Health,Weight Loss,and Surgery Beliefs: Why Patients Choose to Undergo Bariatric Surgery and What Influences Their Choice of Surgery Procedure

Abstract

Introduction:

The purpose of this study was to determine what factors influence an individual's decision to have bariatric surgery, including why they choose a particular surgery type.

Methods:

Thirty bariatric surgery patients (11 gastric bypass [GB] and 19 sleeve gastrectomy [SG]) participated in qualitative interviews pre- and postsurgery. Interviews questioned why patients chose bariatric surgery, their specific procedure choice, timing, and expectations for surgery. Verbatim transcripts were coded using a constant comparative method and a grounded theory approach. Analysis focused on surgery motivations, personal influences, and choice of procedure.

Results:

Five themes emerged regarding the decision to have bariatric surgery: Health, Activity and Lifestyle Interference, Frustration with Weight, Social Influences, and Body Image. Most participants selected GB surgery based on beliefs about weight loss outcomes. Rationales for choosing a SG centered on surgery effects, including perceptions that the sleeve was less invasive or allowed for less restrictive eating habits postsurgery. Surgery veterans emerged as an important influence on the choice of surgery procedure.

Conclusion:

Patients consider multiple factors in their decision to undergo bariatric surgery. Health care professionals should take these factors into account to help patients make informed decisions and to clarify existing misconceptions.

Introduction

Over 600,000 bariatric surgeries are performed annually with the two most common bariatric surgery procedures being the Roux-en-Y gastric bypass (GB) and the sleeve gastrectomy (SG).¹ Both procedures restrict gastric volume and alter appetite hormone signaling leading to reduced intake, enhanced feelings of fullness, and reduced sensations of hunger.² The GB procedure partitions the upper stomach, creating a small gastric pouch, and bisects the small intestine, so that ingested food bypasses the duodenum and proximal small intestine. Alternatively, the SG procedure resects the greater curvature of the stomach, but leaves the pylorus and small intestine intact.² While both surgeries lead to substantial reductions in body weight and result in similar rates of weight loss maintenance, percent weight loss is higher among recipients of GB surgery.³

Differences in surgery procedure lead to differences in physiological responses to food and nutrients. GB is associated with dumping syndrome,⁴ and these patients experience greater prevalence of micronutrient deficiencies.⁵ How patients consider the various nutritional effects of different surgery procedures in their decision-making has not been explored.

Understanding patients' perspectives of bariatric surgery, including their choice of procedures, is important as patients often have inaccurate or exaggerated expectations for surgery outcomes.⁶ Moreover, patients may select surgery procedures without fully understanding limitations. Weinstein & Marascalchi⁷ found that 52% of patients who selected the gastric banding procedure rated “maximum weight loss” as the most important surgery outcome, despite the fact GB and SG result in greater weight loss. The purpose of this qualitative study was to describe patient motivations for seeking bariatric surgery and to identify factors that impacted their choice of procedure.

Materials and Methods

Recruitment

Thirty adult bariatric surgery patients were recruited from an American Society of Metabolic and Bariatric Surgery (ASMBS) accredited surgery center located in Southeast Michigan to participate in a year-long mixed methods study examining weight and dietary changes after surgery. Patients were recruited in 2013 and 2014 during their final presurgery education class, which provided information on postoperation diet progression, recovery expectations, and guidelines for follow-up. Recruitment occurred during this class as all attendees had decided upon their surgery procedure and completed their preoperative preparation requirements. Participants were also recruited through provider referral. To participate, participants had to be 18 years of age or older with either a GB or a SG surgery scheduled and no history of bariatric surgery. As SG surgeries were performed in greater numbers than GB, recruitment aimed to obtain a sample representative of the clinic population, yielding 19 SG and 11 GB patients. Table 1 describes participant characteristics at the time of surgery.

Table 1.

