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Social Resource Management After Gastric Bypass Surgery
How Patients Construct Social Situations
as They Strive Toward Weight Loss
Audrey Z. Baker
Honors Thesis
Spring 2009
Carole Bisogni, Amanda Lynch
Acknowledgments
Thank you to the ten participants who shared their feelings and thoughts with such candor. Though I never met these people, their distinctive words and bracketed mannerisms have given me a few tears and many smiles.
Thank you to this projects principal investigator Amanda Lynch for putting up with my flaky schedule and wine-stained office decorations. I could not have asked for a more dedicated, thoughtful mentor. I still cannot believe you transcribed all those interviews verbatim. I will fondly remember all your comforting MmmHmms sandwiched between participants words. I had so much fun sharing food, family and boyfriend stories with you at every possible procrastinatory moment.
Thank you to my faculty adviser Carole Bisogni for introducing me to the social science of food. You opened up my world. Thank you for connecting me with such a cool honors project, for encouraging my thought processes and for keeping me on task. You are a wonderful listener. I admire your mind and your heart.
Thank you to Steve Hilgartner and Christine Leuenberger for agreeing to read 80 pages of my writing. Both of you have had such a major impact on my academic life. Without the concepts I learned in your courses, this project would not have been possible. Thank you for teaching me.
Thank you to my family and friends, who occasionally remained attentive during staccato tangents about eating identities and perceived retrospective social interactions. I know you were bored, and I know you love me.
Thank you to Professeur Steinman Paris, who taught me Durkheim and social network theory while frantically scribbling matrices all over the blackboard. If you had not looked exactly like George Carlin and worn bright red sweaters, I may have been less riveted to your zippy French lectures. Also, thank you for loving Americans, unlike all the other inhabitants of your beautiful city.
Thank you to Ithaca Coffee Company for permitting colorful explosions of papers across tables, benches and windowsills, day after day. Without your hot cocoa and roomy booth by the huge window, I would have been chilly, disorganized, and scant in people-watching. Abstract
Weight loss surgery involves major changes in physical, psychological, and social aspects of a persons life. This project sought to identify and understand how gastric bypass patients interpret and use social resources in the period following surgery. The researcher analyzed verbatim transcripts from two, in-depth, qualitative interviews with each of six women who were at least 2 years past gastric bypass surgery. Participants ranged in age from 36 to 63 years, varied in household type, lived in Upstate New York, and varied in maintenance of weight loss achieved after surgery. Coding and analysis of transcripts led to the categorization of social resources as to source (close-personal, other gastric bypass patients, spouse, experts, others, mirror), type (prescriptions, examples, appraisals, facilitations, supports), and judgment by the patient (e.g. adequate, inadequate, absent, wanted, unwanted.). A functional social resource management model was developed to represent the patient as an active, self-regulator of social resources. The findings provide concepts and a framework that can be used to advance understanding about how social support is involved in dietary change and health promotion processes.
TABLE OF CONTENTS
Chapter 1 Introduction p. 5
Chapter 2 Background p. 6
Literature Review p. 6
Gastric Bypass Surgery p. 6
Social Support p. 7
Negative Social Support p. 12
Theoretical Perspectives p. 13
Chapter 3 Methods p. 17
Approach p. 17
Interviews & Participants p. 19
Analysis p. 21
Quality Assurance p. 24
Chapter 4 Results p. 25
Functional Social Resource Management p. 25
Examples of Participants Management of Social Resources p. 35
Social Prescriptions p. 35
Social Examples p. 43
Social Appraisals p. 48
Social Facilitations p. 55
Social Reinforcements p. 62
Chapter 5 Discussion p. 68
Critique of Methods p. 68
Major Findings p. 71
Implications for Future Research p. 74
Conclusion p. 79
Appendix A F [Consent Forms, Interview Scripts, Preliminary Analytical Models] p. 80
References p. 93
CHAPTER 1 INTRODUCTION
Weight loss surgery involves major changes in physical, psychological and social aspects of a patients life. The current literature on outcomes of gastric bypass surgery, the most common bariatric surgery in the United States (Elliot, 2003), mainly focuses on its metabolic, physiological and psychological impacts ( ADDIN EN.CITE Buchwald200433833817Henry BuchwaldYoav Avidor Eugene Braunwald Michael D. Jensen Walter PoriesKyle FahrbachKaren SchoellesBariatric Surgery: A Systematic Review and Meta-analysis
Journal of the American Medical AssociationJournal of the American Medical AssociationJAMA1724-1737292Gastric BypassBariatric SurgeryObesityWeight LossMeta-analysis2004October 14, 2004The American Medical AssociationReviewBuchwald, Avidor, Braunwald, Jensen, Pories & Fahrbach et al., 2004; Cottam, Atkinson, Anderson, Grace, & Fisher, 2006; Sjstrm, Lindroos & Peltonen et al., 2004; Karlsson, Sjstrm, & Sullivan, 1998; Boan, Kolotkin & Westman et al., 2004; Delin & Anderson, 1999; Flannery & Weiman, 1989; Malone & Alger-Mayer, 2004; Ogden, Clementi & Aylwin et al., 2005). These individual-level outcomes, however, are interdependent and interact with sociocultural and technological contexts. Modern Western culture emphasizes the importance of physical health and imposes standards for ideal body size, and biomedical technologies create new options to achieve such physical standards.
Social ties with gastric bypass surgery patients, such as medical experts, support groups, and close-personal relationships, are generally acknowledged as involved in health and dietary outcomes of weight loss surgery. However, there is a lack of research related to how gastric bypass patients experience and manage these social influences. This study aimed to identify and understand how gastric bypass patients experienced social support after they had achieved maximum weight loss, typically after 24 months post surgery. The researcher analyzed qualitative data from in-depth, semi-structured interviews with women who had had gastric bypass surgery. Viewing the women as active self-regulators of social influences, the researcher analyzed their reports about social support in the months after they had achieved maximum weight loss.
CHAPTER 2 BACKGROUND
I. Literature Review
Gastric Bypass Surgery
Obesity is considered a significant public health problem in the United States, with almost one-third of the population classified as obese at the turn of the century following a two-fold increase over 20 years (Mokdad, Bowman, Ford, Vinicor, Marks, & Koplan, 2001). Gastric bypass surgery is the most successful known weight loss technique, leading to an average 61% loss of excess body weight ADDIN EN.CITE Buchwald200433833817Henry BuchwaldYoav Avidor Eugene Braunwald Michael D. Jensen Walter PoriesKyle FahrbachKaren SchoellesBariatric Surgery: A Systematic Review and Meta-analysis
Journal of the American Medical AssociationJournal of the American Medical AssociationJAMA1724-1737292Gastric BypassBariatric SurgeryObesityWeight LossMeta-analysis2004October 14, 2004The American Medical AssociationReview(Buchwald, Avidor & Braunwald et al., 2004) and partial maintenance of weight loss for up to ten years ADDIN EN.CITE Buchwald200433833817Henry BuchwaldYoav Avidor Eugene Braunwald Michael D. Jensen Walter PoriesKyle FahrbachKaren SchoellesBariatric Surgery: A Systematic Review and Meta-analysis
Journal of the American Medical AssociationJournal of the American Medical AssociationJAMA1724-1737292Gastric BypassBariatric SurgeryObesityWeight LossMeta-analysis2004October 14, 2004The American Medical AssociationReviewPories199248948917Pories, W.J.MacDonald, K.G.Morgan, E.J.Sinha, M.K.Dohm, G.L.Swanson, M.S.HA BarakatPG KhazanieN Leggett-FrazierSD Long Surgical treatment of obesity and its effect on diabetes: 10 year follow-upAmerican Journal of Clinical NutritionAmerican Journal of Clinical NutritionAm J Clin Nutr582S-585S551992Sjstrm200440740717Sjstrm, LarsLindroos, Anna-KarinPeltonen, MarkkuTorgerson,JarlBouchard, ClaudeCarlsson, BjornDahlgren,SvenLarsson, BoNarbro, KristinaSjostrom, Carl DavidSullivan, MarianneWedel, HansLifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery New England Journal of Medicine2683-269335126Swedish Obese SubjectsDiabetesCardiovascular Risk FactorsGastric BypassBariatric SurgeryLifestyle2004December 23, 2004Research(Buchwald, Avidor & Braunwald et al., 2004; Sjstrm, Lindroos & Peltonen et al., 2004). Gastric bypass surgery combines restriction of food intake by reducing stomach size with decreased absorption of nutrients by circumventing a significant section of the small intestine (Buchwald, 2004). The minimum recommended criteria for gastric bypass surgery eligibility are a body mass index (BMI) of 40 or a BMI of 35 along with considerable health concerns. Weight loss generally plateaus 1 to 2 years after surgery (Buchwald, 2004), prompting maintenance of weight loss and often weight regain ADDIN EN.CITE Buchwald200433833817Henry BuchwaldYoav Avidor Eugene Braunwald Michael D. Jensen Walter PoriesKyle FahrbachKaren SchoellesBariatric Surgery: A Systematic Review and Meta-analysis
Journal of the American Medical AssociationJournal of the American Medical AssociationJAMA1724-1737292Gastric BypassBariatric SurgeryObesityWeight LossMeta-analysis2004October 14, 2004The American Medical AssociationReview(Buchwald, Avidor & Braunwald et al., 2004). Weight loss after gastric bypass surgery is associated with reduction in co-morbidities, such as cardiovascular disease ADDIN EN.CITE Cottam200654954917Cottam, Daniel RAtkinson, James Anderson, AaronGrace, BrianFisher, BarryA Case Controlled Matched Pair Cohort Study of Laparoscopic Roux-en-Y Gastric Bypass and Lap-Band Patients in a Single US Center with Three Year follow-upObesity SurgeryObesity SurgeryObes Surg534-54016ObesityGastric bypassLaparoscopyGastric BandingComparative study2006Schauer200034734717Schauer,Philip RIkramuddin, SayeedRamanathan,RameshLuketich, JamesThe Department of Surgery
University of PittsburghOutcomes after laparoscopic roux-en-Y gastric bypass for morbid obesity.Annals of SurgeryLaparoscopic Gastric Bypass SurgeryAnnals of SurgeryAnn Surg515-5292324LaparoscopyGastric BypassObesityWeight LossComorbidity2000October 2000Lippencott Williams & WilkinsOriginal ResearchSjstrm200440740717Sjstrm, LarsLindroos, Anna-KarinPeltonen, MarkkuTorgerson,JarlBouchard, ClaudeCarlsson, BjornDahlgren,SvenLarsson, BoNarbro, KristinaSjostrom, Carl DavidSullivan, MarianneWedel, HansLifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery New England Journal of Medicine2683-269335126Swedish Obese SubjectsDiabetesCardiovascular Risk FactorsGastric BypassBariatric SurgeryLifestyle2004December 23, 2004Research(Cottam, Atkinson, Anderson, Grace, & Fisher, 2006; Sjstrm, Lindroos, Peltonen et al., 2004) and Type II diabetes ADDIN EN.CITE Greenway200266066017Greenway, Scott EGreenway, Frank LKlein, StanleyEffects of obesity surgery of non-insulin-dependent diabetes mellitusArchives of SurgeryArch SurgArchives of SurgeryArch SurgArchives of SurgeryArch Surg1109-1117137Gastric bypassType 2 diabetesGlucose control2002OctoberPories199248948917Pories, W.J.MacDonald, K.G.Morgan, E.J.Sinha, M.K.Dohm, G.L.Swanson, M.S.HA BarakatPG KhazanieN Leggett-FrazierSD Long Surgical treatment of obesity and its effect on diabetes: 10 year follow-upAmerican Journal of Clinical NutritionAmerican Journal of Clinical NutritionAm J Clin Nutr582S-585S551992(Greenway, Greenway, & Klein, 2002). Weight loss after surgery also corresponds with improved quality of life (Karlsson, Sjstrm, & Sullivan, 1998), including measurements of mental health, fatigue, and activity ADDIN EN.CITE Boan200427827817Boan, J.Kolotkin, R. L.Westman, E. C.McMahon, R. L.Grant, J. P.Weight Loss Surgery Center, Duke University Medical Center, Durham, NC 27705, USA. jarol.boan@duke.eduBinge eating, quality of life and physical activity improve after Roux-en-Y gastric bypass for morbid obesityObesity SurgeryObes SurgObesity SurgeryObes SurgObesity SurgeryObes Surg341-8143(Major): BulimiaGastric BypassMotor ActivityQuality of Life(Minor): AdultAnastomosis, Roux-en-YFemaleFollow-Up StudiesHumanMaleMiddle AgedObesity, Morbid -- physiopathologyObesity, Morbid -- surgeryTreatment OutcomeWeight Loss2004MarPMID: 15072655 Provider: OCLCDelin199925725717Delin, C. R.Anderson, P. G.School of Psychology, University of South Australia, Adelaide, Australia.A preliminary comparison of the psychological impact of laparoscopic gastric banding and gastric bypass surgery for morbid obesityObesity SurgeryObes SurgObesity SurgeryObes SurgObesity SurgeryObes Surg155-6092(Major): Quality of Life(Minor): AdultAgedComparative StudyFeeding BehaviorFemaleGastric Bypass -- methodsGastric Bypass -- psychologyGastroplasty -- methodsGastroplasty -- psychologyHumanLaparoscopy -- methodsLaparoscopy -- psychologyMaleMiddle AgedObesity, Morbid -- psychologyObesity, Morbid -- surgeryPatient SatisfactionQuestionnairesSampling StudiesSupport, Non-U.S. Gov'tTreatment Outcome1999AprPMID: 10340769 Provider: OCLCKarlsson199818818817Karlsson, J.Sjstrm, L.Sullivan, M.Health Care Research Unit, Sahlgrenska University Hospital, University of Gteborg, Sweden.Swedish obese subjects (SOS)--an intervention study of obesity. Two-year follow-up of health-related quality of life (HRQL) and eating behavior after gastric surgery for severe obesityInternational Journal of Obesity and Related Metabolic Disorders Int J Obes Relat Metab DisordInternational journal of obesity and related metabolic disordersInt J Obes Relat Metab DisordInternational Journal of ObesityInt J Obes Relat Metab Disord113-26222(Major): Quality of Life(Minor): Cohort StudiesComparative StudyConfidence IntervalsFeeding Behavior -- physiologyFeeding Behavior -- psychologyFemaleFollow-Up StudiesHumanMaleObesity, Morbid -- surgeryObesity, Morbid -- therapyPostoperative Complications -- psychologySupport, Non-U.S. Gov'tSwedenTime FactorsWeight Loss -- physiology1998FebPMID: 9504319 Provider: OCLCMalone200427927917Malone, M.Alger-Mayer, S.Department of Pharmacy Practice, Albany College of Pharmacy, Albany Medical College, Albany, New York 12208, USA. malonem@acp.eduBinge status and quality of life after gastric bypass surgery: a one-year studyObesity researchObes ResObesity ResearchObes ResObesity ResearchObes Res473-81123(Major): Bulimia -- psychologyBulimia -- therapyGastric BypassQuality of LifeTreatment Outcome(Minor): AdultAgedBody Mass IndexDepression -- epidemiologyFemaleHealth StatusHumanMaleMiddle AgedObesity -- surgerySupport, Non-U.S. Gov'tWeight Loss2004MarPMID: 15044664 Provider: OCLCOgden200544444417Ogden, J.Clementi, C.Aylwin, S.Patel, A.Kings College London, London, UK. J.Ogden@surrey.ac.ukExploring the impact of obesity surgery on patients' health status: a quantitative and qualitative studyObesity SurgeryObes SurgObesity SurgeryObes SurgObesity SurgeryObes Surg266-72152(Major): Health StatusQuality of Life(Minor): Adaptation, PhysiologicalAdaptation, PsychologicalAdultBody Mass IndexCase-Control StudiesComparative StudyCross-Sectional StudiesFeeding BehaviorFemaleGastric Bypass -- adverse effectsGastric Bypass -- methodsGastroplasty -- adverse effectsGastroplasty -- methodsHealth BehaviorHumansMaleMiddle AgedObesity, Morbid -- diagnosisObesity, Morbid -- psychologyObesity, Morbid -- surgeryPatient SatisfactionQuestionnairesWeight Loss2005FebPMID: 15802072 Provider: OCLC(Boan, Kolotkin, Westman et al., 2004; Delin & Anderson, 1999; Karlsson, Sjstrm, & Sullivan, 1998; Malone & Alger-Mayer, 2004; Ogden, Clementi & Aylwin et al., 2005).
