Patients’ long-term experiences following obesity surgery with a focus on eating behaviour: A qualitative study

Abstract

This study explored long-term consequences of obesity surgery. Interpretative phenomenological analysis was used to analyse transcripts of 10 interviews with patients who underwent surgery 8 or more years ago. Experiences were described under three broad themes: eating behaviours, relationship with food and quality of life. Although patients described variability within these themes, describing different patterns of change, analysis revealed associations between themes and outcomes. In particular, those who reported successful weight loss also described the functionalization of food, the development of new coping strategies and a process of positive reinvention creating a new sense of self.

Keywords

bariatric surgery long-term obesity patients’ experiences weight loss

Introduction

Obesity surgery is considered the treatment of choice for morbidly obese individuals (National Institute for Health and Clinical Excellence (NICE), 2012). Research suggests that it is an effective treatment for obesity (Douketis et al., 2005; Kral et al., 2002; O’Brien et al., 2006; Rabner and Greenstein, 1991; Sjostrom et al., 2007) and leads to an improvement in psychological factors such as quality of life (QoL), mood, subjective health status and perceptions of eating control (Karlsson et al., 1998; Ogden et al., 2005). However, similar to other methods of weight loss, weight regain in the longer term is often reported (e.g. Fried et al., 2007; Larsen et al., 2004; Magro et al., 2008; Sjostrom et al., 2007). As a result, researchers have sought to identify predictors of weight loss in this population (e.g. Colles et al., 2008; Larsen et al., 2004).

Eating behaviours in overweight and obese individuals have been identified as being one of the most important causal factors, with a vast amount of literature that links the two (e.g. Hudson et al., 2007; Tuschl, 1990; Wilfley et al., 2003). A large percentage of patients undergoing obesity surgery are thought to suffer from binge eating disorder (BED; Glinski et al., 2001; Powers et al., 1999); however, the effect on weight-loss outcomes in this population is unclear. For example, some studies have found that higher preoperative levels of binge eating predicted poorer weight loss (e.g. Hsu et al., 1997), whereas others have found no evidence to support this (Bocchieri-Ricciardi et al., 2006; Powers et al., 1999; White et al., 2006), and some have even found better weight-loss outcomes (e.g. Latner and Wilson, 2002). In addition, studies have reported that binge eating behaviours can continue or develop postoperatively affecting weight-loss outcome (Hsu et al., 1996; Scholtz et al., 2007), whereas others report a decrease or disappearance following surgery (Colles et al., 2008; Powers et al., 1999; White et al., 2006).

Furthermore, the effect of emotional eating on weight-loss outcome following obesity surgery is also unclear, with most studies to date having only measured emotional eating behaviours preoperatively, even then reporting mixed results. For example, studies have found that higher levels of emotional eating predicted poorer weight loss (e.g. Canetti et al., 2009), whereas others have found no relationship (e.g. Fischer et al., 2007). These studies are based on quantitative data and a deeper understanding of patients’ experiences following surgery which focus eating behaviour is, therefore, required.

Qualitative studies exploring patients’ experiences after obesity surgery are growing and report how surgery generally improves health and well-being (e.g. Bocchieri et al., 2002; Glinski et al., 2001). They highlight the complexity of the role of food and eating behaviours and emphasize the importance of perception of control for weight change (e.g. Ogden et al., 2006). Only one study to date has explored how patients described their experience of obesity surgery with a focus on eating behaviour (Ogden et al., 2006). Ogden et al. (2006) explored and discussed the impact of surgery on eating behaviours, highlighting the roles of restricted consumption, altered food preferences and diet. Since the role of eating behaviours on weight-loss outcomes in patients undergoing obesity surgery is unclear, it seems worthwhile to investigate the role of eating behaviours for weight change, particularly in the longer term.

Therefore, to build upon current research, this qualitative study aimed to explore patients’ experiences following surgery in the longer term, after 8 or more years, with a focus on eating behaviour. The aim was to observe patterns in psychological and behavioural factors, that might help to explain the variability in long-term weight change often observed in patients undergoing obesity surgery.

Method

Design

The study used a qualitative design with in-depth interviews.

Participants

In total, 10 patients were recruited from an online patient support group (Weight Loss Surgery Info; WLSinfo) if they had undergone obesity surgery 8 or more years ago. Of these, one patient had undergone a vertical banded gastroplasty (VBG), three had undergone laparoscopic adjustable gastric banding (LAGB) and the others had undergone gastric bypass procedures (GBP). Eight of the patients had their procedures through the National Health Service (NHS) and two had attended a private hospital. At the time of operation, all patients had a body mass index (BMI) of at least 40 or 35 with comorbidities. At the time of interview, patients ranged in age from 31 to 61 years. Their profile characteristics are shown in Table 1. All patients were given a pseudonym.

