This story is the first of two articles on gastric sleeve surgery.

He played center on special teams for the University of Pittsburgh in the late 1980s and early 1990s. Football brought him from the 220s to the 270s, but after graduating he dropped the extra weight.

Then, life happened. Jim Royal got older, and he began steadily packing back on the pounds, this time as fat, not muscle.

He didn't stop at 270. At his “maximum density,” as he calls it, the Cranberry Township man weighed 384 pounds.

He tried everything to slim down, but nothing would work for long before the fat returned.

Today, at 50, the man on his driver's license looks a little like him, but with a lot more neck tacked on. Everything is too round, too full and too, well, dense.

The real him is back down to his college weight. Pre-football.

“Some people don't even know who I am until I speak, and they recognize my voice,” Royal said. “I never thought I was an ego guy, but, well, there are sometimes when I like to go places where people haven't seen me in a long time.”

Ask him what changed, and he'll tell you “everything.” Royal eats different, cooks different, works different.

That, and he had most of his stomach cut out.

Talk to the average gastric bypass surgery patient — or, more commonly, a gastric sleeve surgery — and they'll tell you they worked their tail off, spent a large sum of cash, experienced physical pain, endured strangers and friends shaming them, and had to almost entirely give up bread. Delicious, soft, beautiful bread.

They also all seem to say the same thing: the surgery changed their lives.

Bypass by the numbers

A map of 2014-2016 obesity rates published by the Pennsylvania Department of Health shows a state cut in half, with a few exceptions. People in the western portion are obese at higher rates than out east.

Butler County is a notable exception with a 29 percent obesity rate, one percentage point below the state average from that time.

Butler's neighbors show the western influence: Venango possessed a 34 percent rate, Clarion a 35, Armstrong a 35 and Lawrence a 34. The counties with the highest rates claimed the state's southwest corner with rates hitting 39 percent.

Dr. Meng-G Martin Lee, a bariatric surgeon for Butler Health System, said the region's high rates contribute to his program's existence.

“There's certainly a need in the community for this type of surgery,” Lee said.

The department couldn't provide figures about how many customers for whom they perform the surgery, but Lee estimated that the team consults with four or five potential new patients a day. Not all get a surgery or are even eligible, but many move ahead with it.

There's another reason why they get so many clients: Only about 7 percent of Butler County residents, ages 18 to 64, are without health insurance, according to the same state data. The rate is among Pennsylvania's lowest, and it's well below the state's overall 11 percent rate.

All the bariatric patients who shared their experiences for this series relied on insurance to front much of the cost. A husband and wife who had the surgery together ran through their entire out-of-pocket maximum amount. Including insurance payments, they paid about $10,000 out of pocket for the process.

Bariatric surgery generally costs between $15,000 and $25,000 on average, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Most BHS patients have insurance coverage for it, but a few pay in cash, according to the BHS bariatric department.

Gastric bypass is the name people know, but 93 percent of such surgeries performed by Lee's department are actually gastric sleeves. Bypasses are reserved for patients with acid reflux symptoms.

The difference is simple: Gastric sleeves involve the removal of most of a patient's stomach. Gastric bypass patients also have most of their stomach removed, but it also involves a partial rearrangement of the small intestine. Food in such patients bypasses part of the digestive tract.

BHS previously offered gastric bands, which represent the lower end of the institute's cost range, but the practice has largely been abandoned industry-wide.

The medical terminology may seem like indecipherable jargon, but for the patients themselves, these procedures can be keys to longer, happier lives. Many say they experience near-immediate change and, over the long-term, a total transformation.

Part two of this series in tomorrow's edition will feature more personal stories about gastric sleeve surgeries and further details about the surgery itself.