Sunday, October 12, 2003

By Cristina Rouvalis, Post-Gazette Staff Writer

At 7:40 a.m., a nurse wheels 346-pound Josh Gee on an extra-strength gurney to Operating Room 11 of Magee-Womens Hospital so he can have his stomach shrunk to the size of a walnut, just as his mother and grandfather did.

Josh Gee, center, has lost 106 pounds since having gastric bypass surgery, following in the footsteps of his grandfather, Ken Pulos, who dropped from 372 to 195 pounds and Josh's mother, Michelle Gee, who went from 322 to 190 pounds. (Steve Mellon, Post-Gazette) Click photo for larger image.

He is 17 and lives outside of Erie, where his middle school years were hell.

But he is having fun now, minutes before he goes under for a Roux-en-Y gastric bypass operation.

Josh's fleshy arms spill out of the blue polka dot-gown and his size-13 feet hang off the gurney. He wiggles his toes and laughs. Then he banters with the nurse about how he might get a junker of a car for his 18th birthday. "I'm counting the months," he says, smiling.

Nothing phases him. Not the 4 in 1,000 odds of dying. Not the possibility of complications such as blood clots. Not the three doctors peering down at him through masks and the seven TV screens and the beeping monitors. Not the fact that he will never be able to gorge himself the way he did at the $7.29 all-you-can-eat special at Tops Chinese Buffet three nights ago.

Minutes before Dr. Philip Schauer cuts through five inches of gleaming yellow fat to change his anatomy, Josh, who was once teased so badly that he wanted to take his own life, feels nothing but calm.

Finally, he thinks.

Finally I will no longer be a fat kid.

"These kids are not freaks," says Schauer before the May 6 operation, the first of five he does that day. Over the next 2 hours and 15 minutes, he will staple Josh's stomach pouch so it can hold one-half ounce of fluid instead of the usual quart, then create a bypass to the lower part of the intestine so less food is absorbed.

Schauer has done gastric bypass operations on hundreds of adults but has only in the past year moved into the controversial waters of adolescent surgery, doing about 15, the youngest on a 15-year-old. (Children's Hospital of Pittsburgh did its first adolescent gastric bypass in September and has done two more since.)

"They are the kid-next-door," Schauer says, "normal kids dealing with an epidemic disease."

The statistics are grim: 1 in 5 American children is overweight, about double the number 25 years ago. While there is a genetic predisposition to obesity, it doesn't explain the alarming societal jump, blamed on everything from supersized fast-food meals to a sedentary lifestyle spent in front of the TV.

Josh's grandfather, Ken Pulos, at 372 pounds. Click photo for larger image.

Josh is in the center of a debate on the merits of elective surgery to help the biggest teenagers with serious medical problems.

In his 4XL shirt and size 48 jeans, Josh isn't only a target for taunts. He is borderline type 2 diabetic -- also called adult onset diabetes -- and has elevated blood pressure. His joints buckle under his girth, his back and hips ache. One of his kneecaps once popped out of the socket.

The number of teenagers undergoing the drastic measure of gastric-bypass surgery is unknown, but the procedure is exploding in popularity among the general population. This year, 103,200 have been performed, up 514 percent from 10 years ago. The procedure has gained acceptance as celebrities such as "Today" show weatherman Al Roker show off their astonishingly thinner bodies.

But some people still wince at the idea of cutting into a teenager and rearranging his innards to stop him from overeating. How young is too young? Will there be some terrible side effects later? Is this the easy way out? To make matters murkier, there are no national guidelines for adolescent patients, although the American Society for Bariatric Surgery is developing a set of criteria.

"It is not cosmetic surgery," says Dr. Sue Kimm, a University of Pittsburgh professor in the department of family medicine and clinical epidemiology. "It is life-changing, potentially life-threatening surgery."

She is concerned about the possibility of weakened bones because peak bone mass forms during the teenage years, and this surgery interferes with the absorption of calcium. "We have no answers. Just questions, and I am concerned that we are not even asking them."

Schauer counters that surgery is not for everyone but that dieting usually doesn't work. For every Jared of Subway fame, he says, there are about 95 other severely obese people who fail to lose weight or keep it off. "Why don't you talk about the kids who have diabetes, who don't go to college, who never realize their potential, who are insecure their whole lives? What about those kids?"

