The moment of realization for Johnnie Stephen came on Aug. 9, 2016 — a date he remembers because it is memorialized by a photograph hanging on his dining room wall.
He and his wife, Michelle, were visiting Branson, Missouri, on vacation and had decided to check out the landlocked tourist town’s curiously located Titanic museum. At the bottom of a replica of the doomed ship’s famed grand staircase, a photographer for the museum asked if they wanted a picture and then snapped the camera’s shutter button. Click.
In his youth, Johnnie had been a boxer, a football player, a power lifter. He had served in the Air Force. But, as he had aged, he had found it harder and harder to keep weight off, and with that weight gain came numerous health problems.
Eventually, he suffered from diabetes, sleep apnea, high cholesterol and high blood pressure. He suffered a stroke in 2013 and struggled through problems with his short-term memory. He could no longer drive.
As a minister at his church in Commerce City, he would sometimes collapse while preaching and Michelle would scramble to the front to revive him. Even that day in Branson, he struggled to walk more than a few paces without losing his breath.
When Johnnie got the photograph back, he stared at it. He was 365 pounds and, at that moment, he felt the future held but one path for him.
“I always believed that I was just a goner,” he said recently.
That moment led Johnnie down a different path toward gastric bypass surgery, one of a number of weight-loss surgeries gaining in patient popularity and medical acceptance across the country. In the five years since his surgery, he has lost 150 pounds and shed many of the health conditions that once ailed him. Michelle, who also struggled with weight due in part to exercise-induced migraine headaches, had the same surgery roughly a year later and has also seen improvement in her health.
But the changes did not come without their own struggles or sacrifices, showing the need for patients to be prepared for what comes after their digestive systems are surgically rearranged.
“I always tell people this is a lifestyle change,” Michelle said. “This is not an in-and-out weight loss thing.”
A new study on the benefits — and risks — of weight-loss surgery
Nationwide, as many as four out of every 10 adults suffer from obesity, according to one federal survey. Colorado fares better — roughly a quarter of adults in the state suffer from obesity as of 2021, making Colorado the state with the second-lowest obesity rate, a fraction of a percentage point behind Hawaii.
But obesity has been rising in all states for the past several decades. In 2011, Colorado’s obesity rate was a little over 20%.
These trends in part explain the increasing popularity of so-called bariatric surgeries, the collection of procedures that fit under the umbrella of weight-loss surgery. The number of bariatric surgeries being performed annually in the United States hit 256,000 in 2019, up from 158,000 in 2011, according to the American Society for Metabolic and Bariatric Surgery. The number declined significantly in 2020 — likely the result of the COVID pandemic — and more recent data is not available.
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While gastric bypass, like what both Johnnie and Michelle Stephen had, was once the most popular form of bariatric surgery, gastric “sleeve” procedures — which remove a portion of the stomach, turning the remainder into a slim tube — are now most common. But the point of both, as well as older forms of surgery, like gastric bands, is to restrict the amount of food patients can consume, resulting in significant weight loss.
They are a last resort for the increasing number of people who have reached the point of last resort, struggling with one of the creeping health crises of our time.
“Patients who seek weight-loss surgery, unfortunately, they’re kind of in this desperation phase,” said Dr. Katayun Irani, a weight-loss surgeon at Lutheran Medical Center in Wheat Ridge.
A new study by Irani’s colleagues in the Intermountain Healthcare system shows how beneficial weight-loss surgery can be.
The study, published in January in the journal Obesity, found that bariatric surgery can significantly reduce a patient’s risk of death for any number of conditions. When looking at all causes of death, mortality in bariatric patients compared with patients of similar ages and body mass indexes was 16% lower. But the study found even bigger decreases for specific conditions — death rates for heart disease dropped 29%, deaths from cancer dropped 43% and deaths from diabetes dropped 72%.
Dr. Nathan Richards, a bariatric surgeon in Utah who was one of the study’s authors, called the findings “remarkable.”
