Research Article

Patients beliefs about gastric banding

Jude Hancock1,*, Sue Jackson 2, Andrew Johnson1
1Department of Diabetes and Endocrinology, North Bristol NHS Trust, Bristol, UK
2Psychology Department, University of the West of England, UK
*Corresponding author:

Jude Hancock, c/o Department of Diabetes and Endocrinology, Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, United Kingdom, BS10 5NB, Email:


Laparoscopic adjustable gastric banding, longitudinal, Obesity, Content analysis, Theory of Planned Behavior

Background and Objectives: Laparoscopic adjustable gastric banding (LAGB) surgery may be an option for tackling obesity in individuals who are unable to lose weight using behavioural methods alone. Beliefs about LAGB are likely to change as experience of living with a LAGB is gained. The objective of the present study was to explore patients’ beliefs towards LAGB prior to, and five years post-surgery.
Methods: This was a prospective longitudinal qualitative study. Semi-structured interviews were conducted with 20 patients (aged 31 to 58 years, 16 female, 19 White, 16 with diabetes) twice; prior to, and five years post-LAGB. Content analysis was carried out using constructs from the Theory of Planned Behaviour as an explicit coding framework to determine salient beliefs at both time points, while t-tests were used to explore weight loss.
Results: Prior to LAGB, beliefs included feeling unhappy with current self, experiencing social stigma as a result of being overweight, a good understanding of what LAGB would do, and both approval and disapproval of undergoing LAGB from family. Five years post-surgery beliefs included feeling happy, life improvements, experiencing problems with the band, continued approval and disapproval of LAGB from family, and social stigma due to having undergone LAGB. Patients lost a significant amount of weight following LAGB (t (19) = 6.3, p < .001).
Conclusion: Results indicate that while weight loss does happen following LAGB, not all experiences of living with a band are positive. Many patients experienced problems with their band, which they felt hindered their weight loss. Beliefs identified in this study may need to be considered during clinical consultations and in planning future interventions to support patients with their weight loss following surgery.
Keywords: Laparoscopic adjustable gastric banding, longitudinal, obesity, content analysis, Theory of Planned Behaviour
In 2013, figures indicated that the UK population were exercising less and eating less fresh produce (1). These factors are contributing to an obesity crisis in the United Kingdom [UK] (2). The National Institute for Health and Care Excellence [NICE] guidelines on the management of obese individuals promotes lifestyle and behavioural interventions as the treatment of choice (3). However, when lifestyle and behavioural interventions fail, bariatric surgery may be an alternative option (3, 4). One such bariatric surgery is laparoscopic adjustable gastric banding [LAGB]. In this procedure, a silicone band is placed around the top part of the stomach to create a small gastric pouch. A length of tube connects the band to a port implanted in the abdominal wall allowing saline to be injected into the band thus adjusting the amount of restriction an individual experiences in relation to food intake (4, 5). Benefits of LAGB include excess weight loss (6), and remission or improvement in co-morbidities (4, 7). However, not all individuals lose weight or have improvements in co-morbidities following LAGB (4, 8, 9).
There is a considerable body of research highlighting the processes underpinning motivation and behaviour change (10 - 12). Driving human behaviour are the underlying beliefs individuals hold about performing the behaviour (13). These beliefs may change over time as experience with performing the behaviour is gained (8, 14). Exploring beliefs individuals hold toward a given behaviour are useful, as helping an individual change negative beliefs into positive beliefs (e.g., a negative belief such as embarking on a diet will mean eating only boring foods, could be changed into a positive belief that embarking on a diet will mean trying new foods and cooking methods) is a useful technique for assisting with behaviour change (13, 15, 16). A useful method for exploring beliefs is to use a theory of behaviour to underpin analysis (17, 18). 
