Introduction

Support group meetings (SGM) are assumed to be an integral part of success after bariatric surgery. In fact, the American Society for Metabolic and Bariatric Surgery has set up the Bariatric Centers of Excellence (BCOEs) program via the Surgical Review Corporation (SRC). The SRC outlines that BCOEs must make available organized and supervised support groups for patients who have undergone a bariatric procedure (http://www.surgicalreview.org/pcoe/tertiary/tertiary_provisional.aspx). Furthermore, starting in July 1, 2007, the SGM requirement from the SRC further states that the SGM must have a licensed health professional present or leading all meetings.

SGM have the ability to aid patients with the drastic dietary and lifestyle changes that accompany bariatric surgery. In addition, patients need help to assure that they do return to their previous dietary and lifestyle habits [1]. Unfortunately, some patients do not attend SGM. Factors related to this lack of participation in SGM are not well understood. This investigation studies these potential reasons as well as the effect of SGM on weight loss. It is our hypothesis that patients who attend SGM (ASGM) lose more weight than those patients who do not attend SGM (NASGM).

Methods

This investigation received an Institutional Review Board exemption as a survey study. Postoperative bariatric patients who were seen in our clinic completed an anonymous questionnaire regarding their opinions of SGM. The Support Group Survey can be obtained through the senior author (AKM). Likert scaling was utilized to determine whether a patient strongly agreed or disagreed with certain SGM related statement (Likert scale: 1 = strongly agreed; 10 = strongly disagreed). Other questions included factors that may be associated with SGM attendance.

For each patient, body mass index (BMI) was computed. Percentage change of BMI was calculated for all patients who had undergone gastric bypass. The patients were then divided into two groups: ASGM (attended postoperative SGM) and NASGM (did not attend postoperative SGM). Comparisons were made between the groups. Statistical analysis was performed with GraphPad InStat Version 3.05 (San Diego, CA, USA). Two-tailed Mann–Whitney tests and Fisher’s exact tests were utilized as appropriate. A p value less than 0.05 was considered statistically significant.

Results

There were 46 patients in this investigation. Most patients underwent a gastric bypass (59% laparoscopic and 13% open), whereas the others underwent laparoscopic adjustable gastric banding (24%), open vertical banded gastroplasty (2%), and laparoscopic revision bariatric surgery (2%). The average number of support groups who attended was 2.5 (range 0 to 36). There were 28 patients whom did not attend any postoperative SGM and 18 patients who ttended postoperative SGM. In the NASGM group, only one (4%) attended a SGM preoperatively, whereas eight (44%) attended a SGM preoperatively in the ASGM group.

There was not a statistically significant difference between the ASGM and NASGM groups on how they thought it was best to remind them about SGM (email: 39% vs. 26%, phone: 39% vs. 29%, and newsletter: 61% vs. 43%). A majority of both groups received the monthly newsletter reminding them of SGM (NASGM = 57% vs. ASGM = 78%; p = NS). Most of the patients who received the newsletter claimed to read all of them (NASGM = 74% vs. ASGM = 88%; p = NS).

We compared the average scores for the Likert statements in the survey between the NASGM and ASGM groups as shown in Table 1. The patients in the NASGM group were more likely to feel that SGM are not needed after bariatric surgery compared to the ASGM group (5.3 vs. 7.1; p = 0.07). The patients in the NASGM group were also more likely to feel that they would lose the same amount of weight with or without attending SGM compared to the ASGM group (5.7 vs. 7.4; p = 0.07). Furthermore, the patients in the ASGM group were more likely to feel that SGM were needed after surgery compared to the NASGM (3.8 vs. 5.2; p = 0.07). None of these differences reached statistical significance. Patients in the NASGM felt family obligations made attendance more difficult compared to the ASGM group (3.8 vs. 6.1; p < 0.03).

Table 1 Responses from the NASGM and ASGM groups
Full size table

The NASGM group did not live farther from the clinic compared to the ASGM group. (NASGM = 53 miles vs. ASGM = 86 miles; p = NS). In addition, there was no difference between the time it took to reach the clinic between the two groups (ASGM = 71 min vs. NASGM = 66 min; p = NS). In the gastric bypass patients in the ASGM group, there was a statistically significant difference in percentage decrease of BMI compared to the gastric bypass patients in the NASGM group (42% vs. 32%; p < 0.03). Follow-up for each group was not significantly different (27 vs. 23 months; p = NS). Table 2 lists many of the answers that patients felt that would most encourage their attendance to SGM. Table 3 displays the topics that patients reported they desire to be discussed at SGM.

