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Surgery for Obesity and Related Diseases ] (2014) 00–00
Original article
Patient expectations of bariatric surgery are gender specific—a prospective, multicenter cohort study Lars Fischera,*, Felix Nickela, Johannes Sanderb, Alexander Ernstc, Thomas Brucknerd, Beate Herbigb, Markus W. Büchlera, Beat P. Müller-Sticha, Rune Sandbue a
Department of Surgery, University of Heidelberg, Heidelberg, Germany b Obesity Clinic, Schoen Klinik Hamburg Eilbek, Hamburg, Germany c Department of General and Visceral Surgery, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany d Institute for Medical Biometry and Informatics, Heidelberg, Germany e Morbid Obesity Center, Vestfold Hospital Trust, Tønsberg, Norway Received September 26, 2013; accepted February 17, 2014
Abstract
Background: The effect of bariatric surgery on weight loss and improvement of co-morbidities is no longer doubted. However, little attention has been given to the treatment goals from the patient’s point of view (patient expectations). The objective of this study was to examine patients’ expectations of bariatric surgery and identify gender differences. Methods: Bariatric patients were asked to complete a questionnaire. Statistical analysis was performed using chi-square, Pearson correlation coefficient, and Wilcoxon rank sum test. Results: Overall, 248 patients participated in this study (69.4% females). The male patients (45.2 yr, SD ⫾ 11.1) were significantly older than the female (41.8 yr, SD ⫾ 12.0; P ¼ .04) and suffered significantly more often from diabetes, hypertension, hypercholesterolemia, and sleep apnea. One hundred thirty patients (52.4%) expected to lose at least 45 kg and 39 patients (15.7%) 4 70 kg. The mean expected excess weight loss was 71.8%. Females expected significantly more often that surgery alone would induce weight loss (P ¼ .03). “Improved co-morbidity” was by far the highest ranked parameter. Conclusion: The male bariatric surgery patients were older and suffered from more co-morbidities. Most of the patients had unrealistic weight loss goals and overestimated the effect of the surgical intervention. However, for both female and male patients, “improved co-morbidity” was the most important issue. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Patient expectations; Weight loss goals; Gender differences; Co-morbidity
The positive effects of bariatric surgery on weight loss and obesity-related co-morbidities, such as diabetes or hypertension, are no longer doubted [1–7]. Bariatric surgery may even significantly improve overall patient survival and reduce cancer incidence among female patients in particular [8–10]. In addition, surgery can be performed safely with *
Correspondence: Lars Fischer, M.D., Department of Surgery, University of Heidelberg INF 110, 69120 Heidelberg, Germany. E-mail: lars.fi[email protected]
regard to morbidity and mortality [11–13] and has proven effective in bringing about diabetes remission that surgeons now perform operations such as gastric bypass on patients with type 2 diabetes and a body mass index (BMI, kg/m2) of o35 kg/m2 for this purpose alone [14–20]. The field of bariatric surgery is still evolving. However, gastric bypass and sleeve gastrectomy are the most commonly performed procedures, both worldwide and in Germany, because of their positive risk/benefit correlation [21–28].
http://dx.doi.org/10.1016/j.soard.2014.02.040 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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L. Fischer et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
The clinical efficacy of bariatric surgery is mostly measured by “hard” endpoints such as weight loss and the reduction of obesity-related co-morbidities. The patient’s perspective, however, including his/her treatment goals and expectations, has received less attention in the literature. The issues most important to patients can be identified and scientifically analyzed by using an approach called ranking [29–32]. Knowledge of patients’ expectations has been shown to affect clinical outcome [29,33–35]. While studies on this subject have been completed [36–40], most focus on weight loss or examine only female or male patients [41– 44]. The goal of this study was to measure the expectations of both male and female patients and identify possible gender differences. Methods
F1
Bariatric patients were invited to complete a questionnaire about their expectations. Patients were deemed eligible for bariatric surgery according to the most recent S3 German guidelines. To qualify, the patients must have exhausted conservative treatment for at least 6 months, undergone a psychosomatic and endocrinologic evaluation, have a BMI of 435 kg/m2 with at least 1 co-morbidity such as diabetes mellitus, hypertension or sleep apnea, or a BMI of 40 kg/m2 or more. Generally, insurance companies agree to cover a surgical intervention, but in most cases not for a certain procedure such as sleeve gastrectomy or gastric bypass. Eligible patients are provided with comprehensive written information regarding the risks and benefits of procedures performed at each center. However, no standardized preoperative education was used during this study. This study was performed in 3 bariatric centers: SchönKlinik Hamburg, Städtisches Klinikum Karlsruhe, and University Hospital Heidelberg. There was no screening list, so the number of patients asked to participate, those who declined participating, and their reasons for doing so, were not systematically recorded. Thus, it was not possible to calculate the “random ratio” or the “enrollment fraction” (proportion of screened to included patients). Furthermore, they were not asked which procedure (for instance sleeve gastrectomy or gastric bypass) they were to receive. The questionnaire (Fig. 1) was developed by Mari Hult (Karolinska Institute, Sweden), Anne Juuti (Helsinki University Hospital, Finland), Signe Röstad (Oslo University Hospital, Norway), Lars Fischer (Department of Surgery, University Heidelberg, Germany), Wouter te Riele (AMC Hospital Amsterdam, Belgium), Kai Orava (Seinäjoki Hospital, Finland), Timo Heikkinen (Oulu, Hospital, Finland) and Rune Sandbu (Morbid Obesity Center Tønsberg, Norway), during the second postgraduate training course of the European Obesity Academy and in collaboration with endocrinologists, psychiatrists, and statisticians. The
questionnaire was prepared in English but, to check the translation, the initial questionnaire was translated into German and then retranslated into English by a native English speaker. The translation was thought to be adequate, as the 2 English versions differed only slightly. The questionnaire consisted of 3 parts. In the first part, patients were asked to provide medical and socioeconomic data such as height, weight, age, educational status, profession, and co-morbidities. The second part asked them to describe their treatment goals in terms of both weight loss and the effect they expected surgery to have. In addition, they were asked to select drawings standardized according to Bulik et al. [45] (permission to use the drawings was obtained) that they considered representative of their bodies before and after weight loss. In the third part, ranking parameters were presented in a randomized fashion. Based on the lessons learned from the POVATI trial [31], part 3a of the questionnaire was designed to prevent systematic errors; i.e., the randomized ranking parameters were rated in importance on a 5-point scale from 1 (not important) to 5 (very important). Because it was anticipated that many parameters would be ranked as very important (i.e., with 5), in part 3b, patients were asked to indicate which of the 14 issues were the highest, second highest, and third highest priority. In a pilot study, the questionnaire was tested with 10 patients for comprehensibility and ambiguity. Neither during the pilot phase nor during the study itself did any patients make recommendations concerning the comprehensibility or ambiguity of the questionnaire. In the analysis of the responses, the results in part 3a of each parameter were evaluated. In addition, a scoring system was used in part 3b, where the most important parameter was given 3 points, the second most important 2 points, and the third most important 1 point. The scores were added to determine the order of importance among the ranking parameters. Ethical approval (S-618/2011) was obtained from the institutional review board, also known as ethical review board. To describe the empirical distribution of continuous parameters, the weighted means and minimum and maximum values were calculated. The distribution of categorical parameters was described by absolute and relative frequencies (count and percentage). Possible differences were analyzed using chi-square, Wilcoxon rank sum test, and Spearman correlation coefficient. Excess weight loss (EWL) was calculated using the formula “(initial BMI final BMI)/(initial BMI - 25) 100” based on the “weight” and “height” as stated in part 1 of the questionnaire and the “expected weight loss” provided by the patients according to the question: “How many kilograms do your expect to lose after surgery?” in part 2 of the questionnaire. All patients were asked to state weight related values in kilograms (1 kg ¼ 2.205 lb).
