Social Support Systems: A Qualitative Analysis of Female Bariatric Patients After the First Two Years Postoperative

Abstract

Background:

Obesity remains a prevalent public health concern in the United States, and as such, bariatric surgery is on the rise. Little research focus has been placed on the psychosocial impacts of the bariatric surgery experience once a patient is past 2 years postoperative. The purpose of this study was to explore experiences of patients who have undergone bariatric surgery at least 2 years prior and to gain an understanding of the successes and challenges they have faced since surgery.

Materials and Methods:

This study used a qualitative research design, guided by a phenomenological approach, to investigate and describe the meaning and essence of experiences of patients with social support after bariatric surgery. Semi-structured interviews were conducted with a sample of nine participants who had undergone bariatric surgery and were 2–7 years postoperative. This study sought to answer the question: What are the meaningful experiences of bariatric patients who are at least 2 years postsurgery?

Results:

Two main themes emerged from the data: (a) interpersonal relationships and (b) bariatric support. Upon further analysis, three subthemes emerged from interpersonal relationships: “We are family,” “I get a little help from my friends…or not,” and “The working world.”

Conclusion:

Support systems ranged from family, friends, and the workplace to bariatric-specific groups. Although all surgeons generally encourage support groups, only half of participants reported attending them regularly. In addition, there is no common standard to which all bariatric clinics are mandated to follow, thus not all support groups are created equal.

Introduction

Obesity rates continue to rise and remain a serious public health concern in the United States. More than two-thirds of adults (68.8%) are considered overweight or obese, and more than one-third (35.7%) of U.S. adults are obese, constituting more than 78 million American men and women.¹ Individuals elect to undergo bariatric surgery hoping to achieve long-term weight loss and to improve obesity-related comorbid conditions.²

However, questions still arise about long-term bariatric surgery success and its effect on weight loss maintenance.^2,3 Past research indicated that about 18 months to 2 years after surgery, weight loss as a results of surgery stops, and a significant number of individuals begin to regain the weight they had lost.^4,5 In addition, general recommendations are that continuing care postsurgery is vital in ensuring long-term success by monitoring weight loss, postsurgical and nutritional complications, and providing continued guidance and support as bariatric patients engage in lifestyle changes.⁵ Weight regain concerns are when support is needed most. Nevertheless, many longitudinal follow-up bariatric surgery studies are short-term and incomplete when evaluating weight loss maintenance and social support.²

Social support can develop from both organic and formal support systems. Organic support includes both family and friendship networks.⁶ Formal support is provided by professionals (such as bariatric support groups through a patient's surgery center) and through social or community bonds (such as online weight loss surgery forums).⁶ Organic support is generally viewed as a more enduring source of support, while other forms of support may be more transient,⁶ though whether one or the other is the “gold standard” of support is not clear. Research indicates that participation and attendance at formal bariatric support groups postsurgery is associated with greater excess weight loss (EWL), but it remains unclear what role organic support plays.^7,8 Meana and Ricciardi found that most relationships in the lives of bariatric patients are not immune to change once the weight starts coming off, and that relationships are interconnected.⁹ A person cannot alter one substantial aspect of life (such as with bariatric surgery) and then expect the change to not have a significant effect on other parts.⁹ Relationships are most prone to change postsurgery, both positively and negatively.⁹ Learning new skills in key areas where change creates tension is essential for reaping the full benefits of surgical weight loss.

Social support is an important component of successful lifestyle change. Individuals with higher levels of social support tend to do better in weight management.⁸ Sarwer et al. found that many marital relationships improved dramatically postsurgery, and that issues regarding divorce were generally tied to poor presurgical relationships.¹⁰ The postoperative period may be quite difficult because of the necessary change in eating habits.^11,12 This may be associated with emotional discomfort, so a personal support system of family and friends should be in place.^11,12 Peer and family support is important in helping people learn greater self-acceptance, develop new norms for interpersonal relationships, and manage stressful work- or family-related situations.¹¹ Social support along with strong family support is of great importance to an individual who has undergone bariatric surgery.

