'The Hungry Gene'

Journalist: Obesity A Critical Global Issue

(CBS)  Journalist Ellen Ruppel Shell tells The Early Show that her new book takes a look at obesity and the historical, political, economic and human toll it has taken.

“The Hungry Gene” takes readers behind the scenes of the food industry, academia and the government, because they are all linked, in some way, by fat. And, Shell writes in her book that obesity is expanding off the United States’ borders and into developing countries.

In her book, Shell makes clear that she is not talking of being slightly overweight, but obese with health problems. She says a combination of vulnerable genes combined with a hostile environment have caused a critical surge in obesity.

Shell lays out the problem of obesity, but she also proposes solutions.

Read an excerpt from Chapter One:

A Weariness of Eating

If you examine a man who suffers from his stomach. All his limbs are heavy. You find his stomach is dragging. It goes and comes under your fingers. Then you shall say concerning him: this is a weariness of eating.

—The Egyptian Book of the Stomach

The first time I set eyes on Nancy Wright, she is flat on her back and cruciate. She is vaguely pretty, her eyes frightened but oddly beguiling. Her thick hair is loose and wavy, auburn with a sly touch of gray at the temples. You can see what some men see in her, and also, perhaps, why two husbands have come and gone. Even as she lies splayed and sedated on a gurney in Operating Room 17 at Beth Israel Deaconess Medical Center in Boston, you can sense that Nancy Wright is possessed of an immutable will.

Nancy once told me that she'd started out life large and kept on going. She didn't mean it as a joke. She weighed ten pounds, four ounces when she came into this world, and through childhood ate herself so big that her father thought she had psychological problems. Nancy didn't see it that way, but she did know that her relationship with food was tempestuous, like a doomed love affair. 'Food has always been my best friend and worst enemy rolled into one,' she told me. Now, in middle age, this dysfunctional relationship has made even simple pleasures difficult. It is getting harder for her to work in her flower garden, harder to play with her five grandchildren. And she keeps getting sick. She has hypertension, high blood cholesterol, and sleep apnea. She hates being so tired all the time, and so feeble, and she has done everything she can think of to fight it. She has tried Weight Watchers, Jenny Craig, and diet pills. All of these worked, for a while. The pounds melted away, and Nancy thought she'd found salvation. She'd buy new clothes and start making plans for a new life. But then, without knowing why, she'd fall off the wagon, and her old life would rush back. It was like waking up to a nightmare.

People tell Nancy she lacks willpower, but they are wrong. She has plenty. She stayed with the same thankless social services job for twenty years. She stayed with the same thankless husband for nineteen. And as a fiftieth birthday present to herself, she quit smoking. She hasn't touched a cigarette in four years, and doesn't plan to touch one ever again. But food is another matter. 'You can live without cigarettes,' she said, 'but you have to eat.'

It all comes down to a balance of power—or, rather, to an imbalance. Nancy can no more tame her compulsion to eat than a marooned sailor can tame his thirst. For Nancy, food is more than an addiction, it is like breathing—a constant, throbbing need.

Dr. Edward Mun understands all this perfectly. Mun is an assistant professor of surgery at Harvard Medical School, and an attending surgeon at Beth Israel Deaconess Medical Center. At thirty-eight he has the self-assured manner and polished good looks of a man born to take charge. But beneath the Ivy League veneer and the designer suit lie hints of a nerdy immigrant boy, a gawky overeager kid who spent his summers squinting through a microscope at science camp rather than hanging out at Little League with his pals. Like Nancy, Ed Mun hasn't always fit in. He was born in Korea and grew up in Gardena, California, the son of restaurant owners who expected much more of their boy than they themselves had managed to achieve. Young Ed did not disappoint; he was the model of the good Asian son. He aced high school, enrolled in Yale University, and graduated in four years with both bachelor's and master's degrees in biochemistry. He further distinguished himself at Harvard Medical School, and nabbed a coveted surgical residency in sunny San Diego. Surgery offered the most money, the most prestige, and the greatest opportunity to perform technically interesting procedures. But Mun wanted more.

