Metabolic surgery: "You don't know what your transformation is going to look like" A medical anthropological research on the perceptions of wellbeing and health among patients who underwent metabolic surgery on Aruba

Name: Marloes van Drie MSc Medical Anthropology and Sociology Supervisor: Dr. Else Vogel Second Reader: Dr. Anja Hiddinga November 11, 2016 Words: 20.664 2

LIST OF ABBREVIATIONS

AAA = American Association of Anthropologists AZV = Algemene Ziektenkosten Verzekering BMI = Body Mass Index HAES = Health At Every Size HOH = Dr. Horacio Oduber Hospitaal GDP = Gross Domestic Product IBISA = Instituto Biba Saludabel y Activo MEP = Movimiento Electoral di Pueblo NCD = Non Communical Diseases UK = United Kingdom WHO = World Health Organisation

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ACKNOWLEDGEMENTS

Before you lies my thesis as an occlusion of my Master of Medical Anthropology. This thesis is not just an occlusion of my master; it is also the end of an adventure. It brought me joy, frustration at times, and above all knowledge about the discipline and about myself. The decision to undertake this adventure was not easily made. After I got my Masters Degree in Psychology, I was certified to work as a Medical Psychologist. However, the study program left me with lots of questions rather than with the so called “tool kit” to enter the work field. In the Master of Medical Anthropology I found the “tools” to further polish my thinking. I am proud that I am capable of presenting this thesis to you. However I owe much thanks to the people who have aided me during this process, and I would not want to start this thesis without using this opportunity to thank them. First and foremost I would like to thank my informants, the wonderful and inspiring people on whose narratives this thesis is built. Without your openness, honesty and vulnerability, I could not have written the document that I finished today. Secondly, many thanks go out to the people I have met on Aruba who helped me realize the research project. These “gatekeepers”, as we call you in anthropological terms, made my stay on Aruba a beautiful and pleasant adventure. Alex Ponson, Yvonne Swierenga and Wendie Botjes, thank you for your interest in this project and thanks for all of the opportunities that you have created for me. I owe much thanks to my supervisor, Else Vogel. Else has helped me to structure my mind and polish my thinking in all the phases that I went through while writing this thesis. The writing process was not always easy and I experienced her supervision as inspiring and motivating. I would like to acknowledge the Department of Medical Anthropology. I learned a lot during the courses I took. Last but not least, Bram and Diane. Thank you for your unconditional support during the writing process.

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TABLE OF CONTENT

1. Introduction 6 Thesis outline 9 2. Methodology, ethics and reflexivity 10 Data collection 10 Data analysis 11 Ethics 12 Reflexivity 13 3. Theoretical framework 15 A history of the globesity epidemic 15 One size does not fit all 17 Conceptualizing the body 18 Metabolic surgery: an uncertain cure 19 4. What is obesity? The meaning of obesity on Aruba 21 Obesity as a dangerous physical condition 21 Obesity as an economical burden 22 Obesity as a result of societal prosperity; the obesogenic environment 26 Obesity as a cultural identity 28 Interim conclusion 28 5. Pursuing good health: a patient’s exploration of metabolic surgery 30 Options to fight obesity 30 Being a good patient and being a good mother, it’s not possible at the same time: role conflicts in health seeking obese individuals 31 ‘They don’t see the real me”: conflicting identities 34 Metabolic surgery: revealing the true self or a quick fix? 35 Interim conclusion 37 6. Rebuilding life after metabolic surgery 38 Changing everyday eating practices 38 Social eating practices 39 Lack of nutrients 41 “Loose” skin and disease 43 Transformations and reflections after metabolic surgery: restoring identity 44 Interim conclusion 45 7. Conclusion and discussion 46 The potential of analysing paradoxes in patients’ lives 47

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Bibliography 49 Annex A 55 Annex B 56

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CHAPTER 1 INTRODUCTION

Bon Bini to Aruba, “one happy island”. This slogan pops into my vision everywhere I go in Aruba. It stands on the first poster I see at the airport, it is printed on billboards along the road and in my apartment it is the first sentence in the manual of the housekeeping to welcome me at my “home away from home”. I arrived at the island for my field study about obesity and metabolic surgery. In the past thirty years the prevalence of obesity has risen drastically in Aruban society with an estimated prevalence of 28% in 1993 to 41% in 2006 (Kock, Thijsen and Visser, 2008). This drastic rise of weight gain is not just occurring in Aruba, it occurs on a global scale over populations (Finucane et al, 2011). The World Health Organisation (WHO) released a report in 2000 that warned against a global “obesity epidemic”. The choice of the word “epidemic” triggers associations with images of close threat to citizens and pending catastrophes (Knutsen, 2015). The biomedical scientific literature I read prior to the fieldwork period continuously emphasizes the great dangers that overweight people are exposed to. The risky state of having “excess” weight severely increases risks on diseases like heart attacks, strokes, pains in joints, arthritis and sleeping problems. The message is clear: being overweight is almost as risky as being terminally ill. If this is to be true, how can Aruba with 78% of overweight inhabitants be the “happiest island of the Caribbean”? Nowadays many Arubans tell that they live on a “heavy island” instead of a “happy island”. By saying so, they link their body weight to their personal experience of happiness/well-being. One of the persons who thinks of herself as heavy is Mila. I met her in the surgical ward, because she wants to undergo weight loss surgery. She is certain that she will become happier when her weight decreases. “My health is going to change because of my weight,” says Mila. She continues: “Once you lost the weight, health will follow. And once your health is better, the other things will follow. I will feel better”. Mila wants to swap her heaviness into happiness. Mila tells me that she is impaired by her weight. She is out of breath sooner than she used to be. Her knees hurt, she’s not able to walk long distances. As she does not have a driving license, she is currently dependent on her family and friends to transport her around the island. Over the past years she tried to lose weight, for example by dieting. However, it was difficult to maintain her diet when she was at family dinners, parties and social activities. The local dishes she had over there did not correspond with what her American diet prescribed to eat. In the end, instead of achieving her deeply desired weight loss, she had only gained weight. Mila’s case is illustrative for many people who struggle with obesity. Her case shows that the understanding of obesity is more complex than the single explanation of a disease-like phenomenon. Her body size also affects her social eating practices and her everyday life practices.

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Paradoxically, even fighting her weight affects her everyday life experiences and social eating practices. Mila hopes that metabolic surgery helps her to achieve her desired weight loss. Metabolic surgery is performed in Aruba’s only hospital since the year of 2002. Back in that year, only ten patients underwent the surgical procedure. They lost up to 85% of their “excess” weight. Nowadays, on a population of 102.000 citizens, more than two hundred patients per year undergo metabolic surgery. Many more patients are subscribed to the waiting list to have the surgery in the future. Mila has also subscribed. Today, she is in the waiting room because she has an appointment with the doctor to have her weight checked. The last time she saw him, the doctor told her that her body weight is 135 kilograms. The doctor calculated that she is able to lose up to 60 kilograms through a gastric bypass: a surgical intervention that downsizes her stomach from approximately 500 millilitres to 50 millilitres, “the size of a kiwi”. The following step in this surgery is the attachment of the stomach pouch to the small intestines. However, the top 1,5 metres of the small intestines are skipped in the re-attachment to the stomach. These first metres are essential for glucose uptake. By skipping the first part of the small intestines and thus reducing nutrient uptake, a successful surgery should result in a substantial loss of weight. Metabolic surgery refers to any kind of surgical interventions that affects metabolic change. The gastric bypass is the most common surgery practiced in Aruba. Sometimes patients undergo a gastric sleeve mastectomy. In this surgery a large part of the stomach is removed with the major difference that the intestines stay untouched. Currently, the ideas about the effectiveness of metabolic surgery changed from initial restriction of food intake to changes in metabolism. From a biomedical gaze, metabolic surgery is regarded successful when physical parameters like permanent weight loss and reduction of comorbidities are achieved (for example the reduction of diabetes related complaints) (Chang et al., 2014; Crookes, 2006 & Buchwald et al., 2004). Research that takes into account life after metabolic surgery, however, reveals a more complex account of when and why surgery may or may not be considered a “success”. Groven, for instance, describes Norwegian patients that experienced metabolic surgery as life changing, difficult, even the primary source that worsened their quality of life (Groven, 2010). Wouters stresses that Dutch patients may feel limited in their daily functioning because of skin abundance, increased diarrhoea and malodorous flatulence and fatigue (Wouters, 2010). Ryan and Murray have written personal accounts of the effects after undergoing surgery on their lives that caused unwanted transformations in their social lives, such as changes in their partner relationships or increased feelings of vulnerability (Ryan, 2005; Murray, 2013). While the biomedical “success” of surgery is understood in terms of decrease of weight and reduction of comorbidities, metabolic surgery may in medical anthropological terms be

8 regarded as an uncertain cure1 (Throsby, 2012). Patients do not know what their “transformation” will look like before they agree to undergo surgery. Karen Throsby researched life after metabolic surgery in the United Kingdom. She writes: “Even though many reach a “healthy” weight, for some, this is at the cost of ill-health. This tension problematizes the presumed positive relationship between health and slimness”, that many patients hope to reach after agreeing with surgery. Especially among this group of metabolic patients ambiguity exists about what is good health and what is not. Additionally, but not less important: the tension between social and biomedical beliefs about weight and health varies tremendously over time and place. These beliefs are built upon historical, cultural and economical elements that are specific to a local context. In my research, this local context is the Aruban culture in which body size is considered a reflection of health on the one side and illness on the other side. Furthermore, body size may for example be understood differently in terms of prosperity/poverty and attractiveness/sloth. I use the everyday life experiences of metabolic patients to gain insight in how metabolic surgery is understood in the specific local context of Aruba. Their narratives tell us what it is like to live with 1) obesity and 2) metabolic surgery and how they try to access health on this “heavy island”. I refer to this type of patient information as, what Jeanette Pols calls, patient knowledge. This is a kind of “expertise” that differs from medical knowledge, but is in no way less valuable (Pols, 2013). Their everyday experiences render how metabolic patients try to embed practical and medical knowledge into their daily lives in order to live with their changed metabolism. In this thesis I explore the understanding of body size, obesity and health from the perspective of Aruban patients who either undergo or underwent metabolic surgery. My goal is not to provide a critical overview of obesity and metabolic surgery. My aim is to map the tensions around obesity and metabolic surgery that are specific to Aruba. I frame my informants as healthcare experts alongside the clinicians. Having the improvement of health as their mutual goal, clinicians and metabolic patients all bring their own kind of “expertise” in obesity specific health care. I argue that the tensions in their understandings of body size, obesity and health before and after metabolic surgery may provide us with valuable insights that may contribute to the improvement of obesity specific health care programs on Aruba.

1 Anthropologist Cassandra White has introduced the concept “uncertain cure” in her ethnography about living with Leprosy in Brazil. I adopt this concept drawing upon Karen Throsby’s interpretations (2012). She used the concept to describe metabolic surgery in her paper “Obesity surgery and the management of excess: exploring the body multiple”

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Thesis outline

This thesis will take the reader through patient experiences as they undergo metabolic surgery. Chapter 2 is about the employed methodology, its ethics, data analysis and limitations. It will also address a personal reflection on the fieldwork and data collection process. Before I discuss and interpret the empirical data, this research will be placed in context by outlining the main bodies of social scientific literature on obesity and metabolic surgery that have informed this study throughout. This outline is to be found in chapter 3. The first empirical chapter is chapter 4. In this chapter I provide a detailed overview of Aruban understandings of obesity and overweight, which are specific to time, location and sociocultural elements. In Chapter 5, I merge the narratives of patients to construct the line of a fictional ‘typical’ patient. The chapter thus traces how patients start to problematize their body weight, aim to reduce it, and ultimately opt for metabolic surgery. In Chapter 6, the narrative of this ‘typical’ patient continues after she underwent surgery. She reflects on life as she knew it when she identified herself as obese and how her life has changed through surgery. This chapter aims to give insight in patient experiences after metabolic surgery. The outcomes of the empirical research will be summarized in the conclusion in chapter 7. This chapter also includes a discussion in which implications for practical outcomes are presented.

