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Since undergoing gastric bypass surgery, the activities of daily life — including playing with her dog, Cuddles, are much more manageable for Adams.
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Kathryn Adams (left) weighs about 150 pounds, down from approximately 400 when the photo above was taken of her and daughter Elizabeth in December 2003. Only recently has she been able to see herself as anything other than the obese person she’s been most of her life. Photo courtesy Kathryn Adams
Kathryn Adams just wanted to be normal. She wanted to fit behind the wheel of her car and through the doors on the stalls in public bathrooms. Especially, she wanted to fit into a seat next to her daughter, Elizabeth, on the rides at Busch Gardens.
She wanted to be able to breathe deeply, without the pressure of pounds of fat on her lungs. As a single mother, she wanted — she had — to live long enough to raise Elizabeth. But in the winter of 2003, her weight hovered around 400 pounds, and when the 5-foot-2 Richmond native was hospitalized at Bon Secours St. Mary's with pneumonia, her general practitioner said that she might not make it through Elizabeth's childhood.
"He said that with all the prednisone and antibiotics I was taking and the fact that I couldn't fully inflate my lungs, I might not live to see Elizabeth turn 18," says Adams, who is now 48. Later, Dr. Neil Hutcher of Commonwealth Surgeons stopped by Adams' room to suggest that she consider undergoing gastric bypass, a surgery that reduces the size of the stomach.
In the next few months, she tried hard. She would lose 20 pounds and then have an asthma attack that would put her back on prednisone, which causes weight gain. She'd gain back the 20 pounds and put on 20 more pounds. But the main problem was that she'd been obese for most of her life. For people like her, losing weight and keeping it off without outside help becomes almost impossible, physicians say.
"In my entire career, I've seen one person do it," says Dr. Richard Atkinson, a professor emeritus of the University of Wisconsin in Madison who researches obesity from his Richmond clinic, Obetech.
About six months after Adams' general practitioner delivered what he hoped would be a wake-up call, she hit bottom hard enough to look into having bariatric (weight reduction) surgery. It was the start of a six-year ordeal that changed her life for the better, but not without exacting a price. She experienced physical complications, and the rapid weight loss left her with loose skin hanging in sheets from her body, nearly as hideous looking, Adams says, as the fat itself. She will have to stick to an extraordinarily strict food regimen for the rest of her life.
"If you think that gastric bypass is a quick fix, that you can do it without taking responsibility, then you shouldn't have it," says Hutcher, who has since become Adams' physician. "You have to make changes for the rest of your life."
As a result, bariatric surgery is suggested only for people who are morbidly obese, defined as having a body mass index — a measure of fat on the body — of at least 40. Still, demand for it has grown because as obesity has become an epidemic, morbid obesity also has increased. About 34 percent of the population is obese, and about 5 percent —15 million Americans — is morbidly obese, according to the Centers for Disease Control and Prevention. About 25.5 percent of Virginia's population is obese, state statistics show.
Hence, while gastric bypass surgery was rare, even highly controversial, 30 years ago, some 240,000 procedures were performed in the United States in 2009, Hutcher says. The Food and Drug Administration has not yet approved marketing of bariatric surgery devices for anyone younger than 18. Still, a study published in September in the medical journal Pediatrics shows that the number of teenagers undergoing weight-reduction surgery has also increased. From 2005 to 2007, 590 Californians between the ages of 13 and 20 underwent gastric bypass surgery or gastric banding, which also constricts the stomach. During that period, the number of gastric banding surgeries increased sevenfold, the study says. Dr. Daniel DeUgarte, a pediatric surgeon and co-author of the study, told Business Week that the rates are increasing because "diet and activity are proven again and again to be ineffective at getting morbidly obese patients to lose weight."
A Lifetime of Poor Eating
In late August, Adams sits at a table in a Midlothian Starbucks, her computer balanced on one of the small tables. She's clicking on pictures of herself at different levels of obesity, and with remarkable openness, she's talking about the experience of being hundreds of pounds overweight.
She can't remember a time when she wasn't fat. A 10-pound baby, she grew into a chubby child and teenager. "I wasn't one to sit down and eat a half gallon of ice cream at a time," she says. "I was a grazer. I would eat all day long and make bad food choices" — like soda, potato chips and chocolate.
During her high school years in Richmond, other kids taunted her. The single person who refrained, a classmate named David Chamberlin who saw past her appearance — to whom she was "never invisible" — has become one of her best adult friends. She opens up her graduation photo. In it, she has large dark eyes and a delicate nose, but the prettiness of her features is nearly lost amid the fat around her face and neck.
Her weight was a source of conflict in her marriages, both of which ended in divorce. Her first husband nagged her to lose weight, though she already wore a size 18 1/2 dress when they married. He insisted that she wear high heels, though balancing her weight on them was difficult, and dress in clothes that he thought hid her obesity. "He wanted me to look good because that would make him look good," she says.
She opens up another photo of herself at Christmas with her mother and siblings. Most of the family looks overweight, but she stands out at double, even triple, the size of an average woman. She points out her brothers. "Their favorite word for me was ‘pachyderm,' and I still resent them for it," she says.
