Bariatric Surgery: Not the ‘Easy’ Way Out—the ‘Healthy’ Way Out

| March 1, 2018

by Mary Ann Rose, EDD, RN; Mary Lisa Pories, PhD, LSW; Donna Roberson, PhD, RN; and Janice A. Neil, PhD, RN

Dr. Rose is a Professor of Nursing at East Carolina University. Dr. Pories is with the College of Health and Human Performance at East Carolina University. Dr. Roberson and Neil are Associate Professors of Nursing at East Carolina University.

Funding: No funding was provided for this article.

Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Abstract: Objective. Bariatric surgery is often stigmatized as the “easy way out” for patients with morbid obesity. However, research suggests that for patients with obesity, the surgery is not viewed as an easy weight loss method but rather a “last resort” toward dealing with their health problems. This qualitative study sought to identify patients’ experiences with negative attitudes following their surgery.

Design. A qualitative design using patient interviews and Colaizzi’s Method of Analysis was used.

Setting. The study took place in a large southeastern regional academic bariatric surgery clinic and Center of Excellence.

Participants. The study included 14 patients who were interviewed at their six-month clinic visit following surgery.

Measurements. Analysis of data was performed using Colaizzi’s Method of Analysis for phenomenological studies.

Results. Subjects described hearing that bariatric surgery was the “easy way out,” particularly in support groups and online. Some participants limited the number of people they told about their surgery to avoid negative attitudes or remarks.

Conclusions. Society still holds the attitude that surgery is the easy way out, but research suggests that patients with obesity opt for surgery most frequently as the “last resort” in the face of relentlessly deteriorating health. A recommendation is made to reframe discussion about surgery toward taking the “healthy way out” rather than the “easy” way. A recommendation is also made to support group facilitators, both face-to face and online, to stress this approach to viewing bariatric surgery in order to combat the negative societal attitude regarding bariatric surgery.

Keywords: Bariatric, easy way out, stigma, weight loss surgery (WLS)

Bariatric Times. 2018;15(3):12–14.

Introduction

Stigma directed against individuals with obesity is still pervasive in Western society. Numerous studies1–8 have confirmed its existence among not only lay people but also among healthcare professionals. People with obesity are often viewed as lazy, unmotivated, lacking in self-discipline, and sloppy.9

The existence and effects of stigma directed at a patient who is either considering bariatric surgery or who has undergone bariatric surgery has been described less fully. There is evidence that bariatric surgery is considered “low effort,” unnecessary, and of less value than lifestyle changes that would result in weight loss. For example, Groven10 conducted a qualitative study of Norwegian post-operative surgical patients in which a major theme identified was that those participants strongly rebutted the notion that weight loss surgery (WLS) was the “low effort” approach to weight loss. Vartanian and Fardouly11 investigated whether teaching individuals about the lifestyle changes required after bariatric surgery would mitigate their negative attitudes, and found that this was to some extent successful.

Negative attitudes regarding surgery were noted in a recent study12 in which participants were asked what factors motivated them to move forward with the surgery. The major theme identified was that health concerns rather than weight loss, per se, prompted the decision to undergo surgery, and many noted that it was simply their “last resort” after repeated weight loss failures. Several participants in that study noted that others accused them of taking the “easy way out.” One woman commented, “Let the ultimate be about you and not about other people and not be moved by the stigma of ‘Oh, you had weight loss surgery—you took the easy way out.’ Because it’s not the easy way out.”

Prompted by these findings, the research team questioned what negative attitudes or remarks related to the surgery itself were actually experienced by patients during the post-operative period. Stigma related to bariatric surgery might be reflected in negative comments or attitudes directed toward the patient when a person became aware that the patient had undergone surgery. Using a qualitative methodology, the research team asked post-op bariatric surgery patients, “How have family, friends, and others reacted to your having weight loss surgery?”  Probing questions focused on patient experiences in telling family, friends, and other individuals about their WLS.

Methods

The setting for this study was a large southeastern regional academic bariatric surgery clinic that is a center of excellence as defined by the American Society for Metabolic and Bariatric Surgery (ASMBS). The clinic serves a referral center for 29 counties that are primarily rural. This purposeful sample included male and female adult WLS patients over the age of 18 who had undergone either a Roux-en-Y or sleeve gastrectomy procedure and were returning for their six-month postoperative follow-up visit.

The research team consisted of four investigators, three doctoral level nursing faculty and one doctoral-level social work/family therapist, all of whom are experienced in qualitative research and bariatric care. They also maintain an established relationship with the research site surgeons and staff who support this study. Following Institutional Review Board (IRB) approval, the potential participants were approached to participate in this study at their six-month postoperative follow-up visit to the surgery clinic. Patients who agreed to be interviewed for the study signed the informed consent documents and were interviewed in the clinic room. Demographic information was gathered as well. Fourteen patients agreed to participate.

Two members of the research team were present for each interview, and all interviews were digitally recorded.  All recordings were transcribed verbatim, removing any participant names, and the research team met at several intervals to review the data and compare findings to identify the prevalent themes apparent in the data.

Analysis of the data followed Colaizzi’s13 method of analysis for phenomenological studies, as listed below:

Investigators independently review the verbatim transcripts several times to immerse themselves in the data.

Investigators underline significant statements and formulated a meaning separately.

Investigators review and agree upon the significant statements and formulate meanings.

Investigators group the common themes into clusters.

Each cluster carefully examined and gradually distilled into emergent themes common to the participants’ experiences.

The research team agreed they had reached a point of saturation14 when no new themes emerged from the data.