Table 1.

Participant characteristics.

Name	Sex	Age (years)	Ethnicity	Weight pre-WLS (kg)	Current weight (kg)	Time since WLS (years)	WLS history
Tamsin	F	31	White	146	83	10	GBP
Nancy	F	52	White	159	95	10	VBG
Michelle	F	42	Black	127	127^a	11	LAGB
Teddy	M	–	White	184	133^a	9	GBP
Jackie	F	55	White	127	131^a	8	LAGB
Esme	F	33	White	146	108^a	8.5	GBP
Katy	F	61	White	123	83	9	GBP
Olivia	F	51	White	140	76	9	GBP
Celia	F	53	White	145	69	10	LAGB
Alice	F	42	White	124	64	8	GBP

WLS: weight-loss surgery; GBP: gastric bypass procedure; VBG: vertical banded gastroplasty; LAGB: laparoscopic adjustable gastric band.

Unsuccessful weight loss. One participant, Teddy, declined to share their age.

Procedure

An advert was placed on the WLSinfo website and interested participants were contacted via telephone. Of the 12 individuals interested in taking part in the study, 1 was 8 months pregnant and 1 had recently received a revision of their GBP and were therefore deemed unsuitable for the study. Information and consent forms were sent to the remaining 10 participants and returned before arranging a mutually convenient time for interview. Telephone interviews were carried out due to the geographical spread of the participants. All interviews were conducted by KVW, a research fellow of psychology, with previous experience of conducting semi-structured interviews. The interviews took place over the phone and lasted between 40 and 64 minutes. All interviews were audiotaped and transcribed. Participants discussed their experience of obesity surgery and described how their weight, behaviour and cognitions had changed over time. After 10 interviews, it was felt that saturation had been reached as no new themes were emerging and similar stories were being told; therefore, no new interviews were arranged. Approval was obtained from the University of Surrey ethics committee.

Interview schedule

An interview schedule was developed through speaking to clinical and research experts in the area of obesity surgery and through existing literature. It was clear that the role of eating behaviours for weight-loss outcome required further investigation and open-ended questions were developed to explore this. Examples of questions used in the semi-structured interview include the following: (a) ‘Can you describe your weight loss following your surgery until the present day?’, (b) ‘Can you explain why you opted for weight-loss surgery?’, (c) ‘How has your life changed following your surgery?’, (d) ‘How has your relationship with food changed following your surgery?’, (e) ‘What do you think has been the biggest difficulty in achieving successful weight loss?’ and (f) ‘Can you describe your eating behaviours before and after your surgery?’. All participants received the same questions, in the same order, and prompts were used if the interviewer felt that participants needed encouragement to provide more details and to speak more freely.

Data analysis

The interviews were analysed using interpretative phenomenological analysis (IPA; Smith, 1996). IPA was chosen because it emphasizes ‘sense making’, attempting to understand how the participant makes sense of their own experiences, while acknowledging the role of the researchers’ own perspective (Smith and Osborn, 2003). In this study, although both researchers were neither obese nor had experienced surgery themselves, both had enough experience working with obese patients, through practice and research, to understand that obesity was not a desirable condition. In addition, both researchers had experience of working with individuals undergoing non-surgical weight-loss interventions and were aware of their limitations. Furthermore, both researchers had previous experience working with individuals undergoing surgical interventions for weight loss and were consistently impressed with the psychological, behavioural and physical outcomes observed. It is therefore possible that such views influenced the nature of the analysis.

The transcripts were read and reread by KVW to ensure familiarity. For each interview, notes were made in the left-hand margin on anything important or significant. Next, theme titles were documented in the right-hand margin. If themes re-emerged, the same theme title was repeated. Next, a table listing themes was constructed, with references to the transcript recorded under each theme. Related themes were given a name to represent the superordinate theme. All the transcripts were then reread by KVW and read by JO to ensure both researchers agreed themes represented the original material. An overall table of themes with subthemes was consequently constructed. Weight loss following surgery was defined as unsuccessful if patients reported that weight had been regained post-surgery or weight loss was not deemed sufficient by the patient.

Results and discussion

All participants described a good initial weight loss after surgery of between 32 and 51 kg in the first 5 months to a year. However, further loss, maintenance or gain up until the current date then varied between participants (see Table 1). Participants described their experiences in terms of three broad themes: (a) eating behaviour, (b) relationship with food and (c) QoL. These different themes will first be explored, and then the subthemes which inform the variability in weight change will then be addressed. In particular, the results indicate that variability in weight change following surgery relates to episodes of emotional eating, the functionalization of food (i.e. eating to survive and stay healthy), the development of new coping strategies and a process of positive reinvention, creating a new sense of self.

