This article critically explores the tension between perceptions of weight loss surgery as a last resort and as a tool. This tension stems from patients’ doubt and insecurity whether expectations for a healthy life will come through. Thus, even after surgery, traditional weight loss methods, including diets and exercise, are considered paramount. Drawing on a series of interviews with Norwegian women, we argue that the commercialization of weight loss surgeries as well as (...) the moral stigmas attached to such operations serve to perpetuate this tension. More specifically, the women were advised to leave their old habits behind, and embrace a healthier and more active lifestyle. In such a climate, we argue that undergoing surgery without subsequently embodying dietary and exercise norms is hardly an option. On the contrary, these become a moral obligation that modern women need to relate to—and perhaps negotiate—in order to repudiate stigmas attached to weight loss surgeries as a quick fix for those incapable of losing weight in the “proper” manner. (shrink)

In this study we explore how a selection of Norwegian women account for their decision to undergo weight loss surgery. We argue that women’s descriptions of their experiences leading up to this choice of action illuminate issues regarding social norms of bodily appearance and personal responsibility. The starting point is women’s own experiences within a cultural context in which opting for WLS often attracts moral scrutiny. Inspired by Merleau-Ponty’s notion of consciousness as embodied and de Beauvoir’s ideas (...) concerning women’s situation, we argue that bodily as well as socio-cultural aspects intertwine with women’s choice of surgery as a means of losing weight. Although society’s stigmatization of women with obesity has been well challenged by scholars in the field of critical fat studies, women with obesity still experience the bodily hindrances associated with being overweight in an intense and subjective way. The findings suggest that women confronting the option of WLS do so in a context of pain, dysfunction and social stigma, a combination which illuminates the intricate ambiguity of the obese body as both subject and object. (shrink)

While health care professionals advise those who have undergone weight loss surgery to increase their levels of physical activity, research suggests that often this is not achieved. This paper explores the experiences of ten Norwegian women as they engaged in physical activity several years after weight loss surgery. In contrast to the existing literature, which explores physical activity post-WLS largely in terms of quantitative data and measurable outcomes, the present study sought to explore women’s (...) lived experiences of physical activity, including the meanings they ascribed to different forms of activity and how such meanings changed over time. The research participants, all of whom had undergone WLS more than five years earlier, described the meanings they attached to becoming physically active, as well as the different activities and movement practices they engaged in, from interval training to mountain hiking and yoga. For all the women, maintaining and increasing their level of physical activity was challenging. On the one hand, engaging in exercise after weight loss improved their sense of joy and well-being and expanded their opportunities to move and act. On the other hand, during physical activity they needed to be constantly alert to symptoms of post-surgical side-effects, including variable energy levels, digestive problems and acute illness episodes. As the women explored their new capacities, it seemed to be important for them to explore various forms of physical activity in order to find the form of exercise which best suited them or which they most enjoyed. In some cases, they constructed new meanings around activities which, prior to surgery, had seemed onerous and bereft of pleasure. We argue that such insights will benefit health professionals who provide advice on physical activity at different post-surgical stages, sometimes to persons seriously concerned about regaining weight. (shrink)

The aim of this article is to explore bodily changes following weight loss surgery. Our empirical material is based on individual interviews with 22 Norwegian women. To further analyze their experiences, we build primarily on the phenomenologist Drew Leder`s distinction between bodily dis-appearance and dys-appearance. Additionally, our analysis is inspired by Simone de Beauvoir, Merleau-Ponty and Julia Kristeva. Although these scholars have not directed their attention to obesity operations, they occupy a prime framework for shedding light on (...) different dimensions of bodily change. In doing so, we were able to identify two main themes: The felt “inner” body versus the visible “surface” body and the “old” body versus the “new” body. In different, though interconnected ways, these main themes encompass tensions between changes the women experienced as contributing to a more “normal” and active life, feeling more accepted, and changes that generated ambivalence. In particular, their skin became increasingly problematic because it did not “shrink” like the rest of the body. On the contrary, it became looser and looser. Moreover, badsmelling folds of skin that wobbled, sweated and chafed at the smallest movement, aprons of fat hanging in front of their stomachs, batwing arms, thick flabby thighs and sagging breasts were described as a huge contrast to the positive response they received to their changed body shape when they were out and about with their clothes on. At the same time, they expressed ambivalence with regards to removing the excess skin by means of plastic surgery. Through their own and other women`s experiences they learned removing the excess skin by means of surgery could be a double-edged sword. By illuminating the experiences of the ones undergoing such changes our article offers new insight in a scholarly debate predominated by medical research documenting the positive outcomes of weight loss surgery. (shrink)

Using a densely constructed ethnographic subject, Josephine, the “ugly duckling,” I use Foucault’s complex notion of an Apparatus to examine how Josephine’s decision to have weight-loss surgery is understandable even though it permanently destroys her normally functioning digestive system. I try to illuminate how the decision is deeply embedded in extraordinarily complex neoliberal biopolitical structures and dynamics of fat hatred camouflaged by liberatory discourses that promise “empowerment,” becoming “normal,” and discovery of her “real self.” I argue that (...) in contemporary America, Fat Hatred must be understood as a powerful systemic structure of racialized gendered oppression, that one tactic to normalize weight-loss surgery involves assimilating it to “normal” cosmetic surgery, and that Josephine must be seen, simultaneously, as legitimizing dominant obesity discourses and practices, enacting genuinely liberating personal choices, demonstrating her status as a “good American bio-citizen,” and contributing to the collective physical health and mental health of the nation since “obesity” is soon to be included in the fifth edition of the canonical Diagnostic and Statistical Manual of Mental Disorders as a mental disorder. (shrink)

