ALDA Hello and welcome to Scientific American Frontiers. I'm
Alan Alda. Our program this week is on a subject we've all heard
about -- the obesity epidemic. More and more adults are obese, children
are obese, and this is not just an American problem -- it's becoming
global. For most people who are a hundred pounds or more overweight,
it's practically impossible to lose the weight and keep it off through
dieting alone. So in spite of the risks -- which are considerable
-- people are lining up to solve their weight problems in the operating
room. That's what we're focusing on tonight -- weight loss surgery.
We're going to see how different kinds of stomach surgery work,
and we'll meet the patients and their surgeons. We're going to look
at an experimental implanted stomach pacer, which is supposed to
make you feel full. And we're going to check in with some old friends
of Frontiers, who've been losing weight -- and gaining it -- for
the last two years. That's coming up on tonight's episode, Surgical
LOST AN ENTIRE PERSON
ALDA (NARRATION) In our episode called "Losing It," we followed
for a year the fortunes of people as they tried to lose weight.
Towards the end, our group got together for a calorie-controlled
reunion. Eight of our group used various diets. Almost all of us
lost weight me included and some had health benefits,
like lower blood pressure. Robin was our champion dieter, losing
ALDA Do you have any health issues that have gone away since you...
ALDA (NARRATION) Now after one more year, half of us have managed
to stay within a couple of pounds of our weights a year ago. Half
of us are regaining weight some quite a lot. The people who
lost the most have now regained the most. This is a near universal
experience in weight loss the more we lose, the harder it
is to keep the weight off. Our bodies fight back in ways that aren't
well understood. Our group included two people, Amy and Rodney,
who had gastric bypass surgery to lose weight. They started out
heavier than the others and, as expected, by the time of our reunion
a year ago, they had lost the most. Their whole attitude to food
ALDA Do you just eat now in a utilitarian way? Or do you enjoy your
I eat because now I have to nourish my body, you know what I mean?
And I concentrate on the protein, because that's what they want
you to get -- 65 to 80 grams of protein a day.
ALDA And is it hard to get that down?
Oh, it's wicked hard.
Yes. Because you're not hungry so you have to remind yourself to
ALDA Is it harder to remind yourself to eat than it used to be to
remind yourself to eat less?
ALDA It is?
ALDA So, is this really good?
It is good.
It is. It really is.
Like Amy says, we're never hungry.
ALDA Is this something you would recommend?
If I'd have kept going the way I was going, there was a danger that
I wasn't gonna live another year...
You know because I was headed for a stroke.
ALDA (NARRATION) Unlike our dieters, in the last year Amy and Rodney
have continued to lose weight Rodney a further 19 pounds,
and Amy 71. From the start, we gave video cameras to our group so
they could record diaries. Rodney used to work hard on the deck
of a fishing boat, and he stayed in shape. Then he bought his own
boat, sat in the skipper's chair all day, and the weight accumulated.
His doctor said he was heading for trouble.
In the last few years I've been diagnosed as a diabetic. I have
high blood pressure. I have sleep apnea. And that's all due to overweight,
being overweight. My knees have been, in the last year, year and
a half, my knees have been killing me. So if I don't do this I'm
looking at knee surgery, replacement. And I just want a better quality
of life in my later years. I worked hard all my years. I want to
enjoy my later years with my grandchildren.
ALDA (NARRATION) Here's the production team bringing Amy her video
How are ya?
Here to set up the camera.
ALDA (NARRATION) Amy and Rodney were both preparing for the most
common weight loss surgery in the US gastric bypass. Contrary
to popular opinion, it's not just an easy option. You still have
to change your eating habits to be successful.
DIARY This week's been kind of rough. I got on the scale and I did
gain a couple of pounds, which I was really discouraged about. And
I think that's where that, "Oh, even though I have a surgery date"
mentality comes in, that I allowed myself to eat the things that
I shouldn't have. So now, you know, tighten up the belt again, and
back to the grindstone. Now that it's only a few hours away, I'm
feeling a little ... I'm not really anxious, I'm just... It's the
unknown, I think.. It's just a lot of emotions come out. Because
you just think about everything. And, I don't know. It's time to
go to bed, though.
ALDA (NARRATION) Amy and Rodney are in a surgical program at a Boston
SHIKORA You all set?
Are you ready?
SHIKORA We are. You're seeing the A-Team today.
ALDA (NARRATION) When Amy had her surgery, two years ago, I was
there to observe.
ALDA If seventy-five to eighty percent of the patients are successful
at reducing their weight, what happens to the other twenty, twenty-five
percent who have had a kind of severe operation. Can it be reversed?