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CHAPTER 2 METHODOLOGY, ETHICS, REFLEXIVITY

2.1 Data collection

This thesis is based on eleven weeks of qualitative ethnographic research conducted on Aruba between January and April 2016. A major advantage of organising fieldwork abroad is the enabling of analysis of everyday routines from an outsider point of view. “The ethnographer, as a stranger, can observe the minutiae of organizational life and, through analysis, offer an account of ‘what is happening’” (Green & Throrogood, 2014: 157). The data collection started in the primary hospital of Aruba, the Horacio E. Oduber Hospitaal. This prominent building is located on the outskirts of Oranjestad, the capital of the island. The primary location of the hospital has a capacity to house 400 patients. Metabolic patients go to a separate ward for their check-ups, approximately 200 meters from the main entrance. This surgical ward contains two small waiting rooms and four offices for the hospital’s surgeons. An important share of my empirical data was gathered in this ward through participant observation. In the very beginning of my fieldwork I was in the ward for approximately four to five days per week. I mostly joined check-ups with patients to familiarize with the language (Papiamento) and the consultations to access metabolic surgery. I additionally attended information sessions where patients could go to get information about the gastric bypass procedure. The surgeon who performed metabolic surgery hosted these sessions. Here I was able to chat with many patients about their views on and concerns with metabolic surgery. I spent my lunch break in the hospital with the doctors and the administrative staff. Thus I was able to observe and collect information by active participation in hospital life. The active participations allowed me to explore both the patient’s and the clinician’s perspectives. Furthermore, I always made sure to transcribe and write out field notes in public spaces. Arubans generally like to chat, so by working in café’s and the library in the hospital I had lots of informal conversations thus getting a sense of general perceptions of eating, health and weight. Furthermore, I formally interviewed 16 patients who either underwent or will undergo metabolic surgery. They informed me about their lived experiences of being obese and opting for surgery. These interviews were recorded and transcribed in a verbatim and lasted approximately 90 minutes. The interviews mostly took place at the homes of the informants and incidentally in a clinical setting (i.e. ward’s waiting room or surgeon’s office). Another 17 health care professionals (ranging from hospital staff, psychologists and dieticians) informed me about the availability of obesity health care. Furthermore, I conducted an interview with the chief of the national health insurance company. Lastly I held an interview with the minister of health. These two interviewees informed me about the island’s obesity politics. Every interview was recorded and took place at

11 the office of the professional. All informants were recruited through gatekeepers in the field (e.g. the governor of the hospital, a prominent socialite). The questions I asked my informants were the same among patients and health care professionals. They covered topics of having/treating obesity and everyday eating experiences, to gain insight in the everyday impact of obesity. I chose to follow the topics of interest that the informants brought up, to “develop their own account on the issues important to them” (Green & Thorogood, 2011). In addition to interviews and observations, I collected all the available literature on obesity on Aruba that I could find. Earlier Aruban research on obesity includes, for instance, a qualitative study on eating habits (1994) and a general monitor of Aruban Health (2012). Furthermore, I collected the documents on public health policies that were publicly available. The first public plan dates from 2009 and was written under supervision of the minister of health at that time, dr. Richard Visser. His policy is maintained until the day of today by the financial support to the governance of Instituto BIba Saludabel y Activo (IBISA, institute for a healthy and active life), which is the governmental institute for health promotion. Finally, I have used auto-ethnography in this research. Auto-ethnography is described as a method and way of reporting where the researcher reflects upon and uses her experiences to understand the field (Wall, 2008). I deemed this important, as before this research I worked as a psychologist in a Dutch obesity clinic. I thus entered the field with my own norms and beliefs about eating behaviour and health. During the fieldwork period I constantly reflected on the information I gathered while I processed the information. For example, one of the questions that I did not know the answer to was why obesity rates in Aruba are higher compared to other Caribbean islands. I have let my search for ethnographic data be guided by these questions during my access to the field. As a consequence, my research project transformed from an initial research about the impact of metabolic surgery into a research that investigates the perception of obesity on Aruba.

2.2 Data analysis

Although the study proposal was based on theoretical frameworks (i.e. deductive analysis), the eventual presentation of results in this thesis was primarily derived from a close reading of the data (i.e. inductive analysis) without trying to fit it within existing theoretical frameworks. Thematic content analysis was applied on all the formal and informal interviews. The transcriptions were manually coded and organised by the ethnographer, according to four major themes that were inductively accomplished. The themes were: 1) norms and values on obesity, 2) everyday eating practices before and after metabolic surgery, 3) healthy living in practice and 4)

12 self-care and coping. Results of the analysis with respect to the data are presented in chapter 4, 5 and 6 and complemented with observations, literature analysis and personal reflections.

2.3 Ethics

The research proposal on which this research is based was officially approved by the University of Amsterdam and by the ethical committee of education of the HOH (Dr. Horacio Oduber Hospitaal). I have very kindly received reimbursement of research expenses from the hospital for the exploitation of this research. However, this compensation has in no way influenced the methodology, research objective or research outcome of this thesis. In accordance with the research ethics of the American Association of Anthropologists (AAA) and of the hospital, the main principles throughout my fieldwork and throughout writing this thesis were informed consent, confidentiality and informant privacy. All interviews were conducted after I verbally explained the agreement of informed consent and possibility to withdraw at any moment without any consequences for the to be received healthcare. For the short conversations I had in cafes and the library, I always asked permission to report their input afterwards and I was never refused to report their answers. Most importantly, I ensured my informants that they would not be identified by their names. This was particularly imperative as Aruba is a small island where everybody knows everybody. Their answers contained personal information to the extent that using their life stories as an illustrative box would lead to violation of their privacy. Drawing upon this given fact, I chose to write chapters 5 and 6 from the point of view of a fictional patient, who is based on the narratives of all my patient informants. Whenever I noticed that my participants were not comfortable in discussing in Dutch or

English, I called in someone who could translate. This sometimes led to interesting conversations in which I was able to include the translator as an informant. For example, in one of my interviews the partner of a metabolic patient helped me to translate my questions. While her husband was enthusiastic about his surgery, she gradually expressed her discomfort about the preparatory procedures her husband attended. Although her husband felt prepared to undergo surgery, she as a wife felt worried about what was going to happen to him and to her family in general. In cases like this, I additionally asked for verbal consent to register the accounts of those who translated.

2.4 Reflexivity

At the very onset of my fieldwork I was concerned whether a person with a BMI (Body Mass Index) of 20,5 kg/ m² is able to write about obesity. I wondered whether I would be able to

13 empathize with people who classify themselves as obese. Furthermore, I feared that my posture provokes feelings of stigmatization and ‘othering’ among persons who identify themselves as fat. However, following Deborah Lupton (2013), everyone is caught up in or reacting to obesity discourse, whether they identify themselves as obese or not. “We are all potentially fat people, unless we take steps to constantly monitor and discipline our bodies” I have worked before as a psychologist in an obesity clinic. On the one hand I feel advantaged as I have seen and treated many obese individuals, I can easily empathise with the patients and relate to what might be relevant for them. On the other hand, my previous interactions as a psychologist were geared towards diagnosing and treating patients, not to learn from them. My existing knowledge was at the onset dominated with medical/psychological understandings and normative judgments about obesity. Therefore I ascertained during my fieldwork that I would be constantly reflexive of my own understandings to actively put them aside. This helped me to fully follow and understand the story that informants told me about obesity and metabolic surgery. Only after I entered the field, I realised that my Dutch origin might affect the data collection process. Aruba was formerly colonized by The Netherlands and although it is officially independent since the status aparte in 1986 (Aruba Gobierno, 2016), Aruba is until today under Dutch political supervision - which for example leads to dependence of Dutch accordance on political decisions. In everyday life, the island’s history with The Netherlands is noticeable through a complex relationship between native Arubans and Dutch inhabitants (12% of the total population, Dutch expats and temporal workers not included (Aruba Health Monitor 2012: 27). Inhabitants who completed their education in The Netherlands (either Aruban or Dutch) are favoured for governmental positions and accompanied civil benefits. To access governmental support one needs to apply in Dutch, although many low-educated inhabitants only speak Papiamento. Aruba has two major political parties, and one of them (MEP, Movimiento Electoral di Pueblo) currently promotes complete separation from the Kingdom of the Netherlands. While I was doing fieldwork, I realised that my major concern should not lie with provoking feelings of inferiority at the informants’ side because of my body size, but rather because of my nationality. In response, to enable myself to open conversations, I tried to learn Papiamento, familiarize with local habits and food. Furthermore, it helped that some inhabitants, whom I befriended, became gatekeepers, expressing their trust in me towards their relatives and friends. A final concern is how to describe patients with a large body size. Following Warin and Gunson I need to acknowledge the ways in which language operates through our bodies and through those of the people I work with (Warin & Gunson, 2013). Some may identify with being obese, while others may not identify with this diagnosis. In this thesis I refer to “obesity” and “being obese” when I discuss the medicalisation of body weight. This generally is accompanied by

14 associations of disease, disciplining the body and moral failure. When I use “large bodies” however, I describe overweight among people who do not identify themselves as obese or do not experience weight-related complications. By separating these two concepts, I distinguish between whether people think of obesity as a problem or not.

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CHAPTER 3 THEORETICAL FRAMEWORK

In the introduction I chose to present the case of Mila, as it resembles the cases of many other Arubans. She is a striking example of 1) a person with severe body weight who feels limited by it and 2) opts for a medical intervention (metabolic surgery) to redirect her life to achieve what she considers ‘healthy’: a life that is not impaired by her weight. In this chapter I will elaborate on these two assumptions. Furthermore, I will provide an overview on relevant social scientific readings that touch upon these assumptions. I will start with outlining the history of obesity and the medicalization of large bodies from a social science perspective, to unravel the context in which obesity is framed today. The next section is concerned with social scientific perspectives on this growing medicalization of body weight. In the following section I discuss the sociocultural understandings of overweight and obesity in general. Here I show that large bodies are not necessarily negatively associated. I will show that elements like time, location and history are important for obesity perceptions. After that, I will touch upon metabolic surgery as a method to reduce body weight and I will outline the main social scientific arguments concerning this intervention. Lastly, I bring forward that every geographical location needs its own research about the meaning and impact of obesity and metabolic surgery.

