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Health-related quality of life and psychological functioning 9 years after restrictive surgical treatment for obesity
Surgery for Obesity and Related Diseases ] (2015) 00–00
Original article
Health-related quality of life and psychological functioning 9 years after restrictive surgical treatment for obesity Stephan Herpertz, M.D.a, Astrid Müller, M.D., Ph.D.b,*, Ramona Burgmer, Ph.D.a, Ross D. Crosby, Ph.D.c, Martina de Zwaan, M.D.b, Tanja Legenbauer, Ph.D.d a
Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital of the Ruhr University Bochum, Bochum, Germany b Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany c Neuropsychiatric Research Institute and University of North Dakota, School of Medicine and Health Sciences, Fargo, North Dakota d Department of Child and Adolescent Psychiatry, LWL University Hospital of the Ruhr University Bochum, Hamm, Germany Received November 11, 2014; accepted April 14, 2015
Abstract
Background: Bariatric surgery leads to initial weight loss that is associated with improvement in mental health; however, long-term effects are uncertain. Objective: To investigate the impact of restrictive surgical treatment for obesity on weight loss, psychological functioning, and quality of life 9 years after surgery. Setting: University hospitals and obesity centers, Germany. Methods: 152 patients undergoing restrictive surgical treatment (SURG), 249 individuals participating in a conventional weight loss treatment (CONV), and 128 obese control participants without weight loss treatment (OC) were studied using a prospective longitudinal cohort design. After 9 years, 55% of SURG patients, 51% of CONV patients, and 65% of OC participants were reassessed. Body mass index, anxiety, depression, self-esteem, and health-related quality of life (HRQOL) were explored. Results: The SURG group had significantly greater weight loss and improvements in physical HRQOL at all postbaseline assessments. Although SURG patients experienced initial improvements in depression, anxiety, self-esteem, and mental aspects of HRQOL, these improvements deteriorated at the 9-year assessment and were comparable to or worse than presurgical levels. Conclusions: Bariatric surgery is an effective treatment for obesity and is linked to maintained improvement of physical aspects of HRQOL. Weight reduction after surgery is also associated with significant initial improvement in mental health that may erode over time. Therefore, psychosocial screening should be included at follow-ups, with referral to mental health professionals as appropriate. (Surg Obes Relat Dis 2015;]:00–00.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Obesity; Bariatric surgery; Health-related quality of life; Depression; Anxiety; Self-esteem; Conventional weight loss treatment
Stephan Herpertz and Astrid Müller contributed equally to this work. This study was supported by the German Research Council (DFG; He2665/2-1, He2665/2-2), the Federal Ministry of Education and Research (BMBF, 01 GI 0836), and the Institute Danone for Nutrition, Germany. * Correspondence: Astrid Müller, M.D., Ph.D., Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, CarlNeuberg-Str. 1, 30265 Hannover, Germany. E-mail: [email protected]
Reliable information on the long-term effects of bariatric surgery on psychological functioning is still scarce. The Swedish Obese Subjects (SOS) study indicated sustained weight loss 10 years after surgery that was significantly associated with improved psychological outcomes [1]. However, more recent data suggest some deterioration in depression over time [2,3].
http://dx.doi.org/10.1016/j.soard.2015.04.008 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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S. Herpertz et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
The present study aimed to evaluate the 9-year outcome of bariatric surgery compared with a conventional weight loss treatment and an obese control group. It is part of the multicenter, prospective Essen-Bochum Obesity Treatment Study [4–8]. Earlier findings from the 2- and 4-year followups of surgery patients indicated a considerable initial weight loss corresponding with significant improvement in mental health but some weight regain and slight declines in psychological improvements at the 4-year assessment in this group [7,8]. It was hypothesized that surgery patients would exhibit greater weight loss and greater improvements in psychological functioning 9 years after baseline than conventionally treated patients and obese control participants. Materials and methods Participants Baseline exclusion criteria were body mass index (BMI) o30 kg/m2, age o18 and 465 years, psychotic disorder, dementia, a time period of less than 1 year postpartum in women, and difficulties understanding the German language. Participants were assessed at baseline (T1), 1-year (T2), 2-year (T3), 4-year (T4), and 9-year (T5) follow-ups. The study protocol was approved by the ethics committee, and all participants gave written informed consent. For the surgery group (SURG), 154 consecutive patients from 6 surgery departments were asked to participate. Of those, 1 person refused and 1 person in retrospective did not meet the inclusion criteria, resulting in 152 patients. Most received restrictive obesity surgery procedures (vertical gastroplasty n = 97, gastric banding n = 51). Of 403 consecutive conventionally treated patients who were approached to join the study at 4 obesity treatment centers, 249 were willing to participate. The conventional treatment (CONV) was based on the Optifast® program (Nestle Inc., Vevey, Switzerland) with weekly group sessions over 1 year, including nutritional counseling, behavioral modification, and a liquid meal replacement for the first 12 weeks. Seven individuals had bariatric surgery between T4 and T5, and their 9-year follow-up data were not used for analysis. The obese control (OC) group included 128 obese individuals who were not in an obesity treatment program at baseline. They were selected randomly from the mandatory residence list of the city of Essen (about 600,000 inhabitants) [4]. No participant of the control group reported having bariatric surgery during the follow-ups.
asthma, chronic bronchitis, osteoarthritis, stroke, cancer, gastric/duodenal ulcer, cholecystitis, kidney disease, back pain, and polycystic ovary) were self-reported. Anxiety and depressive symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS) [9,10]. The Short-Form health survey (SF-36) [11,12] was administered to measure HRQOL. Global self-esteem was measured using the Rosenberg Self-Esteem Scale (RSES) [13]. One-year and lifetime prevalence of mood and anxiety disorders at baseline was assessed with the Composite International Diagnostic Interview (M-CIDI) [14]. Statistical analyses A multinomial logistic regression analyses was performed using baseline characteristics (gender, age, education, marital status, living alone, gross annual income, doctor visits and sick days within last 12 months, and 1year and lifetime mood and anxiety disorder) to predict study group. Propensity score adjustment was used to control for pretreatment differences between the 3 nonrandomized groups. This adjustment method essentially involves using baseline characteristics to determine the probability of each person belonging to a given group. The probabilities were then used as covariates in analyses comparing the groups. Mixed-effects repeated measures linear models were used to compare groups on changes from baseline in questionnaires (HADS, RSES, SF-36) using all available data. Analyses were controlled for baseline measurement and propensity score. Post hoc comparisons between the groups at each assessment were based upon covariate-adjusted contrasts. In addition, completer analyses were performed on those participants who had completed both the 4-year and the 9-year assessments. Results Baseline comparisons Group comparisons on baseline characteristics are presented in Table 1. The SURG group was significantly younger and had a lower income than both the CONV and the OC groups, and was less well educated than the CONV group. The SURG group had significantly higher BMIs, more co-morbid somatic diseases, and lower physical functioning (SF-36) than both control groups and more depressive symptoms (HADS) and lower self-esteem (RSES) than the OC group.
Assessment
Study retention
Weight and height were measured in light clothing without shoes. Sociodemographic data and co-morbid somatic disorders (e.g., hypertension, diabetes, coronary artery disease, hyperlipidemia, sleep apnea, bronchial
Patient flow is shown in Fig. 1. Retention rates for all groups exceeded 50% at the 9-year assessment (SURG: 55.3%, CONV: 50.6%, OC: 64.8%) and were significantly higher for the OC group at both the 4-year (χ2 ¼ 9.19,
9-year Follow-up after Bariatric Surgery / Surgery for Obesity and Related Diseases ] (2015) 00–00
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Table 1 Baseline characteristics by study group Characteristic
SURG Group (n ¼ 152)
CONV Group (n ¼ 249)
OC Group (n ¼ 128)
Significance
Post hoc
Female, n, (%)
102 (67.1)
181 (72.7)
92 (71.9)
—
Age, yr, mean (SD)
39.1 (10.3)
42.2 (10.8)
42.5 (11.8)
Completed highest education level (n, %)
21 (13.8)
97 (39.0)
27 (21.0)
Married, n, (%)
90 (59.2)
142 (57.0)
84 (65.6)
Living alone, n, (%)
24 (15.8)
44 (17.7)
24 (18.8)
Gross annual income Z€75,000, n, (%)
29 (19.1)
117 (47.0)
53 (41.4)
BMI, kg/m2, mean, (SD)
50.7 (8.0)
41.2 (7.5)
35.2 (5.0)
Weight, kg, mean, (SD)
147.2 (27.6)
121.3 (26.0)
100.4 (15.0)
Waist circumference, cm, mean, (SD)
221.9 (258.4)
131.9 (97.4)
144.0 (173.5)
Doctor visits last 12 mo, mean, (SD)
3.0 (8.0)
4.6 (20.2)
.7 (2.6)
Sick days last 12 mo, mean, (SD)
31.3 (76.4)
22.4 (64.1)
30.2 (86.5)
Number of comorbid somatic disorders
2.5 (1.9)
1.9 (1.6)
1.5 (1.7)
χ2 ¼ 1.51; df ¼ 2 P ¼ .471 F ¼ 4.50; df ¼ 2, 526 P ¼ .012 χ2 ¼ 33.36; df ¼ 2 P o .01 χ2 ¼ 2.62; df ¼ 2 P ¼ .270 χ2 ¼ .45; df ¼ 2 P ¼ .799 χ2 ¼ 32.36; df ¼ 2 P o .001 F ¼ 169.79; df ¼ 2, 526 P o .001 F ¼ 130.72; df ¼ 2, 526 P o .001 F ¼ 13.13; df ¼ 2, 526 P o .001 F ¼ 2.90; df ¼ 2, 499 P ¼ .056 F ¼ .77; df ¼ 2, 466 P ¼ .465 F ¼ 12.08; df ¼ 2, 519 P o 0.001
Mood disorder* 1-yr prevalence, n, (%)
25 (22.3)
62 (25.3)
17 (15.6)
Lifetime prevalence, n, (%)
34 (30.4)
88 (35.9)
27 (24.8)
Anxiety Disorder* 1-yr prevalence, n, (%)
29 (25.9)
64 (26.1)
23 (21.1)
Lifetime prevalence, n, (%)
36 (32.1)
90 (36.7)
32 (29.4)
HADS Depression, mean, (SD)
7.3 (3.9)
6.4 (4.2)
5.4 (4.1)
HADS Anxiety, mean, (SD)
6.8 (3.8)
7.1 (4.1)
6.3 (4.2)
SF-36 Physical Component Score, mean, (SD)
35.0 (12.1)
43.9 (11.1)
46.3 (11.0)
SF-36 Mental Component Score, mean, (SD)
44.4 (13.6)
43.8 (14.1)
45.2 (14.6)
RSES Self-Esteem, mean, (SD)
10.3 (3.1)
10.1 (3.4)
11.2 (2.9)
RSES Worthlessness, mean, (SD)
4.3 (3.6)
4.1 (4.2)
3.3 (3.9)
SURG o CONV, OC SURG, OC o CONV — — SURG o CONV, OC SURG 4 CONV 4 OC SURG 4 CONV 4 OC SURG 4 CONV, OC — — SURG 4 CONV,OC
χ2 ¼ 4.10; df ¼ 2 P ¼ .129 χ2 ¼ 4.49; df ¼ 2 P ¼ .106
—
χ2 ¼ 1.10; df ¼ 2 P ¼ .578 χ2 ¼ 2.04; df ¼ 2 P ¼ .361 F ¼ 7.26; df ¼ 2, 509 P ¼ .001 F ¼ 1.47; df ¼ 2, 509 P ¼ .232 F ¼ 36.52; df ¼ 2, 462 P o .001 F ¼ .37; df ¼ 2, 462 P ¼ .690 F ¼ 4.58; df ¼ 2, 508 P ¼ .011 F ¼ 2.53; df ¼ 2, 509 P ¼ .081
—
—
— SURG,CONV 4 OC — SURG o CONV,OC — SURG,CONV o OC —
SURG ¼ Bariatric Surgery Group; CONV ¼ Conventional Treatment Group; OC ¼ Obese Control Group; BMI ¼ body mass index; HADS ¼ Hospital Anxiety and Depression Scale; SF-36 ¼ Short-Form Health Survey; RSES ¼ Rosenberg Self-Esteem Scale. * N ¼ 466.
