OBES SURG DOI 10.1007/s11695-014-1513-6
ORIGINAL CONTRIBUTIONS
Health-Related Quality-of-Life (HRQoL) on an Average of 12 Years After Gastric Bypass Surgery Mustafa Raoof & Ingmar Näslund & Eva Rask & Jan Karlsson & Magnus Sundbom & David Edholm & F. Anders Karlsson & Felicity Svensson & Eva Szabo
# Springer Science+Business Media New York 2015
Abstract Background It is evident that morbidly obese patients have a low health-related quality-of-life (HRQoL), and this low HRQoL has become a common reason for them to seek bariatric surgery. Several HRQoL studies demonstrate a dramatic postoperative improvement, but most of these have had a short follow-up period. Material and Methods An observational, cross-sectional study for HRQoL was conducted to study 486 patients (average age of 50.7±10.0 years, with 84 % of them being female) operated with gastric bypass (GBP) in the period 1993 to 2003 at the University Hospitals of Örebro and Uppsala. Mean follow-up after gastric bypass was 11.5±2.7 years (range 7–17). Two HRQoL instruments were used, SF-36 and the Obesity-related Problems scale (OP). The study group was compared with two control groups, both matched for age
and gender, one from the general population and one containing morbidly obese patients evaluated and awaiting bariatric surgery. Results The study group scored better in the SF-36 domains (all four physical domains and the vitality subscore) and OP scale compared to obese controls, but their HRQoL scores were lower than those of the general population. HRQoL was better among younger patients and in the following subgroups: men, patients with satisfactory weight loss, satisfied with the procedure, free from co-morbidities and gastrointestinal symptoms, employment, good oral status and those not hospitalised or regularly followed up for non-bariatric reasons. Conclusion Long-term follow-up after GBP for morbid obesity showed better scores in most aspects of HRQoL compared to obese controls but did not achieve the levels of the general population. Patients with better medical outcome after gastric bypass operation had better HRQoL.
M. Raoof : I. Näslund : E. Szabo Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
Keywords Gastric bypass . Health-related quality-of-life . Long-term follow-up . SF-36 . Morbid obesity
J. Karlsson Centre for Health Care Sciences, Örebro University Hospital, Örebro, Sweden
Introduction
M. Sundbom : D. Edholm : F. A. Karlsson : F. Svensson Department of Surgical Sciences, Uppsala University, Uppsala, Sweden E. Rask : J. Karlsson Department of Medicine, School of Health and Medical Sciences, Örebro University, Örebro, Sweden M. Raoof (*) Department of Surgery, Örebro University Hospital, 70185 Örebro, Sweden e-mail: [email protected]
The ever growing global obesity epidemic is rapidly becoming a major public health problem. The disease is associated with co-morbidities such as diabetes mellitus, hypertension, dyslipidaemia and cardiovascular disease, as well as psychological problems such as depression and low self-esteem. Morbidly obese (BMI>40 kg/m2) individuals have a low health-related quality-of-life (HRQoL), especially physical aspects [1–3]. This underlines the importance of treating individuals affected and to establish programmes to prevent obesity in society. The negative effects of obesity upon HRQoL
OBES SURG
from the patient’s perspective are often at least as important as co-morbidity associated with obesity. In fact, expectations of improvement in this area are a common reason for patients seeking help through bariatric surgery. However, studies on long-term effects of gastric bypass (GBP) on HRQoL are few, and to our knowledge, this has not been reported for a followup period greater than 6 years after gastric bypass (GBP) [4]. In the present study, the HRQoL of a large group of GBPpatients average of 12 years after surgery were compared with an age- and gender-matched control groups from the general population and obese individuals. The HRQoL of different subgroups within the study group [5, 6] were also analysed.
