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Psychosomatics 49:478-486, November-December 2008
doi: 10.1176/appi.psy.49.6.478
© 2008 Academy of Psychosomatic Medicine
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Impact of Antidepressant Use on Gastric Bypass Surgery Patients’ Weight Loss and Health-Related Quality-of-Life Outcomes

Robert J. Love, D.O., M.S., Ashley S. Love, Dr.P.H., M.P.H., M.S., Steven Bower, M.D., and Walker S. Carlos Poston, Ph.D., M.P.H.

Received October 29, 2006; revised March 28, 2007; accepted April 5, 2007. From Wilford Hall Medical Center and University of Texas Health Science Center at San Antonio, and the University of Missouri–Kansas City School of Medicine. Send correspondence and reprint requests to Dr. Robert J. Love, Psychiatry Resident, Department of Psychiatry, Wilford Hall Medical Center, University of Texas Health Science Center at San Antonio, San Antonio, TX 78249. e-mail: Robert.Love2{at}dover.af.mil
© 2008 The Academy of Psychosomatic Medicine


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
BACKGROUND: Psychological factors may be predictive of post-surgical adjustment and successful outcomes in obesity-surgery populations. OBJECTIVE: The authors compared post–gastric bypass surgery (GBS) outcomes of patients being given active psychotropic treatment for depression, with those of patients without treatment or identifiable need for treatment at enrollment. METHOD: Outcome measures included weight and repeated administration of the Medical Outcome Survey Short Form–36 (SF–36). RESULTS: There was no impact of antidepressant treatment on GBS patients’ weight loss or SF–36 outcomes. CONCLUSION: Therefore, patients with actively treated depression should be expected to have GBS outcomes equivalent to those of patients without identifiable psychiatric illness or treatment.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Obesity is an alarming public health concern in the United States and in the industrialized world.1–4 In the United States, there has been a steady and dramatic increase in the prevalence of obesity that spans across all ages and ethnic groups and exists among both men and women.1,5,6 Obesity is considered a leading risk factors for a variety of severe conditions, including coronary heart disease, type 2 diabetes, asthma, sleep apnea, osteoarthritis of the knee, hypertension, and certain cancers.4,7–12 Obesity also has been linked to increased probability of past-year major depression, suicide attempts, and suicidal ideation among women.13

In addition to the medical consequences of obesity, it has an enormous negative effect on personal functional capacity, as evidenced by negative impact on measures of Health-Related Quality of Life (HR–QOL).2,14–16 HR–QOL measures are used to assess the effects of chronic illnesses on patients, to better understand how an illness interferes with a person’s day-to-day life.17 Candidates for gastric bypass surgery (GBS) represent a unique subsample of the obese population because of their much higher body mass indexes (BMIs) and correspondingly severe comorbid health problems.15,18,19 There is consistent evidence that patients requesting GBS are particularly impaired in terms of quality of life.19–22 Previous studies have shown that those patients who seek GBS have more severe HR–QOL impairment than similarly-obese subjects who do not desire surgery.23,24 However, studies also show that weight loss leads to improvement on quality-of-life measures,25–28 with two recent reports demonstrating stable improvement in HR–QOL at 3 years post-surgery.29,30

GBS has established effectiveness in terms of producing weight loss as well as improvements in HR–QOL.31–33 The surgical treatment of obesity has been demonstrated to be safe and effective in thousands of patients, with 10 or more years of follow-up.34 For example, there is a significant improvement for diabetes, hypertension, and other obesity comorbidities in severely obese patients after GBS, and several researchers have endorsed surgical treatment as a cost-effective treatment for morbid obesity.35–37 It has been suggested that surgery is the most successful treatment for morbid obesity because of its ability to provide significant long-term reduction in body weight not found with nonsurgical alternatives.38–40

