Patients’ perceptions, health and psychological changes with obesity treatment: Success and failure in a triangulation study

Susana Sofia Pereira da Silva, Ângela da Costa Maia

Center for Research in Psychology, School of Psychology, University of Minho, Braga, Portugal.
School of Management and Industrial Studies, Institute Polytechnic of Porto, Porto, Portugal;.

DOI: 10.4236/health.2013.511236                

Abstract

The present study aims to understand changes in health problems, health complaints and coping strategies, during the obesity treatment process with qualitative and quantitative data. Thirty bariatric patients were interviewed before bariatric surgery and at a 12-month follow-up, and fulfilled self-report measures about health problems, health complaints and coping strategies before surgery, at 6-and 12-month follow-ups. Before surgery, failure cases differ from success on the conceptualization of obesity, However, there are no other differences between groups. At 6-and 12-month follow-ups, failure cases had the highest BMI, health problems and complaints and less % EWL than success cases. One year after the surgery, one in each three persons did not lose the expected weight, i.e., are failure cases. Before surgery, there are no differences between success and failure cases in the report of health problems, health complaints and coping strategies, but they have different conceptualizations of their obesity and treatment. One year after the surgery, success cases understood bariatric surgery as an important moment in their lives related to their expected results, whereas failures valued unexpected dimensions and still waiting for a miracle surgery without their personal commitment. Accordingly, it is necessary to consider lifestyle changes in the obesity treatment process.

Keywords

Bariatric Surgery; Success; Longitudinal Study

1. INTRODUCTION

Obesity has increased all over the world, and, in developed countries, it is estimated that 10% - 20% of the adult population has this chronic disease [1].

The impact of morbid obesity and comorbidities, such as diabetes, hypertension, obstructive sleep apnea, dyslipidemia, low self-esteem, increase of morbidity and mortality is presented as a common problem among these subjects and has been studied by several authors [2-4]. The treatment of this multifactorial disease has become a challenge to health professionals and researchers. One of the most effective methods for significant and durable weight loss is treatment that includes bariatric surgery, a procedure that has been associated with several ameliorations in health condition as well as improvements in personal and social dimensions [5]. However, the outcomes of this procedure are not always successful and some failure cases have been reported [6,7] highlighting the importance of a multidisciplinary intervention that prioritizes lifestyle change.

Considering the relevance to better understand this global epidemic and the best way to deal with it, different authors [8-12] have studied the characteristics of obesity and the treatment outcomes. If the data of several studies are consensual regarding health improvements after surgery weight loss [8-10], then that is not the case for medium and long-term consequences [11-13]. Different authors [11-13] reported controversial data, suggesting the need for more studies to contribute to a better knowledge of the obese population and the treatment process. For example, Lier and colleagues [14], in a recent study, concluded that obese patients report more psychiatric disorders than community samples. In their study 43% of 141 patients that were evaluated had a current Axis I psychiatric disorder, and 26% an Axis II personality disorder. On the other hand, Mitchell and Zwaan [15] found that obese patients do not have more psychopathology than community subjects.

In the same way, there is little information about coping mechanisms and their efficacy after bariatric surgery [16]. Fischer and colleagues [17] found that emotional eating, i.e., eating in response to moderate emotional states, is frequent among obese subjects and that the practice of emotional eating can obstruct positive surgery outcomes. In this study, Fischer and colleagues [17] evaluated 144 gastric bypass patients before surgery and concluded that no statistically significant differences in BMI existed between high and low emotional eaters. However, high emotional eaters reported significantly higher rates of eating. On the other hand, Delin and colleagues [18] evaluated 20 patients two years after bariatric surgery and found that emotional eating was negatively associated with weight loss.

Additionally, a good number of studies were conducted after surgery but only few [19,20] have tried to comprehend obese characteristics before bariatric surgery, a fact that was recognized by Engström and colleagues [20] as a weakness in the literature. These authors referred explicitly to the urgency to conduct studies before surgery.

