• E-mail
• Print
• Comment
• Font Size
• Digg
• del.icio.us
• Discuss article

Quality of Life in Obese Subjects Following Biliopancreatic Diversion

Posted on: Sunday, 4 September 2005, 03:01 CDT

In this study, the authors examined health-related quality of life in severely obese patients prior to and following biliopancreatic diversion (BPD). They evaluated quality of life (QoL) by using the Impact of Weight on Quality of Life (IWQOL), a 74- item self-report questionnaire that assesses the QoL in physical and mental areas and the comfort with food. The questionnaire was administered to 50 obese patients prior to and at 1 year following BPD, to 150 postobese subjects at 3 years following BPD, and to 50 lean controls. At 1 year after the operation, the authors found a sharp improvement toward normality in the QoL, and the cross- sectional findings suggest that this result was maintained in the long term. Following BPD, patients' weight loss and long-term maintenance are accompanied by overall beneficial effects on their QoL.

Index Terms: obesity, obesity surgery, quality of life, weight loss

Obesity is a complex and multifaceted disease that is widespread in western countries and growing in the developing world. Obesity markedly limits physical functioning in a person's everyday life because of the excess weight he or she carries; furthermore, because of the medical complications, obesity greatly affects a person's health status, leading to a sharp increase of cardiovascular risk and reducing overall life expectancy. Moreover, in most cases, obesity is aggravated by an impairment of psychological conditions that normally goes hand-in-hand with the poor social considerations toward obese persons that exist in all developed societies. Therefore, it is not surprising that severely obese patients do not have the capacity to live as fully and actively as they would like, and thus experience an overall impaired QoL.1,2

The QoL is a multidimensional construct that is determined by the biological and psychological functioning of the subject and that is strongly affected by social, economical, and ethical factors. The term health-related QoL refers to the physical, psychological, and social domains of health seen as a distinct area that is influenced by a person's experiences, beliefs, expectations, and perceptions. Health-related QoL reflects individual subjective evaluation and reaction to health and diseases.1,3,4

Every clinical attempt to quantify health-related QoL has to rule out any possible effect of the non-health-related factors on individual well-being, and then disease-specific questionnaires are employed.2,5,6 The questionnaire Impact of Weight on Quality of Life (IWQOL) is a particular instrument that measures the effects of weight and food on physical health, on psychological status, and on interpersonal relationships, and, therefore, it is widely used in obesity research.

Following diet reduction or behavior modification therapy, a complete recovery from obesity (a stable return of body weight to the normal range) is very rarely observed. However, fully satisfactory clinical results can be achieved,7 with improvement of health conditions and an increase of both physiological and psychological well-being,8-11 following moderate and reasonable weight loss ensuing from increased physical activity and a self- selected hypocaloric diet, with group support. In any setting, therefore, to assess treatment outcome, biological parameters (e.g., serum glucose concentration) and the results of specific questionnaires exploring the health-related QoL are much more useful than the mere body weight data.

Compared with nonoperative programs, obesity surgery leads to significantly greater weight loss with better long-term weight maintenance. The recovery from most excess weight-related complications brought about by weight loss is clearly a great health benefit for obese persons. However, the different bariatric procedures currently employed may give rise to different effects that influence the physiological status or behavior in the operated subjects, and this could prevent or detract from the improvement of the QoL expected from the weight loss.

In this study, we examined the effect of biliopancreatic diversion (BPD)12 on the QoL. This operation entails a distal gastrectomy and a Roux-en-Y reconstruction, with a 50 cm common channel (Figure 1). This arrangement of gastrointestinal transit determines maldigestion and then malabsorption of fat and starch for delayed mixing between alimentary substrates, bile, and pancreatic juice, which provokes and maintains weight loss.

To investigate the direct effect of weight loss, we evaluated a group of operated subjects prior to and 1 year after the operation. Moreover, we examined the relationships between the extent of weight loss and the weight of stabilization on one hand and the psychological and physical well-being on the other hand in a larger group of postobese subjects at longer term following BPD.

