Bariatric Times

APR 2018

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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Original Research 21 Bariatric Times • April 2018 In Phase 1, following a literature review 18 and 63 patient interviews, 19 a conceptual framework and set of scales were developed to measure concepts that matter to weight loss and body contouring patients. The scales were further refined through 22 patient interviews and input from nine clinical experts. 19 In Phase 2, the scales evidenced reliability, validity, and responsiveness in an international (Canada, United States, and United Kingdom) sample of 403 pre- and post-weight loss and 331 pre- and post-body contouring surgery patients. 16 The BODY-Q is composed of 18 independently functioning scales that measure three domains (appearance [n = 9], HR-QOL [n = 5] and experience of healthcare [n = 4]). In addition, there is a 10-item obesity- specific symptom checklist that is part of the HR-QOL domain. The follow-up survey included 12 BODY-Q scales and the obesity-specific checklist (see Table 1), alongside demographic and weight-specific (current weight and satisfaction with current weight) questions. The experience of healthcare scales were excluded due to potential recall bias given the length of time elapsed since bariatric surgery for many of the participants. Also excluded were the appearance scales measuring excess skin because these were not completed by pre- bariatric patients at Time 1, and body contouring scars because these were not applicable to most participants. Sample. In the field-test study, which took place between November 2013 and July 2014, participants were asked if they would be willing to complete additional follow-up surveys. Of the 354 participants recruited from the St Joseph's Healthcare Hamilton bariatric program, 107 were exploring or seeking bariatric surgery at that time. Of these, 13 did not provide permission for follow-up surveys, one was deceased, and contact details were missing for four. For the 89 remaining subjects, the survey was sent between June 7, 2016 and November 29, 2016, with all follow-up reminders sent by November 29, 2016. Recruitment method. Research subjects with an email address were sent a link to complete the BODY-Q in Research Electronic Data Capture (REDCap), a secure web-based application. 20 Subjects without an email address, and subjects whose email address was no longer valid (email bounced back), were contacted by phone. Subjects for whom we did not have an email or phone, and anyone we could not reach by email or phone, were sent the BODY-Q in the mail. Up to two emailed reminders, spaced by one week, and/or two postal reminders spaced by three weeks, were sent to non-respondents. Subjects received up to two phone call reminders as necessary. Statistical analysis. To identify respondent bias, non-respondents to the follow-up study were compared with respondents to the baseline survey on the following variables: age (continuous), sex (male vs. female), ethnicity/race (white vs. other), BMI (continuous), and initial BODY-Q scale scores. BODY-Q scores range from 0 (worse) to 100 (best) scores based on Rasch logits developed in the field- test sample. Analysis included Chi- square tests to examine differences in categorical variables, and t-tests or the equivalent nonparametric test depending on the normality of the distribution of the scores. For the obesity-specific symptom checklist, the difference in scores from Time 1 to Time 2 for each symptom was computed. In addition, responses were rescored to form dichotomous yes (sometimes/often/ always bothered) versus no (never bothered) variables for each of the 10 symptoms. Chi-square tests were used to examine the significance of change in the proportion of participants to report a symptom before and after bariatric surgery. Clinical change was measured by computing paired t-tests, or the nonparametric equivalent for data without a normal distribution, and computing the effect sizes 21 and standardized response means. 22 The magnitude of the change was interpreted using Cohen's arbitrary criteria (i.e., small, 0.20; moderate, 0.50; and large, 0.80). 