Published online Nov 28, 2023.
https://doi.org/10.17476/jmbs.2023.12.2.44
Increasing Accessibility to Metabolic Bariatric Surgery: A Qualitative Study Based on In-Depth Interviews of Korean Adult Patients With Severe Obesity
Abstract
Purpose
After the initiation of national health insurance coverage in 2019, the number of metabolic bariatric surgeries (MBSs) in Korea has been increasing. Despite evidence regarding its efficacy, many candidates are hesitant regarding surgery for the treatment of severe obesity. This study interviewed patients who received MBS to further understand potential barriers and increase the accessibility of MBS.
Materials and Methods
Eight interviewees who received MBS after 2019 participated. The interviews began in mid-July 2022 over approximately a month. Each one-on-one interview lasted a few hours and was done in person. The interviews were transcribed, and the results were analyzed based on grounded theory.
Results
This study focused on the quality of life before and after MBS. On a scale of 1 to 10, all patients had a high degree of satisfaction in quality of life after surgery (average score: 8.9, sleeve gastrectomy: 8.8, and bypass surgery: 9). Scores did not differ depending on procedure type, but factors that caused satisfaction and dissatisfaction were distributed differently between the 2 procedures.
Conclusion
Quality of life is significantly improved for patients undergoing MBS despite discomfort after surgery. Further promotion of the understanding of obesity as a chronic progressive disease is needed for both surgical candidates and the public to increase acceptance of MBS.
INTRODUCTION
Severe obesity is a growing concern worldwide and has a significant impact due to obesity-related co-morbidities and overall health-related quality of life [1]. Metabolic bariatric surgery (MBS) has been proven to be the most effective and long-lasting treatment of obesity [2]. Nonetheless, the low penetration rate of MBS at a reported 0.5 to 1% remains to be elucidated [3].
With the initiation of coverage of MBS by the Korean National Health Insurance Service in 2019, cases surged in the initial year. Conferences, campaigns, and various media have attempted to proclaim severe obesity as a disease and the long-lasting weight loss and resolution of metabolic disorders after MBS. However, the number of MBS cases remained stagnant despite increased financial accessibility and abundant data on the benefits and safety of MBS.
The disparity of understanding and knowledge on obesity and MBS exists among the public, candidates for MBS, and healthcare providers [4]. The perceptions and experiences of individuals who undergo the operation are valuable in further understanding and bridging the gap between metabolic bariatric surgeons and MBS candidates. This study interviewed patients who received MBS to further understand their motivation, decision process regarding surgery, and change in quality of life after surgery. To increase accessibility to MBS, this qualitative study aimed to recognize potential barriers.
MATERIALS AND METHODS
Patients with severe obesity who had undergone MBS (including sleeve gastrectomy [SG], SG plus duodenojejunal bypass [DJB], and Roux-en Y gastric bypass [RYGB]) at H+ Yangji Hospital after the implementation of the national health insurance coverage in 2019 were recruited randomly regardless of gender, age, or type of surgery. Patients who had had a follow-up period longer than 6 months were asked to participate in the order they visited the outpatient clinic. Patients who agreed to participate were enrolled.
Eight interviewees responded that they were available for an in-depth interview during the study. The in-depth interviews were conducted from mid-July over approximately a month. Each interview lasted from 1 hour to 2 hours and was done 1-on-1 and in person. Questions involved life before surgery, the decision process regarding surgery, and life after surgery. The final set of interview questions was derived from research team meetings and prior research. The relevant questions are listed in Table 1. Before recruitment and conducting the interviews, approval from the Institutional Review Board (IRB) was obtained (IRB 2022-07-012-002).
Each participant was requested to summarize their interview through mind mapping. Mind mapping helps the moderator guide the interviewee's expression of self in an unfamiliar environment. This method has the advantage of verifying the interviewee's expressed feelings during the interview [5, 6]. In this study, factors affecting happiness and unhappiness before and after surgery were mapped out. The participants were instructed to divide the content into 4 sections (before and after surgery, happiness and unhappiness) and provide a maximum of 5 related subjects for each area. The interviews were concluded after this process.
All interviews were transcribed, and the results were analyzed based on grounded theory [7]. The analysis consists of 3 parts: comprehensive background information of the 8 interviewees, the decision process regarding pursuing surgery, and change in the quality of life based on the 2 categories of surgery (the SG group vs. the bypass component group). The rationale for the categorization is discussed in more detail in the background information section.
RESULTS
1. Background information
The following (Table 2) is a summary of the background information of the 8 interviewees. Data were compiled based on the opinions and recollections of the participants. Discrepancies with actual information may exist.
