People have had opinions about Maggie Ervie’s body ever since she was a baby. Maggie, who is 15 years old, has lived her whole life in Marceline, Missouri, a town of just more than 2,000 people 97 miles northeast of Kansas City, reached by driving straight highways that traverse wide cornfields lined by white fences, past sale lots full of shiny blue tractors. Walt Disney spent his boyhood in Marceline, and Mark Twain’s hometown is not far away. The people of Marceline — many descended from farmers, railroaders, and coal miners — have grown up together, as did their parents and grandparents, which makes them a little more comfortable expressing themselves about one another’s business.
When Maggie was still in diapers, a relative leaning over her changing table made a comment to her mother, Erika, about how her “cha cha” was chubby, and when she was in preschool, the playground chaperone would regularly send Erika photos of Maggie’s behind — on the jungle gym, on the merry-go-round — because her jeans, wide at the waist to accommodate her belly, would slip down her hips when she played. In retrospect, Erika can see how the playground monitor might have thought the pictures were cute or funny, but because Erika had been heavy as a child herself, they landed in her texts like taunts. “There’s Maggie’s little booty crack here and there and everywhere,” she recalls. It was hard to find clothes that fit Maggie; Erika had to drive to Kansas City or place special orders at Gymboree and the Children’s Place. When Maggie graduated from kindergarten, her pink ceremonial gown wouldn’t zip up all the way, so the teacher had all the children attend graduation with their gowns open. By elementary school, she had settled on a uniform of leggings and tunics.
Over time, people began to direct their opinions toward Maggie herself, as on the day in fifth grade when everyone had to come to school wearing clothes that represented the Kansas City Chiefs. Maggie, with nothing suitable in her closet, settled on her father’s 3XLT Chiefs shirt. It seemed good enough until one of her friends pointed out loudly that Maggie was wearing her father’s clothes to school, and Maggie, who is usually good-natured, came home crying. There were other times, as when a group of girls would see Maggie go back for seconds in the cafeteria and remark, “I’m so full. I couldn’t eat one more bite. I don’t know how you could eat all that.” But Maggie thought the lunch at school was delicious. She and the cook had a bond: Maggie loved to eat, and the cook, gratified, loved to give her more food.
In Missouri, at the edge of the Corn Belt and one of the leading beef-producing states in the nation, nearly 37 percent of adults are obese, slightly below the national rate. And in Marceline, weight loss is a way of life. At least eight of the Ervies’ friends or acquaintances have undergone bariatric surgery, and Erika can name a dozen people who are on Plexus — a “system” of powders, supplements, and creams that supposedly promotes muscle mass and gut-biome health. For a time, people were getting shots of vitamin B-12 and doses of phentermine from a doctor in town with a cash-only business, and everyone’s always trying keto or Herbalife. There are many larger children at Maggie’s high school, but even so, thinness conveys rank in the pecking order. Wrestling is a popular sport, for boys and for girls, and the athletes “cut weight” before meets by wrapping themselves in trash bags, spitting into a cup, and taking laxatives. Maggie knows a girl whose stepmother requires her to get on a scale before opening the fridge.
So when, in eighth grade, Maggie’s body began to shrink, the town in general approved. When she was 13, her doctor had prescribed Victoza, a GLP-1 agonist that was an early predecessor of Ozempic and Wegovy. Six months later, when Maggie underwent bariatric surgery, she had already become noticeably thinner. Erika remembers her surprise when, on the day of Maggie’s operation, they discovered that a regular hospital gown fit all the way around her body. The following year, when Maggie joined her mother at the town pool for water aerobics, the older women there would compliment Maggie on her appearance and her new two-piece bathing suit with the strawberry pattern, saying, “Aah, Maggie, look at your bikini! I just love it on you. You look so adorable.” And when Maggie switched from the Catholic school to the public high school and joined the cheerleading squad, people began approaching her parents in the bleachers at games, commenting on how pretty she’d become. “She’s always been pretty,” her father, Brett, would respond, and the people would backpedal and agree.
