Feb. 12, 2004

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Tamah Sutfin-Nelson, photo by Helen Sanderson.

by HELEN SANDERSON

IT WAS THANKSGIVING MORNING 2002, BRIGHT AND SUNNY, and Tamah Sutfin-Nelson had brought her dogs down to the river bar underneath Fernbridge. As she watched them chase each other in circles, a man's voice boomed from a truck passing by on the bridge overhead: "Look, everyone, it's a beached whale!"

Moments like that were not uncommon, nor original, but they still had the ability to darken a beautiful day.

Weight has always been an issue for Sutfin-Nelson, a 36-year-old Fortuna resident who works as an in-home caregiver and part-time security guard. Her mother put her on skim milk when she was just 3 months old. She remembers having her meals monitored as early as second grade.

At age 12 she went to "the fat doctor," a family practitioner in Eureka who ran tests on the adolescent girl to make sure that her heart was strong enough to handle weight loss pills.

"It was basically like prescription speed. I would take that in the day, and then I would take something that helped me sleep at night," Sutfin-Nelson said.

She entered her freshman year of high school at 160 pounds. At 5 feet 7 inches, she was hardly petite, but she wasn't obese either. She just thought of herself that way.

"I was the fat cheerleader," she said. "When I look back at pictures of myself then, I look so small, but at that time I felt like I was 400 pounds."

By her sophomore year her weight had climbed to 220. Forcing herself to vomit after eating wasn't helping keep the pounds off, so she started taking methamphetamines, real speed. She continued to use the drug until she was 23, when she became pregnant.

"When I found out [about the pregnancy], quitting speed was not even a question. It wasn't hard at all and I never went back. But food, that's something you can't quit forever, no matter how bad you want to lose weight."

That was the question Sutfin-Nelson confronted a year ago: How badly did she want to lose weight? Years of dieting had proved fruitless. She was now close to 400 pounds, and her doctors were telling her that if she didn't lose weight, the knee problems she'd been experiencing would become worse -- to the point where she would end up in a wheelchair.

There was a way out, possibly -- gastric bypass surgery, an inherently risky operation that shrinks a person's stomach and bypasses most of the small intestine where calories are absorbed. It was a last resort, but Sutfin-Nelson didn't see what choice she had. She'd done some research and felt fairly confident. But she was hesitant to tell her family and friends. No wonder. Her older brother, Jim, had had the operation three years before. He died from complications.

[PHOTO ABOVE LEFT: Tamah Sutfin-Nelson two months before surgery in March 2003.]

Risky business

The probability of a patient dying from the procedure, in which the stomach is reduced to the size of an egg, is estimated at one in 100. The staples used to secure the reduced stomach can come loose, blood clots can develop and infections can set in. In Jim Sutfin's case, it was an infection of the pancreas. [See story below]

Gastric bypass surgeons and patients point out that death is a possibility in all surgeries -- like a liver transplant or heart surgery. The difference is that a gastric bypass procedure is a choice -- an elective surgery that is not performed in an emergency situation. Critics say that both doctors and patients are opting too readily for the surgery, putting the patient unnecessarily at risk and ignoring the emotional problems that come with being chronically obese.

Only a few years ago gastric bypass surgery was considered a radical operation, limited mainly to overweight celebrities like singer Carnie Wilson (daughter of the Beach Boys' Brian Wilson) and comedian Roseanne Barr -- waning stars desperate for Hollywood's validation. But with obesity reaching epidemic proportions -- 39 million adult Americans are obese or overweight, according to the National Institutes of Health -- the procedure's popularity has spread from big cities to breadbasket communities across the nation. The number of surgeries has quadrupled in the past five years. Last year alone, more than 100,000 Americans underwent the $25,000 operation, and waiting lists are growing.

Since the surgery is not performed in hospitals on the North Coast -- no doctor here does it -- Humboldt residents are traveling hours away to get it, to places like San Francisco, Sacramento, Fresno, even as far as the town of Delano, north of Bakersfield. Fledgling gastric bypass, or "bariatric," programs are cropping up closer to home, however. Doctors in Redding; Klamath Falls, Ore.; Coos Bay, Ore.; and Santa Rosa are beginning to accept overflow patients stuck on the waiting lists of more experienced doctors.

