Is there an association between bariatric surgery and changes in relationship status?
In this study of 2 large Swedish cohorts with long-term follow-up, bariatric surgery was associated with increased incidence of divorce and separation as well as increased incidence of marriage and new relationship.
In addition to its associations with obesity comorbidities, bariatric surgery-induced weight loss is also associated with changes in relationship status.
Bariatric surgery is a life-changing treatment for patients with severe obesity, but little is known about its association with interpersonal relationships.
To investigate if relationship status is altered after bariatric surgery.
Design, Setting, and Participants
Changes in relationship status after bariatric surgery were examined in 2 cohorts: (1) the prospective Swedish Obese Subjects (SOS) study, which recruited patients undergoing bariatric surgery from September 1, 1987, to January 31, 2001, and compared their care with usual nonsurgical care in matched obese control participants; and (2) participants from the Scandinavian Obesity Surgery Registry (SOReg), a prospective, electronically captured register that recruited patients from January 2007 through December 2012 and selected comparator participants from the general population matched on age, sex, and place of residence. Data was collected in surgical departments and primary health care centers in Sweden. The current analysis includes data collected up until July 2015 (SOS) and December 2012 (SOReg). Data analysis was completed from June 2016 to December 2017.
Main Outcomes and Measures
In the SOS study, information on relationship status was obtained from questionnaires. In the SOReg and general population cohort, information on marriage and divorce was obtained from the Swedish Total Population Registry.
The SOS study included 1958 patients who had bariatric surgery (of whom 1389 [70.9%] were female) and 1912 matched obese controls (of whom 1354 [70.8%] were female) and had a median (range) follow-up of 10 (0.5-20) years. The SOReg cohort included 29 234 patients who had gastric bypass surgery (of whom 22 131 [75.6%] were female) and 283 748 comparators from the general population (of whom 214 342 [75.5%] were female), and had a median (range) follow-up of 2.9 (0.003-7.0) years. In the SOS study, the surgical patients received gastric banding (n = 368; 18.8%), vertical banded gastroplasty (n = 1331; 68.0%), or gastric bypass (n = 259; 13.2%); controls received usual obesity care. In SOReg, all 29 234 surgical participants received gastric bypass surgery. In the SOS study, bariatric surgery was associated with increased incidence of divorce/separation compared with controls for those in a relationship (adjusted hazard ratio [aHR] = 1.28; 95% CI, 1.03-1.60; P = .03) and increased incidence of marriage or new relationship (aHR = 2.03; 95% CI, 1.52-2.71; P < .001) in those who were unmarried or single at baseline. In the SOReg and general population cohort, gastric bypass was associated with increased incidence of divorce compared with married control participants (aHR = 1.41; 95% CI, 1.33-1.49; P < .001) and increased incidence of marriage in those who were unmarried at baseline (aHR = 1.35; 95% CI, 1.28-1.42; P < .001). Within the surgery groups, changes in relationship status were more common in those with larger weight loss.
Conclusions and Relevance
In addition to its association with obesity comorbidities, bariatric surgery–induced weight loss is also associated with changes in relationship status.
Bariatric surgery is an effective treatment for obesity that results in durable weight loss and positive association with obesity-related morbidities.1,2 There has been a worldwide increase in the number of persons undergoing this treatment in recent years, and in 2013, nearly 470 000 bariatric procedures were performed globally.3 However, while the associations of bariatric surgery with many disease outcomes are well-documented, information about the psychosocial outcomes of bariatric surgery is more limited.4,5 Available evidence suggests that most aspects of quality of life are improved after bariatric surgery.6,7 However, increased incidence of alcohol and substance abuse after some types of surgery, as well as signs of an increased risk of suicide, have been reported.8-12
An early qualitative study reported that bariatric surgery puts tension on the patients’ family relationships and might lead to divorce.13 Divorces after bariatric surgery were thereafter mostly attributed to poorly working marriages in which the extra tension associated with the aftermath of surgery led to divorce.14 A more recent and comprehensive qualitative study15 indicates that there are additional changes in marital and relational dynamics after the bariatric procedure. A narrative review from 201516 highlights the fact that studies of marital relations in patients who have had bariatric surgery are few and limited in scope, and the results should be interpreted with caution. To our knowledge, no studies have investigated whether bariatric surgery is associated with altered chances of finding a new partner. The aim of this study was to analyze changes in relationship status after bariatric surgery in 2 Swedish cohorts with long-term follow-up.