Dietary change after surgery is a complex cognitive and behavioral process with implications for long-term health outcomes. Eating behaviors adopted after surgery contrast sharply to prior eating behaviors. Patients progress from liquids to solid foods over the month following surgery ADDIN EN.CITE Elliot200349049017Elliot, KNutritional considerations after bariatric surgeryCritical Care Nursing QuarterlyCritical Care Nursing QuarterlyClin Care Nurs Q133-138262003Marcason200449149117Marcason, WQuestion of the month: What are the dietary guidelines following bariatric surgery?Journal of the American Dietetic AssociationJournal of the American Dietetic AssociationJ Amer Diet Assoc487-4881042004(Elliot, 2003; Marcason, 2004), and significant attention must be paid to food types ADDIN EN.CITE Elliot200349049017Elliot, KNutritional considerations after bariatric surgeryCritical Care Nursing QuarterlyCritical Care Nursing QuarterlyClin Care Nurs Q133-138262003(Elliot, 2003), portion sizes, meal frequency (Elliot, 2003; Stocker, 2003), and nutrient intake ADDIN EN.CITE Ponsky200550350317Ponsky, Todd ABrody, FrederickPucci, EdwardAlterations in gastrointestinal physiology after roux-en-Y gastric bypassJournal of the American College of SurgeryJournal of the American College of SurgeryJ Am Coll Surg125-1312011Gastric bypassNutrient AbsoptionPhysiologyDigestive System2005JulyReview(Ponsky, Brody, & Pucci, 2005). One physical repercussion of gastric bypass surgery in less than half of all patients is dumping syndrome, involving uncomfortable nausea, diarrhea, sweating, dizziness and other symptoms of acute anxiety (Mallory, MacGregor & Rand, 1996; Brolin, 2002). Dumping syndrome usually occurs after high carbohydrate intake, when sugars pass rapidly from the stomach pouch to the intestine (Brolin, 2002). In all patients, drastic change in eating practices must occur despite little attention to long-term dietary change and accordingly insufficient eating recommendations in the gastric bypass surgery literature (Elliot, 2003). Dietary change and weight loss interact with major changes in other physical, psychological, and social aspects of a patients life.
Social Support
Gastric bypass surgery patients also interact with their surroundings after surgery, and other people can affect an individuals dietary and eating behavior transitions. The literature acknowledges the impact of social interactions on health outcomes by focusing on social support. However, the term social support lacks clarity, and can be confused with other concepts such as caring (Finfgeld-Connett, 2005). Social support is often defined as tangible or intangible assistance provided by one or more individual to another (Langford, Bowsher, Maloney & Lillis, 1997). Finfgeld-Connett (2005) conducted a meta-analysis to clarify social support and identified it as an advocative interpersonal process that is centered on the reciprocal exchange of information and is context specific. Most literature emphasizes reciprocity or exchange of resources as a crucial aspect of social support (House 1981, Tilden & Weinert 1987; Cohen & Syme 1985; Shumaker & Bronwell 1984; Langford et al. 1997; Israel 1982; Heaney & Israel, 1997).
The literature often distinguishes between existence, structure, and function of social relationships (House, 1987; McIntosh, 1991; Thoits, 1982; House & Kahn, 1985). The term social integration is often depicted as the existence or quantity of social relationships, creating the potential for social networks and thus also for social support (Heaney & Israel, 1997). Social networks represent the structural aspect of relationships, illustrating specific webs of social ties centered around an individual (Berkman, Glass, Brissette & Seeman, 2000; Heaney & Israel, 1997). Social support is a function of social relationship networks, or a category of resources provided by network members. Clarification of social support as a structural function of social ties is important because the term social support is sometimes misused to imply quantitative measures of the number of support ties as opposed to measures of quality (Heaney & Israel, 1997). Also, a distinction between structure and function helps guide research focus, since quantitative analyses may be more appropriate for studying network structures while qualitative studies may be more suitable to studying specific functional resources provided by networks (Heaney & Israel, 1997).
Social support is a function of general social networks (Heaney & Israel, 1997), and it can be divided into four types of supportive acts (House, 1981), though each social relationship tends to provide more than one type of social support (Israel & Rounds, 1987; Heaney & Israel, 1997). Emotional support provides trust, caring, love, and feelings of acceptance; instrumental support provides tangible needed services; informational support provides recommendations, guidance and information that can be useful for problem-solving (Cutrona & Russel, 1990; Tilden & Weinert, 1987; Langford et al., 1997); and appraisal support provides information such as constructive feedback used for self-assessment (House, 1981; Heaney & Israel, 1997; Moss, 1973; Langford et al., 1997).
Besides type, the other broadly identified dimension of social support is the source (McIntosh, 1991). Providers of social support for gastric bypass surgery patients may include intact social networks such as family and friends, and new social networks gained as a result of surgery such as healthcare professionals and organized support groups. Family and friends are thought to provide most emotional support, while experts and those who have experienced a similar medical procedure, such as other post-surgery patients in support groups, may provide most instrumental and informational support (McIntosh, 1991). Though emotional support can be the only type measured in studies of social support and quality of life, perceived emotional support has been measured to wane in the long term (Helgeson, 2003). Helgeson (2003) found that 6 months after hospitalization for a coronary health problem, informational support reduced stress most for patients while instrumental support most benefited their spouses (2003). Appraisal support, involving practical feedback on weight loss and decisions, is often not mentioned in studies of social support (Finfgeld-Connett, 2005; Helgeson, 2003). This study differentiated between sources of social resources, such as physicians, family, and support groups, as well as between resource types.
The literature provides two major frameworks for the relationship between social support and health outcomes. The Stress-Buffering model asserts that social relationships protect individuals from stress (Cohen & McKay, 1984, Cohen & Wills, 1985), while the Main Effects model posits that social relationships are beneficial to health regardless of an individuals level of stress (Cohen & Wills, 1985). There is contention within the literature regarding the two models, but they need not be mutually exclusive (Kawachi & Berkman, 2001). The Stress-Buffering model may better explain the functional, qualitative aspects of social relationships and health, while the Main Effects model may better explain linear ties between health and existence, quantity, and structure of social relationships (Cohen & Wills, 1985; Rodriguez & Cohen, 1988). The Stress-Buffering model asserts that stressful events perceived as potentially controllable create needs for tangible and informational support resources (Cutrona & Russel, 1990), while perceived uncontrollable events create needs for emotional support to facilitate the processing of negative emotions (Rodriguez & Cohen, 1998, p. 538). The Main Effects model may best delineate differences between social isolates and those with perceived networks of social support (Cohen & Wills, 1985).
This study sought to illustrate ways that social relationships may affect health outcomes via individual cognition and behavior throughout transitions in eating behavior after gastric bypass surgery. In the current literature, there is considerable uncertainty as to how social support exerts its effects on outcome in health and illness (Weinman, Heijmans & Figueiras, 2003, p. 216). Studies have found varied protective effects of social support on mental health through mechanisms involving perception, affect, stress, and behaviors across social groups (Kawachi & Berkman, 2001). Cohen & Wills assert that stress occurs when one appraises a situation as threatening or otherwise demanding and does not possess adequate coping mechanisms (1985, p. 312). Social support may protect against high levels of appraised stress, and, therefore, against feelings of helplessness and lowered self-esteem by providing the potential for seeking out and utilizing necessary resources (Cohen & Wills, 1985).
The literature discusses social support and health mostly in relation to overall morbidity and mortality (Uchino, 2006; House, Landis & Umberson, 1988) and specific disease outcomes, such as cardiovascular disease (Berkman, 1995; Seeman, 1996) and diabetes (Griffith, Field & Lustman, 1990; Gallant, 2003). Though social support is usually found to have a positive effect on health outcomes in these domains, studies also point to the mediating role of personal perception, belief systems, and self-management techniques (Skinner, John & Hampson, 2000; Berkman, Glass, Brissette & Seeman, 2000; Gallant, 2003). Studies of social support and post-surgical outcomes for Inflammatory Bowel Syndrome patients have found that social support had a positive effect on quality of life after surgery (Oliveira et al., 2007; Moskovitz et al., 2000).
A few studies have examined the helpful effects of social support on dieting or weight loss, but these focused on the existence or lack of social support in facilitating dietary behaviors rather than on specific functions and types of support (de Castro, 1994; Sobal & Nelson, 2003). In a review of the available literature relating social support to chronic illness with emphasis on self-management, Gallant (2003) found that patients with illnesses requiring attention to dietary change, such as diabetes, were particularly susceptible to social support influences. Studies have found that attending support group meetings helps maintain weight loss after bariatric surgery (Elakkary et al., 2006). Regular follow-up medical appointments also correlated with long-term weight loss maintenance (Gould, Beverstein, Reinhardt & Garren, 2007). However, most studies do not address the support roles of other social network members, such as family and friends. The social support literature lacks studies of specific, functional dimensions of social support and how they relate to diet, weight loss, and post-surgical outcomes.
It is important to distinguish between perceived and received social support. Perceived support is measured as resources from social networks that an individual believes are available and intended, while received support is measured as actual extended support as intended by a source. Received support is difficult to measure without observational studies of support transactions and coding for specific support exchanges (Helgeson, 2003), so most studies of social support are based on individual perception. This studys data consist of first-person accounts by gastric bypass surgery patients, enabling analysis of perceived social factor functions.
Negative Social Support
Social relationships can also have a negative influence as sources of conflict, anxiety, and stress. Heaney & Israel (1997) define negative social support as support intended but not perceived to be helpful. Relationships can be perceived as burdens rather than sources of support, or a combination of positive and negative resources (Helgeson, 2003). Unintended support failures occur when people aim to provide support but instead stimulate a negative interaction (Helgeson, 2003). Studies of cancer patients have documented unintended support failures when people try to extend emotional support by being constantly cheerful, while patients would appreciate chances to share other emotions (Dakof & Taylor, 1990). Some cardiac disease patients have also reported perception of too much social support from spouses (Helgeson, 1993). Though negative social support exists, it is not mutually exclusive of positive support and negative interactions have been shown to be stronger predictors of quality of life, possibly because they are less common and more significant to a patient (Helgeson, 2003). Perceived absence of social support correlates with negative health outcomes (House, Landis & Umberson, 1988). In this study, attention was paid to reports of perceived negative and positive social interactions when creating a comprehensive model of social resource management.
II. Theoretical Perspectives
In conducting this project, the researcher drew upon selected theoretical perspectives that shaped how she approached the analysis and interpreted the data. These theoretical orientations integrated existing theories, models, frameworks, and concepts found to be particularly relevant to understanding how gastric bypass patients managed social influences in this study.
A gastric bypass patient is not simply a physical body to be reshaped, but also a complex self whose thoughts and decisions comprise many factors, including cognitive capacity, psychological states, and social contexts. In this study, a patients identity was not viewed as constant, but rather as dynamic and interdependent upon many social factors within a life course system. This perspective draws upon Goffmans dramaturgical perspective (1959; 1963), which views people as actors who perform to convey impressions, with or without awareness of the act, to particular social audiences. Identity is therefore a conglomeration of all roles played by an individual as a fluctuating function of social interactions.
Gastric bypass patients act with intention to achieve personal goals while their choices are also constrained by surroundings. This view draws upon Banduras Social Cognitive Theory (2001), which views behaviors as reciprocally determined results of interactions between the individual, behavior, and environment. While individuals exert ultimate behavioral agency, Thoits emphasizes that individuals are not free agents; their choices and actions are structurally and culturally constrained, sometimes severely (2006, p. 314).
