Support needs of people undertaking bariatric surgery: A narrative review

Nepean Family Metabolic Health Service, Nepean Hospital, Kingswood, New South Wales, Australia Charles Perkins Centre – Nepean, University of Sydney, Sydney, New South Wales, Australia Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia Metabolism and Obesity Service, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia Department of Upper Gastrointestinal Surgery, Nepean and Blacktown Hospitals, Blacktown, New South Wales, Australia Reset Weight Management, Norwest Private Hospital, Sydney, New South Wales, Australia


| INTRODUCTION
Obesity is a complex lifelong disease of excessive adiposity, impairing health and well-being. 1 Intentional weight loss in those with obesity is associated with reduced risk of many chronic diseases and favourable health outcomes. 2 Bariatric surgery, in association with lifestyle change, is currently the most effective and durable strategy for weight management for people living with obesity. 3 The literature supporting the weight and health benefits of bariatric surgery is extensive. However, there are equally as many papers presenting a more circumspect outlook, especially regarding psychosocial outcomes. 4,5 These include difficulties adjusting to a new body after surgery, body-mind disconnect, food-related battles, changes in personal relationships, the need for ongoing life-long lifestyle changes and expectations that surgery will fix more than weight. 4,5 Unrealistic, high expectations of surgery are not uncommon 6 and those undertaking surgery may underestimate or ignore the prospect of challenges after surgery. Many people struggle to attain and maintain weight loss 2 years and beyond, with reversal of health benefits seen. Weight regains of greater than 15% of initial weight loss in 25%-35% of patients, 2-5 years after surgery are reported in the literature. 7,8 The reasons for modest outcomes include (i) hormonal and metabolic adaptations affecting appetite and satiety, (ii) poor nutritional behaviours and intake (iii) physical inactivity (iv) mental health difficulties and (v) surgical failures. 9 Bariatric surgery is underutilized globally for many reasons, including patient and physician attitudes to surgery as a treatment option, low prioritization of obesity treatment overall by policymakers and socioeconomic barriers, as most countries provide bariatric surgery only, or majority, within the private health sector or via health insurance. 10 When bariatric surgery is offered in the public health system, strict eligibility criteria usually apply. Despite accessibility for relatively few people living with obesity, who would otherwise benefit, support and care following surgery is crucial to beneficial health outcomes. The aim of this review is to provide a synoptic overview of the support and care needs of people undertaking bariatric surgery. This includes research from the perspective of those living with obesity on the role health care professionals provide, and related to the efficacy of various technologies, including virtual health care, apps and social media.

| METHODS
A review of the literature was undertaken and included relevant articles sourced from PubMed, MEDLINE and Scopus electronic databases. English language articles exploring support needs for those undertaking bariatric surgery and clinical practice guidelines and recommendations were included. Keywords used in the searches included 'bariatric', the combined term 'metabolic and obesity surgery' and specific surgical terms such as 'sleeve gastrectomy', 'gastric bypass' and 'roux en y'. These terms were linked with themes of 'patient support', 'social support', 'support groups', 'social media', 'health care', 'interventions' and 'technology'. The search aim was to present a balanced and informed review of relevant articles to benefit those working clinically within the bariatric setting.

| Indication for bariatric surgery
Bariatric surgery, in combination with lifestyle support, is currently the most effective and durable strategy for weight management in the setting of obesity and its associated health conditions. 11 The American Society of Metabolic and Bariatric Surgeons and the International Federation for the Surgery of Obesity and Metabolic Disorders recommend bariatric surgery for adults with a BMI ≥35 kg/m 2 regardless of high-risk co-morbidities and for those with metabolic disease and a BMI of 30-34.9 kg/m 2 . 3 Reflecting the complexity of obesity, even after bariatric surgery, international guidelines recommend multidisciplinary involvement pre-and post-surgery to ensure informed consent and care of the person living with obesity. 3

