A Weighty Decision Bangor man undergoes risky abdominal surgery in an effort to reshape his life

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Editor’s Note: Some 64 percent of Americans are obese or overweight. Poor diet and physical inactivity soon may overtake tobacco as the leading cause of death in the United States. In New England, Maine has the highest percentage of obesity among the adult population, and the problem is escalating among children as young as kindergartners. The Bangor Daily News is exploring this complex issue in a series of occasional stories.

When Kent McKusick looks in the mirror these days, he sees a whole new person. In the past 15 weeks, he has lost more than 60 pounds.

He has invested in a flattering new wardrobe. The shape of his face is changing, becoming more angular and expressive. There’s a small, expectant smile that tugs at the corners of his mouth and lights up his eyes.

McKusick looks, in fact, like a man in love – pleasantly preoccupied, astonished to find himself in the throes of an adventure that promises to change his life profoundly for the better.

It’s not sweet romance that’s working this alchemy in the 52-year-old Bangor resident and actor, however, but something a lot less transcendent – major abdominal surgery and a rock-solid commitment to change.

This spring, in a risky procedure, doctors at Eastern Maine Medical Center’s surgical weight loss program reduced McKusick’s stomach from the size of a football to the size of an egg.

They rerouted his intestinal tract to limit the absorption of the nutrients and calories he consumes. For the rest of his life, he must comply with a strict diet and exercise plan or risk uncomfortable and potentially dangerous problems.

It’s a challenging prospect, but McKusick’s got a cheerful take on it. “I’m practicing for being a senior citizen,” he quipped recently, “because now I know I’m going to live that long.”

Surgery was a decision he considered carefully for more than two years. Despite weighing close to 400 pounds at his heaviest and suffering from a cluster of obesity-related medical conditions, he was justly wary of the procedure.

Nationally, one in every 200 people having weight reduction surgery will die during the operation or shortly afterward. Many others will experience serious complications, including infections and malnutrition.

Of those who make a good recovery, almost 30 percent gain their weight back because they don’t stick to the required lifestyle changes.

Despite the alarming statistics, a growing number of Mainers are taking the dramatic step to shake the burden of obesity and the social, psychological and physical ills that accompany it.

Though there are about a dozen surgeons who perform the procedure at seven different hospitals in Maine, patients who choose a multidisciplinary program such as EMMC’s – which offers intensive preparation and follow-up, including nutritional counseling, physical therapy, mental health support and group meetings – may find themselves in better shape than those who go it alone.

Bolstered by the program staff, his personal network of family, friends and colleagues, and his own irrepressible optimism, McKusick took the gamble.

Kent McKusick – theater director, human resources professional, outdoor enthusiast, cat lover, gourmet cook, pillar of church and community, general man-about-town – is committed to nothing less than a new beginning, a second chance at building a whole and healthful life.

A lifetime of overweight

At 52, McKusick had been on a diet his entire life – that’s what it felt like, anyway. “I was heavy by the time I was 5,” he recalled. “I was just a chubby little butterball.”

Like many who struggle with their weight, the Guilford native said food played an important emotional role in his upbringing. Food was used as incentive and reward. It enlivened the family’s celebrations and comforted their sorrows. “It was the focus of our family life,” he said.

“My grandmother was an amazing cook – especially her desserts. In her thinking, if you didn’t have dessert, you didn’t have a complete meal,” McKusick said, musing over a memory of her chocolate fudge cake.

By the time he was in his teens, he was trying to lose weight. “But if I lost 5 pounds, my reward was a doughnut,” he said.

All his family members tended toward the heavy side – “But not like me,” he said. “They were able to lose weight when they needed to.”

McKusick grew into a heavyset young adult, but despite his weight – and almost in defiance of a childhood bout with polio – he was an active, adventurous, outdoorsy person.

In addition to cultivating a longtime love affair with community theater, he became a nationally certified downhill ski instructor and registered Maine Guide.

His muscular bulk worked in his favor when he guided white-water rafting trips, but as he grew older and heavier, it began to slow him down. That made it easier to focus on more sedentary pleasures – including his own considerable talent as a gourmet cook – and easier to pack on the weight.

He tried many times to slim down through diet and exercise, but whatever success he had always was short-lived. His weight just kept going up.

Over time, he started having knee problems, then back pain. In his 30s, he developed high blood pressure and in his 40s, diabetes. At 50, weighing close to 400 pounds, he was diagnosed with sleep apnea, a life-threatening breathing disorder and a common complication of obesity.

These medical issues troubled him. His size was uncomfortable and embarrassing. Climbing a flight of stairs left him exhausted. He had difficulty finding and affording the well-made professional attire his human resources job required.

As founding artistic director of the Northern Lights Repertory Theatre, he loved acting, but always was cast as the fat guy or the funny guy, never as the romantic lead or the mysterious stranger.

He couldn’t ride in a compact car, wear a regular seat belt, tie his shoes or cross his legs. He doubted he’d ever again see the stony summit of a mountain or a remote river canyon – but it was none of these things that finally set Kent McKusick onto the path that would turn his life around.

