Cared For and Not Cured: Obesity Has No After Photo

I’ve had weight loss surgery three times.


In 2009, I underwent gastric banding at age 23. I lost 200 pounds off my high weight, which was a nip under 400. Banding has largely been described as a failed intervention now more than 10 years after the height of its popularity. In 2016, gastric bands accounted for less than 4% of all weight loss surgeries according to the American Society of Metabolic Surgeons (ASMBS).


But, for all the hate, I was still considered successful even with a sudden end in 2014 when the band slipped down on my stomach. There was no underlying reason and it was deemed a “mechanical failure.” I lost 82% of my excess weight, which earned me a few profiles of courage on blogs and in small publications. It sparked my advocacy for obesity care. Many before and many after me ended their gastric banding sagas with removal and little to no weight loss, which still plagues the perception of bariatric surgery today.


I had the band removed at the advice of my medical team and had a sleeve gastrectomy. The main factor preventing me from choosing a gastric bypass or duodenal switch (two other types of surgery that include malabsorbing fat and nutrients) was my desire to have a baby, eventually. Plenty have healthy pregnancies with bypass or switch, but I felt hesitation.


I maintained my weight loss until 2016 when I got pregnant with my daughter.


With pregnancy, I gained back about 70 pounds, which even looking back, was total bullshit. I certainly remember cravings or lusting for unhealthy food, but on the whole I was angry that I didn’t even feel like I enjoyed the time. I still considered myself restricting and conscious of what I was eating, but man did the weight come back at lightening speed.


After having a newborn, a job transition, working a full-time job while running for political office, by 2019, I had put almost 100 of the 200+ pounds I lost back on. I had a personal trainer; tried all the tactics that years and years of taming my body to function and rebound and nothing made a meaningful difference on my weight or size.


That year, I had my sleeve gastrectomy finished into a duodenal switch loop. I use the term ‘finish’ because that procedure is often done in two steps and the sleeve gastrectomy is the first part. For the first time, my weight loss surgery had malabsorption and not only restriction.


Today, I’m 35 and I am at my lowest adult body weight ever and still slowly losing. I have a BMI of 29, which still puts me at the high end of overweight. I’m a pretty routine medium top and size 10 pants. I feel awesome. I exercise and see a therapist regularly. I get taken seriously about other ailments now that health care providers can’t blame everything on my obesity (hello ADHD diagnosis!), and my energy level is incredible. Even those benefits aside, I’d still consider doing it all again if only for less travel trauma. Being fat while flying constantly sends the message that you do not deserve to see new places because your fatness is a burden for even the slightest accommodations. I don’t advocate for treating obesity for the sole purpose of fitting into a world that doesn’t think about your body being comfortable, but it is a stress relief hard to measure.


Talking with Others


Because of my openness about my weight, I get a lot of random phone calls from women who say they are a friend of a friend (or sometimes farther removed) that start like this: “Hi, you don’t know me, but my friend X knows you and thought you’d be willing to talk to me about, uh, bariatric surgery.” This happens to me, on average, at least once a month.


I always engage. And not only because I’m from the Midwest and will try to befriend strangers in an elevator, but because I’ve been there. I know how hard it is to find testimony and dialogue with real people who’ve experienced any level of success after surgery.


The internet is a minefield of horror stories of weight loss surgery complications, regain, keto and intermittent fasting enthusiasts, and so many more who reinforce the false message that needing or qualifying for bariatric surgery makes you a failure. Bariatric surgery is branded as the treatment of last resort. The conductor is yelling ‘this it the end of the line! Please gather your low-carb cookbooks and drop them in the trash as you exit.’


The disapproval of strangers is so funny to me. I get questions like ‘did you do it the natural way?’ I say “well, I eat well and exercise, but I also had bariatric surgery. Can you say more about what you mean when you say ‘natural’?” But I already know what they mean. They think you took the easy way out and how fucking dare you.


But the deepest digs are always from the bless your heart crowd. The sweet, but salty expressions such as ‘you’ve always been beautiful!’ when I update my social media picture that relays a thinner face or body or even an image from an ordinary day at the local gardens, posing with my 4-year-old. These are the comments that make you go ‘bitch, what?’


I have never once said I thought I was ugly. I’ve never said that out loud and possibly not even internally. I have always and still have a healthy self-image. Big, though? Absolutely. At my heaviest, my BMI was 69. Achieved by standing only 63 inches tall I was literally rounder than I was tall. But ugly? Nope.