| Post-surgical psychosocial challenges
People with obesity are at higher risk of poor physical and mental health and are more likely to be targets of discrimination and stigma.
Bariatric surgery can cause psychosocial changes in people, with some people coping better than others. 12,13 There may be initial improvements in psychosocial functioning, mobility, ability to undertake activities of normal living, self-esteem and feeling included in society. 4 However, ongoing 'battles' with food intake and behaviour and feeling uncomfortable in social gatherings are also described in the literature, 4 with control over weight and eating diminishing over time. 5 Weight stigma and body image dissatisfaction can continue post-surgery and are associated with less weight loss, reduced quality of life and poor mental health compared to pre-surgery. 14 A significant number of people with obesity over-estimate potential weight loss following surgery. Possible reasons for this include poor pre-operative education and communication around usual weight loss and regain by the treating team, unrealistic patient expectations and an emphasis on weight as the most important health marker. 15,16 Insufficient weight reduction or weight gain can lead to disappointment personally and within the clinical team. 15 Furthermore, people who have lost smaller amounts of weight, may be considered 'non-responders' or 'failures', even though their health and well-being may have improved.

| Supporting people undertaking bariatric surgery
The type of support required, when and by whom, and if this support impacts outcomes after bariatric surgery, is largely inconclusive.
Qualitative studies using interviews or questionnaires provide a rich source of information, however, study numbers are small, and participants are often recruited from support groups and/or health care organizations. 12,[17][18][19] Therefore, insights may be biased, as cohorts include those already considered proactive in their health. 16 Perspectives of those not engaged in support networks or ongoing health care support may provide differing opinions. Despite these methodological limitations, studies of this nature are important as they offer insight from those with lived experience of bariatric surgery. As such, to assess the most appropriate support and care for people who have had bariatric surgery, these perspectives should be prioritized.

| What supports do those with lived experience of bariatric surgery want?
Health and medical support are essential pre and post-surgery, as is the need for social support. Social support is defined as the psychological and tangible resources provided to an individual enabling more effective coping skills following biological, psychological and social stressors. 20 Support networks have been shown to have an immense influence upon a person's physical, psychological and emotional well-being and longevity. 21 They can include family, friends and colleagues; caregivers and health professionals; social media and support groups. Support may be considered emotional; informational; tangible; affirmational, or appraisal and from belonging or connectedness, for example, to a community or group. 22 Those with lived experience of bariatric surgery express the need for support from a wide network of people and services, and many report the inadequacies of health services to provide this support. 5,18 Achieving patient-defined surgical success, including weight loss and enhanced quality of life, 23 is challenging and reports of triumph and trials 17 and a lonely struggle 16 populates the literature.

| Support from family and friends
People undergoing bariatric surgery indicate they want emotional and affirmational support and encouragement from friends, family, peers and the surgical team. 19 The support of family and friends influences whether bariatric surgery is undertaken. 24 Furthermore, involvement of intimate partners in education pre and post-surgery, has shown to positively impact dietary behaviour, physical activity, intimacy and relationships. 24,25 Lower perceived social support both pre and postsurgery is correlated with higher scores in depression, disordered eating, poorer weight outcomes and greater weight variations. 26 Family encouragement is postulated to promote better adherence to a beneficial lifestyle after surgery.

| Support from health care professionals
Health care professionals are expected to provide specialized advice and encouragement, and address concerns pre and post-surgery. 19 Preferred health care professionals are those considered nonjudgemental and proactive in care. 16,27 Furthermore, patients desire an understanding of the role of each health care professional in a multidisciplinary team; the structure of upcoming appointments; and topics to be discussed. 28 Clinician-produced educational seminars and/or e-bulletins supporting lifestyle change are considered useful. 29 Support from health care professionals, especially in addressing weight regain, is reported widely to be required after surgery. 16,18,19,27 Table 1 outlines the health care supports and interventions reportedly desired by people following bariatric surgery.
Optimal timeframes for follow-up appointments preferred after surgery varies, as does the type of delivery, either in-person or online/via telehealth. 30,35,36 Many want structured appointment schedules 16,27,28,30 and others prefer ad hoc accessibility. 16,27 In a recent study, attendance significantly increased, when health care facilitated post-operative support groups converted from inperson (mean attendance 14.2 participants) to online (mean attendance 20.8 participants) during the COVID-19 pandemic. 31

