INTRODUCTION
Obesity is a major global public health problem. Overweight is present in
two-thirds of the world’s population. It is a disease of chronic and
multifactorial origin that can trigger various conditions such as diabetes,
cardiovascular diseases, osteoarthritis, obstructive sleep apnea, hypertension,
and gastroesophageal reflux. The beginning of the treatment must be
conservative, through diet, psychotherapy, medication use, and physical
exercises, followed by a multidisciplinary team for at least two years1,2.
Patients with initial treatment failure who have a body mass index (BMI) above
35kg/m2 and associated comorbidities or patients with a
BMI>40kg/m2 are candidates for bariatric surgery (BS). The
effects of BS on health are well established, improving health conditions
related to comorbidities and positively impacting the quality of life3,4.
Weight loss after BS causes deformities that can bother the patient, including
excess skin, compromising their body image. The desire for body contouring
surgery (BCS) in post-bariatric patients is due to aesthetic complaints and
functional problems such as difficulty walking and dermatitis5.
Quality of life (QoL) is a broad concept that encompasses an individual’s
perception of their position in life in the context of the culture and value
system in which they live and about their standard goals, expectations, and
concerns. Instruments were created to directly measure the quality of life,
capable of recognizing states of physical, mental, and social
well-being6.
A surgical procedure that improves appearance or functionality can produce
changes that can affect several spheres related to QoL, such as physical
behavior, body image, psychological aspect, sexual life, and social health. Body
image is a multidimensional construct by which individuals understand their
personal representation of body structure and physical appearance concerning
themselves and others. We can evaluate it by sizing and comparing it with
objective measures of body image. Some patients are unable to recognize
themselves properly, presenting body dysmorphism7.
Studies show that post-bariatric patients who undergo BCS after weight stability
have improved long-term weight control8. Some studies have shown improvement in self-image but
not significant improvement in QoL, which can be attributed to a postoperative
period with more complications. However, few studies have evaluated the effect
of BCS on quality of life and body image in post-bariatric patients, mainly in
developing countries.
OBJECTIVE
This study aims to evaluate and compare the quality of life and body image
perception of morbidly obese patients before bariatric surgery (BS), after BS,
before body contouring surgery (BCS), and after BCS.
METHOD
The Ethics Committee approved the study for Research with Human Beings of
Universidade Franciscana with protocol number 2,591,856.
The patients were over 18 years old and signed the Informed Consent Form.
Patients who could not read, interpret and respond to the questionnaires and
had
inadequate correspondence between the groups were excluded.
Inclusion criteria for Group A consisted of morbidly obese patients immediately
before bariatric surgery (BS) at a private clinic; Group B consisted of patients
6 months after BS at the same clinic; Group C consisted of patients after BS
with weight stability who sought a private plastic surgery clinic for body
contouring surgery (BCS) from April 2018 to April 2019, and Group D was
constituted of post-BS and at least one year after BCS surgery from the same
clinic. Patients in Group D had one or more previous BCSs. These patients were
matched by BMI (± 2 kg/m2) and age (± 2 years) before undergoing the BS.
The self-administered SF-36 questionnaire was used to assess the quality of life
(QOL), translated, and validated in Brazil by Ciconelli et al.9. It consists of 36 items,
divided into 8 domains: functional capacity, physical aspects, pain, general
health, vitality, social aspects, emotional aspects, and mental health. It
evaluates both negative (diseases) and positive (well-being) aspects. The score
is calculated on a scale of 0 to 100 points, with higher values corresponding
to
a better perception of QoL. Scores are individually weighted and combined to
calculate physical health components (PHC), which include functional capacity,
physical functioning, pain limitation, and general health and mental health
components (MHC) which includes vitality, social aspects, emotional aspects,
and
mental health.
For body image assessment, the Brazilian Silhouette Scale Adapted for Adults,
proposed by Kakeshita et al.10, was used, in which the patient is asked to choose, among the
available silhouettes, the one that best represents him. The difference between
the current BMI (from the chosen figure) and the real BMI (measured) is
considered a discrepancy in body image because of its overestimation,
underestimation, or lack of distortion.
Data were analyzed for normality using the Shapiro-Wilk test. The ANOVA test of
repeated measures was performed for cases after normality, followed by the post
hoc Tukey HSD test. The Friedman test was used for non-parametric data, followed
by the post hoc Wilcoxon test with Bonferroni correction. IBM SPSS Version 25
software was used as a computational tool for statistical data analysis. For
the
statistical significance level, p<0.05 was used.
