Managing Overweight and Obesity: Bariatric Surgery

What Is It? Surgical procedures on the stomach or intestines to produce weight loss. Surgery enables the body to start losing weight but diet and behavior modification are important determinants of long-term success.

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January 09, 2020

For employers seeking to align their weight management strategy with the latest evidence, this resource offers recommendations on creating a comprehensive benefits package to treat obesity, including behavior-based interventions and pharmacological and surgical treatment.

What Is It?

Surgical procedures on the stomach or intestines to produce weight loss. Surgery enables the body to start losing weight but diet and behavior modification are important determinants of long-term success.

Who Is Bariatric Surgery Indicated For?

92% of large employers cover bariatric surgery.42

Qualifications for bariatric surgery include:62

  • BMI ≥40 (or more than 100 pounds overweight).
  • BMI ≥35 with a weight-related comorbidity, such as hypertension, dyslipidemia, diabetes or osteoarthritis.
  • Inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts.

Eligibility for surgery is also based on a medical evaluation to determine acceptable operative risks, which procedure to apply and how to manage coexisting conditions throughout the surgical treatment process. Candidates also undergo an evaluation by a multidisciplinary team, including a psychological assessment of mental health or substance abuse conditions, as well as a nutritional assessment to educate the patient and implement needed pre-and post-surgical lifestyle changes.

Why Should Employers Cover It?

Bariatric surgery is the most effective treatment to date for significant and sustained weight loss in people with severe obesity.63 Data show that bariatric surgery patients achieve greater weight loss than those following a regimen of diet, exercise and/or prescription medications. In addition to facilitating weight loss, bariatric procedures improve or resolve obesity-related comorbidities.64-69


Bariatric Surgery Efficacy

Weight Loss

Evidence shows that bariatric surgery results in substantially greater weight loss than non-surgical therapy. According to a 2018 evidence review of the three most commonly performed bariatric procedures, at five years follow-up the average total weight loss was 25.5% for Roux-en-Y gastric bypass, 18.8% for sleeve gastrectomy and 11.75% for adjustable gastric band.70

Health Outcomes

Research demonstrates that bariatric surgery is associated with improvements in mortality, diabetes, cardiovascular risk factors, sleep apnea and quality of life. According to the largest comparative study to date, at 10 years follow-up, bariatric surgery was associated with the following outcomes:65-69

  • Significant improvement in glucose control for people with diabetes and reduced incidence of new cases of diabetes.
  • Reduction in cardiovascular risk factors (e.g., hypertension, high cholesterol).
  • Mortality was reduced by 29% after a mean follow-up of 10.9 years.
  • Quality of life improvement in the 2- to10-year follow-up period, with the degree of improvement correlating with the amount of weight loss.

Weight loss is not the only factor that patients and providers should consider when discussing bariatric procedure options. Because each surgery has advantages and disadvantages, shared-decision making conversations should include information on the risks, and potential changes in comorbid conditions with each procedure.


Short-term Complications

The incidence of complications from surgery is increased in patients with obesity, particularly related to thromboembolism and wound healing. Other complications of bariatric surgery may include bleeding, bowel obstruction and cardiopulmonary complications (e.g., pneumonia, heart attack).64

According to one study, 30-day rates of major adverse events (death; percutaneous, operative, or endoscopic intervention; venous thromboembolism and failure to discharge the hospital within 30 days) were 5.0% for Roux-en-Y gastric bypass patients, 2.6% for sleeve gastrectomy patients and 2.9% for adjustable gastric band patients.70

Another analysis of 74,774 bariatric procedures performed between 2011 and 2014 found that the in-hospital mortality rate was 0.29% and the average length of hospital stay was 2.55 days. In 2014, the percentage of in-hospital systemic complications was 2.94% and the percentage of hemorrhagic complication was 2.36%.71

Longer-term Complications

While longer-term complications vary based on the type of bariatric procedure (e.g. complications from the adjustable gastric band may relate to the presence of a foreign object in the patient’s body), adverse events can include ulcers, esophagitis and less severe issues related to dumping syndrome, vomiting and diarrhea.64

Because of complications and rehospitalizations from bariatric surgery, some research suggests that bariatric surgery may not be a cost-saving intervention.* For example, a six-year study of 30,000 Blue Cross Blue Shield beneficiaries found that average pharmaceutical costs and office-based services declined post-surgery; however, higher inpatient costs due to complications negated any savings. The average annual post-surgery costs never dipped below pre-surgery costs ($8,850) for the six years studied, and were no lower than costs for a comparison group of patients with obesity who did not undergo surgery.72

