Research Trends in Measurement of Quality of Life Following Bariatric Surgery: Emerging Interest in Appearance

Abstract

Introduction:

This systematic review identified the instruments used in assessing quality of life (QoL) in bariatric patients. Specifically, we examined how patients' appearance changes following bariatric surgery have been assessed in the literature.

Methods:

A search of the literature was conducted via electronic databases, concerning bariatric patient QoL after surgery. Studies were only included if they were: (1) full-length papers, (2) published in English, and (3) contained empirical use of an instrument to measure bariatric patient QoL postsurgery. The analysis consisted of 198 empirical references with a total of 41 different instruments to measure bariatric patient QoL. These instruments were cited 301 times across the literature.

Results:

Two categories of instruments used for measuring QoL following bariatric surgery were identified: generic and bariatric specific. The Medical Outcomes Study 36-item Short Form Health Survey (SF-36) was most frequently used in literature (n=79, 26.25%), followed by the Moorehead–Ardelt Quality of Life Questionnaire (M-A QoLQ; n=63, 20.93%).

Conclusion:

A growing trend was evident of instruments that include appearance as a measurement construct for QoL in bariatric patients. However, no unified instrument exists for measuring all domains of appearance-related factors following bariatric surgery. Understanding all aspects of bariatric patient QoL, including appearance-related factors, is necessary to provide optimal support postsurgery.

Introduction

Obesity has become a worldwide epidemic, impairing the health and overall quality of life for those who suffer from it.^1–3 Given that nonsurgical treatments for excessive obesity, such as nutritional diet and exercise, are typically less efficacious,⁴ bariatric surgical procedures are currently considered one of the most successful long-term solutions for morbid obesity.⁵ These procedures help to improve health-related quality of life (QoL),⁶ but there are still hardships awaiting an individual following bariatric surgical procedures, such as psychosocial adjustment, nutritional deficiencies, and excess skin.⁷ Although the main goals of bariatric surgery are weight loss, comorbidity reduction, and increased life expectancy,⁸ and there has been evidence that patient motivation to undergo bariatric surgical procedures is mainly health related,⁹ obese individuals also seek the procedure in order to improve their appearance.¹⁰ One study found that nearly 33% of the participants were motivated to get bariatric surgery based on concerns and embarrassment with their appearance,¹¹ while another study indicated that 18% of the participants wished to improve appearance by getting bariatric surgical procedures.¹² This emerging bariatric patient motivation has encouraged research to shift more attention toward examining patient experience with appearance postsurgery.^13,14

QoL is a multidimensional construct. It emphasizes the relationship between one's physical health, psychological state, social relationships, personal beliefs, and salient features of the environment.¹⁵ QoL is therefore a balance between objective functioning and subjective well-being.¹⁶ Appearance can be physical, psychological, and/or social.¹⁷ Overweight and obese individuals tend to be more dissatisfied with their bodies and outward appearance than their normal weight counterparts,¹⁸ and the negative body images are related to low self-esteem, increased symptoms of depression, and social malfunctioning.¹⁹ Changes in physical appearance are an obvious outcome of bariatric surgery,²⁰ and personal feelings about appearance changes are likely to influence the patient's self-perceptions, well-being, health behaviors, and adherence to treatment.²¹ Weight loss surgery typically alters a patient's lifestyle. The outcomes can be physically and psychosocially positive or negative. For instance, it is widely accepted that bariatric procedures produce effective weight loss as well as significantly improve comorbidities associated with obesity.²² However, restricting the stomach from food intake keeps vital nutrients from getting to the body. Patients can experience protein malnutrition and/or altered bone metabolism, which in turn leads to brittle nails, hair loss, and/or osteoporosis.^7,23 Body deformities (i.e., surplus skin) oftentimes result from massive weight loss, causing some individuals psychosocial distress, that is, depression and/or anxiety as well as body image dissatisfaction.²⁴ Thus, it is important to measure the impacts of appearance changes on QoL in postsurgical bariatric patients.

In the clinical setting, understanding patient QoL helps to identify and prioritize problems that may have little clinical reference but strongly affect coping postsurgery.²⁵ QoL measures can also facilitate decision making to provide improved patient satisfaction with treatments.^22,26,27 Many QoL instruments have been used by health researchers to approach subjective measures of impacts of bariatric surgery on QoL in patients, but only a few evaluation tools have been developed specifically to assess QoL following bariatric surgery.²³ To understand research trends in the measurement of QoL in the bariatric literature, this study conducted a systematic review to identify the instruments used in assessing patient QoL postsurgery. Specifically, we examined how patients' appearance changes following bariatric surgery have been assessed in previous studies.

Methods

Data collection

An initial literature search was conducted via the library database of a public 4-year research university in the United States. It then extended to multiple and continuous searches through various journals and citations related to the topic. A search of literature was performed electronically with PubMed, Web of Knowledge Science Citation Index, and PsychINFO (cutoff April 2013), which are databases that include most of the scholarly publications in physical and psychosocial aspects of bariatric patient QoL. Subsequent searches were also performed through major journals related to the topic (e.g., obesity surgery) and citations of obtained articles that were particularly relevant to this systematic review.

