At 1.40pm on 16 June, two nurses wheel Kirsty Franks into the operating room at St Richard’s hospital, Chichester, where her surgeon, Christopher Pring, is waiting. Franks is 19, weighs 114kg (18 stone) and, at 1.5 metres (5ft), this is having a catastrophic effect. Mockery at school has left her anxious and sad, and going out is a torment: the fear of being stared at keeps her virtually housebound. With her health failing, she no longer has anything resembling a normal life. So she has come for a Roux-en-Y gastric bypass, the most radical treatment for obesity. It is, as one surgeon puts it, “a mutilating operation” in which a person’s innards are rearranged with the aim of reducing eating. And it is booming in popularity.
More than 8,000 patients had weight-loss surgery in 2012-13, according to NHS figures – a 30-fold increase in just over a decade. They were not only middle-aged and long-term obese, but teenagers and young people, too: 570 under-25s had surgery between 2010 and 2013, according to the UK National Bariatric Surgery Registry, and nearly 40% of these were “super obese”. Despite healthy eating edicts and government campaigns, they had, in their short lives, already advanced through the obesity categories – obese, severely obese, morbidly obese – and now, at super obese, were more than twice the weight they should be.
Treating the side-effects of type 2 diabetes costs the NHS more than £8bn a year. A gastric bypass costs a relatively affordable £6,000. Pring, a slim, energetic man, says he typically does three bypass procedures every Tuesday at St Richard’s, and around 200 a year (age range 18-70). Today is unusual because he’s spent the morning at his child’s sports day, so has reduced his operating list to two: Franks and a woman in her late 40s.
Franks is now laid on the operating table with a breathing tube in place and a disposable sterile drape leaving only her abdomen exposed. For the past two weeks she has been on a strict diet to prepare her body for surgery: four pints of semi-skimmed milk a day, plus two pints of water or sugar-free squash and a salty drink such as Bovril – but no food. Obesity can lead to a heavy, fatty liver that can obstruct the surgeon’s view of the stomach; this diet is designed to shrink the liver. Franks marked the beginning of her diet (and the end of her old life) with a KFC.
Pring listens to music while he works, and David Bowie’s Rebel Rebel plays as he makes small cuts across Franks’ abdomen. He then inserts five small “portholes” for his instruments, and I begin to see inside Franks’ belly on monitors showing images from Pring’s keyhole camera.
“All the yellow stuff you see is fat,” he says as his camera pushes through skin to gleaming globs deep inside. Franks’ bowels are covered with an apron of it, too, but her stomach looks ordinary: a smooth, bean-shaped bag the size of two fists.
Working with both hands and frowning at the monitor, Pring reduces the size of her stomach by 90% by creating a “stomach pouch”, a stapled-off part the size of an egg. Before the operation, her stomach could accommodate nearly half a litre of food; now, it will hold two tablespoonfuls.
The aim, Pring says, is not only to restrict what Franks eats, but also to inhibit its calorific impact. In other words, to reduce her body’s ability to absorb sugars, fats and proteins. This he achieves by rearranging her intestines, picking through them and, somewhere among the glistening loops, cutting a section in two and rerouting the ends. With the lower end brought up and connected to the newly created pouch, food will empty straight into the middle part of the small intestine, where most digestion takes place. With the stomach pouch too small to churn food, Pring takes the higher bit of cut intestine (which led from the original stomach) and joins it to the lower end of the bypass he’s created. Gastric juices produced by the stomach will flow down this channel to meet food, which will still be broken down and converted into energy, but because it is farther down the digestive system, it will have a reduced calorific effect.
The operation takes just over 80 minutes. Franks is stable throughout, and within a few hours is well enough to take sips of water. Patients are usually ready to go home two days after surgery. Around one in 40 patients develops a complication, such as an internal infection, blood clot, heart or breathing problems. The death rate from such complications is around one in 400 operations.
It will be weeks before Franks will be ready for solid food. But she is doing well. The next morning, Pring sends me a text: “Kirsty well today, been up and about, drinking and she may well go home after lunch.”
