The Impact of Bariatric Surgery on Employment: A Systematic Review

Prevalence of obesity-related multimorbidity and its health care costs among adults in the United States

BACKGROUND

Overweight and obesity are associated with many obesity-related complications (ORCs) and drive increased health care costs. However, data on the impact of obesity severity on multimorbidity and the effect of multimorbidity on cost and health care resource utilization (HCRU) in people with overweight or obesity are limited.

OBJECTIVE

To determine in reference to obesity-related multimorbidity (1) if prevalence increases with higher levels of weight class, (2) if higher levels of weight class are associated with an increased risk of multimorbidity at an earlier age, and (3) how HCRU and health care costs are impacted, including if there is a beyond-additive effect on ORC-related costs.

METHODS

This retrospective cross-sectional study used linked electronic health records (EHRs) and insurance claims from Optum's de-identified Market Clarity Data. Costs were considered from January 1 to December 31, 2019. Patients continuously insured in 2018 and 2019 with at least 1 recorded body mass index (BMI) in 2019 were included. The presence of 17 prespecified ORCs was determined from the database based on the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes. ORC-related medical services costs were based on ICD-10-CM diagnosis codes in the primary position; pharmacy costs were based on National Drug Codes. Total health care costs were the sum of medical services and pharmacy costs. Weight classes were derived from the patients' median BMI in the EHR in 2019.

RESULTS

The prevalence of multimorbidity increased with increasing weight levels (12.3% in overweight and 33.4% in class 3 obesity for ages 19-40 years; 41.5% and 66.6% for ages 41-65 years; and 70.6%-85.9% for age ≥65 years). Ages for predicted 50% risk of having at least 2 ORCs were 59, 54, 49, and 43 years among patients with overweight and obesity classes 1, 2, and 3, respectively. The mean effect of multimorbidity on ORC-related costs was beyond additive in those with obesity, such that the ORC-related costs were about $1,082 (151%), $1,696 (218%), and $2,433 (264%) for class 1, class 2, and class 3 obesity, respectively. This effect was not present for overweight, for which the cost was $310 (42%). Individuals with multimorbidity had higher odds of emergency department visits (odds ratio [OR] = 1.74; 95% CI = 1.73-1.76) and inpatient hospitalization (OR = 3.32; 95% CI = 3.27-3.38).

CONCLUSIONS

The prevalence of obesity-related multimorbidity increased with increasing weight classes within age groups. Obesity-related multimorbidity presented at an earlier age with higher weight class, such that the predicted probability of having obesity-related multimorbidity was more than a decade younger in class 2 and class 3 obesity compared with overweight. It was associated with increased HCRU and higher-than-expected costs exceeding the sum for the ORCs. Early diagnosis and treatment of obesity may be needed to prevent or delay the onset of obesity-related multimorbidity and limit its associated health care costs.

Social isolation but not deprivation involved in employment status after bariatric surgery

An increase in employment rate was observed among individuals who underwent bariatric surgery. This study assessed the relationship between employment rate and weight loss, deprivation, and Bariatric Analysis and Reporting Outcome System (BAROS) scores after bariatric surgery in a deprived area. This retrospective study evaluated the employment rate at a mean period of 2.3±0.1 years after bariatric surgery among 133 individuals. The Evaluation of Deprivation and Inequalities in Health Examination Centers (EPICES score), satisfaction scale, and BAROS (self-esteem, physical activity, social life, work conditions, and sexual activity) questionnaires were used. The mean age of the participants was 45 (range: 19–67) years. Approximately 88% were women. The initial mean body mass index (BMI) was 42.7 kg/m², and about 88% of the participants underwent sleeve gastrectomy. The mean decrease in BMI was 12 ± 0.5 kg/m². The mean EPICES score (N<30), BAROS, and satisfaction scale (range: 1–5) scores were 31.9±18, 1.3±1.1, and 4.27±1.19, respectively. After surgery, 19 participants obtained a job. However, three were unemployed. Based on a multivariate analysis, employed and unemployed participants (77 vs 52) before surgery had a lower initial BMI and better BAROS and satisfaction scale scores. After surgery, there was no difference between participants who obtained a new job and those still did not have a job in terms of questionnaire responses. Obtaining a new job was not associated with BMI, sex, or age differences. However, there was a positive correlation between social life score and weight loss. Bariatric surgery increased an individual’s chance of finding a job independently of deprivation status. Participants with a pre-operative job had a better perception of satisfaction and BAROS scores. Moreover, social isolation was correlated with unsuccessful weight loss.