Search terms were categorized into two focuses: procedural QoL and appearance-related factors. To generate as many results as possible, search terms utilized the Boolean operator “AND” as well as quotations. When possible, we also ran search terms through all text rather than just abstracts (for details, see Table 1). Bariatric surgical procedures are commonly referred to as “bariatric,” “bariatric surgery,” or “obesity surgery,” which is why these were chosen as search terms to pair with “quality of life.” Additionally, “gastric bypass” was used, because it is the most common type of bariatric surgical procedure. Since the literature review suggested that “body image” and “clothing” are two major areas of appearance-related factors, these terms were paired with “bariatric” to cover specific areas of the literature. Finally, the combination of “appearance” and “bariatric” provided a broad search for literature relevant to this systematic review. This search process generated 4,450 article hits in total, and Table 1 summarizes the number of results for each electronic database according to search terms used.

Table 1.

Electronic Database Search Results

	Number of “hits” produced
Search terms	PubMed (text word)	Web of Science (topic)	PsychINFO (all text)
“obesity surgery” and “quality of life”	42	86	8
“bariatric surgery” and “quality of life”	435	866	60
“gastric bypass” and “quality of life”	339	703	25
“bariatric” and “quality of life”	510	923	65
“appearance” and “bariatric”	75	94	12
“clothing” and “bariatric”	9	6	1
“body image” and “bariatric”	88	84	19
Total	1,498	2,762	190

Data analysis

To avoid selection bias, we defined explicit and objective inclusion/exclusion criteria for the database search.²⁸ Studies were only included in this analysis if they were: (1) full-length papers (not just abstracts), (2) published in English, and (3) contained empirical use of an established or developed instrument to measure bariatric patient QoL postsurgery. Since a variety of articles also covered the topic of body contouring patients, only those that measured QoL before the cosmetic procedure were included in this meta-analysis. Due to a large number of data, QoL instruments that were used fewer than five times across the literature were further eliminated, unless they were bariatric specific, or included appearance-related factors in their instruments. Data extraction involved the type and description of QoL instrument(s) used. Frequency of use was coded by the number of times that the instrument was used across the literature.

During the search process, all references related to appearance following bariatric surgical procedures were reviewed. Both empirical and nonempirical references were examined in further detail for content such as body image and clothing. This approach was taken to obtain potentially valuable information from nonempirical studies on appearance-related factors affecting bariatric patients. It also allowed us to understand how overall QoL has been measured following bariatric surgery. In terms of empirical studies specific to appearance following bariatric surgical procedures, data extraction included description of instruments used and justifications for using them. When possible, instruments including appearance-related factors were requested via personal contacts with the corresponding authors of the journal articles for further examination of item measures.

Results

The inclusion criteria, described above, narrowed the findings down to 198 empirical references, and these references were used in further analysis. Within these references, a total of 41 different instruments were utilized to measure bariatric patient QoL postsurgery. Among the chosen references, these various QoL instruments were cited 301 times (i.e., some studies utilized more than one type of instrument to measure bariatric patient QoL postsurgery). The findings were organized as follows: (1) types and frequency of QoL instruments used in bariatric literature, and (2) QoL instruments measuring the impacts of appearance in bariatric patients.

Types and frequency of QoL instruments used in bariatric literature

Table 2 summarizes instruments used for measuring QoL following bariatric surgical procedures. Instruments were organized by the following two categories: generic and bariatric specific. Generic instruments were those that measured overall QoL (typically health related) in patients, whereas bariatric instruments are those specifically developed for postsurgical bariatric patients.

Table 2.

Frequency of QoL Instruments Used in Bariatric Literature

Instrument name	Year developed	No. of times used	Frequency (%)
Generic QoL
MOS 36-Item Short Form Healthy Survey (SF-36)^a	1992	79	26.25
Beck Depression Inventory (BDI-I/II)^b	1961 (I)	27	8.97
	1996 (II)
Impact of Weight on Quality of Life (IWQOL/IWQOL-Lite)^c	1997	23	7.64
	2001 (Lite)
Gastrointestinal Quality of Life Index (GIQLI)	1995	12	3.99
European Quality of Life—5 Dimensions (EQ-5D)	1990	10	3.32
Hospital Anxiety and Depression Scale (HAD)	1983	10	3.32
The Symptom Check List-90 Revised (SCL-90 R)	1983	9	2.99
MOS 12-Item Short Form Healthy Survey (SF-12)	1996	8	2.66
Rosenberg Self-Esteem Scale (RSE)	1991	7	2.33
Body Shape Questionnaire (BSQ)	1987	6	2.00
Eating Disorder Inventory (EDI-I/II)	1983 (I)	6	2.00
	1993 (II)
Nottingham Health Profile (NHP)	1993	6	2.00
Eating Disorder Examination-Questionnaire (EDE-Q)	1994	5	1.66
Multidimensional Body Self Relations Questionnaire (MMBSRQ)^d	1994	4	1.33
Stunkard's Figure Rating Scale (SFRS)^e	1983	4	1.33
Body Attitude Test (BAT)	1995	3	1.00
Body Uneasiness Test (BUT)	1999	2	0.66
Body Attitude Questionnaire (BAQ)	1991	1	0.33
Body-Esteem Scale for Adolescents and Adults (BESAA)	2001	1	0.33
Body Image Quality-of-Life Inventory (BIQOLI)	2002	1	0.33
Body Image Questionnaire (BIQ-20)	1996	1	0.33
Bariatric specific
Moorehead–Ardelt Quality of Life Questionnaire (M-A QoLQ-I/II)	1998 (I)	63	20.93
	2003 (II)
Bariatric Quality-of-Life Questionnaire (BQL)	2005	5	1.66
Post-Bariatric Satisfaction Questionnaire (P-BSQ)	2011	2	0.66
Post-Bariatric Surgery Appearance Questionnaire (PBSAQ)	2008	2	0.66
The Laval Questionnaire	2011	1	0.33
Bariatric Surgery Satisfaction Questionnaire (BSSQ)	2012	1	0.33
Current Body Image Assessment (CIBA)	2006	1	0.33
Sahlgrenska Excess Skin Questionnaire (SESQ)	2013	1	0.33
	Total	301	100.00

References have been included that had versions adapted to other languages.

