Health Related Quality of Life After GastricBypass Surgery

Margaret Malone & Sharon Alger-Mayer &

John M. Polimeni

Received: 11 April 2011 /Accepted: 1 September 2011 /Published online: 17 September 2011# Springer Science+Business Media B.V./The International Society for Quality-of-Life Studies (ISQOLS) 2011

Abstract The majority of studies which have evaluated health related quality of lifeare limited in the duration of follow up. The objective of this study was toprospectively conduct an evaluation using a repeated cross sectional analysis ofseparate patient cohorts who were up to four years after gastric bypass surgery. AdultRoux-en-Y gastric bypass patients were recruited to the study. All patients wererequested to complete a general health status questionnaire, the Short Form-36(SF-36), before surgery or at their post operative out patient follow up visits.Patient weight was documented at each follow up visit. A cross sectionalanalysis was performed to evaluate SF-36 scores in each annual cohort. Dataare reported as mean +/− S.D. Three-hundred-eight patients completed at leastone SF-36 assessment [Initial assessment at the time of surgery, time 1, n=245,1y n=149, 2y n=70, 3y n=59, 4y n=61]. The SF-36 scores were greater (p<0.05)in each of the separate post surgery cohorts for physical functioning, rolelimitations due to physical health, social functioning, pain, vitality, general healthand the physical component summary (PCS) scores. While not comparing changesin scores within individuals over time, these data suggest early improvementespecially in the physical dimension of health related quality of life. In thisanalysis, this finding was also observed in each of the separate cohorts up to4 years after gastric bypass surgery.

Keywords Long term outcome . Gastric bypass surgery

Applied Research Quality Life (2012) 7:155–161DOI 10.1007/s11482-011-9157-3

M. Malone (*) : J. M. PolimeniDepartment of Pharmacy Practice, Albany College of Pharmacy and Health Sciences,106 New Scotland Ave, Albany, NY 12208, USAe-mail: Margaret.malone@acphs.edu

S. Alger-MayerDepartment of Medicine, Albany Medical College, Albany, NY 12208, USA

Introduction

Many studies have reported long term improvements after weight loss inassociated metabolic co-morbidities such as type 2 diabetes mellitus, hyperten-sion and dyslipidemia (Dhabuwala et al. 2000; White et al. 2005; Silver et al.2006). The Medical Outcomes Study: Short Form-36 (SF-36) is a generic healthstatus measure which has been used to assess health related quality of life in avariety of weight management studies, both in non surgery and bariatric surgicalsettings (Wadden and Phelan 2002; Malone and Alger-Mayer 2004; Kolotkin et al.2011). Recently the Bariatric Analysis and Reporting Outcome System was revisedto be used as a method to uniformally assess outcome including quality of lifeacross different programs (Oria and Moorehead 2009) While there are examples inthe literature of studies showing improved quality of life in the first year afterbariatric surgery including data from our center (Malone and Alger-Mayer 2004;Buchwald et al. 2004; Sears et al. 2008), there is limited information regardinglonger term outcomes. In a recent study we found that weight loss outcomes up to sixyears after surgery were not affected by binge eating behavior, depressive symptoms orquality of life prior to surgery (Alger-Mayer et al. 2009). However, since the focus ofthat study was on the predictive value of these factors on post operative weight loss,we did not address the quality of life scores after surgery. Since many patientsexperience their greatest weight loss and health improvements during the first one totwo years after surgery, quality of life assessment based studies which are limited toone year may not be representative of the potential for long term benefit.

In this study the objective was to assess the reported health related quality oflife in separate surgery patient cohorts over a period of up to four years aftergastric bypass surgery.

Methods

Institutional review board approval was obtained. Adult patients who wereundergoing Roux-en-Y gastric bypass surgery at this University based bariatrictreatment center were invited to participate in the study. Patients were requestedto complete the SF-36 prior to surgery or at their annual post operative followup out patient appointments. All patients were followed post operatively by oneof two surgeons and one Clinical Nutrition attending physician.

Health Related Quality of Life Assessment

The SF-36 is a widely used general health status measure which contains 36items in 8 domains of functioning: physical functioning (PF), role limitationsdue to physical health problems (RP), bodily pain (P), general health perception(GH), vitality (V), social functioning (SF), role limitations due to emotionalproblems (RE) and mental health (MH). Each of these items are scored fromzero to 100, with a high score being associated with a high level of functioningin that domain. The SF-36 also contains a single item where patients are askedto estimate their overall health status compared to a year prior, termed a health

156 M. Malone et al.

transition score (HT). The scale ranged from 1 to 5, where 1 = much better, 2 =somewhat better, 3 = about the same, 4 = somewhat worse and 5 =muchworse. Physical(PCS) and mental (MCS) component summary scores are calculated from responsesgiven to the above subscales. (Ware et al. 1993).

