The impact of obesity surgery on psychosocial health The impact of obesity surgery on psychosocial health

Background: As obesity affects different dimensions of health, psychosocial wellbeing of patients can be predicted to significantly improve after bariatric surgery. Method: This qualitative study focused on determining the experience of patients who underwent bariatric surgery and the psychosocial impact of it on their daily lives and provides nurses with detailed information regarding patients’ experience. While some of these outcomes were in line with the literature, they have also revealed new aspects and provided deeper understanding regarding individuals’ experiences. Results: Five themes were identified: limitations in physical activity, social isolation due to negative body image, increased self-esteem, change in romantic relations and fear of weight regain. Conclusion: It is necessary for individuals to be supported for long-term post-operative complications, nutritional state and eating disorders. Nurses can support patients to set achievable goals and realistic expectations in order to obtain satisfactory patient results.


Introduction
Obesity is defined by the World Health Organization (WHO) as excess fat accumulation in the body to the extent that it can impair health.Obesity is a clinical and chronic disease and one of the major health problems in the world 1,2 .According to the WHO, 2.8 million people lose their lives every year due to obesity 3 .According to the OECD 2017 health statistics, 29.2 per cent of Turkish women aged 15 and over were living with obesity, while the rate is 15.3 per cent for Turkish men.This ranked the country as 11 th in the world for obesity.Due to obesity's significant impact on physical and mental wellbeing, individuals with obesity may seek methods to lose large amounts of weight rapidly, and employ radical treatments such as bariatric surgery.Initiatives for prevention of and research into the causes of obesity have also gained attention as a result of increasing severity of the issue.
Bariatric surgery has recently become the most common treatment method for obesity.In 2013, 3250 bariatric surgeries were reportedly conducted in Turkey 4 .Among the methods used in bariatric surgery, intestinal bypass, partial biliopancreatic bypass, gastroplasty and adjustable silicone gastric banding are the most often applied along with less invasive methods such as laparoscopic gastric banding and endoscopic gastric balloon application 5 .Bariatric surgery appears to be more effective due to its provision of relatively rapid and permanent weight loss in morbidly obese patients with a body mass index (BMI) of more than 40 kg/m 2 and are successful in alleviating the accompanying somatic diseases compared to other treatment options.
However, post-operative patient adaptation and outcomes may differ as a result of factors unrelated to the surgery [6][7][8] .As obesity is a multifaceted disease with an impact on different dimensions of health, psychosocial wellbeing of patients Peer-reviewed article can be predicted to significantly improve after bariatric surgery following drastic weight loss in just a few months.Still, in spite of predictions for improvement in body image, studies have shown discrepancies in patient satisfaction for various reasons such as failure to meet expectations or unachievable goals 1,9 .It was indicated that inadequate preoperative preparation may cause psychological distress to patients in the late post-operative period regarding adaptation to the new body image or disappointment in the results 10 .It can be predicted that the negative psychosocial impact of the surgery may hinder early post-operative benefits, as anxiety, depression or distress will not enhance the recovery of the stomach wall or the body.For the late post-operative period, benefits attained by bariatric surgery may not be maintained due to low selfesteem in the individual.

Aim
This study focused on determining the experience of patients who underwent bariatric surgery and the psychosocial impact of it on their daily lives.

Methodology
The study was designed as qualitative, phenomenological research.The study population consisted of patients with morbid obesity who had undergone bariatric surgery in Istanbul University, Cerrahpasa Faculty of Medicine.Ethical approval was obtained from the faculty's ethical committee.The sample was determined with criteria sampling and until the data had reached the satisfactory repetitive pattern; 13 patients were included.Volunteers who had had surgery between six months and five years prior and did not have barriers to communication participated in the research.

Data collection
Individuals were approached face to face at the hospital and invited to participate.Written and verbal consent were obtained from participants individually.Confidentiality was ensured as only the researchers had access to the records, no information will be shared with third parties nor will it be used other than for this study, and participants' identities will not be published.The data was collected by the first author with one-onone, in-depth interviews using a semi-structured questionnaire that included demographic questions.Interviews took between 15 and 25 minutes.A recorder was used for the interviews.Data collection was terminated once statements were repeated or very similar (data saturation).

Analysis
The recorded materials were manually decrypted by the first two investigators.The data was read word by word to derive codes 11 by first underlining the exact words from the text that appear to capture key thoughts or concepts.Preconceived themes or classification were avoided -the data slowly emerged from open ended questions such as 'how would you describe that feeling?', 'what has changed in your relationship, if anything changed after the surgery?' or 'what were your thoughts back then?'.The codes appeared as 'self-confidence, felt better about myself'.The codes we have extracted were repetitive and there were not any new codes identified from the last two participants who were added to comply with a recommendation from reviewers.The three independent researchers determined the themes by conventional content analysis as the aim was to describe the psychosocial impact of bariatric surgery.After the initial analysis, categories determined by each researcher were compared and this discussion resulted in an agreement on the data saturation.The similar or meaningfully similar sub-themes were merged into the main themes; a consensus on the themes was reached by the same process afterwards.

