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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 5 of 9

[30]
As men are underrepresented in the majority of bariatric surgical studies, Natvik et al. conducted a
qualitative focus group study including 13 men who had previously undergone bariatric surgery to better
understand their experience with surgical treatment. The men being interviewed reported that their initial
misconceptions regarding weight loss surgery involved associating the treatment with “vanity, which they
[30]
regard as valueless and shallow and did not relate to” . Prior to surgery, many men in the group had
tried other weight loss options on their own, expressing that autonomy and independence were critical to
addressing weight problems. The majority of men reported having suffered an acute illness such as stroke
or heart attack, which brought up themes of powerlessness and an emerging realization of needing help
for obesity, which they began to understand as a serious illness only after experiencing weight-related
complications.

In this small cohort, evaluation for surgical weight loss treatment was frequently initiated by a healthcare
professional or family member rather than by the men themselves. However, some men reported that the
pursuit of weight loss surgery revived a sense of self-efficacy, which facilitated a commitment to treatment.
While clearly a small study with limited generalizability and potential recall bias, this qualitative exploration
of men’s perceptions of bariatric surgery demonstrated that misconceptions of the purpose of bariatric
surgery, that it is for body image rather than health, may be a significant barrier to appropriate treatment for
men. The findings suggest that effective counseling of obese patients requires a gendered understanding of
how patients individually relate their bodies and how that relationship is connected to what individuals value
most in terms of physical and psychological health, as well as with respect to autonomy and personal agency.

KNOWLEDGE GAP, PROVIDER REFERRAL, AND PATIENT SELECTION PATTERNS
Although patients’ perception and motivation to pursue weight loss surgery play a major role in access to
bariatric surgery, the knowledge gap and increased perceived risk on behalf of providers and patients pose
significant barriers between morbidly obese patients and surgical treatments. In a survey study of over
[21]
470 physicians, Avidor et al. reported that, among primary care physicians as well as other specialists in
obstetrics and gynecology, cardiology, and endocrinology, most physicians had only moderate familiarity
with the NIH morbid obesity management guidelines, safety of surgical options, and the long-term impact
of surgery on weight and comorbidities. Additionally, the dominant reason for physician non-referral was
provider lack of knowledge of a local bariatric surgeon, suggesting that surgical specialists need to improve
outreach efforts and to expand surgical resources to underrepresented regions. Additionally, nearly half
of gynecologists were unaware of published studies on the effects of bariatric surgery on restoring fertility
in morbidly obese females. Furthermore, up to 35% of primary care practitioners surveyed have reported
feeling unprepared to provide long-term medical care for post-surgical patients and less than half felt
[22]
competent to manage medical complications of bariatric surgery .

Additionally, perceptions of weight loss surgery as carrying increased risk further hinder access across
[31]
genders. Funk et al. conducted focus groups with 16 PCPs in Wisconsin to better elucidate their
perception of obesity and weight loss surgery. Interestingly, providers were primarily focused on obesity
being a risk factor for disease instead of considering it a disease in and of itself. This is despite the
American Medical Association resolution in 2013 characterizing obesity as a disease. Additionally, decision
making by PCPs often under-prioritized treatment for obesity and over-emphasized risk of surgery. This
study outlined several factors including PCPs wanting to “do no harm”, and questioning the effectiveness
[32]
of weight loss surgery as reasons for not referring patients . However, the data argue against this, and
repeatedly bariatric surgery has been shown to be equally safe as, and in some cases more safe than, other
[33]
well accepted surgical procedures. Aminian et al. compared the safety of the laparoscopic Roux-en-Y
gastric bypass (LRYGB) to seven other procedures in diabetic patients using NSQIP data between 2007
and 2012. The complication rate of LRYGB (3.4%) was comparable to that of laparoscopic cholecystectomy
(3.7%) and laparoscopic hysterectomy (3.5%), and significantly lower than that of total knee arthroplasty