Theme 1: eating behaviours

Participants described their eating behaviour following surgery, reporting the continuation or disappearance of episodes of emotional eating. For example, Michelle stated,

If I am going to be honest with you, the other part of me would say that it (eating) is emotional … the fact that erm just for a few moments I can forget about whatever it is that’s on my mind … the extra sugar that gives that little bit of satisfaction, because I feel so negative already about myself.

Many others described how following surgery episodes of emotional eating disappeared. Some described how they still have thoughts about eating for comfort, but make a conscious effort to stop themselves. For example, Tamsin stated,

Before the surgery, food was always a comfort thing if I was upset, even now if I was upset my first mental reaction is oh to eat something … I don’t do it anymore but I feel that that (food) would be my comfort way of making myself feel better.

Only one participant (Celia) discussed how pre-surgery she never ate for emotional reasons and still does not.

Supporting existing literature, some described how episodes of emotional eating disappeared following surgery (e.g. Larsen et al., 2004; Laurenius et al., 2012), whereas others reported no difference (e.g. Hsu et al., 1996). These patterns of eating behaviours were related to outcome, and those who described an absence of episodes of post-surgical eating in response to emotions were successful weight losers in the longer term (n = 5). These results suggest that the absence of emotional eating episodes after surgery is associated with a positive weight-loss outcome, however, more quantitative studies are needed to confirm this.

Theme 2: relationship with food

Participants discussed their relationship with food following their surgery. Some described a ‘necessity’ relationship with food, describing how food had become less important to them. For example, Olivia described how she would often forget if she had eaten:

I don’t really crave for food, sometimes I think ‘have I eaten today?’, because food just doesn’t bother me anymore.

Others reported an ‘unrestrained’ relationship with food, describing how they eat when they are hungry and do not forbid themselves anything:

I eat if I am hungry … I don’t ever refuse myself anything. (Celia)

In contrast, some described their relationship with food in a very different light, almost being obsessed with food. For example, Jackie stated,

I don’t know if other obese people are the same, but I do see it as a form of deprivation if I can’t eat what I want to eat when I want, it makes me want it all the more … if one of the good points of your life is food and the idea is that you’ve got to stop eating it in the quantities and possibly some of the things that you do eat, what does it leave you? I just can’t do it.

Therefore, participants described a variation in patterns of change in relationships with food following surgery. Some described how surgery had improved their relationship with food, by reducing its level of importance; others described how their relationship with food is still a poor one, with an increased level of importance exhibiting itself as an obsession. All participants who described a changed relationship with food, one that shifted to a more adaptive one, were successful weight losers (all of the six), whereas participants who described being obsessed with food were unsuccessful weight losers (all four).

Theme 3: QoL

Participants reported their QoL post-surgery, describing how it had either improved or deteriorated. QoL was discussed in terms of changes in both physical and mental health. For example, Tamsin and Nancy both described how, following their surgery, they were in remission from diabetes. Others described how surgery had improved their physical fitness and capabilities. For example, Nancy described how:

Once I had the surgery, and all the weight came off … I was able to exercise.

Others described improvements in mental health following their surgery, for example, Nancy said:

I was at a very severe stage of depression … I got to the point where I did seriously think about ending everything, you know … surgery changed that for me, I am no longer depressed and my outlook on life is good.

However, some participants described the opposite, a decreased QoL, describing how surgery had led to the development of, or accentuation of, depression:

The banding stays on, but I can’t deny I got more and more fed up with it I suppose. Depressed would be a good word. It got me really really depressed. (Jackie)

I was depressed before having the surgery, I thought surgery would take away my problems by stopping me from being able to drink alcohol and eat rubbish food, but it hasn’t which has left me even more depressed than before. (Teddy)

Therefore, some described how surgery led to an increased QoL, describing improvements in mental and physical health, whereas others described a continuation of, or a decrease in QoL in relation to levels of depression. Those who described an increased QoL were all successful weight losers (all six of them), and three out of four participants who described poor QoL post-surgery were unsuccessful weight losers.

The results illustrate how participants described their experience following surgery under three broad themes: eating behaviours, relationship with food and QoL. Within each theme, differing patterns of change emerged, which were associated with weight-loss outcome. The analysis highlighted a number of factors that offer insights into these varying patterns of change, which will now be discussed.

