"In five years it's the hall of fame, baby!"

life as a bariatric all-star

NBA 2010 all-star logo

My surgeon is starting up a Bariatric surgery center in the large Metropolitan health-care system where we both work. I was one of the first patients in this effort, so things are still sort of organizing around me, people are coming on board, etc. Today I met the nutritionist he has recruited for this, and when she came in the room to talk to me she told me I was my surgeon's "all-star patient."

That's nice to hear, and as pandering a reference as that is, it probably contains some kernel of actual truth buried in the congratulatory stroking. I imagine it is a decided minority of bariatric surgery patients who, like myself, spend almost 10 years preparing for their procedure, who did everything they could to not have surgery, for whom surgery was truly the last best option.

However, I can't recommend my process to all people in my situation. The delay may have enabled now irreversible damage from the advancement and exacerbation of the complications of diabetes. It's possible this could have been avoided if I acted surgically sooner. However, in my specific case I still believe there were good reasons to postpone my procedure during those ten years. You can't navigate the bewildering maze of treating obesity without incurring some risk.

My eating disorder needed treatment. Advances in that treatment plan, for me, were excruciatingly slow and hard-won. Also, though no one could have foreseen it, this delay gave sleeve gastrectomy a chance to emerge as an option for me, which I now think was absolutely the right choice, and it gave my surgeon a chance to graduate from college, medical school and then complete his advanced training before taking the knife to my stomach, also a good thing, since I think it's likely he's a better surgeon now than he was ten years ago, probably as a premed student, when all this started for me.

However, I can say that over the years that I've been dealing with this problem, nutritionists and nutritional science have been of very little use to me. They didn't discover the First Law of Thermodynamics, which is all the science that has ever really been useful to me in losing weight, and that's still almost all they have to offer. This Law, restated to be relevant to weight loss, states that to lose weight you have to expend more calories than is in the food you've eaten.

So, when my surgeon wanted me to meet the nutritionist, I was willing, but expectations are low. She was kind, personable, and she just conducted a fairly standard intake interview with me. I have no specific problems with her, it's more the approach of her profession to the obese patient that bothers me. What would have been useful to me thus far was to have a nutritionist's advice concerning a real food alternative to protein shakes during the early recovery phase. I often wonder if whole milk would work just as well. It certainly tastes a lot better.

It has been 7.5 weeks since my surgery and I have lost about 50 pounds, roughly still following the overall trend of a pound a day (I don't lose a pound every day, I've had three plateaus during that period, but that's been the long-term trend). The worship of the scale is so pervasive that everyone focuses on those numbers as the gold standard of evidence that this is "working." Fortunately, I've been playing on that field for so long that I neither fall for the grief of not moving the numbers nor the elation of moving them. Weight is only a very blunt measure of body composition, I derive what pleasure I do with all this more from the improvements in my body contours, the ways my clothes fit, and the ease of movement with my body.

Weight is important, don't get me wrong, just as your net worth is an important bellwether of your financial health, but it's a very blunt measure for day-to-day management. Now that I've lost a significant amount of fat, my sensitivity to water retention is better, and believe me, things change from day to day that move the scale (or prevent it from moving) which don't have anything to do with fat reduction. In fact, the laws of thermodynamics being what they are, it is likely that the actual net reduction of my fat stores is fairly linear, but my weight surely isn't. It stair-steps.

The Physician's Assistant who was interviewing me at the surgeon's office today was impressed by my "good results," by which she meant weight loss, and I could tell from her questions that she was assuming that was the result of carbohydrate restriction. It's not. While it is undoubtably true that proportionally my calories from carbs are way down from pre-surgical levels, I am not eating anything like a proportionately low-carb diet. I like to have energy, so I do eat carbs.