_Background:_ Weight-related stigma is reported frequently by higher body-weight patients in healthcare settings. Bariatric surgery triggers profound weight loss. This weight loss may therefore alleviate patients' experiences of weight-related stigma within healthcare settings. In non-clinical settings, weight-related stigma is associated with weight-inducing eating patterns. Dietary adherence is a major challenge after bariatric surgery. _Objectives:_ (1) Evaluate the relationship between weight-related stigma and post-surgical dietary adherence; (2) understand if (...) class='Hi'>weight loss reduces weight-related stigma, thereby improving post-surgical dietary adherence; and (3) explore provider and patient perspectives on adherence and stigma in healthcare settings. _Design:_ This mixed methods study contrasts survey responses from 300 postoperative bariatric patients with ethnographic data based on interviews with 35 patients and extensive multi-year participant-observation within a clinic setting. The survey measured experiences of weight-related stigma, including from healthcare professionals, on the Interpersonal Sources of Weight Stigma scale and internalized stigma based on the Weight Bias Internalization Scale. Dietary adherence measures included patient self-reports, non-disordered eating patterns reported on the Disordered Eating after Bariatric Surgery scale, and food frequencies. Regression was used to assess the relationships among post-surgical stigma, dietary adherence, and weight loss. Qualitative analyses consisted of thematic analysis. _Results:_ The quantitative data show that internalized stigma and general experiences of weight-related stigma predict worse dietary adherence, even after weight is lost. The qualitative data show patients did not generally recognize this connection, and health professionals explained it as poor patient compliance. _Conclusion:_ Reducing perceptions of weight-related stigma in healthcare settings and weight bias internalization could enhance dietary adherence, regardless of time since patient's weight-loss surgery. (shrink)

This paper draws on research exploring how men narrate their long-term experiences of Weight Loss Surgery [WLS] and is specifically focused on findings relating to male embodiment. Whilst there is concern about increasing obesity and the possible role of bariatric [WLS] surgery in ameliorating this, there has been little research to date exploring men’s longer-term experiences of this. For the purposes of the present study, interviews were conducted with five men who had undergone bariatric surgery (...) at least four years previously. The transcribed interviews were subjected to narrative analysis with the additional incorporation of Watson’s “male body schema” into this process in order to facilitate focus on the embodied nature of the storied accounts obtained. The findings suggested two seemingly contrasting storylines: “ongoing struggles” and “success”. Struggles related mainly to control over eating habits and the visceral challenges of long-term side effects following surgery. Despite these struggles, the men ultimately presented an overriding storyline of embodied “success” in how the surgery had assisted them to live more normatively male lives. Importantly, narratives around struggles were presented as more private stories in contrast to the public emphasis on success. The silencing dynamic implicit in this suggests the likelihood that other men encountering similar experiences would be reticent to reveal their struggles, thereby perpetuating their suffering and leaving popular obesity and weight loss narratives unchallenged. (shrink)

Bariatric surgery is effective on short- and medium-term weight loss, reduction of comorbidities, and overall mortality. A large and increasing portion of the population is eligible for bariatric surgery, which increases instant health care costs. A review of the literature identifies a series of ethical challenges: unjust distribution of bariatric surgery, autonomy and informed consent, classification of obesity and selecting assessment endpoints, prejudice among health professionals, intervention in people's life-world, and medicalization of appearance. Bariatric (...) class='Hi'>surgery is particularly interesting because it uses surgical methods to modify healthy organs, is not curative, but offers symptoms relief for a condition that it is considered to result from lack of self-control and is subject to significant prejudice. Taking the reviewed ethical issues into account is important when meeting persons eligible for bariatric surgery, as well as in the assessment of and decision making on surgery for obesity. (shrink)

Severe obesity has been associated with reduced performance on tests of verbal memory in bariatric surgery candidates. There is also some evidence that bariatric surgery leads to improved verbal memory, yet these findings need further elucidation. Little is known regarding postoperative memory changes in the visual domain and how patients subjectively experience their everyday memory after surgery. The aim of the current study was to repeat and extend prior findings on postoperative memory by investigating visual, verbal, and (...) self-reported everyday memory following surgery, and to examine whether weight loss and somatic comorbidity predict memory performance. The study was a prospective, observational study in which participants underwent cognitive testing at baseline, 1 and 2 years after bariatric surgery. Repeated measures analyses of variance revealed significantly poorer visual and verbal memory performance at the 1-year follow-up, with performance subsequently returning to baseline levels after 2 years. Verbal learning and self-reported everyday memory did not show significant postoperative changes. Memory performance at 1 year was not significantly predicted by weight loss, changes in C-reactive protein levels or postoperative somatic comorbidity. The study demonstrated poorer visual and verbal memory performance at 1-year follow-up that returned to baseline levels after 2 years. These findings are in contrast to most previous studies and require further replication, however, the results indicate that postoperative memory improvements following bariatric surgery are not universal. Findings suggest that treatment providers should also be aware of patients potentially having poorer memory at 1 year following surgery. (shrink)

Despite the reported limited success of conventional treatments and growing evidence of the effectiveness of adult bariatric surgery, weight loss operations for (morbidly) obese children and adolescents are still considered to be controversial by health care professionals and lay people alike. This paper describes an explorative, qualitative study involving obesity specialists, morbidly obese adolescents, and parents and identifies attitudes and normative beliefs regarding pediatric bariatric surgery. Views on the etiology of obesity—whether it should be considered primarily (...) a medical condition or more a psychosocial problem—seem to affect the specialists’ normative opinions concerning the acceptability of bariatric procedures as a treatment option, the parents’ feelings regarding both being able to influence their child’s health and their child being able to control their own condition, and the adolescents’ sense of competence and motivation for treatment. Moreover, parents and adolescents who saw obesity as something that they could influence themselves were more in favor of non-surgical treatment and vice versa. Conflicting attitudes and normative views—e.g., with regard to concepts of disease, personal influence on health, motivation, and the possibility of a careful informed consent procedure—play an important role in the acceptability of bariatric surgery for childhood obesity. (shrink)

