The Impact of Bariatric Surgery on Employment: A Systematic Review

Abstract

Objectives:

Bariatric surgery is described as the most effective treatment for morbid obesity, with significant effects on weight loss and reduction in obesity-related comorbidities. The aim of our study was to carry out a systematic review to investigate the determinants of return to work after bariatric surgery.

Material and Methods:

To identify relevant studies, studies focusing on determinants of return to work after bariatric surgery and published between January 2000 and April 2017, we conducted a systematic literature search in PubMed and Web of Science.

Results:

Eighteen articles were eligible for inclusion. Publications found no major changes or an improvement in prevalence of employment after bariatric surgery, but an important decrease of sick leaves. Conversely, the proportion of disability pensions seems to remain steady or to be only slightly reduced. Concerning return to work conditions, we identified that reduction of comorbidities is an important facilitating factor. Other factors were identified as potential barriers influencing surgical patients not to resume their job. Surprisingly, no article dealt with issues relevant to workstation layout and work organization.

Conclusions:

Bariatric surgery seems to have a positive impact on occupational outcomes, despite some inconsistencies in findings.

Introduction

Bariatric surgery is described as the most effective treatment for morbid obesity, with significant effects on weight loss and reduction of obesity-related comorbidities. An improvement in health-related quality of life is also reported. Occupational outcomes remain a vague determinant of the benefits of bariatric surgery, with a lack of knowledge concerning the correlation existing between work and bariatric surgery.

Obese individuals are characterized by decreased rates of employment in Canada, Europe, and the United States.^1,2 A Canadian study revealed that obesity is associated with reduced workforce participation, regardless of associated comorbidities and sociodemographic factors.¹ Employment rate was higher in the normal weight group (80%) and was reduced depending on the class of obesity (79% in class I obesity, 75% in class II, and 66% in class III). A U.S. study reported that baseline obesity was associated with reduced employment throughout a 19-year follow-up (88% vs. 78% among men and 76% vs. 63% among women).² French authors described a significant difference between unemployment rate of nonobese and obese adults (9% vs. 11%, p < 0.01).³ Moreover, time spent unemployed for the adult working-age population was significantly higher for each kg/m² deviation from the average body mass index (BMI) achieved at age 20.³ The chance of finding a new job after unemployment was significantly reduced. A Swedish study reported that BMI status was associated with the probability of being entitled to a disability pension.⁴

For patients aged 18 to 60 with a BMI ≥40 kg/m² or BMI 35–40 kg/m² with comorbidities in which surgically induced weight loss is expected to improve health condition (international criteria for bariatric surgery), bariatric surgery appears as the cornerstone of obesity management, providing sustainable and durable weight loss. Employment rate of obese persons seems to be even lower for patients seeking bariatric surgery: 55–56% versus 85% in nonobese controls in U.S., Norwegian, and Spanish studies.^5–8 Forty-one percent of these patients report either Medicaid or Medicare in the United States as their principal coverage and 30% of them receive disability pensions in Norway.⁸ Obese individuals had less education than nonobese controls, limiting the access to employment (43% vs. 72% with high school degree, respectively).⁷

Two remarkable systematic reviews report employment outcomes after bariatric surgery.^9,10 One of them focuses on employment status after bariatric surgery.¹⁰ Authors pointed out the limited evidence available in scientific literature regarding occupational outcomes following bariatric surgery. They highlighted the generally positive impact of bariatric surgery on occupational outcomes, inferring that surgery may have wide economic, social, and psychological benefits over and above its immediate health benefits. Our review addresses the issue of practical barriers that surgical patients face when they try to return to employment. The aim of our study was to carry out a systematic review to characterize the terms and conditions of return to work after bariatric surgery. We explored employment status of patients after bariatric surgery, the proportion of sick leaves after surgery, as well as practical arrangements facilitating return to work and job retention.

Material and Methods

The PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement was followed as a formal guideline for this review.¹¹

Search strategy

For our literature review, we included original articles published in peer-reviewed journals between January 2000 and April 2017. Two databases were queried, PubMed and Web of Science, using this search equation: (“employment” OR “unemployment” OR “return to work” OR “pensions” OR “retirement” OR “supported employment” OR “absenteeism” OR “sick leave” OR “sickness absence” OR “disability” OR “occupational status”) AND (“obesity surgery” OR “bariatric surgery” OR “gastric bypass” OR “sleeve gastrectomy” OR “duodenal switch”) (see Supplementary File 1 in the Supplementary Data, which shows extensive overview of search terms; Supplementary Data are available at www.liebertpub.com/bari).

Selection of studies

Two independent reviewers first screened article titles identified during the initial search. The selected titles were re-examined in the abstract review stage, through which two reviewers independently assessed each abstract. In the third stage, the full-text articles were obtained and further evaluated by two reviewers in terms of relevancy, quality, and inclusion/exclusion criteria.

Inclusion criteria

Our inclusion criteria comprised: original articles published in peer-reviewed journals and reporting occupational outcomes such as employment status, return to work, sick leave, and disability pension. Our study population was defined as obese patients older than 18 years and treated with bariatric surgery (see Supplementary File 2 in the Supplementary Data, which shows inclusion criteria).

