Obesity Surgery (2023) 33:920–929

https://doi.org/10.1007/s11695-022-06405-1

ORIGINAL CONTRIBUTIONS

The Effect of Deep Breathing Exercise and 4–7‑8 Breathing Techniques

Applied to Patients After Bariatric Surgery on Anxiety and Quality
of Life
Gülfidan Kurt Aktaş1 · Vesile Eskici İlgin2

Received: 21 September 2022 / Revised: 28 November 2022 / Accepted: 30 November 2022 / Published online: 8 December 2022
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
Background This study aims to determine the effects of the deep breathing exercise and the 4–7-8 breathing technique
applied to patients after bariatric surgery on their anxiety and quality of life.
Methods The research was carried out using the pre-test post-test randomized controlled experimental research design with
a control group. A total of 90 patients (30 patients in the deep breathing group, 30 patients in the 4–7-8 breathing group,
and 30 patients in the control group) who met the research inclusion criteria were included in the study. While routine care
was applied to the control group, 1 group was given deep breathing training, and the other group was given 4–7-8 breathing
training. Personal Information Form, the Obesity-Specific Quality of Life Questionnaire, Status, and the State-Trait Anxiety
Inventory were used for data collection.
Results There was no significant difference between the groups in terms of descriptive characteristics (p > 0.05). It was found
that the post-test State Anxiety levels of the 4–7-8 breathing group were lower than the mean scores of the deep breathing
group and the control group, and the difference was statistically significant (p < 0.05). It was found that the quality of life
scores of the patients in the deep breathing group increased significantly in the post-test compared to the pre-test.
Conclusion The 4–7-8 breathing technique was found to be beneficial in reducing the anxiety level of patients in clinical
practice after bariatric surgery. It was found that deep breathing exercise was also effective in improving the quality of life.
Trial Registration ClinicalTrials.gov Identifier: NCT05492929.

Keywords 4–7-8 breathing technique · Anxiety · Bariatric surgery · Deep breathing exercise · Quality of life

Key Points
• The 4–7-8 breathing technique reduces Anxiety of patients Introduction
undergoing bariatric surgery.
• Deep breathing exercise improves Quality of Life of patients Obesity is a disease that reduces the quality and duration
undergoing bariatric surgery.
• After bariatric surgery, 4–7-8 breathing exercises should be
of life, and its prevalence increases worldwide [1]. Obe-
applied to reduce the anxiety of patients and deep breathing sity affects the quality of life in all areas, including physi-
exercise increase their quality of life. ological, psychological, social, and environmental areas [2].
Obesity leads to anxiety, depression, low self-esteem, and
This study was conducted under the supervision of the second
low body perception in individuals [3]. In the treatment of
author as a master thesis in the Surgical Nursing Department of
Health Sciences Institute. obesity, bariatric surgery is thought to be the most effec-
tive and permanent method for weight loss [4]. The aim of
* Vesile Eskici İlgin bariatric surgery, which is more preferred nowadays than
vesile_eskici_86@hotmail.com before, is to ensure weight loss by decreasing the absorption
Gülfidan Kurt Aktaş of nutrients or reducing the stomach volume and restricting
glfdnkrt.56@gmail.com food intake [5].
1
Ankara City Hospital, University District, 1604. Street No: Unexpected conditions such as bleeding, thromboem-
9, Ankara, Turkey bolism, anastomotic leakage, and atelectasis may develop
2
Department of Surgical Nursing, Faculty of Nursing, Atatürk within the first month after bariatric surgery [6]. In people
University, 25100 Erzurum, Turkey with obesity individuals, lung compliance is reduced due

