Hector Garcia Jr. sat in his new oversized leather recliner as his niece Chelsea Amen delivered a plate of food to him on Thanksgiving. After years of repeatedly gaining and losing hundreds of pounds, Garcia, who at one point weighed 636 pounds, once again was stuck in the back bedroom of his parents’ modest South Side house.

While his family ate together in the small living and dining rooms decorated with crosses and photos, Garcia couldn’t get up to join them. From his chair, he picked up a flyswatter to engage in a playful sword fight with his 6-year-old nephew, Brandon Garcia, who wielded a back scratcher.

Two more of his teenage nieces came in later. Brooke Freed, perched as usual on the armchair of his recliner, used Garcia’s laptop to show him the boots she wanted for Christmas, while Lauren Ibarra settled in for a nap on her uncle’s bariatric hospital bed.

This is Garcia’s childhood home, but as a child he never imagined that for years obesity would confine him to just one room and leave him unable to walk more than a few feet without resting, too big to get into a car, isolated from everyday life, and afraid of falling and possibly suffocating.

Instead, as a little boy he dreamed of being a fighter pilot and even forced himself to watch movies of pilots spinning so he could train himself to not get sick. In front of the television in his bedroom, four miniature fighter planes line the table, symbols of the many hopes lost in Garcia’s lifelong fight with obesity.

Most of all, he wanted to be married and have children — another wish unfulfilled.

"It's hard to fight for my life when I feel that my life is not a life. It's existence. Existence is not enough for me," he said.

"I don't remember a time when I was truly happy. I remember happy moments with family, enjoyable moments, but never truly happy. And I don't know that I'll ever find that and I've come to terms with that, that is what my life will be. The remainder of my life will be lonely, an existence, that's just solitary. And I hope it's not, because God gave me a big heart."

Garcia's story is a familiar one, though an extreme example, even in Bexar County, where almost two-thirds of adults are overweight or obese.

His weight put him in a category known as severely obese, which makes up about 6.3 percent of the U.S. population. The rate of severe obesity is growing even faster than the rate of people who are merely overweight — 33 percent — or obese — 36 percent.

Neither the state nor local health agencies track the percentage of people with severe obesity, which is more dangerous than lesser degrees of obesity because it raises the likelihood of dying prematurely — one recent study suggests 14 years early — from heart disease, cancer and diabetes.

An untold number of people with severe obesity live in isolation like Garcia, unable to find or access the medical and psychological help they need to combat its pervasive effects.

Chubby as a child, Garcia was picked on and ridiculed. He began dieting in high school but always regained the weight he had lost and more.

By his mid-30s, when he reached his peak weight, he had gastric bypass surgery and lost nearly 400 pounds but gradually regained it.

With both knees so damaged by his weight that he barely could move, Garcia mustered the determination to shed about 350 pounds again, this time through dieting and exercise, in order to have double knee replacement surgery when he was 46.

In the two years since then, as his weight approached 600 pounds yet again, Garcia's body became as much a mental prison as a physical one.

To save others from the same pain and alienation, Garcia allowed a San Antonio Express-News photographer to follow him for the past four years to see close up the toll obesity takes.

"My life is a cautionary tale," he said.

Three weeks ago, Garcia strained to lift himself out of his recliner and walk the 40 feet to the front door where his mother stood outside waiting. "Mom, I can't breathe," he gasped as he collapsed in a living room chair.

Feeling left out

By the time he was 5 or 6, Hector realized he stood out because of his weight. He wasn't obese yet, but he was the kid wearing the husky jeans from Sears.

His mother, Elena Garcia, was 14 when she married Hector Garcia, and together they had six children. Hector Jr. was the fourth.

"My mother was a child having children," Garcia said of his childhood. "She didn't know what she was doing. She gave us what she had. We were poor, we didn't have money."

His mother had to learn how to make food stretch, and the family ate the cheapest food available: Beans, rice, vermicelli, Kool-Aid, food cooked with lard.