Data used in this study are from the Swedish Obese Subjects (SOS) study and a register linkage that combined the Scandinavian Obesity Surgery Registry (SOReg)17 with general population comparators from the Swedish Total Population Registry.18 The SOS study was registered at ClinicalTrials.gov (identifier: NCT01479452) and was approved by 7 local ethics review boards (Gothenburg, Lund, Lindköping, Örebro, Karolinska Institute, Uppsala, and Umeå). All participants gave written or oral informed consent. The SOReg study was approved by the regional ethics committee in Stockholm, Sweden. All analyses in the SOReg and general population cohort were performed on deidentified data, obviating the need for informed consent.
The SOS study is a prospective, matched intervention trial, and its design has been described previously.19 In brief, 2010 participants who chose bariatric surgery formed the surgery group, and a contemporaneously matched control group (n = 2037) was created using 18 matching variables (sex, age, weight, height, waist and hip circumferences, systolic blood pressure, serum cholesterol and triglyceride levels, smoking status, diabetes, menopausal status, 4 psychosocial variables [social support, life events, health perception, and psychosocial functioning], and 2 personality traits [monotony avoidance and psychasthenia]). In the surgery group, 265 participants (13.2%) underwent gastric bypass, 376 participants (18.7%) underwent gastric banding, and 1369 participants (68.1%) had vertical banded gastroplasty. The control group received the customary treatment for obesity at their primary health care centers.
Power calculation for the SOS study was based on the primary outcome, which was overall mortality. The inclusion criteria in both surgery and control groups were an age between 37 and 60 years and a body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) of 34 or more for men and 38 or more for women. Both study groups had identical follow-up with physical examinations and questionnaires at baseline and after 0.5, 1, 2, 3, 4, 6, 8, 10, 15, and 20 years. Participants were recruited between September 1, 1987, and January 31, 2001. In the current analysis, the median follow-up time was 10 years, with follow-up examinations occurring until July 1, 2015. This analysis includes 1958 patients who had gastric banding (n = 368 [18.8%]), vertical banded gastroplasty (n = 1331 [68.0%]), or gastric bypass (n = 259 [13.2%]) and 1912 matched, obese controls who had known relationship status at baseline and follow-up.
In addition, this study incorporated data from SOReg, a prospective, electronically captured register for bariatric surgery in which data are stored as part of clinical practice. In brief, SOReg was started in 2007 and is estimated to cover 98.5% of all bariatric procedures in Sweden.17 In this study, we used data from January 2007 through December 2012. In the current analysis, all the 29 234 SOReg participants older than 18 years who had undergone a gastric bypass operation, of whom 12 531 were married and 16 703 were unmarried at baseline, were included. For comparisons of changes in relationship status after bariatric surgery with a general population sample, we matched up to 10 comparators from the Swedish Total Population Registry18 to each included patient who had undergone gastric bypass, using birth year, sex, and place of residence (parish). Extended descriptions of the SOS, SOReg, and general population groups can be found in eAppendix 1 and 2 in the Supplement.
Main Outcome Measures and Follow-up
Relationship status was not a predefined end point in either the SOS study or the SOReg and general population cohort. For the current analysis, the main outcome measure in the SOS cohort was self-reported relationship status (questionnaires at baseline and 0.5, 1, 2, 3, 4, 6, 8, 10, 15, and 20 years after baseline data collection). Relationship status was defined by response to the questions: (1) Are you currently living with a spouse/partner? and (2) Have you gone through a divorce or separated since the previous questionnaire? A positive reply to the first question was interpreted as being married or in a cohabiting relationship. The main outcome measures in the SOReg and general population cohort were date of legal marriage or divorce, as recorded in the Swedish Total Population Registry.
In the analysis of divorce/separation, participants who were widowed were included in the analysis until the date of the death of their spouse and thereafter censored from the analysis. In the SOS cohort, if no separation was reported, the participant was censored at the most recent questionnaire. Participants were also censored at date of emigration or death. Participants in the SOS control group who underwent bariatric surgery and participants in the SOS surgery group who underwent surgical reversal to normal anatomy (eg, band removal) were censored from analysis at the time of surgery.
