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PLOS One logoLink to PLOS One
. 2023 Jul 27;18(7):e0287822. doi: 10.1371/journal.pone.0287822

Weight stigma after bariatric surgery: A qualitative study with Brazilian women

Mariana Dimitrov Ulian 1,*, Ramiro Fernandez Unsain 1,#, Ruth Rocha Franco 2,, Marco Aurélio Santo 3,, Alexandra Brewis 4,#, Sarah Trainer 4,#, Cindi SturtzSreetharan 4,#, Amber Wutich 4,#, Bruno Gualano 5,#, Fernanda Baeza Scagliusi 1,#
Editor: Vidanka Vasilevski6
PMCID: PMC10374044  PMID: 37498887

Abstract

Prior studies suggest that one anticipated benefit of bariatric surgery is the achievement of a thinner body, one that is less subject to perceived negative judgment and condemnation by others. However, additional analyses also indicate that stigma may persist even with significant post-surgery weight loss. To investigate the stigma-related perceptions and experiences of women who have undergone bariatric surgery and the resulting body transformations, we conducted individual, semi-structured interviews with thirty Brazilian women (15 aged 33–59 and 15 aged 63–72). The resulting text was then analyzed using thematic analysis. We found that some form of weight stigma persisted for our participants, regardless of weight loss. Ongoing experiences of stigma were also evidenced by the constant internal and external vigilance reported by the women, as well as their articulated efforts to distance themselves from their previous bodies. Additionally, participants reported being judged for choosing an “easy way out” to lose weight. Those in the older group reported that weight stigma was entangled with ageism: older participants received mixed messages underscoring the ways that weight and age may interact in doubly stigmatizing ways. Family and close peers were especially powerful sources of stigma experiences. Collectively, these results show that weight stigma persists even when people undergo a procedure to lose substantive weight and that the degree and types of stigma experiences are influenced by gender and age. Our study suggest future research should explore whether a targeted approach might be more effective, for example, an approach that would emphasize the importance of developing coping strategies with respect to experiences of stigma and discrimination after surgery.

Introduction

One of the most effective means currently available to individuals seeking to lose weight is bariatric surgery. Bariatric surgery, also known as weight-loss surgery, refers to a number of different procedures, all of which aim to induce severe weight loss through the surgical reduction of the stomach and/or intestines (e.g., [14]). Bariatric patients often have a history of complex anxieties and negative social experiences stemming from weight stigma [58]). The weight loss that accompanies the surgery, therefore, has been generally related to positive changes in body image and social interactions [9, 10].

In Brazil, bariatric procedures have been available at no cost to patients since 1999 through the Unified Public Health System or the Sistema Único de Saúde [11]. In this respect, Brazil parallels certain European countries that have also made bariatric surgeries widely available to citizens within an integrated healthcare system. Brazil is, however, economically, socially, and culturally quite distinct from these other nations. The sociocultural implications of the surgery, including experiences around weight stigma, have been understudied in a Brazilian context. For example, despite the highly-publicized increase in the number of bariatric surgeries performed within the Brazilian public health network, many experts still consider this number insufficient, as only about 8% of all applications for surgery are approved and financed [12]. Also, there are regional inequalities, with the wealthier South and Southeast regions reporting the most bariatric surgeries, and the North and Midwest regions reporting the least [13].

Stigma can be defined as negative judgments and behaviors aimed at a devalued attribute or condition that disqualifies a person or family or community with this attribute or condition from full social acceptance in a particular cultural context. Stigma results from a cascade of social interactions, in which the individual (or family or community) exhibiting the stigmatized trait is distanced from others, all of whom supposedly adhere to a normative standard. This in turn legitimizes various social and economic discriminations and exclusions [14]. Weight stigma is the process by which people with higher body weights are socially classified as less valuable or desirable because of their weight [15]. Following Brewis [16], we define weight stigma as moral discrediting that people experience from others or apply to themselves because of the negative social meanings attached to the size of bodies. Stigma related to very large bodies tends to be especially pernicious. Weight stigma has been identified as an important barrier to obtaining consistent healthcare services [17] and has significant emotional and social impacts for people who are identified as obese [15, 1721].

People with higher body weights often internalize weight stigma and end up agreeing with dominant social messages stating that the adverse judgments of them based on their weight have merit [15, 21, 22]. It is also common that people who have been labeled as “obese,” “overweight,” and/or “fat” feel individually responsible for making specific choices around diet and exercise to achieve a more socially acceptable body, i.e., a thinner body. This idea that individuals should make “good choices” is centered in powerful sociocultural notions around the responsible management of the physical body and in the social science literature has been interpreted as a form of moral biocitizenship [23, 24].

Some previous research, including research within Brazilian populations, has indicated that people with a higher body weight consider bariatric surgery a means to achieve a thinner body, and one that is less subject to the negative judgments of others [25, 26]. Nonetheless, studies also suggest that stigma persists in different forms after bariatric surgery. This persistence may involve negative judgments regarding the decision to do such a procedure and/or of the post-surgical body, and may therefore influence the candidate’s post-surgical dietary adherence and overall well-being [4, 2729]. For example, one study [6] showed that participants who underwent bariatric surgery often heard from their familial and social circles that bariatric surgery was an “easier” method of weight loss in comparison to traditional methods centered on diet and exercise. These traditional methods are often framed as involving moral biocitizenship and “hard work” done upon and with one’s physical body. Doing something the “easy way” was therefore equated with “cheating” at weight loss and thus was a mechanism of stigma creation.

Other research has shown profound shifts in people’s lived experiences in the years after bariatric surgery, mirroring their bodily transformations [3033]. Negative judgments of post-bariatric bodies are commonly reported in the literature, often centering on the persistence of side effects from the surgeries [3438] and/or difficulties with managing the rigid personal habits the surgeries necessitate [3238]. Other negative judgments stem from the shapes and sizes of the bodies produced by the surgery and its accompanying rapid weight loss. Weight loss induced by surgical intervention is so rapid, for example, that it often produces a great deal of excess skin. Furthermore, people tend to lose weight in their heads, arms, and legs before they lose it in their torsos [4]. This pattern of weight loss and loose skin does not always conform to societal body shape ideals, especially for women.

Little is currently known about how women at different life stages (i.e., adulthood vs. elderhood) deal with the profound body transformations caused by the surgery and attendant weight stigma or whether life stage affects the ways in which women assume personal responsibility for maintaining their modified bodies after bariatric surgery. From the more generalized body image literature, we know that body dissatisfaction tends to be fairly stable or to decrease across the life span [39]. However, most studies have not focused on those who lose weight but rather on those who gain weight as they age [40]. Some studies, mostly based in the US and Europe, have shown that older women experience increased body concern as they grapple with feelings of being “trapped” in aging bodies [41]. Higher body weights (past or present) may therefore interact with age and experiences of weight stigma and negatively impact wellbeing in women’s later years. As yet, there is little study on this specific point.

Finally, there is a dearth of research on bariatric surgery and other extreme weight loss experiences in the Global South. Brazil is an interesting location to conduct research in this area of study for a number of reasons, including the fact that sociocultural messages about the “beautiful body”–characterized in women by a thin waist but big breasts and bottoms–are extremely powerful (e.g., [42]). Moreover, the universal healthcare system is offset by extreme socioeconomic inequities, and attitudes about women (both in terms of their relationships with their families and as citizens of the Brazilian state) are undergoing rapid transformation [43].

Therefore, in this study, we aimed to qualitatively understand how weight stigma has affected Brazilian women who have undergone bariatric surgery. Beyond its unique focus on Brazil, our study’s novel approach centers on an age-based description of older and younger women after bariatric surgery, with a particular focus on older women since their experiences are not well documented in the literature. We also were interested in understanding how the participants perceived and internalized (or not) weight and other types of stigmas before and after surgery and how they dealt with the bodily and eating-based transformations brought on by the surgery. Our study can suggest whether a targeted approach might be more effective, for example, an approach that would emphasize the importance of developing coping strategies with respect to experiences of stigma and discrimination after surgery.

Methods

Research setting and study population

The Ethics Committee at the School of Public Health of the University of São Paulo and the Hospital das Clínicas of the School of Medicine of the University of São Paulo (HCFMUSP) approved this study (Approvals 4.031.373 and 4.143.745, respectively). Participants provided both digitally recorded oral consent and digitally recorded informed consent, and both processes were also approved by the Ethics Committee. All research procedures adhered to the regulations in the Declaration of Helsinki as revised in 2008.

This research was carried out at HCFMUSP. This institution is a tertiary, referral-based teaching hospital located in the most populated city in Brazil: São Paulo. To be eligible for bariatric surgery in this institution, patients must have a medical recommendation provided by a private or public clinic. Then, the patient has a trial session with the physicians of HCFMUSP, who evaluate the patient to see if they meet the criteria to be included on the waiting list for bariatric surgery. If successfully placed on the waiting list, the patient then has annual appointments with a surgeon and receives nutritional and psychotherapeutic support. The appointments continue until the surgery is performed, and the wait for surgery can last years. After the surgery, the appointments with the physician are initially frequent, but if the patient appears to be recovering well, the visits become more spaced out. Nutritionists and psychotherapists also provide follow-up care, and, if deemed medically necessary, the patient can be referred to other specialties (e.g., psychiatry).

For this study, we used a purposeful sampling method focused on women who had bariatric surgery at HCFMUSP between one and five years prior to our meeting. Before the onset of the COVID-19 pandemic between November 2019 and March 2020, we directly recruited women who underwent bariatric surgery by visiting the clinic and interacting with post-operative patients. Interested participants provided Author 1 with their names and contact information. During the early months of the pandemic (June 2020 to August 2020), post-operative patients already being followed by the Bariatric Surgery Outpatient Clinics of HCFMUSP were also recruited by us, as the clinic provided a list of names and contact numbers of eligible participants. Forty-six potential participants–whose contact information we either gathered directly pre-Pandemic or was provided to us by the clinic during the Pandemic–were contacted via a WhatsApp message by Author 1. We chose this application because it was the easiest of the secure tools available to participants for facilitating a remote interview. Also, the app’s end-to-end encryption ensured that information was only exchanged between the researcher and the participants, with no access available to any third party.

In the initial contact, Author 1 introduced herself, explained why she was contacting them, the purpose of the research, and clarified that if they agreed to participate, the participation would be voluntary, and the findings would be kept confidential. This study does not qualify as Patient and Public Involvement (PPI) research, because PPI refers to an active partnership between members of the public and researchers, in which members of the public work alongside the research team and are actively involved in contributing to the research process as advisers and possibly as co-researchers [44]. This did not happen in our study.