'I wanted neurosurgery because I thought it was only for the talented few,' he said. 'But the truth is that there aren't that many brain operations. Neurosurgeons do herniated disks and trauma cases. Mostly, it's boring.'

So Mun returned to Boston, to Harvard, and to Beth Israel Deaconess Hospital, to apprentice in general surgery. He removed breast cancers and performed stomach surgery. To his great relief, he didn't find this boring at all. But he did find it frustrating. Breast cancer patients had the habit of scrutinizing the Internet for facts about their disease and hauling reams of downloaded information to his office for review. Mun didn't like the messiness of that, the presumptuousness. Breast cancer, he says, is usually a matter of small incisions and quick recoveries. Yet the patients would piss and moan and demand second opinions. He didn't mind the second opinions, of course, but he did mind being put through the third degree. And he blanched at their sense of entitlement. These women were hot reactors, the sort of patients who required more assurance than he had to offer.

But the stomach was something else altogether. He liked the feel of it, the hard muscularity of the thing. And he liked that stomach patients trusted him, put themselves in his hands. They didn't ask a lot of extraneous questions, didn't expect miracles. He found stomach surgery enthralling, so much so that one would think he had some sort of a belly fetish. But it was nothing like that.

'In Japan and in Korea, tens of thousands of people die from stomach cancer every year,' he said. 'I also lost several relatives to this disease.'

In Korea stomach surgeons are held in the highest esteem. Among these masters was Mun's paternal grandfather, the man in whose steps young Ed was meant to follow. Mun very much wanted to be like his grandfather, and to earn the respect of his demanding parents. So he studied and worked until he became one of the best stomach surgeons at Beth Israel Deaconess Medical Center, which is to say one of the best in the country, and perhaps in the world. But unlike his grandfather, Mun doesn't open many bellies to remove cancerous lesions or to repair ulcers. What Mun does mostly is something very few Korean surgeons—and only a few American surgeons—have ever done or would ever dream of doing. What Mun does is to take perfectly healthy stomachs and replumb them, cutting them loose from their natural moorings at the end of the esophagus and fashioning them into pouches the size of robin's eggs. This procedure, which generally takes Mun about ninety minutes but most other surgeons much longer, is called a Roux-en-Y gastric bypass.

Stomach surgery is a pretty rough ride. People who get their guts whittled and rearranged in this way can't eat much for weeks afterwards, certainly not nearly as much as they did before the change. If for some reason they succumb to the temptation to eat more than the little that their stomach can hold, they vomit. Vomiting is not really a complication of gastric bypass surgery; it is an expected and important side effect.

Gastric bypass patients sometimes lose so much weight that old friends and relatives barely recognize them. The surgery is reserved for those with one hundred or more pounds to lose. On average, patients shed about 60 percent of their excess weight in about eighteen months. It is hard to imagine many people in Korea being interested in such an operation. But in 2000, the year I met Mun, forty thousand Americans underwent gastric bypass surgery, about double the number performed only five years earlier. That number was expected to nearly double again by 2003. Mun doesn't find these figures the least surprising; he knows many people require his services. In Boston his dance card is full. And Nancy is next in line.

* * *

Nancy is five feet three inches tall and, at the time of her operation, weighs 274 pounds. Her BMI is 48.5, well into the morbidly obese range and she thinks she would feel and look much better if she were one hundred pounds or more lighter. She has seen what gastric bypass surgery can do for people: two of her coworkers have been transformed by the procedure, and a year ago her youngest daughter underwent the surgery and dropped ninety pounds. It was her daughter especially who convinced Nancy to give surgery a go, not so much with her words, but by her example. Both mother and daughter, Nancy said, are stubborn as mules. She figures that if gastric bypass worked for her daughter, it will work just as well for her.

