which is to say one of the best in the country, and perhaps in the world. But unlike his grandfather, Mun doesn’t open many bellies to remove cancerous lesions or to repair ulcers. What Mun does mostly is something very few Korean surgeons—and only a few American surgeons—have ever done or would ever dream of doing. What Mun does is to take perfectly healthy stomachs and replumb them, cutting them loose from their natural moorings at the end of the esophagus and fashioning them into pouches the size of robin’s eggs. This procedure, which generally takes Mun about ninety minutes but most other surgeons much longer, is called a Roux-en-Y gastric bypass.

Stomach surgery is a pretty rough ride. People who get their guts whittled and rearranged in this way can’t eat much for weeks afterwards, certainly not nearly as much as they did before the change. If for some reason they succumb to the temptation to eat more than the little that their stomach can hold, they vomit. Vomiting is not really a complication of gastric bypass surgery; it is an expected and important side effect.

Gastric bypass patients sometimes lose so much weight that old friends and relatives barely recognize them. The surgery is reserved for those with one hundred or more pounds to lose. On average, patients shed about 60 percent of their excess weight in about eighteen months. It is hard to imagine many people in Korea being interested in such an operation. But in 2000, the year I met Mun, forty thousand Americans underwent gastric bypass surgery, about double the number performed only five years earlier. That number was expected to nearly double again by 2003. Mun doesn’t find these figures the least surprising; he knows many people require his services. In Boston his dance card is full. And Nancy is next in line.

Nancy is five feet three inches tall and, at the time of her operation, weighs 274 pounds. Her BMI is 48.5, well into the morbidly obese range and she thinks she would feel and look much better if she were one hundred pounds or more lighter. She has seen what gastric bypass surgery can do for people: two of her coworkers have been transformed by the procedure, and a year ago her youngest daughter underwent the surgery and dropped ninety pounds. It was her daughter especially who convinced Nancy to give surgery a go, not so much with her words, but by her example. Both mother and daughter, Nancy said, are stubborn as mules. She figures that if gastric bypass worked for her daughter, it will work just as well for her.

Mun doesn’t know Nancy is stubborn, but he does know that she is an especially good candidate for obesity surgery. For one thing, she is in relatively good health, without the horrific complications suffered by so many of the morbidly obese. For another, she is relatively small. A man of Mun’s experience might well see Nancy that way. The hospital bed waiting outside his operating room is a “Big Boy,” built to hold up to five hundred pounds. Sometimes it takes two Big Boys pushed side by side to hold one of Mun’s gastric bypass patients. Mun remembers a seven-hundred-pounder whom he envisioned falling on him and crushing him to death. Nancy evokes no such grim images. There will be room to spare on her Big Boy.

Still, Mun has not promised Nancy success, or even survival. Gastric bypass kills one out of a hundred patients on the operating table, and not everyone recovers from its complications. There are few controlled studies of the procedure, so no one can speak with authority on its degree of danger. Still, the insurance industry classifies it as “high risk.” The anesthesiologist on duty warns that corpulent patients are tricky, and that Nancy is no exception. Nancy’s veins are buried in a thick layer of fat, making it hard for a needle to find purchase. Like many obese people, her tongue is large and her neck short, making it difficult to guide a breathing tube down her windpipe. It takes a bevy of nurses and doctors several attempts to finagle each of these maneuvers, and with every attempt it looks like Nancy will choke or cry. But she doesn’t, and with time and effort the requisite tubes and needles get coaxed and jabbed into place. Nancy’s eyes flutter and close and the anesthesiologist tapes them shut to prevent the corneas from drying out. Paralyzed from the anesthesia, Nancy draws her breath by machine. Plastic shrouds her face, presumably to shield wayward gore. She emanates fewer signs of life than do the machines to which she is tethered.

