Patient Perspectives on Weight Management and Wellness After Liver Transplantation: A Convergent Mixed Methods Study

Abstract

Introduction

Obesity and metabolic syndrome are common in liver transplant recipients and cause adverse health outcomes. We aimed to elicit patients’ perceived barriers and needs for post-transplant weight loss.

Methods:

A convergent mixed methods approach was used to assess attitudes, needs, and barriers to using resources for weight loss. A cross-sectional survey was administered to liver transplant recipients with a body mass index > 25, and focus groups expanded information on topics of interest. Descriptive statistics, Student’s t-test, and Wilcoxon rank–sum were used to analyze the survey results, and reflexive thematic analysis was performed for focus groups.

Results:

Fifty-three respondents (63.5% male; 88.4% Caucasian; median body mass index 30.7 [27.5, 33.7]) completed the survey (11.9% response rate). The majority (73.6%) believed obesity adversely affected liver grafts. Most patients tried weight loss lifestyle changes (diet modification [86.8%] and exercise [71.7%]). Factors negatively affecting weight management included immunosuppression (49.1%) and fatigue (54.7%). Of the respondents, 42.3% and 18% were likely to consider weight-loss medication and surgery, respectively. Potential liver damage from weight-loss medications (84.9%), medication side effects (60.4%), complications from bariatric surgery (47.1%), and surgery’s impact on the transplanted liver (45.2%) were major concerns. Patients were motivated by the care of their transplanted organ when pursuing weight loss and were concerned about interventions that may damage their transplanted liver. Transplant-specific challenges (impact of emotions through the transplant process, physical limitations, and support from peers and health care personnel) were recurring themes.

Conclusions

Post-transplant patients were largely motivated to lose weight to care for their new liver and concerned about liver damage and side effects when considering medical and surgical weight-loss interventions.

Introduction:

Obesity and metabolic syndrome are prevalent among liver transplant (LT) recipients, and significant weight gain commonly occurs in the first year after transplantation.¹ Obesity independently increases mortality rates after LT and negatively impacts transplant-related outcomes.² Patients transplanted for metabolic disorder–associated liver disease face a high risk of recurrent steatosis and higher rates of cardiovascular-related mortality.^3,4 Weight changes in LT recipients are characterized by an initial decrease to a weight nadir approximately 3 months post-transplant, followed by weight gain over the subsequent one to 5 y.⁵ There is a significant gap in the understanding of LT recipients’ experiences regarding weight loss and weight maintenance, specifically barriers to the utilization of weight management strategies. More information is needed regarding LT patients’ experience with weight-management strategies.⁶

The published weight-loss interventions for abdominal organ transplant recipients include lifestyle interventions, medication- assisted therapy, and bariatric surgery. Lifestyle interventions in postabdominal organ transplant patients can potentially improve the quality of life, muscle strength, aerobic capacity, and reduce cardiometabolic risk factors.^7,8 Early data indicate the safety of weight-loss medications with the use of glucagon-like peptide-1 receptor agonist (GLP1RA) and sodium–glucose cotransporter 2 (SGLT2), but little data are available on LT patients’ willingness to add additional medication regimens or tolerate side effects.^9,10 Similarly, although there are some reported outcome data about simultaneous LT-gastric sleeve, there is limited published literature on the patient perception of and willingness to pursue simultaneous or post-LT bariatric surgery.^11–19

To address the knowledge gap surrounding the attitudes, barriers, and perceptions of LT recipients toward weight-management strategies, a mixed methods approach was used to fully assess patient-perceived barriers to utilizing known weight-management strategies as well as LT-specific concerns in the later post-transplant period.

Methods

We used a convergent mixed research methodology, which integrates quantitative data from surveys and qualitative insights from focus group discussions, to assess post-LT patient experience with weight loss and maintenance, and to understand the attitudes and perceptions of LT recipients.

Participants and recruitment

Adult LT recipients with a body mass index (BMI) >25 kg/m² were recruited at our transplant center from July to September 2022. A survey invitation was distributed electronically through the patient portal as part of the electronic health record following institution’s institutional review board (IRB) policy. Focus group participants were recruited from a pool of adult LT recipients with a BMI >30 kg/m² who had previously agreed to be contacted for research and contacted via phone call. The focus group participants were not limited to survey responders. Given the minimal risk nature of the study, consent was waived. Survey respondents received a $10 e-gift card and focus groups participants a $50 e-gift card in remuneration for their time. Study procedures were approved by the Massachusetts General Hospital (MGH) IRB: 2021P000918.

