key: cord-0816801-vqwtwidq
authors: Youssef, Alaa; Cassin, Stephanie E.; Wnuk, Susan; Leung, Samantha; Jackson, Timothy; Sockalingam, Sanjeev
title: The Impact of COVID-19 Pandemic on Bariatric Patients’ Self-Management Post-Surgery
date: 2021-02-19
journal: Appetite
DOI: 10.1016/j.appet.2021.105166
sha: 9f26798bd7fa50ea3e61b34f5fae5d3f939ca862
doc_id: 816801
cord_uid: vqwtwidq

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had far reaching consequences on the health and well-being of the general public. Evidence from previous pandemics suggest that bariatric patients may experience increased emotional distress and difficulty adhering to healthy lifestyle changes post-surgery. OBJECTIVE: We aimed to examine the impact of the novel COVID-19 public health crisis on patients’ self-management after bariatric surgery. METHOD: In a nested-qualitative study, semi-structured telephone interviews were conducted with 23 post-operative bariatric patients who had undergone Roux-en-Y gastric bypass (RYGB) at a Canadian Bariatric Surgery Program between 2014 -2020. A constant comparative approach was used to systematically analyze the data and identify the overarching themes. RESULTS: Participants (n=23) had a mean age of (48.82 ± 10.03) years and most were female (n=19). The median time post-surgery was 2 years (range: 6 months – 7 years). Themes describing the impact of COVID-19 pandemic on patients’ post-bariatric surgery self-management included: coping with COVID-19; vulnerability factors and physical isolation; resiliency factors during pandemic; and valuing access to support by virtual care. The effects of COVID-19 on bariatric surgery after care differed based on gender and socioeconomic status. CONCLUSION: This study showed the novel COVID-19 pandemic has impacted patients’ ability to self-manage obesity and their mental health in a variety of ways. These findings suggest that patients may experience unique psychological distress and challenges requiring personalized care strategies to improve obesity self-care and overall well-being.

stay-at-home, public health orders, changes in daily routine, and the pandemic uncertainty were 145 major contributors to psychosocial distress. Trying to cope with this distress, participants 146 described finding themselves in a "weird mindset" engaging in new behaviours, such as unusual 147 shopping behaviours (e.g., buying a big bag of chips) and engaging in emotional eating. Notably, 148 while some participants described coping through maladaptive behaviours, other participants 149 tried to seek positive strategies, such as being more physically active, avoiding triggering foods, 150 baking as a soothing tactile activity, and reviewing mindful eating strategies to mitigate 151 problematic eating behaviours, such as emotional eating and grazing (Table. 3). 152

J o u r n a l P r e -p r o o f Participants described engaging in emotional eating as a way to cope with feelings of anxiety or 154 boredom triggered by the pandemic scale and uncertainty. Importantly, despite increased 155 emotional eating during the pandemic, patients described an increased awareness of types of 156 food, quantity, and hunger cues. shelves has triggered something in me that's almost primal. So, consequently, if I go into 206 a store and I've been telling Name-X this too that we're buying things that we haven't 207 bought in years for fear that we won't be able to buy them." (F, 4 years) 208

Participants perceived maintaining their daily routine to be critical for successful self-210 management. Following their daily routine often resulted in meal regularity, improved food 211 choice, and helped control grazing. 212 P13: "I do a lot more grazing. Now with COVID-19, the whole pandemic, meal prepping 213 is definitely difficult. I don't work, so it's easy for me to go into the fridge, anytime. So, I 214 have to really be a little bit more stringent and prep what foods I use to make containers. I 215 don't anymore" (F, 4 years) 216

Losing Work/Life Balance 217 Participants described working from home during the pandemic to be mentally stressful and 218 exhausting. They reported an increased distress due to lack of physical interactions with co-219 workers, increased workload, and working from home to have influenced their eating habits with 220 respect to meal regularity and preparation. any pre-existing mental health conditions. Importantly, these individuals were more likely to be 246 males and to be married (Table. 3 distress requiring them to find strategies to cope with this evolving pandemic situation. 303

Differences in participants' coping strategies, specifically their use of maladaptive versus 304 adaptive approaches, were accounted for in part by individuals' unique challenges and their self-305 reported complex relationship with food. For example, while some patients found baking to be 306 soothing and a means of staying connected, others found cooking and being self-isolated at home 307 to be a triggering environment for emotional eating and grazing. 308 309 J o u r n a l P r e -p r o o f Furthermore, the psychosocial distress secondary to COVID-19 impacted participants' obesity 310 self-management capabilities disproportionally. Some participants described being confused and 311 ambivalent about their shopping behaviours during the pandemic, buying large amounts and 312 unnecessary items due to fears of food insecurity. Others described feeling at their "lowest point" 313 due to being confined in their home and feeling socially isolated. Interestingly, participants with 314 co-existing mental illness (30% of the sample) who had continued access to bariatric support 315 through virtual care during the pandemic found that connecting with their bariatric care team was 316 extremely helpful in managing their eating habits, being cognitively aware of their emotional 317 status, and developing self-compassion and acceptance of their reactions to this unprecedented 318 situation. This support was important to participants because it not only boosted their self-319 efficacy to self-manage their eating behaviours but also instilled in patients the motivation to 320 maintain their daily routine during the pandemic. 321