Mun helps the nurses arrange the layers of sterile drape, leaving exposed a rectangle of stark white skin roughly the area of a shoe box lid, size ten. He paints the rectangle orange with antiseptic. The flesh ripples thickly, like a crème brûlée. Mun grabs a black ballpoint pen and traces down the center line, a little shaky at first, then more or less finding the line he is after, about an eight-inch stretch from the tip of the breastbone to the navel. Seble Gabre-Madhin, a surgical resident, accepts a cauterizing scalpel from a nurse and traces over that line again and again until the skin bursts open with the force of the fat beneath. An observing medical student startles. It’s not the sight that makes him queasy, he whispers, it is the smell, which is savory, like hamburgers spitting on a grill. The translucent fat layer glistens yellow under the operating room lights. The attending nurses hover. Drs. Gabre-Madhin and Mun exchange looks, then press two palms each on either side of the neatly split skin and ease the fat apart, forming a canyon. The walls of the canyon are slippery and lightly variegated with red blood vessels. There is almost no blood.

In The Wisdom of the Body, Sherwin B. Nuland, a clinical professor of surgery at Yale University, writes that the stomach is best understood “seen as a large bag near the upper end of what is otherwise a hollow muscular tube some twenty-five feet long from mouth to anus, the central portion of which is coiled up in the abdomen.” This tube is the gut, and from stem to stern it comprises the pharynx, the esophagus, the stomach, the small intestine, the large intestine (or colon), and the rectum. The gut has an inner and outer layer of muscle, and the stomach has yet a third, to aid in its tireless churning of food.

The muscles and fibrous layers covering both sides of the stomach wall meet and fuse together in the middle of the belly, forming the linea alba, a stout ribbon of tissue stretching from the breastbone to the pubis. Mun deftly splits this, exposing the well-packed contents of the abdominal cavity, the largest orifice in the human body. Nurses position a gray metal circular retractor to hold back the skin and flab. The crater yawns jagged and raw. Mun pulls a glutinous apron of fat and blood vessels outside the wound, and lays it to one side of the torso. The mess on the surgical sheet is ghastly, like a mangled tongue lolling from the mouth of a drunk.

Mun plays archaeologist, pointing out artifacts as he excavates. Plunging his hand into the cavity, he locates the expected umbilical hernia, a weakness in the muscle near the belly button that is common in the obese. Wrist deep, he palpates the taut purple liver. He had mentioned earlier that the livers of the obese can grow monstrous—“sometimes,” he told me, “they are as big as a horse’s liver.” This liver, thank goodness, is not Clydesdale-sized. Mun gently retracts it to examine the junction between the stomach and the esophagus. He is now elbow deep, pawing blind for the start of the stomach. Long seconds pass, and Mun’s brow arches in concentration. No one says a word. This is a tricky business, and even the assisting surgeon, a stout, world-weary young woman, seems to hold her breath.

Suddenly, Mun finds what he’s after. He stops for a moment and looks back at me, triumphant in his sterile mask and lightly fogged glasses.

“I love this organ,” he says, pulling the stomach into glorious view.

Bariatric surgery, as obesity surgery is called, has a controversial history dating back hundreds of years. But the first modern procedure on record was in 1889, performed by Howard A. Kelly, a founding member of the faculty at Johns Hopkins University and its first professor of obstetrics. Kelly was an inventive surgeon and developed numerous surgical devices as well as innovative operative procedures. He seems to have fancied himself quite a sculptor, for he carved layers of fat from the abdomens of unwitting patients while they were under the knife for other problems.

Over the next few decades, reports of similar adventures trickled in from France, Germany, and Russia, and by the early 1920s, obesity surgery had become, if not fashionable, at least less ignominious. Not all obesity surgery patients died from massive infection or blood loss, but enough did that eventually it became clear to most respectable surgeons that slicing large quantities of fat from human bodies was not necessarily the safe and sure approach to treating the overweight that enthusiasts had claimed.

