It is estimated that obesity will eventually affect one in two adults in the U.S by 2030 [1]. The most impactful and durable option for weight loss is bariatric surgery [2]. However, for multiple reasons, outcomes vary widely among patients [3]. One such factor is social support [4], which can affect weight loss, level of depression, and problematic eating behaviors following bariatric surgery [5, 6]. Sources of social support include family, friends, the surrounding community [7, 8], health care providers who provide follow-up visits [9], and in-person group meetings [10, 11]. The importance of postoperative social support led the American Society of Metabolic and Bariatric Surgery (ASMBS) to mandate that accredited bariatric centers offer support groups to all postoperative patients [4]. Unfortunately, although patients agree they require social support following their bariatric surgery [5, 6], there are many barriers that prevent them from attending the clinic follow-ups or the in-person social support meetings. The most common barriers include impaired mobility and lack of transportation [7], long travel distances [8], and being too busy to attend them in person [9].

As a result, many programs have developed online forums where patients can give advice to their peers on questions or concerns that arise during the postoperative period [10]. Despite the appeal and importance of the online social support groups, it is not clear whether their content is as accurate and helpful as the information being exchanged in formal in-person social support meetings. Moreover, only a few studies have explored the types of support these patients receive and whether the patients have seen a meaningful difference in their everyday lives as a result of their participation. Many of these web-based forums/groups may not convey accurate information, and do not have health care professionals monitoring the questions and answers of the platform users [10].

In 2015, our program launched a private Facebook support group supervised by our personnel to provide free and easily accessible social support to our clinic’s patients. This ensures they receive the benefits of a social support group in a monitored and safe environment. The aim of this study was to perform a thematic analysis of the content posted by bariatric surgery patients in our Facebook support group webpage and to assess the impact of Facebook group participation on the perceived social support of our patients.

Methods

Facebook group administration

Our center’s Facebook group is a private, supervised group which was created in 2015. The group was formed to engage our patients in discussions with patients who have similar experiences, to share ideas, have constant access to copies of forms such as our program’s meal plan, and receive answers to questions directly from the health care providers who supervise the group’s activity (such as dietitians, and physician assistants).

Since 2015, all of our new patients are invited to join our Facebook support group during their first office visit provided they have, or are willing to create, a Facebook account. Furthermore, all new members agree to avoid posting comments that are hurtful or demeaning to others, contain profanity, or involve insensitive comments based on race, religion, or personal beliefs. All posts are being pre-reviewed by one of our health care providers who monitors the group’s activity daily. Posts that belong to any of the aforementioned prohibited categories and are being removed. The posts that are deemed to require medical attention (around 6 per week) are not getting approved; on the contrary, the patients are requested to inform their medical provider instead. Additionally, to ensure confidentiality, all requests to join the group are being screened by our administrators. Failure to comply with the group’s rules results in expulsion from the group.

Study design

After obtaining institutional review board (IRB) approval we proceeded with the participants’ recruitment. An announcement was posted in the Facebook group by one of the group’s administrators which invited any interested patient to join the study voluntarily. Patients who had previously agreed to receive email communication from the clinic were sent the study’s nine-item survey, IRB protocol, and description of the Health Insurance Portability and Accountability Act. Patients who agreed to participate completed the survey using Redcap software. The participants could only select one answer to each of the nine questions. The answers were based on a Likert scale (1–5); the specific questions can be found in Fig. 1.

Fig. 1
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Online survey

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In addition, phone calls were made to a 30-participant subgroup who volunteered in the survey to receive a call. In an effort to reduce selection bias, phone calls in this subgroup were made to both highly engaged users and those who were not as much based on their replies on how often they check the Facebook groups’ notifications. This provided further insight into members’ social support experiences. In the end, the interviewers asked eight open-ended questions outlined in Fig. 2.

Fig. 2
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Telephone survey

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To expand upon findings from the survey and interviews, two trained researchers reviewed all the posts and allocated them into categories based on thematic content. Data were extracted and tabulated using a pre-piloted table for synthesis. Any new post that did not fit in the pre-piloted table was noted and discussed with the second researcher to come to an agreement. The frequency of preoperative and postoperative thematic sections were presented separately.

Chi-square was utilized for the thematic comparisons using SPSS 26.0 (SPSS Inc., Armonk, NY).

Results

From 2015 to September 2019, our Facebook group membership increased by 400%, from 301 to 1222. During those 4 years, our patients contributed 12,507 posts, 104,053 comments on the posts (average of eight replies on each post), and 197,594 likes on posts and/or comments.

The survey was answered by 246 patients after the removal of 15 duplicates (20.1% response rate). All respondents answered all of the questions. At the time of questionnaire completion, 236 (95.9%) patients were in the postoperative phase, while the remaining 10 (4.1%) were awaiting their procedure. Given the small number of preoperative patients their responses were excluded from the analysis.

