Importance Weight loss surgery (WLS) has been shown to produce long-term
weight loss but is not risk free or universally effective. The weight
loss expectations and willingness to undergo perioperative risk among
patients seeking WLS remain unknown.
Objectives To examine the expectations and motivations of WLS patients
and the mortality risks they are willing to undertake and to explore
the demographic characteristics, clinical factors, and patient perceptions
associated with high weight loss expectations and willingness to assume
high surgical risk.
Design We interviewed patients seeking WLS and conducted multivariable
analyses to examine the characteristics associated with high weight
loss expectations and the acceptance of mortality risks of 10% or
higher.
Setting Two WLS centers in Boston.
Participants Six hundred fifty-four patients.
Main Outcome Measures Disappointment with a sustained weight loss of 20% and willingness
to accept a mortality risk of 10% or higher with WLS.
Results On average, patients expected to lose as much as 38% of their
weight after WLS and expressed disappointment if they did not lose
at least 26%. Most patients (84.8%) accepted some risk of dying to
undergo WLS, but only 57.5% were willing to undergo a hypothetical
treatment that produced a 20% weight loss. The mean acceptable mortality
risk to undergo WLS was 6.7%, but the median risk was only 0.1%; 19.5%
of all patients were willing to accept a risk of at least 10%. Women
were more likely than men to be disappointed with a 20% weight loss
but were less likely to accept high mortality risk. After initial
adjustment, white patients appeared more likely than African American
patients to have high weight loss expectations and to be willing to
accept high risk. Patients with lower quality-of-life scores and those
who perceived needing to lose more than 10% and 20% of weight to achieve
“any” health benefits were more likely to have unrealistic
weight loss expectations. Low quality-of-life scores were also associated
with willingness to accept high risk.
Conclusions and Relevance Most patients seeking WLS have high weight loss expectations
and believe they need to lose substantial weight to derive any health
benefits. Educational efforts may be necessary to align expectations
with clinical reality.
Bariatric or weight loss surgery (WLS) is one of few obesity
modalities shown to produce long-term weight loss.1-5 Given obesity's profound adverse health and quality-of-life consequences,
as many as 150 000 Americans undergo WLS each year.6
Despite its rising popularity, WLS is not risk free or universally
effective. Data suggest mortality risks range from less than 1% to
as high as 5% in some high-risk groups.1,7,8 Risk of
serious complications and the need for revisional surgery can be as
high as 20%.1,2 High-quality
long-term data on diverse populations in the United States are lacking,
but data from the Swedish Obese Subjects Study suggest that, although
initial weight loss can be impressive within the first or second postoperative
year, recidivism occurs in a large subset of patients.3 Nevertheless, WLS leads to improvement in
comorbidities, especially diabetes mellitus,9,10 even after accounting for
weight regain.3,11 In
the Swedish Obese Subjects Study, the mean sustained weight loss at
10 years was 25% to 26% of initial weight for subjects undergoing
gastric bypass and 14% to 18% for those undergoing gastric banding;
however, about one-quarter of patients undergoing gastric bypass and
three-fourths of those undergoing gastric banding sustained less than
20% weight loss. Moreover, 9% of the gastric bypass patients and 25%
of the gastric banding patients sustained less than a 5% weight loss
at 10 years. A systematic review in 2006 estimated that patients lost
52% to 59% of their excess weight at 8 to 10 years,5 although the review did not account for
the attrition rate of the included studies, which would tend to bias
results toward overestimating weight loss. One recent study from Switzerland
with a follow-up rate of 90% reported a mean weight loss of 58% of
excess weight, with slightly more than one-third of patients sustaining
less than 50% of their excess weight loss (EWL).11
The high cost associated with WLS, its limited long-term outcomes
data, and its potential risks for mortality and morbidity have led
to ambivalence among some clinicians about routinely recommending
this treatment to eligible patients.12 However, we know little about how much patients value weight loss
and how willing patients may be to accept serious risk to achieve
substantial weight loss. Although clinicians and health payers traditionally
focus on medical and economic effects, patients seek surgery for a
variety of reasons.13,14 Obesity's profound physical and psychosocial consequences,15 for example, may lead some patients to
value weight loss to such a degree that they may be willing to undergo
a high risk to achieve substantial weight loss. Although few data
are available about patients' perceptions and expectations of WLS,
studies suggest that populations seeking weight loss treatments in
general often desire a magnitude of weight loss16-18 that
exceeds even the amount that can be sustained consistently by most
patients who undergo WLS. High weight loss expectations may cause
patients to accept higher than reasonable surgical risks and affect
the value they place on levels of weight loss that would lead to important
improvements in comorbidities and reductions in health risk. A better
understanding of the preferences and expectations of patients may
help clinicians better educate and select patients who are most appropriate
for WLS.
