Qual Life Res (2015) 24:493–501
DOI 10.1007/s11136-014-0775-8
Predictors of changes in physical, psychosocial, sexual quality
of life, and comfort with food after obesity surgery: a 12-month
follow-up study
Paul Brunault • Julie Frammery • Charles Couet • Irène Delbachian •
Céline Bourbao-Tournois • Martine Objois • Patricia Cosson • Christian Réveillère
Nicolas Ballon
Accepted: 30 July 2014 / Published online: 12 August 2014
Ó Springer International Publishing Switzerland 2014
Abstract
Purpose Although obesity surgery provides significant
postoperative improvement in quality of life (QoL), it is
still unclear which factors might predict improvement in
QoL after surgery. We aimed to determine which factors
might predict changes in physical, psychosocial, sexual
QoL, and comfort with food 12 months after surgery, by
putting to the test a QoL model based on Wilson and
Cleary’s model.
Methods We included 126 obese patients (48.4 % had
gastric banding, 34.1 % had sleeve gastrectomy, and
17.5 % had gastric bypass). At baseline, we assessed QoL
(Quality of Life, Obesity and Dietetics rating scale), BMI,
depression (Beck Depression Inventory), and binge eating
P. Brunault (&)
J. Frammery
N. Ballon
Équipe de Liaison et de Soins en Addictologie, CHRU de Tours,
Tours, France
e-mail: paul.brunault@gmail.com
J. Frammery
e-mail: frammery.julie@orange.fr
N. Ballon
e-mail: nicolas.ballon@univ-tours.fr
P. Brunault
J. Frammery
N. Ballon
Clinique Psychiatrique Universitaire, CHRU de Tours, Tours,
France
P. Brunault
C. Réveillère
Département de Psychologie, EA 2114 « Psychologie des Âges
de la Vie », Université François Rabelais de Tours, Tours,
France
e-mail: christian.reveillere@univ-tours.fr
C. Couet
I. Delbachian
M. Objois
P. Cosson
Service de Médecine Interne-Nutrition, CHRU de Tours, Tours,
France
e-mail: c.couet@univ-tours.fr
•
(Bulimic Investigatory Test, Edinburgh). At 12 months, we
assessed QoL and BMI. To determine the predictors for
changes in each QoL dimension after surgery, we used
linear mixed models adjusted for preoperative age, BMI,
time, type of surgery, preoperative binge eating severity,
and preoperative depression severity.
Results After 12 months, we found significant improve-
ment in physical, psychosocial, sexual QoL, but not in comfort
with food. Increased weight loss was associated with better
improvement in physical and psychosocial QoL. Higher pre-
operative depression severity predicted poorer improvement
in physical, psychosocial, and sexual QoL. Higher preopera-
tive binge eating severity predicted poorer improvement in
psychosocial, sexual QoL, and comfort with food.
I. Delbachian
e-mail: i.delbachian.chamussy@chu-tours.fr
M. Objois
e-mail: m.objois@chu-tours.fr
P. Cosson
e-mail: p.cosson@chu-tours.fr
C. Couet
Inserm UMR 1069, Université François Rabelais de Tours,
Tours, France
C. Bourbao-Tournois
Service de Chirurgie Digestive et Endocrinienne, CHRU de
Tours, Tours, France
e-mail: c.bourbao@chu-tours.fr
N. Ballon
UMR Inserm U930 ERL, Université François Rabelais de Tours,
Tours, France
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494
Conclusions In addition to weight loss, preoperative levels
of binge eating and depression should be considered as
important predictors for QoL changes after bariatric surgery.
Screening and treatment for preoperative depression and
binge eating might improve QoL after bariatric surgery.
Keywords Obesity
Bariatric surgery
Quality of Life

Wilson and Cleary’s theoretical model
Depression

Binge eating
Introduction
Obesity is a major public health problem associated with
increased mortality [1], increased risk for medical and psy-
chiatric comorbidities [2–4], and decreased health-related
quality of life (QoL) [5, 6]. In patients with severe obesity,
bariatric surgery is currently considered to efficiently pro-
duce long-term weight loss, improve comorbidities and
improve QoL [7]. Among these three different outcome
measures following surgery [8–10], consensus has now been
reached on the importance of QoL as an independent out-
come measure of success [8, 11]. Although it is now widely
demonstrated that bariatric surgery provides, for many
patients, short- and long-term improvement in physical,
psychological, social and sexual QoL [9, 10, 12–18], there
might be variations in postoperative changes for each patient
and in each of these QoL dimensions [9, 10, 12]. Current
research now aims to determine which factors might be
predictive of improvement for each of these QoL dimen-
sions, given that such knowledge might help to determine
which factors should be targeted for potential interventions
that would finally aim to improve QoL after surgery.
