"hindsight is 20-20...."

what i wish i had known six months ago

This essay was composed almost exactly six months after my procedure (actually six months and one day). Looking back now, arguably still at a relatively early period in my recovery, these are the things I wish I had known then that I know now.

1. Morbid obesity is a neuroendocrine disease.

Ironically, the reason I resisted having a gastric bypass, the procedure that everyone originally recommended for me, was that I was uncomfortable with mucking around with the endocrine system in the gut. My concern was that we didn't really understand what was going on, but the object of my concern was the pancreas.

This is ironic because I believe now that I had a far more radical procedure from a metabolic and endocrine perspective, but the system effected was primarily the satiety/reward system in the brain, and the effects on the pancreas and other systems of metabolism are far secondary.

My problem was that my stomach was too big, and the part that was overgrown was also the part that secretes hormones which dramatically influence how much, how often and when I eat. Having a smaller stomach helps from a very simple volume point of view, i.e., I don't need to eat very much to feel full. But, the real change in my body arises from the elimination of a tissue bed in my stomach that was over-producing substances which dramtically influence my hunger/satiety system.

I wish I had known this before the surgery. I wouldn't have seen bariatric surgery so much as a desperate, last-ditch attempt to modify my bad habits, like wiring your jaw shut, or being banished to a desert island for a period of time. For years and years my basic objection to bariatric surgery was that I did not believe that I had a surgical problem. I believed I had a character defect. I agreed to have surgery because I believed I had run out of time to fix my character defect any other way.

In truth, I am no more or less able to manage my impulses and compulsions now (having lost 84 pounds in six months) than I was presurgically. I simply no longer have the interest, desire, or capacity to overeat. I have not overcome some profound defect of character. Overeating simply no longer represents any kind of reward, and my capacity to overeat mindlessly no longer exists. I could still overeat by grazing all day, for example, but it wouldn't get me anything I want, and that would take a lot of time and effort.

I had actually gotten pretty good at managing my compulsive overeating before the procedure. I think this is important to do. It is really important to understand that compulsive overeating is a separate problem from obesity in important ways (e.g., there are many thin compulsive overeaters) even though the conditions often co-arise in the same individual. Surgery doesn't really touch this habit of indulging in self-destructive behavior as a way to manage emotional states.

So, even though I had learned to manage this behavior well, I was unable to significantly move the needle on the scale because I was still struggling with a very large stomach that was over-producing powerful hormones. This made it practically impossible to induce a negative caloric balance of sufficient magnitude for a long enough period of time to effectively lose my excess weight.

This is what separates the morbidly obese from people who simply over-eat out of bad habits and poor choices. When those not afflicted (with whatever morbid obesity is) correct their unwise behavior, their stomach is still a normal size, and their hormone levels are at predictable and manageable levels.

I don't pretend to know what is the cart and what is the horse here. Is it chronic overeating that causes the imbalance? Is it adipose tissue itself? Is it genetic? Did the overeating cause my stomach to grow large or did I overeat because I had a large stomach? Is morbid obesity the behavioral consequence of bad hormones or the hormonal consequence of bad behaviors?

I don't know, but I wish I had known that I had a genuine, identifiable, problem with the size of my stomach, and further, that the part that was hypertrpohied (overgrown) was unceasingly flooding me with hormones that powerfully influence my hunger and satiety systems. I short, I wish I had known I genuinely had a surgical problem.

2. I will lose my ability to derive pleasure from eating.

Related to the hormonal changes that I describe above, my experience of deriving pleasure from food and eating has almost completely vanished. This is a profoundly significant loss. Obesity aside, I used to really enjoy eating, and I used to enjoy a wide variety of foods, and I used to enjoy trying new foods and/or revisiting favorite foods. All that is gone. It is as if I was a music lover who has gone almost completely deaf.

It is tempting to just dismiss this with "well that's a good thing!" But, if one looks carefully, one will notice that it wasn't my enjoyment of food (alone) that was responsible for my obesity. I could enjoy a fresh salad or a nice piece of steamed fish as much or more than something calorically dense and nutritionally empty. I liked all kinds of food. I liked vegetables, salads, fish, and whole grains. Several nutritionists who looked at my food diaries told me that my food choices were for the most part exemplary.

Food and eating was a major pleasure in my life. I planned social events and even vacations around it. Now, frankly, with regard to the hedonistic axis (my ability to enjoy something), it doesn't really matter what I eat. I still prefer certain foods, dishes and cuisines over others, but it is, by comparison to the power of my preferences pre-surgically, a minor preference.

I still plan social occasions around eating, but now that is in deference to others people's interest in doing so, not my own. I'd just as soon sit on a park bench talking to someone as having that conversation over a delicious, interesting and well-prepared meal.

I freely admit that pre-surgically I would have welcomed this wonderful, miraculous change. I honestly believed that part (if not most) of my problem was that I had an uncontrolled, unconscious and poorly regulated preference for the short-term reward of eating over the long-term reward of health. But now that this change has fully manifested, it's not all wonderful and miraculous. The comparison to a music lover going deaf is not casual, that's exactly what it is like. Losing the pleasure from food and eating is a major loss, a huge life change. I wish I had prepared for it.

