Eating themselves up

ariela-beforeMichael knew if he didn’t do something drastic, his weight was going to kill him. For years, his body had been trying to tell him how much it was struggling to carry 149 kilos of bulk on his 1.86-meter frame. There was the sleep apnea that sapped his energy, the high blood pressure that threatened his heart, the alarming shortness of breath. All pointed to organs in distress. 

He had tried for years to lose weight, but nothing seemed to work. Well, nothing worked for long, that is. Sure, there had been diets – so many diets! – and even a solid year of regular exercise, leading to periods when Michael lost enough of his heft that it seemed like he could manage his weight just fine. But the kilos always came back, and then some. When Michael’s doctor warned him that his kidneys were on the brink of irreversible damage from the trauma that obesity causes, he cried “enough!”

In April, at age 50, Michael underwent a duodenal switch, one of several bariatric surgeries used to treat morbid obesity. Part of his stomach and part of his intestines were removed, restricting the amount of food he can ingest and restricting how many of the nutrients his body can absorb. Six months and 60 kg later, Michael knows the surgery has not only changed his life dramatically, it may have saved it as well.

The number of Israelis resorting to these drastic measures is climbing into the hundreds per year. But that is just the tip of the iceberg that is this country’s growing obesity epidemic. Fully 40 percent of Israeli adults are overweight, according to Health Ministry statistics, while another 23% are obese. Thousands are classified as morbidly obese or even superobese. Worse, these numbers are rising all the time.

What this means for the country is nothing short of an emergency. More and more, research shows a clear link between obesity and a wide range of health problems, with significant increases in the risk of developing heart disease, hypertension (high blood pressure), stroke, diabetes, certain cancers (e.g. breast cancer and intestinal cancer), osteoarthritis, breathing problems, and more. The strain that this puts on the public health system and the economy is immense: NIS 10 billion or more per year, in direct costs of treatment and indirect costs from sick days and lack of production, according to various estimates.

Of course, the human costs are tremendous.

“I couldn’t get out of a low beach chair without the help of at least two people,” Michael recalls. “In restaurants, chairs would break under me, and I would be so embarrassed that, rather than complain that the restaurant didn’t have chairs to serve me, I would worry and consider myself lucky if they didn’t demand that I pay to replace the broken chair.”

Ariela, a 58-year-old retired school teacher from Jerusalem, weighed 111 kg before undergoing gastric banding surgery just over two years ago. Before then she took up two seats on the bus. Fibromyalgia caused pain all over her body that nothing could relieve. She was so limited physically that she had to teach in a classroom on the first floor because going up stairs was too difficult, and she couldn’t join class fieldtrips because of the exertion required.

“Any time I didn’t have to be out, I stayed home – in bed – as much as I could,” Ariela says. “You get to a point where you ask yourself, why get my hair done? Why buy nice dresses? What’s the difference?

“When I walked down the street and passed a display window or a mirror, I would turn away so I wouldn’t have to see my own reflection. When I would walk into a room, I would automatically feel embarrassed and inferior, knowing everyone was looking at the fat woman who had just walked in.”

Michael knows the feeling.

“Often, obese people are easygoing and jolly, but that doesn’t mean they’re really happy. That’s just a persona they adopt because they have to, in order to overcome their obesity,” he says. “Ultimately, every obese person wants to stop being fat. They don’t want to have to hide anymore.”

Hiding, Michael adds, begins with fashion.

“You try all sorts of things to look better – tucking your shirt into your pants, untucking your shirt from your pants, whatever. You tell yourself that in certain clothes you don’t look fat. But later, when you see photos of yourself, you realize that no clothing can hide the truth.”

You have to wear something, though, even if it isn’t flattering. And when you’re obese, not much is.

“Clothes shopping is a nightmare when you’re obese,” Michael continues. “Your clothes never fit quite right. You walk into a store and pay a lot for clothes that are of low quality because you have to take whatever they have that fits on you.”

Ariela can empathize.

“I would walk into clothing stores – for ‘big sizes’ – and ask, ‘What’s your biggest size?’” she says.

Constantly losing and regaining weight also wreaks havoc with a wardrobe.

“I would purge my closet of all my ‘heavy’ clothes, only to have to buy more when I would gain weight again,” Michael says.

Like most obese people, Michael and Ariela were often able to lose weight, but never able to keep it off. And every time the number on their scale climbed higher was another stinging failure.

“I have had to fight my weight almost my whole life,” says Ariela. “We’re talking about 30 years of frustration and anguish.