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Patient Expectations Toward Bariatric Surgery / Surgery for Obesity and Related Diseases ] (2014) 00–00
Q3
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Part 1 Date and place:_______________________________
Initials: __ . __ (Surname . Name)
Height: __________cm Weight: _________kg BMI: _______ kg/m
Age:
Occupation ____________________________________
____ years
pension
Relationship
single
married/partner
Smoking
yes
no
Education
unemployed
university education (Bachelor, Master, PhD,…)
school
Co-morbidities
Other: _______________________________________________________ Part 2 1.
Please mark above the numbered line where you consider yourself to be before surgery and below the numbered line where you expect to be after surgery .
2. How many kilograms do you expect to lose after surgery?
_ _ _ _ kg
3. Please mark on the line the proportion of how much weight loss will be due to the operation.
------------------I 100%
50%
0%
Fig. 1. Questionnaire as presented to the patients. In female patients, the ranking parameter “improved fertility” was added.
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Part 3A Please mark what you think best fits your opinion. Feel free to use the whole range of answers. Why did you seek bariatric surgery? How important are the following issues on a scale of 1 (not important for you) to 5 (very important for you)? Not important
1
Important
2
3
Very important
4
5
Improved mental health Improved physical activity Improved in intimacy and partnership Reduction in clothing size Improved fertility Improved social life (e.g., culture, meeting friends) Pain reduction Improved comorbidity such as diabetes, hypertension, sleep apnea, etc. Reduced medication need Increased employment chance Better work performance Weight loss Improved self-esteem Increased life expectancy If none of the above options qualify as your main expectation, please write what your main expectation is here: ____________ Part 3B Please rank the three most important issues from the above-mentioned issues in order 1 to 3, with number 1 being most important. 1. Most important: ____________ 2. Second most important: ____________ 3. Third most important: ____________
Fig. 1. (Continued)
Results
T1
Overall, 248 patients participated in this study (Heidelberg, 166 patients; Hamburg, 72 patients; Karlsruhe, 10 patients) and 69.4% were females. The mean age was 42.8 years (SD ⫾ 11.8 years). The mean BMI was 48.4 kg/m2 (SD ⫾ 8.0 kg/m2). There were no significant differences in BMI between the male and female patients (Table 1). However, the male patients (45.2 yr, SD ⫾ 11.1) were significantly older than the females (41.8 yr, SD ⫾ 12.0; P ¼ .04, Table 1). There were no significant gender differences with respect to marital status education, employment rate, and smoking habits. However, male patients suffered significantly more often from diabetes (oral medication), hypertension, hypercholesterolemia, and sleep apnea and females more often from depression. Using the standardized drawings in part 2 of the questionnaire, patients scored their preoperative body image between 9 and 10 (mean 9.9, SD ⫾ 1.7) and estimated their postoperative body image at between 4 and 5 (mean 4.8, SD ⫾ 1.1). There was a significant positive correlation between preoperative BMI and preoperative body image (r ¼ .52, P o .01), and between expected weight loss (“How many kilograms do you expect to lose?”) and postoperative body image (r ¼ .51, P o .01). However,
the initial BMI of the patients did not correlate significantly with the postoperative body image (r ¼ .28, P o .01); i.e., regardless of their initial weight, patients had similar expectations about postoperative body silhouette. There were no significant gender differences with respect to body image (data not shown). In response to the question, “How many kilograms do you expect to lose?” (part 2 of the questionnaire), 130 patients (52.4%) answered at least 45 kg, 39 patients (15.7%) answered 4 70 kg, and 14 patients (5.6%) answered 100 kg or more. There were no significant differences between male (mean 52.0 kg, SD ⫾ 25.3 kg) and female patients (mean 46.3 kg; SD ⫾ 18.6 kg; P ¼ .13). The mean expected EWL was 71.8 % (SD ⫾ 21.5%), with no significant differences between male (mean EWL 68.9%, SD ⫾ 21.1%) and female patients (mean EWL 73.0%; SD ⫾ 21.6 %; P ¼ .37). More than 88% of the patients wanted to have an EWL 4 50% (Table 2). The vast majority of patients believed that surgery would induce this weight loss, and 45.7% that surgery alone would be suffice, with female patients being of this opinion significantly more often (Table 3, P ¼ .03). The overall percentage of patients who ranked each parameter as very important (i.e., gave the highest score “5” in part 3a of the questionnaire) and gender differences
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Patient Expectations Toward Bariatric Surgery / Surgery for Obesity and Related Diseases ] (2014) 00–00
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Table 1 Description of the study population based on gender, age, body mass index (BMI), socioeconomic issues, and co-morbidities.