"I didn't know anything about nutrition," Elena said.

If someone offered her a salad, she'd say she wasn't a rabbit.

"So we picked up bad eating habits, not because we wanted to but because that's the only thing we could eat," Garcia said.

His parents and his siblings are overweight or obese. Terry, the sister Garcia was closest to, also underwent gastric bypass surgery. She later died of stomach cancer.

Garcia was laughed at by other children and was the last to be picked for sports teams, a stigma that persisted his whole life. He got into frequent fights with classmates in a drainage ditch near his home because "they all wanted to fight the fat kid."

He remembers being called “fatso” and “tubby.”

“They even called me 'hamburger.’ I became an outcast. Kids just didn’t want to hang out with me. They always pushed me to the side,” Garcia said. “I always felt from a very young age that I wasn’t worthy or I wasn’t good enough, and that’s something that’s carried on to my adulthood.”

Recalling the humiliation and isolation he suffered still brought him pain 40 years later.

“I always pictured myself as a child with my head up against glass looking at life happening and I was stuck behind the glass. Because no one, no one wanted the fat kid,” he said, crying.

Complex problem

Garcia said people would dismiss him as lazy or gluttonous, but the mainstream medical community — including the American Medical Association — has come to recognize obesity not as a moral failing but as a chronic disease influenced by genetic, physiological, psychological and environmental factors.

“Personal responsibility is only half the equation,” said Dr. Ruth Berggren, director of the Center for Medical Humanities & Ethics at the University of Texas Health Science Center.

One factor contributing to the obesity epidemic is what some experts call a toxic food environment: oversized restaurant portions, easy access to junk food, the prevalence of drive-throughs, 24/7 marketing of unhealthful foods and a culture that celebrates such high-calorie foods as deep-fried butter.

While some experts blame an excess of calories, other obesity researchers believe eating certain foods — such as refined carbohydrates and high-fructose corn syrup — affects insulin levels and throws the metabolism out of whack, contributing to a disease that can’t be cured simply by putting down the fork and going for a run, said Dr. Brian Sabowitz, medical director of Alamo City Medical Weight Loss.

Then there's the sedentary lifestyle that has become the norm for most Americans: a reliance on cars, computers, TVs and smartphones that make life easier but also make it easier to gain weight.

Genetics also is a culprit in obesity. The working concept, said Dr. John Pilcher, a bariatric surgeon at New Dimensions Weight Loss, is that some people are lucky with their genes, making them less susceptible to an environment that promotes obesity. Others aren't so lucky.

Garcia likely had a genetic predisposition to obesity, said Thomas Wadden, a psychologist and director of the Center for Weight and Eating Disorders at the University of Pennsylvania School of Medicine, who did not treat Garcia.

“He came into the world with the cards stacked against him,” Wadden said. “If you had taken the same individual and placed him in Afghanistan or Iraq, he probably would have been one of the heavier individuals in those countries, but they just don't have the food supply, they don't have the multibillion-dollar marketing campaigns that would have led him to weigh 500 pounds.”

The mix of toxic food environment and sedentary lifestyle has been pernicious and pervasive in the nation since the 1960s, Wadden said, and two-thirds of the population have succumbed to it. People with genetic predisposition are the most adversely affected.

“America will let you achieve your most obese potential,” he said.

Food as comfort

It wasn’t just children who ostracized Garcia. Even as an adult, he felt like a social outcast. Strangers would make faces at him in public. Women saw him as a friend, not boyfriend material. Once, he said, a potential employer took one look at him, balled up his job application and threw it in the trash.

The prejudice against people who are obese is the only one that remains socially acceptable, he said.

“You can say something about a fat person, no one’s going to object," he said. “You say something about a person of color or someone who’s gay or something, they’re on you like stink on a bug. You'd think that as enlightened as we are in this world today, that things would change, but they really don't.”

The more Garcia was rejected, the more lonely he became and the more he turned to eating. He felt like food was a friend.

