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Juliann Sliwa pauses at the edge of the custom-made, extra-wide seat of her battered blue Chevrolet, summoning the energy she needs to get up.
She grips her cane and the top of the car door, then pushes down hard, levering her body upward until she stands on swollen feet, resting for a moment in the clinic parking lot.
Most people would cruise this route in less than a minute, gliding down a cement path before slipping through the glass doors and down the hall to the third door on the right. But Ms. Sliwa bears the weight of more than two large men on her 5-foot-2-inch frame.
It would have been easy to remain in the safety of her St. Catharines, Ont., home today. She drove 50 kilometres to reach this one-storey brick building in an industrial section of Hamilton. OxyContin numbs her screaming joints; Wellbutrin lifts her depression. This 2 p.m. appointment will be today's main event. She'll need a nap when she gets home. But she grinds on.
Finally she reaches the waiting room of the Wharton Medical Clinic's Weight Management Centre and slumps into a chair, grateful it has no armrests. The five-minute trek has left her winded; her breath bursts out in shallow, wheezy gasps.
She submits herself to this punishing walk twice a month, hoping each step will bring her closer to shedding the weight that has dogged her throughout her life. Now it threatens to kill her.
Getting to the clinic is the easy part.
At Ms. Sliwa's first appointment, in July of last year, Sean Wharton, a bariatric specialist and the clinic's director, asked what her goals were.
She was 42 years old and 481 pounds. "I want to tie my shoes," she told him. "I want to cross my legs. I want to dance."
Many of Dr. Wharton's patients have similarly modest goals. Some aspire to see their own photo or to take off their shirt at the beach without shame. Others want to no longer be the "fat mom" at their child's school.
The Wharton clinic may represent their best hope. Some obesity experts say its holistic approach may be a model for how the skyrocketing problem of obesity can be treated.
Here, the goal is to make patients slimmer and healthier - but also better equipped to battle the temptation of the drive-through window.
Patients are monitored, measured, prescribed medication and given diet plans tailored to their weight and metabolic rate. They also meet as often as twice a month with a dietitian and a kinesiologist. A behavioural therapist addresses the emotional triggers driving them to gorge.
The doctor visits are covered by the Ontario Health Insurance Plan, and Dr. Wharton pays the other specialists to keep them on staff. "If I have cancer, I don't pay an oncologist," he argues. "Obesity is a medical condition, therefore patients shouldn't have to pay a dime to come here."
For patients, who arrive weighing up to 600 pounds, the clinic can feel like a life raft tossed to them after a lifetime spent drowning in shame and isolation.
Many patients have stories of hospital equipment that didn't fit, or family doctors who balked at doing a pap smear. Once, Ms. Sliwa had to be weighed in a hospital laundry room.
This dearth of appropriate services in the health-care system stands in stark contrast to Canada's rising obesity rates. One in three Canadian adults are now estimated to be overweight, and almost one in five are clinically obese, according to Statistics Canada. The health-care costs associated with obesity are estimated at $4.3-billion annually, according to a Queen's University study based on 2001 figures.
Even at Dr. Wharton's clinic, Ms. Sliwa is an extreme case.
A healthy person's body mass index (an approximation of body fat), is between 18 and 25. People whose BMI is 45 or more - about 3 per cent of Canadians - are classified as Class 3 obese, and at extreme risk of serious weight-related conditions including diabetes, heart attack, osteoporosis and some cancers.
Ms. Sliwa's BMI, at her first visit, was 86.5.
She's knows what's at stake. "If I don't do something now, I may only have five more years to live," she says. "I have to do this or I'm going to die."
Dr. Wharton recommended that Ms. Sliwa seek gastric bypass surgery - a drastic procedure he advises for about 5 per cent of his patients. The procedure would reduce her stomach to the size of a lemon, dulling her cravings and ability to gorge without feeling sick. Side effects can be serious, but it's the only proven, long-term treatment for morbidly obese patients, Dr. Wharton says.
