Life After the Knife

Far from being a quick fix, weight-loss surgery is merely the start of an arduous physical and emotional journey.

On Denise Stracner’s third date with Andy, a fat woman on a motorized scooter rolled into the Emeryville Starbucks where they sat sipping drinks.

“Can you imagine living like that?” Andy whispered.

“Actually,” Denise replied, trying to keep her voice light, “I can.”

“What do you mean?” asked Andy, whose name has been changed for this article to protect his privacy. With her stylish shoulder-skimming blonde hair, pale blue eyes, slender frame, and professed penchant for adventure, Denise appeared to have nothing in common with a woman who evidently had trouble walking because of her size.

“I’ll tell you later,” she said, thinking of the photograph in her car she’d brought along that day for that very purpose. “I promise.”

She kept her promise later that day, and the story went like this: Three years earlier, Denise, who stands five foot three, weighed 341 pounds. She had dieted off and on since childhood, yet all she’d ever lost permanently was her gall bladder. That was the result of dropping sixty pounds too fast, which had led to a bout with pancreatitis. She was nevertheless healthy and relatively happy. In November 2003, when she embarked on weight-loss surgery, Denise had a live-in boyfriend, an infant daughter of whom she and her ex-husband shared custody, a lovely house in Castro Valley, and a well-paying job as a nurse. By last June, when she answered Andy’s personal ad on Craigslist, she was down to 145 pounds.

That brief snapshot makes the weight-loss ordeal sound painless, but far from it. The common view of these surgeries is that they mark the end of a fat person’s problems, when in reality they represent the beginning of a very long process. And it’s these post-surgical physical, emotional, and financial travails that we seldom hear about. “When people hear ‘weight-loss surgery,’ they often think it means taking the easy way out, that it’s a quick fix,” Denise, 34, explains. “But it’s not. Not in any way, shape or form.”

Weight-loss, or bariatric, surgery has been around since the 1960s, but recent years have witnessed an explosion in its popularity. Last year, 177,600 Americans had one surgical procedure or another, an increase of nearly fourfold from 2001, according to the American Society for Bariatric Surgery. Most of the patients — about 80 percent — are women, in no small part, experts suggest, because fat women in the United States face a greater social stigma than fat men.

The procedures can offer astonishing benefits for people with obesity-related health problems. According to a recently published research review in The Journal of the American Medical Association, 77 percent were cured of diabetes, 70 percent lowered their cholesterol, 78 percent bid adieu to high blood pressure, and 86 percent no longer suffered from sleep apnea. For obese but otherwise healthy patients, a respite from society’s judgment is often reason enough to go under the knife.

Yet the potential downsides are also astonishing. The risk of death, depending on which study you’re looking at, ranges from 0.2 to 2 percent — arguably high for an elective procedure. The popular Web site hosts a memorial page listing 132 members who have died since 2000, a mere fraction of the total post-surgical deaths. Up to 20 percent of patients require subsequent operations to address complications. Common side effects include diarrhea, nausea, vomiting, lactose intolerance, signs of nutrient deficiency such as anemia and hair loss, agonizing stomach pain, and shockingly pungent gas and stool. And those who lose weight successfully often have huge folds of excess skin to deal with.

These post-surgical ordeals, and the accompanying emotional adjustments, can persist for many years. Then there’s the cost: Even if insurance covers the initial surgery, the price of subsequent cosmetic procedures and myriad dietary supplements required for optimal health can add up quickly. To top it all off, there’s no scientific evidence that weight-loss surgery makes people any happier in the long run.

Despite all of this, more and more people are forging ahead. “Even for most people who’ve had serious complications, some lasting years, they say they’d do it again in a heartbeat,” says Dr. Bill Hartman, a San Francisco psychologist who evaluates patients considering bariatric surgery. “For the vast majority of people, their quality of life and health are tremendously improved.”

Denise counts herself among them. “If I’d known how much happier I could be, I would have done it years ago,” she says.

Merely being overweight isn’t enough to qualify. Most surgeons and insurance companies require that patients have a Body Mass Index topping 40 (think five foot four and 240 pounds), or a BMI of 35 (that same person weighing 204 pounds) with an obesity-linked health ailment such as diabetes. There are more than a half-dozen common procedures, but three-quarters of all patients opt for the so-called Roux-en-Y gastric bypass, which dates back to the 1960s. In this surgery, 90 percent of the stomach is permanently sealed off, leaving a walnut-sized pouch to which part of the small intestine is then attached. This severely limits food intake — consume too much and you’ll puke — and not all the calories are absorbed. The modified stomach naturally expands a bit over time, most substantially in patients with a penchant for overeating, so weight loss can be hard to maintain in some cases.