In this context, we studied more than 650 patients seeking WLS
and examined their expectations and motivations and the mortality
risks they were willing to undertake to undergo these procedures.
We also explored the demographic characteristics, clinical factors,
and patient perceptions associated with high weight loss expectations
and patients' willingness to assume high surgical risk.
Study sample, recruitment, and data collection
The Assessment of Bariatric Surgery Study (ABS Study) is a longitudinal
cohort study of patients undergoing evaluation for WLS. The goals
of the ABS Study are to understand patients' perception and decision
making about WLS and the longitudinal effect of WLS on quality of
life and other health outcomes. Study subjects were recruited systematically
from the WLS centers of 2 academic medical centers in Boston, one
of which serves a large racial minority and socially disadvantaged
urban population. To be eligible, patients had to be 18 to 65 years
of age at the time of recruitment, speak English, and have the permission
of their physician for us to contact the patient.
Our study was approved by the institutional review boards at
the Beth Israel Deaconess Medical Center, Boston Medical Center, and
Center for Survey Research at the University of Massachusetts. Recruitment
and consent differed slightly because institutional review board consent
policies differed at the recruitment sites. All potentially eligible
subjects were identified consecutively via appointment logs. Of 615
eligible patients (identified from April 3, 2008, through June 21,
2010) at the first site, 432 enrolled and provided verbal informed
consent via telephone (70.2% response rate). At the second site, we
were required by the institutional review board to obtain in-person
written informed consent. Of 421 potentially eligible patients (identified
from July 1, 2008, through March 3, 2010), 104 underwent surgery before
we could approach them in person and 222 enrolled (70.0% response
rate). We found no statistically significant differences between participants
and eligible nonparticipants by sex or race; however, nonparticipants
were slightly younger (mean age, 42 vs 44 years; P = .006).
Data were collected during a 1-hour telephone interview at baseline
that collected information on patients' demographic characteristics,
self-reported height and weight, quality of life, and perspectives
on their weight, weight loss, and WLS. Interviewers received a minimum
of 3.5 days of training in standardized interviewing techniques, which
included reading questions exactly as written and nondirective probing.
Interviewers were not permitted to provide their own interpretations
of questions, to offer definitions for words in the questions, or
to record an answer that was not provided explicitly by the respondent.
Interviews are scripted and questions are written with the goal of
minimizing extraneous interviewer-respondent interactions that might
lead to interviewer effects. Samples of all interviewers' work were
monitored in real time by a monitor to ensure adherence to study protocol.
A trained study nurse conducted medical record reviews to abstract
additional clinical information, including comorbidities.
Perceptions of Weight and Preferences and Motivation for Weight
Loss and WLS
Body mass index (BMI) was calculated using the patients' self-reported
weight in kilograms divided by their measured height in meters squared
as abstracted from the clinical record.19 We used self-reported rather than measured weight because measured
weights were collected at various time points when patients were trying
actively to lose weight, and hence measured weight may not reflect
the actual or perceived weight of patients at the time of interview.
We asked patients about their weight and their perception of the health
risks posed by their obesity (1 indicates not at all; 5, extremely
high). We also asked patients for the minimal amount of weight they
would have to lose to derive any health benefit. We then asked about
patients' motivation for weight loss and about their ideal weight
(ie, “If you could be any weight, how much would you like to
weigh?”).