Transplant center and weight center alliance

The MGH weight center offers medical and surgical management options to patients. The alliance between the transplant and weight centers allowed for expedited referral for evaluation and enrollment at the weight Center within 30 d for patients referred by the transplant team.

Study procedures and data collection

This study explored weight management experiences of post-LT recipients with a BMI >25 (survey) or BMI > 30 (focus group), highlighting perceptions of and experience using weight-management strategies. All data were deidentified and stored on Health Insurance Portability and Accountability Act–compliant encrypted computers.

Survey

A cross-sectional three-section survey elicited patients’ perceptions of weight management and attitudes toward interventions for post-transplant weight loss. The complete survey is available in Supplemental Appendix 1. The survey was administered using the REDCap platform, which is hosted securely at our institution.²⁰

The first section of the survey included multiple-choice and open-ended questions developed, peer-reviewed, and pilot-tested at our institution. The team that codeveloped and tested the questions included obesity medicine, transplant surgery, transplant hepatology, and nutrition specialists, with consultation from the MGH Division of Clinical Research’s Qualitative and Mixed Methods Research Unit. The survey instrument was adapted from a previously developed survey for kidney transplant recipients, which underwent pretesting and refinement based on participant feedback in that population.²¹

Survey question domains included demographic data, pretransplant and post-transplant experience with weight, barriers to healthy weight maintenance, willingness to use medical or surgical weight-loss therapy, and weight-center resources.

Two additional sections of the survey included the following two validated surveys: the Patient Activation Measure (PAM)-13 and Stages of Change for Weight Loss.^22,23 The PAM-13 questionnaire was used in accordance with the scoring and interpretation guidelines on the official website. PAM-13 is a tool that assesses a patient’s knowledge, skills, confidence, and ability to manage their health by identifying “patient activation.” PAM-13 scoring produces a score on a scale from to 0-100 that correlates to one of the four levels of patient activation. PAM levels 1 and 2 indicate lower patient activation, whereas PAM levels 3 and 4 indicate higher patient activation for weight change.^22,24 The Stages of Change for Weight Loss assesses an individual’s readiness to make lifestyle changes for weight loss through one question that classifies them as precontemplation, contemplation, preparation, action, or maintenance of those lifestyle changes.

Focus groups

Focus groups were selected over interviews because focus groups have been successfully used in the past to discuss weight management issues, and there was a minimal participant risk when discussing the topics of weight management in a group setting.^25–27 A focus group guide was simultaneously developed by the same team using the framework of social cognitive theory looking at the triangulation of environmental factors, personal factors, and behavior on obesity and healthy weight maintenance.²⁸ The survey and focus group guide were developed in consultation with the MGH Division of Clinical Research’s Qualitative and Mixed Method Research Unit (Supplemental Appendix 2). Authors (S.A., L.D., and T.C.) have completed coursework in mixed methods. The domains for the guide included health and weight, transplant-specific barriers to weight management, attitudes toward weight-loss methods and barriers to their use, internal and external weight stigma, and perceptions of potential future interventions. Four virtual focus group sessions were conducted based on participant availability with the intention of fostering patient interactions and a discussion of their unique shared experiences of liver transplantation. Focus groups were held using ZOOM-secured video-conferencing platforms.

The focus groups were moderated by two members of the research team (S.A. and F.F.), and field notes were taken (A.M.). S.A. was a research fellow at the time of the study, who had taken a coursework in mixed methods. F.F. has a master’s level coursework in clinical research and was a senior research coordinator. A.M. was a premedical university student. All three researchers were female and did not have bias assumptions. The three were not funded by the study, did not have a personal history of weight management or transplant, and did not have significant clinical experience in weight management or transplantation. Only participants and researchers were present in the focus groups. S.A. and M.M. spoke with the patients to schedule the focus groups. The participants were made aware of the purpose of the study. The focus groups were audio-recorded, deidentified, and transcribed between April and May 2023.