MATERIALS AND METHODS

IWQOL

The IWQOL is a 74-item self-report and condition-specific instrument that may be used as a treatment outcome measure to assess the effect of weight on QoL in 8 key areas: ( 1 ) general and perceived health, (2) interpersonal relationships, (3) mobility, (4) capacity of work, (5) self-esteem, (6) activity of daily living, (7) sexual life, and (8) comfort with food13 (Table 1). On the IWQOL, higher scores indicate poorer QoL. This instrument shows a high internal consistency, and the subscale scores correlate well with other measures of QoL. Furthermore, the IWQOL demonstrated its research and clinical utility as a QoL outcome measure for clinical trials investigating obesity.13 However, the length of the questionnaire makes it somewhat cumbersome for clinical purposes; an abridged version that measures 6 subscales was therefore developed, validated, and subsequently widely adopted in obesity research.14

FIGURE 1. Schematic representation of biliopancreatic diversion.

Owing to the limitation of the intestinal absorption of energy- rich substrates achieved by the BPD, the operated subjects succeed in attaining and in maintaining a satisfactory weight loss with a free diet and without the need for any major dietary restriction.12 Therefore, when QoL is assessed in postobese individuals having undergone BPD, an evaluation of the individual's relationships with food is mandatory. As a consequence, we conducted this investigation employing the original IWQOL questionnaire, which, unlike the brief 31 -item version, encompasses the mobility and the comfort with food subscales.

TABLE 1. Impact of Weight on Quality of Life Subscales

Subjects

The longitudinal group of this study comprised 50 consecutive individuals (19 males) aged from 20 to 55 years (M = 36), submitted to BPD for obesity12 at the Department of Surgery of the University of Genoa, Italy, from January to December 2001. The patients underwent surgery because of their repeated failed attempts to lose weight with reducing diet; all individuals gave their informed consent. We administered the original version of IWQOL just before BPD and at 1 year following the operation, in conjunction with their regular follow-up visit. Table 2 shows mean and range values of body weight (BW, kg) and body mass index (BMI, kg/m^sup 2^) before BPD and at the 1 st postoperative year.

We obtained cross-sectional data in 150 (59 males; mean age = 41.6 years, range = 22-59 years) postobese subjects at 3 years following BPD surgery performed at the Department of Surgery of the University of Genoa, Italy, from 1997 to 2001. The subjects completed the IWQOL during their 3-year regular follow-up visit. Table 3 shows the preoperative BW and BMI values and those recorded at the time of the visit. All subjects reported good health and claimed to lead a normal life, to eat completely freely, with food intake being similar or only slightly greater than preoperatively, and to have maintained a substantially stable body weight for more than 2 years; moreover, the routine blood analyses were in the normal range in all cases.

Fifty subjects selected from the university personnel and students and comparable with the postobese individuals for age, sex, and BW represented the control group. Table 3 shows mean and range BW and BMI values of the control subjects.

Statistical Analysis

We evaluated the differences between pre- and postoperative data with the Wilcoxon rank test for longitudinal comparison, whereas we assessed the differences between the operated subjects, the postobese individuals, and the controls by using the Mann-Whitney U test for independent data.

In the postoperative sample, we investigated the influence of age, BW, and weight loss on the QoL by using the IWQOL subscale score. The weight loss is usually strongly influenced by the initial BW; furthermore, physical and mental well-being (PWB and MWB, respectively) are obviously strictly interrelated. By consequence, we studied the relationships between data by conducting a multiple stepwise regression model.

For computing purposes, we aggregated the IWQOL subscale scores in cumulative measures reflecting physical and mental well-being. PWB was represented by the cumulative score of general and perceived health, mobility, capacity of work, and activity of daily living IWQOL subscale scores, whereas MWB included the cumulative score of the interp\ersonal relationships subscale, of the self-esteem subscale, and of the sexual life subscale. In this model, we did not evaluate the comfort with food subscale score.