Despite this, when factors other than direct health care costs are considered, bariatric surgery can be cost-effective. For example, bariatric surgery can positively impact length and quality of life. It may also benefit employers through increased productivity, decreased workers’ compensation and decreased disability.73

* Cost savings indicates an intervention that is more effective and less costly than an alternative course of action. Cost-effective means an intervention is more effective than an alternative, but has equal costs; or, has equal effectiveness but lower costs. Cost-effectiveness is generally expressed as a gain in health outcomes at a predetermined reasonable cost.

Bariatric Surgery Utilization

In 2017, an estimated 228,000 bariatric surgery procedures were performed in the United States. Sleeve gastrectomy was performed most commonly (59%), followed by Roux-en-Y gastric bypass (17.8%) and adjustable gastric band (2.77%).74

A longitudinal analysis of bariatric surgery rates among privately insured adults showed a gradual increase in utilization from 2006 to 2009 (43.5 per 1000 patients in 2006 to 70.6 per 1000 in 2009). This increasing trend plateaued from 2010 to 2015.75

Type of Procedure Percentage of All Procedures
Sleeve gastrectomy 59%
Roux-en-Y gastric bypass 17.8%
Adjustable gastric band 2.77%
Balloons 2.75%
Other 2.46%
Biliopancreatic diversion with duodenal switch 0.7%
Revisions include corrective surgeries (due to complications or “incomplete treatment effect”)
or conversions (when a bariatric surgery is changed to a different type of bariatric operation or a reversal restored original anatomy).64
14.14% %

*Data are from the best available inpatient and outpatient datasets. Although this data did not indicate surgery-specific revision rates, studies show that revisions vary by procedure type. For example, one study indicated that subsequent bariatric surgeries (revision or reversal) were required in 0.3% of the Roux-en-Y gastric bypass patients and in 17.5% of laparoscopic adjustable gastric band.64, 76

Bariatric Surgery Centers of Excellence

Ninety-two percent of large employers cover bariatric surgery.42 Among those, 56% require employees and dependents to use an accredited center of excellence (COE).77 Bariatric Surgery COEs are certified by the American College of Surgeons and the American Society for Bariatric and Metabolic Surgery. Many major health plans also designate COEs for obesity surgery. Example criteria for COE designation can be found on the Center of Excellence in Metabolic & Bariatric Surgery website.

Studies indicate that bariatric surgery patients have better outcomes, as well as a better experience, at centers accredited as COEs.78 For example, one study showed high-quality facilities had half the complications during the initial hospital stay as compared to low-quality facilities. Over the 14-month post-surgery period, complications for laparoscopic surgeries were 30% less likely when the procedure was performed at a high-quality facility. Complications after gastric banding surgeries were 50% less likely when performed at high-quality facilities.79

58% of employers use their health plan(s) to contract with bariatric surgery COEs, while just 4% have developed direct contracts.77

Requirement that Bariatric Procedures are Performed at a COE, 2018 
Figure 1: Requirement that Bariatric Procedures are Performed at a COE, 2018

70% of employers with bariatric surgery COEs have a traditional fee-for-service payment structure, 25% have a bundled payment model and 5% have an alternative payment model in place.77