Data analysis

Quantitative and qualitative data were analyzed using a convergent mixed methods approach to provide a comprehensive picture of patients’ experiences.²⁹ The domains of obesity and weight maintenance assessed in the study included environmental influences (demographic data, pre-LT and post-LT status), personal factors (attitudes toward weight-loss methods and perceptions of potential future interventions), and behavioral factors (utilization of weightmaintenance resources, stages of change, and patient activation level) (Fig.).

Fig. –

Diagram of mixed methods data elements based on the social cognitive theory framework. Data elements were available from either the survey or focus group or both.

Quantitative results from the surveys were assessed for normal distribution of data with the Shapiro–Wilk test. Descriptive statistics were reported as mean and percentage or median and interquartile range. Student’s t-test and Wilcoxon rank-sum tests were used as appropriate for comparisons between groups. Statistical analyses were performed using STATA (version 17.0; Stata Corp LLC, College Station, TX).

Qualitative data analysis followed Braun and Clarke’s reflexive thematic analysis.³⁰ Researchers (S.A., K.M., N.R., and M.C.) were familiarized with the data by re-reading text transcripts and free-form survey responses. Three researchers (K.M., N.R., and M.C.) generated codes by identifying meaningful text passages. Codes were grouped into ten categories and three themes. Thematic saturation was reached as no new themes emerged from the data despite an exhaustive review. This aligns with the findings of Guest, Namey, and McKenna, who demonstrated that 90% of themes can be identified within three to six focus groups.³¹ Disagreements in the codes and theme assignments were resolved by consensus. Recurrent themes and quotes were agreed on through an iterative approach, and quotes that best characterized each theme were included. An additional researcher (L.D.) performed the final review. Participants did not provide feedback on the results. The reporting followed the Consolidated Criteria for Reporting Qualitative Health Research checklist (Supplemental Appendix 3).³²

Results

Patient demographics

Participants in the survey and focus groups differed in the baseline data available for analysis. Of 466 eligible LT recipients, 53 completed the survey response rate 11.9%; however, a true response rate cannot be calculated because of the method of survey distribution required by the institution’s IRB. The survey was distributed through patient gateway, but patients may not have been notified of the message or may have opted out of research-related messages. Of those who opened the survey, 81.5% completed it. Self-reported demographics are in Table 1. Patients reported ascites (43.2%) and edema (49.3%) before transplant and 70.5% felt that they lost weight from the loss of fluid at the time of transplant. No significant difference was found between transplant and current weight (P = 0.80). Sixty-seven percent of patients indicated that they had gained weight since COVID.

Table 1 –

Table of demographic and selected survey results for 53 survey recipients.

Survey respondents
Baseline characteristics	Survey respondents number (%) or median (IQR)
Age (y)	64 (58, 68)
Gender
Male	34 (63.5%)
Female	18 (34%)
Other	1 (1.9%)
Race/ethnicity
White	47 (88.4%)
Black	2 (3.8%)
Asian	2 (3.8%)
Hispanic	0 (0.0%)
Other	2 (3.8%)
Level of education
Post-secondary	43 (81.1%)
High school	10 (18.8%)
Relationship status
Relationship (dating or married)	35 (66%)
Not in a relationship	18 (34%)
Time since transplant (y)	5 (2, 7)
Combined liver–kidney transplant	7 (11.3%)
Current weight (pounds)	205 (173, 230)
Current BMI (kg/m2)	30.7 (27.5, 33.7)
Weight before transplant (pounds)	198 (170, 235)
Healthy weight as an adult (pounds)	190 (172, 210)
Aspirational weight (pounds)	182 (150, 200)
Fatty liver before transplant	32 (50.9%)
Alcohol use since transplant
Strictly no alcohol use	50 (94.2%)
Occasional alcohol use	2 (3.7%)
Stages of change
Precontemplation	2 (3.8%)
Contemplation	11 (20.8%)
Preparation	5 (9.4%)
Action	17 (32%)
Maintenance	21 (39.6%)
PAM-13 activation level
Low activation (1-2)	16 (30.2%)
High activation (3-4)	37 (69.8%)

BMI = body mass index; IQR = interquartile range; PAM = patient activation measure.