To get the surgery, she would have to go on a liquid diet for up to several months. The medically supervised program, called Optifast, would shave off pounds and make surgery easier and safer.
If she lost 10 per cent of her weight, or about 50 pounds, she would be physically ready for surgery, Dr. Wharton said. But she also had to be mentally prepared. Bingeing post-surgery could bring serious complications, he warned.
"We're not operating on the person's emotions," Dr. Wharton said later. "So if [patients] still continue to binge eat or [engage in] other destructive types of behaviours, then we're now dealing with a real lethal weapon."
The American surgeon struts across the stage like a preacher.
Tall and slim with a blond crew cut, Steven Hendrick physically embodies what he promises from his scalpel. About 40 per cent of the patients who flock to his Detroit clinic for gastric bypass surgery are Canadian. In 2007, about 900 Ontarians had the procedure in the United States (the $28,000 operation is paid for by the Ontario government), compared with only 300 in Ontario hospitals (where it costs $16,000) because of bed shortages. (A recent $3.7-million infusion from Ontario should shorten the domestic waiting list).
On this cold Tuesday night in February, the doctor has travelled to Brampton, Ont., to recruit more patients.
His audience - some of whose bottoms take up two seats - hang on every word. But of the 50 people at the free lecture sponsored by Dr. Wharton's clinic, none are more enthusiastic than Ms. Sliwa.
Seated in the front row, she takes pages of notes and peppers the doctor with questions. She marks one point with a star: "Bariatric surgery is not a cure but a tool to change habits and manage comorbidities."
That tool is within her grasp. For six months she has religiously followed Dr. Wharton's advice. Since December, she has been consuming only Optifast - or "sludge," she jokes. That week at her weigh-in, she was 429.5 pounds - down 52 pounds.
Celebration is in order, and a few days after the lecture, Ms. Sliwa puts on a red blouse and sparkly earrings and drives an hour to Toronto for a Valentine's Day dance hosted by Curvacious, a social club for plus-sized women and their admirers.
"Here, you get unconditional love," Ms. Sliwa says.
At other nightclubs, the women say, they've endured disgusted stares, hissed "moos" and worse.
"Men think just because we're fat, we're easy!" one woman says over dinner.
But here, slender men ogle them from the bar. No one blinks when a woman pulls a cellphone from her cleavage, or kneels to tie a friend's shoelace, saving her the effort.
Bags of heart-shaped chocolates and Tootsie Rolls are passed around while gossip swirls about breakups, babies and who just lost 100 pounds.
For hours, Ms. Sliwa sits at the edge of the dance floor and delights in the spectacle, occasionally with the arm of her boyfriend, Jeff Burke, draped across her shoulders. They've been together since meeting at a Curvacious event two years ago.
He bobs off to dance, leaving Ms. Sliwa behind.
When a Bob Marley tune booms, she moves her head and waves her arms to the rhythm. "When I used to dance, this was my music," she explains.
She hasn't danced in 11 years.
For years, diet and exercise were championed as the twin strategies for weight loss. But as the obesity epidemic spreads, researchers are exploring why someone like Ms. Sliwa becomes obese.
One of those explanations is genetics. "It's very clear that some individuals are much more susceptible to weight gain than others, and some individuals have much greater difficulty losing weight than others," says Ruth McPherson, a molecular biologist and director of the University of Ottawa Heart Institute's lipid lab, where researchers are studying and comparing the genetics of thousands of lean and obese individuals.
A second, often overlooked, component is mental health. Some people turn to food to ease pain or distress - and some doctors say that these triggers can be the biggest challenge.
"Food is a comfort for all of these people, but there's some who really rely on it," says Joseph Berlingieri, an internist and cardiac specialist who runs Pounds for Health, a medically based weight management clinic in Burlington, Ont.
"It's got a different kind of power. It's their refuge. It's their security."
Doctors have begun adding counselling to their weight-management programs.
But there is an acute shortage of psychiatrists, and therapy fees can be prohibitive, Dr. Berlingieri says.