The self, represented in this study by the gastric bypass patient, regulates her behavior in an ongoing manner as she adjusts perceptions, thoughts, and behaviors to pursue weight loss maintenance goals in a changing environment. This orientation stems from the self-regulation theory of health and illness, which posits that the self is a multi-faceted knowledge structure within which a web of self-representations and identities are connected with multiple sets of scripts and strategies for achieving goals (Cameron & Leventhal, 2003, p. 5). Self-regulation involves feedback loops between perceptions, decisions, and goals (Carver & Scheier, 1981, 1998), emphasizing the links between emotional and cognitive processes (Scheier & Carver, 2003).
Gastric bypass surgery is a turning point, or radical change, in the life course of a patient. This turning point dictates major adjustments in how the individual constructs aspects of the self and ways of dealing with food and eating after surgery. Devine (2005) states that literature reports relatively few turning points in adults lives, so gastric bypass surgery may offer a rare opportunity to study social relationships as reflected by adult behavior surrounding a drastic life transition. As the individual patient proceeds on the life course, she remains the product of all prior life experiences and contexts while continually experiencing transitions as she adjusts to changing contexts and events in her life. This view is based on the life course perspective, which emphasizes the balance between stability and change across the life span of individuals (Wethington, 2005, p. 115). Wethington (2005) describes individuals on the life course as experiencing stable patterns of behavior and health interspersed with transitions in social roles and responsibilities that interact with changing sociocultural externalities and conscious decisions made to improve life over time.
Gastric bypass surgery is a component within a technological system involving physical factors, such as surgical tools and stomach surface area, that interact with other components, such as medical personnel, family, and friends, to produce weight loss. The gastric bypass surgery system is socially constructed because it would not exist without a market niche for its results and active organization of related components. It is also society shaping because its components and outcomes affect components outside of the system, thereby bringing them within, by proliferation of its relatively successful results and general awareness of its existence. This view is based on Hughes (1987) description of both physical and non-physical phenomena as regulatory problem-solving components of complex, dynamic technological systems.
Interactions with the social world shape the thoughts, feelings, and actions of gastric bypass patients in an ongoing process as they perceive and reflect upon observations of and information, appraisals and assistance from others. Previously existing thoughts, feelings, and actions also affect their attention to and interpretations of various types and sources of social influence. Gastric bypass patients interact with multiple social contexts that help shape their perceptions, goals, decisions, behaviors and health outcomes. Social interactions constitute intersections of the patients life with the lives of other people who are also continually involved in their own constructions of self, pursuits of personal goals, and self-regulations of behaviors along life course trajectories. Social factors in individual transitions after surgery comprise intentional, unintentional and negative support as well as other perceived interpretations and manipulations of social interactions. CHAPTER 3 METHODS
I. Approach
This study aimed to gain conceptual understanding of participants experiences of social interactions by employing qualitative methods along with a constructivist approach. This project analyzed a subset of semi-structured, open-ended interviews from an ongoing qualitative investigation. Qualitative methodology allowed the researcher to describe dimensions of social interactions as they seemed to influence participants food and eating management in recalled descriptions thoughts, decisions, and behaviors. While arranged concepts should represent themes grounded in participants varied individual perspectives, the theoretical orientation of the researcher plays a significant role in qualitative research (Corbin & Strauss, 2007).
A constructivist approach is useful in a qualitative study because it assumes that, rather than one fixed reality, there are countless realities that change depending on individual experience (Guba & Lincoln, 1998). Constructivism assumes that individual knowledge is created, rather than excavated and adopted from an ontological reservoir ADDIN EN.CITE Schwandt19984964965Schwandt, T ADenzin, N KLincoln, Y.S.Constructivist, interpretivist approaches to human inquiryThe Landscapes of Qualitative Research221-2591998Thousand OaksSage Publications(Schwandt, 1998). Realities may overlap when individuals share common cultures, values, and knowledge pools, but each person has a unique perspective on life. Participants in this study were viewed as distinctive individuals, offering unique perspectives on their own experiences. While each participant constructs her own reality, their descriptions of food and eating management since gastric bypass surgery yielded certain experiential commonalities. By comparing and contrasting dimensions of individuals recalled social experiences, this researcher built a conceptual process model to represent and organize them.
This study employed a grounded theoretical approach to conducting qualitative methodology. Grounded theory focuses on the construction of theory from data ADDIN EN.CITE Glaser19674984986Glaser, B GStrauss, AThe Discovery of Grounded Theory1967ChicagoAldine Publishing CompanyStrauss19904974976Strauss, ACorbin, JBasics of qualitative research: Grounded theory procedures and techniques.1990Newbury ParkSage Publications(Glaser & Strauss, 1967; Strauss & Corbin, 1998). Rather than using participants as databases with which to support the researchers predetermined ideas, grounded theory acknowledges the importance of participants ideas and the researchers capacity to conceptualize and organize them. Grounded qualitative research begins with open coding, or the organization of descriptive datasuch as the verbalized, interviewed perspectives of six post-gastric bypass patients in this studyinto conceptual categories (Creswell, 1998 p. 241-242; Strauss & Corbin, 1998). Throughout analysis, the researcher compares designated properties and dimensions of concepts (Strauss & Corbin, 1998 p. 19), identifying common themes among them (Creswell, 1998; Strauss & Corbin, 1998).
Since each participant offers a unique perspective, the researcher compares individual viewpoints within the parameters of emerging themes (Creswell, 1998 p. 76). Concepts and themes may thus become increasingly removed from participants actual descriptions, since more abstract concepts have broad applicability (Strauss & Corbin, 1998 p. 23). Categories may become saturated when the research can no longer find new data to support broadened concepts (Creswell, 1998 p. 242). The researcher arranges categories in a logical order supported by the data to create an abstract analytical schema of a phenomenon, a theory that explains some action, interaction, or process (Creswell, 1998 p. 241).
In this study, the researcher developed and compared emergent concepts from the data, developing an analytical process model to explain how participants constructed social resources from perceptions of others words, actions, appearances, and presumed intentions. This Functional Resource Management Model was then applied as a lens with which to further broaden categories representing social interactions as they impacted food and eating decisions since gastric bypass surgery.
II. Interviews & Participants
This study used interviews from an on-going study of dietary change and management of food and eating following gastric bypass surgery. This study is being conducted by graduate student Amanda Lynch, the principal project investigator and the interviewer and transcriber for all data used in this analysis. Lynch (2008) conducted two in-depth, semi-structured interviews in 2006 with 10 adults who underwent gastric-bypass surgery at least 12 months beforehand. All research procedures were approved by the Cornell University Institutional Review Board for Human Participants. Lynch recruited 8 participants by contacting leaders of and attending two gastric bypass support groups in Upstate New York. Participants were not told of the studys explicit goals, and the interviewer shared that she was a graduate student in the College of Human Ecology at Cornell University interested in the experiences of gastric bypass patients as they related to food and eating (Lynch, 2008, p. 33). Participants were offered informed consent and told their interviews would remain confidential, and were compensated with 20 dollars for study participation.
Audio-recorded interviews were conducted in participants homes, bookstores, and hospital cafeterias, selected to be comfortable and accessible to the participant (Lynch, 2008, p. 38). Interviews lasted between 70 and 150 minutes, and the interviewer wrote field notes during and after interviews. Lynch transcribed all interview tapes verbatim, and transcriptions of first interviews helped to develop clarifying questions for second interviews.
To date, Lynchs analysis of the data has not focused on social relationships, though her emerging conceptual model accounts for the overarching role of social context in patients experiences. Interview questions in general focused on eating behaviors, identities related to food, changes in food management after surgery, feelings about weight and health, and the surgery experience. While social concepts emerged throughout the interviews, questions specifically related to social support were: How do others influence your food choices? and How do others influence your eating behaviors? Probing questions more generally related to social support included: How do you manage food and eating-at home; at work; in social situations-? and Tell me about your weight loss after surgery-How was that experience for you? How did you feel? How did others react?
This study analyzed data from a 6 participant subset of the original 10 participants. After reading all 20 transcripts, those of all female participants who were interviewed no earlier than 24 months after surgery were selected. Male participants were eliminated because gender differences may play a role in social resource management. Participants who were interviewed prior to 24 months past their surgeries were eliminated because they had not entered the common weight maintenance phase during which many patients begin to regain weight, and were expected to have related differences in eating and weight management experiences.
The characteristics of the six women whose data were analyzed are shown in Table 1. They ranged in age from 36 to 63 years, and represented different household circumstances and experiences in maintaining weight loss.
III. Analysis
The software program Atlas Ti v5.2 (Scientific Software Development Gmbh, Berlin, 2007) was used to organize interviews and codes throughout analysis. Background theory and literature were used to provide a preliminary perspective that changed throughout organization and analysis of emergent themes and concepts.
This study employed a methodology that emerged continuously while reading, coding and writing. The researcher read interview transcripts while highlighting all portions of text that seemed related to social interactions. The researcher then made lists of over 100 emergent concepts, grouping them into broad categories. She began to recode the list of concepts set in Atlas Ti, and after recoding two transcripts replaced the long code list by organizing the data as blocks grouped into multiple broad categories such as expert advice, social examples of appearance, independent decisions, exercise opportunity, spouse unit mentality, mirror as other and eating strategy change.
The researcher next identified linkages between these broad categories to build a conceptual model that evolved into the Functional Social Resource Management Model. This model represented a system of catalogued situation settings, source types, social resource types, personal transition types and functional judgment types (See Table 2 on p. 27). These model components were applicable to almost all accounts of social interactions as told by participants, so the researcher could juxtapose components of different social resource management situation systems. After using the model to group anecdotes in the interview scripts, the researcher exported coded data from Atlas Ti to Microsoft Word.
Different social resource systems were compared by sources, resource types and participants judgments of resources throughout post-surgical dietary change. Using the Search function in Microsoft Word, the researcher arranged anecdotes by social resource type and participant number and printed them as separate documents. She then manually highlighted segments of anecdotes using different colors for different source types. Resource systems were summarized as two-line fragments on notebook paper, and the researcher circled and highlighted words illustrating common themes such as protein, friend/colleague and perceived disapproval. She used these and referenced coded segments of the original transcripts to further group specific data while writing this studys results section.
ParticipantAgeMarital StatusLiving WithHeightCurrent Weight (in lbs.)Current BMI (kg/m2)Lowest Wt. Since SurgeryHighest Weight (in lbs.)Time Since SurgerySupport Group Attendance163MarriedSpouse5521535.8185>400~5 yrs.Attended341MarriedSpouse5 2.514926.8136>360~7 yrs.Attended640MarriedSpouse5516427.3148320~3 yrs.,
7 mos.Attended752Never MarriedBoyfriend; Father5417630.2159.5303~2.5 yrs.Attended940Never MarriedAlone5317130.31483055 yrs.No longer attending1036MarriedSpouse; Child41031062.52443805.5 yrs.No longer attendingIV. Quality Assurance
Quality of data and analysis was supported by steps the researchers took to enhance credibility, confirmability, dependability, and transferability (Lincoln & Guba, 1985). To augment credibility, interview guides included varied wordings of similar questioDeDens, and the interviewer met with participants several times and asked them to confirm her initial understandings of their responses. This researcher had ongoing discussions regarding her analysis and interpretations of data with the original investigator Amanda Lynch and with their faculty advisor to enhance confirmability. To enhance dependability, this researcher maintained a rigorous audit trail of notes, coding choices, concept development, and other ideas. The participants in this study were purposively selected and the findings are not generalizable to other gastric bypass patients. Details of their experiences and selected demographics are presented to help readers judge the transferability of the findings. Transcripts were deidentified and kept secure, available exclusively to this researcher, her project advisor, and the original investigator.
CHAPER 4 - RESULTS
I. Functional Social Resource Management
a. Overview
b. Analytical Model
c. Social Sources
d. Social Resources and Judgment of Social Resources
e. Social Situations as Parts of Ongoing Transitions
II. Examples of Participants Management of Social Resources
Social Prescriptions
Social Examples
Social Appraisals
Social Facilitations
Social Reinforcements
Functional Social Resource Management
Overview
Analysis of the participants transcripts gave rise to an analytical model for their functional management of social resources. Table 2 outlines the categorized situations, sources, social resources and matched judgments of social resources that emerged as social resource management system components. As participants described anecdotes of social interactions in the contexts of their experiences related to weight loss, they constructed the words, appearances, and actions of other people. The participants recalled anecdotal social situations in response to questions related to eating behavior, dietary change, and food choice. These social situations are viewed as spatiotemporalized sets of circumstances in which the person encountered a social resource, defined as a mechanism that the individual perceived as having influenced her thoughts, feelings, or actions in some way. The resource was therefore functional due to the potential to influence her psychosocial, physical, and health outcomes. The social resource was perceived to be extended to them by a person or social source, of which participants reported several different types. Participants perceived social resources by observing or hearing others, but also through presumptions about the thoughts and behaviors of the perceived sources. The participants also made judgments of social resources, viewing them as variably supportive of their efforts toward weight goals or overall well-being.
Analytical Model
An analytical model was developed from the data and used as a lens through which to further clarify categories and support them with the data. The model represents the process by which participants conceptualized social interactions as recalled in anecdotes about personal food and eating management. Functional Social Resource Management views the participant as actively managing her social resources, in contrast to the participant being viewed solely as a recipient of social support extended to her by well-meaning others. In this model, the individual constructs a resource by judging perceived aspects of the source according to psychosocial factors including personal values and goals. Personal goals were viewed as weight loss and weight maintenance, and dietary change as the collection of emotional, strategic and behavioral transitions recalled as discrete moves toward or away from these goals. Participants constructed social resources by framing their perceptions of others as mechanisms for furthering independent thoughts, strategies and behaviors integral to personal dietary change. A social resource need not be constructed as a positive influence.
This model assumes that the extent to which the participant allowed the social resource to be functional in shaping their beliefs, attitudes, and actions depended upon many factors, including characteristics of the participant, sources, and resources, particular circumstances, and many infrastructural and sociopolitical factors. In addition, by recalling these social situations, study participants indicated a high level of awareness of their active management of social resources. It is likely, however, that other encounters with sources and instances of social resource management occurred for participants that were not memorable or even conscious.