Bariatric Surgery Coverage Checklist

  • Define eligibility criteria for bariatric surgery. Only patients who meet recommended criteria, whose physicians have indicated that weight loss surgery is medically necessary, and who are likely to benefit from the procedure should be approved for surgery. Although some employers may seek documentation of a patient’s agreement to comply with pre- and post-procedure treatment recommendations, or may institute pre-surgery weight loss requirements (e.g. a structured diet program for a minimum of 6 months) before a patient is eligible for surgery, evidence indicates that pre-operative weight loss does not have a clear impact on post-surgical outcomes or weight loss. While individual surgeons may recommend pre-operative weight loss based on the specific needs and circumstances of a patient, mandating this may unnecessarily delay or divert patients from surgery.80,81
  • Specify the procedures covered. Work with your health plan(s) to verify that only bariatric procedures with evidence of effectiveness and low-complication rates are covered.
  • Restrict coverage to qualified providers and facilities. Limit coverage to facilities designated as COEs and experienced, high-volume surgeons who demonstrate a minimal number of post-operative hospitalizations and mortality rates. Request definitive proof of performance as a way to confirm superior outcomes.
  • Provide patients with pre- and post-surgical support. Identify programs or services that can improve patient success, such as bariatric surgery navigators or coaches whose role is to support the employee through the entire surgical journey.
  • 1 | Snook KR, Hansen AR, Duke CH, et al. Change in percentages of adults with overweight or obesity trying to lose weight, 1988-2014. JAMA. 2017;317(9):971-3.
  • 2 | Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity among adults and youth: United States, 2015–2016. NCHS data brief, no 288. Hyattsville, MD: National Center for Health Statistics. 2017.
  • 3 | Waters H, DeVol R. Weighing down America: The health and economic impact of obesity. Milken Institute. 2016. Accessed December 2018.
  • 4 | Agency for Healthcare Research & Quality. Total expenses and percent distribution for selected conditions by type of service for persons aged 20-64 years with private insurance: United States, 2014. Medical Expenditure Panel Survey Household Component Data: generated interactively on June 30, 2018.
  • 5 | Oster G, Edelsberg J, O’Sullivan AK, Thompson D. The clinical and economic burden of obesity in a managed care setting. Am J Manag Care. 2000;6(6):681-9.
  • 6 | Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of US adults. New Eng J Med. 2003; 348(17):1625-38.
  • 7 | Wolin KY, Carson K, Colditz GA. Obesity and cancer. Oncologist. 2010;15(6):556-565.
  • 8 | Lauby-Secretan B, Scoccianti C, Loomis D, Grosse Y, Bianchini F, Straif K. Body fatness and cancer—viewpoint of the IARC Working Group. New Eng J Med. 2016;375(8):794-8.
  • 9 | Arnold M, Pandeya N, Byrnes G, Renehan AG, Stevens GA, Ezzati M. Global burden of cancer attributable to high body mass index in 2012: a population based study. Lancet Oncol. 2014.
  • 10 | GBD 2015 Obesity Collaborators. Health effects of overweight and obesity in 195 countries over 25 years. New Eng J Med. 2017; 377(1):13-27.
  • 11 | Guh DP, Zhang W, Bansback N, Amarsi Z, Birmingham CL, Anis AH. The incidence of co-morbidities related to obesity and overweight: a systematic review and meta- analysis. BMC PublicHealth. 2009;9(1):88.
  • 12 | Coggon D, Reading I, Croft P, McLaren M, Barrett D, Cooper C. Knee osteoarthritis and obesity. Int J Obes Relat Metab Disord. 2001;25:622–627.
  • 13 | Moriarty JP, Branda ME, Olsen KD, et al. The effects of incremental costs of smoking and obesity on health care costs among adults: a 7-year longitudinal study. J Occup Environ Med. 2012;54(3):286-91.
  • 14 | Arena VC, Padiyar KR, Burton WN, Schwerha JJ. The impact of body mass index on short-term disability in the workplace. J Occup Environ Med. 2006;48(11):1118- 1124.
  • 15 | Cawley J, Meyerhoefer C. The medical care costs of obesity: an instrumental variables approach. J Health Econ. 2012;31:219-230.
  • 16 | Andreyeva T, Luedicke J, Wang YC. State-level estimates of obesity attributable costs of absenteeism. J Occup Environ Med. 2014;56(11):1120-1127.