Support groups for people who have either undergone gastric bypass surgery or are contemplating doing so have been in existence for about two years at St. Joseph Hospital in Eureka. Another one got started recently in Fortuna. At a meeting late last month, 10 people expressed interest in having the surgery; another 19 had already gone through it. Nadine Hartman, the 46-year-old Fortuna resident and daycare provider who started the group, is in the latter category. Since having the surgery in Fresno last August, her weight has dropped from the 280 range to around 200.

[ABOVE RIGHT: Tamah Sutfin-Nelson's abdomenimmediately following her gastric bypass surgery in May.]

For many, diets don't work

Dr. Edward Asa Stockton, an orthopedic surgeon in Eureka, has had an even more dramatic result in his own surgery: He lost 160 pounds, dropping from 420 before the surgery to 260 today. The surgery was done three years ago, proof that its benefits last. It would never have happened, Stockton said, through dieting alone.

Other overweight people are coming to the same conclusion -- diets don't work, at least not for the long term. What typically happens is that people initially shed weight only to eventually regain it, and then some. They then go on another diet, and the same thing happens.

The reason lies in the body's metabolism. When a person who once consumed an above-average amount of calories, say 2,600 a day, begins to consume a below-average amount, say 1,400 calories, they slim down. But in time the body reacts to the new eating pattern by slowing down its metabolism. If at some point the dieter begins to eat more than that below-average quantity -- even if it is less than their previous caloric intake, 2,000 calories for example -- their body stores the extra calories in response to their slowed metabolism.

In other words, their body misreads the reduced nutrition as a threat and goes into a self-preservation mode, essentially becoming more successful at holding onto extra fat.

Some people see gastric bypass surgery as an easy way out for an obese population unwilling to work hard enough to stay thin. Patients disagree.

"To say that obesity is a question of willpower is insulting and simplistic," said Susie Spitzer, an RN with Mad River Hospital who underwent the surgery. "We have not failed dieting, dieting has failed us."

Sutfin-Nelson echoed Spitzer's assertion. "I think that fat people have more will power than almost anyone. There isn't an overweight person I know who hasn't starved themselves to try to lose weight."

Spitzer, 55, went on to cite studies that show that only 6 percent of those who have attempted diets succeed -- meaning they keep the weight off for three years or more.

"Atkins, the Zone, South Beach, fen-phen: You name it I've done it all," she said. "When you get down to brass tacks, the yo-yo effect of dieting is bad for your body, and it's bad for your self-esteem."

To even become a candidate for gastric bypass surgery, the applicant must demonstrate that she has tried dieting and that it has failed -- meaning that substantial and long-term weight loss never occurred.

Some critics suspect that dieting programs like Weight Watchers and Jenny Craig are set up this way intentionally: the system reaps huge profits by ensuring that diets are unsuccessful. According to estimates, the dieting industry in America alone rakes in $40 billion dollars annually while obesity rates continue to climb.

Types of surgery

Although the recent popularity of gastric bypass surgery makes it seem like a new operation, a form of the stomach-shrinking surgery has been around since the 1950s.

One of the earliest procedures, known as the jejuno-illeal bypass (JIB), connected the upper part of the small intestine to the lower part. With food essentially bypassing a long middle section of the small intestine where most calories are absorbed, patients could still eat large quantities without absorbing calories or nutrients -- a phenomenon called malabsorption. Patients lost weight from the procedure, but over the long term the lack of nourishment led to life-threatening health effects, including kidney and liver failure. The procedure fell out of favor by the 1970s.

"Twenty to 30 years ago it was basically considered a charlatan operation," Stockton said. "It didn't really catch on again until five or six years ago."

Stomach stapling, called gastroplasty, was introduced in the 1980s. But a problem soon became apparent: The stomach walls would stretch despite the staples and calories were still being absorbed in the intestine. Just as with dieting, people would lose weight only to put it back on.

The solution doctors eventually hit on was to combine the nutrient deprivation technique of the 1950s with the size restriction method of the 1980s.