degree of freedom (df) ¼ 2, P ¼ .010) and the 9-year assessment (χ2 ¼ 6.94, df ¼ 2, P ¼ .031). Those participants with at least 1 postbaseline assessment (n ¼ 465, 87.9%) were more likely to be single (62% versus 41%, χ2 ¼ 11.06, df ¼ 2, P o .001) and have a lower baseline BMI (mean ¼ 42.1, SD ¼ 9.2 versus mean ¼ 45.1, SD ¼ 8.0; F ¼ 6.25; df ¼ 1, 527; P ¼ .013), but did not differ on other demographic or clinical characteristics listed in Table 1.
No significant differences were found between those completing versus not completing the 9-year assessment on gender. Baseline BMI was significantly lower among 9-year completers compared with those not completing the 9-year assessment in both the CONV (mean ¼ 39.8, SD ¼ 6.9 versus mean ¼ 42.6, SD ¼ 7.9; P ¼ .003) and OC (mean ¼ 34.3, SD ¼ 4.2 versus mean ¼ 36.9, SD ¼ 5.8; P ¼ .004) groups, but did not differ significantly in the SURG group (mean ¼ 50.1, SD ¼ 7.0
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S. Herpertz et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
T1 N (%) Total 529 (100) SURG 152 (100) CONV 249 (100) OC 128 (100)
T2 N (%) Total 404 (76.4) SURG 118 (77.6) CONV 191 (76.7) OC 95 (74.2)
SURG 1 deceased 1 chronic illness* 1 pregnancy 4 contact unknown 27 no response/ refusal
CONV 1 deceased 3 chronic illness* 4 pregnancy 5 contact unknown 45 no response/ refusal
OC 1 deceased 1 chronic illness* 2 pregnancy 2 contact unknown 27 no response/ refusal
T3 N (%) Total 336 (63.5) SURG 102 (67.1) CONV 146 (58.6) OC 88 (68.7)
SURG 2 deceased† 2 chronic illness* 15 contact unknown 31 no response/ refusal
CONV 1 deceased† 4 chronic illness* 7 pregnancy 1 bariatric surgery 14 contact unknown 76 no response/ refusal
OC 3 deceased† 1 chronic illness* 4 contact unknown 32 no response/ refusal
T4 N (%) Total 354 (66.9) SURG 101 (66.4) CONV 154 (61.8) OC 99 (77.3)
SURG 2 deceased† 3 chronic illness* 46 no response/ refusal
CONV 3 deceased† 7 chronic illness* 1 pregnancy 1 bariatric surgery 82 no response/ refusal
OC 3 deceased† 1 chronic illness* pregnancy 25 no response/ refusal
T5 N (%) Total 293 (55.4) SURG 84 (55.3) CONV 126 (50.6) OC 83 (64.8)
SURG 6 deceased† 14 chronic illness* 9 contact unknown 39 no response/ refusal
CONV 13 deceased† 23 chronic illness* 1 pregnancy 5 bariatric surgery contact unknown no response/ refusal
OC 6 deceased† chronic illness* pregnancy contact unknown no response/ refusal
Fig. 1. Study flowchart. Asterisks (*) indicate chronic illnesses that influence weight (e.g., cancer, multiple sclerosis, and cortisone medication), and dagger symbol (†) indicates cumulative numbers. T1 ¼ baseline; T2 ¼ 1-year follow-up; T3 ¼ 2-year follow-up; T4 ¼ 4-year follow-up; T5 ¼ 9-year follow-up; SURG ¼ Bariatric Surgery Group; CONV ¼ Conventional Treatment Group; OC ¼ Obese Control Group.
versus mean ¼ 51.3, SD ¼ 9.0; P ¼ .348). SURG patients completing the 9-year assessment were significantly younger than those not completing the 9-year assessment (mean ¼ 37.5, SD ¼ 9.6 versus mean ¼ 41.2, SD ¼ 10.8; P ¼ .026), but did not differ significantly in terms of baseline psychological measures. With regard to the CONV and the OC group, no differences in age or baseline psychological measures were found between 9-year completers and noncompleters.
Changes in sociodemographic variables and somatic comorbidity from baseline to 9-year follow-up Marital status at 9-year assessment did not differ significantly from baseline (see Table 1). Accordingly, the rates of those who were married at the 9-year assessment (SURG: 60.8%, CONV: 58.5%, OC: 66.3%) did not differ between groups (χ2 ¼ 1.31, df ¼ 2, P ¼ .518).
9-year Follow-up after Bariatric Surgery / Surgery for Obesity and Related Diseases ] (2015) 00–00
Considering only those who completed both the 4-year and 9-year assessments (SURG: n ¼ 66, CONV: n ¼ 103, OC: n ¼ 75), no significant changes were found within and between groups in marital status over the course of 9 years (all P values 4 .470). Income decreased in all 3 groups from baseline (Table 1) to 9-year visit (gross annual income Z €75,000; SURG: 14.5%, CONV: 36.8%, OC: 34.2%; χ2 ¼ 11.96, df ¼ 2, P ¼ .003). Similarly, among those completing both the 4-year and the 9-year follow-up (SURG: n ¼ 64, CONV: n ¼ 97, OC: n ¼ 69) an annual income of Z€75.000 was less frequently reported in the SURG group at both baseline (SURG: 29.7%, CONV: 48.4%, OC: 49.3%; χ2 ¼ 7.94, df ¼ 2, P ¼ .019) and 9-year assessment (SURG: 17.2%, CONV: 33.0%, OC: 34.8%; χ2 ¼ 6.81, df ¼ 2, P ¼ .033). With regard to the number of co-morbid somatic disorders, the groups did differ significantly at baseline (Table 1) but not at the 9-year follow-up (SURG: mean ¼ 2.1, SD ¼ 1.8; CONV: mean ¼ 2.3, SD ¼ 1.8; OC: mean ¼ 1.9, SD ¼ 1.9; F ¼ .76; df ¼ 2, 289, P ¼ .466). Considering only those participants completing both the 4-year and the 9-year assessment, the mean number of somatic disorders at baseline was significantly higher (F ¼ 9.296, df ¼ 2, 242, P o.001) among SURG patients (mean ¼ 2.6, SD ¼ 1.8) than that for CONV (mean ¼ 1.9, SD ¼ 1.6) and OC (mean ¼ 1.4, SD ¼ 1.5) participants but did not differ between groups at 4-year (SURG: mean ¼ 2.3, SD ¼ 1.4; CONV: mean ¼ 2.5, SD ¼ 1.3; OC: mean ¼ 2.6, SD ¼ 1.5; F ¼ 1.003, df ¼ 2, 241, P ¼ .369) and 9-year (SURG: mean ¼ 2.1, SD ¼ 1.7; CONV: mean ¼ 2.2, SD ¼ 1.8; OC: mean ¼ 2.0, SD ¼ 1.9; F ¼ .170, df ¼ 2, 241, P ¼ .844) assessments.
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Fig. 2. Weight loss from baseline to 9-year follow-up by study group. (A) Body mass index (kg/m2) from baseline to 9-year follow-up by study group. (B) Percentage weight loss (mean, 95% CI) from baseline to 9-year follow-up by study group. Size of study groups varies depending on assessment year. CI ¼ confidence interval; SURG ¼ Bariatric Surgery Group (n ¼ 152); CONV ¼ Conventional Treatment Group (n ¼ 249); OC ¼ Obese Control Group (n ¼ 128).
