Psychosocial aspect of bariatric surgery

1. Role of Psychosocial Factors on Employment
Outcome One Year After Bariatric Surgery
Sanjeev Sockalingam, MD, FRCPC
Susan Wnuk, PhD
Karin Karkan, BA
Christopher Meaney, MSc
Allan Okrainec, MD, FRCSC
Raed Hawa, MD, FRCPC
Stephanie Cassin, PhD
APM 2014

2. APM 2014
Disclosure: Sanjeev Sockalingam, MD
With respect to the following presentation, there
has been no relevant (direct or indirect) financial
relationship between the party listed above (and/or
spouse/partner) and any for-profit company in the
past 24 months which could be considered a
conflict of interest.

3. Bariatric Surgery is a Treatment for Severe
Obesity
Roux-en-Y GB Sleeve Gastrectomy Lap Band

4. Do these Operations Work?
Resolution of Comorbidities
1 Year Outcome Laparoscopic
RYGB
Lap Sleeve
Gastrectomy
Lap Band
Reduction in BMI - 15.34 - 11.87 - 7.05
Diabetes 83% 55% 44%
Hyperlipidemia 66% 35% 33%
Hypertension 79% 68% 44%
Obstructive Sleep
Apnea
66% 62% 38%
GERD 70% 50% 64%
Hutter et al, Ann Surg, 2011
ACS-BSCN – 109 Hospitals, 28,616 patients 2007-2010

5. Impact of Obesity on Employment
• Obesity results in $44 billion in health costs
– Employees with stage III obesity account for 21%
of this cost
• Obesity results in increased sick leave,
medical claims and workplace injuries
• 32% of bariatric surgery candidates have
claimed at least one disability benefit
compared to 10% for post-op patients
Wolf AM. Obes Res 2002; Schmier JK et al. 2006
Finkelstein EA et al. 2009; Cawley J et al. 2012

6. Background: Studies of Employed Workers
• Preliminary studies report that patients undergoing
bariatric surgery experience:
– Less absenteeism
– 5.7 hour increase in number of hours worked per week
– 22%-25% increase in the number of patients in full time or part
time employment
• Studies are limited by retrospective design, lack of
standardized employment measures and limited
assessment of the impact of psychiatric illness on
employment outcomes
Hawke A et al. 1990; Hawkins SC et al. 2007
Neovius K et al. 2008’ Sampalis JS et al. Obes Surg 2004

7. Study Objectives
• To determine changes in patients’ employment impairment and
productivity 12-months post-bariatric surgery
• To identify potential psychosocial predictors of changes in
employment outcomes after surgery

8. Methods: Study Sample
• Consecutive patients from Toronto Western Hospital
Bariatric Surgery Program who received bariatric
surgery between Feb 2010 and November 2012
(n=223)
• 18 years or older, employed and provided informed
consent
• Bariatric surgery suitability based on NIH guidelines
and patient received Roux-en-Y gastric bypass
unless a sleeve was surgically indicated

9. Methods: Study Measures
• Demographic data and employment type (based on
National Occupation Classification)
• Measures collected pre-surgery and 12-months post-
surgery
• Measured heights and weights
– Calculated % total weight loss (%TWL) = [(pre-surgery
weight – 12 month post-surgery weight)/ pre-surgery weight]
• Employment measure: Lam Employment Absence
and Productivity Scale (LEAPS)
– Total score (0-28) & Productivity Score (0-12)

11. Methods: Study Measures & Analysis
• Other Measures:
– Depression – PHQ9 (0-27)
– Anxiety – GAD7 (0-21)
– Quality of Life – SF36 (Physical and Mental Component
Score)
– Psychiatric Illness – MINI International Neuropsychiatric
Interview
• Data Analysis:
– Power analysis based on other studies of non-bariatric
patients – needed 164 patients
– Calculated difference scores for LEAPS total and
productivity sub-scale & analyzed Wilcoxon Rank Sum
– Multiple linear regression analysis for predictors of LEAP
outcomes

12. Sample Characteristics
Sample Characteristics
Gender (female), n (%) 133 (81.1%)
Age (years) 43.5 ± 9.7
Race (%)
White
Black
138 (84.1%)
10 (6.1%)
Pre-Surgery BMI 49.0 ± 8.0
% TWL at 12 months post-surgery 34.3 ± 11.6
Pre-Surgery Type of Employment
Sales and Service
Business, finance and administration
Education, law and social, community, governmental services
Health
Trades and transport
Natural and applied sciences
Art, culture, recreation
Management
Other
40 (24.4%)
39 (23.8%)
35 (21.3%)
16 (9.8%)
9 (5.5%)
7 (4.3%)
4 (2.4%)
4 (2.4%)
10 (6.1%)
History of a Psychiatric Disorder (excluding Personality d/o), n (%) 89 (54.3%)
History of a Mood Disorder n (%) 57 (34.8%)
History of an Anxiety Disorder, n (%) 22 (13.4%)
History of a Eating Disorder, n (%) 31 (18.9%)
Participant Characteristics
Continuous variables reported as means ± standard deviation

13. Psychosocial and Employment Benefits of
Bariatric Surgery
Employment and Quality of
Life Outcomes
Pre-Surgery
12-Months
Post-Surgery Pvalue
Mean (SD) Mean (SD)
SF-36
SF-36 Physical Score
SF-36 Mental Score
32.10 ± 9.39
49.13 ± 10.42
52.19 ± 6.64
52.89 ± 11.25
P < 0.0001
P = 0.001
Psychological Distress
Measure
PHQ9 (Depression)
GAD7 (Anxiety)
9.54 ± 5.81
5.58 ± 5.34
3.47 ± 4.08
2.60 ± 4.08
P < 0.0001
P < 0.0001
Employment Outcomes
LEAPS Total Score
LEAPS Productivity
6.38 ± 5.30
1.99 ± 2.26
2.61 ± 4.41
0.79 ± 1.87
P < 0.0001
P < 0.0001
N=164

14. Bivariate and Multiple Linear Regression Analysis
of Change in LEAP Total Score

15. Bivariate and Multiple Linear Regression Analysis
of Change in LEAP Productivity Sub-Scale

16. Limitations
• Only examined outcomes in patients who
were employed (focus of LEAPS)
• Did not study the impact of weight based
discrimination on employment outcomes
• Conducted in Canadian sample and unclear
how results generalize to outside of Canada

17. Conclusions
• Bariatric surgery was associated with a significant
reduction in work impairment (negative LEAP difference
score) and significant improvement in work productivity
• Quality of life, depressive symptoms and anxiety
symptoms improved 12-months after bariatric surgery
• Pre-surgery PHQ9, GAD7 and SF-36 MCS were
significant predictors of changes in work-related
impairment and productivity but NOT a history of a
psychiatric illness

18. Conclusions
• Patients with greater work impairment and
psychopathology pre-surgery experience greatest
employment improvement
• Parallel effect on QOL and psychopathology after
surgery reinforces shared patho-etiology between
obesity and mental illness – employment impairment
could improve due to improved psychiatric symptoms
• Future research should build on this study and examine
more specific employment outcomes