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Allied health article

Health and health-related quality of life: differences between men andwomen who seek gastric bypass surgery

Ronette L. Kolotkin, Ph.D.a,b,*, Ross D. Crosby, Ph.D.c,d, Richard E. Gress, M.A.e,Steven C. Hunt, Ph.D.e, Scott G. Engel, Ph.D.c, Ted D. Adams, Ph.D.e

aObesity and Quality of Life Consulting, Durham, NCbDepartment of Community and Family Medicine, Duke University Health System, Durham, NC

cNeuropsychiatric Research Institute, Fargo, NDdDepartment of Neuroscience, University of North Dakota School of Medicine, Fargo, ND

eDepartment of Cardiovascular Genetics, University of Utah School of Medicine, Salt Lake City, UT

Received September 13, 2007; revised February 15, 2008; accepted April 22, 2008

bstract Background: The aim of this study was to examine the differences between male and femalebariatric surgery candidates with respect to health-related quality of life (HRQOL), health, socio-demographic variables, and interactions among these variables in a bariatric surgery practice in theUnited States. Women seek bariatric surgery 5 times more often than men. Research on genderdifferences in HRQOL is limited, and the results are conflicting.Methods: A total of 794 surgery candidates (mean age 42.2 y; body mass index 46.9 kg/m2; 84.8%women) completed both a weight-related (Impact of Weight on Quality of Life-Lite questionnaire)and a generic (Medical Outcomes Study Short-Form-36) measure of HRQOL. Health was evaluatedby questionnaire and clinical interviews.Results: Compared to men, women reported reduced HRQOL on 3 of the 5 scales assessingobesity-specific HRQOL and also the physical aspects of general HRQOL. Women also had doublethe rate of depression (48.5% versus 22.5%), and men had double the rate of sleep apnea (80.3%versus 40.2%). Women were younger, less obese, and were less likely to be married. No genderdifferences were found in the association between HRQOL and co-morbidities. However, anincreasing number of co-morbidities was associated with decreasing physical and mental HRQOL.Additionally, depression was associated with decreased mental HRQOL, and coronary heart diseasewas associated with decreased physical HRQOL.Conclusion: Women’s reduced HRQOL, particularly in self-esteem, sexual life, and physical func-tioning, and their greater rates of depression, might play a role in their decision to seek bariatric surgery.Although we could not determine causality, this study is a first step toward understanding why womenseek surgery 5 times more often than men. (Surg Obes Relat Dis 2008;4:651–659.) © 2008 AmericanSociety for Metabolic and Bariatric Surgery. All rights reserved.

Surgery for Obesity and Related Diseases 4 (2008) 651–659

eywords: Health-related quality of life; Gender; Co-morbid conditions; Gastric bypass surgery

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Supported by a grant from the National Institute of Arthritis, Diabetes,igestive and Kidney Diseases (“Morbidity and Mortality Related toastric Bypass Surgery” R01 DK055006-06A1).

*Reprint requests: Ronette L. Kolotkin, PhD, Obesity and Quality ofife Consulting, PLLC, 1004 Norwood Avenue, Durham, NC 27707.

8E-mail: rkolotkin@qualityoflifeconsulting.com

550-7289/08/$ – see front matter © 2008 American Society for Metabolic and Boi:10.1016/j.soard.2008.04.012

In 2007, an estimated 205,000 people in the Unitedtates underwent a bariatric surgery procedure [1]. Recentata from U.S. and international samples have indicated thatomen are �5 times more likely than men to seek bariatric

urgery [2,3]. The U.S. Nationwide Inpatient Sample re-orted an upward trend in the proportion of women whoere bariatric surgery patients from 1998 to 2002 (from

1% to 84%) [3]. Data collected from 137 bariatric surgeons

ariatric Surgery. All rights reserved.

