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Stigma, bias, and condescension are something that people with obesity deal with on a daily basis and can cause an emotional and mental toll on those patients. They tend to feel like they stand out in any setting they are placed in, as well as struggle with physical movement, with finding clothing that fit, much less express their personal sense of style. Public transportation of any form pose a struggle - the seats are too small and they tend to feel self-conscience about taking space that belongs to someone else. From first hand experience, we know that we are constantly judged by others for the way we look and for the behaviors people assume we have. People generally assume that obese people have traits of laziness, gluttony, and unintelligence. As children we are bullied by other children and that unkindness from others often breaks into adulthood. Fat-shaming is commonplace globally and knows no age limit. It has been shown that obese people tend to be passed over for promotions at work, can find intimate relationships challenging, and often times find themselves trapped in a cycle of yo-yo dieting, weight loss, followed by weight gain repeated multiple times. Social situations can fill us with anxiety. Will I be the largest person in the room? Will I be stared at if I eat something? Is somebody going to make a comment about my weight? Some of us even struggle with body dysmorphia; as a person with obesity, at my heaviest, I failed to see how large I actually had gotten to, now at a much smaller size, I continue to struggle at times with photos, videos, and mirror images of myself, as I now see myself as much larger than I actually am. All of these experiences have a permanent negative effect our self-confidence and self-worth.

As a surgeon, you are frequently faced with patients presenting for the possibility of undergoing bariatric surgery. For most, the idea of bariatric surgery is compelling due to its ease and simplicity as of recent years, and can be considered as an option at any point in their struggle to overcome obesity; maybe they’ve struggled with obesity but their visit to your office to inquire about bariatric surgery is the first time they have thought about dealing with it. Maybe they’ve tried multiple diet and exercise regimens, will drop weight only to gain it back and more as soon as they begin to experience some success. It could be possible that this isn’t their first bariatric surgery and they are seeking a revision. Or they may even have been convinced or coerced to come to the consultation by a family member and are not ready to be there. But one thing remains certain. They are experiencing a range of emotions about this consultation: shame, vulnerability, hopefulness, hopelessness, and defensiveness being commonplace. This first consultation is critical to begin to foster the relationship between the doctor and the patient and to help establish the full extent of the education, preparation, and treatment the patient will need both pre- and post-operatively.

Patients with obesity have had a variety of interactions with doctors, many of them negative. Generally, the first thing they hear from any doctor is a statement about their weight and how it has affected their health negatively. Without going to a doctor who specializes in obesity treatment, patients will hear a variety of advice on how to lose weight, stemming from “eat less and exercise more” to recommendations for prescription drugs or surgical procedures; often these primary care physicians are not as well informed on the treatment of obesity and their advice has little follow-through attached to it.

The medical issue they are attempting to talk to the doctor about can be overshadowed by a focus on their weight. A patient relayed a story about a recent visit to an ob/gyn to discuss her issues with fibroid tumors. She had sought treatment for her fibroids before and was indicating that she had started to experience an ever-present feeling of fullness in her abdomen. The doctor, without further investigation, attributed the feeling she was describing as being related to her weight and his recommendation was for her to lose weight. Whether his assessment was or was not accurate, as the patient, she immediately felt dismissed, unheard, and uncared for. She ended up not following up with that doctor and has yet to get her fibroid tumor issues resolved.

It is essential that there is serious reflection and adjustment on how doctors’ approach, talk to, relate to, and treat patients with obesity. The bias and stigma towards obesity and how the world and individuals treat those with obesity is a very real experience and it is a just as much a reality within the medical profession as anywhere else. If you ask most patients with obesity, there exists an obvious lack of empathy and understanding, and a condescension in how the medical community talks to and about them: a tendency to be talked AT and not TO, and an inconsistency of knowledge regarding the treatment of obesity within the medical community.

Medical professionals wield a powerful ability to influence, educate, and motivate their patients but implicit, intrinsic bias and stigmatization of obesity can have the opposite effect. There is often a lack of basic respect and humanity in the approach of doctors. There seems to be the opinion of “honesty” is best, a sense that people with obesity need to face reality, and if they simply controlled the amount and type of food they ate, and moved more, they would lose weight; the complexity of obesity is misunderstood and the blame for a person’s obesity is placed solely on the behaviors of that person. The medical community has an obligation to openly discuss the bias and stigma that exists and collaborate on strategies and protocols that would embrace obesity as the chronic disease it is and work to make the treatment protocol for patients supportive, informative, and flexible.

1 Considering the Psychology of Obesity

I must make an absolute disclaimer. I am not a psychologist. I have no training in psychology and can only speak from my own experience. There is one thing that I know for sure—the psychology of obesity cannot be ignored. Though I may not be a psychologist, I am an educator. In my humble opinion, the key factor in creating a success story with weight loss, through bariatric surgery or not, is significant and consistent education. This cannot only be the education of the patient but also the education of the surgeon, any other advising healthcare professionals, and the public. If obesity is going to be classified as a chronic disease, then there has to be a more knowledgeable, overarching, and systematic approach to treatment. Bariatric surgery may give a physical advantage to prepare a person’s body for weight loss, but the strength or weakness of a person’s mental health is as much a part of that person’s long-term success with their weight loss journey.