Bariatric surgery is a life-changing procedure that requires a life-long commitment from the individual. The researchers examined 187 bariatric articles for a comprehensive review of the literature, and it appears most research on bariatric surgery focuses primarily on health-related outcomes using quantitative research. There is limited in-depth research that examines personal and psychosocial experiences that patients face following the first year after bariatric surgery. Using a qualitative approach to explore the meaning of the bariatric experience and sharing it with others provides an opportunity for future patients, families of patients, and healthcare providers to gain an understanding of what it is like to undergo a bariatric procedure and to live with the persistent change that accompanies it, after the first 2 years postsurgery and beyond. One of the questions this study explored was some of the roles social support systems played in the postsurgery journeys of participants. Ultimately, this study sought to answer the question: What are the meaningful experiences of bariatric patients who are at least 2 years postsurgery?

Method

This study used a qualitative research design, guided by a phenomenological approach, to investigate and describe the meaning and essence of experiences of patients at least 2 years after bariatric surgery.^13,14 Phenomenological studies are primarily open-ended, searching for themes of meaning in participants' lives.^14,15 Research is conducted through in-depth interviews using open-ended questions as a guide (Table 1). By interviewing participants, a greater understanding of post-bariatric surgery experiences with social support was provided. Moreover, interviews were semi-structured in order to provide more flexibility by the researchers, thus allowing participants to describe their thoughts and opinions freely while not being bound by preconceived questions from the researchers. One of the benefits of using semi-structured interviews with a sample of participants who have all experienced similar social conditions is that it gives power to the stories of relatively few participants,¹⁴ such as life experiences.

Table 1.

Open-Ended Interview Questions

1. How has bariatric surgery has affected your quality of life now that you are 2+ years postop?

2. What is different for you now than after the first year postop?

3. How has bariatric surgery impacted your health? (both positive and negative)

4. How has bariatric surgery impacted your emotional health?

5. How has bariatric surgery impacted your personal relationships?

6. How has weight loss surgery (WLS) affected your nutritional intake?

7. What types of WLS support groups or online communities do you participate, if any? Why or why not?

8. What are the things only people who've had WLS know about that most outsiders would not?

9. What are the cultural/social implications you have experienced since having WLS?

10. Tell me about your personal satisfaction with bariatric surgery.

Participants

Upon approval from the university's Institutional Review Board, data collection began by contacting participants for individual interviews using purposeful convenience sampling in which the researchers contacted potential participants who agreed to be interviewed and who met the study criteria. The use of purposeful convenience sampling enabled relatively easy access to qualified participants.¹³ The participants were recruited from public bariatric support forums that contain hundreds of participants. Although researchers may have posted online to the public forums, personal contact with participants did not occur. The researchers may have recognized online screen names but did not personally know the participants. By contacting participants who met the inclusion criteria for this study, the researchers conducted semi-structured interviews with nine bariatric surgery patients who were at least 2 years postsurgery. Inclusion criteria were those who were at least 2 years postoperative and over the age of 18. Participants were recruited by e-mail/telephone regardless of gender, age, surgery type, ethnicity, or socioeconomic status. The study sample included nine women who ranged from 27 to 57 years of age mean (M=42 years). Seven participants had the vertical sleeve gastrectomy (VSG) surgery, and two had the Roux-en-Y gastric bypass (RYGB). Self-identified ethnicities of participants were Caucasian (n=5), Hispanic (n=2), and African American (n=2). Participants ranged from 2 to 7 years postoperative (M=3 years; Table 2). At the time of the interview, participants lived along the U.S. West and East coasts, the gulf region, as well as the Midwest. Weight before surgery following the preoperative diet ranged from 199 to 298 pounds (M=247.4 pounds). Initial weight loss after surgery ranged from 58 to 116 pounds (M=88 pounds). Weight gain after reaching plateau ranged from 0 to 48 pounds (M=8.7 pounds; Table 3).

Table 2.

Participant Demographics

Name	Age (years)	Ethnicity	Marital status	Time since surgery	Surgery type
P1	54	Caucasian	Divorced	7 yrs. 5 mo.	RYGB
P2	30	Caucasian	Married	2 yrs. 11 mo.	VSG
P3	45	Hispanic	Married	2 yrs. 4 mo.	VSG
P4	27	Caucasian	Married	2 yrs. 5 mo.	VSG
P5	56	Caucasian	Married	3 yrs.	VSG
P6	57	Caucasian	Divorced	2 yrs. 7 mo.	VSG
P7	31	African American	Single	2 yrs. 5 mo.	VSG
P8	34	Hispanic	Divorced	2 yrs. 9 mo.	RYGB
P9	45	African American	Divorced	2 yrs. 5 mo.	VSG

RYGB, Roux-en-Y gastric bypass; VSG, vertical sleeve gastrectomy.

