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. 2022 Dec 7;17(12):e0276167. doi: 10.1371/journal.pone.0276167

Long-term changes in body image after bariatric surgery: An observational cohort study

Laurène Bosc 1, Flore Mathias 1,#, Maud Monsaingeon 1,#, Caroline Gronnier 2,3,#, Emilie Pupier 1,#, Blandine Gatta-Cherifi 1,3,4,*
Editor: George Vousden5
PMCID: PMC9728839  PMID: 36477002

Abstract

Background

While body image improves in the first few months after surgery, data on long-term changes in body image after bariatric surgery are scarce and contradictory.

Methods

We assessed body image through the Stunkard Figure Rating Scale and the Multidimensional Body-Self Relations Questionnaire-Appearance Scale, which measures appearance evaluation and orientation, overweight preoccupation, and self-classified weight. Surveys were conducted before surgery and at regular intervals until 5 years after bariatric surgery.

Results

61 patients were included in the study. No patients were lost to follow-up until 18 months after bariatric surgery. At 5 years, there were 21 patients (34%) lost to follow-up. We detected an overall improvement in body image until 12–18 months post-surgery. Scores declined after 5 years post-surgery but were still higher than preoperative evaluations. Overweight preoccupation did not change throughout the follow-up period. There was a positive correlation between body weight lost and appearance evaluation. There was also a positive correlation between weight loss and the Body Areas Satisfaction Scale. There was a negative correlation between weight loss and overweight preoccupation. Appearance orientation and self-classified weight were not correlated with weight loss.

Conclusions

Body image improved after bariatric surgery but was not maintained for all 5 years after surgery.

Introduction

Body image dissatisfaction is prevalent among the general population [1] and common in patients suffering from obesity [2], women [3], White, and those with a ‘Western lifestyle’ [1]. In patients with obesity, early-onset obesity, obesity-related stigmas, eating disorders, underlying depression, yo-yo dieting effects, and body image distortion are correlated with poorer body image satisfaction [4, 5].

Bariatric surgery (BS) is the most efficient treatment for morbid obesity. Depending on the procedure, it allows for 13–27% body weight loss for up to 15 years post-surgery and reduces obesity mortality by 5% [6]. It also has a dramatic positive effect on obesity-related comorbidities: especially type 2 diabetes but also cardiovascular diseases including hypertension, obstructive sleep apnea-hypopnea syndrome and also non-alcoholic steatohepatitis, osteoarticular disorders [7].

Health is the primary reason reported by patients for seeking bariatric surgery but patients also report a strong desire for surgery to change the appearance of their body [8, 9]. Indeed, approximately one in five bariatric surgery patients identifies appearance concerns as the primary motivator for bariatric surgery [10]. While the weight loss and metabolic outcomes of bariatric surgery have been well-documented, the evolution of body image following bariatric surgery is less investigated [11]. Most studies report only short-term results and the literature on post-operative body image changes and weight outcome is mixed [12–15]. Therefore, if general improvement is typically observed among adults, some also reported improvements in specific body image domains only. The mixed literature may perhaps be related to methodological factors including the variety of body image measures used (more than 20 different body measures which have not been validated most of the time for body image assessment after bariatric surgery) which tap different aspects of body image (cognitive, affective, behavioral or perceptual aspects). Above all, most studies assessed patients through the first 2 years post bariatric surgery while weight regain is observed after the initial post surgical period [6]. The aim of our study was to describe the evolution of body image in a prospective observational cohort for up to 5 years after BS.

Materials and methods

We carried out a single-center prospective observational cohort study in the Obesity Department of Bordeaux University Hospital between October 2011 to April 2012.The inclusion criteria required patients to be over 18 years of age, to speak and to write French and undergoing a preoperative assessment for BS according to international guidelines [16]. Patients undergoing bariatric surgery during this period and who agreed to participate in the study were included. Data were collected during the preoperative assessment, and between 1 and 3 months (M1–M3), 6 and 9 months (M6–M9), 12 and 18 months (M12–M18), and 60 and 72 months (M60–M72) after BS. Body weight, height, body mass index (BMI), and percentage of weight lost after BS were assessed at each of these time points.

The Multidimensional Body-Self Relations Questionnaire-Appearance Scale (MBSQR-AS) [17] 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 MBSRQ–AS has been translated and validated in French [18]. The five subscales of the MBSRQ–AS have good psychometric qualities: the internal consistency ranges from .66 to .88 and test-retest reliability ranges from .78 to .85 for the five subscales in French. The scale has been used in numerous studies focusing on obesity and bariatric surgery.