We also asked patients a series of questions about WLS to try
to understand their decision to seek the procedure. We first asked
about their motivation and to rate how important a series of potential
reasons were (very, somewhat, or a little important vs not important
at all). We asked for the sources of their information about WLS and
which was the most important. To measure patients' expectations for
WLS, we then asked for the highest amount of weight that they might
lose after WLS in the long term and for the lowest and the ideal amounts
of weight they hoped to lose and not gain back. We also specifically
asked them to articulate the least amount of weight they would have
to lose and not gain back to not feel disappointed. We then asked
patients whether they would undergo WLS if some chance of dying from
the WLS existed. Through an iterative process, we elicited the highest
risk they were willing to accept and still undergo WLS.
Quality of Life and Value of Weight Loss
We assessed quality of life and patients' value of different
levels of weight loss by measuring their health utility, the criterion
standard approach to assessing patients' quality of life and preferences
of different health states.20 To
do so, we used an adapted version of the standard gamble method (validated
approach to utility measure). In the standard gamble, respondents
are typically asked to consider the following hypothetical choice:
the certainty of continuing in their current state of health or taking
a gamble. The gamble has 2 possible outcomes: a positive outcome that
is typically perfect health and a negative outcome being death. Participants
were then asked how willing they are to risk dying to achieve perfect
health, with the idea being the higher the risk they are willing to
take to achieve the better outcome, the less value they put on their
current health. Because we were particularly interested in the value
that patients placed on varying degrees of lower weight in addition
to perfect health, we adapted the standard gamble by administering
a series of additional scenarios. We asked patients to envision a
treatment that would produce a permanent weight loss of a specified
amount that required no effort on their part and would produce no
adverse effects. We then specified that the treatment was associated
with a small risk of death, and, through an iterative process, we
asked patients to estimate the highest risk of dying they were willing
to accept to achieve that particular weight loss outcome. The specified
weight loss expressed included 10% and 20% weight loss, their highest
healthy weight (or the weight loss associated with a BMI of 25), and
their perceived ideal weight. In addition, we asked how much patients
were willing to risk to achieve perfect health. In considering these
scenarios, we asked patients to assume that no other weight loss treatments
(including WLS) were available now or in the future.
Using participants' responses to the standard gamble scenarios,
we calculated patients' utility values for their current state and
all the health states set forth in the different scenarios, making
no preconceived assumptions about what their most valued health state
should be. The health and/or weight state (eg, ideal weight, perfect
health) of highest value to the patient (ie, the outcome for which
the patient was willing to accept the highest risk of dying) served
as the reference state with an assigned utility value of 1. For example,
if a patient responds that he or she is willing to accept the highest
risk of dying to achieve their ideal weight and that risk is 10%,
then the patient is calculated to have a current health utility of
0.90.
In addition, we assessed quality of life via the Impact of Weight
on Quality of Life–Lite questionnaire,21 a 31-item instrument developed to capture
5 domains specific to obesity,21 namely,
physical function, self-esteem, sexual life, public distress, and
work. Responses were scored on a scale of 0 to 100 according to standard
methods in each of the subscales and in their global scores, and higher
scores on both scales indicate better quality of life.
Clinical and Demographic Factors
Finally, we asked about participants' demographic and health
behavioral characteristics, including age, sex, race/ethnicity, educational
level, income, marital status, smoking, and alcohol intake. In addition,
we abstracted information about the patients' chronic health conditions
from the medical records.