Thirty women agreed to participate after initial contact by Author 1. The methodological framework of the present study focuses on two distinct age categories. The sample consisted of 30 women who we categorized as “younger” (aged 33–59 years, n = 15) or “older” (aged 63–72 years, n = 15) at the time they underwent bariatric surgery. These sample sizes meet or exceed empirically-based guidelines for achieving thematic saturation in qualitative research [45].

Data collection

Author 1 conducted semi-structured interviews with each of the women who consented to be in the study. Given issues with the proposed length of the initial interview protocols (which averaged three hours), participants subsequently were offered several shorter interviews spread out over time, rather than a single, long session. For most of the participants, two interviews were sufficient to address the interview protocols and prompts, but, in several cases, a third interview was necessary. Author 1 has extensive experience with semi-structured interviews, having conducted this type of research during her M.A. and Ph.D. work. The interview protocol that guided the interviews is presented in S1 File, and the interview schedule is presented in S2 File.

The 2–3 interviews per woman were conducted in the same or consecutive weeks of each other. Pandemic interviews conducted remotely were audio-recorded and then transcribed verbatim by an external company. Non-verbal behaviors such as gestures were observed and recorded in separate handwritten notes. These procedures meet qualitative criteria of methodological rigor [46]. This divided-encounters approach proved more practical and feasible for the participants’ schedules. Notably, the time lapse between the first and second (and, when necessary, third) interviews increased data quality, since it gave Author 1 an opportunity to review recordings of the first encounters and to note gaps that needed more attention in subsequent sessions.

Data analysis

Participants’ life story narratives were assembled from the data collected in the interviews so that we could investigate how interviewees perceived and internalized weight and other types of stigmas before and after bariatric surgery and how they dealt with bodily and eating transformations brought on by the surgery. The interviews were transcribed and then analyzed in Brazilian Portuguese. Here, excerpts that are relevant to the analytic narrative have been translated to English, but we have also retained and provided the original Brazilian Portuguese.

Following Braun and Clarke [47], thematic analysis comprised a series of phases. Initially, Author 1 familiarized herself with the data set by reading and rereading the transcripts and noting down initial analytical observations. Then, Author 1 coded the transcripts, systematically identifying and labelling relevant features of the data in relation to the research questions and grouping together similar data segments. Afterward, we moved on to the development of themes and in this stage of the process, Author 1 worked closely with the other authors. As Braun and Clarke [47] highlight, themes are not simply sitting in the data waiting to be uncovered. Rather, Author 1 clustered together codes to create a plausible mapping of key patterns in the data. The themes were then named, categorized, and organized and the final product then provided a road map for the write-up. Finally, Author 1 presented the analytic narrative with vivid and compelling data extracts.

Results

All thirty women who participated in this study underwent bariatric surgeries between 2016 and 2019, before the onset of the COVID-19 pandemic. We provide an overview of the general characteristics of our participant sample in the table below (Table 1). This information was obtained directly from the participants during the individual interviews (see S1 File).

Table 1. General characteristics of women participating in the study.

São Paulo, Brazil, 2020.

  Younger women (n = 15) Older women (n = 15)
Current age (yr.), mean 45 67
Age at surgery (yr.), mean 43 64
Anthropometry
Current body mass index (kg/m2), mean 31.2 33.9
Body mass index (kg/m2) at surgery, mean 44.9 44.8
Highest body mass index (kg/m2) pre-surgery, mean 51.9 51.9
Lowest body mass index (kg/m2) post-surgery, mean 29.5 31.5
Self-perceived skin color, n
White 4 11
Black 1 2
Brown 10 2
Relationship status, n
Single 3 1
Married 8 6
Common-law marriage 1 1
Divorced 2 3
Widowed 1 4
Education, n
Incomplete elementary school graduation 0 5
Graduated from elementary school 2 2
Incomplete high school graduation 1 1
Graduated from high school 5 4
Incomplete college graduation 0 2
Graduated from college 6 1
Postgraduate-level studies 1 0
Household conformation, n
Lives alone 2 4
Lives with only one family member 2 7
Lives with two family members 5 4
Lives with three or more family members 6 0
Monthly family income (value in U.S. Dollars), n
≤ 397.00 6 8
397.01–794.00 4 6
794.01–1,986.00 4 1
1,986.01–3,972.00 1 0

Overall, we found that after bariatric surgery and its accompanying weight loss, our participants reported that they experienced higher social acceptance in their daily interactions and less discrimination and overt oppression, but they also said that they still faced internalized and reproduced weight stigma. In addition, they assumed specific body-centered attitudes and dealt with conflicting messages regarding their bodies after the surgery. Their interviews yielded four themes regarding these experiences, detailed below, with particular attention paid to the experiences of the older women. All the excerpts that are italicized and have quotation marks around them are English translations and/or original Brazilian Portuguese quotations from the interviews. We could not include all of the original Portuguese quotes due to length limitations, but we consider the inclusion of those highlighting key sociocultural concepts and phrases of vital importance in understanding the participants’ points of view.

Theme 1: Undergoing bariatric surgery means others will judge me

Common experiences among the younger and older participants

Participants routinely mentioned receiving stigmatizing judgments for undergoing bariatric surgery. These judgments came from family members, coworkers, neighbors, healthcare professionals, and strangers. Judgmental statements the women reported to Author 1 included being told that they “took the easy way out” (“você foi pelo caminho mais fácil”), “gave up easily” (“você desistiu fácil mesmo”), and “should have shut their mouths [and just stopped eating]” (“você deveria ter fechado sua boca”). Participants reported that they were also told they were “cowards” for not exercising more self-discipline and “crazy” for undergoing an elective surgical procedure. It was common for our participants to report that they were told by others that they could have lost weight if they had tried other strategies, specifically dieting and food restriction.

Far from the surgery being an “easy way out”, our participants repeatedly said it was the only choice possible and made after exhausting all other options. Before choosing this path, they reported spending years undergoing weight-loss treatments with different healthcare professionals but that these did not result in sustainable changes to their weight. One participant (a younger woman), responding to accusations that she should have relied on dieting, commented, “I have been on a diet since I was three years old. Today I am 34. What would make me achieve it now if I could not lose weight during this period?… Surgery was the most viable method I had at the time to keep myself a healthy person. Other participants reinforced the sentiment that undergoing bariatric surgery is not easy.

Other judgments participants often reported hearing centered on the idea that they only lost weight in the short-term because they had bariatric surgery and as a result, they would be unable to maintain the weight loss. Sonia (a younger woman), for example, mentioned that her sister had started to gain weight. She remembered that their mother suggested the sister ask advice of Sonia about eating and exercise. Sonia’s sister replied, “Mom, she only lost weight because she had bariatric surgery; otherwise, she would have been ‘fat’ all the same. Moreover, soon she will gain weight again, do you think she will stay like this? This is not forever, no.

The experiences of the older participants

Among the older women participants, other judgments were also consistently reported. This group reported, for example, being judged for undergoing the surgery at their (advanced) ages. Maddalena recalled that her son told her that the surgery was an “aggression to the body” (“é uma agressão para o corpo”) and questioned the value of doing it. The older women commented that some of their relatives said they did not want them to do the surgery because they feared the associated health risks for their age cohort. Other relatives voiced concerns that the side effects of the surgery were worse than being “fat”, especially at the participants’ older age. Eugenia, for instance, shared that she heard from others that she “was better before having the surgery, because sometimes she experienced side effects, such as vomiting, even though Eugenia herself emphatically said she felt better post-surgery. Rita reported that when she told family members she could not eat all the food on her plate, her niece said that if it was to be like that (i.e., with restrictions on eating), it would have been better not to have the surgery. Once again, Rita herself felt that having the surgery was for the best.

Theme 2: Constant monitoring after surgery must be “accepted” so I don’t become a “monster” again

Common experiences among the younger and older participants

Post-surgery, participants reported a great deal of surveillance and monitoring. This monitoring was supposed to help maintain the surgery results, i.e., the weight loss. Women reported that monitoring–in the form of visual oversight, food management, and verbal feedback–came from family members, coworkers, clients, health professionals, and strangers. They also reported self-monitoring.

Common comments that the participants received from others stressed that the surgery was only a support and that the participants must do “everything right” to not gain weight again. Sonia (a younger woman) said that after the surgery, it was necessary to adapt and change herself in order to “not go back to be[ing] ‘fat’, to be[ing] a monster, like they [her family] used to say” (“para não voltar a ser gorda, a ser um monstro, como eles [a família dela] falavam”). Participants told us that they saw the monitoring from others in a positive light.

Women also reported that they monitored, and sometimes felt critical of, their own eating. In general, the participants said that even if they felt the desire to eat, they avoided food. Therefore, participants expressed chronic concerns about self-monitoring and behaving “correctly” in relation to eating. During times when they could not sustain this “correct” eating, however, women expressed concern that they should be doing more to improve upon the surgical results. Cristina (a younger woman) said she felt that when she ate more than she was supposed to, “it is as if I were not taking this seriously, I am ashamed of myself sometimes. Another participant, Myrian, remarked, “I joke sometimes, saying, ‘I am obese, take it [some food] away from me because I am obese’… Some people are addicted to cigarettes, I am addicted to food. So if you do not have consciousness about who you are, you will return to what you are. Other participants shared a similar perception.

Participants reported that medical professionals also seemed to extensively monitor them and their weight, as illustrated by the experience of Roberta (an older woman). She said that she went to an appointment at the health center and after the doctor assessed her weight and noted that Roberta had gained two kilograms, he got mad and said, “You will lose the [gains of the] surgery; there is nothing else to be done, what is done is done. If you do not lose more weight, there is no point to return here. When Author 1 asked how she felt about his reaction, Roberta answered, with a resigned tone, that she agreed with him. Similarly, many participants reported being reprimanded by nutritionists for weight gain or weight loss deemed insufficient. For example, Marcia (a younger woman) said, “I had an appointment with [the nutritionist] once. She got mad at me, angry at what I ate. She said: ‘You lost [only a] little weight; you were supposed to have lost more. [It is] because you are eating.’ You know? She was rough, direct. Another nutritionist told Rosana (a younger woman) to lose more weight, proposed changes to her daily eating, and recommended that she should eat food without broth or other liquids.