Among the potential predictors for changes in QoL, the
magnitude of weight loss was initially hypothesized to be the
most important predictor [19]. However, some authors dem-
onstrated that changes in weight and QoL measures were not
linear [20], and some studies even found that the percentage of
excess weight loss had little predictive value of improved QoL
[9, 21, 22]. In obese patients who engage in a medical weight
loss program, improvements in QoL between baseline and
follow-up were greater than predicted by the reduction of BMI
at follow-up [23]. Some other factors were associated with
poorer improvement in QoL after surgery, such as being
female [11, 24], type of surgery [14, 25], or existence of
depressive symptoms [26], with this latter variable being able
to predict changes in QoL beyond weight loss [26]. Sleeve
gastrectomy showed better improvement than gastric banding
in terms of short-term but not medium-term comfort with food
[14], while gastric bypass and sleeve gastrectomy were
associated with better food tolerance than gastric banding
[25]. In bariatric surgery candidates or obese patients,
decreased QoL was associated with factors such as being
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Qual Life Res (2015) 24:493–501
female [27, 28], younger age [27, 29], lower self-esteem [30],
existence of psychiatric disorders such as binge-eating dis-
order [31–33], depression [26, 34, 35], and personality dis-
orders [36]. Although many studies independently assessed
the potential impact of each of these variables, no study has
assessed the relative impact of these variables in an integrative
model. In addition, previous QoL studies conducted in bari-
atric surgery patients sometimes had limitations, including the
assessment of QoL using overall QoL score or only on
physical and/or psychological QoL dimensions, rather than
subscores for each QoL dimension (e.g., physical, psycho-
logical, social, sexual QoL, and comfort with food). In addi-
tion, many previous studies assessed predictors for QoL using
only general health perceptions or generic QoL instruments
(e.g., using the Short-Form Health Survey-36 items = SF-36)
rather than obesity-specific questionnaires (e.g., using the
Impact of Weight on Quality Of Life = IWQOL).
To gain insight into the predictors of changes in health-
related QoL after bariatric surgery, we propose and put to
the test an integrative QoL model that relies on Wilson and
Cleary’s QoL model [37], which is one of the most com-
monly used and referenced models in the health-related
QoL literature [38]. In the present study, we will focus only
on three out of the five levels of health outcome measures
of Wilson and Cleary’s QoL model, namely biological and
physiological variables, symptom status, and functional
status (this latter outcome corresponds to obesity-specific
QoL). Figure 1 presents our working model of predictors
for QoL in bariatric surgery patients, together with defi-
nitions provided by Wilson & Cleary for each outcome.
We hypothesize here that change in each QoL dimension
(physical, psychological, social, sexual and comfort with
food) might be predicted by biological and physiological
variables (BMI, type of surgery), variables related to
symptom status (symptoms of depression and symptoms of
binge eating), as well as individual characteristics (gender)
and environment characteristics (marital status) (Fig. 1).
The aim of this study was to put this model to the test by
determining the predictors of postoperative change in each
QoL dimension (physical, psychosocial, sexual QoL, and
comfort with food) 12 months after bariatric surgery. We
studied the relative impact of age, gender, marital status,
change in BMI, type of surgery, preoperative depression,
and preoperative binge eating on postoperative changes for
each QoL dimension.
Materials and methods
Participants
This cohort study was conducted in the Nutrition Department
of the University Hospital of Tours, France. Out of the initial
Qual Life Res (2015) 24:493–501
Fig. 1 Working model for potential predictors for each QoL
dimension in obese patients undergoing bariatric surgery. Legend In
Wilson and Cleary’s original model, health outcomes are defined as
follows: ‘‘Biological and functional variables’’ focus on the function
of cells, organs, and organ systems (e.g., BMI, medical diagnoses
such as obesity, or results of biological tests). ‘‘Symptom status’’ can
be defined as a patient’s perception of an abnormal physical,
emotional, or cognitive state (e.g., pain, depressive symptoms, or
binge eating symptoms). ‘‘Functional status’’ corresponds to the
ability of the individual to perform particular defined tasks and
population (n = 160), 129 participated in the complete fol-
low-up and 126 completed all measures both at preoperative
and postoperative visits. Since we included only patients who
completed all measures both at preoperative and postoperative
visits, we enrolled 126 obese patients who had undergone
bariatric surgery (either gastric banding, sleeve gastrectomy,
or gastric bypass) between January 2002 and July 2012.
Measures
We assessed patients preoperatively and at 12 months
postoperatively. At the preoperative visit, we collected data
on demographics (age, gender, and marital status), previous
maximal body mass index (BMI), current BMI, history of
previous bariatric surgery, QoL dimensions (using the
Quality Of Life, Oesity, and Dietetics = QOLOD),
depression severity (using the Beck Depression Inven-
tory = BDI), and binge eating severity (using the Bulimic
Investigatory Test, Edinburgh = BITE). The question-
naires were mailed by members of the Nutrition ward
during the preoperative follow-up. At 12 months, we
recorded weight and QoL (QOLOD).
495
corresponds to QoL as assessed by generic or specific QoL
questionnaires (e.g., physical, psychological, social, sexual QoL,
and comfort with food). In addition to these levels of health outcome
measures, Wilson and Cleary also hypothesized that individual
characteristics (e.g., age, gender) and environment characteristics
(e.g., marital status, social support) might directly affect each of these
levels. In this study, we considered marital status as an environment
characteristic, but some other authors might alternatively consider it
as a socioeconomic characteristic (a characteristic that is both
environmental and individual)
The main outcome variable was QoL, assessed with the
Quality Of Life, Obesity and Dietetics (QOLOD) rating scale
[39]. The QOLOD is a French tool derived from the Impact of
Weight on Quality Of Life Questionnaire, which was the first
instrument specifically designed to assess QoL in obesity [40,
41]. The QOLOD is a 36-item scale, each item being rated on
a 5-point scale, which includes five subscales: physical
impact, psychosocial impact, impact on sex life, comfort with
food, and diet experience; higher scores representing better
QoL. Comfort with food refers to the feelings of pleasure and
satisfaction before and after eating as well as the pleasure to
look forward to eating (items examples: «I like to eat» ; «I
have a feeling of satisfaction after eating» ; «I am delighted
by the idea of eating»). In this study, we did not use the diet
experience subscale because of its low internal consistency
(Cronbach’s a was between 0.72 and 0.78 in the initial study).