We characterized our sample in terms of baseline demographic
and clinical characteristics and their perceptions and expectations
of and motivations for undergoing WLS. In bivariable analyses, we
compared patient preferences for weight loss and their willingness
to accept mortality risk using the Pearson χ2 test
for categorical variables and 2-tailed t tests
for continuous variables. Our 2 primary outcomes were disappointment
with a sustained weight loss of 20% and willingness to accept a mortality
risk of 10% or higher to undergo WLS. We used multivariable logistic
regression analyses to examine the relationship between various patient
factors and these 2 outcomes. We used the 20% weight loss threshold
based on evidence that a substantial minority of patients who have
WLS do not sustain this level of weight loss in the long term.3 In sensitivity analyses, we used a threshold
of 50% EWL based on the Reinhold Classification and other long-term
studies.4,5,11 Mean mortality risks for WLS range widely, but even in high-risk
populations the risk is generally less than 5%.2,7,8 We considered
patients who were willing to accept risks of 10% or higher as willing
to accept unreasonably high risk. In sensitivity analyses, we lowered
the risk threshold to 5% or higher; our multivariable results were
similar and are not presented.
We were particularly interested in how these outcomes varied
by sex and race. In our initial multivariable models, we included
sex and race adjusted for age, BMI, educational level, income, and
recruitment site. In subsequent models, we explored the independent
contribution of factors such as self-reported health status, comorbidities
(including heart disease, diabetes mellitus, obstructive sleep apnea,
hypertension, reflux disease, chronic back pain, depression, and other
psychiatric conditions), quality-of-life scores, perception of the
health risk posed by weight, the minimal level of weight patients
believed they needed to lose to derive any health benefit, the patient's
primary source of information, and the importance of different factors
in motivating patients to lose weight. Our final model included the
variables in our initial model and any subsequent factor that was
statistically significantly associated with the outcome at a P value of .05 or confounded the association between
sex or race and the outcome.
At the time of the analyses, 45.0% underwent Roux-en-Y gastric
bypass; 36.2%, gastric banding; and 0.8%, sleeve gastrectomy. The
remaining 18.0% had not proceeded with WLS. Table 1 presents the baseline data of the 654 participants
in our study. Most patients believed that their weight placed them
at a high or an extremely high health risk. Patients cited a variety
of personal reasons as very important in motivating their decision
to seek WLS. They also cited several sources of information about
WLS, with the most important source being their primary care physician,
followed by family and friends.
Patients reported high expectations for WLS (Table 2) and disappointment if they
did not lose and permanently sustain a mean loss of 26% of their weight
or 59% of their excess weight as a result of WLS. Women had higher
expectations for weight loss than men. Expectations also varied by
race.
When asked about their willingness to assume some risk of death
to lose different levels of weight or to achieve perfect health, slightly
more than half were willing to accept any risk of dying to lose 20%
of their weight or to achieve perfect health (Table 3). Slightly more than three-quarters
of the patients were willing to do so to achieve their perceived ideal
or most desired weight, whereas slightly less than 85% were willing
to risk dying to undergo WLS. The acceptable risk of death was highly
skewed, resulting in mean and median risks that were substantially
discordant. Although most patients were willing to accept some risk
of dying to undergo WLS, the absolute risk patients were willing to
accept was quite small and in many cases negligible. For example,
of the 550 patients who were willing to risk dying to undergo WLS,
75 of this subset (13.6%) could not articulate a minimal risk they
were willing to accept and explicitly rejected a risk of 1 in 2000
(0.05%).
From patients' responses to these standard gamble scenarios,
their health utility value for their current state was 0.87 overall
(Table 3), reflecting the group's
willingness to accept a 13% risk of dying to achieve their most desired
health state, including perfect health or lower weight.22 However, health utility values were highly
skewed such that the median utility was 0.98; 48.5% were willing to
take no more than a 1% risk of dying, whereas 42.0% were willing to
accept a 5% or higher risk and 33.1% were willing to accept a 10%
higher risk. Utility values for different health states were commensurate
with patients' willingness to risk death to achieve the respective
conditions, with ideal weight being the most valued health state and
having the highest utility value. Perfect health was valued less than
the patient's perceived ideal weight and less than a BMI of 25 but
more than a 20% weight loss.