Participants consistently reported that they were monitored by many people in their community and social networks regarding their eating choices. Marcia (a younger women) said, for instance, “There was a woman who told me: ‘pasta is fattening’, and then this woman advised Marcia not to eat pasta. Participants reported that they were frequently criticized if they did something that others perceived as jeopardizing their weight loss, such as eating more than they should or consuming what others considered to be “fattening foods.”. Luanna (a younger woman) and Teresa (an older woman) shared a similar, very common narrative around this type of monitoring. Because of the surgery, they could only eat a small volume of food at any given time, so they divided their daily caloric consumption into small portions throughout the day. Their relatives were constantly surprised that they ate several times a day. Luanna said that when her husband saw her eating “again,” he would censure her. She said that she became very angry with his attitude because she only ate when she was hungry, and when she checked her weight, it continued to decrease. Marina (an older woman) said that when she went to see her niece, the niece would put food on Marina’s plate and say, “That is it, that is what you will eat; you will not eat more. Cristina (a younger woman) said that her sisters also “supervised” her eating, telling her to stop eating when they felt she had had enough food and telling her not to buy certain food items at the supermarket. She said she chose to see this support positively: “They are always by my side” (“Elas estão sempre do meu lado”).

Participants shared that relatives were particularly vocal in their monitoring. One articulated justification that underpinned familial monitoring of the post-operative women involved the complexity of the procedure, as illustrated by Bruna (a younger woman). She said she remembered hearing from her sisters, “You take care. You had bariatric surgery, you had such a complicated surgery, [but now] you are gaining weight.

The experiences of the older participants

In addition to being reminded about the complexity of the surgery, the older women participants also shared that their relatives highlighted how worried they were about them during the procedure itself, as well as in the years before the surgery when they suffered from a range of health problems and had difficulty performing daily activities. Teresa, for instance, mentioned that a relative told her, “It is better to stay like this [with a higher body weight] than to die on a surgery table. Older women consistently told Author 1 that relatives would constantly monitor them and voice concern over their choices. Marina said that her niece told her, “If you return to the hospital [because you regained weight], I will not carry you, I will not! These admonitions demonstrated the worry that relatives had that the participants were in danger of returning to their previous conditions.

When we asked our participants how they responded to such admonitions, they told us that they agreed with these comments. As Teresa commented, “They are right. I accept, and I listen to everything, they are right, and I am wrong. In the interviews, women often voiced that they did not want to be a “burden” (“ser um peso”) to their relatives.

Theme 3: Stigmatizing judgments of my bariatric body are everywhere

Common experiences among the younger and older participants

Commonly voiced judgements of participants took many forms. One judgment involved telling post-operative women that they were “too thin,” and, usually, this observation was accompanied by the comment that continued weight loss would make them look bad. Luanna (a younger woman) reported a very typical reaction: “Many people tell me, ‘Do not lose more weight; otherwise, you will be ugly’” (“Muita gente fala: ‘Não emagreça mais não, senão você vai ficar feia’”). Other comments involved asking participants if they were sick because of the weight loss. Catia (a younger woman) reported, for instance, “Sometimes they [neighbors, friends] think I am sick, right?

On the other hand, participants who described experiencing a small weight regain after their initial, sustained weight loss also described being reprimanded by others. For example, Eugenia (an older woman) said that after the surgery, she got “really skeletal” (“eu fiquei esquelética”), and she purposely regained four kilograms to “return to a normal body” (“voltar ao corpo normal”). This increase in her weight reduced the visibility of her loose skin and made her feel more comfortable. Nonetheless, she remembered hearing alarmed messages from family members, many of whom remarked that they were worried: “Oh my, you are gaining weight! She said that this kind of criticism harmed her, lowering her self-esteem, but she also said she could not reply to these comments and just had to accept them because they stemmed from love and concern.

Similarly, participants who did not lose “enough” weight after surgery shared that they were often critiqued by family members who expected dramatic, visible weight-loss in the months post-procedure. Myrian (a younger woman) recalled that her parents questioned the efficacy of her surgery because, according to them, “everybody” who did the surgery is thin–except for Myrian, who still had a higher body weight. As Myrian remarked, “It’s like, 109 kg is still ‘fat’, you know? I am [still] obese [after the surgery]. She pointed out that the doctor considered her surgery a success and told her that she was doing great because she had already lost a certain percentage of weight. Outside the clinic, however, social expectations that a bariatric surgery will produce a skinny self were very common and very powerful. Myrian, for instance, despite critiquing her relatives’ opinions and having the support of her doctor, had mixed feelings about her progress. She said, “Sometimes I really feel like I could have lost more weight. I feel it. I could be a lot thinner.

The experiences of the older participants

Among the older participants, it was common for them to hear that they had aged after the surgery. Arlete said that when she met her friend some months after the surgery, the friend was surprised: “When she saw me, she was so amazed, and it shocked me, you know? [She said] ‘I cannot believe it is you. You look like a ninety-year-old woman!’” Arlete expressed being extremely upset with these comments but said, resigned, that now, “there is no turning back.

The older participants mentioned receiving specific comments about changes in their bodies. For example, Rita said that her friends told her to lose weight in her belly area because everything else was fine. Rita reported that she agreed that it would be perfect for her if she lost weight in the belly–but that this was not something she could control or direct. Carmen mentioned perceiving looks and hearing comments due to the excess skin in her arms after bariatric surgery. Most of the older participants stated that they did not respond to the comments involving their bodies or appearance.

Theme 4: I judge other, “unsuccessful” bariatric patients

Common experiences among the younger and older participants

Participants expressed judgments about other people who underwent bariatric surgery and gained weight after the procedure. Eunice (an older women) expressed that people who did the surgery had an opportunity to have a “good body” (“um corpo bom”) and, therefore, must maintain that good body post-surgery because “The obese [person] is on the verge of death, there is no way out, there is no future for him. Women reported that weight gain meant that a person did not understand the real purpose of the surgery: that it was not the final solution and that an individual still had to work to change eating habits. “People think ‘now that I did bariatric surgery, I can eat whatever I want,’” said Marcia (a younger woman). Overeating and “letting their guard down” about eating were pointed out by our participants as explanations for why people gained weight after the surgery. Carmen (an older woman), for example, made the following observation about her colleague who gained weight post-surgery: “He must have seen some delicacy that whetted his desire, and he could not control himself.”

Participants expressed that the success of the surgery depended on how seriously the patient took the procedure and how strictly they followed the healthcare professionals’ recommendations. The women with whom we spoke also stressed that eating with “control” was an important aspect of the surgery’s success. Having a “good mentality” (“trabalhar a cabeça”), “willpower” (“força de vontade”), and “discipline” (“depende da disciplina”) were all portrayed as virtues in the post-surgical individual. Working at “controlling themselves” (“eu me controlo”), “ignoring desires” (“ignorar desejos”), and “policing oneself regarding the amount of food and the junk-food eaten” (“eu me policio da quantidade da porcaria que eu vou comer”) were likewise portrayed as virtuous. For participants, weight gain in another person after bariatric surgery indicated that the person did not have these virtues. The weight gain was an outward manifestation of something being awry behaviorally–in other people.

In this theme, there were no differences between the younger and the older women narratives.

Discussion

In this study, we aimed to understand the ways in which weight stigma affected a group of Brazilian women who underwent bariatric surgery. We were also interested in understanding how women at different life stages (i.e., adulthood vs. elderhood) dealt with the profound transformations caused by the surgery and attendant weight stigma.

Participants agreed that surgery itself was stigmatized, particularly because it was considered an “easy way out” to lose weight. This same theme of stigma related to surgery as “cheating” has also been observed in ethnographic studies of bariatric patients in the US and Canada [6, 4850]. Similar perceptions have been documented within Australian [27, 51, 52], Norwegian [53], and English and Scottish [33, 54] populations. In these neoliberal contexts, being thin is seen as a personal responsibility [55], and our results suggests that this sample from Brazil seems to conform to this same theoretical framework. This was observed, for example, when different people suggested that participants did not try “hard enough”, with their own personal resources, to meet slender norms, and instead had the bariatric surgery.

Although there is quantitative research on the health-related consequences of bariatric surgery in older patients [55, 56], there is a dearth of qualitative data on the experiences of this population. Our study provides some insight into the experiences of older women who undergo bariatric surgery. For example, our older participants received more mixed messages about their decision to undergo bariatric surgery–part of why they felt more stigma. When women started losing substantive weight, they reported that family members and friends wanted them to eat more and to return to their previous, larger sizes–but older women were more often told that weight loss made them look elderly. Studies of bariatric populations in other national contexts have documented similar communications from friends and family with patients (e.g., [4, 6]). What was novel about our findings is that the women interviewed, and especially the older women with whom we spoke, consistently expressed the strong belief that they just needed to accept negative feedback from their families and communities. This stated acceptance is different from the Brazilian study of Liebl et al. [57] with younger participants, where participants stressed that they did not allow negative, unsupportive people to influence their health decisions. This finding also differs from the findings of a study in the U.S. across age cohorts [4], whose participants similarly stressed that they did not listen to people who said negative things to them post-surgery. In our study, some of this stated acceptance possibly reflects dominant social mores and attitudes around women, and in particular older women [58]. Our study therefore underscores the complex connections between weight and age stigma in the Brazilian context [59].

The bodies of our participants after bariatric surgery were a specific source of stigmatizing messages from others. Our participants expressed an underlying feeling that they were always under evaluation to see if they would maintain the expected body weight (and, for the older participants, an acceptably aging appearance). Our results show that these Brazilian women faced serious obstacles to moving beyond the stigma of their weight–even after losing weight. Studies have shown that, in Brazil, the body that is desired is the one that is worked on, cared for, unmarked (e.g., without wrinkles, stretch marks, cellulite, blemishes), and one without excess “fat” [6064]. Brazilian self-care through exercise, weight management, and cosmetic procedures (among other interventions) is seen as essential to modern Brazilian femininity [64]. In this context, a failure to produce the desired body even after a weight loss surgery potentially connects directly to individual moral failures, which may have the potential to lead to negative mental health outcomes.

Stevens [65] points out that the symbolic “fat” body, which was viewed as “out of control” before bariatric surgery, ideally becomes a slimmer and more disciplined body afterwards. This transformation is understood to be ensured by strict adherence to a particular lifestyle and to disciplinary tools (e.g., physiological limitations and dietary restrictions) that distanced people from the formerly higher-weight, stigmatized body. Participants repeatedly reported feeling the necessity to demonstrate to other social actors (like friends and family) their ongoing commitment to weight loss and to eating with “control.” Similarly, one participant shared that the surgery gave them a chance at a “good” body: a disciplined, non-obese, not-“fat” body. We suggest that our participants understood weight gain to be a return to a “bad” body, since a “bad” body is indicative of a bad person, and a moral failure in this context. As we noted at the outset, this idea that individuals should make “good choices” is centered on the requirement of responsible management of the physical body in order to be a functioning, moral biocitizen [23, 24]. Among our older participants, this seemed to be entangled further with experiences of what was interpreted as ageism: a stereotypical and often negative view of older people as less competent [66]. This view exacerbated attempts by others to monitor the older women.

