How to lose your appetite, 90 per cent of your stomach and 80kg
Between the gobsmacking "before" and the barely-less gobsmacking "after", Nat How, a 30-year-old truckdriver of Otara, Auckland, lost his appetite and 90% of his stomach capacity. In a 90-minute, $15,000 operation in Manukau's SuperClinic, surgeon Richard Babor stapled and snipped How's stomach down from a 1.5-litre pouch to a thin tube the size and shape of a penlight, which can hold only 150ml. One year on from the operation, How is still learning how to use his re-tuned digestive system.
For the first nine weeks he ate blended food only. Once back on solids he celebrated with a tiny bite of steak – which he used to eat in ½-kilo servings every Saturday – and instantly knew he'd made a terrible mistake. He could feel it forcing its indigestible way down his gullet and knew after 10 minutes of nausea it would come back up the same way, and it did.
Everything he eats must be tender and well-cooked. He avoids potatoes, rice and pasta as they swell up in the stomach. Bread's off. He has a new love of soup, lean chicken and protein bars. Food was a huge part of his day, but he has no regrets about farewelling most of his old diet, though it can be a bit galling when "you go to a restaurant and pay $30 to eat nothing".
Back when he was still drinking Powerade, How weighed 188kg and had a body-mass index (BMI) of 65. Over 30 is "obese"; over 40 "morbidly obese; How's score put him in the rarefied category of "super super obese" and it was killing him. He was lethargic – far too tired to play with his stepdaughters. He was too wide for most of the rides at Rainbow's End. His sleep apnoea was so severe he risked losing the licence he needed to drive a road-maintenance truck for Auckland Traffic. His head hurt. One day a vein in his leg spontaneously ruptured covering the shower in blood.
He was angry he'd let himself get so big. Sometimes he'd just go sit in his garage, where there are some sofas and a little bar, and brood, surrounded by the many trophies from when he was a teenager with a promising sports career ahead of him.
Now, though, he's down to 112kg and hopeful of getting it down to 100kg at the gym. You'd hardly call him skin and bone but he's shed as much as some men weigh and it's made him a new man. His energy's back. Sleeps fine. The other day he went to Rainbows End and had a great time.
LUCKY TO BE ILL
In a way How was lucky his weight made him so ill. Babor says there are an estimated 30,000 people in the Manukau Super Clinic's catchment who are "morbidly obese" (ie high enough to cause significant medical problems). Many might benefit from an operation yet only 400 a year are referred and of those the clinic operates on 155, around half of all the public operations done nationwide. Another 700-odd operations a year are done privately.
So there's rationing, "and we try to target those who are going to extract the maximum health benefit from it," says Babor. You need to be not only seriously heavy, but also have something such as type 2 diabetes, severe sleep apnoea (this was How's ticket), or disabling osteoarthritis.
A young mum who weighs 140kg and isn't seriously unhealthy, but doesn't like being overweight? Unlikely. A 60-year-old man weighing 200kg who's had a heart attack and 20 years of diabetes that's caused irreversible harm? Probably won't make the list either.
"There's a sweet spot of people who are in the midrange of obesity and are starting to feel some of the health consequences, yet still have conditions that might be reversible or brought into remission with substantial weight loss."
Even on the sweet spot you have to prove yourself. A precondition for the operation is meeting a short-term weight-loss goal – partly to make the operation safer but also to demonstrate you can modify your eating and exercise, making you less likely to regain all the weight later.
For 12 months How was followed by a film crew for a 10-part TV2 documentary that starts on Tuesday. This article contains serious spoilers of How's story – clearly he gets his operation – but Fairfax knows nothing about the progress of the five other morbidly obese subjects of the documentary who arrive at the SuperClinic full of hope.
How says having a camera on him wasn't always fun, but it probably helped keep him focussed. He was given six weeks to lose 10-12kg and he did even better, losing 15kg by dint of abandoning ordinary food entirely for a food-replacement shake called Optifast. He then waited six months for his operation, and lost 5kg more over that period.