Course of BMI and weight loss
Changes in psychological functioning from baseline to 9-year follow-up
Changes in BMI are shown in Fig. 2A. The mean BMI for the SURG group at baseline was 50.7 kg/m2 (SD ¼ 8.0; 93.4% obesity grade 3, 6.6% obesity grade 2). Nine years after surgery, this group had a mean BMI of 39.4 kg/m2 (SD ¼ 8.7), but 45.2% still had obesity grade 3, 23.8% had obesity grade 2, 20.2% had obesity grade 1, 8.3% were overweight, and 2.4% were normal weight. Percentage weight loss was greater for the SURG group than the control groups at all assessment points (all P values o .001) (Fig. 2B). The CONV group exhibited greater weight loss than the OC group at the 1-year and 2-year follow-ups (P o .001) but did not differ from the OC group at 4-year (P ¼ .471) and 9-year assessments (P ¼ .231). Surgery patients completing the 9-year assessment did not differ significantly in terms of percentage of original weight loss at 9-year follow-up from those not completing the last follow-up visit (mean ¼ –20.6, SD ¼ 15.2 versus mean ¼ –23.5, SD ¼ 12.6; F ¼ 1.168, df ¼ 1, 129, P ¼ .282).
Table 2 presents the propensity score-adjusted changes from baseline by study group and by assessment year. Changes in depression and anxiety. The SURG group had greater impairments in depression than both the CONV and OC groups at the 9-year assessment after controlling for baseline depression scores. HADS depression scores for the SURG group at the 9-year assessment were increased from the 4-year assessment (P ¼ .032) and did not differ from baseline levels (P ¼ .215) (Fig. 3A). Group comparisons on changes from 4-year to 9-year assessment for those completing both assessments (SURG: n ¼ 65, CONV: n ¼ 103, OC: n ¼ 75) indicated that the increase in HADS depression among SURG patients (mean ¼ .1, SD ¼ 3.9) was significantly greater (P ¼ .002) than that for both CONV (mean ¼ –.6, SD ¼ 3.4) and OC (mean ¼ –1.0, SD ¼ 3.4) group participants. The SURG group reported more HADS anxiety than the OC group at the 9-year assessment (Table 2). The scores for the SURG group at the 9-year assessment were significantly
S. Herpertz et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
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Table 2 Propensity score-adjusted changes from baseline by study group by assessment year Variable
HADS Depression
Group
SURG
CONV
OC
SURG versus CONV SURG versus OC HADS Anxiety
SURG
CONV
OC
SURG versus CONV SURG versus OC RSES Self-Esteem
SURG
CONV
OC
SURG versus CONV SURG versus OC RSES Worthlessness
SURG
CONV
OC
SURG versus CONV SURG versus OC SF-36 Physical Component Score
Bariatric Surgery
CONV
OC
Yr 1
Yr 2
Yr 4
Yr 9
Mean 95% CI n
Mean 95% CI n
Mean 95% CI n
Mean 95% CI n
–2.15 (–2.89; –1.40) n ¼ 114 –1.47 (–1.99; –.95) n ¼ 183 –.69 (–1.45; .06) n ¼ 94 –.68 (–1.61; .26) –1.45* (–2.60; –.30) –1.07 (–1.76; –.38) n ¼ 114 –.81 (–1.29; –.33) n ¼ 182 –.98 (–1.68; –.29) n ¼ 94 –.26 (–1.13; .60) –.09 (–1.15; .97) 1.06 (.52; 1.60) n ¼ 117 1.00 (.62; 1.38) n ¼ 179 .65 (.09; 1.20) n ¼ 91 .06 (–.62; .74) .41 (–.42; 1.24) –1.06 (–1.74; –.38) n ¼ 117 –.68 (–1.16; –.21) n ¼ 181 –.65 (–1.34; .05) n ¼ 91 –.37 (–1.23; .49) –.41 (–1.47; .64) 10.81 (8.69; 12.93) N ¼ 104 5.65 (4.17; 7.14) N ¼ 163 1.51
–1.39 (–2.16; –.62) n ¼ 100 –.72 (–1.29; –.16) n ¼ 140 –.60 (–1.38; .17) n ¼ 85 –.66 (–1.65; .32) –.78 (–1.97; .40) –.49 (–1.20; .23) n ¼ 100 –.72 (–1.24; –.20) n ¼ 140 –.77 (–1.49; –.05) n ¼ 84 .23 (–.67; 1.14) .28 (–.81; 1.38) .70 (.13; 1.26) n ¼ 98 .59 (.17; 1.01) n ¼ 139 .78 (.21; 1.35) n ¼ 84 .11 (–.61; .83) –.08 (–.94; .78) –.99 (–1.70; –.29) n ¼ 99 –.28 (–.80; .24) n ¼ 139 –1.08 (–1.79; –.36) n ¼ 84 –.72 (–1.62; .18) .08 (–1.00; 1.16) 10.53 (8.25; 12.80) N ¼ 82 3.56 (1.85; 5.26) N ¼ 113 1.05
–1.08 (–1.88; –.29) n ¼ 92 –.37 (–.93; .19) n ¼ 145 –.25 (–.99; .50) n ¼ 98 –.72 (–1.72; .28) –.84 (–2.01; .34) –.59 (–1.32; .14) n ¼ 92 –.60 (–1.12; –.09) n ¼ 146 –.71 (–1.40; –.02) n ¼ 97 .01 (–.91;. .94) .12 (–.96; 1.21) .46 (–.12; 1.03) n ¼ 94 .33 (–.09; .74) n ¼ 146 .41 (–.13; .95) n ¼ 98 .13 (–.60; .86) .05 (–.80; .89) –.43 (–1.15; .30) n ¼ 94 –.25 –.77; .26) n ¼ 146 –.52 (–1.20; .16) n ¼ 98 –.17 (–1.09; .74) –.09 (–.98; 1.17) 8.04 (5.74; 10.34) N ¼ 79 1.53 (–.14; 3.19) N ¼ 121 .72
.06 (–.78; .91) n ¼ 77 –.99 (–1.60; –.38) n ¼ 119 –1.47 (–2.26; –.68) n ¼ 82 1.05* (.02; 2.12) 1.53* (.29; 2.78) .43 (–.35; 1.21) n ¼ 77 –.34 (–.90; .23) n ¼ 119 –.75 (–1.49; –.02) n ¼ 82 .77 (–.22; 1.76) 1.19* (.04; 2.33) .01 (–.61; .64) n ¼ 75 1.06 (.60; 1.51) n ¼ 119 .92 (.34; 1.50) n ¼ 82 –1.04† (–1.83; –.25) –.91* (–1.82; .00) .59 (–.19; 1.37) n ¼ 76 –.64 (–1.21; –.08) n ¼ 120 –.77 (–1.49; –.04) n ¼ 82 1.23* (.25; 2.22) 1.36* (.22; 2.50) 4.58 (2.14; 7.01) N ¼ 68 .90 (–.88; 2.68) N ¼ 105 –.74
9-year Follow-up after Bariatric Surgery / Surgery for Obesity and Related Diseases ] (2015) 00–00
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Table 2 Continued. Variable
SF-36 Mental Component Score
Group
Bariatric Surgery versus CONV Bariatric Surgery versus OC Bariatric Surgery
CONV
OC
Bariatric Surgery versus CONV Bariatric Surgery versus OC
Yr 1
Yr 2
Yr 4
Yr 9
Mean 95% CI n
Mean 95% CI n
Mean 95% CI n
Mean 95% CI n
(–.67; 3.69) N ¼ 82 5.16‡ (2.48; 7.84) 9.30‡ (6.02; 12.58) 1.15 (–1.61; 3.91) N ¼ 104 1.19 (–.76; 3.14) N ¼ 163 1.05 (–1.81; 3.91) N ¼ 82 –.05 (–3.54; 3.44) .10 (–4.18; 4.38)
(–1.24; 3.35) N ¼ 70 6.97‡ (4.04; 9.89) 9.47‡ (6.00; 12.94) –2.68 (–5.65; .28) N ¼ 82 .65 (–1.58; 2.89) N ¼ 113 3.16 (.16; 6.17) N ¼ 70 –3.34 (–7.15; .47) –5.85* (–10.37; –1.33)
(–1.46; 2.91) N ¼ 81 6.51‡ (3.59; 9.43) 7.31‡ (3.91; 10.72) 1.29 (–1.72; 4.30) N ¼ 79 1.15 (–1.04; 3.34) N ¼ 121 1.46 (–1.41; 4.32) N ¼ 81 .14 (–3.67; 3.96) –.16 (–4.61; 4.29)
(–3.04; 1.56) N ¼ 71 3.68* (.57; 6.78) 5.31† (1.73; 8.90) –4.45 (–7.65; –1.25) N ¼ 68 1.17 (–1.17; 3.52) N ¼ 105 4.18 (1.16; 7.21) N ¼ 71 –5.62† (–9.70; –1.55) –8.63‡ (–13.32; –3.94)
CI ¼ confidence interval; SURG ¼ Bariatric Surgery Group; CONV ¼ Conventional Treatment Group; OC ¼ Obese Control Group. HADS ¼ Hospital Anxiety and Depression Scale, SF-36 ¼ Short-Form Health Survey, RSES ¼ Rosenberg Self-Esteem Scale. * P o .05. † P o .01. ‡ P o .001.
