Obesity is associated with sick leave, disability, and work place injuries.1,2 Bariatric surgery is an effective treatment for patients with severe obesity.3,4 Evidence is limited regarding the relationship between bariatric surgery and work productivity. We assessed working status and productivity change in the first 3 years following surgery for severe obesity.
Methods
Adults with severe obesity undergoing bariatric surgery were recruited (February 2005–February 2009) at 10 US centers for the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study.4 Each center obtained institutional review board approval; participants provided written consent. Three-year follow-up through October 2012 is reported. Assessment of sociodemographic and health status has been described.4 Participants completed the validated Work Productivity and Activity Impairment questionnaire5 presurgery and annually postsurgery. Work status among nonretirees and past-week work absenteeism (missed work due to health) and presenteeism (impaired work due to health) among employed participants were assessed. Mixed models were used to test change over time among those with baseline and at least 1 follow-up assessment, controlling for factors related to missing follow-up data as fixed effects (Table 1). Mixed models were used to examine the associations of surgical procedure and changes in weight, physical function and mental health, and comorbidity resolution, with postsurgery absenteeism and presenteeism in years 1, 2, and 3 controlling for baseline status. Adjusted relative risks and 95% CIs were reported. Analyses were conducted using SAS (SAS Institute), version 9.4. Two-sided P values less than .05 were considered statistically significant.
Table 1.
Model-Based Estimates, % (95% CI)a
|
Overall P Value | Adjusted P Value for Pairwise Comparisonsb
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Baseline | Year 1 | Year 2 | Year 3 | Baseline vs Year 1 | Baseline vs Year 2 | Baseline vs Year 3 | Year 1 vs Year 3 | ||
Employment Statusc | |||||||||
| |||||||||
Employed | 74.8 (72.8–76.9) | 74.0 (71.8–76.2) | 74.9 (72.6–77.2) | 73.0 (70.6–75.5) | .23 | ||||
| |||||||||
Unemployed | 3.7 (2.9–4.5) | 4.2 (3.3–5.1) | 4.9 (3.8–5.9) | 5.6 (4.4–6.8) | .78 | .17 | .02 | .12 | |
| |||||||||
Disabled | 14.0 (12.5–15.6) | 13.1 (11.6–14.7) | 13.4 (11.8–15.0) | 14.1 (12.4–15.8) | .17 | ||||
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Work Productivityd | |||||||||
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Absenteeism (any missed work due to health) | 15.2 (13.0–17.4) | 10.4 (8.4–12.4) | 11.6 (9.4–13.8) | 13.8 (11.4–16.1) | .003 | .05 | .74 | .07 | |
| |||||||||
Presenteeism (any impairment while working due to health) | 62.8 (59.7–65.9) | 31.9 (28.8–35.1) | 35.6 (32.2–39.0) | 41.0 (37.5–44.6) | <.001 | <.001 | <.001 | <.001 | |
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Percentage reduction in productive work due to health problemse | <.001 | <.001 | <.001 | <.001 | |||||
| |||||||||
0 | 37.4 (37.2–37.7) | 68.2 (68–68.5) | 64.9 (64.6–65.1) | 59.5 (59.3–59.8) | |||||
| |||||||||
10 | 18.8 (18.5–19.1) | 14.2 (13.8–14.6) | 15.1 (14.7–15.5) | 13.4 (13.0–13.8) | |||||
| |||||||||
20 | 14.2 (13.8–14.6) | 8.5 (8.2–8.9) | 7.1 (6.7–7.4) | 12.0 (11.5–12.4) | |||||
| |||||||||
30 | 11.8 (11.4–12.2) | 5.0 (4.6–5.4) | 4.2 (3.8–4.6) | 5.3 (4.9–5.7) | |||||
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40 | 6.2 (5.8–6.6) | 2.0 (1.6–2.4) | 2.3 (1.9–2.7) | 3.9 (3.4–4.3) | |||||
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50 | 4.9 (4.5–5.4) | 1.2 (0.9–1.6) | 2.3 (1.8–2.8) | 2.4 (1.9–2.8) | |||||
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>50 | 9.0 (8.6–9.4) | 2.4 (2.0–2.7) | 6.5 (6.0–7.0) | 5.3 (4.9–5.8) |
Poisson mixed models with robust error variance were used for binary measures. Mixed-effects ordinal logistic regression models were used for ordinal measures. Models adjusted for factors related to missing follow-up data (site, age, race, and baseline smoking status in the employment status sample; site, age, and baseline body mass index in the work productivity sample) as fixed effects.
Mixed models were used to test for differences across and between time points. If the overall P value was less than .05, pairwise comparisons were made between baseline and each follow-up to assess the short-term and longer-term effects, and between years 1 and 3 to determine if the short-term and longer-term effect differed. Pairwise P values were adjusted for multiple comparisons using simulation.
