Slim Chance
Diabetes, obesity, and one teenager’s shot at changing her life from the inside out.
By Linda Vaccariello
Illustration by Robert Burch
Last December, a month after her 15th birthday,Alecia Reynolds rolled out of bed at 6 a.m., washed her face, combed her honey brown hair, and dressed for the three-hour drive to Cincinnati Children’s Hospital Medical Center. Her mother, Lisa Combs, filled her purse with rattling containers of prescription drugs—Alecia’s daily medication—and when Alecia’s aunt arrived they loaded into her car and made their way through tiny Booneville, Kentucky, and on past the towns that dot Route 11 as it skirts Daniel Boone National Forest. Alecia doesn’t remember much about the trip, which probably means she slept most of the way. Back then, she slept a lot even when she wasn’t in the car. When you weigh 300 pounds, navigating the world wears you out.
Lisa and Alecia were on their way to Children’s Hospital to see if Alecia was a candidate for bariatric bypass surgery. In 2007 alone, about 200,000 morbidly obese Americans had this procedure in hope of losing massive amounts of weight. In Cincinnati, a handful of them were teenagers. Children’s is part of a national consortium of hospitals studying the effects of bariatric bypass surgery on kids like Alecia. You may have heard about it on Oprah or The Today Show: teenager’s lives being transformed by an operation to help them lose weight.
Expect to see more. Early next year, Pediatrics, the journal of the American Academy of Pediatrics, will carry results of research done at the hospital that demonstrate the dramatic effect the procedure has on Type 2 diabetes in children. It’s an extraordinary finding about a surgery that could put the brakes on a serious metabolic disorder affecting more and more American children. But it’s also a procedure that comes with great risks. It alters organs and has life-long consequences. And when you’re having the surgery at 15 rather than 35 or 55, “life-long” means a whole lot more.
ALECIA REYNOLDS HAS such a pretty face. That’s what people always say about girls her size, but in her case it’s true. She has creamy skin that blushes peachy-pink and long lashes whisking over eyes that twinkle when she flashes her shy grin.
Alecia was a sturdy little kid who became a chunky girl who became a heavy pre-teen. When she was 12, she was diagnosed with Type 2 diabetes—the kind of diabetes that people used to call “adult-onset.” Except that she wasn’t an adult. She was a junior high girl who was gaining weight fast. Eventually she got so heavy that it was hard to fall back on gentle words like “chunky” and “plus-sized.” One crowded, hot day at Kings Island, the ride attendant for the Drop Zone struggled to latch Alecia’s seat restraint. Finally she was asked to get off. The mortifying reason was obvious to all the gawkers: Alecia was too fat to ride.
The diabetes got worse, then tests showed she had high cholesterol and elevated triglycerides, too. She got headaches so bad her vision blurred and she felt like vomiting. She’d gone through puberty when she was only a fourth grader, but her periods stopped at 12. She tried taking the hormones her doctor prescribed, but they had so many side effects she quit after a year. She was always a shy girl; now, self-conscious and lethargic, she stopped going to parties and after-school events. And when she started high school last fall, the good grades that she’d brought home for so many years evaporated.
Her mother could see that Alecia was becoming more and more withdrawn, and it made her heart ache. She knows how it feels. She’s 40 now, but when Lisa Combs was younger she struggled to keep her weight down and eventually lost the battle. Now she was seeing it happen to her daughter: food had become her best friend. “We had to do something,” she says.
Lisa knew people who’d had weight-loss surgery. There was her brother-in-law’s wife—Alecia’s aunt—who was a walking advertisement for what a successful bariatric bypass can do for a person’s health. But Lisa didn’t realize it was an option for her child until a Cincinnati specialist pointed them toward Children’s Hospital. Which is how they found themselves last December, hip-deep in doctors, nurses, nutritionists, and therapists, trying to determine if Alecia qualified for this surgery.
