Physical and Social Health Needs of Postoperative Bariatric Surgery Patients: A Focus Group.

doi:10.21203/rs.3.rs-4992676/v1

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Research Article

Physical and Social Health Needs of Postoperative Bariatric Surgery Patients: A Focus Group.

https://doi.org/10.21203/rs.3.rs-4992676/v1

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Purpose

This qualitative study explored the health needs of patients after undergoing bariatric surgery. The study specifically aimed to describe the unique physical, emotional, and social challenges patients face following surgery in order to inform the development of future obesity treatment programs.

Methods

A ninety-minute focus group was conducted using a semi-structured interview guide. Bariatric surgery patients were enrolled using purposive sampling. The mean number of months since surgery was 20.2 (SD 10.8). The mean age of participants was 53.3 (SD 9.8) years. The focus group was both audio and video recorded, transcribed, and analyzed using topic and analytical coding.

Results

Three main themes emerged revealing postoperative needs for 1) assistance with physical changes and reduced barriers to exercise, 2) reinforcement for healthy eating behaviors, and 3) emotional support from peers, family, and community.

Conclusions

Findings suggest that rehabilitation following bariatric surgery is complex in nature and patients may benefit from both pre- and post-surgery programs that address their unique needs. Weight maintenance and sustaining healthy behavior change post-surgery requires ongoing personal and professional assistance. Interventions should emphasize healthy eating practices, include practical exercise suggestions, and offer social and emotional support.

bariatric surgery

obesity

rehabilitation

social support

focus group

The prevalence of severe obesity (Body Mass Index (BMI) ≥ 40 kg/m²) in the United States is 9.2% of the adult population [1, 2]. As the severity of obesity increases, so does the incidence of comorbidities, including type 2 Diabetes, hypertension, and cardiovascular disease, as well as psychosocial issues like depression, anxiety, and the prevalence of eating disorders [3–7]. Bariatric surgery is recognized as the most effective treatment for severe obesity. Surgery patients often experience resolution or significant improvement in comorbid conditions [8, 9] and lose on average, 65% of excess body weight [10]. Some patients struggle to reach postoperative weight-loss goals or experience weight reoccurrence [11, 12, 13]. Significant weight reoccurrence can be observed within 24 months after surgery in as many as 40–50% of patients [14, 15]. Failure to lose (and regain) weight has been attributed to a failure to make lifestyle changes and poor adherence to a postoperative diet [16, 17, 18]. Thus, despite the impressive success of bariatric surgery as a treatment for obesity, psychosocial, behavioral, and environmental factors likely play an influential role in postoperative outcomes and long-term weight management [19, 20, 21].

Research examining success in obesity surgery outcomes has shown a need for a multidisciplinary approach to improve behavioral changes [22]. Accredited bariatric programs typically include nutrition counseling and some exercise prescription [23]. Weight-loss outcomes are relatively standardized within the first six postoperative months among patients as surgery restricts food intake and promotes gut hormonal changes [8]. However, continued weight loss tends to vary widely over subsequent months and years, with weight reoccurrence being a common incidence [12]. Research suggests that the effects of bariatric surgery decline over time, making adherence to recommended postoperative eating behaviors increasingly difficult for some patients. Patients report gradually returning to maladaptive eating behaviors like grazing, binge eating, and emotional eating. These regressions may be due to a lack of psychological skills necessary to sustain healthy eating practices and suggest that bariatric surgery programs do not effectively address psychological factors that lead to overeating [8]. Existing literature further submits that the powerful physiological effects of surgery cause significant weight loss during the first year despite non-adherence to diet and physical activity recommendations. As the early effects of surgery decline, patients are vulnerable to returning to unhealthy habits [24, 25]. Although patient challenges have been documented, there is relatively little existing empirical research identifying needs in the period when postoperative clinical support falls away and patients are at higher risk for weight reoccurrence.

The purpose of this study was to conduct a focus group with individuals who had undergone bariatric surgery to explore their unique health needs. We sought to better understand patient’s postoperative experience, and more specifically, learn about the physical, emotional, and social challenges patients face. This was a first step toward informing the development of future programs aimed at assisting patients with long-term behavioral rehabilitation following bariatric surgery.

