The Hungry Gene
The Inside Story of the Obesity Industry
by Ellen Ruppel Shell
"Compelling. . . . Journalist Ellen Ruppel Shell takes us into the wide world of obesity, seeking answers to how we got here and how we can get back to thin again." –Gregory Mott, The Washington Post
Imprint Grove Paperback
Page Count 304
Publication Date October 15, 2003
ISBN-13 978-0-8021-4033-3
Dimensions 5.5" x 8.25"
US List Price $14.00
Ellen Ruppel Shell is a correspondent for The Atlantic Monthly and writes for Discover, The New York Times Magazine, Smithsonian, and other publications. She is associate professor and codirector of the Program in Science Journalism at Boston University.
Read More About Ellen Ruppel Shell
America today faces a gathering health crisis of epic proportions. The crisis is obesity and the diseases linked to it–hypertension, diabetes, cancer, and heart disease. While politicians and public officials declare war against fat, and multinational drug companies race to find a cure, the problem only worsens, with experts estimating that fully half of Americans will become obese–and the vast majority of us overweight–within the next quarter century.
In a rare blend of erudition and entertainment, acclaimed science journalist Ellen Ruppel Shell reveals for the first time the secret history and subtle politics behind the explosion of obesity in the United States, and the world. Shell traces the epidemic's legacy to the Ice Age, its rise through the Industrial Revolution and the early days of medicine and into modernity. She takes readers to the front lines of the struggle to come to grips with this baffling plague–from a modest laboratory in Bar Harbor, Maine, where superobese mice were first bred, to Rockefeller University in New York City to witness the cutthroat–and heartbreaking–race to clone the obese gene, to the far-flung tropical islands of Micronesia, where a horrifying outbreak of obesity among native islanders has helped scientists tease out the disorder's genetic and evolutionary roots.
The Hungry Gene offers an unflinching insider's look into the radical and controversial pharmacological and surgical techniques used to combat what drug makers have dubbed the trillion-dollar disease, exposing the collusion between scientists and industry that for so long muddied the waters of obesity research and endangered untold thousands of unwitting victims. With vivid portraits of the scientists involved, Shell illustrates the breakthrough that proved conclusively that obesity is not a matter of gluttony or weak will but of vulnerable genes preyed upon by a hostile environment. Ultimately, she takes aim at the increasingly obesity-enabling culture that lies behind the crisis, telling the hard truths of what must be done to turn the tide on this frightening pandemic. Weaving cutting-edge science, psychology, and anthropology with history, Shell builds a compelling narrative culminating in a thought- provoking–and radical–call to arms. Gripping and provocative, The Hungry Gene is the unsettling saga of how the world got fat–and what we can do about it.
Tags Diet & Nutrition/Diets Gastroenterology Life Sciences/Genetics & Genomics
"The Hungry Gene draws parallels between Big Tobacco and Big Food that are all the more chilling because obesity is expected to overtake tobacco as the number one public health risk factor in the United States within the next decade or two." –Jan Gardner, The Boston Globe
"The Hungry Gene is a fair-minded, clear, and fascinating book about a highly emotional issue: why so many people are becoming so fat. After reading this book I have a much better sense of what science knows about the issue, what is unknown, what is a matter of individual destiny, and what is the result of food-industry strategies. An authoritative introduction to the next big public-health threat." –James Fallows, national editor, The Atlantic Monthly
"Shell takes a provocative look at the history, politics, science and culture of obesity. . . . She is as adept at explaining the physiology of fat as she is at chronicling the desperation of the obese." –The Minneapolis Star-Tribune
Ellen Ruppel Shell's The Hungry Gene is important, richly informative, and written with flair." –Alan P. Lightman, author of Einstein's Dreams
"In The Hungry Gene, one of America's finest science writers tackles one of our most urgent public health issues." –Eric Schlosser, author of Fast Food Nation
"Finally someone has done justice to what may be the most medically, socially, and commercially significant enterprise in all of science. An indefatigable reporter with a novelist's sense of character and drama, Ellen Ruppel Shell has poured all her considerable talent into this engrossing book." –John Horgan, author of The End of Science
"In The Hungry Gene, Ellen Ruppel Shell gives us a clear, inviting, and entertaining look at this fascinating subject, and at the sociopolitical underpinnings to the mysterious–and frightening–obesity pandemic. Beautifully written and scrupulously researched, The Hungry Gene is for everyone who has worried–or wondered–about their weight." –Jon Weiner, Pulitzer Prize­winning author of The Beak of the Finch
"Shell's book explores obesity both nationally and globally. She looks at it through the lens of history, science, economics and politics while interweaving its effects on individuals, cultures and countries. Most importantly, she addresses the nature-or-nurture question. It's both, says Shell. And it's complicated." –Patricia Guthrie, The Atlanta Journal-Constitution