By January 2023, when she turned 15, Maggie had lost more than 80 pounds and grown three inches. That month, the American Academy of Pediatrics released new clinical obesity-treatment guidelines recommending that pediatricians steer their patients along the path she had forged: consider bariatric surgery and medication as early as possible. The guidelines created a public furor. These GLP-1 agonists were new and their long-term effects on children’s minds and bodies entirely unknown. The number of children with eating disorders, including those in larger bodies, had surged during the pandemic, and specialists who treat them feared that the guidelines would place even more clinical scrutiny on adolescents’ weight. Some nutritionists pointed out the risks of malnutrition and side effects, while others worried that doctors’ full-throated endorsement of the drugs signaled the end of any hope that American families might ever learn a joyful, unencumbered relationship with eating. Public-health advocates despaired that prescribing a generation of children GLP-1 agonists was nothing but a Band-Aid solution to the ailments caused by Big Food. Most vocal among the critics were activists from the fat-acceptance movement who had spent the past 20 years pushing clinicians to stop conflating larger bodies with illness. The guidelines’ authors, they pointed out, claimed to focus on ensuring children’s health but had devoted most of the document’s 100 pages to addressing their size — a doublespeak familiar to anyone who grew up under the rule of quick-fix diets and faddish drugs.
Maggie, then in her first year of high school, was unaware of her connection to any of this. She had no self-conception as a pioneer: among the first handful of children to seek out this new class of drugs to control their weight. She had more pressing concerns, such as making new friends and trying to feel comfortable in jeans after a lifetime in leggings.
But if Maggie was sheltered from the onslaught beyond her small town, her mother was not. Erika has also struggled with her weight her entire life and feels the experience defined her; she has done everything she can to reassure Maggie that she is beautiful as she is and to protect her from the casual cruelty of people she encounters. But she also knew from the time her daughter was young that there was something different about her. In a small, dark part of herself, Erika feared that, because of her parenting or her habits or her own history with food, she was the one at fault. Even now, after all the interventions — the doctors, the fighting with insurance companies, the overhaul of the family fridge — this worry has not left her. It has only evolved, because Erika knows her neighbors and people in the world beyond have things to say not just about Maggie’s body but about the treatments she has chosen for it, too.
The first time Maggie entered the childhood-obesity clinic at Children’s Mercy Hospital in Kansas City in October 2019, she was 11 years old and weighed about 250 pounds. Maggie’s liver-function tests were slightly elevated, and her insulin levels were high but not alarmingly so. Her first genetic test had found no markers for obesity. When the doctor took Maggie’s medical history, Erika said her daughter had been insatiable as long as she could remember. She used that word — insatiable. In all of these ways, Maggie was “a typical patient” at the Children’s Mercy clinic, said her doctor, Brooke Sweeney, who has been medical director there since 2014. Maggie’s labs and vitals indicated a child whose health status was not an emergency but whose appetite was in overdrive.
Erika remembers Maggie perched in her high chair in the kitchen at about 2 years old with her grandfather, who was cutting her meat. With her back turned, Erika heard Pa Pa laughing. “She’s eating the whole pork steak!” he said. After dinner, Maggie would often go to the stove and eat the leftovers out of the casserole pan. Or she would say she wanted a snack. Over time, she started visiting the neighbors in the late afternoons, eating dinner with them, then returning home for her own family meal, Erika recalls. “I would say, ‘Did you have supper with the Gordons?’ and Maggie would say, ‘Nope. Uh-uh. They didn’t have supper.’” Erika knew her daughter was fibbing, but she didn’t scold or punish her, not wanting to make Maggie feel ashamed about her appetite.
Erika works as a Spanish teacher at the high school Maggie and her older brother, Brody, attend, so she has the chance to closely observe the other children in Marceline. Friends coming over to play at the Ervies’ house would eat two bites of a sandwich while Maggie would have two sandwiches. Once, Erika approached a girl who had been chubby in middle school but was now thin and asked, “How did you do that?” The girl answered, “I joined every sport.” So in primary school, the Ervies signed Maggie up for soccer, basketball, softball, gymnastics, and competitive cheerleading. For a period, the family vowed to have no second helpings; instead of lingering at the dinner table, they would get up and take a walk or play a game. But mostly, Erika clung to the precept she had received from the staff at the pediatrician’s office: You control what she eats, Maggie controls how much. It seemed like sensible advice, even though Maggie’s appetite made following it virtually impossible. She knew it was unusual, the way she would eat more than her mom and dad. “I tried to stop eating as much as I did, but I couldn’t,” Maggie says. “I would get hungry if I tried.”