RESULTS
Sample characteristics
Twenty-one patients were included in each group (Table 1). A homogeneity test was performed, with no
difference between the paired groups. Patients seek body contouring surgery
(BCS) an average of 3.4 years after bariatric surgery (BS). Patients in the
group after BCS had an average of 2.6 years (± 16 months)
postoperatively.
Table 1 - Characteristics of groups A (n=21), B (n=21), C (n=21), and D
(n=21).
|
A |
B |
C |
D |
Age before
BS
(years - mean SD)
|
37.6 (11.4) |
37.6 (11.4) |
36.3 (9.7) |
37.1 (12.0) |
Current Age
(years - mean SD)
|
37.6
(11.4)
|
38.0
(11.4)
|
39.3
(11.3)
|
39.6
(11.6)
|
| BMI before BS
(Kg/m2 average SD)
|
42.7 (3.5) |
42.7 (3.5) |
42.7 (3.1) |
43.6 (4.5) |
current BMI
(Kg/m2
average SD)
|
42.7
(3.5)
|
29.2
(4.3)
|
26.9
(3.9)
|
25.2
(2.9)
|
Sex
Feminine
Masculine
|
20
1
|
20
1
|
20
1
|
20
1
|
Marital status (%)
Married/SU
Single/div.
|
70
30
|
70
30
|
33
67
|
38
62
|
BS time
(monthsaverage SD)
|
0 |
6 (1) |
41.1 (38.3) |
80.0 (52.7) |
Table 1 - Characteristics of groups A (n=21), B (n=21), C (n=21), and D
(n=21).
Quality of life
QoL was measured and presented as mean and standard deviation values (Table 2). The values of each of the 8
domains and the domains grouped into CS, M, and PHC are presented.
Table 2 - Description of the scores in the mean and standard deviation of
the SF-36 domains in groups A, B, C, and D.
|
A (n=21) |
B (n=21) |
C (n=21) |
D (n=21) |
| Functional capacity |
38.0 (18.2)** |
90.7 (12.5) |
91.1 (9.0) |
86.1 (13.2) |
| Limitations Physical Aspects |
29.7 (42.2)** |
96.4 (11.9) |
95.2 (16.9) |
91.6 (24.1) |
| Pain limitation |
39.4 (22.1)** |
80.4 (17.5) |
71.1 (24.6) |
70.3 (20.6) |
| General state of health |
37.0 (18.2)** |
77.8 (11.3) |
83.8 (12.3) |
79.0 (16.6) |
| Vitality |
38.3 (21.8)** |
83.3 (11.8) |
70.4 (19.9) |
64.0 (20.1) |
| Social aspects |
49.4 (32.9)** |
87.5 (23.0)** |
82.3 (24.8)* |
81.5 (21.1)* |
| Emotional Aspects |
25.3 (43.3)** |
88.8 (28.5) |
74.2 (17.5)* |
76.1 (35.1) |
| Mental health |
53.1 (24.9)** |
80.7 (16.2) |
84.1 (29.0) |
71.2 (16.1) |
| Physical Health Component |
36.1 (18.7)** |
86.3 (8.5) |
84.3 (14.0) |
81.8 (15.6) |
| Mental Health Component |
41.5 (25.0)** |
85.1 (17.2) |
77.9 (19.9) |
73.2 (19.1) |
| BS time (months) |
0 |
6 (1) |
41 (38.3) |
80.0 (52.7) |
| Not valid (of the list) |
21 |
21 |
21 |
21 |
Table 2 - Description of the scores in the mean and standard deviation of
the SF-36 domains in groups A, B, C, and D.
In the domains of physical health components (PHC), such as functional
capacity, physical aspects, pain limitation, and general health status, all
showed a significant difference between Group A and the others B, C, and D
(p<0.001). No significant differences were detected
between groups B, C, and D (Figure 1).
Figure 1 - Graph of the SF-36 Physical Health components.
**p<0.001.
Figure 1 - Graph of the SF-36 Physical Health components.
**p<0.001.
Regarding the domains of mental health components (MHC), we found significant
differences in the domains of vitality, and social aspects between Group A
and Groups B, C, and D. In the emotional aspects domain, Group
A was significantly different from B and D but not from Group C (Figure 2). In the mental health domain,
we found Group A significantly different from Groups B and C but without
significant differences from Group D.