Under the most commonly performed gastric bypass procedure today, known as the roux-en Y, doctors staple off much of the stomach, leaving just a small pouch that can only contain a few ounces of food. The pouch is then connected to the lower part of the small intestine, bypassing about one-third of the digestive tract where calories are absorbed. The procedure is typically completed in about 90 minutes and patients are out of the hospital within three or four days.

A more drastic procedure, called a duodenal switch, actually removes close to 80 percent of the stomach. While the remaining pouch is slightly larger than that in the roux-en Y, allowing the patient to eat more, a greater portion of the small intestine is bypassed, so the body absorbs fewer calories.

Both operations require that patients take vitamins and minerals, particularly pills containing calcium and iron, to maintain normal levels of nutrients after the surgery. Duodenal switch patients, because of the higher rate of malabsorption, tend to lose more weight than those who have the roux-en Y.

In a third, less invasive gastric surgery, a plastic band is placed around the stomach, restricting how much it can contain. With this procedure, patients cannot overeat but they still absorb calories and nutrients as they did before. For that reason, the results are not as dramatic as the other surgeries, but the band is removable and therefore the surgery is relatively easy to reverse.

Hartman, Spitzer and Stockton all opted for the roux-en Y procedure. Not only have they lost weight, but other problems are also beginning to abate. Stockton no longer suffers from sleep apnea. (The stoppage of breathing while asleep.) Spitzer takes only a fraction of her high blood pressure medication and Hartman says that her diabetes is becoming easier to manage.

`Not a magic bullet'

Dr. Alan Glaseroff [photo below left] , who runs a family practice in Arcata with his wife, Dr. Ann Lindsay, is the chief medical officer for the Humboldt Independent Practitioners Association (IPA). He does not think gastric bypass surgery is the answer to the obesity epidemic.

"This surgery is not a magic bullet," Glaseroff said. "But it's promoted that way for people who have been looking for a magic cure for a long time."

"Morbid [extreme] obesity does not happen overnight," Glaseroff went on. "It's the result of an eating disorder that surgery can't fix."

Glaseroff described a patient of his who was suffering from depression. She had the surgery, and although she lost more than 100 pounds, she still had emotional problems. With a postoperative stomach that could only contain four ounces of food, eating for emotional comfort was no longer an option. Although she never had issues with alcohol before, the woman began to drink heavily. She later became suicidal and has since been seeing a counselor.

"Oftentimes obese people use food as a barrier. Maybe the person was molested and food becomes a comfort or a form of protection. They might think, `If I'm fat, my abuser won't find me attractive, they'll leave me alone,'" Glaseroff said. "Years later, their weight becomes an external sign of unhappiness. So the person has surgery, and as they lose the weight they feel like their shield is gone and they're terrified."

After seeing cases like these, while simultaneously being flooded with requests from people needing a doctor's referral to have the surgery, Glaseroff decided that an alternative approach was needed to combat obesity problems locally.

He put a call out to health professionals in the area requesting help to develop a program that worked specifically with severely obese people. He said the response was encouraging. Registered dieticians, doctors, physical therapists and psychotherapists decided to work together on the problem.

Each of the 40 patients in the Morbid Obesity Case Management Program has a nurse assigned to him or her, are medically evaluated and put on a diet and exercise plan along with counseling sessions. Glaseroff says that the people on the program, while still in its beginning stages, are steadily losing weight, and just as important, are dealing with the emotional strain of their weight problems.

A profitable procedure

Since the IPA is a mediator of sorts for insurance providers, people who carry certain insurances -- like some Blue Cross plans -- must get the approval of the IPA before having surgery. And in the past year, the IPA, in part because of Glaseroff, has made it harder for obese people to qualify.

Not only that, the IPA only refers patients to the University of San Francisco Medical Center and Stanford University. In most cases those hospitals require that patients lose 10 percent of their excess weight before surgery.

"There's been this pushback from patients who have surgeons telling them that it's their right to have the surgery, that they shouldn't have to wait. Well, that's an economically driven response," Glaseroff said.