***
I first meet Kirsty Franks on a blustery day in May, at her home in Portslade, East Sussex, where she lives with her mother, Alison, 38, her stepfather, who works for a printer, and their five children, aged 16 to five. I sit on a leather sofa in a pristine sitting room with a large TV and a tropical fish tank. Two English bulldogs, Frankie and Winston, doze behind a baby gate in the kitchen.
Franks is shy, sweet-natured and especially close to her mother, who is friendly and full of concern for her oldest daughter. Franks says for months she’s had one problem after another. She started getting horrible headaches and had several episodes when she couldn’t see properly. “A few weeks ago, I was just sitting there and the room started spinning and my eyes went completely blank. Mum had to ring an ambulance.”
A neurologist diagnosed idiopathic intercranial hypertension, or raised pressure around the brain, a condition common in obese women and one that can lead to blindness. Franks had a tube fitted in the lower part of her spine to drain away the cerebrospinal fluid, but the headaches didn’t go and her neurologist, worried she was losing her sight, asked Pring to fast-track the gastric bypass for which she was already on the waiting list.
Her battle with obesity, she says, began in her early teens: “My weight piled on when I started my periods.” She was bullied at school – “They’d call me fat and say they’d bring painkillers in for me to overdose myself” – and would then buy crisps and chocolate on the way home because food was a comfort and a friend.
By 18, her body mass index was 50, which for an average teenage girl is roughly 57kg (9st) overweight. Skin folds under her tummy became chafed and sore, and sometimes developed infections. On a bad day she had difficulty walking upstairs. But the pain wasn’t only physical. “She feels everyone is looking at her,” her mother says. “We used to go shopping and she’d go, oh, what’s the point, they aren’t going to have any nice clothes in my size, and she’d get really downhearted.”
Franks left school at 18 with a qualification in health and social care, and worked in a care home near Hove. But in the past year she’d felt too ill to work. She met her boyfriend, Jamie, 25, in the doctor’s surgery, when she was 16. “He had stomach pains. I was in for polycystic ovaries and hip pains. The doctor called my name. Jamie heard it and added me on Facebook.” But they are mostly confined to Franks’ home: “People stare. He understands but I think he wishes we could go out. Hopefully, the bypass will change it.”
“Kirsty’s just gone into herself,” her mother says. “Before, she couldn’t wait to get to work. She used to push the old people up the town and take them out. She doesn’t do anything any more.”
“Sometimes I just step into the garden for a bit of fresh air,” she says. But she mostly only goes out for medical appointments. “I can’t remember the last time I went out to the town shopping or anything. It was probably a year ago.”
***
A gastric bypass is the most common bariatric procedure. The other two main types are a gastric sleeve, which involves removing most of the stomach and turning what is left into a thin tube, and a gastric band, where an inflatable device is wrapped around the top of the stomach.
But the gastric bypass is considered the gold standard because of its impressive effects: studies show most patients lose at least two-thirds of their excess weight within a year, and keep it off: 10-year follow-up studies of the Swedish Obese Subjects Trial found an average regain of only 8%. And the health benefits are striking: patients are less likely to have heart failure, arthritis or depression, while 80% of those with type 2 diabetes are completely cured, according to a study published in the American Journal of Medicine in 2009.
“This is health-gain surgery, not weight-loss surgery,” Pring stresses. “It’s a health treatment for type 2 diabetes and high blood pressure and all those metabolic problems that are crippling the NHS and impacting on people’s health.”
Support for bariatric surgery is increasing. In 2006, the National Institute for Health and Care Excellence recommended weight-loss surgery for those with a BMI of 40 or more (or 35-40 and a serious health condition). Last year, the threshold was lowered to those with a BMI of 30 and a serious health condition. There remains, however, a significant divide between what Nice recommends and what the NHS can afford.
Increasing numbers of adolescents are receiving bariatric surgery, but while there is follow-up data for adults (in some cases two decades later), the long-term effect on teenagers is still unknown. The push towards surgery on the young has met with resistance from some medical experts who say it is too extreme to operate on patients whose bodies might still be developing. There are concerns about growth spurts, future pregnancies and whether teenagers grasp the impact of surgery: a bypass creates a state of enforced malnutrition, and patients must take daily vitamins.
