The proportion of obese individuals in Korea has gradually increased. Over the past 11 years (2009–2019), the prevalence of obesity has increased continuously. In particular, the prevalence of class III obesity (body mass index [BMI] of ≥35 kg/m²) has increased in the total population by nearly threefold over the past 11 years, from 0.30% in 2009 to 0.89% in 2019.¹ Since obesity increases the risk of other comorbidities, such as type 2 diabetes mellitus and cardiovascular disease, an increase in obesity in the population may increase the incidence of various metabolic diseases in Korean society.^2-4 Because individuals and/or societies have assumed the cost of treating and managing obesity,⁵ efforts to recognize obesity as a disease and implement early treatment are increasing.

Lifestyle modifications, such as nutritional therapy, physical activity, and behavioral changes, should be used as first-line treatments for obesity. Pharmacotherapy should be considered if sufficient weight loss is not achieved.^6,7 However, among obese patients with a BMI ≥35 kg/m² or both a BMI ≥30 kg/m² and obesity-related diseases who do not achieve the target weight loss of (≥5%) despite non-surgical treatment, bariatric surgery can be considered.

In January 2019, the National Health Insurance plan in Korea began covering bariatric surgery for the treatment of severely obese patients with a BMI ≥35 kg/m² or both a BMI ≥30 kg/m² and obesity-related comorbidities. After the introduction of such insurance benefits in Korea, interest in bariatric surgery increased.^8-10 However, the proportion of patients undergoing bariatric surgery remains relatively low compared to the increasing proportion of obese patients in Korea. Therefore, the causes of this discrepancy need to be analyzed.

Recently, an international study compared the perceptions of obesity between patients with obesity (PwOs) and healthcare professionals (HCPs). The study revealed gaps between the perception of PwOs and HCPs regarding obesity and treatment.¹¹ According to studies that separately analyzed only Korean patients,¹² the initial methods recommended for weight control are nutritional therapy (65%) and physical activity (51%), whereas bariatric surgery made up a small percentage of other treatment recommendations (PwOs 1%; HCPs 11%). Nonetheless, both groups agreed that bariatric surgery is an effective long-term treatment method, with agreement being more frequently reported by PwOs than HCPs (PwOs 59%; HCPs 23%); however, this was the only mention of bariatric surgery in this paper, and data regarding Korean perspectives on bariatric surgery were lacking.

Numerous qualitative papers have analyzed the perspective of patients who underwent bariatric surgery. A paper published by Sharman et al.¹³ discussed the importance of nutritional and psychiatric counseling for patients undergoing bariatric surgery and of relationships with support groups (peers, family and friends, and the general community). The Coulman et al.¹⁴ studied how patients who underwent bariatric surgery adapted after surgery. Breuing et al.¹⁵ identified unmet information needs between patients and medical staff and how to address them. Although these studies have assessed the quality of life of bariatric surgery patients and information asymmetry between patients and healthcare professionals, information regarding how these patients became aware of bariatric surgery and why they chose to undergo the procedure is lacking.

Therefore, in this study, we focused on various perspectives, such as the way patients encountering surgery and satisfaction with information for patients undergoing bariatric and metabolic surgery at a tertiary hospital in Korea.

Study population

A telephone interview was conducted among patients who underwent bariatric surgery at Asan Medical Center between August 2020 and February 2022, focusing on patients who were 6 months post-surgery. To prevent recall bias, only patients who underwent surgery within 2 years from the time of investigation were included, as was the case in another study.¹⁴ A total of 33 patients underwent bariatric surgery during this period, and 21 of them agreed to an interview.

At the beginning of the telephone call, the research objectives were explained to the patients and their agreement to participate was confirmed. The patients were asked various questions within two categories using an open-ended approach. The first category focused on understanding the background behind their decision to undergo bariatric surgery, and the other category was related to the information provided to the patients about their operation. Questions addressing details that could be obtained through chart review, such as the type of operation, insurance coverage, and duration since the surgery, were not included in the interview (Appendix 1).

This study was reviewed and approved by the Institutional Review Board of Asan Medical Center (2023-0202). Informed consent was waived by the board.

Perioperative management

Patients eligible for bariatric surgery were selected based on their history and physical examination. Various tests were performed for the preoperative risk evaluation. Gastroscopy and abdominopelvic computed tomography were performed to identify secondary obesity and check for gastric cancer and Helicobacter pylori infection, both of which are highly prevalent in Korea. Obese patients with sleep apnea may have higher postoperative complications; therefore, a neurologist was consulted, and positive-pressure therapy was implemented if necessary. Patients diagnosed with psychiatric diseases such as depression, bulimia nervosa or at high risk of these conditions were examined by a psychiatrist before the surgery to determine if they required treatment for any mental illness. Patients undergoing surgery received nutritional assessments and counseling from registered dietitians several times before and after the surgery.