3.1 A history of the globesity epidemic

In the year 2000, the WHO released a report that warned against a worldwide ‘globesity epidemic’. Their choice to use the word ‘epidemic’ triggers images of associations with contamination, disease and catastrophes that threaten citizens in their wellbeing (Knutsen, 2015). The framing of obesity as a disease-like phenomenon (Chang and Christakis, 2002; Gremillion, 2005; Jutel, 2006; Nicholls, 2013; Felt et al., 2014) invites for medical anthropological deliberation. Nowadays, the WHO defines obesity as “the condition of abnormal or excessive fat accumulation in adipose tissue, to the extend that health may be impaired” (WHO, 2000). However, instead of assessing obesity by fat accumulation, obesity is in Aruba defined according to the assessment of BMI. But where does the BMI come from and how does it indicate a physical state in which body tissue threatens health? The answer lies in epidemiological research. In the early twentieth century, medical research found that increased risk of mortality was associated with overweight (Ulijaszek & Lofink, 2006). With the goal of statisticians and epidemiologists to assess health risk management, the need for tools to compare body weight across places and over time increased (Hacking, 2007; Fletcher, 2014). Isabel Fletcher, in her history of development of BMI, describes how over the years several tools were developed to assess body fatness. The tools included time-consuming measurements of the abdomen, under

16 water weighing, body imaging through X-ray, ultrasound and anthropometry, of which BMI is the most common one. Ultimately, the BMI was widely adopted as the standard measure to assess body fatness, because the upper end of body weight distribution corresponded with increased risk of mortality and chronic disease: coronary heart disease, high blood pressure, stroke and diabetes II (WHO, 2000), but also because of its user friendliness and low assessment costs (Hacking, 2007). Although it was never meant to apply to individual assessment, BMI has evolved into the preliminary tool that is used today to classify obesity. The categories currently range from underweight (<18,5 kg/m²), normal weight (18,5-25 kg/m²), to overweight (25-30 kg/m²) and obesity (>30 kg/m²). Classifying weight creates insight in who is prone to develop weight-related disease and who is not. The French philosopher Michel Foucault introduced the term biopower for this process of classification. Biopower refers to practices in which epidemiology, statistics, demography and technical information about health and illness among populations may be used to achieve political goals (Rabinow & Rose, 2003). Medical information shapes what is considered “normal” and what is “abnormal” or “deviant” in a social sense. In the case of obesity, this means that through medical, popular and governmental discourses, obese individuals are encouraged to lose weight until they reach the normalized BMI range and to keep their weight lowered to avoid health risks. The classification of weight further provides information on who is at risk to develop comorbidities and who will be at risk to consume costly healthcare (which is an expensive procedure for the state) and who is not. These statements are political as they capture assumptions on how citizens should be to become efficient and burden free for the state. The term governmentality, also coined by Foucault, describes modern states’ regulation of the individual to reduce risk situations that threaten the productivity of the population as a whole. It represents a modern view of health regulation that takes place when nations moralize and direct citizens by influencing their self-care (Foucault et al., 1991). In the Western neoliberal society 2 , governmentality led to a focus on individuals’ responsibility for their own health (Guthman & DuPuis, 2006; Knutsen, 2012). Hence, the obese individual is encouraged to take responsibility for controlling his/her body weight with the ultimate goal to reduce (assumed inevitable) future health risks.

2 I refer to neoliberal society as a social environment that attempts “to tear down what its adherents considered restraints to capital accumulation” (Guthman and Dupuis, 2006: 441). Obesity, in this definition, is regarded as a limitation for optimal development of capitalism. For example, obesity is reducing work related productiveness (Murphy, 2004) and it is problematic for flight companies in terms of fuel costs (Yee, 2004).

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3.2 One size does not fit all

BMI has evolved into a simple tool to assess weight that is medically deemed “normal” and “abnormal”. However, this indicator has it shortcomings to approximate health impairment through body weight. One of the major flaws of BMI as a classification tool is its inability to distinguish between bodily tissue distributions that vary over populations. For example, research showed that BMI and fatness do not correspond well among Chinese populations (Li et al., 2002). Furthermore, the use of BMI cut-off standards as classification of obesity among children is problematic because of altered ratios of body tissue (Cole et al., 2000). These studies and many more show that a certain weight range does not necessarily correspond with increased health risks. Not only BMI has been criticized, obesity itself is also subject of debate. The Western medicalisation of obesity as a dangerous health status resulted in associations with gluttony, sloth, lack of self-discipline and something which individuals chose to “let” happen (Knutsen et al., 2012; Guthman & DuPuis, 2006; Greenhalgh, 2015). Driven by a concern with internalisation of stigma and following eating disorders, feminist scholars have protested against the moral, cultural and aesthetical convictions that favour thinness among females. They unravel the functioning of discourses on obesity as war on large bodies, which is covered under a medically substantiated message (Greenhalgh, 2015; Bordo, 1993). The Health At Every Size movement (HAES) presents a slightly different point of view. Their understanding of obesity bridges the gap between medical concerns about the link between BMI and health on the one side, and feminists’ claims about the cultural war on obesity on the other side. Members of HAES question whether space exists for various opinions in ‘the obesity debate’, which is au courant, dominated by “medically proven” arguments against fat. Relating themselves with fatness rather than with obesity, HAES-members reject moral condemnation that is associated with large bodies. Their main concern is to extend the obesity debate with the intention to disconnect body size from disease3 (Rich, Lee & Aphramor, 2011). The social informed criticism on obesity and body size is important for this research as it outlines the paradoxes in discourses about body weight and health. For example, BMI is now used to assess risks on health impairments due to “excess” weight over populations. However, these risks are impossible to translate directly to the lives of individual persons who identify themselves as obese. Likewise, the experience of being sick cannot directly be translated to body weight. By outlining these discourses, I stress that the biomedical explanation of obesity that link health experiences to “excess” weight is a one-sided explanation of a phenomenon that may be

3 For more information, see the HAES website; www.haescommunity.com

18 explained in various alternative ways. We need to take this into account when we want to learn of patients’ health experiences.

3.3 Conceptualizing the body

In the previous sections I first outlined biomedical understandings of obesity. Secondly, I provided an overview of the main bodies of social understandings of obesity. Furthermore, locally specific elements like differences in culture, economic/social status and food access all have a dominant share in shaping body weight and (aesthetic) bodily perceptions. Thus, these locally specific elements shape various perceptions of obesity over time, place and social meaning making (Garth, 2013). That obesity in local socio-material contexts may take on quite distinct and surprising meanings, is particularly evident in the work of anthropologist Jessica Hardin. She discusses the Samoan understanding of obesity as an embodied form of Mana4, a divine interconnectivity between supernatural forces and the village chief. Corpulence here is the physical proof of presence of divinity (Hardin, 2013). Anne Becker describes obesity as a Fijian protection mechanism against macake, an illness explanatory model that is marked by lack of appetite (Becker, 1995). Eileen Anderson-Fye, in turn, shows how in Belize, ‘curves’, regardless of body size, are associated with beauty, attractiveness and fertility (Anderson-Fye, 2004). Alexandra Brewis, in her geographical assessment of body norms, outlines how Tanzanians wield a fat- neutral consensus that hence does not result in fat stigma. However, Brewis also points to the worldwide migration of Western body ideals. She shows, for example, how as a result, Mexicans and American Samoans wield both positive and negative fat conceptions at the same time: on the one hand, they think of fatness as a sign of good caregivers, and on the other hand they adhere to Western medicalized understandings of fatness as health-threatening (Brewis et al., 2011). Becker also found a transition of ideal body conceptions among Fijians that shifted in only a few decades from corpulent to slim (Becker, 1995). She writes: “The fluidity of body weight ideals is neither unique to Fiji nor historically extraordinary” Indeed, Americans have undergone the same transition in body ideals in the twentieth century, as Susan Bordo points out in her book “Unbearable Weight” (Bordo, 1993). Nowadays, other geographical areas follow: the popular discourse that links large bodies to sickness becomes increasingly prevalent. Likewise, throughout this thesis it will become clear that Aruba’s local understandings of obesity and overweight are subject to change as well.

4 Mana is the supernatural power, the ‘truth’ or prestige among Polynesian, Melanesian and Maori indigenous religions.

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3.4 Metabolic surgery: an uncertain cure

The medicalisation of body weight has won terrain in Aruba’s public healthcare debates. Thus, the management of body weight among individuals has become increasingly important in everyday life. Aruban weight-loss advertisements respond to individuals’ potential to lose weight when they have access to the promoted products. National television commercials promise highly effective weight loss in little time. Contrary to the media’s promises however, enduring weight loss is, mildly said, difficult to preserve. Numerous of biomedical studies showed recidivism up to 97% after joining conservative weight loss programs (Becker, 2013). Metabolic surgery is currently regarded as the most successful resource to realise prolonged weight loss in obesity. Because of it’s potential in realising long-term weight loss and reducing weight related health risks, surgery is gaining attention in anti-obesity policies (Chang et al., 2014; Crookes, 2006). Alterations in patients’ metabolism are currently regarded as the operating mechanism to reduce comorbidities like diabetes and high blood pressure. These alterations affect the body’s uptake of nutrition. Consequently, Aruban patients are required to maintain a strict diet afterwards, to diminish side-effects like vomiting, nausea, diarrhoea and malnutrition. However, even when patients are able to control side-effects in eating practices, the limited feeding options they have left may bore them. Solomon, in his research about life after metabolic surgery, describes how Indian patients lost the joy of eating because of their strict diet (Solomon, 2014). They could not oversee the effect of everyday eating practices after they underwent surgery. Metabolic surgery can be regarded as an “uncertain cure”: patients do not know what their “transformation” will look like before they agree to surgery. Karen Throsby, in her research in the UK (United Kingdom) writes: “Even though many patients reach a “healthy” weight, for some, this is at the cost of ill-health. This tension problematizes the presumed positive relationship between health and slimness that governs the war on obesity.” (Throsby, 2008). The uncertainty of this metabolic cure manifests itself in many different elements. Eveline Wouters stresses the psychological transformations that Dutch women are prone to after they have had surgery. Changes in, for example, their physical bodies and their relationships mould their post- metabolic lives (Wouters, 2010). Karen Synne Groven describes the quality of life after metabolic surgery among Norwegian women. Some find themselves left with excess skin, a disturbed body image and lowered self-esteem (Groven, 2010). A few of her respondents even think of their current life as worse than before they had their surgery. That quality of life may be subject of change over place shows Karen Throsby in her research that dates from 2012. She describes feelings of embodiment and disembodiment of patients that differs over locations. For example, patients may experience improved quality of life among peers, but not in environments where

20 they feel misunderstood or judged. Throsby links the integration of surgery into the patients’ identity to feelings of well-being (Throsby, 2012). Health experiences after metabolic surgery cannot be reduced to lack of weight or comorbidities. These works indicate that post-metabolic understandings of health, from patients’ perspectives, may include moral and aesthetic concerns of how the body should be after surgery, along with how patients expect to embody their new weight into their health identities. The difference in biomedical understandings and patients’ understandings of health calls for further investigation. By giving voice to those who live(d) with large bodies, their knowledge of obesity and metabolic surgery “could be made to utter helpful knowledge for people with chronic disease in its own terms, rather than providing stories and meaning that do not fit into biomedical ways of doing research or approaching disease” (Pols, 2013).

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CHAPTER 4 THE MEANING OF OBESITY ON ARUBA

In this chapter I look at the norms and beliefs about body size and weight that are specific to the local context of Aruba. Earlier I discussed the importance of understanding local norms and beliefs about body size, obesity and overweight. The data includes perceptions on obesity of 1) patients who opted for metabolic surgery, 2) clinical health care professionals and 3) epidemiological health professionals. Earlier I discussed the importance of understanding local norms and beliefs about body size, obesity and overweight. In this chapter I aim to unravel the local understanding of obesity by outlining all the various answers that were given to me in response to the question: “what is obesity on Aruba?” Analysing the opinions of my informants made me aware that obesity can be regarded in many ways, varying from a dangerous physical state, to an economical burden, to a physical proof of dedication to family life. I discuss each of these understandings separately. In this chapter, but also in chapter five and six, the fictional character of Mila is a construct of the narratives of sixteen patients I interviewed during my fieldwork. Their experiences are directly translated without adjustments. I made the choice to bind all the patient’s experiences together in one character to ensure the privacy of my informants. They live at a small island and trusted me with personal anecdotes. In this thesis I wish to provide an honest overview of their narratives without causing the risk that the representation of their stories may be traced back to their actual personalities. As a last remark on the fictional character of Mila; the fact that she is a woman is a deliberate choice. This choice is in the first place based demographics. The majority of metabolic patients on Aruba is female. I therefore interviewed a majority of women during my fieldwork (12 out of 16 informants were female). Another consideration for creating a female ‘typical’ patient is that it allows me to disseminate gendered issues that are concerned with body weight. As Yancey, Leslie and Abel describe, two examples of gendered issues are the barriers for women to become physically active and their central role in feeding families (Yancey, Leslie and Abel, 2006). The following chapters will show that these gendered issues are relevant for the context of Aruba also.

