Jewel’s story: how one teen battled obesity with medicine’s best — and most underused — tool

On April 19, 2017, the second day of her spring break, Jewel Francis-Aburime was lying on an extra-large bed at MedStar Washington Hospital Center in DC, calmly waiting to be wheeled into an operating theater, where surgeons would remove 80 percent of her stomach.

“I’m looking forward to having more clothing options. And stairs — oh, dear god, stairs — I’m looking forward to not hating stairs,” Jewel, 18, said. On a recent tour of the University of Maryland Baltimore County, where she’d been accepted for pre-med in the fall, she counted every one of the 88 steps she had to climb.

Since the age of 13, Jewel — 6 feet tall, square glasses, long cornrows — has been trying to shrink her body. She’s joined gyms. She’s sprinkled Sensa on her food to suppress her appetite. She’s injected herself with B vitamin shots. Nothing worked. Her last of many attempts was the low-carb ketogenic diet, which failed and left her with constant headaches.

As her family’s house in Bowie, Maryland, filled with exercise machines, workout DVDs, and free weights, Jewel grew larger, and the bullying at school got worse. She was now severely obese, weighing nearly 400 pounds, with a clothing size of 26.

Like millions of other Americans with obesity, Jewel has been fighting a war she can’t win. Over the years, research has piled up demonstrating that diets fail most people in the long run, and that exercise isn’t very helpful for weight loss either — particularly for people like Jewel with severe obesity, defined as a BMI of 40 or more. (Jewel’s BMI in April was 52.)

As more and more people find themselves with no real options for weight loss, doctors are turning to bariatric surgery, which involves permanently altering the stomach to restrict the amount of food it can hold.

Some doctors are even now arguing it would be cruel not to recommend a weight loss operation to teens with severe obesity, like Jewel. As Dr. Thomas Inge, a University of Colorado pediatrician who leads the most important ongoing study on adolescent bariatric surgery, sees it, what we now know about the effects of obesity is far more damning that what we know about the risks of surgery. And its potential benefits are great.

Lives are “destroyed by severe obesity,” Inge said. “I’m much more worried about the consequences of not operating [on young people].”

At MedStar, Dr. Timothy Shope, Jewel’s surgeon, swept into her hospital room, white coat trailing behind him, to ask if Jewel had any more questions before her operation. She didn’t.

I’m not nervous. I’m just really looking forward to waking up. That’s what I want right now, to wake up and know it’s done. I’m happy, I’m chill at the same time.

She’d been taking bariatric classes since last fall (an insurance requirement) and had watched dozens of videos on YouTube. The future Jewel had imagined for herself — as a college student, and later a neurologist — hinges on weight loss success.

“This is the beginning of a whole new journey,” she said, just before going into the operating room.

Jewel felt surgery was her last hope of getting to a healthier weight. But it’ll be years before she’ll really know how well it worked. And while her new stomach will make it much harder to eat a lot of food, it may not make her cravings go away. Plus, she still has to live in America, where she’ll be encouraged to overeat every single day of her life.

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Watch Jewel’s journey on YouTube

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The case for teenage bariatric surgery

Though obesity doctors and researchers increasingly favor bariatric surgery, it’s still far from a cultural norm. Only 1 percent of Americans who are eligible get surgery, and surveys show a third still think it’s dangerous or ineffective.

I didn’t know much about weight loss surgery either, until I learned about a study comparing contestants on the Biggest Loser reality TV show, who’d gone on crash diets and exercise programs to lose weight, with people who had gastric bypass surgery.

The researchers found the surgery patients lost weight and saw their metabolisms normalize within a year, to a rate that matched their new body size. The TV show contestants, who dieted and exercised their way to a smaller size, saw their metabolisms slow down and stay that way — even after six years, when they had regained much of their weight, on average. In other words, the studies showed surgery could do less harm to the body and be more helpful for weight loss than the standard prescription on offer in America.

Still, bariatric surgery seemed to me like an extreme response to America’s national eating disorder. How could we cut our way out of a health crisis caused by an environment dominated by cheap, super-alluring processed foods? I was even more disturbed by the thought of doctors operating on young people. It seemed like a desperate last resort.