When Maggie was 4 or 5, Erika took her to a new pediatric-endocrinology clinic affiliated with the University of Missouri. After examining Maggie and watching her run up and down the hospital’s empty halls, the doctor conveyed her bafflement at how a child so fit could be so big and interrogated Erika about her family’s diet. Erika described how her husband, a freight-train engineer, was often away from home, and she worked long days. Dinner for the kids was frequently chicken nuggets and Tater Tots out of the freezer. Brett would eat from a cooler of food during his stints on the railroad, and when he came home, he wanted a family meal of meat and potatoes. This was the era of Michelle Obama’s “Let’s Move!” campaign to end childhood obesity and Michael Pollan’s In Defense of Food, which popularized the saying “Eat food. Not too much. Mostly plants.” Although Americans were aware of the “obesogenic” properties of processed foods — Super Size Me came out before Maggie was born, and some California cities were introducing ballot measures for soda taxes — the public-health community placed the responsibility for obesity prevention not on the food industry but on individuals, urging them to make smarter choices. (No room is more full of thin people than a room of public-health advocates, an obesity researcher told me.) Erika, who had gone to that clinic hoping for a compassionate ear, could feel the disapproval emanating off the doctor. She took Maggie home and never went back.
For two summers, starting when Maggie was 8, the Ervies decided to send her to Camp Jump Start. The prevention gospel then was calories in and calories out, a principle established after the Industrial Revolution, when doctors liked to compare the human body to the latest technology: the steam engine. At Camp Jump Start, the kids exercised all day on a minimalist diet. During Maggie’s first summer, the camp director — a nurse with ideas about the weight-loss properties of mushrooms and onions — informed parents that raisins and sunflower seeds had been removed from the salad bar because the kids were snacking on them excessively. When a child did something commendable, like straightening up her bunk, she would receive a scoop of ice as a “treat.” “Even some of the counselors were crying,” Maggie told me. After her first two weeks, Maggie called her mother and begged to come home, but the camp director advised against it. “She said, ‘If you come and pick her up now, she’s going to weigh 500 pounds when she’s 15, and she won’t live to adulthood,’” Erika said. “I wanted to die inside.” (In an email, the camp’s director, Jean Huelsing, said she had been working with kids for more than 40 years. “I may not be able to help them all,” she wrote, “but I give my all trying.”) Erika kept Maggie at the camp and had to throw away her sneakers at the end of the summer. She had run through the soles. The next summer, Erika sent Maggie back for a mini-session. “It was absolutely awful,” Erika said, “and I was full-in.” It was around then that Maggie began hoarding snacks and candy in a drawer at the far end of the kitchen. They were hers, she would tell her parents, and she was keeping them safe.
In the 2010s, as family doctors and school nurses across the country were instructing larger children to “eat less and exercise more,” clinicians and scientists who specialized in obesity were beginning to understand the phenomenon in a different way. They knew from seeing kids in the clinic that some of them couldn’t lose weight or maintain weight loss no matter how hard they tried. As far back as the early aughts, university hospitals had been performing bariatric surgeries on a small number of these children who fell into an obesity category the Centers for Disease Control and Prevention labels “severe.” It was, to a large degree, the study of post-bariatric patients that led doctors to see obesity not as a matter of simple arithmetic but as a “pathophysiological disorder” of the signals among a body’s gut, organs, hormones, fat tissue, and brain. Not all bariatric patients were able to maintain a lower weight, but for those who did, it seemed the operation had reduced their appetite — not only by limiting how much they could eat but also by rewiring their internal system. This new understanding, coupled with a goal of dispelling the belief that an inability to lose weight reflects a failure of will, led the American Medical Association to establish obesity as a disease in 2013.
