Healthier, smaller and normal

Evening News photo By KIM BRENT

The large incision made for the gastric-bypass surgery adequately healed, Tina returns to Dr. Bell's office in a follow-up visit to have staples removed.

Monroe woman finds weight-loss answer in surgery

BY CYNTHIA RAMNARACE
Evening News staff writer

The scar, with its metal staples, ran like a zipper down Tina Kuhnau's stomach. Monroe surgeon William H. Bell had opened up Tina's abdomen to give him access to the digestive system that he would be rerouting.

Prior to weight loss surgery, Tina's stomach and intestines worked just like any other healthy person's. The food she ate traveled down her esophagus and to her stomach, where strong acids broke down the food. A healthy stomach can hold 3 pints.

Food then traveled to the duodenum, the first part of the small intestine, where bile and pancreatic juices speed up digestion and vitamins and minerals such as iron are extracted. The food continues through 20 feet of small intestine, where more nutrients and calories are absorbed into the system. What is not needed is deposited in the large intestine to be released as waste.

Evening News photo By KIM BRENT

The week before her surgery, Tina meets with Dr. Bell to finalize the schedule and talk through any last minute questions.

The surgery, called Roux-en-Y gastric bypass, disrupted this normal flow of food. The procedure essentially slices the stomach in two, creating one small pouch that is attached to the esophagus, and one large one that will never again see food. A smaller stomach can accept less food and makes a person feel full faster.

Next, the intestine is severed at a point past the duodenum. The intestine is then connected directly to this small stomach pouch. By bypassing the first portion of the intestine, fewer calories and nutrients are absorbed. This also aids weight loss.

At 32 and in relatively good health, Tina recovered well from surgery. Her main complaints were bloating, gas and exhaustion from the decrease in nutrients now getting to her body.

For the first week after the Aug. 30, 2002, procedure, the only nourishment to enter Tina's stomach was clear liquids: first water, followed by diluted juices, sugar-free Popsicles and broth. A meal consisted of no more than ½ cup. This vast calorie reduction forces the body to burn fat for fuel.

Evening News photo By KIM BRENT

Tina Kuhnau describes how the weight loss has effected her life not ony physically but socially and emotionally, as well.

"I have a busy lifestyle," Tina, a hair stylist, said before surgery. "There are the kids and sports. I eat a lot of fast food. They're not the best choices. Obesity runs in my family. My mom, my dad, they're not thin."

Tina's fixation with food began as a child. She and her siblings were allowed to eat whatever they wanted and as much as they wanted. Because of this, Tina said, she never learned to only eat when she was hungry and stop when she was full. Instead, she was ruled by something she calls "head hunger." Sliders from White Castle were one of her weaknesses. She might not be hungry, but the idea of one of those greasy burgers sure seemed like a good one. And it was never just one.

Food becomes the enemy

One of the reasons why gastric bypass surgery works is that the very foods that contributed to weight gain are now the ones that will make a person sick if eaten. Consuming sugar and high-fat foods leads to a condition called "dumping" - nausea, weakness, sweating, faintness and diarrhea. People who had the surgery might try to eat a once beloved treat only to find themselves brutally ill. This response helps end the cravings.

After week one, Tina was able to add dairy to her diet in the form of skim milk and plain yogurt. After that came the addition of food, but as a fully liquid diet consisting of as Cream of Wheat, sugar-free pudding and infant strained fruits. That lasts two weeks.

Stage three is the pureed diet, which includes baby food-consistency items such as mashed potatoes, cottage cheese and applesauce. Poultry and fish could be pureed in a blender and added to soups or omelets. One meal could not exceed one cup of food.

Six weeks after surgery, patients move to soft foods, including ground meats, canned fruits and cooked vegetables. Meals continue to be one cup in size.

The experience, and then the fear, of dumping, helped Tina stick to this diet. But it was not easy.

"I've been having the head hunger stuff," Tina said three weeks after surgery. "I've gotten frustrated a couple of times. I can't cook for my kids. Cheeseburgers - that cooking didn't smell very well. But then my son had Jeno's Pizza Rolls for dinner and I could smell them and I wanted them and I thought about the fat and calories and how it would taste in the blender and then I have to smack myself and say stop it, look at what you've been through."