One theory of behaviour, The Theory of Planned Behaviour (TPB), has been widely used to explore health-related behaviours (13, 19). Theoretically, the TPB assumes behaviour is determined by the intention to perform a given behaviour and the perceived behavioural control (PBC) over performing the behaviour (13). Intention is the motivational component for an individual to perform the given behaviour. PBC is the amount of control an individual has over engaging in the behaviour. The TPB assumes that intentions are determined by three psychological constructs; an individual’s attitude towards the behaviour, subjective norms and PBC. These three constructs are known as direct predictors of intention. Attitudinal, normative and control beliefs underpin each of these psychological constructs, and are known as the indirect predictors (13, 20).  Attitudinal beliefs are those individuals’ associate with performing a particular behaviour; these beliefs may be positive, negative, or both. Additionally, attitudes may be affective (based on feelings towards the attitude object, e.g., LAGB) or cognitive (based on knowledge about the attitude object) (13, 21, 22). Normative beliefs held by an individual pertain to which salient others they believe would approve or disapprove of a course of action, while control beliefs are those concerned with what an individual believes would enable or inhibit them. Understanding the attitudinal, normative and control beliefs individuals hold toward LAGB prior to and following surgery could assist in determining factors that individuals believe may hamper or aid long-term success in weight loss and subsequent weight maintenance (13). 
In the literature pertaining to LAGB, there is a paucity of longitudinal studies exploring beliefs, and changes in beliefs that occur in individuals following surgery (23). Beliefs will change over time as experiences of living with a LAGB are gained (8, 13, 24). The behaviour changes, in terms of diet and exercise, to which an individual must adhere to in order to live with a LAGB is likely to shape these beliefs (25 - 27). Although no existing studies exploring beliefs have been carried out using the TPB psychological constructs to guide analysis, patients’ beliefs toward LAGB (28), other forms of bariatric surgery (e.g., gastrobandoplasty / gastric sleeve, 29), and bariatric surgery in general (8) have been explored. One of these studies used a retrospective design to explore eight patients’ changes in beliefs prior to, and one year following LAGB (28). Findings indicated beliefs about the need for surgery, the understanding that LAGB is not a quick fix, and the importance of support prior to, and one year following LAGB. The use of a retrospective design in this study may have introduced recall bias in the findings, as participants were required to try and remember the beliefs they held prior to surgery. Another study asked 909 patients to express beliefs as to why their bariatric surgery had been unsuccessful in terms of weight loss (8). Findings indicated patients gave non-specific explanations, which were categorised into issues relating to diet, physical activity, motivation, diet-related motivation, and medical conditions or medications affecting physical activity. The authors do not state the types of bariatric surgery the patients had (30), nor do they state the length of time since surgery in this cohort, which is important being that in the first two years following all types of bariatric surgery patients generally lose weight, followed by some weight regain (31).
The aim of the current study was to use qualitative data collected as part of a larger longitudinal mixed methods study to explore beliefs towards LAGB prior to surgery, and five years following surgery using the psychological constructs from the TPB to guide analysis. In the context of this study the target behaviour prior to surgery was defined as, “undergoing LAGB surgery”; and the target behaviour following surgery was defined as “living with a band”. Using existing data to perform secondary qualitative analysis is an effective way to maximise insights from existing data (32, 33).
A prospective longitudinal qualitative study using psychological constructs from the TPB to explore beliefs toward LAGB at two time points; prior to surgery and five years following surgery.
Recruitment of participants took place between 1st January 2007 and 31st December 2009 through a Weight Loss Service in a National Health Service (NHS) hospital in England, UK. Participant eligibility has been described elsewhere (34). In total 45 participants agreed to be interviewed, however, only 20 (44.4%) completed interviews at both pre and five years post-LAGB. These 20 formed the sample for the TPB analysis. The mean age of these participants was 45.8 ± 6.6 years; six individuals were aged over 50 at time of banding. The sample was predominately female (n = 16, 80%). The majority of the sample identified themselves as White (n = 19, 95%), and most had diabetes (n = 16, 80%). Prior to banding the participants’ average weight was 138.5 ± 15.6 kg, five years post-LAGB it was 114.3 ± 16.5 kg.
Interview schedules : Interview schedules were developed based on the existing literature regarding bariatric surgery assessment (35), and conversations with the Weight Loss Service lead clinician (9). The interview schedule encouraged participants to reflect on their beliefs about LAGB (36): e.g., pre-LAGB, ‘What support do you have from family and friends?’ and ‘What are your expectations of the surgery?’; post-LAGB, ‘How much control do you now feel you have with the band regarding your eating and your life?’ and ‘How has living with the band, affected your relationships with other people?’
