“At What Cost?”: Problematising the Achievement of ‘Health’ through Thinness – The Case of Bariatric Surgery
Authors: Simpson Aimee Bernardette 
Published: October 2020

Introduction The current social climate of Western societies understands fatness as the self-inflicted disease ‘obesity’; a chronic illness of epidemic proportions that carries accompanying risks of additional disease and that will eventually lead to death. In recent years, the stigmatisation and general negative societal evaluation of fatness and thus fat identities has increased (Sobal). Primarily, fatness has become a sign of medical deviance in that it is perceived to be a product of unhealthy eating behaviours and physical inactivity (Rothman). As a result, to be fat has become a barrier to entry in terms of employment opportunities, and has restricted the availability of health and insurance services for many (Sobal). Recently there has been a drastic increase in the availability of radical weight-loss solutions that strictly regulate and police fat-bodied deviants, namely in the form of surgery. Bariatric surgery, or weight-loss surgery, physically enforces the achievement of ‘health’ by curing obesity by reducing the size and functionality of the stomachs of the morbidly obese. However, bariatric ‘post-ops’ (short for post-operative) often encounter harmful consequences following their surgery in the form of increased self-surveillance, regulation and control in order to maintain their health through thinness. This article seeks to examine these consequences of surgery as a way to problematise the achievement of health through thinness overall. In order to address this issue, this article first establishes a framework of obesity discourse which enables us to understand how obesity is perceived as a self-inflicted disease in need of medical intervention within modern Western societies. From this position, we can begin to understand the purpose of interventions such as bariatric surgery. While it is acknowledged that surgery provides the morbidly obese with a gateway to health through the achievement of thinness and an escape from a heavily stigmatised identity, it is argued that this is done at the expense of placing increased regulations and surveillance upon individuals. Finally, in drawing on post-op experiences collected for research examining the life impacts of bariatric surgery, this article will examine how post-ops are subjected to intense policing, monitoring and regulating from themselves and others as a result of achieving and maintaining ‘health’ through body size.  Obesity Discourse: Establishing a FrameworkScholars Evans, Rich, Davies and Allwood argue that contemporary Western responses to obesity can be conceptualised as operating within an ‘obesity discourse’ which provides a framework of “thought, talk and action concerning the body in which ‘weight’ is privileged not only as a primary determinant but as a manifest index of well-being” (13). Predominantly, this framework draws upon two key assumptions; that obesity is a legitimate and measurable disease that poses significant medical risks to populations, and that both the cause of and solution to obesity are individual lifestyle choices (Rich, Monaghan and Aphramor). More specifically, the obesity discourse is the result of the combined efforts of an extensive process of medicalisation in conjunction with an increasingly neoliberal approach to healthcare. Since the 1950s, fatness has been widely regarded as the disease ‘obesity’. Sobal argues that this occurred through an extensive process of medicalisation, which can be defined as when non-medical issues and behaviour are redefined and understood as medical problems through the use of medical jargon and medical solutions (Conrad). In particular, fat was portrayed as pathological and requiring medical intervention through “frequent, powerful and persuasive claims that [medicine] should exercise social control over fatness” (Sobal 69).  In particular this has been exercised through the widespread implementation of the body mass index [BMI] into healthcare settings, as it is seen as an accessible, practical and affordable measure of ‘health’ (Ministry of Health). Unlike other markers of health, body weight is highly visible, and thus using it as an overall indicator of health increases surveillance of the self and others within populations. In this way we can see how the medicalisation of fatness works to produce what Bordo refers to as:one of the most powerful normalizing mechanisms of our century, insuring the production of self-monitoring and self-disciplining ‘docile bodies’ sensitive to any departure from social norms and habituated to self-improvement and self-transformation in the service of these norms. (186)Primarily, this is created through a construction of a ‘normal’ body shape or an ‘ideal’ weight, which can be specified