An update on research examining the implications of stigma for access to and utilization of bariatric surgery

Beyond the Physical: Weight Stigma and the Bariatric Patient Journey

Background: Obesity represents a global epidemic associated with significant health risks, including diabetes, cardiovascular disease, and certain cancers. Management strategies have evolved from focusing solely on weight reduction to emphasizing overall health improvements and mitigating associated risks. Methods: This narrative review analyzed the existing peer-reviewed literature across databases such as PubMed, Scopus, EMBASE, the Cochrane Library, and Google Scholar to examine the outcomes of bariatric surgery and its interplay with weight stigma. The review incorporated data from clinical studies, systematic reviews, and meta-analyses, focusing on bariatric surgery and its psychological impact, as well as approaches to mitigate stigma in bariatric care. Results: Bariatric surgery has emerged as the most effective intervention for sustained weight loss and the resolution of obesity-related comorbidities. However, individuals undergoing surgery frequently encounter weight stigma, both pre- and postoperatively, which manifests through discriminatory healthcare interactions, societal biases, and internalized self-criticism. These factors contribute to anxiety, depression, diminished healthcare engagement, and weight regain, ultimately affecting the long-term surgical outcomes. Conclusions: Addressing weight stigma in bariatric care is critical to optimizing outcomes. Interventions such as preoperative counseling, postoperative psychological support, and multidisciplinary care can mitigate the psychological and societal burdens of stigma. This review explores the intricate relationships between obesity, bariatric surgery outcomes, weight stigma, and the health-related quality of life (HRQOL).

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.

Knowledge and Attitude of the Public Toward Bariatric Weight Loss Surgery and Its Impact on Candidates and Patients in the Al-Qassim Region, Saudi Arabia

Background Obesity is defined as abnormal or excessive fat accumulation that presents a serious health risk and is a major public health concern. Obesity prevention and management require evidence-based strategies that emphasize diet and physical activity. Bariatric surgery is also a life-changing procedure that can improve physical and mental health, but the stigma associated with it can prevent people from seeking treatment and affect their lives adversely. Studies have shown that bariatric surgery patients face discrimination from the public and healthcare professionals, which can lead to adverse psychological outcomes and hinder access to quality care. Goals and methods This study intends to explore the stigma related to bariatric surgery in Al-Qassim Region, Saudi Arabia, because it is crucial to understand its prevalence among the public and the influence it has on both those who have undergone the surgery and those who are considering it as an option. The participants had to complete an online questionnaire, comprised a general section and other sections based on whether or not the individual has, has not, or is considering bariatric surgery. Results A total of 988 individuals, 605 of whom were female (61.2%), agreed to participate in the study. The most common body mass index (BMI) category was 18.5-24.9 (43.5%, n=414). The majority of the participants had either agreed or strongly agreed that obesity is a disease (87.8%, n=867) and that genetic factors play a role in causing it (38.8%, n=383). The factors selected most commonly that increase the risk of obesity were "idle and lazy life" (76.5%, n=756) and "eating too much" (75.6%, n=747). Fewer than half of the participants (44.43%, n=439) reported that they had never thought about treating obesity through surgical operations, 9.62% (n=95) had considered it, and 3.74% (n=37) had actually undergone the surgery. Among those who underwent weight loss surgery (n=37), 43.20% (n=16) reported that they received critical comments or poor treatment from the community, 35.10% (n=13) felt ashamed or embarrassed to disclose their surgery, and 37.80% (n=14) avoided social situations or events because of those comments or poor treatment. The comments reported most often were "You have taken the easy way out instead of adopting a healthy lifestyle" (51.40%, n=19) and "Why didn't you try to go on a diet?" (51.40%, n=19). Among those who have intentions to undergo weight loss surgery (n=95), a significant proportion of the participants (43%, n=40) agreed or strongly agreed that concerns about public opinion or community treatment could affect their decision to undergo weight loss surgery. Moreover, 32.6% (n=31) of them agreed or strongly agreed that society has a negative attitude toward individuals who have undergone obesity treatment. When asked whether they had ever avoided telling people that they were considering surgery because of potential adverse reactions, 42.10% (n=40) of the participants responded that they had. Conclusion This study helped bring attention to, and prove, the stigma related to bariatric surgery in Al-Qassim Region. Such stigma has prevented patients from seeking or undergoing a surgical option to manage their weight, even if it is the option recommended for them. As such, public education and awareness campaigns are encouraged to help reduce the stigma, as well as improve access to bariatric surgery for those who need it.

Weight Stigma and Barriers to Effective Obesity Care

Weight stigma is prevalent with negative consequences for health and well-being. This problem is present in health care; stigmatizing attitudes toward patients with obesity are expressed by medical professionals across diverse specialties and patient care settings. This article summarizes the ways in which weight stigma creates barriers to effective care, including poor patient-provider communication, reduced quality of care, and healthcare avoidance. Priorities for stigma reduction in healthcare are discussed, with a clear need for multifaceted approaches and inclusion of people with obesity whose perspectives can inform strategies to effectively remove bias-related barriers to patient care.

