Understanding the psychosocial impact of weight loss following bariatric surgery: a qualitative study

The public health burden of obesity is undeniable [1]. Within the United States, over one-third of adults live with obesity [2] and worldwide over six hundred million adults – 11% of men and 15% of women – live with obesity [3]. Further, a growing number of individuals live with morbid or severe obesity (body mass index > 40 kg/m² [4, 5]), which leads to serious health consequences and contributes significantly to obesity-related health care spending [6]. Bariatric surgery, which includes gastric bypass, sleeve gastrectomy, and laparoscopic gastric banding, is the most effective treatment for morbid obesity [7, 8], often reducing excess weight within one year of surgery for a prolonged duration [9]. Post-surgical weight loss predictably leads to resolution of and/or improved control over obesity-related chronic conditions such as type 2 diabetes mellitus [10, 11].

In addition to poor physical health, individuals with obesity are also more likely to experience poor mental health [12–14] and social dysfunction secondary to factors such as weight-related stigmatization, discrimination, and poor body image [15–17]. Psychosocial changes also occur following major weight loss after bariatric surgery [18]. However, in contrast to the predictable physical health benefits of major weight loss, psychosocial outcomes differ among patients and little is known about the individual-level experiences that may contribute to these variations. For example, many individuals experience decreased depression severity and increased quality of life following bariatric surgery [19–21]. Yet others may experience psychological benefit only in the near-term [22] or not at all [23]. Some may experience worsened mental health following weight loss surgery with several recent reports demonstrating increased rates of post-surgical self-harm, hospitalization for depression, and binge drinking behavior [24–26].

Poor mental health can compromise post-surgical weight loss [27], and psychosocial functioning is commonly assessed prior to bariatric surgery using standardized tools and a clinical interviews [28]. However, there are no definitive guidelines for this process [29] and the accuracy of these assessments may be undermined by patients’ underreporting of psychological dysfunction [30]. Following bariatric surgery, psychosocial functioning is not routinely assessed in the clinical setting. Among researchers, quantitative psychometric tools are commonly used to assess post-surgical depression severity and health-related quality of life (e.g Impact of Weight on Quality of Life, Short Form Survey 36). While these instruments can elucidate general trends and associations, they fail to capture the lived individual-level experiences that may drive variation in outcomes (e.g. increased marital discord following major weight loss [31, 32]). Hypothesized mechanisms for improved mental health include increased self-confidence, improved self-image, and better relationships as a result of major weight loss [33, 34]. Conversely, worsened mental health may be due to unrealistic pre-surgical expectations about the potential physical and mental health benefits of weight loss [35] or unanticipated changes in social relationships [36].

In this study, we conducted semi-structured focus groups with 77 US adults who underwent bariatric surgery, and we characterize the patient-level experiences that may drive differences in psychosocial outcomes after major weight loss. These data may facilitate more personalized counseling prior to bariatric surgery, and may provide patients with a more nuanced understanding of the potential psychosocial risks and benefits of bariatric surgery within the context of their individual lives. Further, these data may inform post-operative strategies to discuss, identify, and treat psychological dysfunction following weight loss surgery.

Through focus groups with patients who underwent bariatric surgery, we characterized the complex changes in psychological and social functioning that occur following major weight loss. Participants described changes related to three major themes: (1) self-perception; (2) perception by others; and (3) social relationships. Each of these themes includes positive and negative experiences that were often interrelated and experienced simultaneously by patients. Taken together, the experiences described by our focus group participants may help to explain the differences observed in recent quantitative studies examining the psychosocial impact of weight loss after bariatric surgery.

Several of our focus group participants noted that their depressive symptoms resolved following bariatric surgery. These findings are consistent with prior literature demonstrating a decrease in the prevalence and severity of mental health conditions following bariatric surgery [38, 42] as well as improved mental health and health-related quality of life two years after bariatric surgery [19, 20, 39]. Other participants discussed positive psychosocial changes that may mediate improvements in mental health and quality of life such as increased self-confidence and improved relationships with spouses, friends, co-workers and social acquaintances. Notably, these experiences support previously hypothesized mechanisms for improved mental health following major weight loss [33, 34]. Changes in self-perception described by participants this study also help put into context recent large registry research demonstrated that a large portion of partients aftery bariatric surgery have a change in relationship status (i.e. married patients become divorces or single individuals get married.) [43]