SHIKORA It can be reversed, but it's very difficult to reverse it.
And if somebody fails, and gains their weight back, or never loses
the weight they should lose, there's no reason to reverse it, because
essentially they've behaviorally reversed it. Now what we're going
to do is go through every layer of the abdominal wall. Everything
you see yellow is usually fat.
ALDA How are you getting through those layers?
SHIKORA This instrument has a little blade at the tip, and when
you hit the trigger the blade juts out and it makes a little cut.
ALDA I see.
ALDA (NARRATION) The laparoscopic instruments are monitored with
a fiber-optic TV camera.
SHIKORA So that's called a linear stapler.
ALDA (NARRATION) The surgeons make a new, smaller stomach out of
the top few inches of the natural one, using an instrument that
staples and cuts at the same time.
SHIKORA We're going to sculpture this little stomach chamber or
ALDA (NARRATION) Amy's new stomach will hold only about one ounce,
whereas her natural one held half a gallon. The natural stomach
will remain in place, to keep generating digestive fluids.
TARNOFF So this part here is going to be her new stomach.
SHIKORA That's the first major portion of the operation is just
getting that pouch created.
ALDA So now you have the esophagus naturally going into that new
ALDA And then you have a new connection from that pouch to the intestine.
ALDA (NARRATION) To connect the pouch to the intestine, the surgeons
first cut the intestine below the stomach and make a new connection
for the natural stomach lower down.
SHIKORA So that's the completed closed connection. So we're down
to the last major step which is connecting the intestine up to that
one ounce stomach chamber.
ALDA (NARRATION) Finally, the intestine that had been cut below
the natural stomach is brought up and connected to the new, small
TARNOFF There we go. Look under here. OK.
ALDA (NARRATION) The procedure takes about 90 minutes total.
SHIKORA So the bulk of the operation is done. We'll throw an extra
stitch or two in a few places and then we close.
ALDA (NARRATION) Four months after surgery, Amy achieved one of
her goals shopping in a regular, not a plus-size, store.
I would never wear a cocktail dress, because I wouldn't want that
much of my body showing. I mean I still have a long way to go, but
I'm at a point now that I can wear a cocktail dress and get away
with it and not be like, everybody looking at you like, What in
the world do you think you're doing? I don't like it. It's too big.
It's like way too big in here. I like this dress. It's longer. It
covers more. I like it. Everything has changed. You're a whole new
person. I met a girl that I went to high school... in a store. And
I said, "Oh, hi," and she goes, "Do I know you?" I lost a person.
I lost an entire person.
It's March today, right? So in the middle of summer I'll be in my
Speedo bathing suit.
ALDA (NARRATION) Rodney was up and about soon after his surgery.
Hi ya. How ya doing?
ALDA Oh you look great -- walking around. When did you have your
ALDA Yesterday and you're already around walking?
I was walking at three o'clock this morning.
Yeah. It felt good to walk. ALAN ALDA Are you in any discomfort?
No, just a little. You know, you know that somebody's done something.
Before I came here, I was like a very closed person, I didn't talk
to anybody. Now they can't shut me up . When I come here I talk
to everybody, you know.
ALDA So what's the relationship between being more open and getting
your diet more...
I don't know I feel comfortable with the people and I know they're
going through the same thing I'm going through. So it's not like
we're trying to, you know hide anything from anyone.
ALDA So does that mean that you're more honest with yourself about
what you're eating?
Yes, yes, yes.
ALDA That's interesting. Being closed off from other people in a
way is a way of being closed off from yourself.
Exactly. This is my attire before I had my operation. Now I can
fit another person in here. I wasn't able to button this shirt.
Now I got a little room. Actually, I've gone down a size. This is
the shirt. Towards the end there these buttons would be like this,
before my operation. I haven' felt this good in a long time. I can't
remember when, to tell you the truth. The energy I have now is unbelievable.
I look at life like I've gotten a second chance at it. I go on vacations.
I go to amusement parks, swimming, wear shorts, go to the beach
-- these are things that I haven't done in years. And it's a brand
new outlook on life. I'm 60, and I'm like I'm 16 again.
ALDA (NARRATION) This is a different kind of obesity procedure,
called a lap-band. It's less risky than a gastric bypass like Rodney's
or Amy's, in which three in a thousand patients will die.
SHIKORA The band is in the abdomen. You can see it , it's up next
to the liver. And we're going to now pass the band around the back
of the esophagus. We're putting this on the way you put a collar
on a dog's neck. And now we're going to buckle the band.