n Age (SD) BMI (SD) Married or stable partnership (%) Children (%) University degree (%) Vocational school (%) Finished at least 8 yr regular school (%) Employment rate (%) Smoking (%) Diabetes (oral medication) (%) Diabetes (insulin) (%) Hypertension (%) Hypercholesterolemia (%) Sleep apnea (%) Depression (%) Joint pain (%) Infertility (%)
All
Female
Male
P value (Wilcoxon test)
248 42.8 (11.8) 48.4 (8.0) 61.9 61.5 12.9 68.9 14.9 52.6 18.6 19.3 16.5 50.0 14.9 20.9 20.9 36.7 n/a
172 41.8 (12.0) 48.5 (7.9) 63.9 64.5 10.4 70.9 16.3 52.0 20.9 15.7 15.1 44.2 11.0 13.4 25.0 40.7 4.1
76 45.2 (11.1) 48.0 (8:2) 57.3 54.6 18.4 64.5 11.8 53.9 13.3 27.3 19.7 63.2 23.6 38.2 11.8 27.6 n/a
n/a .04 n.s. n.s n.s. n.s. n.s n.s n.s n.s. .03 n.s. o.01 .01 o.01 .02 n.s. n/a
SD ¼ standard deviation; n/a ¼ not applicable; n.s. ¼
among the parameters are shown in Table 4. The female patients rated the parameters “improved physical activity”, “pain reduction”, “improved mental health”, “improved self-esteem”, and “reduction in clothing size” significantly more often with “5” (P o .04). In part 3b of the questionnaire, patients were asked to assign a priority ranking to the 14 parameters, using the scoring system mentioned above. “Improved co-morbidity” was given the highest score (313 points), followed by weight loss”, “improved physical activity”, “pain reduction” and “longer life expectancy” (Table 5). The only gender difference was that female patients rated “pain reduction” higher than the male patients, whereas the latter were more focused on “weight loss”. Finally, we examined the correlation between comorbidities (part 1 of the questionnaire) and patients’ preferences. Diabetes patients rated the issues “reduced medication need”, “improved co-morbidity”, and “pain reduction” as a “5” significantly more often than the Table 2 Calculation of the expected excess weight loss based on the initial body mass index and the question, “How many kilograms do you expect to lose after surgery?” in part 2 of the questionnaire. EWL
All (%)
Cumulative (%)
0–10 % 11–40 % 41–50 % 51–60 % 61–70 % 71–80 % 81–90 % 91–100 % 4100 %
2.5 3.8 5.0 16.1 14.7 24.8 18.5 7.5 7.9
2.5 6.3 11.3 26.5 41.2 66.0 84.4 92.0 100
EWL ¼ excess weight loss
remainder of the study group. Patients with hypertension rated “reduced medication need” and “improved co-morbidity” highly, whereas hypercholesterolemia patients placed a high value on “reduced medication need”. Interestingly enough, depressed patients rated “improved self-esteem” as very important significantly more often (data not shown). Discussion Studies dealing with bariatric procedures mainly focus on endpoints such as EWL or diabetes remission. Little attention has been given to the question of whether such endpoints really matter from the patient’s perspective. It may be possible to evaluate the relevance of a given endpoint from a patient’s point of view by using questionnaires to ask patients to rank possible outcomes [31,38,39]. However, in this field, which is evolving so rapidly, the required scientific analysis constitutes a major challenge [29]. The current literature on patient expectations concerning bariatric surgery has not been without limitations, such as including only 1 gender, or a primary focus on weight loss Table 3 Results to the item: “Please mark on the line the proportion of how much weight loss will be due to the operation.” in part 2 of the questionnaire. Expected proportion of surgery on weight loss
All (%)
0–49 % 50 % 51–99 % 100 %
2.4 1.8 12.2 10.0 39.6 38.2 45.7 50.0
n.s. ¼
Female Male patients (%) patients (%) 6.7 14.6 42.7 36.0
P value (ChiSquare) n.s. n.s. n.s. 0.03
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Table 4 Order of the ranking parameters that patients ranked as “very important” (i.e., with “5”) in part 3a of the questionnaire. Parameter
Weight loss Improved physical activity Improved co-morbidity Increased life expectancy Pain reduction Reduced medication need Improved mental health Better work performance Improved self-esteem Improved social life Reduction in clothing size Improved intimacy and partnership Increased employment chance Improved fertility
Overall (%)
Females (%)
Males (%)
P value (chisquare)
87.1 85.9 78.6 76.6 68.5 58.1 50.4 50.4 49.6 47.6 47.2 34.7
86.6 89.5 77.9 76.7 73.8 56.4 58.1 51.7 57.0 51.4 51.7 36.0
88.1 77.6 80.2 76.3 56.7 61.8 32.9 47.3 32.9 38.2 36.8 31.6
n.s. .04 n.s. n.s. .04 n.s. o.01 n.s. .01 n.s. .04 n.s.
34.8
35.6
32.9
n.s.
n/a
14.5
n/a
n/a
n.s. ¼; n/a ¼ not applicable.
issues [34,36,42,43,46]. The present survey on a convenient sample of 248 obese patients examined a range of expectations held by both genders and has revealed 4 major findings. First, compared with female patients, male patients were not only significantly older but also suffered significantly more often from obesity-related co-morbidities. Second, 45.7% of all patients believed their expected weight loss would be due to surgery alone. Third, each gender ranks the importance of some parameters differently, but attaches similar value to the most important expectations (Table 5). Fourth, the correlation between co-morbidities, particularly diabetes, and expectations was significant. The latter 2 findings are a strong indicator that obese patients are aware of their infirmity and its related diseases. Prior studies have shown that patients’ weight loss expectations after surgery are unrealistic [37,38,41]. Our findings were consistent with the literature. In the present cohort, we found not only that 52.4% of all patients expected to lose 445 kg, but also that 45.7% thought that this weight loss would be induced by surgery alone. The mean expected EWL was 71.8%. Even though some
Table 5 Order of the ranking parameters according to the scoring system described in the Methods section. Order
All patients (points)
Female patients (points)
Male patients (points)
1.
Improved co-morbidity 313 Weight loss 196 Improved physical activity 182 Pain reduction 178 Increased life expectancy 115 Improved social life 70 Improved mental health 67 Improved self esteem 64 Reduced medication need 57 Better work performance 46 Other 41 Improved intimacy and partnership 29 Reduction in clothing size 26 Improved fertility 24 Increased employment chance 23
Improved co-morbidity 204 Pain reduction 134 Improved physical activity 131 Weight loss 128 Increased life expectancy 76 Improved mental health 54 Improved self esteem 50 Improved social life 43 Other 37 Reduced medication need 30 Better work performance 27 Improved fertility 24 Reduction in clothing size 21 Improved intimacy and partnership 18 Increased employment chance 17
Improved co-morbidity 109 Weight loss 68 Improved physical activity 51 Pain reduction 44 Increased life expectancy 39 Reduced medication need 27 Improved social life 27 Better work performance 19 Improved self esteem 14 Improved mental health 13 Improved intimacy and partnership 11 Increased employment chance 6 Reduction in clothing size 5 Other 4 n/a (“improved fertility”) -
2. 3.
4. 5.