A recent review of the literature reported a general consensus that psychosocial and behavioral factors contribute to successful postoperative outcomes.41 Some data suggest that patients’ psychological factors may be predictive of post-surgical adjustment in obese surgical populations,42 which has been the case in other surgical populations (e.g., ulcerative colitis), as well.43 It has also been suggested that patients seeking a medical solution for obesity have higher rates of psychopathology than similarly obese people who are not seeking treatment.44 For example, an elevated prevalence of depression among women seeking GBS was recently observed.45 Alternatively, it may be that the experience of undergoing the surgery might lead to the exacerbation of preexisting psychiatric comorbidities. This inference has been based on the fact that increases in suicidal, addictive, and impulsive behaviors occur in some patients after weight loss,8 which could suggest that this procedure may have a negative impact on patients with depression. Alternatively, it has been suggested that GBS is associated with a decrease in depressive symptoms,46 as well as a decrease in antidepressant use after surgery.47 Other recent evidence demonstrated that a history of sexual abuse did not predict failure in post-surgical weight loss.48 We agree with the reasonable assertion that it is important to identify those aspects of patients’ psychological make-up that would be expected to improve or worsen their prognosis, so as to allow practitioners to offer appropriate pre- and post-operative psychosocial intervention for otherwise untreated issues.49 The goal of the present research is to broaden understanding of this population by investigating the interaction of diagnosed and treated depression with weight loss and HR–QOL outcomes among GBS patients.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Sample and Setting
Of 450 patients who had undergone the Roux-En-Y GBS during 1999–2003 at Wilford Hall Medical Center, Lackland Air Force Base, 116 patients had complete data, including presurgical, 6-month, and 1-year post-surgical follow-up measures on the Medical Outcomes Study: Short Form–36 (SF–36) and BMI. Each surgical candidate was assessed by a multidisciplinary team, who evaluated their medical history, physical examination, nutrition evaluation by the registered dietitian, and presurgical psychological evaluation by a psychiatrist, as well as the assessment of health-related quality of life (HR–QOL).

We divided patients on the basis of treatment with antidepressant medications at the time they presented with request for bariatric surgery. Two groups were identified: one group who were actively taking antidepressant drugs (N=48) at the time of enrollment into the study; and a second group who were not taking antidepressant drugs and had no identifiable need for treatment of depression at the time of enrollment (N=68). All patients were individually screened through a complete diagnostic psychiatric interview, which was performed by a representative of the Wilford Hall Medical Center’s psychiatric consultation–liaison team (under the supervision of a board-certified psychiatrist). The results of the individual interviews were documented in consult reports that contained the following information: 1) a full psychosocial history; 2) diagnosis (or absence thereof); and 3) treatment recommendations (which included: suitability for surgery, or recommendations for further psychiatric treatment before surgery). All patients in the active-treatment group had been encouraged to continue treatment with antidepressants under the supervision of their individual providers. Those patients who were referred for additional treatment were not included in the analysis. For this study, we were interested in presurgical psychological evaluation and HR–QOL. Pre-surgical medical screening and all follow-up visits were performed by the Wilford Hall Medical Center’s Gastric Bypass Surgery team. Patients were interviewed before the surgery, 6 months after the surgery (midpoint), and 1 year after the surgery. The Institutional Review Board of the Wilford Hall Medical Center and Brooks Army Medical Center approved the study.

HR–QOL Instrument: Medical Outcomes Study Short Form (MOS SF–36)
Quality of life is defined as "goodness of life" or "person’s well-being,"50 and it is linked with different research disciplines. It is a multidimensional term that focuses on one’s well-being in the society as well as one’s perceived experiences in life.51 However, there is no consensus about the meaning of the term at this time.52,53 Health-related quality of life is one aspect of quality of life. It is "goodness of life" that is affected by health.51 In public health and medicine, health-related quality of life is comparable to a person or group’s perceived physical and mental health over time.17 The SF–36 is a 36-item short form test derived from 245-item Medical Outcomes Study questionnaire, which was devised to measure general health status in population surveys and evaluative studies of health policy.54 The SF–36 has multi-item scales to assess the following eight dimensions: physical functioning, role limitation due to physical health problem, bodily pain, social functioning, general mental health, role limitations due to emotional problems, vitality/energy/fatigue, and general health perceptions. The scores on each of the domains of the SF–36 range from 0 (lowest level of functioning) to 100 (highest level of functioning).

The SF–36 survey has been used in over 700 studies to assess HR–QOL, and it has been validated in many diverse populations.55,56 Numerous studies have shown that the reliability and validity are high. With rare exceptions, published reliability statistics have exceeded the minimum standard of 0.70 recommended for measures used in group comparisons, with most exceeding 0.80.54,57 Reliability estimates for physical and mental summary scores usually exceed 0.90.56 Accordingly, the SF–36 has proven useful in comparing general and specific populations, estimating the relative burden of different diseases, differentiating the health benefits produced by a wide range of different treatments, and screening of individual patients.55

