Body image after bariatric surgery

Body image after bariatric surgery

How is body image defined? There are four different components (perceptual, cognitive, emotional and behavioural) that form our body image.

·         The perceptual component refers to the way in which we visualize our bodies (this is often inaccurate, or we become hyper-focused on specific areas).

·         Cognitive aspects focus on the thoughts, beliefs and judgements that individuals have about their appearance.

·         The emotional component is how someone feels about the way they look, ranging from pride to disgust.

·         The behavioural aspect relates to the actions someone takes because of their body image. This may include avoidance of situations, mirrors etc. It can also include eating behaviours such as restriction and emotionally driven eating.

Body image issues prior to bariatric surgery

Body image dissatisfaction is a common issue amongst people seeking bariatric surgery. It is associated with binge eating, depression and low self-esteem (Sarwer & Steffan, 2015).  Body image disturbance is associated with the development and relapse of disordered eating (Lewer et al., 2017).  In addition, anecdotal evidence indicates that individuals with negative body image often present with very high levels of self-criticism, shame and avoidance – these inadvertently maintain problematic eating behaviours.  These internal reactions are unfortunately reinforced by societal attitudes to obesity/weight stigma. Although body image concerns are usually not the main driver for people seeking bariatric surgery, it is often one of the areas that people hope will improve.

What happens to body image following bariatric surgery

The multiple changes and improvements in weight and health following bariatric surgery are associated with improvements in quality of life and body image following surgery (Sarwer et al., 2010; Sarwer & Steffen, 2015).  Whilst there is a positive shift in pre-to post-op body image, it still tends to remain lower than normative levels amongst the general population (Ivejaz & Grilo, 2018).

There are some specific challenges in terms of body image adjustment that occur following surgery. There is often a time lag on individuals updating their body image which means that they still perceive themselves to be the same weight that they were prior to surgery, despite “knowing” that they have lost weight. In addition, individuals who have experienced abuse may feel more visible and vulnerable in the world as they lose weight leading to anxiety and possible sabotage attempts.

Research on whether the amount of weight lost following bariatric surgery impacts on body image is mixed. However, there is a trend towards greater weight loss being associated with improved body image (Ivejaz & Grilo, 2018). Those people who have early-onset obesity (rather than adult-onset obesity) appear to experience less improvement in their body image, presumably because of the entrenched nature of these negative beliefs (Adami et al., 1998).   Furthermore, there are several studies which indicate that poor body image post operatively is associated with problematic eating behaviours, such as loss of control (binge) eating and night eating (e.g. White et al., 2010).  Consequently, post-operative body image disturbance and dissatisfaction may potentially impact on long-term weight loss outcomes (Micanti et al., 2016). and could be an important area for intervention.

Body image, excess skin & body contouring

Excess skin following massive weight loss is very common and causes multiple physical and psychosocial issues. This can be extremely psychologically distressing and disabling. A recent study found distress about excess skin to be a common risk factor amongst individuals who developed restrictive eating disorders following bariatric surgery (Watson et al., 2018). Kitzinger et al. (2012) found that 75% of women and 68% of men wanted body-contouring surgery. However, the percentage of bariatric patients who undergo body-contouring surgery is much lower, primarily because of lack of access via the NHS in the UK and financial barriers. Research which compares individuals who have body contouring, versus those who have not, report improvements in various body image dimensions. However, a study found that a significant proportion of individuals were dissatisfied with the results of the procedure (27% dissatisfied with abdominoplasty) (de Zwaan et al., 2014) and also with non-contoured areas (Song et al., 2006).

In summary, individuals seeking bariatric surgery have high levels of body image distress before surgery. As a result of weight loss, body image improves to some extent following bariatric surgery but there are additional and new body image adjustments and challenges to negotiate.

#obsmuk invites people affected by or interested in obesity to join us for #obsmuk twitter chat on Wednesday 25^th July at 8pm UK time. We welcome answers to the following questions from a patient lived-experience perspective and from health professionals working in bariatric surgery.

Questions for discussion:

1.    What body image issues and concerns do people experience or describe before surgery?

2.    What body image improvements and concerns arise following surgery?

3.    What pre-op information and advice could be given about body image changes that may occur following surgery? Are patients prepared for these body image changes?

4.    What ideas or strategies are useful in improving or coping with body image changes?

5.    How can we support people who have issues with excess skin?

Dr Denise Ratcliffe