Cross Sectional Analysis of Health Related Quality of Life (SF-36) Scores

All patients who completed a questionnaire at any time point including at the time ofsurgery (Time 1), 1, 2, 3 or 4 years were included. Patient weight was documented ateach out patient visit regardless of whether the patient completed the SF-36. Thetotal body weight (%TBW) and excess body weight loss (%EBW) was calculated forthe individuals at each time point.

Data Analysis

Data are reported as mean +/− SD For the repeated cross sectional analysis a MannWhitney U test was used to compare SF-36 scores between Time 1 and 1, 2, 3 and4 years. For all statistical analyses, only coefficients with a p value of <0.05 wereconsidered significant.

Results

i) Demographic and weight loss data of participants.

308 patients were included, 260 (84.4%) were females. Their age was 45±10 years. Their pre surgery body mass index (BMI) was 52.2±8.6 kg/m2. The datarelated to total body weight (TBW), percent total body weight loss (%TBW) andexcess body weight loss (%EBW) at each time period is presented in Table 1. In thisbariatric program patients are recommended to achieve a 10% TBW loss based ontheir presenting weight prior to surgery. Accordingly the % TBW loss prior tosurgery was 10±6% and % EBW lost was 17±10%. As expected there was someweight regain over the subsequent 4 year follow up period. There was no significantdifference (p=0.279) in the baseline age, gender or weight of the individualsincluded within each time period assessed.

Table 1 Weight observed up to four years after gastric bypass surgery

Parameter Pre surgeryn=308

Surgeryn=308

12 monthsn=265

24 monthsn=220

36 monthsn=163

48 monthsn=125

Total body weight (TBW)Mean SD

321 62 289 54 205 46 207 49 211 51 219 53

% Total body weight (TBW)lost Mean SD

– 10 6 36 9 35 10 33 11 31 11

% Excess body weight (EBW)lost Mean SD

– – 17 10 62 16 61 17 57 18 54 19

Health Related Quality of Life After Gastric Bypass Surgery 157

ii) Health related quality of life assessment during the four year follow up period.

SF-36 scores in all parameters in the patients assessed initially at the time ofsurgery, Time 1, (n=245), were significantly lower than those observed in theseparate surgery cohorts at any of the subsequent time periods assessed (p<0.05)(Table 2). Health related quality of life scores were highest in patients assessed atone year after surgery (p<0.05) (n=149). The majority of SF-36 scores in thepatients assessed at two years (n=70), three years (n=59) and four years (n=61)were lower from those observed in the one year cohort but were higher than thetime 1 cohort scores (p<0.05). The mental component summary score (MCS) wasclose to population norms prior to surgery and was only higher in the one yearcohort (p<0.05). In all subsequent cohorts the MCS scores were not significantlydifferent (p>0.05) from the Time 1 cohort. The health transition scores whichreflected patient responses to the question “how would you rate your healthcompared to one year ago” were significantly lower (indicating a perceivedimprovement) only in the one year cohort.

Discussion

Based on this repeated cross sectional analysis health related SF-36 scores werehigher in each separate surgery cohort for all of the post operative years compared tothe Time 1 cohort suggesting quality of life was better in observed patients up to four

Table 2 Health related quality of life (SF-36) scores up to four years after gastric bypass surgeryfor all participants

SF-36 parameter Time 1n=245Mean SD

One year n=149Mean SD p

Two year n=70Mean SD p

Three year n=59Mean SD p

Four year n=61Mean SD p

PF 55 26 89 18 0.00 85 21 0.00 84 23 0.00 78 24 0.00

RP 40 42 90 27 0.00 87 32 0.00 84 33 0.00 73 39 0.00

RE 66 42 88 29 0.00 75 40 0.07 80 35 0.02 77 39 0.07

SF 65 26 87 21 0.00 81 25 0.00 82 27 0.00 76 27 0.03

P 52 25 76 24 0.00 72 23 0.00 70 25 0.00 69 26 0.00

MH 71 19 80 18 0.00 74 19 0.25 73 17 0.85 72 22 0.56

V 43 21 69 20 0.00 61 22 0.00 58 24 0.00 52 26 0.00

GH 59 21 83 17 0.00 80 17 0.00 82 18 0.00 73 21 0.00

HT 2.4 1.1 1.2 0.7 0.00 2.1 0.9 0.40 2.5 1.0 0.07 2.9 0.9 0.00

PCS 38 10 53 9 0.00 52 9 0.00 50 10 0.00 46 11 0.00

MCS 48 11 53 10 0.00 47 13 0.67 48 13 0.61 48 13 0.62

a PF Physical functioning, RP role limitations due to physical health problems, RE role limitations due toemotional problems, SF social functioning, P bodily pain, MH mental health, V vitality, GH general healthperception, HT health transition compared to one year ago, PCS physical component, MCS mentalcomponent, summary scores.

