Contrasting Views of the Post-bariatric Surgery Experience between Patients and their Practitioners: a Qualitative Study

Bariatric surgeons' views on barriers and enablers to bariatric surgery in Australia and New Zealand: A qualitative content analysis

PROBLEM AND AIMS

Bariatric surgery can be an effective treatment for severe obesity, yet publicly-funded access is often limited. Bariatric surgeons contribute to decisions regarding consumer (non)progression to bariatric surgery. Still, little is known about their views on barriers and enablers to bariatric surgery in the Australian and New Zealand context. The current study addresses this knowledge gap.

METHODS

A qualitative design was utilised. Sixteen bariatric surgeons and registrars from Australia and New Zealand were interviewed about their views on barriers and enablers to bariatric surgery. The data were analysed using qualitative content analysis.

RESULTS

Five content categories were derived from the analysis: 1. patient-related factors; 2. healthcare experiences and clinician-related factors; 3. societal beliefs and attitudes towards obesity, bariatric surgery and bariatric surgeons; 4. economic, governmental and institutional factors; and 5. bariatric surgery in the context of other treatments. A perceived lack of focus on obesity and publicly-funded bariatric surgery was apparent throughout the data in the form of descriptions of stigma, clinicians' disillusionment, patients not being guided and supported, and inadequate regulation and organisation of the field. The role of patients in determining their surgical progression was emphasised.

CONCLUSIONS

Participants discussed numerous barriers but fewer facilitators to bariatric surgery in Australia and New Zealand. Some of their opinions merit exploration with other bariatric multi-disciplinary team members and patients to understand further how the pre-operative process might be enhanced to support patients' needs and improve equity.

Factors Impacting One-year Follow-up Visit Adherence after Bariatric Surgery in West China: A Mixed Methods Study

PURPOSE

Quality follow-up (FU) is crucial after bariatric surgery. However, poor adherence after surgery is prevalent. This research aimed to explore the factors related to FU adherence after bariatric surgery in West China.

MATERIALS AND METHODS

This study used a sequential explanatory mixed-methods research design. Participants (n = 177) were identified from the West China Hospital. Demographic information, disease profile, treatment information, and post-surgery FU information were obtained from the bariatric surgery database of the Division of Gastrointestinal Surgery of the West China Hospital. The survey data were analyzed using logistic regression. Semi-structured interviews with participants (n = 10) who had low adherence were conducted. The recording was transcribed verbatim and entered into qualitative data analysis software. Qualitative data were analyzed using a content analysis approach.

RESULTS

Multiple logistic regression revealed that living in Chengdu (OR, 2.308), being employed (OR, 2.532), non-smoking (OR, 2.805), and having less than five years of obesity (OR, 2.480) were positive predictors of FU adherence within one year. Semi-structured interviews suggested that factors related to adherence to FU were lack of motivation, lack of opportunity, insufficient ability, and beliefs regarding consequences.

CONCLUSION

Factors impacting one-year FU visit adherence after bariatric surgery include not only demographic and disease-related factors but also social and family factors. These results will provide evidence to support healthcare professionals in developing personalized postoperative FU management strategies.

The patient-practitioner interaction in post bariatric surgery consultations: an interpersonal process recall study

PURPOSE

The patient-practitioner relationship is fundamental to rehabilitation practice and patients' health and wellbeing. Dissonance between patients who have had bariatric surgery and health care practitioners about what supportive care and good outcomes are can undermine care. To address the mechanisms of this process, we conducted an Interpersonal Process Recall study.

MATERIALS AND METHODS

We interviewed patients (11), video recorded consultations (10), conducted video-assisted individual interviews with patients (10) and practitioners (11) and a dyadic data analysis.

RESULTS

We identified relational states and shifts in the clinical encounter 2-3 years post-surgery, described in themes: a) Playing by the Book - Making it Easier for Each Other, b) Down the Blind Alley - Giving up on Each Other, and c) Opposite Poles - Towards and Away from Each Other.