Participant Characteristics by Surgery Procedure

	GB	SG
Total participants	11	19
Sex
Female	10	14
Male	1	5
Race
White	7	17
Black	4	2
Marital status
Married	6	12
Single/divorced/widowed	5	7
Type 2 diabetes^a	9	3
Presurgery BMI (mean ± standard deviation)	46.8 kg/m² ± 5.4	48.1 kg/m² ± 8.7
12 month, postsurgery BMI (mean ± standard deviation)	32.7 kg/m² ± 5.1	34.8 kg/m² ± 7.7

Self-reported Type 2 diabetes diagnosis, from researcher developed health questionnaire.

BMI, body mass index; GB, gastric bypass surgery; SG, sleeve gastrectomy surgery.

Informed consent was obtained at the first meeting by the primary investigator (PI) who carried out all research interviews and data collection. Participants met with the PI presurgery, at 6 months and at 12 months postsurgery. At each meeting, a semistructured interview was conducted followed by participant completion of dietary, health, and lifestyle questionnaires. Weights were obtained from medical charts. Participants were monetarily compensated for their time and received a digital food scale at the first meeting. All study procedures were approved by the sponsoring university and hospital Institutional Review Boards.

Interviews

Interviews utilized open-ended questions and a conversational format to elicit detail and description. Presurgery interviews took place at the surgery center. Postsurgery interviews also occurred at alternative locations as mutually agreed upon between the PI and participant. Interview topics covered dietary behaviors, weight management and weight loss, and surgery experiences. Participants were asked to reflect on their decision to have surgery in the first interview and on their choice of procedure in the third. Interviews were audio recorded, transcribed verbatim, and ranged in length from 50 min to over 2 hours.

Analysis

Interview transcripts were coded using NVivo 9.2 (QSR International, 2014). Transcripts at each time point were reviewed in their entirety and coded for any discussion of surgery decision-making, as participants often brought up surgery rationales while discussing dietary behaviors or weight history. Working independently and using an iterative process, each researcher assigned codes describing the varying rationales, motivations, and influences on decisions surrounding timing and choice of surgery. This focused coding was guided by a grounded theory, constructivist approach with codes and categories emerging based on interview content with the intent of describing participants' lived experiences and perspectives.⁸ Memos were created for each time point to organize the codes and descriptions and to aid in the creation of conceptual categories describing the influences and factors. The research team met to discuss similarities and differences in coding and interpretations, coming to a consensus on the categories and themes within surgery decision-making and surgery choice.

Next, the researchers examined each participant's motivations grouping them into one or more categories to confirm that all motivations had been uncovered, that all participants' experiences were represented in the themes, and to identify any negative cases. Negative cases⁹ included individuals who described unique rationales for surgery or who expressed only one uncommon motivation. Categories were refined based on these cases. As the majority of participants provided multiple motivations for seeking surgery, and as participants rarely indicated that one motivation was more important than another, no ranking was made.

A number of credibility checks were performed throughout the research process.⁹ During postsurgery interviews, the PI presented interpretations from previous interviews for verification as a form of member checking. Repeated contact through multiple interviews developed rapport between the PI and participants, improving trustworthiness and increasing participants' openness and honesty in answering questions. Peer-debriefing occurred during research meetings, as emerging themes and interpretations were shared with other members of the research team not involved in this analysis, including a clinician at the surgery center.

Results

Motivations for choosing bariatric surgery

Motivations for pursuing bariatric surgery as an obesity treatment were grouped into five major themes, four reflecting desired outcomes and one describing influences. Table 2 provides example quotes for each major theme.

Table 2.

Themes and Illustrative Quotes for Participants' Decisions to Have Bariatric Surgery

Theme	Illustrative quote
Health	“But my most concern is my health, and my two older sisters…I look at them and they have issues with their knees…they have all kinds of health issues, and they're really struggling. And I see they're like 5 and 6 years older than me so I kind of see a future there and I don't want to go that way.” Melinda, GB
Lifestyle and activity interference	“I was to a point where I couldn't walk, I couldn't walk a block without feeling like I was going to die. Climbing stairs was out of the question. I was sitting on my mother's couch dying…I couldn't work because I would fall asleep constantly and I was so heavy I couldn't move.” Robin, GB
Frustration with weight	“You try some more things, you try some more medicines, you try exercise, and eventually you get to the point where you say, well, obviously these things are not working.” Jonathan, SG
Social influences	“My mom was like ‘well if you want, go through with it.’ My sister was like ‘yeah we will be here to support you.’ And then my aunt was there and she was like ‘go for it!’ …as soon as the holiday is over just call and set up an appointment.” Danielle, SG
Body image	“Other times I'm kind of embarrassed, like how, my size, I've gotten this big. I allowed myself to get here. So I don't want to go anywhere.” Gabrielle, GB

Health

Health included current and future health conditions affected by obesity as well as longevity.