Yo-yo numbers on the scales are often the result. Dr. Berlingieri has been referred patients who lost hundreds of pounds after gastric bypass surgery, only to gain it all back.
"For those kind of people, it's very hard to deal with this [emotionally]. And that would not be the kind of person you send to surgery."
It's an overcast Friday morning in early May, but inside Ms. Sliwa's curtain-drawn living room it's even gloomier. Sunk into a chair, a cluttered table pulled up to her chest, Ms. Sliwa shifts to ease the pressure on her hips. By her elbow is a box stuffed with drugs: painkillers, antidepressants and heart medication.
"See, I told you it would be boring," she tells a visitor.
Most days, her only company is the cast of The Young and the Restless and her two cats, Mordacai and Mr. Mistoffolees. There's also Fran, the woman who stops by five days a week to cook, clean and help her bathe. Without Fran, whose services are covered by disability insurance, Ms. Sliwa would never have clean laundry. She hasn't braved the 18 steps to her basement in 11 years.
She's lived on disability insurance since a car accident in 2004, so instead of work, Ms. Sliwa's weekdays are full of health appointments: twice a month with Dr. Wharton; weekly trips to physiotherapy and counselling. A nurse makes weekly home visits.
The rest of her days are spent napping, scrapbooking or messaging friends. Mr. Burke only manages a visit every couple of weeks.
She also attends a prayer group. Lately, she's leaned on its spiritual support.
"The last while it's not been good," she sighs. "Life and the scale. But life affects the scale."
It's been that way since childhood. She was born the only child in a home where spaghetti sauce simmered on the stove all day and disputes were soothed with Dairy Queen. Once, the kids at school put tacks on her seat to see if she would pop.
She weighed more than 200 pounds in high school, and by the time she reached adulthood she had tried every diet, from cabbage soup to Weight Watchers. But each 50- or 60-pound victory was erased by the binges that followed crisis after crisis, including the death of both parents in her 20s - her father in a car accident and her mother, who was her closest confidante, to cancer. Car accidents in 1999 and 2004 left her with painful nerve damage and ruined knees.
At her heaviest, after the crash four years ago, she weighed 537 pounds.
"It was horrible," she says. "I couldn't breathe."
After the Valentine's Day dance, Ms. Sliwa continued to shed pounds, hitting a low of 404 pounds in April. She hasn't been weighed since, but May has delivered another series of setbacks: the 20th anniversary of her mother's death, and news that she may have to declare bankruptcy.
She's terrified of losing her house. And even though her fridge contains only strawberries, yogurt and bottled water, the comfort of Swiss Chalet is a phone call away. She manages an Optifast drink about once a day, but most of her meals are regular food now.
She feels frustrated and embarrassed by each setback, but also powerless to overcome the demons that drive her to eat. "I feel like a failure; a disappointment," she says. "It's not how I wanted my life to turn out."
In the afternoon, a social worker arrives to fill out an application for community housing.
She asks Ms. Sliwa what she should write about her weight.
"Say what you want to say. The weight has been a major problem and is a vicious cycle," Ms. Sliwa replies.
She mentions she's lost 133 pounds since her high of 537.
"Wow, that's amazing! Don't you think that's amazing?" the social worker exclaims.
Ms. Sliwa says she's too stressed out to concentrate on her diet. It's a phrase she will repeat often in the coming months, and it will bear out in her weight. Over the next two months, she will put more than 20 pounds back on.
But the social worker fixes on the positive.
"What that tells me, Juliann, is if you can do 133, I should be able to do that 10 I put on in Italy."
Ms. Sliwa deadpans. "Ten is my elbow."
Of Dr. Wharton's patients, Chris Dukarich and Andy Murphy represent where Ms. Sliwa aims to be.
Mr. Dukarich, a Hamilton plant worker with big ears and an even bigger laugh, bursts into the Wharton clinic's boardroom on a hot day in July holding a year-old photo of himself dressed in a rented tuxedo - with a 60-inch waistband.