Modified version (Post-Bariatric Surgery Quality of Life, PBSQOL) is included.

Beck Anxiety and Beck Youth Inventories (BAI and BYI) are included.

French (Quality of Life, Obesity and Dietetics, QOLOD) and “kid” versions are included.

Body Image and Satisfaction Assessment (BISA) is included.

Pictorial Body Image Assessment (PBIA) is included.

QoL, quality of life.

Overall, the instrument that was most frequently used in the bariatric literature appears to be a generic QoL instrument, called the Medical Outcomes Study 36-item Short Form Health Survey (SF-36), and modifications of it (n=79, 26.25%). The SF-36 is not specific to the bariatric field, but measures functional health and well-being on physical, psychological, and mental scales,²⁹ and the study by di Gregorio and Palkoner¹⁵ supports this finding. The second most frequently used instrument in bariatric literature was the Moorehead–Ardelt Quality of Life Questionnaire (M-A QoLQ; n=63, 20.93%). This is a bariatric-specific instrument, developed as a part of the Bariatric Analysis and Reporting Outcomes System (BAROS).¹⁶ The M-A QoL utilizes six questions and visuals measuring mood, physical function, social relationships, ability to work, sexuality, and eating behavior.³⁰

Literature also indicated Beck's Depression Inventory (BDI) as one of the supporting psychosocial measures for bariatric patient QoL (n=27, 8.97%).^26,31,32 The BDI uses 21 items to evaluate an individual's cognitive, affective, and somatic depressive symptoms, and was originally developed to measure the presence and severity of depression.^33,34 It has frequently been used to assess the mental health status of bariatric candidates, but has also been utilized to validate instruments specific to bariatric patients' QoL postsurgery.^35,36 In a recent study, scholars found that psychosocial health of the post-bariatric patient directly influences the individual's quality of life in mental and physical health, eating habits, and/or body image.³⁷

Another instrument reoccurring often in bariatric literature was the Impact of Weight on Quality of Life (IWQOL), including the “Lite” version (IWQOL-Lite), which is a generic instrument (n=23, 7.64%). The IWQOL specifically looks at weight-related QoL issues, and it measures 31 items in areas of physical function, self-esteem, sexual life, public distress, and work.³⁸ It was the first instrument constructed specifically for measuring quality of life in moderately to severely obese individuals.³⁹

Scholars recognize the need to develop unified QoL measures specific to bariatric surgery.²⁶ Kitzinger et al.⁴⁰ noted that the discrepancy between studies on the relationship of weight loss to body satisfaction might be that many of the body image assessments that have been used are from outside fields, such as eating disorders. Our systematic review confirmed a lack of consistency for bariatric patient QoL measures in the existing literature (see Table 2), but also identified efforts to generate bariatric surgery–specific instruments.^{23,36,40,41,42–47}

We identified that there are a handful of instruments that have recently been developed to assess QoL specifically for bariatric patients. Besides the M-A QoLQ, the following instruments were developed specifically for bariatric surgical procedures: Bariatric Quality-of-Life (BQL), the Post-Bariatric Satisfaction Questionnaire (P-BSQ), the Post-Bariatric Surgery Appearance Questionnaire (PBSAQ), The Laval Questionnaire, the Bariatric Surgery Satisfaction Questionnaire (BSSQ), Current Body Image Assessment (CIBA), and the Sahlgrenska Excess Skin Questionnaire (SESQ). Of these instruments, the M-A QoLQ seemed to be the most dominant, and it has already been described earlier in this paper. The BQL, the second most frequently used in this instrument category, has been available since 2005, and it has been used six times in literature. The BQL is a 19-item, validated questionnaire that measures psychological well-being, social functioning, physical functioning, and problems and symptoms related to obese patients before or after bariatric surgery.^46,47 In the absence of a psychometrically sound instrument to assess patients' perception of excess skin and body contouring surgery, Mitchell et al.⁴¹ developed the PBSAQ and Kitzinger et al.^40,43 developed the P-BSQ to understand patient expectations for the procedure specifically. The PBSAQ uses 50 questions (including demographics and desire for body contouring surgery) to measure the degree of bariatric patient satisfaction with excess skin,⁵⁵ whereas the P-BSQ utilizes a 5-point Likert scale to assess cosmetic concerns following bariatric surgical procedures.⁴⁰ Myers et al.⁴⁵ developed the BSSQ to understand overall bariatric patient QoL, that is, before and after procedures. The Laval Questionnaire was also recently developed to examine overall QoL in the morbidly obese population before and after bariatric surgery.³⁶ Forty-four items are categorized into the following domains: symptoms, activity/mobility, personal hygiene/clothing, emotions, social interactions, and sexual life. The relative newness of these latter instruments is indicated by their lack of cites, but more importantly the emerging measures of appearance-related factors in QoL post-bariatric surgery.