The Stunkard Figure Rating Scale [19] 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.

Statistical analyses were performed using GraphPadPrism software. Quantitative variables were compared by an analysis of variance (ANOVA). Correlation coefficients (Spearman or Pearson coefficient, depending on the distribution of continuous or non-continuous variables) were calculated. A P-value< 0.05 was considered statistically significant. All quantitative variables are expressed as the mean ± standard error of the mean (SEM).

Each participant received a study information sheet and signed an informed consent form.

Results

Patient baseline characteristics

Sixty one 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 ± 22.7 kg corresponding to an average BMI of 42.4 ± 7.9 kg/m2. A Roux-en-Y Gastric Bypass (RYGB) was performed in 32 patients (52%) while 29 patients (48%) underwent a sleeve-gastrectomy.

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 patients’ characteristics are summarized in Table 1.

Table 1. Characteristics of the bariatric surgery candidates at the preoperative assessment.

Quantitative variables are expressed as the mean ± SEM.

Men/women (%) 23/77
Mean age (years) 45 ± 10
Mean weight (kg) 125.6 ± 22.7
Mean BMI (kg/m2) 42.4 ± 7.9
Onset of obesity
Since childhood (%) 54
Since adulthood (%) 46
Surgery type:
Bypass (%) 52
Sleeve-gastrectomy (%) 48
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BMI = Body Mass Index.

Body weight loss after BS

No patients were lost to follow-up until 18 months after BS. At M60–M72, 21 patients (34%) were lost to follow-up (12 dropouts and 9 missing answers on the questionnaires).

The percentage of body weight loss increased significantly fromM1–M3 (10.62 ± 4.40) until M12–M18 (28.44 ± 7.99%; P<0.05) before decreasing significantly to 22.82 ± 12.05% at M60–M72 (P<0.05). The average BMI decreased significantly from the preoperative assessment (39.59 ± 7.34 kg/m2)until M12–M18 (M1–M3 = 33.80 ± 6.69 kg/m2, M6–M9 = 33.80 ± 6.69 kg/m2and M12–M18 = 31.63 ± 6.38 kg/m2; P<0.05), but increased significantly between M12–M18(31.63 ± 6.38 kg/m2) and M60–M72 (34.12 ± 8.22 kg/m2;P<0.05).

Changes in MBSRQ-AS scores during follow-up

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).

Table 2. The MBSRQ-AS scores (mean ± SEM) during follow-up.

Means with different superscripts are significantly different from each other (P < 0.05).

Preoperative assessment M1–M3 M6–M9 M12–M18 M60–M72
Appearance evaluation 2.30 ± 0.66 2.59 ± 0.72a 3.04 ± 0.76b 3.15 ± 0.78c 2.97 ± 0.80abc
Appearance orientation 3.58 ± 0.56b 3.63 ± 0.55b 3.81 ± 0.53a 3.81 ± 0.50ab 3.63 ± 0.53b
BASS 2.44 ± 0.51 2.76 ± 0.56b 3.05 ± 0.61a 3.24 ± 0.64ac 2.90 ± 0.74bc
Overweight preoccupation 3.29 ± 0.68ab 3.18 ± 0.67ab 3.19 ± 0.75a 3.06 ± 0.62b 2.96 ± 0.70ab
Self-classified weight 4.58 ± 0.60a 4.43 ± 0.71a 3.90 ± 0.76b 3.67 ± 0.72 3.96 ± 0.63b
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BASS = Body Areas Satisfaction Scale.

The appearance orientation scores increased significantly fromM1–M3 to M6–M9 but decreased significantly between M12–M18 and M60–M72. 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 M6-M9 (2.44 ± 0.5 vs 2.76 ± 0.56 vs 3.05 ± 0.61, preoperative assessment vs M1-M3 vs M6-M9, P<0.05). The scores did not change between M6–M9 and M12–M18 (3.24 ± 0.64) but decreased significantly until M60–M72 (2.90 ± 0.74), though they remained significantly higher than at the preoperative evaluation (Table 2). There were positive correlations between weight loss and BASS at M1–M3(r = 0.4, P<0.05), M6–M9 (r = 0.41, P<0.05), M12–M18 (r = 0.39, P<0.05), and M60–M72 (r = 0.36, P<0.05).