Among adults not retired at all nonmissing assessments (n = 1773). Annual retention among participants with baseline data was 75%(1522/2019), 67% (1358/2013), 63%(1262/2009). Employed was defined as employed full-time for pay, part-time for pay, or for pay with unknown hours.
Among adults employed at all nonmissing assessments (n = 1092). Annual retention among participants with baseline data was 75%(944/1265), 67% (847/1264), 64%(810/1263).
Participants indicated how much their health problems affected their productivity via a rating scale (0–10; 0 = health problems had no effect on work, 10 = health problems completely prevented working). The response times 10 is assumed to represent a percentage reduction in productive work due to health problems.
Results
Of 2019 nonretired participants, 1773 (89%) had work factors data at 1 or more follow-up assessment(s) and were included in the analysis. Baseline median age was 45 years (interquartile range [IQR], 36–52); median body mass index (calculated as weight in kilograms divided by height in meters squared) was 46 (IQR, 42–52); 80% were women; 71% underwent Roux-en-Y gastric bypass; and 24% underwent a laparoscopic adjustable gastric band surgical procedure. Weight loss was 28% (95% CI, 27.4%–28.6%) at 3 years.
Prevalence of employment or disability did not significantly change throughout follow-up, from presurgery values of 74.8% (95% CI, 72.8%–76.9%) for employment and 14.0% (95% CI, 12.5%–15.6%) for disability. However, unemployment increased from presurgery to year 3 (3.7%[95%CI, 2.9%– 4.5%] for presurgery vs 5.6% [95% CI, 4.4%–6.8%] for year 3 postsurgery, P = .02) (Table 1).
Of 1265 employed participants, 1092 (86%) were included in the work productivity sample. Prevalence of absenteeism was lower at year 1 (10.4% [95% CI, 8.4%–12.4%], P = .003) vs presurgery (15.2%[95%CI, 13.0%–17.4%]), but did not significantly differ from presurgery at year 2 or 3. Prevalence of presenteeism was lower than presurgery at all postsurgery times but increased from years 1 to 3 (62.8% at baseline; 31.9% at year 1; 35.6% at year 2; 41.0% at year 3).
Improvements in physical function and depressive symptoms were independently associated with lower risks of postsurgery absenteeism and presenteeism, whereas postsurgery initiation or continuation of psychiatric treatment vs no treatment presurgery or postsurgery was associated with higher risks (Table 2). Greater weight loss was independently associated with lower risk of postsurgery presenteeism only. Surgical procedure was not independently associated with either outcome.
Table 2.
Absenteeism (n = 854)b
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Presenteeism (n = 836)b
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ARR (95% CI) | P Value | ARR (95% CI) | P Value | |
Baseline Status | ||||
| ||||
Absenteeism/presenteeismc | 1.93 (1.43–2.61) | <.001 | 1.86 (1.53–2.27) | <.001 |
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Better physical function, per 10 SF-36 points higher | 0.74 (0.62–0.88) | .001 | 0.66 (0.61–0.72) | <.001 |
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Fewer depressive symptoms, per 10 BDI points lower | 0.57 (0.45–0.72) | <.001 | 0.67 (0.59–0.76) | <.001 |
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Surgical procedure (reference = LAGB) | .08a | .36a | ||
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RYGB | 2.18 (1.09–4.36) | 1.29 (0.91–1.85) | ||
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Other | 1.18 (0.76–1.84) | 1.05 (0.87–1.27) | ||
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Presurgery to Postsurgery Change | ||||
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Weight loss, per 5% | 1.04 (0.98–1.12) | .19 | 0.95 (0.92–0.98) | .01 |
| ||||
Improvement in physical function, per 10 SF-36 points higher | 0.66 (0.58–0.76) | <.001 | 0.66 (0.62–0.70) | <.001 |
| ||||
Improvement in depressive symptoms, per 10 BDI points lower | 0.63 (0.51–0.78) | <.001 | 0.70 (0.63–0.78) | <.001 |
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Psychiatric treatment during past year | .01a | <.001a | ||
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Stopping treatment vs continuing treatment | 0.95 (0.59–1.56) | 0.81 (0.64–1.02) | ||
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Starting treatment vs continuing no treatment | 1.41 (0.74–2.68) | 1.37 (1.01–1.85) | ||
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Continuing treatment vs continuing no treatment | 1.64 (1.10–2.46) | 1.38 (1.12–1.70) |
Abbreviations: ARR, adjusted relative risk; BDI, Beck Depression Inventory; LAGB, laparoscopic adjustable gastric band; RYGB, Roux-en-Y gastric bypass; SF-36, 36-Item Short Form Health Survey.