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652 R. L. Kolotkin et al. / Surgery for Obesity and Related Diseases 4 (2008) 651–659

nd �41,000 patients internationally from 1987 to 2004ndicated that 85% of patients were women [2]. The reasonsomen are �5 times more likely than men to seek bariatric

urgery are poorly understood.Studies of bariatric surgery patients have consistently

eported impaired general health-related quality of lifeHRQOL) relative to population samples [4–7]. Similarly,ariatric surgery patients have reported more impairment inbesity-specific quality of life (QOL) than community sam-les [6,8]. Few studies have examined HRQOL in bariatricurgery patients with respect to gender. In the Swedishbese Subjects study [9], a controlled clinical trial of sur-ically versus conventionally treated obese persons inhich 33% of the sample was men, surgically treatedomen (as well as conventionally treated women) reportedreater psychosocial problems in everyday life at baselinen an obesity-specific measure of HRQOL. However, noender differences were found at baseline in the Swedishbese Subjects study using a generic measure of HRQOL.

n a sample of gastric bypass surgery patients with extremebesity (mean BMI 53.3 kg/m2; 18% men), differences inbesity-specific HRQOL were found for both gender andace, with white women reporting the greatest HRQOLmpairments and African-American men reporting the least10]. Two other studies examining gender differences inRQOL in bariatric surgery patients found no differencesetween men and women [11,12]. Using an obesity-specificeasure of QOL, Stout et al. [12] found no differences inRQOL between male and female bariatric surgery patients

16% men). Using 3 of the 4 physical domains of a generalRQOL instrument (physical functioning, physical role

imitations, and bodily pain), Fabricatore et al. [11] alsoound no differences between men and women who soughtariatric surgery (19% men). Thus, research on the HRQOLf bariatric surgery patients by gender is limited, with stud-es reporting conflicting findings.

Studies of bariatric surgery patients have also reportedender differences with respect to preoperative co-morbidonditions. In 300 U.S. patients presenting for bariatricurgery (86.8% women), the prevalence of cardiac diseaseas much greater for men than for women (10.5% versus.9%), as was the prevalence of sleep apnea (57.8% versus4.9%) [13]. However, women had a greater prevalence ofepression than did men (52.5% versus 31.5%). Similarifferences in the prevalence of sleep apnea and cardiacisease for men versus women were found in a recent studyy Tymitz et al. [14]. No differences were found betweenen and women with respect to the prevalence of diabetes,

ypertension, asthma, gastroesophageal reflux disease, orrthritis.

The purpose of the present study was to better under-tand the differences between male and female bariatricurgery candidates with respect to general and obesity-pecific HRQOL, co-morbid conditions, sociodemographic

haracteristics, and the interactions of these variables. To a

ur knowledge, no studies have examined the relationshipetween HRQOL and co-morbid conditions by gender inariatric surgery patients. Specifically, we attempted to an-wer the following questions: (1) whether male and femaleastric bypass candidates differ in terms of sociodemo-raphic and weight characteristics, preoperative medicalo-morbidities, and preoperative HRQOL; (2) whetherRQOL is influenced by the number of preoperative co-orbid conditions; and (3) how specific preoperative co-orbid conditions influence HRQOL, and whether these

nfluences differ by gender. Although these data did notllow us to answer the question of why women are �5 timesore likely to seek bariatric surgery than men, we see this

s an important first step in exploring this question.

ethods

articipants

The sample for the present study consisted of 794 gastricypass surgery patients recruited from a bariatric surgeryractice in Utah for a 2-year prospective study [15]. Thexclusion criteria for the study were as follows: previouseight loss surgery, gastric or duodenal ulcers within therevious 6 months, active cancer (with the exception ofonmelanoma skin cancer), alcohol or narcotic abuse, andyocardial infarction within the previous 6 months.

rocedures

The University of Utah institutional review board ap-roved this study, and all participants provided writtennformed consent. At the initial evaluation, the participants’eight and weight were obtained by the study personnel.he body mass index (BMI) was calculated as weight inilograms divided by the height in meters squared. Beforeurgery, the participants completed 2 measures of HRQOLdescribed in the next section, “Measures”).

