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Does Social Stigma Drive People To Bariatric Surgery?



As regular readers are well aware, bariatric surgery has considerable health benefits in people with severe obesity, who also have health problems (EOSS 2+).

However, it is also widely known, that health concerns alone are not the only factors that drive patients to consider surgical options.

A study by Christina Wee and colleagues from the Harvard Medical School, published in the the Journal of General Internal Medicine, suggests that a key driver of individuals opting for bariatric surgery may be related to social stigma and reduced quality of life rather than worry about their co-morbid conditions.

The study looked at data from a telephone survey of 575 patients with obesity (mean BMI 46) seeking weight loss surgery, using several standardised measures of quality of life and risk tolerance.

While highly variable, mean health utility was significantly reduced, much of which was attributable to public distress, work life and physical functioning. In fact, after adjustment for sociodemographic factors, only public distress and work life subscales on the IWQOL-lite remained significantly associated with patients’ utility. Similar findings were also apparent on the SF-36 assessment.

Overall, despair was great enough that patients were ready to accept a risk of death as high as 13% to achieve their desired health/weight state – a remarkably high number, which, if anything, clearly demonstrates the enormous burden that social and functional distress has on the respondents.

This high level of distress and willingness to accept even just a 1 in 10 chance of surviving the operation (fortunately, the actual risk of surgery is far lower), is perhaps not that surprising, given that these folks were identified based on their interest in surgery.

Thus, a random population sample of folks with a comparable BMI may well prove to be less distressed.

Nevertheless, the fact that a substantial number of people, willing to undergo and accept the risk of surgery are largely driven to this decision based on social stigma and functional distress rather than health concerns, should give pause to anyone interested in the health impact of weight-bias and discrimination.

While I fully support the use of bariatric surgery to address the many otherwise intractable health concerns of individuals with severe obesity, no one should be driven to consider surgery (no matter how low the risk) simply to appease social pressures and arbitrary social norms.

AMS
Edmonton, Alberta

ResearchBlogging.orgWee CC, Davis RB, Huskey KW, Jones DB, & Hamel MB (2012). Quality of Life Among Obese Patients Seeking Weight Loss Surgery: The Importance of Obesity-Related Social Stigma and Functional Status. Journal of general internal medicine PMID: 22956443

11 Comments

  1. Hi Arya
    Interesting point about social pressure before surgery, but we have known for years why people want to lose weight, and it’s certainly not because they want to prevent diabetes or CVD. Perhaps we need to be more realistic?

    Should we, for example, discourage someone with a BMI of 40, who has suffered blatant and repeated discrimination in job interviews because of their weight, to undergo bariatric surgery? Maybe we are on a slippery slope with this issue, but social pressure is more that arbitrary, it’s punishing.

    Erik Hemmingsson, Karolinska Institutet, Stockholm

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  2. Good point Eriik, but in the end, it are the social norms, biases, and misconceptions that need to change. Expecting someone to undergo major surgery just to ‘fit in’, may not be the most reasonable or ethical approach. While obviously, the commercial weight loss industry may not care why people want to lose weight and stands ready to exploit their clients, as medical professionals, we owe it to our patients to help them balance the risks and benefits.
    AMS

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  3. I am not sure if I agree with this study, I know for me, the more I felt pressure to have the surgery the more I resisted it. I did not seriously consider it until my health became so adversely effected I probably would not have lived much longer had I not had the surgery. And then I didn’t decide to have it until I had done much research, I wanted to know the good, the bad, and the ugly…It wasn’t until the surgery had improved and evolved to where it is now, with the gastric sleeve, that I even considered it. My co-morbidity’s were COPD, Diabetes, Sleep Apnea, high blood pressure, sever edema, and so much more. I was on 27 different medications, and on oxygen as well as the CPAP. My goals pertaining to the surgery were never to become “skinny” or thin, rather to become healthier then I was. I am very happy with the choice I made. After losing 200 pounds I am still considered obese but I am happier and healthier then I have been in decades. I no longer have any of the Co Morbidity’s, I am no longer on oxygen or any prescription meds at all other then a rescue inhaler for asthma (which I was born with)… I do not advocate this surgery for “cosmetic” purposes. It is a drastic step to take and if someone does not do the mental and emotional work that goes with it, the surgery itself will be as temporary as an “diet” they have tried and failed on.