Social
Situation
Social
Source
Social
Resource Type
Judgment of Social ResourceGeneral
Post-Surgical Period
Pre-Surgical Period
Remedial
Support Group
Counseling
Medical
Social
Eating Gathering
Workplace/School
Activity/
Outing
Domestic
Close-Personal
Friends/
Colleagues
GBP friends
Relatives
GBS patients
Spouse
Experts
Doctor/
Surgeon
Therapist/
Psychiatrist
Food and Eating Counselor
Support Group Leader
Nurse
General Experts
Others
Normal people
Thin people
Heavy people
Internet group
Encounters
General Others
MirrorPrescriptions
Adequate
Inadequate
[Absent]Examples
Associated
DisassociatedDesirable
Undesirable
[Absent]Appraisals
Body Appraisals
Eating Behavior Appraisals
Weight Loss Method AppraisalsPerceived Approval
Perceived Disapproval
[Absent]Facilitations
Food Availability
Eating Circumstances
Task AlleviationWanted
Unwanted
[Absent]
Reinforcements
Encouragement
ToolsSympathy
Expectations
Situations
Individuals recalled social situations including general post- and pre- surgical experiences assigned no specific surroundings, organized remedial situations intended to benefit the individual as a medical patient, mainstream situations attributable to common life and not necessarily related to gastric bypass surgery or medical patients, and domestic situations occurring within the individuals home. Remedial situations include the support group, or an organized gathering of gastric bypass patients in-person or on-line; counseling, or a pre-arranged appointment between the surgery patient and a professional trained to give guidance on eating, behavior or mental health; and medical, or a pre-arranged appointment with a professional trained to provide surgical, hospital or primary care to the surgery patient. Mainstream situations include the eating gathering, or two or more people in a non-domestic social situation involving food and eating; workplace/school, or a situation that occurs within an institutional work or school setting; and the activity/outing, or a social event notable for exceptional qualities unrelated to food, such as a trip to the mall or a sports game.
Social Sources
Each social resource stems from a social source, defined as the human being, comprised of body and behavior, retrospectively perceived by an individual to have extended words, appearance or actions constructed as a social resource. Several types of social sources were reported by participants.
Social sources emerged as spouse, or husband/boyfriend with whom the individual spends a significant amount of time; as gastric bypass surgery patients, or sources who have also undergone gastric bypass surgery and not referred to as friends; as close-personal, or sources with intimate, non-medical associations with the individual due to time spend together and/or qualified relationship status; as experts, or professionals with specialized authority in relation to the individual; as others, or sources without explicit close relations to the individual; as mirror, or a technical object providing a reflection of the individuals visible exterior; and as celebrities, or well-known figures in the popular media.
Close-personal sources were friends/colleagues or non-relative sources with whom the individual spends time as a social companion, due to qualified friendship and/or recurrent proximity; gastric bypass patient friends, or friends who have also undergone gastric bypass surgery; and relatives, or kin members by birth or by marriage. Expert sources were the doctor/surgeon, the therapist/psychiatrist (provides analysis and counsel on psychological issues), the food and eating counselor (provides analysis and counsel on eating strategies), the support group leader, the nurse, and general experts. Other sources were normal people, thin people, heavy people, internet groups, encounters (non-intimate sources confronted unintentionally throughout an individuals day), and general others.
Social Resources and Judgment of Social Resources
The social resource types that emerged in this study include prescriptions, examples, appraisals, facilitations, and reinforcements. Participants employed social resources in the construction of strategies and behaviors attributed to psycho-physio-social outcomes. Social resources informed rules, tricks and coping mechanisms used in goal-oriented behavioral decisions. Participants used social resources as positive, partial and negative identity reinforcements, validations of worth, outcome warnings, reminders, sources of knowledge, mood regulators and physical assistants in constructions of eating behaviors. The types of social resource judgments that emerged from these data differ based on resource type, and are described below.
Social prescriptions describe perceived instructions, advice or recommendations for an individuals values, goals, strategies or behavior. Participants judged them in situational context as adequate, inadequate or absent (a prescription that should/could have occurred in a situation but was missing). Participants disagreed with some doctors and dietitians regarding approaches to food choice such as protein and dairy intake. Participants felt many experts did not offer adequate methods of discipline, did not offer useful information, and lacked understanding of their emotional, decisional, and behavioral experiences. Participants supplemented gaps in expert prescriptions with independent research and experimentation with eating strategies. Prescriptions by gastric bypass surgery peers (gastrics) were usually perceived as more useful than those by doctors and nutritional counselors. Participants described situations when spouses extended prescriptions for the sake of marital or family compromise, desired control, or due to lack of understanding.
Social examples describe perceived appearance, physical status, values, goals, strategies or behavior of a source in comparison to the self and/or others. Participants judged them in situational context in two tiersassociated (individual connected or related to social example) or disassociated (individual differentiates self from qualities of source represented by social example), and desirable, undesirable or absent. Participants expressed pride, distaste and goals for their own bodies by comparing them to those of others. Participants saw or heard of the weight gain, illness experiences and difficulties of other gastric bypass surgery patients, heeding them as warnings and avenues to avoid. Participants also described the presumed intentions of others as social examples.
Social appraisals describe perceived judgments of the individuals appearance, physical status, values, goals, strategies or behavior. Participants judged appraisals in situational context as the sources intended meanings, as either perceived approval or perceived disapproval. Participants perceived sources as approving and disapproving of participants weights, appearances, personalities, food choices, eating strategies, goals and states of health. Approval from others seemed to validate the worth of undergoing surgery, the worth of their lives and bodies, and the worth of other decisions and behaviors, but it was also met with participants skepticism and resentment. Participants described an awareness of their visibility, seeming to glean both pride and insecurity from potential for and instances of others judging their appearances. Appraisals of eating strategies were also perceived as balancing forces, sources of personal empowerment and instigators for personal transitions.
Social facilitations describe circumstantial factors in situational transitions, such as opportunities and physical surroundings, perceived to have been modified by the existence, proximity, intentions or actions of a social source. Participants judged them in situational context as wanted, unwanted, or absent. Participants recalled situations where others provided them with specific opportunities to make both positive and negative decisions about food and eating. Sources brought notable foods into the home, workplace, support groups, and hospitals, and sources also created chances to dine in a restaurant or at a picnic, commonly encouraging temptations requiring concerted methods of avoidance. Participants recalled others performing duties and chores in their stead, saving them time, pain, and emotional and physical energy.
Social reinforcements describe the existence of social ties perceived to have been emotionally or strategically supportive or unsupportive without explicit perceived resource receipt. Participants attributed the function of reinforcements to encouragement when the individual perceived caring or compassion from a source. Participants also described reinforcements as expectations when the individual felt accountable to the potential or presumed standards of others for her body and behavior. Participants usually described expectations of sources familiar with participants experiences, and found reinforcements supportive of overall stability, discipline, and self-monitored honesty.
Social Situations as Part of Ongoing Transitions
This model recognizes that participants anecdotal social situations were recalled as aspects of lives full of transitions as they adapted to modified bodies and life styles after surgery. Transitions after gastric bypass surgery required individuals to change physical, psychological, and social aspects of their lives in pursuit of weight loss goals. As individuals made drastic alterations in food choice and eating behavior, their eating strategies reflected internal management of various factors, including physical elements, (eg. a shrunken stomach pouch), psychological elements (eg. body image), and social elements (eg. expert advice). Participants described transitions in weight, mobility, comfort, freedom, worldview, identity, body image, social visibility, eating strategies at home and elsewhere, daily routines, and independent decision-making. Participants described disappointment, anger, frustration, comfort, joy, love, happiness, and many other emotional states. They described understanding, jealousy, insecurity, rudeness, and other traits perceived in others and in themselves.
This study considered social resources exclusively from participants retrospective lenses, and analysis focused on their interpretations of social situations. While most participants claimed independent control of behavior and outcomes since surgery, often denying the influence of social sources on their personal choices when asked directly, each described various social situations used in decision-making processes leading to transitions in eating behaviors, body weight, health, and quality of life. Participants described social resources as helping them to adapt to these transitions, or, in many cases, as making post-surgical adaptation more difficult.
Social interactions lent participants descriptions of personal behavior through comparisons to exemplary past situations, to the comments and advice of others, and to perceived personal qualities of others. While participants descriptions of some resources indicate that a social source was perceived to have intentionally influenced decisions or behaviors, others indicate only that participants used perceptions of other people in specific social events to construct social resources. When other people intentionally extended recommendations, compliments or tangible resources to the participants, their actions did not necessarily catalyze reactions desired by the source. Other people acted as regulators of and sources of comparison to appearance and behavior without needing to be conscious of participants awareness of their visible qualities employed as resources.
Examples of Participants Management of Social Resources
The following sections describe participants agentic management of social resources, grouped according to the type of social resource. Examples illustrate how participants were actively involved in evaluating social resources perceived to come from different sources in varying situations and how participants viewed the resources as shaping their beliefs, feelings, and actions.
Social Prescriptions
Social prescriptions emerged as a prevalent resource type, representing situations where participants recalled another person having extended instructions, advice or recommendations. While social prescriptions most often involved practiced health advice from medical professionals, therapists, and eating counselors, social prescriptions also surfaced as instructions from parents, siblings, the media and other gastrics. Pleas by a spouse were another type of social prescription. Prescriptions were sometimes viewed as helpful and sometimes viewed as misinformed, as hurtles for efficacious weight loss strategies and behavior, and as even as a jealous siblings attempt at sabotage.
Expert Prescriptions
Every participant described prescriptions offered by doctors/surgeons. All participants but Participant 6 described prescriptions by food and eating counselors; Participant 6 was also the only one to recall eating strategy prescriptions by her support group leader.
Doctors/Surgeons
Doctors/surgeons prescribed eating strategies involving specific food types such as protein and milk, means to improve health such as serum iron assessments, goals for body weight and reasons to adopt routines such as tak[ing] a load of all these pills. Expert prescriptions lent by different sources often conflicted and were often perceived as absent or misinformed. Perceived inadequate prescriptions were replaced with strategies learned from independent research or from other gastrics. Though Participant 9 described only helpful prescriptions from expert sources, all other participants also reported many shortcomings of information from experts, resulting in difficulties in dietary change since gastric bypass surgery.
Protein Strategies
Protein emerged as an important aspect of dietary change after surgery, and participants reported conflicting information about how to incorporate protein into their diets to achieve optimum health and weight at different stages of surgical recovery and weight loss maintenance. All participants but Participant 9 recalled inadequate protein intake strategy prescriptions by doctors/surgeons, either due to misinformation or conflict with a dietitians recommendations. Participants 1, 3, 6 and 7 disagreed with doctor/surgeon protein strategy prescriptions and enacted at least partially contradictory, independent strategies. Most participants believed they required more protein than their doctors prescribed, and that protein was a useful method for maintaining effective weight loss strategies and good health.
Participant 1 said the doctors think we can get [adequate protein] through eating regular protein, butthe amount we eat, we can not assume we have to eat at least sixty grams or more. Participant 3 reported anger and confusion due to the conflicting opinions of her personal doctor, who said dont have the extra protein because you dont need the extra calories, the dietitian who said yeah, have the protein and the opinions of other gastrics doctors; she concluded that its such a big, broad bunch of ideas, so everyone has to do whats good for themmy rules are to do what feels good for mebecause of what Ive read: Protein heals.
Participant 6 said that according to pretty much everybody thats had [the surgery] and the research that they have done says that you shouldhave sixty to ninety, some will tell you a hundred and twenty [grams of protein]. She integrates protein shakes in her daily eating routine to help absorball the vitamins that a shortened small intestine make more difficult for her body to absorb, but that doctors will tell you that you dont have to do [protein shakes]. She also said her doctor recommended beginning with protein shakes if calories needed to be cut, but that the change made her hungrier and more tired, so I went back to doing two a day.
Participant 7 disagreed with her surgeons aversion to replacing foods with protein shakes as a strategy to manage food cravings. She called his approach old school and thought of him as one of those surgeons thatis not open to anything new.
Participant 10 claimed that neither her doctor nor the dietitians taught her about how the dairy andthe protein prior to surgery you know helps prevent hair lossthings like that and that instead she learned of them through websites and both online and in-person support groups.
Supplement Strategies
Participants recalled prescriptions by doctors/surgeons that factored into strategies for supplementing food and eating with additional over-the-counter nutrient sources. Participant 1 adopted a vitamin supplement routine because were malnourished. In fact Dr. F out in California, he said that we have induced anorexiaand if you try to eat like a normal person, you get very sick. Dr. F prescribed anorexia as an eating identity comparable to gastrics by grouping them as undereating people, which reinforced Participant 1s nourishment strategy despite her being so sick of taking pills.
Participant 6 began to take a combination of soy and black cohosh, when her gynecologist and her surgeon recommended the cohosh as an alternative to pharmaceuticals for ameliorating menopause symptoms that began after surgery. She combined the cohosh with soy because the guy [at] the vitamin store told her of recent findings attributing the combination, and not cohosh on its own, to lessened PMS symptoms, which had changed from very very mild [to] very very bad since Participant 6s surgery.
Eating Strategies
Participants sometimes judged the efficacy of doctors prescriptions against mental strategies that worked best for them in achieving desired weight loss goals after surgery. Participant 1 was immediately attracted to her surgeon Dr. Ss blatant honesty and his recommendations to attend support group meetings and discuss concerns with family members, but felt he didnt have a diet plan sort of deal. She responds well to structure, so after surgery supplemented Dr. Ss oooh, whatever feels good, whatever doesnt hurt, whatever doesnt make you sick eating strategy prescription with the detailed diet plan of Dr. O, recommended by a support group member and available in the support groups database.
Participant 7 agreed with her doctors decision never to prescribe a specific weight goal, since weve failed at so many diets before, if we set ourselves up that way, were going to fail. However, Participant 7 also deemed her surgeon clueless about what gastric bypass patients go through after and that these doctors dont realize what the long term is. She called her doctor excellenttop of his field, as far as surgery goes but that he was unaware of many long term factors after surgery such as mental health, malabsorption and lactose intolerance.
Food and Eating Counselors
Food and eating counselors prescribed participants different strategies for eating to achieve optimal health and weight loss transitions surrounding surgery. Participant 3 reported both adequate and inadequate eating strategy prescriptions by food and eating counselors. Participant 9 reported only helpful prescriptions by food and eating counselors. Participant 6 reported only helpful eating strategy prescriptions by her support group leader. Participants 1, 7 and 10 reported only the inadequacy of prescriptions by food and eating counselors for their eating transitions.