The operation was a laparoscopic sleeve gastrectomy. "Sleeve" because the stomach ends up as a tube, rather like the sleeve of a shirt. "Laparoscopic" means it's a keyhole operation: Babor and assistant cut three small holes in the abdomen for their camera and tools, pump it up with carbon dioxide to make space to work in, hook the liver out of the way then get to work on the stomach: cauterising blood supply then pushing a calibration device via the mouth to the inside of the stomach where it is the template around which Babor staples then stitches the stomach tissue, before cutting away a now-redundant pouch. What's left is 20cm long and has the internal diameter of your thumb.
There are risks: about 2 per cent of stomachs spring a leak and require re-operation. In extreme cases this means months of recovery in hospital instead of a few days. Internationally the surgery-related death rate is one in 1500 patients. Babor says at Manukau there have been 1600 operations and one death.
There can be setbacks: weight typically falls rapidly for six months then slower for another six to 12, after which it plateaus or even bounces back a little. Three or four years down the line, 20 to 30 per cent of patients end up regaining substantial weight and an unfortunate few may regain the lot.
The 80-odd kilos How has shifted since the day he started his pre-op liquid diet is "huge", says Babor. "That's four bags of cement. If I took four bags of cement off you, you're a different person."
The curious thing about the surgery, says Babor, is that no one really knows why it works. Obviously there's the mechanical effect of reducing the volume of food people can eat, "but the more we learn the less we think the restrictive effect is important". Also affected are the hormones and neural signals between brain and gut. There are also changes in bile acid and in the "microbiome" – the bacteria living in the gut . For now, though, it's poorly understood.
Yet this fact remains, "it seems surgery is the only effective way to get patients to lose really substantial amounts of weight and keep it off". Drugs don't work. Diets don't work terribly well except transiently. Exercise has surprisingly little effect.
"Your body is really resistant to all this change."
The real surprise, says Babor, is that in a world of cheap, dense carbohydrates and constant exhortations to consume them, anyone manages to maintain a healthy bodyweight.
Babor's as liable as anyone to raise an eyebrow when he sees a morbidly obese person (he can gauge BMI on sight) sitting sucking a calorie-laden frappuccino, but on an intellectual level he knows it's not that simple. When you have most of a planet fast getting fatter all at once, the problem isn't just about individual choice, and the solution isn't just about education.
"We live in a food environment that's absolutely toxic, and it's not going to change if we allow self-regulation of our food supply. We allow corporations to feed us, and we're like those cattle you see in the massive feed lots in Texas. That's how we treat ourselves."
The operations Babor does might work, but they're not really the answer.
"Surgery is the ambulance at the bottom of the cliff for people willing to take a drastic step and a degree of risk. It's not the solution on a population basis."
DAD'S FAMOUS BURGERS
Nat How's first food memory is from when he was six or seven. His father had a takeaways in Te Awamutu. "People came from all over the place just to eat his burgers."
At family functions, he and his father are the ones in the kitchen. How's roots are Maori and Fijian, but his cooking spans the globe. His father taught him how to make raw fish, chop suey, steak with mushroom sauce, butter chicken. His mother taught him how to bake.
"I make this thing called a double cake – basically two cakes on top of each other, with icing and cream and all that."
Dad played league; Mum was a netballer. In his teens How was a talented wrestler - at 16 he was New Zealand junior champ. After he cracked two vertebrae he switched focus to rugby league, making the under-18 New Zealand team. Sport took him to New York, Japan, South Africa, London. He was 110kg, fit and healthy. But further injuries when he was 18 brought it all to shuddering halt. By 22 he was already so big it was affecting his sleep. He now suspects he replaced sport with eating.
"I don't think I ate differently from people around me, but I ate more. And faster."
A third of New Zealanders are obese, but the figure is 47 per cent among Maori and 66 per cent among Pacific people. How says his parents are big and so are his five siblings. When we head to the Otara shops to shoot video of How strolling past the fried chicken joints, curry houses, bakeries and dairies that once fed him, you can't help noticing almost every passersby is someplace between overweight and vast.
How says his roading workmates are mostly big too. He works 70-80 hours a week, with many night shifts, and at night when you're cold and hungry and want hot food, all you can find is takeaways or a garage pie. Too easy.