Discussion
This study aimed to determine the experience of patients who underwent bariatric surgery and the psychosocial impact of the surgery on their daily lives.After consensus was reached on the material collected by in-depth interviews, five themes were determined.While some of these outcomes were in line with the literature, they also have provided deeper understanding regarding individuals' experiences, and new aspects were also revealed.
The initial theme that emerged was physical limitation.Physical limitation related to obesity creates a vicious cycle; while exercise plays an important role in the prevention of obesity, physical activity is reduced significantly by obesity.Soyuer et al. 12 found in their study that college students with normal weight were more dynamic in physical activities compared to the students with obesity.It was also determined that women without obesity showed on average 24 per cent higher activity scores than the women with obesity in another study 12 .Aldaqal and Sehlo 2 reported that physical functioning was significantly lower in individuals with obesity.The findings regarding physical activity are in line with the related literature; the majority of the participants stated difficulties in daily physical activity determined their decision to undergo surgery.Additionally, social pressure, fear of reaction from loved ones, judgments and discrimination prevented people with obesity from leaving their house which further limited their physical activity.
Another theme was isolation due to negative body image.Body image is also a multi-dimensional concept involving perception, attitudes and behaviours related to an individual's body and appearance 13 .In recent years, especially the media and Western cultures' tendency to market 'skinny' as a beauty ideal, promoting physical appearance before characteristic qualities, can cause individuals with obesity to be exposed to ever more serious discrimination and prejudice in social life 14,15 .Sobal and Stunkard 17 have defined the phenomenon as 'socially accepted prejudice'.People with obesity are afraid of being exposed to or have previously experienced this discrimination, as a result they isolate themselves from society 16 .
Weineland 19 and colleagues reported that social isolation was a major issue for patients with obesity.Some of the patients in the study stated that they preferred not to spend much time outside of their house when they were overweight.This result was predicted and points out the extent of the social trauma, the fear of humiliation and the exclusion that they experience.The social isolation also prevents, or at least discourages, them from participating in physical activities.Therefore people with obesity spend more time alone which can contribute to their unhealthy eating behaviour.
As expected, many studies indicate that individuals who underwent bariatric surgery had higher scores for body image, quality of life and self-esteem 2,17 .It was also reported that as the BMI increases, the self-esteem score decreases in individuals 14 .Additionally, a meta-analysis study revealed that the dissatisfaction rate for body image of individuals with obesity was significantly higher 13,18 .Moreover, individuals with obesity express difficulties with dressing appropriately to the season and social occasion, and that not being able to find the right size clothes increases the problem of their negative body image.Individuals express positive feelings as they approach the body shape they would like to have after the surgery 19 .In the study, the participants stated that as they lose weight, they can get smaller size clothes, so it is easier to find suitable clothing, they feel happier as a result of the availability of clothing and these positive emotions can increase positive body image as it gives confidence.Participants in the study expressed an increase in their confidence after they had lost weight and the surgery affected their body image favourably.As this result was consistent with previous studies, it is undeniable that weight loss affects body image positively which builds self-esteem.
While the majority of individuals in the study expressed positive changes in romantic relationships, some participants stated that this difference was superficial.It was determined that while there was an expectation for romantic relationships to improve after weight loss, parallel to improved body image and self-esteem, there was no change found in the sexual life and partner relations of the individuals in the long-term studies 20 .The changes regarding romantic relationships can be difficult to measure and are highly individual; therefore, this concept will be left to readers' judgement and more research needs to be conducted in the matter.The study revealed that the participants with the same partners were happier in their relationship after the surgery, while some of them expressed this change as a neutral or negative experience, in their words 'flattering but superficial'.
In the literature, it is stated that after bariatric surgery the excessive eating habits of the preoperative period are reduced, as the capacity of the stomach only allows eating small portions.In the long term, patients are expected to maintain normal eating habits.However, eating disorders may continue to distress the patients psychologically after the surgery.They may exercise strict diets on the basis of constant fear of weight regain 21 .In the study, the individuals have expressed a great deal of fear regarding regaining weight and 'going through the same struggles they had experienced in the preoperative period'.Patients' distress may cause eating disorders or other psychological issues and it is a concern for their psychosocial wellbeing as much as their physical health status.For example, some participant's statements regarding vitamin deficiency and being five to six kilograms under the healthy weight indicates that individuals need psychological support and nutritional guidance after the operation.Moreover, the statement of eight out of ten participants regarding the absence of regular exercise underlined the need for post-operative support and education.Additionally, it may be presumed by these findings that the patients felt as if they had no control over their weight management.

Limitations of the study
The study was conducted as qualitative, therefore large samples are both inappropriate and physically impossible for in-depth interview analysis.Additionally, semistructured questions were limited to demographics, weight loss, exercise status and psychosocial impacts of the surgery.

Conclusion
It was observed that obesity has negative impacts on individuals in many aspects of their health.Bariatric surgery, which has been widely used in recent years, seems to increase the quality of life and improve health physically and psychologically in the relative short term.On the other hand, it may be necessary for individuals to be supported to avoid long term postoperative complications related to nutritional state and eating disorders.Nurses can provide support to patients to set achievable goals and realistic expectations.
Above all, raising awareness of and working on issues such as adequate nutrition, physical activity, psychological health and eating disorders should be the primary goal of governments and health workers to prevent obesity which is becoming increasingly endemic in the world.

Table 1 .
Demographics (n:13) S = standard deviation Table1presents the demographics of the participants.The mean age of the participants was 40.66±11.81,69.2 per cent were married and 69.2 per cent had a family history of obesity.The participants' BMI average was 45.01±5.64 and 27.65±7.25before and after the surgery respectively.High school graduates made up 38.5 per cent of the participants and 76.9 per cent were female.The average preoperative BMI was 44.33; the average post-operative BMI was 28.29.Only one out of 13 participants exercises regularly.Eight out of 13 participants included fibre, fresh vegetables and fruit in their diet.