We are fat. So, what’s Ontario doing about it?
June 17, 2011
Moira Welsh, Michele Henry and Emily Mathieu
Frank Vaccaro is trying to get out of bed.
He weighs 500 pounds. The simple act of standing this morning creates such pain that he lies still for 15 minutes, mentally preparing to take it.
Vaccaro’s ankles are swollen and infected. His wife, Mary, helps him into the shower of their rented Malton home. They are careful because he fell once and broke the bathtub. No joke.
Vaccaro is among the almost 60 per cent of Ontario adults who are overweight or obese (grossly overweight) and the percentage is increasing every year. One in four Ontario children is overweight or obese and those numbers are increasing as well.
More than one-third of this group fall into the obese category and these 2.1 million people will likely suffer a myriad of expensive health problems — diabetes, heart disease, destroyed knees, strokes, blood clots, infertility, sleep apnea or cancer.
Ontario lacks a coordinated strategy to deal with obesity, but municipalities and doctors are trying numerous band-aid approaches.
The provincial Ministry of Health Promotion and Sport declined repeated requests to respond to the Star's findings. Friday, health minister Deb Matthews said in an interview that the province is not doing enough.
“This is a big problem and we have to do better. We have to do better. This is going to take all hands on deck. We really are committed to a healthier Ontario.”
In York Region, ambulances have been retrofitted to accommodate a ramp, winch and pulley system strong enough to load stretchers bearing more than 1,000 pounds. Toronto Emergency Medical Services bought extra wide stretchers and dedicates four larger sized vehicles – previously used for tactical calls – to transport patients.
Some 9,000 Ontarians including Frank Vaccaro have paid private medical clinics $18,000 to have an inflatable ring surgically inserted around their stomach to limit food intake, a procedure not covered by OHIP.
Across Ontario, nearly 8,000 patients have been referred for an assessment for a new provincially funded surgery called bariatric bypass that reduces the stomach to the size of an egg. (A normal person’s stomach is the size of a small cantaloupe.) Many wait a year for that initial appointment.
Back at Vaccaro’s house, it’s time for work.
He slowly slides on his shoes. Mary ties the laces. They are white Reebok sneakers, size 13 wide. He buys a new pair every three weeks because his weight wears down the padding so quickly that the bones in his knees burn.
Frank is 44 years old. He drives a coffee wagon. There isn’t room behind the wheel of the truck for his girth, so he sits in the middle, driving with his arms and legs stretched to the left.
Mary waves goodbye. She is 44 years old, a credit union manager and weighs 290 pounds. They have two Shih Tzu puppies, no children. She is on a new diet, buying low-carbohydrate food from a Thornhill doctor.
Together, the couple has spent $40,000 trying to lose weight, including surgery that was supposed to limit an eating habit Vaccaro describes as an addiction.
The Ontario Medical Association (OMA) says the many problems obesity brings annually drains the health care system of at least $1.1 billion and another $1.5 billion in lost productivity.
The OMA wants to make obesity a provincial campaign issue this fall.
Nurse Diane Eley’s breast cancer was related to her obesity. Three weeks ago, the 55 year-old Brampton woman had bariatric bypass surgery.
Eley’s procedure is part of a $75 million provincial program created to give the morbidly obese a second chance at health. More than 1,600 of these surgeries have been performed in the past 16 months.
Under the knife
It is 8:30 a.m. at St. Michael’s Hospital, and Dr. Teodor Grantcharov slices five holes into Eley’s abdomen and begins to remove 90 per cent of her stomach. A video of the operation can be seen on thestar.com.
Grantcharov’s iPod is plugged into the operating room’s stereo system. His playlist is loaded with The Killers, AC/DC and U2.
Bono is singing “City of Blinding Lights” as Grantcharov slips a tiny laparoscopic camera into one incision, then slides his surgical tools down the others.
High-definition video monitors above the operating display colour images of Eley’s digestive system. A registered nurse with a quick smile, Eley wouldn’t shirk from the sight of her pink small bowel stretching metres longer than its name implies.
Something else appears on the screen: layers of bumpy, yellow fat.
“Obesity is the new smoking,” says Dr. Lloyd Smith, who like Grantcharov, performs bariatric surgery at St. Joseph’s Health Centre, where he is chief surgeon.
“Surgery is dealing with the disaster, it’s not dealing with the problem.
“We’re taking people who are killing themselves (with food) and saving their lives. (Obesity) is an example of something that’s entirely preventable.”
Eley has always struggled with her weight. So have her parents and sisters. She is a mother to two adult sons, she raises her 17-year-old granddaughter, and she works long hours as the hospital’s manager of operating room purchasing.