So I endeavored to better understand bariatric surgery — its potential and its pitfalls — and whether there was truly a strong case for young people getting these operations.

I've struggled so much with my weight growing up, and at the time, it was a pretty lonely feeling. ... Teenage bariatric patients are not something you see every day, and I want other teenagers who might be considering [surgery] to understand that they're not alone.

I met Jewel in November 2016, five months before her operation. I was there at pre-op appointments, inside the operating room during her surgery, and I followed her for eight months afterward.

Jewel generously and bravely opened up her world, meeting with Vox videographer Sam Ellis and me on a regular basis. At our request, she used her smartphone — her most prized possession — to file video diary entries, snap photos, and track her weight, moods, side effects, and clothing sizes before and after the surgery. Here’s a video diary of Jewel telling a friend she’d decided to go for the operation.

So what would your reaction be if I told you I was getting weight loss surgery?

It quickly became clear why Jewel turned to surgery to get some control over her weight, and why, given her circumstances, she made the best possible choice.

Bariatric surgery patients live longer, and have a lower risk of cancer and lower rate of Type 2 diabetes. People who get the surgery also weigh significantly less, on average, compared to adults with obesity who don’t get the operation. The most common forms of bariatric surgery in America today, the gastric sleeve and gastric bypass, help people lose about 30 percent of their bodyweight and keep it off. That’s why Medicaid now covers the procedure in 46 states, as do national health systems in countries as diverse as Canada, Brazil, and Israel.

Several compelling longer-term studies have also shown that teens reap similar benefits as adults. Intervening with surgery earlier in life seems to help young people with obesity not only lose weight and resolve their chronic health woes — like diabetes and high cholesterol — but even prevent these conditions from developing in the first place.

At the same time, the more than $60 billion we throw into diets and exercise regimens isn’t paying off. In one of the best long-term studies of weight loss, involving overweight or obese people with Type 2 diabetes, participants following a rigorous education, diet, and exercise regimen only lost an average of less than 5 percent of their original bodyweight after eight years.

People, particularly those with morbid obesity, who can lose even more dramatic amounts of weight without surgery are even more rare. All diets — Zone, Atkins, Ornish — seem to perform equally dismally in the long run, only inducing a few pounds of weight loss for most people after a year. So the diet industry is often peddling a myth that people are desperate to believe.

Yet we still anticipate that diets will work. People with obesity are stigmatized, expected to lose weight by means that have been proven to fail, while we ignore or balk at the only effective treatment on offer.

Going into this story, I thought the solution to the epidemic of childhood obesity was long-term prevention — making it easier for children to eat healthfully, and harder for them to eat junk.

I still believe that.

But preventing obesity in the future doesn’t account for how to help young people like Jewel, who are suffering from severe obesity right now. And that’s where I now see bariatric surgery coming in — even with all of its difficulties and challenges. Following Jewel’s life made it clear that surgery, while no cure, gave her a chance where everything else failed.

April 19: Jewel’s stomach and metabolism are altered forever

In the operating room on the day of Jewel’s surgery, Shope and eight other doctors and nurses in blue scrubs buzzed around her, covering everything except her abdomen in sanitized blue sheets.

The nurses inflated Jewel’s abdomen by pumping it full of carbon dioxide gas, to give doctors more space to work.

The surgeons made four small incisions in the upper and lower corners of her belly, and stuck what looked like four white plugs into the cuts. Through those plugs went the cameras and the instruments they needed to perform the sleeve gastrectomy laparoscopically, eventually cutting Jewel’s stomach down from a wide football into a slim banana.

The gastric sleeve procedure (and the gastric bypass) reduces the size of the stomach, so people can’t eat as many calories. But these surgeries have other physiological effects that help with weight loss, and researchers are only beginning to understand them all. Shrinking the stomach can suppress the hormones that affect hunger and satiety, like the “hunger hormone” ghrelin. The gastric bypass may also reset the body’s metabolic rate, as the Biggest Loser study showed, and alter the gut microbiome in ways that make losing weight easier.