Table 2
Background information of interviewees
The mean age of the 8 interview participants was 41.5 years. Three were male, and 5 were female. The average time from surgery to the day of the interview was 291 days (excluding the participant who had been interviewed 1,064 days after the surgery). The interviewees included 4, 3, and 1 participant who underwent SG, RYGB, and SG plus DJB, respectively. The participants were categorized into 2 groups: the SG group and the bypass group, which included RYGB and SG plus DJB. The malabsorptive component of the surgery and the similarity of quality of life after SG plus DJB were considered more comparable to RYGB than SG.
2. Process of deciding on and pursuing surgery
The reasons for and process of deciding on surgery were examined by summarizing the interview content of all participants regardless of surgical method. The background information from above is inevitably closely related to the reasons and process.
1) Personal history with obesity and its discomforts and process of deciding on surgery
The personal history of becoming obese and its discomforts and the process of deciding on MBS were examined (Table 3). Most interviewees were not obese during childhood but had gained weight after specific life events such as working night shifts, pregnancy, living abroad, and being diagnosed with type 2 diabetes mellitus (T2DM). Most interviewees did not experience specific discomfort due to obesity. However, some expressed dissatisfaction due to reactions from family members (such as their children feeling embarrassed about their parents being obese) and worsening metabolic disorders such as hypertension of T2DM due to increased body weight. Most eventually decided on MBS to overcome these concerns, especially when they experienced sudden fatigue, when concerned family and friends recommended surgery, or after finding information on MBS through various media platforms, including YouTube.
Table 3
Personal experience of obesity
2) Information sources for introduction to and pursuit of surgery
Most participants obtained information through recommendations by acquaintances, healthcare personnel, or media, including YouTube or television (Table 4). All participants emphasized that the content, not just the medium, on MBS was significant. For instance, information on obesity is abundant. However, most information was unrealistic or too vague to be of substantial help, and accessible information on life after surgery is lacking. Some felt that the name of surgeries hindered their understanding of the procedure and even made some feel apprehensive about choosing surgery despite knowing that they were candidates. Such negative initial perceptions appeared to hinder many potential candidates from eventually choosing MBS. The felt future needs of the participants are summarized in Table 5.
Table 4
Sources of information on metabolic bariatric surgery
Table 5
Future needs to increase accessibility to metabolic bariatric surgery
3) Difficulties after surgery
The most common difficulties experienced after surgery were related to diet (Table 6, Supplementary Table 1). Some participants expressed discomfort with having to eat a limited selection of foods at designated times. However, some stated that dietary adjustments were not a problem. Some participants mentioned uncomfortable experiences during social gatherings when other people questioned the reason for their decreased portions and related to physical symptoms such as dumping syndrome, hypoglycemia, or chest tightness.
Table 6
Difficulties after surgery
4) Satisfaction, regrets, concerns, and fears related to surgery
All 8 interviewees expressed high satisfaction with their lives after surgery (Table 7, Supplementary Table 2). Based on a scale from 1 to 10, the satisfaction of the participants ranged from 7 (lowest) to 10 (or even higher, indicating a significant level of satisfaction). Although initial fears about surgery existed, most successfully overcame these and expressed satisfaction with their current lives. Many participants also reported having no worries or regrets about the surgery.
Table 7
Satisfaction, regrets, concerns, and fears related to surgery
5) Final goals after surgery
When asked about their goals after surgery, the most common responses were weight loss and maintenance (Table 8, Supplementary Table 3). Some also mentioned goals related to managing diabetes. Weight loss was sometimes pursued for aesthetic purposes in conjunction with blood sugar control and hypertension management.
Table 8
Final goals after surgery
6) Disclosure of surgery
Responses regarding the disclosure of their surgery related to obesity varied among the interviewees (Table 9, Supplementary Table 4). Some participants shared this information with their families while others did not. Those who did not disclose the information to their family explained they did not feel the need to.
Table 9
Disclosure of surgery
Many participants disclosed the surgery to their workplaces since it was necessary for obtaining a medical absence. However, the level of detail shared varied among individuals. Some chose not to disclose the surgery to friends, and others disliked others discussing or gossiping about their journey regardless of the content.
7) Awareness of obesity as a disease
The surgery examined in this study, MBS, is closely related to obesity. To understand perceptions of obesity as a disease and whether it requires treatment, participants were asked if they considered obesity as a disease that required medical attention (Table 10). The results revealed 3 categories. 1. Obesity was always (even before surgery) considered a disease. 2. Obesity itself is not a disease but, with its metabolic effects, can be considered a disease. 3. Obesity is a disease, but I never felt the need for weight loss.