On the other hand, and independently of the evaluation time, most studies have been done using a quantitative paradigm. This is an important approach, providing relevant data based on the evaluation of several participants, allowing data generalization. However, despite the massive amount of data, several questions remained unanswered, namely the participant’s voice and perspective about obesity and treatment. Only more recently have researchers [7,12,16] recognized the importance of understanding patients’ perceptions, beliefs and expectations about obesity and its treatment. Qualitative research offers the richness of detail currently missing in the literature.

Both quantitative and qualitative approaches have made important contributions to comprehension of obesity. According to the “paradigm of choices” [21], the methodological orthodoxy that opposes quantitative to qualitative approaches should be rejected in favor of methodological appropriateness as the primary criterion for judging methodological quality. This paradigm recognizes that different methods are appropriate in different situations and to answer different research questions.

Triangulation has been suggested as a way to increase the understanding of factors influencing health status by combining research strategies to achieve a multi-dimensional view of the phenomena of interest [22]. Triangulation can include the use of multiple methods, i.e. the use of two methodologies (quantitative and qualitative), because each taps a different aspect or dimension of the problem being studied [22].

The triangulation study that we present here aims to improve on understanding of the personal expectancies and perceptions, as well as the health and psychological changes during the obesity treatment process. The main objective of the study is to comprehend if success and failure subjects differ before surgery, and at 6- and 12-month follow-ups and to what extent they are distinguishable, considering quantitative and qualitative dimensions. For the quantitative analysis we consider BMI, coping strategies, health problems and complaints in the three evaluations times. Triangulated with this quantitative data collection, qualitative interviews before surgery and at the 12-month follow-up were analyzed with grounded theory procedure, in order to understand how the obese think about their obesity and what they expect and think about obesity treatment, specially focusing on perceptions and beliefs about the demands and impact of bariatric surgery. These last questions aim to contribute to the comprehension of the adaptation process after the surgery.

2. RESEARCH DESIGN

2.1. Study Design

Our objective in this triangulation research project was to understand personal expectancies and perceptions before and after bariatric surgery, and to characterize health and psychological characteristics before surgery (time 1), at the six- (time 2) and 12-month (time 3) follow-ups, comparing success and failure participants.

This study included 30 patients in the Multidisciplinary Treatment Center of Obesity in northern Portugal, divided in two groups according to the outcomes 12 months after the surgery: the success group (lost at least 50% excess weight loss-EWL) included 10 (seven women and three men) patients and a failure group (EWL < 50%) with 20 (13 women and seven men) patients. All of the patients that underwent bariatric surgery between June 2008 and June 2009 were assessed. The participants signed an informed consent form that gave permission for the subjects to be included in the study, which was approved by the Ethics Committee of the Hospital.

Table 1 shows the main socio-demographic characteristics of each group of the sample.