Mun doesn't know Nancy is stubborn, but he does know that she is an especially good candidate for obesity surgery. For one thing, she is in relatively good health, without the horrific complications suffered by so many of the morbidly obese. For another, she is relatively small. A man of Mun's experience might well see Nancy that way. The hospital bed waiting outside his operating room is a 'Big Boy,' built to hold up to five hundred pounds. Sometimes it takes two Big Boys pushed side by side to hold
one of Mun's gastric bypass patients. Mun remembers a seven-hundred-pounder whom he envisioned falling on him and crushing him to death. Nancy evokes no such grim images. There will be room to spare on her Big Boy.

Still, Mun has not promised Nancy success, or even survival. Gastric bypass kills one out of a hundred patients on the operating table, and not everyone recovers from its complications. There are few controlled studies of the procedure, so no one can speak with authority on its degree of danger. Still, the insurance industry classifies it as 'high risk.' The anesthesiologist on duty warns that corpulent patients are tricky, and that Nancy is no exception. Nancy's veins are buried in a thick layer of fat, making it hard for a needle to find purchase. Like many obese people, her tongue is large and her neck short, making it difficult to guide a breathing tube down her windpipe. It takes a bevy of nurses and doctors several attempts to finagle each of these maneuvers, and with every attempt it looks like Nancy will choke or cry. But she doesn't, and with time and effort the requisite tubes and needles get coaxed and jabbed into place. Nancy's eyes flutter and close and the anesthesiologist tapes them shut to prevent the corneas from drying out. Paralyzed from the anesthesia, Nancy draws her breath by machine. Plastic shrouds her face, presumably to shield wayward gore. She emanates fewer signs of life than do the machines to which she is tethered.

Mun helps the nurses arrange the layers of sterile drape, leaving exposed a rectangle of stark white skin roughly the area of a shoe box lid, size ten. He paints the rectangle orange with antiseptic. The flesh ripples thickly, like a crème brûlée. Mun grabs a black ballpoint pen and traces down the center line, a little shaky at first, then more or less finding the line he is after, about an eight-inch stretch from the tip of the breastbone to the navel. Seble Gabre-Madhin, a surgical resident, accepts a cauterizing scalpel from a nurse and traces over that line again and again until the skin bursts open with the force of the fat beneath. An observing medical student startles. It's not the sight that makes him queasy, he whispers, it is the smell, which is savory, like hamburgers spitting on a grill. The translucent fat layer glistens yellow under the operating room lights. The attending nurses hover. Drs. Gabre-Madhin and Mun exchange looks, then press two palms each on either side of the neatly split skin and ease the fat apart, forming a canyon. The walls of the canyon are slippery and lightly variegated with red blood vessels. There is almost no blood.

In The Wisdom of the Body, Sherwin B. Nuland, a clinical professor of surgery at Yale University, writes that the stomach is best understood 'seen as a large bag near the upper end of what is otherwise a hollow muscular tube some twenty-five feet long from mouth to anus, the central portion of which is coiled up in the abdomen.' This tube is the gut, and from stem to stern it comprises the pharynx, the esophagus, the stomach, the small intestine, the large intestine (or colon), and the rectum. The gut has an inner and outer layer of muscle, and the stomach has yet a third, to aid in its tireless churning of food.

The muscles and fibrous layers covering both sides of the stomach wall meet and fuse together in the middle of the belly, forming the linea alba, a stout ribbon of tissue stretching from the breastbone to the pubis. Mun deftly splits this, exposing the well-packed contents of the abdominal cavity, the largest orifice in the human body. Nurses position a gray metal circular retractor to hold back the skin and flab. The crater yawns jagged and raw. Mun pulls a glutinous apron of fat and blood vessels outside the wound, and lays it to one side of the torso. The mess on the surgical sheet is ghastly, like a mangled tongue lolling from the mouth of a drunk.

Mun plays archaeologist, pointing out artifacts as he excavates. Plunging his hand into the cavity, he locates the expected umbilical hernia, a weakness in the muscle near the belly button that is common in the obese. Wrist deep, he palpates the taut purple liver. He had mentioned earlier that the livers of the obese can grow monstrous—'sometimes,' he told me, 'they are as big as a horse's liver.' This liver, thank goodness, is not Clydesdale-sized. Mun gently retracts it to examine the junction between the stomach and the esophagus. He is now elbow deep, pawing blind for the start of the stomach. Long seconds pass, and Mun's brow arches in concentration. No one says a word. This is a tricky business, and even the assisting surgeon, a stout, world-weary young woman, seems to hold her breath.

