Extreme Measures

By staff November 1, 2001

Editor's note: due to a production error, another author was incorrectly credited with this story in the November issue of SARASOTA. We regret the error.

Iris Starr landed in Sarasota five years ago to open Saks Fifth Avenue, and immediately became one of the most recognizable faces in town. With her impeccable grooming, New York accent and self-assured manner, she seemed the very epitome of a high-powered fashion executive; and as Saks' general manager, she had the perfect entrée into the social scene. She dressed the most stylish people in town, made it a point to attend her customers' society fund-raisers and worked on dozens of them herself, joining boards and committees from the Sarasota Film Festival to Goodwill to the Y and the Humane Society. Since her arrival here, Iris has helped raise more than $1 million for local charities, won community awards and made the Sarasota Saks a model for local involvement among the 63 affiliates around the country.

Many of her customers became close friends, inviting her to their weddings or their summer homes in the Hamptons, even bringing her thoughtful gifts. After one of her two beloved dogs died, for example, restaurateur Michael Klauber gave her a Shih Tzu puppy.

Iris says she felt immediately at home in Sarasota. "The people here are the nicest bunch of people I've ever met," she declares.

But despite all her friends and accomplishments, Iris was unhappy. At 5-feet, 5-inches tall and 280 pounds, she was, by anyone's definition, fat. For years she had struggled to control her weight, but all her efforts and resolutions had failed, and she felt increasingly powerless over the problem.

Iris-like six million other Americans-fell under the clinical description of morbidly obese, meaning she was more than 100 pounds overweight. "I've been badly overweight for 10 years since I stopped smoking and gained 60 pounds," she says.

But the problem really began even before that. The daughter of Jewish Russian immigrants, she was raised in the Bronx where her father was a kosher butcher with his own shop. Food was central to family life. "We were big meat eaters," she says. "Meals were the most important part of the day. Potatoes, noodle pudding, all that stuff that clogs your arteries. Everybody in the family was overweight."

Like most obese people, Iris had tried every method of dieting: Weight Watchers, liquid diets, fen-phen. She even went to a spa in Tucson, Arizona, for two months in 1990. "It cost $16,000, and this is all I have to show for it," she says, pointing to a ceramic mug that she made at the spa and now keeps on her desk at Saks. "The most I'd ever lose was 50 pounds," she says.

But in other ways, Iris was luckier than most of the extremely overweight. She had to take medicine for high blood pressure and indigestion, and her knees hurt from carrying so much extra weight; but she didn't have diabetes, heart disease or sleeping problems. Confident and outgoing, she was always a stylish dresser, never hiding under big baggy T-shirts or dresses that looked like housecoats. She shopped at Saks in Tampa, which carried large sizes, at Lane Bryant or through catalogs. Then she'd have everything altered to hang properly. "A sloppy fat person makes me nuts," she says.

And Iris' energy level was good, too, high enough to keep her rushing around at work on the floor all day and at social events a few nights every week. Still, she couldn't shop for clothes in her own store (although this winter the Sarasota Saks will start carrying extra-large sizes), and she was surrounded by the obsessively thin culture of the fashion industry. She wanted to be able to dance and not be out of breath, and maybe, just maybe, get asked out on a date.

"I didn't like myself being fat," she says, "but I wasn't sick or embarrassed or shunned like other people. Maybe if my name wasn't Iris Starr, general manager of Saks Fifth Avenue, I might have had more trouble." Still, Iris says, "I couldn't see myself dying as a fat person." So Iris, like 50,000 other patients this year, elected to undergo gastric-bypass surgery-a procedure in which a surgeon staples the stomach shut to a fraction of its original size, then reattaches the small pouch that remains to the small intestine. A normal stomach can hold about a quart of food and liquid; the stapled stomach has the capacity of about a shot glass. Iris says her bariatric surgeon, Dr. Michael Butler, who has offices in St. Petersburg and Altamonte Springs (no surgeon performs the procedure in Sarasota or Manatee counties), held up his thumb and told her that's the size her stomach would be after the surgery.

Developed in the 1960s, gastric bypass is the only method with a successful track record in treating morbid obesity. Despite the constant barrage of information about weight loss in books, magazines and other media, the best efforts of nutritionists, fitness counselors and doctors and the desperate attempts of the overweight, most dieters -whether they're trying to lose 10 pounds or 100 pounds-fail. Five years after the diet, the weight we lose almost invariably comes back, according to a 1993 National Institute of Health study. Think about Oprah Winfrey's public battles.

Not so with gastric bypass. A recent article in the New Yorker reports that most gastric bypass patients lose two-thirds of their excess weight (more than 100 pounds) within a year; and at 10-year follow-ups, most patients had regained only 10 to 20 pounds of their initial weight loss. A 1995 study cited by the Gainesville-based American Society of Bariatric Surgery (ASBS) reports that 14 years after the surgery, most patients still have managed to keep off more than 50 percent of their original weight loss. "No other diet can claim that," says Georgeann Mallory, the executive director of the ASBS.

Caution is in order here, however. Skeptics in the medical community (such as Paul Ernsberger, an obesity researcher at Case Western Reserve, quoted in the New Yorker) say that long-term studies still need to be conducted, and that no one really knows how gastric bypasses will affect patients' health decades down the road.