Exclusion criteria

We excluded articles that (1) assessed strictly health-related quality of life without mentioning employment; (2) focused on population seeking bariatric surgery with no postoperative results; (3) were cost/effectiveness analyses without any report of employment rates; (4) reported short sick-leaves or early returns to work to compare open to laparoscopic techniques; (5) were Letters to the Editor, Protocols, Review articles, and Meta-analyses; and (6) focused on postoperative adherence (see Supplementary File 2 in the Supplementary Data, which shows exclusion criteria).

Data extraction and quality assessment

Data were extracted from included articles and checked for accurateness. Extracted data included: first author; year and journal of publication; country; study design; study population; factors associated with return to work, employment rates, incidence of disability pension, and sick leave before and after surgery. We used different quality assessment tools. For the quality assessment of cross-sectional studies, we used the BSA (British Sociological Association) Medical Sociology Group.¹² For the quality assessment of cohort studies, we used the NOS (Newcastle–Ottawa Scale).¹³ And finally, for the quality assessment of qualitative studies, we used the National CASP (Critical Appraisal Skills Program) Appraisal Tool¹⁴ (see Supplementary File 3 in the Supplementary Data, which shows details on quality assessment).

Results

Our search strategy identified a total of 307 articles, 94 articles were excluded due to duplication. Following a thorough review of full-text articles and after quality assessment, 18 articles were eligible for inclusion, as shown in Supplementary Data (See Supplementary File 4 in the Supplementary Data, which shows the flow chart of the review). Background characteristics (study design, sample, employment rate, disability pension, sick-leave, and factors associated with return to work) are shown in Tables. Five studies have a prospective design^15–19 and 13 have a retrospective design.^20–32 Four studies compare occupational status between surgical patients and a control group.^17,27,29,31 The other 14 studies compare occupational status before and after bariatric surgery in the same population.^{15,16,18–26,28,30,32} Of 18 articles, 9 studies are from Europe (Norway, Sweden, the United Kingdom, the Netherlands, and France),^{16–18,20–22,25–27} 9 studies are from North America (the United States and Canada).^{15,19,23,24,28–32} No study was designed in Asia, Africa, or South America. In most studies, patients were recruited through healthcare systems.

Employment status, sick leave, and disability pension

A majority of authors report no major changes in prevalence of employment before and after bariatric surgery.^{15,16,22,28,32} However, there were changes in employment status of patients: change in employment (starting a new job, increasing of working hours),²⁸ switching from unemployment to employment, or vice versa.¹⁶ A few publications described nonetheless an improvement in employment rate with an increase from 12% to 32% in performing paid work after surgery.^20,21,26 Findings concerning unemployment rate after surgery vary according to studies: authors report an increase,¹⁵ a decrease,²² or no change²⁵ in the proportion of unemployment after surgery. The ability for unemployed patients to find a job after surgery is enhanced, with a proportion of 16–37% re-employment after surgery.^16,29–31 Tables 1 and 2 report detailed employment outcomes after surgery.

Table 1.

