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George Fielding, MBBS
Everybody dreams. What do obese people dream about? Sex, of course, everyday fears, weird things, just like everyone else. Above all else, though, you dream about being thin, free of hunger, and looking normal. Many millions of obese people have this dream but only a few have it come true. Even fewer have it stay true.
Why are so many of us obese? What defines someone as being morbidly obese? .The most commonly used test is the BMI, which takes into account your height in addition to your weigh . It is calculated by dividing your weight in kilograms, by your height in meters squared . For example, if a person were six feet tall (2 meters) and weighed 440 pounds (200 kilograms), their BMI would be 50 (200 divided by 4). Any BMI over 25 is considered overweight. The relationship of BMI to the degree of obesity is as follows:
BMI < 25 Normal, healthy weight
BMI 25 – 30 Overweight
BMI 30 – 35 Obese
BMI > 35 Severe / Morbid Obesity
According to the NIH, you must be at least 100 pounds overweight, 150% of ideal body weight, have a body mass index greater than 40, or 35 with associated so-called co–morbid conditions such as diabetes, high blood pressure, and asthma . Ten percent of Americans and Australians are morbidly obese with a Body Mass Index (BMI) over 35.
There are more morbidly obese people in the USA than the total population of Australia. There are 1.8 million Australians in this category. 1.8 million! That is the entire population of greater Portland, Oregon. Another 30% are obese with a BMI 30–35. Apart from the social handicaps generated by a BMI of 35, these are sick people, They suffer from diabetes in the young, hypertension, asthma, sleep apnea, joint problems, depression, agoraphobia. Diabetes alone will wreak havoc. The biggest factory ever built to make a drug has been built in the US to make insulin for the huge new population of diabetics under thirty. These obese people slowly retreat from life, either because it is too hard physically or they are ashamed of their appearance.
America and Australia have the fattest kids in the world. Picture a Sunday night. Mom's tired after carting kids around all weekend, doing the laundry, making the lunches. ‘Mom can we have a pizza?” Sag. ‘OK'. Child number one pulls out her cellphone while hogging the TV remote and orders the pizza. Some cute guy brings it into the living room, swipes her Visa and the kids instantly get 3000 calories. Oh, and a free 2 liter bottle of soda. Make that 5000 calories. They have not stretched one muscle fiber, have not used up 1 calorie. Two kids – 2500 calories each. No expenditure of energy, not even standing up to change the channel to a better movie between bites. Man used to be a hunter, running after his protein.
Are people surprised childhood obesity has doubled in 10 years? Moreover, that the world has become a fat place? What used to happen? Walking to school, lunchbox, bouncing a basketball, bare feet, playing 'till dark, imagination. stickball, walking to the train station to go into town to see a movie, washing up, taking out the trash, playing with the dog, and fishing with grandpa after having walked one mile to just the right part of the stream. Spaghetti and meatballs on Friday night and hide-and-seek until we couldn't move or it got too dark. It's no surprise. Now we have cars to drive us 3 blocks to the store, moving sidewalks, playstations, computers, chat pages, text messaging, television, dishwashers, sink disposals, remote controls, power windows, escalators, and all types of prepared food delivered. Such reduced energy consumption, so much more food, so much fatter.
Why is it so hard to lose weight? It all boils down to two forces: hunger and mathematics. Take the easy one first, mathematics. In-Out, Consumption-Expenditure, Eat-Burn, Hunger- Control. Eat more than you burn and you'll gain weight. Simple but devastating. Food is everywhere. It's not sensible healthy food but yummy, bad food. It's chocolate, chips, candy, fries and burgers. It's Coke and Snickers bars. “What can one Snickers bar hurt?” It's just that you have to do so much exercise to burn off calories. Sleeping burns 2 calories per minute, sex burns 3, walking 8 and running 20 calories per minute. A Snickers bar is 350 calories. You have to walk for 45 minutes to burn off one candy bar. You pull into the gas station, fill up your tank, buy the ubiquitous Coke and Snickers almost as a reflex, and that's 600 calories. Just like that. You hardly even notice it going in. “But I don't eat much”. One can of Coke a day is 10 pounds of fat in a year. It's middle-age spread! You have to walk for 75 minutes to get rid of those 600 calories.