increased from the 4-year assessment (P ¼ .015) and did not differ significantly from baseline levels (P ¼ .304, Fig. 3B). Among those completing both the 4-year and the 9-year assessment (SURG: n ¼ 65, CONV: n ¼ 102, OC: n ¼ 75), anxiety scores increased from T4 to T5 by an average of 1.1 (SD ¼ 4.0) in the SURG group, compared with .1 (SD ¼ 3.7) in the CONV group and .1 (SD ¼ 3.2) in the OC group. However, this difference did not reach statistical significance. To investigate the clinical significance of the aforementioned results, the percentage of participants above the HADS cut-offs for probable depressive or anxiety disorder (HADSDepr/Anxiety 410) were calculated at baseline and follow-ups among those participants who had completed both the 4-year and the 9-year assessment. Figs. 3C and Fig. 3D illustrate the initial decrease of clinical significant depression/anxiety in the SURG group from baseline to 4-year assessment and the increase later on. Rates of participants with probable depressive/anxiety disorder differed significantly between groups at 9-year assessment (depression: SURG: 18.2%, CONV: 10.1%, OC: 4.0%; χ2 ¼ 7.58, df ¼ 2, P ¼ .023; anxiety: SURG: 22.5%, CONV: 18.4%, OC: 6.7%; χ2 ¼ 7.53, df ¼ 2, P ¼ .023) but not at baseline and 4-year assessment. Changes in self-esteem. RSES worthlessness scores for the SURG group (Table 2) at the 9-year assessment were significantly increased from the 4-year assessment
(P ¼ .030) and were higher but did not differ significantly from baseline (P ¼ .330). Among those who completed both the 4-year and the 9-year assessment (SURG: n ¼ 64, CONV: n ¼ 102, OC: n ¼ 75), worthlessness scores increased significantly more from 4-year to 9-year assessment (P ¼ .034) in the SURG group (mean ¼ 1.1, SD ¼ 3.6) than in the CONV (mean ¼ –.1, SD ¼ 3.3) or the OC (mean ¼ –.3, SD ¼ 3.1) group, and self-esteem changes did not differ among the SURG (mean ¼ –.3, SD ¼ 3.1), the CONV (mean ¼ .8, SD ¼ 3.3), and the OC (mean ¼ .6, SD ¼ 3.3) groups. Changes in quality of life. The SURG group reported greater improvements in the SF-36 physical component score (PCS) at all postbaseline assessments compared with the control groups (Table 2). Although PCS scores were lower for the SURG group at the 9-year assessment compared with the 4-year assessment (P ¼ .010), the 9-year assessment scores remained less disturbed than before surgery (P o.001). On the SF-36 mental component score (MCS), the SURG group experienced greater impairments than both other groups at the 9-year assessment after controlling for baseline scores. MCS scores for the SURG group at the 9-year assessment were deteriorated from the 4-year assessment (P ¼ .006) and were lower but did not differ significantly from baseline (P ¼ .143). Among those completing both the 4-year and 9-year assessments (BS: n ¼ 58, CONV: n ¼ 88, OC: n ¼ 63), changes in
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S. Herpertz et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
Fig. 3. Anxiety and depression from baseline to 9-year follow-up by study group. (A) Unadjusted mean (⫾SE) Hospital Anxiety and Depression Scale (HADS) depression scores by study group. (B) Unadjusted mean (⫾SE) HADS anxiety scores by study group. (C) Percentage of participants who had completed both the 4-year and 9-year follow-up above the HADS depression cut-off (HADSDepr 410). (D) Percentage of participants who had completed both the 4-year and 9-year follow-up above the HADS depression cut-off (HADSAnx 410). In Figures 3A and 3B size of study groups varies depending of assessment year. SE ¼ standard error; SURG ¼ Bariatric Surgery Group (n ¼ 152); CONV ¼ Conventional Treatment Group (n ¼ 249); OC ¼ Obese Control Group (n ¼ 128).
PCS scores did not differ between BS (mean ¼ –3.8, SD ¼ 11.5), CONV (mean ¼ –.8, SD ¼ 12.3), and OC (mean ¼ –1.3; SD ¼ 10.8) groups. Also, no significant group differences were found with respect to MCS changes (BS: mean ¼ –4.4, SD ¼ 16.9; CONV: mean ¼ –.3, SD ¼ 12.6; OC: mean ¼ 1.2, SD ¼ 14.0). The comparison of SURG patients with gastroplasty versus gastric banding indicated that changes in psychosocial measures did not differ on the basis of surgery type (P ¼ .241–.890). Correspondence between changes in BMI and changes in depression, anxiety, and quality of life Changes in BMI over the course of 9 years were significantly associated with changes in HADS depression and SF-36 PCS scores in all 3 groups (all P values o .001). However, changes in BMI were linked to changes in HADS anxiety and SF-36 MCS only in the CONV group (anxiety: P o .001, MCS: P ¼ .012). Among those SURG patients completing both the 4-year and the 9-year assessment, the change in BMI from 4-year to 9-year assessment was
uncorrelated (all P values Z .156) with changes in any of the psychological measures over that same period. Discussion This prospective controlled 9-year follow-up study indicates that bariatric surgery results in long-lasting weight loss and improvement of physical aspects of HRQOL, which is consistent with the findings from prior studies [1,15–18]. In contrast to the SOS study [1], however, the present results do not support the proposed link between long-term weight reduction and continued improvement in mental health after surgery. Although the SURG group had an initial improvement in mental health, this deteriorated between the 4-year and 9-year assessments and was comparable to or worse than presurgical levels. It is important to note that, in those patients completing both the 4-year and the 9-year assessment, change in BMI from the 4-year to the 9-year assessment was not related to change in psychological measures over that period. Therefore, it can be
9-year Follow-up after Bariatric Surgery / Surgery for Obesity and Related Diseases ] (2015) 00–00
assumed that the decline in mental health during this period was related to factors other than weight regain. For example, the deterioration in improvement of mood may have been caused by disappointment from unrealistic expectations about surgical treatment or by the reoccurrence of psychiatric disorders [2,3,19]. Furthermore, changes in eating behavior, medical sequelae after surgery (e.g., plugging), the fear of weight regain leading in some cases to disturbed eating [19– 21], dissatisfaction with body appearance and excess skin [22– 24], or the persistence of problems after weight loss that are blamed on obesity may have contributed to the decline [19,25,26]. Shortcomings of the present study include the relatively low retention rates, the lack of randomization, the use of selfratings to assess mental health aspects, and the lack of information on treatment for anxiety, depression, and eating and weight problems over the period of 9 years. Furthermore, the results are limited to restrictive surgical treatment. It remains unknown whether patients who undergo gastric bypass or sleeve surgery would have similar outcomes. Strengths of the present study are the prospective design with a long-term follow-up, measured weights, and the use of 2 control groups.
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
Conclusions Taken together, the results support the notion that bariatric surgery is an effective treatment for obesity in terms of sustained weight loss and maintained improvement of physical aspects of HRQOL. The findings further indicate that substantial weight reduction after surgery is associated with significant initial improvement in mental health that may erode over time; therefore, psychosocial screening should be included at follow-ups, with referral to mental health professionals as appropriate.
[10] [11] [12]
[13] [14]
Disclosures [15]
The authors have no commercial associations that might be a conflict of interest in relation to this article.
[16]
Acknowledgments
[17]
The authors wish to thank the following persons for their substantial support: C. Fischer, Ph.D., (Ruhr University Bochum), J. Bryjova, Ph.D., (University of Fribourg, Switzerland), M. Kemen, M.D., (Protestant Hospital, Herne), A. Chen-Stute, M.D., (Obesity Centre Oberhausen), T. Hulicz, M.D., U. Machleit, Ph.D., (Augusta Clinics, Bochum), C. Stroh, M.D., (Municipal Hospital Gera), and R. Weiner, M.D., (Frankfurt Sachsenhausen Hospital).
[18]
[19]
[20]
References [21] [1] Karlsson J, Taft C, Rydén A, Sjöström L, Sullivan M. Ten-year trends in health-related quality of life after surgical and conventional
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treatment for severe obesity: the SOS intervention study. Int J Obes (Lond) 2007;31(8):1248–61. Mitchell JE, King WC, Chen JY, et al. Course of depressive symptoms and treatment in the Longitudinal Assessment of Bariatric Surgery (LABS-2) Study. Obesity (Silver Spring) 2014;22 (8):1799–806. Ivezaj V, Grilo CM. When mood worsens after gastric bypass surgery: characterization of bariatric patients with increases in depressive symptoms following surgery. Obes Surg 2015;25(3):423–9. Herpertz S, Burgmer R, Stang A, et al. Prevalence of mental disorders in normal-weight and obese individuals with and without weight loss treatment in a German urban population. J Psychosom Res 2006;61 (1):95–103. Legenbauer T, Petrak F. de Zwaan M, Herpertz S. Influence of depressive and eating disorders on short- and long-term course of weight after surgical and nonsurgical weight loss treatment. Compr Psychiatry 2011;52(3):301–11. Legenbauer TM, de Zwaan M, Mühlhans B, Petrak F, Herpertz S. Do mental disorders and eating patterns affect long-term weight loss maintenance? Gen Hosp Psychiatry 2010;32(2):132–40 Burgmer R, Petersen I, Burgmer M, de Zwaan M, Wolf AM, Herpertz S. Psychological outcome two years after bariatric surgery. Obes Surg 2007;17(6):785–91. Burgmer R, Legenbauer T, Müller A, de Zwaan M, Fischer C, Herpertz S. Psychological outcome four years after bariatric surgery. Obes Surg 2014;24(10):1670–8. Herrmann C, Buss U, Snaith RP. Hospital Anxiety and Depression Scale—Deutsche Version. Ein Fragebogen von Angst und Depressivität in der somatischen Medizin. Bern, Schweiz: Hans Huber, 1995:1995. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67(6):361–70. Bullinger M, Kirchberger I. Fragebogen zum Gesundheitszustand (SF-36). Göttingen, Germany: Hogrefe, 1998:1998. Ware JE, Snow K, Kosinski M, Gandek B. SF-36 health survey: manual and interpretation guide. Boston: The Health Institute, New England Medical Center, 1993:1993. Rosenberg M. Society and the adolescent self-image. Princeton, NJ: Princeton University Press, 1965:1965. Wittchen HU, Lachner G, Wunderlich U, Pfister H. Test-retest reliability of the computerized DSM-IV version of the Composite International Diagnostic Interview (M-CIDI). Soc Psychiatry Psychiatr Epidemiol 1998;33(11):568–78. Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA 2012;308(11):1122–31. O’Brien PE, MacDonals L, Anderson M, Brennan L, Brown WA. Long-term outcomes after bariatric surgery. Ann Surg 2013;257 (1):87–94. de Zwaan M, Enderle J, Wagner S, et al. Anxiety and depression in bariatric surgery patients: a prospective, follow-up study using structured clinical interviews. J Affect Disord 2011;133(1–2):61–8. Kolotkin RL, Davidson LE, Crosby RD, Hunt SC, Adams TD. Six-year changes in health-related quality of life in gastric bypass patients versus obese comparison groups. Surg Obes Relat Dis 2012;8 (5):625–33. Mitchell JE, Crosby R, de Zwaan M, et al. Possible risk factors for increased suicide following bariatric surgery. Obesity 2013;21 (4):665–72. de Zwaan M, Hilbert A, Swan-Kremeier L, et al. Comprehensive interview assessment of eating behavior 18–35 months after gastric bypass surgery for morbid obesity. Surg Obes Relat Dis 2010;6 (1):79–85. Marino JM, Ertelt TW, Lancaster K, et al. The emergence of eating pathology after bariatric surgery: a rare outcome with important clinical implications. Int J Eat Disord 2012;45(2):179–84.
