BODY: The guests at the Christmas party looked like anyone else - ordinary people chatting in small clusters, nibbling appetizers and sipping drinks. But for most, looking ordinary had long been an elusive dream.
The 30 or so guests of honor were previously deemed "morbidly obese," meaning they had been at least 100 pounds over their ideal body weight. That was before they underwent gastric bypass surgery, which greatly reduces the amount of food a stomach can hold. Instead of a storage capacity of one to two quarts, the stomach is stitched up to hold just one to two ounces, and food bypasses much of the stomach and small intestine.
Now, half a turkey sandwich and a bowl of fruit makes them feel as jampacked as a Thanksgiving dinner.
"Before I never felt full, even though I ate and ate," said Debbie Pruitt of Chester, one of the guests at last week's Christmas party for patients who had the surgery at the Medical College of Virginia Hospitals. Pruitt, 40, has lost 123 pounds in 13 months. "Now I eat just a little and I feel stuffed," she said.
Back and joint pain, caused by the stress of carrying so much extra weight, usually dissolves along with the excess fat. More serious health problems, such as high blood pressure and diabetes, also improve dramatically.
Emotional benefits can be equally stunning.
In a culture that glorifies thinness, the seriously obese too often suffer social rejection. "The world treats you differently" when you're overweight, said Gail Mays, who's 42, 5 feet 3 inches tall, and 107 pounds lighter since her bypass surgery last December. She now weighs 124 and wears a size 6 or 8 petite instead of a 22. "I didn't really know how bad the prejudice against heavy people was until I wasn't there anymore," Mays said in a tone of delighted wonder.
"People open doors for you. People look you in the eye. . . . But it's two-fold. You have more confidence. I walk with my head held up instead of down."
Six months after the surgery, her husband, Bill, also underwent the procedure and is also thrilled with the results. At 5 feet 10 inches, he's seen his weight drop from 310 to 225.
His energy level has gone through the roof, he said, and he and his wife now walk 3 1/2 miles every day through their Brandermill neighborhood.
A certified chef, Mr. Mays has given up sugar, which gastric bypass patients have difficulty digesting. Whether the sugar is in liquid or solid form, it causes bypass patients to almost immediately become nauseated, light-headed and sweaty.
Mrs. Mays, who works as an office manager for State Farm insurance, said her sugar cravings have disappeared. She's been amazed by the life changes her weight loss has wrought.
"For the first time in my life someone whistled at me," she said. "In my whole life no one ever whistled at me. I even looked around to see who they were whistling at. And there was no one around but me. I couldn't believe it."
But the best benefit of the surgery, she said, is how much better she feels. "Probably the biggest difference is the energy level," she said. "I feel like a different person. I don't ache, I don't hurt, I don't have headaches any more. . . . I didn't know what it was like to feel this good." * * *
While most of the party conversation was cheerful, talk turned time and again to frustration over insurance coverage for obesity.
Trigon Blue Cross Blue Shield recently announced that beginning Jan. 1, its HealthKeepers health maintenance organization will no longer cover surgery for obesity. Dr. Harvey J. Sugarman, who with his partners, Dr. John Kellum and Dr. Michael Schweitzer, performs about 160 gastric bypass surgeries annually, believes the decision makes little economic sense.
The surgery has a tremendously beneficial impact on so many serious and costly health conditions, Sugarman said, that it's hard for him to understand Trigon's decision. For example, 95 percent of patients with Type II, non-insulin-dependent diabetes show no signs of the illness one year after surgery.
Patients with obesity hypoventilation syndrome, who can't breathe well because their excess weight squeezes their lungs, have "dramatic improvements in blood gases and correction of their breathing problem" after surgically induced weight loss, Sugarman said. Patients with constant headaches caused by similarly high pressures within the brain also benefit greatly: 95 percent have complete correction of their headaches and a decrease in their intracranial pressures at an average of three years after the surgery, he said.
Stress-induced incontinence, which is quite common among the severely obese, usually disappears. So does sleep apnea, a potentially life-threatening disorder in which breathing intermittently stops during sleep.
