Gastric bypass patients reported significant improvements in several domains of quality of life within the first few months of surgery. Both health-related, as well as weight-related, quality of life were well maintained through the second postoperative year and, in many cases, were associated with changes in weight. This replicates the recent findings of Kolotkin et al11
who also found that following a weight loss of 34.2% following gastric bypass surgery patients experienced significant improvements in health-related quality of life. In the present study, the baseline scores of several of the SF-36 subscales were higher than those reported by Kolotkin and colleagues. Following a somewhat larger weight loss of 38.8% (95% CI: 37.1, 40.6) at 92 weeks, we saw a similar magnitude of change in most of the subscales of the SF-36. The present study also expands research in this area by documenting that body image, which is an important aspect of quality of life for many individuals, similarly improves following gastric bypass surgery. Like the changes in quality of life, improvements in body image appear to occur relatively early in the postoperative period, which represents a unique contribution to the literature. After that point, quality of life and body image appear to remain relatively stable.
Larger weight losses were associated with improvements in several domains of quality of life. These included both the physical as well as emotional aspects of quality of life. Greater weight losses also were associated with significant improvements on the BIQOL, which assesses body image quality of life, but not with changes on the BSQ, which assesses more general weight and shape concerns. In some respects, the lack of consistent changes across the body image measures is surprising. However, it may suggest that while larger weight losses are associated with greater improvements in multiple quality of life domains (including body image quality of life), a larger weight loss may not be directly associated with greater improvements in weight and shape concerns, as assessed by the BSQ. Dixon and colleagues similarly found a discrepancy in changes in body image in persons who underwent laparoscopic adjustable gastric banding.18
They found improvements in overall body image satisfaction (as assessed by the Appearance Evaluation subscale of the Multidimensional Body-Self Relations Questionnaire) but not changes in body image investment (as assessed by the Appearance Orientation subscale of the measure).
In general and as anticipated, changes in body image were positively associated with changes in quality of life. However, these relationships were not universal and varied across the two body image measures and the subscales of the two quality of life instruments. Collectively, these results highlight the methodological challenge of selecting the most appropriate measure of body image for a given population. Many of the measures of body image, including the BSQ, were developed from the eating disorders literature. As a result, they may not be the most appropriate measures of body image for obese individuals, let alone those persons with extreme obesity20,27
The body image results of the present study also may be understood in the context of body contouring following bariatric surgery. According to the American Society of Plastic Surgery, approximately 55,000 individuals underwent body contouring surgery following massive weight loss in 2008 28
. Theoretically, body image dissatisfaction has been thought to motivate cosmetic surgery 29
and studies have suggested that body image dissatisfaction predicts interest in cosmetic surgery in the future 30–31
. Dissatisfaction with loose and hanging skin is also thought to play a similar motivational role in the decision to seek body contouring surgery after bariatric surgery 27
. While this relationship has received relatively little empirical attention, it may help explain why larger weight losses are not directly associated with further improvements in weight and shape concerns within the first two years of bariatric surgery.
Body contouring surgery after weight loss is rarely covered by insurance. While patients often indicate they are considering plastic surgery even before they undergo their bariatric procedures, they should be reminded that these procedures will represent a significant out-of-pocket expense. Those individuals who are experiencing significant body image dissatisfaction associated with the physical changes that accompany a massive weight loss also may experience some relief from these symptoms through cognitive-behavioral psychotherapy specifically designed to address body image concerns, rather than surgical intervention.32
While men showed improvement on the SF-36 mental health summary score through postoperative Week 40 and then remained stable, women showed no further improvement on this subscale after postoperative Week 20 and actually a deterioration back to baseline by postoperative Week 92. We saw a somewhat similar pattern of results for married and non-married individuals with the emotional role subscale of the SF-36, where non-married individuals reported an initial improvement in functioning, followed by a deterioration during the postoperative period, when married individuals maintained these improvements through postoperative Week 92. Similar deteriorations in quality of life were seen in the Swedish Obese Subjects trial within the first few years of surgery 10
. Our results suggest that these changes may be more likely to happen to women than men and non-married than married individuals and may underscore the emotional toll that obesity takes on some women 8,32
. Nevertheless, we note that this pattern of results appeared on only selected subscales and was not uniform across the quality of life and body image measures. Furthermore, the clinical significance of these results is unclear.
While this study provides new information on the changes in quality of life and body image, it also has some limitations. Despite our best efforts, we experienced appreciable attrition over the 92 weeks of the study. Some patients were lost to follow up, while others declined further participation in the study, despite our repeated efforts through multiple modalities to retain them in the study. Attrition was not associated with any of the variables of interest in the study. Our data analytic models provide us with some degree of confidence in the validity of our findings. However, they are not a perfect substitute for greater levels of retention. Unfortunately, our experience with study retention appears to be more the rule than the exception in studies that attempt to follow patients for several years after surgery. This underscores the need for all investigators who work in the area of bariatric surgery to communicate to patients the importance of participation in research in this field, so that we can best educate other patients, providers and third-party payers on the benefits of bariatric surgery.
Future studies should continue to build on this investigation. The present study focused on one psychosocial variable under the umbrella of quality of life—body image. However, there are other areas of quality of life, such as marital and sexual functioning, that have received relatively little research attention. Given our finding on the relationship between the magnitude of weight loss and psychosocial improvements, subsequent studies should compare different procedures, which has not been done in most previous studies in the area. Finally, many of the improvements in quality of life and body image were achieved quite early in the postoperative process and well maintained through the second postoperative year. It will be interesting to see if those benefits are maintained over longer periods of time when some patients begin to regain weight.