Of 236 post-LT patients with BMI > 30, 59 had consented to be contacted for transplant-related research, and 20 agreed to participate in focus groups. Fifteen joined one of the four sessions (two groups of three, two of four), each lasting approximately 45 min. Participants were 86.6% non-Hispanic White, 73.3% male, median age 62 (52-67) years, median BMI 33.5 (30.9-38.1) kg/m², and median time since transplant 2.89 (2.29-3.37) years. The overarching theme emerging from the study was LT patients’ motivation to take care of their transplanted liver and preserve their overall health and longevity. Three main themes arose from the qualitative analysis of the patients’ weight management journey: emotions, transplant-specific considerations, and personal support (Table 2). Interestingly, each theme had a positive facilitator aspect for some patients and was identified as a barrier for others in their weight-management journey. Barriers included physical recovery and concerns about harming the transplanted liver with medical or surgical weight-loss methods. Facilitators included support from transplant peers and the medical team.

Table 2 –

Themes and representative quotes from focus groups discussing weight management after liver transplantation.

Theme 1: Impact of emotions on healthy weight maintenance throughout the transplant process
Motivation	“The only one that’s going to change yourself is yourself. You can’t have somebody do it for you.” “I need to lose weight. I want to be healthy and survive.”
Responsibility	“…I have somebody else’s liver, so I have to be extra careful.”
Fears	“Coming out of the surgery, I thought I was going to be having to worry about physical activity, worried about rehurting myself. And then I said to myself, I go, ‘you know what?’ because at first, I was a little hesitant, the first month like, ‘Oh, should I do this? Oh, it might be too much for me.’ And then I just said, ‘Screw it. I’ve worked too hard to live not to live.’ And I just said, ‘If I get hurt or if I tear something, so be it. I’m just going for it.’ And I try to live my life as close as to I’ve ever lived before and not give into it.”
Eating behaviors related to emotions	“My problem was always snacks at night and still is snacks at night. I’ve got to get away from that. If I drop it completely, [inaudible] but the problem is it’s willpower. I can’t do it. That’s it.” “I struggled a bit. But the diet is crucial. A lot of things that I was attracted to, that I wanted to eat all the time, I think a lot of emotional eating, comfort food, and I put on quite a lot of pounds going out to restaurants.”
Theme 2: Attitudes and perceived barriers to weight management specific to transplant
Comorbidities	“I was diagnosed with heart failure. And the medicine they put me on, I could barely move. And I gained a lot of weight. So right now, I’ve been trying to lose weight, and I can’t.” “Because my weight has been a struggle, my diabetes has been a struggle in the two different places because of the medication. They don’t communicate very well. So, I’ve had issues just being on the same page about what I can do and can’t do as far as medications. So that’s been a difficulty too”.
Transplant medication challenges	“Probably the biggest [factor affecting weight gain] being on prednisone… It increases your appetite. You’re always hungry.”
Surgical complications of transplant	“I also had a lot of–a real bad problem with ascites post-transplant, which strangulated my lower intestine, and I ended up getting about 24 cm of that removed in emergency surgery about a year afterward. That’s also affected my digestive system. It made me really acutely aware of food going through, and it’s kind of uncomfortable.”
Physical challenges after transplant	“I have a real hard time staying on my feet for long periods of time. And that also affects my mobility in the long periods to get the exercise that I need. So I’m fighting a lot of fronts, but I’m after it with meds and just sheer–I have a very high tolerance for pain, as most of you probably do by now, so I just kind of grunt through it and do the best I can.” “I could not believe the energy that I had right after my transplant. I had so much endurance. It was like, “Where did this come from?” I get up early in the morning, jump right on the exercise bike, go out walking. I had tons of endurance.”
Medical weight management	“I’m a little weary on medication, as I think most ofus might be. Right. I don’t want [inaudible] into my body too much. It’s a lot of pills, man. I take 26 different pills a day.” “I went to the weight loss clinic and the first thing they said is “medication”. And my primary care said, “Don’t try any of those meds,” because I have diabetes. And with that, I have gastroparesis which is the nerve in my stomach is slowing down. And the side effects would be very contraindicated with my stomach. (…) so, I was like, ‘No. That’s off the table.’ And we tried to explore other types of medications, but it would be detrimental to me.”
Surgical weight management	“[Weight loss surgery] was seriously one of the best things I’ve ever done in my life. My quality of life went up, I mean, so much.” “I’m going to probably, hopefully, maybe have weight loss surgery. It’s not something I want, but I think I’m going to do it because everything will be great.” “It’s also my understanding that they’re looking at incorporating weight loss surgery into the transplant procedure for people that are already overweight. So, if they’ve already got you sliced open, they do both at once in the hopes that that would help you keep the weight off. And I really wish that had been an option for me.”
Theme 3: Support and healthcare system relationships
Health care system perception	“I feel like if there was someone to show me what I could do without putting myself at risk other than the cardio, which I know I do. But the other things like– the classes that I take, they use weights and do sit-ups, however many you can do in a time, and I know I can’t do that right now, so I think that would be helpful.” “There are certain things they tell you that you can’t eat or drink after you’ve had a liver transplant. So I follow those (…) I did see a nutritionist. But I didn’t find that all that helpful. She was just saying eat yogurt in the morning and substitute and don’t eat donuts and stuff.”
Support group perception	“I think it would be better to have– to share goals maybe. If you thought that you had a similar situation with somebody, and you were working in the same direction, and if they had circumstances that match yours, it might be helpful. Because we do have unique problems with our bodies, I think, liver transplants specifically.”

