“But Then I Learned…”: Weight loss surgery patients negotiate surgery discourses

Bariatric surgery stigma from the perspective of patients: A scoping review

AIMS

To explore the experiences and consequences of bariatric surgery stigma from the perspective of bariatric surgery patients and to identify knowledge gaps in the literature.

DESIGN

A scoping review.

DATA SOURCES

Studies published between December 2002 and January 2022 were identified from the following databases: PubMed, Web of Science, PsycINFO and MEDLINE.

REVIEW METHODS

We screened 3092 records and included 28 studies. Findings were grouped thematically using the health stigma discrimination framework.

RESULTS

Patients experienced several types of stigmas, including perceived, experienced, anticipated and internalized stigma, related to undergoing bariatric surgery. Patients were confronted with negative comments and judgement from others when they disclosed their decision to have surgery or when they revealed that they had undergone surgery. These experiences led to conflicts in the decision-making process, such as delaying the choice for surgery, seeking surgery abroad or opting out. Patients who internalized stigma often reported feelings of shame and embarrassment for choosing surgery and felt the need for secrecy or selective disclosure. Stigma experiences were influenced by gender and differed between different subgroups of patients.

CONCLUSION

The stigma surrounding bariatric surgery has detrimental consequences for eligible individuals and bariatric surgery patients. However, the evidence from patients' perspective remains limited. More research into patient's experiences is needed to improve patient care and further educate healthcare professionals. In addition, to better understand the nature and implications of bariatric surgery stigma, future research should be founded on stigma theories and distinguish between the different types of stigmas.

IMPACT

This scoping review contributes to a better understanding of the implications the stigma surrounding bariatric surgery has for bariatric surgery patients before and after surgery. The knowledge generated by this review can inform improvements in the education and management of people living with obesity and bariatric surgery patients.

REPORTING METHOD

The scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews checklist.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

PROTOCOL REGISTRATION

A protocol was not registered for this scoping review.

The Ethical Work of Weight Loss Surgery: Creating Reflexive, Effortless, and Assertive Moral Subjects

While higher-weight bodies have been radically medicalized in modern Western discourse, they are also culturally conceived as a moral project. In clinical settings aimed at transforming the body, the consultation sessions between bariatric professionals and patients reveal nuanced moral deliberations. I suggest that bariatric surgery becomes a site of a "moral breakdown," where professionals direct patients to morally recuperate not only through technologies of the self, such as intensive bodywork and diets, but through "moral laboratories," which invite moments of experimentation in everyday life. Drawing on ethnographic inquiry in a bariatric clinic, I argue that this moral project is understood through new relationships within various registers of patients' subjectivity. First, patients are instructed to "listen to their bodies" and to reconnect to their embodied sensations. They are further guided to cognitively imitate an effortless "thin state of mind." And finally, they are instructed to "put themselves first" by reorganize their interactions with significant others. Professional guidance encourages dialog and reflexivity within the patient that are consonant with neoliberal understandings of the self-disciplined subject, yet they expand, and at times undermine these neoliberal notions by attending to other body ethics and contesting elements of fat stigma.

Sick but healthy: bariatric patients and the social construction of illness and disability

Bariatric (weight loss) surgery modifies the digestive system, which produces impairments and symptoms which might be considered illness or disability. Bariatric patients, however, do not view themselves as ill or disabled, but healthier than before surgery. For this study, 35 bariatric patients - from a clinic located in the Midwestern United States - were interviewed to investigate how moral and medical discourses surrounding obesity impact how patients experience their bodies after bariatric surgery. While previous literature on bariatric patients has explored discourses of medicine, stigma and discipline, fewer have analysed how patients interpret physiological symptoms. Patients often reduce or discontinue medications for chronic illness after bariatric surgery, then replace them with a strict regimen of dietary supplements. Even though these supplements are taken to manage an impaired digestive system, they do not carry the same moral weight as medications for chronic illness. Patients also experience painful and humiliating symptoms after bariatric surgery. Bariatric patients interpret symptoms not as illness, but as important disciplinary tools to lose weight. These findings have implications for the social construction and experience of illness and disability in the context of fat stigma, health morality and biomedicalisation.

Patient motivations and expectations prior to bariatric surgery: A qualitative systematic review

Bariatric surgery is the most effective treatment for weight loss in individuals with severe and complex obesity. While the extant literature has mostly explored clinical outcomes of surgery, recent research has also examined patients' experiences prior to treatment. This systematic review synthesized findings from qualitative studies investigating patients' motives and expectations prior to undergoing bariatric surgery for weight loss. Twenty-eight studies published in English involving 580 participants were identified for inclusion. Data extraction and thematic synthesis yielded four global themes: physiological, emotional, cognitive, and interpersonal/environmental. These represented seven subthemes describing patients' presurgery experiences: relationship with food, physical health, activities of living, personal identity, social relations, presurgery information, and beliefs about surgery. In addition to improving physical and medical comorbidities associated with obesity, participants believed that postsurgery weight loss would produce positive psychosocial impacts by strengthening their personal identities, their relationships, and improving their engagement in public and professional life. The complex and widespread nature of the changes patients expected would result from bariatric surgery highlights the importance of providing pretreatment education focused on psychosocial well-being, as well as concurrent psychological support alongside surgery, to best inform individual treatment selection and clinical practice.

