European Journal of Clinical Nutrition (2016), 19

2016 Macmillan Publishers Limited, part of Springer Nature. All rights reserved 0954-3007/16
www.nature.com/ejcn

REVIEW
Quality of life and bariatric surgery: a systematic review of
short- and long-term results and comparison with
community norms
LCH Raaijmakers, S Pouwels, SEM Thomassen and SW Nienhuijs

Currently the effects of bariatric surgery are generally expressed in excess weight loss or comorbidity reduction. Therefore the aim
of this review was to provide insight in the available prospective evidence regarding the short and long-term effects of bariatric
surgery on Quality of Life (QoL) and a comparison with community norms. A systematic multi-database search was conducted for
QoL and Bariatric surgery. Only prospective studies with QoL before and after bariatric surgery were included. The Quality
Assessment Tool for BeforeAfter Studies with No Control Group was used to assess the methodological quality. Thirty-six studies
met the inclusion criteria. Most studies were assessed to be of fair to good methodological quality. Ten different questionnaires
were used to measure QoL. Follow-up ranged from 6 months to 10 years, sample sizes from 26 to 1276 and follow-up rates from 45
to 100%. A signicant increase in QoL after bariatric surgery was found in all studies (P 0.05), however, mostly these outcomes
stay below community norms. Only outcomes of the IWQoL, SF-36 and OWQoL show QoL outcomes that exceed community
norms. The QoL is increased after bariatric surgery on both the short and long term. However, due to the heterogeneity of the
studies and the generality of the questionnaires is it hard to make a distinction between different surgeries and difcult to see a
relation with medical prot. Therefore, tailoring QoL measurements to the bariatric population is recommended as the focus of
future studies.

European Journal of Clinical Nutrition advance online publication, 2 November 2016; doi:10.1038/ejcn.2016.198

INTRODUCTION review was to provide insight in the available prospective

Morbid obesity is associated with a variety of related diseases such
as diabetes mellitus, hypertension, dyslipidaemia, obstructive
sleep apnea syndrome or osteoarthritis and thereby impairing
life expectancy and Quality of life (QoL).13 QoL can be used to
refer to the physical, psychological, and social domains of health.
These can be seen as distinct areas which can be inuenced by
someones experiences, beliefs, expectations and perceptions.2
Treatment options for morbid obesity vary widely. Medication for
weight loss is limited and shows minimal success in the treatment
of obesity.4 Lifestyle programs are common, but successful long-
term weight loss remains unsure, especially among the morbidly
obese.5 Bariatric surgery is currently the most effective method to
resolve comorbidities and to obtain sufcient weight loss.6 Among
patients with morbid obesity, treatment seeking bariatric surgery
patients are at higher risk of having reduced health-related QoL
compared with non-treatment seeking morbid obese patients.7
A desire for improving QoL is often seen as an important factor for
seeking bariatric surgery.8 Anderson et al.9 showed that bariatric
surgery has a positive long-term effects (minimum of 5 years)
on QoL.
The effects of bariatric surgery are usually expressed in excess
weight loss or comorbidity reduction.10 However, QoL is becom-
ing increasingly important.8 Up to the present day there is no
standard in measuring QoL in bariatric surgery patients. Therefore,
a comprehensive overview is needed of both short- and long-term
effects of bariatric surgery on QoL. For that reason the aim of this
evidence regarding the short-term and long-term effects of
bariatric surgery for morbidly obese adults on QoL. Second, we
compared the QoL values with community norms.
MATERIALS AND METHODS
A systematic literature search was conducted, based on guidelines
extracted from the Cochrane Reviewers Handbook for Systematic
Reviews of Interventions. In this study protocol, eligibility criteria
were created and used to select relevant studies.
Search strategy and data sources
The Cochrane library, Medline, Embase, PsycInfo, CINAHL, Web of
Science and PEDro were searched from the earliest data of each
database up to March 2016. The search string used for the
literature search contained a combination of the following
keywords (or MeSH headings) and was modied for each
database: Quality of Life [MeSH], Bariatric surgery [MeSH] or
Weight loss surgery [MeSH].
Selection of studies
Studies were rst selected on title, afterwards studies were
selected on abstract and nally on full text. Two researchers
reviewed the articles independently (LCHR, SEMT). Afterwards,
disagreements were discussed with a third party (SP, SWN) until

Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands. Correspondence: Dr S Pouwels, Department of Surgery, Catharina Hospital, Michelangelolaan 2, PO Box 1350,
Eindhoven 5602 ZA, The Netherlands.
E-mail: sjaakpwls@gmail.com
Received 2 May 2016; revised 27 July 2016; accepted 4 August 2016
 Quality of life after bariatric surgery
LCH Raaijmakers et al
2
consensus was reached. Inclusion and exclusion criteria were
dened. The following inclusion criteria were followed: the
population had to have a body mass index (BMI) of 40.0 kg/m2
or 35.039.9 kg/m2 with obesity-related comorbidities; aged 1860
years; designs needed to be prospective; QoL data needed to be
available both pre- and post-surgery; and follow-up needed to
exceed at least 6 months. Only having a prospective design was
included as it is regarded as a reliable and valid way to collect
longitudinal data that can be used to assess temporality and
causal relationships.11 The outcome of focus was QoL after
bariatric surgery. Studies that used QoL as primary or secondary
outcome measure were included. Interventions that were included
were all bariatric procedures; Roux-en-Y Gastric Bypass, Adjustable
Gastric Banding, Biliopancreatic Diversion, Vertical Banded Gastro-
plasty and Sleeve Gastrectomy. Only articles in English were
selected. Studies without surgical intervention were excluded.
Furthermore, there was no restriction in the number of patients,
type of surgery, country where the surgery was performed or
instrumentation utilized.
Methodological quality of included studies
For rating the methodological quality, the Quality Assessment Tool
for BeforeAfter Studies with No Control Group was used.12 This
tool assesses the risk of bias with 12 questions. These comprise
the risk for different types of bias, such as selection bias, reporting
bias or observer bias. Two authors (LCHR and SEMT) separately
assessed the methodological quality of the included studies. Both
authors dened the quality of each study as poor, fair or good.
To determine the level of agreement between authors LCHR
and SEMT, a Cohens kappa score was calculated. A Cohens kappa
score between 0.400.75 was considered to be fair to good.
Kappas above 0.75 are considered excellent and below 0.40 are
considered to be poor.13
Data extraction
Detailed information was extracted from studies that met the
inclusion criteria. Study and intervention characteristics were
extracted as well as outcome data. To review the characteristics of
the studies, the following information was extracted: the study
population and number of participants followed-up, type of
surgery and QoL instrument used. Furthermore the difference in
QoL scores preoperative versus postoperative were calculated. In
addition, postoperative scores were compared with community
norms. When possible the pooled summary score was calculated
by multiplying each QoL mean with the number of participants
and divide these by the number of participants in the total study
population. Reviewers were blinded for journal and authors.
Studies varied in recruitment method, setting and measurement
of effects.
Data analysis
Since the data in the studies could not be presented in a
consistent format and systematic reporting of comparable
outcome variables was lacking, a meta-analysis was not con-
ducted and only a systematic review will be undertaken.
After careful consideration by the authors LCHR and SP,
questionnaires were divided in physical and mental components.
This was done by studying original validation literature of the
questionnaires. Sometimes this literature already gave a division
between mental and physical components. Outcomes of these
components were compared with community norms.
Subscales of the SF-36/RAND-36 were combined to two
summary scales, namely the physical component summary and
the mental component summary by using a standardized
algorithm.14
European Journal of Clinical Nutrition (2016) 1 9
RESULTS
Study selection
The multi-database search resulted in 3503 records. There were
eight records identied through other resources, namely reference
lists. After removing duplicates, 1994 records remained. Subse-
quently, articles were screened on title and abstract and the
remaining 74 articles were assessed for eligibility. Of these,
32 articles were excluded for various reasons. Seventeen were
excluded due to the research design, for example, these were
retrospective or cross-sectional.1533 Seven were excluded
because the QoL data were incomplete.3440 Furthermore, ve
studies did not have a research population with a BMI of
40.0 kg/m2 or 35.039.9 kg/m2 with obesity-related comorbid-
ities and aged 1860 years.41 Two studies were cost-utility
studies42,43 and four studies had poor methodological
quality.44,45 Thirty-six studies met inclusion criteria and were
included in this review. The total study selection process is shown
in the PRISMA diagram in Figure 1.
Risk of bias
Quality of methodology was assessed using the Quality Assess-
ment Tool for beforeafter studies with no control group. The
Cohens kappa was 0.67, which is considered to be a good
agreement. Five studies4649 were assessed as having a poor
methodological quality.12 This was due to suspicion for selection
bias, having only one measurement point for the outcome
measures, which decreases the reliability of the outcome
measures or unclear description of the intervention.
The other studies were assessed as having a fair to good
methodological quality. Table 1 gives an overview of the
methodological quality of the included studies.
Data extraction
Due to the heterogeneity of the studies in QoL instruments and
surgical techniques, a meta-analysis was not performed. This
decision is in accordance with a recent systematic review which
concluded that it is extremely difcult to synthesize the results of
bariatric surgery studies due to poor study design and reporting of
patient reported outcomes such as QoL.50
A summary of the results of the 40 included studies is provided
in Table 2.
In total, 7720 unique patients were included. The number of
patients ranged from 26 to 1276 and represented patients from
various countries. Mean age varied between 30 and 46 years and
mean BMI between 43 and 51.7.
The follow-up times for measuring QoL post bariatric surgery
varied from 6 months to 10 years. The follow-up rates varied from
17.8% at 18 months to 100% after 5 years.
Measurement Questionnaires. Ten different instruments were
used to measure QoL. These included both physical and mental
components. Twenty-four studies used the MOS 36-Item Short-
Form Health Survey (SF-36). This generic scale assesses eight
health concepts.51 A division can be made between physical and
mental components. Five studies made use of the short form of
impact of weight on QoL (IWQoL)-Lite measure, which is a 31-
item, self-report, obesity-specic measure of health-related
QoL.52 The QoL, obesity and dietetics (QoLOD) is the French
version derived from the IWQoL and was used in two studies.53
In three studies the Gastrointestinal Quality of Life (GIQLI) index
was used.54 One study used the 15D questionnaire, which is a
generic, 15-dimensional, standardized, self-administered mea-
sure of health-related QoL.55 Another study used the Obesity
and weight loss QoL (OWQoL).56 This study also used the weight
related symptom measure (WRSM) that measures 20 obesity-
specic symptoms using two sets of items.56 The Nottingham
2016 Macmillan Publishers Limited, part of Springer Nature.