Data Analyses
All analyses were performed with the Statistical Package for Social Sciences, Version 13 (SPSS). To overcome the problem of defining ideal weight, we used percentage-of-excess BMI loss (%EBMIL).58 This measure uses ideal BMI as 25 kg/m2, and the equation is %EBMIL=(BMI loss/[baseline BMI–25]) x 100, where BMI loss is defined as BMI baseline subtracted by either midpoint post-surgery (6 months) or 1 year post-surgery. Univariate and bivariate analyses were performed to describe the two samples. Repeated analyses of variance (RANOVA) were executed for three time-points (baseline, 6 months post-surgery, and 1-year follow-up) and were conducted to assess the differences between the groups on HR–QOL measures, with eight domain scores on the SF–36 and BMI as dependent variables and membership in group as independent variable. Post-hoc tests were performed to determine which time-points were significant; p values <0.05 were considered significant. We accounted for preoperative scores in our analyses by performing analyses of covariance (ANCOVA), with preoperative scores as covariate and depression status as groups. Furthermore, we performed a post-hoc test on the three time-points to assess the differences in these time-points and also assessed the reliability of the SF–36.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Sociodemographic and Baseline Characteristics
Age, gender, race/ethnicity, marital status, body weight, and body mass index (BMI) of two groups before surgery are described in Table 1.


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TABLE 1. Baseline Characteristics of Patients in Antidepressant and Non-Antidepressant Group Pre-Surgery



The mean age of the group was 40 years, with a range of 18 to 64 years for both groups. Most of the patients in our study were married (86%–91%), non-Hispanic white (67.9%–79.7%), and women (85%–91%). The average pre-surgical weights were 126.04 (standard deviation [SD]: 21.59) kg and 133.67 (SD: 22.98) kg, for the antidepressant and non-antidepressant groups, respectively. The baseline BMIs were similar for both groups, as well (46.40; SD: 8.21 versus 48.64; SD: 7.56). There were no statistically significant differences between the two groups on any of these variables at baseline (i.e., before the surgery).

Weight and BMI
Body weight and BMI are depicted for the two groups over the three time-points in Table 2. Regardless of group membership, all patients lost weight over time. The weight loss at 1 year after GBS ranged from 13.18 kg to 83.64 kg, with an average of 47.95 (SD: 12.11) kg. The mean percent of excess weight loss was 36.70% (Table 2). Also, we calculated BMI loss (BMIL) from baseline to midpoint post-surgery (BMIL=13.20; SD: 3.28) and baseline to 1 year post-surgery (BMIL=17.52; SD: 4.51). There was a significant reduction in BMI when we compared the BMI loss from midpoint post-surgery to 1 year post-surgery: t[116] = –12.54; p<0.0001. Also, the percent of excess BMI loss (EBMIL) was significant when we compared EBMIL from midpoint post-surgery (69.50%) to 1 year post-surgery (81.87%: t[116] = –13.45; p<0.0001).


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TABLE 2. Mean Weight and Body Mass Index at Pre-Surgery, Midpoint (6 Months) Post-Surgery, and 1 Year Post-Surgery



The RANOVA found significant decreases in both weight (F[2, 114]=1,309.98; p<0.0001) and BMI (F[2, 114]=1,170.98; p<0.0001) across the three time-points. The pre-operative weight and BMI were statistically different from those at 1-year post-surgery, and there were statistically significant differences between midpoint and 1 year post-surgery for BMI (F[2, 114]=157.27; p<0.0001). A similar pattern was seen with percent excess BMI loss (t[114[ = –12.54; p<0.0001). However, there was no significant difference between weight loss, BMI, BMI decrease, and percent excess BMI loss between the groups (Table 3). The ANCOVA results showed similar findings when pre-operative scores were held constant for the analyses.


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TABLE 3. Weight and Body Mass Index (BMI) at Pre-Surgery, Midpoint (6 months) Post-Surgery, and 1 Year Post-Surgery for Antidepressant and Non-Antidepressant Groups



Health-Related Quality of Life
Transformed SF–36 scores of eight domains at baseline, midpoint, and 1-year follow-up are shown in Table 4 for the two groups.