TABLE 2. Mean and Range Values of Body Weight (BW), Body Mass Index (BMI), and Impact of Weight on Quality of Life Scores in Obese Individuals Prior to and 1 Year After Biliopancreatic Diversion (BPD)

We conducted statistical analyses with the Stat-View version 5.0.1 (SAS Institute Inc, Gary, NC).

Results

We summarize the results obtained in the longitudinal group prior to and after BPD in Table 2. As expected, we observed a sharp reduction of BW and BMI mean values at the 1-year follow-up visit. Furthermore, we observed a marked decrease in the IWQOL subscale scores exploring both the physical and the mental domain of QoL, with the consequent reduction of the cumulative scores; by contrast, the score value of the comfort with food subscale remained essentially unchanged in comparison with the preoperative data. Compared with the control findings in obese patients, all the preoperative IWQOL data, except for the comfort of food subscale score, were higher, whereas the values recorded 1 year following BPD were substantially similar to those observed in the nonobese subjects (Table 3).

Table 3 shows the results obtained in the postobese individuals at 3 years following BPD and in control subjects. In the subjects evaluated at 3 years following BPD, the scores of the subscales assessing mental well-being, (ie, interpersonal relationships, self- esteem, and sexual life subscales) were substantially similar to those observed in both healthy controls and in individuals at 1 year after BPD (Tables 2 and 3), whereas we observed higher values of the general and perceived health subscale scores in comparison with the data obtained in healthy subjects and in individuals at shorter term following the operation. For the scores of other IWQOL subscales exploring the physical domain of QoL (ie, mobility, capacity of work, and activity of daily living subscales), the findings were essentially similar to those observed in the other groups of subjects.

Among the long-term post-BPD individuals, female subjects showed higher values in the subscales exploring the mental domain, significantly for the self-esteem and the sexual life scores, whereas we found no differences in QoL outcome in the physical area (Table 4).

In both obese and in postobese subjects, the IWQOL subscale score values were completely unrelated to the BW and BW data. At long term following the operation, PWB and MWB are strictly interrelated (r^sup 2^ = .447), each variable explaining nearly fifty percent of the other one. Multiple regression analysis demonstrated that the cumulative MWB scores and the extent of weight loss were independently related to the PWB score, explaining more than two- thirds of the variance (r^sup 2^ = .701), whereas the age at follow- up and the actual BW values did not predict PWB (Table 5). When we considered the MWB cumulative score as a dependent variable, the score value was significantly correlated (r^sup 2^ = .624) only with PWB, without any independent relationship to other data (Table 6).

TABLE 3. Mean and Range Values of Body Weight (BW), Body Mass Index (BMI), and Impact of Weight on Quality of Life Scores in Postobese Individuals at 3 Years Following Biliopancreatic Diversion (BPD) and in Control Subjects

TABLE 4. Mean and Range Values of Impact of Weight on Quality of Life Scores at 3 Years Following Biliopancreatic Diversion (BPD) in Male and in Female Subjects

Discussion

In this investigation, all of the IWQOL subscale scores were higher in obese patients before BPD than in control subjects, indicating an overall impairment of the QoL under all the areas evaluated. This finding is fully in keeping with other studies carried out in obese individuals using similar psychometric instruments: The data presented here further demonstrate the physical and mental distress of most obese patients, particularly those who seek surgery for weight loss.1,2,15-19

Our primary finding is that the weight loss in obese patients having undergone BPD was accompanied by a marked improvement in the QoL in all the areas explored. In fact, a sharp fall in the IWQOL subscale scores was found at the 1 st postoperative year, the values becoming closely similar to those recorded in healthy control subjects. This study, confirming previous studies conducted with different instruments,20 shows that BPD is followed by an improvement of the overall individual well-being as it is recorded by the IWQOL. Furthermore, these results are quite similar to those seen after other bariatric procedures by means of either the IWQOL or different psychometric instruments.16,21-25 Therefore, such an improvement of QoL appears to be unrelated to the type of operation and seems to be especially dependent upon weight loss.8,9,23,26,27 In fact, less effective procedures for weight reduction give only inconsistent results in terms of improvement in QoL.26,27