Design

This qualitative descriptive study was conducted as a single focus group. A focus group using a semi-structured interview format was chosen to draw upon respondent’s feelings and attitudes with the intent to gain in-depth insight into the post-bariatric surgery experience.

Recruitment

Focus group participants were recruited from a bariatric surgery program in an academic medical center. Institutional Review Board (IRB) approval was obtained from the University of Utah IRB before recruitment began. Purposeful sampling was used. Potential participants were identified during routine follow-up care visits and personally invited to participate in the study. Because patients tended to interact often with health care providers in the months right before and after surgery, an emphasis was made to invite participants who were more than 12 months post-surgery to consider patient’s ongoing needs and how they might be supported long term. Respondents provided informed consent.

Participants

Eligible participants had undergone bariatric surgery (Roux-en-Y/gastric bypass, or gastric sleeve) within 48 months prior to the study and were adults (18–70 years old). Inability to communicate in English was the only exclusion criteria, and no one was excluded for this reason.

Focus Group

The focus group was conducted in-person and led by two trained facilitators. The primary facilitator led a discussion that lasted approximately 90 minutes, with a 10-minute break at the half-way point. The secondary facilitator took extensive notes on a white board and monitored the video and audio recording.

Data Collection

Participants self-reported their age, height, current weight, and number of months since surgery. BMI was calculated as weight (Kg)/height (in meters)². Group discussion was generated and guided by a list of five open-ended questions about post-surgery challenges (see Table 1). Participants were prompted to consider both physical and psychological experiences when responding to questions. The conversation was allowed to flow naturally. Before moving on to the next question, the facilitator would invite participants to speak who had not volunteered comments.

Table 1

Focus Group Discussion Guide
1- Do you find it difficult to maintain your current weight? If yes, why?
2- What was your biggest challenge 0–3 months after surgery? a. 6 months after surgery? b. 1 year after surgery?
3- List any positive or negative changes that have occurred since surgery, in the following relationships or situations: a. In your family b. With your spouse/partner c. In friendships d. In social interactions e. In your work/professional life
4- What is one thing you didn’t expect or wished you had known about weight-loss surgery?
5- What advice would you give to someone thinking about having weight-loss surgery?

Data Analysis

Basic demographic and medical information were descriptively analyzed for the sample. Focus group discussion was both audio and video recorded and transcribed verbatim. The video helped researchers to observe (and preserve) an authentic reflection of personal, lived experiences as body language, gestures, and facial expressions added to qualitative data analysis. Analysis of the discussion consisted of a systematic review of the transcript utilizing content analysis techniques (inductive-deductive processes of coding) to identify themes (distinctive experiences and common feelings of the group). Transcriptions were reviewed by two independent coders who compared notes and examined amalgamated themes. Systematic analysis included dividing data into categories according to responses to the discussion guide as follows: a) post-surgery successes and challenges (questions 1–2); b) relationships and social situations (question 3 a-e); c) additional support needed post-surgery (questions 4–5). Areas of emphasis materialized for consideration as data was thus categorized and three main themes emerged: 1) Physical Changes, 2) Eating Behaviors, and 3) Ongoing Emotional Support.

Nine patients who met inclusion criteria were invited to attend the focus group. Six patients attended (3 being unable to attend due to transportation issues or scheduling conflicts). Participants ranged in age from 38 to 68 years. All participants fell in either the overweight (BMI 25–29) or obesity (BMI ≥ 30) classification (see Table 2). Themes from analysis of the discussion transcription are presented in this section. Selected responses in participant’s own words are provided to demonstrate each theme and illustrate personal views and experiences. Male and female are noted with an (M) or an (F) respectively along with the participant’s age.