Last fall, a carload of hooting teenage boys drove past him as he waited to cross a downtown Bangor street, and one of the passengers leaned out and shouted a violent obscenity at him.

It wasn’t the first time he had been humiliated in public. “People feel very free to insult a fat person,” he said. “But for some reason, that was the one that hit home.”

McKusick contacted his doctor when he got home and was referred to the surgical weight loss program at EMMC.

The high cost of obesity

Like McKusick, many people who are morbidly obese – 100 pounds or more overweight, with a body mass index of 40 or greater – develop chronic medical conditions. Body mass index is calculated by taking a person’s weight in kilograms and dividing by his or her height in meters squared. Someone with a BMI between 25 and 29.9 is considered overweight, and a BMI equal to or greater than 30 is labeled obese.Diabetes, heart and lung disease, arthritis and other joint disorders, pain, skin problems and mental health problems all are predictable issues relating to obesity.

In addition to the toll they take on the obese person and his family, the cost of treating these conditions is a major force driving health care spending in Maine and elsewhere. Effective prevention, management and cure are directly linked to taking weight off and keeping it off.

Lynn Bolduc, clinical coordinator and one of three registered dietitians at EMMC’s program, said weight loss surgery is, for many people, the only way they’ll ever be able to shed the pounds they must lose in order to improve their health.

It’s not a matter of willpower, she said, but of the body’s distorted metabolic needs and a chronic, ongoing appetite.

“It’s a form of addiction. These people are always hungry,” Bolduc said. “They do not know what it means to feel full.”

That – combined with the physical immobility and loss of self-esteem that come with the self-defeating territory of obesity, and the numerous medical conditions that accumulate as a result – makes it so difficult to lose weight that many people simply cannot do it through diet and exercise alone.

Bolduc warned that some people think gastric bypass surgery is a silver bullet that can “fix” their obesity problem. Too often, she said, they approach the process without clearly understanding the risks and commitment involved. And without that understanding and commitment, there is little likelihood of success.

“Some people believe that cutting them open and rearranging them is an end in and of itself,” Bolduc said. “We tell them this is only a tool – diet and exercise are still incredibly important to their success. Not only that, but this surgery will radically change their lives and the lives of the people around them.”

That change is hard to overstate. While there are several types of weight loss surgery, they all involve a drastic reduction in the size of the stomach – from the size of a football to about the size of an egg. Some procedures also reconfigure the intestinal track, limiting the body’s ability to absorb nutrients.

All options require meticulous attention to diet and portion control – immediately after surgery and for life – to ensure adequate nutrition without stretching out the stomach pouch.

Beyond that, there’s a lifetime of disciplined exercise and regular medical checkups. Patients often find themselves going through profound psychological changes, as well, as their physical appearance alters.

“Patient selection is critical,” said Michelle Toder, one of four surgeons who perform the procedures at EMMC. “This operation is really only useful to patients that will follow the protocol.”

That’s why the hospital’s multidisciplinary program, now just 2 years old, includes a careful process of educating and evaluating prospective patients to ensure their understanding and commitment, and to determine if they’re good candidates for the risky surgery.

Accepting the odds

Before Kent McKusick checked into EMMC in March, he spent more than six months being prepped for the long-term lifestyle changes he would need to adopt afterward.

He attended a two-hour preoperative informational class, met with a nutritionist and a physical therapist, dropped in on postoperative support group meetings, underwent a psychological evaluation and read extensively.

Some changes he undertook beforehand, including beginning to alter his diet and establishing a moderate exercise program. He dropped 20 pounds before he even checked into the hospital.

The drawn-out pre-op process ensures that clients know what they’re getting into and that they have opportunities to reflect on their commitment and to cancel if they’re not ready.

It also allows the medical team to evaluate the clients and determine which ones should be “slow-tracked” for surgery to shore up their understanding and resolve, and, occasionally, which ones should be turned away altogether.

“A lot of these people are not very good surgical risks,” Toder said. “If they were healthy enough to be good surgical risks, they probably wouldn’t need the surgery.”

The same medical conditions that bring people in for weight reduction surgery, she pointed out, make them especially susceptible to a host of operating-room hazards, including cardiac arrest, kidney failure and respiratory complications. People whose health is very severely compromised may not be accepted for surgery at all.

During the immediate postoperative period, an obese patient’s difficulty with moving around increases the odds for pneumonia, blood clots and infection. Rarely, the internal staples or sutures that create the egg-sized pouch of a stomach can leak, spilling bacteria into the surrounding abdominal cavity and causing a lethal infection.

Statistically, one in every 200 patients having weight reduction surgery will die during surgery or shortly afterward, and 10 will experience serious complications. About 30 percent come through the surgery well enough but fail to meet or maintain their weight loss goals, usually because they don’t keep up with the diet and exercise components.

But nationally, 60 percent to 75 percent will “succeed” – defined as losing at least half of their excess weight and keeping it off for five years or longer.

The “honeymoon” period for losing weight is the six to nine months immediately after surgery, when people may lose 100 pounds or more, often without much effort, Toder said.

Along with that weight loss, patients often see a dramatic improvement in their overall health. Many report reducing or eliminating the medications they take for diabetes, high blood pressure, pain and other conditions, sometimes literally overnight.