“It is mutilating and, in many cases, irreversible. You can’t say, I want that 90% of my stomach back. If you’ve had a gastric sleeve, it’s in the bin, it’s gone,” says Ray Shidrawi, consultant physician and gastroenterologist at Homerton University hospital in east London, which accounts for 10% of all the UK’s bariatric surgery. (A gastric band is reversible; a gastric bypass can be undone – in theory – but “it’s dangerous and impractical to do so”, according to one surgeon.)
“I see all the complications,” Shidrawi says. “Patients who have to stay on fluids because if they have solid food, it sits there and they vomit it up again.” Shidrawi reviewed 1,947 procedures from 2011 to 2014 and found at least 7% of patients had a “significantly impaired quality of life”, with leaks from the stomach, or a pouch that doesn’t empty. The benefits of surgery, he says, outweigh the risks only for people who would otherwise die from their obesity. Some suffer side-effects, including “dumping”, when sugary or rich foods empty from the pouch into the intestine too quickly, causing vomiting, faintness and diarrhoea. Some patients suffer hair loss at first, due to the trauma of surgery and nutritional deficit. Shidrawi hopes the surgery will be obsolete in 10 years, replaced by something simpler and less invasive.
Young people should be given the chance to control their own weight, argues Dr Jacquie Lavin, head of nutrition and research at weight-loss company Slimming World. “Surgery takes it out of your hands. The message we are giving to young people, especially if their parents have had surgery, is that they don’t really need to do anything, so long as they get to a certain weight, because it will be solved for them. Nor does it address why you’re overeating in the first place.”
But supporters argue that dieting frequently fails. “You can lose a lot of weight with bariatric surgery and you will fit in and save your life. No medicine does that. No amount of exercise. Dieting. Nothing,” says Dr Billy White, consultant in adolescent medicine and clinical lead of the adolescent weight management service at University College London hospitals. UCLH is one of three national referral centres for adolescent bariatric surgery (along with King’s College hospital, London and Sheffield Children’s hospital); 22 young people have had it there since 2007, the youngest of them 15. (The world’s youngest, a two-year-old from Saudi Arabia, had a gastric bypass in 2013, weighing 33kg – 5st 2lb.)
To qualify for bariatric surgery, patients have to show they’ve failed to lose weight either on their own, through community weight management initiatives, such as Weight Watchers, or through multidisciplinary weight management clinics. Adolescent surgery has more conservative guidelines than adult surgery. Nice recommends it only in “exceptional circumstances”, for severe obesity-related problems. Potential patients must go through months of counselling to make sure they understand that their digestive systems are about to change and so must their diets, with only tiny meals for the rest of their lives.
Surgery, of course, doesn’t get to the root cause of why so many young Britons get fat in the first place: the proliferation of fast food outlets in deprived areas, sugary drinks and high-fat, high-sugar foods, poverty, fall-off in physical education in schools, the rise of a sedentary lifestyle and the allure of computer games and laptops. Childhood obesity has more than doubled in the last three decades and while children generally don’t die from obesity, the children who have had surgery were sick and were going to get sicker. Many already had type 2 diabetes, high blood pressure and obstructive sleep apnoea (where breathing stops during sleep). For teenagers sitting on a timebomb, White says, it is a “brilliant intervention”.
The alternative to not operating is worse, agrees Ashish Desai, consultant paediatric surgeon and co-founder of the adolescent bariatric surgery service at King’s College hospital. “People who are obese in middle age are likely to die 10 years younger. The life span of obese adolescents will probably be even shorter.”
But he has reservations about the gastric bypass. “Mainly because patients need to take vitamins for the rest of their lives. Adolescents don’t like taking things for ever, and if they default they will be malnourished, they can develop cancer, they can develop further problems.”
***
Stephen Bradley is 16 and 1.85 metres (6ft 1in), with dark hair and a nascent moustache. Over tea one afternoon at his home in the Midlands, where he lives with his mother Beverley, he explains that he had a gastric sleeve operation a year ago.
He weighed 3.7kg (8lb 4oz) at birth and was a normal size till he was three. “Then almost before my eyes he started getting bigger and bigger,” his mother says. By nine he was seriously overweight.
