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

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Angela C. Glauser, Robin L. Marcus PT, Larissa A. McGarrity, Anne Thackeray PT, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4992676/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract 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 Introduction The prevalence of severe obesity (Body Mass Index (BMI) ≥ 40 kg/m 2 ) 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. Methods 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. Results 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/m 2 ) 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). Discussion 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. Conclusions 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. Declarations 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 References Hales, C. M. (2020). Prevalence of Obesity and Severe Obesity Among Adults. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db360-h.pdf Trust for America’s Health (TFAH) (2022). State of Obesity. 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Predictors of lowest weight and long-term weight regain among roux-en-Y gastric bypass patients. Obesity Surgery, 25 , 1364–1370. doi:10.1007/s11695-014-1536-z Menéndez-González, L., & Orts-Cortés, M. I. (2018). Psychosocial and behavioural factors in the regulation of weight: Self-regulation, self-efficacy and locus control. Enfermería Clínica (English Edition) , 28 (3), 154-161. Van Hout, G. C., Verschure, S. K., & Van Heck, G. L. (2005). Psychosocial predictors of success following bariatric surgery. Obesity Surgery, 15 (4), 552-560. Bandura, A., Freeman, W. H., & Lightsey, R. (1999). Self-efficacy: The exercise of control. Journal of Cognitive Psychotherapy, 13 (2), 158-166. Bandura, A. (2004). Health promotion by social cognitive means. Health education & behavior , 31 (2), 143-164. Locke, E. A., & Latham, G. P. (2013). Goal Setting Theory, 1990 Gary P. Latham & Edwin A. Locke. In New developments in goal setting and task performance (pp. 27-39). Routledge. Ngwazini, C. (2022). Implementation of Nola Pender’s “Clinical Assessment for Health Promotion Plan” to increase patient self-efficacy, weight loss and health promoting behaviors such as improving nutrition and increased physical activity in obese women in a weight loss clinic. [Doctoral dissertation, University of San Diego]. Grave, R. D. (2010). Eating disorders: Progress and challenges. European Journal of Internal Medicine, 22 , 153-160. Greenberg, I., Perna, F., Kaplan, M., & Sullivan, M. A. (2005). Behavioral and psychological factors in the assessment and treatment of obesity surgery patients. Obesity Research, 13( 2), 244-249. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping . Springer Publishing Company. Rajan, T. M., & Menon, V. (2017). Psychiatric disorders and obesity: a review of association studies. Journal of Postgraduate Medicine , 63 (3), 182. Williamson, D. A. (2017). Fifty years of behavioral/lifestyle interventions for overweight and obesity: where have we been and where are we going?. Obesity , 25 (11), 1867-1875. Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin , 98 (2), 310-357. Cohen, S. (1988). Psychosocial models of the role of social support in the etiology of physical disease. Health Psychology , 7 (3), 269. LaRocco, J. M., House, J. S., & French Jr, J. R. (1980). Social support, occupational stress, and health. Journal of Health and Social Behavior , 202-218. Bhuiyan, N., Kang, J. H., Papalia, Z., Bopp, C. M., Bopp, M., & Mama, S. K. (2022). Assessing the stress-buffering effects of social support for exercise on physical activity, sitting time, and blood lipid profiles. Journal of American College Health , 70 (5), 1563-1569. Torrente-Sánchez, M. J., Ferrer-Márquez, M., Estébanez-Ferrero, B., Jiménez-Lasserrotte, M. D. M., Ruiz-Muelle, A., Ventura-Miranda, M. I., ... & Granero-Molina, J. (2021). Social support for people with morbid obesity in a bariatric surgery programme: a qualitative descriptive study. International Journal of Environmental Research and Public Health , 18 (12), 6530. Ahlich, E., Herr, J. B., Thomas, K., Segarra, D. T., & Rancourt, D. (2020). A test of the stress-buffering hypothesis of social support among bariatric surgery patients. Surgery for Obesity and Related Diseases , 16 (1), 90-98. Liu, R. H., & Irwin, J. D. (2017). Understanding the post-surgical bariatric experiences of patients two or more years after surgery. Quality of Life Research , 26 (11), 3157-3168. Tarrant, M., Khan, S. S., Farrow, C. V., Shah, P., Daly, M., & Kos, K. (2017). Patient experiences of a bariatric group programme for managing obesity: A qualitative interview study. British Journal of Health Psychology , 22 (1), 77-93. Natvik, E., Gjengedal, E., & Råheim, M. (2013). Totally changed, yet still the same: Patients’ lived experiences 5 years beyond bariatric surgery. Qualitative Health Research, 23 (9), 1202–1214. Cossrow, N. H., Jeffery, R. W., & McGuire, M. T. (2001). Understanding weight stigmatization: A focus group study. Journal of Nutrition Education , 33 (4), 208-214. Hill, B., Bergmeier, H., Incollingo Rodriguez, A. C., Barlow, F. K., Chung, A., Ramachandran, D., ... & Skouteris, H. (2021). Weight stigma and obesity‐related policies: A systematic review of the state of the literature. Obesity Reviews , 22 (11), e13333. Davidson L. E., Adams T. D., Kim J., et al. (2016). Association of patient age at gastric bypass surgery With long-term all-cause and cause-specific mortality. JAMA Surg. 151(7): 