Some academics and activists criticize the use of the terms “epidemic” and “disease” in describing obesity, arguing in part that such language exacerbates the already widespread phenomenon of “fat shaming.” Danish Asif, a recruiter from Staten Island who had recently lost a hundred and ten pounds, reflected on the indignities of obesity: “Imagine: An old friend from college calls you up, wants to hang out, you’re excited to see him, but then he shows up in a Sentra. You can barely fit. And there’s a beeping the whole time, because you can’t close the seat belt. You get on an airplane, and you know everyone is praying that you’re not going to be seated next to them.” Dietz stresses the importance of understanding obesity as a set of health issues. “We talk about ‘people with obesity,’ not ‘obese people,’ a phrasing that is more about identity,” he said. From a medical point of view, obesity, like asthma, is something that happens to a person—a disease with many etiologies, not all of them well understood. Dietz went on, “Embedded in the stigmatization of obesity is the idea that this is something that people have done to themselves; that’s not the way to understand it.”

“People often have moral judgment in this area,” Marc Bessler, who was among the first physicians in the nation to perform a bariatric surgical procedure laparoscopically, in 1997, told me. “But I don’t think that’s helpful. Our relationship to food is strange. We still don’t fully understand how things like refined sugars are affecting us.” He told a story about a patient who was on a no-carb diet. “He said he was getting along fine until, one day, on the way out to work, he let himself take one small bite of a waffle. Just one bite. He then left the house, got into his car, reversed his car. Then he literally pulled back into his driveway, went back inside, and ate three waffles.”

Bessler’s office is on the fifth floor of a Columbia University Medical Center building, in a hallway with flyers advertising Buddha Body Yoga and Post-Weight Loss Surgery Psychotherapy. Bessler’s father had obesity, and died, at fifty-four, of colon cancer, which obesity is known to make more likely. But Bessler traces his interest in the field of bariatric surgery to his surgical residency: “I was at the hospital Christmas party, and a surgeon I admired, a few drinks in, said to me—about laparoscopy, which was a new thing back then for abdominal surgeries—he said, ‘I’ve seen the future, and we’re gonna be taking colons out through straws.’ I liked that.”

I asked Bessler what he thought about the ecstatic popularity of shows like “The Biggest Loser,” where primarily diet and exercise are used as weight-loss tools. He said, “I’ve operated on two people from ‘The Biggest Loser,’ one person who won. It’s just not a realistic setting, exercising six to eight hours a day. People have jobs.” A study that followed up on fourteen contestants from Season 8 of “The Biggest Loser” found that all but one of the finalists had regained much or most of their original weight, and that these contestants’ metabolic rates had slowed dramatically, making maintaining a healthy weight even more difficult. According to researchers, the shock of sudden weight loss prompts the body to try to put weight back on. For reasons not fully understood, people who undergo gastric bypass do not tend to experience the same sustained metabolic slowing.

I was curious whether Bessler could tell me what kind of person was most inclined to choose bariatric surgery. I thought he might say something about who had a more moralistic view of weight, or who was more trusting of the medical system. Instead, he said, “Well, women, of course. A man who is a hundred pounds overweight, he will still be treated with respect. But a woman who is a hundred pounds overweight—it’s much more difficult for a woman.”

It is clear that obesity, and the stigma associated with it, can’t be solved by hundreds of millions of gastric bypasses and sleeve gastrectomies. One piece of encouraging news is that among two-to-five-year-olds there is evidence that obesity rates may be declining. But there is no such news for adults. George Bray told me, “When the day comes that we can mimic the weight loss without the surgery, I think surgery will fade away. How long this will take, and what form, I can’t hazard a guess.”

The cultural and literary historian Sander Gilman, who wrote “Obesity: The Biography” (2010), told me that, just as “every diet works for some people but no diet works for everyone, bariatric surgery will work for some people but it will not work for all.” He added, “I would suggest that surgery needs to be paired with psychotherapy or behavioral therapy, since there are so often underlying problems to address; you don’t want the symptoms to just transfer to another domain.”

Many diaries by people who have lost weight can be found on the Internet; they sometimes reflect the writers’ frustration at finding themselves still depressed, or still in distress in a relationship, or still mired in a drinking problem. As a woman named Lisa, who posts at gastricbypasstruth.com, writes, “Once the fat is gone, your real problems are no longer masked—they’re out in the open and you have to deal with them. If you’ve always thought skinniness was the cure-all, it can be quite a slap in the face when you get there and find out your problems followed you.”

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There are also physical problems. Most surgical patients need to commit to a lifetime of vitamin supplements and regular checkups, and some people—especially those who choose gastric banding—experience significant discomfort or even vomiting from feeling full. Sugary and fatty foods can cause gastric-bypass patients to have cramping and diarrhea. Furthermore, patients with extreme obesity are often burdened with loose skin after a dramatic weight loss. Paul Mason, a British man who went from nine hundred and eighty pounds to three hundred and fifty, following a gastric bypass, needed to have some seventy pounds of excess skin removed. Bariatric surgeries, which can cost as much as thirty thousand dollars, are covered by many major insurance companies. (Most studies suggest that the expenses are recouped within two to three years, because the surgeries avert future obesity-related medical expenses.) Skin-removal surgeries, which are sometimes even more expensive, are rarely covered.

Roberts loves travelling, and has been to dozens of countries; he planned to visit the ice-and-snow festival in Harbin, China, a month after his surgery. Having had no complications, he went. “I walked around five to six hours a day while I was there,” he said. When I met up with him ten weeks after his operation, he had lost forty-six pounds, and now weighed two hundred and twenty-four. “Which is halfway to my goal of a hundred and eighty,” he said. “Although maybe that goal is too ambitious.”

I asked him if he worried about regaining the weight, as he had after his lap-band procedure. “I know now that when I walk by the ice-cream aisle it’s not a problem for me anymore. I’m not even tempted—I really don’t want it.” After his lap band, ice cream had still been a strong temptation. “I’m optimistic. I can’t really eat red meat anymore, I’m not comfortable with it, and sometimes when my friends go out for dinner before seeing a play I skip the restaurant, even though I like being with friends in that way.” Roberts said that he’d been eating a lot of fat-free refried beans, chicken soup, and salads. He laughed when he mentioned this, as if it were a punch line. “I’ll tell you what I am worried about,” he said. “I’m going to a casino in Atlantic City next week. They know me there, they come by, they see me, and they say, ‘Three-pound lobster?’ and that’s difficult to turn down. I guess I won’t turn it down. I’ll take it, but only eat a small portion, and save the rest for later.”