  • 17 | Van Nuys K, Globe D, Ng-Mak D, Cheung H, Sullivan J, Goldman D. The association between employee obesity and employer costs: evidence from a panel of U.S. employers. Am J Health Promot. 2014;28(5):277-85.
  • 18 | Bray MS, Loos RJ, McCaffery JM, et al. NIH working group report-using genomic information to guide weight management: from universal to precision treatment. Obesity. 2016;24:14-22.
  • 19 | Pigeyre M, Yazdi FT, Kaur Y, Meyre D. Recent progress in genetics, epigenetics and metagenomics unveils the pathophysiology of human obesity. Clin Sci (Lond). 2016;130:943-86.
  • 20 | van der Klaauw AA, Farooqi IS. The hunger genes: pathways to obesity. Cell. 2015;161:119-32.
  • 21 | van Dijk SJ, Tellam RL, Morrison JL, Muhlhausler BS, Molloy PL. Recent developments on the role of epigenetics in obesity and metabolic disease. Clin Epigenetics. 2015;7:66.
  • 22 | Domecq JP, Prutsky G, Leppin A, et al. Clinical review: Drugs commonly associated with weight change: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2015;100:363-70.
  • 23 | Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100:342-62.
  • 24 | Heymsfield SB, Wadden TA. Mechanisms, pathophysiology, and management of obesity. N Engl J Med. 2017; 376:254-266
  • 25 | McAllister EJ, Dhurandhar NV, Keith SW, et al. Ten putative contributors to the obesity epidemic. Crit Rev Food Sci Nutr. 2009;49:868-913.
  • 26 | Levi J, Vinter S, St. Laurent R, Segal LM. F as in Fat: How Obesity Policies are Failing in America 2008: Trust for America’s Health; 2008.
  • 27 | Williamson DF. Descriptive epidemiology of body weight and weight change in U.S. adults. Ann Intern Med. 1993;119(7 Pt 2):646–9.
  • 28 | Woods SC. Body weight “set point”. What we know and what we don’t know. content/uploads/Body_Weight_Set_Point_online.pdf Accessed December 2018.
  • 29 | Polidori D, Sanghvi A, Seeley RJ, Hall KD. How strongly does appetite counter weight loss? Quantification of the feedback control of human energy intake. Obesity. 2016;24(11):2289-95.
  • 30 | Kaplan LM, Golden A, Jinnett K, et al. Perceptions of barriers to effective obesity care: Results from the national ACTION study. Obesity. 2018;26(1):61-9.
  • 31 | Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and The Obesity Society. J Am Coll Cardiol. 2013;online
  • 32 | LeBlanc EL, Patnode CD, Webber EM, Redmond N, Rushkin M, O’Connor EA. Behavioral and pharmacotherapy weight loss interventions to prevent obesity-related morbidity and mortality in adults: An updated systematic review for the US Preventive Services Task Force: Evidence synthesis No. 168. Rockville, MD: Agency for Healthcare Research and Quality; 2018. AHRQ publication 18-05239-EF-1.
  • 33 | Virginia A. Moyer, on behalf of the U.S. Preventive Services Task Force. Screening for and management of obesity in Adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):373-378.
  • 34 | Smith AW, Borowski LA, Liu B, et al. U.S. primary care physicians' diet-, physical activity-, and weight-related care of adult patients. Am J Prev Med. 2011;41(1):33-42.
  • 35 | Ma J, Xiao L, Yank V. Variations between obese Latinos and whites in weight-related counseling during preventive clinical visits in the United States. Obesity. 2013;21(8):1734-41.
  • 36 | Ma J, Xiao L, Stafford RS. Underdiagnosis of obesity in adults in US outpatient settings. Arch Intern Med. 2009;169(3):313-4.
  • 37 | Simkin-Silverman LR, Gleason KA, King WC, et al. Predictors of weight control advice in primary care practices: patient health and psychosocial characteristics. Prev Med. 2005;40(1):71-82.
  • 38 | Stafford RS, Farhat JH, Misra B, et al. National patterns of physician activities related to obesity management. Arch Fam Med. 2000;9(7):631-8. PMID: 10910311.
  • 39 | Steeves JA, Liu B, Willis G, et al. Physicians' personal beliefs about weight-related care and their associations with care delivery: The U.S. National Survey of Energy Balance Related Care among Primary Care Physicians. Obes Res Clin Pract. 2015;9(3):243-55.
  • 40 | Federal Register. Health insurance Issuer standards under the Affordable Care Act, including standards related to exchanges. 45 C.F.R. § 156.125
  • 41 | The New York Times. A.M.A. recognizes obesity as a disease. 2013. Accessed December 2018.