Our participants, especially older women, commonly stated that external warnings, admonitions, restrictions, and advice needed to be tolerated and were even warranted. This may suggest an internalization of certain kinds of stigma by these women–that they believed the stereotypes stating that because they had a higher body weight and/or because they had bariatric surgery and/or because they were older, they were somehow less disciplined and less competent and required supervision by others. Alternatively, it could reflect women’s belief in certain age-related and feminized norms, i.e., one must accept one’s family’s advice and dictates. Illustratively, studies have shown that Brazilian culture encourages acceptance of a situation, as well as lack of inquiry into its causes [67].

In a U.S. study, the authors stressed the importance of the bariatric program’s pre-operative educational classes and post-operative support group in patient long-term success. These classes and groups provided participants with a framework and preparation for understanding the many reactions that their social and work circles might have after bariatric surgery [4]. Most importantly, perhaps, the classes also encouraged challenging situations if they did not enhance wellbeing post-surgery. Although our participants also had pre- and post-operative support groups, this support may have been insufficient to combat stressful social messaging, especially if the support focused exclusively on clinical questions and issues.

Our participants also expressed stigmatizing views regarding other people who gained weight after surgery. For them, those who gained weight must not have been good biocitizens, since biocitizens should be able to demonstrate vigilant and controlled eating. In making these judgments, participants reproduced a moral biocitizenship [23, 24] themselves, as they discussed peers’ mistakes and habits as not-quite-compliant-enough post-bariatric citizens. They internalized that the right way to live after bariatric surgery is to have “willpower,” “control,” and a “good mentality.” Their narratives showed that they tried their best to put this thinking into daily practice, even as their virtuous efforts were called into question when they themselves gained weight or found themselves unable to sustain weight loss. Keeping this articulated perspective (willpower-control-good mentality) at the forefront made participants feel that they were genuinely compliant with what was necessary to succeed after bariatric surgery. This attitude, as reported to us, differentiated them from the “others” (i.e., the “unsuccessful” bariatric colleagues) and resulted in our participants producing themselves as normative subject-citizen-bodies. Participants in the U.S. showed this judgement as well [4]. These attitudes suggest that people who have undergone bariatric surgery, even across different sociocultural or clinical contexts, continue to perpetuate weight stigma.

Finally, it is important to reflect on the impact that the COVID-19 pandemic had on our study and participants. We conducted our research in 2020, at a time when there was collective anxiety about weight gain during lockdown and extensive media messages about higher body weights being a risk factor for COVID-19 complications. It is likely that this historic moment reinforced already existing weight stigma [6870].

Reflecting on the authors’ motivations and positionality with regard to this research, we recognize our privileges as white, middle/upper-class researchers. Also, as of this writing, none of us have a higher body weight. Despite this limitation, we all have been extensively studying weight stigma and the critical weight literature for years. Also, in our previous research, we have been actively listening to women with a higher body weight for years–in some cases, for decades.

Study limitations include the sometimes lengthy periods of elapsed time between the surgeries of participants and the interviews we conducted with them, which may have inconsistently influenced responses. This differential time lapse between the surgeries and participation in the study is, however, similar to other studies with post-bariatric population, which included participants with a mean of 7.7- and 13.7-years post-surgery [71]. Furthermore, the varied lengths of time since surgery meant we captured a diverse set of experiences post-surgery, as the women participants developed increasingly divergent trajectories after the first post-operative months.

Conclusion

Our Brazilian participants faced stigma related to having bariatric surgery, as well as to their body weight. Many of the themes (e.g., surgery as “cheating” and the need to constantly perform self-monitoring) are similar to those identified in studies in the U.S. and Europe. An age-based thematic description of the views and experiences of Brazilian women who underwent bariatric surgery illuminates, in particular, that older women’s experiences were more negative than those documented in the weight stigma literature to date. Our results show that people demanded linear weight loss post-surgery but also connected a certain appearance of thinness to “ugliness”, “sickness”, and, among the older women, “aging”. Thus, a complex web of factors determined which bodies were considered acceptable or not across different lifecycles. The older women also frequently heard from the people around them that the side effects of the surgery were worse than having a higher body weight. All these aspects point to a complicated, possibly globalized or globalizing [72] connection between weight and age stigmas. We suggest future studies in the Global South focus on this understudied phenomenon. Also, future research should explore whether a targeted approach might be more effective, for example, an approach that would emphasize the importance of developing coping strategies with respect to experiences of stigma and discrimination after surgery.

Supporting information

S1 File. Script of the semi-structured interviews.

In this supporting material we present the script that guided the semi-structured interviews.

(DOCX)

S2 File. Schedule of the individual semi-structured interviews.

In this supporting material we present the schedule of the individual semi-structured interviews.

(XLSX)

Data Availability

The data relevant to this paper are available from figshare, https://doi.org/10.6084/m9.figshare.23556324.v1.

Funding Statement

This work was supported by the São Paulo Research Foundation (FAPESP), grant number 2019/00031-0, granted to Mariana Dimitrov Ulian. In addition, Fernanda Baeza Scagliusi received grant by FAPESP (grant number 2017/17424-9) and CNPq (grant number 309514/2018-5). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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28 Dec 2022

PONE-D-22-24534If the weight is gone, is the stigma also gone? A qualitative study of the perceptions and experiences of Brazilian older and younger women who underwent bariatric surgeryPLOS ONE

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PLOS ONE

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"Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

Additional Editor Comments:

The manuscript focuses on a relevant area for research and their results are relevant. There are, however, some flaws that must be corrected. Special attention must be directed to Reviewer #2 comments on the use of stigmatizing language and the "visual analysis" mentioned in lines #208-2015. Methodology section should be improved, including Reviewer #1 recommendation of better description of the characteristics of healthcare and follow up of study participants.The text also requires extensive rewriting to achieve appropriate standards of readability.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Introduction

Line 72-72 – “In Brazil, bariatric procedures have been available at no cost to patients since 1999 73 through the Unified Public Health System or the Sistema Único de Saúde [10]” but even so, it is necessary to consider how is the access to this intervention, as the demand for the procedure is certainly very high. Clarify regional differences and the issue of equity.

Methods - Research Setting and Study Population

The autors inform that patients being followed by the Bariatric Surgery Outpatient Clinics of HCFMUSP.

Describe better how women get there, referral criteria and how they are followed up, how often and for how long is the follow-up, before/after surgery, and by which professionals.

In the lines 650-651 the autors indicate “Although our participants also had pre-operative support groups, this support may have been insufficient to combat stressful social messaging.” This suggests that there is no further follow-up, but the women were recruited at this service after the surgery.

The script used for the interviews was not presented, which guiding questions and the previous experience of the researcher (Author1) was not clarified for carrying out both the interviews and data analysis - this aspect is very relevant for the quality of qualitative research.

Results

On Table 1, complete your title indicating location/year. And explain how this information on the women's characteristics was obtained, whether directly with the women or clinic provided, from a medical record.

Reviewer #2: The links between weight and stigma are a growing research area, and it is encouraging to see more research like this in the Global South specifically. Currently, however, the manuscript requires major revisions to most sections. I’ve provided comments below to try and guide where these revisions would be beneficial.

Title

The title would stand alone better, be more grammatically correct, and be clearer without the question. For example, as “A qualitative study of Brazilian women’s’ perceptions and experiences of weight stigma after bariatric surgery”. I echo the same point for the short title. Perhaps a reframe to “A qualitative study of stigma after bariatric surgery”.

Abstract

• Can you please reframe the following into a research aim/objective (rather than a question): “However, how do bariatric patients perceive and internalize this stigma in different life stages? Specifically, is older age a risk factor?”. The current framing is a little too colloquial.

• Can you explicitly state the method of data analysis used? E.g., was it thematic analysis or something different?

• The abstract is missing a conclusion. Can you please add a sentence concluding your findings, and perhaps suggesting how the findings may be used in the future? You could make your results more concise if you need more word count to allow this.

General

• Can you explain if and how you included patient and public involvement in this work? For example, what stages were they involved and what activities/input did they have.

• Throughout the manuscript, there are quantifying words or sentences for example: ‘For all participants’ or ‘Some of the women’. Please delete the quantifying words.

• The manuscript would benefit greatly from a review of the grammar/scientific writing.

Introduction

• Can the tone of the following sentence be softened: “all of which induce severe weight loss through the surgical reduction of the stomach and/or intestines”. For example, to “all of which aim to induce severe weight loss through the surgical reduction of the stomach and/or intestines”

• Please add references to support: “Bariatric patients often present for surgery with a history of complex anxieties and negative social experiences stemming from weight-related stigma.”

• The word ‘deviant’ isn’t necessary to the message in the sentence on line 82 in the second paragraph of the introduction – can you please remove.

• In the definition of weight stigma by Brewis, stigmatising language itself is used (“being overweight or obese”). Can you please reframe this to move away from this language and use person-first language instead?

• In the introduction (and manuscript) you move between using the term weight stigma and weight-related stigma. Can you please amend the manuscript so you use consistent language throughout?

• In the introduction, you use the stigmatising language of “fat”. Can you please address this throughout the manuscript to use person-first language?

• The introduction is very lengthy and consistently takes multiple paragraphs to make a point that could be made more clearly in one paragraph. Could you please review the introduction to see where content could be made more concise, and therefore clearer for the reader to follow?

• Can you soften the tone in the following sentence: “Weight loss induced by surgical intervention is so rapid that it produces a great deal of excess skin and it also begins at the “ends,” i.e., people tend to lose weight in their heads, arms, and legs before they lose it in their torsos”. For example, to: “Weight loss induced by surgical intervention is so rapid that it often produces a great deal of excess skin. Furthermore, people tend to lose weight in their heads, arms, and legs before they lose it in their torsos, influencing their body shape and size”.

• Despite the length of the introduction, it does not note the potential implications of addressing the research aim. For example, how will this inform public health?

Methods

• Can you please move the ethical approval statement to the start of the methods section?

• Overall, there is a great lack of detail in the data analysis section. Please review and add more detail here to aid the reader to thoroughly understand what you have done with enough detail for them to replicate the processes. For example: You note participants who fit the ‘proposed profile’ were invited to interview - what is the proposed profile? What sampling method did you use? Did you use purposeful sampling, snowball, opportunist? How were the interviews transcribed? Was this by an external company or by the lead author?