A heart monitor buzzed at an even tempo, and the operating room was dark, except for the glow of a TV monitor that projected an image of Jewel’s glistening insides. Her organs appeared to be pink and healthy, unlike those of many older bariatric patients, which are filled with the scars from obesity-related health problems like hernias or diabetes.

For Jewel, the ravages of a lifetime of carrying around hundreds of pounds of extra fat are still years away. That’s because obesity is like smoking — it has a cumulative effect on the body, gradually contributing to disease the longer a person keeps on extra weight. Getting bariatric surgery early on, Shope and other obesity experts think, will help Jewel avoid the diseases that’ll inevitably arrive if she doesn’t lose weight.

Over time, obesity can damage every major system in the body. The more weight a person carries around, the harder the cardiovascular system has to work, and the higher the risk for heart failure, irregular heartbeats, coronary heart disease, and stroke. Extra weight strains the hips, legs, and ankles, increasing the risk of osteoarthritis. Obesity is associated with insulin resistance, which can turn into Type 2 diabetes. Fat cells promote inflammation and alter hormone levels in ways that doctors now think increase the risk of at least 10 types of cancer. Obesity even interferes with the brain in ways that may increase the risk of Alzheimer’s, and stresses the immune system, putting people at a higher risk of dying from infectious diseases.

After 10 am, the surgeons’ real work began: They started to “mobilize” the left side of Jewel’s stomach, cutting it away from the surrounding tissue and organs with a harmonic scalpel. The scalpel sealed the stomach as it cut, snipping yellow sheaths of fat that ran between Jewel’s stomach and the spleen. The operating room filled with the smell of burning hair — Jewel’s cauterized tissue.

Once the stomach was freed up, the surgeons stapled off about 80 percent of it — the portion they’d soon remove. This time they used a linear cutting stapler, which fired six rows of staples and sent a blade down the middle.

Before closing the four holes in Jewel’s abdomen, the surgeons did a “leak test” to make sure her new, much smaller stomach was fully sealed up. This involved filling Jewel’s abdomen with fluid and then forcing air through her stomach. “It’s like testing your tire,” Shope told me.

There was one final step: pulling the portion of stomach that had been stapled off through one of the holes in Jewel’s abdomen. But as Shope began tugging with a clamp, Jewel’s stomach tissue appeared to be stuck. Two doctors joined him in coaxing out the organ, pushing and massaging with all their force. Slowly, what looked like a raw and soft pink sausage emerged through the small incision in Jewel’s belly.

The next day when I visited Jewel at the hospital, the first thing she told me, through a haze of painkillers, was that her abdomen had never hurt so much. All her pain was radiating from her belly, and she couldn’t find a comfortable position.

It’s a lot of pressure. I feel really bloated. There is no comfortable position to be in.

When Shope checked in on Jewel, he reported that the surgery had been a success. She’d lose about 125 to 150 pounds over the next year, he anticipated. That would leave her weighing up to 250 pounds, still obese according to the BMI scale, but “a whole lot healthier,” he said. (Even losing 10 percent of one’s bodyweight can improve health outcomes.)

A fast-food commercial popped up on the TV in Jewel’s hospital room. Jewel had been fasting before the surgery and hadn’t eaten solid food for two weeks. Was she hungry yet? No, she said. And the sight of the food on the TV was making her want to throw up.

Soon, though, she’d have her appetite back. And as I followed her over the next eight months, I saw that the gastric sleeve was no magic bullet. The surgery and its effects proved to be a true mental and physical ordeal.

June 5: a painful chapter ends, and weight loss is behind schedule

By the time Jewel opted for weight loss surgery, at only 18, she felt like she’d struggled with obesity for a very long time. She emigrated from Nigeria with her family at the age of 5, when her parents won the US visa lottery in 2004. In the move, Jewel lost all her friends, didn’t see most of her family anymore, and found herself having to adapt to a new country and culture mostly on her own, while her parents were busy rebuilding their lives in America.

In Nigeria, my mom was a nurse. My dad was a lawyer. The first four months in America, we lived with family friends [in their apartment].

She was a chubby kid back in Nigeria, but like many immigrants to the US, she began to put on weight after arriving here and never really stopped.

