I lost half my weight in 3 years. I have body dysmorphia from all the loose skin I have.

• Betsy Smith weighed 500 pounds at her heaviest in July 2021.
• The 53-year-old lost a total of 270 pounds through diet, exercise, and using Mounjaro.
• She's relieved to have gone from a 6X to a 1X — but worried about excess skin and her body image.

This as-told-to essay is based on a conversation with Betsy Smith, a mother of three from Billings, Montana. It has been edited for length and clarity.

A sign on the wall at the weight management clinic inspires me every time I go for my body composite exam.

"Being overweight is hard," it says. "Losing weight is hard," it says. Then, underneath, it says, "Choose your hard."

It's empowering because it lets you know it's your choice whether to stay heavy or make every effort to get healthy and feel better.

I'm just 12 pounds off my goal of 218 pounds — which means I will have lost 285 pounds since beginning my journey in July 2021 — and I'm determined to reach that number on the scale.

It's been the toughest battle of my life. But I know that it is literally saving my life.

I've always been big

I've always been a big person. I was a 10-pound baby and 23.5 inches long. I stopped growing at 6ft 2in tall — the same height as my dad. It runs in the family. One of my sons is 6ft 5in.

But I'm overweight because I always eat my feelings. Whenever I felt emotional — if something was wrong and I was unable to deal with it — I'd reach for something to eat.

My parents were concerned about my size when I was a child. They took me to the pediatrician for advice. I felt confused in the doctor's office when I was in elementary school because they mentioned words like diabetes.

We tried to work on things like portion control, but it wasn't easy. We would eat inexpensive things like pasta in a big dish in the center of the table.

I was a yo-yo dieter

Carbohydrates were not good for me, but I hated being singled out as the one who wasn't supposed to take as much as the others.

Then, when I was 10, my parents got divorced. It was an emotional upheaval. The summer between fifth and sixth grade, I gained probably 35 to 40 pounds.

Other kids said some nasty things to me, especially in middle school. But I was 6ft tall by 12 and able to defend myself physically. If there were a problem, I'd say, "No, you're not going to do that to me." Instead, I internalized my pain.

I gave birth to my first child at 20 after putting on a lot of weight during the pregnancy. The same thing happened with my other two kids.

Diets have come and gone over the years. They generally involve calorie counting and walking. I once lost over 110 pounds and kept it off for six years, but whenever something went wrong in my life, I'd put it back on.

I was shocked when I registered 500 pounds on the scale

I couldn't move the way I felt like I should be able to move and not be uncomfortable. I'd go up and down the stairs at work and get winded.

Things came to a head in July 2021 when I saw my doctor for the first time since COVID-19. I stepped on the scale and felt mortified. I was 499.9 pounds. "How the heck did this happen?" I thought. I didn't cry but wanted to crawl into a hole somewhere.

I was diagnosed with type 2 diabetes and prescribed medication to lower my blood sugar. I managed to lose 84 pounds before qualifying for an appointment at a weight management clinic in March 2022.

The main reason I lost that initial weight was dental work. My teeth were bad from so many years of abuse and loss of enamel. I got dentures, which allowed me to chew healthy, crunchy food like apples.

But weight management opened up everything for me. They said I was a good candidate for stomach surgery, but I opted out. I underwent therapy, knowing that my brain needed to change my eating habits, not a quick-fix operation.

The doctor put me on the semaglutide injections Trulicity and then Mounjaro. However, I realized that all the medications in the world wouldn't help me unless I learned the foundations of a healthy lifestyle. My intent was to lose the weight and keep it off.

The answers included eating on a schedule. I eat a certain amount — a small meal of around 300 calories — every two and a half hours. It could be a protein shake or yogurt with a couple of strawberries. It could be a quarter of a cup of the leanest ground beef you can get with steamed vegetables.

I limit my carbohydrates and increase my protein intake, such as turkey. I've also learned to enjoy fresh fruit and vegetables, such as tomatoes and cucumbers. I buy the mixed stir fry from Costco without sauce.

For exercise, my husband, Steve, 54, and I set up a gym in our spare room. I ride the recumbent bike for an hour and 15 minutes and do 750 calf raises seven days a week. I also do 200 sit-ups and 200 crunches five days a week.

Now, at 230 pounds, I've gone from a 6X to a 1X. I can wear jeans for the first time in years, lace up my tennis shoes, and carry my dog, Toby, a 19-year-old Yorkie, up and down the stairs 30 times a day.

I'm struggling with body dysmorphia

Unfortunately, I continue to struggle with body image. When they're telling you to lose weight, nobody points out you're probably going to have at least 20 pounds worth of skin hanging on your arms, legs, and stomach. Your clothing doesn't look right and it's uncomfortable because it causes irritation, even infection. Luckily, I have a cortisone prescription from my dermatologist.

I'll see my 500-pound self in the mirror. I often feel like I haven't lost much weight at all. It's only when I compare my before-and-after photos that I really notice the difference.

People said I should consider plastic surgery. But I have trouble thinking about anesthesia. Still, my confidence grows every day. Steve is prouder of me than I am of myself at the moment, but I'm getting there.

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