I’m in a dietitian’s office, located within a bariatric surgical suite, housed on a quiet floor of a large hospital in Boston, Massachusetts. The room is tiny, with bad fluorescent lighting. It’s dominated by a large bookcase filled not with books but with empty yogurt containers, flattened granola bar boxes, and rinsed-clean protein-shake bottles. It’s as if somebody went on a very low-calorie snacking spree and then preserved all the packaging as a souvenir. The dietitian who works in this office uses these packages to illustrate to clients how to put together what she considers a proper meal. But this particular client, a thirty-six-year-old special-education teacher named Gina Balzano, doesn’t really need the lessons.
Gina, one year out from her gastric bypass, has invited me along on this checkup so I can see how it feels to be an “After” in the world of weight-loss surgery. Her dietitian, whom I’ll call Ramona, is a tall, thin woman dressed in shades of brown. “She’s the one we’re all scared of,” Gina tells me before the appointment. “We” are the other patients she bonded with in her support group. And I can see why Ramona triggers their anxiety; she’s unsmiling and pecks skeptically at her keyboard as Gina lists out everything she now eats in a day. Breakfast is an egg muffin, a batch of which she makes once a week from half a dozen eggs and assorted vegetables. Around ten, she eats one Chobani Simply 100 Greek yogurt. “Do you know that brand?” Gina asks Ramona, who nods, flicking her eyes over to the case of yogurt cups. “Oh right, of course, you probably have five over there.”
Lunch and dinner are Blue Apron meals; Gina cooks one each evening to share with her husband, then packs up the leftovers for the next day’s lunch. “I get meals that are between five hundred and a thousand calories for a traditional portion and then I third it for myself,” she says. “I eat three or four ounces of protein and the vegetables, and maybe a tablespoon of the starch. I don’t like to waste room on the starch, I’d rather have the vegetables.” Her afternoon snack is half an Atkins protein bar.
Gina also admits to having had two alcoholic drinks in the past month, which Ramona records with a frisson of disapproval. Gina tells me later that she also eats a small square of dark chocolate every night. “Because I want to feel like a human,” she says. “But I didn’t think Ramona needed to know that.” Gina doesn’t track her total calories, but in general, she shoots for half the portion size listed on any food label. Before her surgery, Gina usually ate three big meals a day: a breakfast sandwich and coffee from Dunkin’ Donuts, some other kind of fast food for lunch, and then a home-cooked dinner. “Now I eat smaller portions but way more regularly,” she says. “It is so much better than being hungry all the time or gross full right after I eat, and then starving for hours.” But although she eats more frequently, her total caloric intake is almost certainly lower: Most weight-loss-surgery patients at Gina’s stage of the process are told to eat between a thousand and fifteen hundred calories per day.
“That’s great,” says Ramona, typing away. “Now you might think about playing with your dinner proportions. Like, you might do just two ounces of protein, instead of three to four, and make up the rest with more vegetables.”
“Okay, great,” says Gina. “I love vegetables. They help my stomach.”
“Well, and the thing is, I otherwise see people’s proteins starting to creep up,” says Ramona. “And it might get to the point where—”
“Where I feel uncomfortable?” Gina asks. Also on the “Don’t Tell Ramona” list is the muffuletta sandwich she ate a few months ago, on a weekend trip to New Orleans. Gina ate more than she normally would because it was so delicious; an hour later, her newly shrunken stomach sent it all back up.
“Well, maybe uncomfortable. Or you might not even feel uncomfortable, that’s the point,” says Ramona. “People start being able to eat a little more now. And I’m sure they told you that everybody hits a low point, a nadir with weight loss, so some regain is normal. That’s why you might want to overshoot a little now. I mean, not really—but because that way you can creep back up and still be at your goal weight.” Ramona talks quickly, in a kind of medical shorthand that Gina has become accustomed to over the past year of these meetings. So it takes me a minute to realize that this is really advice on how to rig the game in Gina’s favor: “Lose more weight than you need,” Ramona is saying, “so when you inevitably regain some, you don’t end up right back where you started.” It’s like a dieting insurance policy, or the kind of tip I’ve seen (and probably written) in many a women’s magazine article. Ramona types some more. “Like, it’s good that you just eat half the protein bar for a snack. I think that’s smart.”
“Well, the whole thing feels like too much,” offers Gina.
“It is too much!” Ramona says. She is suddenly fierce. “I see people all the time, eating the whole thing just because they think it’s a good food. Just because you can or it’s good, doesn’t mean you should.”
She scrutinizes Gina’s food log some more. “So you’re busy. You work a lot. Right? That’s why you use those Blue Apron meals?”
Gina acknowledges that she’s busy, but adds, “I actually think it helps to be busy because I have to plan ahead. I bring my breakfast, lunch, and snacks to work and I’m good to go. And the Blue Apron meals make it really easy to comply.”
“No, I just ask because you may get to the point where you can do it all in your sleep, without that,” says Ramona. By “it all” she means meal planning, grocery shopping, and cooking from scratch. For all the packaged foods littering her office, it seems that Ramona wants her clients to be cooking and eating whole foods—never mind that, as Gina gently points out, Blue Apron meals do require cooking, if not planning and shopping. I wonder if that’s because a diet charted out by a delivery service and interspersed with processed convenience foods falls short of our current cultural ideals about “clean” eating. Ramona doesn’t want her clients merely piecing together their diets from her cabinet of packages as if assembling a jigsaw puzzle. She wants them confidently navigating the entire landscape of food, living life to the fullest—while still only consuming two ounces of protein at a time. She tells Gina: “I’ll give you a cookbook that we made here; it has some great recipes.”
After the food discussion, it’s time for Ramona to present Gina with her Before and After photos. The Before, taken on August 26, 2015, shows Gina, who is five feet, four inches tall, weighing 340 pounds. She wears a loose white tank top and long, baggy black shorts and stands unsmiling against the office wall, resigned to the humiliation of the photo. In today’s After, she weighs 187 pounds and wears a short purple paisley shift dress with black tights and boots. She’s smiling in this shot, still self-conscious about the ritual, but more amused by it this time. And even though, technically, Gina is still obese—her body mass index is 32.1, over the “obese” cutoff of 30, though well down from her original 58.4—the difference in the photos is pretty staggering. She’s lost twenty inches from her hips, nineteen inches from her waist, and three inches from her neck. Earlier in the appointment, a nurse calculated that this means Gina has lost 82 percent of her “excess weight.” That’s a term only loosely defined in the weight-loss-surgery literature, because deciding how much of anyone’s body mass is “excessive” is fairly arbitrary. To put it more accurately, Gina has lost 45 percent of her starting weight. But whichever stat you use, across the office, she is considered the current superstar. It’s a role she’s not entirely comfortable with. “I actually hate Before and After pictures,” she tells me in an email a few weeks before the Ramona meeting. “It was work to love myself before surgery and it’s work now. I am a During, at all times.”
