Michael knew if he didn't do something drastic, his weight was going to kill him. For years, his body had been trying to tell him how much it was struggling to carry 149 kilos of bulk on his 1.86-meter frame. There was the sleep apnea that sapped his energy, the high blood pressure that threatened his heart, brain and kidneys, the alarming shortness of breath. All pointed to organs in distress. He had tried for years to lose weight, but nothing seemed to work. Well, nothing worked for long, that is. Sure, there had been diets - so many diets! - and even a solid year of regular exercise, leading to periods when he lost enough of his heft that it seemed like he could manage his weight just fine. But the kilos always came back, and then some. When Michael's doctor warned him that his kidneys were on the brink of irreversible damage from the trauma that obesity causes, he cried "enough!" In April, at 50, Michael underwent a duodenal switch, one of several bariatric surgeries used to treat morbid obesity. Part of his stomach and part of his intestines were removed, restricting the amount of food he can ingest and restricting how many of the nutrients his body can absorb. Six months and 60 kg. later, Michael knows the surgery has not only changed his life dramatically, it may have saved it as well. The number of Israelis resorting to these drastic measures is climbing into the hundreds per year. But that is just the tip of the iceberg that is this country's growing obesity epidemic. Fully 40 percent of adults are overweight, according to Health Ministry statistics, while another 23% are obese. Thousands are classified as morbidly obese or even superobese. Worse, these numbers are rising. What this means is nothing short of an emergency. Research shows a clear link between obesity and a wide range of health problems, with significant increases in the risk of developing heart disease, hypertension (high blood pressure), stroke, diabetes, certain cancers (e.g. breast cancer and intestinal cancer), osteoarthritis, breathing problems and more. The strain that this puts on the public health system and the economy is immense: NIS 10 billion or more per year in direct costs of treatment and indirect costs from sick days and lack of production, according to various estimates. Of course, the human costs are tremendous. "I couldn't get out of a low beach chair without the help of at least two people," Michael recalls. "In restaurants, chairs would break under me, and I would be so embarrassed that, rather than complain that the restaurant didn't have chairs to serve me, I would worry and consider myself lucky if they didn't demand that I pay to replace the broken chair." Ariela, a 58-year-old retired teacher from Jerusalem, weighed 111 kg. before undergoing gastric banding surgery just over two years ago. Before that she took up two seats on the bus. Fibromyalgia caused pain all over her body that nothing could relieve. She was so limited physically that she had to teach in a classroom on the first floor because going up stairs was too difficult, and she couldn't join class trips because of the exertion required. "Any time I didn't have to be out, I stayed home - in bed - as much as I could," Ariela says. "You get to a point where you ask yourself, why get my hair done? Why buy nice dresses? What's the difference? "When I walked down the street and passed a display window or a mirror, I would turn away so I wouldn't have to see my own reflection. When I would walk into a room, I would automatically feel embarrassed and inferior, knowing everyone was looking at the fat woman who had just walked in." Michael knows the feeling. "Often, obese people are easygoing and jolly, but that doesn't mean they're really happy. That's just a persona they adopt because they have to, in order to overcome their obesity," he says. "Ultimately, every obese person wants to stop being fat. They don't want to have to hide anymore." Hiding, Michael adds, begins with fashion. "You try all sorts of things to look better - tucking your shirt into your pants, untucking your shirt from your pants, whatever. You tell yourself that in certain clothes you don't look fat. But later, when you see photos of yourself, you realize that no clothing can hide the truth." You have to wear something, though, even if it isn't flattering. And when you're obese, not much is. "Clothes shopping is a nightmare when you're obese," Michael continues. "Your clothes never fit quite right. You walk into a store and pay a lot for clothes that are of low quality because you have to take whatever they have that fits on you." Ariela can empathize. "I would walk into clothing stores - for 'big sizes' - and ask, 'What's your biggest size?'" she says. Constantly losing and regaining weight also wreaks havoc with a wardrobe. "I would purge my closet of all my 'heavy' clothes, only to have to buy more when I would gain weight again," Michael says. Like most obese people, Michael and Ariela were often able to lose weight, but never able to keep it off. And every time the number on their scale climbed higher was another stinging failure. "I've had to fight my weight almost my whole life," says Ariela. "We're talking about 30 years of frustration and anguish. I was always on a diet. I drank only diet drinks. I would sit in the teachers' lounge and drink coffee instead of eating lunch. Meanwhile, these thin women would devour these huge sandwiches. I couldn't understand it... People would tell me to lose weight, and it would make me so mad. Losing weight was just impossible." Several years ago, Michael and a friend were watching Dudu Topaz on television when the entertainer challenged the public, offering a new car to the person who could lose the most weight. The two figured