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obesity is a chronic disease which may have a major negative effect on the people 's quality of life ( qol ) .
our country , iran , is considered as a country in the nutrition transition which follows the western lifestyle like the other developing countries . on the other hand ,
iran had the third position in publication about obesity / overweight among the middle east countries .
few studies have tried to understand and assess the meaning of bariatric surgery for the candidates .
some patients think that the bariatric surgery is a miracle and there is no need to participate in the process of long - term medical treatment ; while others think they can continue life without interventional treatments and resist this process in spite of high grades of obesity .
hence , it is needed to have enough information about this disease and different ways to change lifestyle .
this study aims to clarify different aspects of qol of the iranian patients which are affected by obesity and to explore their beliefs and expectations of bariatric surgery . on the other hand
, this study is the first step of designing a qol questionnaire based on our own culture and spiritual states .
in our qualitative content analysis research , we chose 38 morbidly obese patients , by purposive sampling and we continued data collection until saturation of data occurred . in this study , we included patients who have used different medical noninvasive treatments and were unsuccessful in losing weight from the obesity clinic in al zahra hospital , isfahan , from 2014 to 2015 .
these face - to - face interviews took place the day before the surgery in a stress - free quiet room .
we used some open - ended questions such as  why did you decide to treat obesity ?  and  what are your expectations of surgery ?  and we continued based on their responses . for data analysis in this study , we used graneheim and lundman 's method .
we assigned the participants narrations into some codes , and then , we sorted the similar codes according to the main categories of standard qol table which is called  the world health organization 's whoqol - bref qol assessment ,  but with some differences in subcategories .
this survey is the first step of designing a native closed qol questionnaire according to our cultural and spiritual beliefs . to enhance the credibility of our research
, we carried out peer review of narrations , codes , main categories , and related subcategories . to promote transferability of our data , we chose patients with various sociodemographic characteristics and obesity grades .
to enhance the credibility of our research , we carried out peer review of narrations , codes , main categories , and related subcategories . to promote transferability of our data , we chose patients with various sociodemographic characteristics and obesity grades .
twenty - seven women ( 71% ) and 11 men ( 29% ) participated in our study .
the sociodemographic analysis of these 38 morbidly obese patients has been mentioned below : the mean age of this group was 35.29 years ( standard deviation [ sd ] = 11.57 ) , the mean body mass index ( bmi ) was 42.83 ( sd = 6.94 ) , and the mean weight was 117.85 kg ( sd = 20.47 ) . about  marital status :  24 married ( 63.16% ) , 13 single ( 34.2% ) , and 1 divorced ( 2.63% ) . about 
26 under bachelor 's degree ( 68.41% ) , 7 bachelor 's degree ( 18.42% ) , and 5 upper than bachelor 's degree ( 13.17% ) .
moreover , about  professional status :  9 full - time ( 23.68% ) , 13 part - time ( 34.2% ) , 15 unemployed ( 39.47% ) , and retired 1 ( 2.63% ) .
five major categories were used in our study which four resembled the whoqol - bref and one named as  about the causes of obesity . 
these five categories are as follows : 
  physical health  with four subcategories :  pain and fatigue ,  
one interesting point is that even patients without any comorbidities had a fear of them , which brings this in our mind that they are involved as much as patients with comorbiditiespsychological health  with six subcategories :  medication ,   feelings , 
 self - steam ,   thinking / learning ,   body image ,  and  spirituality . 
this subcategory was affected in different aspects such as having obsessive behaviors , paranoidal and suicidal thoughts , aggression , depression , and self - cutting all in the pastsocial relationships  with two subcategories :  practical social support  and  personal relations 
( including relations with self , society , family members , and opposite gender ) . 
relation with opposite gender  was the most frequent part of this category . although most of the participants avoided to have audiotaped interviews , they told us their related problems in details , which we found that it is an important aspect which is affected in patientsenvironment  with five subcategories :  cloth style ,   transport ,   finance ,   leisure ,   home and physical environment .  among these subdivisions ,  cloth style  and  transport  were mentioned at the most , respectivelyabout the causes of obesity :  in this category , participants mentioned pregnancy , long - time immobility after trauma , their own eating behaviors , family susceptibility , associated diseases such as diabetes , big psychological events such as death of parents or migration as the causes of obesity .
