ORIGINAL ARTICLES

Experience of women in the postoperative period of bariatric surgery: a phenomenological study

Deíse Moura de Oliveira¹, Miriam Aparecida Barbosa Merighi², Estela Kortchmar², Vanessa Augusta Braga³, Marcelo Henrique da Silva², Maria Cristina Pinto de Jesus³

¹Federal University of Viçosa
²University of São Paulo
³Federal University of Juiz de Fora

ABSTRACT
Aim: understand the experience of women in the postoperative period of bariatric surgery.
Method: qualitative study based on Social Phenomenology of Alfred Schütz. The study included eight women, whose testimonies were obtained in the period October-December 2012 through interviews with open questions.
Results: The category "Rescue of everyday activities" reveals that surgery allowed the control of chronic diseases associated with obesity, autonomy for self-care and daily activities, the rescue of self-esteem and social inclusion. The category "Challenges" shows that women live with the need to adopt healthy eating habits that can enable the achievement and maintenance of the desired weight.
Conclusion: Although this study evidences a gain in quality of life of the "bariatriczied" woman, it also underscores the need for a shared and longitudinal care with this clientele by a multidisciplinary team, due to the chronic nature of obesity.
Descriptors: Obesity; Bariatric Surgery; Qualitative Research.

INTRODUCTION

The emergence of chronic noncommunicable diseases on the world stage reveals obesity as a growing pandemic and difficult to control ⁽¹⁾. The difficulty of adherence to conventional strategies for the control of obesity - calorie diet, physical activity and, in some cases, antianxiety drugs and appetite suppressants - has led to unsatisfactory answers to the control of this disease in the context of modernity, in which dominates a sedentary lifestyle and eating habits rich in fat and sugar, often easily of access and preparation⁽²⁾.

Faced with the failure of these strategies, bariatric surgery (BS)  emerges as a last obesity treatment option, and the female audience makes up, globally, about 80% of people who undergo it ⁽³⁾. The high percentage of women seeking BS can be justified by virtue of the  pressure of society to achieve an imposed body pattern - to be thin⁽⁴⁾.

The experience of submitting to BS evokes meanings that transcend the surgical procedure. It refers to a unique event provided with successive meanings and new meanings by those who experience it⁽⁴⁾.

The surgical procedure for obesity treatment is a landmark event in the life of the obese because the postoperative periodimplies a series of changes that require adjustments necessary at each step lived in that period. Among these, it highlights the need to break with old eating patterns and to learn to live with the new body obtained from surgery⁽⁵⁾.

Therefore, BS can result in many changes of physical and emotional order, including sexuality, and is seen as a possibility of social reintegration for the bariatrized person⁽⁶⁾. It is emphasized, however,  the need for responsibilization of the operated person with regards to adopting a behavior to keep the weight reached, which must be extended for a lifetime ⁽⁷⁾.

Assuming that the success of the BS is related to adapting to a new lifestyle, which can be constituted as a daily challenge for bariatrized women, the following concerns guided this research: how is the everyday life of women who underwent bariatric surgery? What are their expectations? The objective was to understand the women's experience of the postoperative period of this surgery.

It is highlighted that both health professionals and patients have devoted more attention to the preoperative period of BS, which is inscribed the therapeutic planning. However, this attention is not enough to sustain the surgical results ⁽⁸⁾, which refers to the need to meet the woman's  experience in the postoperative period.

It is believed that this research makes important contributions to the field of health and nursing, to demonstrate how the experience of bariatrized women should be exploited in assistance targeted to this audience.

METHOD

A qualitative study, based on the Social Phenomenology of Alfred Schütz. This theoretical-philosophical framework rests on the view that the human experience is provided with a social meaning, in that understanding of the world is through the bias of one’s own experience articulated to the other. In this study, the experiences narrated by women who had undergone BS culminated in the unveiling of their experiences. These, though entered in the subjective universe of women, also reflect a social meaning set from the interpersonal relations established with others in the everyday world/life.

The social relationship is critical in interpreting the meaning of human action in the everyday world; the scenario where the person lives and on which she has the ability to intervene becoming continuously changing social structures ⁽⁹⁾, which may be revealed in women's experience in the BS postoperative period.

The intervention of man in the world of life is called social action, which is conscious, intentional, purposeful and anchored in existential reasons. Schütz remarks that these reasons are based on the context of experiences, called "reasons why", and also on the projects desired by the person, called "reason for". The set of reasons "for" and "why" composes the flow of action, these being derived from subjectivity, and thus constitutes the conductive wires of human action in the social world⁽⁹⁾.