Looking back, Bradley says he ate because he was hungry and because he liked his mother’s home-cooked food – spaghetti bolognese, lasagne, curry. He stopped eating when he was full, but then he’d quickly feel hungry again. So he’d snack on crisps or roast chicken bites. “Food was constantly on my mind: what’s next? Planning it out. I was probably eating three times what a normal person should eat.” His mother says that if she said no, “he’d have a meltdown. Thump doors, kick things, break things, even threaten to kill himself. In the end, it does grind you down.”
By the age of 12 he had dropped out of school. “When you’re bigger than anyone else, it’s not nice,” he says. He was too short of breath to kick a football around with his nephew or walk anywhere with his friends. His mother would try to push him out of the door to get the school bus: “He’d just turn around and push me back.”
By the age of 13 he weighed 190kg (30st) and had a BMI of 66. He was sedentary and confined to his home. “PlayStation, TV, lazy stuff,” he says. He was shrouded in jogging bottoms and T-shirts, depressed and with low self-esteem.
Bradley ticked all the boxes for surgery, and in his case there was another, less obvious factor. Bradley’s maternal grandmother was anorexic. “I knew what it was like to be starved as a child,” his mother says. “I had a good home but food was the issue. If I was naughty I was sent to bed without tea. I was controlled with food. Then I left home at 16 and, oh God, I could eat anything and everything! There was nobody saying, have you had this out of the fridge? Have you been to the chip shop on the way home? So I did just balloon.” Beverley is now 140kg (22st). (At one point she was 209kg – 33st.) Complications from her type 2 diabetes include fading sight and difficulty walking.
“You don’t want to knock their confidence because my mother did that with me,” she says. Hearing her son crying, “I’m hungry! I’m hungry!” brought back painful memories of herself doing the same as a child. “Looking back it was my fault because I kept on wanting him to eat.”
One day, when Bradley was 13, a social worker knocked on the door. The local authority had alerted social services to his absence from school. “They accused me of overfeeding him and said he either loses weight or goes into care,” his mother says. “I was fighting to keep him at home. We are very close. And it made me feel awful as a parent.”
For two years they lived on a knife-edge. “The social worker could come any day, without notice, between 7am and 7pm. Once I’d accidentally picked up a bottle of squash that was not sugar free and she went absolutely berserk.”
There was no history of neglect or child abuse. Their house is immaculate, the garden full of poppies and runner beans. Bradley’s parents live apart but are still close. His older brother (from Beverley’s first marriage) has a successful job as a teacher and, if anything, is underweight.
“The social worker, though we hated her, said, ‘I’m stuck because there is no other reason Stephen should be taken away. You’re a loving mother. He comes from a beautiful home. I’d hate to put him into care but I’ve got my manager on my back.’” And then he was offered the operation.
On 26 May last year, Bradley was admitted to King’s College hospital. A year on, he has lost 63kg (10st). “I do get hungry,” he says, “I just don’t need to eat so much and I don’t think about food all the time.” For the first time in his life, Bradley experiences fullness. And the changes aren’t just physical. He has an unfamiliar feeling of self-control and confidence. He plans to take GCSEs, learn how to drive and become an engineer.
“It’s very hard to adjust [to the gastric sleeve],” his mother says. “He gets stomach pains and cramps. It’s not as easy as people think. But I have no doubt that if Stephen hadn’t had surgery, he would be 40-plus stone and bed-bound.”
***
Ashley Stevens, 19, was another teenager who couldn’t stop eating. He was 5kg (11lb) at birth, 63kg (10st) at the age of six; 121kg (19st) at 13. By the time he had a gastric band fitted at 16, he weighed 203kg (32st) and had a BMI of 75.
He has lost 83kg (13st) since the operation. I ask him what has changed. He points to a big squashy armchair in the corner of the sitting room, a homely space with a canary, budgie and an exercise bike. Three years ago he’d sit in the chair watching TV, curtains closed, with laptop, mobile and a supply of Chunky KitKats, sweets and crisps. “I went to school, came home, got into my comfies, ate and watched telly. It got to the point where I couldn’t do anything else. My mates would knock on the door and I’d say, no, I’m not well. I wouldn’t go out.”
