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Like many nurses who work with morbidly obese patients, Lois Hill, RN, nurse coordinator for the surgical treatment of obesity at the University of Texas Southwestern Medical Center in Dallas, stresses that education is a critical component of successful weight loss.

Like many of America’s obese adults, nursing consultant Ann Kobs tried everything to battle the severe weight problem that had plagued her for decades. She did Weight Watchers seven times, Optifast twice, and Jenny Craig. She tried psychotherapy and took pills to block fat absorption. She enrolled in two eating disorders clinics. She tried fen-phen, the now discredited diet medication. She lost weight — sometimes 50 or 60 pounds — each time. But, eventually, she gained it all back — and then some.

By the age of 58, Kobs carried 320 pounds on her 5-foot-5 frame. She was struggling with so many diseases related to obesity — late-onset diabetes (typically described as adult onset), high cholesterol, arthritis, high blood pressure, sleep apnea — that she was taking 22 different prescription medications, along with cortisone injections to relieve back pain.

“I was an accident waiting to happen,” says Kobs, RN, MS, whose consulting firm based near Chicago specializes in getting organizations ready for JCAHO accreditation surveys. “I was the one in the airport that you saw being wheeled from gate to gate to catch my plane because I couldn’t walk the distance. I was just so short of breath.”

An endocrinologist mentioned bariatric surgery — from the Greek word meaning the study and treatment of obesity — as an option. Kobs wasn’t ready to hear it, and left his office angry. But she was jolted into reconsidering it after watching a friend die of uncontrolled diabetes and congestive heart failure.

“I thought, ‘Ann, that’s going to be you.’ Then I thought, ‘No, I want to dance at my granddaughter’s wedding.’ I knew I was going to have to take drastic action,” she says.

Girth of a nation

Kobs is not alone. Americans are fatter than ever, with 6 million morbidly obese adults tipping the scales at 100 pounds or more overweight. Morbid obesity is a disease attributed to a complex combination of poor nutrition, lack of exercise, and genetics, as well as cultural, economic, and psychological factors.

Morbidly obese people often develop a raft of conditions associated with being severely overweight — hypertension, diabetes, gallstones, sleep apnea, arthritis, high cholesterol, depression, pneumonia — and, as a result, have a life expectancy 13 to 20 years lower than people who fall within healthy weight ranges.

Women of childbearing age make up almost 80% of those with morbid obesity. More nurses have joined the ranks of the overweight, increasing from 37% in 1980 to 51% in 1992, according to The Nurses’ Health Study.

“Our No.1 population is nurses themselves,” says Barbara Metcalf, RN, program director at Pacific Laparoscopy in San Francisco. “Nurses are so into giving to others that they don’t put themselves first.” Americans aren’t fat for lack of trying to shed the pounds: The nation’s $33 billion diet industry is thriving. But the statistics paint a grim picture for those needing to lose a lot of weight. Ninety-five percent of all people who are morbidly obese will not be able to lose the weight and keep it off.

“By the time patients come to us, they are at wit’s end,” says Venus Gaines, RN, MSN, MBS, director of nursing at Banner Mesa Bariatric Services at Banner Mesa Medical Center in Arizona. “Ninety-nine percent have been obese since childhood. They’ve been discriminated against, ridiculed. They can’t get jobs, they aren’t getting married. They need to do something major and drastic.”

Almost 80% of bariatric surgeries can be performed laparoscopically, with a few small incisions. Three of the most commonly performed procedures are the Roux-en-Y gastric bypass, the duodenal switch, and laparoscopic adjustable gastric banding, the only reversible procedure of the three.

Still, they are not trivial procedures, each entailing possible complications and side effects. In addition, both Metcalf and Gaines say, surgery isn’t the hard part. The real work starts afterward, with a lifetime commitment to exercise and eating small, healthy portions — no carbonated beverages, little or no sugar, pasta, bread, or fatty junk food. If patients eat too much food, or the wrong kind, they can make themselves sick or stretch their new stomach pouch, eventually gaining back some of the weight.

“Our society is very geared toward food,” says Lois Hill, RN, BS, nurse coordinator for the surgical treatment of obesity at University of Texas Southwestern Medical Center in Dallas. “People eat because it makes them feel good, and for social reasons. But patients need to develop other ways of coping with their feelings instead of noshing on Hershey’s.”

Bariatric surgery centers stress a team approach to obesity. In addition to nurse coordinators and surgeons, most centers also include the services of a dietitian, exercise physiologist, and psychologist, all dedicated to preparing patients for surgery and monitoring their substantial follow-up care and support.

“It’s all about education,” Gaines says. “From the day a patient starts coming to us, we start teaching. And if you’re not ready to make these changes, if you’re not prepared, then we won’t do surgery.”

No shortcuts

The changes begin even before surgery, when some programs require patients to practice their new diet and exercise requirements. After surgery, the first week’s food consists of liquid protein drinks. For several weeks after that, protein — turkey or chicken breasts, say — is pureed and eaten with a spoon. After that, the choices become more varied, but for the rest of their lives, the menu for bariatric surgery patients should focus primarily on protein — at least 70 grams a day. Another requirement is relearning how to eat.

“We need patients to chew, chew, chew. At least 20 to 30 chews before swallowing,” Gaines says. “If you don’t chew well, a big wad of food gets lost in the [stomach] pouch, and it’s a lot harder to digest. Most people will chew food one to two times and swallow. We are used to gulping our food.”