Obesity-related health conditions

Over two-thirds of participants reported that health concerns were a leading motivation for bariatric surgery. They hoped surgery would improve or eliminate obesity-related comorbidities and/or that weight loss would provide relief to conditions made worse by obesity such as spinal stenosis and osteoarthritis. Participants also desired to reduce or eliminate medications. Diabetes was the most commonly mentioned comorbid condition and it was frequently identified as a “tipping point” in the decision to have surgery. A recent diagnosis of diabetes or prediabetes, symptoms of a worsening condition (e.g., needing insulin) or fear of long-term complications such as an amputation were strong motivators.

Avoid future health problems

Participants, particularly those who were younger or did not have major health concerns at the present, wished to avoid future health problems. Many wanted to avoid health conditions they observed in family members.

Longevity

Participants viewed their obesity as potentially leading to early mortality. Many participants wanted to ensure that they lived past a certain age or believed that without surgery they “would only be here another 15, 17 years.” Participants with children or grandchildren spoke of the desire to “be there” for their family and/or future grandchildren.

Lifestyle and activity interference

Almost all participants discussed limitations in desired lifestyle and activities due to obesity. They anticipated that weight loss from bariatric surgery would remove barriers they experienced across three lifestyle domains.

Activities of daily living

About half of participants expressed frustration with being unable to do “simple” activities such as bending over to tie a shoe or climb stairs, and described difficulty in completing household chores, gardening, or grocery shopping. These were challenging due to size or left participants “feeling exhausted.” Several participants described “low energy” in general, which impacted their daily activities.

Social activities

Participants describe an inaccessibility imposed by obesity, leaving them unable to participate in activities with friends and family such as vacations or dining. The inability to fit in a booth, an airplane seat, or an amusement park ride and not being able to keep up with others when walking were common sources of frustration and embarrassment, so much so that they were often a deterrent from leaving the house. One participant, Ellen, referred to her weight as a “social burden,” stating “A whole part of your social life is removed if your friends are going to the bar or to dinner and you can't come.”

Physical activity

Participants expressed a desire to be more physically active, to exercise, or “get fit,” including those who had started going to the gym as part of their presurgery preparations. Many noticed that certain activities they used to enjoy were more difficult or uncomfortable such as hiking, playing golf, or playing with children. Some were concerned about losing mobility, while others described physical pain associated with excess weight.

Frustration with weight

Participants believed surgery was their only option for weight loss, saying “I couldn't do it on my own,” and described surgery as a “tool” to manage weight long-term.

Unsuccessful weight loss history

Almost all participants described extensive dieting histories. Participants were “tired of yo-yo dieting,” or expressed frustration that their weight loss was “at a standstill.” Several remarked that they could not lose enough weight, seeming to hit a plateau which still left them very overweight or obese. Many were resigned to the fact that nothing led to long-term success. Most believed that surgery-induced weight loss would be more encouraging than previous weight loss attempts. Participants believed that the surgery would help them “work” to maintain long-term weight loss, serving as a motivator for dietary and lifestyle changes.

“Fed Up” with obesity

Many participants expressed “I don't want to be this size anymore,” referring not just to physical or social limitations but also to the amount of time they had been obese. Participants frequently stated, “I was fed up. I had enough,” or “I just can't do this anymore.”

Social influences

Social influences were family members, friends, coworkers, and health professionals who provided suggestions and support regarding obesity management, or who provided input into the surgery decision-making process.

Health care provider

Several participants reported that their decision to investigate or undergo bariatric surgery was the result of suggestions by primary care doctors, OBGYN, or other (nonbariatric) surgeons. One participant was told that weight loss from bariatric surgery would likely eliminate the need for a knee replacement. Participants trusted their physicians: if their physician felt bariatric surgery was the best course of action, the participant followed that advice.

