Curr Obes Rep
DOI 10.1007/s13679-017-0266-7
OBESITY TREATMENT (CM APOVIAN, SECTION EDITOR)
Quality of Life After Bariatric Surgery
Laura M. Mazer 1 & Dan E. Azagury 2 & John M. Morton 2
# Springer Science+Business Media New York 2017
Abstract
Purpose of Review The purpose of this review is to provide an
introduction to quality of life (QOL) outcomes after bariatric
surgery and a summary of the current evidence.
Recent Findings QOL has been emphasized in bariatric sur-
gery since the NIH Consensus Conference statement in 1991.
Initial studies were limited to 1- and 2-year follow-up. More
recent findings have expanded the follow-up period up to
12 years, providing a better description of the impact on
long-term QOL. Overall, there is little to no consensus regard-
ing the definition of QOL or the ideal survey. Bariatric surgery
has the greatest impact on physical QOL, and the impact on
mental health remains unclear. There are some specific and
less frequently reported threats to quality of life after bariatric
surgery that are also discussed.
Summary Obesity has a definite impact on quality of life,
even without other comorbidities, and surgery for obesity re-
sults in significant and lasting improvements in patient-
reported quality of life outcomes. This conclusion is limited
by a wide variety of survey instruments and absence of con-
sensus on the definition of QOL after bariatric surgery.
This article is part of the Topical Collection on Obesity Treatment
* John M. Morton
morton@stanford.edu
1
Division of General Surgery, Department of Surgery, Stanford
University School of Medicine, Stanford University, 300 Pasteur
Drive, H3591, Stanford, CA 94305-5655, USA
2
Section of Bariatric and Minimally Invasive Surgery, Stanford
University School of Medicine, Stanford University, 300 Pasteur
Drive, H3680A, Stanford, CA 94305-5655, USA
Keywords Bariatric surgery . Quality of life . Patient-reported
outcomes . Obesity
Introduction
Worldwide, the prevalence of obesity has more than dou-
bled since 1980. Currently, over 600 million adults are
obese, and that number will continue to increase. There
are more than 41 million children under the age of five
who are obese or overweight [1]. Obesity has a significant
negative impact on physical, psychological, and social
health. While the physical effects of obesity, including met-
abolic syndrome, hypertension, and diabetes, are well
known, the impact of obesity on psychosocial outcomes
and quality of life is less well explored [2].
Bariatric surgery has emerged as the most effective and
enduring weight loss therapy available, with dramatic weight
loss, reduction or resolution of obesity-related comorbidities,
and a corresponding decrease in mortality and healthcare
costs. These outcomes are objective and quantitative, lending
themselves to analysis. Quality of life outcomes are not only
more challenging to measure and interpret but also very im-
portant when evaluating the impact of bariatric surgery. The
NIH Consensus Statement in 1991 called for consideration of
quality of life outcomes in all analyses of patients undergoing
surgical treatment for obesity [3]. As a result, the Bariatric
Analysis and Reporting Outcome System (BAROS) was in-
troduced in 1997; this system identifies three main areas that
define success for bariatric surgery: percentage of excess
weight loss, changes in medical conditions, and quality of life
[4]. Since the late 1990s and early 2000s, after the NIH con-
sensus statement and the development of BAROS, more and
more studies have included or exclusively focused on quality
of life for patients undergoing bariatric surgery.

This paper seeks to provide an overview of the methods for
reporting and analyzing quality of life measures and the recent
evidence for the impact of bariatric surgery on quality of life
and discuss some implications for clinical practice and
research.
Definitions and Measurements of Quality of Life
“Quality of life” (QOL) is a multi-dimensional concept, incor-
porating physical, psychological, and social aspects [5]. There
is no single fully agreed-upon definition for QOL, as evi-
denced even by the number of interrelated terms that can refer
to the same concept, including QOL, health-related quality of
life (HRQL), health status, functional assessment, or patient-
reported outcomes (PRO) [6, 7]. There are also numerous
survey instruments used to measure QOL and its associated
concepts. These fall into three broad groups: generic surveys
intended for general use, regardless of disease or condition;
disease-specific surveys; and aspect-specific surveys, meant
to capture a specific domain of interest, such as depression,
anxiety, or self-esteem. Table 1 provides examples of these
three classes of surveys from the bariatric surgery literature.