But Ramona loves the photos. “Wow, look at that!” she says, and her face lights up, becoming more animated than she has been for our entire meeting. “Oh, that’s what gets us up in the morning!” She brings the photos over to the nurses’ station and passes them around. Everyone oohs and ahs at the newly trim Gina. “Isn’t that fantastic? That’s amazing. That’s beautiful. Congratulations, Gina.”
We say goodbye and head to the elevators, where Gina’s husband, Nick, is waiting for us to go to lunch. “I do look really different and in a lot of ways, I am different,” Gina says. “But that felt like she was so happy because now she can look at me and not feel sick.”
* * *
Bariatric surgery has long been considered the shameful and risky last resort of the “severely obese,” a category that the Centers for Disease Control and Prevention defines as including anyone with a BMI of 40 or more. The other term that medical professionals use to describe these patients is “morbidly obese.” By invoking morbidity, doctors frame bariatric surgery as a critical health-saving strategy—necessary when someone is too fat to walk, work, or live a normal life—even though from 1995 to 2004 almost 1 percent of bariatric-surgery patients died within the first year post-op, and nearly 6 percent within five years, according to data published in the journal JAMA Surgery. It was a mortality rate verging on what medicine traditionally considers an unacceptable level of risk for any surgical procedure. But a recent refinement of surgical techniques and medical care have brought the one-year mortality risk down to 0.11 to 0.23 percent, depending on the procedure, according to data from 2008 to 2012 published in the Journal of the American College of Surgeons. And the procedure’s popularity is rising correspondingly; surgeons performed almost forty thousand more operations in 2015 than in 2011.
Altogether, 196,000 Americans had some form of weight-loss surgery in 2015. More than half of them had the same procedure as Gina: a sleeve gastrectomy (often referred to as a gastric sleeve), in which a surgeon removes 70 percent to 85 percent of a patient’s stomach, then staples what’s left into a small banana-shaped pouch. Another 23 percent underwent the Roux-en-Y gastric bypass procedure, in which a walnut-sized section is removed from the original stomach and connected directly to the intestines. Food lands in the new, smaller stomach, while the original organ floats nearby, unused. (Less than 6 percent of patients had the once popular adjustable gastric band surgery, in which the stomach remains intact but is corseted by a removable, inflatable band; the remaining cases mostly involved removing gastric bands or converting them to the permanent gastric sleeve.)
In addition to becoming less deadly, proponents of bariatric surgery say it seems to be working better than it did in the past. While the original gastric band surgery was associated with slow weight loss and frequent weight regain (especially once the band was loosened or removed), patients who undergo a Roux-en-Y or gastric sleeve procedure generally lose 25 percent to 35 percent of their original weight. But it’s important to frame that success rate carefully. Losing a quarter or more of your body weight may sound huge, but “most people stay well within the range of what we consider obesity,” notes Arya Sharma, M.D., Ph.D., an obesity researcher at the University of Alberta and the scientific director of the Canadian Obesity Network, a consortium of more than fifteen thousand obesity researchers and health professionals. It’s also unclear how long the weight loss is sustained; as Ramona warns Gina, the data also shows that some weight regain is inevitable. And no one knows much about the long-term impact of these surgeries, because no randomized control trial has been able to follow an entire cohort for more than a few years. One of the biggest, the Swedish Surgical Outcome Study, followed 2,010 surgery patients for almost two decades—but the participation rate dropped to 84 percent after the first ten years, and to 66 percent by the fifteen-year mark. This hampered the researchers’ ability to draw firm conclusions, because nobody knows what happened to the other 34 percent.
But even with all these qualifications, the evidence is clear that surgery offers a more significant and perhaps more durable weight loss than any drug or diet on the market. As we’ll see in this chapter, it does so through a series of biological mechanisms that can totally transform how a person relates to food, in surprising and nuanced ways. Bariatric surgery seems to rewrite our eating instincts, changing a patient’s experience of hunger and fullness so much that Gina really can be done after just half a protein bar. To Ramona, to Sharma, to anyone else working on the front lines of the “war on obesity,” and to many patients who have undergone the procedure and lost weight after decades of failed diets, this is a revelation. But others challenge the premise that fat bodies need to be cut apart and redesigned to make them smaller. And there is something fundamentally flawed about the notion that people need to be freed from their original appetites and taste preferences, especially because sustaining this so-called freedom requires patients to follow all sorts of rules and rituals about what, when, and how often they can eat. “Bariatric surgeons are prescribing for fat people what we diagnose as eating disordered in thin people,” says Deb Burgard, Ph.D., a psychologist in Cupertino, California, who specializes in eating-disorder treatment. She’s also a longtime activist and a co-founder of the Health at Every Size movement, which argues that our culture’s fixation on weight loss is discriminatory and entirely the wrong way to go about improving public health. “They don’t understand the trauma faced by people living in higher-weight bodies and they are not thinking about their role in that trauma. They just see a fat body as proof of an out-of-control hunger, and believe that getting rid of that hunger is the solution. But why would never experiencing hunger be a good thing?”
When Burgard poses that question, I am initially stumped. After all, I lived for two years with a child who never experienced hunger. It was not a good thing. It broke my heart daily. And without the safety net of a feeding tube, Violet’s lack of hunger would have killed her. We are born with the ability to experience hunger because eating ensures survival. But I also know—because I live in the world—that resenting and regretting our hunger has become part of the normal business of living, especially as a woman, especially right now. We apologize for taking a cupcake at the office party, whether we’re truly remorseful or just feel expected to perform our penance. We skip breakfast, yet feel annoyed when our stomach is rumbling for lunch at ten a.m. We go to dinner with friends and order the salad or don’t order the fries because we’re trying to match our appetites up with what everyone else seems to be doing. We joke that we’d never want to be anorexic, but gosh, we admire that willpower. And anyone who lives at a higher weight knows that how he or she displays and responds to hunger will open them to judgment, curiosity, ridicule, stigma. Why would never experiencing hunger be a good thing? For many people, it would be living the dream.
We don’t want to be hungry because our culture has told us that we don’t want to be fat. Sixty percent of Americans are currently trying to lose weight and 75 percent have made some effort in the past, according to a survey published by University of Chicago researchers in October 2016. And there is a deeply held belief in our society—one that runs all the way back to the Bible, to the seven deadly sins—that people get fat because they are gluttonous, slothful, and weak, and lack willpower around food. This isn’t true: Though some obese people do eat compulsively (as do some thin people), the vast majority do not. Only 3.5 percent of women and 2 percent of men are diagnosed with binge eating disorder (itself a complicated psychological condition that is about much more than self-control), while 68.8 percent of Americans are classified as overweight or obese. Even if binge eating disorder is wildly underdiagnosed, it’s a crude mischaracterization to assume that being overweight is only about eating too much. Genetics, biology, psychology, socioeconomic status, and other environmental factors all contribute to body size. “We know there are probably a hundred or more kinds of obesity, each with different causes and clinical characteristics,” says Lee M. Kaplan, a gastroenterologist and the director of the Obesity, Metabolism, and Nutrition Institute at Massachusetts General Hospital. Burgard argues that even attempting to classify obesity by type or origin is misguided: “We have this fundamental misunderstanding that everyone should be close to the same weight, and therefore higher weight bodies can never be healthy and well regulated,” she explains. “But what if most people’s bodies are regulating themselves fine, just at a wider variety of weights than we’ve been taught to consider acceptable?”