Additionally, during the participant’s visit to the generallinical research center or the Cardiovascular Geneticslinic, a medical history was obtained using an extensiveisease endpoints questionnaire. This included a reportededical history of sociodemographic information, coronary

eart disease, angina, clinically diagnosed depression withreatment, hypothyroidism, acid reflux, cancer, and gout. Inddition, complete documentation of the patient’s currentedications was obtained from the prescription bottles

rought in by the participant. Finally, clinical measurementsblood pressure, blood lipids, glucose, hemoglobin A1c, andleep apnea screening) were used to diagnose previouslyndiagnosed conditions. Coronary heart disease was defineds myocardial infarction, coronary bypass surgery, or per-utaneous transluminal coronary angioplasty. Hypertensionas defined as blood pressure of �140/90 mm Hg (averagef 3 measurements with the patient sitting) or the use of

ntihypertensive medications. Diabetes was defined as a

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653R. L. Kolotkin et al. / Surgery for Obesity and Related Diseases 4 (2008) 651–659

asting glucose level of �126 mg/dL or the use of antidia-etic medication. Sleep apnea diagnoses were determinedy the results from limited polysomnographic screeningApnea-Hypopnea Index) or reported continuous positiveirway pressure use, and thus was recorded for only a subsetf the sample (n � 424). Additional details about the designnd rationale of the primary study can be found in the reporty Adams et al. [15].

easures

Two questionnaires were used: the Impact of Weight onuality of Life-Lite (IWQOL-Lite) questionnaire and a ge-eric questionnaire, the Medical Outcomes Study Short-orm-36 (SF-36).

The IWQOL-Lite [16] is a measure of weight-relatedOL, consisting of 31 items that begin with the phrase,

Because of my weight . . . .” Each item has 5 responseptions, ranging from 1, “never true” to 5, “always true.”he IWQOL-Lite provides scores in 5 domains (physical

unction, self-esteem, sexual life, public distress, and work),long with a total score. The scores range from 0 to 100,ith lower scores indicating greater impairment. In nonpsy-

hiatric samples, the IWQOL-Lite has demonstrated excel-ent reliability, with alpha coefficients ranging from .90 to94 for individual scales and .96 for the total score [16] andtest-retest reliability ranging from .81 to .88 for scales and

94 for the total score [17]. Scores on the IWQOL-Lite haveeen shown to correlate consistently with the BMI [16, 17]nd other measures of HRQOL [17], change with weightoss/gain [18,19], and to differentiate obese subgroups onhe basis of treatment-seeking status [8].

The SF-36 [20], a 36-item self-report instrument, is aidely used measure of general HRQOL. The SF-36 con-

ists of 8 subscales (physical functioning, role limitationsue to physical health problems, bodily pain, general health,itality, social functioning, role limitations due to emotionalroblems, and mental health) and 2 summary scores (phys-cal component summary [PCS] and mental componentummary [MCS]). The 2 summary scores represent rela-ively independent (i.e., orthogonal) indexes based on factornalysis of subscale scores using the Medical Outcomestudy data [20]. Estimates of internal consistency for theF-36 have typically been �.80 for all subscales acrossiverse patient groups [21, 22].

tatistical analyses

Male and female gastric bypass patients were comparedy sociodemographic and weight characteristics using inde-endent samples t tests (BMI, age, years of education) andhi-square tests (ethnicity, marital status) based on an alphaevel of .05. Logistic regression analyses were then per-ormed to determine whether men and women differed inhe rates of 9 separate co-morbid conditions. Analyses were

erformed with and without the covariates that differed a

ignificantly by gender (BMI, age, marital status) using anlpha level of .01. This approach was taken to determinehether the differences in the rates of co-morbidities ob-

erved between men and women could be accounted for byifferences in sociodemographic and weight characteristics.ignificant effects were determined from the unadjusted anddjusted analyses. A series of 2 (male versus female gender)y 4 (0, 1, 2, �3 co-morbidities) general linear models werehen performed to evaluate differences in HRQOL by gen-er and co-morbidity. Dependent variables for these analy-es included all scales and the total score from the IWQOL-ite and the PCS and MCS scores from the SF-36. Thenalyses were performed with and without the covariateshat differed significantly by gender (BMI, age, maritaltatus) as determined by an alpha level of .01. Finally, aeries of general linear models were performed using indi-idual co-morbidities and gender to predict the HRQOL.or simplicity, only the IWQOL-Lite total score and theomponent scores from the SF-36 (PCS, MCS) were in-luded as dependent variables in these analyses. The pri-ary tests of interest were the main effect for co-morbidity,hich evaluates whether the presence of a specific co-orbidity influences HRQOL, and the co-morbidity by gen-

er interaction, which evaluates whether this influence ofo-morbidities on HRQOL differs by gender. Again, thenalyses were performed with and without the covariateshat differed significantly by gender (BMI, age, maritaltatus) using an alpha level of .01.