After starting work at 8 a.m. and leaving at 7 p.m., Eley rushed into her evenings, eating pizza or hamburgers with no time to exercise. She grew to 400 pounds. The weight destroyed her knees, leaving bone rubbing on bone. At least one knee needs replacing.
Excess estrogen stored in her body fat was the likely cause of the breast cancer she suffered five years ago.
Eley has a body mass index (BMI) of 52, a measurement that uses weight and height to measure fat. Her BMI puts her in the highest-risk category. A healthy BMI is between 18.5 and 24.9 per cent. Anything above 30 is obese. A BMI above 40 is considered morbid, which is usually accompanied by serious health problems.
Before surgery, Eley went through seven months of counseling and visits with dieticians. Each operation and the pre and post-op follow up costs the health care system about $18,000. To be successful, she will have to completely change her lifestyle, eating nutritious food and exercising.
“There are two people sitting in this body and I would like to be down to one person,” she said in her office at St. Mike’s the day before her surgery. “I was waking up at night, holding my pads of fat, crying that it is going bring my cancer back.”
Big problem, small solution
Grantcharov and two residents stare at the monitor as they first shorten Eley’s small bowel by 1.5 metres. That means food will move more quickly through her digestive system, which will absorb fewer calories and fewer nutrients.
Then, as R.E.M.’s “Bang and Blame” plays in the background, Grantcharov moves to Eley’s stomach and starts cutting. It takes just a few minutes before most of it is gone. He attaches what’s left to her newly shortened bowel, cauterizes the connection, and then closes everything with shiny staples.
Eley’s stomach is now the size of an egg. In time, with healthy eating, it will stretch to the size of a tennis ball. If she sticks with the program, in a few months that yellow fat inside her body will simply burn away.
OHIP used to pay for some patients to have the surgery in U.S. hospitals, but the new Ontario program will get better results, ministry officials say.
Only the morbidly obese or those with deadly health conditions, like Eley’s cancer, are accepted as candidates for this surgery. Those who are simply obese are out of luck.
The program first sends patients through an intense screening program to winnow out those who are not committed to changing their eating and exercise patterns after surgery. The ministry says up to 35 per cent of prospective patients are rejected, roughly 10 per cent of them by their own choice.
So far, $9 million of the program’s $75 million has been spent to expand bariatric centres in hospitals across the province. Some hospitals have used the money for wider operating room beds, new laparoscopic surgical tools and toilets that can bear up to 1,000 pounds.
Excess weight is incredibly stressful on bones. One Toronto area medical worker described a morbidly obese woman who stood up, sheared off her weakened ankle and bled to death.
OMA president Dr. Stewart Kennedy says Ontario has made “good first steps” but little more.
In government, the responsibility for preventing obesity lies with the Ministry of Health Promotion and Sport. Its annual budget of roughly $470 million a year is just a fraction of the $46 billion allotted to the Ministry of Health.
Though the province lacks an overall strategy to reduce obesity there is one positive development.
Starting next September, the province will ban hot dogs, fries and other junk food from school cafeterias.
In the United States, one of the world’s fattest countries, some southern states have been fighting obesity for years. Arkansas’ programs, for example, were the first to halt the rapid rise of obesity among its youth, something Ontario has been unable to do.
Starting eight years ago, Arkansas health officials went into schools and measured the height and weight of elementary students. They discovered that 18 per cent were obese. It was a shocking find.
All three levels of government, federal, state and municipal, worked together on solutions. Officials took junk food out of schools, stopped allowing soft drink companies to give money to the education system, created exercise programs, and built bike paths to get families out of their cars.
The health officials weigh students every year now, turning the scale backwards so children cannot see the results. A report is sent home to their parents with advice on healthy eating and weight loss.
“It is not just policy,” says Ed Barham of the Arkansas public health department. “It’s bigger than any agency or non-profit pushing for this.
U.S. president Barack Obama’s government created a new law forcing all large restaurants to add calories on their menu boards, one part of its strategy against obesity. The changes are expected in 2012.
In Ontario? There are no plans for calorie labeling.
NDP Health critic France Gelinas twice introduced a private member’s bill to get calorie labeling. The OMA has pushed for labeling in fast food chains and high school cafeterias, to no avail.
“It is so important to educate children and parents of children regarding caloric literacy — I think it will have an impact,” said the OMA’s Kennedy.
It isn’t necessary, says the Canadian Restaurant and Foodservices Association. Spokesperson Garth Whyte notes consumers can already find the information on pamphlets or online.