“I was always on a diet,” she continues. “I drank only diet drinks. I would sit in the teachers’ lounge and drink coffee instead of eating lunch. Meanwhile, these thin women would devour these huge sandwiches. I couldn’t understand it… People would tell me to lose weight, and it would make me so mad. Losing weight was just impossible.”

Several years ago, Michael and a friend were watching Dudu Topaz on television when the entertainer challenged the public, offering a new car to the person who could lose the most weight. The two figured Michael had a shot at winning the car and started planning his strategy. “Suddenly my friend turned to me and said, “Wait. For a new car, you would lose weight, but for the sake of your own health, you won’t?!’”

That kind of thinking is common, Michael says – and it hits home. But it’s also a trap.

“Obesity is something you’re ‘guilty’ of, in your own mind and in the minds of others,” he says.” If you have cancer, everyone will embrace you. But if you’re fat, people will say, ‘Get yourself together!’ So you tell yourself, ‘It’s okay, I’ll fix it.’ Ultimately, what you have to realize is that the problem is simply too much for you to handle by yourself.”

OBESITY IS RARELY the result of a lack of motivation to be healthy. For some, getting in shape really is too difficult to do. The effort required to lose enough weight – and, more importantly, to keep it off for good – is so great, doctors say, that few will actually accomplish it on their own.

“Numerous studies have shown that the chance of a morbidly obese person reaching a healthy weight, and maintaining it for at least five years, is less than 5 percent,” says Dr. Subhi Abu Abeid, head of the obesity clinic at Tel Aviv’s Sourasky Medical Center.

One problem is that not everyone realizes how dangerous obesity is, says Abu Abeid.

“It’s important to recognize that we’re talking about a disease,” he says. “A person might say to himself, ‘Yes, I weigh 180 kilos, but I’m strong, I’m okay,’ but that just isn’t the case. He’s sick, and his obesity is his illness.”

Further, he says, “morbid obesity entails a range of illnesses, such as diabetes, high blood pressure, joint problems, sleep problems, emotional problems, infertility, kidney damage, etc.  It’s only a matter of time before someone develops one or more of these complications. You can die from this.”

Indeed, researchers in Europe and in the United States have found that obesity can shorten lifespan by as many as 13 years. In the hopes of preventing that grim prospect, 15 to 20 morbidly obese patients come to Sourasky every month for one of several bariatric surgery options.

“Usually the people who come to us have tried all kinds of diets, pills and other methods that just didn’t work. Beyond a doubt,” he says, “surgery is the most effective treatment for morbid obesity.”

Underlining the message that morbidly obese people rarely ever maintain a healthy weight through diet and exercise alone, Abu Abeid notes that several of the former contestants on the reality weight loss show “The Biggest Loser” have come to him for surgery. “But they want to keep it a secret,” he says with a smile.

The surgeries “are not cosmetic,” Abu Abeid stresses. They make it physically impossible to eat more than a little bit at a time, either by tightening the stomach or cutting most of it away.

They are also unlike surgeries for “normal” people. Treating morbidly obese patients entails unique circumstances.

“It can be difficult to sedate them,” says Abu Abeid. “Sometimes the patients are so large that we need two operating tables just to hold them.”

The surgeries are laparoscopic, he says, which means that “there is no need to open people up.” The surgeries themselves last about an hour, and patients can leave the hospital in one to five days.

After that, though, things get tougher. There are new diet rules to follow (often including pills to ensure sufficient intake of vitamins and minerals), an exercise prescription – and lots of office visits.

“If you have your appendix taken out, you see your doctor twice afterward and that’s it. This, however, requires lifelong follow-up,” says Abu Abeid. “That includes regular check-ups with a doctor, working with a dietician, meeting with a social worker, and sometimes even joining a support group.”

“Some people think it’s hocus-pocus and then they’re done,” laughs Dr. Andre Keidar, who heads the obesity clinic at Hadassah-University Hospital in Jerusalem’s Ein Kerem neighborhood. “But the follow-up treatment lasts the rest of their lives.”

Patients are usually faithful to the program in the beginning, but often they become lax as time goes on.

“The sad fact is that most people aren’t going to change their behaviors much, which is why, without the surgery, they wouldn’t get thin in the first place.”

At both hospitals, prospective patients are given a full description of the options before them. Then, those who are sure they’re interested in one of the procedures have to undergo a series of tests before they can be accepted for treatment. They have to be heavy enough and sick enough to warrant the surgery, but not so sick that the surgery would pose too great a risk.