She was heavy enough, no question. At five-foot-three and 302 pounds, her body mass index—a measurement of the amount of fat on her body—put her in the morbidly obese range. Plus, she had “comorbidities,” a slate of related problems that made her a candidate for serious weight-loss intervention. During her day-long assessment there were the expected questions about Alecia’s family medical history—about her dad, an alcoholic who died when she was too young to remember; about her grandparents and their diabetes and heart disease. There were questions for Lisa, too, about Alecia’s sister, Gena, and her stepdad, Homer Combs. Who else in the family was heavy? What kind of food did Lisa cook at home? Did the family eat together? How often did they eat out? And there were conversations with Alecia that were simply personal. Tell us about your school.... About your friends.... About your life....
Lisa knew that her daughter’s diabetes was getting worse, that she was getting heavier, that Alecia had all sorts of health problems a 15-year-old shouldn’t have. She also sensed that Alecia wasn’t happy in school, but she didn’t know how miserable. Using her shy smile as a mask, Alecia poured it out for the hospital staff. She told them about the teasing and the cruel jokes, about the kids who simply snubbed her. “I used to have friends,” she told the doctors. Now the line of demarcation between popular and outcast had been drawn, and she was on the wrong side. She couldn’t concentrate in her regular classes; in phys ed, while other kids played team sports, her assignment was simply to walk the perimeter of Owsley County High School. It left her exhausted. Just sitting in class she was uncomfortable, wedged into a school desk made for someone half her size, waiting for the bell to ring.
From time to time as Alecia talked, a staff member would turn to her mother and say, “Did you know that?”
“I didn’t have a clue,” Lisa says. “I just about cried.” The next day, back at her machine at the Lion Apparel factory, stitching Velcro to firefighter’s coats, all Lisa could think about was Alecia—uncomfortable, humiliated, and struggling to study.
Shortly before the end of the year, Children’s Hospital notified Lisa that Alecia was approved for a gastric bypass. The new year, they decided, would be a chance at a new life.
ONE IN 50 Americans is classified as morbidly obese—that is, carrying enough weight to shorten life. There are various ways of defining morbid obesity, but in layman’s terms, 100 pounds overweight gets you in the door, and having a serious this-could-kill-you condition such as sleep apnea, cardiac disease, or diabetes makes you Exhibit A.
Children’s Hospital started doing the Roux-en-Y gastric bypass on teenagers in 2001. With the Roux-en-Y procedure, a small pouch at the top of the stomach is sectioned off—this becomes the new stomach—and re-attached directly to the middle of the small intestine. You lose weight for two reasons: first, because the small stomach fills quickly, so you can’t eat much; second, because you’re not absorbing as much nutrition from the food you do eat.
Dr. Thomas Inge, director of the surgical weight-loss program for teens at Children’s, says that the only difference between the adult and teen gastric bypass procedure is “philosophical.” In both cases, he says, “it’s a serious approach to a serious problem.” But Inge and his pediatric colleagues believe that using the procedure for obese teens can have more advantages than waiting until they become obese adults.
The Stanford-trained Inge was part of a summit of pediatric surgeons who began meeting in 2001 to develop guidelines for the surgery in adolescents. You’ll find his name as co-author on a mound of academic papers on the subject, including one (slated to be published next year in Pediatrics) about the effects of the surgery on Type 2 diabetes. Cincinnati Children’s Hospital Medical Center is one of four hospitals (Texas Children’s Hospital, Children’s Hospital of Alabama, and University of Pittsburgh are the others) that make up the Teen-Longitudinal Assessment of Bariatric Surgery consortium, also known as Teen-LABS.
Bariatric surgery for adult weight loss has been around for decades. But using the surgery on obese teens doesn’t have that kind of track record. Nor does it have that many examples. National totals are hard to come by; CCHMC has performed it on fewer than 100 patients since 2001. Under Inge’s direction—with funding from the National Institutes of Health—Teen-LABS researchers are following patients, trying to figure out what it means to have your stomach reduced to the size of an egg when you’re still a growing kid, and to live with that for the rest of your life. “The story that will be told by this study will be very interesting,” Inge says. And kids like Alecia will have starring roles.
IT’S MID-JANUARY, AND there’s good news: Alecia has lost 3.3 pounds since her visit to Children’s four weeks ago. The bad news? She’s still drinking Powerade.
