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This is a summary of what looks to be a very interesting study.  It definitely reflects a lot of things I hear from women on a daily basis in my clinic!  They are very hurtful realities regarding how obese women are viewed in our society and that is something that women struggling with their weight deal with on a day-to-day basis.  There are many reasons why people (women and men) end up having Bariatric Surgery but I am certain that the psychological aspects are a big factor in driving people towards thinking about weight loss surgery for themselves.  This study interviews patients who have had gastric bypass surgery, so the side effects including dumping, food intolerance and gastrointestinal upset are not a standard part of life following other types of bariatric surgery eg Lap band or gastric sleeve surgery.    Anyway, I look forward to hearing the results of the research that she mentions she is planning to do at 10 years following surgery.Steph Ulmer

In a thought provoking doctoral thesis, Karen Synne Groven from the University of Oslo, Norway, examined some of the issues women experience after gastric bypass surgery.

Previous studies on the subject have concluded bariatric surgery has led to an increase in quality of life for the majority of the patients, and have had a tendency to group these operations as either successful or unsuccessful, Groven has concluded somewhere in between.

“Surgery can be both a success and a failure, it is not either/or,” said Groven. “Some things get better, but new problems arise. And how women experience these problems vary significantly.”

For her research, she interviewed 22 women who had a gastric bypass.  The interviewees are between the ages of 24 and 54, most of them were interviewed twice, first about a year after the operation and then about 2.5-4 years after surgery.

Obesity

Her study claims that global figures show that approximately 70% of those who are characterised as morbidly obese are women, and women make up 70-80% of bariatric surgery patients. To a large extent, these figure corresponded with the figures in Norway.

Although one of the surgeons she spoke with characterised morbid obesity as a women’s problem, Groven stressed that there was a lot more behind the figures.

“More and more men have weight loss surgery,” she said. “We must be careful not to label women as this and men as that. Perhaps more women go through surgery because we think of it as more problematic with obese women than men?”

Karen Synne Groven (Photo: University of Oslo)

The target group for the commercial campaigns promoting bariatric surgery is women, and the dieting culture which exploded in the 1960s was also directed at women. The size of mens bodies has not been an issue in the same way.

“Although men are under pressure to be fit, people talk about women in a different way when they are fat,” she adds.

After surgery

Going through gastric bypass surgery is like going through a radical change of both the internal and external body. All of a sudden the once obese women are treated with ‘respect’ in society, nevertheless, underneath the clothes the skin is saggy and it takes a long time to become familiar with the “new” stomach. Food which was easily digested one day makes them sick the next.

“Becoming slimmer and lighter is mostly perceived of as positive. At the same time it is ambivalent, since people start to behave differently towards the women after they’ve had surgery,” she said. “People are friendlier than before, and this may feel extremely provoking. And people often ask very invasive questions concerning the woman’s radical weight loss.”

Some of the women experienced increased self-esteem. They dared to rise to speak in a different manner than before, and people listened to what they had to say at work.

“Being heard is a good thing. But it was nevertheless also a grief, as they realised that they needed surgery in order for it to happen.”

The women also felt some ambivalence towards their “new” naked body. And not least: when do you tell others about the bariatric surgery?

Many kept telling white lies and just told people that they had been on a diet, as they were ashamed to have gone through an operation of this kind.

Loose skin

“It is given little focus before the operation; patients are often told that this is something that can be fixed afterwards. But it is not so easily fixed, and the women are not prepared for the challenge of having to live with the loose skin,” said Groven. “They think of the saggy skin as unattractive, uncomfortable and unfeminine.”

In Norway, in order to get the expenses covered for skin surgery, the women must reach a certain level of weight reduction, and then keep a stable weight. Moreover, skin removal may also involve risk, and not everything can be removed. Some were reluctant to have surgery which could involve risk in connection to future pregnancies.

Five of the 22 interviewees described their quality of life as worse after the operation. For them, life became worse due to stomach and intestine problems which became chronic after surgery.

Whereas the other 17 women talked about surgery as a watershed in terms of becoming more physically active, these five felt that they had no energy at all.

Food

Even those who were eager to change their habits in terms of food and working out experienced challenges concerning food and eating.