It gets worse. You have to burn 7,600 calories to lose 2 pounds. Do the math. One hour walking burns 480 calories. That's 15 hours for 2 pounds! You buy the newspaper on a Sunday, buy a chocolate bar and a Coke, and that's one hour. Who has the time to walk for fifteen hours a week to lose 2 pounds? I'd rather have sex for 30 hours a week. Same number of calories and lots more fun. Nevertheless, seriously, who has the time? It's all mathematics. They don't call it a pure discipline for nothing.
What to do. Firstly, move more. It really is true. Walk up the steps, park the car 500 yards from work, walk the dog, wash the car, fidget, wriggle, play touch football, ditch the golf cart, have lots of sex, swim and walk along the beach instead of looking at it from your air-conditioned living room. Just move. Try to resist computerisation of at least some aspect of life.
Second, do weights and build muscle. Donna Aston, a patently sexy, attractive woman has hit the nail on the head in ‘Fat or Fiction', telling women to do weights. Do not fear tone or strength - treat it as your friend. Eat protein and get strong. Build muscle and lose weight. Why is it so? Mathematics. Get a gram of muscle, burn twenty times the energy of a gram of fat. Therefore, the expenditure is easy: Move more, do weights, get strong. Walking feels nice and is good for your breathing, good for your blood pressure, good for your diabetes, it's companionable when done with a friend, but it's a total waste of time as a weight loss exercise. Fifteen hours of walking to burn 2 pounds of fat. You just don't burn enough energy. Now comes the hard part: eating less. For the dedicated follower of fashion, size 8 acts as a very powerful incentive. For obese people this is the hard part and size 10 is the stuff of dreams! For really obese people it's the nightmare, the scream of which Munch would be proud. The all consuming enemy: hunger.
‘The Full Monty' was a huge hit on Broadway. It had lots of laughs – then, out of nowhere came a sledgehammer. The big, fat guy sang a gentle love song “You Rule My World”, not to his wife lying next to him in bed, but to his stomach, to his hunger. It blew me away. At first we laughed, comedy easily generated by a big roly-poly stomach. He had everyone in his grasp as he described his torment. At the end, he sighed, rolled over and ate a Kit-Kat. I cried.
The world has become a fat place. The World Health Organization has declared obesity as the third of the great epidemics facing the world in the new millennium, along with HIV and tuberculosis. On a world scale, food is the addiction. Many of us have addictions – some legal, some not. Rich heroin addicts, like Eric Clapton or Keith Richards, seemed to cope, even to flourish, in the glare of their addictions. Most just collapse and die slowly. What perverse person came up with heroin chic? The press constantly explores addiction. Hollywood challenges us with the likes of ‘Traffic'. It's still cool, still okay to smoke. How many of our children smoke, particularly our daughters? Same for alcohol, in spades; same for unsafe sex. The very rich can even get counseling for sex addiction. Heaven help us.
All these addictions are ghastly. Yet, somehow, they have the sympathy of the community at large, of the medical profession to a certain extent and of the fourth estate. Hunger just doesn't. Nobody thinks being obese is cool, chic, dangerous or sexy. Can you imagine a new hip movie called “Fat”. Will governments ever have the strength to ban ads for Coca-cola, for fries, for sugar? They might have to. Three cheers for the decision to do away with Marlborough Man, Virginia Slims, Camel, Winston, Parliament and all the other cool adds supporting the other great addiction - the greatest preventable cause of ill health ever known. Advertising for cigarettes has been banned in many places, as has smoking in restaurants, airplanes and hospitals. You can't even get a cigar in the Oak Bar at the Plaza in New York. Maybe one day there'll only be Diet Coke, and it'll be illegal to offer fries with everything.