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Obesity Surgery (2023) 33:920–929
to the increase in pulmonary blood volume and collapse
in peripheral airways. Meanwhile, excessive adipose tis-
sue accumulated in the chest wall and abdomen decreases
lung volume by compressing the rib cage and diaphragm.
Interventions to prevent pulmonary complications in the
postoperative period, such as patient positioning to relieve
breathing, in-bed rotation movements, deep breathing, and
coughing exercises, are the most important parts of nursing
care [7, 8].
Anxiety is a set of natural reactions developed by the
body and the mind against a situation or stimulus that dis-
turbs the individual and endangers the existence. In daily
language, anxiety is expressed as depression and distress [9].
In a review by Gariepy, Nitka, and Schmitz [10], a posi-
tive correlation was observed between obesity and anxiety
disorders in general. Studies have revealed that patients eli-
gible for bariatric surgery among people with obesity indi-
viduals have high levels of anxiety and depression, and the
majority of them have psychiatric disorders [11–18].
Anxiety impacts the quality of life adversely to a sig-
nificant extent. Studies have demonstrated that anxiety and
depression reduce the quality of life by affecting it psycho-
logically and socially [19–21]. The study by Voelkerin [12]
and the systematic review by Kolotkin and Andersen [22]
stated that obesity reduced the quality of life. It is required
to reduce the symptoms of depression and anxiety in order
to lose weight in a healthy way and increase the quality of
life [23].
A study by Ergen [24] recommended routine respiratory
exercises for the management of anxiety in the postoperative
period. In a study conducted by Yekta [25] on mastectomy
candidates, it was observed that rhythmic breathing effec-
tively reduced anxiety. A study by Yusuf, Iswari, Sriyono,
and Yunitasari [26] revealed that deep breathing exercise
after surgery was an effective, inexpensive, easy, and safe
method to reduce the level of anxiety.
Holding the breath for a while ensures that the body
renews its oxygen. The 4–7-8 breathing technique provides
the necessary oxygen support to organs and tissues and helps
to expel carbon dioxide (­ CO2). In the 4–7-8 breathing tech-
nique, an individual inhales for 4 s, holds the breath for 7 s,
and exhales for 8 s. Such practices reduce anxiety both by
distracting attention and providing relaxation by oxygenat-
ing and expelling the C ­ O2 accumulated in the body [27]. A
single study on the 4–7-8 breathing technique was found.
The study by Pandekar and Thangavelu [28] showed that the
4–7-8 breathing technique was effective in reducing anxiety
and depression in moderate chronic obstructive pulmonary
disease (COPD) patients.
It is the responsibility of the nurse providing care to pro-
vide a comfortable environment for the patient and increase
quality of life standards. Furthermore, studies show that the
rate of using non-pharmacological methods, which are under
921
the nurse’s responsibility, is low [29, 30]. In this study, we
foresee that applying non-pharmacological deep breath-
ing exercises and the 4–7-8 breathing technique will help
reduce the anxiety of patients undergoing bariatric surgery
and increase their quality of life, and this is the first study on
this issue. The present study was performed to determine the
effect of deep breathing exercises and the 4–7-8 breathing
technique on anxiety level and quality of life after bariatric
surgery.
Research Hypotheses (H)
H1: The 4–7-8 breathing technique effectively reduces
the postoperative anxiety level of patients.
H2: Deep breathing exercises effectively reduce the post-
operative anxiety level of patients.
H3: The 4–7-8 breathing technique effectively improves
the postoperative quality of life of patients.
H4: Deep breathing exercises effectively improve the
postoperative quality of life of patients.
Methods
Design
The research was conducted using a randomized controlled
experimental research design with a pretest–posttest control
group.
Setting and Sample
The study population consisted of individuals who met
the inclusion criteria and underwent bariatric surgery
between January and April 2022 in Ankara Lokman
Hekim Akay Hospital, Endocrinology and Metabolism
Diseases Clinic. A priori power analysis was conducted
to determine the sample size in this study. The reference
method for Cohen’s standard effect sizes was selected in
the power analysis [31]. Differences between the three
groups (the deep breathing exercise group, the 4–7-8
breathing technique group, and the control group) in
terms of the scale scores were examined using one-way
analysis of variance (ANOVA). In this case, for the t-test
in which each group would be compared, it was found
that if the study was conducted with a total of 66 patients
and 22 participants in each group, 80% power could be
reached at a significance level of 0.05 and a 95% con-
fidence interval. To prevent data loss, approximately
40% backup sample was included in this number, and
the study was completed with a total of 90 patients, 30
in each group, between the specified dates (Fig. 1). In
13
922 Obesity Surgery (2023) 33:920–929

Fig. 1  CONSORT flow diagram

Conformity Assessment (n=91)

Registration
does'nt include (n=0)

Randomized (n=91)

Defining Groups

4-7-8 Breath Group Control Grouph (n=30)