Eating too much, too little, the wrong food or at the wrong time of the day could all result in sudden episodes dumping. Some of the women experienced passing episodes of nausea, tiredness and dizziness, whereas others experienced intense quivering.

The eating disorder is not gone, one of the women explained. Others commented that their heads had after all not been in surgery.

None of the 22 women regret having the operation.

“They say they would have done the same today and that they had no choice considering their life before surgery. Some said that the pains were a small price to pay.”

Groven’s analyses emphasise that the way in which women experience their own body is closely connected to society’s perception of the ideal female body. The way society regard obese women limit the women’s scope of action.

The interviewees felt stigmatised before the operation, and were very preoccupied with the way in which media and science represented weight loss surgery and its effectiveness.

“They are living with a body which is not accepted by society, and they are constantly judged from their size. The message from the media and medical science is that they are likely to get cancer or diabetes unless they lose weight and the surrounding world regards their obesity as self-inflicted. Some have children and are afraid to die and leave them alone,” said Groven.

She plans to conduct further research that will look at the effects of bariatric surgery three-ten years after patients have undergone the procedure.

Overweight and obese people who feel their physicians are judgmental of their size are more likely to try to lose weight but are less likely to succeed, according to results of a study by Johns Hopkins researchers.

The findings, reported in the journal Preventive Medicine, suggest that primary care physicians should lose the negative attitudes their patients can sense if the goal is to get patients with obesity to lose 10 percent or more of their body weight (an amount usually sufficient to reduce blood pressure, cholesterol and diabetes risk).

"Negative encounters can prompt a weight loss attempt, but our study shows they do not translate into success," said study leader, Dr Kimberly A Gudzune, an assistant professor in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine. "Ideally, we need to talk about weight loss without making patients feel they are being judged. It's a fine line to walk, but if we can do it with sensitivity, a lot of patients would benefit."

Gudzune and her team suspected the pervasiveness of negative provider attitudes and weight stigma may be limiting the effectiveness of advice from primary care providers for these patients.

To test that idea, the researchers conducted a national Internet-based survey of 600 adults with a BMI >25 who regularly see their primary care doctors. The participants were asked, "In the last 12 months, did you ever feel that this doctor judged you because of your weight?"

Overall, 21% perceived that their primary care physician judged them about their weight. Respondents who perceived judgment were significantly more likely to attempt weight loss [odds ratios (OR) 4.67, 95% confidence interval (CI) 1.96–11.14], although they were not more likely to achieve ≥10% weight loss [OR 0.87, 95%CI 0.42–1.76].

Among patients whose primary care physicians discussed weight loss, 20.1% achieved ≥10% weight loss if they did not perceive judgment by their primary care physicians, compared to 13.5% who perceived judgment.

Ninety six percent of those who felt judged did report attempting to lose weight in the previous year, compared to 84 percent who did not.

Having a weight loss conversation clearly helped people lose more weight, the study found. Only 9 percent of those who felt judged but did not discuss weight loss with their doctor lost more than 10 percent of their body weight, while 6 percent of those who neither felt judged nor discussed weight loss with their doctor did.

Overall, just two-thirds of participants reported that their doctors brought up weight loss.

"Many doctors avoid the conversation because they don't want to make anyone feel bad, worrying they'll create a rift with their patients if they even bring it up. But that is not in the patients' best interest in terms of their long-term health," said Gudzune.

She added that doctors may need to be taught how to talk about the topic in ways that make patients feel understood and supported. It may also be helpful to start with smaller weight loss steps, such as a 10 percent reduction in weight. A larger long-term goal of losing 70 or 100lbs can be a setup for frustration and failure when tackled all at once.

"We don't want to overwhelm them and if we are their advocates in this process - and not their critics - we can really help patients to be healthier through weight loss.”

The US Preventive Services Task Force has recommended that health care providers counsel obese patients to lose weight, and the Centers for Medicare and Medicaid Services now covers some behavioural counselling related to weight loss.

Other Johns Hopkins researchers who contributed to this study were Wendy Drs L Bennett, Lisa A Cooper and Sara N Bleich.

The research was supported by trainee awards from the National Institutes of Health's National Heart, Lung and Blood Institute's Center for Population Health and Health Disparities, as well as by other NHLBI grants.