Functionalizing food

Patterns of change in the core themes were associated with the functionalization of food. Alice described a change in the way she thinks about food, with a changed relationship:

Your relationship with food doesn’t become a joy anymore, it just becomes a necessity …

Similarly, Olivia described how she no longer thinks about food all of the time and forgets if she has eaten. She described food in terms of it being a necessity to live, rather than living to eat:

… sometimes I think I’ve got to eat, because I have to, but not because I want to. Food really doesn’t interest me anymore … I no longer live to eat.

Some patients described how this new functionalization of food is not just a consequence of decreased feelings of hunger, but is the result of a changed mindset. For example, Tamsin described how:

… if I don’t feel hungry then I don’t eat, whereas before I used to eat when I wasn’t hungry.

Therefore, some described how they had managed to functionalize food following surgery, and four out of the six patients reaching a successful weight-loss outcome described having functionalized food following their surgery. The functionalization of food was associated with emotional eating, in that, patients who described this process no longer ate for emotional reasons. These results suggest that managing to successfully functionalize food might facilitate a positive change in emotional eating. Future research would do well to investigate the underlying mechanisms that lead to the successful functionalization of food in this population. It seems likely that the process of functionalization can, in part, be explained by decreased feelings of hunger resulting from the surgery; however, other factors, such as the development of new coping strategies, might also play a role.

New coping strategies/replacement

Patterns of change in the core themes also seemed to be entwined with the development of new coping strategies relating to eating. All six participants who reported successful weight-loss outcomes described how they had developed new and alternative coping strategies for managing their food intake. Some described how they replaced thoughts about food by engaging in activities involving exercise to distract themselves, and others described using more sedentary strategies. For example, Katy said,

… you still do think about it (food), because you don’t want to go back where you were, and so you think, what you need to do is occupy your mind, go out for a walk, because when you’re out for a walk you can’t open the fridge door, so it’s a case of occupying your mind.

Those who described using sedentary strategies to manage their thoughts and desires described using strategies such as reading a book (Olivia) or relaxing in a bath. For example, Alice described how:

… I go and sit in the bath, and I’m learning to deal with my emotions differently …

In contrast, all four participants reporting unsuccessful weight-loss outcomes described how they still used food in response to emotions and had not developed new ways of replacing their urges for food.

These results suggest that the development of new adaptive coping strategies, which replace the use of food in stressful situations, may be conducive to successful weight loss following surgery. This reflects previous research supporting a link between weight regain and maladaptive coping strategies including eating more (Kayman et al., 1990), and evidence that failed obesity surgery in the short-term is associated with continued use of food for emotional regulation (Ogden et al., 2011). Research indicates that obesity surgery may be successful by helping individuals regain control over their behaviour (Ogden et al., 2006). The results from this study suggest that regaining control may help unlock more adaptive coping strategies, thus promoting longer term weight-loss success. Future studies are needed to explore this further.

Reinvention/identity

Finally, many participants spoke about the process of reinvention, adopting a new identity following their surgery, which was associated with the core themes and weight-loss outcomes. Examples of descriptions used by patients who had successfully adopted a new identity include ‘a thin person’, ‘normal’ and ‘small’. Within the data, links between adopting a new identity and positive outcomes were evident, and patients who adopted a new identity were those who reported positive outcomes relating to weight, relationship with food and QoL (all but one patient who did not mention reinvention). However, half of those who did not reinvent themselves following their surgery were unsuccessful weight losers. For example, Jackie described how being among others, who were also obese, made her feel normal:

After the surgery, what I did enjoy was … going up there as an outpatient, because the whole clinic was full of people who had the same thing as you … I didn’t encounter fattism, we were all fat … and that made me feel, um, quite normal I suppose … I’d go there just for coffee today.

In contrast, Olivia, who reported successful outcomes, described herself in terms of an old and a new me:

I used to go line dancing when I was big … I mean, when I look at pictures of then and now I think, I couldn’t have looked like that … I would never want to go back to the old me.

Celia described how she sees herself as being normal size, but the process of reinvention and adopting a new identity took a long time to come about:

… its only sort of been in the last 3 or 4 years that I can actually look at myself and don’t feel as big as I was … no matter what I did and people told me, I still thought I was fat … I couldn’t focus myself you know, I’d still visualise myself as being that fat person.

Although she had finally adopted her new identity, as a thin person, she described how the conflict relating to identity begun when she started to lose weight, and she had to work hard to achieve this.