“Sometimes those who are turned down for the surgery become quite upset,” Keidar says. And that’s understandable.

“You’re not just talking about a person’s weight, you’re talking about their ability to function, and you’re talking about their emotional wellbeing. Keep in mind,” he says, “many of these patients are very successful in other areas of their lives and they are frustrated to find themselves failing to maintain a healthy weight.”

For those who fit the profile, though, hearing that they are eligible for the surgery is good news. Most of the weight they need to lose will come off within a year of the surgery. And, since the procedure is in the basket of public health services, they won’t have to pay a single shekel for it.

MICHAEL AND ARIELA both came around to the idea of having bariatric surgery pretty quickly. 

“At first the prospect is a bit frightening,” says Michael. “But I’m telling you, it’s great. If only there were surgery to make people stop smoking, and to stop gambling, too!”

Early on, as the kilos melt away, it’s a magical time.

“There’s definitely a ‘wow!’ period that you go through, like when you celebrate being able to wear the kinds of clothes that normal people wear,” he says. “But it feels weird to lose weight so quickly. It happens so quickly that you’re not ready for it emotionally.”

The change is definitely drastic. Michael, who owns a store in a mall, often finds himself greeting customers who don’t realize that the person standing before them now is the same one who served them months earlier.

“They’ll give me this look, like when you think you recognize someone but you’re not quite sure, and they’ll ask, ‘Did your brother used to work here?’ I get that almost every day.”

In his driver’s license photo, Michael is still 60 kg heavier. It’s the same name, the same ID number, the same address. But it isn’t the same person.

He’s happy with his body now, but to see how unnaturally Michael carries his pencil-thin frame is to see the old phrase “I’m a thin person trapped in a fat person’s body” turned around. Michael is now a morbidly obese man living in a lithe body that he doesn’t quite recognize.

“I still can’t think of myself as thin,” he says. “Before, when I would travel, I would worry, what if my luggage is lost? However will I find clothes that fit me? Then my pants size went from 60 to 44, and I was able to shop for pants at any store I wished. Yet every morning, when I pull on my pants, I don’t believe that my legs are going to fit into something so small. And I still feel a rush of anxiety whenever I have to bend down. I have to remember that I can actually change my own shoes now.”

That might not seem like much, but for Michael it’s huge. For years before his surgery, it used to be that one of his employees would always lock up the store at night, because for Michael to bend down to the floor to lock the gate, and then try to raise himself back onto his feet again, would be an ordeal that no one wanted to endure.

His new body may be a gift, but it is one that is taking time to adjust to.

“I used to sweat a lot,” he says. “I thought it was just me, that something was wrong that made me sweat a lot. Well, there was: dozens of kilos of extra weight!”

Michael finds it strange that he is now able to squeeze into his car, even in a tight space in a parking lot, and that once he sits down the steering wheel is not pressed against his belly. He is bewildered that he can fit into the seat of an airplane. After decades of being obese, his mind is still working on the assumption that his body’s proportions are so much larger.

There are also some drawbacks.

“Before, people would automatically let me sit in the front seat of a car because there wasn’t enough room for me in the back seat; it was understood. Now they relegate me to the back seat!” he half-heartedly complains.

Then there is the fear that he will lose “too much” weight.

“I chose this surgery because I didn’t want to be responsible anymore for how much I ate,” Michael says. “I was tired of it. So now it isn’t really up to me. I simply can’t eat large portions.”

Because his meals are so small, Michael has to make sure he eats frequently throughout the day, about every three hours, and make sure he includes plenty of animal protein in his diet.

“Sometimes I miss the old days,” he says, as if in admission, “when I could go to a buffet and just eat everything in sight. Now, when I’m at a buffet or a large meal, I just have a little bite of this and a little bite of that. I’m not even interested like I once was. It may sound strange, but in a way I feel like, by losing my appetite, I’ve lost my best friend.”

Everything he has gone through has been worth it, he says, noting the support of his wife and three kids.

“Without that support,” he says, “I don’t know how I would get through it.”

For Ariela, the surgery has brought only good things.

“I had heard about bariatric surgery on the radio, but figured it wasn’t for me,” she says. “Then a friend who was even bigger than I was underwent the banding surgery and is now really thin. She’s the happiest person in the world now. Anyway, when I did finally go to a presentation at the hospital, I suddenly realized that it was real, and that it was the kind of thing that I could do. Before the presentation was over I was asking for surgery as soon as possible.” 