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	WHO (2004) WHO-special issue-diet, nutrition and the prevention of chronic diseases. Scientific Background Papers of the Joint WHO/FAO Expert Consultation, Geneva. http://www.who.int/nutrition/publications/obesity /PHNvol7no1afeb2004/en/index.html
[2]	Segal, A., Cardeal, M. and Cordás, T. (2002) Obesity: Psychosocial and psychiatric aspects. Revista de Psiquiatria Clínica, 29, 81-89.
[3]	Prochaska, J.O., Norcross, J.C., Fowler, J.L., Follick, M.J. and Abrams, D.B. (1992) Attendance and outcome in a work site weight control program: Processes and stages of change as process and predictor variables. Addictive Behaviors, 17, 35-45. http://dx.doi.org/10.1016/0306-4603(92)90051-V
[4]	Fairbun, C. and Brownell K. (2002) Eating disorders and obesity. The Guilford Press, London.
[5]	Buchwald, H., Avidor, Y., Braunwald, E., Jensen, M.D., Pories, W., Fahrbach, K., et al. (2004) Bariatric surgery: A systematic review and meta-analysis. JAMA, 292, 1724-1737. http://dx.doi.org/10.1001/jama.292.14.1724
[6]	Holzwarth, R., Huber, D., Majkrzak, A. and Tareen, B. (2002) Outcome of gastric bypass patients. Obesity Surgery, 12, 261-264. http://dx.doi.org/10.1381/096089202762552476
[7]	Kaly, P., Orellana, S., Torrella, T., Takagishi, C., Saff-Koche, L. and Murr, M. (2008) Unrealistic weight loss expectations in candidates for bariatric surgery. Surgery for Obesity and Related Diseases, 4, 6-10. http://dx.doi.org/10.1016/j.soard.2007.10.012
[8]	Steinmann, W.C., Suttmoeller, K., Chitima-Matsiga, R., Nagam, N., Suttmoeller, N.R. and Halstenson, N.A. (2011) Bariatric surgery: 1-year weight loss outcomes in patients with bipolar and other psychiatric disorders. Obesity Surgery. http://www.springerlink.com/content/qr27642621w31357/
[9]	Kalarchian, M.A., Marcus, M.D., Wilson, G.T., Labouvie, E.W., Brolin, R.E. and LaMarca, L.B. (2002) Binge eating among gastric bypass patients at long-term follow-up. Obesity Surgery, 12, 270-275. http://dx.doi.org/10.1381/096089202762552494
[10]	Horchner, R., Tuinebreijer, W. and Kelder, H. (2002) Eating patterns in morbidly obese patients before and after a gastric restrictive operation. Obesity Surgery, 12, 108-112. http://dx.doi.org/10.1381/096089202321144676
[11]	Sjostrom, L., Narbro, K., Sjostrom, C., Karason, K., Larsson, B., Wedel, H., et al. (2007) Effects of bariatric surgery on mortality in Swedish obese subjects. New England Journal of Medicine, 357, 741-752. http://dx.doi.org/10.1056/NEJMoa066254
[12]	Ogden, J., Clementi, C., Aylwin, S. and Patel, A. (2005) Exploring the impact of obesity surgery on patients’ health status: A quantitative and qualitative study. Obesity Surgery, 15, 266-272. http://dx.doi.org/10.1381/0960892053268291
[13]	Chantler, P. and Lakatta, E. (2009) Role of body size on cardiovascular function: Can we see the meat through the fat? Hypertension, 54, 459-461. http://dx.doi.org/10.1161/HYPERTENSIONAHA.109.134452
[14]	Lier, H., Biringer, E., Stubhaug, B., Eriksen, H.R. and Tangen, T. (2011) Psychiatric disorders and participation in preand postoperative counselling groups in bariatric surgery patients. Obesity Surgery, 21, 730-737. http://dx.doi.org/10.1007/s11695-010-0146-7
[15]	Mitchell, J. and Zwaan, M. (2005) Bariatric surgery: A guide for mental health professional. Routledge, New York.
[16]	Dodsworth, A., Warren-Forward, H. and Baines, S. (2010) Changes in eating behavior after laparoscopic adjustable gastric banding: A systematic review of the literature. Obesity Surgery, 20, 1579-1593. http://dx.doi.org/10.1007/s11695-010-0270-4
[17]	Fischer, S., Chen, E., Katterman, S., Roerhig, M., Bochierri-Ricciardi, L., Munoz, D., et al. (2007) Emotional eating in a morbidly obese bariatric surgery-seeking population. Obesity Surgery, 17, 778-784. http://dx.doi.org/10.1007/s11695-007-9143-x