"Shell promotes the theory that the "obesity pandemic" is a result of vulnerable genes in a fat-enabling culture. . . . The book goes beyond the earnest zeal, science and history of Fast Food Nation . . . to study the psychology and anthropology of fat as well. Once you've taken in the research from Micronesia to Maine and heard from the stomach-stapled, you may think the author's call for junk-food TV advertising is a good one. . . . It's also [a] relief to see a book hit the shelves this month that takes the issue far beyond the realm of 'miracle" diet guides that don't work." –Leslie Yazel, The Austin American-Statesman
"Shell devotes much of her book to science's quest for the genetic mechanisms governing human appetite, to which she adds informative bulletins from other fields of fat science. . . . She unleashes an all-out assault on consumer culture: as she sees it, an unholy trinity of television, cars, and fast food, all conspiring to ensure that we expend as little energy and consume as much bad food as possible." –Joseph Hooper, Elle
"Shell's specialty is scientists, and her book is largely a story about them. Her characters run the gamut from geneticists to nutritionists studying indigenous people of Micronesia, where a traditional diet of fish and breadfruit has been replaced by, of all things, Spam. The sum of all their tales isn't particularly heartening for those who may be carrying around a few extra pounds." –Stephanie Mencimer, The Washington Monthly
"The Hungry Gene takes us on a fascinating worldwide inquiry into the biological and social roots of the obesity epidemic. Shell is a gifted writer and observer with a fine mastery of her subject, and her book is chock full of wonderful characterizations, rich ironies, and horrifying facts." –Daniel Akst, The Wilson Quarterly
"It is remarkable that a book as excellent as The Hungry Gene can be contained in such a slender volume. . . . [Shell] examines the history of obesity and suggests what can be done to control it. . . . As Shell points out, the obesity pandemic didn't begin the day McDonald's started selling fries." –Brad Evernson, National Post
"She looks at the issues surrounding our collective expansion. . . . Shell's disturbing look at obesity might just be the diet inspiration you need." –Anne Stephenson, The Arizona Republic
"Obesity is quickly surpassing tobacco as the top threat to public health. . . . Shell investigates how western-style commerce and culture have led to the fattening of people around the world and how scientists are isolating genetic, prenatal, and environmental factors that influence a person's body weight." –Science News
"[A] well-written book. . . . [Shell] does an excellent job of showing the reality of the problem of obesity in America and most of the rest of the world. . . . [Shell] writes in a very readable style and explains the technical science in a way anyone can understand." –Nola Theiss, Islander
"This is the kind of book that you take everywhere, because you don't want to leave it, and then read out loud to friends and family and even casual acquaintances because it's so smart and so engaging. Ellen Ruppel Shell is a wonderful writer, and in The Hungry Gene she combines that ability with incisive science reporting to tell a story that–finally–makes some sense of our struggles with obesity." –Deborah Blum, Pulitzer Prize­winning author of Sex and the Brain
"After reading The Hungry Gene, you will never read another diet article, watch another diet pill commercial, or listen to another lecture from your doctor without rolling your eyes. It's a superb and groundbreaking work of sci-ence journalism that takes us on an entertaining–and sometimes frightening–journey through the world of fat, highlighted by Ellen Ruppel Shell's enthralling writing." –Dick Teresi, author of The God Particle
"Shell gives everyone, thin and heavy alike, reason to hope that obesity won't become the cancer of the 21st century." –Charles Mann, author of Noah's Choice
"[A] penetrating look at how and why an increasing number of people in developed nations are obese and what can be done about it. . . . Readers interested in health and science will enjoy this fascinating book." –Vanessa Bush, Booklist
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Discover–Treasures From Friends of Discover 2002
One: A Weariness of Eating
If you examine a man who suffers from his stomach. All his limbs are heavy. You find his stomach is dragging. It goes and comes under your fingers. Then you shall say concerning him: this is a weariness of eating. –The Egyptian Book of the Stomach
The first time I set eyes on Nancy Wright, she is flat on her back and cruciate. She is vaguely pretty, her eyes frightened but oddly beguiling. Her thick hair is loose and wavy, auburn with a sly touch of gray at the temples. You can see what some men see in her, and also, perhaps, why two husbands have come and gone. Even as she lies splayed and sedated on a gurney in Operating Room 17 at Beth Israel Deaconess Medical Center in Boston, you can sense that Nancy Wright is possessed of an immutable will.
Nancy once told me that she'd started out life large and kept on going. She didn't mean it as a joke.