Still, the initial benefits of the surgery can be striking. Diabetes and high blood pressure disappear, sleep problems vanish, arthritis improves and cholesterol levels drop.

And yet, gastric-bypass surgery is controversial. It is a risky surgery, complicated by the long list of tricky medical conditions the very obese already have. About three persons in 1,000 will die from the surgery, according to ASBS's Mallory. Other patients experience serious complications, from bowel obstructions to leaks in their intestines to blood clots. (Iris was well aware of the risks since her older sister had a similar surgery years ago with serious complications. The surgery eventually failed, and her sister had to undergo a second gastric bypass.)

Mallory hastens to add, however, that many other surgeries carry risks as well, and that many morbidly obese patients need such surgeries to replace joints, repair hearts or remove gall bladders that have been damaged because of their weight. Others face premature death because of their medical conditions. And certainly many of them are leading lives of suffering and despair.

Butler runs a support group for gastric bypass patients at Palms of Pasadena Hospital in St. Petersburg, where he does his surgeries. At a recent meeting, patient after patient stood up and recited the problems they face every day. "As big as we are, we're invisible," said one woman. "People don't look at you, don't talk to you." Another patient testified, "I couldn't walk in a shopping mall. I couldn't tie my shoes without getting out of breath." "I've been married for 27 years," said Paula Quillen, a 480-pound Clearwater Beach woman who has a long list of medical problems. "I can't remember the last time I've been able to sleep with my husband because I have to sleep sitting up."

Nonetheless, many doctors and insurance companies, not to mention family and friends, see the surgery as unnecessary. "I've had six doctors tell me I have five years to live; and yet, my insurance company considers the procedure cosmetic surgery," says Quillen. There's a sense that people who resort to this surgery are really just lazy, that they suffer from a simple lack of willpower, says Butler. "There's so much prejudice," he says. "It's the last bastion of prejudice," agrees Mallory. "People look at it [morbid obesity] as sin and sloth."

Instead, say Mallory, Butler and other experts, morbid obesity is a complicated medical disease with roots in genetics, psychology and environment. While environmental causes (eating too many Big Macs and drinking too many chocolate shakes) and psychological reasons (eating out of stress, abuse or neglect) can be controlled to some extent, genetics cannot. "Some people have a propensity to store fat," says Mallory. "If they were shipwrecked on a desert island with no food, they would be the last ones to die."

Despite the controversy, the number of procedures performed has increased at a rate of 25 to 30 percent in the last couple of years. Helping to fuel the increase was Carnie Wilson, the daughter of the Beach Boys' Brian Wilson and a member of the singing group Wilson Phillips, who invited the public to follow her gastric bypass experience on the Internet in 1999. Critics say that this is exactly the kind of salesmanship that shouldn't occur with a serious surgery and that the procedure's $20,000 price tag can encourage unscrupulous surgeons to prey on desperate patients who have a poor sense of self-worth. Such patients are willing to pay the enormous cost of the operation (if insurance doesn't cover it), spend three to five days in the hospital, go through significant pain and a complete change in lifestyle just to fit society's notion of beauty.

Iris says her surgery (for which Saks benefit department paid half; she paid the other half, since her health insurance wouldn't cover it) was very painful; and even six weeks afterwards, she feared she'd made a mistake. Afraid to eat and drink, she landed back in the hospital four weeks after her original surgery because of dehydration.

Initially, Iris had to force herself to get 800 calories a day when her surgeon's nutritionist was urging her to eat 1,000. The diet of a gastric-bypass patient is spartan by American standards. No more carbonated beverages, popcorn, nuts, greasy or fried foods, red meat or sugar-that's right, no birthday cake, no apple pie, no hot fudge sundaes or chocolate cookies-ever again. Because the surgery can impair absorption in the intestine, all gastric-bypass patients will have to take two multi-vitamins for the rest of their lives. They will also have to be extremely conscious of eating their protein first, since the stomach is so small it can be easily filled up by a piece of bread.

So far, says Iris, she doesn't really miss eating, although a juicy steak and a glass of red wine would be nice. She's ecstatic that only three months post-op she's lost 65 pounds and is a size 16-a little more than halfway toward her goal of losing 125 pounds and already four sizes down from her previous size 24. 'I can't believe it's me," she says. She's given away much of her old wardrobe and thrown away eight pairs of shoes. And for the first time, she is buying clothes in the Sarasota Saks. She's also doing water aerobics and walking on the treadmill two to three times a week at Bath & Racquet. She's off her high blood pressure medicine and her prescription for indigestion.

Right now, Iris is in the phase of rapid weight loss; but this period eventually ends and weight loss become more gradual and then stops. Many patients experience a 10- to 20-pound weight gain once the new stomach stretches a bit. They must eat a healthy diet and exercise like everyone else if they want to keep all the pounds off.

Mallory says most patients never regain the original weight, but it's not impossible. "The stomach is a muscle and it will stretch," she says. "You wouldn't be able to eat large meals, but if you nibbled all day long, you could gain weight again. Gastric bypass is only a tool."

Iris says she's not worried about regaining weight. Nor is she worried about the plastic surgery she assumes she'll have to have to nip and tuck all the excess skin that will hang once she's lost all her weight. "Everything is already starting to jiggle," she says. But right now, like many gastric-bypass patients who feel like they're getting their lives back, she's just happy. Her advice to anyone considering the surgery: "Just do it."

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