Employment Status After Surgery

Study	Country	Participants/sample	Study design	Employment status	Other comments on employment
Alfonso-Cristancho et al., JAMA.¹⁵	United States	n = 1773 80% ♀ Median 45 years 71% RYGB, 24% LAGB	Prospective cohort study I 2005–2009 FU 3 years	Prevalence of employment did not significantly change throughout follow-up, from pre-surgery values: 74.8% (95% CI, 72.8%–76.9%) However, unemployment increased from pre-surgery to year 3 (3.7% [95% CI, 2.9%–4.5%] for pre-surgery vs. 5.6% [95% CI, 4.4%–6.8%] for year 3 post-surgery, p = 0.02)
Andersen et al., PeerJ.¹⁶	Norway	n = 22461% ♀Mean 40 years (SD 9)69% DS, 23% SG, 2% GB, 6% revisions	Prospective cohort studyI 2001–2008FU 5 years	The overall rate of employment did not change over time, and was 54% at baseline and 58% at follow-up (p = 0.34)Most individuals were either unemployed or worked full-time (83% at baseline and 82% at follow-up), and the mean full-time equivalent (i.e., the proportion of income that came from paid work) did not change over time (0.46 at baseline and 0.49 at follow-up; p = 0.54)	Being female, being older, having a low education level (only primary school), receiving disability pension and/or not participating in paid work before surgery were important risk predictors for not being employed after obesity surgeryThere were changes in employment status of the individual patients: of the 102 patients who were not employed before surgery, 31 (30%) had become employed after 5 years, and of the 122 patients' who were employed before surgery, 23 (19%) had lost their employment after 5 years
Roger Andersen et al., Obes Surg.²⁰	Norway	n = 5154.9% ♀Mean age 37.7 years (SD, 8.0)DS	Retrospective studyI 2001FU 2 years	The number of patients performing paid work increased from 28 (54.9%) before surgery to 34 (66.7%) at 2 years after surgery, p = 0.031The percentage of the patients performing paid work 2 years after surgery was still somewhat lower than the age and gender adjusted population norm (82.7%)	The average paid work participation per week in those who performed paid work both before and after DS (n = 28) was 31.2 h before surgery and 32.8 h per week 2 years after surgery, p = 0.51The average paid work participation in the 6 patients (2 women and 4 men), who started to perform paid work after DS, was 26.9 h per week 2 years after surgery
Date et al., Surg Obes Relat Dis.²¹	UK	n = 51 (23 morbidly obese and 28 super-obese)69.6%/78.6%♀48/44 yearsLaparoscopic RYGB	Retrospective studyI 2008–2009FU 1 year	Improvement in QOL and employment status was seen in both groups, although it was not significantly different between them, as initially hypothesized(Fisher's exact: p = 0.251)
Durand-Moreau et al., Int J Occup Environ Med.²²	France	n = 80384.9% ♀Mean (SD) 45.6 (11.2) years81.3% RYGB, 0.7% LAGB, 7.6% DS, 10.3% SG	Cross sectional studyI 2012FU 6, 12, 24, 36, 48, 60 months or more	Employment rate remained stable after surgery: Employment rates were 64.4% before and 64.7% after the surgery (p = 0.94)	There were no significant differences in the distribution of occupational categories before and after the surgery, among both women (p = 0.91) and men (p = 0.88)
Hawkins et al., Obes Surg.²⁶	UK	n = 5978% ♀Median 45 years (range 19–63)76% laparoscopic RYGB, 24% LAGB	Retrospective studyI 2004–2006FU 14 months (range 3–32)	There was a 32% increase in the number of respondents in paid work after surgery, 34 (58%) vs. 45 (76%) (p < 0.05)	The proportion of patients in paid work after surgery (76%) compares well with the 2005 UK national average of 75% of women and 88% of men in the 35–49 age group recorded as being in employment
Sockalingam et al., Obes Surg.¹⁹	Canada	Employed patients onlyn = 16481.1% ♀43.5 ± 9.7 years95.1% RYGB, 4.9% SG	Prospective cohort studyI 2010–2012FU 12 months		Improvements in depression, anxiety and mental quality of life were the only significant predictors of work-related impairment and productivityA history of psychiatric illness was not a predictor of change in work-related impairment and productivity after bariatric surgery
Tarride et al., Obes Surg.²⁸	Canada	n = 30485% ♀Mean 46 yearsAll performed surgeries were laparoscopic80% RYGB, 19% SG, 1 DS	Retrospective studyI 2010–2012FU 1 year	There were no major changes in employment status at 1 year following bariatric surgery with 62% working full time, 15% working part time, and 6% on disability	However, more individuals reported a change in their employment status within 1 year following surgery (26%) compared to 1 year before the surgery (9%) (p < 10⁻³)Of these individuals who reported a change over the 1 year following surgery, the majority started a new job (47%) or increased their work hours (32%).
Wolfe and Terry, Obes Surg.³²	United States	n = 9387.1%♀Mean 44.3 ± 9.7 yearsRYGB	Retrospective studyI 2003FU 78.4 ± 35.7 weeks	Occupational status did not change over the time-span of the study	In spite of their reported satisfaction with the impact of weight loss on community and professional relationships, respondents reported no significant change in occupational status as a group, nor as a function of number of years postoperativelyAmount of weight loss was unrelated to the relationship or occupational variables

CI, confidence interval; DS, biliopancreatic diversion with duodenal switch; FU, follow-up; GB, gastric bypass; I, inclusion; LAGB, laparoscopic adjustable gastric band; ND, not described; RYGB, Roux-en-Y gastric bypass; SEK; swedish krona; SG, sleeve gastrectomy; SOS, swedish obese subjects; ♀, women; VBG, vertical banded gastroplasty.

Table 2.