4.1 Obesity as a dangerous physical condition

“What is obesity to you?” This always was the first question I asked my informants in my interviews. Today I speak with Mila. She will undergo surgery in a few days. Last week she agreed to do the interview with me when we met in the ward of the hospital. Currently I am at her home. She does not need to think for a long time before she replies. “What obesity is to me? Obesity is everywhere! Many people on Aruba are overweight. Actually nobody who is overweight is really one

22 hundred percent healthy.” Her statement expresses her conviction that being overweight is naturally related to the experience of health. She continues that the further a person’s body weight is rising, the more she or he becomes unhealthy. I ask Mila what she means by being healthy. This is a question that she cannot answer directly. What she does know, however, is what unhealthiness is. She answers: “Well, for example, I’m not healthy. In my case… my knee, my knee, it hurts a lot. I think because of my weight, and yes… many back problems, much pain in my back. And yes, at work I have to walk up and down all day, my knees, start to… hurt.” Her answer enacts a notion of health defined by the absence of disease and physical complaints. As currently she has physical complaints, she is therefore not healthy. Just like all those others who are overweight. Practically all my informants, both obese individuals and health care professionals, share the opinion of Mila that obesity is both abnormal and unhealthy. The dangerous bodily state that is captured in the bodily condition of obesity is associated with the notion of unhealthiness, or following Mila’s interpretation, the presence of physical pain that is caused by heavy body weight. If there is pain, the body is not healthy. Drawing upon Mila’s statement, she values pain as a sign of danger, a warning call for future physical complaints or diseases, and measures should be taken as soon as possible in order to restore health. Her interpretation of obesity reminds me of medical informed discussions about the “threat” that overweight people are exposed to. In other words, Mila thinks of her body as an “obesity time-bomb”, a bodily state in which it is just a matter of time before disease follows (Evans, 2009).

4.2 Obesity as an economical burden

Many Arubans share the opinion of Mila that health and weight are causally related. It is the message that many citizens have heard since 2009, when the ministry of Public Health started a major campaign to create awareness of the danger of overweight. I am visiting the department of Public Health to meet one of the staff members. We made an appointment to discuss contemporary public health policies that are concerned with obesity. The staff member, mister Palermo, tells me that the former prime minister was the first to prioritize the decrease of obesity on Aruba in 2008. Mister Palermo warns me that although public efforts have been made to inform citizens about the relation between weight and health, recent statistics still show that the body size of Arubans is growing.

The last minister of health really poured himself into the obesity issues. And he was right to do so because he didn’t make it up himself that it is dangerous, there was also a warning from the WHO, that there’s an obesity epidemic coming. And on Aruba we didn’t even reach the top yet.

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And… simultaneously you see an increase of [health] care consumption, exponential. The NCD’s (Non Communicable diseases) will explode and in the end you should spend a quarter of your GDP (Gross Domestic Product) budget to NCD’s, and it’s not possible.

Mister Palermo states that the health care costs are a major concern for the Aruban government. Since the establishment of the publicly funded health insurance company AZV (Algemene Ziektekosten Verzekering) in 2001, every Aruban citizen is insured for health care costs. The website of the insurance clearly outlines who are entitled for covering health care expenses. In other words, every resident of Aruba is obliged to insure himself/herself at AZV. Citizens pay the premium automatically, because a percentage of their salary is collected already before their employer pays them. However, for me as an outsider it was difficult to get insight in these percentages and the insurance company also could not tell me what the premiums per person were. What did become clear during my fieldwork study, is that the AZV distinguishes between employees in the private sector and governmental employees. As far as I am aware, the governmental employees are automatically covered by an extended version of the insurance and pay alternative percentages. Furthermore, the unemployed citizens are not able to pay their health care insurance fees through this percentage-based system, as they do not receive incomes. However, they are insured and therefore their health care costs are divided over those who are employed5. What initially started as a noble initiative to provide health care to all Aruban citizens, turned into a major expenditure for the Aruban government. As the collected premiums through citizens’ salaries are not sufficient, it is the government that now primarily finances the AZV. The decisions of what the health care insurance (does not) cover(s) is based on the indications of health care experts who are working in the hospital. One of the employees of AZV, mister Croes, explains the conditions of the current social insurance system to me:

The minute that a doctor confirms the medical necessity to intervene, for example at the general physicians practice or after referral to a specialist to perform surgery or to prescribe medication, that’s what we pay… We pay that, at the moment it becomes medically necessary, we simply pay it.

Mister Croes tells me that this method of health care coverage is expanding, because of a combination of increase of medical costs and increase of patients that need treatment. He predicts

5 According to the latest statistics dating from 2005, 6,9% of the citizens were unemployed in Aruba (CIA World Factbook).

24 that especially the group of patients who need obesity treatment shall increase in the coming years. He expects an increase in expenses that will not be manageable in just a few years from now. In order to monitor health care costs, the AZV recently went to court to discuss their position in accepting and declining invoices submitted by health care professionals (Bearing Point Caribbean, 2016). However, it was decided that, as AZV is the only health insurance company, they are mandated to pay all invoices whenever a medical indication is provided. But what is the effect for costs coverage of medical treatment of obesity (that is, metabolic surgery)? Is the coverage of costs going to stop when there is no more money available in a few years? I wonder whether the health insurance and the surgeons have discussed which treatments will be insured. One of the surgeons of the hospital provides me with an answer. He tells me that at this very moment the full preparatory program and the surgery are, based on his indication, covered by the health insurance. However, AZV and the government reply to bariatric treatment with mixed feelings. They underline the necessity for treatment options in obesity, but do not think of it as their main priority. The core business of the health insurance company, as mister Croes articulates, is to fund the treatment of health problems that arise because of obesity, like diabetes and sleep apnoea. AZV is, according to him, not responsible for the funds of prevention of obesity. In his opinion, citizens are responsible for the management of their own health. They should avoid everything that is possible to avoid and that might be harmful for their health. The AZV should jump in only in the case if necessary health care. But what is necessary health care? Despite his opinion, mister Croes does not have a clear answer to this question:

Where do we draw the line if you’re going to McDonalds too often? This is a discussion that’s really about the responsibility of the patient. To translate this responsibility in insurance theorems in the sense of increased insurance premiums or that kind of business, that’s hard in the world of public insurance. […] The point is, how do you translate responsibility of the patient, and one way is for example the personal contribution. That stimulates people to stop and think: Well, do I really need to go to the doctor? To stimulate self-care through personal contributions. A kind of BMI premium, for example that people with a BMI of 30 or 40 pay an extra premium. But it’s just not feasible.

Mister Croes ideally sees that citizens are held individually responsible for the monitoring of their own health. However, although he does not think of prevention as the responsibility of AZV, he feels that it is either financially beneficial for AZV to contribute to health education and prevention. Not in the last place to diminish obesity related future health care costs. In 2009, the

25 government established IBISA to canalise the prevention efforts and the promotion of a healthy lifestyle. This executive department of the ministry of public health has achieved fair results on the physical activation of citizens. They organise monthly national runs and they organise physical education at all the Aruban primary schools. However, according to mister Palermo, IBISA doesn’t run on its full potential in the prevention of obesity. He explains to me that lack of money, and bureaucracy as well, hinder the potential of IBISA on monitoring public health. For example, employees who work at IBISA would love to build public areas where people can exercise. They further have plans to educate children about nutrition. However, also for these initiatives finances are currently lacking. Other initiatives in the field of prevention lie in the hands of the White-Yellow Cross, also an executive department of the ministry of public health. They primarily focus on the monitoring of health of Arubans children through yearly medical investigations at schools. Dieticians who work at White-Yellow Cross are mainly concerned with providing education about food, nutrition and health to citizens. I meet with a dietician, Lucy. She primarily works with children between the age of four and eighteen. Her dietary consultations include the monitoring of weight and dietary choices of children. Consultation does not only focus on the child, but also on the education of families. Lucy shows me around her office, a room that is approximately sixteen square meters. Big office cabinets are lining the walls. Lucy tells me that these cabinets contain the medical records of all the Aruban children who are going to primary school. She explains that not all the files contain the same amount of information, because yearly medical check-up is not obligatory. Although children are supposed to have their check-up at the White-Yellow Cross at the age of two and several times while they are going to primary school, these check-ups remain voluntary at all times. Lucy estimates that the absence of obligatory appointments is one of the primary reasons that induce non-compliance among Arubans. She tells me that in her experience, people only go to consultation when they notice their child has physical complaints. Another reason for non- compliance in her opinion is the lack of coverage from the health insurance. People cannot afford her consultations. Therefore, she usually only consults the children who are extremely obese. The health care professionals face a complex dilemma: every single person I spoke with sees (whether the reasons are financial or not) the urge of diminishing the frequency of obesity on the island. By the organisation of food education, the development of public guidelines on nutrition and promotion of activities, (summarized more briefly: by the organisation of prevention) they aim to reduce obesity rates in the future. Paradoxically, in this debate about responsibility, all parties seem to redirect responsibility of monitoring obesity as the priority of any party but them selves. Finances, political interests and lack of resources impede, congeal even, current development and implementation of obesity related policies.

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4.3 Obesity as a result of societal prosperity; the obesogenic environment

The previous subchapters helped me to understand how Aruban citizens regard obesity and why it is an actual problem on the island. To understand why Aruba in particular has these enormous rates of overweight and obesity in comparison to neighbouring islands remains unclear to me. Although this question is not the main question that needs to be answered in this thesis, it helps to explore possible explanations to understand the everyday context and accompanying challenges that overweight people face. I have asked all of my informants why they think that they have become obese, and today I also ask the question to Mila. She immediately pleas that it is because of insufficient funds.

You know, I can go to the supermarket and buy vegetables and fruits and take the salads, but there are people who don’t make much money. And they can’t buy those things, but vegetables are a little expensive, the fruits also. You know, if you’re going to buy papaya it’s 3 dollars, maybe 4. And the people who don’t earn that money can’t buy that. They’ll look for things that are cheap. And you know, the things that are cheap are the things that are not good. I can say, you know, I’m going to buy a package of vegetables of 4 or 5 dollars, but the lady says no I’ll buy a package of rice of 1 dollar.

The things that are cheap are the things that are not good. Vice versa, Mila assumes that “good food” resembles the products that are expensive on Aruba, like fresh fruits and vegetables. But why is “good food” expensive to begin with? Aruba is largely dependent on American and Dutch import of products. Especially modified foods are affordable, as agriculture on Aruba is difficult. The soil is unsuitable for agriculture unless the ground is artificially irrigated. However, purification of water is an expensive procedure and consequently Aruban agriculture is as well. Consequently, fresh products like vegetables and fruits are imported from countries like Venezuela, the United States and the Netherlands. Mila is not the only one who stresses the inconveniences in grocery shopping. Many of my informants showed me that although their intention was to buy food that fitted their desired diet, they felt they lacked resources to purchase and consume these matching groceries, or “good food”. Their experienced obstacles in maintaining a diet are in sharp contrast with the opinion of an Aruban dietician that I spoke during my fieldwork:

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People think that cooking is expensive, but in fact it really isn’t… So I think it’s laziness also. You know what, it’s their lifestyle, they come home from work, they are tired, and Arubans don’t like to cook. Everything here is take away. For the husband and wife to go to work and after come home and cook together… that’s not how many people live.