Body mass index data were based on measured heights and weights; these data were not available for the general population. In the SOS cohort, education level was self-reported and, in the SOReg and general population cohort, data on the level of educational attainment were retrieved from the Swedish Register of Education. Information on previous divorce/separation and years living together/ married was based on self-reported data in the SOS cohort and on data from the Swedish Total Population Registry in the SOReg and general population cohort. Self-reported data on perceived family relations on a 4-grade scale (very good, good, not so good, and not good at all) were available in the SOS cohort but were analyzed here as a dichotomous variable by combining the 2 best and 2 worst responses. Information on participants becoming a widow/widower was based on self-reported data (in the SOS cohort) and on data from the Swedish Total Population Registry (in the SOReg and general population cohorts). Data on health care visits for substance abuse were retrieved from the National Patient Register (which includes inpatient data from 1969 to December 31, 2014, and hospital-based outpatient data from 2001 to December 31, 2014) and converted into a dichotomous variable, as previously described.12 Data on psychotropic drug use before inclusion were retrieved from self-reported data (in the SOS cohort) and from the Prescribed Drug Register (in the SOReg and general population cohort; this register started on July 1, 2005, and data up till September 30, 2015, were used) and converted into a dichotomous variable, as previously described.12
To analyze the association of bariatric surgery with relationship status, the study cohorts were divided according to whether the participants were married or in a relationship or not at baseline. Time to change in relationship status in the surgery and control groups was analyzed with Kaplan-Meier estimates of cumulative incidence and Cox proportional hazard models (expressed as hazard ratios [HR] with 95% CIs). Unadjusted univariate analysis comparing surgical participants with control group participants, as well as multivariate analysis with adjustment for preselected baseline factors known to influence relationship status (age, sex, BMI [in the SOS cohort only], education level, previous divorce/separation, time in current relationship, substance abuse, psychotropic medication, and perceived family relation quality [in the SOS cohort only]) were performed.
Statistical analyses were carried out using Stata, version 14 (StataCorp) and SAS, version 9.4 (SAS Institute Inc). Two-sided tests with a 5% α level were considered statistically significant.
Relationship Status and Characteristics at Baseline
In the SOS study, 2871 of the 3870 included participants (74.2%) were married or living in a relationship at baseline (Table). There were no major differences in characteristics between the surgery and control groups, with the exception that university education was more common and previous divorce/separation less common in the control group compared with the surgery group (Table).
In the SOReg cohort, 12 531 of the 29 234 included participants (42.9%) were married at baseline (Table). Use of psychotropic drugs and substance abuse were more common in the surgery group compared with the general population group, both among those who were married or unmarried at baseline. University education was more common in the general population group compared with the surgery group (Table).
Marriages and New Relationships After Surgery
Among the 999 SOS study participants who were single at baseline, the incidence of marriage/new relationship was higher after bariatric surgery (n = 152 events; incidence rate/1000 person-years, 38.0) compared with controls (n = 76 events; incident rate [IR]/1000 person-years, 19.1; HR = 1.95; 95% CI, 1.48-2.57; P < .001; Figure 1A), and this remained statistically significant after adjustment (adjusted HR [aHR] = 2.03; 95% CI, 1.52-2.71; P < .001; eTable 1 in the Supplement). After 4 years, the cumulative incidence of marriage/new relationship was 20.9% (n = 98 events) in the surgery group compared with 11.2% (n = 47 events) in the control group, and at 10 years, it was 34.8% (n = 146 events) in the surgery group compared with 19.4% (n = 70 events) in the control group.
The incidence of marriage in the SOReg and general population cohort was higher in those who had gastric bypass (n = 1895 events; IR/1000 person-years, 39.1) than in general population comparison group (n = 14612 events; IR/1000 person-years, 31.6; HR = 1.24; 95% CI, 1.18.-1.30; P < .001; Figure 1B; aHR = 1.35; 95% CI 1.28-1.42; P < .001; eTable 1 in the Supplement). After 4 years, the cumulative incidence of marriage was 14.6% (n = 1771 events) in SOReg cohort compared with 11.8% (n = 13661 events) in the general population.
In both study cohorts, the multivariate analyses show that younger age and previous divorce/separation were significantly associated with increased incidence of marriage/new relationship (in the SOS cohort) and marriage (in the SOReg and general population cohort) (eTable 1 in the Supplement). In the SOReg and general population cohort, a history of substance abuse and psychotropic medication use were associated with a decreased incidence of marriage (eTable 1 in the Supplement).
