"Ow! It hurts when I do that."

on working out

picture of hot sauce bottle with the label 'pain 100%' prominently displayed

I have been working-out at the gym regularly for six weeks. Last night, I had my first session with a Pilates instructor (in my home). If lifting weights is like taking down a brick wall with a sledgehammer, then Pilates is like sculpting marble with a fine chisel. The differences in the experiences are striking, but the short-term sequellae (Ow! It hurts when I move anything this morning) are remarkably similar.

I remember thinking during the Pilates work-out that I wasn't really working that hard, that this was more like dancing. Pilates exercises are subtle and tightly controlled. In contrast, lifting weight is a matter of just getting that heavy thing moved to some other position. I can really understand now why they are separate disciplines, each with their own camps of enthusiastic adherents.

I told my Pilates instructor what I had been doing at the gym, and what my trainer thought I needed to attend to, and while she was nice, she clearly thought he was missing a lot of my problems. She concentrated on my posture, how I breathe, and what I was doing with my spine and pelvis. She didn't trash my weight-lifting, or recommend I stop doing it, but she quickly demonstrated to me during our session where she is coming from.

For example, when doing something as seemingly simple as lifting my bent leg off the floor while laying on my back, my instructor kept correcting me "No, don't lift with your hip, use your psoas! Keep your sacrum level! Stop tilting your pelvis! Remember, keep your spine in the neutral position!"

Damn, I thought I knew how to lift my leg off the floor.

I'm making her sound like a Marine drill instructor, and she's not, she's actually a very sweet and soft-spoken friend of mine, but I quickly came to realize that I was mostly unaware which muscles I am using to do which movements, and that this undoubtedly means that I am out of balance and misaligned, just as Pilates theory asserts most people are.

For example, before last night, I just sort of had my brain tell my body "lift your right leg off the floor" by metaphorically shouting at it with a bullhorn, caring only about results. In Pilates, it's more like an encrypted message sent privately to a specific IP/server: "use only the right psoas to lift, keep that thigh rolled inward, sac rum level, pelvis and spine in neutral position, relax the hip muscles, feel the movement along your pelvic floor." It's very different, and quite the mind-body awareness challenge.

The night before, I had a repeat evaluation of my kinesthetic condition by my trainer at the gym and he had a lot of praise for the improvements I've made in certain (much less subtle) diagnostic movements, like a squat with my arms extended over my head. I've obviously significantly strengthened my quads and hip adductors in the last six weeks. I knew this already because I've been increasing the weight I lift with those groups, and it is significantly easier to climb stairs these days. But, it was nice to get independent confirmation of this improvement via his analysis. I've also strengthened my shoulders and lats, my squat is much prettier and more controlled, and I can keep my arms straight above my shoulders throughout the entire movement. When I started, I almost fell over doing a squat like this, and I couldn't control anything.

I'll have an essay later on about "what I wish I had known before the surgery." Until that's written, I can tell you that one thing that I will definitely discuss is my wish that I had known that, in spite of faithfully eating the recommended amount of protein every day after my surgery, I still was going to lose a significant amount of lean muscle mass post-op until I started working-out.

I had an inkling of this (before I started working out) when I noticed that I still had a lot of trouble climbing stairs even though I had lost 50 lbs. I kept wondering when stair climbing (which I do a lot of in NYC, relying on Subways for transportation) was going to get easier. It seemed a little easier, but it still mainly represented an opportunity to practice pain tolerance. Upon reflection I realize this was one of my most eagerly anticipated improvements in my functional status. I hate climbing stairs, and I imagined I looked as functionally disabled as I felt doing it.

Now, while I am not at the point I want to be with climbing stairs, it is much easier.

For about the first two to three weeks of the last six week period, working out was very hard. I felt like I had been beaten with a lead pipe every time I left the gym. I wasn't getting any stronger, I couldn't increase any of my weights, and that wonderful after work-out feeling that is one of the greatest rewards of going to the gym was absent. At the time, I attributed this to being older. The last time I worked-out regularly I was 15 years younger, so I just thought "this is just what it is like to be an old man."