The overweight preoccupation scores did not change significantly until M6–M9 (preoperative = 3.29 ± 0.68, M1–M3 = 3.18 ± 0.67, and M6–M9 = 3.19 ± 0.75;P<0.05). Between M6-M9 and M12–M18, the score decreased significantly and did not change until M60–M72 (Table 2). There was a negative correlation between weight loss and overweight preoccupation at M1–M3 (r = -0.39, P<0.05). The self-classified weight scores decreased significantly from M1–M3 (4.43 ± 0.71) to M6–M9 (3.90 ± 0.76) and M12–M18 (3.67 ± 0.72;P<0.05). These scores increased at M60–M72 (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. Changes in the MBSRQ-AS scores are summarized in Table 2.

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 was no differences between patients with BMI under or over 30 for the other scores that composed the MBSRQ-AS score.

Changes in BD score during follow-up

The mean BD score decreased significantly between the preoperative assessment (3.30 ± 1.01), M1–M3 (2.61 ± 1.04), M6–M9 (1.85 ± 0.95), and M12–18 (1.33 ± 0.96; P<0.05). The mean BD score at M60–M72 was 1.77 ± 1.37 (Table 3). There was a significant negative correlation between weight loss and BD score at M60–M72 only (r = -0.47, P<0.05). Changes in the BD scores are summarized in Table 3.

Table 3. The BD score (mean ± SEM) during follow-up.

Means with different superscripts are significantly different from each other (P < 0.05).

Preoperative assessment M1–M3 M6–M9 M12–M18 M60–M72
BD score 3.30 ± 1.01 2.61 ± 1.04 1.85 ± 0.95a 1.33 ± 0.96b 1.77 ± 1.37ab
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BD = Body Dissatisfaction.

Discussion

While bariatric surgery is by far the most effective treatment for long-term obesity and its comorbidities, less is known about body image following BS especially after the first 2 years after BS. The current analysis, which includes a longitudinal characterization of body image through 5 years provides interesting results about the durability of body image changes after BS. In our study, the appearance evaluation and self-classified weight scores improved until M12–M18 after BS and declined at M60-72 but remained higher than the preoperative scores. These results have already been highlighted in the literature although the follow-up is most often of shorter duration and most studies have a post-operative sample size of fewer than 50 individuals. Indeed, in the systematic review of the literature of Ivezaj et al. [12], out of the 31 observational longitudinal studies, 52% (n = 16) had up to 12 months of follow-up and only 6% (n = 2) up to 48 months. All the studies have shown an improvement in body image after bariatric surgery and some studies have already shown stabilization or a decline of satisfaction scores from 12 or 24 months [20–22]. The studies with the longest follow-up agree that the satisfaction scores stay higher 48 months after BS than before surgery [23–25].

These results have to be faced to the evolution of the BASS. Therefore, the BASS scores only improved until M6–M9 reflecting dissatisfaction with one or more body regions. This could be linked to the appearance of excessive skin that is quite common after massive weight [26, 27]. Body contouring surgery (BCS) could improve body image in these patients [28]. However little is known about the trajectory of body image post-BCS among bariatric surgery patients. BCS after BS seems to improve body image satisfaction only in areas involved in the surgery (not untreated areas) [29] while one longitudinal study suggests that body image satisfaction needs three or more plastic surgeries following BS [30] to score comparable to standards. Only 8 patients from our cohort had undergone BCS after BS but the different types of surgery, the different delays between BS and BCS and short-term follow-up did not allow us to analyze their data.

This dynamic change of body image according to time after BS mirrors the weight loss trajectories that happen after BS [31]. Therefore, viewing post BS events (not only weight outcome) as a dynamic process is more a realistic view of post BS outcomes. This also emphasizes the need for a careful and long-life follow-up after BS. This follow-up needs to include body weight, nutritional status but also body image. Indeed, in non-surgical population, various features of body image dissatisfaction may be a signal for greater eating-disorder psychopathology, which could ultimately impact long-term weight loss outcomes following bariatric surgery [32, 33].

The literature on post-operative body image changes and weight outcome is mixed. Consistent with findings from some previous studies [34, 35], we found a positive correlation between weight loss and appearance evaluation at M1-M3, M6-M9 and M60-M72. There were also positive correlations between weight loss and BASS at all time points between M1-M3 and M60-M72. These positive associations are likely to be of clinical importance. Therefore, improving these dimensions could increase the amount of weight lost after BS. Targeted psychoeducation and assessment of body image throughout the bariatric surgery process both before and after bariatric surgery is mandatory to optimize body weight loss after BS [36].

