It was 4 p.m., and Labonita “Love” Monk had yet to eat that day, despite being surrounded by food. “What time is it?” she asked, looking around the Jonathan Edwards College dining hall, where she works. She had only taken sips of water. Monk wasn’t worried, though.
Since her 2003 gastric bypass at St. Mary’s Hospital, a Yale-affiliated hospital in Waterbury, she was only hungry for one meal a day. “What they did was, they took half my stomach away,” she said matter-of-factly. And she wasn’t wrong.
Monk takes pride in her weight-loss photos. While looking for a before shot, she confessed to me she had gotten “big” because, after she gave birth to her two now-adult sons, she “ate constantly” and “indulged in food.” Bariatric surgeons like to display before and after photos too.
When Monk finally found her before picture, she is drawn to it. “You can see how big my face was,” she points. But often, in the surgeon’s versions, the patients don’t have heads. Instead, their obese bodies fill the image. As the after photos reveal, the goal of any bariatric surgery is reduction: reducing the stomach, which in turn reduces weight, which in turn reduces the occurrence of Type 2 diabetes and other health problems.
Or at least that’s the message Yale New Haven Hospital pushes. Making the stomach smaller is supposed to make patients thinner by forcing them to eat less and resetting their metabolism through hormonal changes.
But is reducing the stomach to the size of an egg really improving patients’ health? A vocal minority would argue no. It merely hides larger bodies from a society that is too prejudiced to accept them. The risks are not only societal: Many studies show that bariatric surgery patients are at increased risk of gastrointestinal problems, depression and death. Still, as the surgery becomes less invasive and more frequently covered by insurance plans, more patients are opting to go under the knife.
After Monk underwent surgery in 2003, she had 38 staples in her chest and couldn’t go back to work for four and a half months. But today, the surgery is most often done laparoscopically, or using small incisions and a tiny camera. Dr. Andrew Duffy was fascinated by the procedure and the challenges of operating on obese patients. Starting out as a minimally invasive gastrointestinal surgeon, he now directs bariatric and metabolic surgery at Yale New Haven Health System, the largest health care system in Connecticut. Last year, the system’s five gastrointestinal surgeons treated about 650 patients — triple the number from three years ago.
Though these surgeries generally net $60,000 to $80,000 and represent a large portion of income for gastrointestinal surgery practices, Duffy’s Temple Street office was unremarkable. The building was beige and the waiting room drab. While Monk’s treatment at St. Mary’s was covered by her employer, Yale New Haven Hospital accepts Medicare and Medicaid for the surgery, both of which have covered the procedure since 2005.
Gastric bypass, the surgery that Monk underwent, is the most drastic type of bariatric surgery, but Duffy, a soft-spoken middle-aged man who sported a tie with autumn leaves, thinks it is also the most successful at inducing weight loss. All types of gastric bypass divide the stomach into two, creating a new, smaller stomach.
For a laparoscopic gastric bypass, Duffy operates through trocars, or thick metal needles that allow him to slide his tools into the stomach. Passing through the custard-yellow fat, lifting up the beet-red liver, Duffy reaches the pale pink stomach.
The first step reduces the total volume of the stomach to no more than three or four tablespoons by stapling the top of the stomach. This cuts the top off from the lower part. The edges of the new, smaller stomach now look like half of a zipper. The bottom of the stomach, while cut off from food, will still be supplied blood and secrete stomach juices into the small intestine. The small intestine is connected to the smaller stomach by burning a hole in the stomach lining and suturing around the seam.
The patient loses weight for up to a year after the procedure — and not just because the stomach can hold less food. The decreased surface area of the stomach and the small intestine change the hormonal makeup of the body. For instance, the surgery reduces cells called ghrelins, hormones that stimulate food intake and weight gain, by 90 percent. And, on top of that, the restricted surface area can absorb fewer nutrients.
“The patients can still get all their nutrients,” Duffy said, so long as “they’re on nutrient supplements for life.” Vitamin B12, calcium, zinc, iron and vitamin D deficiencies are the most common.
Linda Bacon, a professor of nutrition at the University of California, Davis worries for these patients. She is a leader in the Health at Every Size movement, which seeks to separate weight from health. Instead, she argued, doctors should focus on getting patients to eat healthfully and exercise, regardless of body type. As for bariatric surgeons, she thinks they should be honest that they are damaging “a previously healthy organ so that it can’t do its job.”
In many ways, Bacon is the opposite of Duffy. She is from Berkeley, California, bakes her own granola and asked to be called “Lindo.” She first encountered Health at Every Size because of her own challenges with body image. Skeptics who have not met her often assume that she herself is large, but she’s not. She disagrees with the fundamental idea that there is an ideal healthy weight.
Her methodology is, if anything, more data-based than current nutritional medicine. She is unsatisfied with the “common sense” approach to fat. While doing meta-analyses on previous studies and conducting her own research, she found that, once she controlled for health factors like diet, exercise and socioeconomic status, increased rates of disease almost or totally disappear. Studies have shown that obesity is instead correlated with higher survival rates amongst people with diseases including Type 2 diabetes, hypertension, cardiovascular disease and chronic kidney disease and that “obese” senior citizens live longer than thin senior citizens. This currently unexplained phenomenon is called the “obesity paradox.”
Monk never heard this story from her doctors. Now 50 years old, she believes her weight loss will help her live longer. She could not fathom a health philosophy that, like Health at Every Size, didn’t see larger bodies as unhealthy. Instead, she acknowledged only that people with willpower can lose weight on their own. “If a person wants to lose weight, they’re going to lose weight.”
