Hungry Gene: How the World Got Fat and What We Can Do About Itby Ellen Ruppel Shell
In a rare blend of erudition and entertainment, acclaimed science journalist Ellen Ruppel Shell reveals the secret history and subtle politics behind the explosion of obesity. Shell traces the epidemic's inception in the Ice Age, its rise during the Industrial Revolution, and its growth through the early days of medicine and into modernity. She takes readers to the
In a rare blend of erudition and entertainment, acclaimed science journalist Ellen Ruppel Shell reveals the secret history and subtle politics behind the explosion of obesity. Shell traces the epidemic's inception in the Ice Age, its rise during the Industrial Revolution, and its growth through the early days of medicine and into modernity. She takes readers to the front lines of the struggle to come to grips with this baffling plague from a children's food marketing convention, to the cutthroat race to find the obese gene, to a far-flung tropical island, where a horrifying outbreak of obesity has helped unravel the disorder's genetic and evolutionary roots. Offering an unflinching insider's look into the radical and controversial surgical and pharmacological approaches used to combat what drug makers have dubbed the trillion-dollar disease, Shell takes aim at the collusion of industry and government that lies behind the crises and shows conclusively that obesity is not a matter of gluttony or weak will, but of an increasingly greedy culture preying on vulnerable human biology. Gripping and provocative, The Hungry Gene is the unsettling saga of how the world got fat and what we can do about it.
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The Hungry Gene
The Inside Story of the Obesity Industry
By Ellen Ruppel Shell
Grove Atlantic, Inc.
Copyright © 2002
Ellen Ruppel Shell
All right reserved.
A Weariness of Eating
If you examine a man who suffers from his stomach. All his
limbs are heavy. You find his stomach is dragging. It goes and
comes under your fingers. Then you shall say concerning him:
this is a weariness of eating.
-The Egyptian Book of the Stomach
The first time I set eyes on Nancy Wright, she is flat on her back
and cruciate. She is vaguely pretty, her eyes frightened but
oddly beguiling. Her thick hair is loose and wavy, auburn with a
sly touch of gray at the temples. You can see what some men
see in her, and also, perhaps, why two husbands have come and
gone. Even as she lies splayed and sedated on a gurney in
Operating Room 17 at Beth Israel Deaconess Medical Center in
Boston, you can sense that Nancy Wright is possessed of an
Nancy once told me that she'd started out life large and kept on
going. She didn't mean it as a joke. She weighed ten pounds,
four ounces when she came into this world, and through
childhood ate herself so big that her father thought she had
psychological problems. Nancy didn't see it that way, but she
did know that her relationship with food was tempestuous, like a
doomed love affair. 'Food has always been my best friend and
worst enemy rolled into one,' she told me. Now, in middle age,
this dysfunctional relationship has made even simple pleasures
difficult. It is getting harder for her to work in her flower garden,
harder to play with her five grandchildren. And she keeps getting
sick. She has hypertension, high blood cholesterol, and sleep
apnea. She hates being so tired all the time, and so feeble, and
she has done everything she can think of to fight it. She has tried
Weight Watchers, Jenny Craig, and diet pills. All of these
worked, for a while. The pounds melted away, and Nancy
thought she'd found salvation. She'd buy new clothes and start
making plans for a new life. But then, without knowing why,
she'd fall off the wagon, and her old life would rush back. It was
like waking up to a nightmare.
People tell Nancy she lacks willpower, but they are wrong. She
has plenty. She stayed with the same thankless social services
job for twenty years. She stayed with the same thankless
husband for nineteen. And as a fiftieth birthday present to
herself, she quit smoking. She hasn't touched a cigarette in four
years, and doesn't plan to touch one ever again. But food is
another matter. 'You can live without cigarettes,' she said, 'but
you have to eat.'
It all comes down to a balance of power-or, rather, to an
imbalance. Nancy can no more tame her compulsion to eat than
a marooned sailor can tame his thirst. For Nancy, food is more
than an addiction, it is like breathing-a constant, throbbing
Dr. Edward Mun understands all this perfectly. Mun is an
assistant professor of surgery at Harvard Medical School, and
an attending surgeon at Beth Israel Deaconess Medical Center.
At thirty-eight he has the self-assured manner and polished good
looks of a man born to take charge. But beneath the Ivy League
veneer and the designer suit lie hints of a nerdy immigrant boy, a
gawky overeager kid who spent his summers squinting through a
microscope at science camp rather than hanging out at Little
League with his pals. Like Nancy, Ed Mun hasn't always fit in.
He was born in Korea and grew up in Gardena, California, the
son of restaurant owners who expected much more of their boy
than they themselves had managed to achieve. Young Ed did not
disappoint; he was the model of the good Asian son. He aced
high school, enrolled in Yale University, and graduated in four
years with both bachelor's and master's degrees in biochemistry.
He further distinguished himself at Harvard Medical School, and
nabbed a coveted surgical residency in sunny San Diego.