Hunger never goes away. The brain controls hunger. Deep in its most primitive part is the hypothalamus and, deeper still, is the satiety center. The part that makes us feel satisfied. When it works, it tells us we have had enough. When it doesn't work, we have never had enough. We feel as if we are never full, always hungry. This is the root of obesity. What flicks the switch? There are three main inputs: the stretched stomach, hormones such as insulin and growth hormone and relatively new discoveries such as leptin, grehlin and PYY-36. All these factors blend together to activate the satiety center and turn off appetite. Leptin is made by fat cells as a self-regulatory feedback loop. More fat, more leptin, less hunger. As one gets fatter though, the leptin becomes ineffective. Fat people have masses of leptin that doesn't work. They can't tell whether their stomach is full or that their blood sugar, insulin and growth hormone levels are high. Grehlin, a hormone made by the stomach, is at least as important. Researchers in the US and Australia are exploring grehlin, others in London are studying PYY36, and an Australian company is currently trialing a synthetic growth hormone analogue that controls hunger.
Lean body mass, basal metabolic rate (BMR), exercise and random motion all count in the balance of energy, but hunger is the factor that is hardest to control. Thin people are typically born thin and stay thin. They respond to these stimuli appropriately by stopping eating. That is how they stay thin. On the other hand, obese people spend their lives trying to control hunger, dieting, starving, facing obstacles to their willpower every day, while surrounded by food. Can you think of one place in the western world where there isn't food at point of sale to trap dieters into a little frisson of pleasure? The high sugar causes a rise in insulin, which causes a fall in blood sugar, leading to more hunger. The frisson becomes a wave of guilt and of self-loathing that you did not have enough strength to control yourself. The dieter says ‘screw it – what's the point'.
Drugs have failed. Xenical is just the latest in a long line of supposed wonder drugs. Roche pharmaceutical company certainly got the TV add right, a fat dad out of breath at the beach while playing with his son, a fat girl sitting out the dance. Unfortunately, the effect of the drug was limited to losing 5% of body weight, no real benefit if you have a huge body. Appetite suppression does work in the short term and, when coupled with an anti-depressant and meal replacement, can give meaningful weight loss. It's just that you can't live on Optifast forever; and Phentermine sends you a bit loopy and stops you from sleeping. The day you stop, the weight starts coming back on. Fen-phen helped, but caused heart valve disease in a small number of people and was pulled off the US market. Nothing available really works.
Until recently, the medical profession has failed obese people. Many doctors still believe obesity is simply a matter of will power. As long ago as the 1970's, studies showed that doctors felt fat people deserved everything they got. Others showed perceptions of fat people as being weak and less intelligent than thin people. Many studies have confirmed that fat people fare less well in interviews than equally qualified thin people; that they are promoted less frequently; and, are less likely to be made leaders. Doctors share the views of the general population. The difference is that we doctors should be about prevention of disease and healing the sick, without fear or favor. Each year 300,000 people die in the USA from diseases purely caused by obesity, compared to 95,000 caused by breast and colon cancer combined. Obesity is second only to tobacco as the major cause of preventable death in the US. Recent times have seen an increase in understanding of these issues, and obese people are slowly starting to get the help that they need.
On my last weekend on call, I operated on a 35-year-old female alcoholic, bleeding to death, whilst being considered for a liver transplant; on a 72 year-old smoker with a massive bleeding duodenal ulcer; on an 85 year-old with an obstructing colon cancer; on a 22 year-old who jumped 45 feet out of a window; and, on 3 kids with appendicitis. The only patients without self-inflicted disease were the kids. Should I not treat the drinker, the smoker, the suicide or the patient who presented too late? Of course, I should. If a bank robber is shot during a robbery and arrives at the hospital bleeding with a hole in his liver, do I say “Die, bad guy'? If a gay man presents with HIV do I say ‘No, you should have had more will power and you certainly should have worn a condom'? Imagine what would happen. I'd be on the front page in the paper, hounded to hell for my overt prejudice. As I should be.
So why aren't those who refuse to help fat people hounded? Easy. Everybody thinks being obese means you are weak and somehow disgusting, while the drinking, smoking, fast driving, promiscuous, depressed people are deserving of our help. Imagine if the public health system refused to treat the complications of alcohol, smoking, drugs, driving too fast, promiscuity and guns. We wouldn't need a public health system!
