Public perception of bariatric surgery

Abstract

Objective
To investigate the public perception of morbid obesity and bariatric surgery in Saudi Arabia.

Methods
A cross-sectional study was conducted between November 2016 and November 2017 in Jeddah, Saudi Arabia, including Saudis aged ≥18 years. Medical students, physicians, and individuals who underwent bariatric surgery were excluded. Participants were interviewed using a new, validated questionnaire.

Results
We interviewed 1,129 individuals of whom 744 (65.9%) were women. The educational level of most was a bachelor’s degree. Most participants (97.7%) acknowledged the association between obesity and comorbidities. Approximately 22.7% of the participants were unaware of the bariatric surgery procedure. Approximately 18.9% considered it to be a cosmetic procedure. Approximately 50% were unaware of the correct indications for bariatric surgery, and 41.2% were unwilling to seek a bariatric surgeon’s help if diagnosed with morbid obesity. These results were correlated with the participants’ education level.

Conclusion
Our study shows that the public perception of obesity and bariatric surgery in Saudi Arabia is limited. Effective interagency coordination between surgeons, health educators, and other health care providers is required to improve public awareness.

Full text

Public perception of bariatric surgery
Abdulmalik Altaf, FRCSC, DABS, Mohammad M. Abbas, MBBS.
378
ABSTRACT
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Objective: To investigate the public perception of morbid
obesity and bariatric surgery in Saudi Arabia.
Methods: A cross-sectional study was conducted
between November 2016 and November 2017 in
Jeddah, Saudi Arabia, including Saudis aged ≥18 years.
Medical students, physicians, and individuals who
underwent bariatric surgery were excluded. Participants
were interviewed using a new, validated questionnaire.
Results: We interviewed 1,129 individuals of whom
744 (65.9%) were women. e educational level of
most was a bachelor’s degree. Most participants (97.7%)
acknowledged the association between obesity and
comorbidities. Approximately 22.7% of the participants
were unaware of the bariatric surgery procedure.
Approximately 18.9% considered it to be a cosmetic
procedure. Approximately 50% were unaware of the
correct indications for bariatric surgery, and 41.2% were
unwilling to seek a bariatric surgeon’s help if diagnosed
with morbid obesity. ese results were correlated with
the participants’ education level.
Conclusion: Our study shows that the public perception
of obesity and bariatric surgery in Saudi Arabia is limited.
Effective interagency coordination between surgeons,
health educators, and other health care providers is
required to improve public awareness.
Saudi Med J 2019; Vol. 40 (4): 378-383
doi: 10.15537/smj.2019.4.24050
From the Department of Surgery, Faculty of Medicine, King Abdulaziz
University, Jeddah, Saudi Arabia.
Received 26th October 2018. Accepted 28th February 2019.
Address correspondence and reprint request to: Dr. Mohammad Abbas,
Department of Surgery, Faculty of Medicine, King Abdulaziz University,
Jeddah, Saudi Arabia. E-mail: m.abbas1992@gmail.com
ORCID ID: https://orcid.org/0000-0002-5414-7652
www.smj.org.sa Saudi Med J 2019; Vol. 40 (4)
OPEN ACCESS
Obesity is one of the leading causes of preventable
death.1 e World Health Organization (WHO)
uses body mass index (BMI) to classify the severity
of obesity.2 Morbid obesity is defined as a BMI of
40 kg/m2 or higher.2 Obesity has a major impact on
health and health care systems. According to the
WHO’s 2016 data, 1.9 billion individuals in the world
were overweight, and 650 million were obese. In Saudi
Arabia, a nationwide survey of 4,589 individuals in
2005 showed that 28.3% of males and 43.8% of females
were obese.3 In 2005, Saudi Arabia ranked 15th among
countries with the most obese individuals.4 According
to a study published in 2016, the predicted overall
obesity among individuals in Saudi Arabia was 52.9%:
67.5% in females and 38.2% in males.5 Morbid obesity