Employment Status After Surgery Among Unemployed or Underserved Populations

Study	Country	Participants/sample	Study design	Employment status
Alfonso-Cristancho R et al., JAMA.¹⁵	United States	n = 177380% ♀Median age 45 years71% RYGB, 24% LAGB	Prospective cohort studyI 2005–2009FU 3 years	Unemployment increased from presurgery to year 3 (3.7% [95% CI, 2.9%–4.5%] for presurgery vs. 5.6% [95% CI, 4.4%–6.8%] for year 3 postsurgery, p = 0.02)
Andersen et al., PeerJ.¹⁶	Norway	n = 22461% ♀Mean 40 years (SD 9)69% DS, 23% SG, 2% GB, 6% revisions	Prospective cohort studyI 2001–2008FU 5 years	Of the 102 patients who were not employed before surgery, 31 (30%) had become employed after 5 years
Durand-Moreau et al., Int J Occup Environ Med.²²	France	n = 80384.9% ♀Mean (SD) 45.6 (11.2) years81.3% RYGB, 0.7% LAGB, 7.6% DS, 10.3% SG	Cross-sectional studyI 2012FU 6, 12, 24, 36, 48, 60 months, or more	The distribution of nonworkers was significantly (p = 0.04) different before and after the surgery: the number of unemployed people was lower after surgery; more had retiredAfter surgery of the 283 nonworking patients, 204 (72.1%) were still nonworkers, however, 69 (24.4%) found a job
Hanvold SE et al., Obes Surg.²⁵	Norway	n = 16574.5% ♀44.0 ± 8.6 yearsRYGB	Retrospective studyI 2006–2009FU 2 years	There were no changes in the proportion of unemployed participants (37.7% vs. 33.3%, p = 0.189) from pre- to postsurgery
Turchiano M et al., Obes Surg.²⁹	United States	n = 193 unemployed issued from minorities and publicly insured (Medicaid or Managed Medicaid).2 groups: 72 surgery (92%♀, 44.4 ± 11.7 years) and 121 no surgery (76.9%♀, 47.0 ± 13.7 years)	Retrospective studyI 2008–2010FU 2 years	24.1% (14/59) of the surgical patients and 9% (4/46) of the nonsurgical had acquired full-time employment at least 1 year postoperatively (p = 0.04)
Velcu L et al., Surg Obes Relat Dis.³⁰	United States	n = 4189%♀Mean 32.4 ± 3.6 years (range 28–43)Open RYGB	Retrospective studyI 1998–1999FU 1 and 5 years	14 patients (34%) were gainfully employed preoperatively and 27 (66%) were unemployedThe reasons for unemployment were attributed to morbid obesity in 25 patientsFor those who were unemployed primarily because of obesity, at 1 year, only 2 patients had become gainfully employed. At 5 years, only 4 patients had become gainfully employed, for a 16% reemployment rate
Wagner A et al., Arch Surg.³¹	United States	Medically disabled, Medicaid-funded, morbidly obese patientsn = 38 + 16Surgery group: n = 38, 81.6%♀, mean 48 years (range, 27–63 years)Control group (no surgery): n = 16, 68.7%♀, mean 51 years (range, 33–63 years)RYGB	Retrospective studyI 1997–2002FU mean 44 months (range 14–97) for the surgery group and 32 months (range 15–62) in the nonoperative group	37% of morbidly obese Medicaid-funded patients returned to work after RYGB, compared with only 6% of patients in the nonoperative control group (p = 0.02)Reduction of comorbidities is more reliable than the amount of weight lost as a predictor of patients' ability to return to workPatients who had greater than the mean decrease in comorbid conditions at the time of follow-up were statistically more likely to return to work than those who did not have a reversal in comorbid conditions (p = 0.001)

Four out of 18 studies described the management of disability pensions after bariatric surgery. In the United States, a stability in prevalence of disability pensions, or a very limited rate of disenrollment for working-age disabled Medicare beneficiaries, is depicted throughout follow-up.^15–24 In Norway, Andersen et al. found no significant change in the proportion of patients receiving disability pension in a 5-year prospective follow-up.¹⁶ In Sweden, Gripeteg et al. suggest a reduced risk of needing a disability pension after bariatric surgery.¹⁷ Table 3 reports the management of disability pension and state benefits after bariatric surgery.

Table 3.

Evolution of Disability Pensions/State Benefits After Surgery

Study	Country	Participants/sample	Study design	Disability pension
Alfonso-Cristancho R et al., JAMA.¹⁵	United States	n = 177380% ♀Median age 45 years71% RYGB, 24% LAGB	Prospective cohort studyI 2005–2009FU 3 years	Prevalence of disability did not significantly change throughout follow-up: presurgery values of 14.0% (95% CI, 12.5%–15.6%) for disability.
Andersen et al., PeerJ.¹⁶	Norway	n = 22461% ♀Mean 40 years (SD 9)69% DS, 23% SG, 2% GB, 6% revisions	Prospective cohort studyI 2001–2008FU 5 years	The proportion of patients receiving disability pension did not change significantly (32% at baseline and 38% at follow up; p = 0.16).
Gripeteg et al., Int J Obes (Lond).¹⁷	Sweden	Population from the SOS studyn = 40472010: surgery group2037: control group70% ♀46–47.6 years18.7% nonadjustable or adjustable gastric banding, 68.1% VBG, 13.2% GB	Prospective cohort studyI 1987–2001FU 6 months, 1, 2, 3, 4, 6, 8, 10, 15, and 20 years	In men, the unadjusted incidence of disability pension did not differ between the surgery and control groups (n = 156 in both groups).When adjusting for baseline confounders in men, a reduced risk of disability pension was suggested in the surgery group (hazard ratio 0.79, 95% CI, 0.62–1.00; p = 0.05).Furthermore, the adjusted average number of disability pension days was lower in the surgery group, 609 days vs. 734 days (p = 0.01).In women, bariatric surgery was not associated with significant effects on incidence or number of days of disability pension.
Habermann et al., Data Points Publication Series [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US)²⁴	United States	All Medicare beneficiaries, working-age disabled and age eligible, who received a bariatric operationn = 3779974.5% ♀6.6% 18–34 years, 15.6% 35–44 years, 24.1% 45–54 years, 25.8% 55–64 years, 12% 65–66 years, 12.1% 67–70 years, 3.8% 71+ years51.8% Laparoscopic RYGB, 9.2% Open RYGB, 1.1% Laparoscopic DS, 36.4% LAGB in an inpatient, 1.6% LAGB in an outpatient	Retrospective studyI 2006–2009FU 3 years	Disenrollment for working-age disabled Medicare beneficiaries following bariatric surgery was low; fewer than 1% (0.64%) had disenrolled 3 years after the operation, only about 1% 5 years after surgeryRates of disenrollment at 3 years after surgery varied slightly by type of operation (1.2% for DS and 0.69% for LRYGB).