The dietician calls for individual responsibility in adopting a certain (healthier) diet in daily life. Her notion of what weight gain entails, along with many other clinicians, includes the effect of continuous pathogenic habits. Obesity, in her view, is thus a self-inflicted “lifestyle disease” (Manson et al., 2004). The solution lies in changing these habits: thus many clinicians advice obese individuals to “eat less and exercise more” as a remedy for their weight-related problems (Knutsen, 2012). However, those who actually have obesity show that changing these habits is not something that is done easily and certainly not a matter of individual will alone. It is also matter of food availability, family habits, resources and knowledge about nutrients. Researchers and clinicians progressively think of the obesity debate as more nuanced than the individual will to change eating habits. For example, Julie Guthman, professor in food, politics and economy, unravels the false assumption that individuals are responsible for their food choices in a food system where processed and modified food is promoted, affordable and easy to consume, in relation to limited options in healthier and more expensive alternatives. She shows how (especially low class) citizens are influenced in their food related decision-making in the obesogenic environment. Although her book focuses on the US Western food industry (Guthman, 2011), it still is applicable to Aruba’s food system, which is not only featured by prevalent unhealthy food options and expensive imported vegetables, but also by many other elements that challenge individual responsibility for eating decisions. An example is the American cheap fast food chains, brought to the island by American exploiters to make American tourists feel like they are at home. Other examples are the Chinese take-away where people stop by after a long day of working in tourism, and cafeterias in schools and clinics that serve dishes that are limited to fried meat and hariña.

4.4 Obesity as a cultural identity

Ask an Aruban on the street why obesity is so widely present and he or she will answer you that it is because of their culture; an eating culture pur sang. Mila, likewise, tells me:

It’s in the culture I think. When we want to eat we want to eat a lot. So if we have a small serve of meat, the rice that comes with it has to be a lot,

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and the potato has to be a lot too and ehm… how can I put it, you don’t leave the rice and the potato to eat your vegetables first. The culture.

By claiming that it is the Aruban culture to eat large amounts of food, Mila links the aspect of eating high quantities to Aruba-specific culture. In other words: eating a lot means accessing the expression of a shared cultural “Aruban” identity. Cultural identities, from a constructionist point of view, are socially constructed by elements like shared history, language, religion, appearance and ancestry (Nagel, 1994). Claude Fischer (1988) adds food consumption to this list. Based upon the structuralist views of Claude Levi-Strauss and Mary Douglas, he writes: “The way any given human group eats helps it assert its diversity, hierarchy and organisation, but also, at the same time, both its oneness [it amounts to the same thing] and the otherness of whoever eats differently”. In his essay about ‘Self, Food and Identity’ he highlights that eating practices may serve as a marker to dilate one cultural identity from another. Taking into consideration that Aruba has evolved into a post-colonial melting pot of cultures, the Caribbean cuisine is one of the few tangible elements to distinguish locals from foreigners, expats and tourists, by assessing what they have for dinner. Arubans celebrate with and connect through food. Fatness here becomes a sign of caring (the more celebrations you go to, the more you eat). Or otherwise put by the dietician: “Every occasion is an occasion to eat. It’s our culture. Not parties alone, funerals as well. Snacks, cake, pie, croquettes, pastechi.” This eating culture shows similarities with the Samoan eating culture as described by food anthropologist Jessica Hardin. She refers to the Samoan eating culture as a way of expressing “respect and love that sustain emotional and structural connections between groups. […] Sharing food as a symbol of caring and mutual support” (Hardin, 2013).

4.5 Interim conclusion

A variety of anthropological studies and ethnographies have showed that understandings of body size are culturally dependent. This chapter has outlined the norms and beliefs of Aruban informants about body size and weight. The exploration of the meaning of obesity starts at the explanation of body fatness as a physical state that is life threatening; an understanding that is influenced by biomedical discourses and epidemiological findings that link excess weight to health risks. Obesity is furthermore understood as a threat to the country’s economic welfare. Therefore we can likewise see biopower, a concept that was introduced by the French sociologist Michel Foucault, at work in Aruba. Nonetheless, Aruban understandings of body size are not just negatively associated, which is a finding similar to existing anthropological studies on body weight. Obesity is to some understood as a sign of prosperity and welfare, an effect of

29 participation in the obesogenic environment. This finding challenges the association of obesity with lack individual responsibility that doctors, dieticians and other health care professionals place upon heavy weighted individuals. As a final answer to what the meaning of obesity is on Aruba, I frame fatness as a sign of interconnectivity among Arubans, the physical dispensation of Aruban identity through expressions of care and mutual support, found in shared eating habits.

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Chapter 5 PURSUING GOOD HEALTH: A PATIENTS’ EXPLORATION OF METABOLIC SURGERY

Back in the waiting room of the hospital, Mila and I are having a conversation about metabolic surgery. “I hope that my life changes after the surgery. It will be good for me. Healthy eating, my health will improve.” I ask Mila what specific aspects of her life will change after undergoing metabolic surgery. She answers: “Well, when I lose weight, my feet will not be swollen anymore. My blood pressure will become better. Once you feel healthy, the other things will follow. Maybe my self-esteem improves. Maybe the self esteem will rise…” The conversation with Mila about health is the starting point for this chapter. She puts to words what several of my informants stressed: her weight impaired her feelings of health. I follow her from the moment she made the decision to undergo metabolic surgery unto the point where she looks back eight months later.

5.1 Options to fight obesity

Usually, metabolic surgery is not the first attempt of patients to lose weight. My informants have tried to maintain diets and increase their level of exercise. Others also tried to lose weight by drinking herbal tea and by taking “fat-burner” pills. They took counselling sessions at natural healers to measure their metabolism and internal energy balances. They went to personal trainers and coaches to increase their physical exercise. Some of them mentioned that they registered to “lifestyle intervention” programs. These programs are the personal initiative of trainers and/or psychologists and focus on change in lifestyle. One of them even joined a national television show, “the biggest loser”, an elimination competition between persons who think of themselves as obese, in which the one who loses the least amount of weight has to leave. Although many of them tried their best to lose weight permanently, many of their attempts resulted into experiences of failure. Mila explains to me:

There was a while when I lost a serious amount of weight. But after that I gained a lot of weight in return, so… the structure in my diet actually varied a lot. But well.. those diets, they are… how do I put it… they work at the very start. But they didn’t last and I always regained weight. I got stuck in a situation where I actually… where I really bloated. Yes, sorry. My weight really exploded. My original weight of 88 kilo’s went up to 130 kilos in the end.

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Mila tried to lose weight by changing her diet but she experienced the difficulties of persevering this new eating style. I suspect she feels the need to elaborate on why she found it so difficult. She is the mother of two school going children and her husband works in leisure where he makes a small salary to support his family. As I elaborated on in the previous chapter, Mila tells me that the “good food” that she is supposed to eat in order to achieve good health is expensive compared to processed food that she is used to eating with her family. She explains to me that her family eats products like white bread and rice. These products are generally cheap and preservable and high in nutrients; the type of products that keep you satiated the longest for the least amount of money. When she decides to go on a diet, she needs to purchase “good” products like vegetables and fresh fruits complementary to her usual groceries. Thus, she needs to spend even more money on food with a budget that already feels limited. As a consequence she feels embarrassed to spend the family’s budget for groceries that are provided just for her.

5.2 Being a good patient and being a good mother: role conflicts in health seeking obese individuals

Mila’s example shows that pursuing good health through eating is not just a matter of individual will or choice. It is also shaped by the social world where individuals live in. Her case represents the tensions between her role as a patient and a family member. One the one side she is a patient, eligible for metabolic surgery that needs to consume “good food”. This “good food” consists of a diet that was designed for metabolic patients. The diet replaces all kinds of starch with fresh fruits and vegetables, that people usually perceive as expensive. On the other side Mila adopts the role as family member where her household habits dominate how she should eat. These eating styles are not compliant to each other. Consequently Mila experiences difficulties in persevering the diet that she was told to maintain before and after surgery. These difficulties arise from the conflicting expectations that are bound to her role as patient and housemother. Sociologists often refer to conflicting roles as the incongruity of the expectations associated with two or more statuses fulfilled by one individual (Van Sell et al, 1981). Conflicting roles may arise in a variety of options. Mila told me about the tensions between her role as health seeker and her role as housemother as a recent example. However, her very first experience with conflicting roles dates from her time as a student at the Aruban University. She wanted to become a teacher and she attended many classes to certify for teaching undergraduates. To brighten up these long days of studying, she and her classmates went to the next best fast food chain, usually Kentucky Fried Chicken or Mac Donalds, to take a break in between classes. The moment she realised she wanted to lose weight, she realised she needed to cut her visits to the restaurants. Along with her diet, she would have to cut on the social encounters with her classmates. She

32 joined her classmates to the restaurants after all. There she had her portions of fast food and realized that she was not able to integrate her role as dieter in her role as social student. Similar experiences arose when she went to parties while she was dieting. Mila tells me that Arubans like to celebrate every possible occasion with parties. And at these parties, one will find food, plenty of food. Is there a wedding coming up? Don’t bother to have lunch before the party starts, because the invitee is assured of abundances of sweets, snacks and alcohol. Pastries, croquettes, pan dushi and bola (local pies), meat and chicken are regularly on the menu. Not only weddings are the types of celebrations where you can easily skip your meal. Holy communion, birthdays, funerals, Christmas, Eastern, the national holiday (Vlaggendag), the start of summer break, even seminars and trainings are supplied by lots of snacks.

Mila: Here, on Aruba, it’s really hard to stick to a diet, because everywhere you go, ehm, when you go to a party, there’s rice with bacon. There’s pastechi. There’s salad with bacon on top and chicken and everything else, with lots of mayonnaise and it’s difficult to get healthy food anywhere. It’s all so fat and it’s hard to… ehm, like I said… Your spirit to keep it up weakens and you can’t go anywhere for help.

She tells me that saying no to food at these events is similar to saying no to caregiving. Being a good friend resembles the acceptance of food and beverages at a party, where Arubans generally express their generosity and care for each other through food. Mila experienced that refusing these foods, even when she explained she was on a diet, resulted in incomprehension and intolerance from her entourage, as if she refused their attempts to provide good care for her. Her example unravels the complexity of social eating experiences. Eating is not just about nurturing the body, but very much about nurturing relationships with others by enjoying the same foods. Her comment about the hidden social value of eating is in line with what anthropologist Amy MacLennan writes about obesity in Nauru, where social relationships and sharing lifestyle benefits the experience of good health in the community. She argues that carrying out lifestyle is never a determination of an individual alone. Lifestyle is “a sociocultural concept underpinned by modes of production, relations of power, social exchanges, social values, education and status-seeking” (MacLennan 2015: 299). By retreating from the socially conducted lifestyle at celebrations, Mila encounters resistance from those who want her to join and share their commonalities. Mila’s examples are just a few of many. One day I meet with Fabiena, a psychologist who is specialized in counselling obese women in their path to lose weight, and she knows many more

33 examples. She tells me about the conflicting roles of her clients in their role of healthy citizens versus their roles of employees and their roles as caregivers:

When people come to me, they are mostly single parents.. […] So for example, women work usually fulltime, and then they have to take care of their children, often they do not have the social security net, so then they want to go and do sports, but then they say: when will I do it, how will I do it? They don’t go! And eating behaviour… Very quickly in the lunch break they get a takeaway dish, for them but also for their children, or on the street to pass by a truck. No food is being prepared, lots of people go out and eat outside the house, they don’t have the time to prepare dishes. Because they need to work. The children may go to the day care or after- school care, and they have something to eat over there. But well, it happens very often that the children do not get anything at the daycare. Then the mother just gets something to eat really quickly from the truck to help her children to continue the rest of the day.

Fabiena further elaborates on the social consequences of adopting the role of healthy eater over the role of caregiver. She tells me that mothers with a slim body posture face moral condemnation: their bodies are representations of wrong priorities. They reserve time to go to the gym, and leave their children alone in the meantime. Therefore they attest to rather investing in taking care of themselves instead of their families. Fabiena tells me about the societal prejudices that these mothers face:

Some of the women ask their parents: can we maybe arrange for two or three times in the week, that we leave the children with grandma, and then I will go to the gym. Others regard that kind of behaviour as selfish. You’re a mother, you chose to have children, and therefore you also need to be there for them. You need to take that responsibility. And consequently I often see that women cancel their appointments, they drop out and don’t lose their weight.