Family concern

Several participants pursued bariatric surgery after a family member or close friend initiated a conversation about weight and health or suggested bariatric surgery as an option. One participant reported that older family members worried that he would die before them, while another described a conversation where her family gave surgery as an “ultimatum” due to her young age and history of losses and regains of over 100 pounds.

Role modeling

Three participants, all mothers, reported they wanted to be a “role model” for their children. These mothers expressed guilt or fear related to their children's weight. They wanted to achieve a healthy weight and adopt positive dietary behaviors to influence their children.

Social support

Having support of family members was a strong influence that encouraged many to “take the leap.” Friends and family helped participants make dietary and behavioral adjustments before surgery adding to participants' belief that they would be successful.

Body image

Body image centered around physical attributes of the body related to self-esteem, self-image, or personal values ascribed to thinness. This motivation was expressed by a minority of participants wanting to be “skinny,” “slimmer,” or “to look good.” Some participants stated that they did not have pictures of themselves or described “social anxiety” due to weight. Several participants discussed negative self-esteem saying “I don't like me” or “I don't like the way I look” and believed weight loss would improve their body image.

Choice in surgery procedure

Different influences and motivations emerged in discussions of why participants selected a particular surgical procedure. All participants attended presurgery presentations by the bariatric clinic; however, a majority of participants sought other sources of information, including the internet, research studies, and social sources such as support groups. Table 3 provides example quotes for each theme.

Table 3.

Themes and Illustrative Quotes for Participants' Choice in Surgery Procedure and Influence of Surgery Veterans

Surgery procedure	Illustrative quote
GB	“You still have to limit what you eat, and you have to eat the right things, but now I'm more physically going to be forced to that. That's why I wanted the gastric bypass for the diabetes and I want that negative…I get nauseous when I eat sugar, because I shouldn't be eating sugary stuff.” Melinda, GB
GB	“The weight loss window was larger with the regular bypass than it was with the sleeve and the amount of weight I had to lose, I thought “let's go with the bypass” and he agreed, so that's what I went with.” Joelle, GB
SG	“I didn't want to do the full gastric bypass because I don't like the idea that I'm re-routing everything and you end up with more vitamin deficiencies and I already have that, so I didn't want to increase that.” Rachel, SG
SG	“I have probably a little bit more flexibility on what I can and cannot eat this way…” Heidi, SG
Surgery veterans	“And having seen a successful person…I mean he was huge, five bills minimum, and he lost a ton of weight. I don't know what he ended up at last, I saw he had to be 220. I mean he looks fantastic!” Brent, SG
Surgery veterans	“I have three…family members that's had surgery. I've had one that had the sleeve, I have one that—two that had the gastric bypass. Um my cousin like, it's the best thing she ever did in her life.” Kendra, GB.

GB surgery rationales

Four themes describe the decision to undergo GB surgery. Only one participant did not mention any of these reasons, explaining she chose GB solely based on the advice of her doctor.

Better weight loss

A majority of participants' reasons for choosing GB surgery centered around better weight loss outcomes. Participants explained that GB led to more weight loss or expressed concern that they would not lose enough weight with the SG. Several participants viewed the weight loss as “more drastic” and therefore more desirable.

Confidence in procedure

Several participants expressed confidence in the research supporting GB surgery, believing the “evidence” was “more concrete.” They stated that the sleeve was “too new” and felt more comfortable with the bypass because it had been performed longer.

Restrictions

Several participants (including two SG recipients) identified “negative effects” of the GB surgery as a benefit. In particular, they saw dumping syndrome as a means to help control their intake.

Medical conditions

Health and medical conditions were often considered during the decision-making process by many participants. Two participants reported their “research” uncovered that GB was more effective for diabetes remission or elimination of heart burn, leading them to choose GB.

SG rationales

In contrast to GB patients who expressed one primary driving factor in their surgery choice, a majority of SG participants described multiple considerations.

GB “Too Extreme.”