Alecia and her mother forgot to bring the chart they were given to track Alecia’s food and beverage intake, so Shelley Kirk—a clinical dietician and director of HealthWorks!, the hospital’s behavioral weight management program for overweight children and teens—is quizzing them about the past month. Alecia was supposed to switch to skim milk, which she doesn’t like much, and cut out second helpings except for non-starchy vegetables. “Her problem is, she loves potatoes,” says Lisa.
Another important goal has been to eliminate sugary drinks. Alecia’s doing real well with that, Lisa reports. She’s just drinking “water, Crystal Light, and Powerade.”
Kirk looks up when Alecia’s mother says “Powerade.”
“A few times,” says Lisa.
Have they put stickers on the calendar when she goes through the day without Powerade, Kirk asks.
“A few times,” says Lisa.
“So you’re far away from meeting that goal,” says Kirk.
Lisa and Alecia seem less than concerned. One is practically none.
But Powerade, sweetened with high-fructose corn syrup, is a problem. “These drinks fuel hunger,” Kirk explains. “The more you drink, the more you want to eat and drink.”
It’s important to fill out the daily food chart, Kirk tells them; to sit down each evening and talk about what Alecia has eaten. And, Kirk says, it’s important for Lisa to be a cheerleader for Alecia’s success.
“How much do you want to get your nails done?” she asks Alecia. Each kid in the program names a reward that he or she will get if they meet their goals for the month—something like a CD, or a DVD, or a new outfit. Alecia has said she wants acrylic nails, but apparently not enough to go cold-turkey on Powerade.
“If rewards are going to help,” Kirk says to Lisa, “it needs to be something she values and wants to work for. As things get harder, you need to have rewards that matter.”
The issue isn’t just Powerade. These clinic visits in the weeks leading up to Alecia’s surgery are about compliance as well as medical care. When Alecia’s stomach is snipped down to the size of a coin purse, will she follow the hospital’s nutritional instructions? That’s what Kirk is trying to figure out.
When Kirk leaves, exercise physiologist Renee Jeffreys strides in. “Regardless of your weight, you need to be active to be healthy,” Jeffreys explains. She shows Alecia exercises she can start doing at home, before her operation. Alecia gingerly tries squats and dips, using the edge of the exam room’s couch for support, and watches while Jeffreys demonstrates how to stand against the wall with her shoulders pulled back. It’s an isometric exercise—no weights, no workout apparel required. You could do it anywhere, even in front of television. “If you can hold that for a commercial break—rockin’,” Jeffreys enthuses.
The day is a string of meetings like this, with bariatric nurse coordinator Jenny Sweeney sailing in and out to monitor Alecia for glucose tolerance, metabolic action, all sorts of things. One of the conferences is with Rachel Miller, a pediatric and adolescent gynecologist. Miller explains that the surgical team strongly suggests that all girls undergoing the procedure use contraception afterward. It helps regulate the menstrual problems that often accompany obesity. But the more pressing reason: “We don’t want them to get pregnant for one to two years after surgery,” Miller says.
This is not an idle concern. An article in the journal Obesity Surgery reports that between 2001 and 2007, Children’s Hospital performed Roux-en-Y on 47 girls; six delivered babies less than two years later—a higher-than-average rate for unmarried white teens. And while all these girls had healthy babies, the jury’s still out on what the long-term consequences are to their bodies or the development of their offspring. Since then, the surgical weight loss team has been much more aggressive about contraception. So Miller tactfully but directly asks what they want to do about it.
“I don’t want to be a grandma,” Lisa says.
“We’ve had this talk,” Alecia adds politely.
THE PLAN WAS for Alecia to visit CCHMC monthly until her spring surgery. This is the “treatment plan,” explains Jenny Sweeney. When they first started doing these surgeries, Sweeney says, “We’d accept them, and in three or four months they’d come back for surgery and would have gained 15 or 20 pounds.” The point of the treatment plan, she says, “is to see if they will come to appointments, lose some weight, and get as healthy as possible.” It also gives the staff more time to prepare the patient and family for life after surgery. “Some people think this is the easy way out,” says Sweeney. “We put that idea to rest at the first visit. It’s a lot of work.”