ALDA (NARRATION) The tightness of the band can be adjusted, just
in an office visit. It's also possible to remove it, whereas reversing
bypass surgery is very hard. The band creates a small chamber at
the top of the stomach.
SHIKORA The food that's sitting in the little chamber , the tighter
the band is, the slower it can get through, and while there's food
sitting up there at the very top of the stomach, the brain perceives
it as if the entire stomach was full.
ALDA (NARRATION) Patients can defeat the lap band by simply eating
all the time what's called grazing. Over all it's a bit less
effective than bypass surgery. But with both approaches, the key
to success is continuing followup and support, to help control harmful
Before I entered this program I was 375 pounds. This morning, I
weighed 224 and I had the operation six months ago.
ALDA (NARRATION) They've found that patients who skip their followups
are the least successful at losing weight.
I haven't come to one of these support groups that I haven't walked
out of here with a tool. And I'll never forget my very first one
I came to. There was a lady talking about how she controlled what
she ate. And she always would say, she would get a napkin and put
it over half of her plate, and only eat what was exposed. I told
my wife about it, and just the other day, we were eating, and she
noticed that I was eating a little bit more. She grabbed a napkin
and put it over half the plate.
TARNOFF People that are ten years out from these operations report
increased appetite, cravings, all those things, and without a proper
adjustment in psychological behavior and eating patterns, there's
a propensity to regain weight.
SHIKORA The bottom line is none of these surgeries are a cure for
obesity in a vacuum. They all have to be part of a program that
provides the behavior and the counseling.
ALDA (NARRATION) There's now a new development in weight loss surgery.
One of the first beneficiaries lives here. As he was approaching
middle age, Bill found it harder and harder to cope with his weight
When I was forty years old I think I went on my first diet. I had
lost I think, at least three times, sixty or seventy pounds, only
to gain it right back and gain more.
ALDA (NARRATION) Bill was one of the first patients to receive an
experimental treatment being tested by Scott Shikora and his team
the group that treated Amy and Rodney. The new treatment
is much less traumatic than bypass surgery, less invasive even than
the lap band. It's an implantable stomach pacer similar to a heart
pacemaker. Bill is one of an initial trial group who had implants
4 years ago. He's lost 70 pounds, and now he finds he can keep it
Before, I could probably eat two of these sandwiches, where now
I can eat a sandwich and probably I'll hold off until supper time,
because I'll feel a lot more satisfied with this sandwich. Before,
there's cookies, and then I'd graze a little bit for whatever is
in the cabinet. Now I don't have to do that, and I attribute that
to the device.
SHIKORA Now I'm creating the pocket that we're going to plant the
ALDA (NARRATION) The results with Bill's group were promising enough
that a new, large trial is beginning. The surgeons carefully mark
the points on the patient's stomach where the pacer's electrodes
will be implanted. They have to be close to the nerve bundle which
runs from the stomach to the brain.
SHIKORA You see here are the electrodes, and this length has to
be completely covered by stomach wall. So we measure.
ALDA (NARRATION) Implantation is done laparoscopically, for minimum
impact on the patient. The laparoscopic camera shows the electrode
lead being snaked into the abdominal cavity. Now comes the tricky
part. The electrode has to be positioned within the stomach wall.
If it penetrates into the stomach interior, it would cause infection.
So the surgeons use a second camera inside the stomach to check.
SHIKORA We don't want to see any metal.
ALDA (NARRATION) It looks as if the electrode at the top
of the screen has indeed just pierced the stomach wall.
SHIKORA I'm deep, so now I'm going to just back it out and reposition
ALDA (NARRATION) The pacer is turning out to be extremely safe.
To date there have been 600 implants worldwide, without a single
death or even major complication. Scott repositions the electrode,
and they re-check the interior view of the stomach.
TARNOFF See anything Dave?
I do not see the needle.
ALDA (NARRATION) Two electrodes are implanted, and their leads connected
to the pacer.
SHIKORA Alright. Let's check it.
ALDA (NARRATION) Then before it goes into the body, the pacer's
connections are given a final check, using a remote interrogator.
The same system will be used to control the pacer in the coming
months and years.
KOSKO OK, it's good.
ALDA (NARRATION) This is one of 190 patients in the new trial, which
like all such studies has to follow strict rules.
KOSKO The next step is the patient will come back in 14 days, and
at that time they will be randomized to either on or off. It's a
double blinded, randomized, placebo study, so neither the company,
nor Dr. Shikora nor Dr. Tarnoff know who will be on, who will be
SHIKORA Or the patient.
KOSKO Or the patient.