In the SOS surgery group, those whose 1-year weight loss reached or exceeded the median level of 25.0% of body weight had higher incidence of marriage/new relationship (HR = 1.94; 95% CI, 1.32-2.84; P < .001; aHR = 1.98; 95% CI, 1.33-2.93; P < .001) compared with those with weight loss of less than the median level (Figure 2A and eTable 2 in the Supplement). In the SOReg cohort, those whose 1-year weight loss reached or exceeded the median level of 31.8% of body weight had a higher incidence of marriage (HR = 1.35; 95% CI, 1.20-1.51; P < .001; aHR = 1.17; 95% CI, 1.04-1.32; P = .008) compared with those with weight loss of less than the median level (Figure 2B and eTable 2 in the Supplement).
Separations and Divorces After Surgery
Among the 2871 participants in the SOS cohort who were married or were living in a relationship at baseline, bariatric surgery was associated with increased incidence of divorce/separation (n = 235 events; IR/1000 person-years, 16.5) compared with controls (n = 142 events; IR/1000 person-years, 11.1; HR = 1.54; 95% CI, 1.25-1.90; P < .001; Figure 3A), and this remained statistically significant after multivariate adjustment (aHR = 1.28; 95% CI, 1.03-1.60; P = .03; eTable 1 in the Supplement). After 4 years, the cumulative incidence of divorce/separation was 9.4% (n = 128 events) in the surgery group compared with 5.5% (n = 71 events) in the control group, and after 10 years it was 17.1% (n = 211 events) in the surgery group compared with 11.6% (n = 126 events) in the control group.
The incidence of divorce in the SOReg and general population cohort was higher in those who underwent gastric bypass (n = 1380 events; IR/1000 person-years, 37.8) than in the general population comparators (n = 8221 events; IR/1000 person-years, 21.7; HR = 1.74; 95% CI, 1.64-1.84; P < .001; Figure 3B), and this remained statistically significant after multivariate adjustments (aHR = 1.41; 95% CI, 1.33-1.49; P < .001); eTable 1 in the Supplement). After 4 years, the cumulative incidence of divorce was 14.4% (n = 1289 events) in SOReg compared with 8.2% (n = 7657 events) in the general population.
In both study cohorts, the multivariate analyses show that younger age, previous divorce/separation, and shorter time in a relationship/marriage were significantly associated with increased incidence of divorce/separation (in the SOS study) or divorce (in the SOReg and general population cohort) (eTable 1 in the Supplement). In the SOS study, poor family relations before surgery were a strong predictor of divorce/separation (eTable 1 in the Supplement). In the SOReg and general population cohort, a history of substance abuse and psychotropic medication use were associated with an increased incidence of divorce (eTable 1 in the Supplement).
In the SOS surgery group, the association between weight loss and incidence of divorce/separation was not statistically significant (HR, 1.22; 95% CI, 0.91-1.63; P = 0.18; aHR, 1.31; 95% CI, 0.96–1.77; P = 0.08; Figure 4A; eTable 2 in the Supplement). However, in the SOReg cohort, those whose 1-year weight loss reached the median level of 31.4% body weight or more had higher incidence of divorce (HR = 1.58; 95% CI, 1.37-1.81; P < .001; aHR = 1.26; 95% CI, 1.09-1.44; P = .001) compared with those with weight loss of less than the median level (Figure 4B and eTable 2 in the Supplement).
Although improvement in health is usually stated as the main motivator among persons who are about to undergo bariatric surgery, the desire to find a partner is sometimes mentioned among other secondary motivators.20,21 Our results clearly indicate that there is an increased incidence of marriage (compared with the general population) and an increased incidence of marriage/new relationship (compared with controls with obesity) after bariatric surgery. However, we also show an increased incidence of divorce (compared with the general population) and increased incidence of separation/divorce (compared with controls with obesity) after bariatric surgery among individuals who are married or in a relationship at the time of surgery. In addition, a large degree of weight loss is associated with both increased incidence of marriage/new relationship and increased incidence of divorce.