“Food didn’t mistreat me, food never told me anything, never said anything bad to me, so I took comfort in eating,” he said. “And I was making the problem worse.”

Garcia said he didn’t realize the damage he was doing until he was an adult. By then, overeating had become a way of life.

“I didn’t know how else to feel a sense of happiness other than to eat. And I was destroying myself and I just didn’t know it,” he said.

“Even though the act of eating was enjoyable, the result was incredibly disastrous for me, and it made me unhappy.”

To Garcia, food was an addiction, one that he thought can have an even stronger pull than other substances. While it’s possible to live without alcohol or illegal drugs, it’s not possible to live without food.

“Unfortunately, I can’t stop cold turkey,” he said. “That’s what makes it so hard, that you can never stop eating.”

The mental health aspect of overeating often goes unrecognized, said Susan C. Mengden, co-executive director of the Eating Disorder Center of San Antonio partnering with Eating Recovery Center.

“Eating for comfort, overeating consistently, is something that could be a mental illness,” said Mengden, who did not treat Garcia. “It could be an eating disorder.”

Some people turn to eating as a “very comforting, nuturing, relaxing, coping mechanism,” she said.

Binge eating, which can lead to obesity, was recently recognized as an eating disorder by mental health professionals, as are anorexia and bulimia.

Mengden said up to 30 percent of patients seeking weight-loss treatments could fit the criteria for binge-eating disorder.

The real Hector

While the world saw Garcia as “the fat guy,” his family and friends knew the real Hector.

He was a man of faith who earned his bachelor’s degree in Bible ministry and was an active member of the Bandera Road City Church, continuing to tithe even after he was unable to leave his home to attend services.

He was a writer and a poet who poured his feelings into words on a page. When the family sent greeting cards for birthdays or holidays, he was the one to sign them with a thoughtful message. He wrote several chapters of a memoir about life with obesity that he titled “Life Behind the Glass.”

In 2008, he published a children’s book, “Ronnie the Rhino and the Grumpy Old Elephant,” about a rhinoceros treated differently because his horn was in the wrong place — a character who symbolized Hector himself.

He loved sports, especially the Dallas Cowboys, the San Antonio Spurs and the Texas Longhorns. He liked cars and enjoyed watching Formula 1 racing.

Family was the most important thing in his life. Garcia loved his nieces and nephew like the children he always wanted. He helped raise Chelsea as a baby. He taught Lauren how to drive. As teens, his nieces confided in their uncle about boyfriends and school. They turned to him for advice, solace, consolation and humor. When he was confined to his bedroom, his nieces would run to him like he was a magnet, and they spoke on the phone frequently.

“Hector showed us the good in ourselves when we could not see it,” Chelsea said. “He reminded people of their worth. He reminded people that they had a place and that they had purpose, not just in the eyes of God, but in his own heart.”

Life with limitations

Even as Garcia’s weight ballooned, he lived independently and held several jobs, including one at a meat company when he weighed over 600 pounds. He recalled hanging on the meat scales.

“They went up to 1,000 pounds,” he said. “That's how I know what my weight was, too. A normal scale's not going to weigh you.”

About 14 years ago, he had gastric bypass surgery — he called it his “Hail Mary pass” — and lost 380 pounds, slimming down to 240, but it wasn’t the cure he longed for.

Garcia didn’t change his lifestyle post-surgery, and inevitably the numbers on the scale began going in the other direction.

“It helps you lose weight, but it doesn't teach you how to eat,” Garcia said. “People think it’s the miracle pill. I got news for ya. You still have to work at it. But you sit there and eat a bowl of ice cream and potato chips and chocolate bars, you cannot do that.”

Unlike many people with obesity, Garcia didn’t develop diabetes or high blood pressure. He did have arthritis, asthma, sleep apnea and a type of skin infection called cellulitis, all of which have been linked to obesity.

Most significantly, the weight he carried gradually crushed his knees, hobbling his mobility. About 10 years ago, he left his apartment off De Zavala Road and moved back in with parents. He qualified for Medicare and received Social Security disability benefits because he was unable to work outside the home.

