© Borgis - Postępy Nauk Medycznych 4/2013, s. 275-280
*Agnieszka H. Dziurowicz-Kozłowska1, Zbigniew Wierzbicki2, Andrzej Chmura2, Wojciech Lisik2
Funkcjonowanie fizyczne, psychologiczne i społeczne pacjentów poddanych chirurgicznemu leczeniu otyłości
Physical, psychological and social functioning of patients undergoing surgical treatment of obesity**
1Evoluo Foundation, Warsaw
Head of Foundation: Armen Mekhakyan, MA
2Department of General and Transplantation Surgery, Medical University of Warsaw
Head of Department: prof. Andrzej Chmura, MD, PhD
Wstęp. Praca dotyczy funkcjonowania fizycznego, psychologicznego i społecznego pacjentów poddanych chirurgicznemu leczeniu otyłości metodą Pionowej Opaskowej Plastyki Żołądka (VBG). Projekt badawczy osadzono w biopsychospołecznym modelu zdrowia, w którym zakłada się, że stan chorego określany jest zarówno za pomocą obiektywnych wskaźników, jak i na podstawie subiektywnej oceny stanu zdrowia dokonywanej przez pacjenta.
Materiał i metody. Badanie zrealizowano w schemacie podłużnym. Osoby badane trzykrotnie (miesiąc przed VBG oraz w trzy i sześć miesięcy po VBG) wypełniały kwestionariusz Nottingham Health Profile, stosowany do oceny funkcjonowania biopsychospołecznego chorych somatycznie. W każdym z trzech etapów badania wzięło udział 65 osób (52 K i 13 M) w wieku od 21-58 lat (M = 38,56; SD = 8,98) z otyłością prostą.
Wyniki. Operacja VBG pozwoliła uzyskać w badanej grupie procentowy spadek nadmiernej masy ciała (%EWL) na poziomie 39,86% w trzy miesiące po zabiegu i odpowiednio 58,62% w sześć miesięcy po zabiegu. W trzy i sześć miesięcy po przebyciu VBG zaszły istotne pozytywne zmiany w funkcjonowaniu fizycznym (Energia, Ograniczenia Ruchowe, Ból, Zaburzenia Snu) i psychologicznym (Negatywne Reakcje Emocjonalne) pacjentów. W sześć miesięcy po VBG zaszły istotne pozytywne zmiany w funkcjonowaniu społecznym (Wyobcowanie Społeczne) pacjentów.
Wnioski. Operacyjne leczenie otyłości metodą VBG prowadzi do skutecznej redukcji masy ciała. W trzy i sześć miesięcy po VBG poprawie ulega funkcjonowanie fizyczne i psychologiczne pacjentów otyłych. W sześć miesięcy po VBG poprawie ulega funkcjonowanie społeczne pacjentów otyłych.
Introduction. The paper deals with physical, psychological and social functioning of patients undergoing surgical treatment of obesity with the Vertical Banded Gastroplasty (VBG). The research project has been set in the bio-psychosocial health model based on the assumption that a patient’s health state can be assessed with the use of both objective indices and the patient’s subjective evaluation of his or her health state.
Material and methods. The study was based on a longitudinal design. The subjects were measured three times (one month before the VBG and three and six months after the VBG) with Nottingham Health Profile – a questionnaire used to assess patients suffering from somatic diseases. The participants of the study at each of the three stages were 65 patients (52 females and 13 males) at the age 21-58 (M = 38.56; SD = 8.98) with simple obesity.
Results. The VBG surgery led to an average percentage Excess Weight Loss (%EWL) of 39.86% and 58.62% three and six months after the operation, respectively. Three and six months after the operation significant positive changes were noted in physical functioning (Energy, Physical Mobility, Pain, Sleep Disturbances) and psychological functioning (Emotional Distress). Six months after the VBG significant positive changes were noted in the patients’ social functioning (Social Isolation).
Conclusions. The VBG surgery is effective in obtaining a body mass reduction. In three and six months after the VBG there is an improvement in obese patients’ physical and psychological functioning. Six months after the operation there is an improvement in their social functioning as well.
The epidemic level of obesity makes it one of the most important problems and health challenges of the contemporary world (1). In spite of the preventive measures being taken, there is a systematic growth of people with overweight and obesity in the general population (2). Excessive adipose tissue accumulation in the organism has a negative influence on the functioning of many organs and organ systems (3, 4). Such a state creates favourable conditions for ailments following directly from obesity and increases the risk of comorbidities related to obesity. Here, one can enumerate such diseases as hypertension, coronary heart disease, sleep apnoea, impaired glucose tolerance, type 2 diabetes, dyslipidemia, osteoarthritis and certain types of cancer (5, 6). Obesity and its health complications significantly lower life expectancy and lead to a person’s much worse physical functioning (7, 8).
Obesity has an equally negative influence on a person’s psychological and social functioning. A low level of satisfaction with one’s weight and appearance often leads to a decrease in self-evaluation and self-acceptance, and, in consequence, to the formation of a negative self-image as a whole (9, 10). In severely obese patients, one often detects mood disorders, mainly dysthymia and depression as well as anxiety disorders (11, 12). The phenomenon of stigmatization and pejorative stereotypes connected with obesity contribute to the deprecation and discrimination of this group of patients in the social environment (13). Obese people have real difficulties in establishing and maintaining satisfactory interpersonal relationships, both in their personal and professional lives (14). The feeling of lack of acceptance and fear of being rejected make them withdraw from social interactions and lead to their social isolation (13, 14).