Table 3.

Self-Reported Participant Presurgery and Current Anthropometrics

Name	Weight on day of surgery (pounds)	BMI on day of surgery ^*	Lowest weight achieved (pounds)	Postsurgery weight loss (pounds)	Current weight (pounds)	Current BMI ^*
P1	289	49.6	176	113	184	31.6
P2	220	43	162	58	210	41
P3	199	36.4	139	60	139	25
P4	235	36.8	154	81	164	27.7
P5	210	38.4	140	70	145	26.5
P6	243	40.4	128	115	133	22.1
P7	298	48.1	184	114	184	29.7
P8	283	47.1	172	111	175	28.2
P9	240	39.9	170	70	170	28.3

Body mass index (BMI) formula: weight (lb)/[height (in)]²×703.

Qualitative data analysis and coding

There were eight stages used to define the qualitative data analysis of this research. Stages undertaken included: (1) formulation of the research question; (2) data collection; (3) detailed field notes and summarizing; (4) transcription and organizing; (5) coding keywords and potential themes; (6) identifying themes and patterns; (7) defining codes in codebook; and (8) developing the main narrative.¹³

The initial data analysis included field notes, organizing, summarizing, and coding. The secondary data analysis included reviewing the transcriptions for themes, patterns, and narratives that might be used to describe a participant's rich experience. Comparing and analyzing patterns assisted with understanding how coding categories were alike and how they were different. Each audiotaped interview was transcribed verbatim, and field notes were taken during each interview. After transcription, each interview was printed for clarity, and codes were manually generated in order to ensure vital information was complete and considered in this study. Codes were generated based on the conceptual framework of a phenomenological study as described by Hays and Singh¹³ and from the research question. Codes allowed the researchers to provide direct and indirect information, including descriptions and quotes, to support potential themes and patterns. In addition, sticky notes of various colors aided in identifying themes. The first transcript reading helped develop the coding categories, and then the second reading was conducted to start formal coding in a systematic way using colored sticky notes to group related data.¹³ The second transcript reading aided in identifying new categories of information, and the two lists were merged into one, which then represented the final codebook. The transcript of the third interview was compared to the previous code list to see if new categories emerged, and this process continued, comparing each subsequent transcript for coding categories. Themes were eventually developed into a written description of the participants' experiences with bariatric surgery to answer the research question. Quotes from the participants provided a rich and profound description of their experiences.¹⁵

Before and after each interview, the researcher wrote substantial notes in a reflective journal in order to reconstruct the environment in which the interview took place. Information was audio recorded as follows: (1) place, time, date of interview; (2) demographic information on interviewees and additional contextual information; (3) essential questions asked and additional notation recorded, including information that may have added or detracted from the interview; and (4) information that was intentionally or unintentionally missed. Each journal log provided a realistic and accurate account in which the data were gathered.

Data quality concerns and study limitations

Trustworthiness is a concern of every qualitative study. The researchers established trustworthiness through credibility, peer debriefing, and reflexive journaling and field notes.¹³ Establishing trustworthiness of the findings was done by engaging in peer debriefing of instrument protocol and through prolonged discussions during all phases of the research project with peers and fellow researchers. Researcher reflexivity was engaged in by keeping a journal and field notes, which included the researchers' thoughts on participants, interview questions, participants' reactions to the questions posed, and simultaneous data collection and analysis, which involve collecting and analyzing data simultaneously.¹³ Credibility may also be a concern in qualitative data collection. Data quality, meaningfulness, and interpretation were established through depth and authenticity of the collected data. Credibility was improved through the trust that the researchers established using recollections of the researchers' own experiences with bariatric surgery and previous research and engagement with other bariatric patients. Multiple participant viewpoints also added to the authenticity of the data; information included various ages, ethnicities, and geographical locations in order to provide a more in-depth perspective. One limitation in using a purposeful convenience sample is that while many of the participants' answers were similar about their postsurgery outcomes, this population may not be representative of all bariatric surgical experiences.