Postoperative treatment was performed according to the clinical pathway to improve the quality of treatment. The patients received a low-calorie liquid diet on postoperative day 2 (POD2). After the surgery, an upper gastrointestinal series was performed to check for complications, such as leakage or stenosis at the surgical site.

The risk of pulmonary embolism or deep vein thrombosis is increased in obese patients.^16,17 Clinical guidelines recommend the prophylactic use of sequential compression devices, subcutaneously administered unfractionated heparin or low-molecular-weight heparin for these patients.¹⁸ Subcutaneous fractionated heparin was administered to our study patients on POD1−3, except for those were considered prone to bleeding.

After discharge from the hospital, the patients had follow-up visits to the outpatient clinic at 2 weeks, 1 month, 3 months, 6 months, 9 months, and 12 months after surgery, and at 6-month intervals thereafter. Postoperative weight changes were monitored in an outpatient setting, and laboratory tests were performed during the visits to check for any alterations. At every visit, necessary supplements, such as iron, calcium, and vitamins, were prescribed.

Patient characteristics

Of the 33 patients who underwent bariatric surgery at Asan Medical Center during the study period, 21 responded to the telephone interview (Table 1). Of the 21 participants, 19 were females, and the mean age was 40.14 years (range, 25 to 59). The mean BMI at the time of surgery was 41.17 kg/m² (range, 31.55 to 56.17). At the time of the interview, the average BMI was 30.79 kg/m² (range, 21.33 to 49.09). The average percent total weight loss was 25% and percent excess weight loss (%EWL) was 73%. Several patients suffered from one or more comorbidities at the time of surgery, of which hypertension was the most common, being present in 10 patients (47.6%), followed by diabetes mellitus in nine patients (42.9%).

All the patients underwent laparoscopic sleeve gastrectomy and were covered by public insurance. The average follow-up duration since the operation was 13 months (range, 3 to 22). Of the 21 patients, 20 had a regular follow-up on an outpatient basis. One patient received medication whenever needed at a local hospital.

Perceptions of and decisions regarding bariatric surgery at a tertiary hospital

Seventy-one percent (15/21) of the patients were first introduced to bariatric surgery through recommendations from HCPs (Fig. 1). Ten patients (10 of 21) received information about the surgery from their family physician or an endocrinologist who they visited regularly for treatment of metabolic diseases such as hypertension, diabetes mellitus, and hyperlipidemia.

Similarly, 52% (11 of 21) of the patients decided to undergo bariatric surgery based on a recommendation from HCPs. The most common reason influencing the patients’ choice to undergo surgery at Asan Medical Center was the fact that they were already receiving outpatient care in another department within the same center. This made counseling and the surgical process readily available to them, accounting for 17 of 21 cases.

Satisfaction with the information provided during the perioperative period

We asked the patients how they would score the information provided before the surgery (outpatient treatment, pamphlet provision, nutrition counseling, etc.) on a scale of 0–10, and the average score was 8.75. More specifically, the patients were satisfied with the explanation from an overall perspective, the HCPs’ detailed questions and answers, and the QR code provided that linked to an informational video. In contrast, some patients who were dissatisfied mentioned that the depth of the information, particularly with respect to side effects, was limited and difficult to understand; therefore, they searched the internet after being provided information by their HCP. The patients also indicated that the information regarding the recommended diet provided during the nutrition counseling should be more specific.

The average satisfaction score with the information provided after the surgery was 9. Certain patients assigned high ratings due to the exceptional data quality. Conversely, patients noted that the explanation of potential complications was insufficient and that the explanation process was not personalized but rather adhered to conventional practices, consisting merely of predetermined responses.

Concerns regarding bariatric surgery

A total of 18 of 21 (85.7%) patients responded that they were satisfied with their body weight. Satisfaction with body weight did not show a correlation with %EWL. Reasons for dissatisfaction were that the pace of weight loss was slower than expected, it was not easy to lose weight because of age, and it was difficult to maintain weight loss.

When patients were asked what they were most concerned about, regardless of category, the most common issue was that they were worried about regaining weight especially as their appetite gradually increased and their stomach capacity expanded. Patients also expressed discomfort and anxiety related to potential future symptoms, including pain, vomiting, decreased digestive function, and reflux esophagitis.

Additionally, depression and thoughts of self-blame related to eating after the surgery were mentioned. One patient felt burdened by the cost of supplements associated with obesity treatment and was concerned about potential long-term complications.