The most common misconception is that obese people don't try.WRONG! They try all their lives. In the 1980's a study revealed that fat people would rather lose a leg or be blind in one eye than be fat, and would rather be a thin pauper than a fat millionaire. Why? Because they know what everybody thinks. It sucks being fat, to never be seen any other way than just fat. Are all fat people so hopeless? Many fat people have so much that is never seen, buried under a carapace of fat and self defense. Just imagine Big Luciano Pavarotti walks in to your office. You know nothing about opera. However, he has high blood pressure, diabetes, sleep apnea, painful knees and depression. You give him a lecture and tell him to walk and eat less, then send him on his way. As he leaves, he bursts into a bit of Verdi's Requiem. You get goose bumps, and want to cry it's so beautiful. Then you realize it's the same fat guy.
Do obese people try. Ask Jenny Craig (JC). Ask Weight Watchers (WW). When people attend, stick to a program and control hunger, they lose weight. When they stop attending, they instantly put on all the weight. When they go back they are 15-20 lbs heavier than the first visit and the cycle starts again. They all start thinking that JC or WW are the only thing that helps them until they realize that it is a complete waste of time. They give up and just get fatter. In 1991, the National Institute of Health (NIH) reviewed 4500 publications on weight loss and found that the maximum sustainable weight loss byANY diet, exercise or behavioral modification program is 25 pounds. That's two dress sizes!
This is why Fergie has been such a huge success for WW. Tony O'Reilly bought Weight Watchers for $55 million. The world got fat and he got Fergie. She's perfect. The intelligencia sneer, but she represents 50 % of the western world. She's a single mother trying to work and be independent, with two kids. She has a fat bottom, her dresses are a bit tight, and she has been sneered at because she's not a long blonde-haired woman as Princess Diana was. Millions and millions and millions of fat women identify with her. She joined Weight Watchers and lost about 20 pounds and ends up looking great. The NIH report predicts she will keep that weight off and she has. I would too for a few million dollars. Four years out she looks great, the fat women of the world signed up, and O'Reilly sold WW for $150 million.
You can keep 20 pounds off, but you will virtually never, ever, ever keep 50, 100, or 200 pounds off because the hunger will always get you. So, what to do? Well, you either keep trying and go mad, give up, get fatter and go mad, or have an operation. Most obese people do all three. You don't think so? Ask Kate Winslet. She was gorgeous in Titanic looking curvy next to all her 105 lb co-stars, having dieted hard to get there, and become the star. Then she gets fat and tries to be cool about it- “diets are silly”, and how she won't be controlled by Hollywood.
All the women's magazines love it. Then she gets really fat and work dries up. She has to lose weight to get a job, so she diets. The magazine editors feel she has surrendered. They advocated dieting to get ahead. Does this girl actually have a brain? She could say, “Do it, take control, keep trying' etc. Phase 2 kicks in and she gives up and gets slowly fatter. The girls' magazines love her. A men's magazine is accused of morphing pictures of her to make her look more slender. Today as I write this, she's happily married and thin again.
Ask Sophie Dahl. She's size 16, famous because her grandpa wrote amazing books for kids, and because she's like gazillions of women yet somehow became a supermodel. She then lost weight, and suddenly she's famous for dancing with Jagger at the Met bar. She is a size 8 in People magazine. Instead of ‘Well done!', it's editorialised as succumbing to diet fever. For God's sake, the girl was obese and now she's not. Magazines should be praising her, using her to encourage others to keep trying – not making out she is sold out.
How about Phase 3, finally having surgery. Ask Roseanne. She's mean, tough, funny, really powerful, really rich, yet unable to control her appetite, dieting all her life and eventually having surgery. Ask Carnie Wilson, a musician, daughter of a genius, fat since school, hungry, unable to lose weight, all very sad .These are not weak people. They are hungry, obese people who are unable to free themselves from this cage. They haven't surrendered; they have taken control.