Nevertheless, the willpower misconception persists, and it contributes to our sense that being overweight is dysfunctional and abnormal—that the size of our body is proof that our eating is somehow out of control, and that we’ll only have a good life if we can conquer our hunger and lose the weight. Because we think hunger is bad and weight loss is good, the idea that a surgery can remove the former and achieve the latter is deeply seductive. But one consequence of that trade-off is never again eating the other half of the protein bar, let alone the muffuletta sandwich. Is merely removing the experience of physical hunger enough to cancel out that loss? Can someone’s ability to eat really be so permanently transformed? The very reasons for weight-loss surgery’s purported success also require us to ask: Should we be doing it at all?
* * *
Gina and I grew up a year apart in the same midsized wealthy Connecticut town. We were friendly in high school because we were both bookish theater nerds. We lost touch in college, but more recently have run into each other once a year because we frequent the same annual knitting festival.
Although we were raised in the same place, we had different childhoods, because Gina comes from one of our hometown’s few working-class families. Her father was a gunsmith with an eighth-grade education, and her mother drove a school bus. “We were very, very poor,” she tells me as we all order lunch at a Boston pub after the meeting with Ramona. I get a burger with fries, and Nick orders fried chicken. Gina, who went online and studied the menu ahead of time to figure out what she can eat, chooses two appetizers. “And when you’re poor and fat, you’re just so screwed.” Gina was chubby as a little kid and obese as a teenager; everyone in her family is overweight to some degree. Gina used to have to untie her father’s shoes for him at night because he was too tired to bend over and reach his feet. She didn’t realize that was weird until she told a skinny friend, who said she never had to help her own dad like that.
Gina says that on family grocery store trips she never begged for cookies or chips; she wanted oddball things like salsa or canned asparagus. “In retrospect, I think I really craved fresh fruits and vegetables, but I didn’t know how to articulate it. Everything my mom got was canned because we couldn’t afford to buy fresh. She was feeding us on like, forty dollars a week.” The family ate lots of venison because her dad was a deer hunter. On special occasions, there would be her grandmother’s homemade lasagna. “She’d be cutting me a giant portion and telling me to eat it in the same conversation where she told me I was too fat,” Gina recalls. And then there were late-night binges with her dad, during which they ate entire sleeves of Oreo cookies. “I got a lot of mixed messages about food.”
Gina had a childhood friend who lived in the neighborhood and was also poor and overweight. Gina would go to her house after school and eat hot dogs stuffed with cheese. “I would have three,” Gina remembers. “So there was a reason why we were fat. We were not eating healthy, ever.” Gina and her friend went on their first diet at age nine, following a plan from the friend’s doctor—just a one-page list of foods they could eat. Gina stuck with it as much as she could for three or four months. “But there wasn’t a lot of follow-through for diets at my house,” she says. “Like, my dad probably made a ridiculous amount of cream puffs or fried dough pizza, and we just kept eating like that.” Next she joined Weight Watchers—with her father this time, although their progress was once again quickly derailed. “After that, I was pretty much on and off diets all the way through college,” Gina says. She lost some weight on each diet, but never got thin. The least she ever weighed was 198 pounds, when she was twenty-one and had just moved back to her hometown after college. She was miserable and unsure about what she was doing next, so she started the South Beach Diet and began going to Jazzercise classes three times a day. “I think I stayed at that weight about three days,” Gina says. “Then my friend’s mom died and I ate chips again.”
Gina stopped dieting a few years later, after a stint with “one of those strip-mall diet places” where she went for weekly weigh-ins during which a “nutrition counselor” would go over Gina’s diet and then sell her on their protein powders and detox juices. Initially, as always, the diet worked. In fact, this one really worked: Gina lost 80 pounds, getting down to 212 pounds, one of her lowest weights ever. But she was still in the “twenty-something flail period” as she calls it, meaning she was single, broke, and trying to figure out how to get her career off the ground. “I was finally losing a lot of weight, but I was still miserable,” Gina says. “And it was like, ‘Holy shit, being thin doesn’t make you feel better?’”
Gina started to research the diet industry and learned that brands like LA Weight Loss and Weight Watchers build their customers’ diet failures right into their business models. “Every single time I lost weight on a diet, I gained more back,” Gina says. “Every single time.” She’s not alone: Weight Watchers’ own research, as reported in The New York Times Magazine, finds that the average customer will lose 5 percent of her body weight in six months, but regain a third of that weight within two years. For someone starting at 200 pounds, that means a net loss of less than 7 pounds. Only 16 percent of Weight Watchers customers maintain their weight loss for five years, according to a 2007 study published in the British Journal of Nutrition. “[The company] is successful because the other 84 percent have to come back and do it again,” a former Weight Watchers executive named Richard Samber told interviewers in the 2013 BBC documentary series The Men Who Made Us Thin. “That’s where your business comes from.” Weight-loss success rates are similarly dismal for other popular diets like South Beach, Atkins, and the Zone; while most dieters lost around 10 pounds in the first six months—a hollow victory, right there, for many people—virtually everyone regained some of that weight within two years, according to a 2014 review published in Circulation, an American Heart Association journal.
The data isn’t any better for the newer, trendier, less diet-y diets. David L. Katz, M.D., is the director of the Prevention Research Center at the Yale University School of Public Health and himself the creator of several popular programs, including The Flavor Point Diet. He’s the kind of high-profile, well-credentialed obesity expert that women’s magazines and morning shows love because he’s charming and knows how to translate scientific literature into digestible sound bites. And he gives the kind of optimistic advice that makes weight loss sound infinitely doable, if only we would remember to start our days with bowls of Greek yogurt and berries and end them with kale salads. (Katz and his wife also launched a healthy-cooking website called Cuisinicity, the tagline of which is “Love the foods that love you back.”) So it’s fair to say that Katz is pretty pro-diet, or at least, strongly in favor of rules around what we should and shouldn’t eat. And yet, when he compared research on low-carb, low-fat, Mediterranean, Paleolithic, and vegan diets for a 2014 paper published in the Annual Review of Public Health, even he was forced to conclude: “Can we say what diet is best for health? If diet denotes a very specific set of rigid principles, then even this necessarily limited representation of a vast literature is more than sufficient to answer no.”
