I spend much of my life looking at cells through a microscope. Of all the cells I see, few are as distinctive as the human fat cell. Inside, a large fat globule steamrolls the rest of the cell’s contents flat against the outer membrane until the sphere bulges like a mozzarella. Freeze and section this cell through its nucleus and you see a signet ring snugly fit upon a plump finger. When the cell is prepared for the scanning electron microscope, so much fat is lost in the processing that what remains is a three-dimensional shell, the cytoplasm and cell membrane stretched into a rim.
In all its endeavors, the fat cell, or adipocyte, is buttressed by an external network of collagen fibers; myriad capillaries, even occasional nerve twigs, course in between. Gregarious by nature, fat cells gather into millions of lobules, separated from one another yet held together like a vital mosaic by miles of inflexible fibrous tracts.
We are steeped in fat cells. They pervade the great panniculus beneath our skin; they collect around our adrenals and kidneys, in our abdomen and chest and bone marrow, in the grooves of our heart and the subtle spaces of our neck and armpits and groin. Fat cells are everywhere but our central nervous system, lungs, eyelids, ears, penis, and the backs of our hands. They insulate, buffer, and energize us.
Yet when I look through my microscope, my eye often glosses over them. Seeking treachery, I am trained to look for more likely cellular culprits. Unlike cancer cells, fat cells are so often part of the mix in a tissue biopsy that a pathologist can easily take them for granted. Their aggregate size, however, can affect our health; shape the way we think about ourselves and how others think of us; make our lives unbearable.
Patti Fleming is five feet eight inches tall. She once weighed 356 pounds.
She now weighs less than half that. Although her colossal subtraction yields no physical vestige of her former self, in her mind she remains a fat person.
Patti is reluctant to come to my hospital (any hospital) to talk with me, so I take the afternoon off to visit her at work. I am not averse to searching out patients’ stories on their own turf, where they are often more forthcoming than on mine. Patti and I have been introduced by one of my colleagues, a bariatric nurse who knows of my interest in breaking through a pathologist’s ingrained clinical myopia. I wish to think of cells as more than something fixed beneath the lens of my microscope.
We sit in a sterile conference room in the Los Angeles law firm where Patti, who is in her early forties, works as a legal secretary. She wears a short black pleated skirt and an ivory cashmere sweater; her face is pretty and her body trim. She says she can hardly believe she was ever so obese. Her maternal grandmother and her mother “carried weight in their stomachs,” she tells me, but neither so extremely. “I was ten years old when I first noticed my weight,” she says. “I couldn’t get up on a horse as easily as the other girls.” At camp, she ate the same portions of food as the others, and exer-cised every bit as much. Were “fat genes” beginning to express themselves?
“In high school, other kids first talked about me being fat, but I wouldn’t let it happen. I’d miss meals and was very active in sports. I knew that if I ate, I’d get fat.” She laughs. “I felt like if I smelled a cake, I’d gain five pounds.”
Her adipocytes’ penchant for hoarding fat was a secret. Away at work, her parents were unaware that she seldom ate breakfast or lunch. On the weekends, she was out of the house, skipping meals and trying to ignore her hunger. Her private starvation was a mind game, as impermanent as satiation.
The average-sized infant enters this world with approximately five billion fat cells, one-sixth to one-seventh of the adult quota. During the first six months of life, these cells significantly sufflate with fat, but their numbers remain relatively constant. From that point until the end of puberty, the process flip-flops: the number of fat cells increases to adult proportion, but their size does not change. Then, throughout adulthood, we return to the pattern of infancy, plumping up mostly by adding to the fat in our adipocytes. Some of us are capable of distending them by a factor of three or four to a gargantuan three-hundred-micron diameter. If our thirty-five billion adult fat cells enlarge in this way and trigger the formation of additional adipocytes, we can balloon to rotundity and come to resemble the cells themselves.