(n=30) Deep Breath Group(n=31)

tracing

Untracked (n=1)
Untracked (n=0) untracked (n=0)
* Transfer to Intensive

Analysis

Analyzed (n=30) Analyzed (n=30) Analyzed (n=30)

the randomization, patients meeting the research criteria Instruments

were randomly divided into the experimental and con-
trol groups according to the triple block randomization
method. The patients included in the study were assigned
to the groups according to the numbers created by triple
block randomization using the random.org site accord-
ing to the order they were operated. Thus, the group of
patients on the list determined for bariatric surgery that
day was determined according to the order in which they
were operated by considering the row number in the table
created using the random.org site.
Inclusion Criteria Being 18 years old and older or 65 years
old and younger, being on postoperative day 1, having under-
gone bariatric surgery, not having communication barriers,
having the ASA score of I or II, volunteering to participate
in the study.
Exclusion Criteria The presence of major depression or psy-
chosis, having communication barriers, being transferred to
another unit, leaving the study voluntarily.
The Personal Information Form (PIF), State-Trait Anxiety
Inventory (STAI), and Obesity-Specific Quality of Life Scale
were used to collect data.
Personal Information Form It was prepared by the researcher
in the form of 12 questions about the patients’ descriptive
characteristics (age, height, weight, body mass ındex (BMI),
sex, marital status, educational status, economic status, the
presence of comorbidity, a history of previous surgery, a
history of previous hospitalization, smoking and alcohol
consumption).
State‑Trait Anxiety İnventory
It is a test developed by Spielberger et al. [32] that measures
state and trait anxiety levels. Its validity and reliability in
Turkey was done by Öner and Le Compte [33]. The scale
consists of two parts, the “state anxiety scale,” which is

13
Obesity Surgery (2023) 33:920–929
created with the aim of determining the instantaneous feel-
ings, and the 20-item “trait anxiety scale,” which was created
to determine the feelings in general. It is a four degree scale
ranging from “Nothing” to “All.” Scores range from 20 (low
anxiety) to 80 (high anxiety). It was stated that reliability
coefficients determined by alpha correlations of Öner and
Le Compte scale were between 0.83 and 0.92 for the state
anxiety scale and between 0.83 and 0.87 for the trait anxi-
ety scale. In this study Cronbach Alpha internal consistency
coefficient of the scala has been determine fort he State anxi-
ety inventory as 0.92, for the Trait anxiety inventory as 0.74.
Obese‑Specific Quality of Life Scale Patrick, Bushnell,
and Rothman [34] developed the Obese-Specific Qual-
ity of Life Scale (OSQLS) in 2004 to measure the extent
to which obesity affects the quality of life of individuals.
Gündüzoğlu [35] translated it into Turkish and carried out
its validity and reliability analysis. This scale is a 17-item
Likert-type scale scored between 0 and 6. The scale has no
sub-scales. As the score increases, the quality of life also
increases, and as the score decreases, the quality of life
also decreases. Cronbach’s alpha coefficient was found to
be 0.91 in this study.
Intervention
The researcher collected data at Ankara Lokman Hekim
Akay Hospital, Endocrinology and Metabolic Diseases
Clinic between January and April 2022. The patients’ dis-
tribution by groups was determined by randomization. The
groups’ demographic characteristics and homogeneity were
assessed. Verbal consent was obtained from all patients after
an explanation about the study.
The State-Trait Anxiety Inventory and the OSQLS were
applied to the deep breathing exercise group the night before
the surgery, and they were provided with information about
the deep breathing exercise. It was ensured that the patients
performed the deep breathing exercise between postopera-
tive hours 1 and 6 as 10 breaths per hour. The State Anxiety
Inventory and the OSQLS were applied at the end of the
6th hour.
The State-Trait Anxiety Inventory and the OSQLS were
applied to the 4–7-8 breathing technique group the night
before the surgery, and they were provided with information
about the 4–7-8 breathing technique. It was ensured that
the patients applied the 4–7-8 breathing technique between
postoperative hours 1 and 6 as 1 set (4 breaths) per hour. The
State Anxiety Inventory and the OSQLS were applied at the
end of the 6th hour.
The State-Trait Anxiety Inventory and the OSQLS were
applied to the control group the night before the surgery. The
State Anxiety Inventory and the OSQLS were applied at the
end of the 6th postoperative hour without any intervention.
923
Data Evaluation
Data analysis was performed using the Statistical Package
for the Social Sciences (SPSS) 26 package program. When
evaluating the study data, numbers and percentages were
used for categorical variables (e.g., sex), whereas mean and
standard deviation were used for numerical variables (e.g.,
age). The normality assumption of numerical variables was
examined by the Kolmogorov–Smirnov test of normality,
and they were found to be normally distributed. Therefore,
parametric statistical methods were employed in the study.
Differences between the two dependent numerical vari-
ables were examined by the dependent samples t-test. Dif-
ferences between more than two independent groups were
checked by One-way analysis of variance (ANOVA). In case
of a difference as a result of one-way Analysis of Variance
(ANOVA), Tukey’s test was conducted to determine from
which group the difference originated. The relationships
between two independent categorical variables were checked
by chi-square analysis, and the relationships between two
independent numerical variables were checked with Pear-
son’s correlation coefficient. Statistical significance was
interpreted at the 0.05 level in the analyses.
Ethical Principles Before starting the study, the ethical
board approval no. B.30.2.ATA.0.01.00/364 has been taken
from the Medical Faculty Ethical Board of a university. The
patients voluntarily accepting to participate in the study have
been included. Verbal approvals of the patients have been
taken after giving necessary explanations. Participants have
been told that they could leave the study process whenever
they want. The attained data and the identity of the answerer
have been specified to be kept confidential. Because it is
necessary to protect the individual rights, Human Rights
Helsinki Declaration has been respected during the study.
Results
It was revealed that the majority of the groups consisted of
female individuals, who were married, whose income was
equal to their expenses in terms of economic status, who had
another health problem, who had been hospitalized previ-
ously, and who did not consume alcohol. While the majority
of the patients in the 4–7-8 breathing technique group were
high school graduates, the majority of the patients in the
deep breathing and control groups had bachelor’s degrees.
Whereas most patients in the control group smoked, the
majority of the patients in the 4–7-8 breathing technique
and deep breathing groups were non-smokers. The mean
age of the patients in the 4–7-8 breathing technique group
was 35.30 ± 10.32, while it was 35.20 ± 8.36 in the deep
breathing group and 33.50 ± 7.57 in the control group. The
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924 Obesity Surgery (2023) 33:920–929