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Saudi Med J 2019; Vol. 40 (4) www.smj.org.sa
is associated with a number of serious comorbidities
including diseases of the cardiovascular system, diabetes,
and cancers, along with a financial burden on patients
and the health care system.6 e results of numerous
studies published in the last few decades indicated that
bariatric surgery is one of the best treatment options for
morbid obesity.7-9 e Swedish Obese Subjects (SOS)
trial, with a 20-year follow-up, proved that the most
effective long-term treatment method for morbid obesity
is bariatric surgery.10 Previous studies reported bariatric
surgery to be a safe option for the treatment of morbid
obesity with a relatively low complication rate.8,11-14 In
a multicenter study conducted in 2017, complication
rates were as low as 0.6%.11 e long-term sustainability
of weight loss demonstrated in these studies indicated
that bariatric surgery is a better alternative to other
methods of weight reduction that lack long-term
effectiveness.9,15-19 Studies in communities outside
Saudi Arabia have shown that the public’s perception
of bariatric surgery is not accurate.20 One study showed
that patients who underwent bariatric surgery are more
willing to adhere to a better lifestyle.20 According to
a study conducted in Germany, the public seemed
to be rather cautious regarding bariatric surgery.20
However, half of the studied population considered
bariatric surgery as a highly effective method for weight
reduction.20 Furthermore, individuals with a higher
level of education were more likely to consider bariatric
surgery as an option in that study.20 ere is a paucity
of studies that assess public perception of bariatric
surgery in Saudi Arabia. is present study aimed to
assess public perception and basic knowledge of morbid
obesity and obesity surgery in Saudi Arabia.
Methods. is cross-sectional study was conducted
between November 2016 and November 2017,
involving Saudi residents aged 18 and above, in Jeddah,
Saudi Arabia. Each participant was interviewed to
assess their knowledge of obesity and bariatric surgery
using a new questionnaire that was developed based
on previous studies.20,21 Data collectors personally
interviewed adults in the waiting areas of King
Abdulaziz University Hospital, Jeddah, Saudi Arabia.
e period of data collection started on November
2016 until October 2017. Participation was voluntary.
e sample size was determined based on prior
studies.20,21 e questionnaire’s face and content validity
were checked and critiqued by a group of experts. e
questionnaire was piloted on 20 subjects before it was
used in this study. e questionnaire was translated to
patients. e questionnaire had 3 parts: demographic
questions, knowledge about obesity, and knowledge
about obesity surgery. Questionnaire items included
questions on the definition of morbid obesity, health
effects of obesity, knowledge of bariatric surgery, the
most effective method to manage morbid obesity,
knowledge of the indications of morbid obesity, and the
perceived complication rate of bariatric surgery. Medical
students, physicians, and individuals who underwent
bariatric surgery were excluded from the study as their
prior medical knowledge regarding obesity and obesity
surgery might affect the results and cause bias.
We used PubMed database to identify related
articles. Ethical approval was obtained. e study
was conducted according to the principles of the
Declaration of Helsinki. e results were correlated
with the participants’ level of education.
e Statistical Package for Social Sciences (SPSS)
version 21 (SPSS Inc, Chicago, Illinois, USA) was used
to analyze the data. For categorical variables data were
represented as numbers and percentages. For continuous
variables data were presented as mean and standard
deviation. Chi-square test was performed to determine
the significant differences between variables; the
correlation between educational level and other variables
was established using the Spearman correlation. A
p-value of <0.05 was considered statistically significant.
Results. A total of 1,129 individuals were
interviewed based on the criteria of inclusion and
exclusion. e mean age of the participants was
35.19±13.16 years (range: 18-68 years). Of the 1,129
participants, 385 (34.1%) were males (Table 1). All
the interviewees were residents of Saudi Arabia. e
highest educational level was elementary school in
39 (3.5%) participants, middle school in 3 (0.3%)
participants, high school in 301 (26.7%) participants,
a diploma in 42 (3.7%) participants, a bachelor’s degree
in 539 (47.7%) participants, a master’s degree in 145
(12.8%) participants, and doctorate in 60 (5.3%) of
the participants (Table 1). All study demographics are
shown in Table 1.
Approximately 566 (50.1%) of the participants did
not know the correct definition of morbid obesity. Of
the interviewees, 1,069 (94.7%) knew that there is a
difference between obesity and morbid obesity. Among
the survey participants, 1,103 (97.7%) individuals
acknowledged that obesity is a significant cause of
numerous medical diseases (Table 2).
Disclosure. Authors have no conflict of interests, and the
work was not supported or funded by any drug company.