By the mid-twentieth century, obesity surgery had fallen out of favor with all but a few die-hard zealots. George Blackburn was not one of these. Blackburn is a surgeon, and is now director of the Center for the Study of Nutrition and Medicine at Beth Israel Deaconess Medical Center, where Edward Mun works. He is of medium height and robust, with stark white hair cropped into a schoolboy fringe. When we meet he radiates the sort of deep, smoky tan that comes from riding shotgun on a golf cart. There is no telling whether Blackburn plays golf, but I later learn that he gave up performing surgery years ago. He remains a darling on the obesity circuit, however, lecturing at conferences, consulting with industry, and sitting on boards and committees.

Like Mun, Blackburn trained at Harvard as a general surgeon. Like Mun, as a young man he developed a special interest in the stomach and in disorders of the gastrointestinal tract, such as ulcers. He cultivated this interest in the early 1960s, when doctors were not yet aware that ulcers are frequently caused by bacteria and treatable with antibiotics. Back then, dietary changes were the most common ulcer palliative, followed by surgical treatment. Surgery for severe ulcers usually involved removal of part or all of the stomach. It is possible to live and even to thrive without a stomach by eating many small meals and taking daily vitamin injections. Still, a hefty percentage of ulcer patients died of postoperative bleeding, infection, and sometimes starvation. Starvation was also a problem for trauma patients and for patients who lost their appetites after surgery. Blackburn got interested in this problem and decided to make it a subject of study in the early 1970s. To study it, he needed to experiment, and to experiment, he needed people who were willing to starve. He put ads in the Boston newspapers, assuming that he would get little if any response. “I was overwhelmed by the number of people who volunteered,” he says. “Stunned.”

Even more stunning than the number of volunteers was their size. Most were overweight or obese. Blackburn had very little experience with obese patients, and he was unfamiliar with their ways. He assumed, as did most doctors at the time, that fat people were too gluttonous to forgo a single meal, let alone subject themselves to weeks without food. But the overweight and obese volunteers were more than happy to starve. And they didn’t cheat. They faithfully followed Blackburn’s orders, eating only very small amounts of fish, fowl, or meat to keep up their protein levels to maintain as much muscle mass as possible. A month and a half later, they were many pounds lighter, and surprisingly healthy. Thanks to the “protein sparing” regimen, they showed no signs of the muscle wasting or dehydration usually associated with starvation regimens. That was all Blackburn needed to know, and he thanked the volunteers and told them it was time to leave. But he recalls that many—maybe most—begged to stay. “They would do anything to lose weight,” he says. “And I mean anything.”

Blackburn was a surgeon, not an endocrinologist, and he saw the plight of these patients through a surgeon’s eyes. He was intrigued and moved by their pleas, but he had observed obesity surgery as a resident, and he hadn’t liked what he’d seen. True, it had gone beyond the nineteenth-century “slice and dice,” but to his way of thinking it hadn’t gone far enough. The technique of choice at that time was the jejunoileal bypass, in which the intestine was essentially short-circuited to allow most of what the patients ate to slip through unnoticed and unabsorbed by the gut. This method was fairly effective, but the side effects—infection, protein malnutrition, kidney stones, osteoporosis, anemia, and liver failure—were unpredictable and occasionally fatal. “Some people would rather die than be fat,” Blackburn says. And some doctors colluded in the gamble. About 100,000 intestinal bypasses were performed in the 1960s and early 1970s. Still, the high failure and mortality rates of intestinal bypass were troubling, and Blackburn chose to stay clear of the procedure.