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[22] Modarressi A, Balagué N, Huber O, Chilcott M, Pittet-Cuénod B. Plastic surgery after gastric bypass improves long-term quality of life. Obes Surg 2013;23(1):24–30. [23] Steffen KJ, Sarwer DB, Thompson JK, Mueller A, Baker AW, Mitchell JE. Predictors of satisfaction with excess skin and desire for body contouring after bariatric surgery. Surg Obes Relat Dis 2012;8(1):92–7. [24] de Zwaan M, Georgiadou E, Stroh CE, Teufel M, Köhler H, Tengler M, Müller A. Body image and quality of life in patients with and without
body contouring surgery following bariatric surgery: a comparison of pre- and post-surgery groups. Front Psychol 2014;5:1310. [25] Sheets CS, Peat CM, Berg KC, et al. Post-operative psychosocial predictors of outcome in bariatric surgery. Obes Surg 2015;25 (2):330–45. [26] van Hout GC, Fortuin FA, Pelle AJ, van Heck GL. Psychosocial functioning, personality, and body image following vertical banded gastroplasty. Obes Surg 2008;18(1):115–20.
Original article
Health-related quality of life and psychological functioning 9 years after restrictive surgical treatment for obesity Stephan Herpertz, M.D.a, Astrid Müller, M.D., Ph.D.b,*, Ramona Burgmer, Ph.D.a, Ross D. Crosby, Ph.D.c, Martina de Zwaan, M.D.b, Tanja Legenbauer, Ph.D.d a
Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital of the Ruhr University Bochum, Bochum, Germany b Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany c Neuropsychiatric Research Institute and University of North Dakota, School of Medicine and Health Sciences, Fargo, North Dakota d Department of Child and Adolescent Psychiatry, LWL University Hospital of the Ruhr University Bochum, Hamm, Germany Received November 11, 2014; accepted April 14, 2015
Abstract
Background: Bariatric surgery leads to initial weight loss that is associated with improvement in mental health; however, long-term effects are uncertain. Objective: To investigate the impact of restrictive surgical treatment for obesity on weight loss, psychological functioning, and quality of life 9 years after surgery. Setting: University hospitals and obesity centers, Germany. Methods: 152 patients undergoing restrictive surgical treatment (SURG), 249 individuals participating in a conventional weight loss treatment (CONV), and 128 obese control participants without weight loss treatment (OC) were studied using a prospective longitudinal cohort design. After 9 years, 55% of SURG patients, 51% of CONV patients, and 65% of OC participants were reassessed. Body mass index, anxiety, depression, self-esteem, and health-related quality of life (HRQOL) were explored. Results: The SURG group had significantly greater weight loss and improvements in physical HRQOL at all postbaseline assessments. Although SURG patients experienced initial improvements in depression, anxiety, self-esteem, and mental aspects of HRQOL, these improvements deteriorated at the 9-year assessment and were comparable to or worse than presurgical levels. Conclusions: Bariatric surgery is an effective treatment for obesity and is linked to maintained improvement of physical aspects of HRQOL. Weight reduction after surgery is also associated with significant initial improvement in mental health that may erode over time. Therefore, psychosocial screening should be included at follow-ups, with referral to mental health professionals as appropriate. (Surg Obes Relat Dis 2015;]:00–00.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Obesity; Bariatric surgery; Health-related quality of life; Depression; Anxiety; Self-esteem; Conventional weight loss treatment
Stephan Herpertz and Astrid Müller contributed equally to this work. This study was supported by the German Research Council (DFG; He2665/2-1, He2665/2-2), the Federal Ministry of Education and Research (BMBF, 01 GI 0836), and the Institute Danone for Nutrition, Germany. * Correspondence: Astrid Müller, M.D., Ph.D., Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, CarlNeuberg-Str. 1, 30265 Hannover, Germany. E-mail: [email protected]
Reliable information on the long-term effects of bariatric surgery on psychological functioning is still scarce. The Swedish Obese Subjects (SOS) study indicated sustained weight loss 10 years after surgery that was significantly associated with improved psychological outcomes [1]. However, more recent data suggest some deterioration in depression over time [2,3].
http://dx.doi.org/10.1016/j.soard.2015.04.008 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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The present study aimed to evaluate the 9-year outcome of bariatric surgery compared with a conventional weight loss treatment and an obese control group. It is part of the multicenter, prospective Essen-Bochum Obesity Treatment Study [4–8]. Earlier findings from the 2- and 4-year followups of surgery patients indicated a considerable initial weight loss corresponding with significant improvement in mental health but some weight regain and slight declines in psychological improvements at the 4-year assessment in this group [7,8]. It was hypothesized that surgery patients would exhibit greater weight loss and greater improvements in psychological functioning 9 years after baseline than conventionally treated patients and obese control participants. Materials and methods Participants Baseline exclusion criteria were body mass index (BMI) o30 kg/m2, age o18 and 465 years, psychotic disorder, dementia, a time period of less than 1 year postpartum in women, and difficulties understanding the German language. Participants were assessed at baseline (T1), 1-year (T2), 2-year (T3), 4-year (T4), and 9-year (T5) follow-ups. The study protocol was approved by the ethics committee, and all participants gave written informed consent. For the surgery group (SURG), 154 consecutive patients from 6 surgery departments were asked to participate. Of those, 1 person refused and 1 person in retrospective did not meet the inclusion criteria, resulting in 152 patients. Most received restrictive obesity surgery procedures (vertical gastroplasty n = 97, gastric banding n = 51). Of 403 consecutive conventionally treated patients who were approached to join the study at 4 obesity treatment centers, 249 were willing to participate. The conventional treatment (CONV) was based on the Optifast® program (Nestle Inc., Vevey, Switzerland) with weekly group sessions over 1 year, including nutritional counseling, behavioral modification, and a liquid meal replacement for the first 12 weeks. Seven individuals had bariatric surgery between T4 and T5, and their 9-year follow-up data were not used for analysis. The obese control (OC) group included 128 obese individuals who were not in an obesity treatment program at baseline. They were selected randomly from the mandatory residence list of the city of Essen (about 600,000 inhabitants) [4]. No participant of the control group reported having bariatric surgery during the follow-ups.
asthma, chronic bronchitis, osteoarthritis, stroke, cancer, gastric/duodenal ulcer, cholecystitis, kidney disease, back pain, and polycystic ovary) were self-reported. Anxiety and depressive symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS) [9,10]. The Short-Form health survey (SF-36) [11,12] was administered to measure HRQOL. Global self-esteem was measured using the Rosenberg Self-Esteem Scale (RSES) [13]. One-year and lifetime prevalence of mood and anxiety disorders at baseline was assessed with the Composite International Diagnostic Interview (M-CIDI) [14]. Statistical analyses A multinomial logistic regression analyses was performed using baseline characteristics (gender, age, education, marital status, living alone, gross annual income, doctor visits and sick days within last 12 months, and 1year and lifetime mood and anxiety disorder) to predict study group. Propensity score adjustment was used to control for pretreatment differences between the 3 nonrandomized groups. This adjustment method essentially involves using baseline characteristics to determine the probability of each person belonging to a given group. The probabilities were then used as covariates in analyses comparing the groups. Mixed-effects repeated measures linear models were used to compare groups on changes from baseline in questionnaires (HADS, RSES, SF-36) using all available data. Analyses were controlled for baseline measurement and propensity score. Post hoc comparisons between the groups at each assessment were based upon covariate-adjusted contrasts. In addition, completer analyses were performed on those participants who had completed both the 4-year and the 9-year assessments. Results Baseline comparisons Group comparisons on baseline characteristics are presented in Table 1. The SURG group was significantly younger and had a lower income than both the CONV and the OC groups, and was less well educated than the CONV group. The SURG group had significantly higher BMIs, more co-morbid somatic diseases, and lower physical functioning (SF-36) than both control groups and more depressive symptoms (HADS) and lower self-esteem (RSES) than the OC group.