This pre-op period conveniently coincides with the process of establishing whether or not the child’s insurance will cover the surgery’s $25,000 to $50,000 price tag. CCHMC did 11 bariatric bypasses in 2007, compared to 21 in 2004. “[The number] is going down because insurance is a problem,” Sweeney says. Some insurers are excluding the procedure altogether; for others, getting approval takes time.
Alecia’s insurer is Medicaid, which has agreed to cover the surgery. So, when Inge had an opening develop in his winter schedule, Alecia’s gastric bypass was moved up to February. But on the morning the operation was scheduled, after a slew of new tests and medical consults, Inge had bad news: Alecia has Long QT Syndrome. It’s a problem with the heart’s rhythm that can cause irregularity and even death. Ironically, it isn’t caused by her weight and won’t be improved by losing weight. But it might not have been discovered if Sweeney hadn’t been going over her charts with a fine-toothed comb. Taking beta blockers could minimize the condition, but Inge will have to delay her bypass until the drugs have had a chance to work.
So, on the day of her cancelled surgery, the women of Alecia’s family are having lunch with her in the Children’s cafeteria, biding their time until Alecia can go to a hastily arranged appointment with a cardiologist. In addition to her mother, the entourage that rose at 3 a.m. to accompany Alecia includes two grandmothers (one in a wheelchair with an oxygen canister) and her aunt, who also happens to be named Lisa. It is Aunt Lisa who drove everyone up from Booneville, wrangled the grandmothers through the huge hospital complex, and when the surgery was cancelled, called back home to alert the rest of the family and sort out the plans for the afternoon.
The snack-size table fills with burgers and salads and Gold Star cheese coneys as everyone settles down to eat. It’s only noon and it has already been an exhausting day. Alecia arrived apprehensive about her surgery; now she has a new medical condition to worry about. She’s quiet and pale and looks beat. But Aunt Lisa has optimism to spare. “I can do it and come out fine,” she says, reassuring her niece. “And you’re way younger than me.”
Aunt Lisa had a gastric bypass in November 2006. She says she had the surgery because of medical problems—acid reflux so severe it was eroding her esophagus like a rusty downspout, plus irritable bowel syndrome and some intestinal miseries not fit to discuss over Gold Star chili. She wasn’t trying to turn into a fashion model. “I was happy with myself,” she says, “but I’d do anything to get well.” She weighed in at 276; today she’s 158. Her gastrointestinal problems are gone, but psychologically she’s still adjusting to her new body. “When I’m folding laundry, I think, ‘Where’s my clothes?’” she says. Her husband has struggled to come to terms with it, too. “He said, ‘If I wanted a small woman I would have married a small woman,’” she tells me earnestly. Plus, it has been hard to convince some of her family and friends that the modest-sized portions she eats now are sufficient.
As we talk, she nibbles at her lunch, but it’s more food than she can eat. So she picks up an untouched cheese coney. “Here,” she says, and passes it to Alecia.
EVEN IF YOU’RE convinced that the nation’s fat statistics are merely the hysterical hyperbole of an image-obsessed culture, you must admit that it is not normal for a kid to weigh 300 pounds. But it is increasingly common. “We’re seeing morbid obesity at younger and younger ages,” Shelley Kirk tells me. “Young kids, massively overweight. It’s depressing.”
Kirk got interested in working with overweight kids because she grew up around fat adults. Both her parents were obese. Her dad had Type 2 diabetes and her mother had “every comorbidity under the sun—gout, high blood pressure, urinary incontinence, sleep apnea.” Kirk views bariatric surgery as a tool for the most difficult cases—a leg up for those who are dramatically overweight, who have tried and failed to bring it under control. But just like any weight loss effort, it only works long-term if the eating behavior changes permanently. And a child is part of a family that has its own nutritional personality. Kirk’s job is to introduce healthy eating—not just to these kids, but to their families.
She also has to prepare patients for the first few months after surgery, when they must eat like babies: only fluids at first, then purees, then soft foods, then a slow re-introduction of various tastes and textures. Consuming protein—supplements, yogurt, etc.—and staying hydrated are priorities. Because the “new” stomach fills quickly, it’s a juggling act: you have to drink, wait 30 minutes, eat, wait a half hour, drink some more. “It’s hard to get a kid organized around that,” Kirk says. Then there are the vitamins and other supplements—including iron, calcium, B-12, and B-1—that they must take or risk serious deficiencies. Three months post-op, a teen can consume about a cup and a half of food and can eat “anything” in moderation.