Ziegler et al. [39] verified the construction validity and
internal reliability of the questionnaire for each of the four
corresponding dimensions, as well as its concurrent validity
with the 12-item Short-Form Health Survey (SF-12), and its
reproducibility was deemed to be satisfactory with an intra-
class correlation coefficient[0.8 [39].
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496 Qual Life Res (2015) 24:493–501

We assessed depression using the shortened Beck Table 1 Characteristics of our study population at preoperative and
Depression Inventory, which is a widely used 13-item self- 12-months visits
rating scale [42] that has demonstrated good construct Preoperative 12-months p value
validity across cultures [43] and in bariatric surgery pop- visit (n = 126) visit
ulations [44]. (n = 126)
We assessed binge eating severity using the symptom Age at baseline (years) 40.2 ± 10.0 –
score of the Bulimic Investigatory Test, Edinburgh [45], Gender (female) 100 (79.4 %) –
which is a 33-item self-report questionnaire that is a reli- Marital status
able screening tool for binge-eating disorder in obese Single 33 (26.2 %) –
patients [46] and that has already been used with bariatric Married or in a 93 (73.8 %) –
patients [47]. relationship
Type of surgery
Statistical analyses Gastric banding 61 (48.4 %) –
Sleeve gastrectomy 43 (34.1 %) –
Analyses were conducted using the R statistical package Gastric bypass 22 (17.5 %) –
version 2.15.2 [48] with the nlme package [49]. Statistical Previous maximal BMI 51.7 ± 8.6 –
analyses initially included descriptive statistics and Mann– (kg/m2)
Whitney U tests to compare changes in QoL between History of previous 14 (11.1 %) –
baseline and the 12-month visit. We used Pearson’s cor- bariatric surgery
relation tests to assess the association between each QoL Preoperative binge- 11.1 ± 4.8 –
dimension, depression, and binge eating. To determine eating severity (BITE)
which factors were associated with change in each QoL Preoperative 7.3 ± 5.3 –
depression severity
dimension (physical impact, psychosocial impact, impact (BDI)
on sex life, and comfort with food), we used linear mixed BMI (kg/m2) 49.5 ± 8.4 38.8 ± 8.3 \0.001
models adjusted according to preoperative age, type of Quality of life
surgery, preoperative depression severity, preoperative
Physical impact 30.5 ± 8.2 44.0 ± 7.2 \0.001
binge eating severity, and BMI (with the latter variable
Psychosocial impact 34.7 ± 8.8 43.5 ± 8.2 \0.001
being a time-dependent covariate). In our models, type of
Sexual impact 14.0 ± 4.8 16.6 ± 4.0 \0.001
surgery was considered as a dummy variable (gastric
Comfort with food 14.0 ± 4.2 15.0 ± 4.2 0.08
banding vs. gastric bypass; gastric banding vs. sleeve
gastrectomy). We also adjusted our analyses for gender and Descriptive data are means ± standard deviations or number (per-
centage). We compared BMI and QoL between preoperative and
marital status only for sexual QoL but not for the other
12-months visits using Mann–Whitney test
QoL dimensions, as these variables were both marginally
BITE bulimic investigatory test, Edinburgh; BDI beck depression
associated with change in sexual QoL (p [ 0.08), but not inventory
with changes in other QoL dimensions (p [ 0.20). Linear
mixed models have some advantages over classical
ANOVA’s models, including increased statistical power of four QoL dimensions, namely physical impact, psychoso-
compared with univariate models and the possibility to cial impact, and sexual impact. Only the comfort with food
include both categorical and continuous predictors. More- dimension showed a nonsignificant improvement (p = 0.08).
over, we do not need to make any assumptions about the
structure of the residual variances and covariances [50]. Associations between scores in QoL dimensions,
preoperative depression, and preoperative binge eating

Results Higher preoperative depression was significantly associ-

Descriptive data and changes in BMI and in each QoL
dimension after surgery (Table 1)
Table 1 presents the main characteristics of our population at
preoperative and 12-month visits. BMI significantly
decreased from baseline up to the 12-month visit, with a mean
percent excess weight loss at 12 months of 45.9 ± 23.4 %.
At the 12-month visit, we showed an improvement in three out
ated with poorer physical QoL (r = -0.37; p \ 0.01),
poorer psychosocial QoL (r = -0.72; p \ 0.01), poorer
sexual QoL (r = -0,60; p \ 0.01), but not with comfort
with food (r = -0.08; p = 0.35). Higher preoperative
binge eating was significantly associated with poorer psy-
chosocial QoL (r = -0.57; p \ 0.01), poorer sexual QoL
(r = -0.47; p \ 0.01), poorer comfort with food (r = -
0.29; p \ 0,01), but not with physical QoL (r = -0.10;
p = 0.26).

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Qual Life Res (2015) 24:493–501 497

Predictors of changes in each quality of life dimension
(Tables 2 and 3)
Tables 2 and 3 show the fixed effects of the independent
variables on QoL dimensions, namely physical impact,
psychosocial impact (Table 2), sexual impact and comfort
with food (Table 3).