Emotions and motivation for weight management

The first theme describes how emotions have both a positive and/or negative impact on transplant patients’ ability to improve their weight management. Patients expressed a strong sense of responsibility to maintain a healthy weight: “I don’t want to develop a fatty liver because simple fact of the matter, I was given this great gift) concentrating on taking care of what was given to me is where my thoughts are at.” Negative emotions, stress-induced eating, and increased appetite post-transplant often posed challenges: “ …now that I’m healthier and eating like I should, I have gained weight since then, and so there’s also the fear that I also don’t want to continue to gain weight.”(Table 2).

Survey data indicated most patients were in the “maintenance” (37.8%) or “action” (30.2%) stages of change, with motivations including physical well-being (32.1%) and longevity (30.2%). Barriers included fatigue (54.7%) and immunosuppression (49.1%). The cohort’s mean PAM-13 score was 64.8 (standard deviation = 13.8), with 69.8% classified as active (levels 3 or 4), reflecting strong self-management ability. PAM scores did not correlate with the likelihood of seeking medication (odds ratio [OR] 0.99, P = 0.95) or surgery (OR 0.96, P = 0.25), nor were significant differences found in BMI, PAM scores, or stages of weight change by sex, ethnicity, education, or relationship status (all P > 0.05). In addition, 67.9% reported “excellent” or “good” overall health.

Transplant-specific limitations and challenges

A second theme emerged, which consisted of transplant-specific considerations regarding the implementation of weight management strategies. Barriers to weight loss included physical constraints and concerns about the effects of weight loss strategies on the transplanted organ. Concurrently, LT was also a strong motivator to preserve the longevity of the transplanted liver, viewing it as a gift (Table 2).

In the survey, transplant-specific factors such as fatigue (54.7%) and immunosuppression (49.1%) negatively impacted weight loss. Similarly in the focus groups, difficulties related to the transplant process included challenges with comorbidities, transplant medications such as steroids, and surgical complications after transplantation including prolonged recovery time, nerve damage, and lack of strength and stamina. “My energy level is still not that strong. As far as doing a lot of activities or exercising… I really exert myself a lot if I try to do anything extra. So that has been an issue for me since my operation, and this is my third year out…”

Some patients mentioned that overcoming physical challenges such as pain after transplant was paramount to resuming physical activity, with an overall sense of accomplishment for doing so: “When I received the transplant… I was close to death. And coming out of it, I was amazed how quick the recovery was… I mean, a lot of the pain, and then just over time, move, and exercise-induced stuff. I’ve had no setbacks at all. It’s been absolutely fantastic.”

Support and health care relationships

The third theme was the support and health care relationships that patients perceived as advantageous or diminishing to their ability to manage weight (Table 2). In the survey, 70% of patients reported having received counseling from their health care team on weight management. Regarding health care support perception, most focus group participants indicated that transplant providers fostered a safe space: “They listen to whatever I have to ask, even dumb questions I would say, or everything… Anything related to diet or any other exercise, any other, resources are available as well.” Some patients mentioned lack of trust toward providers who would ask patients to lose weight while being overweight themselves. Other patients remarked about the medical team’s guidance being insufficient or not as advantageous to achieve weight loss: “You’re encouraged to lose weight, but you’re not giving guidelines and assistance to it. They tell you to go find your way in how to– no one takes you by the hand and helps you.”