TABLE 5. Results of Multiple Regression for 150 Subjects at 3 Years Following Biliopancreatic Diversion (Physical Well-being)

TABLE 6. Results of Multiple Regression for 150 Subjects at 3 Years Following Biliopancreatic Diversion (Mental Well-being)

As mentioned above, in this investigation, we used the original version of the IWQOL, which includes a specific subscale to probe the subject's comfort with food by means of items such as "I like to eat,""I never get embarrassed about food," or "I pay little attention to eating." The comfort with food observed in obese patients was essentially similar to that recorded in control subjects. Results of previous studies showed that the subscale score increases after a short-term weight loss program, thus reflecting an impairment in the relationship with eating.13 Following BPD, the subjects succeed in reaching and in maintaining a satisfactory weight loss with a substantially free diet. This is most likely the reason the individual's relationship with food remains unaffected, and this undoubtedly impacts positively on the QoL of the BPD postobese persons. On the contrary, because restriction or gastric bypass procedures produce a forced limitation of food intake, it can be postulated that the comfort with food might decrease. From this standpoint, it could be argued that BPD might lead to a greater improvement in QoL than the other bariatric operations do. However, in the studies following restrictive procedures or gastric bypass surgery, the researchers used the new version of the IWQOL, thus making any comparison on this issue impossible.18,21,25,26

A sharp improvement of QoL occurs in both the physical and mental domains following BPD. In the physical domain, the improvement is most likely due to the normalization of body shape and to the recovery from the complications. From a cognitive-behavioral point of view, the improvement in the mental area might be due to the positive reinforcements that subjects receive from coping with their problems and by being able to confront life situations and events with a new, socially accepted somatic morphology.

Because the IWQOL assesses weight-specific QoL, we expected to find a positive correlation between the IWQOL scores and BMI value, as has been seen in previous studies.14 In this investigation, the control subjects and the operated individuals with normal BW and BMI levels showed markedly lower IWQOL subscale score values than did the obese patients, thus indirectly indicating a positive association between body mass and score values; however, among the different groups of individuals, a clear correlation between BMI values and IWQOL partial or total scores was lacking, thus confirming previous results obtained in a similar population of severely obese patients undergoing obesity surgery.21 In extremely obese persons and in postobese individuals following bariatric operations, the relationships between body mass and QoL might be different from those observed in normal or slightly overweight subjects or in mildly obese patients. Furthermore, the hypothesis that the lack of correlation might simply reflect the psychometric properties of the original version of the questionnaire cannot be ruled out.

Although cross-sectional comparisons have to be interpreted with great caution, the findings of this study indicate that the improvements in the mental domain of QoL after BPD remain stable with time. In fact, in the individuals at the 3rd year following operation, the IWQOL subscale scores reflecting MWB are much the same as those of both the control subjects and the individuals at 1 year following BPD. Regression analyses demonstrated a close positive correlation between PWB and MWB, suggesting that in postobese patients, the recovery of a satisfactory QoL in the physical domain is strictly related with recovery in the mental domain, and vice versa. This is in agreement with the behavioral- cognitive interpretation for the sharp psychological improvements observed as a rule following obesity surgery.28,29 The PWB consequent to weight loss facilitates involvement in everyday life, thereby increasing the possibility to receive positive reinforcements and therefore to achieve better psychological conditions; by the same way, a recovery of MWB undoubtedly facilitates engagement in physical activity.

In female postobese subjects, the IWQOL self-esteem and sex subscale scores were higher than in their male counterparts, suggesting under these aspects a poorer postoperative adjustment of the QoL. This is not surprising, considering that in the developed world, the demand for physical appearance is more pressing and the stigma against obesity is stronger for women than it is for men; as a result, for female subjects, a physical and mental rearrangement toward a new body shape is certainly more difficult and more time consuming.