6. 7. 8. 9. 10. 11. 12. 13. 14. 15
n/a ¼ not applicable
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Patient Expectations Toward Bariatric Surgery / Surgery for Obesity and Related Diseases ] (2014) 00–00
patients will actually reach their treatment goals [47], the findings presented here highlight the need to discuss goals that are more realistic with patients, and to make them aware that weight loss is achieved by more than surgery alone, particularly in the long term. This finding is of particular value since it has been shown that unrealistic expectations have an effect on patient compliance [34]. The item related to the effect of surgery (“Please mark on the line the proportion of how much weight loss will be due to the operation.”) in part 2 of the questionnaire left for the participant no option to identify other factors that would be involved in their weight loss (such as lifestyle changes). During this study, however, we were particularly interested in determining to what extent patients think surgery will contribute to their weight loss. The present study is not without limitations. The answers patients gave may not have expressed their own expectations, as much as reflected their desire to meet external expectations, e.g., those of their surgeons. We sought to avoid this risk by assuring patients that their participation was voluntary, and by having a study nurse administer and collect the questionnaire. As a result, surgeons were unaware of the identity of the study participants. Furthermore, the comprehensibility of the questionnaire was a concern. In a pilot study, the questionnaire was completed by 10 patients who, when asked if they had understood the questions, answered that they had. Neither during the pilot study nor the study itself were any comments made, which indicated that the questionnaire was incomprehensible. Even though the questionnaire aimed to cover all relevant issues, 16 of the 248 participants (6.4%) stated at the end of part 3a that “other” reasons were significant to them. These “other” reasons included an improvement in quality of life for 14 patients. This finding convinced us of the need to add the ranking parameter “quality of life improvement” in further studies. Patients’ expectations of bariatric surgery are a multifaceted construct. In this study, we investigate the nature but not the origin of these expectations. We presume that most patients included in this study were driven by their frustration with the multiple diets they had attempted. Others might have been pressured by their families or their physicians. Another important question is whether the bariatric procedure that the patient expects might affect his/her expectations significantly. We concluded after intensive discussion that this is most likely not the case. The bariatric patient’s crucial decision is to go ahead with surgery itself, with most of them not having a certain procedure in mind. Furthermore, the outcome parameters of the questionnaire focus on treatment goals that were considered as “optimal” (such as nadir weight loss) but had no context or accurate basis within the postoperative timeline. For this reason, it may be appropriate to ask patients to provide concrete expectations for postoperative time points of 1, 3, 5, or 10
7
years after surgery. However, these latter 2 issues need to be addressed in future work. Conclusion In this descriptive survey, carried out on a convenience sample, male bariatric patients were older and suffered from more co-morbidities than female patients. Most patients had unrealistic weight loss goals and overestimated the effect of the surgical intervention on their weight loss. However, both female and male patients, and particularly patients with diabetes, ranked the parameter “improved co-morbidity” at the top position. Disclosures Lars Fischer, Johannes Sander, Alexander Ernst and Rune Sandbu were participants in the second European Obesity Academy, which was sponsored by Johnson&Johnson. Fifty of the here presented 115 female patients will be included in a study examine the expectations of female patients in 5 northern European countries. References [1] O’Brien PE, McPhail T, Chaston TB, Dixon JB. Systematic review of medium-term weight loss after bariatric operations. Obes Surg 2006;16:1032–40. [2] Heneghan HM, Cetin D, Navaneethan SD, Orzech N, Brethauer SA, Schauer PR. Effects of bariatric surgery on diabetic nephropathy after 5 years of follow-up. Surg Obes Relat Dis 2013;9:7–14. [3] Arterburn DE, Bogart A, Sherwood NE, et al. A multisite study of long-term remission and relapse of type 2 diabetes mellitus following gastric bypass. Obes Surg 2013;23:93–102. [4] Sjostrom L, Peltonen M, Jacobson P, et al. Bariatric surgery and longterm cardiovascular events. JAMA 2012;307:56–65. [5] Carlsson LM, Peltonen M, Ahlin S, et al. Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. N Engl J Med 2012;367:695–704. [6] Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009;122(248–56):e5. [7] Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724–37. [8] Hauner D, Janni W, Rack B, Hauner H. The effect of overweight and nutrition on prognosis in breast cancer. Dtsch Arztebl Int 2011;108: 795–801. [9] Sjostrom L, Gummesson A, Sjostrom CD, et al. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish obese subjects study): a prospective, controlled intervention trial. Lancet Oncol 2009;10:653–62. [10] Cheraghi Z, Poorolajal J, Hashem T, Esmailnasab N, Doosti Irani A. Effect of body mass index on breast cancer during premenopausal and postmenopausal periods: a meta-analysis. PLoS One 2012;7: e51446. [11] Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity. Cochrane Database Syst Rev 2009:CD003641. [12] Sjostrom L. Review of the key results from the Swedish Obese Subjects (SOS) trial: a prospective controlled intervention study of bariatric surgery. J Intern Med 2013;273:219–34.
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[13] Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery 2007;142:621–32. (discussion 32–5). [14] DePaula AL, Stival AR, DePaula CC, Halpern A, Vencio S. Surgical treatment of type 2 diabetes in patients with BMI below 35: mid-term outcomes of the laparoscopic ileal interposition associated with a sleeve gastrectomy in 202 consecutive cases. J Gastrointest Surg 2012;16:967–76. [15] Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 2012;366:1577–85. [16] Muller-Stich BP, Fischer L, Kenngott HG, et al. Gastric bypass leads to improvement of diabetic neuropathy independent of glucose normalization-results of a prospective cohort study (DiaSurg 1 Study). Ann Surg 2013;258:760–6. [17] Kenngott HG, Clemens G, Gondan M, et al. DiaSurg 2 trial - surgical vs. medical treatment of insulin-dependent type 2 diabetes mellitus in patients with a body mass index between 26 and 35 kg/m2: study protocol of a randomized controlled multicenter trial DRKS00004550. Trials 2013;14:183. [18] De Paula AL, Stival AR, Halpern A, et al. Improvement in insulin sensitivity and beta-cell function following ileal interposition with sleeve gastrectomy in type 2 diabetic patients: potential mechanisms. J Gastrointest Surg 2011;15:1344–53. [19] Scopinaro N, Adami GF, Papadia FS, et al. Effects of biliopanceratic diversion on type 2 diabetes in patients with BMI 25 to 35. Ann Surg 2011;253:699–703. [20] Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012;366:1567–76. [21] Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis 2009;5:469–75. [22] Peterli R, Borbely Y, Kern B, et al. Early results of the Swiss multicentre bypass or sleeve study (SM-BOSS): A prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Ann Surg 2013;258:690–5. [23] Helmio M, Victorzon M, Ovaska J, et al. SLEEVEPASS: a randomized prospective multicenter study comparing laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: preliminary results. Surg Endosc 2012;26:2521–6. [24] Fridman A, Moon R, Cozacov Y, et al. Procedure-related morbidity in bariatric surgery: a retrospective short- and mid-term follow-up of a single institution of the American College of Surgeons Bariatric Surgery Centers of Excellence. J Am Coll Surg 2013;217:614–20. [25] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427–36. [26] Stroh C, Weiner R, Horbach T, et al. New Data on Quality Assurance in Bariatric Surgery in Germany [in German]. Zentralbl Chir 2013;138:180–8. [27] Hallersund P, Sjostrom L, Olbers T, et al. Gastric bypass surgery is followed by lowered blood pressure and increased diuresis - long term results from the Swedish Obese Subjects (SOS) study. PLoS One 2012;7:e49696.