Based in narrative phenomenology, this article describes an example of how lived time, self and bodily engagement with the social world intertwine, and how our sense of self develops. We explore this through the life story of a woman who lost weight through surgery in the 1970 s and has fought against her own body, food and eating ever since. Our narrative analysis of interviews, reflective notes and email correspondence disentangled two storylines illuminating paradoxes within this long-term (...) class='Hi'>weight loss process.Thea’s Medical Weight Narrative: From Severely Obese Child to Healthy Adultis her story in context of medicine and obesity treatment and expresses success and control.Thea’s Story: The Narrative of Fighting Weightis the experiential story, including concrete examples and quotes, highlighting bodily struggles and the inescapable ambiguity of being and having one’s body. The two storylines coexist and illuminate paradoxes within the weight loss surgery narrative, connected to meaningful life events and experiences, eating practices and relationships with important others. Surgery was experienced as lifesaving, yet the surgical transformation did not suffice, because it did not influence appetite or, desire for food in the long run. In the medical narrative of transforming the body by repair, a problematic relationship with food did not fit into the plot. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Calling Obesity a Disease Is A Terrible DecisionMoose FinklesteinFactsThe medical world struggles to see the difference between health and body weight. It is still mostly combined with the strong belief that there is no way a fat person can be fit and healthy. Despite repeated studies and work to show differently, this prejudice remains. This has become part of what I call “Everyone Knows” pseudoscience, where data that (...) have no scientific basis become “fact” due to constant repetition.Obesity is already the cause of great stigma in our society. Fat people are considered “ugly,” fat jokes are acceptable in everyday life, and being called ‘fat’ is, to many, as big an insult as a racial slur. Fat prejudice can approach the levels of racial prejudice (Puhl, Andreyevea & Brownell, 2008). Fat children are bullied, sometimes to the point of suicide. Some studies have found children as young as five trying to diet for being fat, no matter their actual weight. Fat people are more likely to be unemployed or underemployed, and there are prejudicial beliefs that fat workers are more problematic, despite research saying otherwise (Roehling, Roehling, & Odland, 2008).Obesity is seen by the masses as something people choose. However, science disagrees. There has long been a link between depression and obesity. Mental health is tightly tied to obesity, where those who experience weight discrimination are more likely to gain weight, although unhealthy behaviours such as binge eating and exercise avoidance are sometimes seen as a coping mechanism (Sutin & Teracciano, 2013).It has been reported in a number of journals that 90–95% of the people who lose weight regain the weight within 10 years (Mann et al., 2007; Miller, 1999). “Everyone Knows” claims that this is because people go back to bad habits. Science, however, says that there are complex ways the body wants to regain the weight (Sumithran & Proietto, 2013; Sumithran et al., 2011). Worse, dieting may contribute to obesity. Adolescent girls who diet are at 324% greater risk for obesity than those who do not diet (Stice, Cameron, R. P., Killen, J. D., Hayward, C. & Taylor, C. B. 1999). Weight loss dieting may cause other health problems as well, such as immune system problems (Shade ED, et al. 2004).In the medical world, doctors are encouraged to talk to patients about their weight. Every fat person has heard, “What are we going to do about your weight?” The “we” is supposed encourage the patient to feel that the doctor is on the patient’s side in their battle. Yet what many patients hear is, “I don’t see you as a patient, I see you as fat.” Science says that the higher a patient’s BMI the less respect a doctor has for the patient (Huzinga, Cooper, Bleich, Clark, & Beach, 2009).Horror stories about fat people trying to get decent health care are everywhere. For a good example, see Bruce Taylor Seeman’s piece, “The Perils of Obesity May Include the Doctor” (2006). [End Page E1] There are many blogs and stories on the internet about the way patients are not just shamed for their weight, but actively bullied by medical professionals. One blog, The Well Rounded Mama (wellroundedmama.blogspot.com), discusses the bias of doctors against pregnant fat women, who are told things like, “You cannot have a healthy baby when you are this fat” and encouraged to abort. Tales from people told that their weight is the cause for everything and anything can be found on sites like First Do No Harm (fathealth.wordpress.com). Reading blogs by medical professionals can show the disdain they have for fat people. In one, an emergency room nurse declared that all fat diabetics have poor control, based solely on perceptions from her job. Comments were mostly other nurses agreeing with how “disgusting” fat people are to have to deal with. However, Yale University’s Rudd Center for Food Policy & Obesity not only recognizes the problem but aims to help medical professionals eliminate the bias.If obesity becomes a disease, weight loss surgery (WLS) becomes a bigger gold mine. Medical insurance will be more likely to cover weight loss surgery. WLS is an ever-changing target: there... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Obesity Treatment:One Size Does Not Fit AllKarin KwambaiI am obese. That phrase is actually very hard for me to say out loud. Saying it feels as if I am standing at an “obesity anonymous” meeting, except there is nothing anonymous about being fat. Everyone knows it. I often feel that it is the first and only thing people notice about me. I’ve been overweight, chubby, fat my entire life. (...) My mom enrolled me in Weight Watchers when I was 12 years old; I learned to use Molly McButter in front of her and sneak oatmeal cream pies when she wasn’t looking. I’ve learned a lot of maladjusted behaviors around food over a lifetime of trying to lose weight. I’ve tried meal replacement shakes, pills, souping, juicing, and the “Master Cleanse”—a diet of lemonade with cayenne pepper and maple syrup. All of these tactics only messed up my mind and body even more. The summer before my freshman year of college, I literally ate only an apple a day because I was so worried about not making new friends because of my weight. It was not about being healthy; it was about being accepted.Twenty years of blame and shame later, and despite mixed reviews on its success, Weight Watchers is still the first recommendation for weight loss from my doctor, along with Medifast, a 1000 calorie a day diet, or bariatric surgery. My naturopath told me to make my smoothies and spinach salads smaller, and my therapist told me I think too much about exercise and should “just do it.” I have gone many rounds with Weight Watchers and had some success. I have also had success losing weight by tracking food intake and exercise on apps like My Fitness Pal. But like all attempts at losing weight, following medical advice works until it stops working, and the weight comes back—plus some.Obesity as a DiseaseI recently sought treatment with an Obesity Specialist, but after an inspiring complimentary consult where she explained her holistic approach, I found out that my health insurance won’t cover the cost because the diagnostic code for obesity is excluded from my coverage. I have heard that the Affordable Care Act is supposed to impact insurance plans covering the cost of obesity treatment, but that has not been the case for me. In fact, I’ve been forced to pay out of pocket several times for labs that doctors feel the need to run, despite my urging that I am not diabetic. Trust me, I say; I know what diabetes looks like. I have watched family die and seen clients suffer, and I am earning my Masters in Public Health. I had been hopeful that the recent classification of obesity as a disease by the American Medical Association would open treatment doors, but it has not. In fact, I’m concerned that it will close doors for treatment opportunities because of how insurance [End Page 104] companies decide what medical costs they will cover. Obesity seems to be a four–letter word for health insurance companies. My insurance plan will cover prescription medications for high blood pressure, high blood sugar, and high cholesterol, but it won’t cover weight loss medications. Where is the incentive to address weight loss before potentially developing a life–threatening disease? I believe that obesity is a disease; I just don’t trust how the healthcare system will handle the responsibility of addressing it as such.In fact, the debate on whether obesity is a disease or a lifestyle is a frustrating one for me. If we claim lifestyle is the cause of obesity, it means that there is only one factor causing obesity. If that were true, then the commonly prescribed solution of “eat less, move more” would be more effective. The reality is, there is no single cause or cure for obesity; there is no one–size–fits–all treatment approach. It is a complex problem that deserves a complex response in the forms of primary, secondary and tertiary public health interventions. I am hopeful that classifying obesity as a disease will lead to more disease model research... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Obesity as Disease:Definition by DesperationJeremy ShermakI hated removing my shirt. Each visit to my doctor’s office, following a blood pressure and temperature check, the nurse would instruct me to take off my shirt so the doctor could examine me further. She would then leave the room. I remained perched atop the exam table, now half exposed, and a mirror on the wall would not leave me alone. In the (...) reflection, I saw my oversized breasts and “fat roll” oozing out from my pants, hiding my belt. I tried to straighten my back—breathe in, no wait, breathe out—to resculpt the appearance, but it did nothing. I hated myself. Soon, a gentle knock at the door would interrupt the loathing and I’d shake hands with my doctor.I have been obese for the majority of my life—from childhood until I turned 34, when shortly thereafter, I had gastric bypass surgery. Since that time, I have lost 155 pounds and now write this at a comfortable, healthy 180 pounds. That said, my mind remains “obese”. My thinking remains shrouded deep within the obese personality that I embodied for all of those years. I still automatically walk to the big–and–tall section of clothing stores; I don’t recognize the 34–waist pants when they come [End Page 114] out of the dryer; I’m not used to seeing my ribs; and I’m still terrified of that exam room mirror.Upon hearing the news that the American Medical Association (AMA) now classifies obesity as a disease, my initial reaction was that of relief. My recent success was due in large part to the discovery and treatment of hindering endocrinological issues. My history—like repeatedly slamming head–long into a brick wall—suggests that these medically verified roadblocks have existed for some time. Despite my efforts, I didn’t stand a chance.If anyone were a “poster child” for obesity as a disease, it would be me. The lifelong sparring with my weight had its ups and downs; I worked very hard to maintain or lose weight with mixed results. I lost 85 pounds my freshman year of college by running and fervently watching my portions. I kept that weight off for a good five years before the summer of 2003, when I started gaining weight very quickly. I gained 25 pounds in each month of June and July that year, despite maintaining my usual eating habits and running schedule. I soon lost faith. I felt as though I was up against forces that I could not control and I began to forget about losing weight. I didn’t binge, but I didn’t eat well. By 2008, my weight had reached 375 pounds—an all–time personal high.Following a bad relationship and seeking rejuvenation, I embarked on a diet that summer like I’ve never tried before. I cooked everything naturally—from regular dishes like stuffed peppers all the way to condiments like ketchup. It was a militant effort on my part. I lost 50 pounds that summer and felt that I was well on my way back to the body that once felt so comfortable. It was at that point where I hit a wall. I could not get past 321. I can still see that number staring back at me on the scale. It was frustrating. I felt I had done all I could. That’s when I visited a doctor who ran some tests that revealed problems with my hormones and metabolic systems.As it turned out, I had a tumor on my pituitary gland. This may have been the issue all along. That led to low testosterone, which had a really negative impact on my weight loss efforts. After thorough consideration, I decided to have gastric bypass surgery to “reset” my hormones and get a “boost” in my weight loss efforts. It worked.In my particular circumstance, I could view obesity as a disease because its causes, for the most part, were not a result of conscious lifestyle choices. I had no control over the pituitary tumor. However, I know that I could have done more to limit my... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:My Gratifying Testimonial of My Extended Warranties of LifeDanette RaginMy name is Danette Ragin. I am a 2-time kidney recipient who has been diagnosed with ESRD (End Stage Renal Disease). Both transplants were performed in Baltimore, Maryland. I am also a 3-time Donor Family Member and the proud Mom of a living donor.I received the first kidney from a deceased donor on June 22, 2008. The donor was traveling (...) thru Maryland with her family on vacation and experienced heart complications. My second kidney was donated to me by my youngest daughter Angel on December 20. 2016. I am thankful to God for both of my extended warranties. I’d like to share a little about my journey with you.Around the year 2002, I started seeing my PCP (Primary Care Physician) for terrible migraine headaches, which on occasions lasted for weeks. After several tests, she expressed her concerns. I had been spilling protein in my urine and my kidney function was showing some abnormalities. My PCP sent me to see a neurologist after several failed attempts to gain some type of reprieve from the nerve-racking headaches. My nephrologist confirmed my PCP’s diagnosis, and I had visits with the nephrologist every 6 months until they noticed a substantial change.“Ah, Mrs. Ragin, you’re in the beginning stage of End Stage Renal Disease”. Boom! (That hit me like a ton of bricks.) “Umm, you mean I have kidney failure! No! Not me. I’ve worked in dialysis. That can’t happen to me!”Of course, I was in complete denial. Both my PCP and nephrologist were very supportive mentally, physically, emotionally, and even spiritually. This information was so devastatingly painful that I started working harder and longer. I turned into a Superwoman with my family, work, and church. I was trying to drown out the fact that my health was being compromised, refusing to believe this could happen to me. I started to slow down in my daily functions, my appetite decreased, and I lost weight as a result. I thought that my weight loss was bringing my “Sexy Back,” only to realize that I am not exempt from sickness. My nephrologist assured me of a possible solution. He advised me to have my name placed on the waitlist of one of the transplant centers in Maryland.In October 2006, I had surgery to have an A/V fistula placed in my left arm to prepare for possible dialysis treatments in the future. In January 2007, I went to be evaluated for a kidney transplant. I was given 6 weeks to complete all required tests to secure a place on the transplant waiting list. Determination allowed me to complete all tests within 2 weeks.In April 2007, I was approved to be placed on the transplant list. In October, I had a PDC (Peritoneal Dialysis Catheter) placed in my abdomen so that I could dialyze myself at home. I loved it but it didn’t love me. It was removed in January 2008. Right afterward, I received my first unsuccessful call to be transplanted. (The kidneys were cystic and could not be used.) “Bummer.” I also received another call in April 2008 (Easter Sunday). Those kidneys were [End Page 134] at another hospital in Maryland, so if the waiting patient at their facility refused the kidney, I would be next in line. The patient accepted the donation. It wasn’t my turn yet.In the meantime, I had already started hemo-dialysis in mid-March 2008. On Saturday, June 21, 2008, while enjoying the weekend with my family, I received a call around 2:30 p.m. My youngest daughter and I were out shopping. We were in a crowded store that was going out of business, and I felt my phone vibrate. I noticed a slightly familiar number. I stepped out of the store to retrieve the call.“Mrs Ragin...Me: Yes.“Danette Ragin...Me: Yes.“We are calling from the University with an organ offer for you!”I told them they had me at the sight of the first few digits of the phone number they were calling from!In June... (shrink)