She opted for gastric banding – a sort of noose around the stomach that makes it painful to eat too much, which can be tightened or loosened through a button-like apparatus just under the skin over her hip.

“It’s so nice not to have the appetite I once had,” Ariela says, leaning comfortably on her couch. “An obese person never says, ‘I can’t eat another bite.’ They can always eat more. Today, I can eat anything I want, I just can’t eat very much of anything – and the truth is, I don’t want to. I’m looking at those wafers there on the table and I don’t even want them.”

Recuperating from the surgery took about a week, Ariela says, and getting used to her new dietary demands took a little longer. But the benefits have been astonishing.

“I no longer need medication for my blood pressure, and my fibromyalgia is gone. I feel 20 years younger!” she says.

Seeing Ariela now, so petite and so vibrant, it’s hard to believe she’s the same woman who once could barely fit through her own hallway at home. But, even after giving away 40 bags of clothing, she still has a few of her old size 56 pants to prove it.

“Now,” she says, “my being obese is like an episode in the past.”

And she doesn’t miss it one bit.

“Recently I brought home groceries from the store. I had bags full of all these heavy fruits and vegetables that I had to carry up stairs. It was a real workout. Out of curiosity, when I got home, I put them on the scale. They weighed 20 kilos. I said to myself, ‘My god, I barely carried an extra 20 kilos of groceries. Where did I put another 30 kilos of fat? And how did I ever carry them?!’”

Really, she asks, how does anyone?

 

Fighting ‘the barbecue culture’

“I’ve been a failure at treating obesity for the past 25 years,” Prof. Elliot Berry says wryly.

Conquering obesity, the head of the School of Public Health at Hadassah-University Hospital in Jerusalem’s Ein Kerem says with a sigh, “is simple in theory but so, so difficult in practice.” 

Easy in theory, because as long as you ingest fewer calories than you burn throughout the day, you ought to lose weight. Difficult in practice, because so many people eat much more than they need to and exercise much less than they should.

“There is nobody who has been found on this planet who cannot lose weight. By eating less and exercising more, anybody can lose weight,” Berry says emphatically.

“The problem is maintaining it. Some people are metabolically very inefficient, and some are very efficient. Some are like the cows of Pharaoh’s dream [in Genesis] – they can eat up the fat cows and not gain weight. Others can just look at food and gain weight.”

Aside from exceptional cases, though, obesity is a function of behavior rather than genes, Berry continues.

“The great increase in obesity in the past decade means that it has nothing to do with your genes, which couldn’t have changed in such a short period, but rather has to do with your environment,” he says. “Portion size has grown so much in recent years that the calories available to a person have increased, since the 1950s, by 1,000 a day. So there’s too much available out there. And, there’s too little exercise. There’s too much TV, and not enough walking.” 

Further complicating matters are the metabolic changes that take place as one loses weight.

“As you lose weight, you become more metabolically efficient, so you don’t need as much food to maintain your weight. If you don’t continue to decrease your food intake, you’ll gain weight again,” Berry explains.

That’s exactly what happens to a lot of obese people who are only able to temporarily keep weight off.

Alright – that, and the fact that a lot of people seem to be “addicted” to food.

“But exercise is also addictive,” Berry notes. “Look, you can’t expect people to stay on a (restrictive) diet all their lives. It’s just too hard, which is why you have to encourage exercise. You can’t fight fast food, but you can give people the education to make the right choices. People have a whole range of food and lifestyle options, and it’s our job to be role models for them.”

The slim, London-born doctor practices what he preaches, wearing a footstep counter to ensure he moves around enough each day, and running 10k races throughout the year.

Too few people are willing to take a disciplined, lifelong approach to diet and exercise, though, preferring crash diets and pills that Berry says are “for people with more money than sense.”

Often, people only come around once they suffer a serious health problem.

“There’s nothing like a heart attack or diabetes to encourage someone to lose weight,” Berry says.

He’d like to prevent that, of course. He and other health care professionals are trying to fight the “barbecue culture and chronic overeating” that are making obesity so common in Israel, but they feel they can not win that fight alone.

The Health Ministry, Berry says, is acutely aware of the problem, but it has no budget for combating it. Meanwhile, he says, the Treasury is unattentive.

“That’s why I firmly believe that it has to come from the Prime Minister’s Office.”