| Support within peer support groups
Support groups can offer inclusion in a safe and accepting environment, where people with lived experience can share their stories without prejudice. 32 Post-operatively, online or in-person support groups are reported to be crucial for successful outcomes. The reported benefits of peer support include participants providing role-modelling, information and care, concern, empathy and companionship. 17,29,33,38 Participants report a preference for health care professional facilitated support forums. 29 Systematic reviews, albeit somewhat dated now, 34,39 have shown associations between attending support groups and weight reduction.
Those experiencing weight regain and poor body image are particularly more likely to seek inclusion in support groups, including private social media groups. 29,40 2.5 | Effective health care professional supports Weight loss and improvements in health following bariatric surgery, requires significant patient-driven behavioural change, with a lifetime of adherence. 4,41 Guidelines recommend the ongoing involvement of a multidiscipline health care team. 3 Health care professionals, including the bariatric surgeon, physician/general practitioner, dietitian, clinical psychologist, exercise physiologist/physiotherapist and nurses can all provide informational support to people undertaking bariatric surgery. 17 Providing initial education and information about surgery enables people to make an informed choice when giving consent and presents an opportunity to address realistic expectations and follow-up requirements. 41 The value of additional pre-operative exercise, diet and behaviour therapy does not appear to lead to beneficial post-operative weight loss. 42,43 However, evaluations of these preoperative interventions do show a trend towards improvements in post-operative mental health, physical activity and dysfunctional eating and preoperative weight reduction, which may improve operative fitness. 43 Pre-operative education allows the selection of the correct procedure, ensures baseline assessments are completed and that informed consent is possible. 41 In addition, they may help to reduce being lost to medical follow-up post-surgery. 44 Reports that patients may be overwhelmed by information leading up to surgery, is one reason why education before bariatric surgery may not be as effective. 45 It is also likely that motivation for change and receptivity to interventions may be improved only when challenges are encountered postoperatively. 42 Behavioural interventions are recommended to optimize health, weight, and psychosocial outcomes from bariatric surgery. 13 Postoperative interventions, delivered over one year by a MDT, have been found to be favourable for weight management and some health and psychosocial outcomes. 13,42,45 It is hypothesised that during the 12-24-month period immediately post-surgery, where weight loss is  16,27,28 • Yearly, 16,27 fortnightly to monthly 30 • Immediately post bariatric surgery 19 Delivery of service • Ad hoc access 16,27 • Individual routine appts 16,27,28,30 • Health care professional initiated contact 27 • Virtual consults 27,30 • Support groups 16,[27][28][29][31][32][33][34] • eHealth/virtual care 27,28,35,36 • Easy to understand and consistent 16 • Proximity to home 28,37 • Education on bariatric surgery for friends and family 16 Health care professional qualities • Experienced and knowledgeable 16,17,27,28 • Not dismissive of concerns 17,27 • Positive attitude to patient 17,27 • Non-judgemental 16,27 • Same clinician 27 • Not just weight focused 16 Who is preferred • Bariatric nurse 27 • Clinical Psychologist 16,17,27,28 • Dietitian 16,27 • General Practitioner (GP) 27 • Peer Group 16,17,27 typically rapid, self-confidence is elevated and motivation to change is at its peak. 45 Increased weight loss is reported with intensive multidisciplinary team interventions of greater than six months, delivered post-operatively by any health care professional (dietitian, clinical psychologist, or exercise scientist). 42 Attrition rates from follow-up appointments after bariatric surgery are known to be high, as much as 60% in the first year and 72% in the second year following surgery. 30 Barriers to attendance at follow-ups with health care professionals are reportedly due to (i) the occurrence of weight gain/regain, (ii) a mismatch of weight expectations between the treating clinicians and patients (iii) the expectation of clinical disappointment if targets are not met 27 and (iv) the time taken, costs incurred attending appointments, and distance from the service. 18,28 This indicates that there is a need for more effective communication between health care professionals and their patients.

| How can technology be used as a support?
Given the high rates of attrition post-bariatric surgery, time, distance and cost constraints, issues related to weight stigma, and the reported desire for peer-support, utilization of technology must be considered. 46 Three quarters of surgical candidates report accessing the internet while researching the procedure 47 and studies show people are interested in this communication form, especially if incorporated into usual care. Technology has the potential to reach more people than is possible face-to-face; engage with people who are physically, socially, or mentally isolated; and engage for longer periods of time. 48 Virtual care may also present a cost-effective alternative to in-person appointments for clinicians and patients.