Table 2 Comments patients listed that would encourage attendance
Full size table
Table 3 Topics for discussion at SGM
Full size table

Discussion

Our data demonstrate that gastric bypass patients in the ASGM group lose more weight than gastric bypass patients in the NASGM group. Furthermore, distance and time to clinic are not issues in SGM attendance. The issues that determine SGM attendance included family obligations and patient’s belief of the necessity of SGM.

Psychosocial factors that continue after bariatric surgery can affect the rate of compliance and, therefore, weight loss [2]. It is possible that poor eating habits continue after surgery. Patients may need continual education regarding healthy food choices to maximize success after bariatric surgery. Our previous investigations have shown that patients will often not remember certain preoperatively known facts [3, 4]. Organized patient SGM are often used to help with continual education after surgery.

A previous study in gastric bypass patients also showed that patients who participated in group therapy had better weight loss than those who did not participate in support groups [5]. Their data demonstrated a statistical significant difference in weight loss in those patients who attended more than five SGM compared to those patients who attend less than or equal to five SGM during the first year after surgery. In their study, patients in the ASM group had a 55.5% excess body weight loss (EBWL) versus the NASM group who had a 47.1% EBWL. This finding suggests that the repetitiveness of support group attendance during the first 12 months after surgery may be important for sustaining healthy behaviors long term. The SGM in their study were led by the surgeon, nurse practitioner, or nutritionist. The support group leader used the support group as an opportunity to continue patient education in areas such as healthy diet choices, exercise, and emotional eating. The monthly reinforcement and extra social support for these postoperative patients may have assisted in better weight loss.

Another study demonstrated a trend of more weight loss in gastric bypass patients who attended SGM than those who did not [6]. SGM also seem to play a role in patients who undergo laparoscopic adjustable gastric banding. One group demonstrated a higher decrease in BMI in patients who attended SGM [7, 8].

Many patients are not compliant in attending SGM. Our study shed some light on some possible factors. Distance was not an issue in regard to attending SGM in our study. Another study examined the reasons for lack of follow-up compliance for office visits in the post-bariatric surgery population and found that distance to the clinic was not an issue at the initial, 3-month, and 12-month follow-up appointments [9]. The study suggested that possible factors associated in poor follow-up compliance included poor surgical weight loss, weight regain, noncompliance with postsurgical diet, and/or discontentment with the office staff [9].

We feel that the same patients who are noncompliant with office visit follow-ups would be also noncompliant in attending SGM. Although our study did not examine all the specific reasons for lack of support group attendance, we feel that patients who have poor surgical weight loss, weight regain, and/or are noncompliant with the postsurgical diet would be less likely to attend SGM as well. In addition, many patients have not been forthright about the specific reasons due to embarrassment and feelings of failure. Thus, patients, who do not do as well in terms of weight loss, may feel less likely to attend SGM.

Our study does have some limitations. For example, our sample size is relatively small. Thus, the group may not properly represent the whole bariatric surgery population. In addition, we did not have enough patients to examine our laparoscopic adjustable gastric banding population. Despite noting a difference in weight loss, we failed to establish a cause and effect relationship between attendance of SGM and better %EBWL. A randomized trial could be designed to help ascertain if there truly is a cause and effect relationship, although the issue of randomizing patients not to attend SGM may have some ethical concerns. There is a strong possibility of self-selection bias in any study examining the differences in weight loss in patients who attend SGM versus those that do not. It is not definitive whether our findings (or findings of others) of better weight loss were because of inherent patient motivational characteristics, to attending SGM, or both. It could be that those who were most motivated to lose weight were also those most compliant to the recommended care. Recommended care includes following the nutrition and exercise guidelines to enhance weight loss and attending SGM.

Overall, multiple studies [5, 6], including this study, have reported increased weight loss in those patients who attend SGM compared to those who do not. Therefore, the importance of attending SGM should be incorporated in preoperative patient counseling and encouraged during postoperative follow-up visits.