As a surgeon, how much time does your team spend assessing the mental and emotional state of your patients? How much time and consideration goes into your decision to operate on that patient? Are you only considering their physical readiness? How much time is spent considering if the patient sitting in front of you will be able to handle the psychological journey that is just as much a part of the weight loss journey as losing the weight itself? How do previous attempts with bariatric surgery help you gauge if a revision would be successful? Why did past attempts fail? Is there anything deeper than a pre-surgery psychological check? Was an initial pre-surgery psychological check even done?

If you are not considering if your patient will be able to handle the needed changes, both physical and psychological, are you ultimately failing your patients?

The less education, knowledge, preparedness, and self-awareness your patient has, the more likely their weight loss journey will not be successful.

I was not honest with my surgeon about the emotional triggers and adverse experiences that caused me to eat for comfort; in fact, I distinctly remember him asking if I was an emotional eater and I denied it. I’m sure he knew I was lying, but he showed no judgement. His gentle prodding into this area of my obesity may not have garnered the truth from me, but helped prompt the inner dialogue with myself about my eating habits and recognize them for what they were. I gradually was able to transform most of the habits I had and recognize them for what they were.

The more a patient is able to be honest with themselves and their doctors and feel secure enough to open up about their past experiences, their habits, their triggers, and are able to recognize and come to terms with some of their issues, the more successful their weight loss journey will be, especially post-operatively.

2 Education for Success

One of the most important aspects of preparing a patient to undergo bariatric surgery is to educate them as comprehensively as possible on the different types of procedures available. They need to be fully aware and informed of the decision they are about to make, as well as the advantages and disadvantages of each surgery, along with the pre-operative procedures and tests. They should have a full scope of understanding of the purpose of each test and what the results indicate. They should know what their post-operative physical condition will be and they should have planned how they will tackle each stage of the post-operative process, from how, what, and when to eat to how these changes in eating and habits will fit into their daily routine. The more information and support a patient has before, during, and after surgery, for this lifestyle change, the more likely they will begin to make the permanent changes they will need to make to be successful in the long-term.

How much guidance and instruction/support do they get from your office/clinic/hospital both pre- and post-operatively? Does the pre-operative care and post-operative care include psychological services and education on nutrition, meal planning, and tracking their progress? There should be an acknowledgment of the challenges of weight loss: the reality of dealing with stalls, nutritional deficiencies, relationship challenges, and psychological conditions such as body dysmorphia. Patients need to understand that much of their weight loss journey after surgery is going to be about finding out what works for them and how to make those adjustments in their habits permanent. They will need to accept that there will be a trial and error period in learning what they can and cannot eat, how frequently they need to eat, how to get the proper amount of water intake, and what exercise routines are going to work for them. Most of all, patients need to have an understanding of how their relationship with food and their emotions will impact their weight loss journey.

3 Understanding the Necessity of Mind Shift for Success

It was years later, after continuing to put on weight, that I considered having bariatric surgery again. After months of preparing myself for the removal of my lap band and learning about the VSG procedure, I ended up only having my lap band removed and no further surgery. When asked why I was ultimately successful in my weight loss, I could point to many factors: figuring out what diet restriction worked for me without making me feel deprived, tracking my food intake and watching my macros, regular use of a liraglutide, the incorporation of a regular exercise routine into my life and making sure that I made that exercise routine a priority over (almost) everything else, and for the first time working with doctors from whom I felt absolutely no judgement, only support.

I learned that it was vital to put myself first, that the world wouldn’t fall apart if I wasn’t available to everyone else all the time. I attempted to read everything I could about weight loss and bariatric surgery, joined online support groups, and educated myself as much as possible. I started to analyze how my relationship with food was tied to my emotions and life experiences.

But most significantly, what I could identify was that something in my mind completely shifted. I approached my weight loss on a day to day basis. Every day I made choices about what I ultimately wanted to achieve and made decisions that would bring me closer to that goal. I found balance in my lifestyle choices; I forgave myself when I didn’t eat perfectly or missed a day of exercise, but made better choices the following days. I understood these were the choices I would be making for the rest of my life.

At a recent educational conference, we were tasked with connecting a group of hexagons in a way that would show how education could be individualized to ignite passion in learning. There was no correct arrangement. Working through the exercise, I couldn’t help making connections between the hexagons and my own weight loss journey. Ideas such as personalizing the learning journey, learner agency & leadership, identity, culture, & values, and community wellness echoed my own beliefs that these are essential elements to create the paradigm shift necessary to alter the stigma and bias that currently exists in regards to obesity.

As a surgeon, I urge you to consider the full scope of a patient’s obesity before operating on them. Start by assessing why a patient is choosing bariatric surgery, evaluating and supporting their psychological readiness, establish a system for making sure your patients receive the necessary education before the surgery: about the surgical procedure itself, the pre-op requirements, the nutritional information and support they will need to use post-operatively, and the support for the psychological issues they will need to continue to address and lifestyle changes they will need to continue to make. Above all, the incorporation of empathy, understanding, and education for everyone as The treatment of obesity continues to evolve.