Weight regain after bariatric surgery: a phenomenological approach

Abstract

Objective

To understand the experience of weight regain after bariatric surgery.

Methods

Qualitative study conducted in a public hospital in the city of São Paulo. Data were collected between March and May 2017 through interviews with 17 participants and ended when the content of reports fulfilled the goal of the investigation. Analysis of meanings was guided by the theoretical-philosophical framework by Alfred Schütz and experts from the social phenomenology field.

Results

The adopted framework revealed four categories that express the existential reasons of the attitudes of people who regain weight after bariatric surgery: “feeling of failure emerges with weight regain”, “emotional aspects that contribute to weight regain”, “impact of weight regain on physical and mental health”, and “expectations regarding weight regain”.

Conclusion

The results of the present study allow to emphasize the importance of qualified listening and embracement of subjective issues which take into account the relationship that each patient establishes with obesity and bariatric surgery. The aspects of the weight regain experience emphasized in the examined social group may support the improvement of professional practices and add to health teaching, research, and knowledge.

Bariatric surgery; Weight gain; Obesity; Patient care team

Resumo

Objetivo

Compreender a experiência de reganho de peso após a cirurgia bariátrica.

Métodos

Pesquisa qualitativa realizada em um Hospital Público da cidade de São Paulo. A coleta de dados foi realizada entre março a maio de 2017, por meio de entrevistas com dezessete participantes e encerrada quando o conteúdo dos depoimentos responderam ao objetivo do estudo. A análise dos significados foi norteada pelo referencial teórico-filosófico de Alfred Schütz e estudiosos da fenomenologia social.

Resultados

O referencial adotado possibilitou desvelar quatro categorias que traduzem os motivos existenciais do agir de pessoas com reganho de peso após cirurgia bariátrica: “sentimento de fracasso frente ao reganho de peso; “aspectos emocionais que contribuem para o reganho de peso”, “impacto do reganho de peso na saúde física e mental” e “expectativas frente ao reganho de peso”.

Conclusão

Os resultados deste estudo permitem ressaltar a importância da escuta qualificada e o acolhimento das questões subjetivas que levam em conta a relação que cada paciente estabelece com a obesidade e com a cirurgia bariátrica. Os aspectos da experiência de reganho de peso destacados no grupo social estudado podem subsidiar a melhoria das práticas profissionais, o incremento do ensino, pesquisa e do conhecimento em saúde.

Cirurgia bariátrica; Ganho de peso; Obesidade; Equipe de assistência ao paciente

Resumen

Objetivo

Comprender la experiencia de peso recuperado después de la cirugía bariátrica.

Métodos

Investigación cualitativa realizada en un hospital público de la ciudad de São Paulo. La recolección de datos fue realizada entre marzo y mayo de 2017, por medio de entrevistas con diecisiete participantes y finalizada cuando el contenido de los testimonios respondió al objetivo del estudio. El análisis de los significados fue guiado por el referencial teórico filosófico de Alfred Schütz y estudiosos de la fenomenología social.

Resultados

El referencial adoptado permitió revelar cuatro categorías que reflejan las razones existenciales de actuar de las personas con recuperación de peso después de la cirugía bariátrica, “sensación de fracaso contra el peso recuperado; “aspectos emocionales que contribuyen al peso recuperado”, “impacto de la recuperación de peso en la salud física y mental” y “expectativas frente a la recuperación de peso”.

Conclusión

Los resultados de dicho estudio permiten demostrar la importancia de la audiencia calificada y la recepción de preguntas subjetivas que tienen en cuenta la relación que cada paciente establece con la obesidad y con la cirugía bariátrica. Los aspectos de la experiencia de recuperación de peso destacados en el grupo social estudiado pueden subsidiar la mejora de las prácticas profesionales, el incremento de la enseñanza, la investigación y el conocimiento en salud.