She weighed ten pounds, four ounces when she came into this world, and through childhood ate herself so big that her father thought she had psychological problems. Nancy didn't see it that way, but she did know that her relationship with food was tempestuous, like a doomed love affair. "Food has always been my best friend and worst enemy rolled into one," she told me. Now, in middle age, this dysfunctional relationship has made even simple pleasures difficult. It is getting harder for her to work in her flower garden, harder to play with her five grandchildren. And she keeps getting sick. She has hypertension, high blood cholesterol, and sleep apnea. She hates being so tired all the time, and so feeble, and she has done everything she can think of to fight it. She has tried Weight Watchers, Jenny Craig, and diet pills. All of these worked, for a while. The pounds melted away, and Nancy thought she'd found salvation. She'd buy new clothes and start making plans for a new life. But then, without knowing why, she'd fall off the wagon, and her old life would rush back. It was like waking up to a nightmare.
People tell Nancy she lacks willpower, but they are wrong. She has plenty. She stayed with the same thankless social services job for twenty years. She stayed with the same thankless husband for nineteen. And as a fiftieth birthday present to herself, she quit smoking. She hasn't touched a cigarette in four years, and doesn't plan to touch one ever again. But food is another matter. "You can live without cigarettes," she said, "but you have to eat."
It all comes down to a balance of power–or, rather, to an imbalance. Nancy can no more tame her compulsion to eat than a marooned sailor can tame his thirst. For Nancy, food is more than an addiction, it is like breathing–a constant, throbbing need.
Dr. Edward Mun understands all this perfectly. Mun is an assistant professor of surgery at Harvard Medical School, and an attending surgeon at Beth Israel Deaconess Medical Center. At thirty-eight he has the self-assured manner and polished good looks of a man born to take charge. But beneath the Ivy League veneer and the designer suit lie hints of a nerdy immigrant boy, a gawky overeager kid who spent his summers squinting through a microscope at science camp rather than hanging out at Little League with his pals. Like Nancy, Ed Mun hasn't always fit in. He was born in Korea and grew up in Gardena, California, the son of restaurant owners who ­expected much more of their boy than they themselves had managed to achieve. Young Ed did not disappoint; he was the model of the good Asian son. He aced high school, enrolled in Yale University, and graduated in four years with both bachelor's and master's degrees in biochemistry. He further distinguished himself at Harvard Medical School, and nabbed a coveted surgical residency in sunny San Diego. Surgery offered the most money, the most prestige, and the greatest opportunity to perform technically ­interesting procedures. But Mun wanted more.
"I wanted neurosurgery because I thought it was only for the talented few," he said. "But the truth is that there aren't that many brain operations. Neurosurgeons do herniated disks and trauma cases. Mostly, it's boring."
So Mun returned to Boston, to Harvard, and to Beth Israel Deaconess Hospital, to apprentice in general surgery. He removed breast cancers and performed stomach surgery. To his great relief, he didn't find this boring at all. But he did find it frustrating. Breast cancer patients had the habit of scrutinizing the Internet for facts about their disease and hauling reams of downloaded information to his office for review. Mun didn't like the messiness of that, the presumptuousness. Breast cancer, he says, is usually a matter of small incisions and quick recoveries. Yet the patients would piss and moan and demand second opinions. He didn't mind the second opinions, of course, but he did mind being put through the third degree. And he blanched at their sense of entitlement. These women were hot reactors, the sort of patients who required more assurance than he had to offer.
But the stomach was something else altogether. He liked the feel of it, the hard muscularity of the thing. And he liked that stomach patients trusted him, put themselves in his hands. They didn't ask a lot of extraneous questions, didn't expect miracles. He found stomach surgery enthralling, so much so that one would think he had some sort of a belly fetish. But it was nothing like that.
"In Japan and in Korea, tens of thousands of people die from stomach cancer every year," he said. "I also lost several relatives to this disease."
In Korea stomach surgeons are held in the highest esteem. Among these masters was Mun's paternal grandfather, the man in whose steps young Ed was meant to follow. Mun very much wanted to be like his grandfather, and to earn the respect of his demanding parents. So he studied and worked until he became one of the best stomach surgeons at Beth Israel Deaconess Medical Center, which is to say one of the best in the country, and perhaps in the world. But unlike his grandfather, Mun doesn't open many bellies to remove cancerous lesions or to repair ulcers. What Mun does mostly is something very few Korean surgeons–and only a few American surgeons–have ever done or would ever dream of doing. What Mun does is to take perfectly healthy stomachs and replumb them, cutting them loose from their natural moorings at the end of the esophagus and fashioning them into pouches the size of robin's eggs. This procedure, which generally takes Mun about ninety minutes but most other surgeons much longer, is called a Roux-en-Y gastric bypass.
Stomach surgery is a pretty rough ride. People who get their guts whittled and rearranged in this way can't eat much for weeks afterwards, certainly not nearly as much as they did before the change. If for some reason they succumb to the temptation to eat more than the little that their stomach can hold, they vomit. Vomiting is not really a complication of gastric bypass surgery; it is an expected and important side effect.
