“Dear obese PhD applicants: if you didn't have the willpower to stop eating carbs, you won't have the willpower to do a dissertation #truth”
This was the #truth a University of New Mexico psychology professor, Geoffrey Miller, tweeted in 2013.
The tweet generated a firestorm in the media and led to Miller being censured by the university. But as unquestionably cruel and discriminatory as his tweet was, Miller is hardly alone in his negative views regarding people who struggle with excess weight. Fat stigma is one of the last acceptable forms of discrimination in American society, says Arizona State University anthropologist Amber Wutich.
“[Fat discrimination] can be institutional if you go into a waiting room in a clinic and there's not a seat that is the right size for your body, if you go to a store and there are not clothes that fit your body. There's an implicit message there saying, you don't belong here, we're not interested in serving you,” says Wutich, an associate professor in ASU’s School of Human Evolution and Social Change. “We know from research that people with larger bodies have lower chances of advancing in their careers, and that translates into real outcomes in terms of peoples’ ability to get ahead in life, their ability to increase their salaries, their ability to secure retirement.”
The negative consequences of this stigma are strong enough that many people go to great lengths to lose whatever excess weight they have (or think they have). Bariatric surgery—a type of surgery that may reduce the size of the stomach, intentionally create malabsorption, or both—is one path people can take when less invasive options have failed.
One of the most effective kinds of bariatric surgery is gastric bypass surgery. In this procedure, a surgeon cuts and staples the stomach to create a small pouch, which holds less food than the whole stomach. The pouch is connected to a lower portion of the small intestine, causing food to bypass the lower stomach and upper end of the small intestine. This reduces the number of calories absorbed from the intestines. Gastric bypass is the most commonly performed bariatric surgery at Mayo Clinic – Arizona.
A team of ASU researchers is working with Mayo Clinic patients to explore their experiences with bariatric surgery. This team includes Wutich, post-doctoral scholar Sarah Trainer and Alexandra Brewis Slade, director of the School of Human Evolution and Social Change. The Better Post-Bariatric Lives project, supported by the Virginia G. Piper Charitable Trust, is part of the Mayo Clinic-ASU Obesity Solutions initiative.
The researchers interviewed 40 gastric bypass patients at the Mayo Clinic in Phoenix. They are also conducting a broader survey of all the patients who have had bariatric surgery at the Mayo Clinic campuses in Phoenix and Rochester, Minnesota during the last five years.
Each of the patients is interviewed three times–before the surgery, soon after the surgery and several months after the surgery. The patients share their experiences with the program and with navigating the social, physical and psychological consequences of the surgery. They also talk about their experiences living with the label “obese.”
“One of the underpinnings for why we've gotten interested in the bariatric program at Mayo specifically is that it was a condensed, innovative way of looking at this experience of obesity,” says Trainer. “What it is to be obese in the U.S. today, what it is to experience stigma around weight, and then what it is to have that disappear. That was one of the things we were interested in: does fat stigma disappear when the weight disappears, or does suffering endure in some other form?”
Playing against a stacked deck
Obesity is a complex problem that’s both incredibly personal and painfully public. If you carry excess weight, you cannot hide it.
You also cannot escape the near-constant assault of public health announcements telling you everything you’re doing wrong, friends and family who may want to “help” you or simply push you to “work harder,” and an environment that simultaneously condemns fat in all its forms and encourages behaviors that result in weight gain.
“One of the staff at Mayo Clinic talks to patients about the messaging you get in terms of, if you're stressed and you're female you should go eat a tub of ice cream. If you're stressed and you're a male of a certain age you should go to a bar,” says Trainer. “There's such a bombardment of consumption-oriented emotional eating messages.”
What Trainer is describing is one component of the obesogenic environment. This environment is one of the reasons that the common advice that overweight people receive–“eat less, move more”–is acutely unhelpful. The real #truth is that the idea of fixing obesity through sheer willpower is largely false.