The experience of women after BS evokes a social action that unfolds in a continuous way, taking as its starting point a decision for surgery, which unfolds as an intentional and purposeful action to be experienced in the bariatric post-surgery period. This is permeated by a concrete action - which gives a present lived and designed - to anchor their expectations, considering the condition of being bariatrized.

The study was conducted in a Control Service of Hypertension, Diabetes and Obesity (SCHDO). This constitutes a reference to the attendance of obese people in the pre- and postoperative BS in the public health of a municipality in the southeastern region of Minas Gerais, Brazil. The SCHDO provides interdisciplinary care to this clientele, both in an individual mode and in groups.

Inclusion criteria were considered to be adult women who were in post-operative monitoring of BS in SCHDO. Those whose time after surgery was equal to or less than 30 days were not included, considering that the approach to women in this period - permeated by adjustments related to the surgical procedure and the restricted diet - would imply the suppression of relevant aspects of the everyday experience of witnesses, by virtue of being directed to the immediate concerns regarding surgery and dietary issues⁽⁵⁾.

The study included eight women who were approached after the group activities in SCHDO, and  declared agreement to compose the study by signing the Informed Consent.

The statements were obtained in the period from October to December 2012. Interviews were conducted in a private room, in SCHDO dependencies, after the explanation of the research objectives.

We obtained permission to use the recorder, aiming for a full account of  the testimonies and their subsequent analysis.

The interviews lasted an average of 40 minutes, using the following open questions: How has been your daily life after bariatric surgery? Now that you've submitted to surgery, what are your life projects?

The number of participants was not predetermined, having been set at the time the study objectives were achieved.

To guarantee anonymity, the interviewees were identified with the letter "E" (Interview), followed by Arabic numerals according to the order of the interviews and the time in months postoperatively (E1 - 4 months E8 - 36 months). The statements were recorded and transcribed in full.

The organization and analysis of the results were based on students of Social Phenomenology of Alfred Schütz ⁽¹⁰⁾, including a careful reading and critical analysis of the content of the talks, which enabled the identification and description of the meaning of women's experience in the postoperative of BS. The organization of the results fell into thematic categories and the discussion was based on the theoretical-philosophical framework and literature relating to the object of investigation.

This study was submitted to the Ethics and Research Committee of the School of Nursing of São Paulo University, Assent No. 73 616 of 14 August 2012, taking account of the ethical principles of Resolution No. 466, of December 12, 2012.

RESULTS

The participants were aged between 23 and 53 years. Most with obese history since childhood, married with kids and high school as schooling. As for the time of bariatric surgery, four were carried out less than six months before, and four were with a postoperative time  between 12 and 36 months.

The activities of women enrolled in the experience of the BS postoperative period was expressed in the "Rescue of daily activities" (reasons why), which reveals the possibility of controlling coexisting chronic diseases, autonomy for self-care and daily activities, the rescue of self-esteem and social inclusion. The "Challenges" (reasons) shows the need to adopt healthy eating habits that can enable the achievement and maintenance of the desired weight.

Rescue of daily activities
The weight loss triggered in BS postoperative allows women greater control of comorbidities that are related to obesity, especially for hypertension:
I lost 40 kilos, I stopped taking the high blood pressure remedies. Now just take omeprazole and multivitamin. I feel like someone else. (E2-5 months)

With weight loss, women find themselves in a position to do simple daily activities such as walking and performing household chores:
] I could not stand to walk and now I'm getting to walk, I'm having more lightness in my body [...]. Now I walk and I feel great. I come home and I still have a willingness to do my job. (E4-4 months)

An important aspect mentioned by the study participants with regard to the rescue of self-care, made possible after bariatric surgery:
] everything has changed. Today I'll do my personal hygiene myself, which before I could not do [...] I take care of myself [...] workout and run on the treadmill [...] (E5-24 months)

The achievements of a physical nature that women experience with weight loss culminate in improving  their self-esteem:
I now have pleasure when people look at me, especially those who know me. I improved my self-esteem and that in a woman is everything. (E7-18 months)

In the social sphere, weight loss gives the woman the opportunity to feel included in labor and leisure activities:
Now people invite me out. People that excluded me make sure I participate in parties and I always go. (E3-14 months).
I returned to work [...] seven years ago, I could not work because of obesity. (E2-5 months)

Challenges 
To demonstrate their expectations, women reveal in their statements the ongoing concern with the eating habits to be adopted and maintained postoperatively, this being the biggest challenge faced by them.
Participants who underwent surgery for a period less than three months are seen in an adaptive feeding phase, which creates uncertainty as to what they should or should not eat:
] Now I can eat, but I'm afraid of feeling sick, or for any complications to happen. Today, for me, food means limit (E6-2 months).