  • 42 | Business Group on Health. Quick survey findings: Weight management programs & benefits. 2018. Accessed December 2018.
  • 43 | Business Group on Health/Fidelity Investments' Annual Employer-Sponsored Health & Well-being. Making well-being work. Ninth Annual Employer-Sponsored Health and Well- Being Survey. 2018. Accessed December 2018.
  • 44 | The Business Group on Health/Fidelity Investments' Annual Employer-Sponsored Health & Well-being. Moving from wellness to well-being: Seventh annual employer-sponsored health and well-being survey. 2016.
  • 45 | National Institute of Diabetes and Digestive and Kidney Diseases. Prescription medications to treat overweight and obesity. information/weight-management/prescription-medications-treat-overweight-obesity. Accessed December 2018.
  • 46 | Colman E. Food and Drug Administration’s obesity drug guidance document: A short history. Circulation. 2012;125:2156.2164. Accessed December 2018.
  • 47 | Colman E, Golden J, Roberts M, et al. The FDA’s assessment of two drugs for chronic weight management. New Eng J Med. 2012;367(17):1577-1579.
  • 48 | Sherman M, Ungureanu S, Rey JA. Naltrexone/Bupropion ER (Contrave): Newly approved treatment option for chronic weight management in obese adults. Pharmacy and Therapeutics. 2016:41(3);164–172.
  • 49 | Personal communication with Novo Nordisk. December 1, 2017.
  • 50 | Kahan S. Quick takes: What you need to know about the 5 FDA-approved obesity drugs. Accessed December 2018.
  • 51 | Bohula EA, Wiviott SD, McGuire DK, et al. Cardiovascular safety of lorcaserin in overweight or obese patients. New Eng J Med. 2018; 379(12):1107-1117.
  • 52 | Caffrey M. Obesity therapy Saxenda gets cardiovascular safety indication. safety-indication. Accessed December 2018.
  • 53 | Thomas CE, Mauer EA, Shukla AP, Rathi S, Aronne LJ. Low adoption of weight loss medications: A comparison of prescribing patterns of antiobesity pharmacotherapies and SGLT2s. Obesity. 2016:24(9); 1955-1961
  • 54 | Personal communication with RX Connection.
  • 55 | Personal Communication with Express Scripts.
  • 56 | Personal communication with CVS Caremark.
  • 57 | Personal communication with OptumRx.
  • 58 | Glauser TA, Roepke N, Stevenin B, et al. Physician knowledge about and perceptions of obesity management. Obes Res Clin Pract. 2015.
  • 59 | U.S. Department of Health and Human Services. National Institute of Diabetes and Digestive and Kidney Diseases. Prescription Medications for the Treatment 82. Andreyeva, T, Puhl RM, Brownell KD. Changes in perceived weight discrimination among Americans, 1995–1996 through 2004–2006. Obesity. 2008;16:1129- of Obesity. 2016. Accessed December 2018.
  • 60 | Briggs G, Reid TJ. Medical Directors Guide on Obesity. JMCM. 2013;16(4):4-29.
  • 61 | Hendricks, EJ. Off-label drugs for weight management. Dove Press. 2017; 2017(10):223-234. https://www. management-peer-reviewed-fulltext-article-DMSO. Accessed December 2018.
  • 62 | American Society for Metabolic and Bariatric Surgery. Who is a candidate for bariatric surgery? Accessed December 2018.
  • 63 | Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity. Cochrane Database of Systematic Reviews. 2009;2:CD003641
  • 64 | Blue Cross Blue Shield Association. Bariatric Surgery Evidence Review. March 2018.
  • 65 | Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741-752.
  • 66 | Scopinaro N, Papadia F, Marinari G, et al. Long-term control of type 2 diabetes mellitus and the other major components of the metabolic syndrome after biliopancreatic diversion in patients with BMI < 35="" kg/m2.="" obes="" surg.="" 2007;17(2):185-192.="" />
  • 67 | Sjostrom CD, Lissner L, Wedel H, et al. Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric90. Puhl RM, Andreyeva T, Brownell KD. Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. Int J surgery: the SOS Intervention Study. Obes Res. 1999;7(5):477-484.
  • 68 | Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351(26):2683-91. Onufrak S, Zaganjor H, Pan L, et al. Foods and beverages obtained at worksites in the United States. J Acad Nutr Diet. 2019. 2693.
  • 69 | Torgerson JS, Sjostrom L. The Swedish Obese Subjects (SOS) study--rationale and results. Int J Obes Relat Metab Disord. 2001;25 Suppl 1:S2-4.