Diets don’t work because they require us to live in a constant state of war with our bodies. “Whenever you restrict food intake, you’re going to run up against your own biology,” explains Dr. Sharma. “It doesn’t matter what program you follow. As soon as your body senses that there are fewer calories going in than going out, it harnesses a whole array of defense mechanisms to fight that.” When we’re dieting, our bodies try to conserve energy, so our metabolism slows down, the result being that you have to eat even less to keep losing weight. That becomes an increasingly difficult project because our bodies also produce more of the hormones, such as ghrelin, that trigger hunger. There is even some evidence that the bacteria in our guts respond when we eat fewer calories, shifting their populations in ways that will send more hunger signals to our brains.
All these weight-loss deterrents are hardwired into our biology because maintaining our body’s size and fat stores is essential to human survival. This makes sense when you consider how many millennia humans spent living in food-scarce situations. Today, your body doesn’t know if your pre-diet weight was too high; it’s programmed, through eons of evolution, to protect that “set point” at any cost. “It might be six months later, it might be five years later,” says Sharma. “Your body will continue to try to get the weight back. And eventually, it wins.”
Almost nobody understands what a huge role biology plays in weight management. The set-point theory has gotten plenty of attention in the popular press, but even if it hadn’t, most of us have gone on diets, so we know firsthand how difficult they are to maintain. But we don’t accept biology as the explanation because we’re so convinced that weight is about willpower. When we start feeling hungrier, or thinking more obsessively about food, we assume that it’s our own human frailty at work, yet again. Indeed, 75 percent of Americans cite willpower as one of their biggest barriers to weight loss—and almost 60 percent of Americans believe that it’s a person’s individual responsibility to lose weight, according to the University of Chicago study. And most of us are sure diet and exercise is the best way to do that, even though half of people who say they’ve tried to lose weight this way report doing so five or more times over the course of their life. (A fifth of obese people say they’ve tried and failed at diets more than twenty times.) “Most people think there are good people and bad people, and good people are the ones who have willpower and can fight their body’s urges to eat,” explains Kaplan. “I’d argue that nobody can do that except those with anorexia nervosa.”
* * *
This, then, is why the hype around bariatric surgery, which researchers now believe achieves its magical 25 percent to 35 percent weight loss by permanently lowering your body’s set point. Although it has been long assumed that the procedure was successful because smaller stomachs hold less food, studies by Kaplan and others have demonstrated that reshaping the stomach actually reprograms all those fat-defending mechanisms. Bacterial flora in the stomach take on different roles. The gut sends different hormonal signals to your brain, pancreas, and liver, which affect how you experience hunger and fullness. For most adults, a daily diet of 1400 calories would feel punitive; we’d battle constant hunger as our bodies tried to persuade us to eat more. “But after surgery, someone can easily live off fourteen hundred calories per day and not feel hungry,” explains Sharma. “You aren’t starving, because your body isn’t trying to get those calories back.” It doesn’t need them, because it’s not trying to get you back to your original set point of say, 300 pounds. It’s picked a new set point—say, 195 pounds—and is perfectly happy to leave you at this new, lower weight for now.
The surgery also appears to change your body’s metabolic processes and even your taste buds, probably as additional ways of reducing hunger. “After surgery, people can detect sugar in water at much lower thresholds than before,” says Randy Seeley, Ph.D., a professor of surgery at the University of Michigan School of Public Health. Patients also gravitate toward eating less calorically dense foods and smaller but more frequent meals. “Surgeons often think the reason their patients start eating salads instead of Big Macs is because they’ve had a serious conversation about the importance of making these changes,” Seeley notes. “But these people have been hearing those magical instructions their entire lives. Now they can actually follow the advice because their preferences have changed.”
Seeley first demonstrated these changes through animal studies. “It’s easier to show this in rats because they’re not making food choices based on some idea about what weight they should be,” he notes. “But they nevertheless reduce their food intake for several weeks, then go back to eating normally and maintain a fifty percent reduction in body fat for the rest of their lives.” Unlike many humans, rats ultimately seem to be able to eat exactly the same amount of food as they did before the surgery—but only once they’ve lost the weight. When Seeley deliberately starved his rats so they lost even more than half their body weight, then gave them unlimited access to food, the rats regained until they got to their new, lower post-surgery weight. “We’ve changed that set point,” he says.
When I ask Seeley why rats lose more weight post-surgery than people do, he says he thinks it only looks that way because humans diet. “Most people have been trying to override their biology for years through dieting, so even though they’re very overweight, they’re already somewhat below their body’s natural set point before they get to surgery,” he explains. Ironically, many insurance companies also require patients to achieve some degree of weight loss through medication or lifestyle changes before they’ll approve the procedure. That sets patients up to feel like failures when the post-surgery weight loss isn’t as dramatic as they hoped, because they aren’t giving themselves credit for what they managed to lose in a few weeks or months of crash-dieting beforehand. They want to have lost that and then shed an additional hundred pounds. “Of course, without the surgery, they would have regained all of that and more,” Seeley says.
Seeley’s research so underscores the power of these biological changes that he argues that surgery patients don’t need to be put on prescribed diets that restrict their caloric intake. “We do need to educate them about taking extra vitamins and getting enough protein now that they’re eating fewer calories,” he explains. “But my intuition is that adding calorie restriction on top of the surgery will be no more effective.” It could even be counterproductive. Surgery patients who end up restricting calories so dramatically—“overshooting,” as Ramona advised—that they end up below their body’s new set point will find themselves caught in the same old cycle of weight loss and gain, albeit with lower numbers. Do that often enough and you can start to push your set point higher again, because we tend to gain back a little more each time. “And now it looks like the surgery has failed,” says Seeley. Or that the patient has failed at surgery.
* * *
Three days after being discharged from her gastric sleeve surgery in July 2015, Rachel Adkins drank a doctor-prescribed protein shake and immediately began vomiting. Within hours, she had a fever of 103. Her husband drove her to the emergency room near their house in Fishkill, New York, where a CT scan revealed that a leak had sprung in her new, banana-shaped stomach. During her initial recovery in the hospital, doctors had tested the staples holding Rachel’s stomach shut by having her drink a barium solution, and then watching how the liquid moved through her digestive tract on ultrasound. Everything seemed fine. But now one of those staples had popped out.
The protein shake, along with anything else in her stomach, began pooling into her abdominal cavity. Rachel developed sepsis, a body-wide infection that can lead to tissue damage, organ failure, and even death. She was admitted to the intensive care unit and put into a medically induced coma for two days while doctors worked to save her life. A week after she was discharged a second time, Rachel’s left lung collapsed because of accumulating fluid, another post-operative complication that is risked with any kind of thoracic surgery. Over the next two months, Rachel underwent six additional surgeries and spent more nights in the hospital than at home. For the first seventeen days, she ate nothing at all, relying solely on IV nutrition. For another twenty days, she was fed adult formula through a gastrostomy tube, which surgeons implanted in her abdomen. “It’s very strange to feel full when you’re not putting anything in your mouth,” Rachel reports, confirming something I always suspected during Violet’s G-tube tenure.