Identification
Records identified through
database searching
(n = 3503)
Records after duplicates removed
(n = 1994)
Screening
Records screened
(n = 159)
Full-text articles assessed
Eligibility
for eligibility
(n = 74)
Studies included in
Included
qualitative synthesis
(n= 40)
Figure 1. PRISMA owchart.
Health Prole (NHP) was used in two studies and is a measure of
perceived health for use in population surveys which consists of
38 dichotomous items.57 Four studies used the Moorehead-
Ardelt Quality of Life Questionnaire (M-A QoLQII), which is part
of the bariatric analysis and reporting outcomes (BAROS).58 The
obesity-related problems scale (OP) is developed to measure the
impact of obesity on the psychosocial functioning and is used in
one study.59 The SOS study used a variety of validated
questionnaires.
Quality of Life Outcomes. Overall, a signicant increase in QoL
after bariatric surgery was found in all studies. Twenty-four studies
found an increase in QoL after the gastric bypass procedure, four
after biliopancreatic diversion, twelve after gastric banding and
nine studies found an improvement after sleeve gastrectomy.
Some studies included multiple techniques. Furthermore, Grans
et al.46 used the general term bariatric surgery. Martinez et al.49
described the techniques used in the articles as malabsorptive.
Most studies show signicant results after a follow-up of one year.
Studies with a longer follow-up period stated that the maximum
increase in QoL was reached after one year. After one year
patients reach a plateau phase. Freys et al.60 stated that the
increase in QoL was signicant 3 months after surgery. Three
studies did not show a signicant increase in the mental
component part of QoL.46,61,62
Comparison with general population reference samples. Pooled
scores are calculated for the SF-36 and the GIQLI. These provide a
comprehensive overview of the QoL outcomes. The pooled
summary score for the physical component summary of the
SF-36 is +16.70 when preoperative and postoperative outcomes
are compared. Postoperative outcomes compared with the
2016 Macmillan Publishers Limited, part of Springer Nature.
Quality of life after bariatric surgery
LCH Raaijmakers et al
3
Additional records identified
through other sources
(n = 8)
Records excluded
(n = 85)
Full-text articles excluded, with
reasons
(n = 34)
Wrong research design
(n = 17)
No/incomplete QoL data
(n = 9)
No adults undergoing
bariatric surgery (n = 3)
Cost-utility study (n = 2)
Methodological quality
(n = 2)
Follow-up <1 yr (n = 1)
community norms show a pooled summary score of +3.39. This
indicates that patients experience an increase in QoL in the
physical components after bariatric surgery and this even exceeds
the community norms. The pooled summary score for the mental
component summary of the SF-36 is +7.70 when preoperative and
postoperative outcomes are compared. When postoperative
outcomes are compared with community norms, it is seen that
these exceed with +2.19. This indicates that the SF-36 states that
postoperatively patients experience a higher QoL compared with
the community norms. This is in contradiction with the outcomes
of the GIQLI. The pooled summary score of the GIQLI indicates an
increase in QoL postoperatively of +17.08. However, there is a
difference of 6.74 compared with community norms. Table 2.
indicates that all questionnaires show a positive change in QoL
postoperatively. Mostly these QoL outcomes remain below
community norms. However, the IWQoL, SF-36 and OWQoL show
that QoL scores exceed the community norms postoperatively.
The SF-36 consists of a mental and a physical part. Comparing
all studies that used the SF-36, it can be seen that all showed a
higher score on the physical component compared with the
mental component (Table 2).
DISCUSSION
The aim of this review was to obtain a better understanding of the
effects of different bariatric surgery procedures on QoL, in terms of
short- and long-term results. The ndings of this systematic
review were consistent across all studies despite the use of
multiple QoL measures, types of surgery and different countries.
The increase in QoL during the rst year after surgery was shown
to be signicant and remained stable in the subsequent years.
This is in line with the ndings of an earlier review about QoL
European Journal of Clinical Nutrition (2016) 1 9
 Quality of life after bariatric surgery
LCH Raaijmakers et al
4
Table 1. Methodological quality of the included studies using the Quality Assessment Tool for BeforeAfter Studies With No Control Group'

