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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22 Original Research Bariatric Times • April 2018 before and after bariatric surgery for each obesity-specific symptom. The three most common symptoms (items 1–3) prior to bariatric surgery were also highly endorsed at follow-up. The difference in the proportion of participants to report a symptom was significantly lower at follow-up for 5 of 10 symptoms. Change in BODY-Q scores. Table 4 shows the mean scores before and after bariatric surgery, mean difference in scores, p-value, effect sizes, and standardized response means. Significant higher satisfaction with appearance was reported for all areas except for the Upper Arms scale. For the HR-QOL scales, a significant change was reported for Body Image, Physical, and Social. These changes were associated with moderate to large effect sizes (0.60 to 2.29) and standardized response means (0.47 to 1.35). Correlation between %TWL and BODY-Q scores. More improvement in BODY-Q scores correlated with higher %TWL for the following scales: Body (r=0.52, p <0.001), Upper Arms (r=0.31, p=0.024), Back (r=0.39, p=0.005), Buttocks (r=0.34, p=0.018), Hips and Outer Thighs (r=0.29, p=0.044), Body Image (r=0.45, p=0.001), and Sexual (r=0.37, p=0.011). DISCUSSION The BODY-Q represents a new generation PRO instrument developed and validated using a modern psychometric approach to provide a set of unidimensional, scientifically sound scales that measure concepts of interest important to patients undergoing weight loss and/or body contouring. Our findings show that BODY-Q scales were responsive to measuring clinical change in patients who underwent bariatric surgery. The variation in effect sizes and standardized response means, from no change to moderate and large change across scales illustrates why it is important to provide separate results for each scale rather than sum to produce a total score for scales measuring different concepts. Bariatric surgery is often pursued by people aiming to improve their physical and psychosocial HR-QOL. However, massive weight loss often leads to excessive skin, which can have a negative influence on HR- QOL. 24 The BODY-Q was specifically designed to measure outcomes important to patients over the entire patient journey starting at obesity and ending after body contouring to remove excess skin. We found that participants improved in terms of body image, social and physical function, and reported fewer obesity- specific symptoms. Our sample did not improve in terms of psychological and sexual function. These findings are in line with recent systematic reviews of intermediate and long-term HR- QOL in bariatric surgery. One review 3 examined 11 studies focused on the long-term effectiveness of bariatric surgery on quality of life compared to non-surgical interventions. These researchers found that long-term psychosocial quality of life did not appear to improve following bariatric surgery despite significant improvements in physical quality of life over time. Similarly, another review 25 evaluated the impact of bariatric surgery on psychological functioning based on 27 articles and concluded that bariatric surgery results in mental health gains in the short-term, but this effect was not sustained beyond two years post- surgery. Another study 4 compared bariatric surgery with alternative weight-loss interventions and between different bariatric surgical procedures based on 15 controlled trials and showed that physical function consistently improved following bariatric surgery, but that improvements in mental health and psychosocial function were mixed. One study 2 examined short- and long-term effects of bariatric surgery compared to community norms based on 36 studies and found that while quality of life significantly improved after surgery, a few studies showed no significant improvement in the mental health component of quality of life. Authors from these reviews pointed out limitations in current literature (e.g., lack of consensus on the choice of PRO instruments used) and called for more research to gain a greater understanding of the effects of bariatric surgery on the health of patients. Though our sample is small, the authors of a large cross-sectional study of 493 bariatric surgery patients from Denmark compared BODY-Q scores for four phases of the weight loss journey: pre-bariatric surgery, post-bariatric surgery (4/5 or 12 months post-surgery), pre-body contouring surgery, and post-body contouring surgery. 