[28] Fischer L, Hildebrandt C, Bruckner T, et al. Q5774 [29] Fischer L, Deckert A, Diener MK, Zimmermann JB, Buchler MW, 775 Seiler CM. Ranking of patient and surgeonsʼ perspectives for 776 endpoints in randomized controlled trials–lessons learned from the 777 POVATI trial [ISRCTN 60734227]. Langenbecks Arch Surg 778 2011;396:1061–6. [30] Rockwood TH, Church JM, Fleshman JW, et al. Patient and surgeon 779 ranking of the severity of symptoms associated with fecal incon- 780 tinence: the fecal incontinence severity index. Dis Colon Rectum 781 1999;42:1525–32. 782 [31] Rief W, Stock C, Geissner E, Fichter MM. When patient and therapist 783 disagree–discrepancies in evaluation of change [in German]. Psy784 chother Psychosom Med Psychol 1994;44:235–9. [32] Poole NA, Al Atar A, Kuhanendran D, et al. Compliance with 785 surgical after-care after bariatric surgery for morbid obesity: a 786 retrospective study. Obes Surg 2005;15:261–5. 787 [33] King M, Nazareth I, Lampe F, et al. Conceptual framework and 788 systematic review of the effects of participants’ and professionals’ preferences in randomised controlled trials. Health Technol Assess 789 790 2005;9:1–186. (iii-iv). [34] Rabner JG, Dalton S, Greenstein RJ. Obesity surgery: dietary and 791 psychosocial expectations and reality. Mt Sinai J Med 1993;60:305–10. 792 [35] White MA, Masheb RM, Rothschild BS, Burke-Martindale CH, Grilo 793 CM. Do patients’ unrealistic weight goals have prognostic signifi794 cance for bariatric surgery? Obes Surg 2007;17:74–81 [36] Kaly P, Orellana S, Torrella T, Takagishi C, Saff-Koche L, Murr 795 MM. Unrealistic weight loss expectations in candidates for bariatric 796 surgery. Surg Obes Relat Dis 2008;4:6–10. 797 [37] Karmali S, Kadikoy H, Brandt ML, Sherman V. What is my goal? 798 Expected weight loss and comorbidity outcomes among bariatric 799 surgery patients. Obes Surg 2011;21:595–603. [38] Wee CC, Jones DB, Davis RB, Bourland AC, Hamel MB. Under- 800 standing patients’ value of weight loss and expectations for bariatric 801 802 surgery. Obes Surg 2006;16:496–500. [39] Heinberg LJ, Keating K, Simonelli L. Discrepancy between ideal and 803 realistic goal weights in three bariatric procedures: who is likely to be 804 unrealistic? Obes Surg 2010;20:148–53. 805 [40] Foster GD, Wadden TA, Vogt RA, Brewer G. What is a reasonable weight loss? Patients’ expectations and evaluations of obesity treat- 806 807 ment outcomes. J Consult Clin Psychol 1997;65:79–85. [41] Foster GD, Wadden TA, Phelan S, Sarwer DB, Sanderson RS. Obese 808 patients’ perceptions of treatment outcomes and the factors that 809 influence them. Arch Intern Med 2001;161:2133–9. 810 [42] Walfish SB, EC. Male patient presurgical expectations of weight loss 811 from bariatric surgery. Bariatric Nursing 2007;2:281–4. [43] Bulik CM, Wade TD, Heath AC, Martin NG, Stunkard AJ, Eaves LJ. 812 Relating body mass index to figural stimuli: population-based 813 normative data for Caucasians. Int J Obes Relat Metab Disord 814 2001;25:1517–24. 815 [44] Courcoulas AP, Christian NJ, Belle SH, et al. Weight change and 816 health outcomes at 3 years after bariatric surgery among individuals 817 with severe obesity. JAMA 2013;310:2416–25.
Surgery for Obesity and Related Diseases ] (2014) 00–00
Original article
Patient expectations of bariatric surgery are gender specific—a prospective, multicenter cohort study Lars Fischera,*, Felix Nickela, Johannes Sanderb, Alexander Ernstc, Thomas Brucknerd, Beate Herbigb, Markus W. Büchlera, Beat P. Müller-Sticha, Rune Sandbue a
Department of Surgery, University of Heidelberg, Heidelberg, Germany b Obesity Clinic, Schoen Klinik Hamburg Eilbek, Hamburg, Germany c Department of General and Visceral Surgery, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany d Institute for Medical Biometry and Informatics, Heidelberg, Germany e Morbid Obesity Center, Vestfold Hospital Trust, Tønsberg, Norway Received September 26, 2013; accepted February 17, 2014
Abstract
Background: The effect of bariatric surgery on weight loss and improvement of co-morbidities is no longer doubted. However, little attention has been given to the treatment goals from the patient’s point of view (patient expectations). The objective of this study was to examine patients’ expectations of bariatric surgery and identify gender differences. Methods: Bariatric patients were asked to complete a questionnaire. Statistical analysis was performed using chi-square, Pearson correlation coefficient, and Wilcoxon rank sum test. Results: Overall, 248 patients participated in this study (69.4% females). The male patients (45.2 yr, SD ⫾ 11.1) were significantly older than the female (41.8 yr, SD ⫾ 12.0; P ¼ .04) and suffered significantly more often from diabetes, hypertension, hypercholesterolemia, and sleep apnea. One hundred thirty patients (52.4%) expected to lose at least 45 kg and 39 patients (15.7%) 4 70 kg. The mean expected excess weight loss was 71.8%. Females expected significantly more often that surgery alone would induce weight loss (P ¼ .03). “Improved co-morbidity” was by far the highest ranked parameter. Conclusion: The male bariatric surgery patients were older and suffered from more co-morbidities. Most of the patients had unrealistic weight loss goals and overestimated the effect of the surgical intervention. However, for both female and male patients, “improved co-morbidity” was the most important issue. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Patient expectations; Weight loss goals; Gender differences; Co-morbidity
The positive effects of bariatric surgery on weight loss and obesity-related co-morbidities, such as diabetes or hypertension, are no longer doubted [1–7]. Bariatric surgery may even significantly improve overall patient survival and reduce cancer incidence among female patients in particular [8–10]. In addition, surgery can be performed safely with *
Correspondence: Lars Fischer, M.D., Department of Surgery, University of Heidelberg INF 110, 69120 Heidelberg, Germany. E-mail: lars.fi[email protected]
regard to morbidity and mortality [11–13] and has proven effective in bringing about diabetes remission that surgeons now perform operations such as gastric bypass on patients with type 2 diabetes and a body mass index (BMI, kg/m2) of o35 kg/m2 for this purpose alone [14–20]. The field of bariatric surgery is still evolving. However, gastric bypass and sleeve gastrectomy are the most commonly performed procedures, both worldwide and in Germany, because of their positive risk/benefit correlation [21–28].