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TABLE 4. Transformed SF–36 Scores of Eight Domains at Pre-Surgery, Midpoint (6 Months) Post-Surgery, and 1 Year Post-Surgery, for Antidepressant and Non-Antidepressant Groups



There were no statistical differences for change in the eight domains of SF–36 scores between the groups over time. However, regardless of group membership, patients demonstrated significant increases on all eight domains over time: General Health (F[2, 114]=23.65; p<0.0001); Physical Health (F[2, 114]=62.31; p<0.0001); Mental Health (F[2, 114]=12.99; p<0.0001); Role Emotional (F[2, 114]=124.91; p<0.0001); Role Physical (F[2, 114]=33.26; p<0.0001); Social Functioning (F[2, 114]=33.26; p<0.0001); Vitality (F[2, 114]=72.09; p<0.0001); and Bodily Pain (F[2, 114]=29.91; p<0.0001; Table 3). There were significant differences in most of the eight domains at midpoint and 1 year post-surgery as compared with baseline. The results of baseline compared with midpoint post-surgery were the following: General Health (t[114] = –13.199; p<0.0001); Physical Health (t[114] = –35.75; p<0.0001); Mental Health (t[114] = –6.23; p<0.0001); Role Emotional (t[114] = –4.72; p<0.0001); Role Physical (t[116] = –11.43; p<0.0001); Social Functioning (t[114]=1.07; p=0.287); Vitality (t[116]=10.47; p<0.0001); Bodily Pain (t[114]=8.40; p<0.0001). The results of the comparison of baseline with 1-year post-surgery measures were the following: General Health (t[114] = –10.99; p<0.0001); Physical Health (t[114] = –36.48; p<0.0001); Mental Health (t[114] = –5.34; p<0.0001); Role Emotional (t[114] = –4.69; p<0.0001); Role Physical (t[114] = –13.62; p<0.0001); Social Functioning (t[114]=1.82; p=0.282); Vitality (t[114]=11.47; p<0.0001); and Bodily Pain (t[114]=0.510; p=0.611). When the eight domain results were compared with United States norms,55 General Health and Role Physical appeared to be lower at all three time-periods. Nonetheless, Physical Health, Mental Health, Role Emotional, Social Functioning, Vitality, and Bodily Pain increased from baseline, to become comparable with the U.S. norms. The Cronbach {alpha} for the SF–36 was 0.81 at baseline, 0.90 at midpoint post-surgery, and 0.91 at 1 year post-surgery.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
The present research evaluated whether patients treated for depression would have similar outcomes to nondepressed patients after undergoing GBS. As recommended by others, we have provided our results in terms of weight, BMI, and percent excess weight lost, to allow for comparison with other observational studies.58 The current accepted guidelines for gastric bypass surgery suggest that it should be reserved only for those patients with a BMI >40 (or >35 for patients with two comorbid health conditions).59 On average, the patients observed in this study were well within the recommended range for surgical intervention (with an average BMI of 48 at baseline); and, on average, they experienced dramatic weight loss and corresponding change in BMI by the 1-year follow-up. All patients also showed significant improvements in HR–QOL, as measured by repeated administration of the SF–36.

To clarify the role of depression as a moderator of GBS outcomes, we compared a group of patients undergoing treatment with antidepressant medication that was ongoing at the time of the initial surgical consultation, and compared them with a group that had no identifiable psychiatric illness as determined by a diagnostic psychiatric consultation. The two groups did not differ in terms of any of the major identified factors that have been reported to affect GBS outcomes (including gender, age >65 years, race, marital status, baseline weight, or baseline BMI (Table 1).16,18,38,60–63 The patients in this study were all either military members or military dependents, which means that their insurance status/access to care was essentially identical. We assumed that this particular variable was not an issue, because of the nature of the population.64,65

Our results demonstrated that antidepressant use did not appear to have any differential impact on patient outcomes. This contrasts with previous reports that GBS patients with psychiatric disorders can be grouped separately from those without psychiatric disorders.66 All patients experienced significant weigh loss post-surgically, with significant post-surgical decrease in BMI (see Table 2).There was no observed impact of antidepressant use in terms of weight loss at 1 year (Table 3). This would seem to agree with previous findings that patients found to have presurgical psychological difficulties during screening show similar post-surgical improvements as patients without similar difficulties.67 Other researchers have previously reported a lack of association between lifetime Axis I and Axis II psychiatric diagnosis and GBS outcomes.68 It also has been suggested that bariatric surgery may precipitate a decline in psychopathology among surgical patients.69

HR–QOL impairment has been reported to have a more significant association with depression than BMI among patients seeking GBS.70 However, improvements in health-related quality of life (in both physical and mental domains) did not differ between those patients who were known to be on antidepressant medications at baseline and those who were not (Table 4). Our findings are in agreement with others who have reported a significant change in HR–QOL and significant weight loss among patients who have undergone GBS.70–72 The two groups in our study experienced similar weight loss. It may be that the amount of weight lost is the primary predictor in change of HR–QOL.73 On the other hand, our results contrast with findings of improved outcomes in GBS patients who had undergone mental-health treatment.74