Only a few dozen American medical practices specialize in the Duodenal Switch, a more complex and drastic procedure that Denise calls “the Mercedes-Benz of bariatric surgery.” The DS, as it’s commonly known, leaves behind a larger stomach than the Roux-en-Y but introduces major malabsorption via an intricate rerouting of the intestines. DS patients can eat more, but much of it is never absorbed by the body, so they’re likely to lose more weight. A study published in October in the journal Annals of Surgery revealed that 84 percent of DS patients had dropped at least half their excess weight after three years — the medical definition of a successful outcome — compared with 59 percent of those who’d had a Roux-en-Y.

Kimberlee Garfinkle opted for the Roux-en-Y in 2001, and wishes she’d done it years earlier. A dead ringer for actress Parker Posey, the 39-year-old Oakland resident now runs a weight-loss support group at San Leandro Hospital. She credits the surgery with improving nearly every aspect of her life. She’s working in a new field, getting married next month, and hopes to become pregnant within the year. She’s still trying to lose a few pounds — like four out of five patients surveyed up to four years post-op — but life could hardly be better, she says. Unlike Denise, she was miserable prior to her surgery. “I was not in a good place,” Kimberlee recalled over lunch at the Chabot Space & Science Center, where she works. “It was just sheer hating myself. I wouldn’t even make eye contact with people before, because I didn’t want to see how repulsed they were by me.”

Brittany, a Concord resident who requested that her surname not be published, is far more ambivalent about life post-surgery. “I don’t think I’ll ever be able to say if I’m happier now than I was before,” she says. “I don’t know how I’ll feel when I’m fifty — if I live to be fifty. I certainly didn’t change like I said I would. People are like, ‘I’ll never look back,’ but I can’t say that. Not yet.”

Now 25, Brittany was two decades younger than the average patient when she had weight-loss surgery in 2004. She was adamant about having the DS, which her insurance didn’t cover, so she flew to Brazil and paid $10,000, about a third of what the surgery costs in the States. She has since lost 105 pounds. Witty and outspoken, with warm brown eyes and a dark curtain of curls, she projects an aura of self-assurance. Yet she says, “I have never been confident, and I’m not now.”

In the locker room of Bally Total Fitness in Pleasant Hill after a recent workout, Brittany attempts to explain why she considers herself “fat undercover.” She steps into a changing stall, abruptly latches the door, and stands with her back to the mirror. “Can you switch off the light?” she asks, unleashing an awkward laugh. “I feel so silly. This is exactly what it was like with my boyfriend when I first showed him.”

Her hands tremble ever so slightly as she grabs the hem of her long-sleeved T-shirt and lifts it to her shoulders. Crepe-like folds of thin, loose skin cover her modest stomach. She thinks about her “fat gut” a million times a day, she’d previously said.

While weight-loss procedures are increasingly done laparoscopically, with tiny surgical tools that leave only small incision scars, Brittany’s was not. A pearly white-pink scar the width of a rose stem drops from just below her purple sports bra down to her belly button. She pulls her shirt over her head and lets it fall to the floor. “See my stretch marks?”

In fact, it’s too dark in the stall to see the blotches she says mar her shoulders and arms. They’re the reason she insists on wearing a long-sleeved shirt while exercising, and represent, for her, an unanticipated side effect. She turns to face the mirror, and her eyes linger on her collarbone. “See this? I like this bone,” she says. Then, in a sudden burst: “Do you want to see my boobs?”

Giggling at her overenthusiastic invitation, she pulls off her sports bra. “These,” she announces, dropping her hands to her sides, her fingers curling into fists, “are my boobs.” They hang low on her torso, as though the air at their base had been sucked out, leaving a smooth stretch of excess skin there. She bends at the waist. “See?” She cups her breasts where they dangle at mid-thigh-level and groans. “Pretty bad, right?” She tugs her bra back on and tucks her breasts inside it. “I’m not going to show you my crotch,” she says, referring to comments she’d made earlier about her embarrassingly “flabby” pelvic region. She slips her shirt over her head. “So that’s it.”