using the BMI, and acts as a health imperative for individuals to achieve and maintain (Rich and Evans). However, these constructions do not factor in individual variations in body composition and thus represent a medically defined ‘thin ideal’, in that they are unobtainable and unrealistic for most people (Metzl 5). Consequently, the idea of a ‘normal weight’ strengthens contemporary body ideals (Burns and Gavey).The recent move in contemporary Western societies towards a neoliberal model of healthcare has significantly impacted societal attitudes towards fatness. The neoliberal healthcare model emphasises an individual’s choice and responsibility with respect to their health, and the privatisation of healthcare systems overall (Fries). While there is a general belief that this change gives patients more autonomy and input within the medical encounter (Lupton), the move towards a ‘democratisation’ of healthcare in reality further entrenches self-surveillance behaviours within populations by asserting that the responsibility for achieving and maintaining ‘health’ lies at the feet of the individual (Fox, Ward and O’Rourke). In particular, there is an assumption that ‘health’ can be ‘unproblematically’ achieved through individual efforts to discipline and regulate body size (Crawford) and thus individuals are obliged to engage in acts of self-discipline as both a personal and public service (Throsby, War). In this way, those who are labelled as ‘obese’ are not only questioned on their ability to appropriately care for themselves, but also their ability to be a good citizen (Throsby, War). Overall, the obesity discourse has intensified the stigmatisation of the obese in that they are portrayed as morally bad and weak-willed (Sobal) and ultimately reinforced the need for external regulatory bodies such as the weight-loss industry to monitor and control the obese. The combined efforts of the medical and weight-loss industry have produced a single message which suggests that if individuals want to maintain ‘health’ and prevent disease, there must be an enduring commitment to a ‘lifestyle change’. A ‘lifestyle change’ implies that in order to achieve successful weight loss and thus ‘health’, there needs to be enduring amendments to diet and exercise that are perceived as a ‘way of life’ rather than the ‘means to an end’ message marketed by other diet regimes (Fullagar). These changes are necessitated through an assumption that excess body weight is a sign of laziness and poor personal habits (Evans and Colls). Similar to the causes of obesity, there is a definitive notion that individual choices predicate the outcomes of weight loss endeavours. Thus, weight-loss successes and failures directly reflect how well individuals adhered to their ‘lifestyle change’ rather than the reliability and validity of the weight-loss regimes themselves (Saguy and Riley).Addressing Bariatric Surgery: The Solution to Morbid ObesityOver the past decade there has been a drastic increase in the availability of radical weight-loss solutions that strictly regulate and police fat-bodied deviants, namely in the form of surgery. While there appears to be support from the medical community for the effectiveness of a ‘lifestyle change’ as the primary solution to obesity, it should be highlighted that a ‘lifestyle change’ is only seen as a realistic option for certain obesity cohorts. In particular, surgery is reserved for the very highest of obesity cohorts – the morbidly obese – and is presented as their only viable option.  ‘Morbid obesity’ is defined as having a BMI of 40 or higher and is associated with the most risk of comorbid diseases such as type II diabetes, cardiovascular disease and hypertension (Foo et al.). According to the Ministry of Health, for individuals classified as morbidly obese, clinicians in New Zealand should strongly recommend bariatric surgery. Bariatric surgery describes a group of surgical procedures that physically restrict and redesign the stomachs of morbidly obese patients to achieve weight-loss as most procedures are permanent, and are associated with the greatest long-term weight loss in patients (Ministry of Health). Bariatric surgical procedures became popular due to their long-term effectiveness in weight-loss, and cost-effectiveness particularly for countries with public healthcare, through the drastic reduction in public health expenditure for co-morbid diseases such as diabetes and cardiovascular disease (Sampalis et al.). These procedures are considered the only effective treatment option for morbid obesity or a ‘last resort’ (Cranwell and Seymour-Smith; Ogden, Clementi and Aylwin), and consequently the amount of surgeries performed annually within Australasia has increased at an exponential rate (Buchwald and Williams).What makes bariatric surgery so important as a weight-loss method is that it offers the ‘morbidly