Getting around that feeling that she should eat only because it had been a few hours since her last meal, and not because she was hungry, required a psychological shift. One meal at a restaurant was enough for two or three meals for her and doggy bags became a new, common occurrence.

"When I get full, I have to listen," Tina said.

Picking up on the body's satiety cues is important for weight loss surgery patients. The procedure offers no guarantees. If a person keeps his meals small but continues to eat all day long regardless of whether he is hungry, something called "grazing," the surgery will fail because calorie counts aren't falling. Dr. Bell has seen this happen with a few of his other patients.

"It's a life change," Dr. Bell said. "The biggest thing is that a lot of patients ate for comfort, not hunger. They have to get over that. They can't eat for that purpose anymore."

The changes required by weight loss surgery are not temporary. They last a lifetime if a person wants to maintain his weight loss. People who eat past the point of being full can also "eat through" the surgery, meaning they can stretch the small pouch until it is again the size of a normal stomach. If this happens, it will take more food for a person to feel full. This can happen immediately after surgery, or even several years down the road.

Aside from the fear of gaining weight again, and the fear of being sick, there is a positive motivator: the rapid weight loss. Three weeks after surgery Tina had lost 22 pounds. At nine weeks, she was down by 47 pounds. Most mainstream diets recommend dieters keep weight loss to 1 to 2 pounds a week.

"I get compliments up the ying-yang," Tina said. "They're starting to call me 'Skinny Minnie'."

At nine weeks after surgery, in November, 2002, Tina was wearing a size 22 and fantasizing about being a size 18. She had put on a bathing suit for the first time in 12 years. She also started noticing changes in her personally.

"I've taken down almost all my earrings," she said. "I'm tuning down. I think it's because people are noticing my weight loss, so I don't have to try anymore."

Nine months, 100 pounds

"People ask me, 'Where did the rest of you go?' " Tina said last May. She had lost 104 pounds. She was able to go on walks around her Monroe neighborhood. She was also able to eat more of the foods she was accustomed to, but there were still limitations.

"I don't eat stuff I know will make me sick, like cookies or cake," Tina said. "If I go to White Castle I buy one burger instead of six. But my portion sizes are bigger than they were in the beginning. I go and get a Subway round and can still only eat half of it."

Tina's goal weight is 150 pounds, less than half of her starting weight of 318 pounds. That would put her at a body mass index of 26, which is still considered overweight but is a vast improvement from her BMI at 318 pounds, which was 56. A BMI between 18.5 and 24.5 is considered normal. BMI is a measurement based on height and weight. Tina is 5-foot-3.

To achieve this goal, Tina needed to watch her diet but also start exercising. She and her family went for walks around their Harrison St. neighborhood. Health clubs are not for her, but she was happy to be able to play basketball with her sons and ride a bicycle.

"We walk from Harrison to Union. I used to think wow, are we there yet? But now I want to keep going," Tina said.

Since the surgery, getting up and down stairs has become easier. The boost in energy was startling.

"Yesterday I cleaned my entire house, left here, cleaned the salon and could have come home and done more," she said. "You go, 'I can't believe what I just did. I walked and I could do more.' I couldn't do that a year ago."

With 100 pounds lost, she can fit into a size 16. This means she could shop in what she calls "normal size" stores. And not only for clothes. Her feet have also shrunk, from a size 11 to 10.

The surgery still presented its challenges. There were plateaus, where for weeks the number on the scale did not move at all. But Tina learned to drink more water, decrease her carbohydrates and increase her protein.

Getting past the anxiety of a plateau can be the hardest part.

"Everyone says you'll get through," Tina said. "You think, I hope it didn't quit, that it didn't stop working. Am I going to be stuck here? I'm not where I want to be."

'Fat girl' no longer

Not everyone who has weight loss surgery reaches his or her ideal weight. The American Obesity Association reports that by two years after surgery, most patients have lost two-thirds of their excess weight. After five years, patients report maintaining a weight loss of 60 percent of their initial excess weight.

The last time Tina weighed herself, in February, she weighed 192 pounds for a total weight loss of 126 pounds. She is wearing size 14 pants and would be in something smaller were it not for all the extra skin. It hangs from her arms and flaps along her stomach. When her weight loss has leveled off, she hopes to have plastic surgery to remove it.