The obesity epidemic is one of the most serious public health threats confronting the nation and the world. The majority of overweight individuals want to lose weight, but the overall success of self-administered diets and commercial weight loss programs is very poor. Scientific findings suggest that the problem boils down to adherence. The dietary and physical activity recommendations that weight loss programs promote are effective; however, people have difficulty initiating and maintaining changes. Effective Weight (...) Loss presents 25 detailed sessions of an empirically supported, cognitive-behavioral treatment package called Acceptance-Based Behavioral Treatment. The foundation of this approach is comprised of the nutritional, physical activity, and behavioral components of the most successful, gold-standard behavioral weight loss programs. These components are synthesized with acceptance, willingness, behavioral commitment, motivation, and relapse prevention strategies drawn from a range of therapies. ABT is based on the idea that specialized self-control skills are necessary for weight control, given our innate desire to consume delicious foods and to conserve energy by avoiding physical activity. These self-control skills revolve around a willingness to choose behaviors that may be perceived as uncomfortable, for the sake of a more valuable objective. The Clinician Guide is geared towards helping administer treatment, and the companion Workbook provides summaries of session content, exercises, worksheets, handouts, and assignments for patients and clients receiving the treatment. The books will appeal to psychologists, primary care physicians, nutritionists, dieticians, and other clinicians who counsel the overweight. (shrink)