QoL instruments measuring impacts of appearance in bariatric patients

Our analysis identified 15 instruments that have been used to quantify impacts of appearance changes in QoL following bariatric surgical procedures.^{14,19,23,24,33,36,40,41–45,48–60} These instruments have appeared 31 times in 25 references of the chosen studies for this review (Table 3). QoL domains (i.e., physical, psychological, social, and/or economic) are included in their measures of appearance. These domains were aligned with the domains present in Tayyem et al.'s study,²⁶ except the economic domain, which we included in our analysis to distinguish financial concerns associated with bariatric surgery from social and relational aspects of QoL in bariatric patients. The physical domain embodies a person's health and daily functioning; the psychological domain encompasses an individual's self-esteem, mental health, emotions, self-efficacy, and body image; the social domain falls into the realm of relationships (friends, family, professional, sexual) as well as daily activity/roles such as work or leisure; and the economic domain is essentially any cost issues associated with changes in QoL. Upon reviewing appearance-related bariatric measures, it was determined that 14 of the 15 instruments included physical QoL factors, psychological factors were present in 12 instruments, while social factors were present in seven instruments. None of the appearance-related instruments used for bariatric surgical procedures looked at the economic domain.

Table 3.

Domains Included in Appearance-Related QoL Instruments

			QoL domains included
Instrument name	Year developed	No. of times used	Physical	Psychological	Social	Economic
Body Shape Questionnaire (BSQ)	1987	6	×	×
Multidimensional Body Self Relations Questionnaire (MMBSRQ)	1994	4	×	×
Stunkard's Figure Rating Scale (SFRS)	1983	4	×	×
Body Attitude Test (BAT)	1995	3	×	×
Body Uneasiness Test (BUT)	1999	2	×	×	×
Post-Bariatric Surgery Appearance Questionnaire (PBSAQ)	2008	2	×
The Laval Questionnaire	2011	2	×	×	×
Bariatric Surgery Satisfaction Questionnaire (BSSQ)	2012	1	×		×
Body Attitude Questionnaire (BAQ)	1991	1	×	×	×
Body Image Quality-of-Life Inventory (BIQOLI)	2002	1	×	×	×
Body Image Questionnaire (BIQ-20)	1996	1	×	×
Body-Esteem Scale for Adolescents and Adults (BESAA)	2001	1		×	×
Current Body Image Assessment (CIBA)	2006	1	×	×
Post-Bariatric Satisfaction Questionnaire (P-BSQ)	2012	1	×	×	×
Sahlgrenska Excess Skin Questionnaire (SESQ)	2013	1	×

Body satisfaction is one of the key factors that measure psychological aspects of appearance impacts on QoL, and it oftentimes influences the social relationships of bariatric patients. As per Sarwer's⁶¹ suggestion, the Body Shape Questionnaire (BSQ) has become a common measurement of body image in recent bariatric literature. The BSQ is considered valid, reliable, and widely used to measure body dissatisfaction with clinically obese patients through scaled questions from 1=“never” to 6=“always,” such as “Have you felt so bad about your shape that you have cried?”⁶² Although not validated, the BSSQ's nine 5-point Likert scale items (“strongly agree” to “strongly disagree”) aim to understand a patient's overall experience following bariatric surgery, and provide two questions on feelings about appearance and interpersonal concerns: “I feel better about the way I look after having this surgery” and “Since having the surgery, I worry less about what other people will think of me.”⁴⁵ The PBSAQ likewise contains a scaled question from 1=“extremely unattractive” to 9=“extremely attractive” on satisfaction with one's overall appearance.⁴⁶

In assessing the discrepancy of bariatric patients' perception on real and ideal body image, the Stunkard's Figure Rating Scale (SFRS) uses visual figure images with nine silhouettes, ranging in degree from very thin to obese, and asks patients to choose the silhouette that indicates their present and desired body shape. Discrepancies are calculated between the two, measuring degree of body shape disparagement.^57,58 The Multidimensional Body Self Relations Questionnaire (MMBSRQ) measures one's investment in and evaluation of appearance while revealing specific areas of body dissatisfaction.³¹ Song et al.²³ adapted the Body Image and Satisfaction Assessment (BISA) based on body area satisfaction scale of the MMBSRQ to address the bariatric patient's body shape and size, and they also proposed the Pictorial Body Image Assessment (PIBA)—a modified version of the SFRS—including a wider spectrum of body sizes (underweight to severely obese) than the SFRS. The Current Body Image Assessment (CIBA), also developed by Song et al., measures areas of body distress specific to the bariatric patient population. Most recently, Biörserud et al. developed the Sahlgrenska Excess Skin Questionnaire (SESQ), including 30 questions on demographics, activity, daily life, and specific problem areas on the body following bariatric surgery to assess the experience of excessive skin after massive weight loss.⁴³

This analysis identified three QoL instruments that had a construct that pertained to clothing. The Laval Questionnaire³⁶ used a 7-point Likert scale to address the questions “Do you tend to wear clothes that hide your appearance?” (“all the time” to “never”) and “Have you had difficulty in finding clothes for yourself?” (“extremely” to “not at all”). Likewise, the P-BSQ asked one 3-point Likert-type question specific to clothing: “Do you currently suffer from the following problems (in reference to ‘difficulty fitting into clothes’).” Upon contacting Biörserud et al.⁴³ about an unnamed questionnaire that indicated results concerning clothing issues, it was learned that their findings (i.e., problems with clothing fit or self-consciousness with dressed appearances) were actually discovered through open-ended questions on the instrument concerned with how excess skin hindered daily life. It should be noted here that these instruments containing a clothing-specific construct were relatively recently developed, compared to the other bariatric QoL instruments mentioned earlier in this paper. This finding may indicate an increasing awareness of the importance of clothing in measuring the overall QoL in postsurgical bariatric patients.