The choice of survey instrument matters. First, given the
numerous domains that can be encompassed within QOL,
including physical, psychological, social, and environmental
[21], short-form surveys like the SF-36 or one-page surveys
like the Moorehead-Ardelt Quality of Life Questionnaire
[4] do not cover all domains equally. Additionally, some
authors draw a distinction between health status, which can
Table 1 Examples of quality of life instruments used to evaluate
postoperative outcomes in bariatric surgery
Generic
Short form (SF)-36 [7, 8]
Health-Related Quality of Life (HRQL) Questionnaire [9]
Goldberg General Health Questionnaire [10]
EuroQol 5D [10]
Moorehead-Ardelt Quality of Life Questionnaire II (M-A QoLQII)
[11–13]
World Health Organization-Quality of Life-Bref (WHOQOL-Bref) [14]
Disease-specific
Gastrointestinal Quality of Life Index (GIQLI) [15]
Impact of Weight on Quality of Life-Kids [16]
Impact of Weight on Quality of Life-Lite (IWQOL-Lite) [17]
Outcome-specific
Beck Depression Inventory [17]
Hospital anxiety and depression scale [18]
Rosenberg self-esteem scale [18]
Body shape questionnaire [19]
Post-Bariatric Surgery Appearance Questionnaire [20]
Curr Obes Rep
be measured by external parameters, and quality of life, which
is a subjective assessment that can be determined only by the
patient [5]. With this distinction, not every patient-reported
outcome is truly a measure of quality of life. Two patients with
identical health status may have very different subjective as-
sessment of their own QOL. As with all other survey-based
metrics, the results reflect the biases of the survey instrument,
in this case, the providers’ assumptions of what is important to
patients [5].
Many QOL and health status surveys provide population
norms, and many of the studies reviewed in this paper com-
pare obese patients to healthy controls, or to specific other
disease populations [22]. The validity of these comparisons
is unclear. Reference normal populations are usually obtained
through voluntary responses to mailed questionnaires and
tend to overrepresent well-educated, upper-class women [23,
24]. Direct comparison of patients’ own quality of life is a
much more robust metric than comparison of the obese pop-
ulation seeking bariatric surgery with an existing population
norm.
In the sections below, we review several studies that look at
quality of life and its affiliated concepts after bariatric surgery.
While trends become apparent, it is worth noting that many of
these studies do not define QOL or use QOL interchangeably
with health status. They also utilize a huge variety of survey
metrics, potentially limiting between-study comparisons. One
systematic review of patient-reported outcomes in bariatric
surgery evaluated 86 studies and found 68 different validated
measures to report QOL [7]. The most common measure used
was the generic SF-36 Health Questionnaire, and the most
common disease-specific measure was the Impact of Weight
on Quality of Life-lite (IWQoL-lite) (Table 1).
Changes in Quality of Life After Bariatric Surgery
While a few studies are dedicated specifically to patient-
reported outcomes, quality of life, and psychosocial factors
[14, 25, 26], the majority report on quality of life as a second-
ary outcome in studies primarily designed to look at weight
loss or resolution of comorbidities [11, 12]. As noted earlier,
the available studies utilize a wide range of surveys, resulting
in a very diverse collection of outcomes under the heading of
“quality of life.”