Table 2

Focus Group Descriptive Statistics
Participants	Sex (M, F)	Age (yrs.)	Weight (lbs.)	BMI (Kg/m²)	Months since surgery
All (M, SD)	M = 2, F = 4	53.3 (9.8)	221.8 (58.3)	33.9 (8.3)	20.2 (10.8)
1	F	38	315	49.3	4
2	M	49	262	37.7	24
3	M	53	187	25.3	13
4	F	49	156	25.2	16
5	F	68	223	36.0	38
6	F	63	188	30.4	26

Physical Changes: Victories and Challenges

Participants shared a variety of physical experiences in the months after surgery. The most-often reported improvements in physical health included less chronic pain, no longer needing prescription medications, improved blood sugar levels, better quality sleep, and increased motivation for physical activity. “I want to do [physically] active things now. I like going for walks and I get restless if I have to sit for a long time” (F, 49). “My diabetes and high blood pressure are gone! - and I was able to stop taking so many medications. I can’t believe how much better I feel and I never want to go back to how I was before” (M, 53).

Common complaints included: dehydration, fatigue and weakness, food intolerances, hair loss, and constipation. Most participants agreed that these issues resolved within the 6-month postoperative period except for constipation, which seemed to be an ongoing issue for most. The group suggested it would be helpful to prepare patients more thoroughly by addressing these specific issues during pre-surgery classes with dietitians.

They didn’t warn us enough about constipation after surgery. It’s been a major issue for me. I thought it might only be in the first months after surgery, but no! I wish someone had told me that I was going to have to deal with it forever (F, 68).

The group talked about dealing with rapid changes to their bodies and how it affected their self-image. Several people mentioned experiencing body dysmorphia. Family members and friends helped by giving honest feedback, taking “before and after” weight-loss pictures, and offering emotional support when physical changes felt overwhelming. “My spouse keeps telling me how great I look, but it’s hard for me to see it. I know I’ve lost weight, but I still see a fat person in the mirror” (F, 49).

I went to the store with my daughter to buy clothes and I would grab the size I thought I needed and then go in the dressing room. The clothes were way too big and I couldn’t believe it! I kept asking my daughter “Why is this too big?” and she was laughing at me and helping me to get smaller sizes (F, 63).

Participants reported increased motivation for physical activity. Group members talked about personal victories such as climbing a flight of stairs without getting winded, tying shoes, fitting comfortably in seats at events and on airplanes, and being able to play with children and grandchildren. “It’s the little victories that feel so great like space on the sides of me when I’m sitting in the car and being able to go up the stairs without [feeling like] dying” (F, 63).

There was a consensus in the group that motivation for exercise was increased after surgery. Participants said they felt more mobile and capable, experienced less pain, and had improved stamina. They also felt more self-confident about their physical appearance and less self-conscious about exercising in front of others. One woman talked about her goal to go walking daily with a friend and said, “I do better with exercise if I know I have to meet somebody. I need accountability” (F, 49).

The group expressed an increased need for exercise assistance. They felt many exercise classes and videos were geared toward “fit people” and were not tailored to the needs of a person recovering from obesity. One man commented on the fact that he didn’t follow the recommendations given by the exercise physiologist before surgery and stated, “There’s these ‘ologists’ offering to help you, but you have to want to listen to them and do the things they are telling you to do” (M, 53). He felt he was in a better mindset post-surgery and would benefit from a gym orientation and some personal training sessions. A participant said she was going to the gym every week but feeling unsure about what to do. “I go to the gym and feel intimidated. Every day I look at the weight machines and say today I’m going to figure out how to do those, but then I just walk the track and leave and say, maybe tomorrow” (F, 49). “My friend who likes to exercise keeps inviting me to go to the gym with her. I have gone a few times and it’s much less intimidating now” (F, 38).

Eating Behaviors: New Versus Old Habits

Discussion around food and eating dominated a significant amount of time during the focus group meeting. Participants reported both physical, emotional, and social difficulties as they adjusted to new ways of eating. There was much conversation about navigating a changed relationship with food. Comments such as: “I’m not food” (M, 49) and “I’m in control of what I eat. I can say no” (F, age 68). suggested new levels of self-awareness and self-determination. One man talked about his realization that over-eating had simply become a habit. He recognized his pre-surgery tendency to regularly overeat was not dictated by hunger levels, but by psychological needs. “I had a deep-seeded need, a mindset to overeat. I have learned that I don’t need to order or eat large quantities of food. Now I feel better when I don’t overeat” (M, 53).