Gastric bypass patients sometimes lose so much weight that old friends and relatives barely recognize them. The surgery is reserved for those with one hundred or more pounds to lose. On average, patients shed about 60 percent of their excess weight in about eighteen months. It is hard to imagine many people in Korea being interested in such an operation. But in 2000, the year I met Mun, forty thousand Americans underwent gastric bypass surgery, about double the number performed only five years earlier. That number was expected to nearly double again by 2003. Mun doesn't find these figures the least surprising; he knows many people require his services. In Boston his dance card is full. And Nancy is next in line.
Nancy is five feet three inches tall and, at the time of her operation, weighs 274 pounds. Her BMI is 48.5, well into the morbidly obese range and she thinks she would feel and look much better if she were one hundred pounds or more lighter. She has seen what gastric bypass surgery can do for people: two of her coworkers have been transformed by the procedure, and a year ago her youngest daughter underwent the surgery and dropped ninety pounds. It was her daughter especially who convinced Nancy to give surgery a go, not so much with her words, but by her example. Both mother and daughter, Nancy said, are stubborn as mules. She figures that if gastric bypass worked for her daughter, it will work just as well for her.
Mun doesn't know Nancy is stubborn, but he does know that she is an especially good candidate for obesity surgery. For one thing, she is in relatively good health, without the horrific complications suffered by so many of the morbidly obese. For another, she is relatively small. A man of Mun's experience might well see Nancy that way. The hospital bed ­waiting outside his operating room is a "Big Boy," built to hold up to five hundred pounds. Sometimes it takes two Big Boys pushed side by side to hold
one of Mun's gastric bypass patients. Mun remembers a seven-hundred-pounder whom he envisioned falling on him and crushing him to death. Nancy evokes no such grim images. There will be room to spare on her Big Boy.
Still, Mun has not promised Nancy success, or even survival. Gastric bypass kills one out of a hundred patients on the operating table, and not everyone recovers from its complications. There are few controlled studies of the procedure, so no one can speak with authority on its degree of danger. Still, the insurance industry classifies it as "high risk." The anesthesiologist on duty warns that corpulent patients are tricky, and that Nancy is no exception. Nancy's veins are buried in a thick layer of fat, making it hard for a needle to find purchase. Like many obese people, her tongue is large and her neck short, making it difficult to guide a breathing tube down her windpipe. It takes a bevy of nurses and doctors several attempts to finagle each of these maneuvers, and with every attempt it looks like Nancy will choke or cry. But she doesn't, and with time and effort the requisite tubes and needles get coaxed and jabbed into place. Nancy's eyes flutter and close and the anesthesiologist tapes them shut to prevent the corneas from drying out. Paralyzed from the anesthesia, Nancy draws her breath by machine. Plastic shrouds her face, presumably to shield wayward gore. She emanates fewer signs of life than do the machines to which she is tethered.
Mun helps the nurses arrange the layers of sterile drape, leaving exposed a rectangle of stark white skin roughly the area of a shoe box lid, size ten. He paints the rectangle orange with antiseptic. The flesh ripples thickly, like a cr'me br"l"e. Mun grabs a black ballpoint pen and traces down the center line, a little shaky at first, then more or less finding the line he is after, about an eight-inch stretch from the tip of the breastbone to the navel. Seble Gabre-Madhin, a surgical resident, accepts a cauterizing scalpel from a nurse and traces over that line again and again until the skin bursts open with the force of the fat beneath. An observing medical student startles. It's not the sight that makes him queasy, he whispers, it is the smell, which is savory, like hamburgers spitting on a grill. The translucent fat layer glistens yellow under the operating room lights. The attending nurses hover. Drs. Gabre-Madhin and Mun exchange looks, then press two palms each on either side of the neatly split skin and ease the fat apart, forming a canyon. The walls of the canyon are slippery and lightly variegated with red blood vessels. There is almost no blood.
In The Wisdom of the Body, Sherwin B. Nuland, a clinical professor of surgery at Yale University, writes that the stomach is best understood "seen as a large bag near the upper end of what is otherwise a hollow muscular tube some twenty-five feet long from mouth to anus, the central portion of which is coiled up in the abdomen." This tube is the gut, and from stem to stern it comprises the pharynx, the esophagus, the stomach, the small intestine, the large intestine (or colon), and the rectum. The gut has an inner and outer layer of muscle, and the stomach has yet a third, to aid in its tireless churning of food.
The muscles and fibrous layers covering both sides of the stomach wall meet and fuse together in the middle of the belly, forming the linea alba, a stout ribbon of tissue stretching from the breastbone to the pubis. Mun deftly splits this, exposing the well-packed contents of the abdominal cavity, the largest orifice in the human body. Nurses position a gray metal circular retractor to hold back the skin and flab. The crater yawns jagged and raw. Mun pulls a glutinous apron of fat and blood vessels outside the wound, and lays it to one side of the torso. The mess on the surgical sheet is ghastly, like a mangled tongue lolling from the mouth of a drunk.