But insight into obesity’s internal mechanisms did little to shed light on its prevalence. Why were there so many more kids with obesity? And why were so many of them so much more obese? In 2008, 36.5 percent of children ages 2 to 19 were overweight or obese; by 2018, that percentage was 41.5. Prevalence was climbing in children of every racial group, with the highest growth among Black, Hispanic, and Native American communities. By the end of 2020, children who were already obese were gaining weight at an accelerated rate. Pediatricians use growth charts to measure how a child’s size compares with the norm, and as the obesity epidemic escalated, they found themselves plotting more and more patients at the chart’s upper reaches, often above the 95th percentile of BMI, and sometimes off the grid entirely. When a phenomenon becomes so widespread, scientists look for causes beyond individuals and to their environment. The increase in obesity obviously correlated with the food kids ate — addictive, palatable, accessible at all hours — and their lack of physical activity: the phones, yes, but also reduced recess hours, unsafe neighborhoods, and lockdowns. Poverty and hunger correlate with obesity, as do other traumatic childhood experiences such as the death of a parent or sexual abuse. The frontier of obesity research lies here, in understanding how these external factors, as pervasive and variable as the weather, interact with each individual body — disrupting the metabolism, activating genes, or miscuing hunger signals — to produce the condition physicians call “obesity.”
A propensity for obesity is encoded in certain people’s genes. More than 70 genes correlated with obesity are already known, though the presence or absence of an obesity gene does not forecast a child’s future body shape. Nevertheless, the biggest known predictor of whether a child will develop obesity is if her parents have it; there is a 40 percent likelihood with one parent and an 80 percent likelihood with two. The question is which environmental factors (and in which combinations and at what levels of intensity) turn the genes “on.” Then, further into the realm of unknowns: What are the triggers for obesity beyond known genetic predispositions? Toxins in food may modify our DNA, an epigenetic disruption that can be passed to the next generation. Changes in an individual’s gut bacteria, caused by the biochemical composition of food, may have the downstream effect of altering metabolism. “There are many, many, many associations” between the environment and the body that can produce obesity, says Sarah Armstrong, a professor of pediatrics and an obesity specialist at Duke, “but no one smoking gun.”
Past versions of the AAP guidance took a watch-and-wait approach, advising doctors to stage their interventions from least intrusive to most, starting with behavior modification, but research was proving the risks of childhood obesity to be incontrovertible. Of children with obesity, 40 percent were prediabetic as of 2018, more than double the rate 20 years ago. Between 2 and 5 percent of kids have hypertension, which raises their risk of heart attack, organ failure, and stroke. Between 5 and 10 percent of kids — about the same portion that suffer from asthma — have fatty-liver disease, formerly found mainly in older men, particularly those with alcohol addictions. Kids now routinely show up for checkups with sleep apnea, orthopedic problems, menstrual abnormalities, and coronary-artery disease. A 2020 data analysis known as the “Swedish cohort” study showed that obesity in childhood and adolescence was linked to “increased risks of associated morbidity and premature mortality.” In January 2023, the AAP changed its tone. Lifestyle changes were essential, but doctors should intervene with treatment as soon and as aggressively as possible. In the guidelines, the AAP recommended that children with a BMI above the 95th percentile be offered weight-loss medication and those in the level above that — “severe” — be offered bariatric surgery.
The new guidelines were issued, not coincidentally, just weeks after the FDA approved Wegovy for adolescents 12 and up. For the previous decade, the few clinicians who treated childhood obesity had been jerry-rigging solutions. When Claudia Fox started running the pediatric-obesity clinic at the University of Minnesota back in 2011, she shared a nurse with the prominent adult-obesity specialist Charles Billington. Pharmaceutical treatments for adults did exist — and GLP-1s, developed to treat diabetes, were already being used off-label for weight loss — but the pediatric landscape was comparatively barren. So every time Fox was flummoxed by one of her young patients, she would ask that nurse, “What would Charlie do?” And the nurse would recommend a drug Billington prescribed for adults.