3. The mere notion of food and eating will be nauseating on some days.

Imagine this: you are walking down the street, you see a McDonald's on the other side of the street. You can't smell food, you aren't hungry, you normally don't eat at McDonald's and you don't find their food appealing in any way. Yet, the mere sight of the restaurant, merely knowing it is there, makes you severely nauseated. Your mouth is watering, your balance is a bit off, and all you want to do is vomit.

Or, you are asked out to eat with some dear friends. A lot of thought went into to choosing the food and location. The food is beautiful in every way. You take one single bite, and before the food even hits your stomach you begin to salivate copiously and you are severely nauseated. You have to excuse yourself for retching and dry heaves.

Imagine that you have no idea when this is going to happen. On other days, most other days as a matter of fact, you're fine, you simply aren't hungry. Being around food doesn't bother you in any way.

That was my experience in month three and four after the procedure. This is the consequence of the dramtically altered levels of circulating hormones that the part of my stomach that was removed used to produce. This physiologic mechanism is very poorly understood, but there are hormones that the stomach secretes that influence areas of the brain.

I wasn't nauseated because there was actually anything going on with my (remaining) stomach. Walking by the McDonald's didn't have anything to do with my stomach. When this happened at a meal the whole syndrome would come on before I swallowed the first bite. Again, my stomach was not part of the equation here. This was centrally-mediated nausea, analogous to what happens when you get motion sickness.

As is noted elsewhere, I had quite a struggle with getting the pharmacological help I needed to abate this symptom. I went for a couple of weeks during the worst part of this without a remedy because the remedy is cannabis and there's a whole social stigma associated with it's medical use. Also, cannabis is an appetite stimulant and it is understandably counter-intuitive to prescribe an appetite stimulant to a morbidly obese person.

Fortunately, I had a very close and long-standing therapeutic rapport with my family doctor and she stepped in to take care of this for me. I write a lot more about this elsewhere, but I would have liked to have been able to prepare for this beforehand. I am very medically sophisticated and able to navigate the system to a solution, I have no idea what people without my skills do, other than just suffer through this.

4. There will days when I will wake up from a full night's sleep completely exhausted.

Again, this is another neuroendocrine side effect of dramatically altering the levels of hormones circulating in my body that were produced by the part of my stomach that was removed. It is difficult to describe this problem, but I will try.

There were days, and like with the nausea they came without warning, where I would wake up in the morning feeling as though I had not slept in over a day. Again, this is not hyperbole, this is the closest experience I can relate. I would wake up feeling as if I needed a lot of sleep.

One weekend I tried to find out if sleep actually was the problem. I had some time off, so I simply stayed in bed. I slept almost non-stop for a full 24 hours. I got up twice to urinate, but otherwise I simple slept deeply and soundly from 3 pm on Friday afternoon to 3pm on Saturday afternoon.

After those 24 hours I gave up. I was just as exhausted as I was when I went to bed the day before. Unfortunately, I had overlooked one problem with this experiment--I was now both exhausted and profoundly dehydrated. Once you allow yourself to get profoundly dehydrated you won't let it happen again. It sucks.

In any case, there was no real treatment for this side effect. Caffeine had no effect, methylphenidate simply made me alert and exhausted. That was better than being drowsy and exhausted, but it wasn't the drowsiness that bothered me.

I did discover one interesting thing about this. I did have energy reserves. If I needed to be active I could do it. One day I had no choice but to push myself through a very active day--lots of walking, lifting and climbing stairs (moving an office)--while I felt like I needed a lot of rest. I had the energy. I could accomplish everything I needed to do, I just didn't *want* to be active.

So, again, like the nausea, this is not about being energy-depleted. I originally thought this was related to my diet. I was concentrating on getting a lot of protein in my diet, so I was eating comparatively few carbohydrates. I tried re-introducing carbs into my diet. There was a bit of a placebo effect, I thought maybe I felt a little bit better, but once I lived through the day where I had to be very active I realized that I was on the wrong track. This isn't about energy reserves, it is about a centrally-mediated *perception* of energy reserves.

My surgeon told me I would have some "low energy days" to live through. This is a bit like describing a broken leg as "some leg soreness." I've thought a lot about coming up with a term to describe this phenomena, but nothing satisfies me. It remains a mystery to me, but as promised, this no longer happens to me. I hope it is gone for good. I imagine this is probably another centrally-mediated response, a bit of neuroendocrine homeostatic chaos while the brain adjusts to radically altered levels of certain circulating hormones.

I wish I had known about the severity of these episodes. I needed to prepare my employer for this. I missed about a week of work total because there were days when i simply could not come in to work. In fact, in a perfect world I would have taken these last six months off to recover from the surgery. There's a lot to do, and some days you can't do anything.