She managed to lose weight and keep it off once, when she was in her 30s and wanted to get pregnant. Her doctor told her she probably couldn't bear children. Her weight would press on the ovaries; she might have a difficult pregnancy or deliver prematurely. She went on fen-phen, a powerful diet drug combination taken off the market because it caused heart disease in some people. It worked for Adams, helping her lose 70 pounds without repercussions. She dropped to about 330 pounds and became pregnant by a man whom she dated for three years but never married.
During the next nine months, she lost more weight because her morning sickness was severe, and she ate more carefully. In January 1997, when Elizabeth was born full term, 7 pounds and healthy, Adams weighed a relatively low 314 pounds. But she was a single mother, and soon she was stressed out, overcommitted and slipping back into poor eating habits.
She would come home from her job as a claims processor for Anthem, feed Elizabeth, then "grab a couple of tomato sandwiches and chips for myself." At night, she would snack and drink soda while she watched TV and folded clothes.
"In the morning, I would give Elizabeth a good breakfast and have a piece of toast with peanut butter and jelly for myself," she says. "If we went to Wal-Mart, Elizabeth would want a Slurpee or a milk or a juice, and I would get a candy bar."
As the pounds accumulated, she shielded herself from the evidence. She packed up her mirror and put it in her mother's attic. She avoided her reflection in store windows. She went out only occasionally with a friend "who didn't mind that I was fat and who had a big car, a Pontiac," which Adams could get into without struggling.
By the time Elizabeth was in preschool, Adams was back up to about 400 pounds, which was hard on her daughter.
"I'm an older mother, so she got a double whammy," Adams says. "Kids would say, ‘Is that your grandmother?' and ‘Why is she so fat?' I would look at myself in the mirror and see this grotesque woman."
The drag of Adams' weight on her health increased. Her blood pressure and sugar levels rose, serious warning signs considering her family's history of cardiac disease and diabetes. Her asthma had always been chronic, but with so much weight constricting her lungs, her attacks became more frequent, her respiratory problems more severe.
When she came down with pneumonia in the winter of 2003, she was hospitalized for 17 days at St. Mary's. She missed Elizabeth's fifth birthday, which she'd planned to celebrate with a princess tea party. And she was lying in bed when Hutcher, who has performed some 4,000 bariatric procedures, stopped by her room. He suggested she consider gastric bypass and left behind a video explaining the process. "I threw it in a corner," Adams says. "I was in denial. I thought I could do it myself. I'd lost weight before."
In the fall of 2003 — after months of trying and failing to lose weight — Adams finally surrendered. She got in touch with Hutcher's practice, started attending nutrition classes and took steps to meet Anthem's prerequisites for covering the cost of the surgery. She had to demonstrate that she was at least 100 pounds overweight and suffered medical problems because of it. She had to undergo a psychiatric test to prove that she did not have an eating disorder. Six months after that, on March 31, 2004, she checked into St. Mary's for her gastric bypass.
A Smaller Stomach
In the early 1970s, when Hutcher first started performing bariatric surgery, the procedure produced so many serious complications that surgeons often had to reverse it. It's since been refined, reducing risks and giving patients more options. During gastric bypass surgery, the stomach is stapled to create a small pouch. The lower intestine is attached to the pouch, so that digested food bypasses much of the rest of the intestines. In the newer, less invasive gastric banding procedure, also called lap-banding, surgeons place a band around the top of the stomach to create the pouch, and the intestines are left largely intact.
So far, bariatric surgery is the most effective method of weight loss for morbidly obese people because it forces them to eat less, at least for a while. Their pouches can't handle more than a few ounces of liquid or solid food at a time. Many patients lose their appetites for a year or so. Some patients, Adams among them, never regain their appetites.
Statistics supplied by the American Society for Metabolic and Bariatric Surgery in 2010 show that patients lose anywhere from 55 percent to more than 85 percent of their excess weight, meaning the number of pounds by which they're overweight, according to medical standards. Physicians and medical associations have come to embrace bariatric surgery because dieting and exercise so often fail. On its website, the American Diabetes Association says, "Most physicians realize that surgery remains the best option for morbidly obese people."
Along with weight loss, bariatric surgery eliminates or reduces the severity of a slew of serious related health problems — coronary disease, high blood pressure, Type 2 diabetes and sleep apnea, which develops in obese people because the fat on their neck constricts their throats.
Still, the surgery is hardly an easy solution. To get enough nutrition despite the size of the pouch, patients must eat small amounts of food several times a day. Gastric bypass patients, in particular, must take vitamins because their truncated intestinal systems keep their bodies from absorbing nutrients. People like Adams must religiously take B-12 and calcium. And if patients consistently overeat, they can stretch out their pouches and regain lost weight.
"It's a draconian measure because it rearranges what God made," Atkinson says. Which is why Hutcher says bariatric patients must undergo medical monitoring for the rest of their lives. Internists must regularly check the size and condition of patients' pouches, as well as their levels of vital nutrients such as B12.