• You note in the data collection section that “This two-encounters approach proved to be quite effective in obtaining data and resulted in the chance to complete the interview protocol in a way that was practical and feasible for the participants’ schedules”. I’m unclear how conducting two interviews would be more practical and feasible for someone’s schedule than conducting one interview – can you explain? Also, “proved to be quite effective in obtaining data” is very unclear and non-specific. I’m not sure the value this sentence brings or the message you are trying to communicate.

• You state that “Notably, the time gap between the first and second interviews led to increased reflexivity among the participants and the researcher, who reviewed the recording of the first encounter to note gaps that needed to be covered in the second.” Reflexivity is the acknowledgement of your role and influence on the research process, so it does not make sense in this sentence. Perhaps you were meaning data quality? I’d also suggest softening the tone of many of these sentences. You cannot be certain that the time gap you had led to increased (presumably) data quality, but you could say that was the aim/purpose of the time gap.

• I strongly oppose to many of the messages from line 208 to 215, and feel the messages themselves exacerbate the stigmatisation of those living with overweight or obesity. If you are analysing participants experiences (e.g., feeling like they had not lost enough weight), then it is not your role and it is inappropriate to say that you must visually assess/observe their bodies to validate this. Furthermore, the notation of having to “rely on her description” is highly problematic. If you are analysing someone’s experiences, then the analysis and resultant publication should be aiming to represent the voices of the participant, not your assessment as to whether these experiences are reliable. Please remove this paragraph.

• Lines 227 to 229 are hard to follow – can you please rephrase?

• In lines 228-229, you note themes as emerging as significant. These is vast amounts of literature noting themes as “emergent” to be problematic as it suggests that the themes always existed within the data, and voids the influence of our positionality as the researcher on the process. Can you please review this throughout the manuscript to remove this concept?

• In lines 231-233, you state that you identified excerpts of interviews relevant to the themes of interest, but you have not explained the process of theme development at this stage. How did you develop the themes of interest?

• You have not described how the interview schedule was produced or referenced to a copy of the interview schedule in the supplements. Please add these details.

• There lacks a section on the researcher positionality and how they managed the impact of this through reflexivity. Please can the authors address this.

Results

• In Table 1, please remove the percent and standard deviation. These are not generally used in qualitative studies.

• You presented quotations in multiple languages, but have not noted this translation process in the methods section. Please add this information.

• Throughout the results section, you state findings in affirmative language – for example, “she asked if this man had…”. A better/more accurate way of describing the findings is to include acknowledgement of the interpretation of their accounts by including prefaces – for example, such as “the participant described/expressed that she asked the man...”. It would strengthen the manuscript to review and revise these areas.

• The final lines of the first theme (lines 314 to 317) don’t seem to fit with the narrative of the rest of the theme. Can you please review and either remove or clarify their fit with the narrative?

• Line 323 – are these self-appointed by the participant or by their peers?

• Between lines 329 to 335, you describe others having concerns over the participants health. Could you please include a supporting quotation here?

• On lines 348 to 350, you introduce new literature within the results section. You shouldn’t incorporate other literature in this section so could you remove and rephrase this section. For example, you could simply say “Participants who described experiencing small weight regain after weight loss described being reprimanded by others”.

• Line 360 – is “melt off” a quote from a participant or your own writing? If a quote, can quotations marks please be added. If it is your own writing, can it be rephrased to be more in line with the language and writing style of the piece.

• Again in lines 366 to 370, you introduce new literature and compare findings to existing evidence. Please remove this from the results. This is repeated in areas throughout the results section – can you please review this throughout.

• Lines 391 to 392 begin to discuss the results, rather than present the results. Can you please move this to the discussion or remove?

• Line 393 “aggressive” and line 396 “mad”– were these words used by the participants or is this your own language choice?

• Line 400 to 401 – did participants say that the advice was not backed up by evidence, or is this your own commentary? If the latter, please move to the discussion or remove.

• Line 423 – did the participant describe the foods as “fattening foods” themselves? If so, can you please add quotation marks. If not, can you please remove/reframe this concept.

• Lines 444 to 450 do not belong in the results section altogether, and the key points should only remain in the introduction. I recommend to remove altogether and keep the focus to the findings of this particular study.

• Lines 470 to 472 – I recommend to rephrase these lines. Currently, this reads as your perception rather than a reflection of participants voices and experiences.

• Unit of meaning 4 – this title includes non-person first language. Can this please be amended.

• Unit of meaning 4 does not appear to have a well-bounded message or narrative. The points within feel quite distinct from one another at times, and they do not always relate to the overarching title given to the theme. I think this theme needs a reworking entirely to reclarify what the key messages are, and refocused the text to make those clearer.

• Overall, the themes are extremely long which makes it difficult at times to follow the key points – they can get lost in the length of text. Can you review the themes and identify where things could be cut down or made more concise? For example, when a message is communicated, you often include many examples and quotations, and this many are not always necessary to support and evidence the message communicated. You could look to cut down these areas. In addition, much of the themes feels like a reproduction of the contributing interviews, rather than a summative/themed narrative cutting across the interviews, thus contributing to the length of the themes and the dilution of the messages within.

• A key aim of the paper was to compare the differences in experiences of younger and older women, but from how the results are presented (i.e., experiences of each group intertwined throughout, without much comparative analytical commentary) it is not possible to do this. Have you considered separately the results in each theme by younger and older to make clearer distinctions ofaz these experiences?

Discussion

• Lines 561-562. In the introduction, the aim is framed to compare younger and older women, rather than to focused explicitly on the experiences of older women as it is framed in this line. Can you please amend this line to be consistent?

• Paragraph 2 (lines 576 to 589) mostly represents the findings of the study, and there is limited comparison to other available literature. It is also a little to strong to claim this finding to be ‘novel’ due to perceived strength of messaging, and I recommend softening the tone here. In addition, the end of the paragraph lacks cited literature to support the statements made (i.e., lines 586-589). The language/grammar would benefit from reviewing in this area too.

• Consistently throughout the discussion, the paragraphs tend to reproduce the findings of the study, with very limited contextualisation or comparison with the wider literature base.

• Lines 620 to 624 – this sentence is extremely long and hard to follow, and it also introduces several new, large points (e.g., Foucault’s notion of biopower). These concepts should be introduced in the introduction if they are to be discussed because, as currently written, this section does not give enough context or background information for the reader to fully conceptualise the messages intended.

• Paragraph on lines 620 to 634 does not seem to fit with the narrative of the entire manuscript, and the messages made feel extremely distinct and off-topic. I’m unclear how your findings compare to this and fit within these messages. In addition, in areas, it reads to have been influenced by opinions rather than a balanced discussion of this complex area. For example, the description of weight management to be “punitive” and “authoritarian” and aligned with assumptions that “those with a higher body weight lack knowledge and understanding about health practices, make poor choices, and refuse to take responsibility for their health and well-being”. If this section is to remain, it would require reworking to provide a scientifically critical and balanced discussion from multiple lens.

• Line 631 – we do not tend to gender the authors of literature we are citing as we cannot assume one’s gender. Can you please review this throughout the manuscript.

• The manuscript lacks a section highlighting the limitations of the study. Please review and add this to the manuscript. This should include (among others) – the impact of researcher positionality and the recall bias due to the long time span between the surgeries of participants.

Conclusion

• Lines 679-682, and lines 686-687. Insufficient comparison between the groups has been presented through the manuscript as currently written to make a clear conclusion about the differences in experiences. I would recommend reworking the results section to make this potentially possible to conclude, or remove these conclusions.

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2023 Jul 27;18(7):e0287822. doi: 10.1371/journal.pone.0287822.r002

Author response to Decision Letter 0


9 Feb 2023

Dear Editor Professor Dra. Emily Chenette:

We are pleased to re-submit the revised version of the manuscript “If the weight is gone, is the stigma also gone? A qualitative study of the perceptions and experiences of Brazilian older and younger women who underwent bariatric surgery”. We highlight that after the reviewers’ comments, the title has changed to “A qualitative study of Brazilian women’s perceptions and experiences of weight stigma after bariatric surgery”, as suggested. We have extensively revised the manuscript according to the suggestions made by the referee and the editor. An item-by-item response is presented below. All changes in the manuscript are highlighted with tracked changes. We hope that these changes will meet with your approval.

- Editor:

Article formatting

Editor comment: Please ensure that your manuscript meets PLOS ONE’s style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: We have formatted the manuscript accordingly.

Methods

Editor comment: Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified whether: 1) whether the ethics committee approved the verbal/oral consent procedure, 2) why written consent could not be obtained, and 3) how verbal/oral consent was recorded. If your study included minors, please state whether you obtained consent from parents or guardians in these cases. If the need for consent was waived by the ethics committee, please include this information.

Response: We have clarified these aspects in the Methods section and in the online submission information. Regarding the question about why written consent could not be obtained, we conducted the research during the pandemic, and therefore, the interviews were conducted remotely via WhatsApp video calls. Asking the participants for a written consent could be demanding for them, and possibly, excluding. For example, as they would have to print, then scan the signed document and finally send to Author 1, some of them, especially the older women, could have difficulty to do so. Thus, we understood that both oral consent and digitally recorded informed consent would provide access to all participants.

Data availability

Editor comment: In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study’s minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

“Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

Response: We have included or data set, which is available in a public repository from the University of São Paulo, available at: https://repositorio.uspdigital.usp.br/handle/item/399

General comments

Editor comment: The manuscript focuses on a relevant area for research and their results are relevant. There are, however, some flaws that must be corrected. Special attention must be directed to Reviewer #2 comments on the use of stigmatizing language and the “visual analysis” mentioned in lines #208-2015. Methodology section should be improved, including Reviewer #1 recommendation of better description of the characteristics of healthcare and follow up of study participants. The text also requires extensive rewriting to achieve appropriate standards of readability.

Response: We have addressed the aspects mentioned and they are fully addressed in the responses below.

- Reviewer’s Responses to Questions

Comments to the Author

Reviewers’ comments: 1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Response: We have extensively reviewed the manuscript to address these matters.

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

Response: We have included or data set, which is available in a public repository from the University of São Paulo, available at: https://repositorio.uspdigital.usp.br/handle/item/399

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Response: The manuscript was submitted to an extensive English revision by native English speakers.