631–637. doi:10.1001/jamasurg.2015.5501 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 26 Nov, 2024 Reviews received at journal 19 Nov, 2024 Reviews received at journal 18 Nov, 2024 Reviewers agreed at journal 07 Nov, 2024 Reviewers agreed at journal 07 Nov, 2024 Reviewers invited by journal 29 Oct, 2024 Editor assigned by journal 05 Sep, 2024 Submission checks completed at journal 05 Sep, 2024 First submitted to journal 28 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Glauser","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCklEQVRIiWNgGAWjYLCCB0DMB2HaADEPELMR0JKAUJMG1ECilsOEtfDPbr/4IKGGwa6N/Yzxh497zifuZz97gOFD2WGcWiTunCk2SDjGkNzGk2MmOePZ7cQenrwExhnncGthuJGTJpHAxpDMxpBjxsxzAKiFIceAmbcNtxb5GznpPxL+AbXwvzH+/OfAucQe/jcGzH/xaDG4kX6MIbGNwY5NIsdAmuHAgcQeIIOZEY8Wwxs5zBKJfUC3STwrk+w5kGzcc+ONwcGec+k4tcjdSH/44cM3G3t+/uTNH34csJNt788xfPCjzBq39xl4DICERGIDstgBPOqBgP0BiLTHr2gUjIJRMApGNAAAUgpXPjYAQuEAAAAASUVORK5CYII=","orcid":"","institution":"University of Utah","correspondingAuthor":true,"prefix":"","firstName":"Angela","middleName":"C.","lastName":"Glauser","suffix":""},{"id":356107457,"identity":"e3e91820-c331-4d5c-8e3f-e2c7d6c09567","order_by":1,"name":"Robin L. Marcus PT","email":"","orcid":"","institution":"University of Utah","correspondingAuthor":false,"prefix":"","firstName":"Robin","middleName":"L. Marcus","lastName":"PT","suffix":""},{"id":356107458,"identity":"c2ea9c85-9e6a-4370-abec-4ffc65c83343","order_by":2,"name":"Larissa A. McGarrity","email":"","orcid":"","institution":"University of Utah Health","correspondingAuthor":false,"prefix":"","firstName":"Larissa","middleName":"A.","lastName":"McGarrity","suffix":""},{"id":356107459,"identity":"2c891dd9-7c3b-4516-b706-3193ab0a991b","order_by":3,"name":"Anne Thackeray PT","email":"","orcid":"","institution":"University of Utah","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"Thackeray","lastName":"PT","suffix":""},{"id":356107460,"identity":"621a43b8-bc9c-4856-99d9-0fce2c141e15","order_by":4,"name":"Eric T. Volckmann","email":"","orcid":"","institution":"University of Utah Health","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"T.","lastName":"Volckmann","suffix":""},{"id":356107461,"identity":"0b85f422-fb1e-4789-a4b1-5cb66406aab6","order_by":5,"name":"Alexandra L. Terrill","email":"","orcid":"","institution":"University of Utah","correspondingAuthor":false,"prefix":"","firstName":"Alexandra","middleName":"L.","lastName":"Terrill","suffix":""}],"badges":[],"createdAt":"2024-08-28 16:53:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4992676/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4992676/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66054360,"identity":"d946a404-7220-4981-b698-eeefb12acf61","added_by":"auto","created_at":"2024-10-07 09:00:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":583730,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4992676/v1/0c7d4a49-651d-49c3-9915-1ce426ef9978.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Physical and Social Health Needs of Postoperative Bariatric Surgery Patients: A Focus Group.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe prevalence of severe obesity (Body Mass Index (BMI)\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;40 kg/m\u003csup\u003e2\u003c/sup\u003e) in the United States is 9.2% of the adult population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. 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 [\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Bariatric surgery is recognized as the most effective treatment for severe obesity. Surgery patients often experience resolution or significant improvement in comorbid conditions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and lose on average, 65% of excess body weight [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Some patients struggle to reach postoperative weight-loss goals or experience weight reoccurrence [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Significant weight reoccurrence can be observed within 24 months after surgery in as many as 40\u0026ndash;50% of patients [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Failure to lose (and regain) weight has been attributed to a failure to make lifestyle changes and poor adherence to a postoperative diet [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch examining success in obesity surgery outcomes has shown a need for a multidisciplinary approach to improve behavioral changes [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Accredited bariatric programs typically include nutrition counseling and some exercise prescription [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Weight-loss outcomes are relatively standardized within the first six postoperative months among patients as surgery restricts food intake and promotes gut hormonal changes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, continued weight loss tends to vary widely over subsequent months and years, with weight reoccurrence being a common incidence [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Existing literature further submits that the powerful physiological effects of surgery cause significant weight loss during the first year \u003cem\u003edespite\u003c/em\u003e non-adherence to diet and physical activity recommendations. As the early effects of surgery decline, patients are vulnerable to returning to unhealthy habits [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003eThe 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\u0026rsquo;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.