A female participant talked about her experience battling emotional eating. Several other group members said they had similar tendencies to eat to cope with negative or intense emotions. Participants talked about new ways they were managing their emotions and mentioned things such as: confiding in family and friends more often, taking a walk, engaging in new hobbies, or doing yard work. “I don’t need to dictate my feelings with food anymore. If I feel stressed or sad, I do something productive instead of look[ing] for something to eat” (F, 49). Participants also expressed fears and worries about being able to sustain healthy eating behaviors. One woman shared feelings about not being able to eat celebratory and comfort foods anymore. “I’m scared because I’m craving junk food and wanting to eat things I shouldn’t” (F, 63).

The group agreed that one of the biggest frustrations in social situations was eating out. Participants expressed frustrations and shared strategies for dealing with potentially challenging or awkward situations. “I don’t like to eat out anymore because I feel guilty when I waste food” (F, 38). “Waiters get worried when you don’t eat. They keep asking to get you things. I have learned to say, ‘“I’m just here to enjoy the time and company”’ (M, age 49). “I make sure I’m the last person in the food line and then everyone is focused on eating what’s on their own plate and I can take just a little and enjoy talking to others” (F, 63).

Focus group participants had a variety of ideas for meal planning and meal preparation tips. People suggested recipe sharing, cooking demonstrations, periodic emails with bariatric-appropriate foods, and lists to take grocery shopping. “I need ideas about what I can do for meal prep and cooking. Burnout happens. I get so tired of eating the same things and don’t know what else to do” (F, 63). “How about a class about your first trip to the grocery store after surgery. How to approach it. What to buy and what not to buy. What should I be putting in the cart and, in my cupboards now?” (M, 49).

The group as a whole thought training in intuitive eating principles (methods that encourage a healthy relationship with hunger and satiety cues) would be very valuable. Participants shared feelings of shame about wanting to eat certain types of food. They advocated for mindfulness training specifically focused on eating behaviors. “I forget to just enjoy my food. I used to eat really fast, now I don’t eat very much and I hardly feel like it’s worth the effort” (F, 49). “I don’t feel hungry like I used to. I have to set alarms sometimes to remember to eat” (F, 38). “The cravings for sweets and junk food come back. I shouldn’t want them after all this, but I do. I want the treats and I’m eating things I know I will regret eating” (M, 49).

Ongoing Emotional Support

Analysis of the focus group transcription revealed a general anxiety about moving forward after surgery and maintaining a level of success. Participants expressed a lag in motivation, as well as fear and uncertainty after their 1-year “surgery anniversary” when weight loss slows/stops and life settles back to normal. “You feel great in the year after surgery, but then start to feel the creeping back of old habits” (M, 49). “When the weight loss stops or you gain back some pounds, it’s scary. No one wants to fail” (F, 68). Participants talked at length about the need for ongoing emotional support. They expressed fears about returning to unhealthy habits and weight regain. They all expressed a desire for more peer support. Suggestions for increasing peer support included establishing an online chat or social media group, holding in-person support groups more often than once a month, and having a sponsor or buddy in the program. “Where can we get emotional support long-term after surgery? Talking to the psychologist would require a big issue. I need help with smaller day to day issues” (F, 63). “It would be great to have someone to call when you’re struggling -someone who’s been through the program and can talk to you and keep you going” (F, 49). Participants described feelings of fear related to the possibility of losing a renewed self-acceptance or social acceptance. “I’m ok. I’m starting to like myself for the first time in a really long time” (F, 38). “The fear of gaining the weight back is terrifying for me!” (F, 63). Participants generally agreed that they felt changes in the way people interacted with them in social situations. Strangers treated them differently in public, and they noticed changes in interactions with co-workers and acquaintances.

I’ve been fat all my life and some people treat me differently now. I was used to being ignored or looked past, and now people make eye contact and are friendlier. It’s weird. It kinda makes me mad. It’s like I matter more now (F, 49).