26 BODY-Q scores for appearance and HR-QOL were lowest in the pre-bariatric phase, followed by patients in the pre-body contouring phase. The Danish findings suggest that outcomes following bariatric surgery are not optimal until body-contouring to remove excess hanging skin is performed, and they call for longitudinal research to measure the full extent of HR-QOL and appearance change following weight loss and reconstructive treatments. In the present study, the majority of participants reported that they needed body contouring surgery to remove excess skin in order to complete their weight loss journey, which could account for the lack of improvement in psychological and sexual function. This study has some limitations. The response rate was low and our sample size was small. Although we did not find any differences between the group of non-respondents and respondents on demographic, clinical and BODY-Q scores, there could still be bias in the sample of patients who completed our survey. Another limitation is that the participants were from a single bariatric surgery center in Canada and might not represent the bariatric patients in other centres or other countries. Finally, the clinical data collected were self-reported and could have errors due to participants guessing (e.g., date of bariatric surgery). CONCLUSION Participants in our sample were at various stages in their weight loss journey, with many requiring body contouring to remove excess skin after massive weight loss. While it is clear that bariatric surgery leads to improvement in physical health, evidence-based information is still needed to show the full extent of psychosocial, sexual, and body image/ appearance change that follows weight loss across the entire journey. COPYRIGHT © The Author(s). 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// creativecommons.org/licenses/ by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/ zero/1.0/) applies to the data made available in this article, unless otherwise stated. REFERENCES 1. Sarwer DB, Steffen KJ. Quality of life, body image and sexual functioning in bariatric surgery patients. Eur Eat Disord Rev. 2015;23:504–8. 2. Raaijmakers LC, Pouwels S, Thomassen SE, Nienhuijs SW. Quality of life and bariatric surgery: a systematic review of short- and long-term results and comparison with community norms. Eur J Clin Nutr. 2016 Nov 2. [Epub ahead of print] 3. Jumber S, Bartlett C, Jumbe SL, Meyrick J. The effectiveness of bariatric surgery on long term psychosocial quality of life—a systematic review. Obes Res Clin Pract. 2016;10(3):225–42. Epub 2016 Jan 8. 4. Hachem A, Brennan L. Quality of life outcomes of bariatric surgery: a systematic review. Obes Surg. 2016;26(2):395–409. 5. U.S. Food and Drug Administration Clinical Outcome Assessment Qualification Program. FDA, 2015. Accessed 18 Mar 2017. 6. Black N. Patient reported outcome measures could help transform healthcare. BMJ. 2013;346:f167. 7. Basch E. Patient-reported outcomes—harnessing patients' voices to improve clinical care. N Engl J Med. 2017;376(2):105–8. Our findings show that BODY-Q scales were responsive to measuring clinical change in patients who underwent bariatric surgery. TABLE 4. Mean scores pre- and post-bariatric surgery, p-value for paired t-test and Effect Size PART OF THE BODY NO. PRE- MEAN (SD) POST- MEAN (SD) MEAN DIFFERENCE (SD) P ES SRM Arms 53 25.2 (19.3) 28.8 (27.2) 3.6 (23.8) 0.272 0.19 0.15 Abdomen a 53 5.8 (10.6) 25.1 (23.9) 19.3 (24.7) <0.001 1.82 0.78 Back 51 21.1 (22.1) 48.0 (27.8) 26.9 (29.1) <0.001 1.22 0.92 Body 53 14.7 (12.3) 42.9 (18.6) 28.3 (20.9) <0.001 2.29 1.35 Buttocks 50 16.0 (20.0) 39.3 (24.1) 23.2 (25.5) <0.001 1.16 0.91 Hips/outer thighs 51 15.8 (19.9) 38.9 (24.3) 23.1 (26.0) <0.001 1.16 0.89 Inner thighs 51 10.5 (15.1) 27.9 (28.2) 17.4 (27.2) <0.001 1.15 0.64 Body image 51 13.4 (13.6) 37.2 (22.3) 23.7 (22.2) <0.001 1.74 1.07 Physical 49 46.1 (19.7) 76.2 (21.4) 30.1 (23.2) <0.001 1.53 1.30 Pysch 50 55.5 (17.7) 58.4 (21.7) 2.9 (17.6) 0.254 0.16 0.17 Sexual 46 44.7 (21.5) 43.0 (23.5) -1.6 (21.6) 0.615 -0.08 -0.07 Social 50 51.4 (17.0) 61.6 (19.5) 10.2 (21.9) 0.002 0.60 0.47 ES: effect size; SRM: standardized response mean; SD: standard deviation a Nonparametric test performed

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