Beyond weight loss: Quality of life and internalized weight bias in endoscopic bariatric revision

Abstract

We commend Agrawal et al for their insightful and pioneering study, which provides new evidence that revisional endoscopic bariatric therapy (EBT) can significantly improve quality of life and reduce internalized weight bias. Their work rightly demonstrates that these procedures provide benefit beyond weight loss alone. To build on these findings, we suggest that future studies should address certain remaining methodological issues. These include recruiting larger and more heterogeneous cohorts to assess generalizability, using multivariable analysis to control for the confounding effects of anti-obesity medications, and implementing longitudinal assessments to determine the duration of improvements in patient-reported outcomes. Establishing a causal link between early improvements in EBT and internalized weight bias with long-term weight control will be vital to establish the therapeutic value of revisional EBT as part of a comprehensive and multi-modal treatment for obesity.

Key Words: Quality of life; Internalized weight bias; Endoscopic bariatric therapy; Bariatric surgery revision; Patient reported outcomes; Dumping syndrome; Obesity care

Core Tip: The pioneering study of Agrawal et al shifts the focus of endoscopic bariatric revision from weight loss to two critical patient-reported outcomes: Quality of life and internalized weight bias. Their work provides foundational evidence that these procedures offer profound psychological benefits, and address these two core sequelae of obesity. This letter highlights the importance of this paradigm shift and outlines the essential next steps - use of larger cohorts, control for anti-obesity medications, and longitudinal data - to translate these promising findings into robust evidence for the holistic care of patients with obesity.

TO THE EDITOR

We read with great interest the pioneering study by Agrawal et al[1], which provides novel insights into the impact of revisional endoscopic bariatric therapy (EBT) on quality of life and internalized weight bias (IWB). The authors should be commended for shifting the focus beyond traditional weight-centric metrics. Their findings, which demonstrated significant increases in quality of life and decreases in IWB and dumping symptoms, are a critical advancement in evaluating the holistic success of EBT procedures.

A novelty of the study by Agrawal et al[1] is its focus on the psychosocial dimensions of post-bariatric care. Their finding of profound improvements in “role limitations due to emotional problems” is particularly noteworthy. This finding suggests that revisional EBT may significantly alleviate the psychological burden of patients who struggle with regaining of weight and also potentially restore their sense of capability and self-efficacy. Furthermore, their observation of a decreased IWB has substantial clinical importance. IWB can mediate poor mental and physical health outcomes[2]. Therefore, an intervention that mitigates this internalized stigma offers a therapeutic benefit that is distinct from, and perhaps as valuable as, weight loss itself. This means that revisional EBT is not merely an anatomical correction, but can be considered a holistic treatment that addresses core psychological sequelae of obesity.

Although these initial results are compelling and are likely important for patients and clinicians, they also illuminate a clear and necessary path for future research. To translate these promising findings into robust, evidence-based medicine, we suggest the need to address several key issues.

First, the small, homogenous sample of the Agrawal et al’s study[1], although understandable in this initial exploratory study, limits the generalizability of the results. Future studies should strive for larger and more heterogeneous cohorts and should also perform stratification by baseline body mass index, type of primary surgery, revisional technique, type of index surgery (Roux-en-Y gastric bypass vs sleeve gastrectomy), and the specific revisional procedure (transoral outlet reduction vs revision - endoscopic sleeve gastroplasty). This approach will help clarify which patient subgroups derive the greatest psychosocial benefit.

Second, the confounding effect of anti-obesity medications also warrants rigorous control. As the authors note, most patients were on anti-obesity medications (primarily semaglutide), and some even initiated these medications after the EBT. The potent effects of these pharmacotherapies on weight loss, and potentially on psychological well-being[3], could significantly confound the outcomes attributed to the endoscopic procedure. Subsequent investigations should employ a prospective design with multivariable regression analyses to determine the independent effect of EBT.

Finally, the durability of these improvements remains an open question. The assessment of quality of life and IWB at a single post-procedure time (≥ 4 weeks) only indicates short-term impact. Longitudinal studies with repeated assessments at 6 months, 12 months, and 24 months are essential. Such data will enable evaluation of the duration of the psychosocial benefits and assessment of the relationship between improved quality of life/IWB and long-term weight maintenance. It is plausible, although not yet proven, that the rapid post-procedure psychological empowerment and decreased self-stigma improve adherence to lifestyle recommendations, thereby fostering better long-term weight stability.

In conclusion, Agrawal et al[1] have successfully broadened our perspective of the value of revisional EBT. They have provided foundational evidence that these procedures can provide an improved quality of life and freedom from the psychological burden of obesity. The current challenge is for the scientific community to build upon this foundation by performing additional definitive, controlled, and longitudinal studies. These studies may help validate the profound impact of revisional EBT and solidify its role as indispensable component of a comprehensive, patient-centered, and multi-modal approach to obesity care.