He's down to 435 pounds, but still too big for a new heart
One of the latest sources of tension was a hot sausage: a juicy, 250-calorie treat laden with 800 milligrams of sodium.
James Wagstaff-Duncan sorely wanted to eat it.
Edith Bond, his great-aunt, said no way, warning that he was headed to an early grave.
"Y'all want to go before me?" she cried out. "Go right ahead."
Was she being overly dramatic?
Not by much, according to the doctors.
Wagstaff-Duncan is a big man with a bad heart, and he has embarked on a medical experiment that is remarkable even by the outsize standards of the American obesity epidemic.
The 30-year-old North Philadelphia man has struggled with his weight for years, and by last year it had reached 480 pounds — even as his heart grew dangerously enlarged and weak, unable to deliver enough oxygen to his 5-foot, 8-inch frame.
Temple University Hospital physicians said he was near death and needed a heart transplant, but his immense weight made that too risky. Yet his best chance for losing weight — bariatric surgery — was out of the question because his heart was too weak.
The answer, for the time being, was an implantable heart pump called a ventricular assist device (VAD). Wagstaff-Duncan had the pump implanted in September 2015, in hopes that he would grow strong enough to lose a few pounds through diet and exercise. If he made progress, physicians would consider bariatric surgery — rerouting his digestive system to help him lose even more weight. Then they could talk about a heart transplant.
A year later, he has a long way to go.
Wagstaff-Duncan weighed less than 440 pounds soon after his surgery to implant the VAD, having lost lots of fluid weight in the hospital. But in the year since then, he has lost just a few pounds more, and hovers around 435.
The command center in the battle for Wagstaff-Duncan's health is the dining room table in his great-aunt's rowhouse, just a few blocks from the hospital where he had the pump implanted.
Medical supplies cover close to a quarter of the table's surface. There are alcohol swabs and gauze to keep the skin clean where the pump's electrical supply line goes through a hole in his belly, connected to an external battery. There are spare batteries for the pump.
And row upon row of pill boxes, divided into compartments for the time and day of the week. He takes more than 40 pills a day: diuretics to reduce excess fluid and stress on his heart, blood pressure drugs, blood-thinners, gout medicine, a potassium supplement.
Bond, 67, has it all arranged neatly on a bright-green tablecloth.
The table is also where Wagstaff-Duncan eats, as little as he can manage.
Temple nutritionists initially asked him to try a diet of 1,500 calories a day — an amount less than three Big Macs. It was not enough, so now he is shooting for 1,800. (A normal diet for a sedentary man of his height is about 2,400 calories, the U.S. Department of Agriculture says.)
Wagstaff-Duncan said he did not know how much he used to eat, other than that it was "a lot." Now he writes down his totals each day, he said.
Rather than dwell on how far he has to go, he prefers to focus on the fact that he weighs less than he used to. "You've just got to be consistent with it," he said of his new regimen.
The hot sausage episode, in late November, spelled trouble, in part because of the sodium, which would cause Wagstaff-Duncan's body to retain more fluid. He and Bond compromised, and she agreed to let him eat just a few bites.
More often, the menu includes heart-healthy foods such as baked fish, baked chicken, and seafood salad, Bond said. For between-meal snacks, she allows him fruit, or maybe no-salt potato chips.
"I get on him," she said. "They call me the warden."
Wagstaff-Duncan's younger brother and two cousins live in the house, too, and they reinforce the message.
"They watch," he said. "They always ask me, am I supposed to have that? If there's something I'm not supposed to have, they tell my aunt."
He doesn't mind their persistence at all.
"Really, I need it at the end of day."
Walking two blocks
Cardiologist Eman Hamad, medical director of Temple's mechanical circulatory support program, is glad her patient is feeling better, but disappointed with his weight. She and his other physicians have told him he needs to get down to 400 pounds before they will even consider bariatric surgery. From there, he would need to drop down to 270 or so before the doctors would try a heart transplant.
Hamad, who notes that her patient has had counseling from Temple nutritionists and psychologists, wonders whether he is sticking with a strict calorie limit.
"His dietary habits - I think that's a big component," the cardiologist said.
Is it possible that his weight loss is stalled, even at his reduced intake?
The reasons for obesity are many and complex, and the problem is especially prevalent among African American adults, with an obesity rate nearly 1.5 times that of white adults. Researchers blame some of the disparity on the fact that blacks are more likely to live in urban neighborhoods with few supermarkets that sell fresh produce.
Genetics also can play a role, and obesity seems to run in Wagstaff-Duncan's family. An uncle and another great-aunt both have undergone bariatric surgery, he said.
Wagstaff-Duncan's spiral began in 2008, when he weighed 320 pounds. He broke a thigh bone in a car accident, and started putting on weight during a long recovery period, he said.
Obesity is so multifaceted that you can't assume a person weighs too much solely because he eats too much, said Stacey Cahn, a clinical psychologist who specializes in eating and weight disorders at Rowan University's Wellness Center.
Obesity is not due to a character flaw such as lack of willpower, she said. And once obese people start to lose weight, their metabolism slows down, meaning they have to eat less to maintain that lower weight — often even less than someone else who weighed that lower amount to begin with.
"Your body fights to get those pounds back," Cahn said.
The good news is that Temple's big heart patient has regained some semblance of a normal life.
Before the heart pump was implanted, he could not climb the stairs to his bedroom without sitting down multiple times along the way to rest. He felt short of breath even after walking four or five steps on level ground.
Now he says he can do the stairs without stopping and is able to walk two blocks.
"I'm always on the move," he said, citing recent trips to the barber shop, the movies, a bowling alley.
The implanted pump requires vigilance.
The dressing must be kept clean and dry, so taking a shower is a production. He wraps a plastic trash bag around his middle and sits in a chair so he is half in the shower, half out.
And always on his mind is the power supply, so he can keep his batteries charged. An outage in July prompted a quick call to the electric company, and power was restored after half an hour.
Formerly employed as a security guard, he remains on disability.
But Wagstaff-Duncan says he feels optimistic, given that he was near death little more than a year ago.
"I've been living a whole year," he marveled. "I feel good. I feel a whole lot better."