The uncertainty regarding the interplay of psychosocial factors, psychiatric illness (treated or untreated), and GBS makes increasing our understanding of pre-surgical psychological assessment and psychosocial intervention for GBS patients a high priority. Studies attempting to assess the predictive validity of psychosocial factors are rare and, when available, tend to measure post-surgical outcome primarily by weight loss. Other researchers also have indicated that the available information is inadequate and have stated that future studies are needed to further clarify which psychological factors play a role.49,75 A recent review article confirmed that, to-date, there is no commonly used, standardized protocol for pre-surgical psychological screening and a lack of empirical data on those factors that predict successful surgical outcomes.42

Unfortunately, our ability to identify depressive illness was limited to those patients who were either already prescribed medications for depression or those who were identified as depressed and subsequently started on treatment in the initial diagnostic interview. Thus, we were unable to identify any depressive illness that developed after initial presentation. There were no data collected on active depressive symptoms at baseline or follow-up, but the SF–36 does contain subscales that serve as a rudimentary self-report measure of perceived mental health, and there were no statistically significant differences (at baseline or follow-up) between groups on any of the subscales. What we observed in this study was that there was no effect from depression treated with medications at baseline, rather than from active disorder. This study was retrospective; therefore, there was no way to accurately determine to what extent those patients who were identified as actively taking antidepressants continued to do so after the initial screening interview, because that information was not collected subsequently in any systematic way. An additional limitation of the study was that follow-up was limited to 1 year. Others have suggested that initial gains reported in short-term studies may diminish over longer follow-up intervals.19,76 However, there is no consensus, and a recent metaanalysis suggests that GBS benefits are lasting at 3 years.77

We agree with others that psychological factors may be intimately related to weight loss and quality-of-life outcomes in patients seeking, undergoing, and recovering from GBS. Our analysis of the available research supports the assertion that obesity remains a significant burden on the healthcare system and that the cost is growing. We have concluded that the research at this point is still unable to establish any specific psychiatric contraindications to performing GBS procedures. However, we believe that the present research provides additional evidence that the mere presence of clinically identified depressive illness should not be expected to negatively affect GBS outcomes in terms of weight loss or HR–QOL outcome, particularly when that depression is actively being treated. A possible explanation for our results would be that the group we identified, which was receiving treatment, was essentially asymptomatic at baseline because of the effectiveness of that treatment. This would explain the lack of significant differences between groups on the baseline HR–QOL measures. It is conceivable that a similar group of patients with untreated (or inadequately treated) depression would have fared much worse.

Our results indicate that, when compared with a group of patients without identified depressive illness; patients who have a history of treated depression at the time of presurgical screening should be expected to achieve an equivalent decrease in BMI and statistically similar improvement in both mental and physical aspects of HR–QOL. There is a clear need for prospective studies to more thoroughly evaluate psychological factors (both pre- and post-surgically), to identify individual psychological characteristics that might serve as predictors for successful outcomes in this high-interest population. We would emphasize the importance of accurate detection and adequate treatment of depression before the surgical procedure because of our observation that such treatment is associated with positive outcomes in this population.


