Extreme Weight Loss: Life Before and After Bariatric Surgery

SARAH TRAINER, ALEXANDRA BREWIS, AMBER WUTICH, 2020. Extreme Weight Loss: Life Before and After Bariatric Surgery. New York: NYU Press, 213pp., ISBN 978-1-47985-726-5 

Keywords: social norms, obesity, body-positivity, bariatric surgery, global health

The past few decades have witnessed a global rise in the prevalence of obesity. The blame for these trends is often pinned on unhealthy lifestyle practices, namely sedentary living and a high-fat and high-sugar diet. There has been a parallel rise of the body-positivity movement, which aims to drive societal acceptance of diverse body types. The coeval nature of these two facts compels raising a couple of questions: are unhealthy behavioral decisions increasingly making people fat, and is the world now kinder towards fatness? The issue is rather complex, but upon reading Extreme Weight Loss: Life Before and After Bariatric Surgery, it could be argued that the answer is no. 

While the world seems to be getting fatter because of “macro-obesogenic policies” (p. 66), weight-monitoring behaviors have become pervasive everyday practices spawned by medical advice, social norms, and the global weight loss industry – giving rise to a cultural pre-occupation with weight loss. What we see are more and more people embarking on weight reduction journeys, which come to be associated with individualized notions of personal growth and self-actualization. 

Globally, most societies harbor strong anti-fat attitudes, including the ones which were earlier considered to be fat-positive, although such body ideals do not map onto most bodies in these regions. Body size is becoming an axis of social stratification in itself with fatness getting crystallized with other forms of inequalities. The group situated at the farthest end of the body types spectrum – the ones considered morbidly obese – are yet to benefit from any positive consequences of the body-positivity movement. These individuals cannot accept their bodies as they are, and have to make drastic modifications to be accepted as normal in their social contexts. One such measure, the bariatric surgery – a procedure that assists in rapid weight loss by making anatomical changes to the digestive system – is examined at length in the book. Through evidence in the form of illness narratives, the authors forcefully argue the case for re-casting the lay view of bariatric surgery. Instead of considering it as an easy way of losing weight, it should be recognized as a path that requires a consistent and long-term investment of money, emotional, and physical labor both before and after the procedure. The surgery however, is just another struggle in the long series of struggles that fat people face. Instead of curing fatness, it sometimes gives rise to an entirely new set of problems. 

Research in anthropology has explored fatness, but individuals at the farthest end of the spectrum remain under-studied. The authors skillfully illustrate how fatness is not only a scientifically abstract category but is situated in a rubric of social norms regarding success and failure. Often, the need to align with these norms supersedes the motivation to be healthy.  

The project has been methodologically designed as an ethnographic exploration of a surgical-weight loss program in the western USA. Fieldwork was collaboratively conducted by the authors over 36 months in the medical facilities of a large healthcare provider. The collection of techniques used includes participant observation in the bariatric clinic, interviews, and conversations with healthcare providers, and participants of the surgical weight-loss program. A two-wave survey among the patients helped in yielding quantitative information to triangulate the findings. Instead of studying third-world countries, which has been the mainstay of anthropology, the authors lay their focus on the USA. They consider the country to be the “ground zero” (p. 20) of the obesity epidemic, and largely responsible for exporting thin-promoting body norms, as well as the fat-acceptance movement out to the rest of the world. The text is best understood in the context of a globalizing world, where the similarity of experiences is only compounded by the monolithic practices of biomedicine. The authors have offered an analysis based on the categories of gender, race, and socio-economic class, although the extent of comparative analysis is limited by the nature of the case-study design. 

Theoretically, the study is an exploration of social norms prevalent in present-day USA, using the lens of weight and body types. The authors have drawn these insights based on the patient’s self-reporting of their experiences of being obese. The patients are also candidates for bariatric surgery. Studying these patients is useful because these are individuals who after having lived with obesity, undergo a complex procedure that subjects their bodies to a rapid transformation, and makes them undergo a range of experiences related to body weight in a very short period. These are patients who have experienced it all — what it means to be fat, what it means to undergo a drastic physical transformation, and what it means to (somewhat) adhere to social norms by being thin. 

The text of the book runs 213 pages and has been divided into 4 chapters. In each chapter the authors discuss a substantive theme related to weight that emerged out of the ethnographic data. In Chapter 1, the everyday life experiences of bariatric surgery candidates prior to the surgery are documented, including the struggles that ensue while living with very large bodies. Using evidence from medical practice the authors demonstrate how excess weight comes to be understood as a disease in itself — pathologizing fat bodies. Medicalized narratives of the body come to subsume patients’ understandings of self, leading them to the weight-loss clinic. In Chapter 2, it is shown how social, as well as the medical pathologization of fatness, makes fat bodies susceptible to facing stigma, and systematic discrimination ranging from a lack of clothing options to a lack of access to career opportunities. Excess weight signals a lack of self-control and responsibility, laziness, risk, and low morality. Being repeatedly subjected to negative social feedback while suffering from multiple physical issues, weight loss surgery comes to appear to the patients as a necessary measure. Chapter 3 documents experiences of weight loss post-surgery. Resulting from a fundamental modification in their gastric anatomy, the patients work hard to incorporate changes in their daily lives, such as aspects related to eating and working. Nevertheless, weight loss is associated with success and higher social worth. Chapter 4 documents the patients’ continued struggle with their bodies even after the surgery. The surgery leads to iatrogenic consequences such as severe gastric intolerances, nutritional deficiencies, and loose skin; and compels a life-long hyper-awareness regarding eating. Certain patients do not achieve the promised success because they do not lose as much weight as expected, or regain lost weight. The authors problematize the surgery’s claim as the cure for fatness since the strive for normalcy for fat individuals seems to be a long shot. 

The book is a valuable addition to the rich body of writing on the complex status of body weight in human societies. The study features as a part of the authors Sarah Trainer’s, Alexandra Brewis’ and Amber Wutich’s sustained research engagement with the themes of social inequality, obesity, and stigma in the context of global public health. Medical practitioners, public health experts, and scholarly as well as lay readers, who are interested in the themes of social norms would find this book a useful read. The text would also be a helpful addition to medical anthropology reading lists at both undergraduate and graduate levels.  

Jaya Mathur is a PhD candidate at Jawaharlal Nehru University. Broadly, her research interests lie at the intersection of medical anthropology and Science and Technology Studies. For her graduate project, she explores practices of chronic pain management across biomedicine and alternative systems of medicine in the Indian context.

© 2022 Jaya Mathur

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