“We want to avoid a knee-jerk, quick-fix political approach,” Whyte says.
Entrepreneurs have created a surgical solution to the obesity epidemic, making millions of dollars in the emerging marketplace that caters to the overweight or obese.
For a private fee starting at $16,000 (or $21,000 on the four-year payment plan) doctors will surgically insert a silicone band at the top of the stomach to control eating. It can be filled with increasing amounts saline to tighten to band’s grip, or “de-filled” to loosen it.
The clinics that perform the laparoscopic surgery operate with little government oversight. No data is collected on their complication rates, making it difficult to see the results beyond testimonials of success.
Vaccaro had the surgery in May 2009 at Mississauga’s Surgical Weight Loss Centre. He used his savings to pay the $18,000 fee.
In the following nine months, Vaccaro lost 100 pounds. He felt great. But the lap band didn’t stop his emotional drive to eat. It’s just so hard to stay on a diet, especially when food brings such instant pleasure.
Ice cream slid past the band, and so did chocolate, which Vaccaro really, really likes.
Dr. Chris Cobourn performed the surgery. He said all patients are at risk of going back to old eating habits, adding that any bariatric surgery should be viewed as tools “rather than magic solutions.”
Vaccaro says he wishes the clinic had a weekend support group or counsellors available to meet in the evenings, when he was off work.
The band is still in his body, but has deflated over time, so he can eat what he likes now. Often the food is healthy, sometimes it is not.
The simple idea of working off calories through exercise is a moot point, since Vaccaro’s knees are so damaged they cannot hold his weight.
Vaccaro used to be a chef, at an Italian restaurant and a steak house. He’s a big, happy man who enjoyed preparing food for others as much as eating it himself. It was his life: the aroma, the taste and the laughter around a table holding a beautifully prepared meal.
He can’t stand up long enough to do his job now. Instead, he works 11 hours a day driving a coffee wagon to construction sites. He’d rather sell coffee for little money than stay at home.
“I would eat,” Vaccaro says. “I would die.”
Leah Davies got the $16,000 surgery at The Slimband Clinic on Prince Arthur Ave. last August. The private clinic’s website promises easy results and “no more temptation.” Her grandmother saw the advertisements and offered Davies her savings to cover the payment.
“I wanted this to work so badly,” said Davies, 26, who weighs 350 pounds.
Davies told the Star her version of the story: She called the clinic for a telephone consultation in late July last year and signed up. They told her to get blood tests and an electrocardiogram. The lab sent in her results.
Within several weeks of her telephone consultation, Davies said she was on the operating table.
For the first few weeks post-op, she drank liquids. When the first tiny bits of food were allowed, she started choking it up. She vomited her food nearly every day. Davies says she called the clinic repeatedly for help.
“They just asked the same questions over and over, like ‘Are you chewing your food properly?’ I followed the directions perfectly, I was very motivated to make this work.”
After months of vomiting the smallest bites of food, Davies says, she begged her surgeon to remove the band, crying, “I’m starving, I’m starving.”
Slimband’s vice-president of communications and marketing, Lisa Borg, said the clinic’s surgeons could not comment because of patient confidentiality. Borg said Davies should have taken her complaint to the College of Physicians and Surgeons.
On April 12, the surgeon removed the band. Davies said she called the clinic the following day and asked for her grandmother’s money back. She is still waiting.
If the long-used BMI measurement shows that Ontarians are getting fatter, a new method shows the weight gain is even more dramatic.
Dr. Ian Janssen, of Queen’s University’s Centre for Obesity Research and Education (CORE) said researchers are now measuring people’s size based on waist measurements – and have concluded the number of obese in Ontario is much higher.
Fat stored in the abdomen metabolizes differently and is loaded with hormones that circulate throughout the body, increasing the risk of cancer and cardiovascular disease.
“We are actually seeing a shift in the way people distribute fat in their bodies over the past 30 years,” Janssen said.
“It is kind of frightening, actually. For the same weight, people have more fat in their body than 30 years ago. It’s frightening because of the health implications due to abdominal fat.”
It is going to take a massive education program, like the anti-smoking campaign, to teach parents about the impact of low-cost junk food, he said.
Dieticians working in some of Toronto’s low-income neighbourhoods describe children who drink thousands of calories a day in cheap soda pop.
One health worker in the Jane and Finch area gave nutritional counseling to a 280 pound, 11-year-old girl. Her mother didn’t believe anything was wrong with her weight. Eventually, the girl stopped coming.
Data analysis by Andrew Bailey