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Metabolic Surgery 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 3 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. 4 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 5 Bibliography 49 Annex A 55 Annex B 56 6 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. 7 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”.
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