Study 1 2 3 4 5 6 7 8 9 10 11 12 Quality rating

Aarts et al.62 Y Y Y Y N Y Y NA Y N N NA Fair

Aasprang et al.70 Y Y Y Y N Y Y NA Y Y N NA Good
Adami et al.71 Y Y N Y N N Y NA Y Y N NA Fair
Adams et al.72 Y Y Y Y CD Y Y NA Y Y Y NA Fair
Adams et al.73 Y Y Y Y CD Y Y NA Y Y Y NA Fair
Ahroni et al.74 Y Y Y N N N Y NA N Y N NA Fair
Boan et al.75 Y N N CD N Y Y NA Y Y N NA Poor
Brunault et al.76 Y N Y Y N N Y NA Y Y N NA Fair
Brunault et al.77 Y N Y CD N N Y NA N Y N NA Good
Busetto et al.78 Y N Y N N N Y NA Y Y Y NA Fair
Charalampakis et al.79 Y Y Y N N Y Y NA Y Y Y NA Good
Efthymiou et al.80 Y Y Y CD N N Y NA Y Y N NA Fair
Fezzi et al.81 Y Y Y Y N Y Y NA Y Y N NA Good
Freys et al.60 Y Y Y Y N Y Y NA Y N N NA Fair
Grans et al.46 Y N N N N N Y NA Y N N NA Poor
Hansen et al.82 Y Y Y N N N Y NA Y Y N NA Fair
Helmi et al.83 Y Y Y N N N Y NA N N N NA Fair
Julia et al.84 Y Y Y N N N Y NA Y Y N NA Good
Karlsen et al.85 Y Y Y N N N Y NA Y Y N NA Fair
Karlsson et al.86 Y Y Y Y N Y Y NA N Y Y NA Good
Klingemann et al.47 Y Y N CD N N Y NA N Y N NA Poor
Kolotkin et al.87 Y Y Y Y CD Y Y NA Y Y N NA Fair
Kolotkin et al.88 Y Y Y Y N N Y NA N Y N NA Fair
Lee et al.89 Y Y Y CD N Y Y NA N Y N NA Fair
Lier et al.48 Y Y Y N N N Y NA N Y N NA Poor
Major et al.90 Y Y Y CD N Y Y NA N Y N NA Fair
Mar et al.91 Y Y Y Y N N Y NA Y Y N NA Fair
Martinez et al.49 Y Y Y N N N Y NA Y Y N NA Poor
Mathus-Vliegen et al.92 Y Y Y N N Y Y NA Y Y N NA Good
Nadalini et al.93 Y Y Y CD N N Y NA N Y N NA Fair
OBrien et al.94 Y Y Y Y Y Y Y NA Y Y N NA Good
Omotosho et al.95 Y Y Y N CD Y Y N N Y N NA Fair
Peterli et al.96 Y Y Y N N Y Y NA Y Y N NA Fair
Pilone et al.97 Y Y Y Y N Y Y NA Y Y N NA Good
Risstad et al.98 Y Y N N N Y Y NA Y Y Y NA Fair
Suter et al.99 Y Y Y N N N Y NA Y Y N NA Fair
Van Hout et al.61 N Y Y N N Y Y NA Y Y N NA Fair
Warkentin et al.100 Y Y Y N N N Y NA N Y Y NA Fair
White et al.101 Y N Y N Y Y Y NA N Y Y NA Fair
Zijlstra et al.102 Y Y Y CD N N Y NA Y Y N NA Good
Abbreviations: Y, yes; N, no; CD, can not determine; NA, not applicable. (1) Objective clearly stated; (2) eligibility criteria described; (3) representative patient
population; (4) all eligible participants enrolled in study; (5) sample size sufcient; (6) invention description; (7) outcome measures specied; (8) outcome
assessor blinded; (9) loss to follow-up; (10) statistical analysis of outcome measures before and after intervention; (11) interrupted time series design; (12)
individual data used for group-level effects.