Mun plays archaeologist, pointing out artifacts as he excavates. Plunging his hand into the cavity, he locates the expected umbilical hernia, a weakness in the muscle near the belly button that is common in the obese. Wrist deep, he palpates the taut purple liver. He had mentioned earlier that the livers of the obese can grow monstrous–"sometimes," he told me, "they are as big as a horse's liver." This liver, thank goodness, is not Clydesdale-sized. Mun gently retracts it to examine the junction between the stomach and the esophagus. He is now elbow deep, pawing blind for the start of the stomach. Long seconds pass, and Mun's brow arches in concentration. No one says a word. This is a tricky business, and even the assisting surgeon, a stout, world-weary young woman, seems to hold her breath.
Suddenly, Mun finds what he's after. He stops for a moment and looks back at me, triumphant in his sterile mask and lightly fogged glasses.
"I love this organ," he says, pulling the stomach into glorious view.
Bariatric surgery, as obesity surgery is called, has a controversial history dating back hundreds of years. But the first modern procedure on record was in 1889, performed by Howard A. Kelly, a founding member of the faculty at Johns Hopkins University and its first professor of obstetrics. Kelly was an inventive surgeon and developed numerous surgical devices as well as innovative operative procedures. He seems to have fancied himself quite a sculptor, for he carved layers of fat from the abdomens of unwitting patients while they were under the knife for other problems.
Over the next few decades, reports of similar adventures trickled in from France, Germany, and Russia, and by the early 1920s, obesity surgery had become, if not fashionable, at least less ignominious. Not all obesity surgery patients died from massive infection or blood loss, but enough did that eventually it became clear to most respectable surgeons that slicing large quantities of fat from human bodies was not necessarily the safe and sure approach to treating the overweight that enthusiasts had claimed.
By the mid-twentieth century, obesity surgery had fallen out of favor with all but a few die-hard zealots. George Blackburn was not one of these. Blackburn is a surgeon, and is now director of the Center for the Study of Nutrition and Medicine at Beth Israel Deaconess Medical Center, where Edward Mun works. He is of medium height and robust, with stark white hair cropped into a schoolboy fringe. When we meet he radiates the sort of deep, smoky tan that comes from riding shotgun on a golf cart. There is no telling whether Blackburn plays golf, but I later learn that he gave up performing surgery years ago. He remains a darling on the obesity circuit, however, lecturing at conferences, consulting with industry, and sitting on boards and committees.
Like Mun, Blackburn trained at Harvard as a general surgeon. Like Mun, as a young man he developed a special interest in the stomach and in disorders of the gastrointestinal tract, such as ulcers. He cultivated this interest in the early 1960s, when doctors were not yet aware that ulcers are frequently caused by bacteria and treatable with antibiotics. Back then, dietary changes were the most common ulcer palliative, followed by surgical treatment. Surgery for severe ulcers usually involved removal of part or all of the stomach. It is possible to live and even to thrive without a stomach by eating many small meals and taking daily vitamin injections. Still, a hefty percentage of ulcer patients died of postoperative bleeding, infection, and sometimes starvation. Starvation was also a problem for trauma patients and for patients who lost their appetites after surgery. Blackburn got interested in this problem and decided to make it a subject of study in the early 1970s. To study it, he needed to experiment, and to experiment, he needed people who were willing to starve. He put ads in the Boston newspapers, assuming that he would get little if any response. "I was overwhelmed by the number of people who volunteered," he says. "Stunned."
Even more stunning than the number of volunteers was their size. Most were overweight or obese. Blackburn had very little experience with obese patients, and he was unfamiliar with their ways. He assumed, as did most doctors at the time, that fat people were too gluttonous to forgo a single meal, let alone subject themselves to weeks without food. But the overweight and obese volunteers were more than happy to starve. And they didn't cheat. They faithfully followed Blackburn's orders, eating only very small amounts of fish, fowl, or meat to keep up their protein levels to maintain as much muscle mass as possible. A month and a half later, they were many pounds lighter, and surprisingly healthy. Thanks to the "protein sparing" regimen, they showed no signs of the muscle wasting or dehydration usually associated with starvation regimens. That was all Blackburn needed to know, and he thanked the volunteers and told them it was time to leave. But he recalls that many–maybe most–begged to stay. "They would do anything to lose weight," he says. "And I mean anything."