http://dx.doi.org/10.1016/j.soard.2014.02.040 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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The clinical efficacy of bariatric surgery is mostly measured by “hard” endpoints such as weight loss and the reduction of obesity-related co-morbidities. The patient’s perspective, however, including his/her treatment goals and expectations, has received less attention in the literature. The issues most important to patients can be identified and scientifically analyzed by using an approach called ranking [29–32]. Knowledge of patients’ expectations has been shown to affect clinical outcome [29,33–35]. While studies on this subject have been completed [36–40], most focus on weight loss or examine only female or male patients [41– 44]. The goal of this study was to measure the expectations of both male and female patients and identify possible gender differences. Methods
F1
Bariatric patients were invited to complete a questionnaire about their expectations. Patients were deemed eligible for bariatric surgery according to the most recent S3 German guidelines. To qualify, the patients must have exhausted conservative treatment for at least 6 months, undergone a psychosomatic and endocrinologic evaluation, have a BMI of 435 kg/m2 with at least 1 co-morbidity such as diabetes mellitus, hypertension or sleep apnea, or a BMI of 40 kg/m2 or more. Generally, insurance companies agree to cover a surgical intervention, but in most cases not for a certain procedure such as sleeve gastrectomy or gastric bypass. Eligible patients are provided with comprehensive written information regarding the risks and benefits of procedures performed at each center. However, no standardized preoperative education was used during this study. This study was performed in 3 bariatric centers: SchönKlinik Hamburg, Städtisches Klinikum Karlsruhe, and University Hospital Heidelberg. There was no screening list, so the number of patients asked to participate, those who declined participating, and their reasons for doing so, were not systematically recorded. Thus, it was not possible to calculate the “random ratio” or the “enrollment fraction” (proportion of screened to included patients). Furthermore, they were not asked which procedure (for instance sleeve gastrectomy or gastric bypass) they were to receive. The questionnaire (Fig. 1) was developed by Mari Hult (Karolinska Institute, Sweden), Anne Juuti (Helsinki University Hospital, Finland), Signe Röstad (Oslo University Hospital, Norway), Lars Fischer (Department of Surgery, University Heidelberg, Germany), Wouter te Riele (AMC Hospital Amsterdam, Belgium), Kai Orava (Seinäjoki Hospital, Finland), Timo Heikkinen (Oulu, Hospital, Finland) and Rune Sandbu (Morbid Obesity Center Tønsberg, Norway), during the second postgraduate training course of the European Obesity Academy and in collaboration with endocrinologists, psychiatrists, and statisticians. The
questionnaire was prepared in English but, to check the translation, the initial questionnaire was translated into German and then retranslated into English by a native English speaker. The translation was thought to be adequate, as the 2 English versions differed only slightly. The questionnaire consisted of 3 parts. In the first part, patients were asked to provide medical and socioeconomic data such as height, weight, age, educational status, profession, and co-morbidities. The second part asked them to describe their treatment goals in terms of both weight loss and the effect they expected surgery to have. In addition, they were asked to select drawings standardized according to Bulik et al. [45] (permission to use the drawings was obtained) that they considered representative of their bodies before and after weight loss. In the third part, ranking parameters were presented in a randomized fashion. Based on the lessons learned from the POVATI trial [31], part 3a of the questionnaire was designed to prevent systematic errors; i.e., the randomized ranking parameters were rated in importance on a 5-point scale from 1 (not important) to 5 (very important). Because it was anticipated that many parameters would be ranked as very important (i.e., with 5), in part 3b, patients were asked to indicate which of the 14 issues were the highest, second highest, and third highest priority. In a pilot study, the questionnaire was tested with 10 patients for comprehensibility and ambiguity. Neither during the pilot phase nor during the study itself did any patients make recommendations concerning the comprehensibility or ambiguity of the questionnaire. In the analysis of the responses, the results in part 3a of each parameter were evaluated. In addition, a scoring system was used in part 3b, where the most important parameter was given 3 points, the second most important 2 points, and the third most important 1 point. The scores were added to determine the order of importance among the ranking parameters. Ethical approval (S-618/2011) was obtained from the institutional review board, also known as ethical review board. To describe the empirical distribution of continuous parameters, the weighted means and minimum and maximum values were calculated. The distribution of categorical parameters was described by absolute and relative frequencies (count and percentage). Possible differences were analyzed using chi-square, Wilcoxon rank sum test, and Spearman correlation coefficient. Excess weight loss (EWL) was calculated using the formula “(initial BMI final BMI)/(initial BMI - 25) 100” based on the “weight” and “height” as stated in part 1 of the questionnaire and the “expected weight loss” provided by the patients according to the question: “How many kilograms do your expect to lose after surgery?” in part 2 of the questionnaire. All patients were asked to state weight related values in kilograms (1 kg ¼ 2.205 lb).
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Patient Expectations Toward Bariatric Surgery / Surgery for Obesity and Related Diseases ] (2014) 00–00
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Part 1 Date and place:_______________________________
Initials: __ . __ (Surname . Name)
Height: __________cm Weight: _________kg BMI: _______ kg/m
Age:
Occupation ____________________________________
____ years
pension
Relationship
single
married/partner
Smoking
yes
no
Education
unemployed
university education (Bachelor, Master, PhD,…)
school
Co-morbidities
Other: _______________________________________________________ Part 2 1.
Please mark above the numbered line where you consider yourself to be before surgery and below the numbered line where you expect to be after surgery .
2. How many kilograms do you expect to lose after surgery?
_ _ _ _ kg
3. Please mark on the line the proportion of how much weight loss will be due to the operation.
------------------I 100%
50%
0%
Fig. 1. Questionnaire as presented to the patients. In female patients, the ranking parameter “improved fertility” was added.
3
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Part 3A Please mark what you think best fits your opinion. Feel free to use the whole range of answers. Why did you seek bariatric surgery? How important are the following issues on a scale of 1 (not important for you) to 5 (very important for you)? Not important
1
Important
2
3
Very important
4
5
Improved mental health Improved physical activity Improved in intimacy and partnership Reduction in clothing size Improved fertility Improved social life (e.g., culture, meeting friends) Pain reduction Improved comorbidity such as diabetes, hypertension, sleep apnea, etc. Reduced medication need Increased employment chance Better work performance Weight loss Improved self-esteem Increased life expectancy If none of the above options qualify as your main expectation, please write what your main expectation is here: ____________ Part 3B Please rank the three most important issues from the above-mentioned issues in order 1 to 3, with number 1 being most important. 1. Most important: ____________ 2. Second most important: ____________ 3. Third most important: ____________
Fig. 1. (Continued)
Results
T1
Overall, 248 patients participated in this study (Heidelberg, 166 patients; Hamburg, 72 patients; Karlsruhe, 10 patients) and 69.4% were females. The mean age was 42.8 years (SD ⫾ 11.8 years). The mean BMI was 48.4 kg/m2 (SD ⫾ 8.0 kg/m2). There were no significant differences in BMI between the male and female patients (Table 1). However, the male patients (45.2 yr, SD ⫾ 11.1) were significantly older than the females (41.8 yr, SD ⫾ 12.0; P ¼ .04, Table 1). There were no significant gender differences with respect to marital status education, employment rate, and smoking habits. However, male patients suffered significantly more often from diabetes (oral medication), hypertension, hypercholesterolemia, and sleep apnea and females more often from depression. Using the standardized drawings in part 2 of the questionnaire, patients scored their preoperative body image between 9 and 10 (mean 9.9, SD ⫾ 1.7) and estimated their postoperative body image at between 4 and 5 (mean 4.8, SD ⫾ 1.1). There was a significant positive correlation between preoperative BMI and preoperative body image (r ¼ .52, P o .01), and between expected weight loss (“How many kilograms do you expect to lose?”) and postoperative body image (r ¼ .51, P o .01). However,
the initial BMI of the patients did not correlate significantly with the postoperative body image (r ¼ .28, P o .01); i.e., regardless of their initial weight, patients had similar expectations about postoperative body silhouette. There were no significant gender differences with respect to body image (data not shown). In response to the question, “How many kilograms do you expect to lose?” (part 2 of the questionnaire), 130 patients (52.4%) answered at least 45 kg, 39 patients (15.7%) answered 4 70 kg, and 14 patients (5.6%) answered 100 kg or more. There were no significant differences between male (mean 52.0 kg, SD ⫾ 25.3 kg) and female patients (mean 46.3 kg; SD ⫾ 18.6 kg; P ¼ .13). The mean expected EWL was 71.8 % (SD ⫾ 21.5%), with no significant differences between male (mean EWL 68.9%, SD ⫾ 21.1%) and female patients (mean EWL 73.0%; SD ⫾ 21.6 %; P ¼ .37). More than 88% of the patients wanted to have an EWL 4 50% (Table 2). The vast majority of patients believed that surgery would induce this weight loss, and 45.7% that surgery alone would be suffice, with female patients being of this opinion significantly more often (Table 3, P ¼ .03). The overall percentage of patients who ranked each parameter as very important (i.e., gave the highest score “5” in part 3a of the questionnaire) and gender differences
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5
Table 1 Description of the study population based on gender, age, body mass index (BMI), socioeconomic issues, and co-morbidities.