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Public perception of bariatric surgery ... Altaf & Abbas
Most (1,103 individuals or 97.7%) of the
participants knew that there are surgical methods for
weight reduction. A total of 937 (83%) participants
knew someone who had undergone bariatric surgery.
About 304 (26.8%) of the subjects did not know how
bariatric surgery is performed. Moreover, 669 (59.3%)
considered bariatric surgery a medical procedure, 213
(18.9%) considered it a cosmetic procedure, and the rest
were not sure. Of the participants, 778 (69%) thought
that either diet or exercise is the single most effective
method in the management of morbid obesity, while
only 18.2% considered surgery as the most effective
method. Of those who were interviewed, 163 (14.4%)
individuals thought that bariatric surgery is never needed
and 603 (53.1%) did not know the correct indications
for bariatric surgery. About 729 (64.6%) of those who
participated thought that the complication rate of
bariatric surgery is more than 40%, and 400 (35.4%)
thought that it is less than 5%. Of the participants, 465
Table 1 - Study demographics of 1,129 individuals included in the study.
Demographics n (%)
Mean age (years)
Range (years)
35.19 ± 13.16
18-68
Mean height (cm)
Range (cm)
164.66 ± 9.85
120-190
Mean weight (kg)
Range (kg)
77.11 ± 22.76
42-186
Had previous bariatric surgery
Yes
No
0
1,129 (100)
Gender
Male
Female
385 (34.1)
744 (65.9)
Nationality
Saudi 1,129 (100)
Highest educational level
Elementary school
Middle school
High school
Diploma
Bachelor’s degree
Master’s degree
Doctorate
39 (3.5)
3 (0.3)
301 (26.7)
42 (3.7)
539 (47.7)
145 (12.8)
60 (5.3)
Table 2 - Knowledge about obesity.
Knowledge about obesity n (%)
Do you think being overweight
or obese can cause significant
medical problems?
Yes 1,103 (97.7)
No 26 (2.3)
What is morbid obesity?
People who have a BMI of
>24.9 kg/m258 (5.1)
People who have a BMI of ≥30
kg/m2148 (13.1)
People who have a BMI of 40
or of 34–40 with significant
medical problems
563 (49.9)
I don’t know 360 (31.9)
Is there a difference between
obesity and morbid obesity?
Yes 1,069 (94.7)
No 60 (5.3)
Table 3 - Knowledge about bariatric surgery.
Knowledge about bariatric surgery n (%)
Do you know that there are surgical methods to
reduce weight?
Yes 1,103 (97.7)
No 26 (2.3)
What is bariatric surgery?
Weight loss is achieved by reducing the size of
the stomach or by resecting and re-routing the
small intestine
825 (73.1)
Removing excess fat from under the skin by
suction
110 (9.7)
e insertion of a balloon that fills the
stomach and gives the feeling of satiety quickly
49 (4.3)
I don’t know 145 (12.8)
Have anyone you know underwent bariatric
surgery?
Yes 937 (83.0)
No 192 (17.0)
Do you think that surgery for morbid obesity is a
medical procedure or a cosmetic procedure
Medical 669 (59.3)
Cosmetic 213 (18.9)
Not sure 247 (21.9)
What is the single most effective method for long-
term management of morbid obesity?
Diet 345 (30.6)
Exercise 433 (38.4)
Slimming centers 78 (6.9)
Medications 3 (0.3)
Surgery 206 (18.2)
I don’t know 64 (5.7)
When do you think bariatric surgery is needed?
Incorrect 599 (53.1)
Correct 360 (31.9)
Never 163 (14.4)
I don’t know 4 (0.6)
What are the complications’ percentage of
bariatric surgery?
Less than 5% 400 (35.4)
More than 40% 729 (64.6)
If you know a morbidly obese person, would you
recommend that he/she seeks a bariatric surgeon’s
help?
Yes 664 (58.8)
No 465 (41.2)
If you were a morbidly obese person, would you
seek a bariatric surgeon’s help?
Yes 598 (53.0)
No 531 (47.0)