esults

ociodemographic and weight characteristics

The present sample consisted of 674 women (mean age1.7 y, range 19-70) and 120 men (mean age 45.1 y, range8-71). The sociodemographic and weight characteristicsy gender are presented in Table 1. Women had a signifi-antly lower BMI (P � .013), were on average youngerP �.001), and were less likely than men to be married69% versus 56%, respectively). Men and women did notiffer significantly in terms of education or ethnicity.

reoperative co-morbid conditions

Table 2 lists the rates of co-morbidities by gender.omen had significantly greater rates of depression (48.5%

ersus 22.5%), and men had significantly greater rates ofleep apnea (80.3% versus 40.2%), hypertension (52.5%ersus 32.0%), and gout (10.0% versus .7%). Although menlso had significantly greater rates of diabetes (28.3% versus6.8%) and coronary heart disease (5.8% versus 1.2%) inhe unadjusted analyses, when the covariates were included,hese differences approached, but did not reach, the signif-cance level of .01, suggesting that these covariates (BMI,

ge, marital status) accounted for some of the observed

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654 R. L. Kolotkin et al. / Surgery for Obesity and Related Diseases 4 (2008) 651–659

ifferences between men and women in the rates of diabetesnd coronary artery disease.

RQOL differences

Table 3 lists the IWQOL-Lite and SF-36 componentcores by gender and number of preoperative co-morbidi-ies. Women reported significantly more impairment on theWQOL-Lite self-esteem, sexual life, and work scales, asell as the IWQOL-Lite total score and the PCS from theF-36. Significantly greater impairments in HRQOL with

ncreasing number of preoperative co-morbidities wereound for the PCS and MCS component scores from theF-36. Although increasing preoperative co-morbiditiesere also significantly associated with greater impairments

or the physical function and sexual life scales from theWQOL-Lite in unadjusted analyses, these differences ap-

able 1ociodemographic and weight characteristics by gender

ariable Women (n � 674)

ean BMI (kg/m2) 46.3 � 14.0ean age (y) 41.7 � 10.9ean education (y) 13.5 � 3.1

thnicity (n)White 601 (89.2)Hispanic 39 (5.8)American Indian 10 (1.5)Asian/Pacific Islander 2 (0.3)African American 7 (1.0)Other 12 (1.8)Not reported 3 (0.4)arital status (n)Married 377 (55.9)Single 125 (18.5)Divorced 122 (18.1)Widowed 14 (2.1)Not reported 36 (5.3)

BMI � body mass index.Data presented as mean � standard deviation or numbers of patients, w

able 2o-morbid conditions by gender

o-morbid condition Women (n � 674) Men (n �

epression 327 (48.5) 27 (22.5)ypothyroidism 121 (18.0) 15 (12.5)cid reflux 175 (26.0) 19 (15.8)leep apnea† 144 (40.2) 53 (80.3)ypertension 216 (32.0) 63 (52.5)iabetes 113 (16.8) 34 (28.3)out 5 (0.7) 12 (10.0)oronary heart disease 8 (1.2) 7 (5.8)ancer 20 (3.0) 3 (2.5)

OR � odds ratio; BMI � body mass index.Data presented as number of patients, with percentages in parentheses,* Adjusted for BMI, age and marital status.† Sleep apnea data collected for only 358 women and 66 men.