Reflexive researchers' statement

The researchers' personal experiences as bariatric patients included preconceived beliefs that bariatric surgery should be for obese individuals who had failed attempts at losing weight through traditional methods with diet and exercise and who need an additional weight-loss tool to aid in achieving a healthy body weight. Being part of the weight-loss surgery community comes with a very “prosurgery” mentality that the researchers acknowledged. To focus on the participants' experiences after bariatric surgery, the researchers were required to bracket those beliefs. Steps the researchers used to bracket their beliefs started by writing three to five page autobiographies, which not only included their own bariatric stories, but also attempted to identify potential biases and assumptions about obesity and bariatric surgery before beginning the research study. Hays and Wood¹⁴ define bracketing as setting aside any assumptions made in everyday life, and they expressed the need for the researcher to reserve all prejudgments of their experiences and rely on intuition and imagination to obtain the picture of the experience.

Results

Review of the data, including individual interviews and field notes, was conducted to analyze and identify themes of the participants' experiences with social support systems after bariatric surgery. Two main themes emerged from the data: (1) interpersonal relationships, and (2) bariatric support. Upon further analysis, interpersonal relationships had three subthemes: “We are family,” “I get a little help from my friends…or not,” and “The working world.”

Interpersonal relationships

The overarching theme of the nature of interpersonal relationships after the first year had passed emerged from the data as participants described the changing dynamics of their relationships. Relationships, both personal and professional, are impacted by the effects of the surgery, and change as the patient loses weight. This can lead to difficulties and dissatisfaction within these relationships, such as the changing dynamics of friendships incurring jealousy because of the bariatric patient's weight loss or the fact that the friendship was mainly centered around food. On the other hand, some relationships thrive postsurgery. During the weight loss period, many participants found support in unlikely places such as their work environments, where co-workers encouraged healthy eating and exercise. The impact of surgery on relationships is multifaceted and highly dependent on each individual's set of circumstances and experiences.

Instead of sleeping all the time…I have the energy to consider my relationships with people now and my emotions in relation to others. [P3]

We are family

I mean my situation is unique because my husband had it [bariatric surgery] with me. I would say it brought us closer together because we were both fighting the same battle and he gave me strength when I needed it and I carried him when he needed it. [P4]

People didn't think I needed the surgery, like my kids. Everyone looks at me, like at a picture and say, “I didn't know you were that big!,” which goes to show that they don't look at the outside, but what's on the inside. I have always had a really good relationship with my family and they always looked past my weight. [P8]

Well, I know my husband is happier [laughs]. He thinks I'm sexier for sure [laughs].” [P5]

I get by with a little help from my friends…or not?

Most patients find others to be supportive in their bariatric journeys, but negative responses related to jealously or adjustment to an extreme lifestyle change can occur.^16,17 Meana and Ricciardi found that friendship networks incurred the most restructure and change due to the surgery.⁹

I feel like any major life events, like having weight loss surgery, give you clarity about who your real friends are…I think it has made me more reserved with who I trust with information and it was a surprising revelation for me…it wasn't my skinny friends that were really judgmental, it was my heavier friends, who I thought would understand where I was coming from and why I was doing what I was doing. They were the most critical and it was very hurtful. [P4]

I have a few friends who maybe our relationship was built around food, going out to eat and drink…so, now we have very little in common. [P3]

Most people have been very supportive, but I have a couple of girlfriends who are like, “you are too skinny now, you don't need to lose any more weight,” but I just see that as “haterism.” Some of this is coming from a friend who had the [gastric] bypass in 2009 and seemed to gain back most of the weight she lost. [P9]

The working world

It ought to be noted that half of participants discussed their professional/working lives and some of the changes they experienced even though this was not one of the main focuses of this study. Morbid obesity has been associated with lowered participation in compensated work, with increased absenteeism and disability.¹⁸ Working usually enacts structure on a person's life and provides a social network that is different from the interpersonal relationships involving family.¹⁹ Having bariatric surgery was also found to improve the chance of having employment.¹⁹

When I had the surgery, I was at a job and I had three weeks off and the people there encouraged me to use the gym and eat well, so I had a great support team at that time. [P9]

I would say professionally it [bariatric surgery] has allowed me to open doors that I don't know would've been previously opened without the assistance of the sleeve [VSG]. I know I am more confident and I feel not as reserved because I don't feel like I am constantly being judged by my weight. [P4]

At work, I feel more confident and I don't have to call in sick when I have to fly now because I am not going to fit on the airplane seat…we travel a lot for my department, it was just embarrassing and I used to have to ask my coworkers if they could save me a seat and if they minded if I put up the armrest because I didn't fit if the armrest was down. [P8]

Bariatric support

Attending support groups with others losing weight provides peer support and opportunity for guided discussions about changes in body image, meal preparation, relationship issues, and stress management.^11,20–22 Bariatric support group attendance after weight loss surgery is a valuable component of continuing follow-up care. Evidence shows that 1 year after surgery, there are significant differences in excess weight lost between patients who attend support groups and those who do not.^11,22 Support groups can be held in a variety of formats such as structured meetings or online bariatric surgery forums. Participants had various reasons on whether they engaged in bariatric support groups, including barriers to why they did not participate as well.