Numerous academic papers have illuminated not only weight reduction but also the treatment and management of comorbidities as a result of bariatric surgery, leading to an improvement in overall health.^13-15,19 Various studies have addressed improvement of physical capabilities and also the patients’ perceptions of surgery. This paper presents the results of a survey aimed at exploring the perspectives of patients who have undergone bariatric surgery in South Korea, addressing a range of diverse topics.

In our study, among patients who had undergone bariatric surgery, the largest proportion of patients who decided to undergo bariatric surgery were those who had been visiting healthcare providers for the treatment of metabolic diseases and for whom bariatric surgery had been recommended as the next step after lifestyle modification and pharmacologic treatment. Additionally, some patients made this decision due to an increased concern about their own health and a desire for weight control. These findings are consistent with the results reported in previous studies.

Roberson et al.²⁰ conducted a qualitative study to investigate the factors influencing a patient’s decisions to present for outpatient consultation and to undergo bariatric surgery. Many patients reported making the decision primarily for health-related reasons, including the treatment of conditions like diabetes mellitus, hypertension, and hyperlipidemia. Some patients also mentioned that the impact of obesity on their daily lives served as a motivating factor for choosing surgery. Moreover, the influence of external perceptions, including those of family members, played a role in their decision. These findings aligned with those from Hult et al.²¹’s multicenter study, in which a substantial number of patients opted for surgery with the primary goals of weight loss (93.2%) and comorbidity treatment (72.8%).

According to the findings of the Funk study,²² when deciding whether to undergo bariatric surgery, a significant barrier was the lack of knowledge about the surgery itself. Doubts about the outcomes and safety of the surgery also played a substantial role in the decision-making process. In a study by Luck-Sikorski et al.²³ in Germany, the general public’s perception of bariatric surgery was investigated. When classified based on body weight, it was observed that all groups tended to have a negative perception of surgery, perceiving it as “cheating.” The study reported negative perceptions related to surgery, such as not knowing much about the surgery (8.5%), being afraid of bariatric surgery (28.3%), and expecting poor postoperative outcomes (24.5%).

Based on these findings, it can be inferred that efforts should be made to improve not only the perceptions of bariatric surgery among obese patients but also among the general public. Providing high-quality information and raising awareness is crucial in order to promote bariatric surgery as a viable therapeutic option. This, in turn, has the potential to increase the proportion of patients willing to undergo bariatric surgery.

To spread awareness about bariatric surgery, utilizing the internet and social media can be a valuable strategy, as suggested by Zerrweck et al.²⁴ Additionally, using smartphone apps, as proposed by Thomas et al.²⁵, can offer convenient access to information and support. However, it is worth noting that, per recent research on apps related to metabolic and bariatric surgery (MBS), applications targeting the Asian population are not yet widely available. Developing user-friendly apps that provide dietary tools and allow users to track their body weight can also facilitate easy access to expert clinical information on obesity.

It is essential that prospective MBS patients are cautious about the sources of information they use, including those available through YouTube, which hosts a significant amount of promotional content related to MBS. According to Ferhatoglu et al.²⁶’s research, approximately half of the MBS-related videos uploaded to YouTube come from non-professional sources and may offer misleading information. Interestingly, videos featuring patients sharing their experiences tended to have higher Video Power Index than those featuring HCPs. Given this information, creation of a YouTube channel that provides verified academic information may be warranted as a means of MBS promotion from the academic association.

Afonso et al.²⁷ conducted a prospective study to assess how many obese patients who visited the hospital for various reasons were aware of bariatric surgery, and reported that 13% of obese patients were unaware that they met the indications for bariatric surgery. In cases where information accessibility is low, it is likely that the probability of undergoing bariatric surgery is reduced, underscoring the importance of improving awareness and education about bariatric surgery among obese individuals to ensure that those who could benefit from the procedure are informed and have the opportunity to consider it as a treatment option.

Wee et al.²⁸’s research revealed that obese patients were more than five times more likely to consider surgery when it was recommended by HCPs compared to when it was not. Therefore, it is essential for HCPs to proactively initiate discussions about surgery with obese patients who are likely to benefit from the procedure. Intriguing findings from Ferrante et al.²⁹ indicate that when family physicians consider themselves knowledgeable and experienced in bariatric surgery, they tend to recommend it more to their patients. This trend may not be limited to family physicians alone but could extend to physicians in other departments as well. The inference drawn is that physicians who feel confident and informed about bariatric surgery are more likely to recommend it to patients, suggesting the importance of healthcare providers across various specialties being well-informed about and comfortable with discussing bariatric surgery as a viable treatment option for obese individuals.

In our study, some interesting cases emerged where patients initially visited the hepatobiliary department for surgical consultation regarding chronic cholecystitis or pancreatic neuroendocrine tumor but ended up receiving recommendations for MBS for weight management. Additionally, there were cases where patients sought outpatient care for end-stage renal disease and kidney transplantation but were advised to undergo MBS for weight control before the transplant procedure. Furthermore, there were instances where patients received advice on weight management while undergoing treatment for lymphedema following cervical cancer treatment.