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThis 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\u0026rsquo;s feelings and attitudes with the intent to gain in-depth insight into the post-bariatric surgery experience.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment\u003c/h2\u003e \u003cp\u003eFocus 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\u0026rsquo;s ongoing needs and how they might be supported long term. Respondents provided informed consent.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eEligible participants had undergone bariatric surgery (Roux-en-Y/gastric bypass, or gastric sleeve) within 48 months prior to the study and were adults (18\u0026ndash;70 years old). Inability to communicate in English was the only exclusion criteria, and no one was excluded for this reason.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eFocus Group\u003c/h2\u003e \u003cp\u003eThe 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eParticipants self-reported their age, height, current weight, and number of months since surgery. BMI was calculated as weight (Kg)/height (in meters)\u003csup\u003e2\u003c/sup\u003e. Group discussion was generated and guided by a list of five open-ended questions about post-surgery challenges (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). 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.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFocus Group Discussion Guide\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1- Do you find it difficult to maintain your current weight? If yes, why?\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2- What was your biggest challenge 0\u0026ndash;3 months after surgery?\u003c/p\u003e \u003cp\u003ea. 6 months after surgery?\u003c/p\u003e \u003cp\u003eb. 1 year after surgery?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3- List any positive or negative changes that have occurred since surgery, in the following relationships or situations:\u003c/p\u003e \u003cp\u003ea. In your family\u003c/p\u003e \u003cp\u003eb. With your spouse/partner\u003c/p\u003e \u003cp\u003ec. In friendships\u003c/p\u003e \u003cp\u003ed. In social interactions\u003c/p\u003e \u003cp\u003ee. In your work/professional life\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4- What is one thing you didn\u0026rsquo;t expect or wished you had known about weight-loss surgery?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5- What advice would you give to someone thinking about having weight-loss surgery?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eBasic 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\u0026ndash;2); b) relationships and social situations (question 3 a-e); c) additional support needed post-surgery (questions 4\u0026ndash;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.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eNine 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\u0026ndash;29) or obesity (BMI\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;30) classification (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Themes from analysis of the discussion transcription are presented in this section. Selected responses in participant\u0026rsquo;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\u0026rsquo;s age.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFocus Group Descriptive Statistics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003cp\u003e(M, F)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge (yrs.)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWeight\u003c/p\u003e \u003cp\u003e(lbs.)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003cp\u003e(Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMonths since surgery\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll (M, SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;2, F\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.3 (9.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e221.8 (58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33.9 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.2 (10.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e49.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e262\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePhysical Changes: Victories and Challenges\u003c/h2\u003e \u003cp\u003eParticipants 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. \u003cem\u003e\u0026ldquo;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\u0026rdquo;\u003c/em\u003e (F, 49). \u0026ldquo;\u003cem\u003eMy diabetes and high blood pressure are gone! - and I was able to stop taking so many medications. I can\u0026rsquo;t believe how much better I feel and I never want to go back to how I was before\u0026rdquo;\u003c/em\u003e (M, 53).\u003c/p\u003e \u003cp\u003eCommon 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.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThey didn\u0026rsquo;t warn us enough about constipation after surgery. It\u0026rsquo;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\u003c/em\u003e (F, 68).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe 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 \u0026ldquo;before and after\u0026rdquo; weight-loss pictures, and offering emotional support when physical changes felt overwhelming. \u003cem\u003e\u0026ldquo;My spouse keeps telling me how great I look, but it\u0026rsquo;s hard for me to see it. I know I\u0026rsquo;ve lost weight, but I still see a fat person in the mirror\u0026rdquo;\u003c/em\u003e (F, 49).