mean BMI of the patients in the 4–7-8 breathing technique
group was 41.20 ± 5.40, and it was 39.09 ± 5.12 in the deep
breathing group and 38.47 ± 4.27 in the control group. Upon
comparing the descriptive characteristics of the patients in
the 4–7-8 breathing technique, deep breathing exercise, and
control groups, they were revealed to have similar charac-
teristics (p > 0.05) (Table 1).
Whereas the pre-test state anxiety level of the patients
in the 4–7-8 breathing technique group was 42.10 ± 11.53,
this level was 35.87 ± 8.11 in the post-test, and their pre-
test quality of life level was 55.35 ± 19.79, and this level
was 54.43 ± 22.27 in the post-test. While the pre-test state
anxiety level of the patients in the deep breathing group
was 41.30 ± 11.19, this level was 41.53 ± 11.21 in the
post-test, and while their pre-test quality of life level was
52.19 ± 16.29, it was 56.25 ± 16.13 in the post-test. Whereas
the pre-test state anxiety level of the patients in the con-
trol group was 45.90 ± 10.23, this level was 46.80 ± 6.13 in
the post-test, and while their pre-test quality of life level
was 47.17 ± 18.54, it was 53.85 ± 18.69 in the post-test.
As a result of the one-way analysis of variance (ANOVA)
applied, there was no statistically significant difference
between the 4–7-8 breathing technique, deep breathing
exercise, and control groups in terms of the pre-test state

Table 1  Distribution of 4–7-8 breath Deep breath Control Chi p

descriptive characteristics by (n = 30) (n = 30) (n = 30) square
groups
n % n % n %