*p<0.05 was considered statistically significant. P values shown in each column represent a comparisonof scores between time 1 values and those from the selected time period

158 M. Malone et al.

years after gastric bypass surgery. Changes in the physical dimension weremore positively impacted than those in the mental health aspects of theassessment. Consistent with the current national and international data therewere more women than men in each cohort, which may limit the applicabilityof these findings to male gastric bypass patients (Samuel et al. 2006). However,there were no significant differences (p>0.05) in the baseline age, gender orweight of individuals included in each of the separate surgery cohorts which allowscomparison between these groups without concern over these cofounding variableswhich may also affect quality of life.

In our study mental health aspects of the SF-36 were the least affected aftersurgery. However, the MCS scores were close to the population norms beforesurgery and were therefore unlikely to show marked positive change. Othershave also assessed mental health before and after bariatric surgery. In a reviewof the behavioral evaluation of bariatric candidates, it was determined thatpsychiatric status, especially depression, did not predict post operative weightloss (Wadden and Sarwer 2006). In a previous study we observed that pre surgicalbinge eating status, incidence of depressive symptoms and health related quality oflife at baseline also did not affect weight loss outcomes after surgery (Alger-Mayeret al. 2009) We found that our patients did not generally discontinue antidepressant medication after surgery and still required medical care for theirdepressive illness (Malone and Alger-Mayer 2005). Recently we reported thatpatients who were taking antidepressant medication prior to surgery had the sameweight loss outcome as those who were not taking these medications. (Malone etal. 2011). Data have also been reported from a study population of 794 bariatricsurgery candidates showing that the presence of depression affected mental but notphysical health related quality of life (Kolotkin et al. 2008).

Others have assessed patients with obesity related co-morbid diseaseincluding metabolic syndrome to separate the independent effect of theseassociated problems from weight (Tsai et al. 2008). These authors used the SF-36 to assess differences in patients with or without metabolic syndrome whowere seeking weight reduction. They concluded that metabolic syndrome per sedid not affect SF-36 scores instead that lower scores were primarily associatedwith higher weight. Similar to our findings the SF-36 scores in their study wereaffected primarily in the physical domains. In other bariatric populations qualityof life scores on the SF-36 were improved three years after gastric bypass (n=52) and gastric banding (n=52) surgery. The purpose of the study was to comparethe outcome between the 2 procedures. Although gastric bypass patients lost moreweight and showed greater improvement in obesity related co-morbidities thanbanded patients, quality of life was equally improved (Muller et al. 2008).

The present study is limited by the number of patients lost to follow up afterthe first year, which is common in bariatric treatment programs. This preventedus from comparing individual patient’s changes in quality of life over time.However using the findings from this cross sectional analysis, since the patientdemographic data remained constant between cohorts, it may be inferred thatthe observed improvement on SF-36 scores are likely to be representative ofgeneral outcome after surgery at least of those individuals who were motivatedto return for follow up care. Ideally all patients would have completed at least

Health Related Quality of Life After Gastric Bypass Surgery 159

one assessment each year after surgery but this is difficult to achieve in theclinical setting when patients fail to complete and return the questionnaires on aconsistent basis. This issue affects the interpretation of these findings sincepatients who return for clinic appointments may differ in their post operativeoutcome than those that fail to return for follow up, resulting in a skewedpopulation available for assessment. Unfortunately the problem of missing datafrom patients at the extended time periods after surgery is very difficult toavoid. This similar concern has been expressed by other centers and is difficultto resolve, even with an intensive effort to contact patients by telephone andmail to encourage them to keep their follow up appointments (Peluso andVanek 2007). Lastly the SF-36 is a general health status measure which is notintended to specifically evaluate reasons for changes in mental health. Based onour data and other literature it may be necessary to use a more specific measure toassess such changes in overweight and obese individuals as there is limited impacton SF-36 scores in the mental health aspect of health related quality of lifeobserved in most studies (Wadden and Sarwer 2006, Dixon et al. 2004).

