Weight stigma after bariatric surgery: A qualitative study with Brazilian women

PLOS ONE RESEARCH ARTICLE Weight stigma after bariatric surgery: A qualitative study with Brazilian women Mariana Dimitrov Ulian ID1*, Ramiro Fernandez Unsain1☯, Ruth Rocha Franco2‡, Marco Aurélio Santo3‡, Alexandra Brewis ID4☯, Sarah Trainer4☯, Cindi SturtzSreetharan4☯, Amber Wutich4☯, Bruno Gualano5☯, Fernanda Baeza Scagliusi1☯ a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Departamento de Nutrição, Faculdade de Saúde Pública da Universidade de São Paulo, São Paulo, SP, Brasil, 2 Unidade de Endocrinologia Pediátrica do Instituto da Criança do Hospital das Clı́nicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil, 3 Divisão de Cirurgia do Aparelho Digestivo, Unidade de Cirurgia Bariátrica e Metabólica, São Paulo, SP, Brasil, 4 School of Human Evolution and Social Change, Arizona State University, Tempe, AZ, United States of America, 5 Grupo de Pesquisa em Fisiologia Aplicada e Nutrição, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil ☯ These authors contributed equally to this work. ‡ RRF and MAS also contributed equally to this work. * Abstract OPEN ACCESS Citation: Dimitrov Ulian M, Fernandez Unsain R, Rocha Franco R, Aurélio Santo M, Brewis A, Trainer S, et al. (2023) Weight stigma after bariatric surgery: A qualitative study with Brazilian women. PLoS ONE 18(7): e0287822. https://doi.org/ 10.1371/journal.pone.0287822 Editor: Vidanka Vasilevski, Deakin University Faculty of Health, AUSTRALIA Received: September 5, 2022 Accepted: June 13, 2023 Published: July 27, 2023 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0287822 Copyright: © 2023 Dimitrov Ulian et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Prior studies suggest that one anticipated benefit of bariatric surgery is the achievement of a thinner body, one that is less subject to perceived negative judgment and condemnation by others. However, additional analyses also indicate that stigma may persist even with significant post-surgery weight loss. To investigate the stigma-related perceptions and experiences of women who have undergone bariatric surgery and the resulting body transformations, we conducted individual, semi-structured interviews with thirty Brazilian women (15 aged 33–59 and 15 aged 63–72). The resulting text was then analyzed using thematic analysis. We found that some form of weight stigma persisted for our participants, regardless of weight loss. Ongoing experiences of stigma were also evidenced by the constant internal and external vigilance reported by the women, as well as their articulated efforts to distance themselves from their previous bodies. Additionally, participants reported being judged for choosing an “easy way out” to lose weight. Those in the older group reported that weight stigma was entangled with ageism: older participants received mixed messages underscoring the ways that weight and age may interact in doubly stigmatizing ways. Family and close peers were especially powerful sources of stigma experiences. Collectively, these results show that weight stigma persists even when people undergo a procedure to lose substantive weight and that the degree and types of stigma experiences are influenced by gender and age. Our study suggest future research should explore whether a targeted approach might be more effective, for example, an approach that would emphasize the importance of developing coping strategies with respect to experiences of stigma and discrimination after surgery. Data Availability Statement: The data relevant to this paper are available from figshare, https://doi. org/10.6084/m9.figshare.23556324.v1. PLOS ONE | https://doi.org/10.1371/journal.pone.0287822 July 27, 2023 1 / 17 PLOS ONE Funding: This work was supported by the São Paulo Research Foundation (FAPESP), grant number 2019/00031-0, granted to Mariana Dimitrov Ulian. In addition, Fernanda Baeza Scagliusi received grant by FAPESP (grant number 2017/17424-9) and CNPq (grant number 309514/ 2018-5). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Stigma after bariatric surgery Introduction One of the most effective means currently available to individuals seeking to lose weight is bariatric surgery. Bariatric surgery, also known as weight-loss surgery, refers to a number of different procedures, all of which aim to induce severe weight loss through the surgical reduction of the stomach and/or intestines (e.g., [1–4]). Bariatric patients often have a history of complex anxieties and negative social experiences stemming from weight stigma [5–8]). The weight loss that accompanies the surgery, therefore, has been generally related to positive changes in body image and social interactions [9, 10]. In Brazil, bariatric procedures have been available at no cost to patients since 1999 through the Unified Public Health System or the Sistema Único de Saúde [11]. In this respect, Brazil parallels certain European countries that have also made bariatric surgeries widely available to citizens within an integrated healthcare system. Brazil is, however, economically, socially, and culturally quite distinct from these other nations. The sociocultural implications of the surgery, including experiences around weight stigma, have been understudied in a Brazilian context. For example, despite the highly-publicized increase in the number of bariatric surgeries performed within the Brazilian public health network, many experts still consider this number insufficient, as only about 8% of all applications for surgery are approved and financed [12]. Also, there are regional inequalities, with the wealthier South and Southeast regions reporting the most bariatric surgeries, and the North and Midwest regions reporting the least [13]. Stigma can be defined as negative judgments and behaviors aimed at a devalued attribute or condition that disqualifies a person or family or community with this attribute or condition from full social acceptance in a particular cultural context. Stigma results from a cascade of social interactions, in which the individual (or family or community) exhibiting the stigmatized trait is distanced from others, all of whom supposedly adhere to a normative standard. This in turn legitimizes various social and economic discriminations and exclusions [14]. Weight stigma is the process by which people wi (...truncated)