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Saudi Med J 2019; Vol. 40 (4) www.smj.org.sa
(41.2%) stated that they would not to seek a bariatric
surgeon’s help if they were morbidly obese, and 531
(47%) would not advise a morbidly obese person to
seek bariatric surgery (Table 3).
ere was a significant positive correlation between
the level of education attained and the knowledge of
the definition of morbid obesity (-0.090, p=0.002).
Moreover, there was a significant positive correlation
between the level of education and both the knowledge
of the definition of bariatric surgery (-0.185, p<0.001)
and the presence of surgical methods for weight
reduction (-0.126, p<0.001). ere was also a positive
correlation between the level of education and knowing
someone who had undergone bariatric surgery (-0.185,
p<0.001). Considering bariatric surgery as a medical
procedure was significantly correlated with the level
of education (-0124, p<0.001). ere was a significant
positive correlation between the educational level and
falsely thinking that diet or exercise is the most effective
method in managing morbid obesity (0.091, p=0.002).
However, there was no significant correlation between
the level of education and the knowledge of bariatric
surgery indications or the perceived complication rate
of the surgery. Additionally, there was no significant
correlation between the educational level and either
seeking a bariatric surgeon’s help or recommending
bariatric surgery to a morbidly obese individual
(Table 4).
Discussion. e WHO has declared obesity to
be a growing threat and a global epidemic.22 In Saudi
Arabia, the prevalence of obesity is growing, as proven
by numerous studies nationwide.3,5,6 Among the Saudi
population, obesity is more prevalent among women
than among men.5 e national prevalence of obesity in
Saudi Arabia by the year 2022 is projected to be 59.5%
in men and 77.6% in women.5
e proper treatment of morbid obesity may lead
to dramatic favorable effects on the patients’ health as
well as on the health care system. Bariatric surgery is
an effective management option for morbid obesity. An
appropriate perception of a specific medical treatment
among the public is key in ensuring that affected
individuals seek that solution. Multiple factors may
affect the public’s opinion about bariatric surgery, such
as educational level, social and print media, peers’ or
contacts’ experiences, and many others. Print media
are an important factor in influencing the public’s
view of bariatric surgery as negative reportage distorts
the public’s overall awareness of bariatric surgery.23
Choosing bariatric surgery to manage one’s morbid
obesity is affected by the perception of bariatric surgery,
accessibility, finances, and cost.21 e complication rates
of bariatric surgery in centers of excellence are relatively
Table 4 - Correlation with educational level.
Correlation with Educational level Elementary
(n=39)
Middle
(n=3)
High S
(n=301)
Diploma
(n=42)
Bachelor
(n=539)
Masters
(n=145)
Doctorate
(n=60)
Chi-square
p-value
Spearman rank
correlation
(p-value)
Do you think being overweight or obese can cause significant medical problems?
0.211 -0.043
(0.153)
Yes 39 (100) 3 (100) 283 (94.0) 40 (95.2) 521 (96.7) 140 (96.6) 60 (100)
No 0 0 18 (6.0) 2 (4.8) 18 (3.3) 5 (3.4) 0
Do you know that there are surgical methods to reduce weight?
<0.001 -0.185
(<0.001)*
Yes 31 (79.5) 3 (100) 285 (94.7) 42 (100) 539 (100) 143 (98.6) 60 (100)
No 8 (20.5) 0 16 (5.3) 0 0 2 (1.4) 0
What is morbid obesity?
<0.001
-0.090
(0.002)*
BMI >24.9 0 0 12 (4.0) 2 (4.8) 26 (4.8) 16 (11.0) 2 (3.3)
BMI ≥30 3 (7.7) 0 33 (10.9) 17 (40.5) 65 (12.1) 28 (19.3) 2 (3.3)
BMI 34 to 40 with significant medical
problems caused by or made worse by their
weight
25 (64.1) 3 (100) 144 (47.8) 3 (7.1) 282 (52.3) 69 (47.6) 37 (61.7)
I don’t know 11 (28.2) 0 112 (37.2) 20 (47.6) 166 (30.8) 32 (22.1) 19 (31.7)
Is there a difference between obesity and morbid obesity?
<0.001
-0.093
(<0.001)*
Yes 28 (71.8) 3 (100) 285 (94.7) 39 (92.9) 514 (95.4) 140 (96.6) 60 (100)
No 11 (28.2) 0 16 (5.3) 3 (7.1) 25 (4.6) 5 (3.4) 0
What is bariatric surgery?
<0.001
-0.126
(<0.001)*
Weight loss is achieved by reducing the size of
the stomach or by resecting an re-routing the
small intestine
21 (53.9) 3 (100) 199 (66.1) 33 (78.6) 407 (75.5) 104 (71.7) 58 (96.7)
Removing excess fat from under the skin by
suction
8 (20.5) 0 28 (9.3) 3 (7.1) 58 (10.8) 11 (7.6) 2 (3.3)
e insertion of a balloon that fills the stomach
and gives the feeling of satiety quickly
4 (10.3) 0 21 (7.0) 0 19 (3.5) 5 (3.4) 0
I don’t know 6 (15.4) 0 53 (17.6) 6 (14.3) 55 (10.2) 25 (17.2) 0