Regarding support, having a community of post-LT patients with shared goals such as weight loss was beneficial: “I think having, people who are going through the same experience as you with the same frustrations is huge because you didn’t feel like you were talking to a wall or people who didn’t understand your specific circumstances. People think you have a liver transplant, and all of the sudden, everything’s great again. You’re back to your normal life. Well, for a lot of us, that’s just not true. Nothing’s quite the same again. So yeah, having people that understand what you’ve been through and can share their experiences. It is very helpful.”

Strategies for weight management

Lifestyle modifications

In the survey, 87% of patients had attempted diet modification, 77.3% eating a balanced diet, and 32% using a food diary. Similarly, 72% of patients attempted exercise for weight management. Up to 62% of patients exercised outdoors, 43.3% had gym membership in the past, and 32% used a wearable activity tracker. A similar proportion of patients expressed interest in the following future exercise activities: gym membership (23%), personal trainer (21.2%), exercising outdoors (21.2%), and using a wearable activity tracker (38%).

Medication for weight loss

In the survey cohort, 57.7% of patients reported they were unlikely to use pharmacological methods for weight management. Concerns that medication may damage the liver were the most reported (85%), whereas almost two-thirds (61%) had concerns about side effects. No difference in the odds of using medication was found according to age (OR: 1, P = 0.96) or BMI (OR P 1.04, P = 0.50). In the focus groups, the main concern with weight loss medications is the potential adverse effects on the transplanted liver. “Anything with my liver (…) Side effects, especially with new medications, they can say it won’t affect your liver, but then 10, 5 y down the road, it does.” Patients also expressed medication burden, and lack of trust in medications to sustain weight loss over time.

Weight-loss surgery

Ninety-three percent of the survey respondents were unaware that the transplant center had a partnership with the weight center. Barriers to weight center use included the following: distance (64.2%), insurance coverage (45.2%), and uncertainty about weight-center offerings (33%). Of the services offered at the weight center, 43% expressed interest in dietician consultation, 41.5% in meal planning services, and 38% in obesity medicine specialists. Having no out-of-pocket expenses (80.7%) and telehealth (75%) would improve patient interest in the weight center.

Only 18% of survey respondents were likely to pursue weight-loss surgery in the future, and 30.2% would have considered bariatric surgery if performed simultaneously with LT. The main concerns regarding surgery were potential complications (47.1%), effect on the transplanted liver (45%), and surgical safety concerns (43.4%). No difference in the likelihood of considering surgery was found according to age (OR = 0.95, P = 0.25) or BMI (OR = 1.09, P = 0.23).

Many participants in the focus group were unwilling to undergo an additional operation. However, some mentioned that they would be willing to pursue weight loss surgery if it was beneficial for their new organs. “It’s my job to do everything I can to take care of the gift I was given on a donor and his family in every way possible, so the surgery for me is n’t really optional at this point. I’ve shown that I can’t lose the weight strictly through diet or exercise. There’s a number of hormonal and metabolic factors at play that I have zero control over. So, I need to let science developers do this job.” Importantly, when patients who had undergone bariatric surgery shared their experience, the conversation around acceptance and desire for the procedure became more positive for other transplant recipients. “It was just a matter of I’ve had enough surgery. I don’t want any more of it. Now I’m to the point where if it can help me– because it does change your hormones, and so it’ll help my stomach issue. It’ll help my heart. It’ll help my lungs. It’ll help my kidneys. So, I’m giving in. I’m going to go ahead and do it.”

Discussion

Patient motivation is crucial for implementing and sustaining weight-loss strategies.^33,34 In our study, LT patients were motivated by their responsibility to take care for their liver and improve their overall health with physical well-being and longevity being the most common motivators for maintaining healthy weight. Psychosocial factors like mood impact weight loss, with emotions such as stress, fear of injury, and the desire to protect the transplanted organ play critical roles in long-term efforts.^35,36 This aligns with findings from post-kidney transplant patients, where preserving the transplanted kidney’s longevity strongly motivated exercise and weight management.³⁷

Transplant-specific attitudes and barriers

Perceived barriers to weight loss interventions include cost, scheduling, limited physical activity opportunities, unacceptability of diets or programs, and lack of support.^38,39 Our study identify LT-specific barriers to weight loss including fear of harming the transplanted organ, prolonged recovery, additional procedures after transplantation, surgical complications, physical restrictions, stress eating, transplant medication side effects, and lack of energy. These challenges necessitate a multidisciplinary, personalized approach to ensure the effectiveness of weight maintenance interventions. To our knowledge, these LT-specific barriers have not been explored in other studies.