Her size wasn’t lost on her schoolmates. One early memory that still won’t leave her mind: Whenever her elementary school class was split into groups for relay races, and Jewel was put on someone’s team, “the entire team would groan in unison,” she recalled.

[When] we were still very new to the US, McDonald's for instance, was just a place to get cheap food. My parents likely weren't thinking of how healthy it was. And when my parents did start to realize it was a problem, I had become so accustomed to it that it became very challenging for me to stop.

She says the abuse faded by the time she settled into Eleanor Roosevelt High School in Greenbelt, Maryland. But her weight still trips her up every day. She can’t squeeze her arms into the lab coats in biology class. Sitting in school desks gives her numbness and pins and needles in her thighs. She often avoids public speaking or sports — a legacy of the years of teasing. She’d sometimes lie to get out of activities that would make her feel vulnerable in front of others, pretending to be sick and hiding out in the nurse’s office.

That’s why on her graduation day last June, nearly a month and a half after surgery, she was excited to leave school behind.

“I’m really ready to move on,” Jewel said back at home after the ceremony, still in her baby blue cap and gown, her hair smoothed out into waves, her long nails lacquered white.

I’m not crying over high school at all. ... I associated school with sadness and being upset because I was teased a lot because of my weight when I was younger.

The stomach pain and constipation Jewel had after her surgery had faded. But she had new problems to contend with. In April, she learned she didn’t qualify for financial aid at the University of Maryland because her parents make too much money. So she put her dreams of pre-med on hold, deferring college for a year to save up.

Jewel’s slimming had also begun, but it was happening gradually. With bariatric surgery, weight loss in the first six months after the procedure is typically very rapid, eventually plateauing at about a year, after which people regain a small percentage of their original bodyweight.

Jewel wasn’t having the typical experience. She had lost only 20 pounds in the month and a half since her surgery, about half the average in teens following a gastric sleeve by that point. Jewel’s mom, Justina, a nurse who is training to become a doctor, had her own bariatric sleeve surgery three weeks before Jewel. She was already down 40 pounds, from a high of 304.

I’m a bit short of my goal. I didn’t lose as much as I thought I would. But it’s okay. I like to be optimistic — the world will not end. So long as the scale goes in the right direction, I’m okay.

The gap between Jewel’s progress and her mom’s was nagging at Jewel. “My mom was the ideal patient: She has no hunger, doesn’t feel thirst, hardly has an appetite. Me, I still feel hunger, I still feel thirst, I still have an appetite,” Jewel said. “It’s disheartening.”

Jewel even gained a couple pounds in one week, which left her “distraught” and worried her stomach might already be stretching.

There are some things the surgery was helping with, however. Jewel couldn’t eat nearly as much as she used to. She also felt sick after eating greasy and sugary foods, which was helping her avoid them.

June 25: going to work in fast food and feeling famished

Before her surgery, Jewel thought she’d be heading to college. But by mid-June, she needed a job to start saving money.

One of Justina’s patients suggested Jewel try for a job at Checkers, a fast-food chain. Jewel was hired on the spot, and she accepted.

Her first assignment: flipping greasy burgers, the very food she was supposed to be avoiding. The grill left her overheated and tired — she wasn’t used to standing on her feet for so many hours.

Each day, she turned down the free hamburger and fries she was entitled to as an employee. But she felt famished and downed fruit punch from the soda fountain.

By three weeks after graduation, she’d only lost 4 more pounds and suspected it might have been all the calories she’s drinking. (“I don’t want to blame her, but at least early on there were dietary issues” that affected the speed of Jewel’s weight loss, Shope told me later.)

While Shope was confident that Jewel would continue to lose weight, there’s always uncertainty with every bariatric patient, and lots of variation in how people respond. What is clear: For most people, the operation is not an easy fix, and it comes with a range of potential side effects.

The knowns and unknowns of bariatric surgery in teens

Doctors still can’t predict who will succeed with bariatric surgery, and who will be among the one in 10 patients for whom the procedure fails.

There’s also a lot they need to learn about its effects on teens.