Methodological aspects of design, analysis and reporting of studies with work participation as an outcome domain in patients with inflammatory arthritis: results of two systematic literature reviews informing EULAR points to consider

Objective

To summarise the methodological aspects in studies with work participation (WP) as outcome domain in inflammatory arthritis (IA) and other chronic diseases.

Methods

Two systematic literature reviews (SLRs) were conducted in key electronic databases (2014–2019): search 1 focused on longitudinal prospective studies in IA and search 2 on SLRs in other chronic diseases. Two reviewers independently identified eligible studies and extracted data covering pre-defined methodological areas.

Results

In total, 58 studies in IA (22 randomised controlled trials, 36 longitudinal observational studies) and 24 SLRs in other chronic diseases were included. WP was the primary outcome in 26/58 (45%) studies. The methodological aspects least accounted for in IA studies were as follows (proportions of studies positively adhering to the topic are shown): aligning the studied population (16/58 (28%)) and sample size calculation (8/58 (14%)) with the work-related study objective; attribution of WP to overall health (28/58 (48%)); accounting for skewness of presenteeism/sick leave (10/52 (19%)); accounting for work-related contextual factors (25/58 (43%)); reporting attrition and its reasons (1/58 (2%)); reporting both aggregated results and proportions of individuals reaching predefined meaningful change or state (11/58 (16%)). SLRs in other chronic diseases confirmed heterogeneity and methodological flaws identified in IA studies without identifying new issues.

Conclusion

High methodological heterogeneity was observed in studies with WP as outcome domain. Consensus around various methodological aspects specific to WP studies is needed to improve quality of future studies. This review informs the EULAR Points to Consider for conducting and reporting studies with WP as an outcome in IA.

Place Work on a Scale: What Do We Know About the Association Between Employment Status and Weight Loss Outcomes After Bariatric Surgery?

Despite the initial successful weight loss after bariatric surgery, a significant amount of patients experience weight loss failure and weight regain. Several factors are known to contribute to this, though the impact of employment status is unknown. The objective of this systematic review was to examine the impact of employment status on post-surgical weight loss outcomes. Eight studies were included with a follow-up ranging between 2 and 10 years. Employed patients seemed to present more weight loss (9.0-11.0% EWL, 1.3-1.6% BMI loss) compared to unemployed patients, but none of these numbers were statistically significant. Moreover, there were contrasting findings in terms of weight regain. This review may highlight the importance of working status after bariatric surgery and warrants further investigation on this topic.

Effect of bariatric surgery on employment status-a 7 years controlled nationwide registry study

BACKGROUND

Severe obesity is associated with a reduced ability to work. Bariatric surgery is the most effective method to achieve a sustained weight loss. Previous studies have reported conflicting results regarding the effect of bariatric surgery on employment status. To address this, we investigated the effect of bariatric surgery on employment status in the Danish population.

METHODS

In this nationwide study, we identified 5450 subjects who underwent bariatric surgery and 10 900 control subjects matched for age, sex and municipality. From accessible registries, we extracted data regarding employment, absenteeism, sick leave and pension. Using a multistate model, we compared time in occupational states and transitions between these states to determine the effect of bariatric surgery on employment status.

