A weighty decision
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By JENNETTE BARNES
Standard-Times Staff Writer
March 28, 2006 (reprinted with permission)
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Tiffany Machado is preparing to undergo gastric bypass surgery tomorrow to deal with her weight problem. Her father, Gene Machado, will support her journey, which requires years of dieting and counseling.
Photo by Peter Pereira/The Standard-Times | |
Tiffany Machado goes under the knife tomorrow at Tobey Hospital. Her weight has fluctuated dramatically in the last six years. From a high of more than 300 pounds, she reached a nearly healthy weight before jumping back to 235.
Now 21, she has lost enough weight that she barely qualifies for the surgery, but she is determined to move forward.
A very personal, emotional fear plagues her. She worries that she will waste her youth unhappy and battle weight problems all her life.
"I can't tell you I know what it's like to be full," Ms. Machado said. "I can eat, and eat and eat and never have a feeling of fullness, and I need that."
After tomorrow, feeling full will not be problem. She may not feel hunger for two years. Once the hunger comes back, maintaining weight loss can be harder. Patients can stretch their stomachs and regain some of the weight. But hungry or not, they never eat normally again.
After surgery, the functional part of the stomach is smaller than a golf ball and holds only one ounce of liquid.
Patients are instructed to eat frequent, very small meals, and virtually no fatty foods or sweets. Since the intestines can't handle undigested sugar, eating sweets can cause "dumping syndrome," in which the patient experiences nausea, heart palpitations, stomachache and diarrhea.
But that is not enough to deter Ms. Machado.
She traces the rise in her weight back to 2000, when an aunt who was close to her committed suicide.
"And mainly for that reason," she said, "I turned to food. It sounds ridiculous, but that's what comforted me, made me comfortable, helped me cope. And then one day I looked in the mirror and just said, 'How did I let myself get like this?' This is unbelievable."
One of the pitfalls of surgery is that it does nothing to cure the emotional problems that can trigger overeating. Patients may feel better about their bodies, but they are not likely to be relieved of depression or anxiety.
Ms. Machado has been through physical and psychiatric evaluations, nutritional counseling and four sessions of group counseling. In the final session, patients meet others who have had the surgery to learn about their post-surgery experiences.
Ms. Machado lives off Dartmouth Street in New Bedford with her parents and her teenage brother and sister, who are twins. She works as a phlebotomist, drawing blood for testing.
When she thinks about her family's health, she sees a troubling future. While only her grandmother struggles with weight, the family has a history of diseases associated with obesity, including high blood pressure and diabetes.
Her body image is poor, and she blames the breakup of an engagement on the weight.
"Even at my thinnest," she said, "I used to think, 'I'm so fat, I'm so fat, I'm so fat.'"
Her journey into bariatric surgery began on the evening of Dec. 14, 2005. At a time when friends and family were preparing for Christmas, Ms. Machado and a handful of others ventured into a first-floor conference room at Tobey.
Dr. Rayford Kruger, the hospital's primary bariatric surgeon, gave a seminar on Roux-en-Y gastric bypass, the most popular type of bariatric surgery in the United States and the only type performed at Tobey, one of the few hospitals in the state outside Boston performing the surgery laparoscopically.
At the seminar, Dr. Kruger was blunt about the risks. People can die from the surgery, but they also die from obesity.
"The fact that you are obese is a medical problem, which has a risk that includes death," he said.
None of the 150 patients in the Tobey program has died since its inception 15 months ago, he said.
Robin Thompson of Falmouth was in the audience. She has been heavy, in her words, "since day one." She cannot remember anything else.
Three months after the seminar, Ms. Thompson has cleared nearly all the hurdles for surgery. Once she finishes four sessions of group counseling and gets final approval from her insurance company, she will be ready to set a date.
Almost.
From the time patients first see Dr. Kruger, they must lose 10 percent of their excess weight to be eligible for surgery. Shedding those pounds helps give the medical team room to work, improves the patient's overall fitness for surgery, and demonstrates self-discipline.
Ms. Machado had only 11 pounds to lose, but Ms. Thompson is a more typical gastric bypass patient, with more weight to lose. She weighs 360 pounds, so her pre-surgery weight-loss requirement is a substantial 22 pounds.
That scares her, because a knee injury she suffered while getting out of a truck has hampered her mobility.
Unlike Ms. Machado, who has high blood pressure but no other health problems, Ms. Thompson says the obesity affects her more physically than emotionally.
She has diabetes, high blood pressure and diabetic retinopathy, which causes blood vessels to leak into the eye and can lead to blindness.
Hope of halting — or even reversing — those life-threatening medical conditions is what drives Dr. Kruger to promote bariatric surgery, in spite of the risks.
The death rate nationally within a month of gastric bypass is between 0.5 and 1 percent, he said. The American Society for Bariatric Surgery, an association of surgeons, places the risk of dying within one month of surgery at between 0.2 and 0.5 percent at "expert" hospitals, but concedes that the risk can be far higher at inexperienced hospitals.
For comparison, the risk of death from cardiac bypass is no more than 2 percent, according to a National Library of Medicine publication.
As a community-based program not located at a major teaching hospital, the Tobey program does not accept risky cases, including patients who weigh more than 350 pounds at the time of surgery. Tobey also turns away smokers and people younger than 20 or older than 65.
As in most programs, patients must be at least 100 pounds overweight.
The Tobey program expects to grow to 200 cases a year by January, especially in light of the Feb. 21 announcement that Medicare will cover three types of weight loss surgery.
Only programs that are certified by the American College of Surgeons or the American Society of Bariatric Surgery will get Medicare coverage. To be certified, hospitals must perform at least 125 of the surgeries each year, Dr. Kruger said.
When the ruling was issued, not a single program in Massachusetts had that certification.
The requirements could make hospitals less likely to start new bariatric programs, leading more patients to existing programs.
No matter how many cases Dr. Kruger has done, Ms. Machado's father is worried. He tried to talk her out of the surgery more than once, but now he says he supports her decision.
"If something happens, I'm going to be crushed," he said.
His daughter is nervous, but she will have support. Tobey patients must agree to attend a post-surgery support group for at least a year.
Ms. Machado tries to focus on the benefits.
She wants to be healthy and look good. She wonders, though, how she will feel if she gets attention from people who didn't look twice when she was heavy.
Contact Jennette Barnes at jbarnes@s-t.com
Date of Publication: March 28, 2006 on Page A01
Copyright © The Standard-Times 2006. Reprinted with permission.
More Information ~ FREE Seminars
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- First Wednesday of each month
7 p.m.
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6:30 p.m.
Medical Library on the first floor
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43 High Street, Wareham - Second Wednesday of each month (beginning May 13, 2009)
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Southcoast Center for Women's Health
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Important Note to Patients
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Like any major surgery, major abdominal surgeries such as procedures to treat morbid obesity bring a significant risk of complications. It is important to remember that those afflicted with morbid obesity may have additional elevated serious risks, or co-morbidities, including diabetes, hypertension and severe pulmonary issues, which can cause further complications during this or any surgical procedure. This surgery is only performed after patients participate in a lengthy screening and orientation process that involves their families and all of their existing health care providers, including their primary care physician. Patients are also required to undergo medical counseling and engage in health and lifestyle practices that are designed to reduce co-morbidities to whatever extent possible.
You should always contact your Primary Care Physician to discuss any questions or concerns related to your medical history and options for choice, particularly if you are planning to undergo any surgery or partake in a new medical regimen.