Finally, the operation produces lasting results, although Sugarman acknowledged that "there is slippage" over time. The average weight loss is about 120 pounds, and the average patient loses two-thirds of the excess body weight within one year of surgery. The average weight loss at five years is 60 percent of excess weight; at 10 years, it's 50 percent. So it's not a magic cure for obesity, and the patient's continued diligence and commitment are required.
"Patients know in advance that this is an operation that requires their effort," Sugarman said.
"The long-term follow-up shows significant weight loss efficacy up to 14 years after surgery," Sugarman said. No other weight-loss remedy comes close to matching the surgery's success.
But insurance officials point out that medical and insurance costs keep rising, and something has to give.
Health care expenditures now comprise about 14 percent of the U.S. gross domestic product - about one trillion dollars per year, or $ 4,000 for every man, woman and child, according to Brad C. Jones, a health care business attorney and president of MedAccord, a health care management consulting firm in Charlottesville.
"He who pays the piper calls the tune," Jones said. "The new tune is not any health care at any price, without proven performance; payors want . . . a strong relationship between the care provided and the dollar spent."
Brooke Taylor, a spokeswoman for Trigon Blue Cross Blue Shield, said the decision to begin excluding coverage of obesity treatment in the HealthKeepers plan was driven by her company's decision to offer services that "bring the greatest benefit to the most people in a way that's cost effective."
HealthKeepers is the least expensive insurance plan Trigon offers, Taylor said, so it can't include coverage for every conceivable medical malady. Other services that HealthKeepers will discontinue beginning Jan. 1 include coverage for infertility and penile implants.
Trigon has covered gastric bypass surgery through its HealthKeepers HMO since July 1995. Of Trigon's 1.8 million Virginia members, 293,000 are covered by HealthKeepers.
Other Richmond-area HMOs that cover gastric bypass surgery when medical criteria are met include Cigna HealthCare of Virginia, Inc., and PruCare of Richmond. "The reason we made the changes is because the services are all elective in nature and are used by a small percentage of the population," Taylor said. "HealthKeepers works through shared risk. We're trying to ensure that the most people gain the most benefit in the most cost-effective manner. What we found is that a large part of the market doesn't value the services enough to pay more for them."
Taylor also noted that the rising cost of health insurance is forcing some employers to stop offering health insurance benefits of any kind to employees.
"There needs to be some low-cost options in the marketplace - that is a marketplace need," she said. "Many employers wouldn't offer any health insurance coverage if there wasn't a low-cost option. So you have to balance all those things when you decide your benefit plans."
Other Trigon policies will continue to offer obesity treatment, Taylor said. But doctors who treat obesity say that many employers offer only HealthKeepers to their staffs, and employees don't have the option of paying extra for a more comprehensive plan. Their only alternative would be to buy an individual policy on the open market, and then odds are good that obesity treatment wouldn't be covered for at least a year because the obesity would be a pre-existing condition.
The lower-cost HealthKeepers alternative isn't just the choice of small businesses that have a hard time paying for health insurance, though. Beginning Jan. 1, the vast majority of Trigon employees will also have just one insurance option: HealthKeepers.
Dr. Thomas Pozefsky, an assistant professor of medicine at Johns Hopkins University, treats obesity patients and sometimes recommends surgery. While the surgery produces great results, he said, Trigon's decision to stop covering it in its HealthKeepers plan "is reflective of what is probably more typical across the country."
"Here in the Maryland area, I deal with a lot of insurance companies," Pozefsky said. "It's one of those things that insurance companies tend to exclude."
Pozefsky speculated that insurers are more concerned about this year's bottom line than about the cost of diabetes complications or knee and hip replacements that might be necessary five years down the road.
Gastric bypass surgery represents the "third-generation" of surgical procedures to deal with obesity, Pozefsky said, and has proved far more effective in achieving permanent weight loss than its predecessors, and with fewer complications.
"There have been bad results with Generation One, which was intestinal bypass, and Generation Two, which was gastric stapling," Pozefsky said. "I think we're into Generation Three now, with fairly sophisticated procedures, and . . . the results are very good."
Dr. Neil E. Hutcher, whose surgical group, Commonwealth Surgeons, Ltd. at St. Mary's Hospital, performs about 300 gastric bypass operations each year, said he's afraid that Trigon's action will have a domino effect on other insurers that serve Virginia patients, since Trigon is considered the industry leader and trendsetter.