Cirugía bariátrica; Aumento de peso; Obesidad; Grupo de atención al paciente

Introduction

According to estimates by the World Health Organization, over 1.9 billion adults present overweight, among whom at least 650 million are obese.(¹) In Brazil, the number of obese people has also increased: in 2006, 42.6% of the population were considered overweight, and in 2016 this rate grew to 53.8%.(²)

Obesity is a public health problem and bariatric surgery has been considered an important strategy in the treatment of severely obese patients and is currently the most effective and long-lasting treatment in the control of associated diseases.(³,⁴) Nevertheless, some patients do not experience significant weight losses or present weight regain some time after the surgery.(⁵)

Brazilian and international studies seek to discuss weight regain after bariatric surgery using a quantitative approach.(⁶,⁷) However, questions related to the subjectivity of the people who experience this phenomenon are little explored, which calls for the development of investigations that emphasize the standpoint of patients who underwent weight regain in the late follow-up for the surgery. This approach may contribute to a better understanding of their needs and expectations.

Given this scenario, the present study raises the following questions: How do people who underwent bariatric surgery perceive weight regain? What aspects do they consider to be related to weight regain? How do they deal with weight regain? How do they see themselves in the future regarding their weight? The objective of the present investigation was to understand the weight regain experience after bariatric surgery.

Methods

This is a qualitative study based on the Social Phenomenology by Alfred Schütz, which allows researchers to access the consciousness of the people who experience the examined phenomenon, emphasizing the social relationship as a fundamental element in the interpretation of human meanings.(⁸)

Some theoretical assumptions were used to ground the findings: the life-world consists of the sociocultural space of the individual – it is in it that human beings live together and develop bonds in different social relationships. This perspective includes intersubjectivity, which enables the exchange of experiences in an intersubjective and social way.(⁸) The “reasons why” (present and past experiences) and the “reasons for” (projects to be carried out) are the driving force of human actions in the social world. The set of these reasons culminate in the typical characteristics of a certain social group.(⁸)

Data collection occurred from March to May 2017 at the Hospital das Clínicas of the University of São Paulo, School of Medicine in private rooms of the outpatient clinic. Inclusion criteria were people who had undergone bariatric surgery more than one year before data collection and presented weight regain of more than 10% of the lost weight, from both genders, 18 years old or older, living in the metropolitan area of São Paulo.

The contact with participants happened through phone calls, from a list with the names of the patients provided by the institution. To recruit new participants who met the inclusion criteria, weekly visits were paid to the obesity and bariatric surgery clinic to approach patients who waited in the service queue. After a previous approach and explanations about the study, venue, date, and time were set according to the patients’ convenience for the execution of interviews.

Reports were obtained after the signature of free and informed consent forms. Interviews were recorded and transcribed by researcher and lasted 60 minutes on average. The protocol for the present study was registered with and approved by the Research Ethics Committee of the Escola de Enfermagem da Universidade de São Paulo and the Research Ethics Committee of the Federal University of São Paulo – Hospital São Paulo. Confidentiality and anonymity were guaranteed to participants, in accordance with the guidelines that rule human research.

The following questions guided the interviews: How does it feel to see yourself putting on weight again? What do you think is contributing to you putting on weight? How do you deal with weight regain? How do you see yourself in a few years regarding your weight?

When the reports showed convergence concerning meanings and revealed no new contents, it was considered that the data saturation predicted for qualitative research had been reached, and data collection was ended.(⁹) With this procedure, 17 people with weight regain after bariatric surgery were interviewed, and all the reports were included in the study.

The organization and analysis of the meanings originating from the reports followed the steps recommended by social phenomenological researchers.(¹⁰) The transcriptions were read and excerpts of each report were selected. These extracts were rewritten and grouped according to the meaning convergence, allowing the determination of categories which revealed the “reasons why” and “reasons for” of social action.

Results

The sample was 11 women and six men. Their ages ranged from 35 to 69 years, and most underwent bariatric surgery between 2002 and 2012. The weight loss after the surgery varied from 52 to 82 kg, and most patients had a weight regain between 22 and 40 kg.

Alfred Schütz’s social phenomenology allowed to identify four categories that express the existential reasons of the attitudes of people with weight regain after bariatric surgery: “feeling of failure emerges with weight regain”, “emotional aspects that contribute to weight regain”, and “impact of weight regain on physical and mental health”, which correspond to the “reasons why”. The category “expectations regarding weight regain” revealed the participants’ projects, indicating the “reasons for”.