obese’, who are seen as persistently deviating from idealised body norms and unable or unwilling to conform to standardised forms of self-regulation, a reprieve from their stigmatising identity. Indeed, many morbidly obese individuals who are seeking weight loss state that bariatric surgery is their only ‘hope’ or choice, or the ‘right’ choice for them (Morgan; Ogden, Clementi and Aylwin). In particular, the fear of, or the onset of, illnesses associated with obesity can be a major factor in their decision to undergo surgery (Ogden, Clementi and Aylwin). In this way, motivations to have surgery are heavily reflective of obesity discourse in that the presence of body fat is a marker of ‘impending doom’ (Rich, Monaghan and Aphramor). Indeed as Wann highlights:I really do understand why someone would consider this extreme option. The stigma attached to even the slightest amount of body fat can be daunting, and the surgeon’s sales pitch can be very slick. (41)However, as Morgan argues, more must be done to critique bariatric surgery as it largely exemplifies the social forces that control and regulate modern societies. Bariatric surgery physically enforces weight-loss and adherence to acceptable eating practices, and makes dissent both punishable and difficult (203). The removal of a large portion of the stomach means that, bariatric surgery imposes “corporeal order and discipline” (Morgan 203) upon individuals. The stomach not only enforces strict self-surveillance protocols but also an unyielding control over the individual through the “forceful prohibition or ejection” (Morgan 202) of substances. Thus, if individuals fail to regulate and govern their intake, the surgical intervention does it for them. The side-effects of vomiting and dumping syndrome act as a regulation failsafe and a form of punishment – an ‘internal policeman’ (Morgan) – that rejects deviant behaviour and punishes the individual through unpleasant and often painful experience. In this way, bariatric surgery can be viewed as the ‘ultimate weapon’ in the war against obesity as it is a means through which deviant individuals and bodies can be controlled and normalised (Glenn, McGannon and Spence).Bariatric Surgery: For Better or for Worse?In order to interrogate the dominant notion perpetuated through obesity discourse that fatness is a disease and body weight more generally is a legitimate way of measuring ‘health’ overall, this article will now draw on key findings generated from recent research examining the life impacts of bariatric surgery conducted with a support group for bariatric surgery in Auckland, New Zealand. While bariatric surgery is portrayed as a gateway to health, Throsby (Re-Birthday) argues that ultimately it is constructed as a ‘tool’ for weight-loss, rather than a cure-all ‘magic pill’ (130). This means that users are required to engage in normative dieting practices in the midst of developing new techniques of discipline that are specific to the post-surgery experience. In this way bariatric surgery creates new levels of self-surveillance that are unique to post-surgery life (Throsby, Re-Birthday 120). Self-surveillance and policing are methods in which bariatric post-ops are subjected to critique, monitoring and maintenance by both themselves and others. A key aspect of this involves the moral construction of ‘good’ and ‘bad’ foods, which often influenced eating behaviours and narratives whereby bariatric post-ops adhere to normalised understandings of diet, nutrition and health (Simpson 84). This dichotomy of good and bad foods reflects dominant understandings of the causal relationship between food, health and body size. Researchers have noted that there is a significant change in the relationship individuals have with food following surgery, and that often this comes with a serious fear of weight regain, and thus an intense policing of food (Cranwell & Seymour-Smith; Ogden, Clementi and Aylwin). Often, further restrictions are placed on an already restricted diet in order to achieve thinness, which emphasises the importance of achieving and maintaining thinness through the micromanagement of food intake (Simpson). In part, this reflects the way that the rhetoric that equates obesity with individual responsibility can equally ascribe blame to patients for any subsequent weight gain following surgery (Throsby, Re-Birthday 130) and indeed previous research has highlighted extensive fear of weight regain, particularly when users encounter fluctuations in their weight (Cranwell and Seymour-Smith). This is arguably what makes discussions around the concept of ‘maintenance’ so important. Maintenance refers to the monitoring process post-ops enter into after losing a significant portion of their weight and reaching a ‘plateau’, or a point where they stop losing weight; in essence it involves discussions around how to maintain and manage a ‘healthy’ weight (Simpson 79). Largely this draws on the assumption that despite being treated for obesity through a surgical intervention, one can never be recovered or truly ‘cured’ of obesity and thus individuals must engage in consistent monitoring as a preventative measure through ‘maintenance’ (Throsby, Re-Birthday). Maintenance is a complex process for bariatric post-ops; it is inextricably linked to weight management and is therefore a visible and moral indicator as to how ‘well’ post-ops are doing in their weight loss endeavours (Simpson). In this way maintenance is heavily couched in obesity discourse as individuals are expected to integrate self-surveillance and regulation practices into a ‘lifestyle change’ in order to prevent future weight gain (Cranwell and Seymour-Smith). For most, maintenance is difficult, and is understood to require a consistent consciousness of food related behaviours in order to be successful. In the observed support group, participants discussed the observations that they had made about their difficulties with resisting ‘crave’ or ‘bad’ foods (primarily those associated with high calories) that they enjoy, as well as revealing the ways in which they had altered their behaviour to address maintenance concerns (Simpson 79). One participant revealed that recent weight gain was making maintenance ‘very hard’, and it was clear that they attributed this weight gain to personal failings despite admitting that there had been no change to their ‘healthy’ eating behaviour (80). In order to address this issue, the participant admitted that they had resorted to traditional dieting rhetoric and removed dairy from their diet (83). Other support group members encouraged the participant to also remove carbohydrates from their diet (83), which further reinforced the notion that weight is a product of personal choice and individual responsibility (Crawford; Donaghue and Clemitshaw). As a result of the rapid weight loss achieved through bariatric surgery, many post-ops struggle to adjust to their ‘new’ bodies. This makes maintenance increasingly difficult as many individuals continue to see themselves as ‘fat’ despite having achieved a ‘normal’ weight (Simpson). Arguably a key factor in their misinterpretation of their body size and composition is the abundance of excess skin that is left over after rapid weight-loss. Excess skin, which has to be surgically removed and cannot be lost through diet or exercise, is a sore issue for bariatric post-ops, as it is a reminder of their former ‘fat’ selves, and thus a source of continuous dissatisfaction and lowered self-esteem (Groven, Råheim and Engelsrud). This is a common problem for many bariatric post-ops, with many citing that their low-hanging stomach or ‘apron’ is a primary source of anguish. Indeed, one post-op admitted that it was “even harder now because … it doesn’t seem to be going anywhere” (Simpson 63), and another revealed that while they consciously understood that their ‘apron’ was excess skin and not fat, they still used it as a sign that they must continue to lose weight. In this way, the reduction of the ‘apron’ has become a dangerous fixation for this post-op and the way in which they measure their success (Simpson 63).            Further, post-ops were monitored by family and friends, primarily through concerns over their small portion sizes, which led them to develop techniques to escape the scrutiny of others (Simpson 78). One technique that was particularly popular was the use of a smaller side plate during dinner time (Simpson 78). A smaller plate was both an easy way for post-ops to monitor and regulate their portions, and a method of avoiding criticism and monitoring from others as it effectively masked their reduced portions from the gaze of others. Indeed many post-ops lamented over the consistent external pressures from friends and family to increase their intake and discussed further masking techniques such as moving food around the plate to convince others that they were eating (Simpson 78). These behaviours are troubling as they mimic many primarily observed within the eating disorder community (Prestwood) and indeed Rich and Evans highlight that the level of stigmatisation surrounding fat and body size may push obese individuals into disordered relationships with food, exercise and the body (354). This would suggest that the discourses surrounding the bariatric and the eating disorder communities have lines of similarity in that weight and in particular, thinness is privileged as the primary method in which health and overall personal success is measured (Burns and Gavey; Rich and Evans). Concluding RemarksThe existence of behaviours such as maintenance, food policing and body fixation forces us to question the extent to which bariatric surgery is a gateway at all to ‘health’. 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