Blackburn was a surgeon, not an endocrinologist, and he saw the plight of these patients through a surgeon's eyes. He was intrigued and moved by their pleas, but he had observed obesity surgery as a resident, and he hadn't liked what he'd seen. True, it had gone beyond the nineteenth-century "slice and dice," but to his way of thinking it hadn't gone far enough. The technique of choice at that time was the jejunoileal bypass, in which the intestine was essentially short-circuited to allow most of what the patients ate to slip through unnoticed and unabsorbed by the gut. This method was fairly effective, but the side effects–infection, protein malnutrition, kidney stones, osteoporosis, anemia, and liver failure–were unpredictable and occasionally fatal. "Some people would rather die than be fat," Blackburn says. And some doctors colluded in the gamble. About 100,000 intestinal bypasses were performed in the 1960s and early 1970s. Still, the high failure and mortality rates of intestinal bypass were troubling, and Blackburn chose to stay clear of the procedure.
There were other more benign approaches to consider–jaw wiring, for example. Jaw wiring is exactly as it sounds, something Wile E. Coyote might cook up for the Road Runner. As described in the British medical journal, The Lancet, the wiring procedure was simple enough: "Two interdental eyelets were placed in each canine and pre-molar region under local anaesthetic and the eyelets on opposing jaws wired together. Instruction was given on oral hygiene, measures to avoid aspiration, and the use of wire cutters." These "instructions" notwithstanding, expressing oneself through bound jaws was a trial, as was brushing one's teeth or eating anything that could not be slurped through a straw. And vomiting while wired could be lethal. (That is, if one somehow forgot to bring one's wire cutters to an office picnic.) Accidents–and deaths–did occur. And those who endured the recommended six months were horrified to find their weight soar when their jaws–and their appetites–were unleashed. Some physicians tried to stave off this rebound by prescribing a waist cord–a nylon strap tied tightly around the middle of slimmed patients that would remind them to eat sparingly. But most patients did not allow mere nylon to come between them and their calories, and either cut the dreaded things off or allowed themselves to balloon into giant hourglasses, with the waist cord strangling their middles like a noose. Clearly, when it came to weight loss, bondage was not the answer.
A more elaborate and certainly more imaginative scheme was the intra­gastric balloon, threaded into the stomach and blown up to crowd out the space for food. Stomach balloons carried a sort of whimsical allure: what could be more benign than a whisper of latex pumped with air? But the procedure was surprisingly expensive and not particularly effective. It was also dangerous, causing ulcers and erosion of the stomach lining. In 1988 a prominent physician decried the practice as "balloonacy" in an article in the journal Gastroenterology. Surgeons of the time were also experimenting with esophageal banding–inspired, perhaps, by the picturesque cormorant fishers of Japan. Cormorant fishing, or ukai, involves binding the necks of tame cormorants and setting them free to scoop sweetfish from the Nagara River. The birds are then called back or hauled in by their keepers and the fish extracted from halfway down their gullets. Esophageal banding has worked well for generations of fishermen in Japan, where the sport has become something of a tourist attraction. But it enjoyed only a short run in humans, who developed severe and sometimes fatal infections of the esophagus from the binding, and in any case had a greater tendency than birds to complain about fish getting stuck in their throats.
These and other disappointments prompted obesity surgeons to reconsider their options. Should they perhaps return to the stomach as a primary target? After all, the stomach's day job is churning great wads of stuff in a vat of acid, so it is accustomed to rough treatment and less prone to injury than are other more delicate organs. Also, at least theoretically, shrinking the stomach directly limited the amount of space available for food. And for many people a smaller stomach demanded less food than did a larger one. As explained by Columbia University College of Physicians & Surgeons professor Michael D. Gershon, author of an ode to the digestive tract, The Second Brain, when the stomach is full, receptors that respond both to pressure and to nutrients put a signaling system in motion to stop eating. A smaller stomach brings this pressure to bear more quickly. By shrinking the stomach, surgeons discovered that they could curb not only the intake of food, but also, in a surprising number of cases, the desire for food.
Stomach shrinking may not be brain surgery, but it has its challenges. Early approaches involved roping the stomach off near its throat with a one-centimeter-wide plastic tourniquet. There was no cutting, no stitches, no piercing of the stomach wall. The downside was that the bands sometimes worked their way into the stomach's interior, and got tangled into a mess that adhered to the stomach lining, causing pain and damage. A somewhat more complicated version of this approach, vertical-banded gastroplasty, eliminated the tangling problem and became quite popular. Both methods remain in use today, but at Beth Israel Deaconess Medical Center, George Blackburn does not recommend them.
In his drab and sprawling first-floor office, Blackburn keeps what he calls a "sympathy suit," a sort of hair shirt he pulls out for visiting doctors and scientists. The suit is shiny and puffy, like astronaut gear, and is filled with sand. It weighs thirty-four pounds, and donning it is meant to give skeptics some idea of how obese people feel every waking minute. Blackburn believes that the risk of obesity surgery and its complications is nothing compared with the risk of dragging all that excess baggage through life. Although he would almost certainly object, it would not be a stretch to call Blackburn a gastric bypass evangelist. He has seen what obesity can do to the human spirit, and it horrifies him.
