The struggle to stay slim (and healthy)
Surgery is often a life-saving step for people battling severe obesity, but it's only one part of the equation in the fight against fat
In the framed 8-by-10 high school picture perched on a shelf in his parents' living room, Chris Donnelly will always be 190 pounds. His face is slim, his green eyes serious.
Now 37, Donnelly thinks about that picture often. He still looks a lot like that kid. Same thick eyebrows that make him look more serious than he is. Same green eyes and brown hair. There's just more of him than there used to be.
"When I was in college, I had that photo on my desk and a woman said, ‘Who is this guy?'" Donnelly says. "I said ‘That's me.' She said, ‘It doesn't look like you.' That's when I was 250 pounds. Now, I am currently 362 pounds."
There are complicated reasons why Donnelly has gained 200 pounds in the past two decades — reaching 400 pounds at one point — chief among them the literal handful of medications he must wash down each day to keep his epilepsy in check. But regardless of the reasons, he found himself in the same predicament that 15 million American adults now face — being morbidly obese and absolutely sick of it.
So earlier this year, he decided to do something about it. On June 23, Donnelly underwent bariatric surgery at Shands at UF. Under the care of UF surgeon Kfir Ben-David, M.D., Donnelly received an adjustable gastric band, which, when placed around the stomach, restricts how much food a person can eat and how much the body absorbs.
Undergoing weight loss surgery is a drastic choice, and the doctors leading UF's bourgeoning bariatrics program don't let patients make it lightly. But for morbidly obese patients, drastic changes are often necessary to save their lives.
Severe obesity puts people more at risk for a cadre of health problems, namely type 2 diabetes, high blood pressure, high cholesterol, stroke and certain cancers. According to a 2003 study in the Journal of the American Medical Association that looked at how obesity affects different demographics, severe obesity — defined in that report as a body-mass index over 45 — can shave 13 years from a young man's life and eight years from a woman's life.
"We don't do the surgery so patients can go to South Beach and wear their bikinis," says Ben-David, a UF assistant professor of surgery and is the director of the UF College of Medicine department of surgery's bariatrics program. "We do it because we are worried about their comorbidities. There is nothing more enjoyable than a patient coming by the office and saying, ‘Hey I'm no longer taking blood pressure medication.'
"We know from multiple studies that the only thing that is long lasting with regard to their weight loss is bariatric surgery. We know also from good meta-analysis that once patients lose the weight, (other conditions improve)."
And contrary to the misperceptions many Americans might have, weight-loss surgery isn't the easy way out, doctors say. At UF, patients must agree to adhere to a strict set of rules, such as following a specific diet and meeting regularly with a nutritionist and psychiatrist.
"Surgery is not a cure," Ben-David says. "It's just a tool for patients to get a new lease on life. That's what I tell patients. It teaches them how to eat better, that exercise is a very important aspect of their weight loss. If they don't do these things, they don't see the results they want. You're taking a very risky road to surgery. If you're going to do it you should go all the way."
Donnelly first thought about having the surgery a year ago. He mulled over his options for months. When he finally made the decision to have the surgery, he felt relieved.
Three days before his surgery was scheduled, Donnelly was already adhering to what would be his post-surgery diet, a daily lineup of protein shakes, soupy oatmeal and tuna topping out at 800 calories. Sitting in his parents' living room, he described what life would be like if he reached his goal — losing 150 pounds.
"I'd like to be able to walk up a set of stairs without having to do it one leg at a time," he said. "I'd like to be able to sit in a chair longer than 20 minutes. I'd like to be able to drive any car, not just cars that fit me. I could go on and on. I don't want to do anything crazy. I just want to do the simple things. I want to be able to go for a walk on the beach without my legs hurting. I'd like to eventually have a girlfriend. I haven't had a girlfriend in 10 years. Just the simple things in life. I'd like someone to look at me, not just for who I am inside, but for the way I look outside, because unfortunately in life both of those things go together. That's what I'd like."
Now, three months later, Donnelly says he has lost 50 pounds. He tugs at the baggy legs of his blue jeans, size 44s.
"I used to wear stretched-out 48s," he says. "I'm ecstatic."
But he admits it hasn't been easy adjusting to his diet and the surprising mood swings that accompanied the change in his lifestyle. Many patients struggle at first, says Tamara Lux, P.A., a physician assistant who works with bariatrics patients.
"I think for a lot of patients the first six weeks are the hardest," Lux says. "It's not an easy process."
Patients have to keep to a strict diet. Eating too much can stretch out their smaller stomachs or, if they have a gastric band, cause the band to break.
Because of the importance of sticking to their diets, patients spend a lot of time with Sherri Findley, R.D., M.S., after the procedure. The changes patients have to make aren't just about the food they eat, though, Findley says. And food, she says, isn't the singular problem that leads people to become severely obese.