There were other more benign approaches to consider—jaw wiring, for example. Jaw wiring is exactly as it sounds, something Wile E. Coyote might cook up for the Road Runner. As described in the British medical journal, The Lancet, the wiring procedure was simple enough: “Two interdental eyelets were placed in each canine and pre-molar region under local anaesthetic and the eyelets on opposing jaws wired together. Instruction was given on oral hygiene, measures to avoid aspiration, and the use of wire cutters.” These “instructions” notwithstanding, expressing oneself through bound jaws was a trial, as was brushing one’s teeth or eating anything that could not be slurped through a straw. And vomiting while wired could be lethal. (That is, if one somehow forgot to bring one’s wire cutters to an office picnic.) Accidents—and deaths—did occur. And those who endured the recommended six months were horrified to find their weight soar when their jaws—and their appetites—were unleashed. Some physicians tried to stave off this rebound by prescribing a waist cord—a nylon strap tied tightly around the middle of slimmed patients that would remind them to eat sparingly. But most patients did not allow mere nylon to come between them and their calories, and either cut the dreaded things off or allowed themselves to balloon into giant hourglasses, with the waist cord strangling their middles like a noose. Clearly, when it came to weight loss, bondage was not the answer.

A more elaborate and certainly more imaginative scheme was the intragastric balloon, threaded into the stomach and blown up to crowd out the space for food. Stomach balloons carried a sort of whimsical allure: what could be more benign than a whisper of latex pumped with air? But the procedure was surprisingly expensive and not particularly effective. It was also dangerous, causing ulcers and erosion of the stomach lining. In 1988 a prominent physician decried the practice as “balloonacy” in an article in the journal Gastroenterology. Surgeons of the time were also experimenting with esophageal banding—inspired, perhaps, by the picturesque cormorant fishers of Japan. Cormorant fishing, or ukai, involves binding the necks of tame cormorants and setting them free to scoop sweetfish from the Nagara River. The birds are then called back or hauled in by their keepers and the fish extracted from halfway down their gullets. Esophageal banding has worked well for generations of fishermen in Japan, where the sport has become something of a tourist attraction. But it enjoyed only a short run in humans, who developed severe and sometimes fatal infections of the esophagus from the binding, and in any case had a greater tendency than birds to complain about fish getting stuck in their throats.

These and other disappointments prompted obesity surgeons to reconsider their options. Should they perhaps return to the stomach as a primary target? After all, the stomach’s day job is churning great wads of stuff in a vat of acid, so it is accustomed to rough treatment and less prone to injury than are other more delicate organs. Also, at least theoretically, shrinking the stomach directly limited the amount of space available for food. And for many people a smaller stomach demanded less food than did a larger one. As explained by Columbia University College of Physicians & Surgeons professor Michael D. Gershon, author of an ode to the digestive tract, The Second Brain, when the stomach is full, receptors that respond both to pressure and to nutrients put a signaling system in motion to stop eating. A smaller stomach brings this pressure to bear more quickly. By shrinking the stomach, surgeons discovered that they could curb not only the intake of food, but also, in a surprising number of cases, the desire for food.

Stomach shrinking may not be brain surgery, but it has its challenges. Early approaches involved roping the stomach off near its throat with a one-centimeter-wide plastic tourniquet. There was no cutting, no stitches, no piercing of the stomach wall. The downside was that the bands sometimes worked their way into the stomach’s interior, and got tangled into a mess that adhered to the stomach lining, causing pain and damage. A somewhat more complicated version of this approach, vertical-banded gastroplasty, eliminated the tangling problem and became quite popular. Both methods remain in use today, but at Beth Israel Deaconess Medical Center, George Blackburn does not recommend them.

In his drab and sprawling first-floor office, Blackburn keeps what he calls a “sympathy suit,” a sort of hair shirt he pulls out for visiting doctors and scientists. The suit is shiny and puffy, like astronaut gear, and is filled with sand. It weighs thirty-four pounds, and donning it is meant to give skeptics some idea of how obese people feel every waking minute. Blackburn believes that the risk of obesity surgery and its complications is nothing compared with the risk of dragging all that excess baggage through life. Although he would almost certainly object, it would not be a stretch to call Blackburn a gastric bypass evangelist. He has seen what obesity can do to the human spirit, and it horrifies him.

“When I see a young man, a football player type of, say, 280 pounds, I’m able to look into the crystal ball of his future and see diabetes, insulin resistance, a whole slew of problems. Who among us would intentionally let people walk into the lion’s mouth of obesity disease? No, I don’t consider surgery drastic in the least.”