CONCLUSIONS

The post-surgery consultations facilitated responsibility for health and self-care but did not invite dialogues about the psychosocial burdens of living with obesity and undergoing bariatric surgery. Patients and practitioners tried to avoid creating conflict, which in turn seemed to foster distance, rather than human connection. This limits the encounter's benefit to both parties, leaving them frustrated and less willing to either meet again or take any gains into their future lives.IMPLICATIONS FOR REHABILITATIONIllness evokes feelings of stress and uncertainty and is experienced very differently from the perspective of patients and health care practitioners (HCPs), who encounter each other in a field fraught with tension.Bodily changes and difficult emotions related to food and eating are to be expected when undergoing bariatric surgery, and to explicitly "notice, name and validate" emotions can promote the patient's capacity to sustain self-care, lifestyle change, weight loss and health gains.Making interpersonal connection and interaction between patient and HCP the centre of bariatric aftercare can enhance engagement in and outcomes of the post-surgery clinical encounter.

Weight Stigma and Barriers to Effective Obesity Care

Weight stigma is prevalent with negative consequences for health and well-being. This problem is present in health care; stigmatizing attitudes toward patients with obesity are expressed by medical professionals across diverse specialties and patient care settings. This article summarizes the ways in which weight stigma creates barriers to effective care, including poor patient-provider communication, reduced quality of care, and healthcare avoidance. Priorities for stigma reduction in healthcare are discussed, with a clear need for multifaceted approaches and inclusion of people with obesity whose perspectives can inform strategies to effectively remove bias-related barriers to patient care.

Psychopathology predicts mental but not physical bariatric surgery outcome at 3-year follow-up: a network analysis study

PURPOSE

This study aimed to explore the psychopathological variables that may predict bariatric surgery outcomes after 3 years.

METHODS

One hundred ninety-six candidates for bariatric surgery completed self-report questionnaires to assess eating attitudes, eating disorder (ED)-related psychopathology, affective symptoms, interpersonal and psycho-social functioning. One-hundred patients repeated this assessment 3 years after bariatric surgery. A network analysis was run including the pre-surgical measurements in the network. A composite score derived from the combination of the most central network nodes, as well as clinical and socio-demographical variables, was included in a multivariate regression analysis with weight loss, ED psychopathology and psycho-social functioning as outcomes.

RESULTS

Depression, stress, and shape concerns were the most central network nodes. The composite network score predicted higher ED psychopathology and worse psycho-social functioning at 3-year follow-up, but not weight loss. Higher age, restricting type of bariatric surgery and higher pre-operative BMI were further predictors of reduced weight loss and greater ED psychopathology.

CONCLUSIONS

Affective symptoms and shape concern play a central role in the psychopathology of candidates to bariatric surgery and predict post-surgery ED psychopathology and psycho-social functioning. These variables may allow to identify patients with higher pre-operative risk and in need of further psycho-social interventions.

LEVEL OF EVIDENCE

III, evidence obtained from well-designed cohort study.

The role of weight stigma in weight regain in bariatric surgery

Obesity is highly stigmatized, and individuals who undergo bariatric surgery are subject not only to weight stigma, but also to stigma related to the procedure itself. Patients lost to follow-up after surgery make estimating the amount of regain occurring after surgery difficult, and often patients fail to follow up due the shame of weight regain. Patients report difficulty following the diet necessary to maintain weight loss. Additionally, when they seek support after surgery, they often encounter stigmatizing messaging related to weight. Weight bias internalization, weight stigma, and stigma about having the surgery all contribute to feelings of social isolation, disordered eating, and reduced motivation to engage in physical activity. In this chapter, we present evidence for the impact of stigma on bariatric surgery outcomes and discuss the behavioral, physiological, and emotional processes that contribute to weight regain.