- Reviewer 1

Introduction

Reviewer comment: Line 72-72 – “In Brazil, bariatric procedures have been available at no cost to patients since 1999 73 through the Unified Public Health System or the Sistema Único de Saúde [10]” but even so, it is necessary to consider how is the access to this intervention, as the demand for the procedure is certainly very high. Clarify regional differences and the issue of equity.

Response: We have addressed these aspects in the Introduction section.

Methods

Reviewer comment: The authors inform that patients being followed by the Bariatric Surgery Outpatient Clinics of HCFMUSP. Describe better how women get there, referral criteria and how they are followed up, how often and for how long is the follow-up, before/after surgery, and by which professionals.

Response: We have these aspects in the Methods section.

Methods

Reviewer comment: The script used for the interviews was not presented, which guiding questions and the previous experience of the researcher (Author1) was not clarified for carrying out both the interviews and data analysis - this aspect is very relevant for the quality of qualitative research.

Response: In the reviewed version of the manuscript, we included the script that guided the interviews (Supporting Information 1). Also, in the Methods section, we included the previous experience and training of Author 1 regarding conducted individual interviews.

Results

Reviewer comment: On Table 1, complete your title indicating location/year. And explain how this information on the women’s characteristics was obtained, whether directly with the women or clinic provided, from a medical record.

Response: We completed the title indicating location and year. The information on the women’s characteristics was obtained directly with the participants, during the individual interviews. We added this information in the Results section. These questions can be seen in the script that guided the interviews, submitted as a Supplementary Material.

Discussion

Reviewer comment: In the lines 650-651 the authors indicate “Although our participants also had pre-operative support groups, this support may have been insufficient to combat stressful social messaging.” This suggests that there is no further follow-up, but the women were recruited at this service after the surgery.

Response: We have clarified this aspect in the Discussion section.

- Reviewer 2

General

Reviewer comment: Can you explain if and how you included patient and public involvement in this work? For example, what stages were they involved and what activities/input did they have.

Response: Participants were patients who underwent bariatric surgery at Hospital das Clínicas of the School of Medicine, University of São Paulo. Their involvement with the research included the individual semi-structured interviews. They were contacted by Author 1 and, if they agreed to participate, the interview was scheduled. These procedures are extensively described in the Methods section.

General

Reviewer comment: Throughout the manuscript, there are quantifying words or sentences for example: ‘For all participants’ or ‘Some of the women’. Please delete the quantifying words.

Response: These changes were made accordingly.

General

Reviewer comment: The manuscript would benefit greatly from a review of the grammar/scientific writing.

Response: The manuscript was submitted to an extensive English revision by native English speakers.

Title

Reviewer comment: The title would stand alone better, be more grammatically correct, and be clearer without the question. For example, as “A qualitative study of Brazilian women’s’ perceptions and experiences of weight stigma after bariatric surgery”. I echo the same point for the short title. Perhaps a reframe to “A qualitative study of stigma after bariatric surgery”.

Response: The changes in the Title were made accordingly.

Abstract

Reviewer comment: Can you please reframe the following into a research aim/objective (rather than a question): “However, how do bariatric patients perceive and internalize this stigma in different life stages? Specifically, is older age a risk factor?”. The current framing is a little too colloquial. Can you explicitly state the method of data analysis used? E.g., was it thematic analysis or something different? The abstract is missing a conclusion. Can you please add a sentence concluding your findings, and perhaps suggesting how the findings may be used in the future? You could make your results more concise if you need more word count to allow this.

Response: The changes in the Abstract were made accordingly.

Introduction

Reviewer comment: Can the tone of the following sentence be softened: “all of which induce severe weight loss through the surgical reduction of the stomach and/or intestines”. For example, to “all of which aim to induce severe weight loss through the surgical reduction of the stomach and/or intestines”

Response: The change was made accordingly.

Introduction

Reviewer comment: Please add references to support: “Bariatric patients often present for surgery with a history of complex anxieties and negative social experiences stemming from weight-related stigma.”

Response: We added the following references: 1) da Silva SSP and da Costa Maia  (2012) Obesity and treatment meanings in bariatric surgery candidates: a qualitative study. Obesity surgery 22(11), 1714-1722. https://doi.org/10.1007/s11695-012-0716-y; 2) Trainer S, Brewis, A and Wutich A (2017) Not ‘taking the easy way out’: reframing bariatric surgery from low-effort weight loss to hard work. Anthropology & Medicine 24(1), 96-110. https://doi.org/10.1080/13648470.2016.1249339; 3) Hansen, B and Dye, MH (2018) Damned if You Do, Damned if You Don’t: The Stigma of Weight Loss Surgery, Deviant Behavior, 39:2, 137-147, DOI: 10.1080/01639625.2016.1263081

Introduction

Reviewer comment: The word ‘deviant’ isn’t necessary to the message in the sentence on line 82 in the second paragraph of the introduction – can you please remove.

Response: The change was made accordingly.

Introduction

Reviewer comment: In the definition of weight stigma by Brewis, stigmatising language itself is used (“being overweight or obese”). Can you please reframe this to move away from this language and use person-first language instead?

Response: This was a direct citation of the term that the Brewis used. Nonetheless, we understand the need to change, and we have done such change as the following: “Following Brewis [16] we define weight stigma as moral discrediting that people experience from others or apply to themselves because of the negative social meanings attached to the size of bodies”.

Introduction

Reviewer comment: In the introduction (and manuscript) you move between using the term weight stigma and weight-related stigma. Can you please amend the manuscript so you use consistent language throughout?

Response: The change was made accordingly and used the term “weight stigma” throughout the manuscript.

Introduction

Reviewer comment: In the introduction, you use the stigmatising language of “fat”. Can you please address this throughout the manuscript to use person-first language?

Response: The change was made accordingly. We just kept the word “fat” throughout the manuscript when it was an emic word or when referring to authors that employed this word.

Introduction

Reviewer comment: The introduction is very lengthy and consistently takes multiple paragraphs to make a point that could be made more clearly in one paragraph. Could you please review the introduction to see where content could be made more concise, and therefore clearer for the reader to follow?

Response: The change was made accordingly.

Introduction

Reviewer comment: Can you soften the tone in the following sentence: “Weight loss induced by surgical intervention is so rapid that it produces a great deal of excess skin and it also begins at the “ends,” i.e., people tend to lose weight in their heads, arms, and legs before they lose it in their torsos”. For example, to: “Weight loss induced by surgical intervention is so rapid that it often produces a great deal of excess skin. Furthermore, people tend to lose weight in their heads, arms, and legs before they lose it in their torsos, influencing their body shape and size”.

Response: The change was made accordingly.

Introduction

Reviewer comment: Despite the length of the introduction, it does not note the potential implications of addressing the research aim. For example, how will this inform public health?

Response: The change was made accordingly.

Methods

Reviewer comment: Can you please move the ethical approval statement to the start of the methods section?

Response: The change was made accordingly.

Methods

Reviewer comment: Overall, there is a great lack of detail in the data analysis section. Please review and add more detail here to aid the reader to thoroughly understand what you have done with enough detail for them to replicate the processes. For example: You note participants who fit the ‘proposed profile’ were invited to interview - what is the proposed profile? What sampling method did you use? Did you use purposeful sampling, snowball, opportunist? How were the interviews transcribed? Was this by an external company or by the lead author?

Response: The change was made accordingly.

Methods

Reviewer comment: You note in the data collection section that “This two-encounters approach proved to be quite effective in obtaining data and resulted in the chance to complete the interview protocol in a way that was practical and feasible for the participants’ schedules”. I’m unclear how conducting two interviews would be more practical and feasible for someone’s schedule than conducting one interview – can you explain? Also, “proved to be quite effective in obtaining data” is very unclear and non-specific. I’m not sure the value this sentence brings or the message you are trying to communicate.

Response: Our interviews were long, lasting an average of three hours or more. When engaging with the participants, Author 1 exposed the estimate time of the interview and the participants asked to have the interview divided in two encounters, and sometimes, a third encounter was necessary. This was because it was much more feasible to them to provide Author 1 two (or three) shorter encounters than one longer single encounter. In that sense, if we insisted on having the interview in one single encounter, most of the participants could feel discouraged to participate. Therefore, this is what we meant by this proving “to be quite effective in obtaining data”.

Methods

Reviewer comment: You state that “Notably, the time gap between the first and second interviews led to increased reflexivity among the participants and the researcher, who reviewed the recording of the first encounter to note gaps that needed to be covered in the second.” Reflexivity is the acknowledgement of your role and influence on the research process, so it does not make sense in this sentence. Perhaps you were meaning data quality? I’d also suggest softening the tone of many of these sentences. You cannot be certain that the time gap you had led to increased (presumably) data quality, but you could say that was the aim/purpose of the time gap.

Response: The change was made accordingly.

Methods

Reviewer comment: I strongly oppose to many of the messages from line 208 to 215, and feel the messages themselves exacerbate the stigmatisation of those living with overweight or obesity. If you are analysing participants experiences (e.g., feeling like they had not lost enough weight), then it is not your role and it is inappropriate to say that you must visually assess/observe their bodies to validate this. Furthermore, the notation of having to “rely on her description” is highly problematic. If you are analysing someone’s experiences, then the analysis and resultant publication should be aiming to represent the voices of the participant, not your assessment as to whether these experiences are reliable. Please remove this paragraph.

Response: We removed this paragraph.

Methods

Reviewer comment: Lines 227 to 229 are hard to follow – can you please rephrase?

Response: We removed this paragraph.

Methods

Reviewer comment: In lines 228-229, you note themes as emerging as significant. These is vast amounts of literature noting themes as “emergent” to be problematic as it suggests that the themes always existed within the data, and voids the influence of our positionality as the researcher on the process. Can you please review this throughout the manuscript to remove this concept?

Response: We reviewed the manuscript and removed this concept as requested. Also, we clarified about the development of themes in the Data Analysis subsection.

Methods

Reviewer comment: In lines 231-233, you state that you identified excerpts of interviews relevant to the themes of interest, but you have not explained the process of theme development at this stage. How did you develop the themes of interest?

Response: We have clarified the data analysis, as well as the development of themes. It is in the Data Analysis subsection.

Methods

Reviewer comment: You have not described how the interview schedule was produced or referenced to a copy of the interview schedule in the supplements. Please add these details.

Response: We have included a copy of the interview schedule in the Supporting Information. We clarify that we are presenting both the interview script and schedule as Supporting Informations.

Methods

Reviewer comment: There lacks a section on the researcher positionality and how they managed the impact of this through reflexivity. Please can the authors address this.

Response: We have addressed these aspects accordingly at the end of Discussion section.

