Sarah Trainer, Alexandra Brewis, and Amber Wutich. Extreme Weight Loss: Life Before and After Bariatric Surgery. New York University Press. New York. 2021. ISBN: 9781479803958. pp.213
Richard Zimmer (Sonoma State University)
Around the world, and particularly in America, people are concerned about being overweight. They diet, take drugs and exercise to reduce their poundage. They feel ashamed of how they look if they are overweight and they feel they are putting themselves at medical risk if they keep the weight on. Women more than men appear to be concerned about being overweight. Nevertheless, both women and men often turn to different kinds of bariatric surgery as their last, best alternative for losing weight.
Yet is a surgery solution necessary? Are people “fat-shamed” to feel they are somehow deficient, inadequate, or something else? Are they at as much medical risk as they are told by physicians that this is their only alternative? Do the various kinds of bariatric and metabolic surgeries (hereafter, surgery) reduce some medical risks besides Type 2 Diabetes and cardiovascular issues? Will future research suggest that it will continue to do so? And, if they get the surgery, does it provide the necessary cultural, social, psychological, and medical changes they were promised and expected?
These are the questions raised by the three medical anthropologists of Extreme Weight Loss. They have extensive and long-term cross-cultural experience in this area. They built on their own past research and that of others, such as the research delineated in Reconstructing Obesity, to which one of the present book’s authors, Sarah Trainer contributed. In Extreme Weight Loss, they undertook a long-term research project at a weight-reduction clinic that performed many surgeries. They interviewed patients, doctors, and attendant medical personnel, and also went to group sessions. They followed people before and after their operations to see what changed in their lives.
Their research raises important questions. The first, drawn also from feminist perspectives and laid out in many essays in earlier works, such as Reconstructing Obesity, is that what constitutes obesity is a cultural construct, particularly hurtful to women, often the result of mismeasurement. Furthermore, it is loaded with medical assumptions, ones into which potential surgery candidates buy:
“Simply being situated in the clinic and hospital highlighted the medically supported nature of the surgery and its program…. People came into this bariatric program primed to think about morbid obesity as a pathological state simply because such attitudes are so pervasive in American society today” (42).
Moreover, many people opt for surgery to follow someone else’s view as to how they should look: “Shannon raised many specific instances when she was subjected to weight-related teasing, negative comments, and shaming attempts by family and outsiders alike” (55). This has specific resonance in Black communities in the US: “Furthermore, Ava explains, Black women have to conform to far more rigid body and beauty standards than do Black men” (60). But successful outcomes may vary by race and should be taken into account before proceeding, as in this study of Black patients (Reference 2). Nevertheless, for many patients, there are successful outcomes (77). Tiffany, for example, radiated pride and happiness, “…beginning to feel out her position vis-à-vis others, attempting to gauge where her increasingly ‘normal’ body would place her socially” (76).
For people who have gone through the surgery, there is a “honeymoon” period. They may have considerable weight loss and experience changes in how they feel about themselves and their relationships with others. But then the “honeymoon” is over, and the person must be watchful and worry about later post-surgical complications. Many conditions improve, such as Type 2 diabetes and hypertension. Other conditions may develop, “…such as strictures, difficulty swallowing, and infections, among others “(106). The prospective patient is warned about the possible consequences of the surgery beforehand. “Self-monitoring, self-control, and mindfulness around eating after bariatric surgery are imposed by the surgery itself: the reduction of stomach size and bypassing of much of the intestine means that only well-chewed portions of food are tolerated; fats and sugars may become indigestible; and incautious eating or drinking may result in vomiting, diarrhea, or dumping.” (112).
The authors note that many people became vigilant about their eating practices and “…imbue these new habits with moral significance “( 112). This is despite the fact that many people may experience significant skin problems, such as loose skin (119), and hair loss (108). Skin removal surgery can be painful, and, because many insurances do not cover it, expensive ( 127). Many bariatric patients, however, are willing to pay the emotional and monetary “costs” of the surgery: “Like Erica, Tiffany categorized fat as far worse than loose skin, which unlike fat could be disguised, flattened, and covered (2021:130.)” Tiffany saw the surgery as a positive change, “…somewhat dampen[ing] her internal critical voice, which she found to be a huge relief” (130).
What about the long-term effects and changes of the surgery? The authors note that their data were gathered from people less than ten years after the surgery. They observe that they did not meet many people who had been living with the surgery for more than five years, which is also the experience that the clinic they studied had (131.) Many of the patients with whom they spoke felt “normal”: “…. normal meant being able to participate in mainstream US consumerism, fitting in airline seats and restaurant booths, buying new wardrobes, and so on” (134).
Lastly, on this point, new research may suggest non-surgery alternatives as well as benefits. First, there seems to be a genetic component to some severe obesity. This genetic component may be able to be addressed by new chemicals, obviating the need for surgery (Reference 3.) Second, surgery (or perhaps the chemical alternative?) may reduce the risk of esophageal cancer (Reference 1.)
In their conclusion, the authors note that the informants/patients and the clinic they studied are part of a privileged group. Few in the world have access to such services and support. In the remainder of the world, a person does not have these resources and is told that they are the actor who has the power to change their weight: “…successful weight loss is within their grasp” (140). The authors note the power of cultural messages is strong, “…neither easily breakable nor changeable” (140).
The bariatric patients whom they studied “…are perhaps simply more aware and more articulate about the issues at play that are affecting us all” (141). This book is appropriate and useful for upper-division and graduate students in Anthropology, Sociology, Psychology, Biology, Women’s Studies, Cultural Studies, and professionals in the medical field.
Megan B. McCullough and Jessica A. Hardin, eds. Reconstructing Obesity: The Meaning of Measures and the Measure of Meaning. Berghahn. New York.
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Michael H. Wood, Arthur M. Carlin, Amer A. Ghaderi, et al., https://jamanetwork.com/journals/jamasurgery/fullarticle/27271287, 2023)
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