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the only sustainable option for improved health outcomes, resulting in more than 50% loss of excess body
weight at 5 years postoperatively, significant improvements in chronic comorbid conditions, and improved
[6-8]
life expectancy .
Bariatric surgery is among the most common abdominal operation performed in the United States, with
approximately 228,000 cases performed in 2017 [9,10] . Minimally invasive laparoscopic weight loss procedures
now account for over 90% of bariatric surgeries performed, with perioperative mortality rates declining to
[3,9]
less than 0.1% over the past decade . Patients referred for surgical evaluation at a bariatric program are
typically seen by a multidisciplinary care team including a bariatric nurse, internist, psychologist or social
worker, nutritionist, and surgeon to determine eligibility and optimize postoperative outcomes in selected
[11]
patients .

Despite the tremendous benefits and well-documented safety of bariatric surgery, currently fewer than 1%
of Americans medically eligible for weight loss surgery actually undergo treatment [12,13] . Referral patterns by
primary care providers (PCP) seem to the biggest barrier to undergoing bariatric surgery. A recent meta-
analysis suggested that patient and PCP concerns regarding complications and potential death from surgery
[13]
were notable barriers to pursuing weight loss surgery . However, providers who were more knowledgeable
[14]
[13]
about bariatric surgery were more likely to refer their patients for consideration . Additionally, Wee et al.
reported that a recommendation by a PCP increased the likelihood that a patient would consider weight loss
surgery by five times.
While the prevalence of obesity among men and women is similar in the general population, a substantial
gender disparity has persisted over the past decade in bariatric surgery, with women comprising over 80%
of patients undergoing weight loss surgery [2,15] . In addition to socioeconomic factors that influence access to
bariatric surgical care, the complex interplay among gender, psychosocial, and cultural factors may pose an
additional challenge to ensuring that all eligible patients, regardless of gender, are receptive to the option of
weight loss surgery and have realistic expectations of outcomes after treatment.

We evaluated recent studies assessing demographic trends in bariatric surgery, as well as studies examining
utilization and outcomes with a focus on gender disparities. We further evaluated and selected current
literature based on the inclusion of themes relevant to gender-based differences in bariatric surgery care,
including patient and provider perceptions of weight-loss surgery, provider referral patterns, and patient
selection. We then sought to elucidate the sex-based differences in clinical and psychosocial outcomes
after bariatric surgery. Our aim here is to highlight factors associated with the gender imbalance in the
surgical treatment of obesity, review outcomes after surgery, and explore the critical opportunity for further
collaboration between bariatric surgical specialists and PCPs to more effectively address gender-based
disparities in obesity treatment.

BARIATRIC SURGERY ELIGIBILITY AND UTILIZATION
The National Institutes of Health (NIH) obesity management guidelines recommend bariatric weight loss
surgery as a treatment for morbidly obese patients with a BMI > 40 kg/m or a BMI of 35-40 kg/m and
2
2
obesity-related comorbidities [3,16] . Although obesity rates were once higher in female patients compared to
[17]
male patients, these differences have gradually disappeared since the early 2000s . A review of the 2009-
2010 National Health and Nutrition Examination Survey (NHANES) showed that the prevalence of obesity
[18]
was similar among adult male and female patients with a prevalence of 35.5% and 35.8%, respectively .
This suggests that the obesity rate may be climbing more rapidly in male than in female patients. However,
the utilization of bariatric surgery is outstandingly lower among eligible men than women. In an analysis
of the National Hospital Discharge Survey, which provides data on patients who have undergone bariatric
[1]
surgery from 1999 to 2010, Mainous et al. found that, across racial groups, a significantly higher