But we’re image driven as a country. The number one worry from people who pick up the phone and exercise vulnerability is almost always focused on how to make other people comfortable with their decision. 99% of women who call me already know they want to have surgery and so my call is really giving them permission to not care about what people might think or say or how it might look.


For that reason, I have two messages I try to get across in those conversations centered on “should I do this?”

  1. You have a chronic, lifelong, relapsing disease that will require the full spectrum of treatment and lifestyle changes to maintain. It’s not one treatment, it’s many. At some point, you’ll probably be unable to manage your chronic disease and you might regain and lose some amount of weight and it’s important to never see weight as “lost and gone forever” as proclaimed on magazine covers. There is no such thing as an after picture. It is all a moment in time.

  2. You can want to treat your obesity and reject the idea that doing so means that you don’t love yourself. Weight loss for your health isn’t a betrayal of your body positivity or a statement on what you think others should do or not do.


Without at least some level of enrollment on both of these points being true, I’m probably not the best point of view, but no one has ever hung up on me.


Science Alone Is Not Enough


The most significant harm to obesity care are the messages we have internalized about obesity. We currently talk about bodies as things to be fixed. They’re the blight of inactivity and poor decisions. The reality is that every chronic disease is impacted by personal choice and we still need real medical care and treatment. To be clear, obesity is a disease that improves with treatment. It functions like one when you look at the science and it was declared one by the American Medical Association in 2013.


So why can’t people with obesity access care? The short answer is that not enough voices are demanding it and we have to get louder. Until then, insurance companies are mostly getting away with it. There’s no single treatment that works for every person and there’s no cure, but there are a variety of treatments that do work for a lot of people with excess weight, which significantly improve health and/or quality of life.


Why isn’t it enough that there’s treatment that improves a disease?


Top Down Change is Needed


Many healthcare providers like to tell you to eat less, move more, and that alone will ensure success will follow. They don’t discuss other options or even refer you to someone who could help you figure out what it means to develop a plan where you can properly fuel your body and move it in a way that doesn’t cause more harm than good. Their own beliefs, often judgements absent from other diagnoses or discussions, impede their ability to deliver care with real dignity and respect.


Many health insurance companies don’t categorize obesity like the chronic disease that it is. And the exclusions are far beyond weight loss surgery. Under Medicare, an otherwise healthy person who carries excess weight, but doesn’t meet the guidelines for bariatric surgery, can’t access evidenced-based pharmacotherapy (FDA approved medicine). You have to otherwise be made sick by your weight before you can get a prescription medicine covered. The same is true for accessing care from experts like exercise physiologists or dieticians. Right now, that same group can only get obesity care from a primary care physician who often lacks the time to address it or knowledge to treat it.


There are absurd provisions in insurance across the country when it comes to obesity care and coverage language is haphazard at best. Medicare sets the standard for private insurance and state coverage (Medicaid). Broadly, it’s the lowest bar possible when we think of covering and providing access to care for nearly all prevention and disease treatment. What is the least amount of coverage we could give people 65 years and older and individuals with disabilities and still get away with it? Medicare, in many ways, is the minimum wage of health care. Though, I know that there are far crappier and more expensive plans available privately, but the case for Medicare For All is a separate essay.


Why haven’t we been able to access obesity care? What would it take? It’s a straightforward and simple change in our Centers for Medicare and Medicaid (CMS) regulatory guidelines. It would immediately demand change and require care for obesity in plans everywhere. Though an act of Congress could change Medicare coverage, it’s really a regulatory issue that the Secretary of Health and Human Services could change today. And so it is clear: we should advocate for this change.


How Bad is the Bad Coverage?


Like most health care for profit: we continue doing what we can get away with. And many people with obesity worship at the altar of willpower and believe that self-diagnosis and treatment is normal, but it’s not. And it’s easy to let the tide carry us into the banks of bad care or no care when the court of public opinion is not on our side. We’re embarrassed to say and have routinely been sent the message by fatphobic everything that our bodies are unregulated food pullers and levies and not complex machines. Why fight for coverage when even many medical professionals chuckle when you talk about obesity as a disease?