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI 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\u0026rsquo;t believe it! I kept asking my daughter \u0026ldquo;Why is this too big?\u0026rdquo; and she was laughing at me and helping me to get smaller sizes\u003c/em\u003e (F, 63).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants 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. \u003cem\u003e\u0026ldquo;It\u0026rsquo;s the little victories that feel so great like space on the sides of me when I\u0026rsquo;m sitting in the car and being able to go up the stairs without [feeling like] dying\u0026rdquo;\u003c/em\u003e (F, 63).\u003c/p\u003e \u003cp\u003eThere 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, \u003cem\u003e\u0026ldquo;I do better with exercise if I know I have to meet somebody. I need accountability\u0026rdquo;\u003c/em\u003e (F, 49).\u003c/p\u003e \u003cp\u003eThe group expressed an increased need for exercise assistance. They felt many exercise classes and videos were geared toward \u0026ldquo;fit people\u0026rdquo; and were not tailored to the needs of a person recovering from obesity. One man commented on the fact that he didn\u0026rsquo;t follow the recommendations given by the exercise physiologist before surgery and stated, \u003cem\u003e\u0026ldquo;There\u0026rsquo;s these \u0026lsquo;ologists\u0026rsquo; offering to help you, but you have to want to listen to them and do the things they are telling you to do\u0026rdquo;\u003c/em\u003e (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. \u003cem\u003e\u0026ldquo;I go to the gym and feel intimidated. Every day I look at the weight machines and say today I\u0026rsquo;m going to figure out how to do those, but then I just walk the track and leave and say, maybe tomorrow\u0026rdquo;\u003c/em\u003e (F, 49). \u003cem\u003e\u0026ldquo;My friend who likes to exercise keeps inviting me to go to the gym with her. I have gone a few times and it\u0026rsquo;s much less intimidating now\u0026rdquo;\u003c/em\u003e (F, 38).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEating Behaviors: New Versus Old Habits\u003c/h2\u003e \u003cp\u003eDiscussion 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: \u003cem\u003e\u0026ldquo;I\u0026rsquo;m not food\u0026rdquo;\u003c/em\u003e (M, 49) and \u003cem\u003e\u0026ldquo;I\u0026rsquo;m in control of what I eat. I can say no\u0026rdquo;\u003c/em\u003e (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. \u003cem\u003e\u0026ldquo;I had a deep-seeded need, a mindset to overeat. I have learned that I don\u0026rsquo;t need to order or eat large quantities of food. Now I feel better when I don\u0026rsquo;t overeat\u0026rdquo;\u003c/em\u003e (M, 53).\u003c/p\u003e \u003cp\u003e 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. \u003cem\u003e\u0026ldquo;I don\u0026rsquo;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\u0026rdquo;\u003c/em\u003e (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. \u003cem\u003e\u0026ldquo;I\u0026rsquo;m scared because I\u0026rsquo;m craving junk food and wanting to eat things I shouldn\u0026rsquo;t\u0026rdquo;\u003c/em\u003e (F, 63).\u003c/p\u003e \u003cp\u003e 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. \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t like to eat out anymore because I feel guilty when I waste food\u0026rdquo;\u003c/em\u003e (F, 38). \u003cem\u003e\u0026ldquo;Waiters get worried when you don\u0026rsquo;t eat. They keep asking to get you things. I have learned to say, \u0026lsquo;\u0026ldquo;I\u0026rsquo;m just here to enjoy the time and company\u0026rdquo;\u0026rsquo;\u003c/em\u003e (M, age 49). \u003cem\u003e\u0026ldquo;I make sure I\u0026rsquo;m the last person in the food line and then everyone is focused on eating what\u0026rsquo;s on their own plate and I can take just a little and enjoy talking to others\u0026rdquo;\u003c/em\u003e (F, 63).\u003c/p\u003e \u003cp\u003e 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. \u003cem\u003e\u0026ldquo;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\u0026rsquo;t know what else to do\u0026rdquo;\u003c/em\u003e (F, 63). \u003cem\u003e\u0026ldquo;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?\u0026rdquo;\u003c/em\u003e (M, 49).\u003c/p\u003e \u003cp\u003eThe 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. \u003cem\u003e\u0026ldquo;I forget to just enjoy my food. I used to eat really fast, now I don\u0026rsquo;t eat very much and I hardly feel like it\u0026rsquo;s worth the effort\u0026rdquo;\u003c/em\u003e (F, 49). \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t feel hungry like I used to. I have to set alarms sometimes to remember to eat\u0026rdquo;\u003c/em\u003e (F, 38). \u003cem\u003e\u0026ldquo;The cravings for sweets and junk food come back. I shouldn\u0026rsquo;t want them after all this, but I do. I want the treats and I\u0026rsquo;m eating things I know I will regret eating\u0026rdquo;\u003c/em\u003e (M, 49).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOngoing Emotional Support\u003c/h2\u003e \u003cp\u003eAnalysis 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 \u0026ldquo;surgery anniversary\u0026rdquo; when weight loss slows/stops and life settles back to normal. \u003cem\u003e\u0026ldquo;You feel great in the year after surgery, but then start to feel the creeping back of old habits\u003c/em\u003e\u0026rdquo; (M, 49). \u003cem\u003e\u0026ldquo;When the weight loss stops or you gain back some pounds, it\u0026rsquo;s scary. No one wants to fail\u0026rdquo;\u003c/em\u003e (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. \u003cem\u003e\u0026ldquo;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\u0026rdquo;\u003c/em\u003e (F, 63). \u003cem\u003e\u0026ldquo;It would be great to have someone to call when you\u0026rsquo;re struggling -someone who\u0026rsquo;s been through the program and can talk to you and keep you going\u0026rdquo;\u003c/em\u003e (F, 49). Participants described feelings of fear related to the possibility of losing a renewed self-acceptance or social acceptance. \u003cem\u003e\u0026ldquo;I\u0026rsquo;m ok. I\u0026rsquo;m starting to like myself for the first time in a really long time\u0026rdquo;\u003c/em\u003e (F, 38). \u003cem\u003e\u0026ldquo;The fear of gaining the weight back is terrifying for me!