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).