Results

One theme that emerged from the data was a confirmation of the existence of the stigma itself. The majority of participants in this study reported that they themselves did not experience many remarks or behaviors suggesting such stigma, but that they were aware of the sentiment. Most noted that while it was not said to or about them, they heard others discuss their experiences of stigma in their face-to-face postoperative support groups.  Many participants also noted that they read about other people’s experiences of stigma around the surgery in online forums they joined or visited. Most of the participants acknowledged that stigma toward WLS is pervasive.

To some extent, the participants in this study avoided dealing with this problem by limiting whom they told regarding their surgery. A few patients were completely open, one of whom posted on his Facebook page that he had undergone surgery. But others limited whom they told.  One participant noted, “I didn’t let anyone around the way know what kind of surgery I was having, but I let them know that I was going to have surgery.” Yet another participant stated, “Immediate family knew, but socially [I] did not tell anyone. I made a private separate Facebook page for those I wanted to tell.” Another participant commented, “I was gonna (sic) keep it private…probably it was because of fear…of what people would say”. She went on to say that when people noticed her weight loss, she would disclose that she had surgery, and she noted “I think some people, I mean you get, you get some people that are like ‘Oh, OK’ like you haven’t done any work.”

The other major theme was a rather vigorous defense against the idea that bariatric surgery is the “easy way out.” Most participants had heard this particular expression, and some made comments about the idea that bariatric surgery is the easy way out. One participant commented that it really irritated her to hear someone say that surgery was the easy way out, even though the statement was not directed at her.  She said, “you literally change your whole diet…your whole outlook on things, and you know, it just kinda, it, it takes a nerve off…They don’t know how much pressure and stress people put into this with, you know, ‘cuz (sic) you’ve basically lost all your lifestyle that you use to have.” As one participant noted regarding the idea that many people think this is the easy way out, “I think in general that society believes that.”

Discussion

The notion that bariatric surgery is an “easy fix” is alive and well. The idea that obesity is the fault of the individual15 remains prevalent in our society. This societal attitude of blaming individuals for their obesity might lead further to the idea that people with obesity do not deserve what is perceived as an “easy fix.” Another possibility is that the speed of the resulting weight loss, rather than the rigors of surgery and subsequent lifestyle changes, makes the surgical approach seem “easy” in comparison to changing one’s diet, decreasing dietary intake, exercising, or struggling with a weight loss.

The internet contains numerous accounts of patients encountering this negative attitude from others and defending their surgical experience as not “easy.” There are several forums on Facebook that deal with gastric bypass and sleeve gastrectomy support that have thousands of members. A keyword search on one group yielded 24 comments about “the easy way out.”16 One person noted, “It’s not an ‘easy’ way out. I didn’t really know how to address this when someone said it to me”. Another commented, “My family feels that I’m taking the easy way out.”

It was a pleasant surprise to this research team that the participants in this particular study, for the most part, did not experience negative attitudes or behavior related to their surgery. This contradicts the findings of other studies.10,11,15,19 Although personal support without stigma was their experience, these participants were aware of the stigma surrounding both obesity and bariatric surgery that is prevalent in society.

It is interesting to note that several participants in this study limited the number of people whom they told about their surgery. Although some were completely open, others limited this communication, it appeared, in an effort to avoid negative responses from others. Perhaps the increasing safety and effectiveness of the surgery has begun to limit some of the negativity, or perhaps it is due to the increasing number of famous people who have undergone the surgery and have been open in public about it. Al Roker, a TV personality and weatherman, noted, “I wrote this book to share my personal journey [of weight loss surgery] and what I went through, and I hope it will be helpful to whoever reads it.”17 In August 2017, People magazine named 10 celebrities who were open about their weight loss surgery.18 While the impact of celebrities being open about the surgery and all that it entails is unclear, perhaps it is helpful.

Perhaps we should refocus, viewing it not as “weight loss surgery,” per se.  For patients, it is the “healthy choice” rather than the “easy way out.” In our previous study,12 patients overwhelmingly felt that their decision to undergo the surgery was a “last resort”. Thus, the surgery represented for them a dramatic approach to regaining their own health rather than a choice simply to help them lose weight. Trainer and colleagues19 called for such a refocusing, suggesting emphasis on the hard work that must be done postoperatively. We suggest that the refocusing should be toward the return to good health that can occur postoperatively.

Viewing these patients as individuals who are taking responsibility for their own health by undergoing surgery is a useful paradigm shift for healthcare professionals and also the general public. It is clearly realistic and much more positive in describing the decision to opt for surgery.

One far-reaching approach to adopting this more positive attitude might lie in the support groups, those conducted both face-to-face and online. Perhaps this is the time and place for support group facilitators or those running Facebook sites and other online support sites to stress viewing surgery as not the “easy way out” but rather the “healthy way out.” If it is indeed the last resort in a situation of deteriorating health, then undergoing surgery is a step toward regaining health and assuming a healthy lifestyle. With the improvement or amelioration of diabetes, orthopedic problems, infertility, and other complications of obesity20,21 through surgery, the patient is indeed choosing a return to better health.

While dealing with these lifestyle changes, a positive approach as described above would also provide patients with a response to negativity.  When and if confronted with statements concerning the “easy way out,” they could respond by saying, “No, I am taking the healthy way out.”  That response would be true, realistic, and represent progress in changing the stigma of bariatric surgery.

All members of a healthcare team—nurses, physicians, social workers, psychologists, nutritionists, and case workers—could be delivering the same positive message: choosing bariatric surgery is making a decision to opt for the “healthy way out.”

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