Today, which happens to be his 27th birthday, those pants would drop off his 40-inch waist.
"It's more than a celebration," he says of the party planned that evening. "It's a celebration of new life."
The summer has been a series of emotional highs. He went on his first real date, he took off his shirt at the cottage and wasn't embarrassed. He bought cool clothes at regular stores - no longer forced to take what he could find in XXXL.
He calls himself a "reformed eater." Guided by Dr. Wharton's staff, he's gone from living off Slurpees and fast food to meticulously measuring every low-fat meal for its fibre, protein and carbohydrate content.
Since last November, he's lost 128 pounds, shaved 15 points off his original BMI of 54.3 and nearly halved his body's fat composition from 44 to 27 per cent. His cholesterol and blood sugar have plummeted to safe levels, too.
Also at the clinic that day is Mr. Murphy, a 48-year-old cement truck driver. Six months earlier, the father of three swapped super-sized burger combos at Wendy's for Optifast drinks, shedding 130 pounds from his 6-foot-2, 589-pound frame before travelling to Detroit for gastric bypass surgery. Since that surgery in May, he has lost 120 more pounds and counting.
Both men tried other options before winding up in Dr. Wharton's clinic. In three sessions with a Dr. Bernstein clinic, a commercial weight-loss program that costs thousands, Mr. Murphy had lost 180 pounds, 90 pounds and 60 pounds, and gained it back each time.
But they both swear this time is different. Like a reformed junkie, Mr. Murphy says he has a self-imposed ban on ice cream, for example, so he's not like "the fool [drug] addict who think he can do one line, and be okay."
Both say the euphoria of their new lives is too great to lose now. "I still wouldn't go kickin' sand down the beach, but I've gone swimming," says Mr. Murphy, now 339 pounds.
But he regrets the lost moments, like his son's hockey games that he spent in his truck in the parking lot, because he couldn't negotiate the bleachers.
Of the 1,000 patients Dr. Wharton has treated, he estimates more than 100 have lost a dramatic amount of weight like Mr. Murphy and Mr. Dukarich. But he says the scales aren't the only measure of success.
For some, even a 20- or 30-pound weight loss can take them off heart medication, he says. Others may learn proper eating skills so that their children don't follow in their footsteps.
But others may never find the radical change they are looking for.
At her weigh-in today, Ms. Sliwa is 412 pounds, having lost more than the 10 per cent that would make her eligible for surgery.
But right now, that option is off the table. The bottom line, Dr. Wharton says, is that she isn't emotionally ready for surgery. She has told him she doesn't want it.
Still, he says, there have been minor victories and there may be more. She's lost about 70 pounds. She continues to make it to her clinic appointments. "She has not given up," Dr. Wharton says.
On a warm evening in late August, Ms. Sliwa, looking pretty in a new dress and fresh burgundy-coloured hairdo, snaps pictures of the orange moon reflected on still water.
Her club, Curvacious, has sold 120 tickets for this cruise in Toronto's inner harbour. Ms. Sliwa bought the first one.
"This is the only thing getting me through these dark days," she says.
She hasn't been weighed since the scales read 423 at a second appointment in July. But she hasn't been eating well and knows the scale has crept up. "I can feel it," she says.
Her diet - and the surgery - are on hold until her financial and personal life can be sorted out. She declared bankruptcy the previous month and she may still lose her house.
"I hope this gets better," she says. "I hope I get my hope and my positivism back."
At dinner she accepts a second helping of Caesar salad and buttered bread with her roast chicken and baked potato, before digging into dessert. And when the DJ blasts the first dance tune, she claims a seat on the sidelines.
Hours later, as the ship plows toward the dock, she heaves herself to her feet. She extends her camera to Mr. Burke so he can snap a photo of them together.
Instead, he grabs Ms. Sliwa's extended hand and lowers his other arm on her side. He leans in and slowly rocks to the tempo. She stands stiffly at first, as if afraid to move.
Finally, after a tense pause, she gives in.