Michael had a shot at winning the car and started planning his strategy. "Suddenly my friend turned to me and said, "Wait. For a new car, you would lose weight, but for the sake of your own health, you won't?!'" That kind of thinking is common, Michael says - and it hits home. But it's also a trap. "Obesity is something you're 'guilty' of, in your own mind and in the minds of others," he says. "If you have cancer, everyone will embrace you. But if you're fat, people will say, 'Get yourself together!' So you tell yourself, 'It's okay, I'll fix it.' Ultimately, what you have to realize is that the problem is simply too much for you to handle by yourself." OBESITY IS rarely the result of a lack of motivation to be healthy. For some, getting in shape really is too difficult. The effort required to lose enough weight - and, more importantly, to keep it off for good - is so great, doctors say, that few will actually accomplish it on their own. "Numerous studies have shown that the chance of a morbidly obese person reaching a healthy weight, and maintaining it for at least five years, is less than 5 percent," says Dr. Subhi Abu Abeid, head of the obesity clinic at Tel Aviv's Sourasky Medical Center. One problem is that not everyone realizes how dangerous obesity is, says Abu Abeid. "It's important to recognize that we're talking about a disease," he says. "A person might say to himself, 'Yes, I weigh 180 kilos, but I'm strong, I'm okay,' but that just isn't the case. He's sick, and his obesity is his illness." Further, he says, "morbid obesity entails a range of illnesses, such as diabetes, high blood pressure, joint problems, sleep problems, emotional problems, infertility, kidney damage, etc. It's only a matter of time before someone develops one or more of these complications. You can die from this." Indeed, researchers in Europe and the US have found that obesity can shorten life by as many as 13 years. In the hopes of preventing that grim prospect, 15 to 20 morbidly obese patients come to Sourasky every month for one of several bariatric surgery options. "Usually the people who come to us have tried all kinds of diets, pills and other methods that just didn't work," Abu Abeid says. "Beyond a doubt, surgery is the most effective treatment for morbid obesity." Underlining the message that morbidly obese people rarely maintain a healthy weight through diet and exercise alone, he notes that several of the former contestants on the reality weight loss show The Biggest Loser have come to him for surgery. "But they want to keep it a secret," he says with a smile. The bariatric operations "are not cosmetic," Abu Abeid stresses. They make it physically impossible to eat more than a little bit at a time, by either tightening the stomach or cutting most of it away. They are also unlike surgery for "normal" people. Treating morbidly obese patients entails unique circumstances. "It can be difficult to sedate them," says Abu Abeid. "Sometimes the patients are so large that we need two operating tables just to hold them." The surgeries are laparoscopic, he says, which means that "there is no need to open people up." The surgeries last about an hour, and patients can leave the hospital in one to five days. After that, though, things get tougher. There are new diet rules to follow (often including pills to ensure sufficient intake of vitamins and minerals), an exercise prescription - and lots of office visits. "If you have your appendix taken out, you see your doctor twice afterward and that's it. This, however, requires lifelong follow-up," says Abu Abeid. "That includes regular check-ups with a doctor, working with a dietician, meeting with a social worker, and sometimes even joining a support group." "Some people think it's hocus-pocus and then they're done," laughs Dr. Andre Keidar, who heads the obesity clinic at Hadassah-University Medical Center in Jerusalem's Ein Kerem. "But the follow-up treatment lasts the rest of their lives." Patients are usually faithful to the program in the beginning, but often they become lax as time goes on. "The sad fact is that most people aren't going to change their behaviors much, which is why, without the surgery, they wouldn't get thin in the first place." At both hospitals, prospective patients are given a full description of the options before them. Those who are sure they're interested in one of the procedures have to undergo a series of tests before they can be accepted for treatment. They have to be heavy enough and sick enough to warrant the surgery, but not so sick that the surgery would pose too great a risk. "Sometimes those who are turned down for the surgery become quite upset," Keidar says. And that's understandable. "You're not just talking about a person's weight, you're talking about their ability to function, and you're talking about their emotional well-being. Keep in mind, many of these patients are very successful in other areas of their lives and they are frustrated to find themselves failing to maintain a healthy weight." For those who fit the profile, though, hearing that they are eligible for the surgery is good news. Most of the weight they need to lose will come off within a year of the surgery. And, since the procedure is in the basket of public health services, they won't have to pay a shekel for it. MICHAEL AND Ariela both came around to the idea of having bariatric surgery pretty quickly. "At first the prospect is a bit frightening," says Michael. "But I'm telling you, it's great. If only there were surgery to make people stop smoking, and to stop gambling, too!" Early on, as the kilos melt away, it's a magical time. "There's definitely a 'wow!' period that you go through, like when you celebrate being able to wear the kinds of clothes that normal