Michelle Gee, Josh's soft-spoken mother, who is 132 pounds lighter after she had her own gastric bypass operation last February, has heard both sides.

Josh's mother, Michelle Gee, at 332 pounds. Click photo for larger image.

Some people applaud her for letting her son be a third-generation gastric bypass patient.

Others look at her in disbelief and ask, "What kind of mother would let him do this at this age?"

"It's easy for them to make judgments when they don't have to live with it, the health issues, the depression," she says, her voice trailing off.

Drowning in despair

The first taunts pelted Josh in sixth grade, when the 5-foot-5-inch boy crept up to 200 pounds.

Hey, Shamu. Fatso.

He was the new kid, his family having just moved from Erie to Wattsburg, a mostly rural town about 10 miles from Erie. Josh had been chunky since he was 8, but the name-calling from a group of boys hit him like a slap.

By seventh grade, he was begging his mother to home-school him. Michelle didn't feel qualified to teach her first child, an A student who was good in science.

In ninth grade, he dreaded walking into homeroom. Boys sitting behind him would "poke and punch him in the arm," Michelle says. "They poked him with a pencil until he had lead marks in the arm. They slapped him against the head."

One evening halfway through the year, Josh let slip what was happening at the hands of his classmates. His mother, who had become a secretary at the school, had his homeroom changed.

Even now, Josh hates talking about those days. "I forget," he says, grimacing. "They were the school bullies. Most of them were expelled."

He had trouble sleeping. His grades dropped to Cs. He sunk into such a deep depression that he contemplated suicide. "I was thinking about getting a key to the gun closet. I was thinking of knives."

He handed his mother a note telling her he didn't want to live anymore. He couldn't bear to say the words.

As traumatic as that was, his mother stumbled on a diary that showed he had been hiding those feelings since sixth grade. "Everybody at school hates me," she remembers reading. "I don't have any friends. I don't want to live."

Josh received counseling from his pastor in ninth grade and went on the antidepressant Wellbutrin.

Despair is a common denominator among obese children nationwide. A recent study published in the Journal of the American Medical Association showed that when many obese children rate their quality of life, it is as low as that of young cancer patients on chemotherapy.

In high school, things got both better and worse for Josh. He befriended a group of girls who stuck up for him. Whenever one of the boys would mock him, Ashley Sonney, now 17, would call back, "You're dumb. He didn't do anything to you."

Josh would eat lunch with Ashley and her friends, and his mother thought he was turning the corner socially.

But in 10th and 11th grade, the 5-foot-11-inch boy gained 100 pounds, most of it in his stomach. He never ate seconds at meals but would snack, sometimes sneaking cookies from the freezer. He would wolf down three or four heaping plates at the all-you-can-eat buffet, leaving so bloated he could barely walk to the car.

Josh meets with Dr. Philip Schauer, along with his sister, Katie, 10, and his mother, Michelle, on June 13. The surgeon praises his young patient for losing 46 pounds since the gastric bypass but then admonishes him for indulging in french fries. Josh's mother opted for the same operation in February 2002. (Steve Mellon, Post-Gazette) Click photo for larger image.

The bigger he got, the more invisible he became.

"I could have punched people in the back of the head, and they wouldn't have known I was there."

The taunts had died down, but Michelle, who had a front-row seat of the social hierarchy from the school's front office, watched in despair as her son seemed to withdraw into his own fat, spending hour after hour playing video games.

Life-altering decision

Josh, a senior, is sitting in the cafeteria of Seneca High School, giving a tour of the cliques to the uninitiated.

He points out the "popular table" in center court, filled with slim clean-cut girls and handsome boys joking and flirting. Behind them is the long "punk table," where a girl in a midriff and impossibly tight jeans sits on the lap of her boyfriend, a hipster in black. Off to the right is the "computer geek" table, mostly male and studious.

Josh is sitting behind them in a half-empty round table with his younger brother, Jay, and two male friends.

"We are sitting in the 'Who Cares? Table,' " says his friend Cody Heverly, a skinny 16-year-old boy.

"We don't care, as long as we survive," Josh says, laughing.

It is May 3, three days before his operation. Josh is unaware of the agony he will have to endure to try to change his place in the high school social hierarchy.

He sits at the lunch table, holding his arms awkwardly in front of his stomach, as though he doesn't know where to put them. Short brown hair frames his round ruddy face. He doesn't talk much. Only when prodded does the now B student say he likes chemistry class. "We get to blow things up," he says, grinning boyishly.