Poisson mixed models with robust error variance. Associations of surgical procedure, percentage weight loss, and presurgery to postsurgery change in physical function (SF-36 score), depressive symptoms (BDI score), psychiatric treatment (ie, stopped, started, or continued) and comorbidities (ie, remitted, current, no history) with postsurgery absenteeism and presenteeism were examined, controlling for site, sex, race, baseline age, education, body mass index, and either absenteeism or presenteeism, as well as factors significantly related to either baseline absenteeism (ie, physical function, depressive symptoms, past-year psychiatric treatment, severe walking limitation) or presenteeism (ie, physical function, depressive symptoms, past-year psychiatric treatment, urinary incontinence). Several additional baseline factors were considered (ie, marital status, smoking status, substance use disorder, diabetes, dyslipidemia and hypertension, and history of cardiovascular disease, sleep apnea, asthma, and venous edema with ulceration), but were not controlled for because they were not independently related to baseline absenteeism or presenteeism. Postsurgery factors were retained if they reached statistical significance (P < .05). Nonsignificant associations with sex, race, and baseline age, education, body mass index, severe walking limitations, and urinary incontinence are not shown.
Model samples are smaller than the employed sample of 1092 due to missing covariate data.
Absenteeism/presenteeism indicates that baseline absenteeism was controlled for in the absenteeism model and baseline presenteeism was controlled for in the presenteeism model.
Discussion
In this large cohort of adults who underwent bariatric surgery, patients maintained working status and decreased impairment due to health while working. The small increase in unemployment by year 3 may reflect a secular trend in unemployment during the time of the study; the annual average rate of unemployment increased from 4.5% in 2007 to 8% in 2012.6 The reduction in presenteeism following surgery may be explained by weight loss, improved physical function, or reduction in depressive symptoms. The increase in presenteeism between years 1 and 3 may reflect an adaptation to a new health state or deterioration of initial presurgery to postsurgery improvements. The limitations include the attrition rate, self-report data, restriction of the questionnaire to past week absenteeism and presenteeism at each visit, and lack of data on reasons for attrition or changes in employment status. Also, because the study did not have a parallel control group, findings cannot be attributed to the surgery itself.
Acknowledgments
Funding/Support: LABS-2 was a cooperative agreement funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); and by grants K24 DK080775 from NIDDK (Dr Subak), U01 DK066557 from the Data Coordinating Center, U01-DK66667 from Columbia University Medical Center (in collaboration with Cornell University Medical Center CTRC, grant UL1-RR024996), U01-DK66568 from University of Washington (in collaboration with CTRC, grant M01RR-00037), U01-DK66471 from the Neuropsychiatric Research Institute, U01-DK66526 from East Carolina University, U01-DK66585 from the University of Pittsburgh Medical Center (in collaboration with CTRC, grant UL1-RR024153), and U01-DK66555 from the Oregon Health & Science University.
Footnotes
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Alfonso-Cristancho reports being an employee at GlaxoSmithKline and that his work there is not related to the research in this article. Dr Flum reports being an advisor for Pacira Pharmaceuticals, providing expert testimony for Surgical Consulting, and receiving travel expenses from Patient-Centered Outcomes Research Institute. No other disclosures were reported.
Role of the Funder/Sponsor: The NIDDK scientists contributed to the design and conduct of the study, which included collection and management of data. The project scientist from the NIDDK served as a member of the steering committee, along with the principal investigator from each clinical site and the data coordinating center. The data coordinating center housed all data during the study and performed data analyses according to a prespecified plan developed by the data coordinating center biostatistician and approved by the steering committee and independent data and safety monitoring board. The decision to publish was made by the Longitudinal Assessment of Bariatric Surgery-2 steering committee, with no restrictions imposed by the sponsor. As a coauthor, an NIDDK scientist contributed to the interpretation of the data and preparation, review, or approval of the manuscript.
Author Contributions: Dr King 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.
Concept and design: Alfonso-Cristancho, Mitchell, Ramanathan, Sullivan, Flum.
Acquisition, analysis, or interpretation of data: Alfonso-Cristancho, King, Mitchell, Belle, Flum.
Drafting of the manuscript: Alfonso-Cristancho, King, Flum.
Critical revision of the manuscript for important intellectual content: Alfonso-Cristancho, King, Mitchell, Ramanathan, Sullivan, Belle.
Statistical analysis: King, Sullivan, Flum.
Obtaining funding: Mitchell, Belle, Flum.
Administrative, technical, or material support: Alfonso-Cristancho, Flum.
Study supervision: Mitchell, Ramanathan, Belle.
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