Blackburn directs me to Isaac Greenberg, a psychologist who has worked with him for years. Greenberg is on the tall side and slim as a greyhound, but he’s not smug about this. “Thin people think they’re thin because they are doing something right,” he says. “But they are wrong. What surgery has done is blow the psychoanalytic theories of obesity to hell. After the operation, many people lose their obsession with food. No one knows why, but it certainly proves that obesity is not just a psychological disorder.”

Greenberg screens patients to see whether they are suitable candidates for gastric bypass. Most of these people have tried every weight loss scheme in the book. “Programs like Jenny Craig or Weight Watchers are like a virus,” Greenberg says. “People go to meetings, see that other people have lost weight, and they want to catch that virus, too. So they sign up. They lose weight, go off the program, go off the special foods and gain the weight back. So, they return to the program. There are millions of returning customers keeping those outfits in business.”

Greenberg invites me to attend a monthly obesity surgery support group meeting, and one dreary Thursday evening I decide to take him up on it. The group gathers in a basement auditorium at the hospital at dinnertime, but food is not served. The basement is dingy and echoing, and furnished with gray folding chairs. A ramp allows people too large to walk to roll into the room in wheelchairs. Four chairs roll in this evening. In all there are about three dozen participants. Most are in their thirties and forties, but they look older, their faces pasty and drawn, their bodies bloated with disuse. Their thick legs look vestigial. They complain of heart disease, diabetes, arthritis, and their difficulties in finding comfortable shoes. They are roughly divided between those who are scheduled for surgery and those who have recently had it. Few of the postoperative patients are anything close to thin. They have complaints—vomiting, getting food stuck halfway down their throats, hernias, gallstones—and they look just as tired, saggy, and worn as the people who have not yet had the operation. But most seem to agree that these discomforts pale compared to the agony they had endured throughout their presurgical lives.

It is no secret that the very obese live lives of quiet desperation, of humiliation and isolation, and of relentless guilt. Children have said in surveys that they would prefer playmates with missing legs or eyes to those with too much fat. Many obese adults confess that they would prefer to be blind or deaf. No wonder, then, that the fat people who gather together in this dank auditorium would, as George Blackburn predicted, do anything to be thin.

Among them only two, a media manager and a computer programmer, show any visible effect of the surgery. The programmer has lost one hundred pounds. He has 150 pounds still to lose, and he looks peaked, as though fighting a losing bout with the flu. The manager, a tall woman in her early thirties, announces that she is fourteen weeks pregnant. She looks terrific.

“One hundred thirty-seven pounds ago, it took nearly two years for me to get pregnant with my first child,” she says. “This time it took one try.” The room shakes with applause. After the cheers die down, a support group member raises a timid hand to ask if there is “any downside” to the surgery. There certainly is, the manager says cheerfully. “For weeks after the operation I thought I’d made a mistake. I was so sick I could hardly move. I really did think I was going to die.”

Nancy Wright has attended these support group meetings, and she knows exactly what she is in for. She knows that dying on the operating table is a distinct possibility. She knows about the complications—the exhausting anemia, the painful gallstones and incisional hernias, the infections. Hearing about the ghastly aftereffects of the surgery gave her pause, but not doubt. She hasn’t actually witnessed a gastric bypass, doesn’t know in explicit detail all it entails, but she has spoken with Dr. Mun, and she has perfect faith in him.

And Ed Mun has perfect faith in himself. He has completed 110 gastric bypass procedures in the past twelve months, and most have gone like clock-work. One patient blew out her staple line postoperatively and wound up in the intensive care unit for thirty-five days. But she’d had three kidney transplants and a suppressed immune system and was a bad candidate for the procedure from the get-go. Nancy is a textbook case.