23 Pearson correlations were computed between the change scores (i.e., mean Time 1 – mean Time 2) for BODY-Q scales and percentage total weight gain/ loss (%TWL) calculated as follows: ([{weight at the time of bariatric surgery – current weight}/weight at the time of bariatric surgery) * 100]). Data were analysed using SPSS Version 23 [IBM SPSS Statistics, Version 23, IBM Corp]. All statistical tests, p-values <0.05 were considered statistically significant. RESULTS The survey was completed by 58 (response rate 65%) of the 89 participants who were sent an invitation to complete the follow-up survey. The 58 participants did not differ from the 49 non-participants who provided data at baseline in terms of age, sex, ethnicity, BMI, or any of the BODY-Q scores completed by the sample at Time 1. Of the 58 participants, four had not undergone bariatric surgery at follow-up and were excluded from the subsequent analyses. Of the 54 remaining participants, age ranged from 27 to 71 years (mean = 48, SD = 12), 42 (77.8%) were female, and 44 (81.5%) were Caucasian. The mean time since bariatric surgery was two years (SD = 0.5; from 0.4 to 3 years). Baseline BMI was 50 (SD = 7), and was 35 at follow-up (SD = 7). All participants lost weight: mean %TWL was 31 (SD = 9; from 12 to 51). Dissatisfaction with weight was reported by 51 (95%) participants before bariatric surgery and 20 (37%) participants at follow-up. Body contouring to remove excess skin had been obtained by three (6%) participants, while 40 (74%) participants indicated that they needed body contouring to remove excess skin from one or more areas of their body. Change in obesity-specific symptoms. Table 2 shows the number of participants for each possible change in score (deteriorate, stay the same, improve) for each obesity- specific symptom. The item with the most change was "Short of breath with mild exercise?" Here, 36 participants improved by at least one response option. The item with the highest number of participants (N=10) to report a worse score at follow-up was "Feeling off balance?" Table 3 shows the change in the proportion of the sample to report a symptom (dichotomized into never vs. sometimes/often/all the time) TABLE 1. BODY-Q scales/checklist included in follow-up study NAME OF SCALE ITEMS EXAMPLE ITEM RESPONSE OPTIONS Body 10 How your body looks in summer clothes (e.g., shorts, t-shirts) dissatisfied/satisfied Abdomen 7 How your abdomen looks in a swimsuit dissatisfied/satisfied Arms 7 How your upper arms look when you lift them up dissatisfied/satisfied Back 4 How your back looks when you are naked dissatisfied/satisfied Buttocks 5 The size of your buttocks dissatisfied/satisfied Hips & outer thighs 5 The shape of your hips and outer thighs dissatisfied/satisfied Inner thighs 4 How the skin on your inner thighs look dissatisfied/satisfied Body image 7 My body is not perfect but I like it. disagree/agree Physical 7 Walking up or down stairs all the time/never Psychological 10 I am emotionally strong. disagree/agree Sexual 5 I am comfortable having the lights on during sex. disagree/agree Social 10 People listen to what I have to say. disagree/agree Obesity-specific symptoms 10 Short of breath with mild exercise all the time/never TABLE 2. Number of participants to deteriorate, stay the same, or improve from before to after bariatric surgery for each obesity-specific symptom OBESITY-SPECIFIC SYMPTOMS DETERIORATE STAY SAME IMPROVE -3 -2 -1 0 +1 +2 +3 1. Feeling tired during the day 0 1 6 20 18 2 2 2. Back pain 0 2 4 25 12 5 0 3. Joint pain 0 1 6 23 7 11 1 4. Leg pain or discomfort 0 2 3 18 14 9 3 5. Feeling off balance 0 1 9 17 19 3 0 6. Feeling weak 0 0 7 23 15 4 0 7. Short of breath with mild exercise 0 0 1 12 22 7 7 8. Swollen feet 0 0 7 18 15 8 1 9. Skin rash or infection 0 3 4 30 6 5 1 10. Too much perspiration 0 1 3 27 15 1 2 Note: Missing data ranged up to 6 per item TABLE 3. Number (%) of participants to report an obesity-specific symptom (yes/no) before and after bariatric surgery, and Chi-square -value for test of significance SYMPTOM TIME 1 TIME 2 P-VALUE YES NO YES NO 1. Feeling tired during the day 47 (95.9) 2 (4.1) 44 (89.8) 5 (10.2) 1.000 2. Back pain 44 (91.7) 4 (8.3) 41 (85.4) 7 (14.6) 0.096 3. Joint pain 44 (89.8) 5 (10.2) 42 (85.7) 7 (14.3) 0.143 4. Leg pain or discomfort 41 (83.7) 8 (16.3) 30 (61.2) 19 (38.8) 0.004 5. Feeling off balance 34 (69.4) 15 (30.6) 20 (40.8) 29 (59.2) 0.597 6. Feeling weak 35 (71.4) 14 (28.6) 25 (51.0) 24 (49.0) 0.012 7. Short of breath with mild exercise 43 (87.8) 6 (12.2) 22 (44.9) 27 (55.1) 0.027 8. Swollen feet 32 (65.3) 17 (34.7) 20 (40.8) 29 (59.2) 0.126 9. Skin rash or infection 24 (49.0) 25 (51.0) 18 (36.7) 31 (63.3) 0.019 10. Too much perspiration 29 (59.2) 20 (40.8) 21 (42.9) 28 (57.1) 0.001

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