\u0026rdquo;\u003c/em\u003e (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.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI\u0026rsquo;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\u0026rsquo;s weird. It kinda makes me mad. It\u0026rsquo;s like I matter more now\u003c/em\u003e (F, 49).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve had the opposite experience. I used to get stared at a lot. Now I\u0026rsquo;m just an old guy that nobody notices. It\u0026rsquo;s nice\u0026rdquo;\u003c/em\u003e (M, 53).\u003c/p\u003e \u003cp\u003e 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. \u003cb\u003e\u0026ldquo;\u003c/b\u003e\u003cem\u003eMy 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\u0026rdquo;\u003c/em\u003e (M, 53). \u003cem\u003e\u0026ldquo;My family eats what they want and it\u0026rsquo;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\u0026rdquo;\u003c/em\u003e (F, 38). \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t like it when my husband tries to tell me what I should and shouldn\u0026rsquo;t eat. I don\u0026rsquo;t like being watched over\u0026rdquo;\u003c/em\u003e (F, 68). The group proposed a class geared toward educating family members and friends. \u003cem\u003e\u0026ldquo;It would be great to have a class for spouses with information about this whole experience so they can understand what you\u0026rsquo;re going through.\u0026rdquo;\u003c/em\u003e (M, 49). \u003cem\u003e\u0026ldquo;My family needs to know what things are helpful to say, and what is not helpful. I don\u0026rsquo;t need judgmental advice\u0026rdquo;\u003c/em\u003e (F, 38). \u003cem\u003e\u0026ldquo;I need help to be accountable, not to be nagged\u0026rdquo;\u003c/em\u003e (F, 63).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eParticipants 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 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Self-efficacy is thought to be the prime factor for influencing human behavior and is defined as a person\u0026rsquo;s belief in his/her ability to succeed in a particular situation [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Bariatric surgery patients may benefit from programs that aim to enhance self-efficacy for eating and exercise behaviors [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e 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 [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Anxiety, depression, and mood disorders are three to four times higher among individuals with obesity [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Coping is a conscious or unconscious effort to solve personal and interpersonal problems, to minimize or tolerate stress or conflict [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Bariatric patients may benefit from programs that teach adaptive or proactive coping strategies [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA 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 [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] and more specifically, may promote physical activity and reduce sedentary behavior [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Social support is important in preventing and overcoming chronic pathologies [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFocus 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 [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003eIn 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\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFocus Group Feedback\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain Themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAreas of Emphasis for Future Programs\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical Changes\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e\u003cb\u003eVictories and Challenges\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrategies for reducing sedentary behavior.\u003c/p\u003e \u003cp\u003ePractical exercise ideas and instruction.\u003c/p\u003e \u003cp\u003eBody dysmorphia education.\u003c/p\u003e \u003cp\u003eWeight maintenance practices.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEating Behaviors\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e\u003cb\u003eNew vs. Old Habits\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeal planning ideas, tips for healthy food preparation.\u003c/p\u003e \u003cp\u003eRecipe sharing.\u003c/p\u003e \u003cp\u003eCooking demonstrations.\u003c/p\u003e \u003cp\u003eMindful eating education.\u003c/p\u003e \u003cp\u003eEmotional eating education.\u003c/p\u003e \u003cp\u003eEffective coping strategies education.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOngoing Emotional Support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpportunities for peer interaction.\u003c/p\u003e \u003cp\u003eEducational classes for family members.\u003c/p\u003e \u003cp\u003eMethods for combating weight stigma.\u003c/p\u003e \u003cp\u003ePositive psychology practices.