Two years ago, I found myself wearing a medical gown in a suburban outpatient surgical center, being prepped for general anesthesia and thinking to myself “I’m going to feel really stupid about this if I die.”
Because my surgery was completely discretionary. I was there for endoscopic gastroplasty, a relatively new form of bariatric surgery in which a laser scope is inserted down your throat and your stomach is stitched-up from the inside to become a smaller organ.
Relative to traditional bariatric surgery, the big advantage is that with no abdominal incision, the recovery is much easier. That was a huge selling point. The whole idea of getting this surgery that wasn’t medically necessary was a huge source of shame for me. After all, everyone knows that you can lose weight by eating less. If I was halfway honest with myself, it’s not like I’d gotten fat by exclusively eating when I was hungry and I just had no idea, intellectually, how to lose the weight. What I needed to do was eat meals when I was hungry and stop eating after that — not gorge on between-meal or late-night snacks, and not go back for seconds just because something was tasty.
But I couldn’t do that, so there I was getting surgery.
When I first considered bariatric surgery, the recovery time was a deal-breaker. I couldn’t find myself unable to care for my son for days because I needed weight loss surgery. I couldn’t have Kate telling people that I was out of commission because I needed weight loss surgery. The endoscopic option was a game-changer. We’d drive out to the surgical center, Kate would drive me home, and then the next day I’d drive myself back out for a follow up. After that, it would be two weeks of a liquid diet but I’d be fully cleared for all activities. I even had a short trip planned three days after the surgery.
The doctor who performed it was an entrepreneurial type. No insurance, just cash on the barrelhead, so no need for too much pre-surgical screening and evaluation — I was a paying customer, and he was there to do the procedure. I didn’t have diabetes or “prediabetes,” I was just fat and wanted to not be fat. So there I was, preparing to go under general anesthesia. It’s safe, obviously, or they wouldn’t let people do it. But people do die, and in this case I could hardly say I rolled the dice to save my life. I just wanted to lose weight.
And I did! I weighed 272.1 points on September 19, 2021, and 202.6 pounds on September 19, 2023.
Of course there’s more to the story, but that’s the bottom line: I did not die, and I lost a lot of weight. I also gained some lean muscle. Pain in my left knee and right heel improved. It worked. And I thought I might share my story because it could be helpful to others.
Two years of weight loss
They say the typical patient can expect to lose between 15–20% of their body weight during the first year.
My experience was both better and worse than that. I came out of the surgical center groggy, of course, due to anesthesia, and just trying to follow the guidelines to avoid dehydration with a bruised and healing stomach. That meant small, frequent sips of water and nothing else for a couple of days. After that it was a week of clear liquids, then a week of only mushy foods. And it turns out that if you don’t eat anything, you lose weight very quickly — less than two weeks after the procedure, I was down to 258 pounds.
I think most people are aware that not eating will result in weight loss, but severe restriction isn’t tolerable for most people. A while back I had oral surgery to remove my wisdom teeth and repair a large abscess in my jaw. After that I was on a clear liquids diet for a while, and I was constantly hungry (except when doped up on painkillers). I spent a lot of time experimenting with different jello flavors, and when I was cleared to switch to soup, I ate a lot of soup. The bariatric surgery experience was different. It was socially awkward to tell people I couldn’t eat anything, especially since I didn’t want to discuss the surgery, but I wasn’t hungry at all. I wasn’t even craving different flavors. I would get physically weak and lightheaded while going out on walks and need to sit down and take a break — but I never felt the physical pangs of hunger.
After the jaw surgery and weeks of deprivation, I was ravenous once cleared to chew again. After the bariatric surgery, I was cautious. I didn’t want to upset my stomach, so I ate small portions in small bites, and I didn’t snack. And I felt fine. By December 1, I was 231 pounds. And I wasn’t derailed by the holiday season either — by January 1, my weight was 223 pounds.
None of this, to be clear, is an alternative to diet and exercise. What happened is that I was systematically eating much less food than I did before the surgery. Not severe calorie restrictions like in the first couple of weeks, just a pretty normal diet: I’d eat a healthy lunch and a reasonable portion of whatever was on offer for dinner while avoiding snacks and desserts. If I went out to a restaurant, I’d order whatever seemed like the healthy option, usually a fish. In terms of dieting philosophy, I leaned toward the high-fat/low-carb concept, but I wasn’t maniacal about it. There are a lot of disputes about this in the nutrition space, but I think most of us who become overweight do things that everyone knows aren’t good for you, like scarf down a sleeve of Ritz crackers while watching TV. I also wanted to make sure I was losing weight in a healthy way, so I started working out twice a week with a trainer who had me do High-Intensity Interval Training, and I’d also lift weights once or twice a week on my own. Is that the optimal exercise routine? I have no idea. But again, disputes aside, I think everyone knows it’s better to be active than not.
The point isn’t that lifestyle changes don’t require a super-genius — it’s that thanks to the surgery, the changes were easy to adopt. If you don’t struggle with your weight, this is probably hard to empathize with, but those who do struggle generally understand that it’s easy to know intellectually what you should do, but nearly impossible to actually do it. Yet suddenly, it was easy.
Until it wasn’t.
On March 1, 2022, I weighed 211.6 points — I’d lost over 20% of my body weight in less than six months — and it stopped being easy.
If I ate an abstemious lunch, I’d be really hungry all afternoon, fighting the urge to snack.
If I successfully fought the urge to snack, I’d be super hungry at dinner time and tend to overeat.
Excuses to order the tastiest entree on the menu rather than the healthiest started to multiply — we’re celebrating, we’re on vacation, it’s been a long week, etc.