Methods Between 1993 and 2003, 820 patients were operated with Roux-en-Y gastric bypass procedure at the University Hospitals of Örebro and Uppsala. Fifty-five patients died during follow-up, and 20 patients from other countries were not included in this study. The remaining 745 were invited to answer questionnaires by mail; non-responding patients received telephone calls to remind them to answer. The questionnaire asked about their current clinical condition including self-reported weight and medical history since their GBP surgery and contained two quality-of-life instruments (see below). The patients were also invited to leave blood samples for further biochemical analyses, which subsequently were not used in this study. There were no HRQoL measurements available as a baseline, but co-morbidities, drug prescriptions, weight and other relevant clinical information in their record at the time of surgery were collected. Clinical results and more details of the methods and patients have been reported previously [5–7]. Two HRQoL instruments were used, the SF-36 and the Obesity-related Problems scale (OP). Generic HRQoL was assessed by the SF-36 health survey, which comprises eight health domains: physical function (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social function (SF), role-emotional (RE) and mental health (MH). All scale scores range from 0 to 100 with higher scores indicating better health status. Two summary scores, the physical (PCS) and mental (MCS) component summary scores are calculated and standardised through norm-based scoring with a mean of 50 and a standard deviation of 10. A value above 50 on the PCS and MCS indicates better health than the general population, and a value below 50 indicates worse health. The SF-36 has been validated for the Swedish population, and normative data for the general population are available [8]. SF-36 is the most commonly used generic HRQoL instrument and is frequently used for measuring results after bariatric surgery.
The OP scale is an obesity-specific quality-of-life instrument constructed to measure the impact of obesity on psychosocial function. OP comprises eight items with a 4-point response scale. Subjects are asked how bothered were they by their obesity in a broad range of everyday life activities (e.g. private gatherings, going to restaurants or community activities, trying on and buying clothes and intimate relationships). Responses result in a total score ranging from 0 (no impairment) to 100 (maximum impairment). Construct validity and responsiveness of the OP scale have been presented elsewhere [9]. The study group was compared to available data from two control groups, matched for age and gender. The first control group comprised of 1593 persons from the general Swedish population, selected from the Swedish SF-36 normative database [8]. The second group consisted of 972 patients from the database of the Scandinavian Surgery Obesity Registry (SOReg), a Scandinavian quality and research registry for bariatric surgery run by the Swedish Society of Upper Abdominal Surgery (SFÖAK) with the support of the Swedish Association of Municipality and Regional Authorities (SKL). SOReg contains a database for SF-36 and OP, at the time of matching more than 18,000 measurements of morbidly obese patients accepted to bariatric surgery with HRQoL measurements at baseline about 4 weeks before surgery were available [10]. No OP data were available for the control group from the general population. A satisfactory weight loss after bariatric surgery was defined as more than 50 % excess BMI loss (% EBMIL), where % EBMIL is defined as [(baseline BMI–BMI at follow-up)/ (baseline BMI–25)] × 100. Co-morbidity was defined as having daily medical treatment for an obesity-related disease, i.e. diabetes, hypertension, dyslipidaemia, depression, or continuous positive airway pressure (CPAP) for sleep apnoea. The symptoms dysphagia, vomiting, abdominal pain, diarrhoea and dumping were reported on a 5-point Likert scale, grading the frequency as daily, weekly, monthly, each year or never. Patients were also asked to rate their overall satisfaction with the operative procedure. Oral health was evaluated using two validated questions regarding general satisfaction with general oral health and teeth loss [11]. The statistical analyses were performed using SPSS version 21. For continuous variables, student’s t test or Pearson’s correlation coefficients and for ordinal data Spearman’s correlation coefficients were calculated. P values are presented with three digits, meaning that p=0.000 means a p value< 0.0005. The study was approved by the Uppsala Regional Ethics Committee according to Swedish Law.
