A classmate approached young Laura Prince on the school playground and delivered the arrow:

“I hate you.”

During a time when children often judge their peers on outward appearance, the torment of a nine-year-old on Weight Watchers can be especially cruel. As an adolescent, Prince overcompensated for her more than 250 pounds with an extroverted, irresistible charm that remarkably granted her acceptance from the cool kids at high school in State College, Pennsylvania.

“As a fat, red-headed child,” Prince says, “your life is not going to be fun.”

Indeed, her ocean blue eyes and sparkling personality hid a lifetime of pain, the heaviness on the outside a pale comparison to the heaviness in her heart. Over the years, the 5-foot-9 Prince—who at the most weighed 394—perfected the art of covering her sadness and learned how to appear tough on the outside. If it hurt when she couldn’t go into a store and find pretty clothes to wear, when she couldn’t fit comfortably in a movie theater chair or wrap a car seatbelt across her waist, she never let it show.

Big girls don’t cry, but self-respect slowly withers inside.

So, Prince made the decision to alter the course of her life. In November, she underwent a gastric bypass—a surgical procedure developed at the University of Iowa that restricts food intake by stapling off a portion of the stomach and reroutes the upper part of the small intestine so the body absorbs fewer calories and nutrients.

“It’s probably one of the scariest things I’ve done in my whole life,” says Prince, 34, a UI immigration specialist, who dropped about 40 pounds in the two months after her surgery and now weighs well under 300. “I really feel like I’ve been given a second chance at life.”

Such a statement offers insight into why gastric bypass, an operation that some consider dangerous and extreme, is appealing to more and more people. Many medical professionals consider obesity the most serious cause of poor health in America. Patients who struggle with obesity face a 20 percent increased likelihood of death from all possible causes and are at extra risk from coronary heart disease, stroke, diabetes, malignancies, and gall bladder disease. In the morbidly obese, diet and exercise alone can fail to trim the weight necessary to restore health. With your life hanging in the balance and possible salvation behind an operating room door, what else can you do?

Nearly 130 million American adults are overweight and 83 million obese. One in 50 people are morbidly obese, meaning their lives are in serious danger. Each year, the condition contributes to at least 300,000 deaths in the U.S. and $117 billion in direct and indirect healthcare costs, according to the U.S. Surgeon General’s Office. Prevalence in children and teenagers tripled in the last three decades, and if these trends continue, it’s projected that 50 percent of Americans will be obese by 2020.

Dr. James Maher

“I often tell my patients that they’re digging their graves with a knife and a fork,” says Dr. James Maher, co-director of the UI’s Center for Digestive Diseases and the surgeon who performed Prince’s gastric bypass at UI Hospitals and Clinics.

Many people will try anything and everything to lose weight. Increasingly, they turn to the operating room for answers. The American Society for Bariatric Surgery estimates that more than 100,000 people will have a gastric bypass this year, up from 63,000 just two years ago. These patients—including celebrities such as singer Carnie Wilson, Today show weatherman Al Roker, and record producer Randy Jackson—generally lose two-thirds of their excess weight within a year, regaining only an average ten to 20 pounds after ten years.

Perhaps less well-known than the famous faces behind gastric bypass is the fact that the surgery has its origins at the UI. It is here that Dr. Edward Mason, 43BA, 45MD, professor emeritus of surgery, first invented the procedure and began performing it in 1966. Considered the “father of obesity surgery,” Mason developed the gastric bypass as an extension of his work with the surgical treatment of stomach ulcers and cancers. Not only did he help create the American Society for Bariatric Surgery, he was also instrumental in organizing the International Bariatric Surgery Registry, a database of more than 40,000 patients that he continues to direct.

Dr. Edward Mason

“We began using surgical operations in the treatment of obesity with the belief that the risk of an operation was less than the risk of the disease,” Mason says. “This has proven to be true in general, but there will always be room for improvement. Our worldwide goal should be the elimination of the need for obesity surgery. In the meantime, we should save as many lives as possible—and in a way that makes life worth living.”

Up until a few years ago, Prince opposed gastric bypass surgery. She felt it was too outrageous, that perhaps it would endanger her life. Then, in September 2002, an endocrinologist recommended that she consider the procedure—if she ever wanted to have children, but mostly if she wanted to live a long life. “I was convinced I’d die young,” Prince admits. She’d tried every diet and weight loss program imaginable. Nothing worked.

While many people fail at diets, not just anyone battling a weight problem can stroll into a hospital and request a gastric bypass. The procedure is reserved for the morbidly obese—people who are 100 pounds overweight or whose Body Mass Index (also known as BMI, a height-weight calculation) is 40 and has stayed that way for at least three years (see sidebar for details on how to calculate your BMI). Other potential candidates are those with a BMI of more than 35 who also suffer from obesity-related complications such as diabetes, sleep apnea, or high blood pressure. They must present documentation from their physicians testifying that they’ve exhausted all other weight loss measures without success. Other than their obesity and its accompanying problems, patients should exhibit good general health and be prepared to embrace an entirely new lifestyle.