"When I see a young man, a football player type of, say, 280 pounds, I'm able to look into the crystal ball of his future and see diabetes, insulin resistance, a whole slew of problems. Who among us would intentionally let people walk into the lion's mouth of obesity disease? No, I don't consider surgery drastic in the least."
Blackburn directs me to Isaac Greenberg, a psychologist who has worked with him for years. Greenberg is on the tall side and slim as a greyhound, but he's not smug about this. "Thin people think they're thin because they are doing something right," he says. "But they are wrong. What surgery has done is blow the psychoanalytic theories of obesity to hell. After the operation, many people lose their obsession with food. No one knows why, but it certainly proves that obesity is not just a psychological disorder."
Greenberg screens patients to see whether they are suitable candidates for gastric bypass. Most of these people have tried every weight loss scheme in the book. "Programs like Jenny Craig or Weight Watchers are like a virus," Greenberg says. "People go to meetings, see that other people have lost weight, and they want to catch that virus, too. So they sign up. They lose weight, go off the program, go off the special foods and gain the weight back. So, they return to the program. There are millions of returning customers keeping those outfits in business."
Greenberg invites me to attend a monthly obesity surgery support group meeting, and one dreary Thursday evening I decide to take him up on it. The group gathers in a basement auditorium at the hospital at dinnertime, but food is not served. The basement is dingy and echoing, and furnished with gray folding chairs. A ramp allows people too large to walk to roll into the room in wheelchairs. Four chairs roll in this evening. In all there are about three dozen participants. Most are in their thirties and forties, but they look older, their faces pasty and drawn, their bodies bloated with disuse. Their thick legs look vestigial. They complain of heart disease, diabetes, arthritis, and their difficulties in finding comfortable shoes. They are roughly divided between those who are scheduled for surgery and those who have recently had it. Few of the postoperative patients are anything close to thin. They have complaints–vomiting, getting food stuck halfway down their throats, hernias, gallstones–and they look just as tired, saggy, and worn as the people who have not yet had the operation. But most seem to agree that these discomforts pale compared to the agony they had endured throughout their presurgical lives.
It is no secret that the very obese live lives of quiet desperation, of humiliation and isolation, and of relentless guilt. Children have said in surveys that they would prefer playmates with missing legs or eyes to those with too much fat. Many obese adults confess that they would prefer to be blind or deaf. No wonder, then, that the fat people who gather together in this dank auditorium would, as George Blackburn predicted, do anything to be thin.
Among them only two, a media manager and a computer programmer, show any visible effect of the surgery. The programmer has lost one hundred pounds. He has 150 pounds still to lose, and he looks peaked, as though fighting a losing bout with the flu. The manager, a tall woman in her early thirties, announces that she is fourteen weeks pregnant. She looks terrific.
"One hundred thirty-seven pounds ago, it took nearly two years for me to get pregnant with my first child," she says. "This time it took one try." The room shakes with applause. After the cheers die down, a support group member raises a timid hand to ask if there is "any downside" to the surgery. There certainly is, the manager says cheerfully. "For weeks after the operation I thought I'd made a mistake. I was so sick I could hardly move. I really did think I was going to die."
Nancy Wright has attended these support group meetings, and she knows exactly what she is in for. She knows that dying on the operating table is a distinct possibility. She knows about the complications–the exhausting anemia, the painful gallstones and incisional hernias, the infections. Hearing about the ghastly aftereffects of the surgery gave her pause, but not doubt. She hasn't actually witnessed a gastric bypass, doesn't know in explicit detail all it entails, but she has spoken with Dr. Mun, and she has perfect faith in him.
And Ed Mun has perfect faith in himself. He has completed 110 gastric bypass procedures in the past twelve months, and most have gone like clockwork. One patient blew out her staple line postoperatively and wound up in the intensive care unit for thirty-five days. But she'd had three kidney transplants and a suppressed immune system and was a bad candidate for the procedure from the get-go. Nancy is a textbook case.