The one [support group] at my hospital I go to at least once a month because most of the people in the group are bypass [RYGB] or [adjustable gastric] band and nobody had the sleeve [VSG] and I go to help people learn about the sleeve and to check-in…you see some horror stories about people who had surgery and lost 120 pounds and gained back 130. For me, to see you're never out of the woods, you're always going to have to fight with the weight and I always need to stay on top of it. [P7]

I belong to a couple of support Web sites and I also attend once a month support groups that my surgeon puts on…I want to give people hope that that are just starting out and are thinking, “Will I ever lose the weight?” I want to give back in some way even if it's just to show that I'm a success and to answer questions. [P6]

I don't have time to attend my doctor's support group, but feel like now that I'm 2 years out [postsurgery] I'd like to go back to my doctor's relapse group because I can eat so much more and I feel like that could reinforce what I should be doing to get the rest of the weight off. [P8]

I stopped going to my doctor's support group meeting after the first 2 years because of the distance and then it seemed like it didn't apply to me. It mostly focused on the recent [newly postsurgery] bariatric patient like how many ounces of food they should eat and the different stages early out of foods. [P1]

Many participants noted that they now engage in online bariatric forums in an effort to give hope and advice to the “newbies” (newly postops) and to keep themselves accountable during their own continued weight loss journeys.

I go on the forums to read and remind myself…like the people who are about to have surgery and they're so nervous and on the liquid diet…it just kinda puts things into perspective and I realize that my longevity is better for this surgery. I just feel that by reading other people's [online] posts, you're not alone. It helps keep me accountable…it's just for me. [P9]

Discussion

Experiences of participants were profiled in an attempt to share their qualities through profound description. The experiences of all participants' lives after bariatric surgery provided a glimpse of what role social support plays during and long after weight loss surgery. Support systems ranged from family, friends, and the workplace to bariatric-specific groups.

Although all surgeons generally encourage support groups, only half of participants reported attending them regularly. In addition, there is no common standard to which all bariatric clinics are mandated to follow, only sets of recommendations by the American Society for Metabolic and Bariatric Surgery (ASMBS).²³ This means that not all support groups are created equal, and each clinic may subscribe to different postsurgery recommendations for their patients to follow. Many formal bariatric support groups cater to newer postoperative patients (usually during the first year postsurgery),¹¹ and because the experiences of newer postoperative patients and longer-term postoperative patients usually differ, long-term postoperative patients may feel alienated by the topics and discussions at their surgical support group. Moreover, three participants had their surgeries in Mexico, which may have contributed to lack of formal support through their surgeon. Other barriers to formal support group attendance included far away locations, difficult group attendance times, and work and family commitments.

Having bariatric surgery is a lifelong decision that requires follow-up care. These patients face medical and psychosocial challenges that require continuing care for years after surgery, and the hard work begins postsurgery.²⁴ It is also pointed out that not much has been written on the topic of follow-up care, but rather the focus has been on who is a good candidate for surgery rather than what patients go through after the procedure.²⁴

A qualitative study using phenomenological approach was used for this project in order to gain a better understanding of the experiences of participants who were at least 2 years post-bariatric surgery. The use of semi-structured interviews allowed the participants to express their feelings and experiences of life after bariatric surgery. The themes around social support generated from the data collected in this study provided a glimpse of life once the magic of the first year had past and the reality of the surgery had set in.

While obesity threatens to explode into a reverberating pandemic, there is a need to understand and support those individuals who have made the decision to have bariatric surgery. Studies such as this can offer healthcare professionals needed insight and information to be supportive and provide the care necessary to this vulnerable population.

Footnotes

Acknowledgments

The authors would like to thank the women who participated in this study for sharing their time and stories regarding their bariatric surgery experiences.

Author Disclosure Statement

No competing financial interests exist.

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