Better improvement in physical QoL occurred in
patients who had higher weight loss, lower preoperative
depression severity, and were younger patients, but it was
not associated with surgery type or preoperative
binge eating severity (p = 0.08).
Improvement in psychosocial QoL was associated with,
by order of importance, lower preoperative depression
severity, lower preoperative binge eating severity and higher
weight loss, but not with type of surgery or preoperative age.
Enhanced improvement in sexual QoL occurred in patients
who had lower preoperative depression severity, lower

Table 2 Fixed effects of the independent variables on physical and psychosocial quality of life
Effect Physical impact Psychosocial impact
Estimation p value Estimation p value

Intercept 59.82 ± 3.48 \0.001 51.01 ± 3.42 \0.001

BMI -0.35 ± 0.06 \0.001 -0.13 ± 0.05 0.02
Time (T12 vs. T0) 9.72 ± 0.90 \0.001 7.44 ± 0.96 \0.001
Type of surgery
Gastric banding – – – –
Sleeve 0.66 ± 1.03 0.52 1.06 ± 1.00 0.29
Gastric bypass -0.82 ± 1.40 0.56 1.16 ± 1.32 0.38
Preoperative age -0.25 ± 0.05 \0.001 -0.03 ± 0.04 0.55
Preoperative depression severity (BDI) -0.54 ± 0.10 \0.001 -0.88 ± 0.10 \0.001
Preoperative binge eating severity (BITE) 0.20 ± 0.12 0.08 -0.27 ± 0.11 0.02
Results are based on linear mixed models adjusted for preoperative age, type of surgery (gastric banding, sleeve gastrectomy, gastric bypass),
preoperative depression severity, preoperative binge eating severity, and BMI at each visit. Data are parameter estimation ± standard errors. T0
and T12 are assessments at the preoperative and at 12-month postoperative visits, respectively
As an example, line ‘‘BMI’’ shows a significant estimated effect of -0.35 for physical impact, meaning that each increase in one BMI point is
associated with a significant mean decrease of -0.35 in physical quality of life score. Since there was a mean BMI loss of 10.7 kg/m2 between
baseline and the 12-month visit, there was a significant increase of 3.74 (= 10.7*0.35) in physical quality of life score between baseline and the
12-month visit

Table 3 Fixed effects of the independent variables on sexual quality of life and comfort with food
Effect Sexual impact* Comfort with food
Estimation p value Estimation p value

Intercept 22.02 ± 2.25 \0.001 18.67 ± 2.40 \0.001

BMI -0.04 ± 0.03 0.25 -0.04 ± 0.04 0.32
Time (T12 vs. T0) 2.26 ± 0.52 \0.001 0.61 ± 0.54 0.26
Type of surgery
Gastric banding – – – –
Sleeve 0.68 ± 0.65 0.29 0.77 ± 0.74 0.30
Gastric bypass 0.03 ± 0.86 0.97 0.23 ± 0.98 0.81
Preoperative age -0.10 ± 0.03 \0.001 -0.02 ± 0.03 0.49
Preoperative depression severity (BDI) -0.28 ± 0.06 \0.001 0.05 ± 0.07 0.50
Preoperative binge eating severity (BITE) -0.17 ± 0.07 0.02 -0.23 ± 0.08 \0.01
Results are based on linear mixed models adjusted for preoperative age, type of surgery (gastric banding, sleeve gastrectomy, gastric bypass),
preoperative depression severity, preoperative binge eating severity and BMI at each visit. Data are parameter estimation ± standard errors. T0
and T12 are assessments at the preoperative and at 12-month postoperative visits, respectively
As an example, line ‘‘Preoperative depression severity’’ shows a significant estimated effect of -0.28 for sexual impact, meaning that each
increase in one BDI point is associated with a significant mean decrease of -0.28 in sexual quality of life score
*Indicates that results regarding sexual quality of life were also adjusted for gender (p = 0.08) and marital status (p = 0.08)

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498
preoperative binge eating severity and in those who were
younger. Type of surgery and the magnitude of weight loss
were not associated with enhanced improvement in sexual
QoL, while being male (p = 0.12) or being married or in a
relationship at baseline (p = 0.08) were nonsignificant
predictors.
The only factor associated with improved comfort with
food was lower preoperative binge eating severity, while
change in BMI, type of surgery, preoperative age, and pre-
operative depression severity were not predictive for change
in this QoL dimension.
Discussion
In this study, we proposed and put to the test a working
model that aimed to identify preoperative predictors for
changes in QoL after bariatric surgery. In addition to the
previously demonstrated improvements in physical, psy-
chological, social and sexual QoL after bariatric surgery [9,
10, 12–16, 51], we demonstrated that preoperative levels of
depression and/or binge eating should be considered, in
addition to weight loss, as major predictors for poorer QoL
improvement because they were predictive of changes in
all QoL dimensions. We further demonstrated that higher
weight loss predicted enhanced improvement in physical
and psychosocial QoL, but was not associated with change
in sexual QoL and comfort with food.