Table 10
Awareness of obesity as a disease
Actual recognition of obesity, based solely on body weight, as a disease was uncommon. However, most participants recognized obesity as a disease due to various physical discomforts and related co-morbidities (e.g., diabetes, hypertension, depression, restricted mobility). Some participants who considered obesity a disease but had never attempted or felt the need for weight loss. While some had given up on weight loss, others responded that they did not consider weight loss because they did not feel the need to "treat" every illness.
3. Changes in quality of life depending on surgery type
At the end of the interview, participants were requested to summarize their feelings and thoughts during the interview by drawing a mind map that reflected the factors that made their lives happy or unhappy before and after surgery. Examples are shown in Fig. 1.
Fig. 1
Example of mind maps done by participants.
Based on the 8 mind maps, quality of life before and after surgery was categorized and analyzed separately for participants who underwent SG or procedures with a bypass component. The content was organized into 5 categories: physical health, psychological, social, diet, and other aspects.
1) Participants who underwent gastric sleeve surgery
Factors contributing to happiness and unhappiness before and after surgery were examined for 4 participants who underwent SG (Table 11).
Table 11
Factors contributing to happiness before and after sleeve gastrectomy
2) Participants who underwent surgery with a bypass component
Factors contributing to happiness and unhappiness before and after surgery were examined for 3 participants who underwent surgery with a bypass component (Table 12).
Table 12
Factors contributing to happiness before and after surgery with a bypass component
3) Comparison of factors contributing to happiness before and after surgery by type of surgery
Comparing the quality of life of participants who underwent SG and surgery with a bypass component (Table 13), SG and bypass participants had an average of 4 and 5.3 factors that contributed to their unhappiness before surgery, respectively. For factors that contributed to happiness after surgery, SG and bypass participants had an average of 4.8 and 4 factors, respectively. Regarding factors that made life unhappy after surgery, SG and bypass participants an average of 3.3 and 4 factors, respectively.
Table 13
Comparison of the number of factors contributing to happiness before and after surgery between gastric sleeve and gastric bypass participants
For both groups, diet (e.g., eating, drinking alcohol, meals) contributed to happiness before surgery but became a contributor after surgery. Consistent with these findings, "food" was not a factor that had made the participants unhappy before surgery nor was it a contributor to happiness after surgery.
The physical factor was a commonly mentioned (e.g., fatigue, injections, diabetes, hypertension, fatty liver, inability to donate blood, fainting, headaches, stroke) contributor to unhappiness before surgery among the participants. It was a major contributor (e.g., resolution of diabetes, vitality, increased stamina, weight loss, decreased medication intake) to happiness in both groups after surgery. However, various physical factors (e.g., hair loss, hypotension, sagging skin, fatigue, dumping syndrome) also contributed to unhappiness after surgery.
In summary, although no significant differences existed in the average scores of overall satisfaction with quality of life after surgery based on the surgical method, factors contributing to happiness and unhappiness before and after surgery varied.
DISCUSSION
Based on the interview survey results, life before and after surgery for an obese individual was illustrated (Fig. 2). First, participants had become obese due to various factors such as night shifts, childbirth, living abroad, and the onset of diabetes which led to discomfort in their lives or concern from others. This concern and discomfort prompted the pursuit of surgery. Among the 8 participants, 6 had been diagnosed with diabetes before surgery, and most of them also had obesity- related comorbidities (e.g., hyperlipidemia, hypertension, non-alcoholic fatty liver disease). Given the close relation of these metabolic disorders with obesity, most participants experienced complete or partial remission of these conditions.
Fig. 2
Changes in life after surgery.
Second, the participants expressed a high level of satisfaction with the surgery and desired to recommend it to others. All the participants emphasized that their quality of life significantly improved after surgery. The satisfaction level for MBS for the participants was high with an average score of 8.9 out of 10 (gastric sleeve: 8.8, gastric bypass: 9). Accurate, pertinent information facilitated understanding the purpose and effects of MBS although difficulties existed in overcoming doubts and fears about surgery. Satisfaction after surgery was found to be unanimously high. Despite discomforts after surgery, such as dietary restrictions and physical symptoms, most participants strongly expressed satisfaction exceeding any discomfort and absence of regret. Further, they would recommend the surgery to others. Their ultimate goals included additional weight loss with maintenance or preserving the change in symptoms related to obesity (Fig. 2).