In human biopsies, normal fat is a glistening, uniform, cadmium yellow, its texture greasy and soft. In vivo, at body temperature, fat is liquid, oozing in and out of fat cells under neural and hormonal control. There is a perpetual ebb and flow of fat between its mobilized state in the blood (as free fatty acids) and its storage state in fat cells (most as triglycerides). The free fatty acids burn metabolically as a high-potency energy source; what is unused by the body gets restored as triglycerides in the fat cells. Such is the dynamism of fat, a flux complexly modified by how we eat and exercise, as well as by our genes.
When she was sixteen, Patti met Frank Fleming, her husband-to-be. He was unconcerned about her weight and encouraged her not to skip meals. “We enjoyed eating together,” she says. “We ate the same amounts, but he stayed skinny and I got bigger and bigger.”
They overate. Despite studies that suggest altered metabolism or disturbed satiety signals as predisposing factors, one must overeat to realize morbid obesity (which is defined as a weight of one hundred pounds or more above the norm). Whenever Frank gained a few pounds, he easily lost them by cutting out sweets for a week or two. Patti wasn’t so fortunate. From the end of her teenage years until she was forty, she “pushed and shoved” her way through dozens of diets, spending thousands of dollars, losing and regaining hundreds of pounds. She tethered herself to diet food until she could no longer tolerate the tedium. The priceyness of those special packages angered her. Society did, too, for the stigma it placed on her body.
“I tried to exercise,” she says, “but there are no commercial gyms that can hold people who are more than 250 pounds. You break their machines and they want you out of there.” As her weight passed 300 pounds, she found exercise increasingly painful and finally impossible. Even walking down the street was a major effort. Her heart would pound; sweat would pour off her.
Her fat-cell aggregate was now so huge that she could barely keep her head above it. She seemed to be sinking inside herself, too mired to surface. Rather than garnering sympathy, she often repelled people; it was as if her globate habitus revealed all that was inside her, negating the need to look into her eyes or listen to a single word she spoke. It is hard for the morbidly obese to stand up for their rights when others consider their shape a character flaw rather than a disease or a disability. Stop stuffing yourself, people say, ignorant of the power of fat cells. Do a little exercise once in a while. Don’t be so damned lazy.
Imagine fat as an organ tucked within our bodies, one that can rise to roll our features outward or shrink until it fades among the splay of protruding bones. To make sense of this “organ” when it is a lipid-laden albatross, we must hark back to our distant hunter-gatherer ancestors. No fatness there. The constant trekking over long distances in search of scarce foods probably selected against obesity. It has been theorized that these ancestors acquired “thrifty genes” to store the fat of feasts in order to sustain them through famines. In our American surfeit, these ancestral adaptations have become liabilities. Fine-tuned by our individual genetic legacies, each of us settles into a metabolic equilibrium.
For those of us whose genes are all too thrifty, this settling point is a level of excess weight that we cannot reduce without sustained dietary effort. Today, the increasing consumption of cheap, readily available fatty foods is propelling the most metabolically susceptible of us into exorbitant obesity. Once our fat cells become extremely impacted, the recidivism rate of diets is almost 100 percent. For four million morbidly obese Americans, diets strict enough to succeed are by and large too uncomfortable to be feasible. These people have an illness without a cure, one that is often complicated by heart disease, hypertension, diabetes mellitus, sleep apnea, gallstones, degenerative arthritis of weight-bearing joints, and restrictive lung disease.
Sometimes we have the opposite problem. Markedly reduced or absent fat is usually a marker of serious illness or catastrophe. Cancer can cause weight loss; many physical and psychological ailments can erode the appetite; famine or subjugation can bring starvation. Seriously underweight people appear hollowed out, as if their flesh has sunk beneath their skeletons. We feel contempt for the obese but pity for those who have no fat, along with anger if their loss was engendered by tyranny.
Starving fat cells can shrink to a fraction of their former selves. With centrally placed nuclei and globule-free pink cytoplasm, they come to resemble tumor cells. Golden brown lipofuscin pigment granules—footprints of wear and tear—lightly disperse themselves throughout. As part of this involution, fat lobules can deflate into discrete, fat-free balls or, in the severest cachexia, into worm-like streaks as they distance themselves from one another. This fat loss is most apparent beneath the skin and in fat that hovers inside the abdomen.