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  4. Although I agree that people shouldn’t be forced to go through surgery they otherwise don’t want by social stigma, I don’t think that desiring better quality of life should be discounted as a reason. The 30# I’ve lost (along with high blood pressure and chronic joint pain) since my WLS 2 months ago has improved the quality of my life enormously, allowing me to be much more active and engaged with life.

    What I think would be more helpful than just asking if the person would risk death to lose weight would be some real education about what real life will be like after surgery. Each person going into surgery should have a solid understanding of the lifestyle changes they’ll need to live with long term. For instance – social eating coping skills. How do you function comfortably in social eating situations when your capacity is 1/2-1 cup of food? How to deal with questions and comments about one’s weight loss? How to cope while traveling, planning for hydration, dealing with hair loss, ordering off menu in restaurants, living with loose skin, etc.

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  5. When I began to research surgery as an option for me, my BMI was 54. Yet, I was only medicated for asthma. Only being 37 years old and having nearly no co-morbidities, my position in our rationed health care was very low. I would have had to wait at least another 5 years before I could have been eligible. I had to wait over 2 years just to get an appointment in the Calgary weight management clinic. As we all know, obesity and the co-morbidities that go with it are chronic. I understand that while there are sick people who need this surgery, i don’t understand why I must be made to wait until I am sick before I can get a treatment that can help before even more damage has been done to my body/psyche.

    I chose to pay for my surgery in MOntreal. Probably the best $20K I ever spent.

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  6. For me, neither social stigma nor health risk were the drivers, it was quality of life, and inability to function fully at work, thereby creating great stress over how I was going to continue to earn a living. Before researching the actual risk, I had decided for myself 5% risk of death was acceptable. I would not have done it with a 13% risk. I had the surgury done in the US, paid cash for it, that was not easy, but I am so happy with the result. I am steadily losing weight, I feel great. Thanks to you Dr. Sharma, as I first considered the idea after hearing you on CBC radio January 2011.

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  7. I think we have a to dive a little deeper and perhaps look at people in a more whole way. This is not a criticism of Dr. Sharma who I applaud for his sensitivity, perceptiveness and compassion always. In this case, stigma isn’t just stigma. It is the *effects* experienced by the obese person caused by the stigma. These can and do become overwhelming. This stigma will take a loooooooong time to change. In the meantime, we have people who are suffering – being passed over for a job only because they are fat, being passed over for a promotion only because they are fat, being treated with an often palpable air of disdain by supervisors and colleagues only because they are fat, and on and on and on, experiencing social isolation, often, only becasue they are fat. What do these ongoing, cumulative events add up to? Fear. Mounting anxiety. And often, I bet, eventual depression – demoralization. This stigma can also lead to the loss of the ability to earn a living, to the loss of ability to provide for self and family . This stigma can lead to a kind of insidious, chronic bullying in the workplace and in public. How much of this can any one person take? Enough of the chronic effects of this stigma and we are into real mental health issues, which can be every bit as serious as “physical” health issues. In the best of all worlds, I am in Dr. Sharma’s court. But we do not live in the best of all worlds. And fat hatred and stigma will be with us for many, many years to come. Suffering obese people should not be belittled for “superficial” seemingly socially driven motivations in seeking bariatric surgery. As a person who has lost 110 lbs and is at what would be considered an optimum weight, I am grateful that low carb weight loss worked for me and I have been able to maintain my weight, with minor gains and relosses over nearly 12 yearsl. But every person and every trajectory into obesity is different. My weight gain and struggles with weight did not manifest until I was in my early 30’s. This is a very, very different picture than those who have, for instance, struggled with significant weight issues since childhood. Very different factors are at play. All potential bariatric patients should be presented with full information on risks and benefits of surgery and ongoing coping skills (as enumerated by another commenter) to ensure the best decision making for the patient and the best response to surgery. No patient should be denied surgery because they are struggling with years of childhood ostracism/bullying and the ongoing effects of stigma in their adult personal and work lives. Mental health is real. Emotional health is real. We are whole people. Anxiety and depression related to stigma is no less than “physical” disease and may infact contribute to the development of serious phsyical disease. Level the assesssment field. See the suffering for what it is. And continue your work to eradicate stigma. I am a rabid supporter of HAES and a strong supporter of bariatric surgery. I know that everyone is not like me and deserves to be throughly evaluated in light of *their* indepth history and current esperience. Thank you, Dr. Sharma for the work you do.