As a post-op patient at the EMMC center, McKusick’s intake of food and fluids is strictly scheduled and prescribed.

For several months after the surgery, he will eat three very small meals a day – just about a third of a cup at each sitting. He is advised to take at least a half-hour to eat the tiny portion and to chew his food meticulously before swallowing it. Every bite must count, nutritionally speaking – there is literally no room for empty or unplanned calories.

Between these meals, also three times a day, he must take in about 16 ounces of fluids in small sips so as not to overwhelm his digestive tract. His diet is rounded out with a handful of dietary supplements. Alcohol, soda and chewing gum are on the “never-again” list.

But most things improve with time. When we visited McKusick one afternoon about 10 weeks after his surgery, his house was filled with the fragrant smells of garlic and olive oil.

He was puttering happily around the kitchen, cooking up a Boursin cheese sauce for a chicken recipe he found in a cookbook written just for surgical weight loss patients. The recipe, which would make a modest entree for two “normal” appetites, would last him more than a week, he said.

He also works out faithfully at least three times a week at EMMC’s outpatient physical rehabilitation facility on Union Street. As a “graduate” of the hospital’s program, access to the facility and staff is free for three months. On the days he doesn’t use the gym equipment, he walks or swims.

McKusick was able to stop taking his blood pressure medication and his diuretic about a week after surgery.

Tracking the results

Gastric bypass surgery originated in the 1950s as a treatment for stomach cancer. With diseased portions of their stomachs removed, patients lost dramatic amounts of weight.

Doctors did not clearly understand the mechanism or impact of this weight loss, though, and in the 1970s, when the procedure started being used specifically to treat obesity, surgical complications and poor nutritional management contributed to a high failure rate. Most insurers viewed the procedure as cosmetic and refused to cover it.

With obesity now seen as a major public health problem and a driver of health care costs, interest in developing a safe and effective surgical process has grown.

EMMC’s multidisciplinary program has been in place about two years, and there is a similar program in Portland. The surgery also is available at other hospitals in Maine, but without the extensive preparation and aftercare.

Through the Bangor center, more than 400 patients have undergone surgery. Two have died – one very recently from surgical complications, and the other due to underlying cardiac problems.

While the program hasn’t been online long enough to have long-term data, clinical director Lynn Bolduc said the success of EMMC’s patients is in keeping with national trends – about 65 percent of the clients have lost half their excess weight and are keeping it off through lifestyle behaviors.

The center’s policy is to accept morbidly obese patients between 18 and 67 years of age, but Bolduc said there is interest in taking younger people who are experiencing weight-related medical complications.

Because weight control is a key factor in disease prevention and treatment, the surgery no longer is considered cosmetic, and most insurance companies, including Medicare and Medicaid, will pay for the procedure for patients who fit the medical profile.

Statewide, Maine’s Medicaid program paid for 125 weight reduction surgeries in 2003, spending a total of about $400,000, or $3,200 each. Someone without any insurance coverage would pay about $20,000 at EMMC, assuming no serious complications.

Sudden ‘sidestep’

Two weeks ago, Kent McKusick called from the hospital – he had undergone emergency surgery to correct a sudden, potentially lethal problem with his intestine.

His physicians had assured him the problem was not specifically related to his gastric bypass but was a common complication of any abdominal surgery.

Sounding frustrated, McKusick said he was eager to get back to his work, his friends, his exercise routine and his pampered cat Annie – and a week later he was home.

He rejected calling the emergency surgery a setback, preferring the idea of a “sidestep.” But the situation had frightened him badly, he admitted.

“The worst part was having only a half hour to prepare myself for the possibility that I might die,” he said. “The first time, I had over two years.”

But he never has questioned the “rightness” of his decision to have the bypass, he said. Overall, he emphasized, he’s very happy with the changes in his life.

“I’m so aware of how I feel — less pain, more energy. It’s been a very affirming, supportive experience – people who know me really notice it a lot. They say ‘God, You’re changing so fast.’… I’m even thinking about getting a full-length mirror,” he confided. “You’ll find that most obese people don’t have one.”

At about 300 pounds, he still has a long way to go to get to his target weight of 190, but McKusick said knowing he’s on his way has made a big difference to his self-esteem.

“I’m sure most people still see this very heavy guy,” he said. “But it doesn’t bother me. I don’t even notice when people stare anymore. And I haven’t been yelled at once this spring.”

For more information on Eastern Maine Medical Center’s surgical weight loss program, go to www.emmc.org or phone 973-6383. Information also is available at www.obesityhelp.com. Meg Haskell can be reached at 990-8291 and mhaskell@bangordailynews.net.

The “Tipping the Scales: Obesity in Maine” series is a newsroom-wide effort. Today’s special section was reported and written by Bangor Daily News health writer Meg Haskell, illustrated in photos by staff photographer Linda Coan O’Kresik, edited by Style Editor Letitia Baldwin and designed by copy editor Becky Bowden. To comment, call the Style Desk at 990-8270 or e-mail bdnstyle@bangordailynews.net.