after bariatric surgery in long-term studies.63 The increase in QoL
during the rst year can be explained by the experience that
patients lose an impressive amount of weight and experience
the feeling that they are in control of their obesity. Something
they have never experienced before. Patients experience more
mobility and less complications of joint pain due to their weight
loss. However, the weight loss will stabilize after 1 or 2 years,
which causes the correlating stabilization in QoL as well. Long-
term follow-up of QoL is not described very often. The
evaluation of QoL after the rst year is important. This is the
period of weight regain and stabilization, so you might expect a
reduction in QoL. A few studies showed no signicant
improvement in the mental health component of QoL. Mental
health could be a rather constant factor compared with the
physical aspect of QoL. This constant factor is not easily
inuenced by weight reduction, which can result in an increase
in the physical health.
When the physical and mental components of the QoL
questionnaires are compared, it is seen that the items measuring
the physical components of QoL show higher scores. This
reafrms the conclusion that bariatric surgery has a higher impact
on physical components of QoL compared with mental compo-
nents. This suggests that QoL questionnaires should focus more
on these physical components. No differences in QoL outcomes
were seen between different techniques. All techniques showed
an increase of QoL postoperative.
When QoL outcomes are compared with community norms,
contradictory results are seen. The SF-36, OWQoL and IWQoL show
that patients postoperatively show higher QoL outcomes com-
pared with community norms. This can be explained by the way
patients experience their QoL improvement. However it can be
doubted if patients exceed in QoL compared with community
norms. This could suggest that these questionnaires lack methods
to adequately measure QoL improvement.
Our ndings are in line with a recent study done by Lindekilde
et al.64 Our study however, provides a more comprehensive view
of the current state of QoL after bariatric surgery. Lindekilde
et al.64 did provide a meta-analysis, but due to high hetero-
geneity in studies, results remain questionable. This reafrms
our decision to not perform a meta-analysis. Again, Coulman
et al.50 showed that most patient-related outcomes measures
are extremely variable, and standards of study design and

European Journal of Clinical Nutrition (2016) 1 9 2016 Macmillan Publishers Limited, part of Springer Nature.
 Quality of life after bariatric surgery
LCH Raaijmakers et al
5
Table 2. Quality of life instruments and outcomes compared preoperative versus postoperative and postoperative versus community norms

First author Follow-up Type of surgery QoL instrument Change scores Postop scores
population/study QoL preop compared with
population vs postop community normsa