First, here’s what they know: Up to eight years after surgery, teens have typically lost about 30 percent of their original bodyweight. They also see other incredible health benefits. In one long-term study published in the New England Journal of Medicine in 2016, 95 percent of the participants who had Type 2 diabetes saw their diabetes resolve, while nearly 80 percent normalized their high blood pressure. These turnaround rates are more dramatic than what researchers have documented among adults.

Doctors have also learned about potential surgical complications following teenage bariatric surgery, which sometimes requires additional operations and, much more commonly, results in vitamin and nutrient deficiencies.

Not all bariatric surgeries are equally effective, either. The best seem to be the gastric sleeve and the gastric bypass, which vastly outperform the lap band procedure. But the bypass is the riskiest operation, since it involves not only altering the stomach but rerouting the intestines too. And up to 17 percent of adults who have undergone a sleeve operation are later diagnosed with Barrett's esophagus, a complication of acid reflux disease that can lead to cancer. Teens who get the surgery could be at risk too. It’s also not clear how much of their weight loss will be sustained throughout their lives.

I decided to have some chicken and rice for lunch. To the right is Nigerian jollof rice, and to the left is rotisserie chicken. Pre-op, I would have eaten, like, three to four times more rice. One thing I had to adjust to is increasing the amount of protein, relative to everything else.

Then there are the rare but disturbing psychological effects that have surfaced in adults after bariatric surgery, including a slightly elevated post-surgical risk of self-harm, suicide, and drug and alcohol use disorders. Teens’ brains and organs are still developing, and we don’t yet know exactly how side effects will manifest later on.

“There’s still some unknowns,” said Inge, who has led many of the teen bariatric studies. “Maybe they will have mild nutritional deficiencies. But they won’t be in a wheel or walker because their hips and knees are damaged because of their weight.”

August 31: 50 pounds down, but still hungry

By August, Jewel’s weight loss was finally gaining momentum.

Every Wednesday, she’d descend from her purple bedroom to weigh herself on a scale in the corner of the kitchen. It was a new ritual — along with recording the weight, weighing her food, and checking the calorie, carb, and protein counts in whatever she was eating.

Still, each time was nerve-wracking: Would the scale keep moving in the right direction? By how much?

Four and a half months after her surgery, Jewel was losing 2 or 3 pounds every week. That had her feeling a little more confident — but as you can see in this video diary, she was still struggling to reconcile her progress with her expectations, and the fact that she was losing a little less than the average bariatric patient.

I understand by bariatric standards, when you compare me to them my progress isn’t that good. But by my own personal standards, 50 pounds in four and a half months is great. I’m happy for that.

“Isn’t that, like, amazing? No, that’s amazing,” she said up in her room, lined with manga and music posters, and romance novels.

What caused the change? Maybe it’s her new lifestyle. After quitting Checkers in July, Jewel decided to help her family with a new real estate business at home. That gave her time and flexibility to walk outside with her sister or on the treadmill — more regular exercise than she’s ever done.

Jewel also shifted her thinking about the surgery. At first she thought the sleeve would do a lot of the work for her, and control her hunger and appetite. But that wasn’t the case. “My ghrelin did not listen to Dr. Shope,” she said, referring to the hormone that increases appetite. “My ghrelin's just doing its own thing.”

She’s also planning out what she’ll eat each day more carefully. For breakfast, it’s oatmeal and almond milk; then salmon with vegetables or mashed potatoes for lunch or dinner. Protein, fruits, and vegetables now make up a larger part of her diet than they ever have.

These days, the numbers on the scale motivate her. She’s never seen the scale move that far along in the right direction.

“I’m still pretty far from my ideal weight, but I think [my] progress is really good,” she said. “By my own personal standards, 50 pounds in four and a half months is great. I’m happy for that. It makes me excited about more weight I’m sure I’m going to lose in the future.”

We can’t cut our way out of the obesity epidemic

When I asked Jewel why she thinks she gained so much weight over the years, she said simply, “I just ate a lot. All the time.”

That was easy to do in Bowie, as it is anywhere in America. Before her surgery, her go-tos in her neighborhood included McDonald’s, IHOP, Olive Garden, and Cheesecake Factory — where she’d sometimes eat meals with more than a day’s worth of calories. Her mom wanted to give her daughters these foods because she didn’t have them as a kid, growing up in Nigeria. Eating fast food was part of becoming American.