Tina has no regrets about having had the surgery, despite experiencing some normal side effects. Half of all gastric bypass patients develop a vitamin B12 deficiency, Dr. Bell said, which leads to anemia and iron deficiency. Tina now has severe anemia and requires weekly transfusions of iron.

At 18 months after surgery, Tina knows the weight loss is tapering off. But she's happy with what she has attained so far. She's more confident. She's returned those piercings to her ears, because she realized they are part of who she is. One of the greatest benefits, however, is knowing that her diet and her efforts to lose weight have made an impact on her children, now 13 and 10.

"My kids - they're bigger kids and they're starting to recognize there might be a situation with themselves," Tina said. "My eldest told me that he wants to work out. He talked about getting a weight machine."

There are foods that she knows will never again be part of her diet, because eating them still makes her sick. Steak sits in her stomach like a rock. She can't digest the skin on the apple, and she has to suck the juice out of oranges rather than eating the fibrous insides. And there are new additions that she never would have thought she'd enjoy. Things like baby spinach greens and cottage cheese.

"I do it now because it's good for me, and it's not too bad," Tina said.

Admittedly, Tina has her moments of impulse eating. She'll eat half of a Big Mac and regret it, visions of 300-pound Tina filling her mind. But mostly she listens to her body.

"If I'm not hungry, I'm not going to put it in my face," she said.

Her kids now call her "skinny." But despite the smaller-sized clothing and the number on the scale, Tina still has her moments when she feels that nothing has changed. But then she adds another notch to her belt, and knows it has.

She has also let herself dream about things that she never could have done at 318 pounds. Tina would like to go back to school to become a paramedic.

"I was so dead-set to be healthier, smaller and normal," she said.

Aside from the iron problem, Tina said she is much healthier. As for normal, she said she feels more part of the general population now.

"I don't feel gawked at," she said. "I just feel like everybody."

And as for smaller, when she can't see it in the mirror herself, she sees it reflected from other people.

"I didn't feel like people were staring at me because I weight 318 pounds," Tina said. "It's because I'm an attractive woman."

Surgery has limits, risks

Weight loss surgery is not for everyone. It is reserved for the morbidly obese who have a body mass index above 40 or who are more than 100 pounds overweight.

And as with any surgery, it has its risks. According to the National Institute of Diabetes and Digestive and Kidney Diseases, 10 to 20 percent of patients require follow-up surgery to correct complications. The most common problem is abdominal hernia.

Patients also have an increased likelihood of developing gallstones. Thirty percent of patients develop nutritional deficiencies, such as anemia, osteoporosis and metabolic bone disease. Women of childbearing age should avoid pregnancy until their weight becomes stable because the rapid weight loss and nutritional deficiencies can affect the fetus.

While the death rate with the procedure is low, reports the American Society for Bariatric Surgery (ASBS), death does occur. Most common causes are infection, gastrointestinal leaks, ulcers, pulmonary embolism and respiratory or cardiac arrest. In an ASBS study of nearly 11,000 patients who had the procedure done, the death rate within 30 days was .3 percent and complication rate 2.7 percent.

Tina Kuhnau of Monroe had her operation performed at Mercy Memorial Hospital in August, 2002. In January, 2003, the hospital abruptly stopped doing the procedure after severe complications experienced by one of the gastric bypass patients. That patient died six months later.

At the time, MMH said it was re-evaluating the procedure due to its "high risk." The hospital has since decided to cease the program permanently.

The reasons for canceling the procedure were based on logistics, said hospital spokesperson Kathleen Russeau.

"Our beds in the general bed population were not wide enough to even handle that population," she said.

Beds, wheelchairs and rooms would have to be made larger to accommodate patients in the 600- and 700-pound range, she said. Investing in those types of improvements was not financially feasible for the hospital. Imposing weight limits on who could be operated on could be seen as discriminatory to those who are heavier, Ms. Russeau said.

There are other hospitals and treatment centers in Michigan that offer the procedure. The Centers for Obesity Related Illnesses has offices in Jackson, Macomb, Garden City and Warren. Bariatric Treatment Centers can be found in Ypsilanti and Liv-Lite runs a program at Bi-County Community Hospital in Warren.