By 42, Garcia was homebound except for doctors' appointments.

In 2007, after Terry died at 44, Garcia sunk into a deep depression and put on more weight. In a way, he said, he was eating himself to death.

Reaching 600 pounds again woke him up to what he was doing to himself. In late 2010, he recommitted to losing weight.

“She tried so hard to live,” he said about his sister. “And I thought it was disrespectful for me to be killing myself slowly with my weight.”

Sweat and low-cal foods

Barely able to walk because of damage to his knees, he needed surgery to replace both. For the operations to work, he had to lose more than 300 pounds, so he figured out ways to exercise even with bad knees.

He ordered an upper-body pedal exerciser and started out using it a few minutes a day. With that and cutting calories, the weight began to come off. He bought a punching bag. Sitting in a chair, Garcia turned on his mp3 player, strapped on his boxing gloves and shut out the world for 30 minutes, twice a day. Sweat poured off his face.

He taped inspirational quotes around his room. “The physical and hunger pains are nothing, compared to the pain of rejection! Remember that pain and let it drive you to be more than what people choose to see,” read one attached to his mini-fridge.

On the tan wall near his punching bag was a copy of a photo of himself weighing over 500 pounds with the caption, “Never Again! When you’re tired and can’t go on, remember where you were and remember where you’re going. You need to live! People are counting on you and the Lord is counting on you. If you quit … you die! There’s no turning back.”

In a green-colored notebook, he kept a neatly written, detailed journal of everything he consumed and the calorie count. On Feb. 17, 2011, he had a diet shake, fat-free popcorn, a banana, chicken fettucini, 10 fat-free crackers and a granola bar — 1,185 calories.

The regimen was working, and leaving the house became a possibility again. He could walk the length of the short hallway from his room.

Next, Garcia decided to try walking in the pool at Palo Alto College, five minutes from his house. Getting there wasn’t easy. He needed a step stool to get into the backseat of the car, a wheelchair, a walker and the help of his mother.

Getting into the pool wasn’t difficult, but climbing out was nearly impossible. Small steps carved into the wall of the pool were his only option. Pulling on the metal bars to lift his 500-pound-plus body, Garcia had to heave himself up and over. He landed on his back on the cold, wet tile and rested for a few moments, staring at the pool filled with people a quarter of his size.

“It was humiliating. … I ended up flopping out like a dead whale, just throwing my leg over and just rolling out of the pool.”

It was one of many moments when he felt his body betrayed him.

Obesity “strips you of your pride, it takes everything away from you,” he said. “You can’t hide it. It’s always there, it’s always in front so people always see it.”

After that, Garcia found a handicapped-accessible pool at the Westside Family YMCA, where it was easier for him to exercise. Several days a week, Garcia walked back and forth for the length of the pool, up to an hour at a time.

After a few weeks, he started shooting hoops from his wheelchair, eventually standing next to it. His mother chased the balls for him. His father joined in, and the couple walked laps around the court as their son swam.

When the pool closed for renovations, Garcia switched to the Davis Scott Family YMCA on the East Side, started lifting weights and made new friends there.

As Garcia reached his goal weight, his life changed. He left the wheelchair at home and bought a car, no longer dependent on his parents for transportation.

He could wear blue jeans, snapped and zippered, instead of the usual gym shorts. A date of sorts was set up with a Facebook friend he met through a mutual friend. Lupita Mendoza lived in Alabama but would be visiting family in San Antonio. He cut several inches off a black belt. He sprayed on cologne.

They went to Starbucks and stopped by his sister’s Marble Slab franchise next door. It was their only date.

A mental blow

In 2012, Garcia had high hopes the knee-replacement surgery would alter his life.

It didn’t. What he expected would be two separate surgeries turned into four after one knee operation had to be redone and his patella tendon tore.

After months in physical rehabilitation, depression set in as Garcia realized his life would not change in the dramatic ways he had hoped. Depression always led him back to food.