Our main finding is that QoL improvement after surgery
involves different predictors; in addition to weight loss, the
preoperative level of depression is one of the most
important predictors because it was associated with poorer
improvement in three out of the four QoL dimensions
studied here. These results are consistent with the current
literature in health care demonstrating that depression is
one of the most important predictors for a wide range of
QoL dimensions [52–54]. To explain this association, we
might assume that depression has a direct effect on QoL
(through existence of a systematic cognitive bias in infor-
mation processing that leads to poorer overall assessment
of self-reported health outcomes) or an indirect effect
(through increased difficulty in acquiring new coping skills
that could improve QoL).
We also demonstrated that the severity of preoperative
binge eating is an important and independent predictor of
QoL that needs to be addressed specifically. Though pre-
operative binge eating has been inconsistently associated
with weight loss [55], many studies support the detrimental
effects of binge eating on QoL in obese patients [32, 33],
suggesting that binge eating should be considered as an
independent psychopathologic risk factor. Interestingly,
binge eating was the only variable associated with comfort
with food, suggesting that patients with a low comfort with
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Qual Life Res (2015) 24:493–501
food score after surgery might be those for whom binge
eating should be systematically screened and treated as
appropriate.
Our results bring support to the usefulness of assessing
different QoL dimensions and confirm that QoL is a mul-
tidimensional construct that cannot be assessed by a single
measure or a total score, because change in each QoL
dimension implies a specific combination of predictors. As
stated by Fitzpatrick, ‘‘unfortunately, many trials purport-
ing to assess impact of treatment on QoL do not assess the
construct properly or assess a single or limited aspect of
what is a multidimensional construct’’ [56]. Questionnaires
that rely on a single score might assess either overall QoL
or physical or psychological QoL, but they cannot pretend
to assess all QoL dimensions altogether.
Finally, we confirmed that bariatric surgery was asso-
ciated with improved physical, psychosocial and sexual
QoL [9, 10, 12–16, 51], while we found that there was no
improvement in terms of comfort with food. Future studies
should test the hypothesis that patients who develop post-
operative binge eating might have lower comfort with food
or lower food tolerance. This hypothesis is in-line with the
findings that eating behavior does not necessary improve
after surgery [57, 58].
Regarding practical implications, our results support the
idea that bariatric surgery candidates should be systemati-
cally screened and treated for depression and binge eating
[47, 59, 60], because these patients are at higher risk for
poorer postoperative QoL improvement. This finding does
not mean that existence of depressive or binge eating
symptoms before surgery should be considered as a con-
traindication to surgery, but rather that they should be
treated before surgery in order to decrease depression and
binge eating severity and to improve QoL. Patients with
subsyndromal depression or binge eating might thus benefit
from an additional psychological or psychiatric follow-up
initiated before surgery. Such an assessment requires close
collaboration between surgeons, specialists in nutrition
medicine, psychiatrists, psychologists, nurses and dieti-
cians, for example, by regularly participating in staff
meetings. Future studies should assess whether effective
pharmacological or psychotherapeutic strategies targeting
depression and binge-eating symptoms before surgery
might lead to higher QoL improvement after surgery.
Our work had some limitations. First, our working
model should be considered as preliminary because other
variables such as social support or personality character-
istics might also affect changes in QoL. Other potential
limitations of our study include our small sample and short
duration of follow-up. Since changes in weight and in QoL
are usually observed up to 2 years after surgery [8, 9, 12],
studies with longer duration are needed. Such studies
should have high rates of follow-up to decrease the risk of
Qual Life Res (2015) 24:493–501
selection bias. Future studies, conducted in larger samples
and with a longer follow-up duration, might also be able to
take into account more predictors to adjust results for other
potential confounding factors. With increased statistical
power, such studies could also assess more specifically the
potential impact that type of surgery might have on post-
operative changes in QoL. Future studies should also take
into account the fact that sexual QoL is always a difficult
variable to assess—some sexual QoL scales have low
reliability—and it also difficult to comment on sexual QoL
scores. In our study, we observed a disbalance between
men and women, which is in-line with the previous liter-
ature in bariatric patients [61]. Finally, the association
between depression and QoL might also be due to an
overlap between depressive symptoms and quality of life
scores. Future studies should test our working model using
other obesity-specific QoL questionnaires.
In conclusion, our results show that changes in physical,
psychosocial, sexual QoL, and comfort with food after
bariatric surgery involve different predictors. While
improvement in physical and psychosocial QoL is associ-
ated with both the extent of weight loss and the level of
preoperative depression, changes in sexual QoL, and
comfort with food are predicted more by the severity of
preoperative binge eating and/or depression than by the
extent of weight loss.
Acknowledgments We thank Jean-Pierre Chevrollier for his help in
assessing the patients. We thank Loı̈c Benjamin and Susan Benjamin
for revising the manuscript in English.
Conflict of interest PB received financial support from Astra
Zeneca (2014), and Lundbeck (2012 and 2014). NB received finan-
cial support from AstraZeneca (2010), DNA Pharma (2014) and
Lundbeck (2013). JF, CC, ID, CBT, MJ, PC and CR: no conflict of
interest.
Ethical standard Although our study did not require institutional
review board approval because it was not considered to be biomedical
research under French law, this study was performed in accordance
with the ethical standards laid down in the 1964 Declaration of
Helsinki and its later amendments. We also obtained informed con-
sent from each patient to participate in this follow-up study.
References
1. Peeters, A., Barendregt, J. J., Willekens, F., Mackenbach, J. P., Al
Mamun, A., Bonneux, L., & NEDCOM, the Netherlands Epide-
miology and Demography Compression of Morbidity Research
Group. (2003). Obesity in adulthood and its consequences for life
expectancy: A life-table analysis. Annals of Internal Medicine,
138(1), 24–32.