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Public perception of bariatric surgery ... Altaf & Abbas
Have anyone you know underwent bariatric surgery?
<0.001 -0.185
(<0.001)*
Yes 23 (58.9) 3 (100) 231 (76.7) 42 (100) 450 (83.5) 128 (88.3) 60 (100)
No 16 (41.1) 0 70 (23.3) 0 89 (16.5) 17 (11.7) 0
Do you think that surgery for morbid obesity is a medical
procedure or a cosmetic procedure
<0.001 -0.124
(<0.001)*
Medical 16 (41.0) 0 148 (49.2) 14 (33.3) 343 (63.6) 104 (71.7) 44 (73.3)
Cosmetic 17 (43.6) 3 (100) 62 (20.6) 15 (35.7) 95 (17.6) 17 (11.7) 4 (6.7)
Not sure 6 (15.4) 0 91 (30.2) 13 (30.9) 101 (18.7) 24 (16.6) 12 (20.0)
A 25 years old morbid obese, what is the least way for him/her
to get complications during 10 years?
<0.001 0.043
(0.146)
Diet 7 (17.9) 0 92 (30.6) 11 (26.2) 170 (31.5) 58 (40.0) 5 (8.3)
Exercise 15 (38.5) 3 (100) 133 (44.2) 14 (33.3) 220 (40.8) 36 (24.8) 30 (50.0)
Traditional medicine 0 0 4 (1.3) 0 7 (1.3) 0 0
Slimming centers 12 (30.8) 0 24 (8.0) 11 (26.2) 48 (8.9) 13 (9.0) 9 (15.0)
Medications 0 0 0 0 14 (2.6) 0 0
Surgery 5 (12.8) 0 48 (15.9) 6 (42.3) 80 (14.8) 34 (23.4) 16 (26.7)
I don’t know 0 0 0 0 0 4 (2.8) 0
What is the single most effective method for long term
management of morbid obesity?
Diet 9 (23.1) 0 99 (32.9) 7 (16.7) 175 (32.5) 36 (24.8) 19 (31.7)
<0.001 0.091
(0.002)*
Exercise 11 (28.2) 3 (100) 134 (44.5) 18 (42.9) 197 (36.5) 50 (34.5) 20 (33.3)
Slimming centers 9 (23.1) 0 15 (5.0) 8 (19.0) 40 (7.4) 3 (2.1) 3 (5.0)
Medications 0 0 0 0 3 (0.6) 0 0
Surgery 10 (25.6) 0 44 (14.6) 4 (9.5) 94 (17.4) 36 (24.8) 18 (30.0)
I don’t know 0 0 9 (3.0) 5 (11.9) 30 (5.6) 20 (13.8) 0
When do you think bariatric surgery is needed?
Incorrect 20 (51.3) 3 (100) 160 (53.2) 17 (40.5) 300 (55.7) 76 (52.4) 23 (38.3)
0.037 0.025
(0.403)
Correct 13 (33.3) 0 91 (30.2) 19 (45.2) 157 (29.1) 48 (33.1) 32 (53.3)
Never 6 (15.4) 0 50 (16.6) 6 (14.3) 75 (13.9) 21 (14.5) 5 (8.3)
I don’t know 0 0 0 0 7 (1.3) 0 0
What are the complication percentages of bariatric surgery?
Less than 5% 9 (23.1) 3 (100) 100 (33.2) 9 (21.4) 200 (37.1) 45 (31.0) 34 (56.7) <0.001 -0.031
(0.296)
More than 40% 30 (76.9) 0 201 (66.8) 33 (78.6) 339 (62.9) 100 (69.0) 26 (43.3)
If you know morbidly obese person, would you recommend that he/she seeks
a bariatric surgeon’s help?
Yes 25 (64.1) 3 (100) 166 (55.1) 28 (66.7) 324 (60.1) 85 (58.6) 33 (55.0) 0.420 -0.019
(0.522)
No 14 (35.9) 0 135 (44.9) 14 (33.3) 215 (39.9) 60 (41.4) 27 (45.0)
If you were a morbidly obese person, would you seek a bariatric
surgeon’s help?
0.040 -0.045
(0.134)
Yes 26 (66.7) 3 (100) 144 (47.8) 28 (66.7) 283 (52.5) 78 (53.8) 36 (60.0)
No 13 (33.3) 0 157 (52.2) 14 (33.3) 256 (47.5) 67 (46.2) 24 (40.0)
Did our questions make you more aware regarding the need for
obesity surgery? 0.001 0.000
(0.992)Yes 34 (87.2) 3 (100) 170 (56.5) 23 (54.8) 327 (60.7) 83 (57.2) 45 (75.0)
No 5 (12.8) 0 131 (43.5) 17 (45.2) 212 (39.3) 62 (42.8) 15 (25.0)