When Brittany consulted a plastic surgeon a year ago about a breast lift, she was told her insurance would only cover it if she went from her current D cup to an A — that’s how much tissue would need to be removed for her to allege that her breasts were causing unbearable back pain. But she wasn’t in pain, and doesn’t want such a drastic reduction. If she can lose twenty more pounds to reach her goal of 150, she might see about a tummy tuck. She’s also considered laser surgery for her stretch marks. But she won’t be able to afford any of the above in the near future. For now, her body is what it is.

Ninety-five percent of bariatric patients eventually consider subsequent cosmetic surgery, according to a presenter from the University of Pennsylvania at a national bariatric surgery conference last July. That’s no surprise to plastic surgeons, for whom the newly slim have become a booming market. For instance, 68,000 bariatric patients underwent reconstructive procedures in 2005 — a jump of 22 percent over the previous year. That’s despite the fact that insurers won’t cover nonessential cosmetic surgery. In other words, unless excess flesh rubbing against excess flesh gives rise to a chronic rash or infection, a person is pretty much out of luck, even if it means that folding pounds of loose skin into her slacks becomes part of the morning routine.

Local plastic surgeons say weight-loss patients began coming in about five years ago. Dr. Stephan Ronan figures they now make up 10 to 15 percent of his private practice in Danville, and predicts the number will rise to 25 percent over the next few years. “They’re very well educated,” he says. “They just want as much skin taken off as possible. They’re not worried about scars.”

Well, that’s not entirely the case. “How does a single woman like me get back into the dating world?” Denise says she used to wonder. “I have scars every which way but loose!”

Unlike Brittany, Denise couldn’t mask the remaining evidence of her massive weight loss with a long top or a sturdy bra. By the one-year anniversary of her DS, she could practically wrap a thigh in the extra flesh that hung from it. A huge slab of skin flapped below each breast. And she’d developed a hernia so massive that many people assumed she was pregnant. When her patients asked about her due date, she’d give them the date on which she was scheduled to have a tummy tuck and hernia repair. She and her nursing colleagues even joked about it, nicknaming the “baby” Alex. She took it in stride. After all, she’d waited thirty years to be thin — what did another few months matter?

The butt and thigh lift came nine months later, in May 2006. All told, Denise had about fifteen pounds of loose skin lopped off. In her case, insurance covered everything, and the surgeon who’d done her DS at San Francisco’s Pacific Laparoscopy performed all the procedures. While it’s uncommon for a bariatric practice to offer plastic surgery, codirector Dr. John Rabkin says a tummy tuck on a person who’s had weight-loss surgery is completely different than the procedure most plastic surgeons perform on women after their childbearing years. “The reason we got started in this is because, back in the day, the general plastic surgery community not only wasn’t interested, but wasn’t knowledgeable about reconstructive surgery following weight loss,” he says. “The plastic surgery community is very, very late to the game.”

Andy was surprised by Denise’s startling revelation, but he didn’t seem to mind. And when she eventually allowed him to see her naked, he didn’t fixate on her scars. She felt amazed: Her gorgeous new boyfriend, whose body she viewed as absolutely perfect, didn’t seem to notice her scars at all. He also seemed to understand that issues related to the surgery were a big part of her life, from her numerous online forums to the constant stream of instant messages and e-mails that appeared on her laptop to the monthly support group she hosts for pre- and post-op DS patients. In August, he sat in the audience while she gave a nerve-racking lecture to a huge support group in San Francisco. And on the last Saturday in September he accompanied her to Crissy Field to take part in the annual three-mile Walk from Obesity, which is sponsored by Pacific Laparoscopy.

Unable to contain her enthusiasm, Denise started off with a buoyant, silly jog. She bounded ahead of Andy and spent a good portion of the walk chatting with the practice’s three surgeons and some of the other five dozen or so participants. “She’s beautiful,” Andy commented, his eyes following her from a dozen paces behind. “It’s hard to believe she used to be that big.”

For Denise, it’s hard to forget. She and Andy had gone horseback riding the day before, something she’d long wanted to do. A sign posted at the stable stated that riders had to weigh less than 220 pounds, and when she’d gone to write her weight on the registration form, she’d panicked. “For a split second I had a rush of anxiety,” she recalled. “I knew I wasn’t too heavy, but my brain immediately goes there still.”

Denise’s quick clip slowed in the last half-mile of the walk, and her energy flagged. “My hips still bother me when I walk a lot,” she complained, something she rarely does. She’d been working out several times a week with a trainer and hadn’t expected this. Andy, meanwhile, had gone on ahead — she suspected he wanted to sneak a smoke. It’s a habit she’d hated at first, but let it slide because, well, he had to tolerate her scars. It’s a trade-off she’s willing to accept.