While mental health commonly improves following bariatric surgery [19–21], some individuals never have this benefit [23] and others may experience worsened mental health, including increased risk of self-harm [24–26]. Because these prior studies use administrative data and/or quantitative assessments to measure outcomes, they cannot provide insight into the individual-level factors that may either mitigate or potentiate adverse psychosocial outcomes. Prior qualitative work provides limited insight into the live patient experience, and demonstrates that some individuals are dissatisfied with their body image following surgery [40, 41], which may be due to unrealistic pre-surgical expectations [35]. For others, weight loss following bariatric surgery may negatively alter marital dynamics, even leading to divorce in some circumstances [32]. Our findings substantiate and extend these prior qualitative finds among a large patient cohort. We corroborate findings that relationships with significant others may change following major weight loss [43], and we also provide new insight into changes that may occur in other social and professional settings.

Notably, the psychosocial experiences shared by focus group participants could not be dichotomized as “positive” or “negative” due to the complexity of lived experiences. For example, many were pleased with their objective weight loss, but simultaneously struggled with a loss of self-identity. Others described social and professional gains, but also endorsed resentment for not being treated with similar respect before weight loss. This tension between positive and negative psychosocial experiences may explain, at least in part, why positive psychosocial outcomes diminish over time for some [22]. Future work could examine fluctuations in psychosocial experiences – perhaps in conjunction with weight loss and maintenance – to inform the development of targeted support strategies to optimize physical and mental health outcomes.

Our findings should be interpreted in the context of important limitations. First, similar to other qualitative studies, this manuscript may not be generalizable to the broader population of bariatric surgery patients. To minimize this limitation, we purposefully sampled patients throughout the state of Michigan to capture differences in various characteristics including age, gender, race, and socioeconomic status. The collaborative, while only one state, is amongst the largest collaboratives in the country with a diverse case-mix. Second, it is possible that participants with more favorable surgical outcomes participated in this voluntary study and therefore our findings may under-represent the negative psychosocial impact of bariatric surgery. However, we did reach thematic saturation with regards to negative psychosocial factors. Moreover, we reviewed our findings and conceptual model with a subset of bariatric patients to ensure important themes were not overlooked. Third, participants’ responses could have been influenced by recall or social desirability biases. We aimed to limit this bias by utilizing a trained moderator that had no association with the clinical providers within the MBSC. Finally, we did not assess patients at multiple intervals post-operatively, and their response to weight loss may have differed over time. To minimize this potential time-exposure bias, we made sure our sample included patients at multiple points along the post-operative time line. In that context, we did not notice significant thematic differences across different time points after surgery.

Our study has important implications for patients, providers, policymakers. Among patients, these findings may facilitate a more nuanced understanding of the psychosocial changes that may follow weight loss surgery. The themes identified in this study may help providers identify adverse psychosocial outcomes that may otherwise go undetected. While standardized instruments (e.g., PHQ-9) may be used to screen for common mental health conditions (e.g. depression) these measures may not reveal other psychosocial experiences (e.g. marital discord or judgment by former friends), which may contribute to general wellbeing and achieved weight loss [12, 23]. To elicit this information, providers may consider asking patients questions such as “How has your weight loss changed your relationships?” or “Has anyone judged you negatively for having weight loss surgery?” Lastly, among payers, there are opportunities to promote favorable psychosocial outcomes through reimbursement for post-surgical mental healthcare, which may include support groups, couple’s therapy, or one-on-one counseling.

Our study provides new insight into the psychosocial experience of patients following bariatric surgery. By understanding these lived experiences, providers may be better equipped to ascertain and address factors that may contribute to psychosocial dysfunction. Prior to surgery, patients and providers may engage in a more personalized discussion of potential psychosocial risks and benefits of surgery, and anticipatory guidance may be better tailored to the patient’s unique circumstances. For example, a patient whose social life revolves around dining out may be encouraged to explore alternative activities before surgery and to pre-emptively discuss this lifestyle change with friends and family. Post-operatively, bariatric surgery teams and primary care providers may more effectively elicit and address psychosocial struggles by discussing patients’ changes in self-perception and relationships with others. As rates of severe obesity and surgical treatment for the condition continue to rise, these steps are critical to optimize psychosocial functioning among patients who consider and undergo weight loss surgery.