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Woman with diabetes reduces risk to have baby safely

By Shay Maunz

CLARKSBURG, W.Va. -- Nancy Robinson was always a bit "chunky," even as a kid, she said. "I was always a free spirit and dressed cute anyway. I didn't really care if I was a little too big or my skirt was too short."

She played sports in school and "ran around the neighborhood playing all year."

But 20 years later, looking back on her childhood eating habits, she cringes: midday snacks big enough for meals, butter-slathered vegetables at every dinner.

Her eating habits caught up with her in her 20s. At 28, Robinson, of Clarksburg, weighed about 350 pounds. She was morbidly obese with severe diabetes and sleep apnea caused by her weight.

Then she and her husband decided to have a baby. "The doctor said if I got pregnant, taking so much insulin, it would probably kill me," she said.

"I looked at my husband and realized that food was ruining my life, and I had to do something drastic." She had tried fad diets for years. She lost, then regained, 30 pounds many times. She'd seen trainers and doctors. But the amount she needed to lose to have a baby safely was daunting.

Both her parents were obese. When her dad died of obesity-related causes, the emotional toll caused her to eat and gain even more.

In 2011, she underwent Roux-en-Y gastric bypass surgery, a common weight-loss tactic.

"A lot of times, people kind of give me flak for taking the 'easy way' out," Robinson said, "but I'm here to tell you it's not the easy way out."

In gastric bypass surgery, a person's stomach is stapled into a small pouch that can hold only about 4 ounces, a fraction of what it previously could. The surgeon connects the pouch to the small intestine.

Robinson's stomach pouch was so small after surgery that she struggled to consume 600 calories a day. Like many other patients, she had "dumping syndrome" for a while, in which the person feels nauseated and vomits or defecates after eating because their small intestine can't handle the food.

The surgery was only a first step, Robinson said. Now she exercises vigorously six days a week, often with a trainer, and weighs everything she eats. "I needed the surgery," she said. "But it didn't end there. I still had a lot of work to do, and a lot of adjusting to do to this new lifestyle.

"I want to be the kind of mom who runs with her kids, not the one who sits on the bench and watches," she said.

She takes a daily vitamin regimen to make up for what her body isn't absorbing through food. About 10 percent of patients develop lactose intolerance and can't digest milk or milk products. Robinson escaped that but did develop psoriasis. "My doctor wasn't sure if it was because of the surgery or the sudden weight loss," she said.

After surgery, patients often lose between 62 and 70 percent of their excess weight, though many patients regain up to 20 percent, bariatric specialists say.

Robinson's blood sugar dropped into normal range after surgery. According to a 2012 study published in the New England Journal of Medicine, the blood sugar of 42 percent of gastric bypass patients drops into normal range after the surgery restricts the amount they can eat. There are no long-term studies showing if blood sugar stays low.

National experts disagree about the lasting impact and safety of the surgery. "I'm very cautious about who I recommend it to," said Holli Neiman-Hart, residency director in family medicine at the WVU Health Sciences Center. "I think a lot of us who are overweight just want a quick fix, and it's really not that."

Not a decision to take lightly

In 2009, about 250,000 Americans had weight-loss surgery, according to the American Society for Metabolic and Bariatric Surgery. The number has doubled in the past decade. More than 20 million are morbidly obese, so about 1 percent of the eligible population have the surgery.

Guidelines from the National Institute for Health recommend bariatric surgery when a person is morbidly obese (heavier than 99 percent of people at his or her height) or has a BMI of at least 35, with at least one chronic condition such as diabetes or heart disease.

In the 1950s through the early 2000s, the procedure was performed through a sizable incision. "You can imagine, with the health risks associated with [the people seeking surgery] that it was often very risky," said Robin Blackstone, president of the American Society for Metabolic and Bariatric Surgery.

Around 2000, surgeons began to perform the surgery laparoscopically with tiny cameras through incisions less than a centimeter long. Now, about 93 percent of bariatric procedures are done laparoscopically.

Proponents say the death rate is now about 1 in 400 patients, but critics say that ratio includes lap-band surgeries that do not involve cutting the stomach. For bariatric surgery alone, the death rate can be as high as 1 in 200, critics say.

"The biggest problem with it is our inability to predict who is going to do well and who is not," Neiman-Hart said. "It's not a decision that I encourage my patients to take lightly."

Other nonfatal risks include infection, ulcers, heart attack, hernias and wound reopening. "Any time people elect to go in to have surgery, they're weighing individually the risks and benefits," said Blackstone.

Robinson's desire to have a child outweighed possible dangers in her mind, even though she had to pay $16,500 out of her own pocket for the surgery. Her insurance company, United Health Care, would not pay for it.

Nationwide, such surgeries cost between $20,000 and $40,000.

Most major insurance carriers include provisions for weight-loss surgery, but in practice they rarely cover the procedure, a survey of insurance guidelines shows. Aetna's guidelines, for example, say certain Aetna plans exclude coverage of bariatric surgery altogether and that "most" plans require that the procedure to be "approved by Aetna." Cigna and United Health Care include similar notes.

"It nearly broke us," Robinson said. "I mean, we were digging into places we didn't even know were there looking for money." To save on food costs, she even extended the required two-week presurgery diet of liquids and protein shakes to three weeks.

"I had to make up that extra cash somewhere," she said. "There was nowhere else left to find it.

"I said we couldn't afford it, but my husband just said, 'We can't afford not to,'" Robinson said. Without the surgery, they reasoned, they wouldn't be able to live out the lives they had planned. They wanted children and the mobility to travel.

"We decided we had to do it, spend the money," she said. "But it was so hard for us."

Blackstone said, "I always tell my patients that if you can lose 100 pounds and you keep it off, that's the holy grail. It's just that a lot of people can't do that without the surgery. They need tinkering."

Researchers at the Catholic University of Rome compared 30 patients who had gastric bypass surgery with 30 who received conventional medical therapy for diabetes. After two years, 75 percent of the gastric-bypass patients no longer had blood sugar in the diabetic range. All the patients who had medical therapy were still diabetic.

How does the surgery bring blood sugar down into normal range? Experts now realize that effective surgeries affect the body's metabolic processes. "They change the way your hormones work with the brain. They change your preference for food," Blackstone said.

Since her surgery, Robinson has overhauled her life. Her diet and exercise habits have improved substantially, partly because of a change in taste, she said, but also because of a lot of hard work.

Weight-loss surgery isn't a silver bullet for the country's obesity epidemic overall, Blackstone said. "For now, we're using obesity surgery as a window to figure this all out," Blackstone said. "There may always be people who need this kind of surgery, but I'm hoping it will just be in very extreme cases."

Now Robinson is considering teaching Zumba, something she could not do a year ago. "The exercise, not the surgery, got me in shape," she said. "It would be a big mistake to think surgery alone can fix the problem."

She is not yet pregnant, "but it's a lot more fun trying, now that I'm in shape," she said.

Shay Maunz is a West Virginia University journalism student. She wrote this story as part of the "West Virginia Uncovered" class, in cooperation with the Charleston Gazette series "The Shape We're In." Series coordinator Kate Long contributed to this story.


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