Doctors, of course, are aware there's money to be made. The Fresno surgeon who operated on Hartman, the woman who started the Fortuna support group, recently offered to pay rent for a space for the group if 50 people interested in having the surgery show up for a meeting. He has also offered to make the eight-hour drive north to host an informative seminar about the surgery. Fifty more patients, at $20,000 to $25,000 per surgery, equates to $1 million or more.

Still, surgeons require that the patients jump through some hoops before they can have the surgery. Among the list of requirements are a psychological evaluation, documentation of a failed diet history, blood work and an EKG in addition to other lab tests. Also, patients must be overweight by at least 100 pounds. Those with at least three obesity-related disorders -- type 2 diabetes, heart disease, high blood pressure, sleep apnea -- can be somewhat less overweight.

Even in light of the growing requests for the operation, the economic incentive and patients' claims of becoming healthier post-surgery, Glaseroff is not convinced that the weight loss procedure will be around for much longer.

"Ten years from now I imagine that they won't perform it anymore," he said.

The reason? Long-term medical studies will eventually show that the surgery is detrimental to a person's health. Glaseroff cited a Swedish study that is so far the only long-term investigation of the effects of gastric bypass surgery conducted on a large sample of people -- close to 8,000. While the study showed a significant post-operative drop in diabetes among patients, it did not reveal diminished rates of heart disease, the leading cause of death for diabetics.

So what's the solution? Glaseroff said hope lies in advances in pharmaceuticals -- particularly in creating a medicine that controls a hunger-inducing hormone called ghrelin.

`Comfort eating'

Since having a duodenal switch performed, Sutfin-Nelson has lost 143 pounds, but her battle with weight is not over. On average, patients shed pounds steadily for close to 18 months before reaching a size that remains fairly constant. Nine months out of surgery, the rate at which Sutfin-Nelson is shedding pounds appears to be slowing.

She admitted to some "comfort eating." No one could blame her. Just two months ago, her husband Lee, who was not obese, died unexpectedly of heart failure at age 54. Since then, Sutfin-Nelson hasn't been quite as strict with her diet as she should be -- opting, for example, to have a bowl of cereal instead of preparing a small, low-carbohydrate, high protein meal for herself.

If she hadn't had the surgery at all, she has no doubt that she would have turned to food for solace big time.

"I probably would have gained 40 to 60 pounds by now," she said.

[ABOVE RIGHT: Tamah Sutfin-Nelson, six months after surgery, nearly 140 pounds lighter.]

A surgery gone wrong

STANDING 6 FEET 4 INCHES AND WEIGHING 511 POUNDS, 38-year-old Jim Sutfin decided enough was enough. He'd tried diet after diet since high school, and not once was he able to permanently shed weight. It's true, at one point he did lose 180 pounds, but he gained that and more back even as he continued to diet.

In March 2000, Sutfin left his home in southern Oregon and drove to the Sacred Heart Medical Center in Eugene, where Dr. Latham Flanagan was to operate on him. It was no minor surgery that was scheduled. It was a type of gastric bypass surgery called a roux-en Y in which a large part of the stomach is literally stapled shut. Approximately one in 100 people die from it.

His family was supportive, but worried that complications could occur. Sutfin played down their concerns. When his mother said that she would leave her home in Humboldt County to see him through the surgery, he said it would be best if she waited a few weeks instead, so that she would be able to see the results.

When they got the call that he was in intensive care, his mother and his sister, Fortuna resident Tamah Sutfin-Nelson, drove immediately to Eugene. By the time they arrived he had fallen into a coma. Thirty-six hours after surgery, he died, leaving behind his wife, Mary, and three children, ages 11, 9 and 7. The cause of death was "acute pancreatitis," an infection of the pancreas.

In addition to being a tragedy, it was also a shock, as Sutfin, despite his bulk, led a vigorous life. He played volleyball three times a week and was an avid hunter and fisherman. He managed his diabetes with insulin, and aside from knee problems -- something his sister suffers from as well -- he was an active person. That's why doctors had told the family ahead of time not to worry.

For the next two years, his sister -- who successfully underwent a similar procedure last year, researched gastric bypass surgery, partly in the hope of finding an answer to Sutfin's death. But she came up empty-handed.

-- Helen Sanderson

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