Throughout the 2010s — “out of desperation or need,” as Fox puts it — specialists like her were prescribing medicines off-label for kids with obesity. They tried Meridia (later discontinued owing to an increased risk of “major adverse cardiovascular events”); topiramate (approved for migraines and seizures in kids); phentermine, the popular stimulant. So when one of the first GLP-1 agonists, liraglutide (marketed as Victoza and Saxenda), was approved by the FDA for kids 10 and older with type 2 diabetes in 2019, and the following year for weight management for kids 12 and older, it appeared to these doctors like an open door. It was Fox’s colleague Aaron Kelly who two years later presented the findings showing that semaglutide, marketed as Wegovy, was stronger than liraglutide and safe and effective when administered weekly. The trial had been paid for by Novo Nordisk, the Danish pharmaceutical company that manufactures Victoza and Saxenda.
Maggie’s obesity was categorized as “severe,” making her eligible for the most intensive treatments. For her parents, the decision to intervene was like the decision to buy life insurance, Erika told me. Brett had been diagnosed with type 2 diabetes and was prescribed Victoza back in 2015, and Erika is convinced that decades of irregular eating and night shifts on the railroad had made him sick. The Ervies didn’t want the same fate to befall Maggie. But as Maggie remembers it, she wasn’t thinking much about her insulin or her liver. She wanted to be thinner, the sooner the better, and she was frustrated that the family’s insurance company refused to pay for a gastric-sleeve operation until she menstruated for the first time, a phase of her treatment that Sweeney and the Ervies call “period watch.” During one visit to Sweeney’s office, Erika wept with despair: It felt as though the waiting would never end. Maggie started taking Victoza around then, stopped before her surgery, then restarted after the surgery didn’t lead to the dramatic weight loss everyone had hoped for. With the combination, she began shedding pounds. For her part, Erika was grateful to finally be able to entrust the care of her daughter to someone who listened to them. Around the same time, she began taking Victoza for weight loss too.
Before Maggie could start medication or undergo surgery, she had to show her dedication to changing her life. Erika eliminated most of the carbs in the family’s diet, substituting grains, cheese, and fruits and vegetables for potatoes, pasta, and bread. Maggie used a meal-planning app to create weekly dinner menus (stir-fry, quinoa) and found a recipe for “protein balls”: peanut butter, oats, honey, and chocolate chips molded into orbs that look like cookie dough and serve as a quick, high-energy snack. But the Ervies ate dinner with Brett’s parents at least twice a week, and Nanny and Pa Pa served pork steaks, baked potatoes, creamed corn, and hot rolls. Maggie wanted to follow Sweeney’s guidance, but she didn’t want to bring her own food to her grandparents’ house or say “no” to dinner.
Sweeney had described hunger and satiety to the Ervies as two light switches. The hunger switch tells most people to eat, and the satiety switch tells them to stop. Every person has a natural set point of adiposity, or body fat, that changes over time — in puberty, at pregnancy, during old age — but is more or less stable. In people with obesity, that set point is high, often because the switches don’t work. Maggie’s hunger switch was frequently on, but her satiety switch never was. The second time Maggie got a genetic test, two years after her first, the number of markers the tests could discover had more than doubled. This time, the test found two genes linked to obesity. Although Sweeney cautioned Erika against interpreting this result as the sole cause of Maggie’s disease, Erika felt relieved: Maybe it wasn’t her fault.
During the period watch, Sweeney and the psychologist on staff at Children’s Mercy had many conversations with Maggie about her goals and expectations. They didn’t talk about weight or BMI. In fact, when Maggie gets weighed at Children’s Mercy, the number on the scale is covered. What the doctors were asking was whether she had an image in her head of what kind of life she wanted to live and what she wanted her body to be able to do for her.
Maggie, then 12, had a hard time answering this question. As a child, she had loved the Disney princess Rapunzel, but as she grew older, she switched her alliance to Moana because, though the former princess represented liberation from confinement, the latter has more of a social conscience. Maggie was not really on TikTok or Instagram, so she had not been pulled into the magnetic field of any influencer. She loved Taylor Swift, and she liked that Rihanna says whatever she wants. But she didn’t want to be like any of them, not really. What she said was “I want to look like Jessica” (not her real name), a thin, popular girl in her grade.