Inge likes to say that for the first six months, the surgery does the work of weight loss. After that, the patient must become more deliberate about healthy eating and exercise in order to see more pounds come off. Six months post-surgery, she should be pretty well settled in to her “forever” diet—one with limited fat and sugar, based on modest portions of whole grains, lean meat, fruit, and vegetables, enhanced by vitamins and minerals and, when needed, protein supplements.
Yet you hear stories about bariatric patients who lose massive amounts of weight, only to gain it all back. How is that possible with such a small stomach? “They eat small meals of the wrong foods,” says Kirk. Months out from surgery, patients may discover that, even though they fill up quickly, the sense of fullness passes quickly too, and they can eat again. And if they’re eating calorie-dense foods, or constantly sipping juice and energy drinks instead of plain water, it’s a recipe for failure. “You can basically ‘eat around’ the surgery by grazing,” Kirk says. So they need to know what to eat, and when, and resist the urge to snack.
And that’s the problem: We’re talking about teenagers. Compliance is not a hallmark of adolescence. Consider the simple matter of taking a bunch of vitamins multiple times a day: It’s essential, but CCHMC has a hard time getting kids to do it. Inge says he’s known bariatric patients to develop beriberi—a public health scourge in Asia back in the 19th century that’s caused by lack of vitamin B-1. “We tell them, ‘You could end up in a wheelchair,’” he says. Which explains why family support is so important.
Patients need parents who will toss the junk food and fill the fridge with nutritious grub; who’ll always be there to make sure the vitamins get swallowed and the water bottle’s full. They need parents who live well-ordered, stress-free lives; who sit down to regular, healthy meals, encourage exercise, and shower a kid with praise and affirmation. In short, an adolescent bariatric surgery patient will fare best if she’s raised by Ned Flanders.
Good luck with that.
ON MONDAY, APRIL 14, Alecia gets the green light. She’s back for her surgery—this time with her mother and Aunt Lisa, plus her sister, Gena, an eighth grader. Gena’s average-sized; she wears eyeglasses and a black Panic at the Disco T-shirt, and her goth-dark hair is cut in a short shag. She’s brought with her a stack of books and an iPod. When her mother tells a nurse that the family lives in Owsley County, Kentucky, Gena pauses in her reading long enough to add, with wry, academic precision, “Second-poorest county in the nation.”
Alecia is pale and painfully quiet today, and her blood sugar level is 205—very high. “Probably where...you’re upset,” Lisa speculates.
“What are you worried about?” Aunt Lisa asks.
“Just...everything,” Alecia says softly.
Aunt Lisa tries distraction. She promises to take her niece shopping after she has lost weight. “To go into a store and buy clothes—normal clothes in normal sizes—is incredible,” Aunt Lisa says.
A thought strikes Gena. “You better not get into my closet,” she teases.
Alecia takes the bait. “I don’t want to wear any of your clothes,” she says.
Lisa’s nearly as pale as her daughter, but she’s coping with anxiety by answering questions for the members of the bariatric team—nurses, aides, a cardiologist, a research assistant, and two anesthesiologists, among others—who are in and out of the room checking the chart, introducing or re-introducing themselves, reassuring Alecia and her family, and explaining their role in the action that will shortly unfold.
Finally Inge arrives. “How are you?” the surgeon asks his patient.
“Nervous,” Alecia says.
Inge nods. “I know you’re nervous,” he says quietly.
It’s a laparoscopic procedure; there will be just a few holes cut for the surgeon’s tools and one for the camera that will show him where to operate. Alecia knows that; she and Inge have discussed it and she’s seen the small scars on her aunt’s torso. But her big fear is that something will go terribly wrong and Inge will have to set aside his tiny surgeon’s tools and cut her wide open. “Just take care of her,” her mother says.
Shortly after noon Alecia is wheeled off to surgery; it’s nearly 7 p.m. when the family is called into the post-op conference room to meet with Inge. The surgery has taken over six hours—twice as long as Aunt Lisa’s operation; hours longer than Lisa anticipated. When Inge finally joins them in his scrubs, he explains what happened.