Of study patients, 74.1% reported that their disappointing weight
loss would be equivalent to a 20% or greater weight loss; 67.3%, at
least 50% of their excess weight. Figure
1 shows the proportion of patients whose disappointing weight
loss exceeded 20% of their baseline weight across different patient
characteristics before adjustment. After adjustment for age, BMI,
study site, educational level, and income, African American patients
were less likely than white patients to be disappointed with a 20%
weight loss, although this was not the case before adjustment, whereas
women were more likely than men to be disappointed (Table 4). Low quality-of-life scores
on the Impact of Weight on Quality of Life–Lite questionnaire
were also significantly associated with patients' reporting disappointment
with a 20% weight loss (Table 4, model 2) and explained in part some of the observed differences
across race because African American patients were generally more
likely to have higher quality-of-life scores than white patients.
Patients who perceived a need to lose at least 10% or 20% of their
body weight reported being more likely to be disappointed with a 20%
weight loss than those who believed that a 5% to 10% weight loss would
be beneficial. Perception of weight as a health risk, self-reported
health status, comorbid conditions, primary source of WLS information,
and different motivating factors were not significantly associated
with reporting a disappointing weight loss that was above 20% of initial
weight. Our results were similar when 50% EWL was the outcome in sensitivity
analyses (data not shown).
Figure 2 shows the proportion
of patients willing to accept a 10% or higher risk of dying to undergo
WLS. Men and white patients were independently associated with being
more willing to accept high risks, after adjusting for other demographic
factors, BMI, and recruitment site (Table
4). Having a high disappointing weight loss was not associated
with a willingness to accept higher risk. Those with heart disease
and poorer quality-of-life scores were significantly more likely to
accept a high mortality risk. Other factors examined were not important
correlates.
In our study of 654 patients seeking WLS, patients in general
had high weight loss expectations of WLS, with three-quarters of patients
reporting that they would be disappointed with a long-term sustained
weight loss of 20% and two-thirds with an EWL of 50%, although these
levels of weight loss are considered successful outcomes clinically.
Most patients (84.8%) were willing to accept some risk of dying to
undergo WLS, but a much smaller majority (57.5%) were willing to do
so to undergo a hypothetical treatment that would produce a sustained
weight loss of 20%. Moreover, one-fifth of patients were willing to
accept a 10% or higher risk of dying to undergo WLS. Women were more
likely than men to have high weight loss expectations but were less
likely to accept a high mortality risk. White patients appeared more
likely than African American patients to have high weight loss expectations
and were more willing to accept a high risk after adjusting for other
demographic factors and BMI; racial differences, however, were attenuated
when we accounted for quality-of-life scores, which were lower among
white patients.
Although others have suggested that patients seeking weight
loss treatment have unrealistic weight loss expectations,16,18 our study corroborates
and extends published data by documenting that patients seeking WLS
on average value substantial weight loss more than they value achieving
perfect health. Patients were willing on average to accept a higher
mortality risk to achieve ideal weight than to achieve perfect health.
When we looked at correlates of those who would be disappointed with
a 20% weight loss or a loss of 50% of EWL and those who were willing
to accept a higher than 10% risk of mortality from WLS, patients'
quality-of-life scores appeared to be a stronger correlate than health
status; with the exception of heart disease, comorbid conditions were
not significantly associated with either outcome. These findings are
consistent with our hypothesis that quality-of-life considerations
may be as important if not more important than health considerations
to many patients who seek WLS.
Our findings raise questions about whether patients are informed
adequately as they make decisions about WLS. By the time of the interview,
patients had already received some education about the risks and benefits.
Patients were quoted weight losses for the short term ranging from
30% to 80% of their excess weight depending on procedures being discussed
(ie, 60%-80% EWL for gastric bypass and 30%-70% for gastric banding)
at the recruitment practices. Although weight regain and recidivism
were discussed, patients were not given explicit weight loss estimates
for the longer term. Therefore, patients' high expectations for the
long term likely reflect the short-term estimates they were given
before WLS. One-third of patients in our study reported the belief
that they needed to lose more that 20% of their weight to derive any
health benefits, although strong evidence suggests than even modest
weight losses of 5% to 10% can improve metabolic factors and health
risks.2,23 Although
the major WLS procedures are associated with some mortality risk,
a substantial minority of patients were unwilling to accept any mortality
risk to undergo surgery, and more than 40% were unwilling to risk
death to sustain a 20% weight loss. This finding is consistent with
their expectation that WLS should produce a weight loss that is substantially
higher than 20%. These findings persist despite previous long-term
studies3 suggesting that a 20% weight
loss is a reasonable outcome for many patients with evidence of reductions
in comorbidities.3,11 Having high weight loss expectations was not associated with being
willing to accept higher than reasonable surgical risks, which is
somewhat reassuring. Whether high expectations will result in later
dissatisfaction among patients who achieve the amount of weight loss
expected after successful bariatric surgery is unknown and will be
addressed by our group when longitudinal follow-up data from the ABS
Study become available.