Gender 3.641 0.162

Female 23 76.7 20 66.7 16 53.3
Male 7 23.3 10 33.3 14 46.7
Marital status 0.388 0.824
Married 20 66.7 20 66.7 18 60.0
Single 10 33.3 10 33.3 12 40.0
Education status 9.126 0.287
Literate 2 6.7 0 0.0 0 0.0
Primary school 3 10.0 5 16.7 1 3.3
High school 12 40.0 6 20.0 9 30.0
Licence 10 33.3 14 46.7 16 53.3
Degree 3 10.0 5 16.7 4 13.3
Economical Situation 4.224 0.373
Income less than expenses 3 10.0 7 23.3 2 6.7
Income equal to expense 15 50.0 14 46.7 14 46.7
Income more than expenses 12 40.0 9 30.0 14 46.7
Another health problem 4.170 0.149
No 15 50.0 9 30.0 8 26.7
Yes 15 50.0 21 70.0 22 73.3
Previous surgery status 3.824 0.148
Yes 18 60.0 17 56.7 11 36.7
No 12 40.0 13 43.3 19 63.3
Previous hospitalization status 4.170 0.124
Yes 21 70.0 15 50.0 22 73.3
No 9 30.0 15 50.0 8 26.7
Smoking 4.625 0.099
Yes 12 40.0 14 46.7 20 66.7
No 18 60.0 16 53.3 10 33.3
Alcohol use 0.317 0.853
Yes 8 26.7 9 30.0 10 33.3
No 22 73.3 21 70.0 20 66.7
Ave SD Ave SD Ave SD F p
Age 35.30 10.32 35.20 8.36 33.50 7.57 0.394 0.676
Body Mass İndex 41.20 5.40 39.09 5.12 38.47 4.27 2.501 0.088

% percentage, n number, Ave avarege, SD standard deviation, F one way analysis of variance (ANOVA)

13
Obesity Surgery (2023) 33:920–929 925

anxiety, pre-test trait anxiety, pre-test quality of life, and
post-test quality of life levels (p > 0.05), but there was a
statistically significant difference in terms of their post-test
state anxiety levels (p < 0.05). Accordingly, the state anxi-
ety levels of the patients in the 4–7-8 breathing technique
group were significantly lower than the state anxiety levels
of the patients in the deep breathing and control groups. As
a result of the dependent samples t-test, the state anxiety
scores of the patients in the 4–7-8 breathing technique group
decreased significantly in the post-test compared to the pre-
test. The dependent samples t-test showed that the quality of
life scores of the patients in the deep breathing and control
groups increased significantly in the post-test compared to
the pre-test (p < 0.05) (Table 2) (Fig. 2).
There was a statistically significant low negative linear
correlation between pre-test trait anxiety scores and age
(r =  − 0.209). A statistically significant low negative linear
correlation was found between post-test state anxiety scores
and BMI (r =  − 0.229) (Table 3).
Discussion
In this study examining the effects of the 4–7-8 breathing
technique and deep breathing exercises applied to patients
who had undergone bariatric surgery on their anxiety level
and quality of life, the results were interpreted and discussed
in light of close group studies and the literature since there
are limited studies directly related to the subject.
Upon comparing the descriptive characteristics of the
patients in the 4–7-8 breathing technique, deep breathing
exercise, and control groups, they were found to have similar

Table 2  Comparison of pre-test and post-test scale scores within and between groups
1) 4-7-8 breath 2) Deep breath 3) Control F p Difference
(n=30) (n=30) (n=30)
Ave SD Ave SD Ave SD

State anxiety Pre test 42.10 11.53 41.30 11.19 45.90 10.23 1.498 0.229
Post test 35.87 8.11 41.53 11.21 46.80 6.13 11.745 0.000* 1–2.3
t=2.912 t=−0.157 t=−0.462
p=0.007* p=0.877 p=0.647
Trait anxiety Pre test 45.50 7.38 45.33 5.87 46.00 8.36 0.068 0.934
Life quality Pre test 55.35 19.79 52.19 16.29 47.17 18.54 1.530 0.222
Post test 54.43 22.27 56.25 16.13 53.85 18.69 0.128 0.880
t=0.326 t=−2.114 t=−3.185
p=0.747 p=0.043* p=0.003*

Comparisons between groups: F one-way analysis of Variance (ANOVA), Difference Tukey Test
Within-group comparisons: t dependent sample T-test