Objetificação da mulher: implicações de gênero na iminência da cirurgia bariátrica

Resumo: A cirurgia bariátrica, realizada predominantemente em mulheres (80% no Brasil e 77% no contexto mundial), representa, além da prevenção de riscos aos agravos de saúde, uma promessa de bem-estar subjetivo. Neste trabalho, analisou-se, a partir da perspectiva de teorias feministas e psicodinâmicas, associadas à literatura da saúde, narrativas e expressões não verbais de um grupo de mulheres na iminência de tal cirurgia. Os resultados obtidos mostraram que aquele grupo de mulheres buscava a cirurgia como um dispositivo para alcançar a magreza como o padrão feminino idealizado socialmente. O corpo gordo foi reconhecido como uma condição não humana e a cirurgia simbolizada como a libertação dessa condição e o resgate da sexualidade. Concluiu-se, portanto, que as questões de gênero devem ser reconhecidas para apoiarem as equipes de saúde a fim de se mitigar expectativas irreais e melhorar o desfecho do tratamento da obesidade grave.

Behavioral weight management interventions in metabolic and bariatric surgery: A systematic review and meta-analysis investigating optimal delivery timing

Metabolic and bariatric surgery (MBS) yields unprecedented clinical outcomes, though variability is high in weight change and health benefits. Behavioral weight management (BWM) interventions may optimize MBS outcomes. However, there is a lack of an evidence base to inform their use in practice, particularly regarding optimal delivery timing. This paper evaluated the efficacy of BWM conducted pre- versus post- versus pre- and post-MBS. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and included pre- and/or post-operative BWM interventions in adults reporting anthropometric and/or body composition data. Thirty-six studies (2,919 participants) were included. Post-operative BWM yielded greater decreases in weight (standardized mean difference [SMD] = -0.41; 95% confidence interval [CI]: -0.766 to -0.049, p < 0.05; I² = 93.5%) and body mass index (SMD = -0.60; 95% CI: -0.913 to -0.289, p < 0.001; I² = 87.8%) relative to comparators. There was no effect of BWM delivered pre- or joint pre- and post-operatively. The risk of selection and performance bias was generally high. Delivering BWM after MBS appears to confer the most benefits on weight, though there was high variability in study characteristics and risk of bias across trials. This provides insight into the type of support that should be considered post-operatively.

'Shopping for a new body': descriptions of bariatric post-operative adjustment

PURPOSE

Co-morbid conditions resulting from obesity cause 3.4 million deaths per year. Bariatric surgery has become a solution for obesity. Post-operative psychosocial changes can be problematic and must not be neglected. Up to 74% of people with overweight or obesity have body image distortion or dissatisfaction, which may persist even after surgery and weight loss. The questions addressed by this research were: (a) what are the categories of open-ended responses from bariatric surgery patients about their experiences of post-operative adjustment? (b) Do the categories of response support previous quantitative findings of a retained obese identity after surgery?

METHODS

Herman's Dialogical Self Theory provides the basis for understanding the post-operative transition from "I-obese" to "I-ex-obese". Fifty-five bariatric surgery patients (18-30 months post-op) were asked to tell the investigator about their adjustment after surgery. Their open-ended responses were written down and analyzed using content analysis.

RESULTS

Individual responses were analyzed and divided into four dominant categories: (a) shopping for a new body; (b) relationship transitions; (c) focus on the new body; and (d) cheating on the fat person inside.

CONCLUSION

This study presents an opportunity to gain perspective on the physical and psychosocial adjustment after bariatric surgery. The information can be used to guide pre-op and post-op education and counseling efforts for patients. Physical healing should be paired with healthy psychological adjustment to ensure a positive outcome.

LEVEL OF EVIDENCE

Level V, descriptive analysis of previous Level III research.

Overall Treatment Satisfaction 5 Years After Bariatric Surgery

INTRODUCTION

Up to 30 % of patients undergoing bariatric surgery are dissatisfied with treatment outcomes in the long term. The aim of this study was to examine overall satisfaction with treatment 5 years after bariatric surgery and its association with body mass index (BMI) and health-related quality of life (HRQOL).

METHODS

Patients were surveyed 5 years after bariatric surgery; 108 patients had duodenal switch (DS) and 153 patients had laparoscopic sleeve gastrectomy (LSG). The main outcome was overall treatment satisfaction, assessed by a single question, and analyzed by multiple logistic regression. Estimates for continuous independent variables represent the odds ratios (OR) for a 2-standard deviation difference.