‡ Statistically significant (P �.01).

roached, but did not reach, the significance level of .01hen the covariates were included. None of the co-morbid-

ty interactions by gender were significant, suggesting thathe influence of the number of co-morbidities on HRQOLoes not differ by gender.

ndividual co-morbidities and HRQOL

Table 4 lists the logistic regression analysis results ex-mining the influence of individual co-morbidities onRQOL scores. Overall, few individual co-morbiditiesere associated with greater impairments in HRQOL. Theresence of acid reflux was significantly associated withreater impairments in both IWQOL-Lite total score and MCScore. Coronary heart disease was associated with greater im-airments in the PCS score and depression with significantly

Men (n � 120) Significance

50.3 � 25.5 t(792) � 2.48, P � .01345.1 � 11.1 t(792) � 3.22, P �.00113.8 � 4.4 t(767) � 0.61, P � .544

� 2(6) � 4.77; P � .573

112 (93.3)3 (2.5)1 (0.8)0 (0.0)0 (0.0)3 (2.5)1 (0.8)

�2(4) � 26.10; P �.001

83 (69.2)18 (15.0)3 (2.5)2 (1.7)

14 (11.7)

centages in parentheses.

Unadjusted OR (P value) Adjusted OR* (P value)

3.25 (�.001)‡ 3.29 (�.001)‡1.53 (.147) 1.79 (.054)1.86 (.019) 1.80 (.029).165 (�.001)‡ .184 (�.001)‡.427 (�.001)‡ .508 (.002)‡.509 (.003)‡ .553 (.012).067 (�.001)‡ .081 (�.001)‡.194 (.002) .249 (.013)1.19 (.779) 1.76 (.384)

otherwise noted.

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655R. L. Kolotkin et al. / Surgery for Obesity and Related Diseases 4 (2008) 651–659

reater impairments in the MCS score. Again, none of theo-morbidity interactions by gender were significant.

iscussion

Consistent with the published bariatric surgery data [2],his sample of individuals seeking gastric bypass surgeryas predominantly women (84.8%). A key aim of this

esearch was to add to our understanding of why women aretimes more likely to undergo bariatric surgery. From the

esults of this study, several differences were observed be-ween men and women with respect to HRQOL, health, andociodemographic variables. Specifically, women had re-uced HRQOL compared with men on 3 of the 5 scalesssessing obesity-specific HRQOL and also the physicalspects of general HRQOL. Although some significant as-ociations were found between co-morbid conditions andRQOL, these associations did not differ by gender.omen also had double the rate of depression, but men had

ouble the rate of sleep apnea, even after controlling forMI, age, and marital status. Men also had greater rates ofypertension and gout compared with women. With respecto the sociodemographic variables, women were younger,

able 3WQOL-Lite and SF-36 scores by gender and number of co-morbidities

RQOL scale CMC (number of participants)

0 1 2

hysical functionWomen 36.2 � 21.4 (124) 30.7 � 18.8 (203) 27.2 � 18.5Men 39.8 � 23.3 (15) 31.1 � 18.4 (34) 28.0 � 22.2

elf-esteemWomen 21.3 � 20.9 (124) 23.4 � 21.9 (204) 20.4 � 18.1Men 26.9 � 19.7 (15) 32.8 � 22.1 (34) 35.7 � 23.2

exual lifeWomen 47.5 � 32.0 (114) 45.5 � 32.2 (190) 41.3 � 29.8Men 53.8 � 31.8 (15) 51.0 � 30.5 (32) 60.0 � 29.0

ublic distressWomen 40.7 � 23.5 (124) 37.6 � 23.0 (204) 38.3 � 24.6Men 43.3 � 20.1 (15) 39.7 � 22.0 (33) 44.1 � 24.2orkWomen 51.9 � 26.2 (123) 48.1 � 27.8 (200) 44.4 � 25.0Men 58.8 � 17.8 (15) 49.4 � 24.3 (34) 53.1 � 27.4

WQOL-Lite totalWomen 36.9 � 18.1 (124) 34.2 � 17.6 (204) 31.3 � 15.5Men 41.7 � 16.8 (15) 38.1 � 17.7 (34) 39.6 � 17.2

CSWomen 37.2 � 5.9 (124) 35.6 � 5.9 (204) 33.9 � 6.0 (Men 38.3 � 7.0 (15) 37.4 � 5.7 (34) 35.4 � 7.1 (CSWomen 40.7 � 6.7 (124) 40.8 � 7.0 (204) 41.0 � 6.6 (Men 42.0 � 3.6 (15) 39.9 � 5.3 (34) 45.3 � 8.8 (