He tells his friends that he will miss 2 1/2 weeks school for surgery.

He had to go through a lot to get to this point. For a year and a half, he begged his parents, Michelle and Glenn, a welder without a weight problem, to let him get a gastric bypass. Josh had to demonstrate that he had seriously tried dieting before his insurance company agreed to cover the $25,000 operation. He went from one diet to the next -- the protein diet, the carbohydrate diet, the grapefruit diet. He would lose 20 pounds and gain it back -- and then some.

He underwent a rigorous psychological exam to prove that it was his decision, not his mother's, and got nutritional counseling. He was told all the possible complications -- everything from gallstones to blood clots to death. (Studies show various death rates, ranging from .4 percent to 2 percent).

"It was really boring," he says. "They spent two hours telling me all the ways I could die. I don't care about any complications, as long as I don't die."

Three days later, the laparoscopic surgery goes smoothly as Schauer deftly maneuvers instruments that look like oversized barbecue skewers. But Josh wakes up feeling like death.

"Morphine," is the first word out of his mouth.

Two days later, he is still in his hospital bed, groaning.

"He looks so happy, doesn't he? Like a basset hound," said his father, Glenn, trying to get a laugh out of him.

Josh doesn't crack a smile. "I wish I could make this bed larger."

He is released from the hospital the next day, and he can't eat an ounce of cottage cheese without feeling sick.

The next Tuesday, he is back at Magee for a one-week checkup. It was a terrible road trip. The usual 2 1/2 drive takes three hours because Michelle has to stop the van to let Josh run to a restroom and vomit.

He walks into the doctor's office and steps on the scale. Even the 18-pound loss in a week doesn't wipe the look of anguish off his face.

Schauer asks him how he is doing.

Josh doesn't answer.

Sixteen days after his gastric bypass, Josh returns to Seneca High School in Erie, 28 pounds lighter. At lunch he can take only a few spoonfuls of peach yogurt. (Steve Mellon, Post-Gazette) Click photo for larger image.

"Doesn't he talk?" Schauer asks his mother.

Then the doctor tells him he has to relearn how to eat. Slow down. Stop gulping.

"I told you it would be bad," Michelle says on the way out.

"But I didn't realize it was going to be like this," says Josh, terror flashing in his pale blue eyes.

Developing new habits

Then, a week later, the nausea lifts.

Like a baby learning to eat, Josh takes his first bites of turkey and cheese, and it stays down. Every food is a scientific experiment. Can he tolerate it? He takes 30-minute walks around the grounds of the house, filled with cats, ducks and pigs.

By the time he goes back to school on May 22, he weighs 318, down 28 pounds, and he can eat a few ounces of macaroni and cheese and lettuce. His pants practically falling off him, he regales his classmates with hospital war stories. "I kept hitting the morphine button. I had so many drugs."

During lunch, he takes dainty bites of peach yogurt while his friends shovel in Belgium waffles and sausage.

A week later, at his health teacher's prodding, he gives a talk about his surgery for his final project.

"Did they take your stomach out?" one boy asks.

"No, it has to be there."

Other kids ask him what he can eat. Just 1 to 2 ounces per meal at this point. And five vitamins a day, something he will have to do for the rest of his life. But no sugar, lest he risk "dumping" -- severe nausea, dizziness and sweating.

"Josh, what are you getting yourself into?" Adam Morton asks playfully.

Everyone laughs, but not at Josh, who smiles, too.

The next week, he discovers he can eat maybe 10 McDonald's french fries and half a cheeseburger. His former self would have inhaled a Big Mac, large fries and a shake. Michelle steers him away from junk food, but she thinks it's OK to let him indulge occasionally.

But when he comes in for his appointment on June 13, Schauer applauds him for losing 46 pounds but chews him out for his junk-food indulgence. He wants to scare him out of becoming part of the 15 percent to 18 percent of patients who gain back significant weight in a few years.

"FRENCH FRIES! FRENCH FRIES! FRENCH FRIES!" Schauer booms theatrically. "What is wrong with this? We need to talk about this. Josh, this is major, major surgery for a major, major health problem. It will help you with portions, but selecting foods, you have to do it for yourself.