In obesity walks of years past, a group of fat-acceptance activists had assembled along the route to raucously protest the surgery, which their Oakland-based National Association for the Advancement of Fat Acceptance openly condemns (see “Fat! Fit? Fabulous?” feature, 9/13/06). This year, ringleader Marilyn Wann took a less-direct tack. Instead, her crew gathered near the Powell Street BART, where they distributed fliers and invited skeptical shoppers to stand on a flashily decorated scale that divulges not a number, but a feel-good adjective. “A bunch of people did a ‘Walk from Obesity’ this morning to raise money for weight-loss surgeons,” Marilyn called out to a clump of people walking by. “Isn’t that just icky?”

Brittany has heard about Marilyn, and thinks the activist has the right idea about self-acceptance. She wishes she could follow the group’s lead — or her own boyfriend’s, for that matter. Jeff weighs more than three hundred pounds, and his cavalier attitude toward his appearance is one of the things Brittany most admires about him. “He thinks that he is rather svelte, like, ‘I carry my weight well!'” she says over lunch at a Berkeley raw-foods restaurant, dropping her pitch into a macho-man imitation. She sighs and rolls her eyes. “His ego is completely full!”

She hadn’t figured on ending up with a big guy post-surgery. “I was going to find my Ken, because I was going to be the Hispanic-looking Barbie,” she says. But then she fell for Jeff, who contacted her via a little over a year ago. Meeting men offline as a thinner person wasn’t what she’d expected. “I hate when guys check me out. It really pisses me off! Which is funny, because I used to want attention,” she muses. “I wanted people to think that I’m attractive.

“When you’re fat … ” Brittany’s voice drops to a whisper, and she blushes and casts a quick glance around the restaurant. “I mean, I’m still chunky,” she says. “Well, you envision the life of a thin person. You picture that you’ll become a social butterfly and will be embraced by everyone. I’m not a pessimist, but I don’t wake up every day now and go, ‘Weehee!’ Now I just focus on other things about my body that I don’t like.”

Brittany’s ambivalence doesn’t make her too popular in support-group circles. One time, she recalls, she told a group, “I think we took an easy way out,” and the entire room fell silent. She thinks her perspective is rooted in the fact that her mother shed two hundred pounds through diet and exercise just a few years before Brittany flew to Brazil for surgery. “I told them, ‘C’mon, my surgeon cut me like a fish!'” she recalls. “‘They just stared at me. But it was the easy way out. I know that, because my mom is constantly struggling not to gain weight, and she’ll be doing that until the day she dies.”

Indeed, when she and her mother join a reporter for dinner in Oakland a week later, Brittany mentions that her mom hasn’t eaten all day just so that she could dine out. Allison nods, a bit sheepishly.

After losing all that weight, Allison’s type 2 diabetes is gone, and following reconstructive surgery, so is much of her excess skin. She likes that she now blends in, but it was a rough transition. “I was not prepared for how horrible my body would look after I lost weight,” she says. Nor was she prepared for the slim pickings of her new, slim dating world. “When I tell a woman about it, they say, ‘Wow! You lost two hundred pounds?’ Men are turned off. I think some of it is that they fear you might go back to that.”

Brittany doesn’t like to tell anyone she’s lost serious weight, either. She didn’t disclose it to Jeff until they’d been dating for six weeks. Her boss, with whom she works very closely, has no idea. “When I tell people, it’s like admitting that I put a Band-Aid over this big fucking problem,” she says. “It is like announcing that I fucked up so much that I couldn’t do it on my own.”

Her mother stares at her across the table, her eyes sad. “I think Brittany went into it, too, thinking that it would fix everything,” Allison suggests quietly. “Like I did.”

Brittany looks up from her salad and replies that she just wanted to be thinner. “I thought it wouldn’t matter how I got there.”

Scant research has been done on the psychological impacts of bariatric surgery, and what does exist isn’t particularly conclusive. One study, published last March in the journal Obesity Surgery, surveyed people when they applied for a weight-loss procedure. Two-thirds of them wound up having the surgery. When surveyed four and a half years later, patients in both groups had lost weight, but there was no reported difference between them in terms of psychological well-being — although the bariatric patients lost far more weight on average, both groups showed fewer problems. Nor was there was any correlation between weight loss in bariatric patients and their ultimate levels of anxiety, depression, binge eating, and psychosocial stress.

