Health and Weight Stigma at All Sizes: Lisa DuBreuil, LICSW

BEDA promotes cultural acceptance of, and respect for, the natural diversity of sizes, as well as promoting a goal of improved health, which may or may not include weight change.  The views expressed by our featured bloggers are their own.

Lisa Du Breuil Lisa DuBreuil, LICSW is a clinical social worker who treats people dealing with addictions, eating disorders and problems post-WLS at an outpatient psychiatry clinic in Boston. Lisa graduated from Boston University’s School of Social Work with a Master’s degree in 1994. Lisa practices from a Health At Every Size (HAES) perspective and particularly enjoys introducing people to the HAES tenets as part of their journey to good self care.

Weight Stigma and Weight Loss Surgery

In my work I’ve asked clients to teach me about life post Weight Loss Surgery (WLS). I’ve yet to meet anyone who made the decision to have their surgery lightly, or who didn’t try to prepare for the behavioral changes these surgeries require. I’d like to think I’ve learned a lot, thanks to my clients; things like, it takes a lot of work to take care of one’s self properly following a weight loss surgery and it takes a real dedication to daily self care and to regular blood work and follow up appointments with bariatric specialists. It means taking several daily supplements (and sometimes medications) for the rest of one’s life. It means choosing foods very carefully, and eating with great mindfulness and attention all the time since one small mistake may mean hours of discomfort or disabling fatigue. Behaviors that I have always thought of as ‘disordered’ – such as chewing small pieces of food at least at least 20 times before swallowing or eating on a rigid schedule – become many clients’ ‘new normal’.  It strikes me that there is very little room for error following a bariatric surgery, and I think that’s a lot of pressure to live under.

About eight years ago I began seeing people in my practice who developed addictions and/or eating disorders after having a weight loss procedure. I see many patients with co-occurring substance abuse and disordered eating issues (complicated biopsychosocial illnesses which almost always start in someone’s teens or twenties), but these WLS clients were mostly in their thirties, forties and fifties and telling me that they’d never had a substance abuse problem until their surgery.

I started reading everything I could about bariatric surgeries and their side effects. I read the research literature about WLS side effects, I scoured personal blogs, news articles, online support forums, and of course all the comment sections attached to the above. I started keeping notes on all the problems and illnesses people were reporting, like last week when I had lunch with a friend who has a rare blood disorder that has caused some pretty scary medical crises. She told me that the specialist who treats her said he has a number of new patients showing up with late-onset cases and what they all have in common is a history of WLS.  I made sure to add that to my notes.

Many stories are heartbreaking. Of course it is very sad when anyone develops a serious health problem or illness but for me there’s something tragic about problems developing after an elective procedure intended to make people healthier and happier.  These days most addiction specialists will tell you that a new patient referral with a WLS history is not something unusual, in fact it’s fairly routine. There are post-WLS patients who develop addictions to alcohol, cocaine or painkillers, who are now anorexic or bulimic, who develop compulsive shopping or gambling problems and people who have lost (or almost lost) their professional licensure, career or a marriage due to their new addiction post-WLS.

One particularly horrifying ‘side effect’ is that post-WLS patients have a significantly higher risk of death from suicide than the general population.[1] Some clients have shared that they regret their surgery and we do some work around their feelings of shame or embarrassment about this perceived “mistake”. Given what I have seen with complications, I can understand their feelings, but not everyone regrets their surgery.

I’ve read comments online from people detailing the sometimes life-threatening problems they’ve developed but then ending with “but I’d go through it all over again because it’s helped me get ahead at work” or “it was worth it because I can fit into the chairs no matter where I go”. When someone tells me that they don’t regret WLS, I believe them. My job isn’t to judge whether someone should or should not have gotten WLS, or how they should feel about it, I believe we’re all making the best decisions we can with the information we have at any time.  The only person who gets to decide if a complication or side-effect is ‘too big a price’ is the person who is experiencing it. I have to wonder though: if we lived in a culture where everyone could trust there would be a chair that fits them, would these surgeries be so popular?

I myself am quite fat and have been for about 20 years. Fat people are under enormous pressure to lose weight; they are not hired for jobs, they are denied promotions, or fired because of their weight; healthcare professionals assume fat people are lazy, noncompliant, undisciplined, and have low willpower.  Being fat even makes you less likely to go to college; even after adjusting for intelligence and family income[2]. Some women would rather be blind or lose years off their lives than to be seen as fat[3], just read the comments section of any online piece on the “obesity epidemic” to get a taste of what people think about fat people. Today in America, too many of us are either living miserably in an unacceptable body or we’re terrified of becoming unacceptable. Weight stigma isn’t good for any of us. 

While many mental health issues would require psychological clearance prior to WLS, “the presence of depression due to obesity is not normally considered a contraindication”[4]. If you are constantly told that you can’t be healthy, you’re stupid, you won’t get ahead, you’re lazy, etc… wouldn’t you be depressed? Is that really ‘depression due to obesity’ or is it ‘depression due to stigma’? Are we using an elective surgery with significant risks and adverse side effects to try to rescue people from the effects of stigma?

To manage health as well as weight stigma I use the Health At Every Size (HAES®) approach. HAES is based on the idea that the best way to improve health is to honor your body. It supports people in adopting health habits for the sake of health and well-being rather than weight control[5]. HAES has helped me complete my recovery from  binge eating disorder (BED), rediscover the joy of moving my body and breaking a sweat, and helped me understand the growing body of evidence that I don’t have to lose weight in order to protect and enhance my health. Taking good care of the body I am in right now and not chasing numbers on a scale is my best bet for continued wellness. I know now that pursuing weight loss leads to weight gain over time[6] and makes people less healthy in the long run. I use the HAES approach with all my clients regardless of body size to help them  in maintaining sobriety and improving their self-care without focusing on the scale.

And yet, living in this fat-loathing culture I continue to be vulnerable.

A while back my young daughter entered a new daycare program and when I picked her up one evening a boy came over to us and said to me “You are fat” and I handled it as I usually do. I said “Yes, I am fat” in a neutral voice, as I would if he commented on my blue eyes or brown hair. At that point three other boys, hearing me, began chanting “You’re fat! You’re fat!” for several moments until the teacher came over. My brave daughter, holding my hand tight, then said to them “I don’t like it that you were making fun of my Mom” and the teacher had them apologize.

As my daughter and I walked away I found myself near tears and full of shame for exposing my daughter to that experience. If I wasn’t so fat, it would not have happened and I had a thought that shocks me to this day. I found myself thinking “maybe I should have a gastric bypass… at least I’d be thinner – for a few years anyway – and then I could say that I did everything possible.”

In that moment, walking away with my little girl, I was desperate. I was so afraid of how my being fat would affect her life and I was desperate to protect her. After a few minutes I calmed down and was able to see that it wasn’t actually my precious body that was the problem, it was society’s opinion of it that was the problem (thank you HAES!). I was able to move past it and didn’t give WLS for myself another thought but this experience certainly helped me think more deeply and subsequently explore more with my patients their reasons for pursuing WLS. More than one has told me “Really, I was just tired of being fat”.

Fear and desperation, those are my concerns about these surgeries. Too many people, living in this fat loathing culture, are desperate and I worry that some people are hoping these surgeries will rescue them from the unrelenting pressure fat people experience, pressure to do something, anything, not be fat anymore. I am concerned that our cultural belief that being fat is one of the worst things you can be  – a belief shared by many health care  professionals – leads people to choose a surgery with a growing number of complications in a bid not to be that worst thing.