“When you have more than 60% of your population either overweight or obese, you’re talking about a national crisis,” Berry says. “When obesity is beginning to show up in populations, like Ethiopian and Yemenite immigrants, who had no tradition of obesity, there’s a serious problem. This issue has to become a national priority.”

 

Losing bat wings and saddlebags

newjerseytummytuckbeforeDr. Benny Meilik strides through the halls of Sourasky Medical Center in his light blue scrubs, having just finished another surgery. Like the patients he sees in his private office just two blocks away, this one was looking for a tighter tummy and a more attractive appearance. The difference, however, was huge – several dozen kilos’ worth of difference, actually.

While massive weight loss from bariatric surgery usually leads to a much improved appearance and level of function, some patients continue to suffer. Their unwanted weight may be gone, but the skin that once covered it stays behind. What’s left is a drooping mass of flesh that hangs off the body.

This has nothing to do with muscle tone, Meilik explains. “They can practically live in the gym,” he says, “but the excess skin will remain.”

Upstairs in his office, Meilik reviews photos of his patients before they undergo body contouring, the advanced plastic surgery procedures that follow massive weight loss. The images, frankly, are shocking. The grotesque folds and pockets of flesh so change the look of these people that they make the skin seem like melted wax. One could be forgiven for thinking it the work of make-up artists for a ghoulish scary movie. It looks unnatural and grotesque – and the patients feel that way, too. 

“It’s not just tough to look at, it’s extremely uncomfortable. As these extra folds of skin rub against each other constantly, the friction can cause rashes, scabs and foul odors. It really is like a handicap, and these people are suffering because of it,” says Meilik.

“A large percentage of the people I treat are single, or divorced, and although they have lost a tremendous amount of weight the extra skin makes their bodies quite unattractive. There’s no way that they can expose themselves before someone else; there’s no chance that they can maintain a physical relationship. I have had patients tell me, ‘I preferred being obese. Before, I was fat, but my body looked normal. I could go to the beach. I had no problem getting into bed with someone. Now…!’” 

One of Meilik’s patients, an obese teenager who has not had bariatric surgery, suffered so much from the teasing he endured over his drooping, flabby chest that he did not leave his house for three years. Meilik performed a breast reduction that, while not solving the boy’s obesity, allowed him to wear normal clothing and gain the confidence to rejoin society.

“That’s why this is so important – and people don’t realize it – because it isn’t just about cosmetics, it’s about allowing people to function like normal people, to give them a body they can feel comfortable in.”

To help people suffering from this condition, doctors like Meilik have had to develop techniques so far beyond the normal demands of plastic surgery that they have become a special field of their own. Even the nomenclature for the unique folds and bulges of skin is new, and is constantly changing, he notes.

“In the States, they call the flesh that dangles under the arms ‘bat wings.’ The sagging pockets on the hips are ‘saddlebags.’ In Israel we don’t use such disparaging terms,” he says.

The surgeries can last up to nine hours to complete with the help of a specially trained crew. The most severe cases call for a “total body lift” – an elaborate process of  liposuctioning away fat and tissue, and cutting and pulling and reshaping off skin.

“For someone like this, a tummy tuck and a breast reduction just aren’t enough,” Meilik says. Actually, Meilik might rebuild a woman’s sagging breasts and tighten her back at the same time by trimming the “lateral chest roll” that remains after her weight loss and stuffing it into her chest. Likewise, he can use rolls of skin from the lower back and hips to “build” a firm, round bottom.

The transformation is downright Frankenstein-like. And it really does, well, bring people to life.

“They’re better physically, emotionally and socially after undergoing this treatment,” Meilik says.

For the doctor, with his piercing blue eyes and trim beard, this is turning into quite a rewarding second career. He only started studying medicine at the age of 28, after flying planes in the air force. He doesn’t have to come here each week for the grueling surgeries; if he wished, he could stay in his private practice and stick to the much simpler – and much more lucrative – nose jobs, tummy tucks and breast enlargements. Yet Meilik spends a great deal of time at the hospital with these unique patients because the challenge of helping them is so stimulating, and the reward of seeing them happy is so great.

“This is what I’m talking about,” he says, turning to photos of a woman with a nasty sunburn. “This is a 53-year-old woman who had lost 90 kg after bariatric surgery, and was so excited about her new figure after the body lift we did for her that, just three weeks after surgery, she went to the beach – for the first time in her life.”

Clearly, she has taken to her new, normal figure. As for the painful lesson about exposure at the beach, Meilik says with a smile, “She’ll learn.”

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