Participant 1 believed some of her dietitians prescriptions would help other patients, but that she already knew the eating strategies they taught. Participants 3 and 6 discussed the utility of learning from their respective dietitian and support group leader to eat in stages progressing from liquids to pured to soft foods after surgery; for Participant 3, these prescriptions led to a trickIf I could sift it through my teeth, then I knew I chewed it thorough enough.
Participant 6 said that after being scared by realizing her ability to still eat after surgery, she learned coping mechanisms from a therapist who taught her to stop and think about why you are doing it. Participant 9 repeatedly commended prescriptions by counselors in a pre-surgery education program for gastric bypass surgery patients, saying they prepared her not to eat emotionally, to practice portion control and to manage stress.
Dairy Prescriptions
Dairy food management emerged as a common example of how participants addressed strategies prescribed by food and eating counselors. Participant 1 used to fight with the dietitians because they said gastric bypass patients required milk, while she believed its considered liquid sugar and that most gastrics become lactose intolerant. She learned to replace cravings for milk with soy milk from obesityhelp.com, which tells you everything and from my mentor MC.the guru who had had the surgery ten years ago and now trains doctors in the benefits of protein and other food and eating options.
Participant 3 discussed dietitians conflicting opinions about milk, and her resulting strategy to run down the middle. If I feel like having a little milk, I have a little milk. If I dont feel like having milk, I dont have milk.
Participant 7 disapproved of her nutritionist, who was a joke this little skinny size three person telling you how to eat afterwards and knowing from the research that everything she tells you is wrong. The nutritionist told her to drink Carnation Instant Breakfast and not milk, which she couldnt doand I cant absorb the protein in it anyway. At least tell me to drink soy milk if youre going to go that far; at least tell me something I can have.
Close-Personals
Told You So
Participants also cited eating prescriptions by relatives, friends, and spouses that factored into personal transitions. Participant 7s mother had taught her to chew food to death, which proved to be a useful habit after surgery. Participant 9 said that before surgery she would be like, screw you if anybody told her you shouldnt be eating that, but that since surgery one gastric bypass patient friend has changed her food choices on occasion by saying youre going to get sick from thatbecause she knowsthat it makes me sick.
Sabotage
Participant 7 perceived some of her sisters prescriptions as direct attempts to interfere with the weight loss success of both her and her boyfriend during the first year after surgery. Her sister would say you can have a little piece of this, a little piece of this while Participant 7 believes her sister knew it would make her sick. At a birthday party, the sister repeatedly suggested eating cake, which became a chance for Participant 7 to demonstrate her independent eating strategies by eating a small amount of frosting before handing back the offered fork. She sometimes gets angry with her sisters coercive eating prescriptions, but attributes them to her sisters insecurity. In one situation, Participant 7 made her sister stay with her while she dump[ed] on ice cream, which she described as uncomfortable and disturbing, and since then her sister has been less prone to encourage improper eating behaviors.
Domestic Dos and Donts
Participants described prescriptions for food choices and eating behaviors by spouses who were familiar with or took part in participants domestic eating, illustrating both helpful and unhelpful interactions with spouse partners. Participant 1s spouse still expects me to cook you know and do things, and that it took awhile to [say] get it yourself, Im not going to anymore. She continued to cook for him sometimes, but found that difficult.
Participant 6 described a compromise that developed from domestic food choice preferences offered by her husband. She tends to strictly compare information on labels when making food choices, but when this led to buying fat free sour cream her spouse told her Honey, dont buy the fat free sour cream, its disgusting! Despite its higher fat and calorie content, Participant 6 and her spouse compromised with light sour creamLight, he doesnt mind so much!
Participant 10s spouse also had surgery, and she described him as both helpful and a hindrance. Her husband tried to encourage her to make better choices, telling her oh dont eat that and that shes not hungry when she claims to be. While this sometimes acts as a reciprocal means to stay on target for Participant 10 and her husband, it works negatively too when he shares and encourages her impulses, such as craving something sugary.
Social Examples
Participants employed social examples by comparing the appearance, physical status, values, goals, strategies or behavior of a source to her own or those of others. Participants either associated or disassociated with the resource, and usually indicated whether she found the example desirable or undesirable for herself. All participants described other gastric bypass patients as examples of eating strategies, eating behaviors and aspects of the body or health. Participant 10 also spoke of her husband, another gastric, as an example. Many participants described the broadcast experiences of television celebrity gastrics as examples. Participant 3, 6, 7 and 10 described heavy people as examples, and Participant 3 and 10 used normal people and thin people as examples. Participants 9 and 10 discussed behaviors of relatives and friends as social examples. Participant 3 described her reflection in the mirror as a social example, explicitly disassociated from her self.
Gastrics
Participants described other gastrics as examples of eating behavior in the context of specific situations, of health and appearance, of eating strategies and of eating schemas. Participant 1 discussed three situations where she disassociated from the behavior of individual gastrics. When explaining how she lost weight more quickly than expected by just being compliant after surgery, Participant 1 compared herself to another woman in her support group, who ate chocolate chip cookies the day she left the hospital after surgery. While the participant would never think of eating [this way] when I came home from the hospital, she also regretted that after being so good for four years she had now begun to test the waters with cookies. Participant 1 also described a situation at a picnic when one gastric ate an entire hamburger, the roll and a sausage, while the participant [didnt] know how she ate it, because I could only eat half of a hamburger. She thought it might be due differences in stomach pouch size, claiming her surgeon did a good job. In another situation, Participant 1 compared her behavior to a gastric girlfriend who packs it in by eating all of an appetizer and salad ordered at a restaurant, while the participant saved leftovers for the next days lunch. She called her friend the one that eats, and differentiated herself as someone who after I finish the salad, Im done. Done! Ive had enough. Maybe one bite.
Participants repeatedly compared the health and appearances of generalized groups of gastric bypass surgery patients to their own, either having witnessed or been told of them. In most cases, participants disassociated from these examples and found them undesirable. Participant 1 disassociated from those who underwent laparoscopic surgery, who she perceived to have an easier time than she did with an open roux-en-Y surgery. However, she believes her difficulties with sickness after surgery made me stronger [and]more compliant than those who have had both types of surgery. Participant 3 described her experiences with minor dumping in comparison to stories of serious cases of dumping, saying she has been hot and sweaty and had to just kind of crap in the bathroom, lay down maybe half hour and felt OK afterwards a few times, but that others have experienced vomiting, cramping and diarrhea for a few hours at a time. Participant 7 explained how protein has helped me lose weight, in a healthy way by comparing her own strategy to those of gastrics who do not use protein supplements. She believes gastric bodies begin to deteriorate from malabsorption after surgery without protein and become gray ghosties, as evidenced by her description of a man she had met and thought he had AIDS. Thats how bad he looked. His teeth fell out. He was totally gray.
Other gastrics were also referred to as social examples of undesired weight gain. Participant 7 disassociated herself from many support group members who had regained weight by not following the rules of the pouch. She also wanted to go over and shake support group members who dont seem to understand why they stopped losing weight after six months but who went to McDonalds and they got a Happy Meal sitting in front of them. Participant 9 knows its possible to regain weight because she has seen it happen with other gastrics, and as a result she thinks aboutwhat am I going to eat?making the right choiceeveryday.
Gastric bypass patients were also sources for social examples of associated personal body weight concepts. Participant 6 united herself and all gastrics by social stigma, saying that while they experience a variety of specific outcomes after surgery, all parallel each otheranybody that has been extremely obese youve lived in that sheltered world because you put yourself therebecause the world puts you there. She said that after surgery and weight loss, all of a sudden as that [weight] falls away, you dont have that security anymore. So you have to face the world, which makes you face you. Participant 10 associated with her gastric husband as so fat, saying they fail together at exercising and losing weight by constantly having to start from ground zero after continually allowing the first little distraction [to]throw it all off.
Heavy & Thin Others
Many participants saw heavy people as examples of a former, pre-surgical self and have associated more with thin people since surgery. Participant 1 has found herself resenting when others make snide remarks about a fat person since her surgery, having never seen a heavy person until I had my surgery. She feels the urge to ask obese encounters in the grocery store if they have considered bariatric surgery, but is afraid of their reactions. She also understands that she is still considered obese by medical standards. Participant 3 associated with the eating behaviors of a normal thin person since surgery, and then I look at the heavy people and see huge mounds of food on their plates. And thats similar to how I used to eatalthough I spent my whole life dieting. Participant 7 said she finds it difficult to see an obese person, and want[s] to run up and hug them and say, Oh my God, there is help. Theres a future, there is life. You can get better. Because I know what it was like to struggle. Participant 6, however, said she did not change her identity after losing weight, since although many other heavy people want to be somebody else, she has always liked herself as a person and just wanted to change my body. Participant 10, who did not maintain weight loss since surgery, still associates more with heavy people and disassociates from thin people, saying that food and taste have always been important to her and that her skinny friend eats the nastiest stuff, but she doesnt careeverything possibly healthy, shes got zero percent body fat. I cant do that.
Colleagues & Relatives
Participant 9 discussed two situations where she disassociated from the eating behaviors of colleagues and relatives. She described a change from constantly thinking, what can I have next to her current, less food-centric eating schema by comparing her mindset to coworkers who discuss what to order for lunch while eating food from McDonalds. While she associated with this way of thinking before surgery, she found it laughable during the interview. Participant 9 also disassociated from the behaviors of her brother and sister-in-law at a restaurant to describe how she has retrained her portion control strategies since surgery. Her relatives had huge things of Chicken French and pasta and bread and all this stuff and I look at it and I go, oh my God I remember the days when I could eat that whole thing, plus salad, plus bread. Oh my God!
Participant 10 described growing up in an extended family with high rates of obesity, chronic disease, and early mortality. She attributed her decision to undergo gastric bypass surgery to these cautionary examples of health, and attributed much of her failure to maintain weight loss after surgery to being raised among people who were often eating or discussing food. She linked her love-haterelationship with food to her familys central focus on food that brought everybody together but also contributed to a high prevalence of obesity and disease in her family.
Reflections
Many participants said their decision to have bariatric surgery stemmed from watching the experiences of gastric bypass celebrities such as Al Roquer, Carnie Wilson and Rosanne Barr, whose struggles with obesity were felt to mirror their own. Some participants also described their reflections in mirrors as disassociated examples of appearance, claiming they could not relate to the person they saw. Person 3 said, looking in the mirror and seeing the new you took a long, long time Wow, thats me? Nah, it cant be me. This paralleled her disassociation with the you are so skinny identity that others began to tag to her after weight loss, and it took a long time for her to stop disagreeing with them.
Social Appraisals
A participant recalled social appraisals when she perceived a source to judge (offer a qualified opinion on) her appearance, physical status, values, goals, strategies or behavior. Participants usually either indicated perceived approval (a positive connotation to the appraisal), or perceived disapproval (a negative connotation). Every participant recalled appraisals by relatives or friends. Every participant discussed appraisals by general others, and Participants 1, 9 and 10 mentioned appraisals by specific encounters. Participants 1 and 3 described social appraisals by spouses, either as absent or disapproval. All participants but Participant 10 recalled expert appraisal situations.
Body Appraisals
Relatives & Friends
Relatives and friends were often perceived to have judged visible aspects of a participants body. Participant 1 felt good when her sons said Mom, where are you? when she lost weight. However, growing up her mother was perceived to have disapproved of Participant 1s appearance, which she found hurtful. Participant 3 perceived her sister, who had been always been skinny but recently gained weight, to be jealous of her weight loss because she would hear remarks behind my back about her appearance. However, her husbands side of the family and her friends would compliment her by saying things like youre looking good.
Participant 6 recalled a time when her young nieces, not meaning to be rude, asked her if she needed help tying her shoes; this appraisal of her weight was a defining moment in Participant 6s decision to have bariatric surgery. Participant 6 was pleased when a friend commented, oh my god youve lost so much weight! at a picnic; she recalled this to explain her willingness in certain circumstances to tell others of her surgery.
Participant 7s daughter was perceived to disapprove of her thinner body by saying you look fragile now and teasing oh, here comes skinny; the participant was once bothered by her daughters comments but is now used to them. Participant 7 also feels proud when friends dont know who she is and say, that cant be you?!
Participant 9 was embarrassed when others, such as a girl at work, asked to see before photographs of her; she perceived this as a judgment thing. She is kind of particular about who I tell about her surgery, but seemed pleased to recall a situation when a friend did not recognize her after surgery. Participant 9 also recalled seeing herself in post-surgical photographs and not realizing it was her until her sister-in-law said thats you and confirmed that she still looks like that. She was pleased by the way she looked in the photograph and how she looks in the mirror, but she disagrees when others say her face and stuff are much thinner or look any different than before surgery.
Spouses
Participants did not describe perceived approval of their appearances by spouses, but some participants described their absence. Participant 1 wished her husband would comment on her appearance, but he never really praised me. She said it would help [to get] an atta girl every now and thenit would be nice to get a compliment on how I look and that if her husband ever said she looked good it would be a cold day in hell. Not owning any long mirrors, she recalled having to rely on her reflection in a window and on the opinion of a girlfriend to appraise her appearance in a wedding ensemble for her sons wedding, since her husband wont give me an honest answer.
Others
General others and encounters were also perceived to have appraised participants appearances. For instance, Participant 6 believed that when obese, others look at you for your body, but that she never wanted to be just a body to somebody.
Participant 1 said that people see you differently, tend to open the door for her and that I get smiles now. At a picnic, a man was speaking to her husband and said wheres your fat wife? at which point she turned around and said Im his fat wife, thank you very much. She loved it when his jaw dropped right to the floor.
When Participant 3 had lost too much weight during a stressful time in her life right after her sister died and a tornado hit, people told me I looked like hell; she then tried to gain some weight, but at the time of the interview was again trying to lose some, but not too much, weight. Others also tell Participant 3 Oh youre changed, which she perceived as an appraisal of more than just her appearance, though a comment based on her looks. She wishes people would just see me rather than her body when assessing aspects of her identity.