Next SectionIn an online study conducted separately in the UK and the US, participants rated the acceptability and fairness of four interventions: two types of financial incentives and two types of medical interventions. These were stated to be equally effective in improving outcomes in five contexts: weight loss and smoking cessation programmes, and adherence in treatment programmes for drug addiction, serious mental illness and physiotherapy after surgery. Financial incentives were judged less acceptable and to be less fair (...) than medical interventions across all five contexts. Context moderated the relative preference between rewards and penalties: participants from both countries favoured rewards over penalties in weight loss and treatment for serious mental illness. Only among US participants was this relative preference moderated by perceived responsibility of the target group. Overall, participants supported funding more strongly for interventions when they judged members of the target group to be less responsible for their condition, and vice versa. These results reveal a striking similarity in negative attitudes towards the use of financial incentives, rewards as well as penalties, in improving outcomes across a range of contexts, in the UK and the USA. The basis for such negative attitudes awaits further study. (shrink)

At extreme altitude (>5,000 – 5,500 m), sustained hypoxia threatens human function and survival, and is associated with marked involuntary weight loss (cachexia). This seems to be a coordinated response: appetite and protein synthesis are suppressed, and muscle catabolism promoted. We hypothesise that, rather than simply being pathophysiological dysregulation, this cachexia is protective. Ketone bodies, synthesised during relative starvation, protect tissues such as the brain from reduced oxygen availability by mechanisms including the reduced generation of reactive oxygen species, (...) improved mitochondrial efficiency and activation of the ATP‐sensitive potassium (KATP) channel. Amino acids released from skeletal muscle also protect cells from hypoxia, and may interact synergistically with ketones to offer added protection. We thus propose that weight loss in hypoxia is an adaptive response: the amino acids and ketone bodies made available act not only as metabolic substrates, but as metabolic modulators, protecting cells from the hypoxic challenge.Also watch the Video Abstract. (shrink)

While previous studies have suggested that there exists a relationship between obesity and executive function (EF), the mechanisms and causal relationship between them remain unclear. There are important clinical implications of determining whether EF can predict and treat obesity. We conducted a multilevel meta-analysis of randomized controlled trials (RCTs) and longitudinal studies. Specifically, we investigate (a) whether EF interventions have an effect on weight loss, (b) whether baseline EF can be a predictor of future weight loss (...) through obesity intervention, and (c) whether early-life EF can predict future weight loss. Eight RCTs and 17 longitudinal studies with a total of 11,393 participants were identified. We found that (a) EF interventions may not have an effect on weight loss, (b) baseline inhibition (β = 0.259,p= 0.03) and delay discounting (β = −0.17,p= 0.04) significantly predict future weight loss through obesity intervention, (c) age (F= 13.666,p= 0.005) moderates the relationship between working memory and weight loss through intervention, but not weight status, type of intervention, and percentage of female, and (d) early life inhibition (β = 0.185,p= 0.07) is a marginally significant predictor of future weight loss. Our results seem to support the assumption that the relationship between EF and obesity is not direct, and a higher-order factor, such as genes, may link obesity and EF. Building on the preliminary findings, further studies focusing on EF and obesity are needed in the future. (shrink)