Trigon's decision to eliminate obesity treatment from the HealthKeepers plan is short-sighted, Hutcher said.
"Here we give life," Hutcher said. "We do away with diabetes, bone and joint complaints, high blood pressure.
"But our patients don't have a lobby. They don't have anyone to stand up for them. You try to eliminate coverage for an AIDS patient and there would be demonstrations in the street. Until we can get a lobby or someone who will speak for this large number of large people, they're going to take the brunt" of cost-saving strategies.
Sugarman said he and Hutcher met recently with Trigon officials to point out all the costly health problems that are eliminated after patients are no longer dangerously obese.
"I've said to them - what's going to be your cost five years from now, when you have to pay for total hips and total knees that these people are going to break down? . . . What about diabetic blindness, or their intensive care unit treatment for their breathing problems? And they have no answer for that."
Gastric bypass surgery costs about $ 20,000 to $ 30,000, while hip and knee replacements cost $ 30,000 to $ 40,000. It's difficult to estimate the cost of diabetes complications, because they can be so varied. And the value of holding on to eyesight or avoiding amputation is incalculable.
Both Sugarman and Hutcher stressed that their concern is not based on fear of losing patients and their business, since HealthKeepers' clients represent a small percentage of their surgical patients. "It's for our patients, not for profit," Hutcher said. "I get paid so little from HealthKeepers that next to Medicaid, the lowest reimbursement is HealthKeepers. So it's not my money that's got me on this crusade."
Added Sugarman: "It's just so sad. These patients are so miserable and they are so ill. And the nice thing about the surgery is that all of it, except the joint damage, is reversible.
Besides the measurable physical improvement, something inexplicable seems to happen to the attitudes of gastric bypass patients, Hutcher said.
Their addiction to food is less urgent, and lasting weight loss is possible. "It's a life-altering experience, and not just from a physical point of view," Hutcher said. "Somehow, food is no longer the central part of their life.
"I call it 'putting out the fire.' The fire is this all-consuming feeling that burns within these patients that has them thinking about food - pursuing food, being guilty about food -- day and night. They wake up in the morning thinking about what they will eat and they go to bed at night planning tomorrow's meal. . . . What we do puts that out, so that the patient becomes the master rather than the slave of the appetite."
Hutcher is at a loss to explain why patients are suddenly in harmony with a daily caloric intake of about 1,200 calories and are able to give up sugar. "But it's profound," he said. "They wake up almost in the recovery room and feel that they're different. One of the most common things my patients say is 'Well, doc, you really messed with my mind, didn't you?'" * * *
Something radical has changed in Becky Miller's attitude toward food. Before her gastric bypass surgery in June 1996, the 27-year-old mother of two weighed nearly 400 pounds.
"I ate a lot of sweets," she said. "I could stop on the way home from work and eat a box of Ho-Ho's - I mean a 12-pack of Ho-Ho's.
"Now I don't eat sweets at all."
She's lost 227 pounds and weighs less than when she was 11.
"I had tried everything - every diet, diet classes," Miller said. "I just couldn't stick to it. But with this, it was a once-in-a-lifetime opportunity. I don't want to do anything to mess it up."
Concern for her children made her realize she had to get a grip on her weight problem. "I was afraid of dying - that I was going to die from being overweight," said Miller, a Hopewell native and master docket clerk with the Social Security Administration.
Health problems before her surgery included back pain, knee pain, incontinence and fatty infiltration into her liver that worried her doctors.
"My chest would hurt and I would wonder if I was having a heart attack," she said. "It was scary being so overweight."
Now she coaches soccer, has home exercise equipment that she uses regularly, and has realistic hope for a normal life.
"It's incredible to watch her out there chasing 10-year-olds on the soccer field," said her husband, Tim. "Now it's my kids begging me to slow down," she said.
"This was definitely a lifesaver for me." MORBID OBESITY
* Definition: Morbid obesity is defined as 100 pounds or more overweight or at least twice the ideal body weight.
* Problems: Morbid obesity creates serious problems ranging from headaches to worn joints to diabetes complications such as diabetic blindness.