As an effect of the social expectations of how women should divide their time in order to be a good mother, some women cancelled their appointments with psychologist Fabiena. The role of mother and the role of healthy citizen could not be embodied within the same person.

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5.3 'They don’t see the real me': conflicting identities

Although the narratives of my informants varied in what they had experienced in their lives, they all had in common that they felt uncomfortable with their role as obese patient. It didn’t match with how they thought of themselves; they felt trapped in their obese bodies. Throughout our conversation Mila gives several examples of how people didn’t perceive her true identity because of her weight. For the sake of maintaining overview, I will discuss her conflicting identities by theme. Mila elaborates on her considerations to undergo metabolic surgery. She tells me: “Actually nobody who is overweight is really one hundred percent healthy.” I ask her if she thinks that she is unhealthy. She doesn’t directly answer and thinks a little while. “…Well, no I don’t think so. I have problems with my knees, they hurt. But that will go away whenever I lost the weight. And also the risk of the long term diseases, you know? The heart and coronary disease and diabetes.” In this passage, Mila links the health risks that she experiences to her current state of obesity, not to her self. However, being obese is in her eyes a physical state where she is currently charged with. She perceives obesity as temporary and she is sure that a physical state without excess weight, and therefore without unhealthiness, matches her true self. The incongruence in Mila’s experiences of her self does not limit to health experiences, they also apply to the social experiences. “I myself notice it when I cross the street.” Mila says when I ask her about her experiences with her weight. She refers to her weight as a cover that disables others to see her slim, beautiful self. She elaborates: “Do you know the crossover at main street? The place where it is busy constantly? I see the cars stopping for other women, slim women, beautiful women. But when they see me, they drive along. It hurts.” In this passage, Mila explains how the reaction of others on her appearance affects her feelings. Although Arubans do not hold predominantly negative assumptions about large bodies, Mila has experienced that passengers treat her differently from slimmer women; the women who have a physical appearance that she desires to have. That corpulence may cover one’s true self is not a negative consequence by definition. I spoke to a former obese patient who I keep anonymous for the sake of her privacy. She refers to obesity as “weight for protection of yourself”. At first I do not immediately understand what she means, so I ask her to elaborate on her statement. She describes the literal thickening of the skin as a mechanism to reduce attractiveness of women, to protect themselves from sexual harassment and domestic violence inside the house. Obesity here is understood as a shield to protect the self from danger from outside the body. She continues:

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Lots of women on Aruba are fat, chubby, and it’s not because of the food. It’s because of molest. Many of them, I think even up to 70 percent, are victim of sexual assault, sexual assailing, yes. They need the weight, to thicken their skin.

The link between obesity and domestic abuse has been made earlier and elsewhere. Searching the Internet I found many articles who link obesity to abuse. Yount and Li write about excess energy intake and increase in sedentary lifestyle among Egyptian women who are victims of domestic violence (Yount & Li, 2010). Greenfield and Marks write about the excess use of food as a reaction to childhood abuse in the United States. According to them, eating becomes a mediator of risks on domestic violence (Greenfield & Marks, 2009). Talking about domestic violence is a delicate matter that Arubans generally not discuss with each other overtly. Thus it is surprising that my anonymous informant was not the only one who told me about her suspicion of a relation between obesity and domestic violence. The statement that this former patient brings forth is an example of the gendered understanding of obesity on Aruba, i.e. an understanding obesity that is specific to females. I tried to gain insight in demographic information about prevalence of abuse on Aruba but no document reports on the quantity of cases of abuse. The Health Monitor (published in 2012) does mention 182 cases of child abuse. I have asked my informants who brought up this issue how large they estimated the problem. Most of them did not know exact numbers. Furthermore, they did not know where violated women could go for help, and one of my informants noted that as long as there is lack of help for these women, obesity will remain as a way to protect themselves.

5.4 Metabolic surgery: revealing the true self or a quick fix?

Lastly, Mila tells me about her embodied experiences of incongruence when she was a student. “When I was younger… I had a face, so puffy. And yes, my social life back then was also not so pleasant anymore because I didn’t want to go out because I didn’t feel well. I was in this vicious circle of… I don’t feel well so I’m going to eat more, and yes… My friend said let’s go out, but well, I had nothing to wear, to put on, so… it wasn’t a pleasant feeling.” Although Mila wanted to go out, she felt she was held back by her weight. The social world she ventured in was full of media references to postures that did not resemble her physical posture. Although she had a body that was normative to the Aruban population, her body was not normative to the bodies exposed in media. Due to this confrontation; she felt like she had a non-normative body in a social world of normative bodies. She was not comfortable about her clothes, she was not comfortable about her

36 body and she felt exposed in her social world. Her physical appearance was not representable of her true self; she felt trapped in a large body. Interestingly, similar experiences of “living in the wrong body” have been described among transgenders and people who choose cosmetic surgery and voluntary amputations. The commonality they share is the experience of “being at odds with the self” (Doyle and Roen 2008, emphasis added). Doyle and Roen suggest that any form of surgical intervention on physical appearance may contribute to the reunification of an embodied experience of the self. In other words, surgery may be used as a method to achieve a body that is integrated with the self: a method for those who feel obese to reveal the slim person inside them. In this light, metabolic surgery is not merely an intervention that facilitates reduction of comorbidities. The effect goes beyond physical outcomes: it aims to reconcile personal identity and bodily appearance. Karen Throsby describes similar accounts among patients who underwent metabolic surgery in the UK. Her informants referred to life after metabolic surgery as a “re- birthday” and “new me”. She argues that the adoption of this positive identity claim contributes to the normalization of surgery and to rebut accusations of having cheated to access weight that is deemed medically healthy (Throsby, 2008). In her paper she highlights the tensions that patients experience when they want to integrate surgery into their lives. The equation between metabolic surgery and cosmetic surgery has not only been made by social scientists, but also by my informants. Mila mentions the resemblance too, although in a somewhat different understanding. She tells me that metabolic surgery ‘abroad’ (for example Colombia or Brazil6) is by many seen as an expensive form of cosmetic surgery. It is perceived as an alternative for liposuction or beautification interventions to reach idealized body standards.

Now there are lots of people who say that bariatric surgery is like cosmetic surgery. It is regarded as a way, for a group of people who can afford it, to lose weight quickly. […] The surgery is just a tool to gain control over… the fluctuation of weight and mostly to reduce calorie intake.

Mila’s framing of metabolic surgery as a tool to gain control over food intake incorporates the underlying assumption that those who choose surgery use it as an easy alternative of dieting, a way of “cheating”. Karen Throsby describes similar notions of obesity surgery in the UK context (Throsby, 2008). Patients should try to gain control over their weight by dieting, exercising and

6 Alexander Edmonds wrote an about Brazilians’ right to beauty which they aim to reach through plastic surgery. He moves in the third part of his ethnography Pretty Modern: Beauty, Sex and Plastic Surgery in Brazil to the discussion of gender and sexuality in sharp contrast to socio-biological theories. For example, women use plastic surgery to “restore” their bodies after labour.

37 other conservative methods. In order to achieve this sense of control, they shift their individual responsibility of disciplining their bodies towards health care professionals. To use Harry Solomon’s words about metabolic surgery in India, the gastric bypass enables a “short cut” to normalised body weight without undertaking individual efforts (Solomon, 2014). However, metabolic surgery is contrastingly framed by Felder, Felt and Penkler (2015) as a tool to relief patients from the difficult task to discipline their eating behaviour. Mila also contrasts the so- called medical tourists against metabolic patients. “Medical tourists”, in Mila’s words, “travel to Colombia for a quick fix. They go there because in Colombia there is no waiting list, no intake procedure and no obligation for follow-up”. Furthermore, Mila adds that medical tourists may undergo surgery anonymous and it thus leaves them unexposed to accusations of “cheating” by others. Patients who engage with the procedure on Aruba, however, do not opt for a quick fix but for a surgical tool that helps them to reach normalised notions of body weight. They undergo a straining intake procedure and some of them are on the waiting list for a long period of time before they undergo surgery. According to Mila and in contrast to Colombia, it takes dedication and a determined spirit to opt for surgery on Aruba. She thus distinguishes between medical tourists and patients in terms of accusations of cheating versus a tool to re-access bodily control.

5.5 Interim conclusion

This chapter is concerned with the phenomenological analysis of individual’s choices to agree with metabolic surgery. The chapter draws upon the narratives of 16 obese individuals who decided to either undergo, or underwent the surgical intervention which connects their reduced stomach to their reduced intestines. In order to understand what made them opt for surgery I have outlined how they experienced their lives as obese individuals. I have aimed to provide insight in what they thought was troubling about being fat and how they have attempted to lose their body weight. I have used the concept of conflicting roles to describe the tensions in their lives as a patient at the one side, and a mother, friend, student, caregiver and head of households at the other side. Conflicts do not only arise in societal roles but also within a person, within embodiment and identity. The concept of conflicting identities describes the tensions within an individual, in which feelings of disembodiment are discussed. The chapter is concluded with the introduction and explanation of metabolic surgery as an intervention to diminish the tensions in the lives of my informants with the ultimate goal to integrate conflicting identities. As a nuance to this explanation, metabolic surgery in itself is full of tensions and is here framed as an uncertain cure; individuals who opt for the procedure never know what the outcome will be. The next chapter focuses on the patients experiences after surgery.

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CHAPTER 6 REBUILDING LIFE AFTER SURGERY

In this chapter I will express the post-surgical experiences of my informants through continuing Mila’s story, approximately eight months after she got accepted into surgery. Before I start, I want to emphasize that no story of a metabolic patient is the same and all the narratives deserve their share in this thesis. Taking the privacy of my informants into account, with the personal details they told during their frank conversations with me, I still choose to bind them into one fictional character. In the selection process of my informants I tried to interview patients with divergent experiences, running from paramount positive to absolute negative narratives. Five of my informants underwent the surgery without complications, recovered quickly and adjusted well to their new diet. They think of the surgery as a new chance to reach a healthy life. The majority of my informants, however, experienced (physical) inconveniences. They had dumping: the feelings of sickness, nausea and sweating that arise when metabolic patients eat fast or swallow large pieces of food, so that the food literally dumps into their tiny stomach. Still, these informants are mostly positive about their engagement with metabolic surgery. Two of my informants have predominantly negative experiences after undergoing metabolic surgery. One of them lost her weight so rapidly that she was hospitalized for over six months for malnutrition. Another patient underwent surgery two years ago and until this very day she experiences unexplained pain in her stomach.

6.1 Changing everyday eating practices

That being said, I will discuss the informants’ salient experiences through the fictional conversations with Mila. I visit her at her home, a colourful one-level house in far-South village of Aruba, eight months after Mila received her surgery. When I see her, I notice that her posture changed dramatically. Although she is still beautifully dressed up, she lost serious amounts of weight. She tells me: “I lost 78 kilos in the past eight months.” We take a seat at her backyard, because she rather not wants her husband and sons to hear what she is about to tell me. I ask her how she feels after the surgery. With a little touch of astonishment in her voice she replies that she is well beyond expectations. She elaborates:

I am fine actually. Right now I know how to eat, when and how much. However it wasn’t easy at the beginning. I threw up a lot. Yes, because sometimes I wanted to eat the same amount as before the surgery. So I didn’t want one egg, I wanted two. And I ate, and after one and a half I threw up. I couldn’t eat for six months, couldn’t keep anything inside.

