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Post-surgical improvements in body image not maintained

Body image improves after bariatric surgery, however, the effect is only temporary was not maintained for five years after surgery, according to researchers from Bordeaux University Hospital, Pessac, France. The findings were reported in the paper, ‘Long-term changes in body image after bariatric surgery: An observational cohort study’, published in PLOSone. The study authors concluded that the use of questionnaires specific to bariatric surgery, including the BODY-Q questionnaire, would improve researchers understanding of this change over time.

The researchers stated that although health is the primary reason given by patients for seeking bariatric surgery, approximately one in five bariatric surgery patients identifies appearance concerns as the primary motivator for bariatric surgery. However, they noted that whilst weight loss and metabolic outcomes from surgery are well reported, the reported evolution of body image following bariatric surgery sparse. Therefore, the carried out a study to describe the evolution of body image in a prospective observational cohort for up to five years after surgery.


For the study, the Multidimensional Body-Self Relations Questionnaire-Appearance Scale (MBSQR-AS) and the Stunkard Figure Rating Scale were used to assess body image satisfaction:

  • The MBSQR-AS assesses self-attitudinal aspects of the body-image construct and is composed of 34 questions divided into five sections: 1) ‘appearance evaluation’ measures feelings of physical attractiveness or unattractiveness, with a high score indicating satisfaction with one’s own appearance; 2) ‘appearance orientation’ measures the extent of investment in one’s appearance. A high score indicates a greater investment; 3) ‘body areas satisfaction scale’ (BASS), where a high score indicates general satisfaction with most areas of one’s body and a low score indicates dissatisfaction in the size or appearance of several areas; 4) ‘overweight preoccupation’ measures fat anxiety, weight vigilance, dieting, and eating restraint; and 5) ‘self-classified weight’ measures how one perceives his/her weight, from very underweight to very overweight.

  • The Stunkard Figure Rating Scale presents a series of nine male and female schematic silhouettes ranging from skinny to obese. Participants are asked to choose the silhouette that corresponds to their ideal body size (IBS) and the silhouette that reflects their current body size (CBS). Body dissatisfaction (BD) is calculated by subtracting the ideal body size from the current body size. A positive score indicates a desire to be thinner, while a negative score indicates a desire to be heavier.

In total, 61 white patients (female, n=47, 77%) were included in the study. Their mean age was 45±10 years. The average baseline bodyweight was 125.6±22.7kg (average BMI of 42.4±7.9kg/m2). A Roux-en-Y Gastric Bypass (RYGB) was performed in 32 patients (52%) while 29 patients (48%) underwent a sleeve-gastrectomy. At years 5-6, 21 patients (34%) were lost to follow-up (12 dropouts and 9 missing answers on the questionnaires).

At baseline the mean scores for the MBSQR-AS sections were as follows: appearance evaluation = 2.30 ± 0.66, appearance orientation = 3.58 ± 0.56, BASS = 2.44 ± 0.51, overweight preoccupation = 3.29 ± 0.68 and self-classified weight = 4.58 ±0.60. The average anxiety score was 7.43 ± 3.42, and the mean depression score was 4.97 ± 3.17. The average BD score from the Stunkard Figure Rating Scale was 3.30 ± 1.01.


The percentage of body weight loss increased significantly from months 1-3 (10.62 ± 4.40) until months 12-18 (28.44 ± 7.99%; p<0.05) before decreasing significantly to 22.82 ± 12.05% at months 60–72 (p<0.05). The average BMI decreased significantly from the preoperative assessment (39.59 ± 7.34 kg/m2) until months 12–18 (p<0.05), but increased significantly between months 12–M18 (31.63 ± 6.38 kg/m2) and months 60–72 (34.12 ± 8.22 kg/m2; p<0.05).


The appearance evaluation scores increased significantly from the preoperative period (2.30 ± 0.66) to the M12–M18 assessment (3.15 ± 0.78;P<0.05) and remained significantly elevated through M60–M72 (Table 2). There were positive correlations between weight loss and appearance evaluation at M1–M3 (r = 0.44; P<0.05), M6–M9 (r = 0.42; P<0.05), and M60–M72 (r = 0.33; P<0.05).

The appearance orientation scores increased significantly from months 1–3 to months 6–9 but decreased significantly between months 12–18 and months 60–72. At that last time point scores were not statistically different from the pre-surgery scores. There was no correlation between weight loss and appearance orientation during follow-up.


The BASS scores increased significantly from the preoperative assessment to months 6-9 (2.44 ± 0.5 vs 2.76 ± 0.56 vs 3.05 ± 0.61, preoperative assessment vs months 1-3 vs months 6-9, p<0.05). The scores did not change between months 6–9 and months 12–18 (3.24 ± 0.64) but decreased significantly until months 60–72 (2.90 ± 0.74), though they remained significantly higher than at the preoperative evaluation. There were positive correlations between weight loss and BASS at months 1–M (r = 0.4, p<0.05), months 6–9 (r = 0.41, p<0.05), months 12–18 (r = 0.39, p<0.05) and months 60–72 (r = 0.36, p<0.05).


The overweight preoccupation scores did not change significantly until months 6–9 (preoperative = 3.29 ± 0.68, M1–M3 = 3.18 ± 0.67, and months 6–9 = 3.19 ± 0.75; p<0.05). Between months 6-9 and months 12–18, the score decreased significantly and did not change until months 60–72. There was a negative correlation between weight loss and overweight preoccupation at months 1–3 (r=-0.39, p<0.05). The self-classified weight scores decreased significantly from months 1–3 (4.43 ± 0.71) to months 6–9 (3.90 ± 0.76) and months 12–18 (3.67 ± 0.72; p<0.05). These scores increased at months 60–72 (3.96 ± 0.63) but remained lower than the preoperative scores (4.58 ± 0.60). There was no correlation between weight loss and self-classified weight score during follow-up.


At last follow-up, the appearance evaluation was significantly higher in patients that had achieved a BMI <30 kg /m2 compared to those who did not (3.44 ± 0.65 vs 2.83 ± 0.79). There were no differences between patients with BMI under or over 30 for the other scores that composed the MBSRQ-AS score.


The mean BD score decreased significantly between the preoperative assessment (3.30 ± 1.01), months 1–3 (2.61 ± 1.04), months 6–9 (1.85 ± 0.95) and months 12–18 (1.33 ± 0.96; p<0.05). The mean BD score at months 60–72 was 1.77 ± 1.37. There was a significant negative correlation between weight loss and BD score at months 60–72 only (r=-0.47, p<0.05).


“To our knowledge, it is the only study with so many body image assessments five years after bariatric surgery. The duration of our study allowed us to detect changes between one and five years after bariatric surgery,” the authors concluded. “Interestingly, we studied individuals from the same ethnic background that can potentially influence body image. To our knowledge, this element has never been studied after bariatric surgery…Of note, our data did not allow us to study the relationships between post-BS body image changes and factors associated with greater body image dissatisfaction in obese patients such as early-onset obesity, episodes of obesity-related stigma, eating disorders, underlying depression, yo-yo dieting, and overestimating weight.”


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