Monk’s thoughts mirror Duffy’s language. However, Duffy added that poor self-control and exercise are only part of the picture. There are “genetic issues, a lot of behavioral, psychosocial issues” and a pattern of coping with stress by eating. He proudly displayed a framed article on his office wall about the center at Yale New Haven’s St. Raphael Campus, which opened a bariatric center in 2016 that offers extra-large chairs, hallways, beds and equipment to help safely lift obese patients. The article boasted that the staff was trained in fat suits to practice sensitivity.
Duffy does agree with Bacon that dieting is ineffective. Only 5 percent of people over their “target” weights, he believes, lose weight by dieting. The rest go through “weight cycles.” Their weight drops at first, but eventually their metabolism slows and their weight goes back to where they started.
But Duffy said that the surgery, by changing the hormone balance, can reset the metabolism. When Duffy spoke of why patients fail to lose weight from bariatric surgery, have side effects or do not recover from diabetes, he said that it all came down to the patient not following the diet and exercise plan. Duffy acknowledged that as high as 20 percent of patients gain back all of their weight because, “invariably, they didn’t stick to the diet.”
Having surgery was Monk’s own idea. Since she had kids, she had been trying to lose weight using pills, Weight Watchers and Lean Cuisines. Because of her epileptic seizures, scoliosis and asthma, her family doctor was adamant that she lose weight. She found out that AT&T, her employer at the time, had added the surgery to its employee insurance plan. Monk was intrigued. Could this be the solution she’d been looking for?
Bacon has compassion for people who choose to get the surgery. “To get the message all the time that there’s something wrong with you, I understand why someone wants to escape that pain,” she said. But doctors often only want to talk about weight loss and not the larger picture of health outcomes. The private weight loss industry, which rakes in $58.6 billion annually, does not help the information war.
As a result, giving up on weight loss is hard for people to accept. When Bacon performed her first study at UC Davis, half of the women were in the “control” group, which lacked any diet and instead followed the Health at Every Size program. Bacon recalled that the women in the control group were visibly disappointed. “If they could have walked out then, I think they would have.”
But the women on the diet eventually regained the weight they lost, while the Health at Every Size group instead showed improved physical health, self-esteem and relationships with food. As one of the Health at Every Size participants said after the study, “I know that everything I want in life is available to me now, not 20 pounds from now.”
Bacon explained the weight-cycle phenomenon as a reaction to the low calorie intake of most diets. The body thinks it is famished, which causes the metabolism to slow down. Bariatric surgery, Bacon noted, may follow weight-gain pattern, but long-term data is not available right now. She argued that everyone has a “set point,” or a normal body weight, which correlates to a healthy diet and exercise rather than body mass index.
Duffy said that he thinks the current longest bariatric surgery studies are five years long. But Bacon found that in dieting studies, patients regained the most weight in 10 years.
The fundamental difference between these two camps is perhaps most obvious when looking at the surgery’s adverse effects. Monk was one of the 15 percent of patients that did not experience dumping syndrome after surgery. If a patient with dumping syndrome eats too much, she vomits. If she eats sugary or fatty foods, she gets diarrhea. Duffy explained that, if the patient gets a spike in sugar, “the body says ‘Whoops, missed that one,’” and the patient experiences a spike in heart rate, sweats and diarrhea for a couple hours afterward — “for their trouble,” he said, adding that it’s “usually not very pleasant.” All of this causes patients to ask themselves, “‘What did I just do?’”
As Duffy explained it, dumping syndrome is not a side effect but an intentional safeguard that helps patients stay successful. He attributed patients’ adverse reactions to meat and dairy projects to the same cause.
In Bacon’s view, doctors need to start “taking responsibility” instead of “blaming patients when they start to show the signs of malnutrition.” The most telling data, she said, is what’s not being published. The full story is hidden when “people are ashamed to talk about all of the ways in which the surgery hasn’t been successful for them” because they’ve been told that the only important outcome is whether or not they lose weight.
But to Monk, losing weight was the main goal. When she finally found the before photo she was looking for, she pointed out her face to me. She nodded her head, as if agreeing with her doctor. “I was big,” she said.
Duffy hears his patients’ desperation, which is why he’s a “true believer” in the procedure he performs. He knows that there is fat prejudice; he sees discrimination in airline seats, job interviews and in his patients’ stories. He loves his job because he believes the surgery gives people a new start.
Monk switched back and forth.
“I do not regret getting the surgery,” she said, because it changed her life and body image. And yet it “messed with her mind,” she continued, saying that she required therapy, which is consistent with research showing increased rates of depression following the surgery — not all that surprising given the quick change in hormone levels. Duffy thinks that every patient is different but that the group that gets the surgery tends to have a lot of “psychobehavioral issues.”
And at one point Monk even told me that she “wouldn’t recommend the surgery” to anyone. Studies have found a seven-fold increase in the death rate of patients in the first year after the surgery — that is, they are seven times more likely to die than other people within the same BMI range and age group.
Bacon was clear that she wanted to “honor the experiences” of patients who opt to get the surgery. She understands their vulnerable position, the “lies” that they are fed and the hope that they feel looking at possible outcomes. But she said that she wishes doctors would pay more attention to the anecdotal stories not being captured by researchers because what we will find when we listen is “really, really depressing.”
Perhaps the most telling part of Monk’s story is not hers at all. When she worked at AT&T, she had four friends who got the surgery with her. She went first, outside the Yale system at St. Mary’s, and her friends followed months later at St. Raphael. Two of them are still dealing with gastrointestinal complications. One of them is involved in a lawsuit. And the other two died. Monk did not know how or why, only that one died in surgery and the other immediately after. For these two friends, there were no after photos to show.