And gastric bypass surgery is not without risks. The Mayo Clinic says that while serious problems are rare, gastric bypass can lead to blood clots, including pulmonary embolisms that damage lung tissue and can cause death. Leaking at the staple lines of the pouch can require emergency surgery, though more often it's treated with antibiotics. It's rare, but sometimes the opening to the stomach becomes so small it must be widened through more surgery. Lesser complications can include, among other problems, gallstones, hernias, bleeding ulcers and depression, because patients expected the surgery to fix their lives.
"It's no silver bullet," says Chamberlin, Adams' close friend and the classmate who never teased her during her teenage years. "It has its own dark side. The amount of maintenance it requires, for one. And there's a way that you can eat around it — stretch your stomach out. So there can be a paranoia," an irrational fear, he says, of regaining the weight and becoming severely obese again. "I don't think Kathryn was prepared for all of the stuff that comes with it."
Rapid Weight Loss
For Adams, complications from her gastric bypass were almost immediate. As a result of the procedure, a capillary bled into her new pouch. After she woke from anesthesia, she began vomiting blood. Her three-day stay at St. Mary's stretched into nine days. Soon after she returned to her home, the pain in her stomach grew so severe she couldn't eat or drink. Dehydrated, she was readmitted to St. Mary's and placed on intravenous fluids.
"But they gave me too much," she says. There was so much liquid in her body that it started to seep out of the pores of her legs. "They call it weeping leg."
But she also started dropping pounds. Sticking to her prescribed diet, she consumed Carnation instant breakfast for the first two weeks. For the next two weeks, she ate yogurt and other liquid foods, and then she graduated to scrambled eggs and overcooked macaroni and cheese. Within a month, she had lost about 50 pounds. By Christmas of 2004, nine months after the surgery, she had lost 100 pounds. Within three years, she had lost about 250 pounds.
Her blood pressure and blood sugar levels dropped. She still suffered from severe asthma attacks, but they were less frequent. She could breathe and walk more easily, and all of it changed her life. She started socializing more, and she went to Busch Gardens with Elizabeth and "rode all the rides."
Adams was happier and healthier in all respects but one. Like many people who have rapidly lost an enormous amount of weight through gastric bypass surgery, she had an "apron," a sheet of skin hanging from her stomach down to below her pelvis. In other places where she'd been fattest, her upper arms and thighs, loose skin hung from her body. "When I would look in the mirror, I would still see a fat woman," she says, as she sips her low-fat, sugar-free Caramel Macchiato. "I didn't see it as skin, I saw it as fat. I still saw a grotesque woman."
By late 2009 and early 2010, Adams' joy over losing so much weight had been replaced by a persistent depression. In reaction, she all but stopped eating. By her own count, she ate 200 or 300 calories a day. Her vitamin B12 level dropped far below normal. Her melancholy deepened until, she says, "I really thought I was losing my mind. I managed to get to work and do what Elizabeth needed, and then I'd go to bed."
‘Make Me Normal'
This past summer, Adams returned to Hutcher. "I told him, ‘Help me lose the skin, make me normal,' " she says. By then, she was without a job. After getting laid off by Anthem in 2007, she took another position with a health care company. But during her depression, she exhausted her medical-leave days, and the firm let her go last spring, she says. With no employee health care, she appealed to Medicaid. The agency agreed to cover the surgery after seeing photos of Adams' loose-skin "apron" and her accompanying infections.
On Aug. 31, she checked into St. Mary's Hospital again. Once she was anaesthetized, Hutcher made a long, surgical cut from her breastbone to her pelvis, and from there, he made incisions to both sides of her hips, creating a huge T on her torso. He sliced away 12 inches of skin and 7 pounds of fat that had accumulated on the inside of her abdomen.
A week afterward, Adams lies on her recliner in her house while her friend Tina Gilbert putters, wiping shelves and picking up glasses. Gilbert also had bariatric surgery, in her case the less invasive lap band. She describes Adams as a kind of mentor. "She told me that I absolutely had to follow the rules — do exactly what they said, eat as they said, take my vitamins," says Gilbert, who has lost 72 pounds since her procedure in February.
Adams says she hopes to be able to find a job and return to work in a month. She is restricted from lifting anything heavier than 10 pounds until 12 weeks after her surgery. Because of the sheer size of her incision, she has to squeeze in and out of a tight girdle that keeps her skin in place while it heals. Excess skin remains on Adams' thighs and upper arms, but she says she has no appetite for more surgery.
Still, on this day, she is cheerful. She has painted her toenails and fingernails pink to match her cotton robe and slippers, and she talks virtually non-stop.
It took her a few days, she says, to summon the courage to look at her body post-surgery. She was afraid of seeing the incision and imagining the scar. But after she'd taken a shower one day, she stepped in front of the mirror in her bedroom.
"It was worse than I expected," she says. The incision was raw and ragged. "I looked at myself and I thought, ‘I traded loose skin for a road map.' Then I realized that's OK because a road map is better than what I had. I realized that for the first time in my life, I didn't see this grotesque person in the mirror."