| Virtual care
Virtual care including telehealth, text messages, telephone, online programs, videoconferencing, mobile applications and audio-visual media, is emerging as an effective modality for delivering healthcare interventions to patients. 35,48,49 Due to the need for safe patient care during the COVID-19 pandemic, there has been an exponential rise in the use of telehealth and other virtual healthcare strategies. 50 Virtual care offers an alternative to face to face consultations and is available to most health care professionals to be used when clinically appropriate. It can be used for individual or group consultations and within multidisciplinary clinics. 50 Many public and private health care services employ a hybrid model of care (virtual and face-to-face communication), benefiting both the clinician and health care recipient. 51 There are, however, many barriers to using virtual care 50 which are presented in Box 1.
Virtual care has been found to be useful in obesity treatment and management and studies show it to be as effective as usual care in weight loss and maintenance following bariatric surgery. 52 Furthermore, interventions using virtual care have shown improvements on validated questionnaires for measuring disordered eating, binge eating, food addiction and emotional eating. 52 This could be due to increased availability of support from the health care team and patient preference when discussing sensitive issues.

| Apps
There are many apps available to use on smartphones marketed to individuals who have had bariatric surgery. These apps track weight, food intake, exercise, activities and sleep patterns and provide information, recipes, and offer reminders. 53 Some apps also link users, providing a community of consumers who can offer advice and support to each other. It has been suggested that people most at risk of missing appointments and who are difficult to reach, may potentially benefit from the use of mobile applications. 53 Heuser et al 54 developed an app providing surgical and dietary education and the ability to record symptoms. They compared 30-day post-operative outcomes between those using the app, (n = 396) and those not using the app (n = 458). Although length of stay, emergency admissions and readmissions were not different between the two groups, those who used the app for 30 days reported that they needed to call the hospital less, had a better postoperative experience and were more able to manage symptoms at home. However, this contrasts with another study that found some app users felt less involved in post-bariatric surgery programs and more burdened with recording when compared to those engaging in care face-to-face. 55 The PromMera Swedish study, a large randomized controlled design study evaluating a smartphone app supporting lifestyle change is ongoing. This study will offer much needed information on whether People, especially those long-term post-surgery, look for encouragement and inspiration from social media, less so education. 40 Feelings of connectedness and linking with a personal 'buddy' enabled emotional support. Connectivity with health care professionals via these forums was also considered beneficial. 46 People seeking bariatric surgery information and support are turning to social media, the internet and online platforms. 46,49 Young adults, in particular, are using a wide range of social media platforms including YouTube, Facebook and Instagram, to gain health information. 58 Members of social media sites commonly seek assistance and validation from other users for medical and nutritional concerns, recommendations for tools and products, and to post about appearance changes and weight loss progress. Post responses are based largely on personal experience. 59 Social media platforms can promote misinformation, weight bias and may adversely affect mental health. 60 Information provided on these sites is usually unregulated, with content uploaded from those with lived experience, marketers, advertisers and sometimes, from health experts. 58 A study reviewing post bariatric surgery nutrition advice on YouTube, found information to be of low educational quality. 61 Furthermore, dietary advice provided on social media has also been found to be largely inaccurate or ambiguous. 59 Guidance should be provided to people following bariatric surgery cautioning against the misinformation available on the internet.
Health care practitioner moderated social media, as part of clinical care, may present an opportunity to provide education, motivation, support and a chance for members to learn from others with lived experience. 40 3 | CONCLUSION Significant adaptations to lifestyle after bariatric surgery, especially related to dietary and social behaviours and a changed appearance, can be challenging for many people. The literature clearly reports that people with lived experience value non-judgemental support and care from their medical and health care team to help them cope. Support from social networks of family, friends and peers is equally important.
The value of these social supports can be overlooked and underutilized by health care professionals, which presents a missed opportunity for meaningful connections and interventions. Utilizing technology, as a means of connecting with and supporting people undertaking bariatric surgery, may present an opportunity for health care professionals, however, further investigations with outcomes measures are required.

AUTHOR CONTRIBUTIONS
All authors reviewed and approved the manuscript.