The press's perception of this is odd, to say the least. Roseanne gets her surgeon on TV and tells Americans how happy she is, yet there is never a comment from the press about her weight loss. It is very moving and humbling to hear Carnie Wilson talk about her surgery. She had the guts to put her surgery live on the internet, millions have seen it and she is less than half her body weight prior to surgery; yet every press report editorializes her surgery as drastic, last resort, desperate . That is exactly how she felt prior to surgery - drastic, desperate and hungry. The second major finding of the NIH in 1991 was that surgery is the only treatment for morbid obesity that works and surgery is now encouraged. Ten percent of Australia, USA, UK and Europe are eligible by NIH guidelines to have surgery because they are severly obese. How can one picture such a large number of people? What is 10% of the adult population of the US? It's the population of New York City, or the population of Australia! An American tourist arrives at Sydney airport. Every single person they see in Australia on their vacation is obese enough for the US Government to recommend surgery. The French Government does too – and pays for it. Why? Because they want to prevent disease
No wonder the public health systems in Australia, and Europe are collapsing. It soon will occur in the U.S. They are being squashed under the mass of diabetics, heart attack victims, stroke victims, asthmatics, sleep apneics, breast and pancreas cancer victims and joint replacements, a mass that simply did not exist fifteen years ago. Guess what. Surgery fixes them. Roseanne, Carnie, Sharon, and the other 100,000 people who have had obesity surgery last year are right. They are the ones taking control, freeing themselves from a lifelong nightmare. The only known cure, yes cure, for diabetes, sleep apnea and asthma is weight loss. The only known proven long term path to weight loss greater than 25 pounds is surgery.
Obese people have surgery for one reason - to be not obese. The driving force behind the decision varies: Wanting a life, being healthy, coming off multiple medications, fear of early death, wanting to be alive for their families, playing with their children, getting a job, getting a promotion, having sex, getting pregnant, having a child, sleeping without a C-PAP mask, having their wife sleep in the same room because the snoring has stopped!!! You know, normal life. Stuff like sitting in a movie seat, a plane seat, on a toilet seat, a bus seat. Not to mention walking up five stairs, up the street, out of the house, anywhere without gasping, going to the beach, the gym, and a clothing store without feeling like a freak show. Stuff like having sex and being the one who moves, actually seeing your penis or vulva.
How do I know all this? Easy. In the last 7 years, I have operated on over 2000 morbidly obese patients in Brisbane and I've heard it all a thousand times. They just want a life. Sure, they're scared, sure, it's a big step - but hell, nothing else has worked. Most have been to JC and WW at least three times, taken all the pills, done all the diets, sensible or not, done the walking, the gym, the nutritionists, the calorie counting and the starving. None of it works long term. So they come in, nervous, a deep part of them sure it's a con like everything else, ready for failure, yet desperate for success. They have already seen my nurse, nutritionist and psychologist, have read all the handouts and surfed the internet for hours. Eventually I tell them OK - I will do it. Often they just cry. Why on earth would they cry? Relief that it is actually going to happen, that someone believes they have tried, that they don't have to do another stupid, doomed diet. So they cry.
How else do I know? Easy - I'm one of them. I've had surgery too. It's weird hearing 2000 people tell you your own life story.
I was the fat kid in elementary school. I saw my first doctor to see if I had an endocrine gland problem when I was ten. I didn't – I just ate too much. So, I was put on my first diet. It was torture. I cheated all the time because I was starving. I was very active, played all the sports and was also quite brainy. We never had TV so I read a lot and played music. I just ate all the time. Clothes were a problem. Nothing fitted, so Mom made them. I was called every simile and metaphor for fat imaginable. Not surprisingly, I became completely determined to beat all the bastards. I lived starving hungry.
When I was nearly fifteen it started to change. Alec Evans, a teacher at school changed my life in a real Mr. Chips moment. I'm sure Alec can't remember, but he encouraged me to get fit and do weights, to try hard and not to be fat. Another teacher, Brian Short, taught that pursuit of excellence was a good thing and that winning was good. My father taught me that all people have equal rights. So, armed with strength, power, a fierce will to win and a brain, I set out to conquer the world and I have done so pretty much.