n Age (SD) BMI (SD) Married or stable partnership (%) Children (%) University degree (%) Vocational school (%) Finished at least 8 yr regular school (%) Employment rate (%) Smoking (%) Diabetes (oral medication) (%) Diabetes (insulin) (%) Hypertension (%) Hypercholesterolemia (%) Sleep apnea (%) Depression (%) Joint pain (%) Infertility (%)
All
Female
Male
P value (Wilcoxon test)
248 42.8 (11.8) 48.4 (8.0) 61.9 61.5 12.9 68.9 14.9 52.6 18.6 19.3 16.5 50.0 14.9 20.9 20.9 36.7 n/a
172 41.8 (12.0) 48.5 (7.9) 63.9 64.5 10.4 70.9 16.3 52.0 20.9 15.7 15.1 44.2 11.0 13.4 25.0 40.7 4.1
76 45.2 (11.1) 48.0 (8:2) 57.3 54.6 18.4 64.5 11.8 53.9 13.3 27.3 19.7 63.2 23.6 38.2 11.8 27.6 n/a
n/a .04 n.s. n.s n.s. n.s. n.s n.s n.s n.s. .03 n.s. o.01 .01 o.01 .02 n.s. n/a
SD ¼ standard deviation; n/a ¼ not applicable; n.s. ¼
among the parameters are shown in Table 4. The female patients rated the parameters “improved physical activity”, “pain reduction”, “improved mental health”, “improved self-esteem”, and “reduction in clothing size” significantly more often with “5” (P o .04). In part 3b of the questionnaire, patients were asked to assign a priority ranking to the 14 parameters, using the scoring system mentioned above. “Improved co-morbidity” was given the highest score (313 points), followed by weight loss”, “improved physical activity”, “pain reduction” and “longer life expectancy” (Table 5). The only gender difference was that female patients rated “pain reduction” higher than the male patients, whereas the latter were more focused on “weight loss”. Finally, we examined the correlation between comorbidities (part 1 of the questionnaire) and patients’ preferences. Diabetes patients rated the issues “reduced medication need”, “improved co-morbidity”, and “pain reduction” as a “5” significantly more often than the Table 2 Calculation of the expected excess weight loss based on the initial body mass index and the question, “How many kilograms do you expect to lose after surgery?” in part 2 of the questionnaire. EWL
All (%)
Cumulative (%)
0–10 % 11–40 % 41–50 % 51–60 % 61–70 % 71–80 % 81–90 % 91–100 % 4100 %
2.5 3.8 5.0 16.1 14.7 24.8 18.5 7.5 7.9
2.5 6.3 11.3 26.5 41.2 66.0 84.4 92.0 100
EWL ¼ excess weight loss
remainder of the study group. Patients with hypertension rated “reduced medication need” and “improved co-morbidity” highly, whereas hypercholesterolemia patients placed a high value on “reduced medication need”. Interestingly enough, depressed patients rated “improved self-esteem” as very important significantly more often (data not shown). Discussion Studies dealing with bariatric procedures mainly focus on endpoints such as EWL or diabetes remission. Little attention has been given to the question of whether such endpoints really matter from the patient’s perspective. It may be possible to evaluate the relevance of a given endpoint from a patient’s point of view by using questionnaires to ask patients to rank possible outcomes [31,38,39]. However, in this field, which is evolving so rapidly, the required scientific analysis constitutes a major challenge [29]. The current literature on patient expectations concerning bariatric surgery has not been without limitations, such as including only 1 gender, or a primary focus on weight loss Table 3 Results to the item: “Please mark on the line the proportion of how much weight loss will be due to the operation.” in part 2 of the questionnaire. Expected proportion of surgery on weight loss
All (%)
0–49 % 50 % 51–99 % 100 %
2.4 1.8 12.2 10.0 39.6 38.2 45.7 50.0
n.s. ¼
Female Male patients (%) patients (%) 6.7 14.6 42.7 36.0
P value (ChiSquare) n.s. n.s. n.s. 0.03
455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 Q7509
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Table 4 Order of the ranking parameters that patients ranked as “very important” (i.e., with “5”) in part 3a of the questionnaire. Parameter
Weight loss Improved physical activity Improved co-morbidity Increased life expectancy Pain reduction Reduced medication need Improved mental health Better work performance Improved self-esteem Improved social life Reduction in clothing size Improved intimacy and partnership Increased employment chance Improved fertility
Overall (%)
Females (%)
Males (%)
P value (chisquare)
87.1 85.9 78.6 76.6 68.5 58.1 50.4 50.4 49.6 47.6 47.2 34.7
86.6 89.5 77.9 76.7 73.8 56.4 58.1 51.7 57.0 51.4 51.7 36.0
88.1 77.6 80.2 76.3 56.7 61.8 32.9 47.3 32.9 38.2 36.8 31.6
n.s. .04 n.s. n.s. .04 n.s. o.01 n.s. .01 n.s. .04 n.s.