Suter et al.99 379/379 RYGB BAROS NA NA

Freys et al.60 13/73 LGB GIQLIb Total: +17.0 Total: 13.8
Lee et al.89 175/223 LVBG GIQLIb Total: +2.3 Total: 17.3
Peterli et al.96 217/217 LSG and RYGB GIQLIb Total: +29 Total: +2.2
Mathus-Vliegen et al.92 49/50 AGB HRQLc Well-being: 3.1 Well-being: NA
Distress: 11.6 Distress: NA
Depression: +0.6 Depression: +0.58
Appearance: +6.2 Appearance: 7.37
Self-Regard: +6.1 Self-Regard: 5.37
Adami et al.71 50/50 BPD IWQoLd Physical: 57.8 Physical: 37.9
Mental: 28.8 Mental: 47.7
Boan et al.75 40/40 RYGB IWQoL-Lited Total: 51.4 Total: 12.9
Fezzi et al.81 77/78 LSG IWQoL-Lited Total: 34.21 Total: +83.3
Kolotkin et al.87 308/421 RYGB IWQoL-Lited Total: 54.0 Total: 20.1
Kolotkin et al.88 616/825 RYGB IWQoL-Lited Total: 43.4 Total: 11.7
Charalampakis et al.79 111/118 LSG Moorhead-Ardelt II Total: +2.35 NA
Helmi et al.83 63/95 LAGB Moorehead-Ardelt Total: +0.93 NA
score and 15de Total: +0.04 Total: 0.01
Klingemann et al.47 62/139 RYGB NHPf Energy: 32 Energy: +13
Pain: 19 Pain: +14
Emotional reactions: 6 Emotional reactions: +8
Sleep: 2 Sleep: +24
Social isolation: 8 Social isolation: +8
Mobility: 28 Mobility: +5
Martnez et al.49 100/100 Malabsorptive Bariatric NHPf (and BAROS) Energy: 67.0 Energy: +11.6
surgery Pain: 61.7 Pain: +6
Emotional reactions: 56.9 Emotional reactions: +2.6
Sleep: 62.6 Sleep: +13.4
Social isolation: 65.8 Social isolation: +15.6
Mobility: 57.2 Mobility: +8.8
Brunault et al.76 126/126 AGB, LSG or RYGB QoLODg Physical impact: +13.5 NA
Psychosocial impact: +8.8 NA
Social interaction: +2.6 NA
Comfort food: +1.0 NA
Brunault et al.77 103/131 LAGB+LSG QoLODg Physical impact: +11.8 NA
Psychosocial impact: +7.6 NA
Social interaction: +2.5 NA
Comfort food: +0.8 NA
Depression: +2.5 NA
Van Hout et al.61 107/135 VBG RAND-36h Physical: +13.2 Physical: +0.2
Mental: 1.4 Mental: +0.3
Zijlstra et al.102 45/91 LAGB RAND-36h Physical: +8.6 Physical: 2.7
Mental: +0.1 Mental: 3.0
Risstad et al.98 55/60 RYGB and BPDDS SF-36 and obesity- NA NA
related problems
scale
Aarts et al.62 105/131 RYGB SF-36i Physical: +17.0 Physical: +4.6
Mental: 2.2 Mental: 0.3
Aasprang et al.70 46/50 BPDDS SF-36i Physical: +15.6 Physical: 1.6
Mental: +7.7 Mental: 4.5
Adams et al. 72
402/420 RYGB SF-36 i
Physical: +9.39 Physical: 4.6
Mental: +2.82 Mental: 5.3
Adams et al.73 387/418 RYGB SF-36i Physical: +12.5 Physical: 6.1
Mental: +4.2 Mental: 4.7
74 i
Ahroni et al. 141/195 LAGB SF-36 Physical: +15.1 Physical: +2.4
Mental: +6.6 Mental: +2.4
Busetto et al.78 208/230 LAGB SF-36i Physical: +27.9 Physical: +29.8
Mental: +21.9 Mental: +24.1
80 i
Efthymiou et al. 80/80 SG, RYGB+BPD SF-36 Physical: +33.4 Physical: +2.9
Mental: +16.9 Mental: +5.0
Grans et al.46 26/26 Bariatric surgery SF-36i Physical: +22.6 Physical: +0.9
Mental: 1.9 Mental: 9.5
82 i
Hansen et al. 55/121 RYGB SF-36 Physical: +19.3 Physical: +6.0
Mental: +10.3 Mental: 4.9
Julia et al.84 71/124 RYGB SF-36i Physical: +13.7 Physical: +2.6
Mental: +2.9 Mental: 1.4

2016 Macmillan Publishers Limited, part of Springer Nature. European Journal of Clinical Nutrition (2016) 1 9
 Quality of life after bariatric surgery
LCH Raaijmakers et al
6
Table 2. (Continued)