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The moment she got out of surgery, Mila noticed differences in her sensations of digestion, compared to before she underwent surgery. Her process of recovery was a process of developing bodily awareness of the digestion of food. She compares that period with the birth of a baby who needs to learn to eat. A newborn who needs to understand how to drink. By the process of trial and error she was obliged to change her eating practices from what she was used to eat to what she could digest with her new stomach. Her taste changed: earlier she loved pork, but now she cannot stand it anymore. Then again, she now really likes to have cucumber and carrots, foods she never cared for before. She continues: “You don’t do the surgery if you want to continue eating like before.” The re-creation of her eating pattern brought Mila feelings of excitement, proudness and perseverance. Another element that made the awareness of her body signs extra relevant is that the digestion of food was unpredictable to her. At the one day she could digest porridge just fine, at the other day it caused her stomach-aches, nausea or a bloated feeling. What the cause of this change in digestion tolerance was, however, never became clear to her. She further noticed that she was not able to consume some of the foods that she earlier considered as her favourite products, like hotdogs, fried rice and bola, because “it simply comes out again”. This section shows that Mila developed an awareness of her body signs that differed from how she was aware of het body before surgery. The altered experience of Mila’s body reminds me of what Karen Synne Groven, following Drew Leder, calls the dys-appearance of the body. This concept is used to describe the experiences of alienation with the body when it functions differently from how persons experienced their body in the past. In her research about post- metabolic patient experiences in Norway, Groven uses this concept to describe the bodily sensations after metabolic surgery. The patients’ bodies may feel like an “other” body opposed to the self (Groven, 2010). Some patients, like Mila, perceived the alienation as a useful way to learn to eat again. Other patients experienced the alienation of their body as worse compared to their life before surgery. Groven thus shows that quality of life improvement after surgery is uncertain; the outcomes differ per person.

6.2 Social eating practices

The above-described change in body perception brought Mila opportunities to change her everyday eating practices. However, the change in bodily awareness also brought her feelings of discomfort. An hour has passed since I started talking with Mila. She seesaws a little back and forth on her chair as she remarks she wants to excuse herself. She needs to interrupt our conversation to get a snack. Since she underwent her surgery, she never experiences feelings of hunger or appetite anymore. This is, in her own words, because the surgeon has cut off the part of her stomach where her saturation hormones were. Thus, she tells me she can’t trust her body to

40 tell her when to eat and how much to eat; she is dependent on the clock to tell her when to have her meals. In the hospital the nurse told her that she has to eat every two hours. Because Mila notices it is eleven o’clock, she pauses our conversation to get her snack. This interruption is something she would never have done earlier. It makes her feel embarrassed. Eating is not just a matter of nourishing the body; it is also a social matter. Sharing meals connects and solidifies individuals through mutual shared experiences of taste, spent time and attention7. The above stated excerpt is one example of the ways in which since her surgery, Mila ‘s time bound eating schedule has affected the sociality of eating in daily life. The necessity of eating small meals at fixed times interferes with family conventions as well. She now prepares separate things for her family and herself, marking a prominent change in daily life:

I prepare separate meals for my husband and children. I eat meat, fish, all those things […] So when I cook for my husband and children I make rice or fries for them, stuff like that. But for me, I eat more the things like lettuce and ehm… vegetables. […] I leave the hariña out. Sometimes I eat yoghurt, sometimes at night, and their plate contains something completely different. In past times it was hard, because what they prepare is very tasty. But now it’s not hard anymore.” I ask Mila how she experiences those separate meals and she replies rather indifferent. “It doesn’t really matter, it is what it is. Because I got used to it. In the hospital they tell me that it’s not good for my health. And I tell [my husband and children] too: it’s not good for my health. You see, when I cook I can choose what I want to eat and that is really convenient for me. It gets more difficult when I cannot choose.

She mentions the parties she goes to. Generally all the products over there contain farina. This is the one product she cannot have according to the clinicians. It sometimes feels lonely, when she is at a large buffet, watching everybody eat for two hours or more, while she can only eat a few bites during a few minutes. For Mila, undergoing the surgery created a somewhat different conflict in roles, compared to the conflicts she experienced earlier. She cannot actively participate in the social eating practices and be a healthy patient at the same time. What differs from before the surgery however, is that she now is obligated to put her role of healthy patient central. If she does not prioritize this role, she will experience nausea and other physical

7 See the review of Mintz and Du Bois for the anthropology of eating (Mintz and Du Bois 2002). Their paper touches upon classic food ethnographies, including the exploration of the role of food in rituals, and the meaning of eating and sharing cuisines in shaping group identities.

41 complaints. By telling herself that it is for the good of her health, she feels able to keep her diet up regardless of in which situation she is. She thus makes effort to integrate her role of healthy patient and social participant. However, the attempt to integrate these roles is not easy. She keeps facing situations in which she feels lonely by the fact that she cannot participate in eating practices of others. She tells me about the times that she and her family go out on Sunday afternoons:

Sometimes we go on a trip, on Sundays usually. We make a trip with the car and we pass by the stalls with fries and ice-cream along the way. And I tell my husband and my boys: no, I don’t want that. Yesterday evening was the same thing, my son got an ice cream and my husband got an ice cream and they asked me, do you want an ice cream? I told them no… you know, when they have fruits there I would like to have that instead. But they didn’t have that, only ice creams. And after six o’ clock I don’t eat anything anymore, just water, just water. And if I’m hungry I’ll have an apple or an orange, something like that. But it’s hard sometimes… to always have to eat differently.

The examples that Mila provides shows us that although she was aware of the alterations she needed to make in her diet after surgery, she did not foresee the feelings of loneliness and “not fitting in” that would occur to her in social eating practices. In a geographical location like Aruba, where eating is an important element to connect to one another, metabolic surgical effects go beyond altered choice of diet.

6.3 Lack of nutrients

Her stomach-aches and the frequency of vomiting frightened Mila. She often worries that she will not be able to absorb a sufficient amount of nutrients from the food she takes. She shows me a few papers and pamphlets that she received in the hospital. One of these papers highlights the “rules” of eating after undergoing metabolic surgery. No drinking and eating at the same time, small bites only, chew at least twenty times, and the most important rule of them all: no hariña. No starch. No rice. No pasta. No bread. No pastries. None of that. I know this document; one of the clinicians at the obesity ward gave it to me. I immediately think of what the doctors told me about Arubans’ ‘Indian genes’ and their inability to digest starch and carbs. This is a theory that reminded me of many other similar theories, for example Asians’ inability to process dairy and Japanese who “miss the gene” for the digestion of alcohol. According

42 to the surgeon, native Arubans from Indian descent cannot digest starch well. The result: storage of the nutrients in fat accumulation cells, the onset of obesity. Although in contrast with worldwide nutritional guidelines which promote a limited intake of farina, the clinicians in the obesity clinic state that the complete cut-off of farina out of the diet of their patients will improve their health, based on their congenital intolerance for carbohydrates. Mila has tried to eat according to the post-metabolic rules. “The only thing is”, she sighs, “There is so little left I can take. I’m worried about my vitamins, my blood values.” She tells me about the stories she heard of people who kept losing weight, who never settled at a certain point. Those people started to lose their hair. Mila has heard Iris’ story; she was hospitalized for malnutrition because she was not able to absorb her food anymore. She also heard about Lavinia, the daughter of a friend of hers. Lavinia underwent metabolic surgery and in the following year, while she was losing her weight, she became pregnant. Lavinia’s tragic story resulted in the labour of a little stillborn baby. She linked her loss to the alterations that were made inside her body through the surgery. The insufficiency to absorb the daily-recommended dose of vitamins and minerals from food intake is a familiar side effect among people who have had metabolic surgery. In biomedical papers, clinicians stress the importance of monitoring the blood values of vitamin B12, iron and calcium (James et al 2016; Aasheim et al 2009). Patients on Aruba are recommended to take the “Fit for me” nutritional supplements twice a day. The supplements are the solution from the medical world to counter the risk of malnutrition, which patients are advised to use during their whole life. Mila walks to her kitchen and returns with a bottle full of capsules. Hardly any capsules have been taken out.

You see, the thing is, you have a small stomach. You cannot take the pills, swallow them at once. The pills they describe in the hospital are especially imported from Holland. Fit for me is how they are called. But with my little stomach I can’t swallow them! Defeats the purpose.

Swallowing the capsules as a whole made her sick. Furthermore, she has to wake up half an hour earlier than usual, because she cannot combine the supplements with her breakfast, simply because taking in both was too much and often resulted into feelings of dumpings. Mila’s solution was to buy liquid supplements on her own behalf, but she realises that many other Arubans cannot afford these expensive liquids.

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6.4 “Loose” skin and disease

I ask Mila about the chance of malnutrition. She answers: “You know what, I think it is better to do the gastric bypass only when you have 100 kilos or more. If you have 80 kilos, why would you do it? […] You will be more slim… too slim.” I ask her what she considers as ‘too slim’ and she starts to sum up features that characterize post-metabolic patients who lost too much weight. They have grey skin tones, bald spots on their heads, they look tired and they have the “loose” skin at their arms and legs. “Loose skin” refers to the abundance of skin of patients, generally under the upper arms, upper legs, bottom, belly and breasts; the area where fat tends to accumulate in the body.

I know women who felt so miserable. They looked grey and their skin was too loose for them. People constantly asked them whether they were sick. Some might think they have cancer instead of a gastric bypass.

Not only Mila, but all of my informants made the reference to physical appearance and terminal disease. Mila referred to it as cancer, others referred to it as diabetes, influenza or Brua. Brua is the collective name for Antillean primeval forces. The power of Brua connotes both positive and negative attributions and can be sent upon others to foster prosperity or tribulations. Apparently, the contrast of "excess" weight compared to malnutrition brings forth associations of obesity as a protective mechanism against famine and disease. This is in sharp contrast to the comparison between "excess" weight and fit, slim bodies. In this light, obesity is a sign of unhealthiness. A natural healer whom I interviewed during my fieldwork also noticed Arubans’ keenness to ‘vitality signs’: characteristics of the body of one’s behaviour that signal health, such as a glowing skin and a fit body. He told me that Aruba’s history with tuberculosis, bad hygiene and famine has made its citizens aware of any sign that threats their vitality. One of the major signs in tuberculosis is the rapid loss of weight. Nowadays, tuberculosis is rarely seen on the island, but the association with weight loss and disease is still prominent. These associations with disease affected the way patients experience surgery as a ‘success’ or failure. Still, the way patients and medical experts experience surgery as a 'success' may differ. Some patients I spoke to considered themselves too thin, too “sick” looking. They decided to increase their food intake to undo the excess of their skin and the effect of their surgery, despite the experience of dumpings or nausea. For them, compared to the physical appearance of a person who is terminally ill, their earlier corpulence was the lesser of two evils. After surgery, these multiple, complex and conflicting valuations of health and ill-health enter the spotlight of patients’ lives. My informants associate excessive weight with unhealthiness,

44 but at the other side of the spectrum is skin abundance and thinness simultaneously a sign of vitality threat. The ideal of vitality is, according to them, to be found in the middle of this spectrum: in the characteristic preference of curvaceous Caribbean men and women.

6.5 Transformations and reflections after metabolic surgery: restoring identity

During our conversations patients provided numerous examples that there is more to undergoing metabolic surgery than just scheduling an operation room and performing the intervention. By looking back at how Mila experienced undergoing the surgery, she told me about lots of wonderful outcomes, but also recounted sad stories of what it is like to have obesity and what it is like to undergo metabolic surgery. Mila remarks that although metabolic surgery is “just a mechanical procedure”, it brings along major changes. “That experience, that transformation from that you have a disease which requires medical intervention and after the surgery you have a different level of wellbeing. Nothing compares to this surgery.” We come to the end of our conversation and she notes that although she experienced difficulties and was forced to deal with lots of emotions, overall she is generally thankful and content that she has had the surgical intervention. It’s easier to move around, she has more energy left compared to what she used to have. While she sums up these benefits, she gets off her chair and walks into her house. A moment later she returns with a photograph in her hand. “Look!” she says to me “this is what I looked like when I was at my heaviest.” The picture she shows me captures the image of a woman with the same features as Mila; the only thing is that she has a posture that is at least twice the size of present-day Mila.