Over half of the SG recipients viewed GB as “too invasive,” “drastic,” or “severe.” Participants stated that they did not want to be “re-routed” or to have “the physiology of your body” changed, indicating that the physical changes were unappealing or “doing artificial things to your body.” Many participants also stated that they did not want malabsorption of nutrients. Several liked that the stomach was “still there” after surgery. The SG was also viewed as having fewer negative side effects. Seven participants did not want dumping syndrome to “eat socially,” “indulge” occasionally, or in case they “screw up and eat something sweet.” Some participants felt dietary restrictions would hinder successful weight loss because they would feel deprived, “cheat,” and return to unhealthy eating habits.

Confidence in procedure

Many sleeve participants described a strong sense of trust in their “research” on the sleeve procedure. Acknowledging the sleeve was a newer procedure, many understood that it was a more common procedure, which added to their trust in its effectiveness.

Not a Lap-band

About half of participants discussed initially considering a “Lap-band,” ultimately deciding against this procedure. Reasons included not wanting a “foreign object” in their body, disliking the adjustment procedure, and concern for band erosion over time. Only one participant specifically mentioned inferior weight loss outcomes from the Lap-band.

Bypass “back-up” plan

A few participants mentioned that if the SG did not work, they would be able to “have my sleeve converted into a bypass later” to “jump start” weight loss again. Two of these participants implied that their surgeon recommended SG, in part, because of this reason.

Medical conditions

The SG was viewed as less disruptive to the management of conditions such as Crohn's disease, endocrine disorders, and kidney stones. Medications were often a determining factor: Participants chose a SG if their health condition required medications contraindicated following GB surgery. Anti-inflammatories for arthritis or pain were most frequently mentioned.

Influence of surgery veterans on selection of bariatric surgery

Surgery veterans refer to acquaintances, family members, friends, or colleagues who had a bariatric surgery procedure. Twelve SG and 10 GB patients reported that their surgery choice was influenced by a surgery veteran. Surgery veterans' personal testimonies, health improvements, and weight-loss results either encouraged participants to undergo the same type of procedure or prompted them to select the alternative. Participants' observations of the postsurgery behavioral and dietary practices of surgery veterans also impacted their choice of procedure.

Discussion

This study explored the motivations and influences on patients' decisions regarding bariatric surgery. Health emerged as the most common motivation, followed by obesity-related activity limitations and a history of unsuccessful weight loss attempts. When deciding between surgery types, participants balanced the desire for weight loss and health improvements with their perceptions of the surgery, specifically, invasiveness of the procedure and potential negative side effects. Social influences were prominent in both the decision to have surgery and the choice of procedure. These results suggest that patients incorporate information from multiple sources and include personal, social, and surgical factors into their final decision.

To the authors' knowledge, this is the first in-depth exploration of the factors considered when deciding on a bariatric surgery procedure. That GB surgery was believed to be more invasive than the SG was surprising, as both surgeries alter the digestive tract. A majority of SG patients chose their procedure because it was “less drastic” and provided fewer side effects, while several GB recipients chose their procedure specifically for the greater restrictions. This study highlights the importance of understanding how patients conceptualize side effects of the surgery, particularly as it impacts food intake and absorption. Participants associated SG with less malabsorption, which may negatively impact postsurgery nutritional status if they interpret this to mean that they do not need supplements.¹⁰ In addition, several SG patients wanted to avoid dumping syndrome. Although once thought SG did not cause this effect due to the preservation of the pyloric sphincter, recent studies have found about a quarter of patients experience symptoms.¹¹ Thus, SG patients may struggle postsurgery with this experience if they are not prepared for it.

Patients' preference for surgery procedure based on beliefs about restrictive elements may impact weight loss. Patients who perceive the SG as less restrictive may be less willing to make necessary dietary and lifestyle changes needed for optimal weight loss. Conversely, those choosing the GB believe that it will deter them from eating high calorie foods may be more likely to regain weight if they do not experience negative side effects. Most studies find no relationship between dumping syndrome and weight loss,¹² thus beliefs that negative effects will deter unhealthy eating may provide patients with a false sense of security. The underlying personality or psychological factors impacting patients' desire for external controls on eating or discomfort with having restrictions represent an area of further study.