Procedure: Ethical approval was obtained from North Bristol NHS Trust Research Ethics Committee. Informed consent was obtained from all participants prior to interview. The interviews were generally carried out in a room within the weight loss clinic arranged to coincide with participants’ routine clinic appointments. Each interview was recorded and transcribed verbatim (36). To ensure anonymity, participants were assigned numbered identifiers.
Data Analysis:
Guidelines recommend using content analysis and a top-down approach to group beliefs (37, 38), thus the theoretical underpinning guides the analysis (rather than the data as would be the case in a bottom-up approach) (21, 39). Therefore, the following analytical process was adopted for the current study. Transcripts were read, re-read and annotated by hand using the TPB constructs as markers for beliefs. All beliefs elicited were then listed in a table according to TPB construct and belief valence (positive or negative).  This table was then analysed to explore frequency of beliefs. Salient beliefs were determined using the ten percent rule, where beliefs mentioned by a minimum of ten percent of the sample were considered salient (40, 41). In order to reduce bias and address credibility, themes were verified by another member of the study team (42).
Paired sample t-tests were used to explore whether the whole sample, and various demographic sub-groups, had lost a significant amount of weight five years post-LAGB. Where appropriate, effect sizes were quantified using Cohen’s d (43).
Results: Table 1 shows the salient positive and negative beliefs by TPB construct prior to surgery, and Table 2 beliefs five years following surgery. Both tables show the number of individuals reporting the salient belief, for example, the first row in Table 1 illustrates for affective beliefs of a positive valence, nine individuals from the sample of 20 expressed feelings of hope, which equates to 45% of the sample. Participants could hold more than one belief within a TPB construct and valence direction; for example, have two negative affective beliefs and three positive affective beliefs. In the following sections quotes to illustrate beliefs are presented with the participant identifier (e.g., P13). 
Beliefs about LAGB prior to surgery 
In terms of attitudes, cognitively, everyone in the sample had a good understanding of the mechanisms of LAGB and what the surgery would entail (e.g., P10, “This ring to inflate or deflate”), believed LAGB would help with comorbidities (e.g., P13, “Get my diabetes under control”), and were realistic that LAGB is not a quick solution to weight loss (e.g., P16, “It's going to take quite a while for me to lose that weight, I mean it was explained to me that it's not a quick fix”). Participants were aware of their current poor health (e.g., P13, “I was just having health problem after health problem”), believed they experienced social stigma due to being obese (e.g., P5, “'People in society my size are seen as lazy, stupid” ), and were aware there would be some trial and error with eating following LAGB (e.g., P23, “As regards to eating afterwards, it's all like liquid and trial and error, some people can eat things and another person can't have the same”). Affectively, being obese meant individuals reported feeling low and unhappy (e.g., P14, “at the moment I'm on a downer, I'm really low”), with many feeling worried and fearful about the surgery and life with a band (e.g., P23, “I don't know what'll happen to that (loose skin), so it's a bit worrying really”), and feeling embarrassed about their current size (e.g., P16, “‘I just get embarrassed now”). Salient positive beliefs held included hope for the future after surgery (e.g., P44, “hopefully anyway what I lose I'm not going to regain”), feeling happy to have the opportunity to have a LAGB (e.g., P14, “when I come out of it, in the outpatients department, skipping and jumping”), and feeling positive about the future (e.g., P27, “I'm very positive about it”).
In terms of normative beliefs, two reference groups were cited as people who both approve and disapprove of LAGB; family members which included spouses, parents, children, siblings and extended family (e.g., approve, P53, “He (husband) feels that if this is what I truly want then he's, he's behind me 100%'”; disapprove, P14, “My sister feels that I could do, starve myself”), and GP (e.g., approve, P23, “'My doctor first asked me if I was interested in this”; disapprove, P4, “He laughed at me, told me to go away and go on a diet”). Half the sample had friends who approved of LAGB (e.g., P15, “All my friends have been really, really supportive”). There was a strong belief that society views LAGB as an easy option for weight loss (e.g., P40, “The easy option, and the easy way out”).