Impact of Bariatric Surgery on Health-Related Quality
of Life
The most commonly used generic measure of quality of life
after bariatric, the SF-36, is a measurement of HRQL, or
perceived health status, asking respondents to reflect spe-
cifically on how their physical or mental health is impacting
their life [5]. There are numerous studies that have utilized
Curr Obes Rep
this instrument. Kolotkin et al. compared 323 patients after
gastric bypass with 257 individuals who sought but did not
undergo bariatric surgery. At 2 and 6 years of follow-up, the
surgery cohort had significantly higher scores on both the
SF-36 and the disease-specific IWQOL-Lite [27, 28]. The
peak of quality of life improvements was seen at the 2-year
time point, and although differences persisted at 6 years,
there was some weight regain and an accompanying decline
in HRQL [27]. In a comparison of surgery and optimal
medical management with type II diabetes, both the adjust-
able gastric band [29] (AGB) and Roux-en-Y gastric bypass
(RNYGB) [30] result in significantly greater weight loss
and better glycemic control. Quality of life was again mea-
sured with both the generic SF-36 and the disease-specific
IWQOL. In this study, when the control group received
optimal medical therapy, there was no significant difference
in SF-36 scores. The disease-specific metric, however,
showed significant improvements in quality of life after
the bypass [30].
Adams et al. compared patients undergoing RNYGB
with weight-matched controls who received no treatment
[31]. All main outcome measures, including weight loss
and comorbidities, were improved in the surgical cohort.
When looking at quality of life outcomes on the SF-36,
patients reported significant improvement in the physical
components of the questionnaire, but no improvement on
the mental health sections. In a 12-year study of RNYGB,
Raoof et al. had similar results, with patients showing sig-
nificant improvement specifically in the physical compo-
nents of the SF-36 [32]. In a study comparing preoperative
patients, patients 1–2 years from RNYGB, and patients at
least 7 years from RNYGB, Neto et al. found that while
general health perception and vitality were durably im-
proved postoperatively, there was no difference between
the groups in mental health or social functioning [33].
Impact of Bariatric Surgery on Overall Quality of Life
Many of the largest and longest-running studies of bariatric
surgery outcomes report on quality of life as a secondary,
rather than primary, outcome. The available details on the
methodology and results are therefore somewhat limited.
Himpens et al., for example, report on 9-year outcomes for
126 patients after the RNYGB [12] and 53 patients after
laparoscopic sleeve gastrectomy (LSG) [11]. In both stud-
ies, the authors report BAROS scores, which utilize the
Moorehead-Ardelt Quality of Life Questionnaire II. In
both studies, the authors report long-term positive quality
of life outcomes, although the results are limited to a per-
centage of patients who indicate they are “happy or very
happy with the procedure” and would opt to have the op-
eration again.
Impact of Bariatric Surgery on Outcome-Specific Quality
of Life
Most outcome-specific quality of life studies focus on depres-
sion and anxiety symptoms or eating habits. There are overall
mixed results. Buddeberg-Fischer et al. followed 131 patients
who applied for bariatric surgery, comparing the surgical co-
hort (57 patients undergoing gastric band and 12 undergoing
RNYGB) with the untreated control group [34]. After four and
a half years, the surgical group lost significantly more weight,
but did not have significantly higher quality of life, or lower
incidences of depression, anxiety, or binge eating. In the long-
term follow-up for the Swedish Obese Subjects (SOS) study,
patients treated with a variety of bariatric procedures were
compared with medically treated patients over 10 years [35].
Depression symptoms were significantly decreased at 10 years
post-surgery, but there was no change in overall mood or in
anxiety symptoms.
Relationship of Type of Procedure to Quality of Life
Outcomes
Numerous studies attempt to compare outcomes between dif-
ferent bariatric procedures. Overall, the LSG, AGB, and
RNYGB have all demonstrated significant improvements in
quality of life in studies with at least 1-year follow-up [9, 12,
14, 15, 36, 37]. Direct comparisons of quality of life outcomes
between two or more procedures are rare. Peterli et al. ran-
domized 217 patients to either sleeve gastrectomy or gastric
bypass and found significant and comparable improvements
in quality of life at 1 year after either procedure [15]. Other
studies have shown significantly greater improvements in
quality of life with the bypass in comparison with the gastric
band after 1 year [38], 3 years [39], or sleeve gastrectomy after
4 years [40]. Similar results are seen in adolescents, where
patients after gastric bypass have a significantly greater im-
provement in quality of life after 3 years than those undergo-
ing the LSG or AGB [16].