[18]	Delin, C., McK Watts, J. and Bassett, D. (1995) An exploration of the outcomes of gastric bypass surgery for morbid obesity: Patient characteristics and indices of success. Obesity Surgery, 5, 159-170. http://dx.doi.org/10.1381/096089295765557962
[19]	Van Gemert, W., Severeijins, R., Greve, J., Groenman, N. and Soeters, P. (1998) Psychological functioning of morbidly obese patients after surgical treatment. http://www.nature.com/ijo/journal/v22/n5/abs/0800599a.html
[20]	Engstrom, M., Wiklund, M., Olsén, M., Lonroth, H. and Forserg, A. (2011) The meaning of awaiting bariatric surgery due to morbid obesity. The Open Nursing Journal, 1-8.
[21]	Patton, M.Q. (1990) Qualitative evaluation and research methods. 2nd Edition, Sage Publications Inc., Thousand Oaks.
[22]	Nakkash, R., Afifi Soweid, R.A., Nehlawi, M.T., ShediacRizkallah, M.C., Hajjar, T.A. and Khogali, M. (2003) The development of a feasible community-specific cardiovascular disease prevention program: Triangulation of methods and sources. Health Education & Behavior, 30, 723-739. http://dx.doi.org/10.1177/1090198103255521
[23]	Silva, S. and Maia, A. (2008) Socio-demographic questionnaire.
[24]	McIntyre, T., McIntyre, S. and Redondo, S. (1999) Portuguese version of ways of coping questionnaire.
[25]	Parkes, K. (1984) Locus of control, cognitive appraisal, and coping in stressful episodes. Journal of Personality and Social Psychology, 46, 655-668. http://dx.doi.org/10.1037/0022-3514.46.3.655
[26]	De Haes, J., Van Knippenberg, F. and Neijt, J. (1990) Measuring psychological and physical distress in cancer patients: Structure and application of the Rotterdam Symptom Checklist. British Journal of Cancer, 62, 1034-1038. http://dx.doi.org/10.1038/bjc.1990.434
[27]	McIntyre, T. and Gameiro, J. (1997) Portuguese version of Rotterdam Symptoms Checklist (RSCL).
[28]	Silva, S. and Maia, A. (2007) Self report diseases checklist.
[29]	Silva, S. and Maia, A. (2012) Obesity and treatment meanings in bariatric surgery candidates: A qualitative study. Obesity Surgery, 22, 1714-1722. http://dx.doi.org/10.1007/s11695-012-0716-y
[30]	Silva, S. and Maia, A. (2013) Patients’ experiences after bariatric surgery: A qualitative study at 12-month follow-up. Clinical Obesity. http://dx.doi.org/10.1111/cob.12032
[31]	Strauss, A.C. and Corbin, J.M. (1990) Basics of qualitative research: Grounded theory procedures and techniques. 2nd Edition, Sage Publications, Inc., Thousand Oaks.
[32]	Corbin, J.M. and Strauss, A.C. (2007) Basics of qualitative research: Techniques and procedures for developing grounded theory. 3rd Edition, Sage Publications, Inc., Thousand Oaks.
[33]	Richards, P.L. (2009) Handling qualitative data: A practical guide. 2nd Edition, Sage Publications Ltd, Thousand Oaks.
[34]	Silva, S. and Maia, A. Psychological and health comorbilities before and after bariatric surgery: A longitudinal study.
[35]	Torgerson, J. and Sjostrom, L. (2001) The swedish obese subjects (SOS) study—Rationale and results. International Journal of Obesity and Related Metabolic Disorders, 25, S2-S4. http://dx.doi.org/10.1038/sj.ijo.0801687
[36]	Kitsantas, A. (2000) The role of self-regulation strategies and self-efficacy perceptions in successful weight loss maintenance. Psychology & Health, 15, 811. http://dx.doi.org/10.1080/08870440008405583
[37]	Ogden, J., Clementi, C. and Aylwin, S. (2006) The impact of obesity surgery and the paradox of control: A qualitative study. Psychology & Health, 21, 273. http://dx.doi.org/10.1080/14768320500129064
[38]	Horwath, C.C. (1999) Applying the transtheoretical model to eating behaviour change: Challenges and opportunities. Nutrition Research Reviews, 12, 281-317. http://dx.doi.org/10.1079/095442299108728965
[39]	Prochaska, J.O., DiClemente, C.C. and Norcross, J.C. (1992) In search of how people change. Applications to addictive behaviors. American Psychologist, 47, 1102-1114. http://dx.doi.org/10.1037/0003-066X.47.9.1102
[40]	Kinzl, J.F. (2010) Morbid obesity: Significance of psychological treatment after bariatric surgery. Eating and Weight Disorders, 15, e275-e280.