Discussion

This systematic review identified two categories of instruments used for measuring QoL following bariatric surgical procedures: generic and bariatric specific. Overall, the SF-36 appeared most frequently as a generic measure of bariatric patient QoL, and the M-A QoLQ was the most frequently used among bariatric-specific instruments. The BDI was also a consistent measure, specifically aimed at psychosocial factors of QoL for the bariatric patient. Along with the M-A QoLQ, the BQL index was another bariatric-specific instrument frequently used in the bariatric literature.

Figure 1 is a summary chart that shows the number of references by type of instrument that measures QoL in bariatric patients since 1997. Besides the generic and bariatric-specific type of QoL instrument, the “combination” category was added to indicate references that used both generic and bariatric-specific instruments in a study.^23,36,45,48 QoL instruments including appearance-related factors in their measures were labeled as “appearance-related.” Figure 1 illustrates longitudinal research trends in assessing patient QoL following bariatric surgery. Overall, there is a growing trend of the measurement of QoL in post-bariatric surgical patients, and bariatric-specific instruments have been developed and implemented since 2000. This also shows an emerging interest in appearance in evaluating bariatric patients' QoL following surgery.

FIG. 1.

QoL instruments used in bariatric literature.

Despite the aforementioned research trends in bariatric literature, there still remains a gap in understanding the various QoL domains that surround appearance following bariatric surgical procedures. Drastic physical changes to a bariatric patient's body postsurgery contribute to overall QoL for the individual having undergone the procedure. Appearance can be physical in terms of how the body transforms postsurgery, but also psychological in how the patient perceives his or her changing (or unchanging) shape and size. Additionally, appearance plays a role in social interactions with clothing and body image, and continuous needs for replacement of clothing, as their body changes, create a financial burden for bariatric patients.⁶³ Assessing such physical, psychological, and social domains alongside economic issues for the bariatric patient could aid in improving the patient's overall well-being. Nearly all of the instruments we found that attempt to measure appearance-related factors in QoL following bariatric surgical procedures examined physical and psychological domains, while some looked at social factors. However, none of the appearance-related instruments used for bariatric surgical procedures addressed the economic QoL domain. This analysis confirms that no unified instrument yet exists for assessing all domains of appearance-related factors in post-bariatric patients' QoL, including physical, psychological, social, and economic domains.

There was a recent emergence of instruments that include clothing in the measurement of the post-bariatric patients' QoL. Scholars have argued that clothing plays an important role in appearance management and feelings of self-worth.^64,65 Particularly for the obese population, clothing tends to function as a camouflage or concealment of their body parts.^66,67 Bariatric patients experience massive weight loss and thus drastic changes of body size and shape. Weight loss surgery is likely to introduce them to a new “me” with their much more slender bodies. Tiggemann and Lacey⁶⁵ asserted that clothing should be considered in understanding one's body experience with weight loss because clothing influences one's appearance along with the body itself. The improved appearance helps bariatric patients to gain positive self-esteem and self-confidence, and further offers more satisfying social relationships.⁶⁸ In this event, clothing may be used to reveal their body silhouettes and reflect their positive QoL. However, the unexpected consequences of surgery such as excess skin are often evident in post-bariatric patients, resulting in body dissatisfaction and negative self-image.²⁴ In this case, clothing will continue to serve as a means of camouflaging and concealing their hanging body parts that they do not want to show to others.

Conclusions

Aside from bariatric studies, QoL has also been widely studied in cancer treatment,⁶⁹ and is currently emerging as a major factor for transgender lifestyle transitions.⁷⁰ While these areas differ somewhat from bariatric surgical procedures, each offers valuable information on how appearance can affect an individual's well-being as his or her body changes from treatment. Bodily experience, whether actual or perceived by an individual and during interaction with other individuals, is essentially the most important factor in each of these populations. For example, a cancer patient undergoing chemotherapy or mastectomy might experience hair loss or scars that influence clothing choices because of embarrassment,⁷¹ much like the massive weight loss patient who develops surplus skin or scarring from body contouring.⁷² Likewise, Ainsworth and Spiegal⁷³ found that transgender individuals who had not undergone facial feminization surgery or gender reassignment had lower psychosocial QoL, paralleling the obese individual that has not yet undergone bariatric surgical procedures or the postsurgery body contouring candidate.^11,13 Annunziata et al.⁷¹ found that measures of body satisfaction in oncology were often taken from outside fields, such as eating disorders. They also stressed the importance of developing field-specific instruments. This echoes the argument of bariatric scholars.^14,40 A question then arises of how we can better measure QoL for those individuals that are undergoing dramatic appearance changes. In a broader scope, future studies could aim to compare these populations of different treatments to understand better appearance-related factors in bariatric patients' QoL.