Most survey and focus group participants attempted lifestyle modification interventions for weight loss, with nearly 90% of the survey respondents trying diet modifications and over 70% exercise. Focus group participants noted that apps for tracking food intake, managing cravings, and receiving exercise guidance could improve accountability and success. Although lifestyle modification strategies have shown potential in weight-loss success in some abdominal organ transplant recipients,^19,40 guidance from the transplant team may enhance LT patient adoption.

Barriers to weight-loss medication and surgery were also discussed. Less than half of the participants were likely to use medication for weight loss, citing concerns about liver damage, side effects, and excessive existing medications which aligned with concerns identified in the focus groups. Prior studies have shown nonadherence to medication in post-transplant setting, so addition of obesity medication in the post-LT setting requires patient discussion, given the prioritization of immunosuppression medication complance.^41,42 It is important to note the landscape of obesity treatment has evolved significantly since then, particularly with the emergence and growing use of newer antiobesity medications. Future studies should evaluate attitudes toward these newer therapies specifically, as they may shift perceptions and increase willingness among transplant recipients.

In the survey, fewer than 20% of the patients indicated that they were open to bariatric surgery. The focus group cohort initially expressed skepticism due to concerns about having an additional operation. The initial negative opinions regarding weight loss surgery in the LT population were consistent with findings in the general population, where the overestimation of risks, unrealistic expectations, and unfamiliarity with surgery outcomes may lead to concerns about pursuing bariatric surgery.⁴³ However, in our study, a change in perception was seen after the focus group participants who had undergone bariatric surgery shared their positive experiences.

Support relationships

Previous studies suggest that active health care team support increases patient motivation for weight loss.^33,44–46 The transplant center’s partnership with the weight center offers multidisciplinary support across different disciplines for patients to feel more supported and achieve more effective weight loss. Most of the surveyed patients were unaware of the transplant center’s partnership with the weight center. Participants had mixed perceptions of the transplant center support for weight loss, similar to a UK study where some patients hesitated to engage with general practitioners for weight management, finding their guidance unhelpful or unsuitable.⁴⁷

Peer support in health care enhances social relationships, reduces morbidity, and supports adjustment and recovery from chronic diseases.⁴⁸ In the LT setting, weight management support groups help patients discuss exercise, nutrition, and health checks, positively impacting daily activities.⁴⁹ Participants in our study valued weight-management transplant support groups for fostering understanding and learning from others on similar journeys. Peer support can shift perceptions and approaches to weight loss, highlighting its potential in future interventions for LT patients.

Limitations

This study has some limitations. First, the small sample size was a result of the low survey response rate, with only 11.9% of the LT recipients completing the survey. Similarly, recruitment to the focus groups was limited, and one-fifth of recruited participants did not attend a focus group session. This may limit the generalizability of the findings and contribute to participation bias. The cross-sectional nature of the study design limits capturing changes in patients’ perceptions over time, and participants in the study were over several years from LT, which may limit the applicability of the results to the immediate postoperative period. Future studies should include longitudinal assessments to provide more reliable results. Similarly, both the focus groups and surveys used self-reported data from patients, which might have been subject to recall bias. Although one question from the PAM-13 questionnaire was not included for all patients, it was managed by following the scoring guidelines of the tool as “n/a,” limiting the impact of the omission.

Conclusions

Post-transplant status adds additional complexity to weight loss and weight maintenance in LT recipients. Although LT patients have concerns and motivations similar to those of the general population, transplant patients are also motivated by their second chance in life resulting from the LT and their responsibility to care for the transplanted liver. However, LT patients also face barriers specific to their post-transplant recovery, including immunosuppression medications, medical comorbidities, and concerns for potential negative side effects of surgery and medical weight loss on the transplanted organ. The transplant clinic team and post-transplant peer support can be important aids in the weight-loss journey ofLT recipients. The results of this study will inform future intervention development for weight management in LT recipients.

Supplementary Material

Supplementary data related to this article can be found at https://doi.org/10.1016/j.jss.2025.06.041.