IWQOL-Lite � Impact of Weight on Quality of Life-Lite; SF-36 � Medphysical component summary; MCS � mental component summary; C* Adjusted for body mass index, age, and marital status.† Statistically significant (P �.01).

ess obese, and less likely to be married. f

Previous research on HRQOL differences between malend female bariatric surgery patients has been limited, andhe findings have been inconsistent [9,10,12]. Unlike thetudy by Stout et al. [12], which found no differencesetween men and women using the IWQOL-Lite, theresent study found gender differences in the self-esteem,exual life, and work domains, as well as the total score.lthough the study by White et al. [10] reported genderifferences on the IWQOL-Lite scales, these differencesccurred in the physical function, self-esteem, sexual lifeomains and the total score. Thus, 2 of the 3 studies assess-ng HRQOL using the IWQOL-Lite questionnaire reportedender differences in self-esteem and sexual life, suggestinghat these areas might be particularly salient for women whoeek bariatric surgery.

In the study by Karlsson et al. [9], the single-domainbesity-Related Psychosocial Problems scale [23] was used

o assess obesity-specific HRQOL. These investigatorsound that female bariatric surgery patients reported moresychosocial problems in everyday life because of weighthan did men. The present study’s findings, using a differentbesity-specific instrument, are consistent with their results.owever, unlike the study by Karlsson et al. [9], which

Unadjusted significance Adjusted significance*

�3 Gender CMC Int Gender CMC Int

21.6 � 17.5 (162) .089 �.001† .307 .010† .019 .32930.4 � 20.1 (37)

19.1 � 20.6 (162) �.001† .359 .039 �.001† .761 .01841.3 � 24.5 (37)

31.7 � 31.1 (144) .002† .006† .404 .001† .018 .40043.4 � 27.9 (36)

32.0 � 24.3 (162) .034 .524 .522 .073 .263 .40442.8 � 28.1 (37)

39.3 � 28.0 (161) .004† .267 .270 .004† .299 .31054.2 � 23.4 (37)

26.2 � 16.8 (162) �.001† .132 .161 �.001† .175 .18839.6 � 18.6 (37)

33.1 � 5.9 (162) .010† .000† .955 .002† .005† .95935.3 � 7.3 (37)

39.2 � 7.2 (162) .015 .007† .034 .087 .003† .01941.7 � 6.9 (37)

tcomes Study short-form 36; HRQOL � health-related quality of life; PCSco-morbid condition; Int � interaction.

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ound no gender differences in general HRQOL, women in

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656 R. L. Kolotkin et al. / Surgery for Obesity and Related Diseases 4 (2008) 651–659

he present study were more impaired in the physical as-ects of general HRQOL than were men.

It has been suggested that the effect of obesity onRQOL might be 1 of the primary reasons individuals seek

reatment [24,25]. The greater degree of HRQOL impair-ent in the seekers of bariatric surgery compared with

bese individuals who seek other treatment alternatives [8]uggests that HRQOL impairment might be an importanteterminant of who seeks bariatric surgery. Although weould not determine causality from this study, it is likelyhat women’s greater HRQOL impairments play a role inheir preponderance as bariatric surgery patients. Many ofhe impairments found in women seeking bariatric surgeryere psychosocial (i.e., high rates of depression and re-uced self-esteem and sexual life), and it is possible thathese psychosocial concerns are the driving force behindheir decision to seek bariatric surgery. However, the pres-nce of a reduced physical HRQOL in women also suggestshat physical conditions, as well as psychosocial concerns,re relevant in their decision to seek bariatric surgery. Afterdentifying 187 items related to extreme obesity, Duval etl. [26] asked bariatric surgery candidates to find the itemsost significant for them and to rate each item’s impor-

ance. Men and women identified similar areas of signifi-ance; however, women reported a greater overall effect ofbesity and they rated dissatisfaction with physical appear-nce as second in importance. In contrast, this was rated aseventh in importance by men. Thus, the effect of weight onOL and life satisfaction appears to be much stronger for