Intentional weight loss can increase health risk in the long‐term, despite short‐term benefits, because human adipose tissue is widely contaminated with various lipophilic environmental contaminants, especially persistent organic pollutants (POPs). Recently, chronic exposure to low POPs has emerged as a new risk factor for common metabolic diseases and cardiovascular diseases. The amount of POPs released from adipocytes to the circulation increases during weight loss, thereby increasing POPs exposure of other critical organs. Possible harmful effects due to (...) release of POPs during weight loss are opposite to those usually expected from losing weight. It is speculated that this tradeoff can explain recent puzzling findings on intensive weight loss. The presence of POPs in adipose tissue adds a challenge to weight management and an optimal strategy of weight management needs to consider both fat mass and dynamics of POPs. (shrink)

This case study considers the ethical defensibility of recommending weight loss as a treatment for patients with higher body mass indexes. Recommending weight loss may be motivated by clinicians’ biases toward people living in larger bodies, misperceptions about weight and its relevancy to overall health, and a failure to consider other ethical factors such as those related to equity and the social determinants of health.

Healthcare professionals may confront ethical issues in practice, particularly when their values conflict with that of their patients or clients. This paper explores an ethical case study in which a dietitian who practices Health at Every Size® has an older adult client who wishes to lose weight. The dietitian believes that losing weight is inappropriate for this client. Using a framework for ethical decision making, this article explores the problem or dilemma, identifies the potential issues involved, discusses the (...) relevant ethical codes, laws, and regulations, and explores possible courses of action and their consequences. By exploring an ethical issue that healthcare professionals may encounter in practice, we can gain a deeper understanding of ethical decision making. (shrink)

Behavioral weight loss interventions that promote healthy eating as a way to achieve and maintain healthy weights do not work for most people. Most participants encounter significant challenges to behavior change and do not lose weight or maintain meaningful weight loss. For some, there may be negative consequences of participating in a BWLI, including social, psychological and economic costs. The literature is largely silent on these negative unintended consequences, but they are important for both practical (...) and ethical reasons. If efforts to eat healthier have too many negative consequences for individuals and groups, then these efforts are unlikely to be effective, and promoting them may not always be ethical; this would boost the case for moving away from individual-focused efforts as part of healthy eating efforts. Alternatively, if we can make BWLI interventions more effective and more ethical by mitigating these unintended consequences, then it may be too soon to give up on individual-focused efforts. We make a case for systematic assessment and reporting of the unintended consequences of BWLI. This could contribute to more effective and ethical BWLI and inform obesity interventions and policies more broadly. (shrink)

Obese people consume significantly greater amounts of health resources. This study set out to determine if health resource utilization by obese people decreases after losing weight in a comprehensive medically supervized weight management programme. Four hundred and fifty-six patients enrolled in a single-centred, multifaceted weight loss programme in a universal health care system were studied. Patient information was anonymously linked with administrative databases to measure health resource utilization for 1 year before and after the programme. Mean (...) body mass index (BMI) decreased by more than 15%. The mean annual physician visits (pre = 9.6, post = 9.4) did not change significantly after the programme. However, patients saw a significantly fewer number of different physicians per year following the programme (pre = 4.5, post = 3.9; P < 0.001). Mean annual number of emergency visits (pre = 0.2; post = 0.2) and hospital admissions (pre = 0.05; post = 0.08) did not change. Neither baseline BMI, nor its change during the programme, influenced changes in health resource utilization. Our study suggests that weight loss in a supervized weight management programme does not necessarily decrease short-term health resource utilization. Further study is required to determine if patients who maintain their weight loss experience a decrease in health utilization. (shrink)

The recent rise of injectable ‘wonder drugs’ for weight loss has been rapid and unregulated (so rapid that it has resulted in a worldwide shortage of Ozempic). We analyse the commercialisation of these drugs, and the political manoeuvres companies engage in to leverage and manufacture the gendered capitalism of ‘care’. Marketing relies heavily on situating ‘obesity’ as a chronic disease influenced by genes or other aspects of biology, working therefore to supposedly mitigate the blame and shame of the (...) taken-for-granted aetiology of ‘obesity’, overwhelmingly understood as excess food intake and insufficient activity. Armed with this evidence, women are told to ‘stand up against weight care judgement’ and to engage in ‘shame free’ care. Pharmaceutical interventions are at the ready to inject this weekly dose of care, producing freedom through neoliberal pleasure but, ironically, in doing so, sacrificing the pleasure of food and non-conditional self-acceptance as vital forms of self-care. (shrink)

Glucagon-like peptide-1 receptor agonists are effective for treating obesity, but the high cost of these medications endangers the financial viability of our health care system. To ensure that these drugs are available to Medicare beneficiaries, pharmaceutical manufacturers must lower their prices.