When Participant 10 had first lost weight, people would just look at you differently. She found it empowering that they would be surprised because of what they would saywith their eyes. At the time of the interview, it was embarrassing for Participant 10 to tell others of her surgery, since she had regained her pre-surgical weight. She perceived people in the surgeons office to assume ooh shes going to have surgery or to think tsk tsk, [the surgery] didnt work so well for her, which was an appraisal situation recalled immediately after Participant 10 said Ive definitely disappointed myself.
Experts
One participant perceived body appraisals from expert sources. Participant 9 experienced a pick me up when her doctor said Look, its Skinny! Skinnys here in the week before the interview. At her doctors medical office, the nursing staff always tell me how great I look and she goes there when feeling bad about myself or that she is gaining weight [and] feelin really crappy because the staff remember me how I was. No other participants recalled appraisals of body appearance by expert sources.
Eating Behavior Appraisals
Friends & Relatives
Participants also perceived others to have judged their visible eating behaviors. When Participant 1 orders courses at a restaurant and cannot eat the main course, her family gets very frustrated although she takes home leftovers. Participant 6 explained that she tailors food choices because she does not want to disappointmy mother or father, although they dont necessarily say anything to me, but in my head Im likeOh my God are they watching me? She considers her family a great support system and says she makes better food choices based on what level of disappointment I perceive them to have with my food choices.
When Participant 9 goes out to dinner with gastric friends, they tease her because like Participant 7, she often does not buy food or eat, but does try to split stuff a lot of times. Participant 10s friends keep you on your toes by mocking her when she is not social, and asking whyd you bother? when she makes good food choices for a couple days before eating something junkie. She believes they want you to do good [and] they dont try and actually sabotage you, but its easily done since eating is how we mingle and these friends are all really good cooks.
Others
Participant 1 was thrilled when she ate only a small amount of her meal at a restaurant and the waitress charged her for a childs portion after being told of the participants surgery. Participant 6 felt that although she was used to it now at the time of the interview, everybody kind of looks at me when she removes a roll before eating her food at a restaurant or when she eats very small amounts of pasta. Participant 9, however, says that since surgery its more enjoyable to go out to a restaurant because when she was heavy others would say well you shouldnt be having that and strangers would be really rudeand they think theyre being helpful! while its nice now because people arent looking at what youre eating. Nevertheless, Participant 9 also noted that since surgery when she scoops out bagelspeople look at me and go But thats all the good doughy stuff! Participant 10 eats less in public than in private because people watch you, as when she did not join friends in eating chicken wings at a bar because she perceived people to assign her the stigma of like, the fat girl.
Spouses
Participant 1 recalled a few instances when her husband seemed to disapprove of her eating behavior. She called him oblivious, and that he questions her protein shake routine by asking Is this necessary? and How come you have this stuff? since normal people dont. Participant 1 believes her husband doesnt understand why I eat so little.
Weight Loss Method Appraisals
Friends and expert sources were perceived to have appraised participants decisions regarding weight loss methods. Participant 1 struggled for the first three months after her surgery, but her nurse told her I really didnt think you were going to make it but look at you now! Look what youve done! Youre walking, youre doing all of this stuff that youve never done before. Participant 1 recalled this run in with her nurse as signifying her own complete change as a complete 360. I took risks, risks, risks. Im not a risk taker.
When Participant 3 first had surgery, her dietitian said Yes! to approve the participants decision to gee Im throwing out all these Weight Watchers books. Im throwing out the scales, Ill never have to worry about it again. However, Participant 3 believes the dietitian had been wrong since you gotta watch it forever.
Participant 7s doctor told her you know more than I do, claiming to be a doctor and not a nutritionist and telling the participant if its working, do a great job. Just keep doing it.
Participant 10 called many of her social friends, especially eating buddies, [and] older people who did not understand that surgery was an optionnaysayers, claiming they were skeptical that the surgery would not work for her because at the time [gastric bypass surgery] was just so relatively new coming on the scene fast and furious.
Social Facilitations
Participants described situations when the existence, proximity, intentions or actions of sources mediated their decisions and behaviors by changing situational factors through provisions of food, eating/exercise events and assistance with chores and obligations. Social facilitation resources most often emerged as food availability, or when participants perceived specific foods to be accessible in a situation due at least partially to a social source. A spouse, friends/colleagues or relatives provided most food availability to participants. Gastric bypass surgery patients also provided food availability, including during support group sessions. Most often, food availability was framed as unwanted for weight loss maintenance. Other facilitations were eating circumstances, when participants perceived specific circumstances involving eating have occurred at least partially due to aspects of a social source. Participants did not always specify a source when recalling eating event facilitations, but these social situations would not have occurred without the organized existence of others. Participants also recalled instances of task alleviation, when sources performed chores and duties that the participant would have otherwise completed; task alleviations were most often wanted by participants.
Food Availability
Domestic Life
Participants often perceived facilitations of food availability as provided by spouses and children in the home. For instance, Participant 3s husband sometimes isnt very helpful as far as foods in the house, but she makes independent food choices despite his facilitation of unwanted domestic food availability.
Participant 1 considers herself a grazer who makes poor food choices more often because her husband is a junk food junkie [who] has to have this stuff, but she is also capable of turning down temptation. Participant 1 called her husband a saboteur of her post-surgical eating strategies. While she used to be very good about not touching [his junk food], over time she has become more prone to occasionally sneak whatever hes got. When Participant 1was being very compliant after surgery, her husband would place five boxes of Little Debbies in the kitchen but she was good I couldnt believe that I was so good not touching them. In one situation, Participant 1s husband surprised her with a smile and huge cinnamon roll, but when she turned it down he replied What can you eat?! In another case he offered a bowl of potato chips saying you havent had some in a long time, but Participant 1 refused this trigger food and asked her husband to not bring them in the house.
Participant 6s husband likes junk food, but they have created compromise techniques to maintain distinct eating strategies and help the participant meet post-surgical goals. Her husband, who has never had an issue with food, at first did not understand the food choice and eating behavior changes Participant 6 made after surgery, but he must have thought about it he changes things to make it easier on me. When they moved in together, Participant 6 suddenly found she had eaten a whole sleeve of Oreos, not realizing her behavior until she began to dump and was sick for two hours. Since then, her husband has padlocked most unwanted foods in a cabinet downstairs. Her husband keeps pretzels in the house to take to work, which she sometimes eats to avoid eating his potato chipsthough he tries to buy them in flavors she does not enjoy. When sugar-free creamer for coffee became available in stores, Participant 6s husband accommodated her needs by offering to switch to the new product.
Participant 10 finds that because she is always rushing to transport her daughter to activities and help her with homework, she has no time to prepare the kind of meal I would like to make. Instead, she relies on unhealthy options that can be prepared quickly such as some sort of processedor pre-made rice dish, burgers or pizza. Participant 10 discussed her husbands and daughters limited food preferences as obstacles for her ability to eat a variety of healthy foods. While she eats all vegetables, her family is only willing to eat a few types so she must cook similar meals repeatedly. She says both she and her husband get bored with the same stuff, and that I wanna be able to cook more and I want to cook healthy, but I havent explored it yet, that much. When asked if she has developed any strategies to integrate her familys eating styles and her own goals, Participant 10 said its not worth it since I could cook it, but they still wouldnt eat it. Sometimes she will make myself a separate vegetable that they dont like, but, but thats it.
Special Occasions
Participants recalled festive social situations where uncommon food choices were available in atypical contexts. Participant 1 ODd on turkey the first Thanksgiving [after surgery] because they left me alone in the kitchen and I kept cuttingand I forgot that I had a small stomach! She became ill and was not able to eat turkey with her family in the dining room, instead leaving the table to go to sleep. The situation taught her not to touch [turkey] until its cut.
Eight years after her surgery, Participant 3 felt she had recently been stressed and that her old pattern just came back, with a vengeance while preparing coffee and hamburgers for a picnic. She could not wait to eat a hamburger because she was hungry, and worried that she would go outside with everybody else andeat another one. Though luckily the tool [gastric bypass surgery] worked and Participant 3 was too full to eat more, she was scared that such a thought pattern had resurfaced in recent months.
Participant 3s sister-in-law encouraged her to go out for chicken wings, which she ate because they were good. Whyd you [sister-in-law] have to do this to me? Not her faultbut they were good! While she does not blame her sister-in-law for her eating behavior, Participant 3 realizes that these desirable chicken wings would have been unavailable had the opportunity to eat them not been presented.
At a Fourth of July party or a birthday party, Participant 6 will have a piece of brownie, though in other situations she would not eat brownies. She treats herself to her downfall when at a special event since she has always loved browniesI just wont eat the whole pan anymore, like I would have [before surgery].
Participant 6 described an ice cream cake her sister-in-law made for a nieces birthday the day after the interview, and that she had pledged not to eat because she knew it would make her sick. After getting quite sick from eating cake at a previous celebration of her moms birthday even though it had made her sick before, her perspective on food and eating had changed. She had become ill and considered why does it make me feel so horrible? which she had never thought [about before the surgery since] nothing ever made me sick, but now, I actually stop and think, what is in that? Participant 6 said that her husbands family helps accommodate her eating needs since surgery by asking can you eat this? but that then you go to a picnic when theyre having hotdogsHelp!
Medical Settings
Participants discussed situations where medical experts provided unwanted foods after surgery. Participant 1 discussed situations in the hospital after surgery where she actively questioned unwanted food options at meal times. The medical staff would get upset with me because I wouldnt eat, [but] they were giving me yogurt. Twenty-five grams of sugar in the yogurt. Whats wrong with that picture? She became wary of other foods provided in the hospital, for instance mak[ing] sure the Jello is covered and says diet on it, cause they liable to switch and give you the sugar one. Another time, Participant 1 was served chicken breast alone on a plate and then tried to convince the dietitian that she was able eat other foods such as raw vegetables. There was also always milk on her meal trays despite having told the medical staff she couldnt drink milk due to lactose intolerance.
Participant 3 said some doctors and dietitians would just go to Wal-Martor CVS cause its closest to find food products to recommend to patients after surgery. These experts would pick up whatever they got becausethey just dont know.
Workplace
Participants described situations when the eating behaviors of colleagues affected their thoughts about food and eating. Participant 1 used to eat garbage everyday at work for lunch, which included huge servings, fried foods and sodas. After surgery, her colleagues at work still ate these foods and she found it frustrating to be unable to partake in these eating behaviors.
Participant 10 participates in casual food competitions with her family and her colleagues. She and her colleagues feel obligated to feed each other. They are all good cooks, and they share unhealthy foods that are always carb-loaded, sugar-loaded, you know, just bad as a way of communicatingthats our social thing especially for occasions such as birthdays.
Eating Circumstances
Spouses, relatives and general social sources provided participants with specific circumstances for eating that affected or could affect their food choices and eating behaviors in particular contexts.
Domestic Dining
Participant 6s husband became so frustrated with his wifes look of pain and horror [when she] got something stuck while trying to keep up with him during meals at home that he leaves the table and sits at the computer when he is done eating, where they can see each other but I dont feel the pressure to keep up with him. Participant 6 recalled this transition to describe how other people do become involved innot necessarily the surgery, but how you manage the surgery and your bodys requirements and your bodys limitations.
Social Temptations
Participants described temptations perceived to be facilitated by specific social circumstances involving eating. Participant 6 said social situations in general [are] a bad influence on me because she becomes tempted to eat what everybody else is eating. As a preventative strategy before social situations involving food, Participant 6 drinks a protein shake before leaving home to feel full during the social event.
Participant 10 said that in interactions with family, friends and colleagues, everything revolves around food. She feels helpless to control her eating behaviors when others persistently discuss and provide food and eating opportunities.
Participant 10 also recalled both good and bad support group members. While the successful members encouraged disciplined behavior, unsuccessful members would say Eeehh, dont worry about it, lets just go have junk food or whatever. By providing opportunities for temptation such as unhealthy foods during meetings and permissive comments about eating them, Participant 10 believes support groups can easily bring you down. She recalled support group meetings where every timethere was like unhealthy stuff. As a result, she stopped attending support group meetings to remain away from temptation although she had found encouragement from successful support group members.
Task Alleviation
Participants recalled situations when others, especially relatives, friends and spouses, helped them by performing tasks the participants would normally have done themselves. Tasks included cooking, grocery shopping, cleaning the house and taking care of children. While sources often helped alleviate these tasks to aid participants during post-surgical recovery, some participants also wished othersespecially spouseswould contribute more to daily and domestic chores.
Social Reinforcements
Participants discussed how social sources could act as fortifications for transitions after gastric bypass surgery, explaining how the sheer availability or existence of others could be emotionally or strategically supportive or unsupportive. These social reinforcements were described as sources of encouragement or a lack of encouragement, and as tools that helped participants stay honest, stay in check, stay disciplined and keep on the straight and narrow. Some sources were also perceived as failed tools that could easily bring you down.
Encouragement
Participants described relatives and friends (especially those who had undergone gastric bypass surgery), support group members, doctors and therapists as sources of encouragement, or expressions of caring, compassion or understanding. Support groups were perceived as empathy sources. Many participants also described the lack of encouragement offered by spouses.
Close-Personals
Participants felt that close-personal social ties offered encouragement to support their decisions and well-being. Participant 3 perceived encouragement from her sister, who underwent gastric bypass surgery after the participant, and felt her sister was also encouraged by her. Her sister was there and I was there for her, was behind her all the wayshe was support for me.
Two days after her surgery, Participant 6 questioned her decision to have bariatric surgery, crying and telling her mother I cant believe I just did this to myself. Her mother calmed her down, saying Honey its fine. Youre just on medication and once you heal, youll be okay, its not going to be that bad. Her mother also reported feeling so bad eating in front of [her daughter], but Participant 6 assured her she had no desire to eat anyway.
Participant 7s parents were sources of total support, though at first they counseled the participant against having the surgery; eventually, her father grew to be all for ithe wanted me to be healthy, to get back to work, to have a life. My dad is very proud of me. Hes my best friend. Participant 7s daughter worries that her mother is frail, expressing fears that shed crush the participant. Participant 7 laughed at this notion, saying Im probably the toughest woman shell ever meet!