Terrifying and life-threatening consequences like these have become more rare as bariatric surgery has advanced, but they still happen. Other complications that aren’t life-threatening, but that are certainly life-hampering, are more common. Many patients develop nutrient deficiencies caused by the body’s new inability to fully absorb what it needs from food. And 85 percent of people who have the gastric sleeve or Roux-en-Y procedures will experience “dumping syndrome,” in which undigested food hits the small intestine too quickly and causes pain, bloating, vomiting, and diarrhea. And all of that is just what may happen in the first few months. “There are a huge number of things that nobody has figured out yet, like how do medications get metabolized by your body now?” Burgard points out. “What we really need to ask is, how is it going to be in someone’s long-term health interest for them to essentially be malnourished for the rest of their lives?”
The answer to that question depends on whether you think weight is synonymous with health. To pretty much everyone in the bariatric-surgery community, it is, which means that achieving permanent weight loss trumps all other concerns. Just as when treating a child who doesn’t eat, behavioral feeding therapists focus on getting calories in by any means necessary—no matter the risks to that patient’s long-term relationship with food—bariatric surgeons think solely in terms of getting calories out of their patients’ stomachs, because they are so sure that doing so will save their lives. Despite the complications she experienced, Rachel also frames her surgery as a life-saving intervention. At five feet, six inches tall, she weighed 437 pounds when she decided to have the procedure. By early 2015, she had developed type 2 diabetes, along with elevated blood pressure and cholesterol. She had also given up teaching dance, a lifelong passion, because she felt her size made it too difficult to be so physically active. And her surgeon told her afterward that once he opened her up, he could see that she was close to liver failure.
Not every obese person experiences these kinds of health issues. Sharma is the author of research showing that around one in five obese people have very few, if any, related health problems and that for people in the overweight range, the connection between weight and health is even less pronounced. Yet he is still quick to frame bariatric surgery as more about health than weight loss. “I send patients for surgery when they have severe obesity and a health problem for which weight loss is the best solution,” Sharma explains. “Let’s say they have really bad pain in their knees. To get out of that wheelchair, they have to lose some weight.” As a moderate thinker on these questions, Sharma doesn’t demand extreme weight loss: “They don’t have to hit a BMI of 25. If you define success based on whether their health problems get better, we know that even just a five percent weight loss leads to very significant improvements.” But he does emphasize that bariatric surgery has been linked to a 50 percent reduction in patients’ risk of dying from heart disease as well as a 90 percent reduction in a patient’s risk of dying from diabetes (though only about half of diabetic patients are able to come off medication entirely after bariatric surgery). The data on other conditions, like sleep apnea, is less clear; patients may be less dependent on respiratory assistance, but most will still need support.
To many doctors, minimizing the threat of these conditions through weight loss far outweighs the relatively smaller risk for severe surgical complications, and even the much larger chance that a patient is signing on for a lifetime of complex nutrition management and digestive issues. But there is another interpretation of the literature. In the late 1990s, while researching her doctoral dissertation on the relationship between health and weight, Linda Bacon, now an associate nutritionist at the University of California at Davis, was shocked to discover a large swath of research suggesting that being classified as overweight or obese on the body mass index was a deeply flawed indicator of one’s health and longevity. “Every study I found suggested that the BMI cutoff points for overweight and obese should actually be raised; that we were putting too many people in those categories when their weight didn’t actually correlate to much in the way of health problems,” she says. Instead, in June 1998, the National Institutes of Health’s Obesity Task Force lowered the cutoff points. “Just like that, twenty-nine million Americans who had gone to bed with normal, healthy bodies woke up the next day and were fat,” Bacon explains. “The task force had looked at all of the same evidence as me and essentially thrown out the data.” Bacon draws a line between that decision and the marketing of two weight-loss drugs by major pharmaceutical companies. “If you make more fat people, you have a bigger market.”
But as she continued to study the issue, Bacon began to collect more evidence for her argument that it isn’t fat cells that are killing us—it’s a combination of several other factors. Unhealthy lifestyle choices are the most obvious, but Bacon also points to social inequalities. For example, rates of diabetes, asthma, and other conditions often linked to weight are also higher in neighborhoods like Sherita Mouzon’s, where people struggle with systemic poverty and discrimination, and also have less access to safe outdoor spaces, walking paths, and grocery stores. And Bacon argues that doctors fail to take into account the detrimental health effects of living with weight stigma, which has been well documented as a risk factor for depression and low self-esteem. Studies have also found that doctors and other healthcare providers spend less time with obese patients, offer less education, and even admit to liking their fat patients less. Such distaste is certainly not lost on obese patients, who report seeking medical care less often because they expect to be shamed for their weight—and who may well end up sicker as a result. In 2008, Bacon made her case in a book called Health at Every Size: The Surprising Truth About Your Weight, and the HAES movement entered public consciousness in a much bigger way.
If you’re now thinking, “Okay, sure, walking paths are great, but we still need to lose the weight,” consider Bacon’s favorite analogy: Yellow teeth are common among lung cancer patients—but that doesn’t mean a patient’s teeth caused her lung cancer. It means that both are things that can happen when you smoke cigarettes. And correlation is not causation. Excess body weight, Bacon argues, hasn’t been shown to cause the litany of health problems we associate with it—all we know from decades of epidemiological research is that higher body weight often coexists with diabetes, heart disease, sleep apnea, and so on. But just as having your teeth bleached won’t improve your lung health, significant weight loss isn’t the most logical tool if you want to lower your blood sugar or blood pressure—mostly because such weight loss isn’t attainable or sustainable for the vast majority of us; remember those 84 percent of Weight Watchers clients, returning to the fold every few years.
Moderate weight loss does correlate with improvements in many of these conditions, but again, it’s difficult to parse out whether those benefits accrue specifically from having a smaller body, or from adopting certain lifestyle habits—less soda, more sleep, less television, more walking—that sometimes also lead you to drop a jean size. “I’m not saying that everybody who is fat is healthy. I’m not saying that everybody is at an ideal weight. I’m not dismissing the relationship between weight and health,” Bacon says. “What I am saying is that the relationship between weight and health has been wildly exaggerated. And when we focus exclusively on fat, we miss opportunities to make changes that have been proven to be successful.”