I was counting calories as rigorously as I could with the MyFitnessPal app and I wasn’t gaining weight, but I was plateauing and finding it nearly impossible to drop additional pounds. Over the summer we went with another family to Italy for two weeks and in order to not be a pain in the butt, I just let all that go. I was surprised (but not too surprised, actually, because you hear this all the time) to discover when I got back to America that I didn’t gain any weight in Italy. So I got stupid and decided my vacation experience meant I’d reached a new equilibrium of the promised results and could just chill and stop counting calories.
Within six months of not counting, I’d gained over 20 pounds.
In January of this year, I went back on the program — time-restricted eating, counting calories, 10,000 steps per day, and a new exercise regime with super slow weightlifting — and again found that I could pretty easily get back down to ~210, but it was a struggle to get from there to 200. I think most doctors would say the surgery successfully revised my body’s weight setpoint downward by a large factor, but now I’m just in the regular struggle zone.
The limits of acceptance
I’ve read a decent amount of “fat acceptance” literature and takedowns of diet culture, and if I just thumb through the books and articles produced by that community, I’m more likely than not to agree with what they’ve written.
One thing that really resonates with me is the experience of being a fat person who suffers from some specific medical ailment and wants medical advice about that ailment, but instead receives a lecture about how it would help to lose weight. This is not helpful advice, because it’s not always medically relevant and when it is, most people don’t have a good option to lose weight. But the knowledge that this is what doctors are going to talk to you about sometimes makes you want to avoid seeing a doctor. That makes your health problems worse. So rather than helping people with obesity-related medical ailments, our culture of fat-shaming is generating worse health outcomes for heavy people. This is also true indirectly — stress and isolation are unhealthy, and in people with a tendency to overeat, those factors promote additional overeating. Trying to make people who are overweight feel bad about themselves is a strategy America has been trying for a couple of generations, and it just doesn’t work.
At the same time, I find the fat acceptance movement to be in some ways profoundly misguided:
I was very annoyed that doctors consulted about my knee and heel problems would lecture me about weight loss. I was extremely grateful to the third doctor who eventually gave me actionable suggestions for stretches that would help — and they really did help. But the fact is, getting the surgery and losing a bunch of weight helped much more than the stretches.
Being physically active is an important determinant of health, totally independent of its impact on weight, but realistically it is easier to have an active, movement-rich lifestyle if you’re not fat.
The statistical evidence that being overweight is causally associated with diabetes, heart disease, and other problems is overwhelming.
More broadly, if you look at the large U.S.-European life expectancy gap, I just don’t think it’s possible to explain it without reference to America’s much higher rate of obesity. So this isn’t just a small side thing or a topic of purely personal concern. People will reach incorrect views about important political and economic policy issues if they don’t see Americans’ obesity as a significant headwind to improving our health outcomes.
That’s why I think the rise of the GLP-1 agonistic medications is such an exciting development — it’s clear that a lot more people are comfortable with taking medication than with getting surgery, and precisely because all these critiques of diet culture have a lot of truth to them, it’s really important that we develop better medical interventions.
Why this problem is so hard
Over many years of struggling with my weight, I’ve read a lot of advice and found most of it to be of very limited utility.
One big reason for that is that while imitating the lifestyle habits of healthy people sounds like an intuitive strategy, I think it’s actually a pretty bad one. In other contexts, we get this. I try to imagine an alcoholic who’s just suffered some huge personal setback and is now determined to get his life on track asking me for advice on how to manage alcohol consumption more effectively and I’d tell him … try to drink less alcohol? Except maybe it’s okay to cut loose sometimes… but not too often? Ultimately, I just don’t know; it’s not a problem I have. When I was younger, I used to drink a lot — sometimes to excess — but never in a way that interfered with my life. And as I got older and my body’s resiliency declined and my family responsibilities grew, I just did it less. At this point, I have zero drinks most weeks. And when I do drink, I’ll have one or two, sometimes even less than one. A few weeks ago a good friend wanted to split a bottle of wine, so we did and I got drunk and didn’t feel great the next day, but it was a good time. No problem!
The whole point, though, is that for a lot of people, this is a problem, just like I can never understand the mindset of people who’ll happily order something tasty and then only eat half of it because they’re not hungry anymore. If I’m going to make a healthy choice, I need to make it up front. If food is on the plate and it’s any good, I’m going to eat it.
A perspective that I found useful, despite a lack of actionable advice, is what Daniel Lieberman calls “evolutionary mismatch” in his book on the evolution of the human body. For hundreds of thousands of years, people lived in circumstances where starvation and malnutrition were very real threats to survival and the ability to reproduce. So the fit and healthy way to live was to be like me — broadly omnivorous, curious about trying new foods, and generally inclined to eat plenty of food when food is available. Storing and preserving food is challenging, but most humans are very good at storing extra food on the body to give you a buffer in lean times. But in modern society, people very rarely face genuine lean times — contemporary Americans spend a dramatically lower share of our income on food than we did a couple of generations ago, to say nothing of pre-industrial or pre-agricultural people.
If you eat extra in times of plenty to balance out weight loss during times of scarcity, but the scarcity never really comes, you will get fat. Food becomes just one more thing on a long list of human behaviors — alcohol, gambling, cocaine — that are good fun enjoyed in moderation by many people but pathologically overconsumed by others. Except with the wrinkle that you can’t just quit food cold turkey.
This is why, again, medical interventions are incredibly useful and why I don’t think it’s a coincidence that Ozempic seems to have benefits for compulsive behavior in general.
But I’m also curiously watching to see what the longer-term outcomes are. My experience with a different intervention is that it was miraculous until it wasn’t. I’m extremely grateful to be a merely overweight person now rather than someone with Class 2 obesity. And yet it’s still a bummer to have stalled out at a point where the same basic behavioral issues reassert themselves. We’ll see where I am in a year, and where the medications go.