Stevens holds up an old-fashioned sweet jar filled with boiled sweets: rhubarb and custard, pineapple chunks, apple chunks. “I got that for Christmas and it’s still full. I would have eaten that in a week before. I still like sweets, and because I can’t drink fizzy drinks I have these little cubes because they taste like Coke – I have a suck on that, but after one I don’t want any more.”
Overeating isn’t just unpleasant now – when he once ate half a fried chicken at Harvester, he threw it up – his appetite has gone. “Food was a really big part of my life,” he says. “Now it’s not.”
One of the criticisms of weight-loss surgery is that it doesn’t necessarily promote healthy eating. “It’s amazing what you can liquidise,” Dr Lavin says. And Stevens’ taste hasn’t changed. He hasn’t stopped eating ice-cream, milk shakes, Cheesy Wotsits and chocolate. He just eats less of them. The day we meet he had a milk shake for breakfast and says he won’t need to eat again until about five. He is a teenage boy of 1.9 metres (6ft 3in), eating around 700 calories a day. “I’ve got my supplements and SlimFast shakes to give me vitamins and proteins,” he argues, and besides, he is happy. He is engaged to be married, can now fit on the rollercoasters at Thorpe Park, sleep without four pillows – “If I lay flat I couldn’t breathe” – and no longer has to buy clothes from Fatboys 95, an outsize clothing store in Gravesend, where he took a seriously big XXXXXL.
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The weight management clinic at the Aneurin Bevan hospital, Ebbw Vale, is in an obesity hotspot: 27% of people in Blaenau Gwent are obese (the UK average is around 25%). “The worst is probably the US, but we’re not far behind,” says Dr Nadim Haboubi, an Iraqi-born consultant physician, with a special interest in gastroenterology and nutrition, who runs the centre – the only NHS-funded multidisciplinary clinic in Wales. Patients here are mostly over 18, but occasionally younger; the day I visit there is a woman with a BMI of 100.
There is nothing unusual about the clinic’s prescription – eat less and move more – but the “motivational interviewing” technique of Haboubi (BMI 25) is unconventional. He coaxes and teases; he is a cheerleader and interrogator. “What did you eat for dinner?” he asks one patient. “Chicken? How many?”
He tells them about his weakness. “Coconut. I love coconut. And sometimes I can’t resist Bounty bars. So I open the bar and because they come in twos, I put one in the bin and one in my mouth. I don’t put one in my mouth first, because I love it so much I know I’m not going to put the second in the bin. So I discipline myself.
“We gain their confidence and they tell us their secrets. Food is secret. How much I eat – it’s like smoking, it’s like sex, it is very, very personal.” Some simply eat too much; others are battling darker forces. “Recently a woman told me that when she was a child she was sexually assaulted by her father. Nobody knew about it, it was the first time she had opened her heart.
“These people hate the way they look,” he continues. “They hate their bodies and isolate themselves because they are so massive, and that’s where we work on raising self-esteem. We say love your body, it’s precious, adore it, it’s not a dustbin.”
I speak to Sarah Palmer, 23, a single mother with a two-year-old son. She weighs 159kg (25st). Her GP referred her to the clinic but she is keen to avoid surgery. In the four months since she first came, she has lost 3kg (7lb). “I don’t want to cheat and have surgery. I want to do it all myself,” she says. “As soon as I came here, I thought, I’ve got someone on my side.”
***
Last week I had a conversation with Kirsty Franks. It has been three months since her operation and she has lost 32kg (5st). It has already made a huge difference to her life. Back in May, she rarely went out; by July she was having meals out with friends. “The hardest thing has been getting used to being able to eat only a tiny mouthful of food,” she says. She has sometimes eaten more than she can handle and ended up vomiting in the toilet. She has also found her tastes have changed. “I don’t like dairy products or bread and the smell of any takeaway makes me feel sick. So finding things to eat each day is hard.” The day we speak she has had mashed potato and tuna. “I can eat things like soup but always feel full after a mouthful.”
Unfortunately, her headaches haven’t improved and she has been back in hospital having further tests. But she sounds upbeat. “I’m hopeful that will get better but even if it doesn’t, I’m very glad I had the gastric bypass. It’s helped me in many other ways. My confidence is growing and my health is getting stronger.” And she has another unfamiliar feeling: “I am very proud.”
Some names have been changed.