Bacon’s argument has resonated with me since I first read her book almost a decade ago, but I’ve been trying to choose a clear winner in the health/weight debate for just about as long and I’ll admit, it often feels like an impossible task. Both sides are impeccably footnoted, with decades of studies; for every published position paper claiming that weight really does trigger health problems, there is another emphasizing that correlation is not causation—and back and forth the arguments fly. There are smart, good, caring people working on both sides of this aisle. But I will note that while there is significant money to be made in weight loss (whether you’re a drug manufacturer, a diet coach, or yes, a bariatric surgeon), there is far less profit in telling people to stop trying to change their bodies. And I find it revealing that the purported health benefits of weight loss are not the bariatric-surgery industry’s primary marketing tool. Visit the website of any bariatric surgeon, or jump into an online support forum, and what you’ll mostly find are sad Before and triumphant After photos. “The right reason for any patient to seek surgery is better long-term health outcomes and not ‘to fit into their old clothes,’” says Seeley. “But are some patients more motivated by the weight loss? Sure.”
It’s not just that “some patients” are more motivated by weight loss. Everyone is motivated by the promise of weight loss, whether we weigh 400 pounds or 140. When asked about their motivation, 93 percent of dieters said “overall health” was a major or minor driver—but nearly as many (89 percent) said they were driven by a desire to improve their appearance or “how my clothes fit.” In other words, many of us aren’t trying to make ourselves smaller just because we’re passionate about preventing diabetes. We care about being thinner because our culture prefers smaller bodies and well-controlled appetites to big, unruly ones. And bariatric surgeons, obesity researchers, and other healthcare professionals are not exempt from this bias—in fact, research suggests that as a group, they display even higher levels of it than laypeople do.
* * *
Rachel’s first real meal was a small plate of finely chopped chicken, served as a test run near the end of her hospital stay. Rachel’s father sat with her while she ate it, trying to be positive. “He kept saying ‘That looks delicious!’” she recalls. “And the weird thing is, it was. I mean, in retrospect, it was probably so gross. But I hadn’t eaten food in so long; I hadn’t had any kind of texture in my mouth. So that texture felt amazing.” She ate a few spoonfuls and immediately felt full. Such a small portion would never have satisfied Rachel before her surgery, when she regularly consumed upward of six thousand calories per day. “I was a secret car eater,” she says when we meet for lunch in March 2017. “I’d try not to eat all day, then hit the drive-through and get three cheeseburgers. It was super shameful.”
The plate of chicken was actually the start of Rachel’s second time learning to eat again after weight-loss surgery. She had a gastric band placed in 2010, but had to have it removed four years later because it caused vomiting whenever she ate something even a little bit tough to digest, like meat or even crackers. “If I didn’t chew my food thoroughly enough, or if I ate something kind of dry, I’d feel it getting stuck in the top of my stomach and then it would come right back up,” she recalls. “What did stay down was milkshakes, pasta, all the bad food that’s easy to slide through.” Rachel weighed 335 pounds before the lap band surgery and lost 110 pounds within the first year. But she ultimately regained it all, and then kept gaining after the band came off. “Once the restriction of the band wasn’t there anymore, I just fell back into eating whatever, whenever I wanted,” she explains. “I don’t think my body or my mind was ready to deal with my issues.”
Because gastric banding is designed to be temporary, research suggests that patients don’t see the same kind of profound biological shifts in taste and metabolism as have been documented with permanent bariatric procedures. But even with permanent gastric-bypass procedures, the pronounced changes in food preferences, for example, seem to dissipate for many patients as they adjust to life at their new set points. Lab rodents appear to adapt to this and maintain their new set point despite being able to eat more food. But the return of a larger appetite is much more fraught for human patients. If you frame weight loss as a matter of willpower, suddenly feeling hungrier when you aren’t yet “thin enough” feels like you aren’t trying enough. You have to reckon once again with craving “all the bad food,” as Rachel puts it; with once again wanting to eat the second half of the protein bar that Ramona is so convinced they shouldn’t need. Old habits, like binge eating, may return.
Marci Evans, a dietitian with a private practice in Boston, treats people struggling with disordered eating post-surgery, and wonders how much a surgeon’s technique can shape both the intensity and the duration of any resulting changes in hunger and fullness cues. “Anecdotally, I’ve seen patients from a surgeon who I know to be rather conservative do much better afterwards than folks who have had their stomach so dramatically altered that they’re going to have to figure out how to live on five hundred calories per day and a ton of supplements,” she says. She points to one client who had one of those more conservative surgeries, meaning the surgeon left more of his original stomach intact. He had also done a lot of work on his emotional eating issues prior to his surgery. Afterward, he expressed relief that his hunger now seemed better regulated and closer to “normal.” He was able to eat what Evans considered to be an adequate diet with plenty of variety. But she says he’s the exception to the rule. “My clients are often very unsettled by the way their body is now responding to food,” she explains. “Because psychologically, it’s not like they got a lobotomy. They still have that drive to eat.” We’re not rats, isolated in our cages. Any changes to our biology have to interact with our psychological and cultural understanding of food. And nobody knows yet precisely how one shapes the other.
* * *
As a social worker in the outpatient psychiatry program at Massachusetts General Hospital, Lisa DuBreuil has worked with people struggling with eating disorders and drug or alcohol addictions for the past fourteen years. About nine years ago, she and her colleagues began noticing a new pattern of patients: Adults in their thirties, forties, or fifties who were suddenly developing a substance abuse problem or an eating disorder for the first time in their lives. And these newly struggling patients had something in common. They had all undergone some form of weight-loss surgery. Seeley calls the increased risk for alcoholism “small but real,” and when DuBreuil dug into the literature, she found that as many as 28 percent of patients develop a problem with alcohol. For two thirds of them, this is a new addiction. Nobody’s sure why, but research that tracked people after Roux-en-Y bypass surgery found that their bodies were more sensitive to alcohol post-surgery. “Drink for drink, their brains are exposed to more alcohol now” because they metabolize it differently, DuBreuil explains. “And that increases your risk for developing a problem.”
This change in alcohol processing may be related to the other biological shifts that occur with surgery. Another theory is that during the initial post-operative period, when food becomes less rewarding, people may be more inclined to seek out alternatives, especially if they once relied on food as a coping strategy, or as a way of connecting emotionally and socially with others. DuBreuil frames the issue a little differently: “Many of the people I work with struggle with the fact that they don’t get hungry anymore,” she explains. “But they’re also carrying around decades of cultural experiences and psychological attachments to food. So yeah, maybe their preferences have changed and they don’t like cookies anymore. But now they have to contend with the fact that they’re from a big Italian family and everyone is supposed to adore Nana’s cookies, and how do they manage not wanting to eat them anymore?”
Some experts explain the rise in alcoholism after surgery as a kind of “addiction transference.” Rachel now considers herself a recovering food addict and looks back on her months of life-threatening surgical complications as a kind of hard-core detox program. “You learn really quickly that you don’t have to eat to survive,” she tells me. At first, I’m confused: We do, of course, need to eat to survive. But for Rachel, “eating” had always meant bingeing; she only felt satisfied by a meal when she’d eaten a huge quantity of food and reached the point where she couldn’t fit another bite in her body. “Of course, twenty minutes later, I would feel awful. But I had this mind-set that if I didn’t eat a ton of cheeseburgers or other shitty foods, I would die,” she explains. “Now I know I don’t need ten thousand calories in a day. I can live on much smaller portions and feel fine.”
