Andrea Huffman of North Augusta spent years on a dieting roller coaster. After each diet her weight would climb and her spirits would sink.
"I was so depressed about it," she said. "It's like there was nothing I could do. I was embarrassed to be in public."
She was 31 years old and weighed more than 260 pounds.
During a vacation with her husband and three children, Mrs. Huffman had no energy and watched from the sidelines as her family enjoyed their time together.
That's when she decided to take a dramatic step. She began to investigate bariatric surgery - procedures that alter the digestive process to restrict the amount of food a patient can eat or digest.
"I wanted to learn the bad and the good. I wanted to know what kind of struggles I would face," she said.
By the time she went to see Harold Engler, a surgeon who performs gastric bypasses on the morbidly obese, she was confident that it was the right choice.
"I was not scared; I was not worried," she said. "I knew what I was in for. You can't go into it thinking this is a quick fix."
That was in March 2000. She was a size 24. Today she is a size 12.
Dr. Engler has performed more than 2,000 such surgeries on patients ranging in age from 14 to the mid-60s.
According to the Centers for Disease Control and Prevention, 97 million obese people live in the United States. The American Society for Bariatric Surgery estimates that about 45,000 surgeries are done each year.
There are several types of bariatric surgeries. One is gastric banding, in which a band is placed around the top of the stomach, creating a small pouch and a narrow passage into the rest of the stomach. Another is vertical banded gastroplasty, in which both a band and staples are used to create a small stomach pouch.
Mrs. Huffman had gastric bypass surgery, the most common procedure for treating morbid obesity in the United States. The operation restricts the amount of food the stomach can hold by stapling off a small section to serve as the stomach. The rest of the stomach is bypassed, which reduces absorption of calories and nutrients.
The pouch at the top of the stomach is directly connected to the small intestine, which normally connects to the bottom of the stomach. The patient loses weight because only small amounts of food are consumed and aren't completely absorbed. A normal stomach can hold more than three pints of food. After surgery, a patient can't eat more than an ounce or two.
Patients must take daily vitamins to provide the nutrients that the body doesn't get because of reduced absorption.
Because the stomach, which normally dilutes food before it reaches the intestines, is taken out of the process, patients are unable to eat some foods, including greasy fried foods and refined sugars.
"The intestine is not prepared for it," Dr. Engler said.
Patients must relearn how to eat after surgery.
"You are just not capable of having the eating habits you did before," Mrs. Huffman said. "You are extremely limited for the first three months. You have to learn what your body will tolerate and what it won't."
Patients who sneak sweets, such as a bowl of ice cream, may experience weakness, cramps, nausea, diarrhea, sweats or fainting, which quickly puts an end to cheating.
"Once you try it and you see how it makes you feel, you won't have those cravings anymore," Mrs. Huffman said. "Besides, after you've lost the weight, and you know what you went through to get there, you don't want to do anything to go back."
A new life
Rees Matthews is another of Dr. Engler's patients. He was 49 and weighed 413 pounds when he underwent gastric-bypass surgery in July 2000. Since then, he has lost 120 pounds and 20 inches from his waist. He bubbles over with enthusiasm about his new life.
"It's like being born again. Now I am free from the bondage of being morbidly obese. I just wish I had done it 20 years ago."
Mr. Matthews said he literally feels like a different person.
"I had tried everything but heroin and crack cocaine," he said.
He was tired of being embarrassed about the limitations that his weight put on his life.
"Before, sometimes I would have to sit on the side of the tub and rest when I was taking a shower," Mr. Matthews said. "I couldn't even reach around to my back."
Today, there is no stopping him. He says he is on fire.
"It's a joy just to get up. There's nothing I can't do," he said. "Well, I haven't tried break-dancing yet."
Mr. Matthews didn't feel this good right after the operation. He lost a lot of blood during his surgery and spent nine days in intensive care. For two weeks afterward, he repeatedly wondered why he had agreed to the surgery.
"I don't sugarcoat it. It's a painful operation," he said. "This ain't no walk in the park."
Patients who have these types of surgeries have to adhere to strict diet limitations for the rest of their lives.
What's most important, they limit the amount of food they eat. After surgery, a 6-ounce meal (about the amount of yogurt in a single-serving container) can leave him feeling as though he had finished Thanksgiving dinner.
"Basically, you eat child-size portions," he said.
Mr. Matthews said his diet consists of broiled fish, baked chicken, lots of leafy green vegetables and fruit.
"Some people say that they will really miss pizza," he said. "But if you have the surgery, you just won't want it."
Help from all sides
In many bariatric surgery programs, dietitians and psychologists help patients change behaviors after surgery.
Robert Martindale, chief of nutrition services in the gastrointestinal surgeries section of Medical College of Georgia, said patients receive diet education in addition to learning about the medical and surgical aspects of the bariatric approach. They also meet with Christian Lemmon, a psychologist and director of the eating disorder program at Medical College of Georgia, before undergoing surgery.
Dr. Lemmon said that most of his patients suffer from some form of depression. It's a common result of the surgery, too.
"First of all, it's a major surgery. You're on your back for a long time," Dr. Lemmon said.
Patients also go from three meals a day to a liquid diet and slowly, over a few months, reintroduce solid foods into their systems. This can be a difficult transition for patients who sought comfort from food.
Dr. Lemmon said at least one-third of his patients are binge-eaters. They are typically not eating in response to hunger, but to emotion, he said. They need to learn how to use other outlets in place of food.
Not an easy road
To have bariatric surgery, patients must weigh at least 100 pounds more than ideal body weight, although surgery can be considered at a lower weight if the patient has other health problems.
Previous intestinal problems would prevent a person from having the surgery. However, other health problems, such as heart disease, wouldn't necessarily make a patient ineligible because being morbidly obese poses greater health risks than the condition the patient suffers from. And the hypertension, diabetes and other conditions should improve or be alleviated after the surgery if the patient adopts new eating habits.
Because this surgery is normally considered a life-saving procedure, most insurance companies will cover it. Dr. Engler writes a letter of necessity for each patient.
"In the early days, (the insurance companies) excluded it," Dr. Engler said. "But it is getting so much better that it is much more available to patients now."
Dr. Engler said that in his experience, one out of 100 patients will have complications.
The surgery is as invasive as a hysterectomy, and includes all the risks associated with such surgeries, such as the general risk of anesthesia.
The American Society for Bariatric Surgery lists more than 30 complications that may result from the surgery. They range from manageable, such as acid reflux, to potentially serious, staple line disruption - which allows leaking from or into the stomach - or anemia, to serious complications like internal bleeding or severe infections.
Patients must also adhere to the dietary restrictions after surgery.
Dr. Martindale advises patients to try all conservative weight-loss approaches first and to opt for surgery only as a last resort.
Hospital bills for the procedure cost about $15,000, but with anesthesiology and other additional costs, the expense can easily reach more than $20,000.