Mun reminds me of this as he manipulates Nancy’s guts, maneuvering the left side of her stomach down into the operating field and into his line of vision. He takes care not to damage the spleen, which bleeds uncontrollably if torn, or the pancreas, which is filled with enzymes that can leak out and, as he puts it, “eat everything up.” The stomach is glistening, firm. It is easy to imagine how demanding that stomach can be. Mun sizes it up and gets to work. Taking aim with his Endo-GIA II stapler, which cuts as well as rivets, he divides the stomach into two parts and staples the top portion into a twenty-milliliter pouch, about two tablespoons. An organ that could once proudly contain a quart of Häagen-Dasz can now barely hold a shot glass of yogurt. The bottom section will still secrete stomach juice, but it won’t nag Nancy for food. Mun feels down the small intestine, past the duodenum to the jejunum, slices through the sausagelike structure and nails it to the stomach pouch with his EEA circular stapler, creating a passageway the circumference of an M&M. Mun regards the EEA fondly, and praises its smooth, powerful action. The device spits out sixty-four stainless steel staples at a trigger pull, accomplishing in a split second what once took long minutes of painstaking needlework. Like a rodeo star roping a calf, Mun grabs the slippery bypassed end of the small intestine, flips it, and staples it to the lower small intestine, forming a Y. Stapling the jejunum to the stomach pouch will keep Nancy from cheating. For some reason doctors can’t quite agree on, contorting the gut this way causes it to shoot caution signals to the brain when fatty or, in particular, sweet food passes through. These signals spark a violent “dumping” reaction—the body rejects the treat as it would poison, sparking cramps, hot flashes, pain, and diarrhea. For a few months at least, Nancy’s stomach will no longer have the power to demand a Snickers bar. Mun has tamed it.

Looking up, Mun checks his watch: it is just over an hour since the first incision. Inhaling deeply, he stands back and admires his work: perfect, and in less time than it takes most people to balance their checkbooks.

Three hours after the operation, Nancy is awake and hurting in her Big Boy. She is exhausted, gray with fatigue and pain. “That was no walk in the park,” she says. I ask if she has any regrets, or—worse yet—any thoughts of food. “No way,” she says, her eyelids fluttering. “That’s behind me now.”

At nine o’clock the next morning, Edward Mun performs his seventh gastric bypass of the week. He is to leave that night for Korea, to attend his elementary school reunion. The fact that he has agreed to fly halfway around the globe to gather with childhood friends somehow doesn’t surprise me. Mun is a man of deep loyalty and total dedication; a man who, as Nancy knew, can be trusted. Time is short but Mun is willing to take some moments to reflect. He tells me that that morning’s patient was a particularly tough one. She weighed more than four hundred pounds and had an inflamed gallbladder that needed to come out. Two other surgeons had turned her down for surgery because of her size, but Mun hadn’t flinched. When he opened her up he found the largest gallstone he’d ever seen stuck to the wall of her gallbladder. He cut it out, and the woman lost three hundred cubic centimeters of blood. Most surgeons would have stopped there, but Mun went ahead with the bypass.

“I thought about putting it off, but I decided to go ahead,” he said. “Gastric bypass was her only chance. This operation is not an elegant solution. On some levels it’s barbaric. But, let’s face it, it’s all we’ve got.”

Like Nancy, more than nine million American adults are “morbidly obese,” roughly one hundred pounds or more overweight. Ten million more are almost there, teetering on the edge. But one need not reach this milestone to pass muster for surgery. People with “co-morbidities”—diabetes, heart disease, high blood pressure and the like—qualify at lower weights, and some physicians—among them, George Blackburn—argue that the bar should be lowered further, to include the still larger number of people who are obese, but not morbidly so. So many patients are clamoring for gastric bypass that experienced surgeons are overwhelmed. At a lecture I attended on surgical techniques at an annual meeting of the North American Association for the Study of Obesity, doctors overflowed the room, and stood straining to hear from the hall. The speakers, all obesity surgeons, promoted a slew of new techniques, including some that sounded only slightly less draconian than the old slice-and-dice approach. They also raised the specter of performing the operation on children as young as twelve. Such radical tactics are justified, they said, to stem the tide of an epidemic that is all but smothering us.