“We’re demonstrating that the benefits aren’t just short term,” he said. “This isn’t just a one and done. This is durable benefit, largely because the weight tends to stay off.”
But the study also showed a darker side to the experience for some patients. Among patients who got bariatric surgery and were between the ages of 18 and 34, the risk of dying by suicide was roughly 2.5 greater.
The study looked at more than 20,000 patients, leading Richards to conclude that the finding isn’t a data fluke but instead a real phenomenon.
“That caused us to pause, bluntly, and say, ‘Hey what’s going on here?’” Richards said.
“For a long time obesity has had this stigma around it”
To Richards, the answer to his question became clearer the more he thought about his patients.
Many arrived at his clinic after years or decades of struggling with weight. They had felt societal judgment for their size and the perception that it was their fault they were not slimmer. Surgery carried so much expectation and hope for them.
After surgery, some had expected weight to melt off effortlessly — and if that didn’t happen, they were devastated. Some dealt with other emotional and mental health issues that they had long responded to by using food as comfort. After surgery, that was no longer an option.
“The perception is that they’re worse off and that this is hopeless, in this susceptible group that already suffers disproportionately from mental illness,” Richards said.
Irani, the doctor at Lutheran Medical Center, said some patients aren’t prepared for the metabolic changes their bodies will go through. Patients may be at increased risk of alcoholism because they will metabolize alcohol faster, causing them to get drunk more easily.
For these reasons, both Irani and Richards said bariatric surgeons are coming to understand the importance of providing long-term, consistent follow-up care to patients, including providing them with the opportunity for mental health support.
“For a long time obesity has had this stigma around it,” she said. So care after surgery, she said, “is really kind of a long-term thing.”
A new life — with plenty of changes
Both Johnnie and Michelle Stephen said they are lucky that they met Irani, who performed their surgeries. Prior to visiting her weight-loss clinic, both said they had struggled to find doctors who took their weight seriously as something negatively impacting their health.
Johnnie said doctors tried to treat with an increasing number of medications all the problems he now associates with his weight. Michelle said doctors would often dismiss her concerns about her own weight.
“They would just say, ‘You’re young, you can exercise,’” Michelle said.
Surgery, and the weight loss that came after it, has given them back their lives, they say. Both say they are now more active — Johnnie says his blood pressure, cholesterol and blood sugar are at healthy levels, while Michelle says her migraines are more manageable. They both have jobs they enjoy, something they struggled with when they were heavier. Johnnie is preaching at church with renewed energy. They can play with their grandkids.
“I always thought I wouldn’t make it to 60,” said Johnnie, who is now 63. “I have a new outlook on life.”
“We’re two different people,” Michelle said.
But those changes required significant adjustments.
After gastric bypass, Michelle’s and Johnnie’s stomachs are about the size of an egg. They had to essentially re-learn how to eat. Too much food, as Johnnie found out early in his recovery, quickly led to vomiting. Things they once enjoyed — spicy Mexican food, for instance — are now off the table.
A typical meal might include a credit-card sized amount of meat and a quarter cup of vegetables. They eat slowly, chewing their food over and over so that it digests more easily.
It’s not a radical diet — they are quick to say that they eat mostly what anybody else does. But it is a controlled one.
“When we have dinner with friends, they say, ‘Is that all you’re going to eat?’” Michelle said.
Both experienced hair loss after surgery, a common side effect. Michelle’s grew back. But after decades of having long dreadlocks, Johnnie’s did not.
They check regularly with Irani’s staff for nutritional help or to ask about medications — some are now off-limits. They have become informal patient advocates for the clinic, with Johnnie sometimes speaking at events or support groups.
Friends and family members now seek them out for advice about whether they should get weight-loss surgery or for help with adjusting post-surgery. And, to everyone, they have the same message.
“It’s a lifestyle change,” Johnnie said. “It’s not something where you get done and five years later you say you’re going to go back to what you’re doing.”