Examining weight bias before and/or after bariatric surgery: A systematic review

Research examining weight bias in the bariatric population, who may be at greater risk of weight stigma, is scarce. The present study aimed to systematically review the literature for quantitative evidence that explores the medical, psychosocial, and behavioral sequelae associated with experienced, internalized, and/or externalized weight bias in patients seeking or who have undergone bariatric surgery. Five databases were systematically searched for English peer-reviewed quantitative studies, which examined weight bias in a sample of individuals seeking or who had undergone bariatric surgery. Risk of bias was assessed. Twenty-nine studies were included, of which 13 examined internalized weight bias, 12 examined experienced weight bias, 4 examined both, and 0 examined externalized weight bias. Most studies were cross-sectional, and the results showed high risk of bias. The results suggested that both experienced and internalized weight bias were associated with a host of negative psychosocial, behavioral, and medical sequelae. The findings of this review underscore the need for more rigorous research to better understand the relationship between weight bias and bariatric surgery, particularly longitudinally. Future patients may benefit from research developing interventions for reducing weight bias prior to and following bariatric surgery in order to reduce the associated negative correlates and improve outcomes.

Stigma Toward Bariatric Surgery in the Netherlands, France, and the United Kingdom: Protocol for a Cross-cultural Mixed Methods Study

Background

Bariatric surgery is an effective procedure for the treatment of obesity. Despite this, only 0.1% to 2% of eligible individuals undergo surgery worldwide. The stigma surrounding surgery might be a reason for this. Thus far, no research has systematically studied the nature and implications of bariatric surgery stigma. The limited studies on bariatric surgery stigma are often conducted from the perspective of the public or health care professions and either use small and nonrepresentative samples or fail to capture the full essence and implications of the stigma altogether, including attitudes toward patients and perpetrators of the stigma. In addition, studies from patients’ perspectives are limited and tend to address bariatric surgery stigma superficially or implicitly. Finally, the extent to which cultural factors shape and facilitate this stigma and the experiences of patients have not yet been researched.

Objective

This study aimed to explore the perceptions, experiences, and consequences of bariatric surgery stigma from the perspective of the public, health care professionals, and patients before and after bariatric surgery. Furthermore, although the concept of stigma is universal, every society has specific cultural norms and values that define acceptable attributes and behaviors for its members. Therefore, this study also aimed to explore the extent to which cultural factors influence bariatric surgery stigma by comparing the Netherlands, France, and the United Kingdom.

Methods

This paper describes the protocol for a multiphase mixed methods research design. In the first part, we will conduct a scoping review to determine the current knowledge on bariatric surgery stigma and identify knowledge gaps. In the second part, semistructured interviews among patients before and after bariatric surgery will be conducted to explore their experiences and consequences of bariatric surgery stigma. In the third part, surveys will be conducted among both the public and health care professionals to determine the prevalence, nature, and impact of bariatric surgery stigma. Surveys and interviews will be conducted in the Netherlands, France, and the United Kingdom. Finally, data integration will be conducted at the interpretation and reporting levels.

Results

The study began in September 2020 and will continue through September 2025. With the results of the review, we will create an overview of the current knowledge regarding bariatric surgery stigma from patients’ perspectives. Qualitative data will provide insights into patients’ experiences with bariatric surgery stigma. Quantitative data will provide information related to the prevalence and nature of bariatric surgery stigma from the perspective of the public and health care professionals. Both qualitative and quantitative data will be compared for each country.

Conclusions

The findings from this study will lead to new insights that can be used to develop strategies to reduce bariatric surgery stigma and improve access, use, and outcomes of bariatric surgery.

International Registered Report Identifier (IRRID)

PRR1-10.2196/36753

Hair Loss After Metabolic and Bariatric Surgery: a Systematic Review and Meta-analysis

BACKGROUND

Hair loss is a common complication after metabolic and bariatric surgery (MBS). There is a lack of published systematic review in the scientific literature on this topic. The aim of this study was to perform a systematic review and meta-analysis on hair loss after MBS in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines.

METHODS

PubMed, CINAHL, EMBASE, Web of Science, SCOPUS, and four Chinese databases were searched. Data were pooled using Review Manager 5.3 and Stata 12.0, and subgroups were performed if necessary and feasible.

RESULTS

A total of 18 studies (n = 2538) were included. The pooled results showed that the incidence of hair loss after MBS was 57% (95% CI 42-71%). It decreased with longer follow-up times. Hair loss was significantly more common in younger (mean difference (MD), - 2.45; 95% CI, - 4.26 to - 0.64; p = 0.008) women (OR, 3.87; 95% CI, 0.59 to 17.59; p = 0.08). Serum zinc (standardized mean difference (SMD), - 1.13; 95% CI, - 2.27 to 0.01, p = 0.05), folic acid (SMD = - 0.88, 95% CI - 1.29 to - 0.46, p < 0.0001), and ferritin levels (SMD, - 0.22; 95% CI, - 0.38 to - 0.05; p = 0.01), but not serum iron and vitamin B12, were associated with hair loss following MBS.

