"the only thing that never changes is change..."

33 months

I have been contacted by a number of people who have been reading my writing here recently. I'm not sure what happened, but I did promise myself that if people started reading this stuff I would keep writing. Thanks to those of you who have been courageous enough to just e-mail me out of the blue. If you haven't yet mustered up the courage, the address is rdewald at rdewald dot com.

I am 33 months post-op at this writing. Things are still changing. My body is still evolving, my relationships are still getting sorted out, and I am still learning more about what and how it is best for me to eat.

I am still obese. My BMI is stil over 30, but my weight has not varied more than a few pounds either side of 285 in the last 14 months. My body contours are unsatisfying, but I have not yet elected plastic surgery, and frankly I am still undecided about it (those around me aren't, it's a unanimous "do it" from my friends and professional advisors).

I am satisfied with my health status. Every time I visit my family doctor she discontinues another medication. On my last visit we discontinued my low-dose statin (anti-cholesterol drug). Now I am just taking a low-dose anti-hypertensive (an ACE-inhibitor) to protect my kidneys which were abused by uncontrolled type-II diabetes for years and years, omeprazole for heartburn (something new post-op) and a vitamin-D3 supplement (which likely has little to do with the surgery). Many apparently healthy and active 52 year old men take more medication than I do.

chol panel

My last blood-work (five weeks ago) was shockingly good. I have an athlete's cholesterol profile. My hemoglobin A1C, (which at one point pre-op was a genuinely alarming 11.2%) is now 6.5%, still high, but below the 7% considered diagnostic of type-II diabetes.

I am satisfied with my functional status. I just returned from a difficult 12 mile, two-day hike in the Rocky Mountains above 10,000 feet in altitude (I live at sea level). I out-hiked my experienced hiking companions in both speed and endurance. I did not experience the intense post-hike muscle soreness of which everyone else in my hiking party complained.

I can sit comfortably in public seating of any kind. I can climb stairs, get up from the floor, bend over and tie my shoes, ride a bicycle, etc, etc, etc.. Now my physical limitations involve lack of skill rather than lack of capacity, endurance or ability.

I am still learning to eat, or my system is still changing, I'm not sure which. I experience chronic nausea, which sounds awful, but it really is a very minor annoyance. I have gotten used to it, the commercial cannabis preparation I am prescribed (dronabinol, generic Marinol) works effectively, and I strongly suspect that in my case the situation is largely, if not completely, due to a hiatal hernia that was missed pre-operatively.

I experience a wave of mild nausea right when the first bit of food in an eating session reaches the top of my stomach. It take a few minutes to subside, and certain foods bring it on reliably--crusty bread and grilled meat are the most reliable culprits. I think it is a mechanical problem, my theory is that the food bolus gets lodged in the herniated pouch momentarily, that fires off stretch-receptors in the very top of my stomach which then tell the brain "stop, your stomach is dangerously full!"

After a minute or two, the nausea abates, though it doesn't disappear, and I continue eating. I have gotten used to eating when nauseous. If I have taken a 5mg dronabinol beforehand, which I sometimes do when I know I am likely to encounter a problem food in a social situation (like a dinner date at a Steak House), the nausea is just barely noticeable.

I eat five times a day--breakfast, brunch, lunch, early dinner, and late dinner. None of these meals are big, but lunch is typically the biggest. On a typical day I will have an egg and (most of) a slice of toast for breakfast, some roasted almonds with raisins for brunch, perhaps 4 nigiri-sushi pieces and some miso soup for lunch, a piece of fruit for early dinner, and a salad and a cooked vegetable for late dinner. That is enough food to maintain my 285 pounds (I was 415 pre-op, I am 6 feet tall). Those meals are reliably 3 hours apart--7am, 10am, 1pm, 4pm and 7pm. The main social hassle with that is eating at 10am and 4pm when no one else does.

I prefer food that is pasty and nutritionally dense. Mashed potatoes are probably my single favorite post-op food, though I actually don't eat them often (BBQ brisket was my favorite pre-op food). Potatoes in general have been the biggest food surprise. I wasn't much of a fan before the surgery. I ate them, but it was not a favorite food. Post-op I don't think there is a way that potatoes are served and prepared of which I am not a devotee. I like chips, baked, mashed, fried, boiled, etc. This is a mystery to me.

I prefer salad when eating out because it is a food that takes up a lot of room on the plate but not much in my stomach. I underestimated my discomfort with the social consequences of not eating very much. I am constantly thinking that people think I don't like their food or something when I eat about a third of what I have been served. People constantly misunderstand why I am eating between their meals (brunch and early dinner), so I tend to do that eating in solitude because it's just easier.

So, I can eat a salad and it looks to everyone else that I'm simply "watching what I eat" instead of being some parsimonious under-eater. This problem, the social perception of what I am doing, is much more important to me than I thought it would be.