First author Follow-up Type of surgery QoL instrument Change scores Postop scores
population/study QoL preop compared with
population vs postop community normsa

Kolotkin et al.87 308/421 RYGB SF-36i Physical: +16.9 Physical: 1.5

Mental: +7.0 Mental: 0.1
Kolotkin et al.88 616/825 RYGB SF-36i Physical: +11.3 Physical:6.2
Mental: +3.8 Mental: 2.4
Lier et al.48 87/127 RYGB SF-36i Physical: +16.5 Physical: 2.2
Mental: +0.9 Mental: +2.8
Major et al.90 65/65 LSG or LRYGB SF-36i Physical: +17.8 Physical: +6.9
Mental: +11.5 Mental: +0.2
Physical: +12.7 Physical: +2.6
Mental: +3.5 Mental: +0.4
Mar et al.91 79/82 RYGB SF-36i Physical: +18.8 Physical: 0.6
Mental: +7.9 Mental: +1.2
Nadalini et al.93 ?/110 RYGB, LSG, or Gastric SF-36i Physical: +9.4 Physical: +2.2
Banding Mental: +5.0 Mental: 2.5
OBrien et al.94 98/101100/101 Perigastric LAGBPars SF-36i Physical: +13.8 Physical: +0.9
Flaccida LAGB Mental: +4.0 Mental: 4.1
Physical: +12.7 Physical: +0.3
Mental: +7.0 Mental: 3.4
Omotosho et al.95 30/30 RYGB SF-36i Physical: +10.7 Physical: +2.5
Mental: +3.6 Mental: +5.6
Pilone et al.97 324/334 LGB SF-36i Physical: +26.5 Physical: +29.1
Mental: +24.0 Mental: +26.2
Fezzi et al.81 77/78 LSG SF-36i Physical: +15.7 Physical: +3.4
Mental: +13.7 Mental: +1.9
Karlsen et al.85 139/146 RYGB SF-36i, OWLQoLj, Physical: +16.8 Physical: +0.8
WRSMk Mental: +9.6 Mental: +0.6
Total: +42.7 Total: +13.1
Total: 25.2 Total: +0.8
Warkentin et al.100 130/150 Bariatric surgery SF-36iIWQoL-Lite Physical: +6.2 Physical: 2.1
Mental: +1.0 Mental: 2.2
Total: 26.9 Total: +38.1
White et al.101 357/357 RYGB no depression RYGB SF-36i Physical: +16.3 Physical: 0.7
with clinically signicant Mental: +1.3 Mental: +4.0
depression Physical: +15.9 Physical: 3.3
Mental: +6.6 Mental: 4.8
Karlsson et al.86 983/1276 AGB, VBG or RYGB SOS quality of Health perception: +5.8 Health perception: 16.4
life surveyk Social interaction: 3.2 Social interaction: +4.1
Obesity-related problems: Obesity-related
28.3 problems: +21.3
Overall mood: +0.14 Overall mood: +0.13
Depression: 1.4 Depression: +0.8
Anxiety: 1.4 Anxiety: +0.2
Abbreviations: AGB, Adjustable Gastric Banding; BAROS, bariatric analysis and reporting outcomes; BPD, Biliopancreatic Diversion; GIQLI, Gastrointestinal
Quality of life Index; HRQoL, health-related quality of life; IWQoL, impact of weight on quality of life; LGB, laparoscopic gastric banding; LSG, laparoscopic
sleeve gastrectomy; LVBG, laparoscopic vertical banded gastroplasty; NHP, Nottingham health prole; OWQoL, obesity and weight loss quality of life; QoLOD,
quality of life, obesity and dietetics; RYGB, Roux-en Y Gastric Bypass; WRSM, weight related symptom measure. aCommunity norms were extracted from
different resources: SF-36;103 IWQoL;52 QoLOD no normative data available; GIQLI;54 Moorehead-Ardelt no normative data available; 15D;104 OWQoL and
WRSM;105 SOS Quality of life survey;93 NHP;105 HRQL no normative data available; RAND-36.106 bGIQLI107111; scale range 0144; higher scores represent
better QoL. cHRQoL; Well-being, scale range 242, higher score indicates more dysfunction; distress, score range 636, higher scores indicate more
dysfunction; Depression, score range 060, higher score indicates more dysfunction; appearance, score range 535, higher score indicates less dysfunction,
Self-regard, score range 749, higher score indicates less dysfunction. dIWQoL; scale range 0100; high scores represent worse health. e15D = 15-dimensional
HRQoL measure; scale range 01; higher scores represent better QoL. fNHP; scale range 0100; higher scores represent better QoL. gQoLOD (French version
IWQoL); physical impact, psychosocial impact, sexual impact, comfort with food; scale range 0100; higher scores indicate better QoL. hRAND-36 = RAND-
-36 = Dutch version of SF-36; score range 0100; higher scores indicate a better QoL. iSF-36 = Short Form 36 Health Survey; scale range 0100; high scores
represent well-being. jOWQoL; scale range 0102; higher scores indicate better QoL. kWRSM; scale range 0120; higher scores indicate greater symptom
distress. lSOS QoL survey = battery of generic and condition-specic measures; health perception, scale range 0100, high scores indicate well-being; social
interaction and obesity-related problems, scale range 0100, high scores indicate dysfunction; overall mood, scale range 14, high scores represent well-being;
depression and anxiety, scale range 021, high scores represent symptoms.