CONCLUSIONS

Hair loss is common after MBS especially in younger women, and those with low serum levels of zinc, folic acid, and ferritin. Prospective studies on larger cohorts are needed.

Concept of overweight bias among healthcare professionals: An evolutionary concept analysis

The aim of this concept analysis was to identify the attributes of overweight bias among healthcare providers (HCPs) and create a clear definition to guide the recognition of overweight bias among HCPs. Settings within the healthcare system are not exempt from bias and the stigmatization of persons with obesity. Overweight bias among HCPs may negatively impact health care and health outcomes. Rodger's evolutionary method was used to guide this concept analysis. The databases CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, and PsycINFO were searched. The analysis provided clarification of the concept to facilitate HCP self-awareness of overweight bias. A definition of the concept of overweight bias among HCPs is provided along with its attributes, antecedents, and consequences.

Interpersonal difficulties in obesity: A systematic review and meta-analysis to inform a rejection sensitivity-based model

Obesity is associated with difficulties due to stigma and loneliness. These impact negatively on individuals' quality of life and behaviour change efforts. Increased sensitivity to others' negative feedback might play a role in the maintenance of these difficulties and could be addressed in psychological interventions. We conducted a systematic review of interpersonal difficulties in individuals with obesity, across the lifespan. We investigated early interpersonal adversity (i.e. frequency of teasing/bullying), perceived interpersonal stress and quality of social life, based on a rejection sensitivity model. The databases PubMed, Web of Knowledge and AGRIS, Embase, Medline and PsychINFO were searched for published peer-reviewed journal articles (1980-June 2018). Thirty-two studies met inclusion criteria. Results from the meta-analyses (n = 16 studies) indicated that overweight/obese individuals reported more frequent experiences of teasing/bullying, greater interpersonal stress and poorer quality of social life than healthy weight individuals. Findings in the systematic review aligned to this evidence. Psychological interventions targeting increased sensitivity to negative interpersonal feedback could improve interpersonal functioning and, in turn, eating behaviours in individuals with obesity.

Secretive eating and binge eating following bariatric surgery

OBJECTIVE

Some individuals eat furtively and conceal evidence of eating, and this seems to occur beyond binge-eating episodes. This type of secretive eating is common among youth and emerging evidences suggests that it is a relevant marker of eating disorder psychopathology among adults with significant eating and weight concerns.

METHOD

We assessed secretive eating, loss-of-control (LOC) eating, and eating disorder psychopathology using investigator-based interviews among treatment-seeking adults experiencing LOC eating following bariatric surgery (N = 168). Participants also completed an established depression measure; height and weight were measured.

RESULTS

Overall, 37% of patients reported secretive eating: 54% of patients who met criteria for binge-eating disorder except for the size criterion ("bariatric BED") and 25% of patients with subthreshold bariatric BED reported secretive eating. Many clinical variables were higher among patients with secretive eating compared to those without secretive eating; however, only eating disorder psychopathology severity and body dissatisfaction remained significantly higher among patients with secretive eating compared to those without when bariatric BED status was also included as a variable in the model.

DISCUSSION

Findings suggest that among post-bariatric surgery patients with LOC eating, secretive eating signals more severe eating disorder psychopathology overall and specifically related to dissatisfaction with weight and shape. Bariatric BED status, however, has a stronger association than secretive eating with many clinical variables. Secretive eating should be assessed and considered when addressing weight and shape concerns among patients experiencing LOC eating after bariatric surgery.

Association Between Different Indicators of Obesity and Depression in Adults in Qingdao, China: A Cross-Sectional Study

Background: This study was designed to investigate the perceived relationship between body weight and depression risk in a Chinese population in Qingdao, China. Methods: A population-based cross-sectional survey was performed with 4,573 participants (between 35 and 74 years) from the year 2009 to 2012 in Qingdao, China. We applied the Zung self-rating depression scale to ascertain the level of depression in participants. The associations between different indicators of obesity [body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR)] and depression were assessed by logistic regression based on the Chinese criteria of obesity. Sensitivity analysis was done based on the Asian and WHO criteria of obesity. Results: The Zung scores for the 243 participants (5.2%) were over 45 and they were entitled as depression. Furthermore, multivariable logistic analyses revealed that being overweight [odds ratios (OR): 1.48, 95% confidence intervals [95% CI]: 1.08-2.03] and having abdominal obesity (WC category in Chinese criteria) (OR: 1.47, 95% CI: 1.08-2.00) were often associated with a higher risk for depression compared to normal weight subjects. Sensitivity analysis revealed that abdominal obesity (Asian criterion) (OR: 1.41, 95% CI: 1.03-1.91) was a significant risk factor for depression. Similarly, being overweight (WHO criterion) (OR: 1.39, 95% CI: 1.03-1.87) was an obvious risk factor for depression. Conclusion: Being overweight and having abdominal obesity (WC category) were found to be linked with a higher risk of depression. However, abdominal obesity (WHR category) was not associated with depression.