34.8
35.6
32.9
n.s.
n/a
14.5
n/a
n/a
n.s. ¼; n/a ¼ not applicable.
issues [34,36,42,43,46]. The present survey on a convenient sample of 248 obese patients examined a range of expectations held by both genders and has revealed 4 major findings. First, compared with female patients, male patients were not only significantly older but also suffered significantly more often from obesity-related co-morbidities. Second, 45.7% of all patients believed their expected weight loss would be due to surgery alone. Third, each gender ranks the importance of some parameters differently, but attaches similar value to the most important expectations (Table 5). Fourth, the correlation between co-morbidities, particularly diabetes, and expectations was significant. The latter 2 findings are a strong indicator that obese patients are aware of their infirmity and its related diseases. Prior studies have shown that patients’ weight loss expectations after surgery are unrealistic [37,38,41]. Our findings were consistent with the literature. In the present cohort, we found not only that 52.4% of all patients expected to lose 445 kg, but also that 45.7% thought that this weight loss would be induced by surgery alone. The mean expected EWL was 71.8%. Even though some
Table 5 Order of the ranking parameters according to the scoring system described in the Methods section. Order
All patients (points)
Female patients (points)
Male patients (points)
1.
Improved co-morbidity 313 Weight loss 196 Improved physical activity 182 Pain reduction 178 Increased life expectancy 115 Improved social life 70 Improved mental health 67 Improved self esteem 64 Reduced medication need 57 Better work performance 46 Other 41 Improved intimacy and partnership 29 Reduction in clothing size 26 Improved fertility 24 Increased employment chance 23
Improved co-morbidity 204 Pain reduction 134 Improved physical activity 131 Weight loss 128 Increased life expectancy 76 Improved mental health 54 Improved self esteem 50 Improved social life 43 Other 37 Reduced medication need 30 Better work performance 27 Improved fertility 24 Reduction in clothing size 21 Improved intimacy and partnership 18 Increased employment chance 17
Improved co-morbidity 109 Weight loss 68 Improved physical activity 51 Pain reduction 44 Increased life expectancy 39 Reduced medication need 27 Improved social life 27 Better work performance 19 Improved self esteem 14 Improved mental health 13 Improved intimacy and partnership 11 Increased employment chance 6 Reduction in clothing size 5 Other 4 n/a (“improved fertility”) -
2. 3.
4. 5.
6. 7. 8. 9. 10. 11. 12. 13. 14. 15
n/a ¼ not applicable
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Q3
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Patient Expectations Toward Bariatric Surgery / Surgery for Obesity and Related Diseases ] (2014) 00–00
patients will actually reach their treatment goals [47], the findings presented here highlight the need to discuss goals that are more realistic with patients, and to make them aware that weight loss is achieved by more than surgery alone, particularly in the long term. This finding is of particular value since it has been shown that unrealistic expectations have an effect on patient compliance [34]. The item related to the effect of surgery (“Please mark on the line the proportion of how much weight loss will be due to the operation.”) in part 2 of the questionnaire left for the participant no option to identify other factors that would be involved in their weight loss (such as lifestyle changes). During this study, however, we were particularly interested in determining to what extent patients think surgery will contribute to their weight loss. The present study is not without limitations. The answers patients gave may not have expressed their own expectations, as much as reflected their desire to meet external expectations, e.g., those of their surgeons. We sought to avoid this risk by assuring patients that their participation was voluntary, and by having a study nurse administer and collect the questionnaire. As a result, surgeons were unaware of the identity of the study participants. Furthermore, the comprehensibility of the questionnaire was a concern. In a pilot study, the questionnaire was completed by 10 patients who, when asked if they had understood the questions, answered that they had. Neither during the pilot study nor the study itself were any comments made, which indicated that the questionnaire was incomprehensible. Even though the questionnaire aimed to cover all relevant issues, 16 of the 248 participants (6.4%) stated at the end of part 3a that “other” reasons were significant to them. These “other” reasons included an improvement in quality of life for 14 patients. This finding convinced us of the need to add the ranking parameter “quality of life improvement” in further studies. Patients’ expectations of bariatric surgery are a multifaceted construct. In this study, we investigate the nature but not the origin of these expectations. We presume that most patients included in this study were driven by their frustration with the multiple diets they had attempted. Others might have been pressured by their families or their physicians. Another important question is whether the bariatric procedure that the patient expects might affect his/her expectations significantly. We concluded after intensive discussion that this is most likely not the case. The bariatric patient’s crucial decision is to go ahead with surgery itself, with most of them not having a certain procedure in mind. Furthermore, the outcome parameters of the questionnaire focus on treatment goals that were considered as “optimal” (such as nadir weight loss) but had no context or accurate basis within the postoperative timeline. For this reason, it may be appropriate to ask patients to provide concrete expectations for postoperative time points of 1, 3, 5, or 10
7
years after surgery. However, these latter 2 issues need to be addressed in future work. Conclusion In this descriptive survey, carried out on a convenience sample, male bariatric patients were older and suffered from more co-morbidities than female patients. Most patients had unrealistic weight loss goals and overestimated the effect of the surgical intervention on their weight loss. However, both female and male patients, and particularly patients with diabetes, ranked the parameter “improved co-morbidity” at the top position. Disclosures Lars Fischer, Johannes Sander, Alexander Ernst and Rune Sandbu were participants in the second European Obesity Academy, which was sponsored by Johnson&Johnson. Fifty of the here presented 115 female patients will be included in a study examine the expectations of female patients in 5 northern European countries. References [1] O’Brien PE, McPhail T, Chaston TB, Dixon JB. Systematic review of medium-term weight loss after bariatric operations. Obes Surg 2006;16:1032–40. [2] Heneghan HM, Cetin D, Navaneethan SD, Orzech N, Brethauer SA, Schauer PR. Effects of bariatric surgery on diabetic nephropathy after 5 years of follow-up. Surg Obes Relat Dis 2013;9:7–14. [3] Arterburn DE, Bogart A, Sherwood NE, et al. A multisite study of long-term remission and relapse of type 2 diabetes mellitus following gastric bypass. Obes Surg 2013;23:93–102. [4] Sjostrom L, Peltonen M, Jacobson P, et al. Bariatric surgery and longterm cardiovascular events. JAMA 2012;307:56–65. [5] Carlsson LM, Peltonen M, Ahlin S, et al. Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. N Engl J Med 2012;367:695–704. [6] Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009;122(248–56):e5. [7] Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724–37. [8] Hauner D, Janni W, Rack B, Hauner H. The effect of overweight and nutrition on prognosis in breast cancer. Dtsch Arztebl Int 2011;108: 795–801. [9] Sjostrom L, Gummesson A, Sjostrom CD, et al. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish obese subjects study): a prospective, controlled intervention trial. Lancet Oncol 2009;10:653–62. [10] Cheraghi Z, Poorolajal J, Hashem T, Esmailnasab N, Doosti Irani A. Effect of body mass index on breast cancer during premenopausal and postmenopausal periods: a meta-analysis. PLoS One 2012;7: e51446. [11] Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity. Cochrane Database Syst Rev 2009:CD003641. [12] Sjostrom L. Review of the key results from the Swedish Obese Subjects (SOS) trial: a prospective controlled intervention study of bariatric surgery. J Intern Med 2013;273:219–34.
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