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Aly et al. Mini-invasive Surg 2020;4:21 I http://dx.doi.org/10.20517/2574-1225.2019.57 Page 3 of 9

proportion of eligible women received bariatric surgery compared to eligible men. Another review of the
Nationwide Inpatient Sample database from 2002 to 2011 showed similar results. Of the 810,999 patients
[19]
who underwent bariatric surgery over that 10-year period, only 19.3% were men . These data imply that
there is a gender-based disparity in the utilization of weight loss surgery among eligible patients.

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 [1,15] . The increased proportion of younger
women undergoing weight loss surgery 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 [14,15,20] . Indeed, over 70%
of referrals to bariatric surgical programs in the published literature are female and about half of the referrals
are initiated by patients rather than by primary care physicians or other referring doctors [20-22] . These patterns
suggest that patient-driven requests for evaluation at the primary care level are relevant to the gender
imbalance seen among patients ultimately selected for surgical treatment. Additionally, bariatric surgery
utilization by young women may reflect fertility issues as a result of obesity, resulting in surgical treatment to
improve chances of a successful pregnancy and to reduce the risks of pregnancy-related complications [23,24] .

In contrast, social, cultural, and reproductive pressures to address weight perhaps provide less of an impetus
for morbidly obese men to pursue surgical treatment earlier. 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 morbidly obese women [1,15] . This delayed presentation for
surgical treatment among men increases their risk of morbidity, disability, and mortality. In addition, among
patients who initially attend a bariatric program for consideration of surgery, men are significantly more
[20]
likely than women to drop out of the process without undergoing surgery (OR = 0.527, P < 0.001) .
Although obesity rates are equal among genders, men are significantly less likely to be referred or undergo
bariatric surgery. Understanding the gender-based differences in referral, program attrition, and utilization
of bariatric surgical treatment are relevant to ensuring that high risk patients are adequately identified
before potentially disabling and life-threatening comorbidities develop.

GENDER-SPECIFIC WEIGHT PERCEPTIONS AND QUALITY OF LIFE
The gender disparity among bariatric surgical patients may in part be explained by gender-based differences
in perceptions of body weight and obesity-related quality of life, which may have an impact on the motivation
[25]
to request evaluation for surgery, as well as follow through with treatment. In a study by Tsai et al. , data
from NHANES were used to evaluate gender-specific weight perception across increasing BMI. Compared
with their female counterparts, overweight and obese men were less likely to have an accurate weight
perception, weight dissatisfaction, and attempted weight loss. Some studies have found more pronounced
gender-based difference among obese blacks compared to whites, suggesting that ethnicity and culture
[1]
influence perceptions of ideal body weight .
2
In a study of over 330 patients with a BMI of 35 kg/m or higher recruited from primary care practices,
[14]
Wee et al. assessed the relationship among obesity, perception of body weight, and patient quality of life
via the Impact of Weight on Quality of Life-lite (IWQOL-lite) survey, which was specifically designed for
use with obese individuals. IWQOL-lite examines domains including physical function, public distress,
self-esteem, sexual life, and work. In this patient sample, women were disproportionately negatively affected
by their weight compared to men, with statistically significantly lower Quality of Life (QOL) overall scores,
as well as in the specific domains of weight-related social stigma, self-esteem, public distress, and physical
functioning.

[26]
White et al. identified similar gendered patterns in obesity-related QOL using IWQOL-lite in a study
of 512 individuals actively undergoing evaluation for bariatric surgery. Despite having the lowest overall