I have dozens of one-cup food containers. Larger ones aren't useful to me. I use the freezer at home a lot more than I did pre-operatively. I cook on the weekends and defrost during the week. I eat fresh vegetables at dinner, but a bunch of broccoli will last me three days, so I have to choose carefully. It took a long time to get sufficiently organized so that I wasn't buying produce, chilling it as it became garbage, and then throwing it away.

I participate in a CSA (community-supported agriculture) project, a local farm delivers vegetables weekly under a long-term contractual arrangement. I split what is called a "half-share" with a neighbor, but frankly I let her have 2/3rds of it, so I essentially eat 1/6 of what a small family usually eats from the CSA.

Caloric density was a problem for me before the surgery. I was constantly vigilant about how many calories I was eating, trying to keep the number down. Now, while I still consider caloric density (mainly for portion sizes), nutritional density is a far greater concern. I only have so much volume to work with, I can't waste any space, so foods that used to dominate my diet like low-fat diary, sugar-free preparations, popcorn, and celery sticks are far less common.

A1C

I don't eat anything my great grandmother wouldn't recognize as food. This means I do not eat artificially-sweetened foods of any kind, I avoid eating low-fat preparations of any food. I do not eat industrial food like Cheetos, Pringles, Cheese-whiz, soft-serve ice cream, gummi bears or anything that contains high fructose corn syrup (HCFS). HFCS is a marker of industrial food, i.e., it's use in preparation means the food was primarily designed to sit on a shelf rather than to digest in your stomach.

I avoid low-fat diary because I want to limit my intake of diary fat by simply limiting my intake of diary products. Diary products like milk, butter and cheese are sources of fat and calcium in my diet, not protein. I don't need a lot. I use half-and-half in my coffee, I garnish with cheese, and I have a glass of milk almost weekly (a small glass is most of a full meal). I drink un-homogenized milk that comes from pasture-grazed cattle. I eat butter from the same diary.

Because I eat so little food it no longer matters what a pay for it per unit volume. I can indulge my desire for organic, locally-sourced, humanely-produced foods without having to consider the premium price. At the volume of food I eat, the mark-up is financially inconsequential. Even with the skills I have acquired and my care in shopping, I still throw away food because it goes bad before I can eat it (of course, that is in some measure because I do not buy foods that are designed to sit on a shelf).

Getting adjusted to eating was the easy part, managing my relationships is much more complicated and fraught with hazards.

I'm not sure how much of this has to do with obesity, but I used to believe that I had to suffer some modicum of abusive behavior in my relationships in order to remain in them. This was a largely unexamined notion, I wasn't consciously aware of how it operated in my life. In fact, I didn't really know this belief was there until it was gone.

This notion is more powerful as one reaches further into my past, so the relationships most afflicted with it were my oldest ones, my friends from high school and college. In a sense, I have trained them to treat me in a certain way that can be functional in a socially volatile group. I took the role of the scapegoat, the identified problem, the person who made others feel better about themselves by comparison.

As distasteful as it sounds, this role comes with significant rewards. I didn't have to explain failure, didn't have to compete for the prize (relationship/financial status) and I was always included with the group for the comforting effect of having someone (else) who is always the loser. It is a valuable role, particularly in status-conscious groups. I felt included and accepted because I was. I was included and accepted as an inferior, but since everyone (most importantly myself) agreed on that status, it wasn't a problem.

I was the designated driver, every woman's male confidant and the person everyone could depend upon to be willing to go out when asked. I would be the third, fifth or seventh wheel to bring stability to an otherwise uncertain social situation. I confused the comfort and stability I brought with love. I convinced myself that because people wanted me around they loved me. I believed that the abuse I suffered was only a consequence of my own lack of social acceptability, which I explained with my fat. Of course I woud end up alone in the living room while everyone else had retreated to a private room to make-out. I was the fat kid.

When I lost enough weight so that I was no longer a social freak (small children used to stop dead in their tracks and start mouth agape at me and say "Mommy, why is that man so fat?"), I no longer functioned in this role. Now, no one can look at me and instantly form a theory to explain why I am alone, isolated, and willing to wait on everyone else to have fun. The role shattered.

Some of the people I thought were my closest life-long friends no longer really like me. I am no longer the loser. I am no longer the person they could rely upon to bolster their self-worth by comparison. Wives and girlfriends started to compare me favorably to their mates (this particularly didn't go well, as you might imagine). I began to exceed other's performance professionally, in sporting activities, etc. This didn't go well for those old friends.

This was really hard. I had spent a lifetime thinking these friends were something they weren't. I am still, this very day, getting adjusted to this, and I expect this adjustment period to persist for a while still. It is difficult to go on having a significant piece of the history of your emotional life pulled up by the roots, but on I go.

Friends I made more recently are different. Many of them rejected and reacted against these unconscious patterns to which I had grown accustomed. They refused to accept my inferiority complex and challenged it's assumptions regularly. They admire and respect my life and my accomplishments. Getting used to dealing with conflicts and disappointments as an equal was really difficult. I couldn't retreat to my role as the fat kid who rarely really tries and thusly always loses.

This is a lot harder than figuring out how to eat.

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