  REFERENCES

 
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 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Ford E, Mokdad A, Giles W: Trends in waist-circumference among U.S. adults. Obes Res 2003; 11:1223–1231[Medline]
  2. Ford ES, Moriarty DG, Zack MM, et al: Self-reported body mass index and health-related quality of life: findings from the Behavioral Risk Factor Surveillance System. Obes Res 2001; 9:21–31[Medline]
  3. Popkin B, Doak C: The obesity epidemic is a worldwide phenomenon. Nutrition Rev 1998; 56:106–114[Medline]
  4. Mokdad AH, Ford ES, Bowman BA, et al: Prevalence of obesity, diabetes, and obesity-related health risk factors. JAMA 2003; 289:76–79[Abstract/Free Full Text]
  5. Flegal KM, Carroll MD, Ogden CL, et al: Prevalence and trends in obesity among U.S. adults, 1999-2000. JAMA 2002; 288:1723–1727[Abstract/Free Full Text]
  6. Ogden C, Flegal K, Carroll M, et al: Prevalence and trends in overweight among U.S. children and adolescents, 1999-2000 (see Comment). JAMA 2002; 288:1728–1732[Abstract/Free Full Text]
  7. Pi-Sunyer F: Comorbidities of overweight and obesity: current evidence and research issues. Med Sci Sport Exercise 1999; 31:S602-S608
  8. Hsu LK, Benotti PN, Dwyer J, et al: Nonsurgical factors that influence the outcome of bariatric surgery: a review. Psychosom Med 1998; 60:338–346[Abstract/Free Full Text]
  9. Kral JG: Morbid obesity and related health risks. Ann Intern Med 1985; 103:1043–1047[Medline]
  10. Pugh RN, Hossain MM, Malik M, et al: Arabian peninsula men tend to insulin-resistance and cardiovascular risk seen in South Asians. Trop Med Int Health 1998; 3:89–94[CrossRef][Medline]
  11. Ford ES: Body mass index and colon cancer in a national sample of adult U.S. men and women. Am J Epidemiol 1999; 150:390–398[Abstract/Free Full Text]
  12. Ford ES, Mokdad AH, Giles WH, et al: Geographic variation in the prevalence of obesity, diabetes, and obesity-related behaviors. Obes Res 2005; 13:118–122[Medline]
  13. Carpenter KM, Hasin DS, Allison DB, et al: Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study. Am J Public Health 2000; 90:251–257[Abstract/Free Full Text]
  14. Fine JT, Colditz GA, Coakley EH, et al: A prospective study of weight change and health-related quality of life in women. JAMA 1999; 282:2136–2142[Abstract/Free Full Text]
  15. Kolotkin RL, Crosby RD, Pendleton R, et al: Health-related quality of life in patients seeking gastric bypass surgery vs. non-treatment-seeking controls. Obes Surg 2003; 13:371–377[CrossRef][Medline]
  16. White MA, O’Neil PM, Kolotkin RL, et al: Gender, race, and obesity-related quality of life at extreme levels of obesity. Obes Res 2004; 12:949–955[Medline]
  17. Centers for Disease and Control: National Center for Chronic Disease Prevention and Health Promotion: Health-Related Quality of Life:2006, Atlanta, GA,2006
  18. Kolotkin RL, Crosby RD: Psychometric evaluation of the impact of weight on quality of life-lite questionnaire (IWQOL-lite) in a community sample. Qual Life Res 2002; 11:157–171[CrossRef][Medline]
  19. de Zwaan M, Lancaster KL, Mitchell JE, et al: Health-related quality of life in morbidly obese patients: effect of gastric bypass surgery. Obes Surg 2002; 12:773–780[CrossRef][Medline]
  20. Kral JG, Sjostrom LV, Sullivan MB: Assessment of quality of life before and after surgery for severe obesity. Am J Clin Nutr 1992; 55:611S-614S
  21. Fontaine KR, Bartlett SJ: Access and use of medical care among obese persons. Obes Res 2000; 8:403–406[Medline]
  22. De Zwaan M, Mitchell J, Howell L, et al: Two measures of health-related quality of life in morbid obesity. Obes Res 2002; 10:1143–1151[Medline]
  23. Fontaine KR, Bartlett SJ, Barofsky I: Health-related quality of life among obese persons seeking and not currently seeking treatment. Int J Eating Disord 2000; 27:101–105[CrossRef][Medline]
  24. Crosby RD, Kolotkin RL, Williams GR: Defining clinically meaningful change in health-related quality of life. J Clin Epidemiol 2003; 56:395–407[CrossRef][Medline]
  25. Fontaine KR, Barofsky I, Andersen RE, et al: Impact of weight loss on health-related quality of life. Qual Life Res 1999; 8:275–277[CrossRef][Medline]
  26. Fontaine KR, Barofsky I: Obesity and health-related quality of life. Obes Rev 2001; 2:173–182[Medline]