“This surgery offers a great opportunity for health, but it also really alters the way a person lives,” Maher says. “We look for motivated, committed people who will be able to successfully make these changes for a lifetime.”

Laura Prince underwent the common Roux-en-Y operation, illustrated above. During the procedure, surgeons bypass about two feet of the small intestine and reconnect it to a newly-created stomach pouch.

Gastric bypass patients, with stomachs reduced to about the size of an egg, can hold about two ounces of food per meal and must take multivitamins the rest of their lives to supplement their restricted diets. Patients must make sure they consume protein-rich foods and refrain from drinking water before, during, or immediately after meals so the stomach doesn’t get too full—although it’s important that they drink eight glasses of water throughout the day.

When she decided to have the surgery, Prince had prevention in mind—she hadn’t yet developed any health problems from her condition, and she didn’t want to. In April 2003, she met with Maher to discuss her case and begin an eating plan that required her to lose 30 pounds before the surgery. She lost 40. The plan also prepped her for the changes she would have to make in her eating habits and portion sizes after the procedure. “In the cases of those who fail, it’s almost always the way they eat afterward,” Maher explains.

Prince proved a model candidate for gastric bypass. Maher performed minimally invasive laparoscopic surgery, which left Prince with six marks the size of pencil erasers across her abdominal wall that will eventually leave no scars at all. Her recovery thus far has been flawless and complication-free. She tolerates all foods, follows the rules religiously, and exercises seven days a week.

“I didn’t have major surgery to fail at this,” says Prince, whose snacks are three glasses of skim milk a day. “I know I’m in it for the long haul. You have to be dedicated and have self-control. You have to do it for yourself. You have to tell yourself that you are of value. The end result is: you’d like to live longer.”

While Prince is the poster child for positive results, the operation is certainly not without risk. The International Bariatric Surgery Registry estimates that three in 1,000 patients will die within four weeks of weight loss surgery. Complications include ulcers, leaks in the surgical staple line, vomiting, and diarrhea. Iowa Methodist Hospital in Des Moines came under recent scrutiny when six patients died in 2003 after having gastric bypass surgery there. In addition, some surgeons worry that the popularity of the procedure—and its $15,000 to $20,000 pricetag—will influence bad doctors, driven by economic factors, to jump on the bandwagon and offer the surgery without proper training. Maher and Mason, concerned about reports of surgeons who perform the complex operation after only weekend training sessions, strongly recommend that a patient considering gastric bypass ask about the number of operations for obesity a particular surgeon has performed.

“We believe that the operative risk can be held at a very low level and that there can be continued improvement in the safety, efficacy, and quality of life if all dedicated obesity surgeons will join the International Bariatric Surgery Registry and follow their patients for life,” says Mason, who has himself expressed concerns about the long-term effects of altering the normal digestion process. He would like to see greater use of simple mechanisms that do not interfere with a person’s regular absorption of nutrients from food, which can cause anemia and bone disease.

In 1980, Mason began performing a simple stomach stapling surgery called vertical banded gastroplasty (VBG), which does not involve an intestinal bypass, and he has since promoted this and similar procedures as the preferred initial approach to treating obesity. However, more VBG patients struggle to maintain weight loss than those who have gastric bypass. Maher points out that the gastric bypass, of all operations for obesity, appears to afford the greatest results in terms of weight loss, which ultimately clears up the health problems associated with obesity. In 80 percent of cases, Maher says, gastric bypass surgery eliminates diabetes altogether.

The benefits may be alluring, but Prince offers a cautionary note to people who consider gastric bypass the lazy approach to shedding pounds. “It’s not the easy way out. This is not a quick fix. This is a lifelong investment in your health,” she says. “I’m not ashamed to say I had it. I’m trying to live a healthier life.”

Now on her way to achieving her goal weight of 180 pounds, Prince admits that she grieved a bit for her former self. Tears brim when she describes how her father, with kindness behind his words, said he’s going to have to get used to thinking about her as a thin person. And, she still worries about what people think of her—if they are laughing at her or talking behind her back. “[Denigrating obese people] is one of the last acceptable prejudices,” she says. “Society teaches you that you’re worthless, that fat people are stupid and smell bad. People can laugh at you in your face and think it’s OK.”

Slowly, she’s healing those wounds. Letting go of the old Laura was tough, but she’s discovered pride in having a waist for the first time, wearing jeans, and being able to cross her legs. When she steps on the scale now, the dial no longer swings past the maximum weight listed.

Prince looks forward to the day when she just won’t be noticed anymore—except for the person of worth that she is and always has been. “I’m grateful every day that I wake up,” she says. “My experiences have really taught me how to treat people. Every person deserves to be respected. That’s been such a great life lesson for me.”
For us all.

Any comments about this article? E-mail kathryn-howe@uiowa.edu.