The recovery ofQoL in the physical domain was obviously dependent on the extent of weight loss regardless of any psychological change, a finding in full agreement with De Zwaan et al.'s results obtained following gastric bypass.21

At the 3rd year after BPD, the Mobility, the Capacity of Work, and the Activity of Daily Living subscale scores were similar to those recorded in the controls and in the 1-year postoperative subjects, thus suggesting the stability of the postoperative recovery of the QoL under these physical aspects. Nevertheless, at long term, the general and perceived health scores were higher compared with the values observed in the controls and in the 1-year post-BPD individuals. However, these values were markedly lower than those observed in obese preoperative patients.

All of the 3-year subjects were in very good physical condition and led a completely normal life; therefore, an impaired perceived health could reflect distresses unrelated to bodily appearance. In our clinical practice, regular follow-up ends at the 3rd year following BPD, and we examined the operated subjects only upon their request. It can be hypothesized that the impaired perceived health in subjects 3 years after BPD simply reflects fears of abandonment and needs of being followed for a longer time. In selected individuals, an extended follow-up period might lead to further improvement in QoL.

In conclusion, in this investigation, we demonstrated that the weight loss following BPD is accompanied by a marked improvement in QoL. It can be inferred that this improvement is stable at long term. Longitudinal studies at very long term following the operation are nonetheless still needed to confirm these results.

REFERENCES

1. Kolotkin RL, Meter K, Williams GR. Quality of life and obesity. ObesRev. 2001;2:219-229.

2. Fontaine KR, Barofsky I. Obesity and health-related quality of life. ObesRev. 2001 ;3:173-182.

3. Testa MA, Simonson DC. Assessment of quality-of-life outcomes. N Engl J Med. 1996;334:835-840.

4. Fontaine KR, Bartlett SJ. Estimating health-related quality of life in obese individuals. Dis Manage Health Outcomes. 1998; 3:61- 70.

5. Kolotkin RL, Crosby RD, Williams GR. Assessing weight-related quality of life in obese persons with type 2 diabetes. Diabetes Res Clin Pract. 2003 ;61:125-132.

6. Guyatt GH, Feeny DH, Patrick DL. Measuring health-related quality of life. Ann Intern Med. 1993;! 18:622-629.

7. Wing RR. Behavioral approach in the treatment of obesity. In: Bray GA, Bouchard C, eds, Handbook of Obesity, Clinical Applications. New York: Marcel Dekkar Inc; 2004:47-168.

8. Samsa GP, Kolotkin RL, Williams GR, Nguyen MH, Mendel CM. Effect of moderate weight loss on health-related quality of life: an analysis of combined data from 4 randomized trials of sibutramine vs placebo. Am J Manag Care. 2001 ;7:875-883.

9. Rippe JM, Price JM, Hess SA, et al. Improved psychological well-being, quality of life, and health practices in moderately overweight women participating in a 12-week structured weight loss program. Obes Res. 1998;6:208-218.

10. Mathias SD, Williamson CL, Colwell HH, et ai. Assessing health-related quality-of-life and health state preference in persons with obesity: a validation study. Qual Life Res. 1997;6:311- 322.

11. Kolotkin RL, Crosby RD, Williams GR, Hartley GG, Nicol S. The relationship between health-related quality of life and weight loss. Obes Res. 2001;9:564-571.

12. Scopinaro N, Adami GF, Marinari UM, et al. Biliopancreatic diversion. World J Surg. 1998;22:936-946.

13. Kolotkin RL, Head S, Brookhart A. Construct validity of the Impact of Weight on Quality of Life Questionnaire. Obes Res. 1997;5:434-441.

14. Kolotkin RL, Crosby RD, Kosloski KD, Williams GR. Development of a brief measure to assess quality of life in obesity. Obes Res. 2001;9:102-111.