The increased incidence of marriage and new relationship after bariatric surgery is in line with previous research showing that bariatric surgery is associated with increased quality of life,6,7 positive changes in social life,22,23 and increased romantic interest from others.22,24 These associations may be enhanced by a large weight loss and hence contribute to the observed increased incidence of marriage/new relationship. However, for patients who are in a relationship at the time of surgery, these changes, as well as the responses of spouses/partners to these changes, may affect the dynamics of the relationship. Although most postbariatric surgery patients and their partners report an overall maintained or increased quality in the relationship,25-27 partners of patients who have undergone bariatric surgery sometimes report feeling jealous or no longer needed.15,23 Qualitative studies of bariatric surgery point to the sense of a “joint journey”28(p54) as an important part of successful weight loss and weight maintenance,25,29 but also to maintain a healthy relationship.28,30 To ensure that patients about to undergo bariatric surgery and their partners have a better chance of handling potential tensions in their relationship, they should be informed of this risk. On the other hand, patients who have undergone bariatric surgery might be empowered to leave an unhealthy relationship. It has been suggested that bariatric surgery in patients with a poorly working marriage puts extra tension on the relationship, possibly leading to divorce.14 This is supported by our observations in the SOS study, in which poor family relationships before surgery was the strongest predictor of increased incidence of separation and divorce. Hence, separation or divorce after bariatric surgery should not only be interpreted as an adverse effect of the surgery but could also demonstrate that physical and psychological improvements after bariatric surgery might give patients in unhealthy relationships the confidence and self-esteem to end those relationships.
Our results are based on data from 2 large, prospective Swedish cohorts with long-term follow-up periods. In the SOS cohort, the data are self-reported and include romantic cohabitation, with or without legal marriage. In Sweden, couples often cohabit for several years before marriage or remain unmarried,31 and information on cohabitation is therefore important. The data from SOReg and the general population cohort are derived from Swedish national registers. Although these registers have almost 100% coverage, they only include legal marriages and divorces, and hence couples living in a relationship without being married and separating from such relationships are not captured in the SOReg and general population analyses. This could possibly lead to an underestimation of the associations of bariatric surgery with relationships. The SOReg cohort has more participants, more modern bariatric surgery procedures (ie, gastric bypass), and a wider age span than the SOS study. Thus, the 2 cohorts complement each other in addressing the question of relationship status after bariatric surgery. However, the matching procedures, composition of the control groups, and end points differ, making direct comparisons of the results from the 2 cohorts difficult.
A limitation of this study is that the included cohorts were not randomized; the SOS study could not be randomized for ethical reasons, and the SOReg cohort is a register that captures patients who undergo bariatric surgery. In addition, our study only includes persons living in Sweden, and it is unknown if the results can be generalized to other countries and cultures.
Our data suggest that bariatric surgery–induced weight loss influences interpersonal relationships. For persons with obesity who are single, a better chance of finding a partner might be added as yet another positive association of bariatric surgery–induced weight loss. Increased incidence of divorce and separation after bariatric surgery might be associated with increased tension in already vulnerable relationships or to improvements that empower patients to leave unhealthy relationships.
Corresponding Author: Per-Arne Svensson, PhD, SOS Sekretariatet, Sahlgrenska University Hospital, Vita stråket 15, SE-413 45 Gothenburg, Sweden (firstname.lastname@example.org).
Accepted for Publication: January 8, 2018.
Published Online: March 28, 2018. doi:10.1001/jamasurg.2018.0215
Author Contributions: Dr Bruze had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Bruze and Holmin contributed equally as co–first authors.
Study concept and design: Bruze, Holmin, Neovius, Carlsson, Svensson.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Holmin, Carlsson, Svensson.
Critical revision of the manuscript for important intellectual content: Bruze, Peltonen, Ottosson, Sjöholm, Näslund, Neovius.
Statistical analysis: Bruze, Holmin, Peltonen.
Obtained funding: Sjöholm, Neovius, Svensson, Carlsson.
Administrative, technical, or material support: Sjöholm, Näslund, Neovius, Svensson, Ottosson.
Study supervision: Peltonen, Näslund, Neovius, Carlsson, Svensson.
Conflict of Interest Disclosures: Dr Carlsson has obtained lecture fees from AstraZeneca, Johnson&Johnson, and Merck Sharp & Dohme (MSD). Dr Näslund has obtained personal fees for speeches and consultation from Baricol Bariatrics AB. Dr Neovius has obtained fees from Intrim International AB. No other disclosures were reported.
Funding/Support: This project was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (grant R01DK105948), the Swedish Research Council (grant K2013-54X-11285-19; K2014–99X-22495–01–3), and Sahlgrenska University Hospital Regional Agreement on Medical Education and Research research grants.
Role of the Funder/Sponsor: The funding organizations for this study had no involvement in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Additional Contributions: We thank the staff members at the SOS Secretariat and at 480 primary health care centers and 25 surgical departments in Sweden that participated in the SOS study. We also thank Rosie Perkins, PhD, University of Gothenburg, for editing the manuscript. She was compensated for her contributions.
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