  27. Fontaine KR, Barofsky I, Bartlett SJ, et al: Weight loss and health-related quality of life: results at 1-year follow-up. Eating Behav 2004; 5:85–88
  28. Engel SG, Crosby RD, Kolotkin RL, et al: Impact of weight loss and regain on quality of life: mirror image or differential effect? Obes Res 2003; 11:1207–1213[Medline]
  29. Poves I, Cabrera M, Maristany C, et al: Gastrointestinal quality of life after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2006; 16:19–23[Medline]
  30. Puzziferri N, Austrheim-Smith IT, Wolfe BM, et al: Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg 2006; 243:181–188[CrossRef][Medline]
  31. Mathus-Vliegen EM, de Weerd S, de Wit LT: Health-related quality of life in patients with morbid obesity after gastric banding for surgically-induced weight loss. Surgery 2004; 135:489–497[CrossRef][Medline]
  32. Ahroni JH, Montgomery KF, Watkins BM: Laparoscopic adjustable gastric banding: weight loss, comorbidities, medication usage, and quality of life at one year. Obes Surg 2005; 15:641–647[CrossRef][Medline]
  33. Nickel C, Widermann C, Harms D, et al: Patients with extreme obesity: change in mental symptoms three years after gastric banding. Int J Psychiatry Med 2005; 35:109–122[Medline]
  34. Kral JG, Brolin RE, Buchwald H, et al: Research considerations in obesity surgery. Obes Res 2002; 10:63–64[Medline]
  35. Martin LF, Tan TL, Horn JR, et al: Comparison of the costs associated with medical and surgical treatment of obesity. Surgery 1995; 118:599–607[CrossRef][Medline]
  36. Allison D, Zannolli R, Narayan K: The direct healthcare costs of obesity in the United States. Am J Public Health 1999; 89:1194–1199[Abstract/Free Full Text]
  37. van Gemert WG, Adang EM, Kop M, et al: A prospective cost-effectiveness analysis of vertical banded gastroplasty for the treatment of morbid obesity. Obes Surg 1999; 9:484–491[Medline]
  38. Stunkard A, Stinnett J, Smoller J: Psychological and social aspects of the surgical treatment of obesity. Am J Psychiatry 1986; 143:417–429[Abstract/Free Full Text]
  39. Martin LF, White S, Lindstrom W Jr: Cost-benefit analysis for the treatment of severe obesity. World J Surg 1998; 22:1008–1017[CrossRef][Medline]
  40. Sugerman HJ: Gastric bypass surgery for severe obesity. Sem Laparoscopic Surgery 2002; 9:79–85
  41. Sarwer DB, Wadden TA, Fabricatore AN: Psychosocial and behavioral aspects of bariatric surgery. Obes Res 2005; 13:639–648[Medline]
  42. Greenberg I, Perna F, Kaplan M, et al: Behavioral and psychological factors in the assessment and treatment of obesity surgery patients. Obes Res 2005; 13:244–249[Medline]
  43. Weinryb RM, Gustavsson JP, Barber JP: Personality predictors of dimensions of psychosocial adjustment after surgery. Psychosom Med 1997; 59:626–631[Abstract/Free Full Text]
  44. Fitzgibbon ML, Stolley MR, Kirschenbaum DS: Obese people who seek treatment have different characteristics than those who do not seek treatment. Health Psychol 1993; 12:342–345[CrossRef][Medline]
  45. Wadden TA, Butryn ML, Sarwer DB, et al: Comparison of psychosocial status in treatment-seeking women with class III vs. class I-II obesity. Surg 2006; 2:138–145
  46. Dixon JB, Dixon ME, O’Brien PE: Depression in association with severe obesity: changes with weight loss. Arch Intern Med 2003; 163:2058–2065[Abstract/Free Full Text]
  47. Holzwarth R, Huber D, Majkrzak A, et al: Outcome of gastric bypass patients. Obes Surg 2002; 12:261–264[CrossRef][Medline]
  48. Oppong BA, Nickels MW, Sax HC: The impact of a history of sexual abuse on weight loss in gastric bypass patients. Psychosomatics 2006; 47:108–111[Abstract/Free Full Text]
  49. Glinski J, Wetzler S, Goodman E: The psychology of gastric bypass surgery. Obes Surg 2001; 11:581–588[CrossRef][Medline]
  50. Hanestad B: Errors of measurement affecting the reliability and validity of data acquired from self-assessed quality of life. Scand J Caring Sci 1990; 4:29–34[Medline]
  51. Bowling A: Measuring Health: A Review of Quality-of-Life Measurement Scales, 3rd Edition. New York, Open University Press, 2005
  52. Ferrans C, Powers M: Quality-of-life index: development and psychometric properties. Adv Nurs Sci 1985; 8:15–24[Medline]
  53. Farquhar M: Definition of quality of life: a taxonomy. J Adv Nurs 1995; 22:502–508[CrossRef][Medline]