I think this illustrates a problem I am having communicating with my bariatric team. It revolves around an assumption they make about my dietary habits. They aren't aware that I lost 110+ pounds BEFORE surgery (they never asked) by weaning myself away from a Western diet of highly-processed edible food-like substances. I have been taking the advice of writers like Nina Plank, Alice Waters and Michael Pollan for a number of years. My dietary habits for the year or two before surgery are not why I am obese.

this is not food

To paraphrase and borrow from Mr. Pollan's latest book, Food Rules, my food is not delivered to me through a car window, and it hasn't been for years and years. My food doesn't have a shelf-life, and I cook almost all of it. The food I eat will rot if I don't eat it, and in a few days. My food is not packaged, it is not accompanied by advertising campaigns or health claims. The pasture-fed beef I consume doesn't have "high in Omega-3's" stamped on the side of it, though it is. My produce doesn't claim to be full of antioxidants, though it is.

I simply eat real food, things my great-grandmother would have recognized and understood how to cook. I had hoped that this practice alone might be enough to restore me to health, but it wasn't. However, I do continue to be convinced that this practice is a very important adjunct to what else I've been doing.

Nutritionists have a very high hill to climb with me. I find most of them to be judgmental and working with them to be just an overall buzz-kill. I haven't had enough experience with the one my surgeon recruited to form an opinion, that's not what this is about, but over the life-span of my struggle with obesity I have found woefully little useful from their discipline overall.

It wasn't that long ago that margarine, with it's trans-fats and all, was believed, by nutritionists mind you, to be a healthful alternative to real butter. Even this very day I find it alarming that everyone asked me if I was still consuming protein drinks, as if something cooked by a pharmacist in a lab could possibly have a role in my long-term nutritional management. I drank the shakes when I had to get some calories somehow while my stomach healed, that was appropriate (mainly because it was the only thing I knew to do at the time), but such an edible food-like substance will not pass my lips routinely when I can eat real food. It concerns me that people expect that it might.

This problem I have illustrates what I think is the biggest single problem facing bariatric medicine. There's a very strong pull to act as if there is a single explanation for why people become obese and persist in the condition. There's not. I may look like another 350 lb 49 year-old man, but that doesn't mean that my path to this condition has much to do with his. Obesity is incredibly complex, and in the face of that complexity bariatric clinicians must rigorously battle the human tendency to stereotype and homogenize.

the bell curve

This is life out on the tail of the bell curve, the life of the bariatric "all-star" patient. I don't blame or find fault with the bariatric community overall for wanting to put up a united front against the onslaught of nutritional and food-marketing idiocy in which their patients are typically steeped. Most people in the environment I'm in do eat crap, protein shakes would be an improvement for someone typically getting their protein from commercially-fried chicken and industrially-prepared ground meats. Vitamin-fortified breakfast cereal is probably a step up from a grand-slam trans-fat nightmare breakfast. That's just not me, I wish it were more obvious. It's just lonely out here on the tail end of the bell curve.

At this point, the only discomforting development I am still dealing with post-surgically is what I've come to call "low energy days." Occasionally, I just have a day when I am fatigued from the time I get up, and nothing changes that, not even staying in bed. My surgeon warned me about this, and for a while I thought it might be related to a deficit in carbohydrate intake, but I'm not so convinced of that link now that I've experimented with "treating" it with my diet.

I am also told this condition will resolve on it's own, and I'm looking forward to that, because it is a little bit like having the flu, but without the body aches, fever and other symptoms. I just feel like I should stay in bed, but even staying in bed doesn't really help. These "low energy days" are not that frequent, I feel fantastic most days, but they happen often enough to remain an irritant.

Other than that, most everything else is very positive and much improved. I enjoy eating more, I sleep much more soundly, wake up more rested. Moving about is easier, things just feel better. I'm getting very welcome attention from women, and everyone seems to be beset with this notion that I am successful and capable individual all of a sudden. Even if the progress I have made to this day was all I could ever hope to achieve I would do this over again, three times. I'm no longer dying, slow though it was. Day by day, my health is getting better. That hasn't been the pattern for 20+ years. I'm really very much alive.

next - bariatric surgery bitch session