And, just as Seeley’s research suggests, she doesn’t even crave the same kinds of food as she did before the surgery. For most of her life, Rachel’s favorite foods were pasta, bread, and dessert. She’s the oldest of five children, and all her family’s celebrations revolved around that kind of comfort food. Like Gina, she spent years cycling between intensive dieting efforts—Rachel’s list includes Weight Watchers, Atkins, SlimFast, and “those diet pills that make you feel like you’re on speed”—and periods of intense binge eating. Every diet failed after two or three months because the deprivation was unsustainable. She couldn’t replace the foods she craved with healthier alternatives and feel the same kind of satisfaction.”My taste buds are one hundred percent different now,” she says. “I was never a vegetable eater and now I really do like them.”
It’s impossible to know if the shift has occurred because Rachel has finally internalized the importance of vegetables for her health, or because her biological food cravings have been reprogrammed. But whether that means that she was previously addicted to the pasta and desserts she now avoids is a controversial question in obesity research. When rats at the Monell Chemical Senses Center in Philadelphia were given unlimited access to chow that had been flavored with a noncaloric sweetener or a noncaloric fatty flavor, they didn’t gain any more weight than when they were given unlimited access to their regular, unflavored chow. This finding prompted the study’s lead author, Michael Tordoff, Ph.D., to conclude that it isn’t taste that drives us to overeat certain foods. He hasn’t yet attempted the study with human subjects, but suspects the results would be similar. “How a food tastes might trigger you to eat more the first time you have it, but it doesn’t compel you to eat it endlessly,” he says. “The evidence that food can be a true addiction doesn’t really hold up.” Seeley agrees: “If you are hungry, you will obsess about obtaining food. That is how the system is supposed to work. I don’t think that counts as addiction.”
The food-addiction theory may also be another way of stigmatizing the choices we make around food. “The thing is, we’re all food addicts,” says DuBreuil. “We’re neurologically wired to enjoy food and to want to eat when we see others eat. We’re supposed to connect food with love and caring.” After all, for most humans, the first experience of eating is intertwined with love, when our mothers hold us and feed us with their own bodies. “Yet our culture pathologizes the idea that food is love,” she notes. “We’re just supposed to eat to survive.” To derive too much comfort, too much pleasure from food is interpreted as a sign of addiction, but DuBreuil argues that the behavior even of eating-disorder patients desperate to binge is quite different from the life-destroying choices her drug- or alcohol-addicted clients sometimes make to obtain their highs. And perhaps if we stopped shaming people for loving to eat, they could love food in a less complicated and frenetic way.
If food addiction is real, the hardest thing about it must be that going cold turkey is not an option because we all have to eat food and we have to do it many times a day. After her “detox,” Rachel remembers feeling terrified to eat a two-ounce serving of mashed potatoes or yogurt once she was finally cleared to eat solid foods again after the chopped chicken. “I didn’t want to put anything in my mouth that could rip that hole open again,” she says. She also didn’t trust herself not to slip back into old habits. Eating didn’t feel safe. Three weeks after she was discharged, Rachel’s parents took her out to dinner at one of their favorite restaurants. But instead of celebrating, Rachel sat in the booth and cried. “I was so scared to eat this turkey dinner,” she says. “I didn’t want to make myself sick. I didn’t want to overeat. I was scared to put anything in my mouth.” DuBreuil has heard similar stories from her patients; she believes that the stringent framework for eating that patients are subject to after surgery further reinforces the feeling that they can’t trust themselves around food. She also hears how they grieve for the loss of old mealtime experiences. “Sharing meals is probably our best way to bond and connect, other than sex,” she notes. “It doesn’t make you an addict to miss that. It makes you human.”
* * *
Sometime after Gina decided to stop dieting, she began reading about the HAES movement and trying to figure out whether she could find a way to accept being fat. It was true that she didn’t have any of the traditional obesity-related health problems. And she understood that eating well and exercising made her feel better regardless of what happened with her weight. She wanted to feel at peace with her body, but she was also still using food to deal with every kind of emotion, especially negative ones. She weighed 250 pounds when she and Nick got married in 2010. They started trying to have a baby a few months later, but it didn’t happen. Every month, Gina faced up to that disappointment, and every month, she coped by eating. She also stopped exercising regularly because she had a long commute and a stressful job. On her lunch breaks, she would drive to the nearest McDonald’s and order a Quarter Pounder with cheese and fries, plus a four-piece order of chicken nuggets with sweet-and-sour sauce. Then she would eat it all while sitting in her car, listening to NPR. “It was pretty luxurious,” she says now. She felt better—comforted, relaxed, and numbed—in the moment. Until the guilt hit.
Gina had always suspected she might have a binge-eating disorder, but whenever she brought it up, her mother would say, “No, you’re fat. If you had an eating disorder, you’d be thin.” But sometime in 2011, as their efforts to conceive became more fraught, Nick started to notice Gina’s tendency to cope through food. “Nick was like, ‘Hey, your eating is fairly disordered. I noticed you bought that chocolate cake and ate the whole thing when you got upset,’” she recalls. “And it was okay, because it was a husband talking to his wife.” Gina began to realize that eating the whole cake didn’t make her feel better. “It actually makes you feel like shit.”
Over the next few years, Gina did a lot of work on her emotional eating. She stopped driving to McDonald’s for lunch and started going for walks, and then getting a salad or sandwich at Panera. She started exercising after work—not to lose weight, but because she started to see how exercise could provide an outlet for all those negative emotions. “I’m just a much nicer person when I’m exercising,” she says. One day she found that she could eat a slice of cake—but just a slice. Gina never sought professional treatment for her binge eating; years of relying on misguided diet “experts” left her determined to do this herself. It wasn’t always a straightforward process. And it didn’t correspond to getting thin; Gina’s weight continued to climb, hitting 280 and then 325. She still wasn’t getting pregnant and the infertility anxiety made everything harder. The couple met with two infertility specialists and they both said the same thing: Obesity was probably causing all of their problems, but unless Gina lost weight, she wouldn’t be a good candidate for in vitro fertilization. They both recommended bariatric surgery.
“I kind of hit rock bottom, when the second doctor told us that,” Gina says. “I always thought if I’m so fat that I need surgery, that means I’ve failed as a person.” But then she realized that it wouldn’t really be about the weight loss. “I was at the point where I really would have cut off an arm to have a baby,” she explains. “And once I got there, it was like, ‘Okay, why not cut off part of my stomach?’” The irony, of course, was that by the time Gina made the decision, she hadn’t had a binge-eating episode in almost a year. She really did feel good about her body, about being a fat person who defied stereotypes by exercising and eating well. And now she felt as if she was about to undermine all of that, by trying—in the most dramatic way possible—to make herself permanently thin. “I felt like a fraud,” she says. “But I really wasn’t doing this to be a certain size.”