“I’ve had the opposite experience. I used to get stared at a lot. Now I’m just an old guy that nobody notices. It’s nice” (M, 53).

Focus group participants discussed the importance of having supportive family and social relationships hat encouraged healthy behavior. They talked about experiences that were both helpful and unhelpful. “My wife has followed the diet with me and will cook and eat the things I need to have. She has become healthier too and we have encouraged each other along the way” (M, 53). “My family eats what they want and it’s hard on me when we have family parties and stuff because they are all eating and saying how great everything tastes and I can only eat a little bit and then I just sit there” (F, 38). “I don’t like it when my husband tries to tell me what I should and shouldn’t eat. I don’t like being watched over” (F, 68). The group proposed a class geared toward educating family members and friends. “It would be great to have a class for spouses with information about this whole experience so they can understand what you’re going through.” (M, 49). “My family needs to know what things are helpful to say, and what is not helpful. I don’t need judgmental advice” (F, 38). “I need help to be accountable, not to be nagged” (F, 63).

Participants reported a variety of physical and emotional challenges as they recovered from weight-loss surgery. It is evident that rehabilitation following bariatric surgery is complex in nature and patients may benefit from multi-disciplinary postoperative programs that address their unique needs. Timing of programs could also be important in bariatric populations, as patients report diminishing barriers to health behaviors in the months following surgery, and a lag in motivation and/or anxiety about maintaining adherence to diet and exercise recommendations as clinical support tapers off. Data analysis from this focus group revealed a need for postoperative programs that reinforce healthy eating and exercise and provide strategies to combat environmental and personal factors such as low self-efficacy or maladaptive coping skills. Low self-efficacy has been identified as a personal risk factor for obesity [26, 27]. Self-efficacy is thought to be the prime factor for influencing human behavior and is defined as a person’s belief in his/her ability to succeed in a particular situation [28–29]. Bariatric surgery patients may benefit from programs that aim to enhance self-efficacy for eating and exercise behaviors [30, 31].

Focus group participants shared struggles with emotional eating and a history of maladaptive coping behaviors. The prevalence of eating disorders in individuals with obesity is higher than those of typical weight [32]. Anxiety, depression, and mood disorders are three to four times higher among individuals with obesity [33, 34]. Coping is a conscious or unconscious effort to solve personal and interpersonal problems, to minimize or tolerate stress or conflict [35]. Bariatric patients may benefit from programs that teach adaptive or proactive coping strategies [36].

A need for ongoing emotional and social support was also a central theme of this focus group study. Research has shown that social support moderates or buffers the impact of psychosocial stress on physical and mental health [37, 38, 39] and more specifically, may promote physical activity and reduce sedentary behavior [40]. Social support is important in preventing and overcoming chronic pathologies [41]. Patients may benefit from programs that include opportunities to interact with peers. Recent research among bariatric patients has shown emotional support from peers to be most relevant to weight loss and weight maintenance postoperatively [42]. Studies have also suggested that social support is helpful with weight management in various forms including family, friends, work colleagues, virtual support groups, and bariatric-specific groups [43, 44].

Focus group discussion revealed feelings of shame regarding certain eating behaviors and body weight. There exist widespread cultural stereotypes toward people with obesity in the United States. Weight stigma includes prejudicial attitudes directed toward overweight individuals and is usually expressed though discrimination. Individuals with obesity are highly aware of stigma and members of this focus group expressed fear of losing the respect of others and themselves if they were to regain weight. Weight reoccurrence after bariatric surgery has been associated with emotional stress, shame, and self-contempt [45]. Feelings of shame are often induced in a culture with strong anti-overweight attitudes. Individuals with obesity might experience verbal harassment and/or judgmental stares while eating or exercising at the gym, and these types of experiences may contribute to the uncertainty and anxiety individuals feel when trying to make lifestyle change [46, 47]. Bariatric patients may benefit from programs that aim to educate individuals about the myths of weight stigma. Overcoming shame caused by weight stigma may be fundamentally necessary for lasting obesity rehabilitation as weight stigma may be an obstacle for the adoption of healthy behaviors and weight maintenance.