RESULTS

Five years after surgery, 82.4 % of the patients were very satisfied or satisfied, whereas 17.6 % were unsure or dissatisfied. The following variables assessed at 5 years were associated with being dissatisfied/unsure: a higher BMI (OR = 6.1, 95 % CI = 2.7-14.0, p < 0.001), reduced obesity-specific HRQOL (OR = 3.0, 95 % CI = 1.1-7.8, p = 0.03), and reduced mental HRQOL (OR = 0.3, 95 % CI = 0.1-0.8, p = 0.02). We also found that a higher proportion of patients who underwent LSG, compared to DS, reported being dissatisfied/unsure (OR = 3.3, 95 % CI = 1.3-8.8, p = 0.01).

CONCLUSION

Reduced mental HRQOL and obesity-related HRQOL, as well as higher BMI, were associated with less satisfaction with overall treatment outcomes 5 years after bariatric surgery. Differences in overall treatment satisfaction by type of operation warrant further investigation.

A novel patient-reported outcome monitoring with clinical feedback system in bariatric surgery care: study protocol, design and plan for evaluation

BACKGROUND

Consultations before and after bariatric surgery should include structured assessments of patients' health-related quality of life (HRQOL) and mental health. One way to conduct this assessment is to implement patient-reported outcome monitoring with a clinical feedback system (PRO/CFS).

AIM

We will explore patients' and healthcare professionals' experiences when a PRO/CFS is an integrated part of bariatric surgery care.

METHODS AND ANALYSES

This is a design paper in which a PRO/CFS will be implemented in two bariatric outpatient clinics. All patients who have an appointment with a healthcare professional prior to, and 3 and 12 months after surgery, will be asked to complete six digital questionnaires measuring HRQOL, mental health, bowel symptoms and eating self-efficacy prior to each consultation. A digital summary report generated from the patient's responses will form the basis for the clinical consultation. A team of patient representatives, healthcare professionals and researchers will be involved in all phases of designing the PRO/CFS to ensure its relevance for clinical consultations. The patients' experiences will be explored with a generic 12-item questionnaire, developed for use in outpatient clinics, prior to and 12 months after bariatric surgery. We will conduct focus-group interviews with patients and healthcare professionals to explore their experiences when PRO/CFS is integrated into the consultations.

ETHICS AND DISSEMINATION

Written informed consent will be obtained for all participants in the study. The project is approved by the Norwegian Centre for Research Data, Department of Data Protection Services (ref. no. 282738). The project has also undergone Data Protection Impact Assessments, both at Førde Hospital Trust and at St. Olav Hospital (registration no. 2016/3912). Data from the qualitative and quantitative studies will be kept in de-identified form in a secured research database, and the findings will be published in international peer-reviewed journals and presented at scientific conferences.

Patients' experiences of life after bariatric surgery and follow-up care: a qualitative study

OBJECTIVES

Bariatric surgery is the most clinically effective treatment for people with severe and complex obesity, however, the psychosocial outcomes are less clear. Follow-up care after bariatric surgery is known to be important, but limited guidance exists on what this should entail, particularly related to psychological and social well-being. Patients' perspectives are valuable to inform the design of follow-up care. This study investigated patients' experiences of life after bariatric surgery including important aspects of follow-up care, in the long term.

DESIGN

A qualitative study using semistructured individual interviews. A constant comparative approach was used to code data and identify themes and overarching concepts.

SETTING

Bariatric surgery units of two publicly funded hospitals in the South of England.

PARTICIPANTS

Seventeen adults (10 women) who underwent a primary operation for obesity (mean time since surgery 3.11 years, range 4 months to 9 years), including Roux-en-Y gastric bypass, adjustable gastric band and sleeve gastrectomy, agreed to participate in the interviews.

RESULTS

Experiences of adapting to life following surgery were characterised by the concepts of 'normality' and 'ambivalence', while experiences of 'abandonment' and 'isolation' dominated participants' experiences of follow-up care. Patients highlighted the need for more flexible, longer-term follow-up care that addresses social and psychological difficulties postsurgery and integrates peer support.