Notably, there may be a gender-specific response to psychosocial distress. In this study, women 322 were more likely to use food to cope with stress, whereas men were more likely to have had 323 better self-control or and coped through other strategies. This finding is consistent with the 324 existing literature on alcohol use trends during COVID-19, which showed that women were 325 more likely to consume larger amounts of alcohol due to stress, while men consumed more 326 alcohol due to boredom during COVID-19 (Canadian Centre on Substance Use and Addiction, 327 2020). In addition, the theme of self-managing physical and mental well-being appeared to be 328 influenced by health inequities. Participants who reported feeling "minimal impact" of COVD-329 19 on their health and lifestyle were more likely to have "financial security", space and 330 equipment at home to stay physically active, and emotional support. were less likely to report concerns including emotional eating and fear of weight regain as they 346 were still within their peak weight loss period and perceived higher levels of self-regulation due 347 to the physical control of the surgery (Table.1 ). An important implication of this study is 348 underscoring the potential of virtual care to promote access to bariatric care and support to 349 deliver evidence-based treatment to mitigate distress and help patients set realistic behavioural 350 goals that support self-managing their eating habits and emotional well-being during isolation 351 female participants, therefore allowing to examine gender-specific response. A possible 357 limitation to this study is the lack of ethnic diversity due to the small sample size and limitations 358 to recruitment during the pandemic. Although our sample size (n=23) was relatively small, we 359 adopted a rigorous qualitative analysis approach: independently coding the data, iterative 360 research team discussions, and validating emerging themes with a number of participants. 361

Theoretical saturation was achieved through our sampling methods with over 18 hours of 362 interview data and 500 pages of transcripts for our analysis. 363

This study investigated the impact of COVID-19 on bariatric patients' post-operative self-365 management during quarantine or self-isolation. Findings from this study revealed how the 366 increased mental health distress secondary to the COVID-19 pandemic has negatively impacted 367 individuals' capacity to self-manage their eating-habits and emotional well-being during 368 quarantine. As a result, patients had to develop new coping strategies to mitigate COVID-19 369 related distress. While some were able to find positive coping strategies to stay connected and 370 maintain their daily lifestyle routine, majority of participants reported coping in maladaptive 371 ways. Moreover, findings from this study bolster the importance of leveraging virtual care to 372 maintain access to obesity care during COVID-19 restrictions and to provide personalized 373

Tables 449 J o u r n a l P r e -p r o o f P8: "Ask me when the last time was I made an apple pie. Again, three years ago maybe. So, I was making an apple pie. I was literally kneading pastry. They said that this thing about people baking is that it's a tactile thing, that people are so longing to touch, and they can't, that they have gone into this thing. It's why people are making bread. It's the run on the flour and all that in the store, is just because baking is very soothing, it reminds them of their childhoods, whatever. It's all of that sort of stuff. So, I think that people's relationships with food is really complicated, and especially if you're someone who has had a problem with obesity" (F, 4Y) P20: "When COVID hit, I didn't go shopping for at least the first month, and then it was another month after that, I think, I had to go to Costco because I ran out of all my vitamins. It was just a very stressful experience just because of what is going on with COVID and the masks and the people up in your face. It was a completely, spontaneous, emotion-driven, "I have to have those Doritos." Everything else in my basket was healthy, but it was just that one thing. That will happen occasionally". (F, 1Y)

Engaging in "end-of-world" eating P8: " I found that the last little while in the whole COVID situation, I thought ….if this is the apocalypse, I might as well enjoy myself. I might as well eat the cupcake. It was like, what's the point? But now seven or eight weeks into this, reality dawns and you feel like doing what we're supposed to do, whatever, we're not going to get sick, there's a really low probability of getting ill. So, you have to get yourself healthy, and that means getting more of that J o u r n a l P r e -p r o o f weight off." (F, 4Y)

P8: "We were doing all their shopping …. our neighbour down the street, really athletic woman, we said, we're going shopping, was there anything she wanted. I want a big bag of chips. And I thought she was joking. And I said, yeah, yeah. And she said, no, I want a big bag of chips. And I went, okay. And then we both sort of looked at each other in the store and went, well, if Name-X is getting a big bag of chips, we need a big bag of chips. So, there has been this weird mindset" (F, 4Y) P20: "I found shopping during COVID very stressful and ended up eating chips that I shouldn't have eaten, things like that." (F, 1Y) P23: "We've all joked about the COVID-15 that we put on. I think everybody joked about it, but it's serious. Definitely, for someone like me in this program, that's a big deal to put that weight on. It's not as easy for us just to take that weight off." P5: "Let's say every bariatric patient, as every person in the world, is going through a difficult time right now for different reasons. For people who struggle with their mental health, and many people struggled with their mental health even before J o u r n a l P r e -p r o o f the surgery, this is also a form of trauma, this is also a trigger, this pandemic." (F, 1Y)

Fearing food insecurity P8: " I'm coping but in bad ways. Do you know what I mean? I found that a lot of the issue is around food itself and food insecurities and going into stores and seeing empty shelves has triggered something in me that's almost primal. So, consequently, if I go into a store and I've been telling Name-X this too that we're buying things that we haven't bought in years for fear that we won't be able to buy them." (F, 4Y) 

Psychosocial predictors of quality of life and weight loss two years after bariatric 424 surgery: Results from the Toronto Bari-PSYCH study

The Impact of COVID-19 on Bariatric 427 Surgery: Re-Defining Psychosocial Care

Canadians' mental health during the COVID-19 pandemic

Attachment style and emotional eating in bariatric surgery candidates: The mediating role of 431 difficulties in emotion regulation

Toronto Bariatric Interprofessional Psychosocial Assessment Suitability 434 Scale: Evaluating A New Clinical Assessment Tool for Bariatric Surgery Candidates

COVID-19 related stress exacerbates common physical and mental pathologies 438 and affects treatment (Review)

Bariatric Surgery During COVID-19 Pandemic from 441 Patients' Point of View-The Results of a National Survey

Differences in physical and mental health-related quality of life 445 outcomes 3 years after bariatric surgery: a group-based trajectory analysis. Surgery for Obesity 446 and Related Diseases