Review of Extreme Weight Loss: Life before and after Bariatric Surgery. Sarah Trainer, Alexandra Brewis, and Amber Wutich, New York: NYU Press, 2021, 232 pp.

Reviewed Book

Extreme Weight Loss: Life before and after Bariatric Surgery. Sarah Trainer, Alexandra Brewis, and Amber Wutich, New York: NYU Press, 2021, 232 pp.

Extreme Weight Loss: Life before and after Bariatric Surgery. Sarah Trainer, Alexandra Brewis, and Amber Wutich, New York: NYU Press, 2021, 232 pp.

Bodil Just Christensen

Technical University of Denmark

Lotte Holm

University of Copenhagen

Within the past two decades, social science studies of obesity treatment and bariatric surgery have proliferated, shedding light on the lived experience of body transformations induced by surgery and normative conceptualizations of body size. Extreme Weight Loss by Sarah Trainer, Alexandra Brewis, and Amber Wutich represents the first extensive ethnography about bariatric surgery, a most welcome, important, and highly informative book that situates itself within classical medical anthropology and distinguishes itself from interdisciplinary research exploring treatment improvements and critical fat studies as an account of the lived experience of going through obesity surgery.

The book builds on data from 24 months of fieldwork in a large bariatric clinic in the western United States. Trainer, Brewis, and Wutich collaborated closely in both data collection and the subsequent analysis and writing up of the material. The data include field notes from participant observations in the clinic, interviews with patients, and a survey sent out in two waves to the patient cohort of the clinic.

Trainer, Brewis, and Wutich offer an effective and affecting ethnographic account of what it means to undergo extreme weight loss. The analysis is presented thematically, describing the medicalization of obesity, the stigmatization of fat bodies, and the restrictions on daily life that surgery imposes on patients. Thus, chapters mimic the general process of undergoing bariatric surgery, starting with the reasons and motivations for opting for bariatric surgery, followed by descriptions of short- and long-term outcomes of the operation.

Rather than emphasizing theoretical considerations, the book focuses on ethnographic detail, offering thorough and nuanced descriptions of patients’ obesity-linked struggles, concerns, and importantly, their suffering. Thus, we learn about the multiple diseases that biomedicine links to obesity and how severe obesity is conceptualized as a disease (e.g., in categories such as “morbid obesity”).  The authors detail how patients have internalized this medicalization and its ensuing logic of risk as authoritative knowledge. For many patients, this logic is the main explanatory framework for their decision to undergo surgery. Through pre-surgery behavioral change classes and procedures to have their surgical candidacy confirmed, patients learn about their numbers (blood pressure, blood sugars, BMI) and thus become more aware of the pathology of their situation.

The book also analyzes the multiple forms of stigma that patients report (i.e., stigma related to body norms, moral worth, and structural stigma). Body norms are in play when patients’ bodies are seen and experienced as abnormal, disgusting, and unacceptable. Moral worth is activated when obese bodies are seen as sign of moral failure, lacking the discipline to put in the work needed to combat obesity. Structural stigma affects patients’ everyday lives as they deal with, for instance, airplane seats, restaurant booths, off-the-rack-clothing, and supermarket aisles, that do not accommodate their big bodies. 

For many patients, surgery is the solution to life-long attempts and failures to achieve normal weight and to succeed in life, whether personally or professionally. The radical weight loss patients experience after surgery is accordingly described as a success. Most patients lose most of their excessive body weight, and this is seen as a sign of successful compliance, linked to increased control of food and eating, to resolved disease symptoms, and to changes in personal “numbers” indicating substantial health improvement. Such changes lead to reduced experience of stigma and a growing feeling of fitting in and being normal. The surgery is also linked to severe unpleasant experiences of nausea, food cravings and dumping (i.e., acute and extreme discomfort following undigested food being “dumped” directly from the stomach pouch into the small intestine). In patients’ narratives, however, this is interpreted simultaneously as punishment for non-compliance and as positive retraining to think about food and eating in a new way—leading to personal growth.

Still, bariatric surgery results in permanent changes and potential complications that demand that patients carefully monitor their behavior and bodies for the rest of their lives. Some patients experience serious negative health consequences of the surgery, leading to severe long-lasting suffering. Others maintain that losing the fat body was worth the trade-off with other kinds of trouble or suffering because these were seen as less serious than their previous ill-health. Most importantly, being less stigmatized outweighed the problems associated with the surgery.

The authors use the narratives and discourses of weight-related experiences among patients as a lens to dissect the wider social context of fat stigma and medicalized frameworks, which govern mainstream cultural perceptions. They show how medicalization both depoliticizes and individualizes obesity and reinforces contemporary body ideals despite the paradoxical fact that the majority of Americans are either overweight or obese.

The methodological design of the study is presented in detail in an appendix—particularly valuable for students and researchers. This includes the questionnaire used in the survey and a thorough account of the time-consuming and lengthy work involved in getting access to and carrying out fieldwork in the highly regulated space of the bariatric clinic. Managing and maintaining multiple sets of relations at many levels, formal and informal, were necessary to perform the ethnographic study.

The thematic focus of the analysis—while useful in outlining patient experiences—leaves little space for individual weight loss trajectories following patients from pre-surgery visits to long-term follow up, and the book does not describe how surgery influences the subjective experience of the interplay between eating habits, family relations, and identity work. While this is a result of the authors’ analytical choices, readers seeking accounts of individual patients’ comprehensive experience of living through obesity surgery may be disappointed.     Non-U.S.-based researchers (such as us) may find this book especially useful as an account of obesity surgery in a specific U.S. context. We recognize many overlapping themes with our own research in Denmark. However, the socioeconomic background of patients in the United States and Denmark differs greatly, as surgery is free for individuals fulfilling medical requirements in countries such as Denmark with universal welfare systems. Analyses of how individuals with low socioeconomic status live through obesity surgery would complement the rich in-depth ethnography presented in this book—a profound, thorough, and much-needed account of experiencing bariatric surgery.