*significant correlation.
Table 4 - Correlation with educational level. (continued)
low.8,10-14 Bariatric surgery is usually the ultimate option
for people suffering from morbid obesity. In this study,
more females than males were interviewed, accounting
for the difference in the prevalence of obesity between
the 2 genders in Saudi Arabia. Our results show an
obvious deficiency in the knowledge about bariatric
surgery among the population studied. is large
knowledge gap may cause a reluctance in accepting
bariatric surgery as an option. e false perception
about the complications of bariatric procedures likely
has a major impact on the decision to undergo bariatric
surgery in individuals who require such treatment.
Although a majority of the participants acknowledged
the impact of morbid obesity on health, in that it causes
a variety of medical problems, they lacked knowledge
of the fact that the most effective method for morbid
obesity management is bariatric surgery. ere is little
awareness about the proper definition of bariatric
surgery, indications, and the correct complication rate.
Contrary to what one might expect, the educational level
did not have a significant impact on the subject’s view
on bariatric surgery and the willingness to seek bariatric

384
Public perception of bariatric surgery ... Altaf & Abbas
Saudi Med J 2019; Vol. 40 (4) www.smj.org.sa
surgery, or to recommend it as an option for treatment
for morbid obesity. Different methods might be useful
in overcoming the public’s false perception of bariatric
surgery. As social media has become a major source of
easily accessible information, bariatric surgeons may
use this platform to spread accurate knowledge about
bariatric surgery. Additionally, use of print media is of
paramount importance as we have learned that they
influence public perception. Organizing nationwide
public awareness campaigns may also help educate
people about obesity, its complications, its prevention,
and the management options available, and importantly,
to deliver accurate information about the benefits,
indications, and complication risks of bariatric surgery.
Study limitation. e study was conducted in one
region of the country. We would hence recommend
conducting similar studies in different regions and local
communities, or a nationwide study, to further clarify
this issue and have a more comprehensive view, as the
first step in solving a problem is detecting its existence.
In conclusion, the study shows deficiency in the
public’s basic knowledge of obesity and bariatric
surgery. Educational level does not affect an individual’s
knowledge or opinion regarding bariatric surgery.
Surgeons and health educators, among others, should
act accordingly to improve public awareness in this
regard.
Acknowledgment. We would like to thank www.editage.com
for English language editing.
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