Participants who had a time of postoperative between four and six months - frankly weight loss phase - highlight the importance of following the diet required in order to give continuity to the ongoing weight loss:
] I try to feed myself well, do not eat candy, do not drink soda, and do not eat fried food. I eat vegetables and fruit, do not eat rice. At least for now, I'm not having any desire to eat candy. (E1-4 months)

Women with a period longer than 12 months postoperatively recognize the chronic nature and complex of obesity and the difficult diet to maintain, even if the body no longer represents the disease:

] I went through this whole process and I do not want to get fat again [...] the candy remains in my life. I had the surgery in the stomach, but the head still wants candy. [...] I feel I'm regressing [...] gained weight [...] continue with to believe I am fat. (E8-36 months)

DISCUSSION

The "reasons why", which reflect the experiences of women in the postoperative period of BS, reveal positive aspects observed in the daily lives of participants. These relate to restoring their health and daily activities, to rescue their self-esteem and social inclusion, considered common events in the social group studied.

From their living with obesity and subsequent experience with BS, the women set a new stage for their actions everyday, restructuring themselves in different ways in the world of life, considering the biographical situation they are in - bariatrized.

The geographic situation locates the human being at a certain time and space and is configured from their previous subjective experiences. These add a wealth of knowledge that is available and accessible, formed initially by the parents and teachers and subsequently restructured from experiences of the everyday world ⁽⁹⁾. This was evidenced in this study, in which women biographically situated in the BS postoperative drew upon their previous experiences with obesity in the intersubjective context to restructure themself before the lived present.

Considering the experience in the BS postoperative the participants in this study expressed the control of comorbidities that accompanied them prior to submission to the surgical procedure. The literature shows that obesity is directly related to other chronic conditions, especially hypertension, type 2 diabetes, osteoarthritis, sleep apnea, cardiovascular diseases, among others⁽¹¹⁾.

Phenomenological study in the United States, with couples who have undergone BS together, pointed, in the experience of participants, to a reduction in the use of medicines and improvement of comorbidities - especially Mellitus diabetes and hypertension - which reduced the need for medical intervention and brought positive impact to their lives ⁽⁶⁾.

This study showed that, with their reduction in weight, the women began to perform everyday tasks for which they were seen to be previously limited. This is supported by the literature, which indicates the weight loss achieved with BS ls an enabler of the resumption of daily activities, due to the improvement of energy and body mobility, previously limited due to the excess weight ⁽⁶⁾.

The rescue of women's autonomy to carry out their daily activities reflect in the improvement of their self-concept, since they begin to see themselves like someone capable of self-care, of taking care of their home and family members - roles socially assigned to women -  and unfolding in improving their self-esteem.

This is consistent with findings in national and international literature, which state that the possibilities of accepting, feeling included socially and with care, offered by weight loss, are closely linked to the return of self-esteem and a positive self-concept that gives the feeling of regaining control of their lives ^(4,12).

Such control is related to the achievement of the desired weight, which produces reflections in all areas of a person's life. A phenomenological research conducted in Denmark with young women undergoing BS revealed that improving the appearance, conquered after weight loss, resulted in positive perceptions of the thoughts, feelings and, above all, the body image of the participants, contributing to long-term maintenance of weight loss reached ⁽⁵⁾.

Such evidence is shown to be relevant, since a positive body image, resulting from self-esteem and self-concept, greatly reflects on the mental health of persons under the BS who  reached the desired weight⁽¹²⁾.

Regarding the social dimension, the findings of this research indicate positive aspects in relation to social inclusion, as evidenced after the weight loss. Qualitative study in Norway showed that the sense of compliance with the standard body imposed by society presented itself as a facilitator for social cohesion of the operated, referring to the return of human dignity in the social context. It is noteworthy that, by submitting to the BS, the participants had a desire to feel themselves socially accepted ⁽¹³⁾. In this sense, the weight loss evokes a sense of social adaptation that allows performing daily activities and the resumption and strengthening of social bonds.

It also highlights the return to work activities experienced by the women. In this regard it is noted that the weight loss mediated by BS favors the return to work, allowing the integration of the individual in the social sphere, including the professional context ⁽¹⁴⁾.

Regarding the "reasons for" inscribed on the experience of the participants of this study, it is evident that social action in progress regards to addressing the challenges posed in everyday life after bariatric surgery existence. These challenges locate women biographically on expectations, which are related to the desire to lose weight and/or maintain the achieved weight, depending on the postoperative phase they are in.

These challenges are present in the reality of people living with the chronic nature of obesity, who need to understand not only the genesis of the disease, but also the impact of their daily actions to achieve and maintain the desired body weight ⁽¹⁵⁾.

