Bariatric Surgery Improves Physical, Not Mental, Health
NATIONAL HARBOR, MD.—People who are obese improve enormously in physical health after bariatric surgery but experience no improvements in mental health, a new study shows.
The average surgical patient showed no measurable change in mental health from preoperative levels and remained below the national average on all measures of social, mental and emotional function, the researchers found.
“After surgery, people are healthier physically but not necessarily happier,” said co-investigator Naveen Ballem, MD, the director of bariatric surgery at the Glen Ridge Surgery Center in Glen Ridge, NJ.
Ronald Clements, MD, lead investigator of the study, reported the results at the 2008 annual meeting of the American Society for Metabolic and Bariatric Surgery. Dr. Clements is an associate professor of surgery at the University of Alabama in Birmingham (UAB) and a bariatric surgeon at the UAB Medical Center Kirklin Clinic.
Bariatric surgeons and other bariatric specialists, as well as patients, had mixed feelings about the study. Most experts said the research confirms the physical benefits of surgery but demonstrates that many patients, even those with successful weight loss, struggle psychologically after surgery.
“Certainly I’ve seen that in my practice—divorces, separations are not uncommon after weight loss. Patients have lost weight but deal with some new stresses, as well as some old ones. Now, though, they can no longer use food as a way to relieve their stress,” said Dr. Ballem.
“I think that’s quite sad [that patients reported no improvement in mental health],” said Ramsey Dallal, MD, chief of bariatric and minimally invasive surgery at the Albert Einstein Healthcare Network in Philadelphia.
But the study leaves no doubt as to the long-term physical benefits of surgery.
“This is an interesting study that provides solid evidence for what many bariatric surgeons already believe, that weight-loss surgery positively impacts our patients across many facets of their lives,” said Aurora Pryor, MD, an assistant professor in general surgery and bariatric surgeon at Duke University Medical Center, Durham, NC.
The surgery patients scored as well as the general population on all emotional and physical factors postoperatively and even slightly higher at some points, although the difference never reached statistical significance, she noted.
The study is based on 902 consecutive patients who underwent Roux-en-Y gastric bypass at UAB. The patients completed self-assessments of their quality of life using the Short Form-36, a multipurpose health survey used frequently by researchers. All subjects completed the questionnaire once before their surgery and then were asked to repeat it every year after surgery. At the time of the analysis, data was available for 725 patients after one year, 244 after two years, 135 at three years, and 48 after four and five years postoperatively.
The researchers studied the year-to-year trends among surgical patients and compared their answers to similar surveys done for the general public in 1998.
Presurgery, the participants scored significantly worse than the reported U.S. norms on all measures of health, but especially on physical function, physical role (which indicates problems with work or other daily activities as a result of physical problems), emotional role (which indicates problems with work or other daily activities as a result of emotional problems) and mental health.
One year post-surgery, the patients reported a dramatic improvement in physical health—a 70% improvement, according to researchers’ calculations. The mean body mass index dropped from 49 kg/m2 to 29 kg/m2, whereas the quality-of-life assessments showed patients’ physical function and physical role improved to match and marginally surpass the national average. The patients’ level of vitality, too, improved to the same level of the average American.
Most of the improvements in health-related quality of life occurred within 18 months of surgery, the period typically associated with the greatest amount of weight loss. After the two-year mark, the patients reported no measurable improvements in health, nor did they report any deterioration.
However, the patients’ mental health remained unchanged throughout the five-year period. The subjects’ scores were lower than the general population presurgery and remained worse than U.S. norms five years post-surgery.
Patients also reported other health problems. They had more bodily pain after surgery, a statistically significant increase from preoperative levels and far above the national average.
“That’s something we have to explain to our patients. You will lose weight, you will be in much better health physically, but all your personal problems are not going to be solved,” said Dr. Ballem.
Researchers were surprised that patients gave lower scores for their overall general health after their surgery than they had preoperatively, despite improvements in physical health. That could be because patients have greater expectations of their health after surgery, which requires further investigation, said Dr. Ballem.
The study investigators could not say if the overall quality of life is directly dependent on the amount of weight loss. Dr. Ballem said patients who lose more weight are generally in better overall health because of the change in comorbid disease and improved mobility.
The postoperative experience differs for every bariatric patient, said Pamela Davis, RN, a certified bariatric nurse and the bariatric program director at the Centennial Center for the Treatment of Obesity in Nashville, Tenn. She underwent a laparoscopic Roux-en-Y gastric bypass in 2001 and now leads support groups for bariatric patients and candidates for surgery.
“My quality of life has improved on all levels, all levels. That’s typically what I hear back from our patients whether it’s a support group or not. I’m not going to say 100% of our patients are 100% happy all of the time but certainly the overwhelming majority would say their health is better on all accounts,” she said.
“I would say this study is evidence that losing weight is not going to solve all your problems. A good bariatric team needs to address all the components of health, not just your weight.”
This is the first time that long-term quality of health, including mental and emotional health, has been studied in U.S. patients. Dr. Ballem, who conducted the study during a fellowship at the University of Alabama, said he and colleagues hope to publish their findings in a medical journal.
During the last decade, the rate of bariatric surgery has increased more than sixfold (Am J Public Health 2006;96:1187-1189). Study after study has shown that the surgery has a dramatic effect on body weight and comorbidities such as hypertension, diabetes, lipid disorders and sleep apnea. However, little is known about the surgery’s long-term effects on quality of life, particularly on mental health. A Spanish study, published in 2006, showed that surgical patients had significant improvements in self-esteem, work conditions, physical activity and sexual interest and activity. However, when patients had depression or insufficient weight loss, they had poorer outcomes in all areas of physical, social and mental function (Obes Surg 2006;16:580-585). The Swedish Obesity Study showed that, compared with obese people who did not have the surgery, bariatric surgical patients showed significantly better outcomes on current health perceptions, social interactions, psychosocial functioning and depression, but no significant differences for overall mood and anxiety (N Engl J Med 2004;351:2683-2693).
Kelli E. Friedman, PhD, assistant professor and psychologist at the Duke Center for Metabolic and Weight Loss Surgery, Duke Health Systems, Durham, NC, said many patients have improvements in mood symptoms immediately after surgery but some return to their previous psychological symptoms after the initial excitement of the weight loss diminishes.
“However, I do think it is important to note that surgery patients likely experience improvements in some mental health symptoms, especially when compared with matched controls, although [they were] not looked at in this study,” she said in an e-mail.
The latest study highlights the need for patients to have treatment of significant psychological symptoms before surgery and to continue mental health treatment after surgery, she said.
Observers said the study was well designed and included a large number of patients. However, they noted that only a minority of the original patients completed surveys after more than one year after surgery. The two- to five-year trends in the study should be considered preliminary findings, they cautioned.
The original article appeared in General Surgery News
ISSUE: OCTOBER 2008 | VOLUME: 35:10