Mun reminds me of this as he manipulates Nancy's guts, maneuvering the left side of her stomach down into the operating field and into his line of vision. He takes care not to damage the spleen, which bleeds uncontrollably if torn, or the pancreas, which is filled with enzymes that can leak out and, as he puts it, "eat everything up." The stomach is glistening, firm. It is easy to imagine how demanding that stomach can be. Mun sizes it up and gets to work. Taking aim with his Endo-GIA II stapler, which cuts as well as rivets, he divides the stomach into two parts and staples the top portion into a twenty-milliliter pouch, about two tablespoons. An organ that could once proudly contain a quart of H"agen-Dasz can now barely hold a shot glass of yogurt. The bottom section will still secrete stomach juice, but it won't nag Nancy for food. Mun feels down the small intestine, past the duodenum to the jejunum, slices through the sausagelike structure and nails it to the stomach pouch with his EEA circular stapler, creating a passage­way the circumference of an M&M. Mun regards the EEA fondly, and praises its smooth, powerful action. The device spits out sixty-four stainless steel staples at a trigger pull, accomplishing in a split second what once took long minutes of painstaking needlework. Like a rodeo star roping a calf, Mun grabs the slippery bypassed end of the small intestine, flips it, and staples it to the lower small intestine, forming a Y. Stapling the jejunum to the stomach pouch will keep Nancy from cheating. For some reason doctors can't quite agree on, contorting the gut this way causes it to shoot caution signals to the brain when fatty or, in particular, sweet food passes through. These signals spark a violent "dumping" reaction–the body rejects the treat as it would poison, sparking cramps, hot flashes, pain, and diarrhea. For a few months at least, Nancy's stomach will no longer have the power to demand a Snickers bar. Mun has tamed it.
Looking up, Mun checks his watch: it is just over an hour since the first incision. Inhaling deeply, he stands back and admires his work: perfect, and in less time than it takes most people to balance their checkbooks.
Three hours after the operation, Nancy is awake and hurting in her Big Boy. She is exhausted, gray with fatigue and pain. "That was no walk in the park," she says. I ask if she has any regrets, or–worse yet–any thoughts of food. "No way," she says, her eyelids fluttering. "That's behind me now."
At nine o'clock the next morning, Edward Mun performs his seventh gastric bypass of the week. He is to leave that night for Korea, to attend his elementary school reunion. The fact that he has agreed to fly halfway around the globe to gather with childhood friends somehow doesn't surprise me. Mun is a man of deep loyalty and total dedication; a man who, as Nancy knew, can be trusted. Time is short but Mun is willing to take some moments to reflect. He tells me that that morning's patient was a particularly tough one. She weighed more than four hundred pounds and had an inflamed gallbladder that needed to come out. Two other surgeons had turned her down for surgery because of her size, but Mun hadn't flinched. When he opened her up he found the largest gallstone he'd ever seen stuck to the wall of her gallbladder. He cut it out, and the woman lost three hundred cubic centimeters of blood. Most surgeons would have stopped there, but Mun went ahead with the bypass.
"I thought about putting it off, but I decided to go ahead," he said. "Gastric bypass was her only chance. This operation is not an elegant solution. On some levels it's barbaric. But, let's face it, it's all we've got."
Like Nancy, more than nine million American adults are "morbidly obese," roughly one hundred pounds or more overweight. Ten million more are almost there, teetering on the edge. But one need not reach this milestone to pass muster for surgery. People with "co-morbidities"–diabetes, heart disease, high blood pressure and the like–qualify at lower weights, and some physicians–among them, George Blackburn–argue that the bar should be lowered further, to include the still larger number of people who are obese, but not morbidly so. So many patients are clamoring for gastric bypass that experienced surgeons are overwhelmed. At a lecture I attended on surgical techniques at an annual meeting of the North American Association for the Study of Obesity, doctors overflowed the room, and stood straining to hear from the hall. The speakers, all obesity surgeons, promoted a slew of new techniques, including some that sounded only slightly less draconian than the old slice-and-dice approach. They also raised the specter of performing the operation on children as young as twelve. Such radical tactics are justified, they said, to stem the tide of an epidemic that is all but smothering us.
Nancy can't help but agree. She and I speak a month after her surgery, and she is cautious, but upbeat. She still cannot eat much, but then, she doesn't want much. She is living on nibbles of yogurt and scrambled eggs and instant breakfast mix, and hoping for the best. Gastric bypass patients lose most of the weight they lose quickly, in the first eighteen months, but that, Nancy knows, is the grace period. The hard part comes later, when the novelty of the procedure dims, and old habits start to surface. Often the pounds creep back. Somehow the magic wears off and the pouch gets stretched enough to accommodate the slowly sneaked calories. Or the person cheats by sipping high-calorie drinks all day long, or sucking down tubs of melted ice cream. Nancy knows that this could happen, and it worries her. But for now she is satisfied that the choice she made was the best one. For now, she is in control.
"I know this is no miracle cure," she says. "I know it's going to get rougher. I don't know what's going to happen two or three years down the road. This was a big step, and a terrifying one. But when it comes right down to it, I had no choice. It was my only chance at a life."
Excerpted from The Hungry Gene: The Science of Fat and the Future of Thin
©2002 by Ellen Ruppel Shell. Reprinted with permission from Grove Atlantic, Inc. All rights reserved.
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