Table 2.

The five key themes and examples of supporting quotes.

Theme 1: “It worked!”
Subtheme: I lost weight and that was great	“[Before surgery I couldn’t] wipe my bum … cut my toenails … pick anything up off the floor … put my knickers on easily … [Now] I’m active … I can bend over and put on my shoes. I can do all the things I couldn’t do before … It’s just like I’m a different person [5].” “My husband was actually pushing me around in wheel chair [before surgery] and now I’m up and walking and doing everything everyone else is … Look I’m 67, 68 this year and I can ‘out-walk’ most of the old girls as I call them [3].” “There’s things like being able to play with my child, comfort getting down on the ground, getting up, ease of walking up hills, better sex life [9].” “I can walk upstairs now; my knees don’t hurt. I can pick up kids from the ground … I can move around freely. I don’t feel like my arms are hitting the doorways when I walk through [4].” “He [the surgeon] performed a miracle on me and he gave me back my life. I didn’t have a life back then … I could barely get anywhere … I remember going to the lake here years ago with a couple of my children … and I sat down on the grass and it suddenly dawned on me—I didn’t know how I was going to get up off the ground. It makes me feel really emotional talking about it now … I was so fat and so bloody tired [6].” “The desire to eat reduced enormously [2].” “I’ve always been an overeater and a compulsive binger before the surgery and now I find that I can eat compulsively if I need to, but I don’t put on weight. I don’t much, but if I do, there’s not the consequences there used to be [5].” “I still look in shop windows now to make sure I’m still thin [6].”
Subtheme: My health improved and I’m going to live longer	“My sleep apnea improved; my asthma improved … My peak flow was better. Yeah, so it was an all-round improvement [8].” “I don’t have type 2 diabetes which is what I had before. Within days, it was gone [7].” “I don’t have a blood pressure problem anymore, I’m no longer pre-diabetic … It’s just like I’m a different person. I don’t get breathless, I don’t have sleep apnoea. My lungs are fine now. … I don’t get asthma now, so I haven’t needed to take Ventolin [5].” “When I arrived in Wellington [for surgery], I had injections for diabetes but by the time I left the following Wednesday, I didn’t have to have them anymore [6].” “Basically, all my readings [HbA1c, cholesterol, BP] are now normal … [I have] increased my expected life expectancy, probably 10–15 years in my opinion [9].” “I believe if I wasn’t dead, I’d be bloody close to it, if I hadn’t had that operation [6].”
Subtheme: My quality of life is better	“I’ve gone from zero to ten in my quality of life [5]”. “I’ve got a job, which I would have never of got being as big as I was. Everything really got better. I could look after the house better. I could look after my family better … I was happy to go out [6].” “I could shop in normal shops. Didn’t have to go to special ‘big girl shops’ and that was amazing [4].” I remember on Christmas day … it was the first time I was wearing a brand-new dress, brand new me, and everyone was really supportive, and I feel that was the turning point with my mind and body. The connection with my weight and depression [4].” “My relationships with my family and friends improved [8].” “I have found the love of my life, we’re getting married next year … I feel comfortable touching my partner and … that would have never happened before [4].” “I’m not sitting around doing nothing, not able to do anything. I’ve got a life. So, my behavior has improved a lot. And I’ve made friends, I’ve made several friends [5].”
Subtheme: My mental health has improved	“I feel like when you’re looking at me, you can go on my personality a bit, rather than immediately looking at me and seeing me as obese [4].” “My mood … has been a lot better since the surgery … I’m still on meds but it’s had a huge impact on my mental health … My self-esteem is really good. I want to live rather than wanting to die. Huge changes [5].” “I’ve got a better frame of mind [3].” “It made it [my mental state] better in the long term … I’ve moved out of home. When I was at my worst, I thought I’d never leave, thought my Mum would be my carer for the rest of my life. It’s better, it’s just better [4].”
