Dramatherapy for Psychological and Social Well-Being in Obesity and Bariatric Care

Obesity is a major public health concern worldwide and represents a particularly important challenge in France and in the Hauts-de-France region, where prevalence rates exceed 20% of the adult population. Obesity is associated with increased morbidity and mortality, including cardiovascular diseases, type 2 diabetes, respiratory disorders, musculoskeletal conditions, and psychological distress. In this context, bariatric surgery has become an increasingly common therapeutic option for patients with severe obesity and is currently integrated into multidisciplinary care pathways including medical follow-up, nutritional counseling, psychological support, and adapted physical activity (APA).

Despite the recognized effectiveness of bariatric surgery and APA programs, many patients continue to experience difficulties related to body image, emotional regulation, self-esteem, problematic eating behaviors, and long-term adherence to lifestyle changes. These psychosocial dimensions may negatively affect the sustainability of treatment benefits and contribute to weight regain or reduced quality of life over time. International literature therefore emphasizes the importance of comprehensive interventions integrating psychological and psychosocial support alongside standard medical and nutritional care.

Adapted physical activity is recognized as an essential component of obesity and bariatric care. APA contributes to improvements in physical condition, body composition, psychological well-being, and quality of life. However, long-term adherence to physical activity programs remains challenging for many patients, particularly because of stigma, altered body perception, anxiety related to movement, and low self-confidence.

Dramatherapy (DT) is a creative therapeutic approach using theatrical tools such as role play, improvisation, embodiment, storytelling, symbolic expression, and group interaction to facilitate emotional expression, body awareness, psychosocial adjustment, and identity reconstruction. Although dramatherapy and related creative arts therapies have shown promising effects in mental health and psychosocial rehabilitation, their integration into obesity and bariatric care pathways remains largely underexplored. To date, no randomized controlled trial has systematically evaluated the effects of combining dramatherapy with adapted physical activity in patients with obesity enrolled in medical or bariatric care pathways.

The present study is a monocentric randomized controlled trial conducted at the Institut de l'Obésité of Clinique ELSAN Saint-Omer (France), in collaboration with the URePSSS research laboratory (ULR 7369, Université du Littoral Côte d'Opale). The study aims to evaluate the effects of adding dramatherapy to a standardized APA program in adult patients with obesity participating in either a medical obesity care pathway or a bariatric surgery pathway.

Participants will be recruited during routine consultations within the obesity care program. Eligible participants are adults aged 18 years or older with:

* BMI ≥ 40 kg/m²; * or BMI ≥ 35 kg/m² with obesity-related comorbidities; * or BMI ≥ 30 kg/m² associated with eating disorders or problematic eating behaviors.

Participants must be enrolled in a medical or bariatric care pathway including APA, be able to participate in the study procedures, and provide written informed consent. Exclusion criteria include major medical contraindications to APA or group participation, severe unstable psychiatric disorders, severe cognitive impairment, unstable medical treatment significantly affecting weight or mental health, inability to comply with follow-up procedures, or inability to provide informed consent.

The study follows a randomized controlled design with two parallel groups:

1. Standardized adapted physical activity alone (control group); 2. Standardized adapted physical activity combined with dramatherapy (experimental group).

Randomization will be stratified according to care pathway type (medical versus bariatric). The study uses a two-stage randomized consent design inspired by Zelen methodology. Participants initially consent to participation and randomization, while a second specific consent is requested only from patients allocated to the additional dramatherapy intervention.

The APA program consists of 12 supervised sessions over 6 weeks, delivered by qualified APA professionals. Sessions include cardiovascular exercises, muscle strengthening, and progressive movement activities adapted to the physical capacities of patients with obesity.

The dramatherapy intervention is delivered by a qualified and experienced dramatherapist. It consists of six weekly group sessions lasting approximately 90 minutes each. The intervention uses theatrical expression, role play, improvisation, breathing exercises, body-oriented activities, symbolic work, and collective interaction to improve body awareness, emotional regulation, self-esteem, social interaction, and engagement in care. For patients enrolled in bariatric pathways, dramatherapy may be delivered during pre-operative and/or post-operative phases depending on the timing of inclusion.

The primary objective is to evaluate the effect of adding dramatherapy to APA on quality of life at the end of care compared with APA alone. Quality of life will be assessed using the French version of the EQVOD questionnaire.

Secondary objectives include evaluating:

* eating behaviors and problematic eating regulation using the TFEQ-R18 and SCOFF questionnaires; * body image and body-related quality of life using the BIQLI; * self-efficacy using the General Self-Efficacy Scale (GSES); * anxiety and depressive symptoms using the Beck Depression Inventory-II (BDI-II); * adherence and participation in APA programs; * anthropometric outcomes including body mass index, abdominal circumference, and body composition.

Assessments will be performed at several time points:

* baseline/pre-care assessment; * beginning of care; * end of care; * 6-month follow-up; * 12-month follow-up.

The study also includes a complementary qualitative and ethnographic component intended to enrich interpretation of quantitative findings and explore the subjective experience of participants. Semi-structured interviews, participant observation, body mapping techniques, and identity boxes will be used to investigate body perception, emotional experiences, psychosocial trajectories, relationship to food and movement, and perceptions of dramatherapy and obesity care pathways.

Quantitative analyses will include descriptive statistics, repeated-measures analyses, mixed linear models, subgroup analyses, and exploratory multivariate analyses. Qualitative data will be analyzed using thematic content analysis and triangulated with quantitative findings within a mixed-methods framework.

The target sample size is 250 participants. This sample size was determined to ensure adequate statistical power for the primary outcome analysis while accounting for potential attrition during long-term follow-up.

The expected duration of inclusion is approximately 1 year and 6 weeks. Individual participation lasts 6 weeks for the intervention phase, with follow-up assessments extending to 12 months. The total duration of the research project is estimated at 36 months.

This study aims to provide new evidence regarding the integration of creative therapeutic approaches into obesity and bariatric care pathways and to evaluate whether combining dramatherapy with adapted physical activity may improve psychological well-being, body-related outcomes, adherence to care, and quality of life in patients with obesity.

• Change in Eating Disorder Screening Score Assessed by the SCOFF Questionnaire [Срок оценки: Baseline, end of care approximately 6 weeks, 6 months, and 12 months]
• Change in Eating Behaviors Assessed by the Three-Factor Eating Questionnaire-Revised 18-Item Version [Срок оценки: Baseline, end of care (6 weeks), 6 months, and 12 months]
• Change in Body Image-Related Quality of Life Assessed by the Body Image Quality of Life Inventory [Срок оценки: Baseline, end of care (6 weeks), 6 months, and 12 months]
• Change in Self-Efficacy Assessed by the General Self-Efficacy Scale [Срок оценки: Baseline, end of care (6 weeks), 6 months, and 12 months]
• Change in Depressive Symptoms Assessed by the Beck Depression Inventory-Second Edition [Срок оценки: Baseline, end of care (6 weeks), 6 months, and 12 months]
• Adherence to Adapted Physical Activity Assessed by Attendance Rate [Срок оценки: During the 6 week period]
• Change in Body Mass Index [Срок оценки: Baseline, end of care (6 weeks), 6 months, and 12 months]
• Change in Body Weight [Срок оценки: Baseline, end of care approximately 6 weeks, 6 months, and 12 months]
• Change in Abdominal Circumference [Срок оценки: Baseline, end of care approximately 6 weeks, 6 months, and 12 months]
• Change in Body Composition Assessed by Bioimpedance Analysis [Срок оценки: Baseline, end of care approximately 6 weeks, 6 months, and 12 months]