How to lose a lot of weight not in a hurry
John, a 50-year-old man with a cherubic smile, nodded at me on the Zoom screen and said hello. It was clear from the first moment I saw him why he was talking with me. At 5’10” and 350 pounds, his goal was to get down to 200 pounds—a weight he hasn’t seen since his 20s. Six months ago, his doctor told him he’s probably a few months away from having to inject insulin, and that woke him up. He had gotten used to being heavy ever since high school, but now, he said, he was going to finally make a change.
John came with a plan: start with Ozempic, a medication he’d read could melt pounds away, then ease off later with diet and exercise. “I think this will get me going,” he said, his voice hopeful but hesitant. “I’ll lose the weight first, then you’ll help me put together a diet and exercise plan. Within 18 months, I’ll be in good shape and I’ll have tapered off the Ozempic.”
“Got it,” I said. “Before we go there, let’s look at all your options.”
Fasting
Fasting is a debt-based approach to losing weight. When you lose fat, you don’t lose any fat cells. The fat cells you have get skinnier, and they want the weight back. Fasting also loses muscle, which is hard to get back. You never want to lose muscle if you don’t have to. Since fasting is not a lifestyle change — it puts your body into emergency mode — it isn’t sustainable. While it may help lose weight, it doesn’t help keep the weight off, and keeping the weight off is 2/3 of the effort. Fasting doesn’t produce permanent weight loss; it kicks the can down the road rather than doing it right from the start.
Semaglutide
Ozempic and Wegovy are the same drug. It’s a GLP-1 medication that curbs appetite and slows digestion, helping people lose weight—potentially 40–60 pounds in a year for someone like John. It also lowers insulin resistance and cuts heart-disease risk by about 20 percent. It sounds like a way to jump-start his journey, and even Peter Attia has admitted it could work for people like John.
Essentially, the drugs mimic fasting. They force weight loss but incur a debt that must be repaid later. Many people are now going toward Mounjaro, which includes a second method of action and helps people lose more weight. Both cost around $1200 per month.
These drugs are not your friend. They are like a devil you make a deal with, and the devil always wins. You must keep taking it forever — at the same high price per year — or the weight comes roaring back, often replacing muscle with fat, leaving people worse off. People love the “honeymoon period,” where the weight magically disappears, but then they are left in a state where nothing tastes good and they must keep paying to not go back the way they were before.
In just a few years Semaglutide is already a $25 billion industry, because it has about the best business model any drug company could ever dream of: fast, superficial results and customers who become fully dependent, paying monthly rent forever.
John plans to taper off and rely on diet and exercise, but studies show that’s a risky bet. After Ozempic, John would need to master the same diet and exercise habits he’s struggled with for years, but now with more cravings and a more ferocious headwind — he’ll be working against the drug rather than his own body. At 50, with a history of skipping exercise, there’s no evidence he can easily “pay back” this loan by suddenly becoming a different person.
Surgery
Gastric bypass is likely John’s best bet to lose 150 pounds and keep most of it off. The roux-en-Y procedure creates a small stomach pouch the size of an egg and reroutes the digestive system, so he eats less, feels less hungry, and absorbs fewer calories. For John, this could mean losing 90–120 pounds in two years with a reasonable hope of keeping it off. It reduces insulin resistance immediately and eases joint pain, helping him move more at 50. But it requires tiny, protein-packed meals and regular exercise forever—habits John’s never stuck with.
Sleeve gastrectomy removes most of the stomach, leaving a small tube that holds less food and cuts hunger. It’s simpler but less effective than bypass, and some regain weight without sticking to small meals and exercise.
The gastric band, or lap-band, puts a tight band around the stomach to limit food intake, adjustable by a doctor. It’s the least invasive, but John might only lose 35–70 pounds, and many patients need the band removed later.
The best option
“John,” I explained, “both the drug and fasting are nonstarters. If you’re going to do one of those, at least fasting is a lot cheaper, but both will give the same result — weight loss followed by weight gain. This is not how you start your permanent weight-loss journey.”
I recommended he start the ketogenic diet and exercise program now, get into ketosis and the gym, start with a serious commitment to six hours of cardio per week plus stretching and movement, and see where we are in six months. We can assess our further options at that time.
It wasn’t exactly what he wanted to hear — he’d been imagining getting compliments from all his friends on losing weight so quickly. But my words sunk in. John didn’t need to be told that planning to exercise was very different from actually exercising, managing the schedule, building the habits, wanting to do the work every day rather than looking for excuses. But he did need to hear that it was the right next step.
The first three months
The most important part of the plan is getting into ketosis and exercising 8-10 hours a week. If John can’t do that, nothing is going to work. He’s never been in ketosis. He’s never exercised regularly. This has to be step one, or there will never be a step two.