reporting are often limited. Thus, heterogeneity was considered
too high for a meta-analysis. QoL was measured using a variety
of different instruments. The SF-36 was used most frequently
(n = 16). Both generic as obesity-specic instruments were used,
all measuring different aspects of QoL. Tayyem et al.65 showed
that neither the generic instruments nor the obesity-specic
instruments were adequate instruments in terms of content
validity.
Directions for future research
In current QoL research in bariatric surgery there is heterogeneity
in used questionnaires, but most of them contain a physical and

European Journal of Clinical Nutrition (2016) 1 9 2016 Macmillan Publishers Limited, part of Springer Nature.

mental component. Recent reviews about QoL in bariatric surgery
all showed that the current questionnaires are not specic enough
to adequately determine QoL shortly after bariatric surgery,66,67
but also on the long-term.68,69 None of the existing reviews
compared QoL measures with community norms. And the
question remains which aspects do patients think are important
in their own QoL. In other words are we measuring the
adequate components of QoL in bariatric surgical patients?
Future research should focus on investigating the items that
patients nd important in their QoL. A way to investigate this
matter is to do focus groups with bariatric surgical patients
(at different time periods) to determine important aspects of
QoL. Because these aspects can change, due to the earlier
mentioned stabilization of weight loss after approximately two
years, it is very important to ask patients in different time periods
before and after bariatric surgery. In our opinion, a new
instrument to measure the bariatric-specic QoL needs to be
composed and has to take into account the physical, mental but
also the items identied by patients themselves (items obtained in
focus groups).
Limitations
This review has several limitations. First, the studies were
heterogeneous with respect to QoL instruments, follow-up length
and surgical techniques. As result of this heterogeneity, a meta-
analysis was not performed. Furthermore, publication bias could
arise because of inadequate reporting of data. Follow-up rates
were high or poor reported and could lead to selection bias and
attributes to incomplete data. The instrument used for methodo-
logical assessment did not cover all important aspects. For
example, it did not include whether institutional review board
approval was given to the studies before start. However, this
review has several strengths as well. The total sample size was
relatively large (N = 5347). This has a positive inuence on the
generalizability of the results. The inclusion of solely prospective
studies increases the reliability of the results.
CONCLUSION
This systematic review of 28 pre- and post-studies showed a
signicant improvement of QoL for all different types of surgery.
Ten different instruments for determining QoL were used. Mainly
short-term follow-up results showed a signicant improvement,
but also long-term improvements were reported. Comparison to
community norms show contradictory results. Therefore, QoL
questionnaires must be focused on the bariatric population to
distinguish differences between surgical procedures and QoL
changes during follow-up. Current QoL questionnaires show that
patients postoperatively show higher QoL outcomes compared
with community norms. This could suggest that these ques-
tionnaires lack methods to adequately measure QoL improve-
ment. Therefore a comprehensive instrument needs to be
developed.
CONFLICT OF INTEREST
The authors declare no conict of interest.
AUTHOR CONTRIBUTIONS
Study design and data collection: LCHR and SEMT. Manuscript creation: LCHR,
SP, SEMT and SWN. Manuscript revision: LCHR, SP, SEMT and SWN. Final
approval: LCHR, SP, SEMT and SWN.
2016 Macmillan Publishers Limited, part of Springer Nature.
Quality of life after bariatric surgery
LCH Raaijmakers et al
7
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