STAT ANXİETY LİFE QUALITY

PRE TEST POST TEST PRE TEST POST TEST
56.25
55.35
48.8
46.8

54.43

53.85
41.53
42.1

41.3

52.29
35.87

47.17

4-7-8 BREATH DEEP BREATH CONTROL 4-7-8 BREATH DEEP BREATH CONTROL

Fig. 2  Pre-test post-test mean scores between groups

13
926
Table 3  Examining the Relationships between pre-test and post-test
scale scores and age and BMI
Age BMI
Pre test State anxiety R 0.003 − 0.087
P 0.978 0.415
Trait anxiety R − .209* 0.071
P 0.048 0.507
Life quality R − 0.201 0.165
P 0.057 0.119
Post test State anxiety R − 0.182 − .229*
P 0.086 0.030
Life quality R − 0.150 0.083
P 0.159 0.437
R Pearson correlation coefficient *:P < 0.05
characteristics. The absence of a statistically significant dif-
ference between the groups indicates that all three groups
are similar. The similarity of the groups is thought to be
important in terms of reliability in evaluating the effects of
the 4–7-8 breathing technique and deep breathing exercises
on anxiety level and quality of life (Table 1).
Studies showing that surgical interventions cause anxiety
in individuals are available [36–40]. It is known that anxiety
and depression adversely affect recovery in the postoperative
period, increase the length of hospital stay and hospitaliza-
tion costs, cause dysfunction, increase the suicide rate, and
reduce the quality of life [41].
A study found that 31% of the patients had anxiety symp-
toms after bariatric surgery [42]. In another study carried out
with bariatric surgery candidates, approximately 34% of the
patients were diagnosed with anxiety disorder [43].
In this study, no statistically significant difference was
found between the groups in terms of the state and trait
anxiety pre-test mean scores (p > 0.05) (Table 2.). The fact
that the groups’ mean scores were similar and statistically
insignificant in the pre-test is an expected situation and a
result that increases the study’s power since no application
was performed.
Upon comparing the intra-group pre-test and post-test
scale mean scores, while the patients in the 4–7-8 breath-
ing technique group had moderate anxiety in the pre-test,
it decreased to mild anxiety in the post-test, and their state
anxiety level decreased significantly (p < 0.05). It was found
that the state anxiety levels of the patients in the 4–7-8
breathing technique group were significantly lower than the
state anxiety levels of the patients in the deep breathing exer-
cise and control groups in the post-test (p < 0.05) (Table 2.).
Breathing techniques bring the body into a state of deep
relaxation. Holding the breath for a while ensures that the
body renews its oxygen. Techniques, such as 4–7-8 breathing
exercise, provide the required oxygen support to organs and
13
Obesity Surgery (2023) 33:920–929
tissues and help to expel C­ O2. Such practices reduce anxiety
by both distracting and providing relaxation by oxygenat-
ing and expelling the ­CO2 accumulated in the body. It was
expected to reduce anxiety due to these effects.
There are national publications on the 4–7-8 breathing
technique, and only one international study was found on
the said issue. The study by Pandekar and Thangavelu [28]
demonstrated that the 4–7-8 breathing technique effectively
reduced anxiety and depression in moderate COPD patients.
This study is extremely important in terms of being a source
for the literature.
The results of the present study are similar to the litera-
ture and confirm hypothesis H1, stating: “The 4–7-8 breath-
ing technique effectively reduces the postoperative anxiety
level of patients.”
With deep breathing exercises, the muscle strength of
the diaphragm increases, the lung tidal volume capacity
increases, the excretion of secretions is facilitated, and it
provides calmness with mobility to the lungs and chest wall
[44]. In the current study, no statistically significant differ-
ence was detected between the mean state anxiety scores in
the pretest–posttest intra-group comparison of the patients
performing deep breathing exercises. It is thought that this
result originates from the fact that the study was conducted
in a private hospital, all patients were informed about deep
breathing exercises during the preoperative period and prac-
ticed them actively. However, since the researcher also had
deep breathing exercises done, it is remarkable that the post-
test state anxiety mean scores of the patients performing
deep breathing exercises were lower than the mean post-test
anxiety scores of the patients in the control group, although
there was no significant difference between them.
Studies conducted with different sample groups have
revealed that the groups to which deep breathing exercises
were applied had lower mean anxiety scores, which is simi-
lar to the literature [45–50].
It is thought that the absence of a statistically signifi-
cant difference in this study originated from the fact that
the study was conducted in a private hospital, the patients
were informed in detail before the surgery, and they had
knowledge about deep breathing exercises. It is known that
private hospitals providing services under free competition
conditions are more willing to inform patients and their rela-
tives in order to ensure customer satisfaction and provide
detailed information to patients both before they come to
the hospital and during their hospital stay [51]. Information
in the literature supports our interpretation.
The study results do not support hypothesis H2 stating,
“Deep breathing exercises effectively reduce the postopera-
tive anxiety level of patients.”
This study determined that the state anxiety levels of the