able 4ssociation between individual comorbidities and HRQOL

o-morbid condition Effect IWQOL-Lite total

Unadjustedsignificance

Adjustedsignifican

epression Main .053 .043By gender .946 .963

ypothyroidism Main .602 .596By gender .050 .011

cid reflux Main .003† .002†By gender .533 .494

leep apnea Main .740 .685By gender .610 .618

ypertension Main .289 .540By gender .257 .210

iabetes Main .616 .776By gender .435 .424

out Main .784 .845By gender .480 .523

oronary heart disease Main .811 .933By gender .888 .700

ancer Main .084 .097By gender .297 .267

Abbreviations as in Table 3.* Adjusted for body mass index, age, and marital status.† Statistically significant (P �.01).

omen than for men, and women place greater importance s

n physical appearance than do men. Previous research hashown that women are more likely to have weight and bodymage concerns [27], and men are more likely to identifyhemselves as light, regardless of their actual weight28,29]. Additionally, the preponderance of women as bari-tric surgery patients could also be understood within theontext of women’s general health-seeking behavior.omen are much more likely to seek out medical services

han are men [30].The present study found gender differences in the rates

f co-morbid conditions that were similar to those reportedy Residori et al. [13], in which the sample was also pre-ominantly female. Residori et al. [13] reported a greaterrevalence of sleep apnea in men (57.8% men versus 24.9%omen) and depression in women (52.5% women versus1.5% men). Another study [11], using an inventory tossess the presence of depressive symptoms rather thanlinical diagnoses of depression, found no gender differ-nces in bariatric surgery patients with respect to depressiveymptoms, suggesting that the method of assessment muste considered when comparing results across studies.

One of the important contributions of our report is thevailability of data for both HRQOL and co-morbid condi-ions—and thus the opportunity to study the interrelation-hips of these variables. With respect to general HRQOL,e found that as the number of co-morbid conditions in-

reased, the HRQOL decreased in both the physical andental (i.e., psychosocial) domains. These differences re-ained even after controlling for BMI, age, and marital

PCS MCS

Unadjustedsignificance

Adjustedsignificance*

Unadjustedsignificance

AdjustedSignificance*

.062 .08 .001† �.001†

.858 .846 .420 .359

.574 .653 .903 .819

.011 .048 .493 .245

.338 .208 .003† .005†

.151 .217 .027 .047

.335 .544 .411 .598

.815 .780 .941 .981

.008† .126 .541 .708

.522 .622 .780 .659

.026 .104 .949 .642

.834 .755 .293 .204

.203 .341 .390 .236

.242 .171 .167 .123

.001† .006† .967 .643

.313 .568 .447 .651

.071 .184 .608 .941

.210 .184 .917 .900

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tatus. For obesity-specific QOL, both physical function and

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exual life domain scores diminished as the number ofo-morbid conditions increased. However, these differencesid not remain statistically significant after controlling forMI, age, and marital status. Several of the individualo-morbid conditions were associated with decreasedRQOL. As might be expected, the presence of depressionas associated with decreased mental (i.e., psychosocial)RQOL. Unlike the study by Fabricatore et al. [11], we didot find an association between depression and the physicalspects of HRQOL. However, methodologic differencesetween these studies might explain this discrepancy. Al-hough Fabricatore et al. [11] used an inventory to assess theymptoms of depression, we used documented evidence ofiagnosed clinical depression. Another not unexpected find-ng was the presence of coronary heart disease being asso-iated with decreased physical HRQOL. Although the pres-nce of acid reflux was also associated with decreasedental HRQOL and decreased overall obesity-specificRQOL, it is difficult to interpret these unexpected find-

ngs.One of the limitations of this study was the lack of

eographic heterogeneity in the sample, which might limithe generalizability of the results. Another limitation washat the data did not include all co-morbid conditions asso-iated with obesity. Most noteworthy is the absence ofrevalence rates of arthritis. In the study by Residori et al.13], 91% of the bariatric surgery patients and 27.3% of theatients in the study by Livingston et al. [31] had arthritis.