The surgery, in short, did not appear to solve patients’ emotional problems. Yet within the group that hadn’t had surgery, weight loss appeared to impart positive psychological impacts. These people, the authors explained, “can attribute their success to their own willpower and determination, while the surgically treated patients achieved their weight loss mainly through technical intervention. Furthermore, the surgery patients are possibly disappointed that they have not lost more weight, and must also grapple with food ingestion.”

The researchers could have been reading Brittany’s mind. She’s not merely dissatisfied with her reflection, but she also feels less healthy than before, and less motivated to eat well and exercise. In the old days, she would hit the gym regularly and rarely got winded. Now she avoids workouts. She also gets exhausted easily, which makes it hard for her to stay on top of her legal studies college coursework while juggling a job as a personal assistant. She still eats plenty of junk food, and says she may check out Overeaters Anonymous. “I’m more obsessed with food than ever,” she laments.

But what bothers her most, perhaps even more than the nagging feeling that she hasn’t really changed that much, is that she feels unequipped to deal with the unpredictable, shame-inducing bathroom disasters. “You know you’re going to have bathroom issues, but you really don’t know until you’re living it,” Brittany says. “Pills? Sprays? I don’t believe in that crap. You spend $30 on a liquid that you drop in the toilet, and it’s supposed to smell like roses. Well, it doesn’t!”

When she first started dating Jeff, she was so terrified at the prospect of him entering a bathroom after she’d used it that she went to extremes to avoid using his bathroom. She popped Gas-X like candy. “I know where all the public bathrooms are within a two-mile radius of his apartment,” she says. “At first, I’d tell him I needed to go to Walgreens at two in the morning — and don’t come with me!” Starbucks remain a trusty standby: “I’ve doubled my caffeine intake just so I won’t feel bad,” she explains.

The unique odors produced by DSers, as they call themselves, are a frequent topic of conversation at Denise’s support group meetings. One newcomer at a meeting last fall was particularly vocal. “DS poop is completely different than normal poop. The stink is the worst!” exclaimed the fortysomething woman, who walked with a cane. She went on to describe her bad eating habits, horrible bouts of diarrhea, and months of mysterious bone pain, which it turned out were caused by a long-term lack of vitamin D. Still, she concluded, “I never had one minute of regretting the surgery.”

The contents of a two-foot-wide drawer in Denise’s kitchen convey a good idea of the kinds of dietary and health concerns people grapple with post-surgery. It’s crammed with prescription prenatal multivitamins (she’s not pregnant), calcium citrate, Vitamin D, probiotics (bacteria believed to aid digestion), antibiotics, a prescription painkiller, stool softeners, Ultra Lactase (like about half of patients, she became lactose-intolerant following her surgery); Gas-X; Beano; Airborne; and Aleve. She swallows at least eleven vitamins a day, plus two Aleve (for lingering tummy-tuck pain), and up to ten Gas-X or Beano, which she carries everywhere. The rest she takes as needed.

“Does anyone have dating stories?” Denise asked her group once the potty talk subsided. One woman chimed in to say she felt far more approachable when heavy. “So was I,” Denise agreed with a sigh. “Men seem intimidated by me now. But that’s because everyone knows that fat girls are easy and they’re not going to say no, right?” The group tittered. “Has anyone found that for a while, dating was your new addiction?” A few heads bobbed. According to Hartman, the psychologist, people commonly embark on dating sprees after they lose significant weight. For her part, Kimberlee dated many men in quick succession. She viewed it as catching up for the formative years she’d missed.

When someone in the group asked Denise if her transformation was complete, she nibbled her lower lip for a long moment. “No, not yet,” she said. “I feel like I’m seven-eighths of the way done. I think I’ll just know when I’m there.” She padded across the carpeted room to a table near the doorway and returned with a small basket filled with Pacific Laparoscopy business cards. “Does anyone need one?” She passed the basket around. Denise carries these cards around with her, always ready to make a referral.

Denise and Andy broke up at the end of October, following a six-month romance Denise has come to compare to her very first, way back in high school: “Andy was the new, thin Denise’s first love,” she explains. They’d had a few nasty fights, and she called it quits after spending a very long night wishing she were anywhere but his apartment. Still, she’s crushed. In an effort to put him behind her, she threw herself back into dating. In the two months that followed, she dated more than fifteen men, most of whom she met online. She saw a few of them again, but none swept her off her feet, which is what she wanted. And then there was Ron.