2. Guh, D. P., Zhang, W., Bansback, N., Amarsi, Z., Birmingham,
C. L., & Anis, A. H. (2009). The incidence of co-morbidities
related to obesity and overweight: a systematic review and meta-
analysis. BMC Public Health, 9, 88. doi:10.1186/1471-2458-9-
88.
499
3. Luppino, F. S., de Wit, L. M., Bouvy, P. F., Stijnen, T., Cuijpers,
P., Penninx, B. W. J. H., et al. (2010). Overweight, obesity, and
depression: A systematic review and meta-analysis of longitudi-
nal studies. Archives of General Psychiatry, 67(3), 220–229.
4. Petry, N., Barry, D., Pietrzak, R., & Wagner, J. (2008). Over-
weight and obesity are associated with psychiatric disorders:
Results from the national epidemiologic survey on alcohol and
related conditions. Psychosomatic Medicine, 70(3), 288–297.
5. Fontaine, K. R., & Barofsky, I. (2001). Obesity and health-related
quality of life. Obesity Reviews, 2(3), 173–182.
6. Ul-Haq, Z., Mackay, D. F., Fenwick, E., & Pell, J. P. (2013).
Meta-analysis of the association between body mass index and
health-related quality of life among adults, assessed by the SF-36.
Obesity, 21(3), E322–E327.
7. Sjöström, L., Lindroos, A. K., Peltonen, M., Torgerson, J.,
Bouchard, C., Carlsson, B., et al. (2004). Lifestyle, diabetes, and
cardiovascular risk factors 10 years after bariatric surgery. New
England Journal of Medicine, 351(26), 2683–2693.
8. Ballantyne, G. (2003). Measuring outcomes following bariatric
surgery: Weight loss parameters, improvement in co-morbid
conditions, change in quality of life and patient satisfaction.
Obesity Surgery, 13(6), 954–964.
9. Herpertz, S., Kielmann, R., Wolf, A. M., Hebebrand, J., & Senf,
W. (2004). Do psychosocial variables predict weight loss or
mental health after obesity surgery? A systematic review. Obesity
Research, 12(10), 1554–1569.
10. Van Hout, G. C., Boekestein, P., Fortuin, F. A., Pelle, A. J., &
van Heck, G. L. (2006). Psychosocial functioning following ba-
riatric surgery. Obesity Surgery, 16(6), 787–794.
11. Torquati, A., Lutfi, R. E., & Richards, W. O. (2007). Predictors of
early quality-of-life improvement after laparoscopic gastric
bypass surgery. American Journal of Surgery, 193(4), 471–475.
12. Karlsson, J., Taft, C., Ryden, A., Sjostrom, L., & Sullivan, M.
(2007). Ten-year trends in health-related quality of life after
surgical and conventional treatment for severe obesity: The SOS
intervention study. International Journal of Obesity, 31(8),
1248–1261. Epub 2007 Mar 13. doi:10.1038/sj.ijo.0803573.
13. Sabbagh, C., Verhaeghe, P., Dhahri, A., Brehant, O., Fuks, D.,
Badaoui, R., et al. (2010). Two-year results on morbidity, weight
loss and quality of life of sleeve gastrectomy as first procedure,
sleeve gastrectomy after failure of gastric banding and gastric
banding. Obesity Surgery, 20(6), 679–684.
14. Brunault, P., Jacobi, D., Léger, J., Bourbao-Tournois, C., Huten,
N., Camus, V., et al. (2011). Observations regarding ‘quality of
life’ and ‘comfort with food’ after bariatric surgery: Comparison
between laparoscopic adjustable gastric banding and sleeve gas-
trectomy. Obesity Surgery, 21(8), 1225–1231.
15. O’Brien, P. E., Dixon, J. B., Brown, W., Schachter, L. M.,
Chapman, L., Burn, A. J., et al. (2002). The laparoscopic
adjustable gastric band (Lap-Band): A prospective study of
medium-term effects on weight, health and quality of life.
Obesity Surgery, 12(5), 652–660.
16. Robert, M., Denis, A., Badol-Van Straaten, P., Jaisson-Hot, I., &
Gouillat, C. (2013). Prospective longitudinal assessment of
change in health-related quality of life after adjustable gastric
banding. Obesity Surgery, 23(10), 1564–1570.
17. Faulconbridge, L. F., Wadden, T. A., Thomas, J. G., Jones-Cor-
neille, L. R., Sarwer, D. B., & Fabricatore, A. N. (2013). Changes
in depression and quality of life in obese individuals with binge
eating disorder: Bariatric surgery versus lifestyle modification.
Surgery for Obesity and Related Diseases, 9(5), 790–796.
18. Sarwer, D. B., Spitzer, J. C., Wadden, T. A., Mitchell, J. E.,
Lancaster, K., Courcoulas, A., et al. (2014). Changes in sexual
functioning and sex hormone levels in women following bariatric
surgery. JAMA Surgery, 149(1), 26–33.
123
500
19. Karlsson, J., Sjöström, L., & Sullivan, M. (1998). Swedish obese
subjects (SOS)–an intervention study of obesity. Two-year fol-
low-up of health-related quality of life (HRQL) and eating
behavior after gastric surgery for severe obesity. International
Journal of Obesity and Related Metabolic Disorders, 22(2),
113–126.