Surgery offered the most money, the most prestige, and the
greatest opportunity to perform technically interesting
procedures. But Mun wanted more.
'I wanted neurosurgery because I thought it was only for the
talented few,' he said. 'But the truth is that there aren't that many
brain operations. Neurosurgeons do herniated disks and trauma
cases. Mostly, it's boring.'
So Mun returned to Boston, to Harvard, and to Beth Israel
Deaconess Hospital, to apprentice in general surgery. He
removed breast cancers and performed stomach surgery. To his
great relief, he didn't find this boring at all. But he did find it
frustrating. Breast cancer patients had the habit of scrutinizing
the Internet for facts about their disease and hauling reams of
downloaded information tto his office for review. Mun didn't like
the messiness of that, the presumptuousness. Breast cancer, he
says, is usually a matter of small incisions and quick recoveries.
Yet the patients would piss and moan and demand second
opinions. He didn't mind the second opinions, of course, but he
did mind being put through the third degree. And he blanched at
their sense of entitlement. These women were hot reactors, the
sort of patients who required more assurance than he had to
But the stomach was something else altogether. He liked the feel
of it, the hard muscularity of the thing. And he liked that
stomach patients trusted him, put themselves in his hands. They
didn't ask a lot of extraneous questions, didn't expect miracles.
He found stomach surgery enthralling, so much so that one
would think he had some sort of a belly fetish. But it was
nothing like that.
'In Japan and in Korea, tens of thousands of people die from
stomach cancer every year,' he said. 'I also lost several relatives
to this disease.'
In Korea stomach surgeons are held in the highest esteem.
Among these masters was Mun's paternal grandfather, the man
in whose steps young Ed was meant to follow. Mun very much
wanted to be like his grandfather, and to earn the respect of his
demanding parents. So he studied and worked until he became
one of the best stomach surgeons at Beth Israel Deaconess
Medical Center, which is to say one of the best in the country,
and perhaps in the world. But unlike his grandfather, Mun
doesn't open many bellies to remove cancerous lesions or to
repair ulcers. What Mun does mostly is something very few
Korean surgeons-and only a few American surgeons-have
ever done or would ever dream of doing. What Mun does is to
take perfectly healthy stomachs and replumb them, cutting them
loose from their natural moorings at the end of the esophagus
and fashioning them into pouches the size of robin's eggs. This
procedure, which generally takes Mun about ninety minutes but
most other surgeons much longer, is called a Roux-en-Y gastric
Stomach surgery is a pretty rough ride. People who get their
guts whittled and rearranged in this way can't eat much for
weeks afterwards, certainly not nearly as much as they did
before the change. If for some reason they succumb to the
temptation to eat more than the little that their stomach can hold,
they vomit. Vomiting is not really a complication of gastric
bypass surgery; it is an expected and important side effect.
Gastric bypass patients sometimes lose so much weight that old
friends and relatives barely recognize them. The surgery is
reserved for those with one hundred or more pounds to lose.
On average, patients shed about 60 percent of their excess
weight in about eighteen months. It is hard to imagine many
people in Korea being interested in such an operation. But in
2000, the year I met Mun, forty thousand Americans underwent
gastric bypass surgery, about double the number performed
only five years earlier. That number was expected to nearly
double again by 2003. Mun doesn't find these figures the least
surprising; he knows many people require his services. In
Boston his dance card is full. And Nancy is next in line.
* * *
Nancy is five feet three inches tall and, at the time of her
operation, weighs 274 pounds. Her BMI is 48.5, well into the
morbidly obese range and she thinks she would feel and look
much better if she were one hundred pounds or more lighter.
She has seen what gastric bypass surgery can do for people:
two of her coworkers have been transformed by the procedure,
and a year ago her youngest daughter underwent the surgery and
dropped ninety pounds. It was her daughter especially who
convinced Nancy to give surgery a go, not so much with her
words, but by her example. Both mother and daughter, Nancy
said, are stubborn as mules. She figures that if gastric bypass
worked for her daughter, it will work just as well for her.
Mun doesn't know Nancy is stubborn, but he does know that
she is an especially good candidate for obesity surgery. For one
thing, she is in relatively good health, without the horrific
complications suffered by so many of the morbidly obese. For
another, she is relatively small. A man of Mun's experience
might well see Nancy that way. The hospital bed waiting outside
his operating room is a 'Big Boy,' built to hold up to five
hundred pounds. Sometimes it takes two Big Boys pushed side
by side to hold
one of Mun's gastric bypass patients. Mun remembers a
seven-hundred-pounder whom he envisioned falling on him and
crushing him to death. Nancy evokes no such grim images.
There will be room to spare on her Big Boy.
Still, Mun has not promised Nancy success, or even survival.
Gastric bypass kills one out of a hundred patients on the
operating table, and not everyone recovers from its
complications. There are few controlled studies of the
procedure, so no one can speak with authority on its degree of
danger. Still, the insurance industry classifies it as 'high risk.'