When starvation remains unabated and the body’s fat stores are eventually spent, proteins are burned to fuel the last, flickering glow of life force. But proteins are essential for maintaining cell function. When they are depleted to half their normal level, death ensues.
I ask Patti to recall a typical day lived inside her atypical body. She tells me that she always felt uncomfortable when she awoke. She slept on her side because she couldn’t breathe on her back; her arms and hands often got caught underneath her body, cutting off her circulation and waking her. By morning, her upper limbs were numb and swollen, and her back and neck were sore. Her side of the mattress was cratered when she arose. She covered the sinkhole with a blanket so that Frank couldn’t see it.
“I never ate breakfast,” she says. “I got up, showered, and drove to work. The car seat creaked beneath me. I could hardly reach the steering wheel because my belly was in the way, and my feet went numb from body compression. Once I was rear-ended and my weight broke my seat in half.”
Patti encountered little discrimination in her office, but lunches were difficult. She worried about fitting into a colleague’s car en route to a restaurant. Once there, she prayed for a table and chairs because she couldn’t wedge into a booth. Maître d’s and waitresses ignored her. Does anyone her size really want more food? And sitting so close to others, she worried that the smell of her belly ooze would be detectable. Beneath her massive bulge of abdominal fat, ulcerated skin rashes wept until the itch was unbearable and the smell was rank. None of her medications brought relief. At home, she could raise the bulge of her abdomen and sit in the sway of a fan until the forced air dried her wounds, but at work there was no respite.
Patti also fretted about personal hygiene. “Morbidly obese people won’t tell you this,” she says, “but they can’t wipe themselves properly after they use the bathroom. They can’t reach their tush. At home I could clean my private parts with a hand shower. If I was sick, I had to rely on Frank to wipe me. He never said a word, but I was humiliated. At work, I kept a bottle washer with me. I’d wipe myself with it the best I could, but how uncomfortable was that?”
By the afternoon, Patti was emotionally and physically exhausted. Her legs swelled from supporting her body. Sciatica pierced her lower back like a fiery poker. She knew she would be too weary to cook dinner, so she usually bought fast food on the way home.
Some nights, parent meetings at the children’s school could go on for hours. “The chairs in the auditorium were little plastic things. I’d stand but eventually they’d say, ‘Sit.’” So she would cautiously spread herself over the chair, her legs and thighs bearing much of her load while she braced her arms against the armrests.
“What about sex?” I ask, emboldened by her candor.
Patti gazes at me patiently. No question is too personal; she wants to be as clear and open as she can in order to make people understand that morbid obesity is not a choice but an affliction. “I was pretty tired by then. Besides, it wasn’t even enjoyable. I was confined to the missionary position and I couldn’t stay there for long because I’d begin to choke.”
Her lumbering lack of mobility in bed was just one more failure among her many. Beaten daily into feelings of inferiority, Patti lost hope that she could ever change. “You’re hardly alive when you’re so huge,” she says quietly. “I’d think about my kids, how embarrassed they were for me, how I couldn’t really be there for them. I’d have given anything to lose weight permanently, but I just couldn’t do it.”
Surgeons fix bodily things. What is removable, if diseased or malfunctioning, they can remove, and what is irremovable, they can sometimes imaginatively bypass. (Witness the skirting of coronary-artery blockages with leg-vein grafts.) The disappointing long-term results of medical, drug, and behavioral therapies for obesity in extremis have increased the number of referrals for a different kind of bypass: bariatric surgery, which circumnavigates portions of the stomach.
In 1997, Patti Fleming learned from her physicians that perhaps, after all, she need not surrender all hope. Without bariatric surgery, she would not likely live to see her grandchildren; with it, she came to believe that she might prolong her future and even recapture her past, the years before her fat cells established an absolute dictatorship within her body.
The size and structure of the stomach pouch, the nature of the intestinal renovation, are intimately related and the subject of much surgical bandying. One such gastrointestinal resection—the Roux-en-Y gastric bypass—is currently the procedure of choice at UCLA; it is the one that Patti Fleming agreed to undergo. The bariatric team believed that she was a good candidate for the procedure, that she could commit herself to a draconian modification of her gastrointestinal tract and her life.
