It is well known that significant barriers exist between morbidly obese patients and bariatric surgical treatment, and, although these barriers exist for both men and women, there is clearly a gender disparity with far fewer eligible men receiving appropriate treatment, according to researchers from Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA. The findings were featured in the paper, ‘Gender disparities in weight loss surgery’, published in the MIS journal Metabolic and Bariatric Surgery.
The authors noted that less than 1% of Americans medically eligible for bariatric surgery actually undergo treatment and whilst the prevalence of obesity among men and women is similar in the general population, there is a substantial gender disparity with women comprising over 80% of patients undergoing bariatric surgery.
To investigate possible reasons for this disparity, they assessed recent studies reporting the demographic trends in bariatric surgery, as well as studies examining utilisation and outcomes with a focus on gender disparities. They reported that several studies demonstrate that a higher proportion of female bariatric surgery patients are younger (less than 45 years old), compared to their male surgical counterparts. They hypothesise that this may be due to strong cultural and social pressures to seek a thin body weight ideal resulting in higher patient request and referral for surgical evaluation. Indeed, about half of the referrals for female patients are initiated by patients rather than by primary care physicians or other referring doctors. They also noted that bariatric surgery utilisation by young women may reflect fertility issues as a result of obesity.
Conversely, male patients typically present for surgery at an older age and with more comorbidities, including more than double the prevalence of coronary artery disease and history of myocardial infarction compared to their female counterpart. In addition, men are significantly more likely than women to drop out of the process without undergoing surgery (p<0.001).
Furthermore, men are less likely to have an accurate weight perception, weight dissatisfaction and attempted weight loss, suggesting a culture influence perceptions of ideal body weight, as well as weight-related social stigma, self-esteem, public distress and physical functioning.
“These studies suggest that psychosocial distress associated with obesity is more strongly experienced by women and perhaps may explain part of the trend to presentation at a younger age, when social and cultural pressures are strongest…” they write. “Thus, a vital step in counselling patients for weight loss and consideration of bariatric surgery may involve helping patients identify morbid obesity as a serious health problem through its impact on aspects of day-to-day life that matter most to the individual, with sensitivity to gendered patterns of self-perception and coping with obesity-related impairments.”
In a study by Wee et al (Sex, race, and consideration of bariatric surgery among primary care patients with moderate to severe obesity. J Gen Intern Med 2014;29:68-75), which explored demographic and quality of life factors affecting patient consideration of bariatric surgery, they reported that the majority of patients were aware of weight loss surgery, and overall 37% had ever seriously considered undergoing surgical treatment. However, 40% of women had considered surgery compared to 22% of men (p<0.05). Only 35% of this patient cohort reported ever having received information about surgical weight loss options from a provider, with no gender differences. However, women were more likely to have received a physician recommendation for surgery compared to men (22% vs. 14%, p<0.05).
Although referral patterns seem to be a larger barrier for access to weight loss surgery, the authors noted that patient selection by bariatric surgeons may also be implicated in the gender disparity. However, the overrepresentation of women undergoing bariatric surgery likely occurs prior to evaluation by a bariatric surgeon and is either related to referral patterns or patient preference.
“Primary care providers, who continue to be the most important source of patient referral, are in a frontline position to identify patients who may benefit from surgery and to understand patients’ health-related and social values, working closely with those who may be reticent to consider bariatric surgery and less likely to independently express interest in a surgical evaluation when appropriate,” the authors concluded. “Individualised multidisciplinary support remains vital throughout both the evaluation and treatment process to ensure commitment to surgery and long-term success, as surgical weight loss can truly result in profound positive changes across all aspects of life.”
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