"There's a huge mental component," she says. "There are a lot of theories about what it takes to lose weight and people get confused. Also, the types of food we eat, our foods have been processed so much we don't get a sense of satiety."
Clues from the brain
To the outside observer, the roots of obesity seem obvious: too many calories and too little exercise, and at the most basic level this is true. But the roots of causation are much more tangled and complex, and UF researchers are trying to understand how everything from resistance to the hormone leptin to genetic causes such as Prader-Willi syndrome affect the trajectory of obesity.
Mark Gold, M.D., the chair of the College of Medicine department of psychiatry, thinks the brain offers significant clues about what is happening in the bodies of people who are obese. Research has shown that brain scans of morbidly obese individuals look strikingly similar to brain scans of alcoholics.
Beyond that, Gold has discovered that overeating changesthe pleasure-reinforcement circuits of the brain that closely resembles changes caused by addictive drugs.
"It has to do with the texture, the smell, the sight of the food and the reinforcement that is produced by the food," Gold says. "People say they eat because it makes them feel good. The reinforcement for eating is great, but the negative for not eating or satiety is insignificant. Our group has always taken the position that just saying no to food is pretty difficult, if not impossible, especially if it is great food."
Other clues in the brain? PET imaging shows the amount of the brain linked to eating sensations is actually larger in an obese person than in a thin person. Gold and his McKnight Brain Institute team have shown that after an obese person starts eating, it takes longer for glucose to reach the brain. It takes 25 minutes instead of 12, meaning it takes longer for an obese person to feel full.
Gold believes imaging the brain before and after bariatric surgery may provide valuable information about the brain-obesity relationship.
"Even though bariatric surgery is effective and widely used to treat obesity, how it works and what changes it causes in the brain are not known," Gold said. "Stomach constriction alone does not explain the success of the treatment. We think it changes the reinforcement produced by eating."
An ounce of prevention
Not every obesity expert has the same theory for what causes obesity, but there's one area where everyone agrees: Stopping obesity has to start with children.
"We have to start making sure our kids know how to eat healthy, that exercise is part of their daily routines like brushing their teeth," Ben-David says. "Nine million adolescents are morbidly obese. We have to start early and think preventive. Right now we're thinking defensive."
Jennifer Miller, M.D., a UF pediatric endocrinologist who studies obesity, says while the number of obese children has stabilized in recent years, the degree of obesity is becoming worse in children, and the number of them becoming obese before age 4 has grown. This can lead to not only typical obesity-related diseases but also damage in children's developing brains, Miller says.
"We're seeing, in general, about a 15 to 20 point IQ difference in children who become obese in early childhood versus those whose weight is normal for their height in childhood," Miller says.
With children, experts agree change needs to come from the top of the family tree.
"The whole family needs to make it a priority to have a healthy weight, to eat well and make sure kids exercise from the beginning. That's the biggest part of the problem we see," Miller says. "If the family doesn't set a good example the kids aren't going to do it. By the time children are adolescents it's hard to change behaviors."
Miller has recommended some patients for bariatric surgery — adolescents are only candidates after they have stopped growing — but she's cautious about it. Doctors don't fully know the long-term consequences of weight-loss surgery in teens.
"We get a lot of parents who think this is going to be a cure-all, and to be truly successful you have to have a healthy diet and exercise," Miller says. "I just think the parents and the kid have to really be ready for it. Most of the kids I have referred have been 18 and older. I just don't know if before that if they have that grasp of mortality."
To really combat the obesity epidemic, it's going to take a complete lifestyle change, not just for individual families, but for the country as a whole, Findley says. Americans eat too many processed foods — a choice that's hard for many to avoid given that so many foods are processed — eat their meals too quickly and don't eat often enough, the nutritionist says.
"When we wait too long between eating, lots of things happen. We can release chemicals that make us crave fat and sugar," she said. "It makes it difficult for us to deny the vending machine or fast food, and we have a tendency to overeat at our next meal. Also, be mindful of what you eat. Chew slowly.
"I always have this belief system that I never judge my success by getting people to change but by exposing people to ideas. If we can start throwing these ideas out there, it will start to sink in."
For Donnelly, the ideas are sinking in. He knows his weight loss, the outcome of his surgery, of the life-changing decision he made, comes down to the choices he makes now. The actual surgery was only a fraction of the solution.
He thinks of the photograph, the one taken of him in high school, every time he steps on the scale. He knows he'll likely never be 190 pounds again, but he can get close.
"I can get down to 250 pounds," he says. "I will make sure I do it. With the help of Dr. Ben-David and (his P.A., Tamara) Lux I will do it. I can't be 400 pounds. At 400 pounds I can't walk up stairs. Right now I am going up one stair at a time. At 250 pounds, I will be able to go up like a normal person. That's what keeps me going."