FACTORS AFFECTING THE PREFERENCE OF POPULATION IN LOSING WEIGHT BY EITHER BARIATRIC SURGERIES OR CONSERVATIVE STRATEGIES IN SAUDI ARABIA

1. Department of Surgery, College of Medicine, Taif University, KSA. 2. Department of Surgery, Benha Teaching H., General Organization of Teaching Hospital and Institutes, Egyp. 3. Medical Intern, College of Medicine, Taif University, KSA. 4. Emergency Medicine Resident, King Abdulaziz Medical City, Riyadh City, KSA. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 30 June 2021 Final Accepted: 31 July 2021 Published: August 2021

Obesity has become a common public health issue in the Kingdom of Saudi Arabia (KSA), and it is affecting all adults [3]. In KSA, more than 60% of the population are obese, and studies have revealed that obesity prevalence is higher among females [3,7]. A survey was conducted in 2019 to determine the general public's knowledge of bariatric surgery complications. The abovementioned study discovered that two-thirds of the people polled were aware of the risks of bariatric surgery. The participants who had previously undergone weight loss surgery were more conscious [8]. Another survey conducted in 2019 to determine public understanding of bariatric surgery determined that 22.7% of the participants were unaware of the procedure, 18.9% thought that it was a cosmetic procedure, and 50% were unaware of its criteria [9].
As published studies in Saudi Arabia about factors affecting the preference of population in losing weight either by bariatric surgeries or conservative strategies are scarce, the aim of this study was to assess these factors which affecting the preferences.

Subjects and Methods:-
This study was a cross-sectional study; it was performed during the period of January to March 2020. The study was conducted on adult male and female population who lived in different regions of KSA. The participants agreed to answer the questionnaire to assess the effect of different characteristics of the respondents on their preference of losing weight by either bariatric surgeries or conservative strategies.
The data were gathered using a self-administered questionnaire that was circulated through social media (i.e., WhatsApp, Twitter, and Facebook). The questionnaire requested information on the following topics: 1) characteristics of socio-economic status (i.e., age, gender, nationality, marital status, education level, income, and region) and clinical characteristics of the respondents (i.e., body mass index and chronic diseases). 2) Food habits, lifestyle (physical activity), and dieting attempts by the respondents. 3) Awareness of bariatric surgery. The participants were divided into two groups. The participants in group I favored traditional techniques (e.g., dietary change, medicine, or other approaches) over bariatric surgery. Whereas the participants in group II preferred bariatric surgery.
Statistical analysis: For data processing, IBM SPSS version 20 (IBM Corporation, Armonk, NY, USA) was used. The participants' information was provided in the form of numbers and percentages. The chi-square (2) test was used to assess the correlations between various characteristics of the respondents and their preferred methods of losing weight, and the analysis was deemed statistically significant at the p-value of 0.05.

Compliance with ethical requirements
The research protocol was accepted by Taif University research ethics committee. Participants' anonymity was maintained by omitting their names and any other information that could be used to identify them.