  • 70 | Arterburn D, Wellman R, Emiliano A, Smith SR, Odegaard AO, Murali S, et al. Comparative effectiveness and safety of bariatric procedures for weight loss: A PCORnet cohort study. Ann Intern Med. 2018;169(11):741-750.
  • 71 | Zhang L, Scott J, Shi L, Truong K, Hu Q, Ewing JA, et al. Changes in utilization and peri-operative outcomes of bariatric surgery in large U.S. hospital database, 2011-2014. PLoS ONE 2017:12(10); e0186306.
  • 72 | Weiner JP, Goodwin SM, Chang H, et al. A 6-year follow-up of surgical and comparison cohorts using health plan data. JAMA Surg. 2013;148(6):555-562.
  • 73 | Salem L, Jensen CC, Flum DR. Are bariatric surgical outcomes worth their cost? A systematic review. J Am Coll Surg. 2005;200(2):270-278.
  • 74 | American Society for Metabolic and Bariatric Surgery. Estimate of bariatric surgery numbers, 2011-2017. surgery-numbers. Accessed December 2018.
  • 75 | Alalwan A. National trends in utilization of bariatric surgery. Value in Health. 2018: 21(S248).
  • 76 | Courcoulas AP, Christian NJ, Belle SH, et al. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310(22):2416-2425.
  • 77 | Business Group on Health. 2019 Large Employers' Health Care Strategy and Plan Design Survey. 2018. Accessed December 2018.
  • 78 | Azagury D, Morton JM. Bariatric Surgery Outcomes in US Accredited vs Non-Accredited Centers: A Systematic Review. Journal of the American College of Surgeons. 2016;223(3):469-77.
  • 79 | Business Group on Health. Impact of bariatric surgery on health care costs and utilization: Towers Watson National Data Cooperative Study. August 2010.
  • 80 | American Society for Metabolic and Bariatric Surgery. Preoperative supervised weight loss requirements. supervised-weight-loss-requirements. Accessed December 2018.
  • 81 | Krimpuri RD, Yokley JM, Seeholzer EL, Horwath EL, Thomas CL, Bardaro SJ. Qualifying for bariatric surgery: is preoperative weight loss a reliable predictor of postoperative weight loss? Surg Obes Relat Dis. 2018;14(1):60-64.
  • 82 | Andreyeva, T, Puhl RM, Brownell KD. Changes in perceived weight discrimination among Americans, 1995–1996 through 2004–2006. Obesity. 2008;16:1129-1134
  • 83 | Durso LE, Latner JD, White MA, Masheb RM, Blomquist KK, Morgan PT, Grilo CM. Internalized weight bias in obese patients with binge eating disorder: associations with eating disturbances and psychological functioning. Int J Eat Disord. 2012;45(3):423-7.
  • 84 | Eisenberg ME, Berge JM, Fulkerson JA, Neumark-Sztainer D. Associations between hurtful weight-related comments by family and significant other and the development of disordered eating behaviors in young adults. J Behav Med. 2011;35(5):500-8.
  • 85 | Puhl RM, Moss-Racusin CA, Schwartz MB. Internalization of weight bias: Implications for binge eating and emotional well-being. Obesity. 2007;15(1):19-23.
  • 86 | Schvey NA, Puhl RM, Brownell KD. The impact of weight stigma on caloric consumption. Obesity. 2011;19(10):1957-62.
  • 87 | Wott CB, Carels RA. Overt weight stigma, psychological distress and weight loss treatment outcomes. J Health Psychol. 2010;15(4):608-14.
  • 88 | Pearl RL, Wadden TA, Hopkins CM, et al. Association between weight bias internalization and metabolic syndrome among treatment-seeking individuals with obesity. Obesity. 2017;25(2):317-322.
  • 89 | Amy NK, Aalborg A, Lyons P, Keranen L. Barriers to routine gynecological cancer screening for white and African-American obese women. Int J Obes. 2006;30(1):147-55.
  • 90 | Puhl RM, Andreyeva T, Brownell KD. Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. Int J surgery: the SOS Intervention Study. Obes Res. 1999;7(5):477-484. Obes. 2008;32(6):992-1000.
  • 91 | Onufrak S, Zaganjor H, Pan L, et al. Foods and beverages obtained at worksites in the United States. J Acad Nutr Diet. 2019. Accessed January 2019.
  • 92 | Puhl RM, Himmelstein MS, Gorin AA, Suh YJ. Missing the target: Including perspectives of women with overweight and obesity to inform stigma‐reduction strategies. Obes Sci Pract. 2017;3(1):25–35.

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  1. What Is It?
  2. Who Is Bariatric Surgery Indicated For?
  3. Why Should Employers Cover It?
  4. Bariatric Surgery Efficacy
  5. Safety
  6. Bariatric Surgery Utilization
  7. Bariatric Surgery Centers of Excellence
  8. Bariatric Surgery Coverage Checklist