QoL measures are useful in the clinical setting because they provide knowledge that can inform health policy and changes in practice.²² Bariatric support includes educational seminars, support group meetings, social programs, and electronic resources, which can accurately inform patients about what to expect from surgery, as well as how to cope with the lifestyle transition.⁷⁴ Currently, appearance concerns are present in the form of clothing exchange programs.^63,75,76 Due to the increase in body contouring procedures, appearance has also emerged as a factor to look at for multidisciplinary approaches to bariatric surgery.⁷ However, bariatric programs often neglect appearance-related coping with financial burden and psychosocial distress. Abela et al.⁷ suggested that the overall aim of a bariatric program is to restore the patient back to normal physical and psychosocial functioning. Understanding all aspects of bariatric patient QoL, including appearance-related factors, is necessary to provide optimal support postsurgery.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

References

World Health Organization. Obesity and overweight. Available at www.who.int/mediacentre/factsheets/fs311/en/index.html. Accessed January 10, 2013.

Ogden

, Carroll

, Kit

, Flegan

. Prevalence of Obesity in the United States, 2009–2010. No. 82. Data Brief. Hyattsville, MD: National Center for Health Statistics, 2012.

Flegal

, Carroll

, Kit

, Ogden

. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA, 2012; 307:491–497.

Padwal

, Klarenbach

, Wiebe

, Birch

, Karmali

, et al. Bariatric surgery: a systematic review network and network meta-analysis of randomized trials. Obes Rev, 2011; 12:602–621.

Picot

, Jones

, Colquitt

, Gospodarevskaya

, Loveman

, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Techno Assess, 2009; 13:i–216.

Maggard

, Shugarman

, Suttorp

, Maglione

, Sugerman

, et al. Meta-analysis: surgical treatment for obesity. Ann Intern Med, 2005; 142:547–559.

Abela

, Stevens

, Reddy

, Soldin

. A multidisciplinary approach to post-bariatric plastic surgery. Int J Surg, 2011; 9:29–35.

Chikunguwo

, Brethauer

, Schauer

. Bariatric surgery. In: Bland

, Büchler

, Csendes

, Garden

, Sarr

, Wong

(eds). General Surgery, second ed. London: Springer, 2009:557–566.

Munoz

, Lal

, Chen

, Mansour

, Fischer

, et al. Why patients seek bariatric surgery: a qualitative and quantitative analysis of patient motivation. Obes Surg, 2007; 17:1487–1491.

10.

Sarwer

, Dilks

, Spitzer

. Weight loss and changes in body image. In: Cash

, Smolak

(eds). Body Image: A Handbook of Science, Practice, and Prevention, second ed. New York: Guilford, 2011:369–377.

11.

Libeton

, Dixon

, Laurie

, O'Brien

. Patient motivation for bariatric surgery: characteristics and impact on outcomes. Obes Surg, 2004; 14:392–398.

12.

Dixon

, Laurie

, Anderson

, Hayden

, Dixon

, O'Brien

. Motivation, readiness to change, and weight loss following adjustable gastric band surgery. Obesity (Silver Spring), 2009; 17:698–705.

13.

Klassen

, Cano

, Scott

, Johnson

, Pusic

. Satisfaction and quality-of-life issues in body contouring surgery patients: a qualitative study. Obes Surg, 2012; 22:1527–1534.

14.

Sarwer

, Wadden

, Moore

, Eisenberg

, Raper

, Williams

. Changes in quality of life and body image after gastric bypass surgery. Surg Obes Relat Dis, 2010; 6:608–614.

15.

Di Gregorio

, Palkoner

. Quality of life after obesity surgery, an evidence-based literature review: how to improve systematic searches for enhanced decision-making and clinical outcomes. Obes Surg, 2001; 11:318–326.

16.

Muldoon

, Barger

, Flory

, Manuck

. What are quality of life measurements measuring?. BMJ, 1998; 316:542–545.

17.

Cash

, Fleming

. The impact of body image experiences: developing of the body image quality of life inventory. Int J Eat Disord, 2002; 31:455–460.

18.

Sarwer

, Thompson

. Obesity and body image disturbance. In: Wadden

, Stunkard

(eds). Handbook of Obesity Treatment. New York: Guilford Press, 2002:447–464.

19.

Foster

, Wadden

, Vogt

. Body image in obese women before, during, and after weight loss treatment. Health Psychol, 1997; 16:226–229.

20.

Sarwer

, Fabricatore

. Psychiatric considerations of the massive weight loss patient. Clin Plast Surg, 2008; 35:1–10.

21.

Rumsey

. The psychology of appearance: why health psychologist should “do looks.”. Euro Health Psych, 2008; 10:46–50.

22.

Buchwald

, Avidor

, Braunwald

, Jensen

, Pories

, Fahrbach

, et al. Bariatric surgery: a systematic review and meta analysis. JAMA, 2004; 292:1724–1737.

23.

Song

, Fernstrom

. Nutritional and psychological considerations after bariatric surgery. Aesthet Surg J, 2008; 28:195–199.

24.

van Hout

GCM

, Fortuin

FAM

, Pelle

AJM

, van Heck

. Psychosocial functioning, personality, and body image following vertical banded gastroplasty. Obes Surg, 2008; 18:115–120.