Plus, they weren’t fully attuned to how this kind of eating could be harmful, Jewel said. “I don't think my parents had too many issues with unhealthy or overly processed food in Nigeria. So when they came here, it wasn't something that was really on their mind.”

Researchers now see obesity as a disease driven by patterns of overeating, which in some people triggers the expression of certain genes and traits that make them more susceptible to gaining a lot of weight. Those genes have always been there, but what’s changed in the past 40 years is that our environment became increasingly saturated with cheap, ultra-processed foods. “The obesity epidemic occurred because the food environment has changed remarkably,” said obesity researcher Kevin Hall at the National Institutes of Health.

American adults and children are now the heaviest in the OECD, and while the rate of obesity in youth has stagnated in recent years, 17 percent of children and adolescents struggle with obesity. That’s more than 12 million young people. And as America’s diet has been exported around the world, kids in other countries are quickly catching up.

It was really just, “Hey, I have $5 and want some food, let’s go to McDonald’s, “because it was the most convenient option for our family situation (new immigrants just starting out, not much money, etc).

There is only one way to fully turn this problem around, and it doesn’t involve surgery; it involves changing the environment to make it hard again for children and adults to overeat.

That requires policy and regulation. But the Trump administration has reportedly decided childhood obesity is not a priority, and White House officials have been trying to reverse the small policy gains to address childhood obesity made by previous administrations, including healthy school lunch regulations.

Many of the more than 25 doctors and health researchers I spoke to for this story expressed regret that we’re at the point in the uncontrolled epidemic that operating on young people feels like an answer. None of them believed surgery would stop the spread of obesity. As NIH’s Hall said, “We’re not going to cut our way out of the obesity epidemic.” However, they agreed surgery is a proven tool that should be considered more often.

October 4: adjusting to a different body and facing the long road ahead

By October, six months after her operation, the scars on Jewel’s belly had healed and her confidence continued to grow. One cool and sunny afternoon, she went shopping at Target in Beltway Plaza, a strip mall in Maryland. It was her first time at a store that wasn’t dedicated to plus-size women, and she circled the racks slowly, unsure of which sizes to pull. She settled on two tops, grabbing each in at least three or four sizes, from L to XXXL.

The first shirt she tried on was silky and sleeveless, in a shade of red-orange that popped against her skin. “This is an XL,” she announced, as she emerged from the changing room. “[I’m] someone who's used to three- and four-XL, and not used to shopping at Target, not used to being able to shop at Target. ... It's weird. It's so weird,” she said smiling.

I told Jewel that an XL is equivalent to a size 16.

“You're lying,” she said.

“I'm serious,” I replied.

“I'm not a size 16. The size 16 did not fit me. I don't believe you,” she said.

This is the size 14/16 dress in all its glory!

Jewel’s self-image hasn’t yet caught up to the changes in her body. And there are changes. With nearly 60 pounds lost, her bones are already beginning to protrude from her frame in new ways. At night, when she curls up to go to sleep, she can feel shoulder blades and clavicles she didn’t even know were there. She’s noticed her wrists look bonier, that her knuckles are coming out, and that her feet seem to be shrinking.

Still, the weight is coming off slower than Jewel expected, and slower than her mom, who has now lost about 80 pounds. Even between mother and daughter, in the same household, the responses to surgery have been different and surprising.

Jewel has also learned about the unique obstacles that come with being a teenage bariatric patient. She can’t control her food or schedule as much as an adult might. She sometimes forgets to take the vitamins she’s supposed to every day. What impact this will have on her body as she ages, only time will tell.

For now, Jewel is focused on all the positive changes in her life and moving ahead. She’s working on her university applications for next fall, hopeful about going back to school.

Before her Target stop, Jewel circled the mall in search of lunch. Among the choices on offer: Chinese food, ice cream, cotton candy, popcorn, cookies, candies, pizza, or chicken wings. Finding healthy options in America remains a daily battle, and one Jewel knows she’ll have to fight for the rest of her life. Whether she manages to avoid eating junk food, she says, still depends on her “mental and emotional strength” — even after losing 80 percent of her stomach.