Conclusion

Quality of life is impacted by many issues unrelated to weight or bariatric surgery.Our findings are consistent with other studies which show that health related

quality of life scores especially those in the physical functioning dimensionwere higher in each of the separate surgery cohorts assessed after surgerycompared to the scores before surgery. This positive impact on these assessedoutcomes was observed for up to four years after surgery in those patients whoreturned for clinic appointments. None of the currently available data cananswer whether these findings can be extrapolated to those patients who do notfollow up with their recommended post bariatric surgery annual follow up visits.

References

Alger-Mayer, S., Rosati, C., Polimeni, J. M., & Malone, M. (2009). Pre-operative binge eating status andgastric bypass surgery: a long term outcome study. Obes Surg, 19, 139–145.

Buchwald, H., Avidor, Y., Braunwald, E., Jensen, M. D., Pories, W., Fahrbach, K., et al. (2004). Bariatricsurgery: a systematic review and meta analysis. JAMA, 292, 1724–1737.

Dhabuwala, A., Cannan, R. J., & Stubbs, R. S. (2000). Improvement in co-morbidities following weightloss from gastric bypass surgery. Obes Surg, 10, 428–435.

Dixon, J. B., Anderson, M., Cameron-Smith, D., & O’Brien, P. E. (2004). Sustained weight loss in obesesubjects has benefits that are independent of attained weight. Obes Res, 12, 1895–1902.

Kolotkin, R. L., Crosby, R. D., Gress, R. E., Sc, H., Engel, S. G., & Adams, T. D. (2008). Health andhealth related quality of life: differences between men and women who seek gastric bypass surgery.Surg Obes Relat Dis, 4, 651–659.

Kolotkin, R. L., LaMonte, M. J., Litwin, S., Crosby, R. D., Gress, R. E., Yanowitz, F. G., et al. (2011).Cardiorespiratory fitness and health related quality of life in bariatric surgery patients. Obes Surg, 21,457–464.

Malone, M., & Alger-Mayer, S. (2004). Binge status and quality of life after gastric bypass surgery. ObesRes, 12, 473–481.

160 M. Malone et al.

Malone, M., & Alger-Mayer, S. (2005). Medication use patterns after gastric bypass surgery for weightmanagement. Ann Pharmacother, 39, 637–642.

Malone, M., Alger Mayer, S., & Polimeni, J. M. (2011). Antidepressant drug therapy does not affectweight loss one year after gastric bypass surgery. Obes Surg. doi:10.1007s11695-010-0351-4.

Muller, M. K., Wenger, C., Schiesser, M., Clavien, P. A., & Weber, M. (2008). Quality of life afterbariatric surgery: a comparative study of laparoscopic banding vs bypass. Obes Surg, 18, 1551–1557.

Oria, H. E., & Moorehead, M. K. (2009). Updated Bariatric Analysis and Reporting Outcome System(BAROS). Surg Obes Relat Dis, 5, 60–66.

Peluso, L., & Vanek, V. W. (2007). Efficacy of gastric bypass in the treatment of obesity relatedcomorbidities. Nutr Clin Pract, 22, 22–28.

Samuel, I., Mason, E. E., Renquist, K. E., Huang, Y. H., Zimmerman, M. B., & Jamal, M. (2006).Bariatric surgery trends: an 18 year report from the International Bariatric Surgery Registry. AmJ Surg, 192, 657–662.

Sears, D., Fillmore, G., Bui, M., & Rodriguez, J. (2008). Evaluation of gastric bypass patients one yearafter surgery: changes in quality of life and obesity related conditions. Obes Surg, 18, 1522–1525.

Silver, H. J., Torquati, A., Jensen, G. L., & Richards, W. O. (2006). Weight, dietary and physical activitybehaviors two years after gastric bypass. Obes Surg, 16, 859–864.

Tsai, A. G., Wadden, T. A., Sarwer, D. B., Berkowitz, R. I., Womble, L. G., Hesson, L. A., et al. (2008).Metabolic syndrome and health related quality of life in obese individuals seeking weight reduction.Obesity, 16, 59–63.

Wadden, T. A., & Phelan, S. (2002). Assessment of quality of life in obese individuals.Obes Res, 10, 50s–57s.Wadden, T. A., & Sarwer, D. B. (2006). Behavioral assessment of candidates for bariatric surgery: a

patient orientated approach. Obesity, 14, 53s–62s.Ware JE, Snow K, Kosinski M, Gandek B (1993) SF 36 health survey, manual and interpretation guide.

Boston, New England Medical Center, The Health Institute.White, S., Brooks, E., Jurikova, L., & Stubbs, R. S. (2005). Long term outcomes after gastric bypass. Obes

Surg, 15, 155–163.

Health Related Quality of Life After Gastric Bypass Surgery 161