In lieu of an abstract, here is a brief excerpt of the content:Editors’ NoteJames M. DuBois, Ana S. Iltis, and Heidi A. WalshFrom childhood, David Slakter had undergone tests and invasive procedures to monitor his nephritis. It was not a surprise when in 2015, doctors told him he needed a kidney transplant. The wife of a childhood friend was a close match and gave him one of her kidneys. Before his transplant, aerobic exercise was difficult; a few months after transplant, (...) Slakter could ride his bike, hike, and work out with a personal trainer. He no longer had to weigh food or gauge his potassium consumption, a concern for people with kidney failure. For Slakter, “life post-transplant has been a significant improvement.”Individuals or family members of those who have received an organ transplant from a living or deceased donor share their stories in this issue of Narrative Inquiry in Bioethics. The symposium is titled “Receiving the Gift of Life: Stories from Organ Transplant Recipients.” Organ transplantation can extend an individual’s life by decades. It can also greatly improve an individual’s quality of life, as was Slakter’s experience. At the same time, organ transplantation is expensive and stressful. Recipients can experience complications, including organ rejection, and there are few appealing alternatives.After her heart transplant, author Leilani R. Graham required four open-heart surgeries, ECMO, and an intra-aortic balloon pump. She experienced delirium, necrotizing pneumonia, and severe muscular atrophy that required her to re-learn how to walk. She struggled with weight gain, explosive mood swings, hair loss, and was terrified that her body would reject the new heart. For Graham, “[Transplant] was not the miracle [she] was hoping for.” Graham says she felt unprepared for and inadequately informed about what to expect after her transplant, which left her “battered, beaten, and bruised” with a 12-inch line from neck to navel and “bullet holes” up and down her torso from the chest tubes. When reflecting on her experience post-transplant, Graham says, “It wasn’t the physical trauma that hurt the most. It was that no one seemed surprised [by the aftereffects of transplant].” Seemingly no one, that is except Graham, who calls on transplant providers to “prioritize empathy.”The symposium editors are Jason T. Eberl and Tristan McIntosh. Three commentary articles, written by Macey Leigh Levan, Heather Lannon, and Vidya A. Fleetwood, Roslyn B. Mannon & Krista L. Lentine, offer important insights into the authors’ stories. The editors thank Mid-America Transplant, the UCSF Lung Transplant Program, Donor Connect, William L. Freeman, MD, MPH, MJIL, CIP, Janet Monk, and the individuals who gave anonymous donations to support the publication of this issue, an open-access VOICES edition of the symposium, and accompanying teaching guides.The research article in this issue, “‘A Shell of My Former Self’: Using Figurative Language to Promote Communication about Patient Suffering,” was written by Tyler Tate, Elizabeth Stein, and Robert A. Pearlman. The relief of suffering is a primary goal of medicine. However, the authors note that clinicians often miss or ignore suffering because they focus on the causes rather than the experience of suffering, or the subjective nature of suffering makes it difficult to discuss. The authors believe that “the key to communicating about suffering lies in finding [End Page vii] the right kind of words to describe the experience” and say that figurative language offers a promising approach. In their research, the authors performed qualitative analysis on 52 works of literature and identified 254 excerpts of figurative language with themes of non-physical or psychological suffering. The authors found 13 salient themes: brokenness, diminishment, disorientation, drowning, emptiness, imprisonment, battle, darkness, isolation, invisibility, lifelessness, punishment, and torture. The authors reiterate that developing a shared language of suffering could foster a therapeutic patient-clinician relationship and improve clinicians’ ability to recognize and address a patient’s experience of suffering.María Susana Ciruzzi wrote the first of two case studies included in this issue. “The Sword of King Solomon” addresses a tragic and difficult subject—how to navigate the situation posed by conjoined twins when “any decision will produce damage and suffering.” The case involves two infant male patients born at 37 weeks gestation as omphalo-ischiopagus conjoined twins... (shrink)

Outcome-adaptive randomization (OAR) has been proposed as a corrective to certain ethical difficulties inherent in the traditional randomized clinical trial (RCT) using fixed-ratio randomization. In particular, it has been suggested that OAR redresses the balance between individual and collective ethics in favour of the former. In this paper, I examine issues of welfare and autonomy arising in relation to OAR. A central issue in discussions of welfare in OAR is equipoise, and the moral status of OAR is crucially influenced by (...) the way in which this concept is construed. If OAR is based on a model of equipoise that demands strict indifference between competing interventions throughout the trial, such equipoise is disturbed by accruing data favouring one treatment over another; OAR seeks to redress this by weighting randomization to the seemingly superior treatment. However, this is a partial response, as patients continue to be allocated to the inferior therapy. Moreover, it rests upon considerations of aggregate harms and benefits, and does not therefore uphold individual ethics. Issues of fairness also arise, as early and late enrollees are randomized on a different basis. Fixed-ratio randomization represents a fuller and more consistent response to a loss of equipoise, as so construed. With regard to consent, the complexity of OAR poses challenges to adequate disclosure and comprehension. Additionally, OAR does not offer a remedy to the therapeutic misconception—participants’ tendency to attribute treatment allocation in an RCT to individual clinical judgments, rather than to scientific considerations—and, if anything, accentuates rather than alleviates this misconception. In relation to these issues, OAR fails to offer ethical advantages over fixed-ratio randomization. More broadly, the ethical basis of OAR can be seen to lie more in collective than in individual ethics, and overall it fares worse in this territory than fixed-ratio randomization. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Stepping Off the Edge of the Earth:A bariatric patient’s journey out of obesityNikki MassieI have been overweight my entire life. When I was born—three weeks early—I weighed 9 lbs., 3 oz. I proceeded to trend on the high end of the weight percentile for my age. By the time I was 14 years old I’d surpassed 200 lbs. By the time I graduated high school I’d hit 250 (...) lbs.Even today, after losing a considerable amount of weight from having Roux–en–Y gastric bypass surgery, I am still considered overweight according to the body mass index.All this is to say that the way I think about my health, my body and my life is very much from the perspective of someone who has never experienced the so–called condition of being “normal.”Enough is EnoughI’ve been asked many times how I decided to have bariatric surgery. The answer isn’t simple. Because I’d been overweight all my life, the notion of being anything but overweight seemed a bit absurd to me. Not absurd as in, “I would not be happy if I were smaller” but more like, “I don’t know if this could ever happen for me and, if it did, who would I be?”Truth be told, I wasn’t entirely unhappy as an overweight woman. By the account of my primary care physician I also was not necessarily unhealthy for an overweight person. I didn’t have high blood pressure or diabetes (I wasn’t even pre–diabetic). My heart seemed to work fine. I was just very, very large.However, I’d been large (or larger than others) my entire life. In many ways my very identity was inextractable from that fact. While I can’t speak for my entire culture, my experience as an African–American woman is one where women of size were not reviled, but celebrated. Being too thin was always presented to me as a negative cultural value, I believe because it was associated with drug use.That means that growing up I didn’t have some of the experiences other obese people had. There were a few people who teased me but they were the exception, not the norm. I don’t recall being lonely because of my size. I dated avidly throughout my adolescence. I was asked to, and went to, both my proms.I proceeded into young adulthood with a few bumps along the way. I suffered a bout of depression in my sophomore year of college and just after my 21st birthday I found the first signs of what would be massive hair loss from alopecia areata (although did not know that’s what it was at the [End Page 107] time). Otherwise, I was fairly healthy and no more or less happy than any other 21 year–old I knew.At age 22, I had my first child, a daughter. This was the beginning of an upward weight climb that took me from being very overweight into very obese. At age 21, I weighed about 240 lbs. (I am 5 ft. 8 inches tall). By the time I was 26 (and after I had a second daughter), I weighed in at 340 lbs.At this point I began to want to lose weight. I no longer liked the way I looked in pictures. My increased clothing size and cost depressed me even further. My attempts at dieting, however, failed miserably. I did seek help from my primary care physicians (I went through several throughout my young adulthood). Each time I’d be given a copy of the food pyramid and a pamphlet explaining the health benefits of losing weight.But how? How exactly does one lose weight? In my mind it was some strange combination of sadistic exercise and starvation. That’s what I saw in magazines. Women who ate the equivalent of one meal per day who exercised many hours a day. I had no desire to do either and so I continued on my trend upward.During that time my mother (now deceased) worried about my weight a lot. I’d... (shrink)