Respondents were 90.2% females with an average age of 45.2 ± 11 years. The majority of the patients had private insurance (69%) A total of 57 (24.2%) of the postoperative group had undergone revisional surgery. The majority of the respondents had joined the Facebook group before undergoing surgery (72.5%). More than 50% of the Facebook members checked the group’s notifications daily or more frequently, such as whenever they got a notification or every couple of hours (Fig. 3).

Fig. 3
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Facebook activity

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Members reported that the group helped them do well with their procedure overall (3.3/5). Specifically, they felt that it provided emotional support (3.5/5), and the group provided useful information (3.7/5) while avoiding unnecessary anxiety despite being exposed to the various experiences of their group peers (1.5/5). Additionally, they felt understood by others (3.9/5) and connected with other people who had similar experiences (3.1/5). However, responders felt that the group offered limited help in controlling eating habits (2.7/5).

Ten common themes were identified in the submitted posts: seeking advice/ asking questions (regarding surgery, diet, physical activity, or “other”), an attempt to motivate others, current status updates (posts such as “I am waiting for insurance approval” or “I am 2 months out of surgery and everything is going well”), giving advice/educational posts, sharing failures, administrators’ instructions (regarding upcoming events or information for pre- or postoperation subjects), any physical activity post (excluding questions about physical activity), random/humorous posts, and “other”. The frequency of posts in each category can be found in Table 1. In 42% of motivational posts, “before” and “after” pictures were included.

Table 1 Post categories
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The phone interviews unanimously suggested that the Facebook group was very useful. Specifically, the interviews revealed that the constant social support by their peers “who share similar experiences” along with the “quick responses to my questions by the health care providers” were invaluable. Many referred to the group as the sole source of social support as they “live too far away from the clinic” or “do not have time to attend the social support meetings”. The majority of patients described the group as “uplifting” and that it motivates them to continue as they have “incentives to do better”, and “I am not alone as many are going through the same struggles”. They enjoy the ‘’tips on their journey by people who have walked the same steps’’ and the instant feedback our dietitians provide on the calorie content of food our patients want to consume; specifically, many patients post a picture of the calorie content of foods and the dietitians instruct them on whether it is consistent with the recommended meal plan or if it is better to be avoided.

Moreover, some patients preferred to mainly post and ask questions specifically related to themselves as “many people are posting each day and not all the information is relevant to each and every one of us”. That being said, most respondents stated that both writing and reading posts were equally important as “some of us do not feel comfortable sharing personal experiences but love reading posts and providing answers whenever we can”. It is worth noting that the vast majority did not post during the preoperative period as they “did not feel the need to do so”, and “were mostly absorbing all the information that was being shared among other members”.

There were several topics that were identified as being helpful, but the ones that stood out were “motivational/success posts”, “healthy recipes”, and the “do’s and don’ts” from the health care professionals.

While the large percentage of participants did not have bad experiences, some reported they “dislike the negativity of some individuals” and did not like some of the rules such as “family members are not allowed” or “some posts are not getting approved because they are deemed medical”.

Most patients could not compare in-person with online support groups due to not having attended in-person groups. Those who had, however, informed us that “people in person do not share as much information as through Facebook”, “people in the in-person meetings stay quiet most of the times”, and “in-person meetings are taking place in odd hours”. In contrast, they viewed Facebook as being “very convenient, easy to navigate, and do not need to drive to get my questions answered and receive support”.

Finally, regarding the question of whether they were feeling understood by the Facebook group’s members the answers were positive. Many patients have “made close friends” through the group’s interactions, and some even mentioned that they “feel like I belong somewhere”. There were some mixed answers, often because they “felt connected and benefited by the group” but wouldn’t say they felt close to the other members per se.

Discussion

The purpose of this study was to investigate the feasibility of a Facebook group for bariatric surgery patients, and assess patient engagement, and their perception of the social support value it provides. Results showed that our program’s Facebook group grew rapidly, with most participants checking it on a daily basis which further highlights its impact in their lives. We discovered that most of our patients join our group in the preoperative supervised weight loss period which allows them to learn valuable information from their experienced peers. As indicated by our thematic analysis, 39.4% of the preoperative patients update the group on their current status (e.g., having done the preoperative class, the insurance has approved them, the date that surgery is scheduled), while 17.6% asked questions regarding diet, and 12% asked questions about their surgery (17.6% and 12%, respectively). In the course of the phone interviews, participants indicated that they prefer reading through all the posts to learn from the more experienced patients and prepare themselves for the surgery and the postoperative period. In contrast, the postoperative patients showed a thematic shift to more motivational discussions (26.9% from 7.7%, p < 0.001), more education posts to help the other patients (7.4% from 2.1%, p = 0.05), and fewer updates on their current status (11% from 39.4%, p < 0.001). While further research is needed, it appears that the kind of social support postoperative patients need shifts from acquiring knowledge to seeking inspiration and encouragement. The recognition that the kind of support patients need after surgery changes is presumably behind the decision by some programs to have separate support groups for pre- and postoperative patients. After the surgically enforced weight loss during the first postoperative year or two, the need for behavioral adherence to avoid weight regain becomes more apparent and thus promotes a greater interest in motivational postings. Our results corroborate the multidimensional nature of social support [11, 12]; in the present study, preoperative concerns as reflected in Facebook postings are thematically different from postoperative posting activity. While encouragement from others on Facebook may be perceived as generally helpful, our participants did not see Facebook social support as assisting them in adhering to the meal plan. This is generally consistent with findings that an intensive seven-day smartphone-based chat group only temporarily changed consumption of fruits and vegetables and reduced unhealthy snacking [13].