15.Mannucci E, Ricca V, Barciulli E, et al. Quality of life and overweight: the obesity related well-being (Orwell 97) questionnaire. Addict Behav. 1999;24:345-357.

16. Sullivan M, Karlsson J, Sjostrom L, et al. Swedish obese subjects (SOS)-an intervention study of obesity. Baseline evaluation of health and psychosocial functioning in the first 1743 subjects examined. Int J Obes Relat Metab Disord. 1993;17:503-512.

17. De Zwaan M, Mitchell JE, Howell LM, et al. Two measures of health-related quality of life in morbid obesity. Obes Res. 2002;10:1143-1151.

18. Kolotkin RL, Crosby RD, Williams GR. Health-related quality of life varies among obese subgroups. Obes Res. 2002;10:748-756.

19. De Zwaan M, Mitchell JE, Howell LM, et al. Characteristics of morbidly obese patients before gastric bypass surgery. Compr Psychiatry. 2003;44:428^34.

20. Marinari GM, Murelli F, Camerini G, et al. A 15-year evaluation of biliopancreatic diversion according to the Bariatric Analysis Reporting Outcome System (BAROS). Obes Surg. 2004; 14:325- 328.

21. De Zwaan M, Lancaster KL, Mitchell JE, et al. Health-related quality of life in morbidly obese patients: effect of gastric bypass surgery. Obes Surg. 2002;12:773-780.

22. Dymek MP, Le Grange D, Neven K, Alverdy J. Quality of life after gastric bypass surgery: a cross-sectional study. Obes Res. 2002;10:1135-1142.

23. van Gemert WG, Adang EM, Greve JW, Soeters PB. Quality of life assessment of morbidly obese patients: effect of weightreducing surgery. Am J Clin Nutr. 1998 ;67:197-201.

24. Arcila D, Velazquez D, Gamino R, et al. Quality of life in bariatric surgery. Obes Surg. 2002;12:661-665.

25. Dymek MP, Le Grange D, Neven K, Alverdy J. Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: a brief report. Obes Surg. 2001;11:32-39.

26. Hell E, Miller KA, Moorehead MK, Norman S. Evaluation of health status and quality of life after bariatric surgery: comparison of standard Roux-en-Y gastric bypass, vertical banded gastroplasty and laparoscopic adjustable silicone gastric banding. Obes Surg. 2000;10:214-219.

27.Horchner R, Tuinebreijer MW, Kelder PH. Quality-of-life assessment of morbidly obese patients who have undergone a Lap-Band operation: 2-year follow-up study. Is the MOS SF-36 a useful instrument to measure quality of life in morbidly obese patients? Obes Surg. 2001;11:212-218.

28. Stunkard AJ, Wadden TA. Psychological aspects of severe obesity. Am J Clin Nutr. 1992;55(suppl 2):524S-532S.

29. Herpertz S, Kielmann R, Wolf AM, Langkafel M, Senf W, Hebebrand J. Does obesity surgery improve psychosocial functioning? A systematic review. Int J Obes Relat Metab Disord. 2003;27(11):1300- 1314.

Gian Franco Adami, MD; Giovanni Ramberti, MD; Annalisa Weiss, MD; Flavia Carlini, MD; Federica Murelli, MD; Nicole Scopinaro, MD

Drs Adami, Ramberti, Weiss, Carlini, Murelli, and Scopinaro are with the Dipartimento di Discipline Chimrgiche, Facolt di Medicina e Chirurgia, Universit di Geneva, Genoa, Italy.

NOTE

For comment and further information, please address correspondence to Prof. Gian Franco Adami, Dipartimento di Discipline Chirurgiche Universit di Geneva, largo Rosanna Benzi 8,16132 Genoa, Italy (e-mail: adami@unige.it).

Copyright HELDREF PUBLICATIONS Summer 2005

Source: Behavioral Medicine

More News in this Category