ALDA (NARRATION) The patients will be followed for a year. That's
Stephanie on the table. A couple of days later we visited her at
home. Only people who would qualify for bypass surgery, by being
at least 100 pounds overweight, are in the trial. But the pacer
is potentially a more attractive option than surgery.
I wasn't comfortable with such a harsh surgery, and cutting my stomach
down, and knowing that there are so many complications. I don't
think I was at that point where I was able to risk my life for it,
because it wasn't destroying me physically. I was still able to
ALDA (NARRATION) They found in Bill's trial that the pacer only
seems to work for people, like him, who are grazers constantly
eating, but a little bit at a time. Somehow the pacer makes you
feel full, and grazers can respond to that signal. It doesn't work
for binge eaters people who eat a lot and ignore all fullness
Which of the statements do you agree with most?
ALDA (NARRATION) So in the new trial, likely binge eaters like this
have been screened out.
I feel incapable of controlling urges to eat. I have a fear of not
being able to stop eating voluntarily.
ALDA (NARRATION) Whereas Stephanie's classic grazing behavior is
the kind they can probably change.
I try to take small portions and then eventually I just get bored
with the food, and I'll stop eating it. And then half and hour,
maybe not even an hour, later I'll start snacking. And I pretty
much will do that continually for the rest of the night.
ALDA (NARRATION) We're back with the obesity surgical group. Bill's
on the table, fully awake. Using local anesthetic, Mike Tarnoff
is replacing Bill's pacer, because its battery has run down.
TARNOFF So there's the device. There's the single lead.
ALDA (NARRATION) Bill's early model pacer used one implanted electrode.
Two seem to be better, although it's not really clear why.
TARNOFF There's some thought now that by using the dual lead system
we're capturing more of the neurovascular bundle.
ALDA (NARRATION) Exchanging the pacer is a simple matter. New units
run for up to 18 months, depending on the particular patient. We'll
see why in a moment, when Bill's new pacer is switched on.
TARNOFF Right, give that another push. OK.
ALDA (NARRATION) The system is interrogated.
HARRISON OK, impedance numbers look. OK.
ALDA (NARRATION) And in goes the new one.
TARNOFF Bill, we're just putting some stitches in. Everything looks
Let me just have you sit up here now. Just sit on the side of the
bed here. Get your balance a little bit.
ALDA (NARRATION) Next it's time to switch on. Now the pacer's interrogated
through the skin.
HARRISON We're going to turn the device on, and you let me know
what you're feeling -- any symptoms, like cramping, stimulation.
OK I can feel something now, shooting right across here.
HARRISON So you're feeling it up in your chest?
It's like a tightening in here, right across, a shooting pain.
HARRISON We don't want the patient walking out of here with that
feeling. So what I'm going to do is to set the device so that it's
pacing, but just below the threshold of his symptoms. Do you still
have the symptom?
HARRISON No. It's gone?
It's gone, yeah.
HARRISON Patients have very different sensations with this pacing.
When we go through the programming, I'm actually quite amazed at
how many different symptoms we get. Some patients almost feel nothing,
even with very high voltage, and other patients are very sensitive
to this pacing.
ALDA (NARRATION) Battery life will depend on how high the pacing
voltage has to be set. If the pacer is eventually approved, it'll
be an important new weapon in the battle against obesity. It's much
less risky than the bypass surgery that Amy and Rodney had. So it
could be used for children or the elderly both groups with
increasing numbers of the obese, but for whom major surgery is too
drastic a step. It seems startling to be talking about such widespread
use of surgical treatments for obesity, but for Scott Shikora, this
is something we have to do.
SHIKORA We hear a lot of comments about, Why are you treating people
when their problem is they just can't stop eating? But obesity is
a much more complex problem than that, and it is a disease. And
if we're willing to do heart surgery, and lung surgery on smokers,
and we're willing to do liver transplants on patients who have destroyed
their livers from alcohol, I don't see how obesity is different.
People are very condescending to people that are obese, right? I
think it's the last of the great prejudices. You can't call a man
an ethnic name, but you could call him, or use the word "fat", and
no-one would be ashamed of it. You know, no-one would even pick
up on it, you know what I mean? I would say to anybody that thinks
that, you know, devices or whatever... I'm losing it a little bit
on this, but... People that never had a weight problem don't understand
what it is to have a weight problem. They're very sympathetic to
everything other than -- that person did it to himself, and they
don't realize that a lot of us didn't do it to ourselves.
SHIKORA By performing surgery we're giving people another shot at
life. They can live longer, they can live healthier, and they can
be more productive.