Predictors of Quality of Life Outcomes Postoperatively
A number of potential predictor variables for postoperative
quality of life have been explored, including the degree of
excess weight loss. The correlation between degree of weight
loss and postoperative QOL is not consistent amongst studies.
In one study of 459 patients undergoing AGB procedure, per-
centage of excess weight loss was unrelated to degree of QOL
improvement at 4-year follow-up [37]. In another study of 50
patients undergoing AGB, however, degree of QOL improve-
ment was strongly correlated with the degree of excess weight
loss at 1 and 5 years as measured by the generic Health-
Related Quality of Life Questionnaire [24, 9]. Similarly,
studies of patients undergoing gastric bypass show a

correlation between degree of weight and improved QOL [25]
and show that loss of <50% of excess body weight is a pre-
dictor of overall poorer QOL [32, 10, 41]. Strain et al. follow-
ed 105 patients undergoing gastric bypass, duodenal switch,
or sleeve gastrectomy and found no correlation between de-
gree of weight loss and QOL outcomes measured with SF-36
or depression symptoms measured with the Beck Depression
Inventory [17]. In one study, patients who were undergoing
gastric bypass as a revision from a prior operation had poorer
postoperative quality of life [32] although in a prospective
database of patients undergoing LAGB or VBG, the need
for reoperation was not a predictor of poorer quality of life
[42].
Preoperative depression symptoms have also been identi-
fied as a predictor of lower QOL changes after bariatric sur-
gery [10, 43]. Overall, however, the majority of studies
looking at psychosocial predictors of outcomes after bariatric
surgery focus on weight regain. There are few studies specif-
ically examining predictors of poor quality of life response
after surgery.
Specific Threats to Quality of Life After Bariatric
Surgery
Overwhelmingly, the available literature demonstrates consid-
erable improvements in multiple quality of life domains after
bariatric surgery [44]. There are, however, threats to quality of
life after bariatric surgery that warrant specific mention. These
are likely rare events, although it is also possible that these
outcomes are more common than described in large-scale
studies, since they may contribute to the loss of follow-up that
is an acknowledged challenge for postoperative bariatric sur-
gery outcomes. Below, we discuss several specific negative
QOL outcomes that can occur after bariatric surgery and may
warrant specific attention in preoperative planning and post-
operative care.
Social Stigma Against Bariatric Surgery
The social stigma against obesity also extends to surgical
treatments for obesity [22]. Especially when postoperative
complications lead to new health problems, patients may
feel that these issues must be kept private. Patients have
reported feeling well supported when things are going
well and they are losing weight, but a lack of support
for postoperative complications, including nutrient defi-
ciencies or chronic pain [45]. Sarwer et al. found that
weight-related stigmatization was associated with poorer
postoperative quality of life and increased depression
symptoms [46].
Curr Obes Rep
Excess Skin
One infrequently discussed physical complication of bariatric
surgery is the development of skin folds as patients lose sig-
nificant weight. While not frequently mentioned in large-scale
outcome studies, up to 95% of patients undergoing a gastric
bypass express dissatisfaction with excess skin, and 74% ex-
press a desire for plastic surgery to remove excess skin [47].
Excess skin after massive weight loss can have physical con-
sequences, including dermatitis, ulcers, and chronic pruritis
[48]. It can also lead to psychological and quality of life con-
sequences, including social limitations, physical activity, sex-
ual activity, and self-esteem [49]. Furthermore, most patients
seek plastic surgery for excess skin specifically to improve
quality of life [50] and patients who do undergo body
contouring procedures have significantly higher health-
related quality of life than patients who undergo gastric bypass
without plastic surgery [51].