The doctors urged her to think differently, to imagine a self that was Maggie, not Jessica. “That’s not a goal,” they told her. “To look like somebody else can’t be your goal.” Maggie said she understood, but in the long car rides back to Marceline, she would ask her mother why. Why couldn’t she look like Jessica? Is it bad to want to look like Jessica?
Over the past 20 years, the fat-acceptance movement has forced people to recognize the ways in which mainstream culture’s near-universal obsession with thinness punishes those in bigger bodies. Researchers have shown that the bullying, shaming, neglect, and ostracism — including by doctors — that comes with being larger is associated with depression, anxiety, suicidality, and eating disorders. People who are obese tend to avoid doctors’ offices; studies show that doctors spend less time with patients who are obese and tend to reflexively attribute health problems to excess weight. A 2016 study published in the International Journal of Obesity demonstrated the crudeness of BMI as a singular measure of obesity-related illness: Nearly a third of people classified by the BMI as “obese” were metabolically healthy, while about the same proportion of “normal weight” people had cardiometabolic disorders. In defiance of the incessant demands to become thin, the fat activists say their best defense is to stand up in their bodies with pride.
But in the Ervies’ largely white, conservative world, the notion of fat acceptance has not taken hold. The family doesn’t like to use the word fat. They prefer chunky, chubby, big, bigger, and heavy. Erika still thinks about the humiliations of her own childhood, how her father had demeaned her for her size and made her eat Lean Cuisine when the rest of the family had fried chicken and mashed potatoes. For her, the pervasive callousness against bigger people overshadows any dream of body-size pride or equity. When Maggie was in middle school, the cruelty from girls she had known her entire life reached a crescendo. Brett says Maggie and Erika “share a brain,” but while Maggie can’t quite recall the bleak details anymore, Erika remains defensive. “Her friends just dropped her,” she says bitterly. Both have a hard time untangling regular middle-school tribalism from unkindness directed at Maggie because of her size. She was at her heaviest just when middle-schoolers are at their most malevolent, but she sees that her body gave her friends an excuse to isolate her. “They’re skinny,” she says, simply. “They want their friends to be the same as they are.”
Even for families who live in places more aligned with the fat-acceptance movement, these medications can seem like an obvious choice. It’s one thing to be proud of your body, some parents say; it’s another to subordinate one’s health to that pride, as some of the most radical fat-activist groups seem to endorse. After the new AAP guidelines were released, activist groups began circulating a statement of principles from the Health at Every Size movement, which included the claim that any treatment for obesity is equivalent to “harm.” Edward Kent, a 16-year-old in Minneapolis, was diagnosed with fatty-liver disease when he was 15 and began taking Wegovy this past January. The side effects he experienced were intense — acute diarrhea, bouts of nausea that made him stop and sit down. But his liver-function tests are now normal. “The fat-power people are coming from a past of shame, and they’re trying to make being big okay,” his mother, an OB/GYN named Barbara Van Eeckhout, told me. “I agree. Be who you are. But don’t shame people who want to be thinner. The world is not built for overweight people.” Edward agrees. “If being medically obese is impacting your ability to live,” he told me, “you should be able to do whatever is best for you.”
On the Wednesday after Halloween, about two and a half years after Maggie began taking Victoza, Erika and I went to watch cheerleading practice. We sat on a cushioned bench on a low tier of bleachers lining a basketball court. Nine girls attended practice that day, all in white T-shirts and short black gym shorts, a stiff white-and-yellow bow perched on their heads. They started with a round of stretches: hurdlers, lunges, splits. In unison, they counted off reps in low, booming grunts that echoed off the walls of the high-school gym.
Maggie had done competitive cheerleading through fourth grade but quit when she found she could not tolerate much exertion. Running made her uncomfortable and self-conscious, and she could not do the cartwheels and round-offs that the other girls could. Her weight gain had altered her gait, so she walked on the sides of her feet. Today, she still can’t tumble because the residual loose skin around her abdomen (in the world of bariatrics, this is called an “apron”) keeps her off-balance. But she has a role on the squad as a “base,” someone sturdy and strong enough to hold a teammate aloft. The soles of her feet now touch the ground, so she can run, jump, yell, and dance in formation and shake gold pom-poms with everyone else. When the girls take laps around the court, Maggie is in the middle of the pack.