Assessment
Study retention
Weight and height were measured in light clothing without shoes. Sociodemographic data and co-morbid somatic disorders (e.g., hypertension, diabetes, coronary artery disease, hyperlipidemia, sleep apnea, bronchial
Patient flow is shown in Fig. 1. Retention rates for all groups exceeded 50% at the 9-year assessment (SURG: 55.3%, CONV: 50.6%, OC: 64.8%) and were significantly higher for the OC group at both the 4-year (χ2 ¼ 9.19,
9-year Follow-up after Bariatric Surgery / Surgery for Obesity and Related Diseases ] (2015) 00–00
3
Table 1 Baseline characteristics by study group Characteristic
SURG Group (n ¼ 152)
CONV Group (n ¼ 249)
OC Group (n ¼ 128)
Significance
Post hoc
Female, n, (%)
102 (67.1)
181 (72.7)
92 (71.9)
—
Age, yr, mean (SD)
39.1 (10.3)
42.2 (10.8)
42.5 (11.8)
Completed highest education level (n, %)
21 (13.8)
97 (39.0)
27 (21.0)
Married, n, (%)
90 (59.2)
142 (57.0)
84 (65.6)
Living alone, n, (%)
24 (15.8)
44 (17.7)
24 (18.8)
Gross annual income Z€75,000, n, (%)
29 (19.1)
117 (47.0)
53 (41.4)
BMI, kg/m2, mean, (SD)
50.7 (8.0)
41.2 (7.5)
35.2 (5.0)
Weight, kg, mean, (SD)
147.2 (27.6)
121.3 (26.0)
100.4 (15.0)
Waist circumference, cm, mean, (SD)
221.9 (258.4)
131.9 (97.4)
144.0 (173.5)
Doctor visits last 12 mo, mean, (SD)
3.0 (8.0)
4.6 (20.2)
.7 (2.6)
Sick days last 12 mo, mean, (SD)
31.3 (76.4)
22.4 (64.1)
30.2 (86.5)
Number of comorbid somatic disorders
2.5 (1.9)
1.9 (1.6)
1.5 (1.7)
χ2 ¼ 1.51; df ¼ 2 P ¼ .471 F ¼ 4.50; df ¼ 2, 526 P ¼ .012 χ2 ¼ 33.36; df ¼ 2 P o .01 χ2 ¼ 2.62; df ¼ 2 P ¼ .270 χ2 ¼ .45; df ¼ 2 P ¼ .799 χ2 ¼ 32.36; df ¼ 2 P o .001 F ¼ 169.79; df ¼ 2, 526 P o .001 F ¼ 130.72; df ¼ 2, 526 P o .001 F ¼ 13.13; df ¼ 2, 526 P o .001 F ¼ 2.90; df ¼ 2, 499 P ¼ .056 F ¼ .77; df ¼ 2, 466 P ¼ .465 F ¼ 12.08; df ¼ 2, 519 P o 0.001
Mood disorder* 1-yr prevalence, n, (%)
25 (22.3)
62 (25.3)
17 (15.6)
Lifetime prevalence, n, (%)
34 (30.4)
88 (35.9)
27 (24.8)
Anxiety Disorder* 1-yr prevalence, n, (%)
29 (25.9)
64 (26.1)
23 (21.1)
Lifetime prevalence, n, (%)
36 (32.1)
90 (36.7)
32 (29.4)
HADS Depression, mean, (SD)
7.3 (3.9)
6.4 (4.2)
5.4 (4.1)
HADS Anxiety, mean, (SD)
6.8 (3.8)
7.1 (4.1)
6.3 (4.2)
SF-36 Physical Component Score, mean, (SD)
35.0 (12.1)
43.9 (11.1)
46.3 (11.0)
SF-36 Mental Component Score, mean, (SD)
44.4 (13.6)
43.8 (14.1)
45.2 (14.6)
RSES Self-Esteem, mean, (SD)
10.3 (3.1)
10.1 (3.4)
11.2 (2.9)
RSES Worthlessness, mean, (SD)
4.3 (3.6)
4.1 (4.2)
3.3 (3.9)
SURG o CONV, OC SURG, OC o CONV — — SURG o CONV, OC SURG 4 CONV 4 OC SURG 4 CONV 4 OC SURG 4 CONV, OC — — SURG 4 CONV,OC
χ2 ¼ 4.10; df ¼ 2 P ¼ .129 χ2 ¼ 4.49; df ¼ 2 P ¼ .106
—
χ2 ¼ 1.10; df ¼ 2 P ¼ .578 χ2 ¼ 2.04; df ¼ 2 P ¼ .361 F ¼ 7.26; df ¼ 2, 509 P ¼ .001 F ¼ 1.47; df ¼ 2, 509 P ¼ .232 F ¼ 36.52; df ¼ 2, 462 P o .001 F ¼ .37; df ¼ 2, 462 P ¼ .690 F ¼ 4.58; df ¼ 2, 508 P ¼ .011 F ¼ 2.53; df ¼ 2, 509 P ¼ .081
—
—
— SURG,CONV 4 OC — SURG o CONV,OC — SURG,CONV o OC —
SURG ¼ Bariatric Surgery Group; CONV ¼ Conventional Treatment Group; OC ¼ Obese Control Group; BMI ¼ body mass index; HADS ¼ Hospital Anxiety and Depression Scale; SF-36 ¼ Short-Form Health Survey; RSES ¼ Rosenberg Self-Esteem Scale. * N ¼ 466.
degree of freedom (df) ¼ 2, P ¼ .010) and the 9-year assessment (χ2 ¼ 6.94, df ¼ 2, P ¼ .031). Those participants with at least 1 postbaseline assessment (n ¼ 465, 87.9%) were more likely to be single (62% versus 41%, χ2 ¼ 11.06, df ¼ 2, P o .001) and have a lower baseline BMI (mean ¼ 42.1, SD ¼ 9.2 versus mean ¼ 45.1, SD ¼ 8.0; F ¼ 6.25; df ¼ 1, 527; P ¼ .013), but did not differ on other demographic or clinical characteristics listed in Table 1.
No significant differences were found between those completing versus not completing the 9-year assessment on gender. Baseline BMI was significantly lower among 9-year completers compared with those not completing the 9-year assessment in both the CONV (mean ¼ 39.8, SD ¼ 6.9 versus mean ¼ 42.6, SD ¼ 7.9; P ¼ .003) and OC (mean ¼ 34.3, SD ¼ 4.2 versus mean ¼ 36.9, SD ¼ 5.8; P ¼ .004) groups, but did not differ significantly in the SURG group (mean ¼ 50.1, SD ¼ 7.0
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T1 N (%) Total 529 (100) SURG 152 (100) CONV 249 (100) OC 128 (100)
T2 N (%) Total 404 (76.4) SURG 118 (77.6) CONV 191 (76.7) OC 95 (74.2)
SURG 1 deceased 1 chronic illness* 1 pregnancy 4 contact unknown 27 no response/ refusal
CONV 1 deceased 3 chronic illness* 4 pregnancy 5 contact unknown 45 no response/ refusal
OC 1 deceased 1 chronic illness* 2 pregnancy 2 contact unknown 27 no response/ refusal
T3 N (%) Total 336 (63.5) SURG 102 (67.1) CONV 146 (58.6) OC 88 (68.7)
SURG 2 deceased† 2 chronic illness* 15 contact unknown 31 no response/ refusal
CONV 1 deceased† 4 chronic illness* 7 pregnancy 1 bariatric surgery 14 contact unknown 76 no response/ refusal
OC 3 deceased† 1 chronic illness* 4 contact unknown 32 no response/ refusal
T4 N (%) Total 354 (66.9) SURG 101 (66.4) CONV 154 (61.8) OC 99 (77.3)
SURG 2 deceased† 3 chronic illness* 46 no response/ refusal
CONV 3 deceased† 7 chronic illness* 1 pregnancy 1 bariatric surgery 82 no response/ refusal
OC 3 deceased† 1 chronic illness* pregnancy 25 no response/ refusal
T5 N (%) Total 293 (55.4) SURG 84 (55.3) CONV 126 (50.6) OC 83 (64.8)
SURG 6 deceased† 14 chronic illness* 9 contact unknown 39 no response/ refusal
CONV 13 deceased† 23 chronic illness* 1 pregnancy 5 bariatric surgery contact unknown no response/ refusal
OC 6 deceased† chronic illness* pregnancy contact unknown no response/ refusal
Fig. 1. Study flowchart. Asterisks (*) indicate chronic illnesses that influence weight (e.g., cancer, multiple sclerosis, and cortisone medication), and dagger symbol (†) indicates cumulative numbers. T1 ¼ baseline; T2 ¼ 1-year follow-up; T3 ¼ 2-year follow-up; T4 ¼ 4-year follow-up; T5 ¼ 9-year follow-up; SURG ¼ Bariatric Surgery Group; CONV ¼ Conventional Treatment Group; OC ¼ Obese Control Group.
versus mean ¼ 51.3, SD ¼ 9.0; P ¼ .348). SURG patients completing the 9-year assessment were significantly younger than those not completing the 9-year assessment (mean ¼ 37.5, SD ¼ 9.6 versus mean ¼ 41.2, SD ¼ 10.8; P ¼ .026), but did not differ significantly in terms of baseline psychological measures. With regard to the CONV and the OC group, no differences in age or baseline psychological measures were found between 9-year completers and noncompleters.
Changes in sociodemographic variables and somatic comorbidity from baseline to 9-year follow-up Marital status at 9-year assessment did not differ significantly from baseline (see Table 1). Accordingly, the rates of those who were married at the 9-year assessment (SURG: 60.8%, CONV: 58.5%, OC: 66.3%) did not differ between groups (χ2 ¼ 1.31, df ¼ 2, P ¼ .518).