25.

Higginson

, Carr

. Measuring quality of life: using quality of life measures in the clinical setting. BMJ, 2001; 322:1297–1300.

26.

Tayyem

, Abdulmajid

, Atkinson

, Martin

. Analysis of health-related quality-of-life instruments measuring the impact of bariatric surgery: systematic review of the instruments used and their content validity. Patient, 2011; 4:73–87.

27.

Ferrans

, Zerwic

, Wilbur

, Larson

. Conceptual model of health-related quality of life. J Nurs Scholarsh, 2005; 37:336–342.

28.

Crombie

, Davies

HTO

. What is Meta-Analysis? What Is…? Series. Available at www.whatisseries.co.uk/whatis/. Accessed April 3, 2012.

29.

Ware

. SF-36^® Health Survey Update. Available at www.sf-36.org/tools/SF36.shtml#LIT. Accessed May 21, 2012.

30.

Sauerland

, Saad

, Meyer

, Neugebauer

. Measuring quality of life in bariatric surgery. Chir Gastroenterol, 2005; 21:31–33.

31.

Dixon

, Dixon

, and O'Brien

. Body image: appearance orientation and evaluation in the severely obese. Changes with weight loss. Obes Surg, 2002; 12:65–71.

32.

Dymek

, le Grange

, Neven

, Alverdy

. Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: a brief report. Obes Surg, 2001; 11:32–39.

33.

Masheb

, Grilo

, Burke-Martindale

, et al. Evaluating oneself by shape and weight is not the same as being dissatisfied abut shape and weight: a longitudinal examination in severely obese gastric bypass patients. Int J Eat Disord, 2006; 38:716–720.

34.

Masheb

, White

, Toth

, Burke-Martindale

, Rothschild

, Grilo

. The prognostic significance of depressive symptoms for predicting quality of life 12 months after gastric bypass. Compr Psychiatry, 2007; 48:231–236.

35.

Moorehead

, Ardelt-Gattinger

, Lechner

, Oria

. The validation of the Moorehead–Ardelt quality of life questionnaire II. Obes Surg, 2003; 13:682–692.

36.

Therrien

, Marceau

, Turgeon

, Biron

, Richard

, Lacasse

. The laval questionnaire: a new instrument to measure quality of life in morbid obesity. Health Qual Life Outcomes, 2011; 9:1–8.

37.

Kubik

, Gill

, Laffin

, Karmali

. The impact of bariatric surgery on psychological health. J Obes, 2013; 2013:837989.

38.

Duval

, Marceau

, Pérusse

, Lacasse

. An overview of obesity-specific quality of life questionnaires. Obes Rev, 2006; 7:347–360.

39.

Kolotkin

, Ross

, Kosloski

, Williams

. Development of a brief measure to assess quality of life in obesity. Obes Res, 2001; 9:102–111.

40.

Kitzinger

, Abayev

, Pittermann

, Karle

, Bohdjalian

, et al. After massive weight loss: patients' expectations of body contouring surgery. Obes Surg, 2012; 22:544–548.

41.

Mitchell

, Crosby

, Ertelt

, Marino

, Sarwer

, et al. The desire for body contouring surgery after bariatric surgery. Obes Surg, 2008; 18:1308–1312.

42.

Baillot

, Mampuya

, Comeau

, Méziat-Burdin

, Langlois

. Feasibility and impacts of supervised exercise training in subjects with obesity awaiting bariatric surgery: a pilot study. Obes Surg, 2013; 23:882–891.

43.

Biörserud

, Nielsen

, Staalesen

, Elander

, Olbers

, Olsén

. Sahlgrenska excess skin questionnaire (SESQ): a reliable questionnaire to assess the experience of excessive skin after weight loss. J Plast Surg Hand Surg, 2013; 47:50–59.

44.

Kitzinger

, Abayev

, Pittermann

, Karle

, Kubiena

, et al. The prevalence of body contouring surgery after gastric bypass surgery. Obes Surg, 2012; 22:8–12.

45.

Myers

, Adams

, Barbera

, Brantley

. Medical and psychosocial outcomes of laparoscopic Roux-en-Y gastric bypass: cross-sectional findings at 4-year follow-up. Obes Surg, 2012; 22:230–239.

46.

Steffen

, Sarwer

, Thompson

, Mueller

, Baker

, Mitchell

. Predictors of satisfaction with excess skin and desire for body contouring after bariatric surgery. Surg Obes Relat Dis, 2012; 8:92–97.

47.

Carlin

, Zeni

, English

, Hawasli

, Genaw

, et al. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg, 2013; 257:791–797.

48.

Weiner

, Sauerland

, Fein

, Blanco

, Pomhoff

, Weiner

. The bariatric quality of life (BQL) index: a measure of well-being in obesity surgery patients. Obes Surg, 2005; 15:538–545.

49.

Ortega

, Fernandez-Canet

, Álvarez-Valdeita

, Cassinello

, Jose Baguena-Puigcerver

. Predictors of psychological symptoms in morbidly obese patients after gastric bypass surgery. Surg Obes Relat Dis, 2012; 8:770–776.

50.

van Hout

, Hagendoren

, Verschure

, van Heck

. Psychosocial predictors of success after vertical banded gastroplasty. Obes Surg, 2009; 19:701–707.

51.