Alecia’s abdomen is short and thick, and the amount of fat in it was dramatic. “She carried so much obesity centrally, it was hard to see,” he explains. In addition Alecia’s liver was enlarged and dotted with deposits of fat. “We needed to do this sooner,” he tells them.
As ominous as that may sound, he assures the family that Alecia is doing fine. In fact, her blood sugar dropped to 157 in the recovery room. Right now, he says, “very powerful things are happening in her gut.” Even though her new stomach hasn’t seen a scrap of food, even though she hasn’t lost an ounce of weight, something has changed. Her body is telling her diabetes to simply go away.
THE U.S. CENTERS for Disease Control and Prevention has a booklet about diabetes titled Diabetes: Deadly, Disabling, and on the Rise, which pretty much captures the tone of any discussion of the disease these days. The CDC lists it as the nation’s number six cause of death, and the American Diabetes Association estimates that one out of every five health care dollars is spent on a diabetic. In the U.S., 20.8 million people have been diagnosed with diabetes; the CDC predicts that number will double by 2050.
Ninety to 95 percent of diabetes is Type 2—the disease associated with weight gain. In Type 2 diabetes, the insulin that’s produced doesn’t work as well as it should, and then the cells that produce insulin start to fail. Depending on the progress of the disease, the patient can be at risk for blindness, kidney failure, and cardiac and vascular disease.
Type 2 used to be called “adult-onset diabetes” because it was rare in young people. That’s changing. Dr. Lawrence Dolan, a pediatric endocrinologist at CCHMC, says he used to see one or two Type 2 patients a year in his practice. “Now we consistently have 23 to 25.”
Why the increase? “We don’t know,” says Dolan. “That’s the most honest answer.” The rise in childhood obesity is believed to be one culprit. It may be, he says, that the stress of obesity triggers diabetes in kids who are genetically predisposed that way; instead of becoming diabetic at middle age, they develop Type 2 long before their first gray hair.
One of the most dramatic—and widely touted—effects of bariatric bypass surgery is the way it can rapidly improve Type 2 diabetes. The reason isn’t entirely clear, Dolan says. It may be that, after the surgery, the rearranged gut produces different chemical signals that interact with the insulin-producing pancreas in a more helpful way. “But it could be a ton of other things that could potentially explain this process,” Dolan adds.
Whatever the cause, the results are impressive. Inge says that most of his surgical patients are ultimately able to stop taking insulin. It’s one reason he believes that morbidly obese teenagers shouldn’t have to wait until adulthood for the surgery. “We have reason to think we can do a better job of reversing the disease” if the surgery is done early, he says. In Inge’s view, “earlier” also means “less fat.” Here’s why: most patients lose about a third of their weight through surgery, which means that a five-foot-three, 300-pound kid who drops 100 pounds is still obese. “In point of fact,” Inge says, “we may have been too conservative [in establishing weight/body mass index guidelines].” In some cases, he adds, “We may need to offer surgery before patients become morbidly obese.”
This is “not surgery to the masses,” Inge says; it’s a procedure for kids who have a complex tangle of obesity-related conditions. At CCHMC, guidelines restrict the treatment to adolescents who are dangerously obese and who, because of their weight, have serious health problems such as diabetes, cardiac disease, and sleep apnea. But if you’re prone to medical cynicism, the idea of surgery for “less obese” teens can raise the uncomfortable specter of gastric bypass as the default solution for a nation of plump kids—the tonsillectomy of the 21st century. On the Internet there’s no shortage of information about the dangers of the surgery for adults—complications that range from vomiting and diarrhea to malnutrition and death. Early indications are that adolescents tend to have fewer complications. But the Teen-LABS effort—no matter what kind of data it collects by 2011—can’t predict what it means to live with a gastric bypass for 50, 60, or 70 years.
Sandy Szwarc, a registered nurse, New Mexico–based food writer, and author of a blog called Junkfood Science, rails against the surgery and against the upbeat media exposure the Teen-LABS consortium has gotten. She cites a February episode of Oprah, with its it-saved-my-life teen stories, pointing out that long-term studies involving adolescents haven’t been done.