“It was more of a mental blow to me,” he said. “It was a sense of discouragement because it’s like everything that I’ve been through you would have thought that something would have gone well for me. But it was more of the same.”

Being unable to exercise routinely was another setback.

“I got into the mindset where I wasn’t doing things regularly, and it became increasingly hard for me to return back to the gym,” he said.

Obesity as a disease

There is no easy solution to the problem of severe obesity.

Treatment for obesity tends to be seen as a dichotomy: lifestyle modifications — diet and exercise — or surgery. While losing weight through diet and exercise is possible, keeping it off long-term is tremendously difficult, as most people with obesity can attest.

Bariatric surgery, including gastric bypass, is the most aggressive approach. Although it can be risky, it’s the fastest way to lose hundreds of pounds. Surgical procedures also can affect the metabolic or hormonal changes that play a role in hunger and satiety.

“It changes the body's set point so that after surgery, the body is aiming for a lower weight level,” Pilcher said. “The key patient responsibility going forward is to not do things that will disrupt that improved metabolic balance.”

In other words, patients who don't change their habits after surgery — such as Garcia — will find that number on the scale will begin to climb again.

In the middle of those two options, though, is nonsurgical medical treatment, also called physician-supervised weight loss.

A small cadre of physicians known as obesity medicine specialists offer a comprehensive approach that typically involves nutrition education, a tailored exercise plan and anti-obesity drugs. They also address patients’ sleep habits and stress management and provide psychological support.

“In terms of care, one big thing that’s just starting to become more acceptable is the idea that this is a chronic disease and it requires medical therapy and medication just like any other chronic disease,” said Dr. Deborah Bade Horn, president-elect of the American Society of Bariatric Physicians and medical director of the Center for Obesity Medicine and Metabolic Performance at the University of Texas Health Science Center at Houston.

“Sometimes people don’t see that. They just jump from lifestyle (intervention) to surgery and say, 'Oops, I failed both, now what do I do?’”

Financial barriers

When diet and exercise didn’t result in sustainable weight loss, Garcia tried to find in-patient care for people with obesity, including a clinic at the University of Michigan and a nursing home in Andover, Ohio. He emailed a doctor who starred in a reality TV show about an obesity clinic.

None of those panned out. He wouldn't qualify because he wasn’t an in-state resident, or he couldn’t afford the fee, or his knees wouldn't allow him to participate in the required exercise. In one case, he languished on a wait list for years.

“I was angry that society basically said, 'You're not worth helping. You're fat, you're obese, you did it to yourself, and we're not going to help you,’” he said. “But if I was a drug addict or an alcoholic, I would have 50 different places I could go to for help.”

A major barrier to medical treatment for many patients with obesity is cost and the lack of insurance coverage.

A consultation with an obesity medicine specialist typically costs $150 to $400. Follow-up visits can cost $50 to $150. Such specialists operate cash-only practices because of the enormous number of denials they receive for including the diagnosis of obesity on a claim, said Dr. Jennifer Seger, a diplomate of the American Board of Obesity Medicine who runs the medical weight-loss program at BMI of Texas in San Antonio.

The Affordable Care Act does not require insurers, including those participating in the health insurance exchanges, to cover obesity treatment options, Dr. Steven R. Smith, president of the Obesity Society, said in a statement.

“And while coverage for bariatric surgery for severe obesity is spotty, at best, coverage for obesity drugs and other evidence-based treatment options is excluded,” he said.

Some employer plans cover bariatric surgery, which can cost $15,000 to $30,000, although the policies may require the patient to pay a special deductible, Horn said; physician-supervised weight-loss rarely is covered.

Medicare and Medicaid don’t cover anti-obesity medication, which can cost as much as $200 a month for newer drugs, she said. There is coverage for behavioral counseling, but “it’s so poorly reimbursed that it's not viable to implement,” she said. “It reimburses at about $25 a visit, which won’t keep a physician's door open.”