on the other hand , most of these causes are controllable , and it seems that awareness about obesity can prevent us from it . 
   physical health  with four subcategories :  pain and fatigue ,  
one interesting point is that even patients without any comorbidities had a fear of them , which brings this in our mind that they are involved as much as patients with comorbidities  psychological health  with six subcategories :  medication ,   feelings , 
 self - steam ,   thinking / learning ,   body image ,  and  spirituality . 
this subcategory was affected in different aspects such as having obsessive behaviors , paranoidal and suicidal thoughts , aggression , depression , and self - cutting all in the past  social relationships  with two subcategories :  practical social support  and  personal relations  ( including relations with self , society , family members , and opposite gender ) .
although most of the participants avoided to have audiotaped interviews , they told us their related problems in details , which we found that it is an important aspect which is affected in patients  environment  with five subcategories :  cloth style ,   transport ,   finance ,   leisure ,   home and physical environment .  among these subdivisions ,  cloth style  and  transport  were mentioned at the most , respectively  about the causes of obesity :  in this category , participants mentioned pregnancy , long - time immobility after trauma , their own eating behaviors , family susceptibility , associated diseases such as diabetes , big psychological events such as death of parents or migration as the causes of obesity . on the other hand ,
most of these causes are controllable , and it seems that awareness about obesity can prevent us from it .
the details of interviews , narrations , and categories have been sorted in a table which we will provide it for the interested readers through e - mail .
the main results of our article are the results of qol questionnaire in our sample study .
we reviewed the patients feelings , beliefs , and expectations of surgery to assess their attitudes regarding obesity definition , their eating behaviors , spiritual , and occupational challenges , and then , we reported their narrations in five main categories : ( 1 ) physical health , ( 2 ) psychological health , ( 3 ) social relationships , ( 4 ) environment , and ( 5 )  about the causes of obesity  with some subcategories for each category .
some categories of our table may be applied to other countries in spite of various culture or spiritual beliefs . by considering
the results of other similar studies , obese people believe that bariatric surgery changes their lifestyle and has a fundamental influence on their treatment .
understanding of patients concerns , problems , and expectations is the foundation of the surgical approach and ignoring them may lead to disaster in contrast to common belief about bariatric surgery . on the other hand , bocchieri et al . stated that being aware of patients perceptions about eating behavior , obesity and its treatment has a crucial impact on the success of the bariatric surgery regarding the spiritual aspects , nam s has shown in their study that spiritual group of rural african - american women had greater achievement toward marinating normal bmi and weight loss in comparison to the similar non - spiritual group .
reeves rr indicated in their study on african - americans in the southeastern united states that they did nt find any significant association between weight and patients spirituality state .
but they observed lower probability of lifetime smoking and less alcohol use and lower energy intake in obese patients with greater spirituality state .
in other words , people with lower bmi usually do not have spiritual problems , but larger sample is needed to prove this theory scientifically . about our study limitations , it is important to mention that most of the patients did not allow us to audiotape the interviews .
furthermore , our results in spiritual and cultural parts can be generalized just to the countries with similar states .
furthermore , ignoring a patient 's various aspects of life disrupts the obesity treatment , especially bariatric surgery .
background : obesity is a known prevalent major health issue . the aim of this study is to assay iranian patients problems with obesity and their expectations of bariatric surgery.materials and methods : in this study , we included patients who have used different medical noninvasive treatments and were unsuccessful in losing weight from the obesity clinic in al zahra hospital , isfahan , from 2014 to 2015 . 
 morbidly obese patients were interviewed using some open - ended questions , and then , directional content analysis of data was done.results:analysis of data showed five main categories including ( 1 ) physical health , ( 2 ) psychological health , ( 3 ) social relationships , ( 4 ) environment , and ( 5 )  about the causes of obesity  with some subcategories for each category.conclusion:this study is the first step of designing a quality of life questionnaire while we focused on spiritual and cultural states of iranian people .