Five studies out of 18 described the management of sick leave before and after surgery. The five studies report a significant decrease in absenteeism rate after bariatric surgery.^{15,16,18,23,27} Prevalence of presenteeism was decreased after treatment, and at all postsurgery times.¹⁵ Improvement of physical function and reduction of depressive symptoms were independently associated with a reduced risk of postsurgery absenteeism and presenteeism. Higher weight loss was independently associated with a reduced risk of postsurgery presenteeism.¹⁵ Conversely, female sex, low income, and a history of sick leave were associated with an increased rate of absenteeism during follow-up after surgery.²⁷ Table 4 reports the management of sick leave and its evolution.

Table 4.

Evolution of Sick Leave After Surgery in Employed Populations

Study	Country	Participants/sample	Study design	Sick-leave
Alfonso-Cristancho et al., JAMA.¹⁵	United States	n = 177380% ♀Median age 45 years71% RYGB, 24% LAGB	Prospective cohort studyI 2005–2009FU 3 years	Prevalence of absenteeism was lower at year 1 (10.4% [95% CI, 8.4%–12.4%], p = 0.003) vs. presurgery (15.2% [95% CI, 13.0%–17.4%]), but did not significantly differ from presurgery at year 2 or 3Prevalence of presenteeism was lower than presurgery at all postsurgery times but increased from years 1 to 3 (62.8% at baseline; 31.9% at year 1; 35.6% at year 2; 41.0% at year 3)Improvements in physical function and depressive symptoms were independently associated with lower risks of postsurgery absenteeism and presenteeism, whereas postsurgery initiation or continuation of psychiatric treatment vs. no treatment presurgery or postsurgery was associated with higher risksGreater weight loss was independently associated with lower risk of postsurgery presenteeism only
Andersen et al., PeerJ.¹⁶	Norway	n = 22461% ♀Mean 40 years (SD 9)69% DS, 23% SG, 2% GB, 6% revisions	Prospective cohort studyI 2001–2008FU 5 years	Although the overall rate of employment remained unchanged, the number of days of sick leave per year was much reducedFor patients who were employed at both time points, there was a reduction from a mean of 56 to a mean of 28 (p = 0.002) and from a median of 40 to a median of 5
Ewing et al., Obes Surg.²³	United States	n = 15087.5% ♀12.6% 20–29 years,28.7% 30–39 years, 38.5% 40–49 years, 18.2% 50–59 years, 2.1% 60–69 yearsLaparoscopic GB, LAGB	Retrospective studyI 2003–2005FU 1 year before and after surgery	Patients reported a median and mean of 33 (SD 10) days lost from work due to illness or injury in the year before surgeryIn the year after surgery, patients reported a median 0 and a mean 1 (SD 4) days lost from work
Jönsson E et al., Obes Surg.²⁷	Sweden	n = 4971 surgery groupn = 49,710 control groupAmong surgery group: 75% ♀Mean age 40.4 ♀/42.8 ♂	Retrospective studyI 2010FU 3 years	Patients with obesity had preoperatively a 3.5-fold higher absenteeism. During follow-up, the ratio relative to the reference population remained constant. An increase of 12–14 net absenteeism days was observed in the first 3 months after surgery. Female sex (OR 1.5, CI, 1.13–1.8), preoperative antidepressant use (OR 1.5, CI, 1.3–1.9), low income (OR 1.4, CI, 1.2–1.8), and a history of sick leave (OR 1.004, CI, 1.003–1.004) were associated with increased absenteeism during FU
Mathus-Vliegen et al., Surgery.¹⁸	Netherlands	n = 14749 operated patients matched with a control group (98 normal weight)69% ♀35.0 ± 7.4 years50% LAGB, 50% open adjustable silicone gastric banding	Prospective studyI NDFU 1 year	Before surgery, as to work productivity, 8 of 34 employed obese patients had almost 4 times more days of sick leave in the previous month compared with 12 of 80 employed subjects of the reference group (12.5 ± 5.1 days vs. 3.4 ± 2.7 days)After surgery, days of sick leave decreased to the level of the reference group (6.3 ± 4.5)

Return to work

Factors associated with return to work after bariatric surgery were identified. Being female, being older, having a low education level, receiving disability pension, and/or not participating in paid work before surgery were important risk predictors for not being employed after obesity surgery.¹⁶ Reduction of depressive disorders and anxiety and improvement of health-related quality of life were significant predictors of an increased work performance and a decreased work-related impairment. A medical history of psychiatric disorders was not a predictor of change in work-related impairment and productivity after bariatric surgery.¹⁹ Finally, reduction of comorbidities is a predictor of patients' ability to return to work.³¹ Conversely, the scale of weight loss was not related to professional variables.^31,32 Table 1 reports predictors of return to work.