As with non-surgical treatments focused on weight loss, BS implies a continuous process of confrontation of varying challenges to the operated person, who must follow a new lifestyle, so that the surgical procedure is set in a successful experience ⁽¹⁶⁾.

The present study showed that the participants situated biographically in the postoperative period of up to three months showed insecurity in relation to food intake, becoming one of the first challenges after surgery. The literature indicates that after the surgery, depending on the food restriction in the initial period - from hospitalization for three months - highlights the significant weight loss, but it is a moment filled with fear and uncertainty, generators of anxiety, which is characterized as an important adaptive phase ⁽¹⁴⁾.

Scientific evidence indicates that after the first six months from surgery, the diet of the bariatrized is practically normal, but in small portions. During this period, the weight loss becomes slower, remaining stable up to two years after surgery, at which time the challenge is now to maintain a proper diet to prevent weight regain ⁽¹⁷⁾.

The interviewees who have reached the mark of one year or more of surgery bring challenges related to maintenance of achieved weight, since they are close to or have reached the desired weight loss. From then they go on to live with uncertainty and fears related to the constant threat and / or occurrence of weight regained due to the recovery of bad eating habits. This finding is presented consistent with a Brazilian study of people undergoing BS, mostly women. This revealed that the regained weight was directly proportional to the resumption of poor eating habits and the elapsed time of the surgery, most commonly from the second postoperative year ⁽¹⁸⁾.

The evidence from this study and those described in the literature shows itself relevant, since the weight regained may have negative consequences for the bariatrized women. A qualitative study in Campinas, São Paulo, with women in the BS postoperative pointed out that, despite the social reintegration experience, recovery of quality of life and improved self-esteem, they expressed feelings of defeat and failure with gradually regained weight. In this sense, they face a constant challenge to stay motivated to keep the weight loss achieved with BS ⁽¹⁹⁾.

Importantly, there is a complexity of issues involved in changing habits, because cultural, historical, social, economic, educational, family, and personal issues, among others factors, interfere directly in the change process of habits and behaviors ⁽²⁰⁾.

From the results of this research, we can reflect that the implied social action in the experience of the bariatrized women is expressed in how they are organized in the uniqueness and into the social context so that, from the condition in which they are, they can seek and achieve your new life projects. This leads to a change in the existential nature of the participants, including their relationship with food, their cultural and behavioral patterns, predictors of weight gain that led to BS. 

The experience in the everyday world is permeated by experiences that make a person be guided to set a new scenario of action, considering their biographical situation and the store of knowledge available to them. In proposing to redefine such a scenario, they interpret the world with new possibilities, which present challenges to be faced. From this context, one has the ability to transform and change the social reality in which one lives ⁽⁸⁾.

The projects mentioned by the participants of this study are configured as possibilities of change that are envisioned before the new scenario (social reality) defined from the BS. This unfolds in a continuous process of transformation of themselves and experienced social reality.

Given the above, the results of this study show that, to position themselves in a biographically bariatrized condition, the women brings to explain the lived present, their store of knowledge and prior experience with obesity, structured prior to BS. This collection is restructured from its new biographical situation, which positions itself on the everyday challenge of facing the changes necessary for achieving a lifestyle compatible with the loss of the desired weight, which must be perpetuated throughout life. Therefore, the social action unveiled in this study reveals itself in the flow of "reasons why" and "reasons for" that make up the experience of women who have submitted to BS.

CONCLUSIONS

Understanding the women's experience with postoperative BS flags the importance of valuing subjectivity in the surgical treatment of obesity. Such a valuation should be set up within health practices, at the opening of spaces - both individual and collective - so the bariatrizeds may expose their experiences, in particular the challenges faced, in order that they may find the service support to achieve and maintain the desired weight.

Although evidence shows a gain in women's quality of life after BS, this study draws attention to the enrolled chronic obesity, which requires a shared and longitudinal care with this clientele by a multidisciplinary team. It is noteworthy in this regard to stress the importance of primary health care, its proximity to the territory where the bariatrized women live, and the possibility of creating a link with this audience, which can help in maintaining healthy eating habits and preventing regained weight.

The fact that this study was conducted with a particular social group, subscribed to a specific service of obesity control, makes it impossible to generalize its results, which constitutes a limitation of the current investigation. However, it presents scientific evidence that should be considered by health professionals in caring for people who underwent BS.

Qualitative surveys that look into psychosocial aspects of the people who experience the BS postoperative deserve to be expanded in order to give to health professionals, including nurses, access to research results that reveal the marked uniqueness in the experience of these people who are assisted every day in health services.

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Received: 03/02/2015
Revised: 12/14/2015
Approved: 01/11/2016