Suddenly, Mun finds what he's after. He stops for a moment and looks back at me, triumphant in his sterile mask and lightly fogged glasses.

'I love this organ,' he says, pulling the stomach into glorious view.

Bariatric surgery, as obesity surgery is called, has a controversial history dating back hundreds of years. But the first modern procedure on record was in 1889, performed by Howard A. Kelly, a founding member of the faculty at Johns Hopkins University and its first professor of obstetrics. Kelly was an inventive surgeon and developed numerous surgical devices as well as innovative operative procedures. He seems to have fancied himself quite a sculptor, for he carved layers of fat from the abdomens of unwitting patients while they were under the knife for other problems.

Over the next few decades, reports of similar adventures trickled in from France, Germany, and Russia, and by the early 1920s, obesity surgery had become, if not fashionable, at least less ignominious. Not all obesity surgery patients died from massive infection or blood loss, but enough did that eventually it became clear to most respectable surgeons that slicing large quantities of fat from human bodies was not necessarily the safe and sure approach to treating the overweight that enthusiasts had claimed.

By the mid-twentieth century, obesity surgery had fallen out of favor with all but a few die-hard zealots. George Blackburn was not one of these. Blackburn is a surgeon, and is now director of the Center for the Study of Nutrition and Medicine at Beth Israel Deaconess Medical Center, where Edward Mun works. He is of medium height and robust, with stark white hair cropped into a schoolboy fringe. When we meet he radiates the sort of deep, smoky tan that comes from riding shotgun on a golf cart. There is no telling whether Blackburn plays golf, but I later learn that he gave up performing surgery years ago. He remains a darling on the obesity circuit, however, lecturing at conferences, consulting with industry, and sitting on boards and committees.

Like Mun, Blackburn trained at Harvard as a general surgeon. Like Mun, as a young man he developed a special interest in the stomach and in disorders of the gastrointestinal tract, such as ulcers. He cultivated this interest in the early 1960s, when doctors were not yet aware that ulcers are frequently caused by bacteria and treatable with antibiotics. Back then, dietary changes were the most common ulcer palliative, followed by surgical treatment. Surgery for severe ulcers usually involved removal of part or all of the stomach. It is possible to live and even to thrive without a stomach by eating many small meals and taking daily vitamin injections. Still, a hefty percentage of ulcer patients died of postoperative bleeding, infection, and sometimes starvation. Starvation was also a problem for trauma patients and for patients who lost their appetites after surgery. Blackburn got interested in this problem and decided to make it a subject of study in the early 1970s. To study it, he needed to experiment, and to experiment, he needed people who were willing to starve. He put ads in the Boston newspapers, assuming that he would get little if any response. 'I was overwhelmed by the number of people who volunteered,' he says. 'Stunned.'

Even more stunning than the number of volunteers was their size. Most were overweight or obese. Blackburn had very little experience with obese patients, and he was unfamiliar with their ways. He assumed, as did most doctors at the time, that fat people were too gluttonous to forgo a single meal, let alone subject themselves to weeks without food. But the overweight and obese volunteers were more than happy to starve. And they didn't cheat. They faithfully followed Blackburn's orders, eating only very small amounts of fish, fowl, or meat to keep up their protein levels to maintain as much muscle mass as possible. A month and a half later, they were many pounds lighter, and surprisingly healthy. Thanks to the 'protein sparing' regimen, they showed no signs of the muscle wasting or dehydration usually associated with starvation regimens. That was all Blackburn needed to know, and he thanked the volunteers and told them it was time to leave. But he recalls that many—maybe most—begged to stay. 'They would do anything to lose weight,' he says. 'And I mean anything.'