Nancy can’t help but agree. She and I speak a month after her surgery, and she is cautious, but upbeat. She still cannot eat much, but then, she doesn’t want much. She is living on nibbles of yogurt and scrambled eggs and instant breakfast mix, and hoping for the best. Gastric bypass patients lose most of the weight they lose quickly, in the first eighteen months, but that, Nancy knows, is the grace period. The hard part comes later, when the novelty of the procedure dims, and old habits start to surface. Often the pounds creep back. Somehow the magic wears off and the pouch gets stretched enough to accommodate the slowly sneaked calories. Or the person cheats by sipping high-calorie drinks all day long, or sucking down tubs of melted ice cream. Nancy knows that this could happen, and it worries her. But for now she is satisfied that the choice she made was the best one. For now, she is in control.

“I know this is no miracle cure,” she says. “I know it’s going to get rougher. I don’t know what’s going to happen two or three years down the road. This was a big step, and a terrifying one. But when it comes right down to it, I had no choice. It was my only chance at a life.”

Two

WALKING NAKED

The Son of Man has come eating and drinking; and you say, “Behold, a glutton and a drunkard, a friend of tax collectors and sinners!”

—Matthew 11:18, Luke 7:33

… take no baths, sleep on a hard bed and walk naked as long as possible.

—Hippocrates, On Diet

Pudge is not a new thing. Consider the Venus of Willendorf, a hand-sized 25,000-year-old sculpture of oolite limestone. The Venus was unearthed early in the twentieth century in a cave excavation near the Austrian village whose name she bears. Her face is obscured by a decorative overlay of what looks very much like cornrows. She has erupting breasts, a Falstaffian stomach, and what appear to be no feet. She is lushly, voluptuously obese.

Willendorf is but the oldest in a long line of Paleolithic Venus figurines found scattered from southwestern France through Italy, Austria, and Turkey, to the north shore of the Black Sea. About one hundred such statues have been unearthed, and they are thought by archaeologists to be among humankind’s earliest artworks. All these Venus statues, even the French ones, are grotesquely fat. Their marked similarities have prompted some anthropologists to conjure a continentwide “paleo-porn” cult, a delicious concept, but one not supported by evidence. Less fanciful observers consider them mere fertility goddesses, an interpretation that is probably closer to a truth we are likely never to know. What is certain is that artists of the period were realists, and that some Venuses show distinct knee abnormalities common in the super-obese. This makes it likely that the finely sculpted figures were modeled not from artistic inspiration, but from real life. Obesity, then, may have its roots in the Stone Age.

The Paleolithic era was a hardscrabble time. Glaciers spanned much of Europe, and the only reliable vegetation was moss, lichens, and grass, leaving humans to feed mostly on still-warm flesh ripped from the carcasses of other living creatures. Being alive meant being fit enough to scavenge or run down one’s dinner. So the figurines present a puzzle: How did these women manage to grow fat in such lean times? Did adoring acolytes ply them with choice morsels? Did they trade favors for food? Whatever their tactics, the results were remarkable, for obesity was otherwise unheard-of in traditional hunter-gatherer societies.

It was not until the Neolithic revolution of ten thousand years ago that agriculture offered the first viable option to all that frantic stalking of prey and gnawing of flesh. Agriculture had the startling consequence of making food perennially available, first in the Fertile Crescent of the Middle East, then in China, Egypt, and western Europe. Agriculture also made possible the domestication of animals—and the steady consumption of animal fat. This bounty allowed a small elite to grow larger and fatter than they otherwise might have, though not all were eager to admit it. Egyptian pharaohs entombed themselves in chambers etched with depictions of their own gorgeous physiques, but studies of their mummified remains betray rolls of belly fat. (Servants were likely the living models for those hard-body renderings.)