See a primary-care doctor for tests (blood sugar, cholesterol, thyroid) and clearance for exercise, given pre-diabetes and joint issues. Discuss bypass eligibility (BMI >40 qualifies) with a bariatric surgeon for future planning and insurance coverage.
Have a coach. A coach will keep him accountable. You don’t want to give your coach a list of excuses why you weren’t able to work out three times last week — that’s not going to cut it. Make agreements and keep them.
Keto diet
Plan to get into ketosis and stay there. Get the How Not to Get Sick Cookbook and find other resources. Don’t wing it.
Focus on protein (80–100g/day): eggs, grilled chicken, fish, Greek yogurt, protein shakes.
Add fiber: 2–3 cups vegetables (spinach, broccoli), ½ cup whole grains (quinoa, brown rice).
Zero alcohol. Don’t drink calories unless it’s a whey-protein shake. Start drinking more water.
Zero sugar. Substitute alulose if needed.
Cut all carbs: No bread, muffins, grains, snacks, soda, fast food, or sweets.
Examples:
Breakfast: Greek yogurt with alulose, or eggs and strip steak
Lunch: chicken salad, olive oil dressing
Dinner: baked or grilled fish, green beans, olives
Snacks: nuts, cheese, keto snacks
Evening snack: high-protein yoghurt
One meal a week, give yourself a reward without losing ketosis. It could be buckwheat pancakes with alulose syrup or eggs benedict with whole-wheat english muffin.
Exercise 30-minutes per day
Walking doesn’t count. Work out as hard as you are able. Treadmill, stairmaster, elliptical, bike, rower - whatever you will do for 30 minutes, work up a sweat, and count the number of calories expended. Start with 300 calories per session and go up eventually to 600.
Within two months, try to be at one hour per day and 600 - 800 calories. Start a movement, yoga, or stretching class that you have to go to twice a week. Not so much for the results but for the habit.
Support
Make sure you are in ketosis and stay there. Your breath should smell like acetone (nail-polish remover). Don’t break ketosis.
There will be setbacks. Come up with a plan for making yourself work out daily. Specify what happens if you don’t. Get a buddy or someone to keep you accountable. Don’t make bad decisions based on not feeling like it. Find a way to keep your commitment. This is the hardest part, so build systems to get around your mood and feelings and justifications.
Don’t focus on how many pounds you lose! Focus on your ability to adopt and maintain your new routines and stay in ketosis. Don’t try to lose too many pounds too quickly - make sure you’re getting enough food daily to maintain your muscle mass.
Months 3–6: ramp up, don’t slide back
Build all your shopping routines. Manage all your work-out clothes and washing routines so everything is ready for going to the gym. Manage your schedule around your workouts. Join some classes and teams, commit to weekly runs or other activities with others in the same situation. Prioritize the workouts, so if something has to give it’s not the exercise.
Work on getting 7+ hours of sleep per night.
Identify sources of stress and manage them. Remove external stress as much as possible. Seek any additional resources you need.
Drink even more water.
Plan a trip that involves a big hike or camping trip or bike ride where you’ll be on your feet burning calories 8 hours a day for several days. There are hundreds of multi-day endurance events of all kinds happening around the country every year. A big trip takes planning, preparation, thinking more about diet, and coordinating with others toward a common goal. It brings people together who can support each other.
Work more on balance, stretching, movement. See Lee Weiland’s videos for inspiration.
Don’t focus on pounds lost! Don’t lose too many too quickly — make sure you’re eating a sustainable diet that prevents loss of muscle.
Six-month assessment
At this point, John’s mind should be in a better place to make a good decision. He should have researched the surgery options. We can decide whether to add surgery to his already good habits or continue building on the success so far. At this point, the most important thing is to not slide back, because the weight wants to come back.
The ketogenic diet should be doing half the work and the exercise the other half. If things are going well at this point, surgery in the next six months would give an added boost to what he’s doing already and help lock in gains.
Or not — it’s entirely possible to lose 150 pounds and keep it off, but it’s better in that case to move on to half-marathons, wilderness backpacking, distance swimming, extended bike road trips, endurance events, and other hard challenges. Are you ready to climb Mt Shasta now, John? Even if you go and don’t make the summit, you’ll have something to aim for next year.
Summary
While it’s possible for John to lose all 150 pounds on his own, there are other options. No amount of drugs or surgery is going to give John the body he really wants. Rather than paying rent to Eli Lilly, embracing his new athletic life will pay him dividends forever. It will lead him to meet new people, have amazing experiences, build his confidence by accomplishing hard missions, and feel great from head to toe. It may even land him another job that he could never have gotten without getting in shape.
John exhaled, nervous but nodding. It was time to actually start doing what he had been avoiding for his entire adult life. His road to losing 150 pounds won’t be quick—50 years of habits and a body that fights change make it a long journey. But a journey like this requires small steps at the beginning, not a giant leap.