Results

Reviewer comment: In Table 1, please remove the percent and standard deviation. These are not generally used in qualitative studies.

Response: We removed the percent and standard deviation from Table 1 accordingly.

Results

Reviewer comment: You presented quotations in multiple languages, but have not noted this translation process in the methods section. Please add this information.

Response: We have added this information accordingly.

Results

Reviewer comment: Throughout the results section, you state findings in affirmative language – for example, “she asked if this man had…”. A better/more accurate way of describing the findings is to include acknowledgement of the interpretation of their accounts by including prefaces – for example, such as “the participant described/expressed that she asked the man...”. It would strengthen the manuscript to review and revise these areas.

Response: We have reviewed and revised these areas accordingly.

Results

Reviewer comment: The final lines of the first theme (lines 314 to 317) don’t seem to fit with the narrative of the rest of the theme. Can you please review and either remove or clarify their fit with the narrative?

Response: We have removed these lines.

Results

Reviewer comment: Line 323 – are these self-appointed by the participant or by their peers?

Response: The comments were expressed by other people. We changed the text to clarify the message.

Results

Reviewer comment: Between lines 329 to 335, you describe others having concerns over the participants health. Could you please include a supporting quotation here?

Response: We included supporting quotations in this paragraph.

Results

Reviewer comment: On lines 348 to 350, you introduce new literature within the results section. You shouldn’t incorporate other literature in this section so could you remove and rephrase this section. For example, you could simply say “Participants who described experiencing small weight regain after weight loss described being reprimanded by others”.

Response: We removed citation and made the change in the paragraph as suggested.

Results

Reviewer comment: Line 360 – is “melt off” a quote from a participant or your own writing? If a quote, can quotations marks please be added. If it is your own writing, can it be rephrased to be more in line with the language and writing style of the piece.

Response: The use of the word “melt off” was a choice of the Authors. Nonetheless, we agree that it was not in line with the language and writing style of the manuscript and have changed it accordingly.

Results

Reviewer comment: Again in lines 366 to 370, you introduce new literature and compare findings to existing evidence. Please remove this from the results. This is repeated in areas throughout the results section – can you please review this throughout.

Response: We removed lines 366 to 370 from the results and revised the entire section to remove other citations that were previously included.

Results

Reviewer comment: Lines 391 to 392 begin to discuss the results, rather than present the results. Can you please move this to the discussion or remove?

Response: We removed lines 391 to 392 as requested.

Results

Reviewer comment: Line 393 “aggressive” and line 396 “mad”– were these words used by the participants or is this your own language choice?

Response: We changed these lines to clarify that these words were used by the participants.

Results

Reviewer comment: Line 400 to 401 – did participants say that the advice was not backed up by evidence, or is this your own commentary? If the latter, please move to the discussion or remove.

Response: We removed lines 400 to 401 as requested.

Results

Reviewer comment: Line 423 – did the participant describe the foods as “fattening foods” themselves? If so, can you please add quotation marks. If not, can you please remove/reframe this concept.

Response: We have clarified line 423 to show that this was how the participants described the foods and included a supporting quotation.

Results

Reviewer comment: Lines 444 to 450 do not belong in the results section altogether, and the key points should only remain in the introduction. I recommend to remove altogether and keep the focus to the findings of this particular study.

Response: We removed lines 444 to 450 as requested.

Results

Reviewer comment: Lines 470 to 472 – I recommend to rephrase these lines. Currently, this reads as your perception rather than a reflection of participants voices and experiences.

Response: We have removed lines 470 to 472 as requested.

Results

Reviewer comment: Unit of meaning 4 – this title includes non-person first language. Can this please be amended.

Response: We have included person-first language, except when the participant herself voiced a non-person first language, such as “fat” (in Brazilian Portuguese, “gorda”).

Results

Reviewer comment: Unit of meaning 4 does not appear to have a well-bounded message or narrative. The points within feel quite distinct from one another at times, and they do not always relate to the overarching title given to the theme. I think this theme needs a reworking entirely to reclarify what the key messages are, and refocused the text to make those clearer.

Response: We have reworked on this theme and changed its title to clarify the message.

Results

Reviewer comment: Overall, the themes are extremely long which makes it difficult at times to follow the key points – they can get lost in the length of text. Can you review the themes and identify where things could be cut down or made more concise? For example, when a message is communicated, you often include many examples and quotations, and this many are not always necessary to support and evidence the message communicated. You could look to cut down these areas. In addition, much of the themes feels like a reproduction of the contributing interviews, rather than a summative/themed narrative cutting across the interviews, thus contributing to the length of the themes and the dilution of the messages within.

Response: We have extensively revised the Results section, cut down some information and made it more concise.

Results

Reviewer comment: A key aim of the paper was to compare the differences in experiences of younger and older women, but from how the results are presented (i.e., experiences of each group intertwined throughout, without much comparative analytical commentary) it is not possible to do this. Have you considered separately the results in each theme by younger and older to make clearer distinctions of these experiences?

Response: As suggested, we have separated the results in each theme by: 1) Common experiences among the younger and older participants and; 2) The experiences of the older participants.

Discussion

Reviewer comment: Lines 561-562. In the introduction, the aim is framed to compare younger and older women, rather than to focused explicitly on the experiences of older women as it is framed in this line. Can you please amend this line to be consistent?

Response: The change was made accordingly.

Discussion

Reviewer comment: Paragraph 2 (lines 576 to 589) mostly represents the findings of the study, and there is limited comparison to other available literature. It is also a little to strong to claim this finding to be ‘novel’ due to perceived strength of messaging, and I recommend softening the tone here. In addition, the end of the paragraph lacks cited literature to support the statements made (i.e., lines 586-589). The language/grammar would benefit from reviewing in this area too.

Response: We have expanded the comparison to other available literature in Paragraph 2 and softened the tone regarding the novel finding. Finally, the manuscript was submitted to an extensive English revision by native English speakers.

Discussion

Reviewer comment: Consistently throughout the discussion, the paragraphs tend to reproduce the findings of the study, with very limited contextualisation or comparison with the wider literature base.

Response: We revisited the Discussion and made extensive changes, as well as included more contextualization or comparison with the wider literature base.

Discussion

Reviewer comment: Lines 620 to 624 – this sentence is extremely long and hard to follow, and it also introduces several new, large points (e.g., Foucault’s notion of biopower). These concepts should be introduced in the introduction if they are to be discussed because, as currently written, this section does not give enough context or background information for the reader to fully conceptualise the messages intended.

Response: To attend the following comment of the Reviewer, we have removed Lines 620 to 634.

Discussion

Reviewer comment: Paragraph on lines 620 to 634 does not seem to fit with the narrative of the entire manuscript, and the messages made feel extremely distinct and off-topic. I’m unclear how your findings compare to this and fit within these messages. In addition, in areas, it reads to have been influenced by opinions rather than a balanced discussion of this complex area. For example, the description of weight management to be “punitive” and “authoritarian” and aligned with assumptions that “those with a higher body weight lack knowledge and understanding about health practices, make poor choices, and refuse to take responsibility for their health and well-being”. If this section is to remain, it would require reworking to provide a scientifically critical and balanced discussion from multiple lens.

Response: We have removed Lines 620 to 634.

Discussion

Reviewer comment: Line 631 – we do not tend to gender the authors of literature we are citing as we cannot assume one’s gender. Can you please review this throughout the manuscript.

Response: We believe it is essential to point out that all the authors who sign this article stand out for investigating the different social markers of difference, including gender and sexuality, from an intersectional perspective. In this sense, the assumption of a particular gender is far from our perspective. If we de-gender an author, we would use the pronouns he and him, which are already gendered. Therefore, we decided to continue to refer to the authors as they refer to themselves as a gender through their productions and first names. We believe that de-gendering authors, without their consent, could become a lack of respect for their gender ascriptions.

Discussion

Reviewer comment: The manuscript lacks a section highlighting the limitations of the study. Please review and add this to the manuscript. This should include (among others) – the impact of researcher positionality and the recall bias due to the long time span between the surgeries of participants.

Response: We have included a section highlighting the limitations of the study as requested.

Conclusion

Reviewer comment: Lines 679-682, and lines 686-687. Insufficient comparison between the groups has been presented through the manuscript as currently written to make a clear conclusion about the differences in experiences. I would recommend reworking the results section to make this potentially possible to conclude, or remove these conclusions.

Response: We changed the focus of the article to do a description of older and younger women after bariatric surgery. We also have separated the results in each theme by younger and older to make clearer distinctions of these experiences (as highlighted in a response above). With these changes, we believe that the Conclusion is now sufficient support the data presented.

We thank you again for the valuable contributions of the reviewer and yourself and for the opportunity to submit our manuscript for your consideration.

Kind regards,

The authors.

Attachment

Submitted filename: Response to Reviewers.docx

Decision Letter 1

Vidanka Vasilevski

9 May 2023

PONE-D-22-24534R1A qualitative study of Brazilian women’s perceptions and experiences of weight stigma after bariatric surgeryPLOS ONE

Dear Dr. Dimitrov Ulian,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

The revisions to the study have improved the quality of the paper, however there remain a few minor readibility issues that need to be rectified prior to publication.

Some references need to be added/edited in the introduction section.

The full paper requires English language editing, engaging an editing service may support this. There are many long and complex sentences that need refining also.

In the research setting and study population section, the eligibility criteria includes gendered language (i.e., her). I assume men and women would be eligible for bariatric surgery, therefore referring to 'her' only is not appropriate.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #2: (No Response)

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Reviewer #2: Yes

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Reviewer #2: N/A

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: Thank you for your responses to my comments - the article is reading much better. To note - your responses should direct the reviewer to the page and line numbers where the edits in text have been made and, if possible, provide the edited text within your response also. It makes the process of peer review substantially more time consuming and difficult to not be given direction or detail within responses.

Original reviewer comment: Can you explain if and how you included patient and public involvement in this work? For example, what stages were they involved and what activities/input did they have.

Author response: Participants were patients who underwent bariatric surgery at Hospital das Clínicas of the School of Medicine, University of São Paulo. Their involvement with the research included the individual semi-structured interviews. They were contacted by Author 1 and, if they agreed to participate, the interview was scheduled. These procedures are extensively described in the Methods section.

Reviewer response: Patient and public involvement (PPI) is an active partnership between members of the public and researchers, where the public are involved in aspects of the study/research (such as informing the study design, supporting with analysis). The participants of the study do not count as PPI. You can read more about this on: https://www.rds-sc.nihr.ac.uk/ppi-information-resources/ Can you please provide a response given this explanation of PPI.