  54. Ware J, Snow K, Kosinki M, et al: SF-36 Health Survey: Manual and Interpretation Guide. Boston, MA, The Health Institute of New England Medical Center, 1993
  55. Manocchia M, Bayliss MS, Connor J, et al: SF-36 Health Survey Annotated Bibliography, 2nd Edition (1988-1996). Boston, MA, Health Assessment Lab, New England Medical Center, 1997
  56. Ware JE Jr, Kosinski M, Bayliss MS, et al: A comparison of methods for the scoring and statistical analysis of the SF-36 Health Profile and summary measures: summary of results from the Medical Outcomes Study. Med Care 1995; 33:AS264-AS279
  57. McHorney CA, Ware JE Jr, Lu JF, et al: The MOS 36-Item Short-Form Health Survey (SF-36), III: tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care 1994; 32:40–66[Medline]
  58. Dixon JB, McPhail T, O’Brien PE: Minimal reporting requirements for weight loss: current methods not ideal (see Comment). Obes Surg 2005; 15:1034–1039[Medline]
  59. National Institutes of Health: National Institute of Health Clinical Guide on Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Bethesda, MD, 1998
  60. Kolotkin RL, Crosby RD, Williams GR: Health-related quality of life varies among obese subgroups. Obes Res 2002; 10:748–756[Medline]
  61. Flum D, Salem L, Elrod J, et al: Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures (see Comment). JAMA 2005; 294:1903–1908[Abstract/Free Full Text]
  62. Ray EC, Nickels MW, Sayeed S, et al: Predicting success after gastric bypass: the role of psychosocial and behavioral factors. Surgery 2003; 134:555–563; Discussion pp 63-64[CrossRef][Medline]
  63. Keller GM: Differences in self-esteem of severely obese men and women seeking gastric bypass Roux-en-y surgery. Fresno, CA, Alliant International U
  64. Latner JD, Wetzler S, Goodman ER, et al: Gastric bypass in a low-income, inner-city population: eating disturbances and weight loss. Obes Res 2004; 12:956–961[Medline]
  65. Martin LF, Tan TL, Holmes PA, et al: Preoperative insurance status influences postoperative complication rates for gastric bypass. Am J Surg 1991; 161:625–634[CrossRef][Medline]
  66. Guisado JA, Vaz FJ, Lopez-Ibor JJ Jr, et al: Eating behavior in morbidly obese patients undergoing gastric surgery: differences between obese people with and without psychiatric disorders. Obes Surg 2001; 11:576–580[Medline]
  67. Vallis TM, Butler GS, Perey B, et al: The role of psychological functioning in morbid obesity and its treatment with gastroplasty. Obes Surg 2001; 11:716–725[CrossRef][Medline]
  68. Black D, Goldstein R, Mason E: Psychiatric diagnosis and weight loss following gastric surgery for obesity. Obes Surg 2003; 13:746–751[Medline]
  69. Maddi SR, Fox SR, Khoshaba DM, et al: Reduction in psychopathology following bariatric surgery for morbid obesity. Obes Surg 2001; 11:680–685[CrossRef][Medline]
  70. Fabricatore AN, Wadden TA, Sarwer DB, et al: Health-related quality of life and symptoms of depression in extremely obese persons seeking bariatric surgery. Obes Surg 2005; 15:304–309[CrossRef][Medline]
  71. Dymek MP, le Grange D, Neven K, et al: Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: a brief report. Obes Surg 2001; 11:32–39[CrossRef][Medline]
  72. Dymek MP, Le Grange D, Neven K, et al: Quality of life after gastric bypass surgery: a cross-sectional study. Obes Res 2002; 10:1135–1142[Medline]
  73. Guisado JA, Vaz FJ, Alarcon J, et al: Psychopathological status and interpersonal functioning following weight loss in morbidly obese patients undergoing bariatric surgery. Obes Surg 2002; 12:835–840[CrossRef][Medline]
  74. Clark M, Balsiger B, Sletten C, et al: Psychosocial factors and two-year outcome following bariatric surgery for weight loss. Obes Surg 2003; 13:739–745[CrossRef][Medline]
  75. Wee CC, Jones DB, Davis RB, et al: Understanding patients’ value of weight loss and expectations for bariatric surgery. Obes Surg 2006; 16:496–500[Medline]
  76. van Hout GCM, Boekestein P, Fortuin FAM, et al: Psychosocial functioning following bariatric surgery. Obes Surg 2006; 16:787–794[Medline]
  77. O’Brien PE, McPhail T, Chaston TB, et al: Systematic review of medium-term weight loss after bariatric operations. Obes Surg 2006; 16:1032–1040[CrossRef][Medline]




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