onclusion

The results of this study of bariatric surgery patientsound important differences between men and women withespect to preoperative HRQOL, health, and sociodemo-raphic variables. Women’s HRQOL was impaired relativeo men’s, particularly in the areas of self-esteem, sexual life,ork, and general physical HRQOL Women also experi-

nced double the rate of depression, and men experiencedouble the rate of sleep apnea. Women in this study alsoended to be younger and less obese and were less likely toe married. Thus, gender differences in HRQOL showromise as a potential explanation for the reason 5 timesore women than men seek bariatric surgery.

isclosures

R. L. Kolotkin received compensation in her role asonsultant for the grant, and she received royalties fromuke University for use of the IWQOL-Lite questionnaire.

eferences

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[3] Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgicalprocedures. JAMA 2005;294:1909–17.

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[9] Karlsson J, Sjostrom L, Sullivan M. Swedish Obese Subjects(SOS)—an intervention study of obesity: two-year follow-up ofhealth-related quality of life (HRQL) and eating behavior after gastricsurgery for severe obesity. Int J Obes Relat Metab Disord 1998;22:113–26.

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between men and women who

trongly affect one another. Such studies will advance

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Am 2007;91:451–69, xi–xii. 2004;188:105–10.

Editorial comment

Comment on: Health and health-related quality of life: differences

seek gastric bypass surgery

As bariatric surgery has grown in popularity during theast decade, so has interest in the psychosocial aspects ofxtreme obesity. Within the past several years, a number ofcholarly reviews have detailed the psychosocial burdenssociated with the experience of being extremely obese1–6]. The report by Kolotkin et al. [7] adds to this infor-ation and attempts to provide at least some answers to the

eason the vast majority of individuals who seek bariatricurgery are women, although the population-based statisticsave indicated that the rate of extreme obesity among mennd women is not as disparate [8].

Kolotkin et al. [7] asked 794 candidates for bariatricurgery to complete 2 widely used psychometric measuresf quality of life. The women, although younger and lessbese than the men, endorsed lower levels of physical func-ioning, as well as greater impairments in self-esteem andexuality. Women also reported more than double the rate oflinically diagnosed and treated depression compared withen. Although these results are not particularly surprising to

hose who work with bariatric surgery patients on a regularasis, they underscore the emotional toll many women withxtreme obesity experience.

One of the most novel and likely important findings fromhis study is the association between a greater number ofo-morbidities and reductions in both physical and mentalealth-related quality of life. Although research on all as-ects of bariatric surgery is increasing, all too often thetudies have been limited to either the physical or psycho-ocial aspects of extreme obesity. If we are to trulynderstand the experience of the bariatric surgery pa-ient— both pre- and postoperatively—we must consideroth the physical and psychological aspects of extremebesity, not in isolation, but as variables that often

ur scientific knowledge and also hold the greatest po-ential to affect clinical care.

Although the present paper adds to our understanding ofhe quality-of-life experiences of individuals interested inariatric surgery, it tells us little about the postoperativehanges that occur in these domains. As is widely known, arowing number of investigations have demonstrated im-rovements in mortality associated with surgically inducedeight loss [9–16]. These weight losses are, in most cases,

ccompanied by significant improvements in many domainsf psychosocial functioning, including quality of life andeductions in depressive symptoms [1–6]. However, just asbesity-related co-morbidities do not improve or resolve forvery patient, the psychosocial issues also do not alwaysmprove. Every bariatric surgery program has witnessedatients who continue to struggle with disordered eating,epression, and extreme body image dissatisfaction, evenfter experiencing a successful surgical outcome from aeight and co-morbidity reduction perspective. As sug-ested by at least 2 recent studies, the emotional chal-enges associated with the experience of bariatric surgerynfortunately leads a greater than expected number ofatients to turn to suicide [9,17]. Although the reasonsor this are not well understood at present, it underscoreshe need for additional quality research, such as thatound in the present study, to help us better understandhe psychological factors that lead to the decision tondergo bariatric surgery, as well as the changes in theseariables that occur postoperatively.

isclosures

The author claims no commercial associations that

ight be a conflict of interest in relation to this article.