Depression and Anxiety
The impact of bariatric surgery on depression and anxiety is
unclear. There are many studies that demonstrate a decrease in
depressive and anxiety symptoms after surgery [26, 18]. There
are small studies that have shown an increase in major depres-
sion after bariatric surgery, however [52]. Depression either
pre- or postoperatively is associated with decreased weight
loss and poorer postoperative quality of life [10, 43], empha-
sizing the importance of understanding the impact of bariatric
surgery on depression symptoms.
Alcohol Use Disorder
Alcohol use disorders have been shown to increase after bar-
iatric surgery, particularly when patients are followed beyond
the first postoperative year [52, 53]. This may be due to im-
paired alcohol metabolism after Roux-en-Y gastric bypass;
postoperative patients report feelings of mental intoxication
with much lower levels of alcohol, and a different constella-
tion of physical symptoms, including lower levels of diapho-
resis, flushing, and hyperactivity [54]. This changed metabo-
lism may explain why an increase in alcohol and other addic-
tive disorders is associated with Roux-en-Y gastric bypass,
but not with laparoscopic gastric banding or sleeve gastrecto-
my [55].
Conclusions
Success after bariatric surgery is measured by a number of
different factors. The amount of weight loss, the retention of
weight loss, and the resolution of obesity-related comorbidi-
ties are essential. Improvement in quality of life and
Curr Obes Rep
psychosocial outcomes is also an important factor though
more difficult to measure. Obesity has a definite impact on
quality of life, even without other comorbidities [2, 56], and
surgery for obesity results in significant and lasting improve-
ments in patient-reported quality of life outcomes. The quality
of life improvements after surgery are particularly dramatic in
the realm of physical functioning, which is not surprising giv-
en the impact of the surgery on comorbidities. Data on the
impact on mental and social metrics of quality of life are more
mixed. All of these may be useful to assess cost-effectiveness
studies which may incorporate Quality-Adjusted Life Years
based upon Quality of Life assessment.
Bariatric surgery’s impact on quality of life has been dem-
onstrated in numerous large multi-center trials, but there are
two important limitations to the literature that have relevance
to clinical practice. First, the existing literature relies heavily
on 1-year outcomes. Although some studies have begun to
present longer-term outcomes for quality of life [35], these
are still in the minority. The vertical banded gastroplasty,
which demonstrated excellent short-term weight loss and
quality of life outcomes, was shown in 5- and 10-year fol-
low-up to have extremely high rates of weight regain, with
associated regression in quality of life outcomes [57, 58].
The story of the vertical banded gastroplasty is a reminder
of the need for long-term quality of life outcomes, to ensure
that the gains seen in shorter-term studies are enduring. In
contrast, the RYGB has demonstrated long-term mainte-
nance of weight loss and QOL studies have demonstrated
maintained QOL at 7 to 12 years postop [12]. Second, studies
evaluating quality of life after bariatric surgery use a huge
variety of survey instruments. The SF-36 is the most com-
mon general quality of life instrument, while the Moorehead-
Ardelt Quality of Life Questionnaire II is the BAROS-
preferred instrument. Dozens of other general, disease- and
aspect-specific surveys are used. The variety of instruments
limits the ability to compare outcomes across studies, espe-
cially when results are not clear-cut. Physical aspects of
HRQL are the most dramatically improved after bariatric
surgery, while mental health questions on general surveys
and outcome-specific questionnaires for anxiety and depres-
sion show mixed results.
Finally, there are uncommon but important threats to qual-
ity of life after bariatric surgery. These include a perceived
lack of support due to a social stigma against the surgery, the
consequences of excess skin and the potential need for plastic
surgery, depression and anxiety symptoms, and alcohol use
disorders. Although these outcomes are a minority of patients,
it is essential for a bariatric surgery program to recognize and
have plans in place in order to limit their impact on patients’
postoperative quality of life.
Overall, bariatric surgery remains the most effective, dura-
ble, and efficient treatment for obesity, and the physical gains
are mirrored by significant improvements in quality of life.
Compliance with Ethical Standards
Conflict of Interest Laura M. Mazer, Dan E. Azagury, and John M.
Morton declare they have no conflict of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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