20. Mar, J., Karlsson, J., Arrospide, A., Mar, B., Martı́nez de Aragón,
G., & Martinez-Blazquez, C. (2013). Two-year changes in gen-
eric and obesity-specific quality of life after gastric bypass.
Eating and Weight Disorders, 18(3), 305–310.
21. Dixon, J. B., Dixon, M. E., & O’Brien, P. E. (2001). Quality of
life after lap-band placement: Influence of time, weight loss, and
comorbidities. Obesity Research, 9(11), 713–721.
22. Fezzi, M., Kolotkin, R. L., Nedelcu, M., Jaussent, A., Schaub, R.,
Chauvet, M. A., et al. (2011). Improvement in quality of life after
laparoscopic sleeve gastrectomy. Obesity Surgery, 21(8),
1161–1167.
23. Rothberg, A. E., McEwen, L. N., Kraftson, A. T., Neshewat, G.
M., Fowler, C. E., Burant, C. F., et al. (2014). The impact of
weight loss on health-related quality-of-life: Implications for
cost-effectiveness analyses. Quality of Life Research, 23(4),
1371–1376.
24. de Zwaan, M., Lancaster, K. L., Mitchell, J. E., Howell, L. M.,
Monson, N., Roerig, J. L., et al. (2002). Health-related quality of
life in morbidly obese patients: Effect of gastric bypass surgery.
Obesity Surgery, 12(6), 773–780.
25. Overs, S. E., Freeman, R. A., Zarshenas, N., Walton, K. L., &
Jorgensen, J. O. (2012). Food tolerance and gastrointestinal
quality of life following three bariatric procedures: Adjustable
gastric banding, Roux-en-Y gastric bypass, and sleeve gastrec-
tomy. Obesity Surgery, 22(4), 536–543.
26. Masheb, R. M., White, M. A., Toth, C. M., Burke-Martindale, C.
H., Rothschild, B., & Grilo, C. M. (2007). The prognostic sig-
nificance of depressive symptoms for predicting quality of life
12 months after gastric bypass. Comprehensive Psychiatry, 48(3),
231–236.
27. De Zwaan, M., Petersen, I., Kaerber, M., Burgmer, R., Nolting,
B., Legenbauer, T., et al. (2009). Obesity and quality of life: A
controlled study of normal-weight and obese individuals. Psy-
chosomatics, 50(5), 474–482.
28. Korhonen, P. E., Seppälä, T., Järvenpää, S., & Kautiainen, H.
(2014). Body mass index and health-related quality of life in
apparently healthy individuals. Quality of Life Research, 23(1),
67–74.
29. Wang, J., Sereika, S. M., Styn, M. A., & Burke, L. E. (2013).
Factors associated with health-related quality of life among
overweight or obese adults. Journal of Clinical Nursing,
22(15–16), 2172–2182.
30. Lerdal, A., Andenæs, R., Bjørnsborg, E., Bonsaksen, T., Borge,
L., Christiansen, B., et al. (2011). Personal factors associated with
health-related quality of life in persons with morbid obesity on
treatment waiting lists in Norway. Quality of Life Research,
20(8), 1187–1196.
31. Masheb, R. M., & Grilo, C. M. (2004). Quality of life in patients
with binge eating disorder. Eating and Weight Disorders, 9(3),
194–199.
32. Perez, M., & Warren, C. S. (2012). The relationship between
quality of life, binge-eating disorder, and obesity status in an
ethnically diverse sample. Obesity (Silver Spring), 20(4),
879–885.
33. Sandberg, R. M., Dahl, J. K., Vedul-Kjelsas, E., Engum, B.,
Kulseng, B., Marvik, R., & Eriksen, L. (2013). Health-related
quality of life in obese presurgery patients with and without binge
eating disorder, and subdiagnostic binge eating disorders. Journal
of Obesity, Article ID 878310. doi:10.1155/2013/878310. Epub
2013 Mar 13.
123
Qual Life Res (2015) 24:493–501
34. Andersen, J. R., Aasprang, A., Bergsholm, P., Sletteskog, N.,
Våge, V., & Natvig, G. K. (2009). Predictors for health-related
quality of life in patients accepted for bariatric surgery. Surgery
for Obesity and Related Diseases, 5(3), 329–333.
35. Fabricatore, A. N., Wadden, T. A., Sarwer, D. B., & Faith, M. S.
(2005). Health-related quality of life and symptoms of depression
in extremely obese persons seeking bariatric surgery. Obesity
Surgery, 15(3), 304–309.
36. Kalarchian, M. A., Marcus, M. D., Levine, M. D., Courcoulas, A.
P., Pilkonis, P. A., Ringham, R. M., et al. (2007). Psychiatric
disorders among bariatric surgery candidates: Relationship to
obesity and functional health status. American Journal of Psy-
chiatry, 164(2), 328–334.
37. Wilson, I. B., & Cleary, P. D. (1995). Linking clinical variables
with health-related quality of life: A conceptual model of patient
outcomes. JAMA, 273(1), 59–65.
38. Bakas, T., McLennon, S. M., Carpenter, J. S., Buelow, J. M.,
Otte, J. L., Hanna, K. M., et al. (2012). Systematic review of
health-related quality of life models. Health and Quality of Life
Outcomes, 10, 134.