Figure 2 - Graph of SF-36 Mental Health components.
*p<0.05;
**p<0.001.
Figure 2 - Graph of SF-36 Mental Health components.
*p<0.05;
**p<0.001.
The SF-36 domains were grouped into Physical Health Components (PHC) and
Mental Health Components (MHC), showing a significant difference between the
group before BS and the others (Figure 3).
Figure 3 - Graph of the physical and mental health components grouped
together. **p<0.001.
Figure 3 - Graph of the physical and mental health components grouped
together. **p<0.001.
Body image
Regarding body image, the mean BMI in Group A was 42.7kg/m2, Group
B 29.2kg/m2, Group C 26.98kg/m2, and Group D 25.27 kg/m2. The difference
between Group A and the others was significant (Table 3).
Table 3 - Descriptive table of the Real BMI, Silhouette, and Body Image
Distortion in groups A, B, C, and D. And the time of BS in
months.
|
A |
B |
C |
D |
|
Average (SD) |
Average (SD) |
Average (SD) |
Mean (SD) |
| Real BMI (kg/m2)
|
42.7 (3.4)** |
29.2 (4.3) |
26.9 (3.9) |
25.2 (2.9) |
| Silhouette BMI
(kg/m2)
|
44.2 (3.9)** |
28.7 (3.8) |
30.1 (6.9) |
30.4 (6.2) |
| Average distortion (kg/m2)
|
1.5 (5.1) |
-0.5 (4.3) |
3.2 (4.4)* |
5.2 (5.3)* |
| BS time (months) |
0 |
6 (1.0) |
41.12 (38.3) |
80.0 (52.7) |
Table 3 - Descriptive table of the Real BMI, Silhouette, and Body Image
Distortion in groups A, B, C, and D. And the time of BS in
months.
Regarding the BMI of the perceived silhouette, the average of Group A was
44.28 kg/m2, Group B 28.75 kg/m2, Group C 30.10
kg/m2, Group D30.47 kg/m2, being significant the
difference chosen between Group A and the others (Figure 4). Mean distortion is the difference between
actual BMI and perceived silhouette BMI.
Figure 4 - Graph of mean BMI (Kg/m2) and silhouettes of
groups A, B, C, and D. **p<0.001. BMI - body
mass index.
Figure 4 - Graph of mean BMI (Kg/m2) and silhouettes of
groups A, B, C, and D. **p<0.001. BMI - body
mass index.
An average distortion of 1.53 kg/m2 was identified in Group A, and
in Group B, it was -0.47 kg/m2, in Group C 3.11 kg/m2,
and in Group D 5.20 kg/m2, which means that patients
overestimated their real image in groups A, C, and D, with significant
differences between Group B with C and D. In Group A, only one patient was
considered without distortion, while in Group B 6 (28%), C 1 (4.8) and D 3
(14.4%). Group B had 10 (48%) underestimates, while groups A, C, and D
mostly overestimated 13 (62%), 15 (72%), and 16 (76%), respectively (Figure 5).
Figure 5 - Graph of mean body image distortion (Kg/m2) in
groups A, B, C, and D. **p<0.001.
Figure 5 - Graph of mean body image distortion (Kg/m2) in
groups A, B, C, and D. **p<0.001.
DISCUSSION
Bariatric surgery (BS) is already well established in the treatment of morbid
obesity, reducing mortality and being effective in the treatment of
comorbidities4,11. Patients report substantial
improvement in obesity-related complaints, but the duration of these changes
and
weight maintenance or recovery are unknown12.
In this study, the quality of life (QoL) and body image (BI) of morbidly obese
subjects undergoing BS and body contouring surgery (BCS) in a private clinic
were evaluated, and a significant improvement was found in the physical domains
of QOL after BS, with no significant differences over time. The same finding
was
described by Driscoll et al.13. However, there was a worsening in the QoL scores of domains
related to mental health, probably due to problems related to excess skin and
sagging. QoL is a construct that includes several domains related to physical
and psychological health, such as body image. Patients seeking BCS feel
uncomfortable with their body image, which worsens their QoL. Studies regarding
QoL after BCS are inconsistent14.
Song et al.5 found lower SF-36
quality of life rates in patients who sought BCS than in patients who never
sought BCS, suggesting that post-bariatric patients who did not desire BCS had
already achieved BS goals and that flaccidity did not cause any functional or
psychological harm.