Concerns suggesting that the use of Facebook is associated with lower well-being [14] necessitate additional research on the use of Facebook for social support vs. “real-world” contacts in the bariatric surgery population. Obesity has been associated with greater sensation of loneliness [15,16,17]. Unfortunately, technology-based interventions for loneliness were not found to be effective in a recent meta-analysis [16]. However, to what degree the use of Facebook can counteract loneliness and facilitate in-person connections in the bariatric population remains to be seen.

As expected, patients expressed gratitude for the easy availability and trustworthy support of our physician assistant and dietitians. These sentiments were reported especially by those who are living far from the clinic, or who do not have time to join the in-person meetings.

As it is suggested in the literature, patient social support is very important and beneficial, especially for bariatric patients [18, 19]. More importantly, in concordance with our results, as Hameed et al. [6] have shown, more than 50% of the postbariatric surgery patients desired greater social support, especially during difficult pre- and postoperative periods. To be most effective, however, the kind of social support offered may need to be tailored to the individual. For example, a high level of weight-related social support was associated with less weight regain after bariatric surgery only in patients who experienced high levels of stress [20].

To the best of our knowledge, our Facebook study is the first that has provided easily accessible and constant social support to bariatric surgery patients and at the same avoided problems such as inaccurate information and negative posts associated with non-professionally monitored platforms [21]. As a content analysis of the various Facebook groups has shown [10], physicians should exercise caution when recommending them to patients since the content may be unhelpful. It is worth noting that our Facebook support group combines two of the three key forms of support described by the qualitative study of postoperative women by Ogle et al. [22]. Specifically, it entails support from both health professionals and other bariatric patients (“like others”) and only lacks the support from spouses, family members and friends (“close others”).

In our thematic analysis, we encountered more posts containing before/after pictures of the patients (42%), compared to other online support groups (18.5% in other Facebook groups and 2.6% in Facebook pages) [10]. We believe this is mainly due to the greater perceived safety and privacy afforded by a monitored online group, while the patients in the non-protected social support groups feel vulnerable and do not trust them [21].

Our findings have several implications for bariatric surgery practice. They suggest that the Facebook group is very well received by our patients, who feel it provides similar or better support with greater convenience than in-person support groups. It appears the Facebook group provides patients a sense of feeling understood. In addition, they find motivation to stay “on track” in their journey along with their peers. However, it should be noted that in order to function optimally, a private Facebook group needs to be well monitored, demanding time and devotion from the clinic’s personnel. In order to maintain safety and privacy, it is essential that staff members ensure that only the clinic’s patients are joining. Additionally, one or more physician assistants and dietitians are needed in order to field questions appropriate to the scope of their practice and to screen out posts that might not be appropriate. Finally, an online-based group for social support is not a panacea; many patients are not keen with technology or do not have routine access to the internet and thus cannot benefit from it; thus, we believe that it should be used concurrently with in-person group meetings so all patients have access to social support.

Our study points to the need for additional research regarding the extent to which Facebook use by bariatric surgery patients promotes real-world (in person) connection, adherence to recommnendations, enhanced quality of life, and weight loss.

The main limitation to our study is the low response rate to the online questionnaire. This might expose our findings to selection bias as the respondents might have been only the members who are more engaged with the group. Furthermore, questionnaire studies have the inherent risk of response bias, socially desirable responding, and/or impression management. Finally, the phone interviews were conducted only with patients who agreed to be interviewed, which could have introduced selection bias as well.

Conclusions

Facebook groups provide various types of social support to patients after bariatric surgery. Peers educate, answer questions, and motivate other patients by sharing their positive experiences. These groups work best when experienced bariatric personnel monitor the group’s activity to screen for inappropriate posts, to ensure that reliable information is being exchanged, and to provide answers to questions not appropriately addressed by the group. Further study is needed to determine if this kind of social connectedness impacts patient outcomes such as weight loss and quality of life.