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Considering only those who completed both the 4-year and 9-year assessments (SURG: n ¼ 66, CONV: n ¼ 103, OC: n ¼ 75), no significant changes were found within and between groups in marital status over the course of 9 years (all P values 4 .470). Income decreased in all 3 groups from baseline (Table 1) to 9-year visit (gross annual income Z €75,000; SURG: 14.5%, CONV: 36.8%, OC: 34.2%; χ2 ¼ 11.96, df ¼ 2, P ¼ .003). Similarly, among those completing both the 4-year and the 9-year follow-up (SURG: n ¼ 64, CONV: n ¼ 97, OC: n ¼ 69) an annual income of Z€75.000 was less frequently reported in the SURG group at both baseline (SURG: 29.7%, CONV: 48.4%, OC: 49.3%; χ2 ¼ 7.94, df ¼ 2, P ¼ .019) and 9-year assessment (SURG: 17.2%, CONV: 33.0%, OC: 34.8%; χ2 ¼ 6.81, df ¼ 2, P ¼ .033). With regard to the number of co-morbid somatic disorders, the groups did differ significantly at baseline (Table 1) but not at the 9-year follow-up (SURG: mean ¼ 2.1, SD ¼ 1.8; CONV: mean ¼ 2.3, SD ¼ 1.8; OC: mean ¼ 1.9, SD ¼ 1.9; F ¼ .76; df ¼ 2, 289, P ¼ .466). Considering only those participants completing both the 4-year and the 9-year assessment, the mean number of somatic disorders at baseline was significantly higher (F ¼ 9.296, df ¼ 2, 242, P o.001) among SURG patients (mean ¼ 2.6, SD ¼ 1.8) than that for CONV (mean ¼ 1.9, SD ¼ 1.6) and OC (mean ¼ 1.4, SD ¼ 1.5) participants but did not differ between groups at 4-year (SURG: mean ¼ 2.3, SD ¼ 1.4; CONV: mean ¼ 2.5, SD ¼ 1.3; OC: mean ¼ 2.6, SD ¼ 1.5; F ¼ 1.003, df ¼ 2, 241, P ¼ .369) and 9-year (SURG: mean ¼ 2.1, SD ¼ 1.7; CONV: mean ¼ 2.2, SD ¼ 1.8; OC: mean ¼ 2.0, SD ¼ 1.9; F ¼ .170, df ¼ 2, 241, P ¼ .844) assessments.
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Fig. 2. Weight loss from baseline to 9-year follow-up by study group. (A) Body mass index (kg/m2) from baseline to 9-year follow-up by study group. (B) Percentage weight loss (mean, 95% CI) from baseline to 9-year follow-up by study group. Size of study groups varies depending on assessment year. CI ¼ confidence interval; SURG ¼ Bariatric Surgery Group (n ¼ 152); CONV ¼ Conventional Treatment Group (n ¼ 249); OC ¼ Obese Control Group (n ¼ 128).
Course of BMI and weight loss
Changes in psychological functioning from baseline to 9-year follow-up
Changes in BMI are shown in Fig. 2A. The mean BMI for the SURG group at baseline was 50.7 kg/m2 (SD ¼ 8.0; 93.4% obesity grade 3, 6.6% obesity grade 2). Nine years after surgery, this group had a mean BMI of 39.4 kg/m2 (SD ¼ 8.7), but 45.2% still had obesity grade 3, 23.8% had obesity grade 2, 20.2% had obesity grade 1, 8.3% were overweight, and 2.4% were normal weight. Percentage weight loss was greater for the SURG group than the control groups at all assessment points (all P values o .001) (Fig. 2B). The CONV group exhibited greater weight loss than the OC group at the 1-year and 2-year follow-ups (P o .001) but did not differ from the OC group at 4-year (P ¼ .471) and 9-year assessments (P ¼ .231). Surgery patients completing the 9-year assessment did not differ significantly in terms of percentage of original weight loss at 9-year follow-up from those not completing the last follow-up visit (mean ¼ –20.6, SD ¼ 15.2 versus mean ¼ –23.5, SD ¼ 12.6; F ¼ 1.168, df ¼ 1, 129, P ¼ .282).
Table 2 presents the propensity score-adjusted changes from baseline by study group and by assessment year. Changes in depression and anxiety. The SURG group had greater impairments in depression than both the CONV and OC groups at the 9-year assessment after controlling for baseline depression scores. HADS depression scores for the SURG group at the 9-year assessment were increased from the 4-year assessment (P ¼ .032) and did not differ from baseline levels (P ¼ .215) (Fig. 3A). Group comparisons on changes from 4-year to 9-year assessment for those completing both assessments (SURG: n ¼ 65, CONV: n ¼ 103, OC: n ¼ 75) indicated that the increase in HADS depression among SURG patients (mean ¼ .1, SD ¼ 3.9) was significantly greater (P ¼ .002) than that for both CONV (mean ¼ –.6, SD ¼ 3.4) and OC (mean ¼ –1.0, SD ¼ 3.4) group participants. The SURG group reported more HADS anxiety than the OC group at the 9-year assessment (Table 2). The scores for the SURG group at the 9-year assessment were significantly
S. Herpertz et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
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Table 2 Propensity score-adjusted changes from baseline by study group by assessment year Variable
HADS Depression
Group
SURG
CONV
OC
SURG versus CONV SURG versus OC HADS Anxiety
SURG
CONV
OC
SURG versus CONV SURG versus OC RSES Self-Esteem
SURG
CONV
OC
SURG versus CONV SURG versus OC RSES Worthlessness
SURG
CONV
OC
SURG versus CONV SURG versus OC SF-36 Physical Component Score
Bariatric Surgery
CONV
OC
Yr 1
Yr 2
Yr 4
Yr 9
Mean 95% CI n
Mean 95% CI n
Mean 95% CI n
Mean 95% CI n
–2.15 (–2.89; –1.40) n ¼ 114 –1.47 (–1.99; –.95) n ¼ 183 –.69 (–1.45; .06) n ¼ 94 –.68 (–1.61; .26) –1.45* (–2.60; –.30) –1.07 (–1.76; –.38) n ¼ 114 –.81 (–1.29; –.33) n ¼ 182 –.98 (–1.68; –.29) n ¼ 94 –.26 (–1.13; .60) –.09 (–1.15; .97) 1.06 (.52; 1.60) n ¼ 117 1.00 (.62; 1.38) n ¼ 179 .65 (.09; 1.20) n ¼ 91 .06 (–.62; .74) .41 (–.42; 1.24) –1.06 (–1.74; –.38) n ¼ 117 –.68 (–1.16; –.21) n ¼ 181 –.65 (–1.34; .05) n ¼ 91 –.37 (–1.23; .49) –.41 (–1.47; .64) 10.81 (8.69; 12.93) N ¼ 104 5.65 (4.17; 7.14) N ¼ 163 1.51
–1.39 (–2.16; –.62) n ¼ 100 –.72 (–1.29; –.16) n ¼ 140 –.60 (–1.38; .17) n ¼ 85 –.66 (–1.65; .32) –.78 (–1.97; .40) –.49 (–1.20; .23) n ¼ 100 –.72 (–1.24; –.20) n ¼ 140 –.77 (–1.49; –.05) n ¼ 84 .23 (–.67; 1.14) .28 (–.81; 1.38) .70 (.13; 1.26) n ¼ 98 .59 (.17; 1.01) n ¼ 139 .78 (.21; 1.35) n ¼ 84 .11 (–.61; .83) –.08 (–.94; .78) –.99 (–1.70; –.29) n ¼ 99 –.28 (–.80; .24) n ¼ 139 –1.08 (–1.79; –.36) n ¼ 84 –.72 (–1.62; .18) .08 (–1.00; 1.16) 10.53 (8.25; 12.80) N ¼ 82 3.56 (1.85; 5.26) N ¼ 113 1.05
–1.08 (–1.88; –.29) n ¼ 92 –.37 (–.93; .19) n ¼ 145 –.25 (–.99; .50) n ¼ 98 –.72 (–1.72; .28) –.84 (–2.01; .34) –.59 (–1.32; .14) n ¼ 92 –.60 (–1.12; –.09) n ¼ 146 –.71 (–1.40; –.02) n ¼ 97 .01 (–.91;. .94) .12 (–.96; 1.21) .46 (–.12; 1.03) n ¼ 94 .33 (–.09; .74) n ¼ 146 .41 (–.13; .95) n ¼ 98 .13 (–.60; .86) .05 (–.80; .89) –.43 (–1.15; .30) n ¼ 94 –.25 –.77; .26) n ¼ 146 –.52 (–1.20; .16) n ¼ 98 –.17 (–1.09; .74) –.09 (–.98; 1.17) 8.04 (5.74; 10.34) N ¼ 79 1.53 (–.14; 3.19) N ¼ 121 .72
.06 (–.78; .91) n ¼ 77 –.99 (–1.60; –.38) n ¼ 119 –1.47 (–2.26; –.68) n ¼ 82 1.05* (.02; 2.12) 1.53* (.29; 2.78) .43 (–.35; 1.21) n ¼ 77 –.34 (–.90; .23) n ¼ 119 –.75 (–1.49; –.02) n ¼ 82 .77 (–.22; 1.76) 1.19* (.04; 2.33) .01 (–.61; .64) n ¼ 75 1.06 (.60; 1.51) n ¼ 119 .92 (.34; 1.50) n ¼ 82 –1.04† (–1.83; –.25) –.91* (–1.82; .00) .59 (–.19; 1.37) n ¼ 76 –.64 (–1.21; –.08) n ¼ 120 –.77 (–1.49; –.04) n ¼ 82 1.23* (.25; 2.22) 1.36* (.22; 2.50) 4.58 (2.14; 7.01) N ¼ 68 .90 (–.88; 2.68) N ¼ 105 –.74
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Table 2 Continued. Variable
SF-36 Mental Component Score
Group
Bariatric Surgery versus CONV Bariatric Surgery versus OC Bariatric Surgery
CONV
OC
Bariatric Surgery versus CONV Bariatric Surgery versus OC
Yr 1
Yr 2
Yr 4
Yr 9
Mean 95% CI n
Mean 95% CI n
Mean 95% CI n
Mean 95% CI n
(–.67; 3.69) N ¼ 82 5.16‡ (2.48; 7.84) 9.30‡ (6.02; 12.58) 1.15 (–1.61; 3.91) N ¼ 104 1.19 (–.76; 3.14) N ¼ 163 1.05 (–1.81; 3.91) N ¼ 82 –.05 (–3.54; 3.44) .10 (–4.18; 4.38)
(–1.24; 3.35) N ¼ 70 6.97‡ (4.04; 9.89) 9.47‡ (6.00; 12.94) –2.68 (–5.65; .28) N ¼ 82 .65 (–1.58; 2.89) N ¼ 113 3.16 (.16; 6.17) N ¼ 70 –3.34 (–7.15; .47) –5.85* (–10.37; –1.33)
(–1.46; 2.91) N ¼ 81 6.51‡ (3.59; 9.43) 7.31‡ (3.91; 10.72) 1.29 (–1.72; 4.30) N ¼ 79 1.15 (–1.04; 3.34) N ¼ 121 1.46 (–1.41; 4.32) N ¼ 81 .14 (–3.67; 3.96) –.16 (–4.61; 4.29)
(–3.04; 1.56) N ¼ 71 3.68* (.57; 6.78) 5.31† (1.73; 8.90) –4.45 (–7.65; –1.25) N ¼ 68 1.17 (–1.17; 3.52) N ¼ 105 4.18 (1.16; 7.21) N ¼ 71 –5.62† (–9.70; –1.55) –8.63‡ (–13.32; –3.94)
CI ¼ confidence interval; SURG ¼ Bariatric Surgery Group; CONV ¼ Conventional Treatment Group; OC ¼ Obese Control Group. HADS ¼ Hospital Anxiety and Depression Scale, SF-36 ¼ Short-Form Health Survey, RSES ¼ Rosenberg Self-Esteem Scale. * P o .05. † P o .01. ‡ P o .001.