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eStrengths\u003c/h2\u003e \u003cp\u003eA 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.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eSample 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) [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. 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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Research and Practice\u003c/h2\u003e \u003cp\u003eRehabilitation 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 \u003cem\u003erecovering\u003c/em\u003e from obesity. Support group meetings included mindfulness training, and recipe sharing. Results may continue to aid in the development of future weight-management programs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFocus 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.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo funds, grants, or other financial support was received.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e \u003cp\u003eThe authors have no financial or competing interests to declare that are relevant to the content of this article.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval:\u003c/strong\u003e \u003cp\u003eThis 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.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate:\u003c/strong\u003e \u003cp\u003e All participants provided their own written informed consent prior to participating in this study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003ePatients signed informed consent regarding publishing their data.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll 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.\u003c/p\u003e\u003ch2\u003eAvailability of data and material:\u003c/h2\u003e \u003cp\u003eDe-identified data and materials (semi-structured interview guide) are available upon reasonable request from the corresponding author.\u003c/p\u003e\u003ch2\u003eCode availability:\u003c/h2\u003e \u003cp\u003eN/A\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHales, C. M. (2020). Prevalence of Obesity and Severe Obesity Among Adults. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db360-h.pdf\u003c/li\u003e\n\u003cli\u003eTrust for America\u0026rsquo;s Health (TFAH) (2022). State of Obesity. 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K., Chung, A., Ramachandran, D., ... \u0026amp; Skouteris, H. (2021). Weight stigma and obesity‐related policies: A systematic review of the state of the literature. \u003cem\u003eObesity Reviews\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(11), e13333.\u003c/li\u003e\n\u003cli\u003eDavidson L. E., Adams T. D., Kim J., et al. (2016). Association of patient age at gastric bypass surgery With long-term all-cause and cause-specific mortality. \u003cem\u003eJAMA Surg.\u003c/em\u003e151(7): 631\u0026ndash;637. doi:10.1001/jamasurg.2015.5501\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-social-science-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"diss","sideBox":"Learn more about [Discover Social Science and Health](https://www.springer.com/journal/44155)","snPcode":"","submissionUrl":"","title":"Discover Social Science and Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"bariatric surgery, obesity, rehabilitation, social support, focus group","lastPublishedDoi":"10.21203/rs.3.rs-4992676/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4992676/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis 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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA 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.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree 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.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eFindings 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.\u003c/p\u003e","manuscriptTitle":"Physical and Social Health Needs of Postoperative Bariatric Surgery Patients: A Focus Group.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-07 08:52:04","doi":"10.21203/rs.3.rs-4992676/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-26T08:44:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-19T16:44:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-18T22:34:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200606361889637222952517788885806051677","date":"2024-11-08T03:51:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310597028036101141745281431578919510879","date":"2024-11-07T21:51:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-29T09:38:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-06T01:27:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-05T07:57:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Social Science and Health","date":"2024-08-28T16:52:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-social-science-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"diss","sideBox":"Learn more about [Discover Social Science and Health](https://www.springer.com/journal/44155)","snPcode":"","submissionUrl":"","title":"Discover Social Science and Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"25500c71-caca-4f32-afdd-25b531ec94d2","owner":[],"postedDate":"October 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-01-10T02:38:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-07 08:52:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4992676","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4992676","identity":"rs-4992676","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}