Results:-
In this study, a total of 603 participants responded and completed the survey. Most of the respondents were females (59.5%); 526 (87.4%) respondents were Saudis; 47.0% of the respondents were 18-24 years old, and 56.8% were unmarried. Most of the participants had higher education (74.8%). The percentages of our participants from different regions were similar.
There was a total of 518 (86%) participants in group I, and 84 (14%) in group II. In group I, 390 (75.3%) participants preferred to lose weight by conservative strategies because those approaches were deemed healthier; 71 (13.7%) participants mentioned that conservative strategies were safer than surgery; 46 (8.9%) mentioned that they were afraid of complications, and 11 (2.1%) mentioned that conservative strategies were cheaper than surgery. In group II, 41 (48.8%) participants preferred to lose weight by surgery because it was faster than conservative strategies; 32 (38.1%) reported that it was the only solution, and 11 (13.1%) reported that it was easier than conservative strategies (Table1).
953 Table 2 shows that there was no statistically significant association between the preference of bariatric surgery and age, nationality, marital status, sex, education level, and income of the participants. In contrast, there was regional variation with respect to the preference of bariatric surgery with a statistically significant association (p = 0.032), where the highest preference for group II (34.5%) was in the western region, and the highest preference (25.9%) for group I was in the eastern region. Table 3 shows that for group I, 221 (42.7%) participants had normal weight, 138 (26.7%) were pre-obese, 121 (23.3%) were obese, and 38 (7.33%) were underweight. For group II, 58.3% were obese, 34.5% were pre-obese, 7.2% were normal, and none of the participants were underweight; there was a statistically significant difference between the two groups (p = 0.0001). No statistically significant difference was observed between the two groups according to the presence of chronic disease (p ≥ 0.05). Out of all participants, 34.9% of group I and 37.6% of group II wanted to lose less than 50% of their excess weight; 54.6% of group I and 57% of group II wanted to lose 50-100% of their excess weight, and 6.8% of group I and 19% of group II wanted to loss more than 100% of their excess weight without any significant difference between the two groups. Table 4 shows that compared to group I, group II has a significant higher percent of the participants who usually eat breakfast, lunch, and dinner every day, have soft drinks as beverages between meals, and eat fast food more than 2 times per week. Group 1 has a significantly higher percent of those who eat fruit and vegetables everyday compared to group II. In contrast, a nonsignificant difference was observed between the two groups according to nutrients in the diet of the participants, healthiest cooking method, and healthiness of the diet.
Group I had a statistically significantly higher percent of the participants who reported to always engage in physical activity throughout the year (19% vs. 7%). While group II had a significantly higher percent of the participants who had more than 6 attempts of losing weight in the last 5 years (59.5% vs. 16.4%) and who thought that their families would support their efforts in improving their food habits (78.6% vs. 26.4%) (p ≤ 0.05). A non-significant difference was observed between the two groups according to hours of practice, what they preferred to do during free time, and their lifestyle (p ≥ 0.05) ( Table 5). Table 6 shows that group II has a statistically significantly higher percent of the participants who consider bariatric surgery as an effective approach for weight loss (100% vs. 51.7%), who believe that they will lose more weight with bariatric surgery (95.2% vs. 57.5%), and who believe that surgery will cause a drastic change in their lifestyle (81% vs. 58.3%) (p ≤ 0.05).