patients in the 4–7-8 breathing technique group were sig-
nificantly lower than the state anxiety levels of the patients
Obesity Surgery (2023) 33:920–929
in the deep breathing and control groups. The said result
indicates that although the 4–7-8 breathing technique is new,
it attracts the attention of patients, effectively reduces the
anxiety level and is a more successful and applicable method
than deep breathing exercises.
Anxiety impacts the quality of life adversely to a sig-
nificant extent. The general picture that emerged in a study
demonstrates that anxiety impairs quality of life and social
functionality in many areas of life [19].
Upon comparing the pretest–posttest mean quality of life
scores of the 4–7-8 breathing technique group, no statistical
significance was determined. Although the quality of life is
affected by many factors, it is thought that the practice does
not affect the quality of life since it is a new practice. The
results of this study do not confirm hypothesis H3 stating:
“The 4–7-8 breathing technique effectively improves the
postoperative quality of life of patients.”
When the pretest–posttest mean quality of life scores
of the patients in the control group were compared, it was
revealed that their quality of life levels increased signifi-
cantly (p < 0.05). Studies have determined a significant
increase in the quality of life of patients after bariatric sur-
gery [52–55]. The results are similar to the literature, and it
is considered that quality of life levels may not be related to
weight loss but to meeting patients’ expectations.
When the intra-group pre-test-post-test quality of life
mean scores of the patients in the deep breathing group
were compared, it was observed that the mean quality of life
scores increased significantly (p < 0.05) and the quality of
life improved. There is no study in the literature evaluating
the impacts of deep breathing exercises applied after bariat-
ric surgery on quality of life. Studies conducted with differ-
ent sample groups demonstrate that deep breathing exercise
increases the quality of life [56–61]. The research results
are similar to this study. The results of the study support
hypothesis H4, indicating, “Deep breathing exercises effec-
tively improve the postoperative quality of life of patients.”
A statistically significant low negative linear correlation
was determined between the pre-test and post-test mean
anxiety scores and age (r =  − 0.209) (Table 3). Likewise, in
the studies by Taşkın [62] and Dugas, Gosselin, and Ladou-
ceur [63], a significant negative correlation between anxiety
and age was found. Again, studies have reported that the
level of preoperative anxiety increases as age decreases [64,
65]. It is thought that young people’s use of technology in
many areas of their lives, being able to follow communica-
tion tools more closely, being aware of negative events in
the field of health, and a more fatalistic perspective with the
increasing age may affect this result [66].
Although it is considered that there is a positive correla-
tion between obesity and anxiety, there are studies indicat-
ing no significant correlation or showing a negative correla-
tion between them [67–69]. This study found a statistically
927
significant, negative and weak correlation between post-
test state anxiety scores and BMI (r =  − 0.229). Studies
have revealed that anxiety and depression levels decrease
as BMI increases [70, 71]. In some people, as anxiety lev-
els increase, their eating tendency also increases, and their
anxiety levels decrease as they eat. As a result, they may be
overweight but have lower anxiety levels. The results of this
study are parallel with the literature.
Limitations and Generalizability of the Study
The study’s limitations are that it was conducted at a single
hospital and was single-blinded. The results of this study can
be generalized to the determined population.
Conclusions
It was determined that the difference between that the State-
Trait Anxiety Inventory and OSQLS mean scores was simi-
lar and was not statistically significant in the pre-test in each
of the three groups, the state anxiety level decreased in the
post-test compared to the pre-test in the intra-group com-
parison of the 4–7-8 breathing technique group, the anxiety
level of the 4–7-8 breathing technique group was lower and
statistically significant compared to both groups, and the
quality of life score increased in the post-test compared to
the pre-test in the intra-group comparison of the deep breath-
ing group. In line with these results, it is recommended that
nurses should research the current alternative methods and
know non-pharmacological methods such as the 4–7-8
breathing technique, in-service training on the importance
and application of the 4–7-8 breathing technique should be
provided, more randomized controlled studies on this issue
should be conducted, and the research results should be
reflected on patient care.
Acknowledgements Thanks to all for their participation in this study.
This study has been registered with the Clinical Trials Registry
(NCT05492929).
Author Contrıbutıon Gülfidan Kurt: conceptualization, methodology,
software, formal analysis, investigation, resources, data curation, writ-
ing—original draft, visualization; Vesile Eskici İlgin: conceptualiza-
tion, methodology, validation, writing—review and editing.
Declarations
Ethical Approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
13
928
Conflict of Interest The authors declare no competing interests.
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