'No one is as invested in your continued good health as you should be:' an exploration of the post-surgical relationships between weight-loss surgery patients and their home bariatric clinics

This article traces the post-surgical relationship between weight-loss surgery (WLS) patients and their home bariatric clinics. Following surgery, there is substantive drop off in patient attendance at both follow-up appointments and support groups. While barriers to follow-up are often discussed with the bariatric literature, patients themselves are typically defined as the problem. Based upon a thematic analysis of 217 blog posts and comments in two top patient-led online forums, I demonstrate that bariatric patients tell a more complex story about their post-surgical lives. I argue that WLS patients constitute a population with highly specialised medical needs that is caught between the requirements for living with surgically altered digestive systems and a lack of sufficient post-operative follow-up care from their home bariatric clinics. Although online forums provide spaces for patients to examine these post-operative social and clinical experiences in critical terms, seek information and get support, ultimately the conversations serve to underline the value of personal responsibility for post-operative outcomes-a framing that echoes that of the bariatric profession. This framing should be understood within a larger climate of weight-based stigma and discrimination as well as neoliberal healthism.

Patient experiences of adjusting to life in the first 2 years after bariatric surgery: a qualitative study

There is currently little research into the experiences of those who have undergone bariatric surgery, or how surgery affects their lives and social interactions. Adopting a constructivist grounded theory methodological approach with a constant comparative analytical framework, semi-structured interviews were carried out with 18 participants (11 female, 7 male) who had undergone permanent bariatric surgical procedures 5-24 months prior to interview. Findings revealed that participants regarded social encounters after bariatric surgery as underpinned by risk. Their attitudes towards social situations guided their social interaction with others. Three profiles of attitudes towards risk were constructed: Risk Accepters, Risk Contenders and Risk Challengers. Profiles were based on participant-reported narratives of their experiences in the first two years after surgery. The social complexities which occurred as a consequence of bariatric surgery required adjustments to patients' lives. Participants reported that social aspects of bariatric surgery did not appear to be widely understood by those who have not undergone bariatric surgery. The three risk attitude profiles that emerged from our data offer an understanding of how patients adjust to life after surgery and can be used reflexively by healthcare professionals to support both patients pre- and post-operatively.

Negotiating options in weight-loss surgery : "Actually I didn't have any other option"

In this study we explore how a selection of Norwegian women account for their decision to undergo weight loss surgery (WLS). We argue that women's descriptions of their experiences leading up to this choice of action illuminate issues regarding social norms of bodily appearance and personal responsibility. The starting point is women's own experiences within a cultural context in which opting for WLS often attracts moral scrutiny. Inspired by Merleau-Ponty's notion of consciousness as embodied and de Beauvoir's ideas concerning women's situation, we argue that bodily as well as socio-cultural aspects intertwine with women's choice of surgery as a means of losing weight. Although society's stigmatization of women with obesity has been well challenged by scholars in the field of critical fat studies, women with obesity still experience the bodily hindrances associated with being overweight in an intense and subjective way. The findings suggest that women confronting the option of WLS do so in a context of pain, dysfunction and social stigma, a combination which illuminates the intricate ambiguity of the obese body as both subject (of agency) and object (of moral and medical scrutiny).

The experience of regaining weight following weight loss surgery: A narrative-phenomenological exploration

Weight loss surgery (WLS) is gaining ground as the most effective treatment against obesity. In the literature, however, we see a divide among individuals who have undergone WLS based on the amount of weight lost and maintained: successful and unsuccessful patients. In this article, we focus on the notion of unsuccessful patients-exploring the accounts of three women who have regained weight following WLS. In doing so, we endeavor to better understand how weight regain has meaning, and its impact and implications for the lives of individuals who undergo WLS. The findings reveal how weight-regain stories are easily silenced, buried beneath social, cultural, and institutional/medical narratives of successful weight loss and transformation. People who have such experiences may feel reticent to reveal them and in doing so increase their own suffering, therefore leaving the popular narratives unchallenged.

'Fat girls' and 'big guys': gendered meanings of weight loss surgery

Over 80% of weight loss surgery (WLS) patients are women, yet gender is overwhelmingly absent in WLS research. This article discusses the findings of 54 interviews with twenty-one women and six men waiting for WLS in Newfoundland and Labrador, Canada. We critically examine the ways that gender shapes the meaning of WLS in these narratives. We explore gendered meanings in participants' perspectives on their embodied experiences before surgery, social support as they decided to undergo the procedure, and their expectations for their lives after WLS. We draw on feminist theory to explain how these findings counter the dominant gender-neutral medical model of obesity.

Felt stigma and obesity: introducing the generalized other

People with a big body are tainted in western societies. Although most research on obesity occurs in the medical context, few studies investigate characteristics and effects of feelings and fears related to the fat stigma in the absence of overt discrimination. By linking Norbert Elias's and George H. Mead's theoretical frameworks, this paper offers a different approach to understanding and investigating felt stigma. The study is based on secondary data (25 semistructured interviews with children and adolescents). It explores internalized societal perspectives on overweight and obesity and inquires into the way in which interviewees handle the blame frame of personal responsibility during their interview. The preliminary findings suggest that specific forms of managing one's self-presentation in interviews indicate felt stigma. Consequently, the paper argues for an analytical approach that extends the focus on the content of interviews to include its dynamics.