39. Ziegler, O., Filipecki, J., Girod, I., & Guillemin, F. (2005).
Development and validation of a French obesity-specific quality
of life questionnaire: Quality of Life, Obesity and Dietetics
(QOLOD) rating scale. Diabetes & Metabolism, 31(3 Pt 1),
273–283.
40. Kolotkin, R. L., Head, S., Hamilton, M., & Tse, C. K. (1995).
Assessing impact of weight on quality of life. Obesity Research,
3(1), 49–56.
41. Kolotkin, R. L., Head, S., & Brookhart, A. (1997). Construct
validity of the impact of weight on quality of life questionnaire.
Obesity Research, 5(5), 434–441.
42. Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric
properties of the beck depression inventory: Twenty-five years of
evaluation. Clinical Psychology Review, 8(1), 77–100.
43. Nuevo, R., Dunn, G., Dowrick, C., Vázquez-Barquero, J. L.,
Casey, P., Dalgard, O. S., et al. (2009). Cross-cultural equiva-
lence of the beck depression inventory: A five-country analysis
from the ODIN study. Journal of Affective Disorders, 114(1–3),
156–162.
44. Krukowski, R. A., Friedman, K. E., & Applegate, K. L. (2010).
The utility of the beck depression inventory in a bariatric surgery
population. Obesity Surgery, 20(4), 426–431.
45. Henderson, M., & Freeman, C. P. (1987). A self-rating scale for
bulimia: The’BITE’. British Journal of Psychiatry, 150(1),
18–24.
46. Ricca, V., Mannucci, E., Moretti, S., Di Bernardo, M., Zucchi, T.,
Cabras, P. L., et al. (2000). Screening for binge eating disorder in
obese outpatients. Comprehensive Psychiatry, 41(2), 111–115.
47. Brunault, P., Jacobi, D., Miknius, V., Bourbao-Tournois, C.,
Huten, N., Gaillard, P., et al. (2012). High preoperative depres-
sion, phobic anxiety, and binge eating scores and low medium-
term weight loss in sleeve gastrectomy obese patients: A pre-
liminary cohort study. Psychosomatics, 53(4), 363–370.
48. R Development Core Team. (2012). R: A language and environ-
ment for statistical computing. R Foundation for Statistical Com-
puting, Vienna, Austria. Consulted at: http://www.R-project.org.
49. Pinheiro, J., Bates, D., DebRoy, S., Sarkar, D., & R Core Team.
(2010). nlme: Linear and nonlinear mixed effects models. R
package version 3.1-97. http://cran.r-project.org/web/packages/
nlme/. Accessed 10 Aug 2014.
50. Hoffman, L., & Rovine, M. J. (2007). Multilevel models for the
experimental psychologist: Foundations and illustrative exam-
ples. Behavior Research Methods, 39(1), 101–117.
51. Sarwer, D. B., Lavery, M., & Spitzer, J. C. (2012). A review of
the relationships between extreme obesity, quality of life, and
sexual function. Obesity Surgery, 22(4), 668–676.
Qual Life Res (2015) 24:493–501
52. Reich, M., Lesur, A., & Perdrizet-Chevallier, C. (2008).
Depression, quality of life and breast cancer: A review of the
literature. Breast Cancer Research and Treatment, 110(1), 9–17.
53. Taylor, R. S., Sander, J. W., Taylor, R. J., & Baker, G. A. (2011).
Predictors of health-related quality of life and costs in adults with
epilepsy: A systematic review. Epilepsia, 52(12), 2168–2180.
54. Ruo, B., Rumsfeld, J. S., Hlatky, M. A., Liu, H., Browner, W. S.,
& Whooley, M. A. (2003). Depressive symptoms and health-
related quality of life: The heart and soul study. JAMA, 290(2),
215–221.
55. Livhits, M., Mercado, C., Yermilov, I., Parikh, J. A., Dutson, E.,
Mehran, A., et al. (2011). Preoperative predictors of weight loss
following bariatric surgery: Systematic review. Obesity Surgery,
22(1), 70–89.
56. Fitzpatrick, R., Fletcher, A., Gore, S., Jones, D., Spiegelhalter, D.,
& Cox, D. (1992). Quality of life measures in health care. I:
Applications and issues in assessment. British Medical Journal,
305(6861), 1074–1077.
501
57. Colles, S. L., Dixon, J. B., & O’Brien, P. E. (2008). Grazing and
loss of control related to eating: Two high-risk factors following
bariatric surgery. Obesity (Silver Spring), 16(3), 615–622.
58. Lautenbach, A., Kulinna, U., Löwe, B., & Rose, M. (2013).
100 kg more or less, still the same person (and disorder): From
overweight to underweight–exacerbation of an eating disorder
after bariatric surgery. International Journal of Eating Disorders,
46(3), 280–283.
59. Niego, S. H., Kofman, M. D., Weiss, J. J., & Geliebter, A. (2007).
Binge eating in the bariatric surgery population: A review of the
literature. International Journal of Eating Disorders, 40(4),
349–359.
60. Sarwer, D. B., Wadden, T. A., & Fabricatore, A. N. (2005).
Psychosocial and behavioral aspects of bariatric surgery. Obesity
Research, 13(4), 639–648.
61. Buchwald, H., Avidor, Y., Braunwald, E., Jensen, M. D., Pories,
W., Fahrbach, K., et al. (2004). Bariatric surgery: A systematic
review and meta-analysis. JAMA, 292(14), 1724–1737.
123