Results Questionnaires were received from 486 patients (65 %) of which eight questionnaires were not complete and one or
OBES SURG
more of the SF-36 dimensions and/or OP could not be calculated. Mean BMI was 43.5±6.71 and mean weight was 118.85 kg at baseline. Mean follow-up after gastric bypass was 11.5±2.7 years (range 7–17). Sixteen percent (n=78) were men. The mean age at follow-up was 50.7±10.0 years. A substantial proportion, 29 %, had GBP performed as a revisional procedure because of poor weight loss or intolerable side effects from a previous bariatric procedure; similar numbers of patients were operated in Uppsala and Örebro (237 and 249, respectively). HRQoL in the Study Group vs. the Two Control Groups Compared to the group of bariatric surgery candidates awaiting surgery, the study group had significantly better scoring in the four physical domains, the physical component summary score (PCS) and the vitality (VT) subscale of SF-36, as well as in psychosocial functioning (OP). Compared to the general Swedish population group, however, the SF-36 values were significantly below the norm. Age There were significant correlations between age and HRQoL in the study group, with better outcome for younger patients in six of the 11 domains, strongest for the physical component summary score (PCS; r=−0.19;
ORIGINAL CONTRIBUTIONS
Health-Related Quality-of-Life (HRQoL) on an Average of 12 Years After Gastric Bypass Surgery Mustafa Raoof & Ingmar Näslund & Eva Rask & Jan Karlsson & Magnus Sundbom & David Edholm & F. Anders Karlsson & Felicity Svensson & Eva Szabo
# Springer Science+Business Media New York 2015
Abstract Background It is evident that morbidly obese patients have a low health-related quality-of-life (HRQoL), and this low HRQoL has become a common reason for them to seek bariatric surgery. Several HRQoL studies demonstrate a dramatic postoperative improvement, but most of these have had a short follow-up period. Material and Methods An observational, cross-sectional study for HRQoL was conducted to study 486 patients (average age of 50.7±10.0 years, with 84 % of them being female) operated with gastric bypass (GBP) in the period 1993 to 2003 at the University Hospitals of Örebro and Uppsala. Mean follow-up after gastric bypass was 11.5±2.7 years (range 7–17). Two HRQoL instruments were used, SF-36 and the Obesity-related Problems scale (OP). The study group was compared with two control groups, both matched for age
and gender, one from the general population and one containing morbidly obese patients evaluated and awaiting bariatric surgery. Results The study group scored better in the SF-36 domains (all four physical domains and the vitality subscore) and OP scale compared to obese controls, but their HRQoL scores were lower than those of the general population. HRQoL was better among younger patients and in the following subgroups: men, patients with satisfactory weight loss, satisfied with the procedure, free from co-morbidities and gastrointestinal symptoms, employment, good oral status and those not hospitalised or regularly followed up for non-bariatric reasons. Conclusion Long-term follow-up after GBP for morbid obesity showed better scores in most aspects of HRQoL compared to obese controls but did not achieve the levels of the general population. Patients with better medical outcome after gastric bypass operation had better HRQoL.
M. Raoof : I. Näslund : E. Szabo Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
Keywords Gastric bypass . Health-related quality-of-life . Long-term follow-up . SF-36 . Morbid obesity
J. Karlsson Centre for Health Care Sciences, Örebro University Hospital, Örebro, Sweden
Introduction
M. Sundbom : D. Edholm : F. A. Karlsson : F. Svensson Department of Surgical Sciences, Uppsala University, Uppsala, Sweden E. Rask : J. Karlsson Department of Medicine, School of Health and Medical Sciences, Örebro University, Örebro, Sweden M. Raoof (*) Department of Surgery, Örebro University Hospital, 70185 Örebro, Sweden e-mail: [email protected]
The ever growing global obesity epidemic is rapidly becoming a major public health problem. The disease is associated with co-morbidities such as diabetes mellitus, hypertension, dyslipidaemia and cardiovascular disease, as well as psychological problems such as depression and low self-esteem. Morbidly obese (BMI>40 kg/m2) individuals have a low health-related quality-of-life (HRQoL), especially physical aspects [1–3]. This underlines the importance of treating individuals affected and to establish programmes to prevent obesity in society. The negative effects of obesity upon HRQoL
OBES SURG
from the patient’s perspective are often at least as important as co-morbidity associated with obesity. In fact, expectations of improvement in this area are a common reason for patients seeking help through bariatric surgery. However, studies on long-term effects of gastric bypass (GBP) on HRQoL are few, and to our knowledge, this has not been reported for a followup period greater than 6 years after gastric bypass (GBP) [4]. In the present study, the HRQoL of a large group of GBPpatients average of 12 years after surgery were compared with an age- and gender-matched control groups from the general population and obese individuals. The HRQoL of different subgroups within the study group [5, 6] were also analysed.