CONCLUSIONS

This research highlights unmet patient need for more accessible and holistic follow-up care that addresses the long-term multidimensional impact of bariatric surgery. Future research should investigate effective and acceptable follow-up care packages for patients undergoing bariatric surgery.

Experiences of Weight-Loss Surgery in People With Serious Mental Illness: A Qualitative Study

BACKGROUND

Bariatric surgery is seldom accessed by people with serious mental illness, despite high rates of obesity in this population. It is sometimes assumed that patients with complex psychiatric histories will have poor post-surgical weight loss or exacerbation of psychiatric symptoms, although this is unsubstantiated.

OBJECTIVES

A qualitative descriptive study to explore personal experiences and the impact of bariatric surgery on physical and mental well-being and life-quality in individuals with serious mental illness.

METHODS

Nine adults with a history of bariatric surgery and concurrent severe depressive disorder, bipolar disorder, or schizoaffective disorder were interviewed about their experiences of bariatric surgery and its outcomes using semi-structured interview schedules. Data were transcribed and inductive thematic analysis undertaken.

RESULTS

Five broad themes emerged: (1) surgery was highly effective for weight loss, and resulted in subjective improvements in physical health, quality of life, and mental health described as being able to live a life; (2) recovering from surgery was a tough road, notably in the post-operative period where negative sequelae often anteceded benefits; (3) post-operative support was important, but sometimes insufficient, including from families, mental health services, and surgical teams; (4) most considered surgery life-changing, recommending it to others with mental illness and obesity, two had different experiences; (5) participants considered it discriminatory that people with mental illness were not referred or declined weight loss surgery.

CONCLUSIONS

Participants benefited from bariatric surgery and felt it should be offered to others with mental illness, but with additional care and support.

Exploring isolation, self-directed care and extensive follow-up: factors heightening the health and safety risks of bariatric surgery abroad among Canadian medical tourists

PURPOSE

This article explores first-hand accounts of Canadian bariatric patients' experiences of seeking and obtaining weight loss surgery abroad through the practice of medical tourism. While researchers have identified many of the challenges and associated health and safety risks imposed on patients by engaging in medical tourism generally, little is known about the specific challenges experienced by Canadians seeking bariatric surgery abroad.

METHOD

To better understand these challenges, we conducted thematic analysis on interviews conducted with 20 former Canadian bariatric tourists.

RESULTS

Our analysis illuminated three key challenges Canadians face in obtaining bariatric care: (1) stigma and isolation from friends, family and medical professionals; (2) self-directed navigation of domestic and destination health care systems; and (3) challenges with obtaining adequate follow-up care in Canada.

CONCLUSIONS

While these challenges identified by participants may occur in other forms of medical tourism, it appears that these challenges are occurring simultaneously in cases of bariatric tourism by Canadians. These challenges appear to work in conjunction to heighten the health and safety risks potential Canadian bariatric tourists may be exposed to. Unless structural changes occur to increase domestic availability of bariatric surgery, Canadians are likely to continue seeking this care abroad.

I Am As Normal As Everyone Now. . . : Examination of Experiences of Patients Undergoing Bariatric Surgery According to Roy's Adaptation Model: A Qualitative Study

The aim of this study is to examine experiences of patients undergoing bariatric surgery according to Roy's adaptation model (RAM). This is a qualitative study with a phenomenological design. The sample included patients undergoing bariatric surgery (N: 32). Of all the patients 84.37% were female and 59.38% were married. According to results of the content analysis, adaptive patient behavior was described by the themes "My life has changed", Everything is beautiful" "I can cope" and "Luckily, I have them" and their nonadaptive behavior was described by the themes "What if I cannot succeed", "Bad news" and "So many people, so many views". Patients having bariatric surgery experience various difficulties in adapting to their life and bodies, but the surgery leads to improvements in their body image, social life, personal relationships, and maintenance of roles. However, some patients can be afraid of postoperative complications and experience anxiety about regaining weight.

'Damned one way or another': Bariatric surgeons' reflections on patients' suboptimal outcomes from weight loss surgery

OBJECTIVE

A minority of patients show sub-optimal outcomes after weight loss surgery. Research has identified predictors of poor outcomes focusing on the patients' perspective. No research has explored surgeons' accounts.