Despite promising early work into the role of immune cells such as eosinophils in adipose tissue (AT) homeostasis, recent findings revealed that elevating the number of eosinophils in AT alone is insufficient for improving metabolic impairments in obese mice. Eosinophils are primarily recognized for their role in allergic immunity and defence against parasitic worms. They have also been detected in AT and appear to contribute to adipose homeostasis and drive energy expenditure, but the underlying mechanisms remain elusive. It has long (...) been recognized that immune cells such as macrophages respond to external signals to regulate adipose homeostasis and energy balance, however, less is known about the relevance of eosinophil activity in AT. As the authors propose in this review, given recent debate over the relative importance of their tissue‐specific abundance, the stage is now set for exploring the functionality and activation states of AT eosinophils. (shrink)

Probability weighting is a marked feature of decision-making under risk. For poor people in rural areas of developing countries, how probabilities are evaluated matters for livelihoods decisions, especially the probabilities associated with losses. Previous studies of risky choice among poor people in developing countries seldom consider losses and do not offer a refined tracking of the probability-weighting function. We investigate probability weighting among smallholder farmers in Uganda, separately for losses and for gains, using a method that allows refined tracking of (...) the PWF for a population with low levels of literacy. For losses, we find marked probability weighting near zero, which is in line with evidence found in Western labs. For gains, the absence of probability weighting is remarkable, particularly its absence near 100%. We also find marked differences in probability weighting for traditional farmers which are in line with the observed livelihoods strategies in the study area. (shrink)

In many scientific, economic and policy-related problems, pieces of information from different sources have to be aggregated. Typically, the sources are not equally competent. This raises the question of how the relative weights and competences should be related to arrive at an optimal final verdict. Our paper addresses this question under a more realistic perspective of measuring the practical loss implied by an inaccurate verdict.

In lieu of an abstract, here is a brief excerpt of the content:Tackling AdversityJohn HermanekAs a very active and athletic 21–year–old I was involved in an accident that would change my life forever, but not necessarily for the worse. I was hit by a drunk driver in a pick–up truck while riding my motorcycle. Ironically, I was on my way to sell the motorcycle but never made it that far. I suffered a broken hand, femur, multiple lacerations and the most (...) severe injury of them all, the loss of my right leg just below the knee. I kept the fact that I owned a motorcycle from my parents by storing it at a friend’s house so I knew the news of my injury would be twice as surreal to them. I remember telling the ER nurse that I needed to be the one that called them to tell them what happened. She said she could not do that, but I told her that she did not know my mother and I was able to talk her into accommodating me.It was the summer between my junior and senior year of college and I had had just made Indiana University’s football team as a walk–on linebacker (without having played HS football) so life was good and there was pretty much nothing holding me back or anything I felt I could not do.In an instant the life I once knew would never be the same and I truly wanted to die but little did I know that life would get better, not worse. After keeping my lower leg attached with surgical tape for a week, the inevitable could not be avoided. It was devastating news. At first I refused to sign any papers authorizing the amputation surgery but I was told if I did not, I would surely die as gangrene had set in. I remember scribbling my signature and then throwing the pen—a doctor’s dream I’m sure but I have to believe they’ve seen it all before. I was in traction for the first six weeks and had lost 60 pounds. Two weeks after being removed from traction I was able to get upright but was extremely weak. The emaciated and ghostly white image of me was tough to look at in the mirror, especially with half my right leg missing. That really took some getting used to. At that point, it was like a bad dream and I wasn’t sure what to make of all of it but one thing for certain was that reality had sunk in. Surprisingly, it was at that point that I quit feeling sorry for myself and instantly knew what had to be done.I knew I needed help and I could not do it alone so with the help of my family and friends, I started to put goals in place for myself. First on the list was to gain some weight back so I resumed working out (mostly weightlifting) and turned to my mother’s [End Page 192] great cooking. There were some highs and lows during that process particularly with my first prosthetist (also an amputee) who told me my days of any type of sports activities “were over.” That was pretty devastating news to me but it didn’t take me long to realize he was only telling me things that he himself was never able to accomplish as an amputee and that just created more of an incentive for me because I knew deep down it was possible because I already had the drive and determination. Just under a year later I was back to a regular exercise program, my “pre–accident” weight and feeling healthy and in shape again.I have since become more appreciative of what I have. I used to box in college and in 1991, entered the Chicago Golden Gloves Super heavyweight (senior novice) division. Senior novice means you’ve had five or less fights at that time and that you were at least 21. I lost my first fight in 1991 on a controversial decision and came back in 1992 and had three fights. Just shy of 35 years old, my first opponent... (shrink)