For example, did you know obesity is considered a cosmetic issue in the state of Louisiana under Medicaid? From their payer perspective, lip injections are as permissible and necessary as weight loss surgery. There are groups working to fight discriminatory policies in insurance plans, such as mandatory six-month waiting periods for surgery (spoiler: they only delay effective care and give you worse outcomes), but it’s a game of Whack-A-Mole. They gain ground somewhere; access is tightened up elsewhere.


And, insurance companies have a long history of telling us what they think about people affected by obesity through policy. In 2007, Blue Cross and Blue Shield of Tennessee had a policy, now defunct thanks to the work of advocacy organizations, that put a requirement for IQ testing for people with severe obesity seeking access to weight-loss surgery. So, the leap that people make to defend their intelligence in a fat body isn’t hard to understand. Usually about 30 minutes into the friend of a friend call the emotional fatigue has set in and I hear utterances of things like “I’m not a stupid person. I’m actually really successful.”


Disease Awareness Needs Diverse Voices


About 60% of the country has access to coverage for weight loss surgery, but less than 1% who meet the guidelines have it. Surgery isn’t the right path for all folks, but obesity isn’t getting worse because people aren’t having surgery. Obesity isn’t improving because we’re not getting to the root issue, which is disease awareness and the idea that it’s a conversation of treatment that needs to happen parallel to prevention. Obesity is a disease that can improve with treatment. Not treating people who have a disease and want it to be treated is wrong. It is malpractice.


The internalized bias of the random callers make my headphones feel like they are bursting into flames. Rage shoots down my spine as I hear their stories I’ve lived, new atrocities I hadn’t yet thought of, and how glaringly absent true medical care has been for them. It’s an exhausting experience to speak and never be heard and it’s not uncommon for people to get deeply personal with me. By the end of the call, we always reach the rage stage. Admittedly, I’m always ready to be the hype woman. I love to see people win and I will gas them right up as they get angry. And we need more of that anger to be channeled into demanding care. We’ve tried playing nice and it’s not working.


As an aside, the pronouns I’ve used about my phone calls are intentional. In 10 years of getting these calls, I’ve never received a call from a man. That isn’t to say that men don’t call other men, struggle with weight or have trouble accessing care for their obesity, but there is something particularly sharp and gutting about the feelings and experiences of women. It’s the same feelings I shared with my friend Krystal who was my person when I was making the decision to have surgery. For women, I’ve found weight to be a piece of their identity more frequently. It’s the standard of beauty they’ve never or no longer fully meet by failing to maintain or achieve a thin body; the preferred bodies that bystanders want us to inhabit, especially if we want authority or leadership on anything.


I also get that it’s a point of privilege to talk about my weight and obesity care as an advocacy issue. I’m a straight, able-bodied, white, middle-income woman. In private moments, plenty of my black female friends disclose the hate they get about their weight, but it’s still unmatched by the racism they endure, for example. I say this to acknowledge that the bodies we live in are not treated the same and weight bias is often only one form of oppression and marginalization happening. The energy to fight is finite and precious, but I know a diversity of perspectives is not only important, but critical for policy and public discourse shifts. I do not misconstrue silence as apathy, but I understand my capacity is not exhausted because I benefit from the dominant culture. I see what I’m sharing as an open invitation to hear from diverse voices, including gender identity, race, disability, sexual orientation, and all the other ways that make my singular perspective just that. I’m calling on our systems to be and do better for everyone, but my plea is not meant to be representative of the lived experiences of all people living with obesity.


The Bottom Line


It doesn’t matter what’s driving your attempts for obesity care. You might want to manage a co-morbidity made worse by excess weight or you simply want to feel better when you play with your kids on the floor or after a day of errands or out on a vacation. Obesity requires real medical care and our self-defined failures are often completely absent of comprehensive interventions.


Talking about our weight often peels open a can of shame. It evokes a fight or flight response. The flight is often inward. A covering in the form of declined invitations, positioning your body in photos, driving 10 hours to avoid the humiliation that your body will experience on a 90-minute flight, or even the freeze up that happens when your doctor says something ridiculous or belittling when you came in for an earache and leave with a food pyramid or MyPlate diagram.


The fight is making the appointment with medical professionals and asking for help and not taking their uncalled for taunting or leaving without what you need. The fight is writing your member of Congress to consider obesity a disease so we can access science-based treatment that we make decisions around with expert medical professionals. The fight is choosing to say what you really want to say to fat-shamers: “I’m a grown woman and you’re not allowed to speak to me that way.”


We have a nation of flight around obesity care, but it’s time for the fight.


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