Although they’ve been friends for two years, he’s recently started showing up with flowers and little gifts. She enjoys his company, finds him attractive, and probably would consider dating him seriously if not for the fact that when they’d first met — after she’d lost a lot of weight but prior to her reconstructive surgeries — he’d only wanted to be friends. Why didn’t he want me then? is the question that often echoes in her head when they’re together. Hartman says it’s common for someone in Denise’s position to harbor conflicting thoughts, such as “I can’t forgive him for not liking me before,” and “I wasn’t satisfied with the way I looked, so how can I hold it against him for feeling the same way?” Denise thinks that perhaps if she could answer the big question she continually struggles with — Am I the same person now? — she could figure out what to do. But she’s just not sure.

Her ex-husband Kerry has noticed some personality changes. Over a recent lunch with his ex at Costco’s food court, he says he’s glad she had the surgery, but that he wouldn’t look twice at her now. “I’m just attracted to larger women,” he says. “Sometimes I’ll look at her wearing a tank top in the summer, with her bones sticking out, and I’ll think, ‘She really needs to gain some weight.'”

Denise beams.

“Still, I think it was a good decision,” Kerry continues. “The biggest change I’ve seen in her is her attitude. She was giving in to everyone before — except for me. Once she got the surgery, she became more about ‘me,’ and after she lost the weight, even more so. There’s been more of a balance lately, but sometimes I get frustrated with her. She can be selfish.”

Still, Kerry concedes Denise is a better mother now. “I did this for her,” Denise says, referring to her daughter. “I’ll never forget when she sat with her legs wrapped around my middle for the first time, after my tummy tuck and hernia repair. She said, ‘Mommy, you have a heartbeat!'”

“I actually thought she was going to die at one point during the tummy tuck,” Kerry reveals. “I was scared I was going to be a single father.”

“All I did was pass out and lose some blood,” Denise chides. “It wasn’t serious. So tell her,” she says, tipping her head toward a reporter. “What was your very first comment to me after that surgery?”

Kerry blushes. “Uh, something like, ‘Wow, you need a boob lift now, huh?'”

Denise rolls her eyes and laughs. “Yep, that’s it. Nice, right?” She’s mentioned before that without her padded bras from Victoria’s Secret, she’s flat-chested. “That’s gonna be a tough choice,” she says earnestly of the potential boob job.

Kerry grins and leans back in his chair. “You’re going to have to find a man who’ll accept it,” he tells her. “And that’s going to be hard, especially in California. You’re not going to find someone to accept you for who you are, for what you went through.”

“I disagree!” Denise interjects hotly. “Andy did.”

“I don’t think Andy fully accepted you,” counters Kerry, who met him a few times when their daughter changed hands.

“I think you’re dead wrong,” Denise snaps back.

“I still love her to death,” Kerry explains after a long pause. “I just don’t want to see her get hurt.”

Andy isn’t all Denise misses. She grieves for Lane Bryant, too. When she happened past the plus-size store during a recent date with Ron, she found herself on the verge of tears. “That store clothed me forever, and now, it’s not going to be a part of my life anymore,” she later explained. “I know it sounds weird, but I swear to God, it’s like losing a boyfriend.” She asked Ron if he’d walk through the store with her. Kimberlee, for her part, was ecstatic the day she dialed customer service to cancel her store credit card. “It was so empowering,” she recalls.

A few days after her visit to Lane Bryant, Denise plops a neatly folded gray Nike T-shirt, soft green knit pajamas, and a pair of jeans on her bed. They’re her “before” clothes. “They always say you should save some as a reminder,” she says. She gazes affectionately at the T-shirt: “This was my favorite because it was a 4X men’s, so it was kind of baggy on me, not snug like everything else I owned.” She holds it to her torso, and speaks nostalgically: “Doesn’t it just blow your mind?” She wore the pajamas in the days following her DS, she explains, and she’d long loved her size 28 Venezia jeans — Lane Bryant’s line — because they had a bit of stretch in them. Now she wears size 8, but hates to shop. She’s overwhelmed by the vast selection of clothes now available to her. Most of her new wardrobe consists of hand-me-downs.

She refolds the clothes and returns them to a shelf in her closet, then turns to face the mirror opposite. For the first time in recent memory, Denise has not made any New Year’s resolutions. There’s no more flesh to wish away. Her eyes scan her reflection. “No one is totally happy with themselves, but I feel like I’ve finally accepted myself,” she says. “I’m okay with who I am. Before, I worried a lot about people liking me. Now it’s like, if you don’t like me, c’est la vie, honey! Your loss. I think that’s the big difference in who I am now: I don’t feel like I have to try to make people like me.”

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