The overweight preoccupation and appearance orientation scores were only slightly modified during follow-up and the average score at 5 years was not significantly different from the preoperative average. The lack of improvement in this aspect of body image has already been described in the literature [22, 23, 37]. This indicates that body weight remains a major concern for BS patients even after significant weight loss [38, 39]. Indeed, these scores remained positive throughout the follow-up period, suggesting: i) a persistent desire of patients to be thinner than they are, ii) that their perceived body remains different from their ideal body, and iii) that they constantly see themselves as heavy even after significant weight loss. These results are similar to those of previous studies [40, 41], although one study showed a significant reduction in the determination for weight loss at 6 months post-BS [42].

These results suggest that patients may still identify as obese, even after BS, as indicated by their tendency to overestimate their weight [43]. In patients suffering from anorexia nervosa, weight overestimation is well described and may correlate with dysfunction of the parietal cortex [44]. A similar mechanism has been suggested after rapid weight loss in BS patients where proprioceptive information is not updated, which leads to a distorted body schema. Consequently, patients feel heavier than they actually are [45].

Although we can’t claim causality between body weight loss and body image, we suppose that the decline of body image satisfaction long after bariatric surgery should prompt clinicians to think about ways to improve body image. Virtual reality could be an option. Indeed, according to the ‘allocentric lock hypothesis’, patients suffering from obesity may approach their body image from an allocentric frame of reference by adopting the point of view of an outside observer toward their own body, and this point of view is not updated after weight loss [46–48]. Memories of stigmatizing experiences can contribute to allocentric locking. The inability to update the allocentric representation therefore locks the patient into a dissatisfying body. Despite efforts to modify their weight, they will always be present in a body that differs from reality [49, 50]. Two case series showed significant improvements in the satisfaction scores of BS patients after 6 weeks of virtual reality [51, 52]. However, more studies and longer follow-up periods are needed to clarify the impact of this practice.

To our knowledge, it is the only study with so many body image assessments 5 years after bariatric surgery [53, 54]. The duration of our study allowed us to detect changes between 1 and 5 years after BS. Interestingly, we studied individuals from the same ethnic background that can potentially influence body image [55]. To our knowledge, this element has never been studied after bariatric surgery. In addition, we used 2 measures of body image.

However, none of the questionnaires we used were specific to BS. However, this is also the case for most published studies in this field. Indeed, a recent review identified only six questionnaires specific to assessing body image in patients after BS [56]. The BODY-Q questionnaire, developed specifically in 2012 for BS patients, seems to be the most appropriate for addressing these specific issues [57]. However, none of these questionnaires are translated or validated in French. The Figure Rating Scale has many limitations: limited range of figures are presented on the scale (it is indeed not a tool for subjects with super obesity), illustrations may not capture all the different body types, and validity may vary by ethnic group. Nevertheless, this tool was used frequently when we started collecting data and is still used today [58]. In addition, it has the advantage of being quickly administered, showing a strong correlation with the body mass index. It provides a simple, self-administered technique of collecting estimates of body dissatisfaction, and avoids variability that might be caused by language deficits. An interesting option could have been the use of the Body-Image Assessment for obesity or BIA-O as a figural rating scale (the first one adapted specifically for use in obesity) [59].

Twenty-one patients (34%) were lost to follow-up during the study. This difficult observance of follow-up after bariatric surgery is indeed well described in the literature and multiple factors have been suggested as risk factors for this attrition (distance to travel to the clinic, younger age, unemployment, financial factors, psychological issues) [60]. 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.

Conclusions

Our data show that body image improves after BS, but this effect is only temporary. The use of questionnaires specific to BS, including the BODY-Q, would help us better understand this change over time.