Methods Between 1993 and 2003, 820 patients were operated with Roux-en-Y gastric bypass procedure at the University Hospitals of Örebro and Uppsala. Fifty-five patients died during follow-up, and 20 patients from other countries were not included in this study. The remaining 745 were invited to answer questionnaires by mail; non-responding patients received telephone calls to remind them to answer. The questionnaire asked about their current clinical condition including self-reported weight and medical history since their GBP surgery and contained two quality-of-life instruments (see below). The patients were also invited to leave blood samples for further biochemical analyses, which subsequently were not used in this study. There were no HRQoL measurements available as a baseline, but co-morbidities, drug prescriptions, weight and other relevant clinical information in their record at the time of surgery were collected. Clinical results and more details of the methods and patients have been reported previously [5–7]. Two HRQoL instruments were used, the SF-36 and the Obesity-related Problems scale (OP). Generic HRQoL was assessed by the SF-36 health survey, which comprises eight health domains: physical function (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social function (SF), role-emotional (RE) and mental health (MH). All scale scores range from 0 to 100 with higher scores indicating better health status. Two summary scores, the physical (PCS) and mental (MCS) component summary scores are calculated and standardised through norm-based scoring with a mean of 50 and a standard deviation of 10. A value above 50 on the PCS and MCS indicates better health than the general population, and a value below 50 indicates worse health. The SF-36 has been validated for the Swedish population, and normative data for the general population are available [8]. SF-36 is the most commonly used generic HRQoL instrument and is frequently used for measuring results after bariatric surgery.
The OP scale is an obesity-specific quality-of-life instrument constructed to measure the impact of obesity on psychosocial function. OP comprises eight items with a 4-point response scale. Subjects are asked how bothered were they by their obesity in a broad range of everyday life activities (e.g. private gatherings, going to restaurants or community activities, trying on and buying clothes and intimate relationships). Responses result in a total score ranging from 0 (no impairment) to 100 (maximum impairment). Construct validity and responsiveness of the OP scale have been presented elsewhere [9]. The study group was compared to available data from two control groups, matched for age and gender. The first control group comprised of 1593 persons from the general Swedish population, selected from the Swedish SF-36 normative database [8]. The second group consisted of 972 patients from the database of the Scandinavian Surgery Obesity Registry (SOReg), a Scandinavian quality and research registry for bariatric surgery run by the Swedish Society of Upper Abdominal Surgery (SFÖAK) with the support of the Swedish Association of Municipality and Regional Authorities (SKL). SOReg contains a database for SF-36 and OP, at the time of matching more than 18,000 measurements of morbidly obese patients accepted to bariatric surgery with HRQoL measurements at baseline about 4 weeks before surgery were available [10]. No OP data were available for the control group from the general population. A satisfactory weight loss after bariatric surgery was defined as more than 50 % excess BMI loss (% EBMIL), where % EBMIL is defined as [(baseline BMI–BMI at follow-up)/ (baseline BMI–25)] × 100. Co-morbidity was defined as having daily medical treatment for an obesity-related disease, i.e. diabetes, hypertension, dyslipidaemia, depression, or continuous positive airway pressure (CPAP) for sleep apnoea. The symptoms dysphagia, vomiting, abdominal pain, diarrhoea and dumping were reported on a 5-point Likert scale, grading the frequency as daily, weekly, monthly, each year or never. Patients were also asked to rate their overall satisfaction with the operative procedure. Oral health was evaluated using two validated questions regarding general satisfaction with general oral health and teeth loss [11]. The statistical analyses were performed using SPSS version 21. For continuous variables, student’s t test or Pearson’s correlation coefficients and for ordinal data Spearman’s correlation coefficients were calculated. P values are presented with three digits, meaning that p=0.000 means a p value< 0.0005. The study was approved by the Uppsala Regional Ethics Committee according to Swedish Law.
Results Questionnaires were received from 486 patients (65 %) of which eight questionnaires were not complete and one or
OBES SURG
more of the SF-36 dimensions and/or OP could not be calculated. Mean BMI was 43.5±6.71 and mean weight was 118.85 kg at baseline. Mean follow-up after gastric bypass was 11.5±2.7 years (range 7–17). Sixteen percent (n=78) were men. The mean age at follow-up was 50.7±10.0 years. A substantial proportion, 29 %, had GBP performed as a revisional procedure because of poor weight loss or intolerable side effects from a previous bariatric procedure; similar numbers of patients were operated in Uppsala and Örebro (237 and 249, respectively). HRQoL in the Study Group vs. the Two Control Groups Compared to the group of bariatric surgery candidates awaiting surgery, the study group had significantly better scoring in the four physical domains, the physical component summary score (PCS) and the vitality (VT) subscale of SF-36, as well as in psychosocial functioning (OP). Compared to the general Swedish population group, however, the SF-36 values were significantly below the norm. Age There were significant correlations between age and HRQoL in the study group, with better outcome for younger patients in six of the 11 domains, strongest for the physical component summary score (PCS; r=−0.19;
