"OP scores are transformed to a 0-100 scale. A higher score indicates greater problems. ^Confidence interval.

"OP scores are transformed to a 0-100 scale. A higher score indicates greater problems. ^Confidence interval.

Summary: How Obese Patients Differ From other Chronic Populations

• Poorer functioning and mental well-being than unselected cancer survivors 2-3 years after diagnosis; comparable to those with recurrence

• The more overweight, the worse HRQL

• Better functioning than patients with disabling conditions, e.g. rheumatoid arthritis, chronic pain conditions

• Poorer mental well-being than the disabled, e.g. those with rheumatoid arthritis or with spinal cord injuries more than 2 years after injury

HRQL and Obesity III: Psychosocial Functioning

Impairment in psychosocial functioning among obese subjects has been documented in several reports during the last decades (18,61). Most studies, however, have been conducted in small samples of severely obese subjects before and after surgical treatment for obesity and generalizations are therefore uncertain. The validity of these studies is fur ther hampered by the high dropout rates and their failure to include control subjects, long-term follow-ups and standardized instruments, which greatly jeopardize the interpretability of the data.

Psychosocial dysfunction related to overweight is probably not well covered by generic instruments and an obesity-specific scale (Obesity-related Problem scale, OP; see Appendix) was developed in the SOS study to assess the impact of obesity on psychosocial functioning. The module comprises eight questions on how bothered patients are by their obesity in everyday life activities. Psychometric properties were shown to be satisfactory in the first 1743 subjects examined (39), later cross-validated in more than 2000 consecutive SOS subjects (62). The OP scale showed only moderate correlations (r = 0.41-0.54) with other HRQL measures and thus provides unique information on the quality of life of obese subjects. Table 33.4 illustrates that the psychosocial burden of obesity is substantial. Women perceived markedly more problems in every area regardless of degree of overweight, while men reported more problems the higher their BMI. As expected, the general trend for both men and women pointed to more concerns regarding activ ities in public places, such as trying on and buying clothes and bathing in public places. It has also been documented in the SOS intervention study that obese who choose surgical treatment report markedly more psychosocial dysfunction at baseline than do matched obese controls (19).

Summary: How Obesity-related Psychosocial Problems are Perceived

• Worst in public places, e.g. trying on and buying clothes, bathing

• Women much worse than men

• In men, the more overweight, the more psychosocial problems

HRQL and Obesity IV: Responsiveness to Weight Loss

Surprisingly little is known about the influence of weight reduction on psychosocial functioning and well-being in overweight or obese persons (63), and very few studies have measured the effects of weight loss on physical functioning, role functioning, vitality or other important aspects of health status. It is also unclear how weight gain which occurs after initial weight loss during the course of treatment affects the quality of life of the obese patients (64). Some recent studies that have used standardized self-report instruments for outcome assessment suggest that weight loss in obese subjects (e.g. after diet and lifestyle modification treatment) is mostly associated with improvements in mood (63). Positive long-term changes in functional health (Sickness Impact Profile) in moderately obese women were found after compliance in a 2-year weight loss programme (55). In a recent study, the SF-36 Health Survey was used to assess quality of life change in moderately obese women after a 12-week weight loss programme (65). Significant improvements in physical functioning, vitality and mental health were found in the intervention group, while no such improvements were noted in the control group.

Several studies on the outcome of weight-reduction surgery in severely obese subjects have reported very positive effects on psychosocial functioning and well-being (18). Responsiveness to weight loss after obesity surgery on the different quality of life domains is, however, still unclear, especially in the long-term perspective. Obviously, it would be of great clinical value to clarify how the magnitude of weight loss affects quality of life, e.g. how much weight reduction is required to improve the general health perceptions of the patient. With regular use of well-established, standardized HRQL instruments in obesity research it would be possible to calculate a dose-response relation between weight loss and the various quality of life parameters.

HRQL Change in the SOS Intervention Study: the SOS Quality of Life Survey

The following examples are based on severely obese patients followed for 4 years in the SOS intervention study (Karlsson et al., unpublished data). A battery approach was applied in the SOS study to assess quality of life. The SOS Quality of Life Survey (see Appendix) is intended to tap a broad range of health impacts of obesity, and generic instruments or subscales on functioning and well-being are supplemented by obesity-specific modules.