Ratcliff

, Eshleman

, Reiter-Purtill

, Zeller

. Prospective changes in body image dissatisfaction among adolescent bariatric patients: the importance of body size estimation. Surg Obes Relat Dis, 2012; 8:470–475.

52.

de Panfilis

, Cero

, Torre

, Salvatore

, Dall'Aglio

, et al. Changes in body image disturbance in morbidly obese patients 1 year after laparoscopic adjustable gastric banding. Obes Surg, 2007; 17:792–799.

53.

Leombruni

, Plerò

, Dosio

, Novelli

, Abbate-Daga

, et al. Psychological predictors of outcome in vertical banded gastroplasty: a 6 months prospective pilot study. Obes Surg, 2007; 17:941–948.

54.

Bracaglia

, D'Ettorre

, Gniuli

, Gigliofiorito

, Gentileschi

, Mingrone

. Morbidly obese patients undergoing bariatric and body contouring surgery: psychological evaluation after treatments. J Plast Reconstr Aesthet Surg, 2011; 64:1246–1248.

55.

Foster

, Wadden

, Vogt

. Body image in obese women before, during, and after weight loss treatment. Health Psychology, 1997; 16:226–229.

56.

Madan

, Beech

, Tichansky

. Body esteem improves after bariatric surgery. Surg Innov, 2008; 15:32–37.

57.

Munoz

, Chen

, Fischer

, Sanchez-Johnsen

, Roherig

, et al. Changes in desired body shape after bariatric surgery. Eat Disord, 2010; 18:347–354.

58.

Neven

, Dymek

, le Grange

, Maasdam

, Boogerd

, Alverdy

. The effects of Roux-en-Y gastric bypass surgery on body image. Obes Surg, 2002; 12:265–269.

59.

Pecori

, Cervetti

GGS

, Marinari

, Migliori

, Adami

. Attitudes of morbidly obese patients to weight loss and body image following bariatric surgery and body contouring. Obes Surg, 2007; 17:68–73.

60.

Teufel

, Rieber

, Giel

, Hunnemeyer

, Enck

, Zipfel

. Body image after sleeve gastrectomy: reduced dissatisfaction and increase dynamics. Obes Surg, 2012; 22:1232–1237.

61.

Sarwer

, Wadden

, Fabricatore

. Psychosocial and behavioral aspects of bariatric surgery. Obes Res, 2005; 13:639–648.

62.

Hrabosky

, Masheb

, White

, Rothschild

, Burke-Martindale

, Grilo

. A prospective study of body dissatisfaction and concerns in extremely obese gastric bypass patients: 6- and 12-month postoperative outcomes. Obes Surg, 2006; 16:1615–1621.

63.

Janeway

, Sparks

, Baker

. The Real Skinny on Weight Loss Surgery: An Indispensable Guide to What You Can Really Expect!. Onondaga, MI: Little Victories, 2005.

64.

Frith

, Gleeson

. Clothing and embodiment: men managing body image and appearance. Psychol Men Masculin, 2004; 5:40–48.

65.

Tiggemann

, Lacey

. Shopping for clothes: body satisfaction, appearance investment, and functions of clothing among female shoppers. Body Image, 2009; 6:285–291.

66.

Grilo

, Reas

, Brody

, Burke-Martindale

, Rothschild

, Masheb

. Body checking and avoidance and the core features of eating disorders among obese men and women seeking bariatric surgery. Behav Res Ther, 2005; 43:629–637.

67.

Kwon

Y-H

, Parham

. Effects of state of fatness on weight conscious women's clothing practices. Cloth Textiles Res J, 1994; 12:16–21.

68.

Kinzl

, Schrattenecker

, Traweger

, Aigner

, Fiala

, Biebl

. Quality of life in morbidly obese patients after surgical weight loss. Obes Surg, 2007; 17:229–235.

69.

Avis

, Smith

, McGraw

, Smith

, Petronic

, Carver

. Assessing quality of life in adult cancer survivors (QLACS). Qual Life Res, 2005; 14:1007–1023.

70.

Murad

, Elamin

, Garcia

, Mullan

, Murad

, et al. Hormonal therapy and sex reassignment: a systematic meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol, 2010; 72:214–231.

71.

Annunziata

, Giovannini

, Muzzatti

. Assessing the body image: relevance, application and instruments for oncological settings. Support Care Cancer, 2012; 20:901–907.

72.

van der Beek

, te Riele

, Specken

, Boerma

, van Ramshorst

. The impact of reconstructive procedures following bariatric surgery on patient well-being and quality of life. Obes Surg, 2012; 20:36–41.

73.

Ainsworth

, Spiegal

. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Qual Life Res, 2010; 19:1019–1024.

74.

Markel

, Mattar

. Essentials of a bariatric program. In: Nguyen

, Maria

, Eric

, et al. (eds). The SAGES Manual. New York: Springer, 2008:37–42.

75.

Geggis

. Clothing swap helps slimming patients. The Daytona Beach News Journal. Available at www.news-journalonline.com/news/local/east-volusia/2011/02/01/clothing-swap-helps-slimming-patients.html. Accessed January 21, 2013.

76.

Senkel

. Patients thankful for clothing exchange program. Obesity Help. Available at www.obesityhelp.com/forums/amos/Patients-Thankful-for-Clothing-Exchange-Program.html#.TxHzGX2qMgg.email. Accessed January 14, 2013.