Supporting information

S1 File

(XLS)

Click here for additional data file. (403.5KB, xls)

Acknowledgments

We thank the Bordeaux University Hospital which allowed this work. We thank the subjects who participated to this work. The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see: http://www.textcheck.com/certificate/AbjS4I

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

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Decision Letter 0

Anca Mihaela Pantea-Stoian

15 Mar 2022

PONE-D-21-30163

Long-term changes in body image after bariatric surgery: an observational cohort study

PLOS ONE

Dear Dr. Gatta-Cherifi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 28 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Anca Mihaela Pantea-Stoian, md, phd

Academic Editor

PLOS ONE

Journal requirements:

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Furthermore, please amend your manuscript to adhere to our submission guidelines with respect to language describing demographic groups. Outmoded terms and potentially stigmatizing labels should be changed to more current, acceptable terminology. Specifically, we recommend that “Caucasian” should be changed to more appropriate term(s) such as 'White'

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Additional Editor Comments:

Dear Authors,

The article is interesting and valuable. However, there are some improvements to make:

1. Line 56: The authors mention that bariatric surgery also significantly improves most obese patients' comorbidities. Could you please detail (for example, diabetes, metabolic syndrome, hypertension..)?

2. It would be interesting if you could make some correlations between several factors and the change in body image over time, such as sex, age, the onset of obesity, type of BS, comorbidities, weight loss.

3. Do you have separated the patients who achieved BMI <30? It could show different results between the groups. It is interesting to explain the results, for this cluster of patients .

4. Please explain and extend the discussion about the reasons for the dropouts after 18 months.

5. Refresh the whole manuscript, correct miswriting, and check the punctuation.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

********** 

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

********** 

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Authors,

The aim of following patients' body images for a longer period after bariatric surgery is a very important point considering it may help to build strategies to achieve better and prolonged results, even if not using the most appropriate tools. Just wondering if you had separated the patients who achieved BMI <30 it could show different results between the groups. Also, I wondered if wouldn't be interesting to refer to the reasons for the dropouts after 18 months.

I suggest you review the writing as there are a few miswriting and check the punctuation.

Reviewer #2: The paper is an original article regarding the body image perception and its variation in patients that underwent bariatric surgery. The topic is extremely interesting. The paper is written in a fluid English language and based on a solid statistical analysis. Some issues could be improved before publication:

1. Line 56: The authors mention that bariatric surgery also bring important improvement in comorbidities that most obese patients have. Could you please detail (for example: diabetes, metabolic syndrom, hypertension..)?

2. It would be interesting if you could make some correlations between several factors and the change in body image over time, such as sex, age, onset of obesity, type of BS, comorbidities, weight loss

********** 

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2022 Dec 7;17(12):e0276167. doi: 10.1371/journal.pone.0276167.r002

Author response to Decision Letter 0

11 May 2022

Please see below for a point-by-point response to the comments and concerns. All page numbers refer to the revised manuscript file with tracked changes.

Additional Editor Comments:

Dear Authors,

The article is interesting and valuable. However, there are some improvements to make:

1. Line 56: The authors mention that bariatric surgery also significantly improves most obese patients' comorbidities. Could you please detail (for example, diabetes, metabolic syndrome, hypertension..)?

We thank the reviewer for this pertinent comment. We detailed that in the manuscript.

2. It would be interesting if you could make some correlations between several factors and the change in body image over time, such as sex, age, the onset of obesity, type of BS, comorbidities, weight loss.

We thank the reviewer for this comment. We did not find any correlation between the factors you mentioned above and the change in body image over time.

3. Do you have separated the patients who achieved BMI <30? It could show different results between the groups. It is interesting to explain the results, for this cluster of patients .

As you requested, we had a look at patients according to their final BMI i.e > 30 or < 30 and we added a sentence in the manuscript (lines 171-174).

4. Please explain and extend the discussion about the reasons for the dropouts after 18 months.

As you suggested, we explained that in the discussion (lines 273-276).

5. Refresh the whole manuscript, correct miswriting, and check the punctuation.

We checked the whole manuscript to ensure that the text is optimally phrased and free from typographical and grammatical errors.

Reviewer #1: Dear Authors,

The aim of following patients' body images for a longer period after bariatric surgery is a very important point considering it may help to build strategies to achieve better and prolonged results, even if not using the most appropriate tools. Just wondering if you had separated the patients who achieved BMI <30 it could show different results between the groups. Also, I wondered if wouldn't be interesting to refer to the reasons for the dropouts after 18 months.

I suggest you review the writing as there are a few miswriting and check the punctuation.

Reviewer #2: The paper is an original article regarding the body image perception and its variation in patients that underwent bariatric surgery. The topic is extremely interesting. The paper is written in a fluid English language and based on a solid statistical analysis. Some issues could be improved before publication:

1. Line 56: The authors mention that bariatric surgery also bring important improvement in comorbidities that most obese patients have. Could you please detail (for example: diabetes, metabolic syndrom, hypertension..)?