Poor HRQL at baseline was dramatically improved after obesity surgery, while stable ratings over time were observed in the control group. Powerful improvements after 6 and 12 months in the surgical group were followed by a slight to moderate decline at 2- 3- and 4-year follow-ups. It was demonstrated that improvements in HRQL after 6 months were weakly related to weight loss, while this association was strengthened at 2-year follow-up (19). Thus, short-term change on HRQL indicators in weight loss studies should be interpreted with caution. Long-term follow-up is most likely necessary to confirm the effects of obesity interventions on quality of life.

In Figure 37.7, the percentage bothered on each item of the Obesity-related Problem scale (OP) are shown at baseline and at 2- and 4-year follow-ups. Great improvements can be seen from baseline to intermediate (2-year) and long-term (4-year) follow-ups in all activities covered by the OP scale. The OP scale has proved the most responsive HRQL measure in relation to weight loss over 4 years in the SOS intervention study (19,66). The results are strengthened by the fact that the dropout rate in the surgery group was extremely low even after 4 years (about 17%).

To enable comparisons of the effect of obesity


% bothered when taking part in the following activities: Private gatherings in my own home

Private gatherings in a friend's or relative's home

Going to a restaurant

Going to community activities, courses, etc

Holidays away from home

Trying on and buying clothes

Bathing in public places (beach, public pool)

Intimate relations with partner

0 20 40 60 80 100

% bothered

Figure 33.7 Psychosocial dysfunction in severely obese subjects prior to treatment and at 2- and 4-year follow-ups after surgical intervention in the SOS study (n = 213). The percentage bothered (mostly bothered and definitely bothered) is given for each item of the OP scale

Private gatherings in a friend's or relative's home

Going to a restaurant

Going to community activities, courses, etc

Holidays away from home

Trying on and buying clothes

Bathing in public places (beach, public pool)

Intimate relations with partner

0 20 40 60 80 100

% bothered surgery on the different quality of life domains, change scores from baseline to follow-ups were transformed to standardized response means (SRM; Meandiff/SDdiff) (49). Effect sizes of HRQL change after 6, 24 and 48 months are displayed in Figure 37.8. SRMs for weight change were also calculated as a point of reference and, as expected, the effect size after gastric surgery was large (data not shown). SRM for weight loss was largest after 6 months (2.75) but declined after 2 years (1.95) and 4 years (1.60). A similar trend was noted for the HRQL measures. Great changes in eating behaviour (TFEQ) were observed after surgical intervention, i.e. patients reported more restrained eating (RE) and less disinhibition (DI) and hunger (HU). The early changes, however, declined slightly over time. Improvements in functional health (SIP) were largely in leisure activities (RP) and social interaction (SI). Relatively small improvements (SRMs around 0.20 to 0.50) were seen in the general health (GHRI-CH) and mental health (MACL, HAD, SE) domains as well as in global quality of life (QL).

HRQL Improvements in Relation to Weight Loss After Surgical Treatment

HRQL changes 4 years after obesity surgery were related to the magnitude of weight loss; improvements were stable over time in patients with substantial weight loss ( > 30 kg; around 30%), while a regression was observed in patients with less weight reduction. If weight loss was minor ( < 10 kg), patients tended to return to their baseline levels.

A dose-response relation was observed between weight loss and improvements in psychosocial functioning (OP). The surgically treated subjects were grouped by amount of weight loss (kg) 4 years after surgery and the mean OP-scale scores were calculated for each measurement time point. There were no significant differences between groups at baseline. After 6 months, levels of psychosocial problems were substantially reduced in all groups, with a more positive trend seen in subjects with major long-term weight reduction. A distinct pattern of change among groups was observed, namely, subjects with more favourable long-term weight

0,20 0,40 0,60 0,80 1,00 Standardized Response Mean (SRM)


Figure 33.8 Effect of obesity surgery on health-related quality of life (HRQL) at short-term (6 months), intermediate (2 years) and long-term (4 years) follow-ups in the SOS intervention study. HRQL change scores from baseline to follow-up are transformed to standardized response means (SRM). SRM is calculated as the mean change score divided by the standard deviation of change (Meandiff/SDdift, Katz et al. (49)).

TFEQ, Three-Factor Eating Questionnaire; RE, restrained eating; DI, disinhibition; HU, hunger. OP, Obesity-related Psychosocial Problems.

SIP, Sickness Impact Profile; A, ambulation; HM, home management; RP, recreation and pastimes; SI, social interaction. GHRI, General Health Rating Index; CH, current health.

HAD, Hospital Anxiety and Depression scale; A, anxiety symptoms; D, depression symptoms. MACL, Mood Adjective Check List. SE, Self-esteem. QL, Overall quality of life

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