It’s not only the easiness when I move, but also I feel more confident. In only a short amount of time I lost a lot of weight… but ehm… also in that period I became more confident. My husband also told me I became a lot more attractive and he had to get used to the fact that I look completely different. To be honest, we had fights sometimes. He thought I also acted very different… because well… he became jealous because I became physically capable of much more things.

The transformation that Mila experienced simultaneously with the weight that she lost also had impact on her relationship. Although she never thought that she as a person would change through this surgery, she and her husband needed to find a new balance in their relationship because she felt more active. She increasingly initiated activities in daily life. She tells me about her husband’s feeling of admiration, but also his jealous comments towards her when

45 she wanted to go out without him. In a way she understands what it’s like for him, because she also sees what happened to her friends who underwent metabolic surgery:

They don’t recognize themselves anymore. Or… when they were fat they were in a relationship and now they lost weight and they… they are not the same person anymore. It’s hard because you’re not only bringing yourself in the mix but also the partner and the children and that’s more difficult. I have a friend and she lost the weight and she doesn’t recognize herself anymore. It’s just the conception of: now I’m a Barbie. I can do whatever I want. She went and did things she never did before…. She was reckless. Going out every night, partying, until three o’ clock, four o’ clock in the morning. Then… rising at six, going to her job. Cocktail party in the night, going out again.

The relationship of her friend did not survive the surgery.

6.6 Interim conclusion

This chapter brings in the reflections of my informants of how they experienced their daily life after metabolic surgery. By bringing in individual excerpts of everyday situations after surgery, I expound what it is like to undergo metabolic surgery for the individuals that I interviewed during my fieldwork. This chapter has touched upon the changes that my informants experienced in their lives, which are full of tensions. Their experiences of “learning to eat from scratch “like a baby” brought them on the one hand a new chance to adopt an alternative lifestyle and on the other hand it isolated them from their lives as they knew it. Consequently, they sometimes felt proud of themselves, but sometimes they also felt lonely, misunderstood. They sometimes felt healthy because of their reduced weight, and other times they felt like they were running sick because of missing nutrients and excess skin. The chapter ends with examples that my informants gave about the surgery’s impact on their identity and their relationship with significant others; which sometimes helped them to flourish, but at other times greatly disturbed social life as they knew it. This chapter shows that undergoing metabolic surgery is not an “all good” intervention. The narratives of my informants serve as testimonials that highlight the complexity of rebuilding life afterwards; they come with a variety of tensions that patients need to integrate in their everyday life in order to embody their life as a post-metabolic patient.

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CHAPTER 7 CONCLUSION AND DISCUSSION

In this thesis I have explored perceptions of body size, obesity and health from the perspective of Aruban patients who underwent metabolic surgery. An important discussion I have joined in this thesis is what the understanding of health, body size and obesity is. Their interpretations are inseparably intertwined with culture, economy and history. Hence, I have argued that ethnographic social scientific research may contribute to the explorations of these understandings in the local context of Aruba. I explored the concepts of body size, obesity and health by analysing the everyday life practices of metabolic patients. Their everyday experiences render how patients try to embed practical and medical knowledge into their daily lives in order to live with obesity or altered metabolism. The “expertise” that they have developed, their patient knowledge, tells us what it is like to live with 1) obesity and 2) metabolic surgery and how they try to access health in the social world that they venture in (Pols, 2013). I have argued that the many tensions that arise in their everyday lives may help us to gain insight in how metabolic surgery is understood in the specific local context of Aruba. I have relied on anthropological literature to inform me about what kinds of tensions have been described thus far. One of the most prominent tensions in obesity debates concern the medicalisation of body weight. I have touched upon the globesity epidemic and I have explained why this formulation refers to threat and danger (Knutsen, 2015). I have linked Foucault’s concept of biopower to Aruban debates that bring up individual responsibility in monitoring body weight. In line with this thinking, “excess” weight is in Aruba likewise seen as dangerous and unhealthy. Simultaneously, however, large bodies also reflect prosperity and welfare, they are an effect of participation in the obesogenic environment. This finding challenges the association of obesity and lack of individual responsibility that clinicians, dieticians and trainers place upon heavy weighted individuals. I found other tensions in the polarisations of on the one side, fatness versus fitness and on the other side, fatness versus malnutrition. When Arubans contrasted their fatness against the image of fit bodies and slim models, they valued their fatness as impairment to their health. However, patients also contrasted fatness against malnutrition. They associated loss of body weight with underlying disease like cancer and with famine. Baring in mind that all foods in Aruba are imported, consequently the security of food changes from day to day. In this light, fatness becomes protective, necessary and comforting even, with the ultimate goal to be able to survive in times of famine. Lastly, I analysed tensions in obesity by using the concepts of conflicting roles and conflicting identities. I have used the concept of conflicting roles to describe the tensions in their lives as a patient at the one side, and a mother, friend, student, caregiver and head of households at the other side. These roles seem compatible at daily practices like the practice of self-care. Incompatible roles, however, arise in social contexts, when persons find

47 themselves in celebrations and parties where affection and interconnectivity are expressed through sharing meals and plates. The exploration of these tensions in gendered as I chose to express these conflicts through the fictional character of Mila. Many of the previously explained tensions apply to the lives of both men and women. However, some conflicts mainly address the lives of women (e.g. domestic violence). Other conflicts mainly address Aruban men. For example, paradoxes that are gendered towards men are the incompatible roles of being a patient and being an employee. Many men have multiple jobs. They refer to take away meals as time saving and practical in their busy lives. These take away meals however (generally junk food), do not fit in their roles of being a healthy patient. The patient role seems to be in conflict with the role of guest or friend in these social contexts. Conflicting identities unravel patients’ experiences of being trapped in the wrong body. I have introduced metabolic surgery in this thesis as an option to reconcile and relieve these tensions in patients’ lives. This idea is in line with what Karen Throsby calls “the re-birthday of the new me” after metabolic surgery (Throsby, 2008). However, I argue that when I frame metabolic surgery as an uncertain cure instead of a tool to relieve tensions, another set of tensions will be unveiled that are relevant to the everyday practices of patients. Patients do not know what their life is going to look like after surgery. They hope that their transformations will improve their quality of life. In my analysis I found that the transformations that my informants experienced, however, are full of paradoxes. Their experiences of “learning to eat from scratch “like a baby” brought them on the one hand a new chance to adopt an alternative lifestyle and on the other hand it isolated them from their social eating practices as they knew it. Consequently, they sometimes felt proud of themselves, but sometimes they also felt lonely, misunderstood. They sometimes felt healthy because of their reduced weight, and other times they felt like they were running sick because of missing nutrients and excess skin. The empirical chapters end with examples that my informants gave about the surgery’s impact on their identity and their relationship with significant others; which sometimes helped them to flourish, but at other times greatly disturbed social life as they knew it. My aim was to map the tensions around obesity and metabolic surgery that are specific to the local context of Aruba. I have framed my informants as healthcare experts alongside the clinicians. Having the improvement of health as their mutual goal, clinicians and metabolic patients all bring their own kind of “expertise” in obesity specific health care. In conclusion, I argued that the understandings of body size, obesity and health on Aruba are multisided and complex. I framed metabolic surgery as an uncertain cure, which unravels alternative paradoxes in patients’ everyday lives. As a final remark, I argue that the tensions that come forth in understandings of body size, obesity and health before and after metabolic surgery

48 may provide us with valuable insights that may contribute to the improvement of obesity specific health care programs on Aruba.

The potential of analysing paradoxes in patients’ lives

Although the aim of this thesis was not to judge or criticize metabolic surgery, this thesis brought forth some insights that may be used to design and improve health care that is concerned with metabolic surgery. These insights build upon the perspective that the impact of surgery is not only explained in biomedical terms, but also impacts the patients’ social and daily life. When we take these insights into account, we may increase our capability to align health care with what patients need before and after surgery. One suggestion is the establishment of a patient support group. In such a setting, metabolic patients are given a platform to share their experiences with those who opt for surgery. Other recommendations to improve obesity health care include the cooperation between medical and non-medical disciplines that both aim to tackle obesity. A multidisciplinary centrum for obesity treatment (of which metabolic surgery is one of the facets) might facilitate this cooperation.

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ANNEX A SEMI STRUCTURED INTERVIEW

Voorstellen onderzoeker Uitleg onderzoek - Doel: ervaringen van patiënten die GB willen/gehad hebben vastleggen om zorg rondom GB te kunnen verbeteren - Uitleg anoniem verwerken gegevens - Toestemming vragen om gesprek op te nemen met voice-recorder - Vragen voor aanvang interview?

Voorstellen participant - Leeftijd - Werk/school/dagbesteding - Woonsituatie - Relatie

Beleving van obesitas hebben - Hoe is obesitas ontstaan? Wat waren kenmerkende periodes in leven voor gewichtstoename? - Heeft u negatieve of juist positieve momenten meegemaakt omdat u obesitas had? - Hoe voelde u zich over uw overgewicht? - Hoe denken mensen in Aruba in het algemeen over overgewicht?

Eetbeleving - Hoe ervaart u het volhouden van het dieet voor/na de GB? - Op welke momenten neigt u meer te eten? (eetstijlen: emotioneel, extern en/of lijngericht?) - Wat at u het liefst? Wat veranderde er in uw eetpatroon op momenten dat u wilde afvallen? (En voor GB: wat is er veranderd in uw smaakbeleving/honger/eetgewoontes/lifestyle na de GB?) - Wat vindt u belangrijk om te weten (kennis) over eten en lifestyle?

Verwachtingen GB - Wat maakte dat u koos voor een GB? - Wat verwacht u voor de toekomst na een GB? (Gaat er veel veranderen of blijft het zoals nu? Ziet u moeilijkheden? Waar hoopt u op en waar bent u bang voor? Lifestyle aanpassingen op lange termijn?) - Hoe heeft het GB traject tot nu toe effect gehad op uw dagelijks leven? - Heeft u bepaalde kennis, hulpverlening of expertise gemist in het traject? - Van welke problemen hoopt u af te komen/bent u afgekomen na een GB? (Fysiek, emotioneel, sociaal)

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ANNEX B ETHICAL CLEARANCE OF HOH HOSPITAL

Dr. Horacio E Oduber Hospitaal Aruba Dr. Horacio E. Oduber Hospital Boulevard #1 Oranjestad Aruba Tel: (+297) 527-4000 E-mail: [email protected]

Betreft: Letter of consent Naam student: Marloes van Drie Aruba, 14 april 2016

Geachte heer/mevrouw,

Namens de Onderwijscommissie van het HOH Ziekenhuis bevestigt ondergetekende dat het onderzoeksvoorstel van UvA-student Marloes van Drie gelezen is. Middels deze brief verklaart ondergetekende dat het onderzoeksvoorstel zowel praktisch als ethisch is goedgekeurd. Er is toestemming verleend om het onderzoek uit te voeren in/buiten het ziekenhuis in de periode 29 januari 2016 tot en met 16 april 2016. Er is haar toestemming verleend om gebruik te maken van de wetenschappelijke faciliteiten van het ziekenhuis. Tevens is toestemming verleend om de wetenschappelijke bevindingen te publiceren via relevante wegen (zoals de UvA masterthesis database en wetenschappelijk relevante tijdschriften).

Hopende u voldoende geïnformeerd te hebben,

Met vriendelijke groet,

Dhr. E. Cilie Mw. E. Van der Burg Medisch directeur HOH ziekenhuis Secretaris Raad van Bestuur