In a roundabout way, Gina’s decision to abandon the elusive goal of weight loss may be why she has been so successful since having her surgery. Unlike many patients, she’s not disappointed to find herself still obese. “A girl stood up at our surgery patient support group and said she’s still waiting to get her bikini body,” Gina tells me. “I think: ‘You have a body. Put a bikini on it if you want to.’” In the first weeks after her operation, Gina was fascinated to realize how food would now work—that in the early months, two tablespoons of peanut butter would leave her full for several hours, and that even now, a year later, a hundred-calorie cup of yogurt does the same. But even though her overall caloric intake is less now, and she eats smaller, more frequent meals, Gina doesn’t think of how she’s eating as a diet, but rather, as what works best for her body. “I truly believe there are no good foods or bad foods,” she says. “Nothing is off limits. So if I want some ice cream, I have it. The difference is now I don’t eat my feelings.”
I see this in action when we’re at lunch. Gina orders corned beef sliders and a salad off the appetizer menu. But she has a bite of Nick’s fried chicken and later, a few forkfuls of my Oreo cheesecake for dessert. If I didn’t know she’d had the surgery, I’d think nothing of her choices. In contrast, when I go to lunch with Rachel almost two years after her surgery, she orders only a side of spinach artichoke dip. It comes in a small ramekin surrounded by pita chips; she ignores the chips and eats only a few spoonfuls of the dip before stopping. I’m acutely aware of how much longer it takes me to eat my Chinese chicken salad, of how much food is left on her plate. Often, Rachel tells me, she doesn’t even order for herself in restaurants anymore, but just picks off her husband’s plate. At home, she weighs and measures everything to stay on top of her portion sizes. Holidays, work parties, and other social gatherings that revolve around food are stressful in a way they never were before, because Rachel knows she’ll not only have to navigate how to eat, but also the curious looks and “Oh you’re so good!” commentary from people who can’t believe how little she’s eating.
DuBreuil says that when she first started working with post-surgery patients, she had to recalibrate her responses to habits like not ordering in restaurants, weighing portions, or chewing every bite twenty times, all of which would be listed as classic examples in any textbook on disordered eating. “But for these folks, it’s the new normal,” she says. And in the right context, such habits can be a form of self-care: “If you’re doing these things because you’re listening to your body, that’s different from doing them to get your body down to a certain size,” DuBreuil says. The hard part is telling the difference. In their quest to reach a certain size, surgery patients have already agreed to drastically alter their anatomy. How do they now listen to their body after having cut away a part of it because a doctor told them it couldn’t be trusted?
This is why many in the HAES community are so critical of the procedure’s risks that they’re reluctant to endorse any version of it. When I emailed Linda Bacon to ask for her thoughts on weight-loss surgery, she wrote back that she wasn’t interested in talking: “I’m just pained and disgusted by what goes on behind the scenes,” she said, noting that few studies have been done by researchers without some bias or a conflict of interest. But DuBreuil and Evans, who both identify as HAES-oriented practitioners, feel strongly about the need to find common ground. “I think we’re starting to realize that actually, it’s the people who go for these surgeries who need the most support,” says DuBreuil. “Compared to larger-bodied people who don’t pursue weight-loss surgery, these folks are more likely to have diagnosable anxiety, depression, and other mood disorders. They’re more distressed by living in their fat bodies.”
Still, DuBreuil acknowledges that she’d rather see fewer patients resorting to surgery. The HAES approach to health is arguably kinder, gentler, and safer. After all, you get to keep your stomach and enjoy your food. But it’s not necessarily easier. It means abandoning the notion that you’ll someday be thin, or at least, significantly thinner than you are now. That’s a difficult dream to give up on, especially for women who have been conditioned to want it since we were given our first Barbie dolls. And especially for obese people, who have to put up with a near-constant train of unsolicited advice and opinions about their size and their eating habits. When Gina was nineteen years old, she walked out of a gas station holding a bag of candy and a guy leaned out of his car to yell, “Fat bastard!” at her. “I actually wasn’t totally ashamed of my body by that point,” she recalls. “I knew I was fat, but I didn’t realize I was heckled-by-strangers fat until that moment. Then I told my family and friends and they weren’t all that surprised.”
And street harassment isn’t the only way fat people are stigmatized; many public health campaigns trade in various forms of weight stigma as a way of giving obese people wake-up calls. In 2012, Georgia received criticism for a campaign called Strong4Life that featured photos of fat children with slogans like “Fat kids become fat adults” and “It’s hard to be a little girl when you’re not.” If the goal of such messaging is to persuade fat people that they should try hard not to be that way, Gina says, it sort of works. “That one comment at the gas station galvanized me into hyper-dieting mode for pretty much all of my twenties.” Stop trying to lose weight, stop internalizing such messages, and you’re always going to be the fat person daring to eat candy in public. Or interviewing for a job. Or getting your annual checkup and hearing that maybe you should think about losing a few pounds, no matter how good your health is right now.
It’s understandable that many larger people would rather abandon the fight to make the world accept them at that size. And maybe Seeley’s research will ultimately make it easier for them to do so. “My goal is actually to put the surgeons out of business,” he tells me. The more he understands about how surgery works to change appetite, the closer he is to developing a drug that would do the same thing, without the same risks. “If scientists can come up with something that lets people change their body size as safely as we can change our hair color, I’d actually be less concerned about it,” DuBreuil says. “Because I believe everyone has the right to body autonomy.” But she also wonders how that ability would further reinforce our cultural standards of beauty, already so often conflated with our definition of health.
For Rachel, nothing about either of her surgeries felt as easy as changing her hair color. And yet, when I ask whether she’d do it all over again, she doesn’t hesitate: “In a second,” she says. Rachel is still obese, but she has lost 180 pounds. She’s teaching dance classes again. And whether because of the weight loss or her healthier eating habits and increased physical activity, she no longer needs diabetes medication. Her liver function is normal and she has seen all her other measures of health improve. “It’s like I’ve had this whole awakening,” she says. The specific eating regimen has become close to second nature. “I feel like I enjoy food in a different way now,” she tells me over the half-eaten spinach dip. “I enjoy flavors. Before, it was just about quantity; I got pleasure in my body when I ate a huge amount whether it tasted good or not. Now I enjoy the taste even if it is just for three or four bites. And I feel good when I finish a meal and I didn’t overeat. I know I’m not going to feel that shame and regret later.” Rachel is reaching the end of the typical post-operative weight-loss trajectory; all the data suggests that she’s likely at her nadir and can expect to regain some of what she’s shed. Still, she says, she hopes to lose more weight. “I just want to feel healthy,” she tells me. Somehow, despite everything that has changed for her, that label continues to feel out of reach.