It is a courageous endeavor to submit one’s obese body to the knife in this way, to pucker billions of fat cells in the hope of renewal. None of Patti’s family or friends encouraged her to have the bypass. Surely another diet is preferable to an operation. She ignored them.
Patti awoke from the surgery frightened by what had been permanently perpetrated. Her 1,700-milliliter stomach had been miniaturized to 35 milliliters. The loss of 1,665 milliliters drastically reduced her stomach’s capacity to process, absorb, and propel foods; her small intestines had been reconstructed to reduce the number of calories they could absorb. For the rest of her life, she would have to supplement her new diet with vitamin B12 injections. She would have to limit her food intake to frequent, small-portioned meals or suffer the consequences: the trim new stomach pouch, unable to handle at one sitting a food serving larger than a hard-boiled egg, or one that had been chewed fewer than thirty to forty times, would dump its unprocessed contents into the small bowel. The result would be abdominal pain, nausea, diarrhea, dizziness, heart palpitations, even loss of consciousness.
Patti’s postoperative abdominal cramping was so severe that it made the deliveries of her children, without anesthetic, seem like child’s play. Today, support groups are commonplace before and after bariatric surgery, but in 1997 they had not yet been organized, so Patti endured her flesh wounds as she had her obesity—largely on her own.
From minuscule drinks of water, she progressed to clear fluids and sugar-free Jell-O. By the third week, the cramping and wound pain had subsided and she could swallow liquid meals (Carnation Instant Breakfast, Slim-Fast). By the sixth week she was consuming high-protein, pureed foods along with a few soft foods (nonfat cottage cheese, water-packed canned tuna). By the eighth week she was eating fruits and vegetables. Pangs of withdrawal from fats and sweets seemed to rack every shriveling fat cell. She could not even drink a soda; the carbonated bubbles took up too much space.
Fat cells were releasing their stored triglycerides, and free fatty acids in the blood stream were burning like oil. Fat was melting into energy. Patti felt her clothes loosening. She still weighed more than 300 pounds, but Frank, who had opposed the surgery, noticed the shrinkage and cheered her on. For the first time in many years, she felt the urge to exercise. She swam in her apartment complex’s outdoor pool at night, when the neighbors could not see her. As the pounds dropped, Patti’s high blood pressure returned to normal and the arthritic pains in her feet, knees, back, and neck subsided. She was no longer primed for illness.
Six months after her surgery, Patti’s jaw, elbows, shoulders, breasts, buttocks, knees, and even her lap emerged from her dwindling sphere. She could sit in a regular chair without bruising her hips; cross her legs; manipulate exercise equipment; climb in and out of a car with ease; fit into a restaurant booth.
“I lost so much weight in the early stages,” she says, “that I didn’t know what size I was. But it took my breath away when I first went to Victoria’s Secret to buy underwear and to Robinsons-May for my clothes. I never went back to Lane Bryant again.”
The lighter she got, the greater her incentive to retrieve all that she had missed. In her new 169-pound body—that is where she settled—Patti Fleming interacts casually with people and has rediscovered sports. She camps, water-skis, and kayaks, as she did in her youth. She often chooses tight-fitting dresses.
The Roux-en-Y is less a solution than a tool. It has allowed Patti to deplete her fat cells and to sustain this reduction as long as she plays by the rules, most of which prevent her from taking as much pleasure from eating as she used to. “If I get stressed and forget to eat slowly,” she says, “the food gets stuck. It’s like an elephant walking on my sternum. Frank will quickly spot fast eating and hold my hand. It’s one of our secret little communications. He knows how hard I’ve worked to get where I am.”
On the stage of my microscope, fat cells, whether too large or too small, aggregate in a lobular, geometric precision. Theirs is a glomerate beauty, an abundance or dearth of pure energy. In this microcosm I can see the power of their mutability. No other human cells can so rampantly rise or fall and, like millions of fiery suns burning bright or burning out, alter our universe.