Blackburn was a surgeon, not an endocrinologist, and he saw the plight of these patients through a surgeon's eyes. He was intrigued and moved by their pleas, but he had observed obesity surgery as a resident, and he hadn't liked what he'd seen. True, it had gone beyond the nineteenth-century 'slice and dice,' but to his way of thinking it hadn't gone far enough. The technique of choice at that time was the jejunoileal bypass, in which the intestine was essentially short-circuited to allow most of what the patients ate to slip through unnoticed and unabsorbed by the gut. This method was fairly effective, but the side effects—infection, protein malnutrition, kidney stones, osteoporosis, anemia, and liver failure—were unpredictable and occasionally fatal. 'Some people would rather die than be fat,' Blackburn says. And some doctors colluded in the gamble. About 100,000 intestinal bypasses were performed in the 1960s and early 1970s. Still, the high failure and mortality rates of intestinal bypass were troubling, and Blackburn chose to stay clear of the procedure.

There were other more benign approaches to consider—jaw wiring, for example. Jaw wiring is exactly as it sounds, something Wile E. Coyote might cook up for the Road Runner. As described in the British medical journal, The Lancet, the wiring procedure was simple enough: 'Two interdental eyelets were placed in each canine and pre-molar region under local anaesthetic and the eyelets on opposing jaws wired together. Instruction was given on oral hygiene, measures to avoid aspiration, and the use of wire cutters.' These 'instructions' notwithstanding, expressing oneself through bound jaws was a trial, as was brushing one's teeth or eating anything that could not be slurped through a straw. And vomiting while wired could be lethal. (That is, if one somehow forgot to bring one's wire cutters to an office picnic.) Accidents—and deaths—did occur. And those who endured the recommended six months were horrified to find their weight soar when their jaws—and their appetites—were unleashed. Some physicians tried to stave off this rebound by prescribing a waist cord—a nylon strap tied tightly around the middle of slimmed patients that would remind them to eat sparingly. But most patients did not allow mere nylon to come between them and their calories, and either cut the dreaded things off or allowed themselves to balloon into giant hourglasses, with the waist cord strangling their middles like a noose. Clearly, when it came to weight loss, bondage was not the answer.

A more elaborate and certainly more imaginative scheme was the intragastric balloon, threaded into the stomach and blown up to crowd out the space for food. Stomach balloons carried a sort of whimsical allure: what could be more benign than a whisper of latex pumped with air? But the procedure was surprisingly expensive and not particularly effective. It was also dangerous, causing ulcers and erosion of the stomach lining. In 1988 a prominent physician decried the practice as 'balloonacy' in an article in the journal Gastroenterology. Surgeons of the time were also experimenting with esophageal banding—inspired, perhaps, by the picturesque cormorant fishers of Japan. Cormorant fishing, or ukai, involves binding the necks of tame cormorants and setting them free to scoop sweetfish from the Nagara River. The birds are then called back or hauled in by their keepers and the fish extracted from halfway down their gullets. Esophageal banding has worked well for generations of fishermen in Japan, where the sport has become something of a tourist attraction. But it enjoyed only a short run in humans, who developed severe and sometimes fatal infections of the esophagus from the binding, and in any case had a greater tendency than birds to complain about fish getting stuck in their throats.

These and other disappointments prompted obesity surgeons to reconsider their options. Should they perhaps return to the stomach as a primary target? After all, the stomach's day job is churning great wads of stuff in a vat of acid, so it is accustomed to rough treatment and less prone to injury than are other more delicate organs. Also, at least theoretically, shrinking the stomach directly limited the amount of space available for food. And for many people a smaller stomach demanded less food than did a larger one. As explained by Columbia University College of Physicians & Surgeons professor Michael D. Gershon, author of an ode to the digestive tract, The Second Brain, when the stomach is full, receptors that respond both to pressure and to nutrients put a signaling system in motion to stop eating. A smaller stomach brings this pressure to bear more quickly. By shrinking the stomach, surgeons discovered that they could curb not only the intake of food, but also, in a surprising number of cases, the desire for food.

Excerpted from The Hungry Gene: The Science of Fat and the Future of Thin

© Copyright 2002 by Ellen Ruppel Shell. Reprinted with permission from Grove Atlantic, Inc. All rights reserved.