But that’s the point of Teen-LABS, contends Inge: to gather that data and to assess the benefits and risks. “We’ve passionately argued this is not cosmetic surgery,” Inge says. “[It’s not] something for someone who needs to lose 30 pounds to be a cheerleader. The risk/benefit ratio has to be in favor of surgery.”
For her part, Szwarc (who declined to be interviewed for this story) is concerned about what’s being left out of the chipper stories about weight-loss surgery for teens. “Remember,” she writes, “even reality TV isn’t real.”
HERE’S HOW REALITY went for Alecia. The day after her procedure, she had a CAT scan that revealed a blockage at the Roux-en-Y intersection: nothing was getting through to her intestine. She vomited up the contrast solution, then kept vomiting—dry heaves that wracked her body and terrified her mother. Inge whizzed her back into surgery and found a spot where a small amount of bleeding had left a clot. After that, she got a stubborn low-grade fever. Her mother slept in her room and monitored every sip of water or broth her daughter took, breathing a sigh of relief when each mini-mouthful stayed down. When Alecia finally went home a week after her surgery, it was days before she could sleep lying flat. Arrangements were made for a visiting teacher to tutor her at home for the rest of her freshman year.
Two weeks after her discharge, Alecia returned to Cincinnati for her first checkup. She’d lost 18 pounds; her mother was thrilled. “Nine pounds a week,” she told me the day after her check-up. “The most [the hospital] has had a patient lose before has been eight pounds a week.”
But once Alecia began eating pureed food, her weight loss slowed. The CCHMC nutrition staff went over the eating plan. What was she consuming? When was she having it? It sounded like the food diary discussion from her pre-surgery visit, but this time there was a difference: Alecia’s attitude. Gone was the seeming indifference that had accompanied the Powerade discussion a few months before. When I ask her what happened, Alecia answers like a scientist with new research data. “I was taking in too many calories,” she explains eagerly. One of the culprits: refried beans, which she loves. Yes, it’s pureed, and it’s protein, and it’s on the list of acceptable soft foods for post-surgical patients. But for her it was a calorie bomb, so it went off the menu, replaced by soup beans, cottage cheese, and scrambled eggs.
Victory over her diabetes has been gradual, too, but by five and a half weeks after her surgery, she was requiring only a small amount of medication. She became responsible for managing her Type 2 diabetes with “lifestyle changes”—exercise and a healthy diet—just like millions of other Americans.
There have been other changes. Her headaches went away, and she started taking walks each afternoon with her mother and Gena. Her folks fixed the family’s above-ground pool, and on hot days the girls swim. The family bought a treadmill, and when it rains Alecia uses it to get her exercise. She has energy and wants to do, well, things. “It’s weird,” she told me two months after her surgery. “Now I can’t stand to sit in the house and not move around.”
She doesn’t think she looks that different, but she can tell by her drooping clothing that her body has changed. And when, with the permission of her doctors, she joined her classmates for the end-of-year trip to Six Flags Kentucky Kingdom, lots of kids said they were surprised and happy to see her. She seemed quietly pleased to tell me about it—especially the part about riding all the rides without ever being turned away.
I visited Alecia at her family’s home in Booneville on a bright and balmy morning in May. We sat at the dining room table beneath the small reproduction of The Last Supper and looked through a family album filled with school papers and hand-drawn pictures, formal portraits, and snapshots of holidays and happy times. Flipping through the pages, her mother stopped at a photograph of Alecia in a black formal dress, ready for the seventh-grade Valentine’s Day dance. The Valentine’s picture was snapped right before Alecia started to withdraw from the social whirl of junior high life. “Her last dance,” Lisa says, tapping the photo wistfully.
There are pages left in the album for more pictures, but Alecia isn’t ready to speculate about what might go on them. Before her surgery, when I asked her about plans for the future, she’d give me answers that seemed chosen for their ability to please an adult with a notebook. Now she seems comfortable with the uncharted territory ahead. “I knew when I woke up [from surgery], ‘I’m never going to be the same again,’” she tells me. Beyond that, she says, “It’s too early to know.”
Originally published in the September 2008 issue.