What infuriates Erika still is the perpetual implication that she could have tried harder to help Maggie lose weight. She recently received a mailing from Living Well Foundation, the parent organization for Camp Jump Start. “Do No Harm!” the headline on the brochure reads. The AAP, the brochure continues, “now recommends intense treatment for those 6 years old and up. This intense therapy includes weight-loss drugs — never before tested on children — to begin as young as 12 years of age and teens evaluated for weight-loss surgery.” And then: “Living Well Foundation believes that there is a better way!”
In September, Maggie and Erika flew to Orlando to attend the annual conference of the Obesity Action Coalition, a support-and-advocacy group for people who have sought or are seeking what OAC calls “evidence based” medical treatment for their obesity. OAC is primarily funded by the pharmaceutical industry: The conference’s sponsors included Novo Nordisk, the manufacturer of Wegovy; Eli Lilly, the manufacturer of Mounjaro; and Boehringer Ingelheim, whose competitor, Survodutide, was in Phase III clinical trials. For the first time, the organization invited about a dozen teenagers and their caregivers, comping their hotel rooms and giving each pair more than $1,000 for airfare and extras, which some, including Maggie and Erika, spent on Disney World tickets. The kids gathered there were from all over the country. Some had undergone bariatric surgery, some were on medications, and some were considering the former, the latter, or both. Mostly, they hung out together drinking Starbucks and sitting by the pool or going up and down the stairs in the hotel, overjoyed to meet others like themselves. It was this experience of feeling less alone that made Maggie and Erika want to reveal themselves as fully as they did over many days of meeting and speaking with me. “A lot of the kids at OAC didn’t have any friends,” Maggie told me.
At the conference, Maggie and Erika attended focus groups led by Lilly researchers, who reassured the children that they were not guinea pigs while asking what would entice them to or discourage them from participating in clinical trials. The kids were bewildered by these questions. In the main ballroom, Fox, whose research is partially funded by Novo Nordisk, gave a lecture on the AAP guidelines. “Of course” kids need to take the medications for the rest of their lives, she said, “because obesity doesn’t just go away like an ear infection does.”
In October, I asked the Ervies why they thought, with so many big kids in town, that they were the only family they knew of who had pursued this aggressive medical intervention for their child. Erika considered it during the drive to the school and for most of cheer practice. As we sat on the bleachers, she reflected on the overwhelming pressure parents feel for their children to be “fine.” Erika knows some parents whose children might have benefited from medications, accommodations, or therapies but who refuse help in order not to suffer their own discomfort. The back-and-forths about childhood obesity, she says, “mimic how people used to think about mental health.” Not so long ago, anxiety and depression were believed to be states of mind under an individual’s control, and medications a cheat for people lacking the fortitude to see themselves through.
What makes obesity different from other conditions treatable by medication, though, is that it’s necessarily tied to eating. From the instant a child is born, a parent’s first concern is to feed and nourish her, so when the act of eating draws attention to itself, becomes the basis of a child’s pain or sickness or the verdict on a parent’s competence, the rejection from the world can be total. To Erika, the disgust she perceived from people about the way Maggie ate as a child felt like “the opposite of ‘There but for the grace of God go I,’” she says. She believed the revulsion covered up something primal and self-protective, a fear of uncontrollable impulses mixed with a gratitude that their own families weren’t “that way.” Erika understands this, the awe and horror and sadness of beholding someone out of control of themselves, because she feels it too when she watches a show like My 600-lb Life. Except in her case, because she has been there and Maggie has been there, it makes her want to cry. And when Maggie flips through family albums, looking at pictures of the trip to Universal Studios they took in the spring before her surgery, she is so distressed at her former size and the memory of how she felt in her body that she turns her face away. These images don’t reflect who she was on the inside: someone social, athletic, attractive to others.