Lowering body weight as a result of conservative methods of treatment (such as a diet with energy deficit, physical activity, pharmacotherapy, psychological support, or participation in complex weight loss programs) brings obese patients considerable health benefits and improves their psychosocial functioning (15, 16). However, classic methods of treating obesity are not sufficient to ensure optimal and permanent weight loss in all cases. When traditional coping strategies fail and the problems connected with excess weight become more severe, operative treatment should be considered.
Bariatric surgery is the most effective form of treatment of obesity class III, also called pathological obesity (17). It makes it possible to considerably reduce overweight and sustain this effect. At the same time, however, it is the most invasive of the available methods of obesity therapy. The surgical procedures it involves are connected with an increased risk of complications (17). For these reasons, bariatric surgery is used only in the case of patients with unquestionable therapeutic indications who meet strict qualification criteria (18, 19).
There are three main groups of operative techniques used in surgical treatment of obesity: restrictive (limiting the stomach volume), malabsorptive (disturbing the process of absorption) and mixed (restrictive-malabsorptive) (20). Vertical Banded Gastroplasty (VBG) constitutes a typical example of a restrictive operative technique (21). Its mechanism consists in creating conditions of an energy deficit resulting from a significant decrease in the amount of food taken at one time. On average a VBG surgery leads to a 55-65% excess weight loss (22, 23).
The present paper concerns physical, psychological and social functioning of obese patients undergoing surgical treatment with the VBG method. The patients’ functioning was studied in the pre-operative period as well as three and six months after the surgery. The research project was conducted within the bio-psychosocial health model. This paradigm assumes that a person’s general functioning, both in health and disease, is affected by mutually combined biological, psychological and social factors (24). The psychophysical functioning is regarded as a dynamic process depending on the person’s health situation, which is changing in time (25). Furthermore, it is assumed that a person’s condition is determined not only on the basis of objective indicators such as laboratory, function, or imaging tests, but also on the basis of a subjective health evaluation done by the patient (26).
RESEARCH QUESTIONS AND HYPOTHESES
In the present study the following research questions and hypotheses have been posed:
1. What is the process of patients’ weight reduction like at different stages following the VBG surgery, i.e. three and six months after the operation?
H1 The surgical treatment of obesity with the use of the VBG method leads to a significant weight reduction at each successive stage of the study.
2. What is the direction and scope of changes in physical, psychological and social functioning of obese patients undergoing the VBG treatment at each successive stage of the study, i.e. three and six months after the operation?
H2.1 Physical functioning of obese patients who have undergone a VBG surgery shows improvement at each successive stage of the study.
H2.2 Psychological functioning of obese patients who have undergone a VBG surgery shows improvement at each successive stage of the study.
H2.3 Social functioning of obese patients who have undergone a VBG surgery shows improvement at each successive stage of the study.
MATERIAL AND METHODS
The study followed a longitudinal design. Obese patients qualified for bariatric treatment with the VBG were measured three times: one month before the surgery (Stage 1) as well as three (Stage 2) and six months (Stage 3) after the surgery. Access to the peritoneal cavity was obtained by means of the abdominal section. The study was conducted between December 2006 and January 2011at the Department of General and Transplantation Surgery of the Medical University of Warsaw.
The sample for the study included 65 patients (52 females, 13 males) at the age ranging from 21 to 58 years (M = 38.56; SD = 8.98) with simple obesity class II (35 ≤ BMI < 40; N = 3) and class III (BMI ≥ 40; N = 62). In the pre-operative period the value of BMI ranged from 38.10 to 64.29 kg/m2 (M = 48.71; SD = 6.77).
All the subjects had been qualified for the VBG in the process of a multistage evaluation conducted by a multidisciplinary committee. In the sample under study, no medical or psychological contraindications for the surgical treatment had been noted.
Apart from weight and excess weight values, the index used for the measurement of the subjects’ weight was the value of the Body Mass Index (BMI). The BMI shows the ratio of a person’s weight measured in kilograms to the squared value of his or her height measured in metres (27).
The instrument used to measure the quality of the subjects’ bio-psychosocial functioning was the Nottingham Health Profile (NHP), a self-descriptive questionnaire developed by S.M. Hunt, J. McEwen and S.P. McKenna and adapted in Poland by B. Bojarska, R. Pikuła and K. Wrześniewski (28, 29). The NHP questionnaire has two parts: the main one and the supplementary one. In the present study, only the main part was used. It contains items related to currently experienced problems in physical, psychological and social functioning related to one’s health state. It contains 38 short statements referring to six subscales. For the needs of the present study, each of the original subscales was assigned to one of the three dimensions of the individual’s functioning: physical (Energy, Physical Mobility, Pain, Sleep Disturbances), psychological (Emotional Distress) and social (Social Isolation). The results are calculated separately for each of the six subscales. The higher the score, the higher the impairment of a given dimension. Both versions of the NHP, the original one and the Polish one are characterised by fully acceptable values of validity and reliability measures (29, 30).
The initial analyses of the data included computing descriptive statistics, examining the normality of the distributions and checking the relationship between the control variables (gender, age, marital status, education, professional activity, a dwelling place, financial situation, the need of social approval) and the dependent variables under study. The control variables and the dependent variables were not significantly related.
The main analyses involved computations appropriate for repeated measures designs with dependent samples. The first step was the Friedman ANOVA by ranks test – a nonparametric alternative to one-way repeated measures analysis of variance (31). Whenever the Friedman test showed a significant result, in the next step the Wilcoxon matched pairs test was used – the most powerful nonparametric alternative to the t-test for dependent samples (31).
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