DESIGN

Ten Bariatric surgeons were interviewed using a critical incident approach to explore their explanations for sub-optimal outcomes in the context of a real-life case. Data were analysed using thematic analysis.

RESULTS

Three main themes were developed: 'Challenges to success' highlighting the role of psychosocial issues, poor adherence and patient non-disclosure; 'Ideal world solutions' describing who should identify and address psychosocial issues; and 'Real world compromise' reflecting the impact of limited resources and weighing up risk between carrying out versus not carrying out surgery. Transcending these themes was the notion of 'responsibility' with surgeons balancing the role of the patient, themselves and the health care system.

CONCLUSION

Some surgeons concluded that if they had known before surgery what they know now, they may not have operated. All emphasised that they could only know what was disclosed by the patient, that they were not convinced that not operating would have resulted in better outcomes in the longer term and many felt that they were 'damned one way or the other'.

A review of systematic reviews on the effects of patient-reported outcome monitoring with clinical feedback systems on health-related quality of life-implications for a novel technology in obesity treatment

Patient-reported outcome monitoring with clinical feedback systems (PRO/CFS) has been employed in many disease states to measure and improve health-related quality of life (HRQOL). Exploring the role of PRO/CFS in treatment for obesity may prove valuable. Systematic reviews were summarized to determine the effectiveness of PRO/CFS on HRQOL in any disease area. Primary studies evaluating the effect of PRO/CFS on HRQOL in treatment for obesity were also considered for inclusion. Systematic searches were performed in The Cochrane Library, PROSPERO, Epistemonikos, HTA, DARE, CINAHL, Medline, Embase, PsycINFO, BMJ Clinical Evidence, PDQ-Evidence and PubPsych. Two reviewers independently screened references until final inclusion and critically appraised included reviews using PRISMA checklist. Five systematic reviews and no primary studies met inclusion criteria. Although results were inconsistent, effectiveness of PRO/CFS on HRQOL was demonstrated in some diseases/treatments (e.g. psychiatric treatment; symptom burden in cancer treatment). No trials using PRO/CFS in treatment for obesity were identified. In some trials, PRO/CFS was not fully integrated into consultations, thereby PRO/CFS was not extensively studied. General effectiveness of PRO/CFS on HRQOL is inconclusive due to heterogeneous and statistically insignificant findings, and lack of stringency in conceptualization and execution of PRO/CFS. There are no data relevant to treatment for obesity. Future studies should use rigorous methodology to examine the effectiveness of PRO/CFS in treatment for obesity.

Loss-of-control eating after bariatric/sleeve gastrectomy surgery: Similar to binge-eating disorder despite differences in quantities

OBJECTIVE

To characterize loss-of-control eating following sleeve gastrectomy surgery by comparing relevant patient groups.

METHOD

Participants were 431 adults seeking treatment for eating/weight concerns categorized into one of four groups: 1) overweight/obesity (OW/OB), 2) binge-eating disorder (BED), 3) "Bariatric Binge-Eating Disorder" (Bar-BED) defined as meeting all criteria for DSM-5 binge-eating disorder, except for the requirement of an unusually large amount of food, following sleeve gastrectomy surgery, and 4) "Bariatric Loss-of-Control Eating" (Bar-LOC Only), defined as experiencing at least once weekly loss-of-control eating episodes during the past month without the other associated clinical features and distress that characterize Bar-BED, following sleeve gastrectomy surgery.

RESULTS

The Bar-BED and BED groups reported comparable levels of overall eating-disorder and depressive symptoms, and these levels were significantly higher than those levels reported by the OW/OB and Bar-LOC Only groups. Adjusting for age, body mass index, and race did not change the overall pattern of findings.

CONCLUSION

"Bariatric Binge-Eating Disorder" shares clinical features of DSM-5 binge-eating disorder, regardless of the quantity of food consumed. Careful assessment of loss-of-control eating, associated behavioral features, and distress is warranted following surgery. More broadly, our findings highlight the importance of assessing loss-of-control eating across patient groups with obesity.