In our study, African American patients and men were less likely
to have high weight loss expectations after adjusting for BMI and
other demographic factors. This finding is consistent with previous
literature suggesting different preferences for weight loss between
white and African American patients and may explain the lower utilization
of WLS in racial minorities.24-27 White women in particular were much more likely than men or African
American women to have overly optimistic weight loss expectations,
and this difference may reflect different societal standards for ideal
weight in these different groups. Future studies will need to compare
the weight loss preferences of white and minority populations in primary
care or community settings to examine whether our findings generalize
to obese patients who are medically eligible for WLS.
Our study should be interpreted in the context of its limitations.
Although our study sample is large and demographically diverse by
design, all patients were recruited from 2 WLS centers in Boston.
Most of our data were self-reported and may be biased by the educational
level and health literacy of our subjects, especially with regard
to our standard gamble and preference questions, which are cognitively
challenging and require reasonable numeracy. To address this issue,
our survey was designed with multiple follow-up questions and was
administered by a trained interviewer; we also adjusted our multivariable
models for educational status. Nonetheless, residual bias may remain.
Finally, patients were interviewed before WLS and after they were
seen at WLS centers; however, their perceptions and understanding
may have evolved over time after the interview with additional discussions
with their providers.
In summary, our study finds that obese patients seeking WLS
value substantial weight loss more than they do perfect health. Most
of the patients also have high weight loss expectations of WLS, and
one-fifth were willing to accept a mortality risk greater than 10%
to undergo these procedures. Poorer quality of life was a significant
correlate of high weight loss expectations and the willingness to
accept high risk, whereas health status was less influential, suggesting
the importance of quality-of-life considerations. Given patients'
misperceptions, clinicians should ensure that patients are educated
adequately about the potential risks and sustained benefits of WLS
so that patients make truly informed decisions about WLS.
Correspondence: Christina C. Wee,
MD, MPH, Division of General Medicine and Primary Care, Department
of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave,
Boston, MA 02215 (cwee@bidmc.harvard.edu).
Accepted for Publication: October 22,
2012.
Author Contributions: Ms Huskey had
full access to the data. Study concept and design: Wee, Hamel, Apovian, Blackburn, Marcantonio, Schneider, and Jones. Acquisition of data: Wee, Apovian, Bolcic-Jankovic,
Colten, Hess, and Jones. Analysis and interpretation
of data: Wee, Hamel, Apovian, Huskey, Marcantonio, and Jones. Drafting of the manuscript: Wee. Critical revision of the manuscript for important intellectual content: Wee, Hamel, Apovian, Blackburn, Bolcic-Jankovic, Colten, Hess,
Huskey, Marcantonio, Schneider, and Jones. Statistical
analysis: Huskey. Obtained funding: Wee, Apovian, and Jones. Administrative, technical,
and material support: Wee, Apovian, Blackburn, Bolcic-Jankovic,
Hess, and Jones. Study supervision: Wee,
Apovian, Blackburn, Bolcic-Jankovic, and Jones.
Conflict of Interest Disclosures: None
reported.
Funding/Support: The study was funded
by grant R01 DK073302 from the National Institutes of Health (principal
investigator, Dr Wee).
Role of the Sponsors: The National
Institutes of Health had no role in the design and conduct of the
study; in the collection, analysis, and interpretation of the data;
or in the preparation, review, or approval of the manuscript.
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