Erika believes the medication and surgery gave Maggie an opportunity to remake her life — early, before she goes to college and makes the friends who will sustain her adulthood. Maggie had always been a happy and resilient child, mostly insulting the bullies back, rather than taking what they said to heart. In middle school, Erika saw her daughter starting to crumble, and she feared that too much of that sadness would take a toll. “I don’t think she would have had the same personality if she had continued to be as big,” Erika says. But now Maggie has a new identity as a child so determined to become thinner that she changed her life and endured years and years of treatment — and will endure many more. Erika worries about that, too. “I’m like, Did I project all this? Did I? It ended up being a bigger deal than I ever wanted it to be.”
When Maggie joined the cheerleading team at the beginning of her sophomore year, she gained access to a group of older girls who hadn’t known her before. She is able to move among them as herself, not as a person who went through a radical physical change. The older girls say “hi” to her in the halls, and they talk to her in study hall and weight-lifting class. She sometimes receives DMs from other larger girls at school asking who her doctor was or how she became so thin, and she answers them but they don’t acknowledge one another in the halls.
What Maggie didn’t like about her life before, she told me, was that she stood out when she wanted to blend in. So much of her present happiness is related to the feeling of finally being a normal teenager, a girl who can wear jeans and spend her babysitting money on cutoffs so shredded her father teases her about them, saying, “I have more material in my hat.” She can go shopping at an actual store for a dress to wear to the homecoming dance. In her bedroom, she takes the dress out of the closet; hot pink and silky, it is the fanciest thing she has ever worn. A friend’s mom did her makeup and nails and took a photo that Erika posted on Facebook. In it, seven girls, all with curled hair and bright body-hugging dresses, are turned sideways to the camera.
These days, Maggie is messaging with boys on Snapchat, and the older girls are inviting her to parties — all of which makes Maggie newly alluring to the friends who excluded her in middle school. Maggie has mixed feelings about this. She doesn’t hold grudges. She lives in a tiny town and has a deep loyalty to that, to the intimacy bred by generational roots and long proximity. So when the middle-school friends ask her to hang out, she goes, partly because of her history with them and partly out of allegiance to her old self.
Recently, a senior invited Maggie to a party. Her brother drove her, and within 45 minutes they were home again. Upon arriving, the older kids gave her alcohol, which she drank quickly and instantly vomited up. Sweeney had cautioned her about this early on. Bariatric surgery makes people extremely sensitive to alcohol, but that warning had not registered when Maggie was 13.
The alcohol was mentioned at Maggie’s six-month checkup in November. Sweeney reiterated the message with more emphasis this time. Not only does alcohol have a stronger effect on bariatric patients, but in adults, there’s a higher risk of abuse. “Be careful with your body,” she told Maggie. “Yours is a very sensitive body. Be cautious, my friend.”
Then Maggie asked whether it was possible to switch to Wegovy. The Victoza was no longer working, she said. She could feel herself wanting to snack more after dinner, sitting in front of the TV and grabbing some cheese or maybe some nuts. Erika confirmed this: “She’s making healthier choices, but it’s the familiar level of ‘What’s next, what’s next.’” Sweeney now showed the Ervies Maggie’s growth chart and indicated her new, lower “set point.” This was stable, she said. With the surgery, medication, and Maggie’s exercise and eating habits, her weight changes have remained within four pounds for a year. For the first time since she was a toddler, she is back on the first page of the growth chart and not in the large unbounded space above it. Her blood work is normal.
So Maggie is fine, and if she wanted to stay at her present size, that would be fine, Sweeney said. But her obesity will require a lifetime of management. For her part, Sweeney did not want to prescribe Wegovy. The Ervies’ insurance won’t cover it, and it’s far more powerful than Victoza. Maggie was lucky to be born when she was, Sweeney said, because as she grows up, she will have access to all these new medications, which over time will grow cheaper, more accessible, and easier to use. She has plenty of time to try these new drugs. In the meantime, the doctor could prescribe an additional drug regimen: not a GLP-1 but phentermine, the classic stimulant, in the mornings and topiramate, which can have a sedative effect, at night. Both would help control her appetite. Did Maggie want to try that? Curled up in a chair with her hair in a bun and wearing a shy smile and leopard-print slides, Maggie said she did.
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