In light of themes that emerged from our overall data analysis, bariatric patients could benefit from future programs that include assistance with 1) navigating physical changes to their bodies and reduced barriers to exercise, 2) strategies for building healthy eating habits and rejecting old practices, and 3) ongoing emotional support from peers, family, and community (see Table 3).

Table 3

Focus Group Feedback
Main Themes	Areas of Emphasis for Future Programs
Physical Changes: Victories and Challenges	Strategies for reducing sedentary behavior. Practical exercise ideas and instruction. Body dysmorphia education. Weight maintenance practices.
Eating Behaviors: New vs. Old Habits	Meal planning ideas, tips for healthy food preparation. Recipe sharing. Cooking demonstrations. Mindful eating education. Emotional eating education. Effective coping strategies education.
Ongoing Emotional Support	Opportunities for peer interaction. Educational classes for family members. Methods for combating weight stigma. Positive psychology practices.

Strengths and Limitations

Strengths

A focus group design for this study was useful for purposes of investigation. The open-ended questions format encouraged participation and discussion. We invited a small group of peers who were representative of the bariatric program in terms of age and gender. Participants were all post-surgery patients at different stages of recovery, which allowed for both common experience and a variety of personal experiences. The participants were acquainted with the group facilitator and there was an established rapport, which encouraged a sense of comfort. Focus group studies within the postoperative bariatric population are relatively rare and insights from this sample adds to this limited knowledge base.

Limitations

Sample size for the study was small with six patients attending. The mean age of the group was 53.3 yrs. (SD 9.8) which was older than the average bariatric patient in the United States: 39.5 yrs. (SD 10.5) [48]. The group lacked diversity; all were Caucasian and English speaking. Participants were selected and personally invited by the principal investigator. They were identified as patients who were making efforts to maintain healthy lifestyle changes. It is possible that they agreed to be in the study because they had a positive surgery experience and held progressive views about incorporating effective post-surgery programs.

Implications for Research and Practice

Rehabilitation needs identified through this qualitative analysis informed changes made to the bariatric program in our study. For example, educational content was incorporated to address issues of constipation, dehydration, and food intolerances. An exercise class was tailored to the needs of patients recovering from obesity. Support group meetings included mindfulness training, and recipe sharing. Results may continue to aid in the development of future weight-management programs.

Focus group discussion suggested weight maintenance and sustaining healthy habits post-surgery requires ongoing personal and professional support. Psychosocial factors should be considered when designing lifestyle change programs for bariatric surgery patients. Interventions should include elements to develop the skills necessary to maintain long-term adherence to changed habits of health behavior. Focus group feedback revealed postoperative patients may most benefit from rehabilitative programs that include assistance with exercise, strategies for healthy eating practices, ongoing social and emotional support, and education for combatting the damaging psychosocial effects of weight stigma.

Funding:

No funds, grants, or other financial support was received.

Conflicts of Interest:

The authors have no financial or competing interests to declare that are relevant to the content of this article.

Ethics approval:

This work is original and has not been published elsewhere in any form or language. International Review Board (IRB) approval from the University of Utah IRB was obtained, and research was conducted in accordance with the 1964 Helsinki Declaration or comparable standards.

Consent to participate:

All participants provided their own written informed consent prior to participating in this study.

Consent for publication:

Patients signed informed consent regarding publishing their data.

Author Contribution

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Angela Glauser and Alexandra Terrill. The first draft of the manuscript was written by Angela Glauser and all authors provided feedback and edited subsequent versions of the manuscript. All authors read and approved the final manuscript.

Availability of data and material:

De-identified data and materials (semi-structured interview guide) are available upon reasonable request from the corresponding author.

Code availability:

N/A

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No competing interests reported.

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Physical and Social Health Needs of Postoperative Bariatric Surgery Patients: A Focus Group.

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Physical Changes: Victories and Challenges

Eating Behaviors: New Versus Old Habits

Ongoing Emotional Support

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