How has been supported from the outset by his colleague Mili Tovia, who had the same operation a year earlier. Tovia warned him about the perils of "head hunger", when you want a midnight feast but don't need it. He warned him that sometimes he'd want to sit alone and cry because everyone else was out there eating normally and you just couldn't have it.
How was 26 when a doctor first suggested he seek surgery, but he wanted to do it with exercise and willpower, by throwing out the deep-fryer and switching to low-fat everything. At 28 he swallowed his pride and asked if he could have the referral after all.
The weight could still all return.
"That's at the back of my mind. You don't want to go back. You still have to work at it."
Has he reflected on why he got so big?
"Lifestyle. Me, my father, my brothers, we all lead very busy lives with our work. It's real easy to be out on the road and grab something from the takeaway and eat it on the go. It's time management."
Before the operation he hadn't really considered the bigger picture, but he has now.
"I really think they should start taxing chocolate and soft drinks, and take away the tax for fresh fruit and veges."
Would that have actually helped him?
"Definitely. A 1.5-litre bottle of coke is cheaper than a bottle of milk. Which one are you going to get? Especially living on the wage that we do. We're not millionaires. We live within our means."
He didn't used to mind Warriors and All Blacks endorsing junk food but he does now.
"As a culture our kids are the ones suffering, yet they're looking up to these people who are endorsing KFC, Wendy's, Powerade."
How has turned his back on all that crap, and says he's not bothered by the prospect of a life of tiny bowls of oats and breadplate-sized dinners. The pleasure he has foregone doesn't need replacing with something else. He's happy "as long as the people around me are happy".
When he was big people were mostly polite, except for the occasional idiot who might approach him as he was putting out cones or redirecting traffic.
"They'd drive up and say 'Where do I have to go?', and I'd say, 'Oh, just follow the detour.' And they'd say 'Ah you useless f***ing fat c***. You're always closing the f***ing road.'
"The way you deal with it is to laugh and smile."
Sometimes, though, he'd have a bit of fun.
"The thing I always used to say was, 'I might be fat. I can get skinny. But you can't cure ugly. So."
WHAT NAT HOW USED TO EAT IN A DAY:
* A pie for breakfast on the way home from work.
* Four double-slice toasted sandwiches (white bread, cheese, ham or bacon), washed down with a 1.5l bottle of fizzy.
* A huge curry takeaway, or a stew from home.
* And between meals, anything he could get his hands on: three or four large bags of potato chips, a couple of bottles of Powerade, another couple of 1.5l fizzies, a packet of biscuits. The occasional bag of lollies, despite not being "a big sugar person".
Here's what Nat How ate over one day a couple of weeks ago:
* A small dip-bowl of oats with low-fat milk and yoghurt for breakfast.
* A protein bar and some yoghurt.
* Soy chicken with egg whites and mixed veges served on a breadplate for dinner.
* A little watered-down fruit juice. No snacks.
IF NOT SURGERY, WHAT?
If bariatric surgery is the ambulance at the top of the cliff, Auckland University's Professor Boyd Swinburn has spent the decades trying to build the fence at the top. The nutrition and population health expert says public debate around obesity resembles the conversation around tobacco of 50-60 years ago.
"We seem to be going down exactly the same track we went down with tobacco, with opposition between industry and public health and with politicians running for cover until they're forced to make changes."
Swinburn says there's widespread agreement among public health researchers worldwide that its time to implement preventive solutions such as taxes on sugary drinks, restrictions on junk-food marketing and the delivery of healthy food services to schools and education centres.
But such policies face fierce industry opposition and are hampered by political ideologies that wrongly believe "a bit of education and the market will sort it out". There's currently a lack of public clamour for such moves but Swinburn believes that's changing fast. Recent research into Mexico's tax on sugary drinks show it reduced soda sales by 12 per cent in a year, and by 17 per cent in lower socio-economic groups.
But do regulatory responses mean individuals don't have to take any responsibility for their own decisions to guzzle fried chicken and soft drinks and never exercise?
Not at all, says Swinburn. Individual responsibility and family responsibility are "fundamental", but it's up to society "to make it easy for individuals to make the healthy choice. At the moment the commercial sector is engineering the environment so that unhealthy choices are the easy choices."
★ The Big Ward starts Tuesday February 16, 7.30pm on TV2
- Sunday Star Times