Specific issues concerning obesity at workplace

Authors have addressed the issue of discrimination that obese people experience at workplace. Obese patients have a reduced rate of employment than the general population, either before or after bariatric surgery (54% before and 58% 5 years after surgery, vs. 83% in the Norwegian general population).²⁰ They also present a higher rate of absenteeism. The rate of absenteeism among obese patients preoperatively was 3.5-fold higher throughout the study period compared with a Swedish reference population.²⁷ The ratio of absenteeism between the patient cohort and the reference population remained constant throughout the study period. Finally, women had a higher absenteeism rate compared to men, both in the study group and in the reference population.²⁷

In another study, authors conclude that obese workers are less productive due to fewer days at work. Whereas workers have on average 250–3 = 247 productive days per year in a reference population, obese workers have 250–33 = 217 productive days.²³ The distribution of occupational categories in the obese population differs from the distribution in the general population. Women who underwent bariatric surgery were less likely to have an intermediate profession (25.8% in the general population vs. 15.6% after surgery), and they were more likely to work as employees (47.1% in the general population vs. 58.7% after the surgery). Prevalence of obesity in women was higher in the population characterized by the lowest socioeconomic status.²²

Hawkins et al. mention that surgical patients have an improved ability to accomplish tasks, less limits in the scope of work, and less difficulty to perform work, than obese patient who did not undergo surgery.²⁶ Velcu et al. report that, after weight loss, the social integration of patients by their coworkers at workplace was increased and they had more chances to be professionally promoted at workplace.³⁰ Attitudes and behaviors in the work environment seemed to change after surgery. In some cases, snacking at work was no longer tolerated after the bariatric surgery of a coworker, and rules were established to support and promote healthy dietary habits.

Discussion

Our review provides an overview of the professional impact of bariatric surgery by characterizing the barriers faced by surgical patients when they try to return to work. We identified risk markers for professional exclusion and factors we could act on to improve the chance of professional reintegration. We identified that reduction of comorbidities is an important facilitating factor of professional reintegration.³¹ Conversely, being female, being older, having a low education level, receiving disability pension, and/or not participating in paid work before surgery are potential barriers to job retention and professional reintegration.¹⁶

Surprisingly, no article addresses the question of workstation layout and work organization, which we believe to be crucial to maximize the chance of returning to work. Occupational health physicians can assist patients, if necessary, to adapt work organization to encourage job retention of employees who have undergone a bariatric surgery. Surgery side effects, such as malaises or digestive disorders, might affect the workflow.³³ In these cases, occupational health physicians may be helpful, by educating and preparing employees for their return to work, advocating, for example, reorganizations of work station, or return to work part-time. Occupational physicians can also recommend to employees to request for an administrative certification of their disabilities. This procedure may give them access to specific rights aimed at maintaining employment.

Durand-Moreau et al. remind us that several studies have investigated the specific problems that overweight people may face at work: their personal protective equipment that may not fit their anthropometric characteristics, the main professions that are associated with obesity, especially men working in transport, professional factors, especially the impact of shift work, which increases the risk of being overweight, macroeconomic consequences, and increased work injuries and absenteeism.²² Obese patients often experience discrimination at work. Companies have tested programs to reduce weight with short-term but not long-term efficiency. Turchiano et al. remind us that obese individuals are at a distinct disadvantage at workplace.²⁹ Obese patients face numerous obstacles in the process of obtaining and maintaining their job. They face discrimination at all stages of the hiring and employment process and have rates of medical disability three times higher than their normal weight peers.²⁹

Consistent with the findings of Sharples et al.,¹⁰ our review reveals that the employment rate is not significantly improved nor changed after bariatric surgery, we found no major changes or an improvement in prevalence of employment after surgery.^{15,16,20–22,25,26,28–32} However, studies report a major decrease of sick leave after surgery.^{15,16,18,23,27} The proportion of disability pension seems to remain steady,^15,16,24 or to be slightly reduced.¹⁷

Our literature review provides an overview of occupational outcomes, employment status, sick leave, work organization after return to work, among obese patients treated with bariatric surgery. As mentioned in the Sharples and Cheruvu review¹⁰ and in the following correspondence,^34,35 we have included studies published recently, between 2000 and 2017, to provide some insight into occupational outcomes after bariatric surgery in a manner that would be relevant to modern medical practices.³⁵ Strictly following PRISMA statement, our results consolidate Sharples and Cheruvu's review with a strict method. Our strong point is to take a close interest to the practical arrangements of return to work, to discrimination at workplace, and to the evolution of disability, which cannot be separated from the concept of job retention. Data gathered in this field were scarce, which makes it difficult to conclude in terms of the determinants of return to work after bariatric surgery. Our review highlights the need of new research.