Feeling of failure emerges with weight regain

Taking into account failure feelings before weight regain, the participants expressed defeat, shame, guilt, sadness, and despair:

[…] today I feel really embarrassed […] I’ve gotten my share of guilt […]. I1 […] Putting on weight bothers me, makes me very sad and upset, depressed, because my dream was to be between 55 and 60 kg. I6 [...] It is a feeling of despair [...] it is depressing, because it is unachieved goals. So I get frustrated because I step on a scale and see that I put on weight again or kept that weight […]. I15

Emotional aspects that contribute to weight regain

The reports showed that anxiety affects the emotional stability of the interviewees and makes them seek comfort in the ingestion of food:

[…] I get nervous, anxious, I feel like eating. It seems that eating satisfies me […] I2. [...] when I feel lonely I feel like eating everything around, grazing. […] nibble something that I think that fills this emptiness […]. I8 […] I take it out on alcohol. […] what makes me put on weight is alcohol. I am not going to have a beer and order lettuce and tomato, unfortunately appetizers seem to come together. I9 […] I am anxious because I live by myself. [...] It is an emptiness that nothing fulfills. [...] I eat a lot [...] one thing leads to another, I get upset, lonely, and what satiates me is eating […]. I12

Impact of weight regain on physical health

Other reports emphasized the impact of weight regain on physical health and the consequences of putting on weight:

[…] my legs cannot bear my weight anymore. I am already having serious problems with my knees […]. I4 With the increase in weight, the daily routine gets very complicated, because I do not leave home, I do not move, I feel a lot a pain. […] some time ago I went out, danced, even fat and with some limitations. Now I cannot see myself leaving home to go anywhere. I6 […] I care because of the health issues, because all the problems I used to have are back […].I14

Expectations regarding weight regain

The interviewees declared that they wish to lose and control weight to impact on their quality of life positively, but need professional support to achieve this goal, mostly to deal with emotional issues:

[…] I want to travel, do what I like, be free and thinner. I3 […] I do not want to be fat. I want to be much more cheerful, do everything I like. I4 […] I want to lose weight and be well again. Everything I learned about losing weight I will apply again. I11

Some participants long for a new bariatric surgical procedure and plastic surgery to improve their self-esteem:

[…] plastic surgery in the belly is something I want to do to stir up my life, my self-esteem. I5 […] I want to lose around 50 kg and have the plastic surgery. […] because there is a lot of skin left, it impairs hygiene, appearance, and sex life. I13 […] I liked the idea of having another surgery, but we always think of the suffering it is […] I confess that I was excited when they said: “you are going to lose weight”. […] the perspective is to lose weight, join the plastic surgery program, get the skin cut off, and have a life. I17

Discussion

The experiences resulting from weight regain after bariatric surgery make up the knowledge background acquired by obese people in the social reality in which they are inserted. This background reflects on the way they deal with the weight regain (“reasons why”). What these people live in the social world grounds the projects they aim to develop to reach the initial goal, the weight loss of the physical body (“reasons for”). The set of specificities of people who gain weight after bariatric surgery (“reasons why and for”) constitutes the typical characteristics of this social group (typification).

The interviewees expressed feelings of frustration and failure and reported the need to eat when they feel anxious, nervous, or depressed for not having achieved the goal of keeping the target weight. These results corroborate the findings reported in a study carried out in Norway in which participants referred to fear to lose control and put on weight again, associating weight regain with feelings of defeat and shame.(³)

Bariatric surgery is aimed at controlling obesity, but does not address the psychic dynamics that leads people to resort to food as a mediator to handle their conflicts. In these patients, the body has been cared for, but the emotional issues which resulted in the dysfunctional eating behavior may persist.(¹¹)

An investigation with women submitted to bariatric surgery revealed that those who reached the mark of one year of surgery or more began to have difficulties to keep their weight. From that moment, these patients had to live with uncertainties and fears related to weight gain as a consequence of resuming inadequate eating habits.(¹²) As time passes by, these people get back to their previous experiences regarding obesity in the life-world.

