Fitting in
Teen girls have long been judged and shamed for being overweight, said Lisa Miller in New York magazine. For some, new obesity treatments offer a way to remake their lives.
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, Mo., 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.
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. 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 gutbiome health. There are many larger children at Maggie’s high school, but even so, thinness conveys rank in the pecking order.
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. 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 3 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.
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.
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 liverfunction tests were slightly elevated, and her insulin levels were high but not alarmingly so. 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.
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.
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. 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 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. 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.
Maggie’s obesity was categorized as “severe,” making her eligible for the most intensive treatments. Maggie started taking Victoza before her bariatric 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.
Brooke Sweeney, the medical director of the childhood obesity clinic, 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. 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?
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.
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. 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.”