In terms of control beliefs, the salient enabling beliefs were that LAGB would help control food intake (e.g., P13, “The banding will help with the amount that I actually eat”), changing habits such a eating style, cooking methods and portion sizes would help long-term (e.g., P16, “I would have to learn to eat very slowly'”), and having support from others living with a band would be beneficial (e.g., P4, “It's been really beneficial to talk to people that have had it done”). Inhibiting beliefs about life with a band included dwelling on past failed diet attempts (e.g., P4, “'I've yo-yo dieted for years”), a lack of willpower to change habits (e.g., P16, “I don't have great will power (laughs)”), and doing limited physical activity due to current size (e.g., P15, “'Every single step hurts then I'm sweating terribly”).
Beliefs about LAGB five years post-surgery
After five years of living with a band, cognitively, most of the sample believed their life had improved as a result, (e.g., P39, “'It has changed my life”), they didn’t regret having it done (e.g., P29, “I don't regret anything, and I wouldn't do anything differently”), and they had seen health improvements (e.g., P47, “My diabetes is really under control now”). However, participants also held negative beliefs toward LAGB in relation to their diets following surgery (e.g., P37, “I desperately miss eating bread”), life following LAGB was not as they had hoped (e.g., P42, “After five years, I'd, I would like to uh, to it have been a bit more, less weight, less tablets, less insulin”), and many had experienced unpleasant side effects (e.g., P2, “It was making the oesophagus stretch”). Affectively, participants felt happy (e.g., P14, “I'm happy, I'm contented”), confident (e.g., P13, “I do have you know, high confidence in myself”), and positive/grateful for having had a band (e.g., P29, “I'm eternally grateful for being allowed to have it done on the National Health”). Nevertheless, negative feelings were also present, a number of participants felt disappointed/down with their life following LAGB (e.g., P40, “I'm disappointed in myself really because I, I know I could've lost a lot of weight by now”), guilty for not having lost as much weight as they had hoped (e.g., P5, “I always feel guilty when I come and haven't lost weight because I feel I'm letting them down”), and lonely/abandoned in the years after their LAGB surgery (e.g., P14, “I have had a lonely journey”).   
In terms of normative beliefs, similar to pre-surgery, two reference groups were cited as those who both approved and disapproved of LAGB; family members (e.g., approve, P4, “My family have been very supportive”; disapprove, P14, “He (husband) didn't like it”) and Health Care Professionals (HCPs) (e.g., approve, P37, “My doctor's very supportive”; disapprove, P42, “He (GP) says, I can't give you anything because you've got a gastric band”). Furthermore the participants still held their pre-LAGB belief that people generally do not approve of LAGB (e.g., P16, “Some people had, oh it's the easy way out”). The Bariatric Specialist Team (BST) were a salient reference group who approved of the LAGB (e.g., P4, “They're (BST) all really helpful, I mean um, if ever you know I've had a question or anything they're easy to contact”). 
In terms of control beliefs, enabling beliefs were held in relation to LAGB (e.g., P4, “You still see food and think 'mmm, yes, I'll have that' and the band says, no thank you, no you won't”), eating behaviour (e.g., P15, “Tiny little bits, and chewed very well”), and being active to aid weight loss (e.g., P10, “I'm just trying to keep as active as possible”). Inhibiting beliefs included problems with the band (e.g., P37, “I had a problem with um, the band getting clogged up at one time”), comfort eating (e.g., P16, “I was a mood eater as well (laughs) and sometimes I've fallen back into that pattern again”), and social eating (e.g., P29, “You can't just go out for a meal, and sit down and have a normal meal with people”).
Weight loss following LAGB
Table 3 shows the weight data prior to and five years following LAGB surgery for the whole sample, and demographic sub-samples. Compared to baseline, by five years post-LAGB the sample had lost a significant amount of weight (t (19) = 6.3, p < .001). The mean difference in weight loss was 24.3kg, which calculations demonstrated was a very large effect size (d = 1.5). Gender analysis revealed females lost a significant amount of weight post-LAGB (t (15) = 5.8, p < .001), but males did not (t (3) = 2.3, p = .11). Comparing age group (aged ≤49 or ≥50), results indicated both younger (aged ≤49) and older (≥50) groups lost a significant amount of weight post-LAGB (t (13) = 5.1, p < .001 and t (5) = 3.5, p = .02, respectively). Splitting the sample by pre-LAGB diabetic status demonstrated individuals with diabetes lost a significant amount of weight post-LAGB (t (15) = 6.1, p < .001), whereas those without diabetes did not (t (3) = 2.0, p = .14). Of the 16 individuals with diabetes prior to LAGB, only five of these no longer had diabetes five years post-LAGB (i.e. blood glucose levels as per NICE guidelines, 44).