Although not a common rationale, several participants commented on the ability of the SG to be converted to the GB in the event they experienced inadequate weight loss. The literature is mixed with regard to the acceptability of this tactic and whether it results in substantially more weight loss.^13,14 Insurance companies vary with their approvals for a second bariatric surgery, particularly if there is no evidence of an anatomical or technical problem with the first surgery or if there is a question of patient compliance with postsurgery dietary and lifestyle changes.¹⁵ The perception of a “back-up” if weight loss fails may also impact postsurgery dietary behaviors, therefore, it is important that surgeons identify this belief and understand insurance policies regarding a revision.

This study confirms findings that health is a primary motivator for bariatric surgery.^7,16 Health concerns were also a factor in choice of surgery procedure, particularly for patients with arthritis or regular joint pain or those with preexisting conditions that impacted the gastrointestinal system. This is consistent with typical patient-provider discussions that occur as part of preoperative visits at the clinic: health conditions that favor gastric sleeve recommendations include need for nonsteroidal anti-inflammatory medications, tobacco use, and history of intestinal surgeries or colitis or preexisting malabsorptive conditions. A history of esophageal conditions, such as Barretts esophagitis, active reflux, favor a GB recommendation. Participants' incorporation of health in their discussion of surgery decisions suggests that they were knowledgeable about surgery effects on specific conditions and suggests that these types of decision-making discussions between patients and health care providers are effective.

In addition, this study highlights that the lived experiences of obesity—including pain and difficulty with social and physical activities—factor prominently into the decision. As in other studies, patients expected to experience improvements in physical and social functioning.⁶ In this study, we felt that patients considered these lived experiences as separate from health, although others have incorporated the experience of obesity within the dimension of health and “low energy levels.”¹⁷ Body image, which is frequently cited as a motivation for bariatric surgery,¹⁶ was mentioned by a minority of participants and rarely as a determining factor.

An interesting phenomenon uncovered was the influence of surgery veterans on choice of procedure, consistent with other research.^17,18 While some participants acknowledged that unsuccessful weight loss was due to veterans' failures to make necessary behavioral and dietary adjustments postsurgery, several were persuaded to choose a different surgery. The influence of surgery veterans points to the role a bariatric surgery support group can play in helping patients decide on the most appropriate operation.

A limitation to this qualitative investigation is understanding the effect clinic staff had on the effect of participants' perceptions of surgery procedures and whether educational efforts changed participants' final choice of procedure. Patients in this program (including participants) routinely meet for a curriculum-based private and group-based education with a bariatrician, dietitian, psychologist, and exercise physiologist. Over their preoperative preparation period, which may span up to 12 months, the team evaluates the pros and cons of each procedure and advises and educates in this regard certain health conditions. By the conclusion of the preoperative program, patients have invested months of education and consideration with the multidisciplinary team and surgeon who have likely influenced the surgical choice.

While we cannot say for certain where participants developed a perception that the sleeve was less invasive or less drastic than a bypass, it is likely that participants constructed their perceptions based on their own research, knowledge of the human body, clinic visits, surgery veterans, and possibly other sources.

Due to the small sample size, the findings of this study may not be generalizable to other surgery populations, particularly men or minorities. This study took place in southeast Michigan at an AMSBS accredited surgery center, which provides a high level of support for pre- and postsurgery patients; thus, findings may not apply to patients in other states or different types of surgery centers. Although there was evidence of theoretical saturation¹⁹ in the emergent themes and categories, it is possible that other influences and experiences were not represented within this study.

Conclusions

Selection of bariatric surgery procedure should be based on a patient's health, weight loss needs, individual preferences, risk factors, and surgeon expertise.²⁰ Ultimately, it is the patient's decision which surgery to undergo and they may have decided on their preferred procedure before surgical consultation.⁷ It remains important for clinicians to inquire about the factors patients considered in their decisions, as this will reveal patient expectations for weight loss and health along with their understanding of the surgery. Future research should focus on the relationships between surgery motivations, expectations, postsurgery behavior change, and weight loss.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was funded in part by the Oakland University-Beaumont Hospital Multidisciplinary Research Award.

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