The life-world, also known as the world of social relationships, is the setting of experiences lived in the daily routine, which represent intersubjective actions that allow exchanges and interactions which promote the understanding of the experienced questions.(⁸)

The interviewees reported difficulty to manage their emotional balance and consequently use food as an outlet for stress and anxiety. Loneliness and sadness were also mentioned as driving forces to consume high-calorie foods excessively. The results of an integrative review show that binge eating is a frequent behavior, and that bulimia, the grazing behavior, and night eating syndrome stand out among these people. The authors observed that dysfunctional eating behaviors are frequent among candidates for bariatric surgery and may emerge or worsen after the surgical intervention.(¹³)

Bariatric surgery resulted in a significant weight loss of the interviewees. Nevertheless, these changes did not guarantee existential satisfaction to them, who are constantly tested by the emotional instability they reported. Food seems to be a factor that controls and organizes their lives and everything revolves around it. It plays an important mediation role, regulating negative feelings and working as a coping strategy to face the difficulties that come up. This pattern is described as “emotional eating” and refers to the habit of resorting to food to obtain comfort and stress relief or to get a reward.(¹¹)

The patients interviewed in the present study declared that they eat incorrectly, nibbling too much and ingesting high-calorie foods such as sweets, cookies, and chocolate. One of the patients pointed out the consumption of alcohol as a factor that contributes to weight regain. A study carried out in Brazil with people who were submitted to bariatric surgery and had weight regain showed that the main causes of this phenomenon were the resumption of previous eating habits, the increase in alcohol consumption, and a sedentary lifestyle.(¹⁴)

The experienced beliefs, values, and eating habits reflect the way the participants of the present investigation perceive the relapse of obesity and associate it with the factors that contribute to weight regain. These factors are directly related to the biographical situation and natural attitude, that is, the way human beings act in the social world.(⁸)

The reports revealed that physical limitations, frequent pain, and impaired social relationships were perceived as a consequence of weight regain. It is common that obese people have chronic pain, and the weight loss caused by bariatric surgery may be an important aspect of pain rehabilitation. However, when weight regain occurs, the pain episodes resume.(¹⁵) The physical limitation regarding work activities, pain, psychological problems, and obstacles to developing social roles are also stressed as a consequence of obesity.(¹⁸)

Obtaining professional support that helps people deal with emotional issues was an expectation which stood out as a “reason for” in the action of bariatric patients before weight regain. In the examined group, emotional support was cited as necessary in the treatment, and some interviewees showed the need for professional follow-up to assist them to cope with the situations resulting from the surgery and weight regain.

A systematic literature review identified studies on the effectiveness of bariatric surgery to improve the quality of life of operated patients in the long run. The review reinforced how persistent psychosocial factors that affect obesity are and emphasized the need for psychological support after the surgery to work on the patients’ quality of life.(¹⁷)

The demand for plastic surgeries was an expectation of the interviewees to fix the impacts of weight loss and increase self-esteem. Plastic surgeries must be performed when the weight stabilizes after bariatric surgery or when the remaining skin and fat excess hinder patients’ locomotion or cause additional complications.(¹⁸)

The main limitation of the present study is the fact that it was carried out with a specific group of people who were assisted in a single public healthcare service, inserted in a certain social reality. It is noteworthy that the development of other investigations with people from different contexts will not necessarily converge to similar results. However, the findings of the present study may enrich the understanding of weight regain after bariatric surgery, in addition to encourage new investigations on the subject.

Conclusion

The present study indicates how complex and little understood the weight regain phenomenon is regarding its biopsychoemotional aspects. The experience of weight regain after bariatric surgery is attributed to emotional instability and reveals the disappointment caused by putting on weight and the expectation of losing weight again. The discussion confirms the need to improve healthcare professional practices and health teaching and knowledge. Multiprofessional healthcare teams must invest in meetings with patients after bariatric surgery, sharing decisions and promoting their autonomy aiming to keep their weight. It is important that professionals broaden their knowledge, exchange experiences, and seek training constantly on the several aspects involved in bariatric surgery, giving special attention to the subjective nature of the topics associated with weight regain.

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Publication Dates

• Publication in this collection
  Jul-Aug 2018

History

• Received
  1 May 2018
• Accepted
  27 Aug 2018