The anesthesiologist on duty warns that corpulent patients are
tricky, and that Nancy is no exception. Nancy's veins are buried
in a thick layer of fat, making it hard for a needle to find
purchase. Like many obese people, her tongue is large and her
neck short, making it difficult to guide a breathing tube down her
windpipe. It takes a bevy of nurses and doctors several attempts
to finagle each of these maneuvers, and with every attempt it
looks like Nancy will choke or cry. But she doesn't, and with
time and effort the requisite tubes and needles get coaxed and
jabbed into place. Nancy's eyes flutter and close and the
anesthesiologist tapes them shut to prevent the corneas from
drrying out. Paralyzed from the anesthesia, Nancy draws her
breath by machine. Plastic shrouds her face, presumably to
shield wayward gore. She emanates fewer signs of life than do
the machines to which she is tethered.
Mun helps the nurses arrange the layers of sterile drape, leaving
exposed a rectangle of stark white skin roughly the area of a
shoe box lid, size ten. He paints the rectangle orange with
antiseptic. The flesh ripples thickly, like a crème brûlée. Mun
grabs a black ballpoint pen and traces down the center line, a
little shaky at first, then more or less finding the line he is after,
about an eight-inch stretch from the tip of the breastbone to the
navel. Seble Gabre-Madhin, a surgical resident, accepts a
cauterizing scalpel from a nurse and traces over that line again
and again until the skin bursts open with the force of the fat
beneath. An observing medical student startles. It's not the sight
that makes him queasy, he whispers, it is the smell, which is
savory, like hamburgers spitting on a grill. The translucent fat
layer glistens yellow under the operating room lights. The
attending nurses hover. Drs. Gabre-Madhin and Mun exchange
looks, then press two palms each on either side of the neatly
split skin and ease the fat apart, forming a canyon. The walls of
the canyon are slippery and lightly variegated with red blood
vessels. There is almost no blood.
In The Wisdom of the Body, Sherwin B. Nuland, a clinical
professor of surgery at Yale University, writes that the stomach
is best understood 'seen as a large bag near the upper end of
what is otherwise a hollow muscular tube some twenty-five feet
long from mouth to anus, the central portion of which is coiled
up in the abdomen.' This tube is the gut, and from stem to stern
it comprises the pharynx, the esophagus, the stomach, the small
intestine, the large intestine (or colon), and the rectum. The gut
has an inner and outer layer of muscle, and the stomach has yet
a third, to aid in its tireless churning of food.
The muscles and fibrous layers covering both sides of the
stomach wall meet and fuse together in the middle of the belly,
forming the linea alba, a stout ribbon of tissue stretching from
the breastbone to the pubis. Mun deftly splits this, exposing the
well-packed contents of the abdominal cavity, the largest orifice
in the human body. Nurses position a gray metal circular
retractor to hold back the skin and flab. The crater yawns jagged
and raw. Mun pulls a glutinous apron of fat and blood vessels
outside the wound, and lays it to one side of the torso. The
mess on the surgical sheet is ghastly, like a mangled tongue
lolling from the mouth of a drunk.
Mun plays archaeologist, pointing out artifacts as he excavates.
Plunging his hand into the cavity, he locates the expected
umbilical hernia, a weakness in the muscle near the belly button
that is common in the obese. Wrist deep, he palpates the taut
purple liver. He had mentioned earlier that the livers of the obese
can grow monstrous-'sometimes,' he told me, 'they are as big
as a horse's liver.' This liver, thank goodness, is not Clydesdale-sized.
Mun gently retracts it to examine the junction between the
stomach and the esophagus. He is now elbow deep, pawing
blind for the start of the stomach. Long seconds pass, and
Mun's brow arches in concentration. No one says a word. This
is a tricky business, and even the assisting surgeon, a stout,
world-weary young woman, seems to hold her breath.
Suddenly, Mun finds what he's after. He stops for a moment
and looks back at me, triumphant in his sterile mask and lightly
'I love this organ,' he says, pulling the stomach into glorious
Bariatric surgery, as obesity surgery is called, has a
controversial history dating back hundreds of years. But the first
modern procedure on record was in 1889, performed by
Howard A. Kelly, a founding member of the faculty at Johns
Hopkins University and its first professor of obstetrics. Kelly
was an inventive surgeon and developed numerous surgical
devices as well as innovative operative procedures. He seems to
have fancied himself quite a sculptor, for he carved layers of fat
from the abdomens of unwitting patients while they were under
the knife for other problems.
Over the next few decades, reports of similar adventures trickled
in from France, Germany, and Russia, and by the early 1920s,
obesity surgery had become, if not fashionable, at least less
Excerpted from The Hungry Gene
by Ellen Ruppel Shell
Copyright © 2002 by Ellen Ruppel Shell.
Excerpted by permission.
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