Thus, it is appropriate to consider MBS a potential treatment option in various medical specialties and scenarios. The 2022 guideline from the American Society for Metabolic and Bariatric Surgery⁷ suggest that MBS may be considered a viable option for patients who are candidates for total knee arthroplasty, those awaiting organ transplantation, and individuals with cirrhosis and heart failure for whom the surgical risks are considered manageable.

To promote greater consideration of bariatric surgery in various medical contexts, educational opportunities for healthcare providers who frequently encounter obesity-related cases, such as family physicians and endocrinologists, should be increased. Additionally, promoting awareness among medical professionals from other departments is crucial. Both objectives can be achieved by providing information about the advantages and indications of bariatric surgery through open-type conferences that facilitate the exchange of information and discussions related to bariatric surgery. Broader education of HCPs in various specialties regarding the benefits and risk of bariatric surgery may also improve patient care, as positive outcomes have been reported in studies that combined surgical and pharmacological treatments,^30,31 and having a multidisciplinary team focused on obese patients has been shown to result in higher quality care to patients and reduce complications.^32,33 A multidisciplinary approach to both pre- and postoperative patients may therefore help ensure comprehensive care and better patient outcomes.

Previous studies assessing the contentment of obese patients have primarily focused on the assessment of health-related quality of life (HRQOL) in conjunction with patient satisfaction. According to a study by Hegland et al.^{34, 8}2.4% of patients responded as being “very satisfied” or “satisfied” with their bariatric surgery. When HRQOL was assessed using the Short Form 36 (SF-36) questionnaire, the Physical Component Score (PCS) averaged 45.8±11.4, and the Mental Component Score (MCS) averaged 46.4±11.8 points. It was reported that there was a tendency for patients with higher BMI, higher Obesity-Related Problem Scale scores, and lower MCS scores to respond as “dissatisfied” or “unsure” regarding their satisfaction. In Arman et al.³⁵’s study, patients who had undergone laparoscopic sleeve gastrectomy over 11 years prior were surveyed for satisfaction using a Likert questionnaire. The mean overall satisfaction score was reported as 8 on a scale of 0−10. These findings demonstrate a general trend of positive satisfaction among bariatric surgery patients, with certain factors such as higher BMI, obesity-related problems, and lower mental component scores potentially influencing satisfaction outcomes.

Our study focused on the first question from Arman’s questionnaire, which is whether patients are satisfied with their current weight: 85.7% of respondents in our study reported being satisfied with their current postoperative weight. In future studies, inclusion of additional factors, such as current eating habits, satisfaction with quality of life, retrospective considerations of whether they would undergo bariatric surgery again, and whether they would recommend it to others, could allow a more comprehensive analysis of patient satisfaction. It might also be worthwhile to explore whether bariatric surgery patients who were satisfied with the information provided exhibit an improved quality of life later. When developing the content of patient interviews in this study, there was uncertainty about whether it should take the form of a qualitative investigation or a quantitative study focused on proportions. Given the lack of either qualitative or quantitative research results related to Korean patients on this topic, this subject is likely to generate substantial interest in the future.

As for the limitations of our study, first, the number of patients participating in the survey was relatively small, and since it was a single-center study, there may have been selection bias. Further research is needed before considering our results representative of patients who have undergone bariatric surgery in South Korea. Second, unlike other survey studies that confirmed participation in advance through means like e-mail, we inquired about the willingness to participate during phone calls and proceeded with the questionnaire immediately. This approach made it difficult to engage in in-depth conversations with the patients, depending on their circumstances. Third, the involvement of a physician in conducting the interviews, rather than an independent third party unrelated to the treatment, may have affected the responses related to patient satisfaction. Fourth, we did not measure patient satisfaction and quality of life using objective tools employed in other studies. Fifth, since the study was conducted at a single time point, we were unable to assess how patient satisfaction might change over time, both before and after surgery.

In conclusion, the significance of this study lies in it being the first to explore the viewpoints of Korean patients with obesity who have undergone bariatric surgery. We anticipate completing additional multicenter studies that will provide more reliable insight into bariatric surgery from the patients’ perspective.

The authors declare no conflict of interest.

Study concept and design: SGO and MWY; acquisition of data: SGO, CSK, SHM, CSG, ISL, BSK, and MWY; analysis and interpretation of data: SGO, SAJ, JHY, and MWY; drafting of the manuscript: SGO and MWY; critical revision of the manuscript: SGO and MWY; administrative, technical, or material support: MWY; and study supervision: MWY.