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  8. I recently read an article in the Hindustan Times (India) about women wanting to have bariatric surgery so that they could be ‘desirable’ enough to find a suitor to marry. Societal pressures on brides-to-be clearly span the globe, and this vulnerable group needs particular attention from us, as health care providers, to explore their motivations for surgery.

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  9. I remember hearing a talk once from a famous actress. She was commenting on the various monority groups and how unfortunate for us all they they existed. She indicated sadness that there should need to be affirmative action to ensure equal paying jobs for women and people of various color or ethnic backgrouns. She stressed the benefits of promoting Human Rights over all else and working to reduce and ultimately elimenate the needs for womens or other “groups” rights.

    As an obese man living in Canada I have experienced many times the feelings of sorrow, sadness and even depression that come from the rude and thoughtless actions of others about my obesity. I have also found that by developing my sense of humour, some humility and some good communications skills I can kill off most of my enemies with kindness pretty easily 🙂

    All of the above being said, I am very suprised how often I am reminded that the idea of body image for men is almost non existent and that for women it is magnified to a point where most women feel the need to fit in (no pun intended toward obesity).

    Finally I note to you that in our Weight Wise group here in Whitehorse of 20 participants in my group I am one of only two men participating. Something is wrong here that is a bit of the opposite of what DR. Sharma discussed above in his blog post. While I think there is a definite issue with more women perhaps feeling the pressure of the surgical option to relieve social pressure, there is not enough pressure on men to seek the improvements in health that can come to them from at least participation in the “Weight Wise” program, and ultimately surgery as well!

    VIC
    =+=

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  10. Dear Dr. Sharma,

    Thank you for expressing your concerns here about bias, social stigma, and false beliefs as potentially significant drivers of bariatric surgery profits (earnings and/or sources of revenue). I realize that you do not present this issue (explicitly) in terms of economic benefits for health care providers (although, in your comment to Erik, you mention the “exploit[ive]” practices of “the commercial weight loss industry”). However, the ethical dilemmas—faced by professionals such as yourself, who specialize in bariatric medicine or who simply care for patients suffering from weight bias and stigma—must at times (I imagine) feel burdensome and distressing when one’s professional (and personal) ethical/moral obligations to patients must be balanced with the inherent potential for conflicts of interest (in terms of income benefits vs patients’ risks/benefits.)

    Please understand, this is not an accusation or moral judgement but an honest expression of empathy. An individual health care professional cannot, of course, stop health risks and suffering caused by socially constructed forces of domination and control (such as stigma, bias & social norms), but when one’s source of income (and one’s other material and social benefits) are enhanced, at least in part, as a result of those same social forces (which create significant harm and suffering), I wonder about the potential health risks and suffering which may also result for caring and empathetic professionals who struggle with their awareness of these tragic inequities—and who confront equally powerful social forces which limit their capacity to reduce suffering.

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  11. Here is an excellent example of what pervades our cultural beliefs about fat people. And this is a medical blog with many medical/healthcare providers speaking. Did I see it as an RN practicing in the American healthcare system for 30+ years? Oh yes. Did it affect me as a nurse trying to advocate for patients and their families and loved ones in critical care settings, public health and public health mental health care settings? Oh yes. The cruelty, the hatred even as expressed in this blog is beyond imagining. And what is really stunning is the horrible ignorance expressed herein by physicians, nurses and others. And it is just a snapshot. One, little, horrifyingly ugly snapshot.

    http://www.epmonthly.com/whitecoat/2011/01/caring-for-morbidly-obese-patients/

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