people wear," he says. "But it feels weird to lose weight so quickly. It happens so quickly that you're not ready for it emotionally." The change is definitely drastic. Michael, who owns a store in a mall, often finds himself greeting customers who don't realize that the person standing before them now is the same one who served them months earlier. "They'll give me this look, like when you think you recognize someone but you're not quite sure, and they'll ask, 'Did your brother use to work here?' I get that almost every day." In his driver's license photo, Michael is still 60 kg. heavier. It's the same name, the same ID number, the same address. But it isn't the same person. He's happy with his body now, but to see how unnaturally Michael carries his pencil-thin frame is to see the old phrase "I'm a thin person trapped in a fat person's body" turned around. Michael is now a morbidly obese man living in a lithe body that he doesn't quite recognize. "I still can't think of myself as thin," he says. "Before, when I would travel, I would worry, what if my luggage is lost? However will I find clothes that fit me? Then my pants size went from 60 to 44, and I was able to shop for pants at any store I wished. Yet every morning, when I pull on my pants, I don't believe that my legs are going to fit into something so small. And I still feel a rush of anxiety whenever I have to bend down. I have to remember that I can actually change my own shoes now." That might not seem like much, but for Michael it's huge. For years before his surgery, it used to be that one of his employees would always lock up the store at night, because for Michael to bend down to the floor to lock the gate, and then try to raise himself back onto his feet again would be an ordeal that no one wanted to endure. His new body may be a gift, but it is one that is taking time to adjust to. "I used to sweat a lot," he says. "I thought it was just me, that something was wrong that made me sweat a lot. Well, there was: dozens of kilos of extra weight!" Michael finds it strange that he is now able to squeeze into his car, even in a tight space in a parking lot, and that once he sits down the steering wheel is not pressed against his belly. He is bewildered that he can fit into the seat of an airplane. After decades of being obese, his mind is still working on the assumption that his body's proportions are so much larger. There are also some drawbacks. "Before, people would automatically let me sit in the front seat of a car because there wasn't enough room for me in the back seat; it was understood. Now they relegate me to the back seat!" he halfheartedly complains. Then there is the fear that he will lose "too much" weight. "I chose this surgery because I didn't want to be responsible anymore for how much I ate," Michael says. "I was tired of it. So now it isn't really up to me. I simply can't eat large portions." Because his meals are so small, Michael has to make sure he eats frequently throughout the day, about every three hours, and make sure he includes plenty of animal protein in his diet. "Sometimes I miss the old days," he says, "when I could go to a buffet and just eat everything in sight. Now, when I'm at a buffet or a large meal, I just have a little bite of this and a little bite of that. I'm not even interested like I once was. It may sound strange, but in a way I feel like, by losing my appetite, I've lost my best friend." Everything he has gone through has been worth it, he says, noting the support of his wife and three kids. "Without that support," he says, "I don't know how I would get through it." For Ariela, the surgery has brought only good things. "I had heard about bariatric surgery on the radio, but figured it wasn't for me," she says. "Then a friend who was even bigger than I was underwent the banding surgery and is now really thin. She's the happiest person in the world now. Anyway, when I did finally go to a presentation at the hospital, I suddenly realized that it was real, and that it was the kind of thing that I could do. Before the presentation was over I was asking for surgery as soon as possible." She opted for gastric banding - a sort of noose around the stomach that makes it painful to eat too much, which can be tightened or loosened through a button-like apparatus just under the skin over her hip. "It's so nice not to have the appetite I once had," Ariela says, leaning comfortably on her couch. "An obese person never says, 'I can't eat another bite.' They can always eat more. Today, I can eat anything I want, I just can't eat very much of anything - and the truth is, I don't want to. I'm looking at those wafers there on the table and I don't even want them." Recuperating from the surgery took about a week, Ariela says, and getting used to her new dietary demands took a little longer. But the benefits have been astonishing. "I no longer need medication for my blood pressure, and my fibromyalgia is gone. I feel 20 years younger!" she says. Seeing Ariela now, so petite and so vibrant, it's hard to believe she's the same woman who once could barely fit through her own hallway at home. But, even after giving away 40 bags of clothing, she still has a few of her old size 56 pants to prove it. "Now," she says, "my being obese is like an episode in the past." And she doesn't miss it one bit. "Recently I brought home groceries from the store. I had bags full of all these heavy fruits and vegetables that I had to carry upstairs. It was a real workout. Out of curiosity, when I got home, I put them on the scale. They weighed 20 kilos. I said to myself, 'My God, I barely carried an extra 20 kilos of groceries. Where did I put another 30 kilos of fat? And how did I ever carry them?!'" Really, she asks, how does anyone?