Patients undergoing BCS continued to have lower QoL scores than the others, with
scores similar to those prior to BS. This fact can be explained by some
dissatisfaction or frustration after the procedure. Domains such as vitality
and
social aspects remained stable regardless of BCS. Emotional aspects improved
after BCS.
When evaluating the body image chosen by the patients, we noticed a tendency for
the groups to overestimate themselves, opting for larger silhouettes, except
for
the group of 6 months after BS, in which the choice of silhouette was smaller
than the actual one. Patients with better quality of life and mental health tend
to have a more positive self-image. These patients, at 6 months of BS, were
still losing weight and realizing the benefits of BS. The body image distortion
did not change after the BS, and the patients who sought the BCS showed an
overestimation of the image, which was even greater in the patients who
underwent the BCS. They returned to scores on similar mental health scales as
before the BS.
Notably, many patients want to perform others after a body contouring procedure,
changing only the focus of their complaints. Changes in body image perception
may be evidence of body dysmorphic disorder, which may be related to worsening
mental health components after BCS15-17.
In 2016, a qualitative study was carried out on the quality of life of
post-bariatric patients, finding that their expectations regarding BCS were very
high, leading to late frustration. Specific questionnaires for the bariatric
population present domains about appearance and expectations, which can capture
the main changes promoted by the BCS18.
The samples were matched by BMI and age before performing the BS. Only 30% of
patients who undergo BS subsequently seek BCS. Cost can be considered a barrier
since 80% report the desire to perform body contouring surgeries after
significant weight loss. The comparison made between patients before the BS,
regardless of whether they wanted to undergo body surgery or not, may be a bias
in the study since the patients who have some discomfort about the image are
precisely those who seek the BCS with a higher incidence of image disturbance
in
this population.
The 36-item Medical Outcome Short Form Health Study Questionnaire (SF-36) is a
generic self-administered questionnaire that is easy to interpret and has good
reproducibility. He captured changes in mental health patterns throughout morbid
obesity treatment. These studies’ findings align with the literature, which
identifies the unequivocal benefits of BS on QoL in the physical aspects, but
not so clear in the mental health aspects. When combined with the SF-36 and the
silhouette scale, it was possible to identify the association between mental
health and body perception distortion in these patients.
Preparation for BS should take into account the presence of body dysmorphic
disorders in this population since the body changes resulting from significant
weight loss can be a source of great anxiety and, in order to be successful in
BCS, the expectations of these patients must be adequate and prepared even
before the BS.
Paul et al.19 describe results
of physical and mental improvement in patients operated on in Poland, using the
National Health Fund, in which the preparation of patients with support groups
and longer hospitalizations had greater positive effects in patients with worse
scores before BS. The improvement was uniform in the perception of other areas,
and no patient was dissatisfied with the procedure result.
In Brazil, not all BCS procedures are covered by health plans, and, in some
cases, patients even gain weight to meet BMI criteria and undergo BS.
This study had limitations due to the small sample size, which did not detect
other differences. Comparisons were made with different patients who, despite
the pairing, had socioeconomic variables that could interfere with general
health and QoL, making multivariate analysis impossible. In addition, a generic
QoL questionnaire was used, which may not capture specific small changes in this
population. More studies are necessary to understand the relationship between
body image and quality of life in post-bariatric patients.
CONCLUSION
Post-bariatric patients seek body contouring surgeries because they have a worse
quality of life after weight stability and the appearance of sagging. With
bodily procedures, there is an improvement in emotional aspects, but a worsening
in mental health components associated with increased body distortion,
suggesting greater dysmorphism in these patients. Better preoperative
preparation and adaptation to expectations can improve the satisfaction of these
patients.
1. Universidade Franciscana, Programa de
Pós-graduação em Ciências da Saúde e da Vida, Santa Maria, RS,
Brazil
2. Universidade Federal de Santa Maria,
Departamento de Cirurgia, Santa Maria, RS, Brazil
3. Universidade Federal de Santa Maria,
Departamento de Estomatologia, Santa Maria, RS, Brazil
Corresponding author: Giancarlo Cervo Rechia Rua
Pinheiro Machado, 2494 Sala 402, Santa Maria, RS, Brazil., Zip Code: 97050-600,
E-mail: giancarlorechia@hotmail.com