increased from the 4-year assessment (P ¼ .015) and did not differ significantly from baseline levels (P ¼ .304, Fig. 3B). Among those completing both the 4-year and the 9-year assessment (SURG: n ¼ 65, CONV: n ¼ 102, OC: n ¼ 75), anxiety scores increased from T4 to T5 by an average of 1.1 (SD ¼ 4.0) in the SURG group, compared with .1 (SD ¼ 3.7) in the CONV group and .1 (SD ¼ 3.2) in the OC group. However, this difference did not reach statistical significance. To investigate the clinical significance of the aforementioned results, the percentage of participants above the HADS cut-offs for probable depressive or anxiety disorder (HADSDepr/Anxiety 410) were calculated at baseline and follow-ups among those participants who had completed both the 4-year and the 9-year assessment. Figs. 3C and Fig. 3D illustrate the initial decrease of clinical significant depression/anxiety in the SURG group from baseline to 4-year assessment and the increase later on. Rates of participants with probable depressive/anxiety disorder differed significantly between groups at 9-year assessment (depression: SURG: 18.2%, CONV: 10.1%, OC: 4.0%; χ2 ¼ 7.58, df ¼ 2, P ¼ .023; anxiety: SURG: 22.5%, CONV: 18.4%, OC: 6.7%; χ2 ¼ 7.53, df ¼ 2, P ¼ .023) but not at baseline and 4-year assessment. Changes in self-esteem. RSES worthlessness scores for the SURG group (Table 2) at the 9-year assessment were significantly increased from the 4-year assessment
(P ¼ .030) and were higher but did not differ significantly from baseline (P ¼ .330). Among those who completed both the 4-year and the 9-year assessment (SURG: n ¼ 64, CONV: n ¼ 102, OC: n ¼ 75), worthlessness scores increased significantly more from 4-year to 9-year assessment (P ¼ .034) in the SURG group (mean ¼ 1.1, SD ¼ 3.6) than in the CONV (mean ¼ –.1, SD ¼ 3.3) or the OC (mean ¼ –.3, SD ¼ 3.1) group, and self-esteem changes did not differ among the SURG (mean ¼ –.3, SD ¼ 3.1), the CONV (mean ¼ .8, SD ¼ 3.3), and the OC (mean ¼ .6, SD ¼ 3.3) groups. Changes in quality of life. The SURG group reported greater improvements in the SF-36 physical component score (PCS) at all postbaseline assessments compared with the control groups (Table 2). Although PCS scores were lower for the SURG group at the 9-year assessment compared with the 4-year assessment (P ¼ .010), the 9-year assessment scores remained less disturbed than before surgery (P o.001). On the SF-36 mental component score (MCS), the SURG group experienced greater impairments than both other groups at the 9-year assessment after controlling for baseline scores. MCS scores for the SURG group at the 9-year assessment were deteriorated from the 4-year assessment (P ¼ .006) and were lower but did not differ significantly from baseline (P ¼ .143). Among those completing both the 4-year and 9-year assessments (BS: n ¼ 58, CONV: n ¼ 88, OC: n ¼ 63), changes in
8
S. Herpertz et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
Fig. 3. Anxiety and depression from baseline to 9-year follow-up by study group. (A) Unadjusted mean (⫾SE) Hospital Anxiety and Depression Scale (HADS) depression scores by study group. (B) Unadjusted mean (⫾SE) HADS anxiety scores by study group. (C) Percentage of participants who had completed both the 4-year and 9-year follow-up above the HADS depression cut-off (HADSDepr 410). (D) Percentage of participants who had completed both the 4-year and 9-year follow-up above the HADS depression cut-off (HADSAnx 410). In Figures 3A and 3B size of study groups varies depending of assessment year. SE ¼ standard error; SURG ¼ Bariatric Surgery Group (n ¼ 152); CONV ¼ Conventional Treatment Group (n ¼ 249); OC ¼ Obese Control Group (n ¼ 128).
PCS scores did not differ between BS (mean ¼ –3.8, SD ¼ 11.5), CONV (mean ¼ –.8, SD ¼ 12.3), and OC (mean ¼ –1.3; SD ¼ 10.8) groups. Also, no significant group differences were found with respect to MCS changes (BS: mean ¼ –4.4, SD ¼ 16.9; CONV: mean ¼ –.3, SD ¼ 12.6; OC: mean ¼ 1.2, SD ¼ 14.0). The comparison of SURG patients with gastroplasty versus gastric banding indicated that changes in psychosocial measures did not differ on the basis of surgery type (P ¼ .241–.890). Correspondence between changes in BMI and changes in depression, anxiety, and quality of life Changes in BMI over the course of 9 years were significantly associated with changes in HADS depression and SF-36 PCS scores in all 3 groups (all P values o .001). However, changes in BMI were linked to changes in HADS anxiety and SF-36 MCS only in the CONV group (anxiety: P o .001, MCS: P ¼ .012). Among those SURG patients completing both the 4-year and the 9-year assessment, the change in BMI from 4-year to 9-year assessment was
uncorrelated (all P values Z .156) with changes in any of the psychological measures over that same period. Discussion This prospective controlled 9-year follow-up study indicates that bariatric surgery results in long-lasting weight loss and improvement of physical aspects of HRQOL, which is consistent with the findings from prior studies [1,15–18]. In contrast to the SOS study [1], however, the present results do not support the proposed link between long-term weight reduction and continued improvement in mental health after surgery. Although the SURG group had an initial improvement in mental health, this deteriorated between the 4-year and 9-year assessments and was comparable to or worse than presurgical levels. It is important to note that, in those patients completing both the 4-year and the 9-year assessment, change in BMI from the 4-year to the 9-year assessment was not related to change in psychological measures over that period. Therefore, it can be
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assumed that the decline in mental health during this period was related to factors other than weight regain. For example, the deterioration in improvement of mood may have been caused by disappointment from unrealistic expectations about surgical treatment or by the reoccurrence of psychiatric disorders [2,3,19]. Furthermore, changes in eating behavior, medical sequelae after surgery (e.g., plugging), the fear of weight regain leading in some cases to disturbed eating [19– 21], dissatisfaction with body appearance and excess skin [22– 24], or the persistence of problems after weight loss that are blamed on obesity may have contributed to the decline [19,25,26]. Shortcomings of the present study include the relatively low retention rates, the lack of randomization, the use of selfratings to assess mental health aspects, and the lack of information on treatment for anxiety, depression, and eating and weight problems over the period of 9 years. Furthermore, the results are limited to restrictive surgical treatment. It remains unknown whether patients who undergo gastric bypass or sleeve surgery would have similar outcomes. Strengths of the present study are the prospective design with a long-term follow-up, measured weights, and the use of 2 control groups.
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
Conclusions Taken together, the results support the notion that bariatric surgery is an effective treatment for obesity in terms of sustained weight loss and maintained improvement of physical aspects of HRQOL. The findings further indicate that substantial weight reduction after surgery is associated with significant initial improvement in mental health that may erode over time; therefore, psychosocial screening should be included at follow-ups, with referral to mental health professionals as appropriate.
[10] [11] [12]
[13] [14]
Disclosures [15]
The authors have no commercial associations that might be a conflict of interest in relation to this article.
[16]
Acknowledgments
[17]
The authors wish to thank the following persons for their substantial support: C. Fischer, Ph.D., (Ruhr University Bochum), J. Bryjova, Ph.D., (University of Fribourg, Switzerland), M. Kemen, M.D., (Protestant Hospital, Herne), A. Chen-Stute, M.D., (Obesity Centre Oberhausen), T. Hulicz, M.D., U. Machleit, Ph.D., (Augusta Clinics, Bochum), C. Stroh, M.D., (Municipal Hospital Gera), and R. Weiner, M.D., (Frankfurt Sachsenhausen Hospital).
[18]
[19]
[20]
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