Discussion:-
According to WHO, obesity is prevalent in 35.4% of Saudi Arabians, which indicates inefficiency or lack of preventive measures [10,11]. However, there is a lack of knowledge in Saudi Arabia about factors that affect people's favorite weight loss methods. As a result, we conducted this study among Saudi Arabia's adult population to determine factors that affect whether people choose to lose weight through bariatric surgery or through more conservative methods.
A total of 602 people participated in the survey, with 86% preferring to lose weight through lifestyle changes (conservative management); 75.3% favor the conservative approach because it is better; 8% favor the conservative approach because they are afraid of surgical risks, and only 14% prefer bariatric surgery to lose weight. Another research conducted in Saudi Arabia showed a similar result, with 87.5% of the participants not considering surgery as a first resort for weight loss without diet or exercise [12].Another survey determined that the majority of people (77.6%) thought that bariatric surgery was not the right way to lose weight [13].A separate study included 151 patients, with 50 opting for conservative treatment, and 101 opting for bariatric surgery [14].Participants in previous studies who chose surgical treatment wanted to boost their self-esteem, and many were concerned about losing control of their weight [15,16].
There was no statistically significant link between bariatric surgery preference and age, nationality, marital status, sex, education level, or income in this sample. Two experiments conducted in Saudi Arabia yielded similar results [17,18]. Another study was performed in Pennsylvania [19]. Approximately 56% of our participants had BMI that was higher than average (pre-obese: 27.7%; obese: 28.2%). With a statistically significant difference between the two groups, 92.8% of them tended to lose weight by surgery. This result confirms a previous study conducted in Pennsylvania, which observed that there were substantial differences in BMI between the two groups, with those who chose surgery usually being heavier than those who chose weight loss by conservative measures [19].In addition, conservative approach patients were observed to have a slightly lower BMI in other trials [20,21].Obese 954 people were observed to prefer bariatric surgery over other options (e.g., diet and exercise) because it was a quicker and simpler way to lose weight.
The majority of participants in this study did not have any chronic diseases (e.g., asthma, diabetes, and sleep apnea). In comparison, recent studies have shown that obesity-related comorbidities (e.g., type 2 diabetes and obstructive sleep apnea) can be strengthened or reversed after bariatric surgery [21,22]. The results of this study may differ because the majority of the sample size had a younger age.
This study showed a statistically significant difference between the two groups on eating fruits and vegetables (pvalue = 0.0001) because participantsin group I reported eating fruits and vegetables every day, while only 23 (27%) participants in group II reported that. This result is consistent with the results in previous studies [7,8]. Another study observed that obese patients seeking bariatric surgery lost control over their intake of high-fat, high-sugar, and/or high-salt foods but not fruits, vegetables, or grain products [23].
Regarding fast food consumption, more than one-half of the participants from group II eat fast food more than 2 times per week. In a previous study, fast food consumption has been linked to higher BMI, weight gain, and difficulty sustaining weight loss [2]. In this study, 56% of the participants in group I drink mineral water between meals, while 65.5% of group II do not, and 62% of group II eat breakfast, lunch, and dinner every day. According to the results of another study, the majority of patients (92.1%) reported eating dinner on a regular basis; although slightly over half (54.0%) of the participants reported eating breakfast on a regular basis prior to bariatric surgery [13].
In this survey, the majority of group II participants stated that they tried at least 6 times to lose weight in the previous 5 years. A similar result was obtained in a study performed in Al-Madinah, which determined that the majority of respondents sought conventional approaches to lose weight (dieting) [24]. In our view, more people attempt to lose weight by conservative approaches and fail, which affects their ability to choose.
This study showed that group I had a statistically significantly higher percent of the participants who thought that their families would support their efforts in improving their food habits. According to previous studies, the frequency and importance of family meals are linked to the family's perceived support, especially in terms of intangible resources as well as overall happiness with life and food [25].Family social engagement has been shown to be an important factor in promoting and sustaining positive healthy behavior changes [26].Family is a source of behavior change, especially when it comes to maintaining an attainable target weight and engaging in regular physical activity [26].Almost one third of group II participants never engaged in any physical activity. Previous studies have shown that candidates for bariatric surgery have low levels of physical activity. Candidates for surgery showed a slightly lower activity counts per hour and spent fewer minutes per day doing physical activity than the controls [27]. This study showed that all participant in group II considered bariatric surgery as an effective approach for weight loss. A similar result was obtained in Al-Madinah, which showed that the majority of people thought that bariatric surgery was a successful way to lose weight [13]. According to a study conducted in Riyadh, 79% of the participants claimed that bariatric surgery was a successful method for weight loss [28]. Other studies contradicted this result and indicated that surgery was not a good way to lose weight [18].
The majority of group II participants assumed that surgery would result in a significant improvement in their lifestyle. This is supported by a previous study [29]. Patients' everyday life experiences and social lives significantly changed 5 years after the gastric bypass surgery, and they were mostly happy with their lives.

Limitation:-
The fact that the questionnaire was distributed through social media and those participants estimated their height and weight was a limitation of this study. As a result, there could be a shortage of correct height and weight measurements.

Conclusion:-
In summary, the aim of this study was to identify factors that affected people's weight loss preferences in Saudi Arabia, i.e., whether they preferred to use bariatric surgery or more traditional methods. Traditional weight loss approaches were preferred by the majority of our participants over bariatric surgery.In contrast, higher BMI participants were more likely to undergo surgery. Serious illnesses, eating habits, physical activity, and dieting attempts are important factors that affect weight loss plan choice.

Recommendations:-
The study recommends that credible sources of knowledge about bariatric surgery be made available to the public.
To correct misconceptions about bariatric surgery, effective health education campaigns about obesity and bariatric surgeries should be implemented.

Funding
This study received no particular support from state, private, or non-profit funding agencies.

Conflicts of interest
There are no conflicts of interest.

Ethical approval
Registered at Taif university research Ethical committeebetweenSEP 2020 to SEP 2021 (Application number 42-0007)