I have a beautiful partner and four great kids. I became a surgeon by age 29, and was in private practice by age 34. I played rugby quite well and later coached, and played two musical instruments well enough to be in a band until I was 43. I read thousands of books, listened to masses of music, travelled the world, surfed at the beach from the age of twelve, bought a share in a house in Burgundy and drank more great wine than was strictly necessary. I simply took life by the throat. I find surgery a joy. I have operated as a guest surgeon in Britain, France, Japan, Singapore, Hong Kong, Bangkok and the USA. I love teaching, surely appear arrogant to many and make minimally invasive surgery look as hard as pulling on socks. All this, yet I just could not stop eating, I could never control hunger. The pain and humiliation of always being hungry and fighting it just exhausted me. Despite living a life where false modesty has been a wasted emotion, deep down I felt like a failure. Pick a vegetable – done ‘em all; I have been on a soup and broccoli diet, grapefruit, Israeli army, Pritikin, high carb, low carb, high protein, no protein, starvation, eat what you like, run 8 miles a day, do weights till my shirts burst, swim a mile a day and die of boredom. How about pills? Done them all too, Adifax, Phentermine, Optifast, Zoloft. I was always hungry.
Since 1980, I have lost 70 lbs four times. Each time took about 18 months. I felt like a different person each time. I'm strong, confident, aggressive, very sexual, and in control. Then, whoosh - blink and it's all back on, plus some. People reckon fat people don't try. All you do is try, fail, then try again and still fail. I once saw a T-shirt ‘I'm not an alcoholic I'm a drunk - alcoholics go to meetings'. Same with food. Foodaholics go to meetings too - WW, JC,. Fat people are just fat, like alcoholics are drunks. It never goes away. Try being 200 pounds, then being 300 pounds. You still think like the 200-pound tough guy, but look and feel like a big, smart, aggressive blimp. Imagine Pussy, not Tony Soprano. Therefore, you start back on the road, dieting, running, working too hard, over-compensating in everything to override how awful you feel.
This was the cycle of my life for twenty years. Then I got sick - all kinds of sick. Asthma, reflux, sleep apnea, depression and finally heart arrhythmias. I was forty-two, taking ten tablets, in the middle of a mid-life crisis to end them all.
Working like a lunatic, out-of-breath all the time, tired all the time, going a bit crazy. Bob Dylan said it best, “My feet are so tired, my brain is so wired”.
As well as all my usual surgery, I was doing ten bariatric operations a week, putting in gastric band and doing bypasses. I had been converted to the cause four years previously and was very happy with the results. Strangely enough, this was the most satisfying work I had done - making people healthy and happy, giving them a normal life. The patients' stories were all the same as mine. I held off and held off. One day I cracked, weighed myself and nearly fainted at the figure, 290 pounds. I sat down, rang my friend, Paul O'Brien, in Melbourne, and booked myself in for a gastric band procedure. I took control.
Many doctors have written about being on the other side, on the receiving end. We all find it an awkward place. As a group, surgeons are famed for their inability to give in, to admit frailty. As an old patient once said "The only difference between God and a surgeon is that God doesn't think he's a surgeon". Flying to Melbourne to have the surgery I was scared, nervous of powerlessness, anxious about complications. Nevertheless, I was thrilled to be gaining control. I had seen it help so many of my own patients. I would gain control. Moreover, I have - 44 months, no hunger and 70 pounds down. I feel great, am off all my pills, have boundless energy to do anything I want without getting tired. One night in the hospital, three days off work, five tiny cuts, eating slowly, eating small meals, never being hungry. That's the biggest blessing, never being hungry. I occasionally vomit if I eat too fast. I can't eat a steak. Who cares? Not me. I'm not hungry and I feel full easily.
Who'd believe that such a simple thing as a gastric band, a little piece of silicone with an internal adjustable balloon, could render such a service? Hunger no longer rules my world. A fat boy's dream has come true. I still dream about sex too, but I don't get out of breath, even in my dreams.