Theme 2: Don’t get me wrong—it was a tough road
	“I was on antipsychotics and antidepressants. Quite big doses … and then with the general anesthetic I was delusional, hallucinating after the surgery … I still needed my psych meds and I couldn’t drink water or swallow, so he had to leave a drain into my old stomach through which we syringed the meds … To start with I was a bit screwed up. A bit angry and found it hard, but I’m so glad I did it [5].” “The surgery itself—it hurt like heck! It was very, very tough in the first few weeks [4].” “It’s a bit of a tough road after surgery … but so worth it [5].” “I was losing weight immediately and I could see it every day just getting better. I looked good. I thought, ‘Am I a failure?’ because my mind wasn’t getting better [4].” I suppose I was a bit naïve really. I thought my biggest problem was that I was overweight and thought—I really thought—that I wouldn’t be depressed [if I lost weight] and I’d be deliriously happy, but it didn’t quite work like that [6].” “I used to vomit all the time [after surgery]. My friends would be embarrassed, I was embarrassed, it was unpleasant. People would talk about it [8].” “I’m still really careful today especially if I go out because the last thing you want to do is be hanging over the toilet at somebody’s house [6].” “So, I’m regularly drinking more alcohol, probably not that often to the point of being intoxicated, but I think there might be grounds for that connection of transfer of addiction from what was quite strong food addiction to drinking extra alcohol [9].” “I’m an addictive personality. I did have a period where I drank a lot … But anyway, I’ve stopped drinking completely now. I haven’t drunk for six months and I’m not going to [5].”
Theme 3: Peri-operative support is really important
	“I was a bit befuddled. I had to take my husband to explain it a bit more … not that they didn’t explain it properly, I didn’t take it in properly [3].” “I had support. I had my mum and I had a counselor at the time. If I didn’t have people to talk it through, then I would have regretted it. I’d probably be worse—I don’t know what would have happened [4].” “I don’t think you realize how much support you need afterwards. Just someone to talk to about what’s going on [4].” “…After the op, I really thought there wasn’t a lot back up. It would have been good to meet a few people and have this support group because you just have to figure it out yourself [7].”
Theme 4: Value of surgery
Subtheme: It was all worth it—do it!	“So, my life turned around … My mum died four and a half years ago, and I was so pleased that mum was able to see me slim before she died. Because I know—I was 50 years old when mum died—just over, and I know my mum used to worry her guts out about me. Mums worry their guts out about kids forever. It was just the best really. It was the best decision we ever made [6].” “…I would recommend it to anybody…. you still have issues; you still have to look after controlling your eating and all the rest of it, but the benefits have been quite significant [2].” “I would say, make sure you have the support. Do it. Do it, it’s amazing [4].” I can’t eat a lot of the food my family eats, but I would not ever change what I did. Not ever … I just would not swap for anything, not even for money. That’s how much it has helped me in my life [6].” “I’m really glad I did the full thing, that [my surgeon] did with the whole open surgery … I think some of the others are a bit transitory and don’t last [5].”
Subtheme: It wasn’t worth it—don’t do it	“I get my medication daily because at one stage, this was after the op, I was in tremendous pain and I was eating every pill … I was just taking them like lollies [candy] and it wasn’t making the pain any better [7].” “My olanzapine and Epilim … was not getting into my stomach … So, three days after the surgery … I suddenly went really manic. And I thought what the hell was wrong with me? … But my weight did go down to 70 kgs. I was pleased, but just unwell just all the time. So, I got it taken out … and once the band came out the medication started to work, pretty much straight away … [If people with SMI have surgery] the drugs won’t work and the person will be even sicker. But if [if they don’t have surgery] they gain too much weight then they’ll get diabetes and die anyway … you’ve got to weigh it up. [1].”
Theme 5: The health system is discriminatory
	“I think that it’s just wrong to group people and say, ‘you’ve had mental illness, not going to do surgery…’ Because for me, I wouldn’t be here if I didn’t have the surgery. It makes me a bit sad that if I didn’t have my parents and I was to go public, they would just say ‘no’ and I would be still be stuck where I was. And that was living hell. I would really like it to change. It saved my life; it can save someone else’s life [4].” “I think it should be the opposite. I think that the people with mental illnesses and bad self-esteem because of their weight should be the first on the list because it has such a huge drastic change in your, um, your being able to live a life, being able to live an active, enjoyable life and self-esteem. [5]. “I think it’s disgusting. It’s not a choice we make to feel this way and it’s not fair to judge and to say, ‘you are depressed so we can’t deal with you’ [6].” “It’s a mistake and they should reassess … it would be hugely beneficial to New Zealand hospitals to make this surgery available publicly to much higher number of people [9].”