Original reviewer comment: Can you please reframe the following into a research aim/objective (rather than a question): “However, how do bariatric patients perceive and internalize this stigma in different life stages? Specifically, is older age a risk factor?”. The current framing is a little too colloquial. Can you explicitly state the method of data analysis used? E.g., was it thematic analysis or something different? The abstract is missing a conclusion. Can you please add a sentence concluding your findings, and perhaps suggesting how the findings may be used in the future? You could make your results more concise if you need more word count to allow this.

Author response: The changes in the Abstract were made accordingly.

Reviewer response: You have not added the method of data analysis used to the abstract – please address this. The conclusion added goes beyond what your findings can support, and should be softened in tone to be more appropriate to the levels of findings. Specifically, the findings do not inform a targeted approach, however they might suggest future research should explore whether a targeted approach might be more effective.

Original reviewer comment: In the introduction, you use the stigmatising language of “fat”. Can you please address this throughout the manuscript to use person-first language?

Author response: The change was made accordingly. We just kept the word “fat throughout the manuscript when it was an emic word or when referring to authors that employed this word.

Reviewer response: Can you please edit the text to have quotation marks (or something similar) to make it clear to the reader than the remaining use of the word ‘fat’ is not your words, but quoting participants etc.

Original reviewer comment: Line 631 – we do not tend to gender the authors of literature we are citing as we cannot assume one’s gender. Can you please review this throughout the manuscript.

Authors response: We believe it is essential to point out that all the authors who sign this article stand out for investigating the different social markers of difference, including gender and sexuality, from an intersectional perspective. In this sense, the assumption of a particular gender is far from our perspective. If we de-gender an author, we would use the pronouns he and him, which are already gendered. Therefore, we decided to continue to refer to the authors as they refer to themselves as a gender through their productions and first names. We believe that de-gendering authors, without their consent, could become a lack of respect for their gender ascriptions.

Reviewer response: From viewing the submitted manuscript, I see that this section has now been deleted. Regardless, it is important to clarify this point. Not assuming gender wouldn’t ever result in the automatic use of he/him – if pronouns were ever essential to be used, the pronouns used generally are they/them when not assuming gender. In addition, you cannot be sure of a person’s gender from their first name – this bears no reflection of gender. I’m unsure what the authors mean when they say ‘their productions’. Generally, ‘the authors found’ or ‘the study found’ is used instead of gendered terms – this is the practice you have used elsewhere in this article.

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Reviewer #2: Yes: Dr Rebecca A Jones

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Attachment

Submitted filename: Stigma qual review (R2). docx.docx

PLoS One. 2023 Jul 27;18(7):e0287822. doi: 10.1371/journal.pone.0287822.r004

Author response to Decision Letter 1


13 Jun 2023

Dear Editor Professor Dr. Emily Chenette:

We are pleased to re-submit the revised version of the manuscript “Weight stigma after bariatric surgery: A qualitative study with Brazilian women”, as suggested. We have extensively revised the manuscript according to the suggestions made by the referee and the editor. An item-by-item response is presented below. All changes in the manuscript are highlighted with tracked changes. We hope that these changes will meet with your approval.

- Editor:

Introduction

Editor comment: Some references need to be added/edited in the introduction section.

Response: We have corrected the references accordingly.

Methods

Editor comment: In the research setting and study population section, the eligibility criteria includes gendered language (i.e., her). I assume men and women would be eligible for bariatric surgery, therefore referring to ‘her’ only is not appropriate.

Response: We have changed that as requested (page 7, lines 181, 182).

General comment

The full paper requires English language editing, engaging an editing service may support this. There are many long and complex sentences that need refining also.

Response: Three native English speakers have revised independently the text to address these questions. The changes regarding English language editing were not highlighted throughout the manuscript.

- Reviewer 1

Abstract

Original reviewer comment (R1): Can you please reframe the following into a research aim/objective (rather than a question): “However, how do bariatric patients perceive and internalize this stigma in different life stages? Specifically, is older age a risk factor?”. The current framing is a little too colloquial. Can you explicitly state the method of data analysis used? E.g., was it thematic analysis or something different? The abstract is missing a conclusion. Can you please add a sentence concluding your findings, and perhaps suggesting how the findings may be used in the future? You could make your results more concise if you need more word count to allow this.

Author response (R1): The changes in the Abstract were made accordingly.

Reviewer response (R2): You have not added the method of data analysis used to the abstract – please address this. The conclusion added goes beyond what your findings can support, and should be softened in tone to be more appropriate to the levels of findings. Specifically, the findings do not inform a targeted approach, however they might suggest future research should explore whether a targeted approach might be more effective.

Response (R2): The method of data analysis was informed as the following (page 2 lines 42-43): “The resulting text was then analyzed using thematic analysis”. To clarify, thematic analysis was the method used for data analysis. Regarding the conclusions, we have changed as suggested. In the previous version, it was as the following: “Our study can thus inform a more targeted approach to care for different cohorts who undergo bariatric surgery, an approach that would emphasize the importance of developing coping strategies with respect to experiences of stigma and discrimination after surgery”. We have changed in the revised version of the manuscript to (page 2, lines 53-56): “Our study suggest future research should explore whether a targeted approach might be more effective, for example, an approach that would emphasize the importance of developing coping strategies with respect to experiences of stigma and discrimination after surgery.” We have also added this information in other sections of the manuscript (i.e., at the end of Introduction and at the end of Conclusions).

Introduction

Original reviewer comment (R1): In the introduction, you use the stigmatising language of “fat”. Can you please address this throughout the manuscript to use person-first language?

Author response (R1): The change was made accordingly. We just kept the word “fat throughout the manuscript when it was an emic word or when referring to authors that employed this word.

Reviewer response (R2): Can you please edit the text to have quotation marks (or something similar) to make it clear to the reader than the remaining use of the word ‘fat’ is not your words, but quoting participants etc.

Response (R2): We have added quotation marks to make it clear to the reader that the remaining use of the word ‘fat’ is not our words, but quoting participants or authors that employed this word.

Methods

Original reviewer comment (R1): Can you explain if and how you included patient and public involvement in this work? For example, what stages were they involved and what activities/input did they have.

Author response (R1): Participants were patients who underwent bariatric surgery at Hospital das Clínicas of the School of Medicine, University of São Paulo. Their involvement with the research included the individual semi-structured interviews. They were contacted by Author 1 and, if they agreed to participate, the interview was scheduled. These procedures are extensively described in the Methods section.

Reviewer response (R2): Patient and public involvement (PPI) is an active partnership between members of the public and researchers, where the public are involved in aspects of the study/research (such as informing the study design, supporting with analysis). The participants of the study do not count as PPI. You can read more about this on: https://www.rds-sc.nihr.ac.uk/ppi-information-resources/ Can you please provide a response given this explanation of PPI.

Response (R2): Thank you for your comment. We have not understood that this was the aim of your question, we apologize for that. We have clarified the Patient and Public involvement as the following (novel information is in bold), in the Methods section (page 8, lines 208-212): “In the initial contact, Author 1 introduced herself, explained why she was contacting them, the purpose of the research, and clarified that if they agreed to participate, the participation would be voluntary, and the findings would be kept confidential. This study does not qualify as Patient and Public Involvement (PPI) research, because PPI refers to an active partnership between members of the public and researchers, in which members of the public work alongside the research team and are actively involved in contributing to the research process as advisers and possibly as co-researchers. This did not happen in our study (NIHR, 2023).

General comment

Original reviewer comment (R1): Line 631 – we do not tend to gender the authors of literature we are citing as we cannot assume one’s gender. Can you please review this throughout the manuscript.

Authors response (R1): We believe it is essential to point out that all the authors who sign this article stand out for investigating the different social markers of difference, including gender and sexuality, from an intersectional perspective. In this sense, the assumption of a particular gender is far from our perspective. If we de-gender an author, we would use the pronouns he and him, which are already gendered. Therefore, we decided to continue to refer to the authors as they refer to themselves as a gender through their productions and first names. We believe that de-gendering authors, without their consent, could become a lack of respect for their gender ascriptions.

Reviewer response (R2): From viewing the submitted manuscript, I see that this section has now been deleted. Regardless, it is important to clarify this point. Not assuming gender wouldn’t ever result in the automatic use of he/him – if pronouns were ever essential to be used, the pronouns used within English written language are they/them when not assuming gender. In addition, you cannot be sure of a person’s gender from their first name – this bears no reflection of gender. I’m unsure what the authors mean when they say ‘their productions’. Generally, ‘the authors found’ or ‘the study found’ is used instead of gendered terms – this is the practice you have used elsewhere in this article.

Response (R2): We thank you for your clarification. If the section was in the manuscript, we would certainly change it according to your recommendations.

We thank you again for the valuable contributions of the reviewer and yourself and for the opportunity to submit our manuscript for your consideration.

Kind regards,

The authors.

Attachment

Submitted filename: Response to reviewers (R2) 13.06.23.docx

Decision Letter 2

Vidanka Vasilevski

15 Jun 2023

Weight stigma after bariatric surgery: A qualitative study with Brazilian women.

PONE-D-22-24534R2

Dear Dr. Dimitrov Ulian,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Vidanka Vasilevski

Academic Editor

PLOS ONE

Additional Editor Comments:

Rather than returning the paper for minor revision, I decided to accept the paper and ask you to make one minor change once you get to the copy edit stage. The first sentence in the introduction does not make sense: 

"One of the most effective means currently available to individuals seeking to lose weight deemed medically excessive is bariatric surgery." 

I believe the term excessive in the above sentence may need to be replaced with necessary?

Can you please rectify this when you review the copy edit of your paper prior to submission.

Acceptance letter

Vidanka Vasilevski

19 Jul 2023

PONE-D-22-24534R2

Weight stigma after bariatric surgery: A qualitative study with Brazilian women.

Dear Dr. Dimitrov Ulian:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Vidanka Vasilevski

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 File. Script of the semi-structured interviews.

    In this supporting material we present the script that guided the semi-structured interviews.

    (DOCX)

    S2 File. Schedule of the individual semi-structured interviews.

    In this supporting material we present the schedule of the individual semi-structured interviews.

    (XLSX)

    Attachment

    Submitted filename: Response to Reviewers.docx

    Attachment

    Submitted filename: Stigma qual review (R2). docx.docx

    Attachment

    Submitted filename: Response to reviewers (R2) 13.06.23.docx

    Data Availability Statement

    The data relevant to this paper are available from figshare, https://doi.org/10.6084/m9.figshare.23556324.v1.


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