Only about half of the participants disclosed their surgery to others. Reasons for those who did disclose the surgery included being indifferent to the opinions of others or needing to inform their workplace for a leave of absence. Conversely, reasons for not disclosing included feeling no need to share or being reluctant for others to discuss their condition without their knowledge. This inability to or discomfort with sharing information with close family members is a significant obstacle in deciding on MBS as a treatment for severe obesity. This sensitivity to perceptions—or misconceptions—of obesity among the public remains a substantial reason to forgo surgical treatment.
Third, many participants desired to increase awareness of MBS so others would receive treatment for obesity and live a “new life” as they had. The participants professed the need for more promotion through broadcasting media emphasizing that the public does not understand the concept of treating obesity let alone choosing MBS. The most influential recommendation and advocacy for 2 participants came from their local internal medicine doctors, who had been treating their diabetes and informed them about MBS. They pursued MBS without much concern because it had been recommended by a trusted medical specialist. Conversely, 4 participants who had also been receiving diabetes treatment for diabetes had never heard about MBS from their medical doctor. Some faced opposition from their doctors once they mentioned they were considering MBS. Surgery is a specialized field difficult for the public to understand. Most of the participants felt that the recommendation of MBS as a treatment by a “doctor or specialist” would greatly assist in the decision to choose surgery.
Interestingly, some felt that the terminology of the surgery was off-putting. Despite the recommendation for surgery by their medical specialists, these participants felt doubt and fear because of the name of the operations. The term “sleeve gastrectomy” in Korean might be interpreted as “removing the stomach,” and participants perceived the wording as frightening. Misunderstanding and stigma regarding obesity remain prevalent. Even the participants who chose to undergo MBS could not come to a consensus on whether obesity was a medical condition. Reconsidering the verbiage surrounding the operations and improving public awareness may help promote the understanding of obesity as a progressive chronic disease that requires medical and surgical treatment. These efforts will eventually allow candidates for MBS to receive the required help and attention.
Finally, although numerous studies have been conducted on changes in body weight and remission of obesity-related comorbidities, qualitative research related to the change in quality of life after MBS remains lacking. This study is significant since it attempts to understand the experience of the patient undergoing MBS and the low penetration rate of MBS to a greater extent.
The limitations of the study are the short time frame of the study, possible selection bias of the participants, and limited funding. Participants willing to partake in the in-depth interviews may have had greater satisfaction with the surgery than those who did not undergo MBS. Although participants who had a follow-up of at least 6 months were included, the improvement in quality of life might be considered short-term and unsustainable in the long term. Large-scale qualitative studies are necessary to further understand the long-term effects on the quality of life of the patients undergoing MBS.
CONCLUSION
In conclusion, quality of life is significantly improved for patients undergoing MBS, exceeding any expected and experienced discomfort after surgery. However, more than half of the participants feeling uncomfortable disclosing undergoing MBS to their acquaintances implicates the existing stigma on obesity in society. Despite these misconceptions about severe obesity and MBS, the recommendation of MBS by a primary care physician was considered the most trustworthy and persuasive method. Further promotion of the understanding of obesity as a chronic progressive disease is needed for not only candidates but also primary care physicians and the public to increase acceptance of MBS as the most effective method of treatment for severe obesity.
SUPPLEMENTARY MATERIALS
Difficulties after surgery (supplement to Table 6 of the manuscript)Supplementary Table 1
Satisfaction, regrets, concerns, and fears related to surgery (supplement to Table 7 of the manuscript)Supplementary Table 2
Final goals after surgery (supplement to Table 8 of the manuscript)Supplementary Table 3
Disclosure of surgery (supplement to Table 9 of the manuscript)Supplementary Table 4
Funding:No funding was obtained for this study.
Conflict of Interest:None of the authors have any conflict of interest.
Author Contributions:
Conceptualization: Jun M.
Data curation: Chung Y, Jun M.
Formal analysis: Chung Y, Jun M.
Investigation: Chung Y, Jun M, Jeon D, Paik B, Kim YJ.
Methodology: Chung Y, Jun M.
Project administration: Kim YJ.
Supervision: Kim YJ.
Writing - original draft: Chung Y, Jun M.
Writing - review & editing: Chung Y, Jun M, Jeon D, Paik B, Kim YJ.
References
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Crowe M, Sheppard L. Mind mapping research methods. Qual Quant 2012;46:1493–1504.
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National Research Council for Economics, Humanities and Social Sciences. Developing national child and youth well-being indicators in South Korea [Internet]. Sejong: National Research Council for Economics, Humanities and Social Sciences; 2019 [cited 2023 Nov 22].Available from: https://repository.nypi.re.kr/handle/2022.oak/5820.
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