Participant 9s brother has been a constant source of sympathy, though before her surgery he was just worriednot supportive at all and discouraged both her and her sister from having the surgery. However, since witnessing all the benefitsmy health is so much better, I feel better about myself, all the positives that come from it, her brother has become very supportive. Participant 9s sister traveled to take care of me for a week after the participants surgery, helping her with shopping and other needs. Her sister was probably my biggest supporter and the experience likely helped her sister prepare for what she was going to be going through with her own upcoming surgery.
Support Groups
Participants felt support group members were able to empathize with their experiences. Participant 3 felt you have to rely onthe other weight loss peoplebecause nobody else really understands or is in it with ya. She felt other gastrics could understand what its likethey know the same things while her family members could not understand the emotional struggles related to wanting to eat or not wanting to eat, or that food is driving you crazy at the timeor somebody is pushing food at you and you dont want itall the different things of dieting pressures.
Participant 9 said that people who have been through [the surgery] know all the struggles youve been through, theyve see where you were, and because theyve been through it themselves, they can really appreciate, and be supportive. She feels that others simply offer sweeping eating instructions, as they did when she was overweight, since they havent been through it. For Participant 9, it was really helpful to have somebody that had been through it and they could sympathize.
Experts
Some participants recalled encouragement from medical personnel. Participant 3 described her therapist as an outlet that helped her alleviate emotional eating after surgery, saying you get into therapy and you never leave there either! Participant 6 felt her surgeon genuinely cared, asking her How are you doing? and always willing to answer any questions. The surgeons nurse practitioner, interns and secretary were all so nice so wonderful and so fantastic that she felt compelled to succeed after surgery so as not to let them down.
Lack of Encouragement - Spouses
Participant 1 felt her husband offered no support and had no clue what her surgery or post-surgical transitions entailed, despite the risks and drastic change inherent to the procedure. She thinks he should be main support, but instead considers her new eating strategies ridiculous and so the participant must do all of this on my own. Participant 3 says she never receives compliments from her husband, who gained weight since her surgery and is now too chicken to undergo bariatric surgery.
Social Tools Staying on the Straight and Narrow
Many participants described gastric bypass surgery as a tool; they also described other people as instruments to help keep them steady throughout post-surgical transitions. These social tools most often described functions of other gastrics, but relatives and general others also helped participants stay on track as they struggled with changes in body, health and eating after surgery.
Participant 1 called the surgery just a tool, while what goes on in your head is another story. Thats why we have the friends here [at support group]. She believes the support group is supposed tokeep you on the straight and narrow and that you have your nutritionist, you have your counselor, emotional counseling, you have your exercise, and you should have your support groups. If you have those I dont think Id be where I am today if I didnt have those.
Participant 3 said to counter an addiction to food you reallyneed the support. She worried that in the future she might regain weight if I dont stay on track and I dont use these tools that are given to meIf I dont follow the rules, if I dont stay in checktalk to people, stay with my groups. To her, gastrics have the potential to help each other with the hard part being disciplined.
Participant 6 said her support group is what keeps me honest by having to physically present myself to them. She believes the process is internal, rather than influenced by the specific words or actions others. Since other gastrics can relate to her experiences, she feels she must represent my surgeonthe surgerymyself and wants to give somebody else hope by exemplifying success. She does not want to let the support group down, and said that some members who regained weight felt ashamed in front of their gastric peers and stopped attending group.
Participant 6 also said her father, brothers and best friend have kept me honest with myself by reminding her to remain the same person she was before weight loss, since this surgery was not to change who I was.
Participant 7 also thinks the support group keeps me honest by helping restrict her behaviors to those she feels comfortable reporting to other members, so as not to feel like a hypocrite. She feels that without having [my]self surrounded by people that are going through the same issues and then being on the support groups onlineI could lose my path pretty easily. In contrast, she said her friends, family and colleagues revolve around food when socializing, which encourages poor eating habits.
CHAPTER 5 - Discussion
This study aimed to identify and understand how gastric bypass patients interpret and use social resources in the period following surgery. This study focused on describing participants active management of social interactions as recalled in their descriptions of food and eating management more than two years after their surgeries.
1. Critique of Methods
Approach and Data Collection
The constructivist approach employed in this qualitative study allowed concepts and themes related to social support to reflect participants views. Through the two in-depth interviews, participants provided extensive detail about their experiences, goals, and feelings regarding life after surgery. Participants reported a wide array of social interactions and interpretations of these interactions, allowing the researcher to identify and compare many varied functions of social interactions for the management of personal transitions accompanying dietary change after gastric bypass surgery.
Interview questions encouraged open discussion about personal changes in health, body, food choice and eating, but were limited in questions related to social interactions. In response to the question How do others influence the changes you have made, participants often claimed independence from social influence, indicating the potential personal effects of social interactions separate from those explicitly acknowledged. Participants may explain the utility of conjuring past social interactions to describe personal transitions differently than was described in this study. Also, participants have experienced many more social situations since surgery than those relayed in interviews and described in this study.
During interviews, participants interacted with the interviewer as she asked them questions, summarized their responses for clarification and offered brief words of understanding. A limitation of the data is that participants likely reported only selected social interactions that were memorable to them in the context of the interview. Their reports were also influenced by the social context of the interview and their perceptions of the interviewers demeanor, appearance, and interactions. Their descriptions of social interactions were shaped by their memory, mood, and the context of the interview. Another limitation of the study may be that the researcher did not participate in the interviews; however, throughout analysis the researcher was able to check her interpretations with the interviewer, who was the principal investigator and data collector.
Sample
This study used a small sample of six women recruited from two support groups in Upstate New York, and the results cannot be generalized beyond this particular group of participants. In addition to being similar in many sociodemographic characteristics, these women all were or had been members of support groups, suggesting that they found social resources provided during group sessions at least somewhat useful. By volunteering to participate in the study, they demonstrated confidence and comfort in talking about their experiences with a stranger. The level and nature of social interactions described by these patients as well as their interpretations of social interactions may be different from those among the general population of gastric bypass patients.
Analysis
The results gleaned from this analysis represent only one analysts perspective. Though the analysis was reviewed by other researchers, participants reports of social interactions could be analyzed and interpreted differently. While this researcher aimed to summarize and qualify the data according to participants explicit descriptions and explanations, certain word choices offered in this studys results and conclusions likely deviate from participants exact intended meanings.
Another issue with analysis was that social situations could not be arranged in the order in which they occurred, so social resource management could not be studied as a learning process through which participants applied perceptions from one situation to interactions and perceptions in subsequent situations. Though timeline analysis was not the aim of this study, the data indicates that the perspectives, behaviors, and physical states of participants and social sources changed over time and it is likely that approaches to social resource management also changed progressively for each individual.
Participants in this study described social situations to illustrate answers to questions about personal food choices and eating behaviors through exemplary instances of the past. This does not indicate that social factors determined the personal outcomes recalled by individuals, but that individuals considered them pertinent in descriptions of their own behavior.
II. Major Findings
This study offers a unique perspective on the utility of social relationships and interactions after gastric bypass surgery. The researcher viewed anecdotes of social interactions as discrete situations in which the participant constructed the source, resource, and judgment of the resource. By coding each anecdote for these components, the situations could be characterized and compared. Not only was this analytical approach helpful for organization of the data, it also suggests that the participants conceptualized recalled social interactions in this way. This might imply that people undergoing goal-oriented personal change process social interactions as resources to manage along with technical and other resources, or that they frame social interactions as resources when considering them in retrospect.
Social Support & Social Resources
The four types of social support identified in the literature (Cutrona & Russel, 1990; Tilden & Weinert, 1987; Langford et al., 1997; House, 1981; Heaney & Israel, 1997; Moss, 1973; Langford et al., 1997) were represented in this studys results. Emotional support, providing trust, caring, love, and feelings of acceptance, is represented most by the perceived encouragement provided by social sources. Instrumental support, providing tangible needed services, is represented most by perceived task alleviation and food availability of social facilitations. Informational support, providing recommendations, guidance and information that can be useful for problem-solving, is represented most by social prescriptions. Appraisal support, providing constructive information used for self-assessment, is represented most by social appraisals. However, the literature largely ignores social examples, which were commonly reported by participants in this study as they described their experiences.
By replacing social support, the extension of caring, tangible services, helpful information and constructive feedback for the intended benefit of an individual in need (Cutrona & Russel, 1990; House, 1981; Heaney & Israel, 1997; Tilden & Weinert, 1987; Langford et al., 1997), with social resources, this study emphasized the active role of gastric bypass surgery patients in a systematized, dynamic self-regulation of social stimuli, personal strategies and behaviors toward weight loss and other post-surgical goals. Participants made use of the perceived recommendations, visible appearances, behaviors, judgments, eating events, and sympathy of others.
The concept of actively constructed social resources differs from the literatures perspective (Langford, Bowsher, Maloney & Lillis, 1997; Finfgeld-Connett, 2005; House 1981, Langford et al. 1997; Israel 1982), which describes individuals perceptions of extended support that may or may not reflect the intended consequences of sources. Intended support perceived as unhelpful has been called negative social support (Heaney & Israel, 1997), or an unintended support failure (Helgeson, 2003); however, knowing both the intentions of a support giver and a recipients judgment of given resources would be a difficult research task. Instead, this study distinguished resources constructed by participants, regardless of a sources intentions. While using gastric bypass surgery as a technical tool for changes in lifestyle and eating behaviors, participants also constructed meanings and uses for the actions, words, appearances and existence of other people to help them make independent food and eating decisions.
Participants in this study rarely mentioned social reciprocity or the exchange of resources, which the literature presents as central to social support (House 1981, Tilden & Weinert 1987; Cohen & Syme 1985; Shumaker & Bronwell 1984; Langford et al. 1997; Israel 1982; Heaney & Israel, 1997). While intended support could require past, expected, or eventual resource return by the recipient, social resource management for personal transitions after gastric bypass surgery exists independent of requisite resource return. Participants sometimes mentioned the potential reciprocal benefits of social interactions, such as when a sister planning to have surgery observed a participants surgical outcomes, but the data focused on participants personal outcomes rather than those of sources.
Social support can be defined as an exchange of social resources (Cohen & Syme, 1985; Thoits, 1985), and the terms have been used interchangeably in many studies (Cohen, Gottlieb & Underwood, 2000). Cohen & Wills (1985) measured social support as the perceived availability of social resources suitable to needs created by a stressful event, finding consistent evidence for the role of social support in reducing psychological detriments of stress. This study supports the claim that perceived social resources serve a functional role in psychological outcomes after gastric bypass surgery, but unlike in the Stress-Buffering model (Cutrona & Russel, 1990) finds that participants used resources to assist personal transitions rather than to protect them from stress as they adjusted after surgery. Social resources may have been suitable to participants ongoing needs, but stress did not emerge as a necessary situation component. However, it is possible that participants would not have recalled social interactions in descriptions of their food choice and eating behavior management had they not been experiencing stress during situations for which social resources met specific needs.
This analysis emphasized the role of judgment in active management of social resources. Participants recalled both sought and encountered social resources, often judging recommendations, others appearances, appraisals, social circumstances, caring, and general social integration against psychosocial standards, such as personal values and goals, while claiming these resources had no influence on personal decisions and behaviors. Social resources emerged to be useful tools in the management of food and eating transitions not only due to perceived need for their potential effects, but also due to judgments of interactions with, observations of and presumptions about other people that factored into perceptions, decisions, strategies and behaviors throughout post-surgical dietary change.
III. Implications for Practice and Research
Leading up to and after surgery, patients in this study formed adaptable social resource networks to further their weight loss goals. Active management of the words, actions, and appearances of other people acted as a tool to supplement patients surgeries. Members of the medical industry comprised only a modest portion of the social resources positively integrated into the strategies and behaviors of patients, often seeming to inhibit their success and necessitate the construction of independent, opposing tactics.
Social networks were reported to improve health and quality of life in patients by assisting participants decisions to make active changes in everyday food choice and eating behaviors. The medical system required surgical candidates to attend psychological and physical evaluations with professionals. Doctors, surgeons and nurses provided hospital attention. Dieticians met with patients in and out of the hospital. Support groups provided patients with regular feedback and friendships. Close-personal relationships assisted patients with aspects of dietary change and weight loss in a variety of settings. Spouses participated frequently in patients daily eating situations.
Despite the obvious role of medical personnel and other social sources in dietary change and related health outcomes elucidated in this study, the contemporary medical system does not focus on social resources as major functional components of biomedical interventions for weight loss. Surgeons emphasize directional information and tangible, technical devices and procedures, leaving psychological and nutritional support to other specialists. If both integration in and functional assistance from social networks of experts, close-personal relationships, and concepts of general others compared to the self have the potential to support patients in meeting health care and personal goals after gastric bypass surgery, then the medical industry might improve efficacy of biomedical weight loss systems by creating ways to center individual patients within a collaborative social resource system.
The results of this study could be applied to future clinical social intervention studies. For instance, since some doctors were reported to be misinformed about the utility of protein and other dietary strategies for positive surgical outcomes, additional interviews might survey for the extent of this and other issues in populations of bariatric surgery patients. An educational campaign could update a network of patients, medical providers, and support group leaders on the current medical and credible internet literature related to post-surgical dietary needs and strategies, offering a shared understanding of evidence-based guidelines. Periodic discussion sessions between network members might encourage greater understanding among surgeons of long-term psychological, social, and physical impacts of surgery. The observed and recorded content of such discussions could also be applied to future medical and social science research. Family members and friends could be included in campaigns and discussions, and the curriculum might include ways to involve non-medical social ties in promoting healthy eating behaviors at home, in the workplace, in restaurants, and at special events. Surgical patients could be interviewed before surgery, during recovery and over two years after surgery, and qualitative results could be compared to those of this study. Participants in such a study might discuss less reliance on independent research and the examples and suggestions of other gastrics, since experts would presumably offer them more complete, holistic bariatric surgical care. However, patients might also discuss less sustainable food choice and eating behavior management, since there could be less necessity to seek out non-medical assistance with transitions.