But after the surgery, she finds she’s eating fewer calories. Her smaller stomach puts a hard stop on how much she can get down.

“This [surgery] makes it a lot easier to eat less food, and basically that's the foundation of losing weight,” she explained.

Jewel settled on lunch at Jodeem, a West African restaurant, where she had to ask the server to give her a smaller portion of her chicken curry, plantains, and rice. She sat down with the white cardboard box and slowly picked away at the food. She now asks for her food to go right at the outset, because she can never finish her meals.

Jewel chewed her lunch carefully. If she takes bites that are too big, and eats too quickly, she feels cramps, her stomach painfully contracting and relaxing. Halfway through her meal, she felt full and had to stop eating.

Looking back at her past year, she says she’d do the surgery all over again. So would her mom, who says it’s led to “a rebirth” and wishes she had done it earlier.

Jewel would also recommend the surgery to other teens with severe obesity. The trouble is many doctors are still hesitant to do so. A survey of more than 700 primary care doctors found that nearly half would never refer their obese adolescent patients for surgery, in part, the researchers suggested, because they weren’t sure of the long-term consequences.

“The contrarian view is that we don’t know about the long-term health consequences of surgery,” said Dr. David Arterburn, an obesity expert at Kaiser Permanente Washington Health Research Institute. “But my response to that is that we do know the long-term consequences of severe obesity.”

As bariatric procedures have proven to be safer and more effective over time, medical practice now lags the evidence, said Joe Nadglowski of the Obesity Action Coalition, a membership organization for people with obesity. Out of the 20 million people who are eligible, fewer than 1 percent get a bariatric surgery for weight loss, according to the Obesity Society.

Though the number of adolescents getting the surgery grew from 51 in 1997 to more than 1,600 in 2009 (the most recent year data is available), it’s still a tiny fraction of the 4.5 million Americans under 19 with severe obesity who’d be eligible.

For me, [surgery has] been very positive [but] it wasn't perfect. It wasn't super, super ideal, which I think is something to learn from. ... I think it helped me grow as a person.

Insurance coverage hasn’t caught up either, Nadglowski added. One study found that fewer than half of adolescents who were cleared for an operation were able to get insurance coverage on the first try. Even when they do gain coverage, there are other barriers to access, such as high copays, which Nadglowski attributes to stigma.

“There’s an attitude that people are at fault for their obesity, that it’s a failure of personal responsibility,” he said.

Right now, Jewel considers herself lucky to have gotten surgical help for obesity, though she admits it’s been no magic fix. As of December 8, she weighed 310 pounds. She wants to get down to 160 pounds, less than half of her pre-surgery weight.

If Jewel gets there — and she is very determined — she’d be an outlier among bariatric patients. For most people, weight loss plateaus at about a year. After that, teens who’ve had a gastric sleeve typically regain about 3 percent of the weight they lost. Three years after surgery, they’re down 26 percent down from their original bodyweight, on average.

But there are also extremes on both ends. In one longer-term study of bypass patients, 13 percent lost as much as 45 percent of their original weight after seven years — and another 5 percent of patients had only lost 10 percent of their weight.

That’s why surgery isn’t the end-all solution to obesity. We need a treatment that doesn’t require a major operation, that can reliably get people with obesity and severe obesity back to a healthy weight they can maintain.

If Jewel has an average response, she’s already close to hitting a wall with her weight loss. Whatever happens next, it’ll be a long road ahead. But for the first time in her life, she is moving toward her goal weight, not away from it. “As long as it's going down,” she said.

Here I am, making my last video diary for you guys, 76 pounds lighter than when I started. It is amazing. It is fantastic. It’s beautiful how life can change like that, so unexpectedly.

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Credits

Editor: Eliza Barclay
Visuals editor: Kainaz Amaria
Special projects editor: Susannah Locke
Family photos and video diaries: Courtesy of Jewel Francis-Aburime
Video: Sam Ellis
Copy editor: Tanya Pai
Fact-checker: Tim Williams