5. I will lose a very substantial amount of lean body mass.

About three months ago, right before I started going to the gym (and three months after the surgery), something puzzled me. I had lost about 45-50 pounds but climbing stairs was as hard or harder than it was pre-surgically. Moving around was no easier, I was really wondering when I could begin to enjoy the ease of movement that I anticipated would come with shedding the pounds. How much weight did I have to lose before climbing stairs was no longer abjectly painful?

After I started going to the gym things immediately got worse. Now, I was not only feeling weak, but I was also sore. I felt old and weak. I had been a gym rat about 15 years previous, lifting weights was one of the things I tried over the years to treat my obesity, and I began to notice that I couldn't lift anything like the amount of weight I used to lift when I weighed more than 100 pounds more.

My trainer was very helpful here. He performed a kinesiology evaluation on me and identified the muscle groups that were weakest and devised a training regimen that targeted those groups. I began doing that work, and for the first three weeks it was hell. Every time I left the gym I felt like I had been badly beaten with a lead pipe. That is not hyperbole.

Even more helpful, and equally important, was my decision to consult with a pilates and yoga instructor. As I began to work with her the truth began to dawn on me. My core (the muscles in my torso) was profoundly weak. I had heretofore practically no awareness of these muscles, what they did, and how this influenced my well-being, posture and movement.

At the same time, I developed a condition called chondromalacia patella in my right knee. My knee cap was tracking outside of the groove it was supposed to be in when I walked, and this caused it to degrade and injure the cartilage around it, which caused a painful burning sensation when I walked.

What I believe was happening is that my leg adductor muscles (those that cause your legs to come together) and my quadriceps (those that cause the lower leg to straighten and extend) had lost so much mass post-surgically that they were no longer strong enough to hold my kneecap in place.

I have a friend who is a prosthetist to thank for this insight. He shocked me one day when we were sitting together on his couch. He looked at my hands and told me he could see unequivocal evidence of frank muscle wasting (even though I weighed more than 350 pounds at the time). We also discussed the chondromalacia patella, he was very familiar with this condition because he treats it in his practice with a knee brace. He told me what was likely going on and got me the brace I needed.

I also went to see an orthopedic surgeon who confirmed this likely diagnosis and agreed with everyone's recommendation for treatment--weight-lifting. I need to strengthen my adductors and quadriceps so they would pull my kneecap back into the proper position when I walked.

This was when the lights came on. My core? Weak. Working out? Painful and difficult. Kneecap? Slipping out of place because of weak musculature. Sure, I had lost a lot of weight post-surgically, but in spite of having a high proportion of protein in my diet (much more than half of my calories come from protein), a lot of that weight had been in my musculature. I needed to do something about that.

So, fortunately, I was a patient in a bariatric program that referred me to a gym and a trainer who was prepared to meet me where I was. Beyond that, I was very fortunate to know a talented Pilates instructor who was also willing to help.

So, about four weeks after I began working-out things finally began to turn around. I felt good when I left the gym. Tired, but pleasantly so. Gradually, my knee hurt less and less. Now, three months after that knee pain emerged it is gone. I essentially doubled the amount of weight I can lift with my adductors and I increased my quad strength enough to lift 50% more weight than I could when I started. I feel great when I leave the gym these days.

The Pilates work has started to straighten my posture, but most importantly I am aware of my core musculature and I've made real progress with rebuilding it. I now believe a recovering bariatric surgery patient needs both strength training and something like yoga and/or Pilates in order to address the gestalt of rebuilding musculature that has been decimated by the post-surgical wasting that is part and parcel of rapid weight-loss secondary to a profoundly negative caloric balance.

So, in summary, what I wish I had known is that recovery from surgery was going to require that I rebuild my musculature. Fat tissue is not lost selectively post-surgically. I just lost weight, weight of all kinds, fat tissue included. I wish I had known I was going to go into the rebuilding process with a wasted musculature and that the first few weeks would be extraordinarily difficult.

For a while, I just thought I was an old man who couldn't take going to the gym.

I think it is important for the reader to understand that this essay is not a survey of bariatric patients, it is not meant as a prognosticator for those seeking surgery. My post-operative course is just my own, what happened to me might not happen to other people.

Nor is this a litany of complaints about how my surgeon did or didn't prepare me for surgery. There should have been much more education before the procedure but I don't believe that patients should approach something like this passively, just taking the information they are given.

The problem really is that there's no one to pay for the kind of preparation that I would have liked to have had presurgically, nor are there that many people who could have done it. I'm not sure anyone but a post-surgical patient can understand all this well enough to explain it.

Further, I'm not entirely sure I would have heard the information had it been given to me. Before the surgery I was singularly focused on my fear of dying as a novel anesthesia patient. There wasn't anything anyone could have done about that. It is important to remember that a bariatric patient comes to surgery after having failed to lose weight repeatedly. Many things have been promised to help them lose weight and every last one of them has failed.

So, when a bariatric surgical candidate hears advice about weight loss they are doing so having lived through countless instances of broken promises and failed interventions. This radically degrades the credibility of the medical community, so much of what is said goes in one ear and out the other.

Hindsight is indeed 20-20.

next - a quantum leap of self-regard