“One aspect of American culture is we highly value work and dedication and doing things independently for ourselves,” says Wutich. “This whole cultural discourse around fat is wrapped up in these larger American values about independence and work. So if you have a large body then you should be able to fix it by yourself and you should work harder and harder to do that. I think the scientific evidence increasingly indicates that that's really a set of cultural ideas–that's not really how it works if you want to lose weight.”
No matter their willpower, most adults in the U.S. today have to work for a living. That work often requires long hours of sitting still. Exercise and cooking at home consumes time that people could use to make money, take care of children or elderly parents, or finish their education. Many U.S. cities are not designed for walking or biking safely, and gym memberships are costly. And then, of course, there are all those consumption messages Trainer spoke of. The odds are stacked against weight loss no matter how hard you work.
Even if a person succeeds in losing weight, keeping it off is another story. Research shows that the theoretically simple formula–eat less, move more–is not even an accurate picture of how weight is really gained or lost. For instance, in order to maintain weight loss, a person who has been obese must consume significantly fewer calories a day than a person who weighs the same but has never been overweight, according to Rudolph Leibel, co-director of the New York Obesity Research Center, in the documentary, The Weight of the Nation.
The psychological toll of having a large body in a fat-phobic society can be as damaging as any physical ailments that obesity might create.
“I think it's quite clear at this point and well documented that the anxiety and distress and hysteria that's part of the public discourse around obesity is larger than the actual health threat warrants,” says Wutich.
For example, depression is common among people who struggle with obesity, and can in turn make losing weight even more difficult. Depression can negatively affect physical activity levels and body image, and some antidepressant medications can cause weight gain. And like obesity, mental health issues also tend to be stigmatized by our society.
Patients tell their own stories
An important aspect of the Bariatric Lives project is that it lets the patients speak for themselves. Although there is a lot of literature on obesity, very little of it includes the voices of people who have actually been obese. Rectifying this is one benefit of the cultural anthropological perspective the project draws on, says Wutich, as it calls for a “radical immersion in peoples’ lives.”
One of the most interesting things the researchers have learned is that contrary to popular belief, patients didn’t regret going through with the surgery. No matter what complications they had, the patients were glad they had the surgery and typically “couldn’t get over how much better they felt,” according to Trainer.
“They can do things they couldn’t do before,” she says, citing activities like walking up stairs without pain, siting in a booth at a restaurant and riding comfortably on an airplane.
One participant said she had recently gotten on a plane and didn’t need to worry about whether the seatbelt would fit or not. Even more meaningful was the fact that the seating was first-come-first-served, and a couple invited the participant to sit next to them.
“That would never have happened a year ago,” she said.
Patients also said they disagreed with the common rhetoric that weight loss surgery is an “easy way out,” or “cheating.” One participant commented, “It just ended up being a tool, a very big, very useful tool, but it is a tool nonetheless.”
“One of the fascinating things we found is that people who've experienced bariatric surgery are taking this idea and pushing back on it by saying, actually, bariatric surgery is really hard and not everybody can handle it,” says Wutich.
The Mayo Clinic bariatric program is one of the most comprehensive in the country, and involves both extensive pre-surgery preparation and post-surgery requirements. This includes attending support groups, visiting a psychologist, learning about mindful eating and emotional eating, learning about nutrition, working out plans for how to eat, and long-term appointments with dietitians and nurses. All of these things take a significant amount of time and commitment, of which the actual surgery is only one part.
Keeping the weight off is a lifelong challenge. But in general, as long as they follow the guidelines of the program, the Mayo Clinic patients have been successful at maintaining their weight loss, says Trainer. And despite any complications they might experience, the surgery seems to be benefitting patients overall.
“The Post-bariatric Lives project gives us a chance to embrace hope along with our participants,” says Wutich. “People are making a change in their lives, they're going on this exciting new journey, and we get to go along with them.”