But, other old men enjoy working out, so I just persisted, hoping that at some point my body would adapt, or catch up, or something. For those first couple of weeks, this wasn't fun. I literally felt like I had been badly physically beaten after every work-out. Everything was sore, any movement was painful, and resting afterwards just made it all worse.

Then, some time during week three, there was a sudden change. It was not gradual, it was not subtle. Suddenly I could life more weight, suddenly my muscle soreness was down to a manageable level, suddenly I felt only pleasantly tired after a work-out. It all clicked into place at once, this was not simple adaptation of my body, something fundamentally changed in a quantum fashion.

hot sauce labled 100% pain

Who knows what changed? There's probably not any money to be made by the pharmacological industry by this phenomenon, so there will probably never be any research into it in this country, but something did happen. Working-out and it's consequences are largely back to where they were for me 15 years ago.

Paradoxically, even now, I was stronger before the surgery than I am now. I was also stronger the last time I was regularly going to a gym (1994-1995), I remember what I used to lift back then and I'm at about 70% of those weights these days.

Here's the lesson: when you lose weight rapidly after surgery, one needs to expect that a significant part of that loss will be lean muscle. Therefore, strength-training in the post-surgical period is essential. Bariatric patients need to know about this and understand why.

You see, so much of the advice given to post-op bariatric patients is condescending, anecdotal, and delivered with an undertone of disapproval and disgust. "The surgery is just a tool. This requires a lifestyle change. You are going to have to change the way you eat, it is a lifetime commitment. You can't just expect to be cured after surgery, there's still going to be a lot of work to do"

My response to all this pre-op advice from baratricians pre-operatively was a big, forgive me, "Fuck you." Show me the evidence for this nagging, let's see your randomized controlled, double-blind studies that demonstrate the value of regarding one's self as a behavoiral failure because of intractable obesity. Think with your brain, not your biases. After all, you call yourselves scientists.

My pre-op diet was exemplary and I was pretty active for a 400 lb man. I lost 110+ pounds pre-operatively, so don't come around, look down your nose, and tell me about the "lifestyle changes" I need to make post-operatively. You literally do not know what you are talking about until and unless you have walked a mile in my shoes, and I have yet to meet a bariatrician, or bariatric surgeon, who also is/was a bariatric patient. I know they must exist, but I can tell you that in my experience they are not the norm.

If there's one single thing that has most surprised me that I've learned from this experience thus far, it is that intractable obesity is largely a neuroendocrine disease, an imbalance in the behavioral energy homeostasis systems in the brain and gut. This environment that we live in, with the cheap, calorically dense food, and the plotting by the commercial food industry to condition over-eating as a way to boost their profits, is a big contributor, but the basic problem is not that there's the enormous swath of society that cares more for the short-term reward of satiety than the long-term reward of a healthy weight.

It is not that simple.

Every one of you would be fat if you had my pre-op hormones and wiring. I am not some self-destructive gluttonous freak. Something was wrong with me, no different on a macro level than something being wrong with someone whose colon turns into cancer. The surgery offers a fix for this, just as a prefrontal lobotomy offered a fix for certain intractable psychiatric disorders in the 1960's. Bariatric surgeons know little more about what they're doing now than the equally well-intentioned and dedicated neurosurgeons knew in the 1960's when they took a long knife to the cortex. They just know it works, or seems to, in the short/mid-term.

But, they all believe, along with most all of you (unless you suffer from extreme, intractable obesity), that they understand what makes people obese. If they did, this might not be a surgical problem, and inducing a negative caloric balance through diet and exercise wouldn't fail 95% of the time it is tried.

Obesity is still a mystery, folks. The next time you look at a fat person, particularly an extremely fat person, struggling just to walk down the street, try to find some compassion in your heart instead of the usual disapproval. There, but for God's Grace, go you.

See you at the gym.

next - fear of flying