Drastic Cuts
Once morbidly obese RNs resume active, healthy lives
thanks to bariatric surgery — and a new outlook on diet
By Janet Wells
November 15, 2004
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.”
Kobs quickly adapted to eating six small meals a day — and small is the operative word. Since undergoing Roux-en-Y gastric bypass, in which a stomach pouch is created that is about the size of a walnut, meals can’t be more than half a cup. A meal for Kobs might be a packet of string cheese or a protein bar. Weight loss is achieved by limiting the quantity and absorption of food.
Kobs discovered one of the drawbacks to her surgery the day she took her grandkids out for ice cream and experienced the “dumping syndrome,” which occurs when the stomach’s contents enter the small intestine too quickly. “I had two teaspoons of Ben and Jerry’s, and I had to head for the parking lot to throw up,” she recalls. “I thought I was going to die. All the blood was rushing to my gut, I started sweating and felt sick because of the high content of carbs.”
But Kobs doesn’t feel deprived. “Before surgery I never met a sweet that I didn’t like, trust me. But I just don’t miss it,” she says. “I’m rarely hungry.”
Although Kobs is ecstatic about the outcome of her surgery, she admits that she was a reluctant convert, spending almost a year researching the procedure before she went under the knife.
“I was very, very picky about who was going to do my surgery. I did not want a surgeon who does a gallbladder, then a hip, then a bypass. I wanted someone who would show me his outcomes. That was hard to find. I also wanted a comprehensive program.”
Living in Phoenix at the time, Kobs found what she was looking for in the Wish Center in Chicago. “All they do is bariatric surgery. Their offices have broader chairs. Prior to surgery you have 14 hours of face-to-face time with all of the team members.”
Nearly two years later, Kobs not only weighs a whopping 175 pounds less, but her life — and her health — have taken a dramatic turnaround. She is a newlywed who wore a size 10 dress at her wedding. And she is free of diabetes, high blood pressure, and cholesterol, as well as sleep apnea and back pain. The only pills she takes are hormones, vitamins, and calcium.
“I feel better now at 60 than I did at 30,” Kobs says. “I have loads of energy.”
The new you
Kobs’ case is not unusual. A recent study in the Journal of the American Medical Association found that bariatric surgery not only helps people shed pounds, but also appears to alter the patient’s body chemistry, relieving conditions such as diabetes that can lead to heart attacks, strokes, or kidney failure.
Kobs’ 35-year-old daughter, Amy Summers, a nurse practitioner in Ohio, was so impressed by her mother’s experience she underwent bariatric surgery in August. The results? Summers, CNP, MS, who weighed 280 pounds at the time of her surgery, lost 45 pounds after nine weeks, and she’s confident that’s just the beginning.
Bariatric surgery isn’t cheap. But with annual medical spending on overweight and obese patients estimated at almost $93 billion — 9% of U.S. health expenditures — many insurers are willing to pony up part or all of the $15,000 to $30,000 tab.
San Diego nurse Nancy McGovern had to pay more out of pocket for her bariatric surgery, in part because she chose a more expensive and complex procedure out of the area.
McGovern had seen two coworkers cope with the side effects of gastric bypass surgery, and decided it wasn’t for her. “They had vomiting problems, dumping syndrome, and weren’t losing weight all that easily. I knew that it wouldn’t work for me,” she says.
After spending time on the Internet, McGovern found that Pacific Laparoscopy in Northern California specialized in the duodenal switch procedure. According to the JAMA study, the duodenal switch results in the greatest weight loss, but is a more complicated, lengthy surgery.
McGovern, 58, couldn’t be happier. Weighing 315 pounds when she had surgery in July 2001, she lost 160 pounds in 18 months. “I had struggled with weight all my life. Three to four years before surgery, I just gave up.”
McGovern’s weight had forced her to give up her job as an emergency department nurse. Even a more sedentary job as an advice nurse in Kaiser Permanente’s regional call center was a struggle.
“There were only certain chairs that I could use and certain places that I could sit. There was no elevator, and I had to go up stairs extremely slowly, going up 12 steps to a landing, then resting and going up another 12. Going down, I was terrified I was going to fall.”
Now, having gone from a size 36 to a size 12 or 14, she zips up and down the stairs at work, and sits in a regular chair. Her foot and back problems, sleep apnea, respiratory distress, and depression have disappeared.
“I’m living today the way I always wanted to live. I can eat normally, I’m not starved. I can do what I want physically when I want,” she says. “I have been given my life back.”
Bariatric surgery is an extreme solution. Have you lost more than 30 pounds without surgery and kept if off for four or more years? Tell us how you did it and we’ll print some of the letters in our January “Taking Care of Ourselves” issue.