Our study has some limits. First, this review brings to light some inconsistencies. It is surprising that obesity surgery seems to slightly improve or maintain the employment rate and reduce absenteeism, but does not reduce disability. As pointed out by Habermann et al., ideally, bariatric surgery should result in decreased weight-related comorbidities and increased ability to work, thereby reducing the need for disability benefits,²⁴ especially since the reduction of comorbidities following bariatric surgery and long-term weight loss have been described.³⁶ Gripeteg et al. underline that among individuals who receive a disability pension, obese individuals leave the work force 2–4 years earlier than normal weight individuals and that the three most common reasons for receiving a disability pension in Sweden are cardiovascular and musculoskeletal diseases and psychiatric disorders, all related to weight status.¹⁷ Bariatric surgery in obese individuals improves physical and psychosocial functioning and reduces several obesity-related comorbidities. This apparent stability in disability pensions after obesity surgery may be due, in part, to the existence of other disabilities among disability pension beneficiaries (e.g., mental health problems). In addition, comparing results of studies conducted in different countries with different health insurance systems may be associated with the introduction of bias.^17,35 More studies are warranted to further explore the complex causes for loss of working ability before and after bariatric surgery.

Second, all included studies were designed in high-income countries. If obesity used to be depicted in high-income countries in the past, it now represents a worldwide spread burden and affects also low- and middle-income countries.

Third, we could not perform comparisons between studies considering that different methodologies were used to determine employment status and rates. Unemployment levels should be analyzed according to the geographical setting of a study, considering that the organization of healthcare systems and professional environments varies greatly depending on countries. Our results are based on a majority of North American studies: nine^{15,19,23,24,28–32} versus nine studies from European countries,^{16–18,20–22,25–27} with distinct healthcare systems.

Surgical patients should be medically and socially supported in their return to work, as part of the recovery process and medical care. Assessing the level of assistance required to achieve a social and professional reintegration implies considering the clinical situation, along with the geographical, social, and economical settings in which the analysis is performed, considering that the organization of occupational medicine and occupational health varies greatly between countries.

Conclusions

Obese patients who underwent bariatric surgery face many barriers when they try to return to employment. Studies suggest that bariatric surgery has generally a positive impact on the professional integration of patients, however, data characterizing the determinants of return to work are scarce in the scientific literature. Our systematic review provides an overview of the risk markers for professional exclusion and factors we could act on to improve the chance of professional reintegration. Surgical patients should be medically and socially supported in their return to work, as part of the recovery process and medical care.

Institution and Ethics Approval

This article does not contain any studies with humans or animals performed by any of the authors.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

References

Klarenbach

, Padwal

, Chuck

, Jacobs

. Population-based analysis of obesity and workforce participation. Obesity (Silver Spring), 2006; 14:920–927.

Tunceli

, Li

, Williams

. Long-term effects of obesity on employment and work limitations among U.S. Adults, 1986 to 1999. Obesity (Silver Spring), 2006; 14:1637–1646.

Paraponaris

, Saliba

, Ventelou

. Obesity, weight status and employability: empirical evidence from a French national survey. Econ Hum Biol, 2005; 3:241–258.

Neovius

, Johansson

, Rössner

, Neovius

. Disability pension, employment and obesity status: a systematic review. Obes Rev, 2008; 9:572–581.

Balduf

, Kohn

, Galanko

, Farrell

. The impact of socioeconomic factors on patient preparation for bariatric surgery. Obes Surg, 2009; 19:1089–1095.

Lund

, Karlsen

T-I

, Hofsø

, Fredheim

, Røislien

, Sandbu

, et al. Employment is associated with the health-related quality of life of morbidly obese persons. Obes Surg, 2011; 21:1704–1709.

Caixàs

, Lecube

, Morales

M-J

, Calañas

, Moreiro

, Cordido

, et al. Weight-related quality of life in Spanish obese subjects suitable for bariatric surgery is lower than in their North American counterparts: a case-control study. Obes Surg, 2013; 23:509–514.

Hernæs

UJV

, Andersen

, Norheim

, Våge

. Work participation among the morbidly obese seeking bariatric surgery: an exploratory study from Norway. Obes Surg, 2015; 25:271–278.

Herpertz

, Kielmann

, Wolf

, Langkafel

, Senf

, Hebebrand

. Does obesity surgery improve psychosocial functioning? A systematic review. Int J Obes Relat Metab Disord, 2003; 27:1300–1314.

10.

Sharples

, Cheruvu

CVN

. Systematic review and meta-analysis of occupational outcomes after bariatric surgery. Obes Surg, 2017; 27:774–781.

11.

Moher

, Shamseer

, Clarke

, Ghersi

, Liberati

, Petticrew

, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev, 2015; 4:1.

12.

Blaxter

. Criteria for the evaluation of qualitative research papers. Med Sociol News, 1996; 22:4–7.

13.

Stang

, Wingert

, Hartling

, Plint

. Adverse events related to emergency department care: a systematic review. PLoS One, 2013; 8:e74214.

14.