FINDINGS

Before surgery, cases had an absolute risk increase (95% CI)(ARI (CI)) and a relative risk (RR (CI)) of being in full-time employment of -0.12 (-0.14 to -0.10) and 0.84 (0.82 to 0.86) and were more often unemployed or in a subsidised job than the background population. Taking into account the employment status before surgery, the bariatric surgery group increased their probability of being in full-time employment 1-3 years after bariatric surgery. However, this positive effect was not present with a longer duration of follow-up. Being male, above 50 years of age, or employed as a craftsman or office worker were associated with a sustained positive effect of being in full-time employment (ARI (CI) and RR (CI) 0.05 (0.04 to 0.05) and 1.05 (1.04 to 1.06), 0.06 (0.06 to 0.07) and 1.08 (1.07 to 1.09) and 0.05 (0.05 to 0.06) and 1.05 (1.05 to 1.06), respectively).

INTERPRETATION

Compared with a matched control group, those undergoing bariatric surgery did not improve their employment status in the long term. Certain subgroups had a more sustained positive effect.

Earnings and employment for women after bariatric surgery: a matched cohort study

BACKGROUND/OBJECTIVES

Bariatric surgery induces durable weight loss and improves health and quality of life. Less is known about how bariatric surgery affects labour market outcomes. This study examined the development of earnings and employment status among women with obesity who underwent bariatric surgery versus matched comparators.

SUBJECTS/METHODS

This study included two cohorts of women in Sweden who gave birth between 1992 and 2014: a cohort with bariatric patients and their full sisters (sister cohort) and a cohort with bariatric patients and comparators matched on BMI, education, birth year, and previous cardiovascular, psychiatric, and musculoskeletal inpatient care diagnoses (BMI-matched cohort). Taxable annual earnings were retrieved from the Swedish Income Tax Register from 2 years before to 5 years after surgery. Employment status was measured dichotomously (employed/not employed) based on earnings data. Adjusted mean and prevalence differences were estimated for earnings and employment by ordinary least squares regression.

RESULTS

The sister cohort included 1400 patient-sister pairs. At baseline, patients and their sisters were of similar age (38.3 vs. 38.6 years) but had different BMI (37.3 vs. 26.7 kg/m²). The BMI-matched cohort included 2967 patient-comparator pairs with similar age (36.1 vs. 36.2 years) and BMI (37.1 vs. 37.0 kg/m²) before surgery. During follow-up, similar developments of earnings and employment status were observed between bariatric patients and the comparators in both cohorts. When comparing absolute levels of earnings in the sister cohort, the difference in earnings at 2 years before surgery [mean difference -$4137 (95% CI -5245 to -3028)] was similar to the difference in earnings at 5 years after surgery [-$5620 (-7024 to -4215)]. Similar results were found in the BMI-matched cohort, but of smaller magnitude.

CONCLUSIONS

Bariatric surgery had little influence on the development of annual earnings and employment for women with obesity in Sweden over 5 years after surgery.

Implications of Professional Occupation Related to Obesity in Patients Undergoing Bariatric Surgery

Obesity is an epidemic with severe consequences on the professional development of patients. Bariatric surgery has proven to be a safe treatment with effective results in weight control. The aim of this study is to assess the implications of professional occupation in relation to the development of obesity and weight changes after bariatric surgery. We analyzed 500 obese patients (77.8% women, 22.2% men) who underwent one anastomosis gastric bypass surgery at the Centre of Excellence for the Study and Treatment of Obesity and Diabetes (2014–2019), assessing the influence of professional occupation on body composition and evolution of weight loss up to two years after surgery. Preoperative obesity type III and IV was higher in men than in women (45.9–19.8% vs. 43.7–9.5%; respectively). Prevalent clinical history in women was depression (46.7%), varicose veins (35.6%), and thyroid disease (9.7%), while in men it was respiratory failure (98.2%), high blood pressure (56.8%), hepatic steatosis (82%). Postoperative weight loss was effective in every professional field, reaching normal weight values from 12 months after surgery.