We thank the reviewer for this pertinent comment. We detailed that in the manuscript.

2. It would be interesting if you could make some correlations between several factors and the change in body image over time, such as sex, age, onset of obesity, type of BS, comorbidities, weight loss

As explained before, we did not find any correlation between the factors you mentioned above and the change in body image over time.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file. (15.5KB, docx)

Decision Letter 1

Thomas Tischer

11 Aug 2022

PONE-D-21-30163R1Long-term changes in body image after bariatric surgery: an observational cohort studyPLOS ONE

Dear Dr. Gatta-Cherifi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Your manuscript has been seen by two additional reviewers and their comments are attached below. We would like to ask you to address the concerns of reviewer #3 and respond to the comments of reviewer #4, specifically:

  • please discuss the limitation regarding the Figure Rating Scale

  • please review current literature to ensure that the most recent literature on the topic has been included

  • note that citing the reference requested by Reviewer 4 is not a requirement for publication

Could you please revise your manuscript to include their concerns?

Please submit your revised manuscript by Sep 25 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Thomas Tischer

Staff Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: No

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: The authors responded to the queries in the revised version. I have no further issues. I recommend publication.

Reviewer #3: This manuscript reports on data that is almost a decade old, for reasons that are unclear. Since that time, research in this area has grown to a size larger than suggested here. Much of the referenced literature is dated and many more recent empirical papers and reviews on this topic were missed. Further, the Figure Rating Scale is no longer viewed as an appropriate measure of body image dissatisfaction. It certainly not validated for those with clinically severe obesity. The results of the MBSRQ-AS replicate those from other studies. So, it's not clear what this small, dated study adds to the literature.

Reviewer #4: Long-term changes in body image after bariatric surgery: an observational cohort study.

Bariatric surgery and reconstructive procedures after weight loss are one of the most important and popular surgeries nowadays. On the other hand, the problem lies not only in the body structure and obesity. There is very an important, maybe the most important part how to prepare our patients’ mentally for the surgical journey. The surgery itself may give us a false belief that the patient is treated. But the psychiatric part may be as important as 80% of the treatment. It would be interesting to focus on the surgical outcome in comparison with the mental preparation before the surgery.

I find the study interesting. The manuscript is well organized, and statistically well prepared. Maybe the idea is not new, and the outcome is similar to the other studies, even the one presented by my team in 2020 The long-term effect of body contouring procedures on the quality of life in morbidly obese patients after bariatric surgery

doi.org/10.1371/journal.pone.0229138.

The strength of the study is long followed for up to 5 years. The response rate of the study is 66% which is more than needed to assess as a valid study. One of the most important parts of the manuscript is to show that after 5 years there is a decline in the body assessment, but it is still higher than before bariatric surgery. So we can say that the patient qualification process was proper.

There is my summary

1. The authors have responded properly to the reviewers

2. The study is valuable due to the long follow up

3. The response rate is 66% - enough to publish

4. Would be better to have a multicenter study, but thanks to long follow-up it should be considered valuable.

5. Please add the mentioned study

6. In the next studies I would recommend the assessment of the body reception and psychiatric evaluation of the patients.

I recommend this manuscript be accepted as an original article, please add the publication I mentioned.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes: Marek A Paul

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2022 Dec 7;17(12):e0276167. doi: 10.1371/journal.pone.0276167.r004

Author response to Decision Letter 1

20 Sep 2022

Dear Editor and Reviewers,

Thank you for giving us the opportunity to submit another revised version of the manuscript “Long-term changes in body image after bariatric surgery: an observational cohort study” for publication in PLOS ONE.

We appreciate the time and effort that you and the reviewers dedicated to providing feedback on our manuscript and are grateful for the insightful comments on and valuable improvements to our paper. We have incorporated most of the suggestions made by the reviewers. Those changes are highlighted within the manuscript.

Please see below for a point-by-point response to the comments and concerns. All page numbers refer to the revised manuscript file with tracked changes.

Reviewer #3: This manuscript reports on data that is almost a decade old, for reasons that are unclear. Since that time, research in this area has grown to a size larger than suggested here. Much of the referenced literature is dated and many more recent empirical papers and reviews on this topic were missed. Further, the Figure Rating Scale is no longer viewed as an appropriate measure of body image dissatisfaction. It certainly not validated for those with clinically severe obesity. The results of the MBSRQ-AS replicate those from other studies. So, it's not clear what this small, dated study adds to the literature.