Obesity doctors blame the lack of coverage on the bias against obesity and the belief that it’s caused by weak self-control. They argue that while people with obesity do need to work to lose weight through diet and exercise, some need medical care to manage their disease — just like patients with high blood pressure or diabetes. Doctors also point the finger at lobbying by insurance companies.

Many physicians remain optimistic, though, especially as more medical organizations recognize obesity as a diease. The ACA likely will cover intensive behavioral therapy in the future, Sabowitz said.

'Food never rejects me’

Whether treatment could have saved Garcia is unknown.

In the last year or two, he rarely left the bedroom that had become his whole world. Even making his way to the bathroom across the hall could be a monumental task.

He spent hour after hour in his oversized recliner, working, writing, watching TV and emailing his friends. The blue Mitsubishi sat in the driveway, driven only by his relatives.

Above his bariatric medical bed was a pull-up bar to help him up and next to it was a breathing machine to assist while he slept. There was a television, a small refrigerator and a set of drawers with one that held “cheat” food, like Ding Dongs and candy orange slices.

A racing helmet was on display in a glass case, near framed photos of Terry and his beloved nieces.

In early 2013, he began a home-based job as an employment recruiter, using a phone and his laptop computer to match potential employees with employers. While it brought in a paycheck, with which he put money toward household expenses, it didn’t get him out of the recliner.

“I’m chained to this room,” he said. “This room has become almost a prison to me.”

Not only was it difficult for him to maneuver, but he also felt awkward in public: “I always feel like people are looking down on me.”

His mother brought him food and took away the empty plates. For breakfast, it was two slices of toast, two eggs and bacon. For lunch, he ate what his parents ate: enchiladas, vermicelli, beans, hot dogs, hamburgers. For dinner, his mother — exhausted from being the primary caregiver for her son and her husband, who has diabetes and neuropathy — often brought him a box of 20 Chicken McNuggets from McDonald’s or other fast food he requested.

“They were the wrong things, but I would give in because I was so tired,” Elena said. If she tried to refuse his requests for food, her son would get angry.

Garcia likened his mental state to a flat tire, afraid that he didn’t have the energy to inflate it again, or even the desire. He asked a doctor who visited him for an antidepressant prescription. He would have crying spells. “I just want to die,” he would tell his mother.

“I overeat because food never rejects me,” Garcia said, “but the truth is, it’s actually rejecting me now, because it’s killing me. It’s going to reject me up to the point where it takes my life if I’m not careful.”

In the last few months of his life, Garcia’s breathing became more labored. His doctor told him to see a lung specialist for chronic obstructive pulmonary disease, which gradually impairs the lungs.

Garcia refused, remembering the difficulties of maneuvering his body into the car to get to the dermatologist’s office for his most recent medical appointment for cellulitis. After that, he didn’t leave the house.

He wouldn’t tell his worried mother exactly how much he weighed, but he talked about starting a diet again after the holidays.

Elena knew it only was a matter of time before obesity claimed his life, but a mother never is really prepared.

On Dec. 8, less than three weeks after Garcia’s 49th birthday, his mother came home after a week in the hospital for surgery on an umbilical hernia. She wanted to surprise her son and husband. She didn’t have her house keys, and she and her daughter rang the bell.

By the time her son walked the short hallway to the front door, he was struggling to breathe. He fell into a chair, turning purple. Elena phoned paramedics, then she called neighbors to help her lift her son to the floor as the dispatcher instructed. His sister attempted mouth-to-mouth resuscitation. EMS arrived and set to work on Garcia, but it was too late.

“Two minutes, that’s all it took,” said Elena, crying, two weeks after his death, the exact cause of which is unknown. “I thank the Lord that he didn’t suffer. He suffered so much his whole life.”

Still, she felt his life served a higher purpose. She hoped his story would inspire others to take control of their health. And she herself has a way to honor him.

“I made a promise to mijo,” she said, gazing at a portrait of her son in her living room. “I’m going to lose that weight.”

lkrantz@express-news.net

jbelasco@express-news.net