The results of this longitudinal study using a TPB framework to explore beliefs toward LAGB provide evidence that some beliefs change over time with experience of living with a LAGB, whereas other beliefs become more salient. For example, prior to surgery participants felt happy about having the opportunity to be banded, while five years following surgery many more participants felt happy with their life. Similarly, prior to LAGB many participants believed band would support their weight loss, but five years later all the participants believed the band was an enabling factor in their success. These results support the view that beliefs change with first-hand experience of living with a band.
Findings indicated participants believed that problems with the band had inhibited their control over their weight loss, and for the majority having a band was not as they had hoped. This corroborates findings that bariatric surgery is not successful for all patients (4, 9). It also suggests that LAGB is not an ‘easy option’ for weight loss, which many participants believed society feel it is, and has been suggested to be the case in other research (28, 45 - 47). Furthermore, although a potential benefit of LAGB is improvement in (i.e., a glycated haemoglobin level of 6.0% or less, 48), or remission of diabetes (3, 4); in the current study most participants were still living with diabetes five years following their surgery. This potentially contributed to the belief that life following LAGB was not as they had hoped. 
At both time points family members were a salient reference group who both approved and disapproved of participants’ decision to be banded. Support is a key feature of behaviour change (16, 49), as the support of others helps those living with a band adapt to dietary and psychosocial changes (50). If family members are not supportive this can impact negatively on eating behaviours (49). A finding of concern was the disapproval associated with LAGB some participants experienced when dealing with HCPs. This may have been a contributory factor to the participants’ reported feelings of abandonment following surgery. The finding that participants believed both society and some HCPs disapprove of LAGB suggests more education is required to raise awareness of the challenges people experience living with a band in order to improve their health.
In terms of weight loss, this sample was successful in reducing their weight five years following LAGB. Females lost a significant amount of weight five years following LAGB, but data indicated the males in the sample did not. This finding needs to be interpreted with caution given the small number of males in the sample; however, previous research has indicated that males do lose less weight than females following LAGB (51). Similar to previous research, younger and older individuals both lost a significant amount of weight five years following LAGB (52, 53). 
Strengths and limitations
Strengths of this study are that existing data was utilized to explore beliefs toward LAGB prior to, and five years following surgery in individuals with first-hand experience using the psychological constructs of the TPB as a framework for analysis (32, 33). In addition, the longitudinal data has enabled identification of beliefs that change and those that remain stable over time (13, 24). Furthermore, in the current study, participants were asked to reflect on the factors that had enabled and inhibited control of behaviour following banding. Using this approach has allowed insights to be gained on the actual enabling and inhibiting factors that individuals living with a LAGB face in order to change behaviour lose and successfully maintain weight loss. A limitation of this study is that the small sample of patients was from a single Weight Loss Service; therefore the beliefs held by this sample may not be representative of other geographical areas. It must also be acknowledge that using the data for secondary analysis meant that interview questions were not posed to participants using recommended belief elicitation wording for the TPB (20). Therefore beliefs elicited may be different if the recommended TPB question wording were to be used. 

This longitudinal exploration of beliefs toward LAGB using a TPB framework has highlighted the positive and negative experiences of living with a band. Consideration of these experiences during clinical consultations may be useful for assisting in continual behaviour change and subsequent maintenance following LAGB. Furthermore, these beliefs may be used for developing new interventions to support individuals undergoing LAGB. Comparison of these findings with other existing datasets would be useful to determine whether beliefs vary in other geographical areas and in those populations with different demographic characteristics.

The authors would like to acknowledge the wider team involved in the data collection for this research; Hilary Holloway, Marianne Morris, Karen Lilly and Bev Corbett.

This work was supported by money generated through commercial research studies and a charitable fund.
Disclosure statement
The authors declare no conflict of interest.


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Published: 23 December 2016

Reviewed By : Dr. Carla Vartanian, Dr. Joo-Ann Ewe, Dr. Fabiane Valentini Francisqueti ,


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