The Functional Social Resource Management model could be applied to future qualitative research on gastric bypass surgery patients, other medical patients, and other groups of people who have managed personal behavioral transitions toward a common general goal. By conducting open-ended retrospective interviews centered on questions of personal change in these populations, researchers could code the data according to sources, social resources, and judgment as situational systems to elucidate specific impacts of social interactions on individuals decisions, feelings, behaviors, and health outcomes. Using the Functional Social Resource Management model, personal strategies, behaviors and outcomes could also likely be differentiated, linked to specific social resources and compared in any population defined by personal transitions toward a common goal. A future study might expand on this one by analyzing relationships among sources, social resources, judgments of resources, and participants perceived psychological, social and physical transitions.
Future research could analyze functional outcomes of social resources recognized in this study, work that was beyond what could be accomplished in this project. Participants seemed to use social resources to reinforce changing identities, maintain discipline, and practice degrees of independence or compliance. Participants seemed to bolster concepts of self or identity by comparing their bodies and eating strategies to the perceived intentions, appearances, degrees of success, and knowledge of specific and general others. Social examples, providing visible points of comparison, provided an obvious means to distinguish oneself from others and relate oneself to demonstrations of desirable outcomes. Participants seemed acutely aware of their visibility, perceiving judgment by others who could see their bodies and behaviors. Participants felt compelled to be honest with themselves because their progress would be visible and reported to others. Many participants also recalled unwanted food availability situations as temptations that were avoided by asserting disciplined eating strategies. Participants did not blindly accept expert advice, often supplementing its shortcomings by constructing independent eating strategies. When describing others influence on their food choices and eating behaviors, most participants believed their decisions and behaviors were produced independently or internally.
The Functional Social Resource Management model may be useful for both intra- and inter-population comparisons. While this study describes common social resource management themes for six gastric bypass surgery patients in Upstate New York, it is possible that specific regional differences and similarities might be clarified if the same model were applied to gastric bypass surgery patients in a different town, a metropolis or a different country. This could also apply between age groups, genders, income levels, and many other population characteristics. If the Functional Social Resource Management model were applied to interview transcripts from other types of medical patients undergoing similar transitions and reaching for the same general outcomes, researchers might be able to compare differences in how specific sources or social resources impact one population compared to another. This comparative technique might allow for adjustments in medical service allocation, both within and between specific underserved medical patient populations.
Conclusion
Gastric bypass surgery is a technical component in a complex system of interacting sociocultural, physical and psychological factors. Morbidly obese individuals who decide to have surgery also make active decisions regarding food choices and other behaviors that affect their weight loss and health outcomes. As this study illustrates, patients actively manage the words, actions and appearances of people in their social networks as they work toward personal goals. Social resources can be both helpful and harmful to achieving post-surgical goals, and patients in this study judged their utility against individual values to integrate explicit aspects of prescriptions, examples, appraisals, facilitations and encouragement into strategies, choices and behaviors amounting to personalized degrees of surgical outcome success. While researchers and practitioners of bariatric surgery and other medical care acknowledge many roles of patient psychology in physical outcomes, this study warrants more medical attention to social networks as tools for patients as they accomplish and grapple with major changes in their bodies and everyday lives.
APPENDIX A
Experiences of Change after Gastric Bypass Surgery
Have you had gastric bypass surgery?
Are you interested in telling your story?
If you are over the age of 18 and if it has been at least one year since your surgery, you may be eligible to participate in a study about gastric bypass surgery.
This study is being done by a graduate student in the College of Human Ecology at Cornell University. It will examine the ways in which gastric bypass surgery has affected your eating behaviors, your weight, your health, and your life. It involves nothing but your time and your willingness to tell your story in two private, confidential interviews. For participating in the study, you will receive a compensation of twenty dollars. All aspects of the research have been reviewed and approved by Cornells Institutional Review Board Committee on Human Subjects.
If you would like to learn more about this study, or would like to sign up to participate please contact:
Amanda Lynch
HYPERLINK "mailto:ail7@cornell.edu"ail7@cornell.edu
607-351-9572
APPENDIX B
Experiences of Change after Gastric Bypass
Consent Form
You are invited to participate in a research study of the experiences of people who have had gastric bypass surgery. You were selected as a possible participant from your involvement with a gastric bypass support group, and you expressed interest in this study. I ask that you read this form and ask any questions you may have before agreeing to be in the study.
Background Information: The purpose of this study is to explore the experiences of people who have had gastric bypass. The goal is to better understand the experience of change after surgery, especially changes in food and eating, weight, and quality of life.
Procedures: If you agree to be in this study, you will be asked to participate in two interviews. The interviews will include questions about your past and present food choices and eating behaviors, your weight before and after surgery, and changes in your life since gastric bypass surgery. I am only interested in your experiences. There are no right or wrong answers.
Each interview will last about one hour, or for as long as your feel comfortable talking. Each interview will be audio tape recorded and transcribed. Your name will not be associated with the tape or with the interview transcripts.
Risks and Benefits of Being in the Study:
There are no anticipated risks for you participating in this study, other than those encountered in day-to-day life.
There are no direct benefits to participating in this study. Indirect benefits to participation are to add to current knowledge about the experiences of gastric bypass patients, with the hope that it can improve patient care before and after gastric bypass surgery.
Compensation:
To compensate you for your participation, you will receive twenty dollars, at the conclusion of the second interview.
Voluntary Nature of Participation:
Your decision whether or not to participate will not affect your current or future relations with Cornell University. If you decide to participate, you are free to withdraw at any time without affecting those relationships. You may refuse to answer any questions at any time during an interview; this will not affect your ability to receive compensation.
Confidentiality:
The records of this study will be kept private and confidential. In any sort of report I might publish, I will not include any information that will make it possible to identify you or anyone else mentioned during the course of the interview. Research records will be kept in a locked file. Interview audio tapes will be kept in a secure and locked box. The tapes will be labeled with a number which refers to the interview. Only the researcher will have access to the records and tapes.
Contacts and Questions:
The researcher conducting this study is Amanda Lynch .Please ask any questions you have now. If you have questions later, you may contact her by e-mail: HYPERLINK "mailto:ail7@cornell.edu"ail7@cornell.edu or by phone: 607-351-9572. If you have any questions or concerns regarding your rights as a subject in this study, you may contact the University Committee on Human Subjects (UCHS) at 607-255-5138, or access their website at http://www.osp.cornell.edu/Compliance/UCHS/homepageUCHS.htm.
You will be given a copy of this form to keep for your records.
Statement of Consent: I have read the above information, and have received answers to any questions I asked. I consent to participate in the study.
Signature ___________________________________
Date ________________________
Please sign below if you are willing to have this interview recorded on audio tape.
I am willing to have this interview recorded on tape:
Signed: ____________________________________
Date:________________________
This consent form will be kept by the researcher for at least three years beyond the end of the study and was approved by the UCHS on June 2, 2006. APPENDIX C
FIRST INTERVIEW
Date: Time: Location:
ID#
First we will be talking about your current and previous experiences with food and eating.
Take me through a typical day of eating for you.
Tell me about your experiences with hunger.
How do you know when you are hungry? Example..
How do you deal with hunger? Example
Tell me about your experiences with being full.
How do you know when you are full?Example..
How do you deal with fullness? Example
What have your experiences been taking nutrition supplements?
Protein, Vitamin/Mineral, Herbal, Other (as they define them)
What supplements are you taking now?
How is that working for you?
What type of eater would you describe yourself as? (What type of an eater are you?)
What is easy about eating?
When and where does this happen?
What is difficult about eating?
When and where does this happen?
Are there any foods you cant eat? Tell me about them.
What are the most important things in choosing what to eat? What are the least important?
How have these factors changed since surgery?
How do others influence your food choices?
Tell me about a time when this happened.
How do others influence your eating behaviors?
Tell me about a time when this happened.
How do you view/approach food and eating?
In what ways has this view/approach changed since surgery?
Tell me why you think you view food and eating in this way.
How do you manage food and eating?
At home?
At work?
In social situations?
What is positive? What is negative?
Going back to the typical day we talked about before. How is this different from a typical day of eating prior to gastric bypass surgery?
Why do you think these changes have occurred?
Tell me more about..
How would you describe yourself as an eater before gastric bypass surgery?
How have your food choices changed?
Give me an example of something you used to do but do not do any more.
Give me an example of something you do now, that you never used to do.
Why do you think your food choices changed?
How have your meals and snacks changed?
Patterns?
Size?
How have your eating and drinking habits changed?
Can you give me some examples?
What are the things you usually do? What are the things you avoid doing?
If not volunteered, probe for:, chewing, drinking, etc.
How did you come to make changes in food and eating? (What was the process of changing what and how you eat?)
Why do you think your eating habits changed?
What has been easiest to change in regards to food and eating?
Can you give me an example?
What has been hardest to change in regards to food and eating?
Can you give me an example?
How do you feel about the changes you have made?
Is there anything else, in regards to food and eating you might change?
How do others help the changes you have made?
Can give me an example?
How do others hinder the changes you have made?
Can you give me an example?
How would you describe your relationship to food now?
How is that different from before surgery?
How do you feel about it?
Do you have any other comments or thoughts related to food and eating before or after gastric bypass surgery, that we havent covered so far?
Thank you very much for your time!
SECOND INTERVIEW
Date: Time: Location:
ID#
In this interview we are going to discuss your experiences with weight and with gastric bypass surgery. First , I would like to talk about your weight and dieting history.
Tell me about your weight and growth experiences in childhood and adolescence.
What was your perception of your weight as a child? Adolescent? Adult?
When were you first aware of your weight?
When did you feel that your weight became an issue?
What did you do, once you were aware of this?
Why do you think you had a problem (or issue?) with weight?
Tell me about your experiences with dieting for weight loss.
What types of diets have you tried in the past? Give me an example.
What was the experience like?
Why do you think these approaches didnt work for you?
Surgery History:
Tell me about your experience of gastric bypass surgery.
Can you give me examples of a positive experience? Negatives?
Who were your sources of support after surgery?
Tell me about your decision to have surgery:
(At the end of their answer.)
What type of surgery?
When: Where:
Describe your diet progression AFTER surgery, as best you can recall:
How was this progression for you?
How did you learn about what to eat after surgery?
What sources of information did you use?
Tell me about your weight loss after surgery.
How was that experience for you? How did you feel? How did others react?
How do you feel about your current weight?
Why do you think you have lost weight since surgery?
Do you have any strategies for weight loss (or weight maintenance)? Tell me about them.
How did you form these strategies.
Can you give me a specific example of when you would use a particular strategy?
How has your health changed since surgery?
Why do you think your health has changed?
How has your life changed since surgery?
Positives?
Negatives?
How do you feel about your decision to have surgery?
If you were to give someone who was thinking about having gastric bypass some advice, what would you tell them?
Is there anything else youd like to share with me about your experience with gastric bypass surgery?
Thank you very much for your time!
APPENDIX D
SELECTED DEMONGRAPHIC INFORMATION
Participant #: __________
Are you: ( Male ( Female
What is your age: ________ years
Are you currently:
( Working at a job or business full time
( Working at a job or business part-time
( Retired
( Student
( Not working/ Unemployed
( Other _____________________
If employed:
What is your current occupation?: __________________________________
What are your prior occupations?:
___________________________________
___________________________________
___________________________________
What is the highest level of education you completed?
( No schooling completed
( Nursery school to 6th Grade
( 7th or 8th Grade
( 9th to 11th Grade
( 12th Grade No Diploma
( High School Graduate High School diploma or Equivalent (Ex. GED)
( Some college credit, less than one year
( 1 or more years of college no degree
( Associate Degree
( Bachelors Degree
( Graduate/Professional Degree
What is your marital status?
( Never Married
( Married
( Married and separated
( Divorced
( Widowed
What is your current living arrangement?
( Live alone
( Live with spouse/partner
( Live with roommate/unrelated adult
( Live with relatives (not spouse/partner)
How may other adults over age 18 live in you household? ________________
How many children live in your household who are:
Less than 2 years old? ___________
2-5 years old? ___________
6-12 years old? ___________
13-18 years old? ___________
What is your Race/Ethnicity (check all that apply):
( White
( Black, African American, or Negro
( Spanish, Hispanic, or Latino
( American Indian or Alaska Native (Print name of enrolled or principle tribe) ___________________________
( Japanese
( Korean
( Vietnamese
( Native Hawaiian
( Guamanian or Chamorro
( Samoan
( Other Pacific Islander
( Asian Indian
( Chinese
( Filipino
( Other (print race) _______________
Selected Other Information
How much do you currently weigh? _____ pounds
a. What is your lowest weight, since reaching adulthood? ________pounds
b. What is your heaviest weight, since reaching adulthood? ________pounds
What is your current height? ____ ft ____ in
Place an X next to the category that best fits your current smoking status.
_____ current smoker
_____ nonsmoker (never smoked)
_____ nonsmoker (former smoker)
Place an X next to the category of your total household income.
_____ Less than $10,000
_____ $10,000 to $19,000
_____ $20,000 to $29,000
_____ $30,000 to $39,000
_____ $40,000 to $49,000
_____ $50,000 to $59,000
_____ $60,000 to $69,000
_____ More than $70,000
APPENDIX E
First Emergent Analytical Model The Eating Self
APPENDIX F
Second Emergent Analytical Model
Functional Social Resource Management Model
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While other participants also described perceived attempts to hinder their disciplined eating strategies, these were framed more as unwanted food availability [see below] than as purposefully unhelpful behavioral prescriptions as defined by this study.
While this is the opinion of the participant, principal investigator Amanda Lynch believes that patients normally have either one or the other surgery, not both.
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PAGE 1
Table 1: SELECTED PARTICIPANT CHARACTERISTICS
Retrospective Recall
TIME
TIME
Table 2:
FUNCTIONAL SOCIAL RESOURCE MANAGEMENT
SITUATION
Event of Surgery
RESOURCE
Personal Transitions
Weight Loss & Weight Maintenance Goals
EXTERNAL
Eating
Strategy
PHSYIO
Body
Health
Internal Health and Body
EATING
SCHEMA
Values
Goals
INTERNAL
Perception
RE-SOURCE
Judgment
Eating
Strategies
Situational
Routinized
EATING
BEHAVIOR
EXTERNAL
EXTERNAL
SOURCE
SITUATION
JUDGMENT OF RESOURCE
Eating
Strategy
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