Participant’s descriptions of how their identity had changed from an old to a new one, moving from a ‘fat’ to a ‘thin’ self, were related to positive patterns of change in the core themes as well as weight loss. Previous research suggests that a changed relationship with food following surgery is an important predictor of successful weight-loss behaviours (Wood and Ogden, 2012). However, the results of this study suggest an additional link, adoption of a new identity, which might explain longer term weight-loss outcomes. Previous research suggests that identity is central to understanding behaviour (West, 2006), and that reinvention, with a shift in identity to a new healthier self, is important for sustained behaviour change (Ogden and Hills, 2008). The results of this study provide support for this.

Conclusion

This study aimed to explore patients’ experiences following surgery in the longer term, with a focus on eating behaviour. The results suggest that following obesity surgery, health outcomes, such as QoL, relationship with food, eating behaviour and weight loss, in the longer term are varied. This study identifies some possible explanations for these variations involving three cognitive processes, namely, functionalization of food, the development of new coping strategies and the ultimate process of reinvention.

Participants who reported successful weight-loss outcomes indicated an increased functionalization of food, regarding food as a tool to stay healthy, rather than a means of buffering negative emotions. Previous research suggests a positive association between patients’ relationship with food and weight-loss outcomes (e.g. Hsu et al., 1996; Scholtz et al., 2007); however, these findings suggest an additional link, namely, the functionalization of food. Functionalizing food may allow for consolidation of positive thoughts and behaviours related to eating, resulting in sustained behaviours in the longer term. Undeniably, in the short-term, surgery facilitates a change in relationships with food and eating behaviours by its sheer restrictive nature. However, after a year or two, some patients report a change in this restriction and often revert back to old habits and behaviours. The results of this study suggest that functionalizing food could help to avoid this, facilitating sustained behaviour change in the longer term, although longitudinal studies are needed to confirm this.

Furthermore, successful weight loss was also associated with the use of a variety of strategies to cope with thoughts about food, both sedentary and active. Although clinicians acknowledge the importance of psychological aspects of obesity surgery, with many specialist teams supporting patients with the development of strategies to replace the use of food as an emotional buffer, this study highlights the importance of such strategies for successful weight-loss outcome in the longer term. In the first year following obesity surgery, physical restrictions to food intake are at their optimum, however, when these limitations start to subside could be a crucial point when clinicians must intervene to teach adaptive coping and replacement strategies.

Finally, participants who reported successful outcomes also described a process of reinvention. It seems likely that this process, that is, adopting a new ‘thin’ or ‘normal’ identity, could, if successful, facilitate longer term sustained behaviour change. This supports previous research conducted by Ogden and Hills (2008), who suggest that reinvention, with a shift in identity to a new healthier self, is important for sustained behaviour change. In a dynamic and interactive way, adopting a new identity, which may take time to achieve, influences thoughts, beliefs and behaviour in the longer term, affecting patients’ ability to maintain successful outcomes.

Given the qualitative nature of this study, the results reflect participants’ reports about thoughts and behaviours following their surgery, rather than indicating an objective measure, and although associations are made within the data, its cross-sectional nature leads to an inability to determine causal relationships. The study did not employ an objective assessment of weight change, such as percent excess weight loss, neither did it use objective criteria to classify weight-loss success and failure. Assessment of weight change was based solely on retrospective recall of the past eight or more years, and participants were categorized as unsuccessful weight losers if they reported that weight had been regained post-surgery or weight loss was not deemed sufficient. Therefore, any conclusions must be drawn with caution. In addition, the study did not employ objective criteria to measure eating behaviours, and participant self-reporting of both current and past eating behaviours might have been based on their own definition of these behaviours, rather than based on diagnostic reports. Future research should employ objective measures in order to confirm the current findings. Finally, participants volunteered for the study in response to an advert placed on a weight-loss surgery website. It is possible that participants who self-selected for this study differed to those who did not volunteer, therefore, selection effects cannot be ruled out. Consequently, future research is needed to confirm the current results.

Notwithstanding the limitations, the results from this study indicate that longer term changes following obesity surgery are varied and involve key themes relating to eating behaviour, relationship with food and QoL. The results also suggest that the variability seen within these themes was influenced by processes involving the functionalization of food and the development of new coping strategies. Furthermore, success across a number of domains relating to weight loss and shifts in the core themes was associated with an ultimate process of positive reinvention, as the individuals created a new identity and a new sense of self. New identity as a thinner person may well be the result of successful weight loss and maintenance, and the accompanying positive shifts in cognitions. In addition, however, it is likely that this relationship is a dynamic one, with such an identity also being a contributor to future success. Therefore, as the individual becomes increasingly embedded within this new identity, the potential loss of self that would result from any further weight gain becomes too hard to contemplate, let alone experience.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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