"If you go back to your junk-food habits-- pizza, Coca-Cola, french fries -- you will put that weight back on."

All in the family

At a family picnic at Presque Isle State Park on June 30, three generations of Gees -- Josh, his mother and grandfather -- are tanning their markedly thinner bodies and avoiding most of the junk food on the table.

Josh weighs 260, down 88 pounds in three months. As he glances up at the hard-bodied girls in bikinis, he eats two Pringles before handing the can to his brother.

Dr. Philip Schauer performs a gastric bypass operation on 17-year-old Josh Gee at Magee-Womens Hospital May 6 to shrink his stomach. Joshweighed 346 pounds before the surgery. (Steve Mellon, Post-Gazette) Click photo for larger image.

The teenager who was once a nutritional disaster now checks the information on packages to make sure he ingests less than 20 grams of sugar and 8 grams of fat. He cheats less than either his mother or grandfather.

"Josh does the best of all of us," says Michelle, 37, who occasionally eats candy, her weakness.

Josh is also laughing and talking much more than before and fighting less with his younger brother and sister.

People treat him differently at the Red Lobster, where he works as a bus boy. Customers who never used to make eye contact with him smile at him, sometimes mistaking him for their waiter.

"It's kind of upsetting. I am the same person. What's wrong with people?"

For the first time in years, he can look back and actually see a calf muscle. "Wow," says Josh, who swims at the YMCA a few times a week.

But he is still self-conscious about his stomach, wearing a T-shirt as he wades into the water on this sunny day.

Not his grandfather, Ken Pulos, an animated 60-year-old who had his surgery in June 2002. At water's edge, he whips off his shirt to show off his body. He is 181 pounds thinner than his old 372-pound bulging self. Excess skin folds up on his stomach.

The retired welder is also a gastric bypass evangelist.

"He tells everyone under the sun," his wife, Sharon, says. "I say, 'No, you are not going over there and telling them they should get surgery.' It's embarrassing. I try to hide somewhere."

Pulos says, just the other day he referred a 450-pound man in the grocery store to Schauer.

"I just think it is the greatest thing ever for losing weight. People say, 'Why don't you just quit eating, push yourself away from the table?' It's not that easy. It's like an alcoholic. You live for food."

Though the grandfather never pushed Josh into surgery because of his age, he's nudging his son, Bobby, and Bobby's wife, Jackie, to the operating table.

Jackie is nervous as she awaits insurance approval. She has four kids. What if something happens to Bobby or Jackie? "We didn't decide to do it," she says glumly. "Grandpa said this is what we should do. We said, 'OK.' "

Food and weight are preoccupations in this big-boned family. Michelle has stopped making mashed potatoes and gravy for family dinners and cooks more vegetables. But she worries that all this talk of food and weight loss will give her thin 10-year-old daughter, Katie, hang-ups about eating.

Then there is her second child, Jay, 16 and up to 300 pounds. He has asked his mother, "When am I going to have the operation?"

Michelle, who says she wouldn't consider it because her second son doesn't have health problems, responds, "You don't need surgery."

A brand new day

Josh walks into high school on the first day of school Sept. 8 exactly 100 pounds lighter. He wears a 2X maroon shirt, size-38 blue jeans and a tentative smile.

"Hey, you're getting skinny," a boys calls out.

He likes hearing it but isn't sure how to take it. "I never received compliments before. It's like your first time walking."

His eyes seem bigger. His neck has reappeared. His walk is bouncy, no longer a somber trudge. His blood sugar and blood pressure have dropped to within normal range.

A few days later, a boy taunts him, yelling, "You're still fat."

"He's skinnier than you," someone yells back, silencing him.

On Oct. 2, Josh turns 18. He weighs 240, 106 pounds less than he did five months ago, about 60 pounds over his target weight. He looks happy and relaxed in his new body.

At lunch, he jokes with his friends -- some from the old "Who Cares?" table, but some friends from homeroom, too. "I eat with a bunch of guys," says Josh, whose stomach has stretched a little and he can eat 4 to 5 ounces per sitting.

Next year, Josh hopes to study forensic science and criminal justice at Edinboro University of Pennsylvania so he can be a detective. Most of his college classmates will never know he was ever a fat, tormented boy.

As for his last months of high school, a building filled with some memories he would rather forget, he has no illusions that he'll ever be popular.

For Josh Gee, it's OK not to stand out.

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