Boyce

, Browne

, Greenhalgh

. The experiences of professionals with using information from patient-reported outcome measures to improve the quality of healthcare: a systematic review of qualitative research. BMJ Qual Saf, 2014; 23:508–518.

15.

Alfonso-Cristancho

, King

, Mitchell

, Ramanathan

, Sullivan

, Belle

, et al. Longitudinal evaluation of work status and productivity after bariatric surgery. JAMA, 2016; 316:1595–1597.

16.

Andersen

, Hernæs

UJV

, Hufthammer

, Våge

. Employment status and sick-leave following obesity surgery: a five-year prospective cohort study. PeerJ, 2015; 3:e1285.

17.

Gripeteg

, Lindroos

, Peltonen

, Sjöström

, Narbro

. Effects of bariatric surgery on disability pension in Swedish obese subjects. Int J Obes (Lond), 2012; 36:356–362.

18.

Mathus-Vliegen

, de Weerd

, de Wit

. Health-related quality-of-life in patients with morbid obesity after gastric banding for surgically induced weight loss. Surgery, 2004; 135:489–497.

19.

Sockalingam

, Wnuk

, Kantarovich

, Meaney

, Okrainec

, Hawa

, et al. Employment outcomes one year after bariatric surgery: the role of patient and psychosocial factors. Obes Surg, 2015; 25:514–522.

20.

Roger Andersen

, Aasprang

, Bergsholm

, Sletteskog

, Våge

, Karin Natvig

. Health-related quality of life and paid work participation after duodenal switch. Obes Surg, 2010; 20:340–345.

21.

Date

, Walton

S-JY

, Ryan

, Rahman

, Henley

. Is selection bias toward super obese patients in the rationing of metabolic surgery justified?—a pilot study from the United Kingdom. Surg Obes Relat Dis, 2013; 9:981–986.

22.

Durand-Moreau

, Gautier

, Bécouarn

, Topart

, Rodien

, Sallé

. Employment and professional outcomes in 803 patients undergoing bariatric surgery in a French reference center for obesity. Int J Occup Environ Med, 2015; 6:95–103.

23.

Ewing

, Thompson

, Wachtel

, Frezza

. A cost-benefit analysis of bariatric surgery on the South Plains region of Texas. Obes Surg, 2011; 21:644–649.

24.

Habermann

, Durham

, Dorman

, Jarosek

, Virnig

. Trends in bariatric surgery in Medicare beneficiaries: Data Points # 17. In: Data Points Publication Series [Internet]. Rockville, MD: Agency for Healthcare Research and Quality (US); 2011. Available at www.ncbi.nlm.nih.gov/books/NBK115074 Accessed May 11, 2018.

25.

Hanvold

, Løken

, Paus

, de Brisis

, Bjerkan

, Refsum

, et al. Great health benefits but no change in employment or psychopharmaceutical drug use 2 years after Roux-en-Y gastric bypass. Obes Surg, 2015; 25:1672–1679.

26.

Hawkins

, Osborne

, Finlay

, Alagaratnam

, Edmond

, Welbourn

. Paid work increases and state benefit claims decrease after bariatric surgery. Obes Surg, 2007; 17:434–437.

27.

Jönsson

, Ornstein

, Goine

, Hedenbro

. Diabetes resolution and work absenteeism after gastric bypass: a 6-year study. Obes Surg, 2017; 27:2246–2252.

28.

Tarride

J-E

, Breau

, Sharma

, Hong

, Gmora

, Guertin

, et al. The effect of bariatric surgery on mobility, health-related quality of life, healthcare resource utilization, and employment status. Obes Surg, 2017; 27:349–356.

29.

Turchiano

, Saunders

, Fernandez

, Navie

, Labrador

, Parikh

. Bariatric surgery may improve employment status in unemployed, underserved, severely obese patients. Obes Surg, 2014; 24:692–695.

30.

Velcu

, Adolphine

, Mourelo

, Cottam

, Angus

LDG

. Weight loss, quality of life and employment status after Roux-en-Y gastric bypass: 5-year analysis. Surg Obes Relat Dis, 2005; 1:413–416; discussion 417.

31.

Wagner

, Fabry

, Thirlby

. Return to work after gastric bypass in Medicaid-funded morbidly obese patients. Arch Surg, 2007; 142:935–940; discussion 941.

32.

Wolfe

, Terry

. Expectations and outcomes with gastric bypass surgery. Obes Surg, 2006; 16:1622–1629.

33.

Dugan

. Part II. Returning to work following bariatric surgery. AAOHN J, 2008; 56:532.

34.

Charras

, Savall

, Descazaux

, Soulat

J-M

, Ritz

, Herin

. Comment on: systematic review and meta-analysis of occupational outcomes after bariatric surgery. Obes Surg, 2017; 27:811–812.

35.

Sharples

. Response to comment on: systematic review and meta-analysis of occupational outcomes after bariatric surgery. Obes Surg, 2017; 27:813.

36.

Sjöström

, Lindroos

A-K

, Peltonen

, Torgerson

, Bouchard

, Carlsson

, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med, 2004; 351:2683–2693.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.82 MB