Response:

Thank you for taking the time to review our article.

Indeed, our data are almost a decade ago since one of our goal was to follow patients during 5 years that means that the study started almost a decade ago.

We agree that the Figure Rating Scale has many limitations: limited range of figures are presented on the scale (it is indeed not a tool for subjects with super obesity), illustrations may not capture all the different body types, and validity may vary by ethnic group. Nevertheless, this tool was used frequently when we started collecting data and is still used today [58].

In addition, it has the advantage of being quickly administered, showing a strong correlation with the body mass index. It provides a simple, self-administered technique of collecting estimates of body dissatisfaction, and avoids variability that might be caused by language deficits.

An interesting option could have been the use of the Body-Image Assessment for obesity or BIA-O as a figural rating scale (the first one adapted specifically for use in obesity) with the BODY-Q as already mentioned in the manuscript [59]. The BIA-O was however much less used than the FRS in the bariatric surgery literature.

We think that the current research could add to the literature because it is the only study with so many body image assessments 5 years after bariatric surgery. We added this information in the manuscript [53, 54].

We thank the reviewer for giving us the opportunity to read again the literature. We have now cited additional recent studies in our paper.

[28] Paul MA, Opyrchał J, Knakiewicz M, Jaremków P, Duda-Barcik Ł, Ibrahim AMS, Lin SJ. The long-term effect of body contouring procedures on the quality of life in morbidly obese patients after bariatric surgery. PLoS One. 2020 Feb 21;15(2):e0229138.

[37] Perdue TO, Schreier A, Swanson M, Neil J, Carels R. Majority of female bariatric patients retain an obese identity 18-30 months after surgery. Eat Weight Disord. 2020 Apr;25(2):357-364.

[53] Mento C, Silvestri MC, Muscatello MRA, Rizzo A, Celebre L, Cedro C, Zoccali RA, Navarra G, Bruno A. The role of body image in obese identity changes post bariatric surgery. Eat Weight Disord. 2022 May;27(4):1269-1278

[54] Bertoletti J, Galvis Aparicio MJ, Bordignon S, and Marceli Trentini C. Body Image and Bariatric Surgery: A Systematic Review of Literature.Bariatric Surgical Practice and Patient Care. Jun 2019.81-92.

[58] Parzer V, Sjöholm K, Brix JM, Svensson PA, Ludvik B, Taube M. Development of a BMI-Assigned Stunkard Scale for the Evaluation of Body Image Perception Based on Data of the SOS Reference Study. Obes Facts. 2021; 14(4):397-404.

[59] Williamson DA, Womble LG, Zucker NL, Reas DL, White MA, Blouin DC, Greenway F. Body image assessment for obesity (BIA-O): development of a new procedure. Int J Obes Relat Metab Disord. 2000 Oct;24(10):1326-32.

Reviewer #4:

I find the study interesting. The manuscript is well organized, and statistically well prepared. Maybe the idea is not new, and the outcome is similar to the other studies, even the one presented by my team in 2020 the long-term effect of body contouring procedures on the quality of life in morbidly obese patients after bariatric surgery

doi.org/10.1371/journal.pone.0229138.

The strength of the study is long followed for up to 5 years. The response rate of the study is 66% which is more than needed to assess as a valid study. One of the most important parts of the manuscript is to show that after 5 years there is a decline in the body assessment, but it is still higher than before bariatric surgery. So we can say that the patient qualification process was proper.

There is my summary

1. The authors have responded properly to the reviewers

2. The study is valuable due to the long follow up

3. The response rate is 66% - enough to publish

4. Would be better to have a multicenter study, but thanks to long follow-up it should be considered valuable.

5. Please add the mentioned study

6. In the next studies I would recommend the assessment of the body reception and psychiatric evaluation of the patients.

Response :

Thanks for your comment. Your study using the BODY-Q is very interesting and we have added your reference to our manuscript at line 211 [28].

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Decision Letter 2

George Vousden

2 Oct 2022

Long-term changes in body image after bariatric surgery: an observational cohort study

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Acceptance letter

George Vousden

9 Nov 2022

PONE-D-21-30163R2

Long-term changes in body image after bariatric surgery : an observational cohort study

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