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Obesity is related with several sleep disorders and affects the quality of life. In this research it was aimed to evaluate the effects of bariatric surgery on sleep disorders and sleep quality.
Methods
The study was conducted on 454 patients who underwent bariatric surgery at the Departments of General Surgery of Üsküdar University, Hitit University, Ondokuz Mayis University, and sleep disorders were evaluated at University of Health Sciences Erenköy Mental and Nervous Diseases Training and Research Hospital, Department of Neurology. Sleep quality of the patients, reporting complaints about sleep. was assessed with the Pittsburgh sleep quality index (PSQI), risk of obstructive sleep apnea syndrome was questioned with the Berlin Sleep Questionnaire (BSQ), excessive daytime sleepiness was screened with the Epworth Sleepiness Scale (ESS). The Insomnia Severity Index (ISI) was used in patients who identified insomnia and the restless legs syndrome severity scale (RLSS) index was also evaluated in patients with the complaints of RLS before and after the bariatric surgery.
Results
Among 454 patients, 207 of them (45.6%) have informed complaints about sleep. After bariatric surgery, all scores indicating impaired sleep quality (BSQ category 1 and category 2, RLS index, ESS, PSQI, ISI) decreased significantly in patients (p = 0.000). BSQ- scale scores had the greatest decrease among other scales. Patients also reported fewer complaints of sweating, sexual dysfunction, gastroosephageal reflux, teeth clenching, dry mouth, morning headache, nocturia, and daytime sleepiness after the surgery (p < 0.05). The decrease in body mass index (BMI) was significantly correlated with BSQ-OSAS total (r=-0.143; p < 0.05), RLS (r=-0.410; p < 0.05) and PSQI sleep latency (r = 0.174; p < 0.05). However, the correlation between BMI reduction and ESS, PSQI and ISI scores was found statistically insignificant. (p > 0.05). Effect of BMI difference on BSQ-OSAS was statistically significant (OR=-0.041; p < 0.05). Effects of BMI difference (OR=-0.490; p < 0.05) and having thyroid comorbidity (OR=-24.752; p < 0.01) on RLS were also statistically significant.
Conclusion
Bariatric surgery has a positive and healing effect on sleep apnea and restless legs syndrome in favor of this group of patients.
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Introduction
Individuals with a body mass index (BMI) above 25 kg/m2 are considered to have obesity. The World Health Organization declared obesity a major public health problem and a global epidemic in 1997 [1]. Since obesity is a multidimensional and multifactorial health problem, it both reduces the quality of life of individuals and leads to other diseases [2]. For this reason, the struggle against obesity has gained more importance in recent years. Methods such as nutrition, lifestyle, physical activity and proper nutritional intake are preventive solutions against obesity [3‐5]. On the other hand, since losing weight is much more difficult than gaining weight in obese individuals, medical and surgical treatment methods are more prominent [6]. Bariatric surgery methods are basically surgical methods that aim to reduce food intake by bypass or by reducing the stomach volume [7]. After these methods, the patient loses weight rapidly and many complaints accompanying obesity decrease as the amount of food consumed decreases [8].
Sleep refers to the basic resting process required for individuals’ vital activities. Sleep quality and sleep disorders may also be related with obesity and directly affect the quality of life. There are studies reporting that obesity negatively affects sleep quality through various mechanisms [9, 10]. Lee and Chao reported that there is a bidirectional and direct relationship between sleep and obesity [11]. While obesity negatively affects sleep quality, irregular sleep prevents weight control. Patel et al. revealed that there is a relationship between decreased amount of sleep and obesity and also reported that obesity and many sleep disorders and their prognosis are in a relationship [12]. Mitchell et al. reported that there is a direct relationship between obesity and sleep patterns starting from adolescence [13]. Obesity and physical activity play an important and significant role in sleep regulation, which is necessary for a healthy life [14].
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Though the relationship between obesity and sleep quality have been shown [11‐14], studies on sleep disorders and sleep quality after elimination of obesity through bariatric surgery are relatively limited. Besides, revealing how sleep quality and complaints about sleep disorders change after bariatric surgery and analyzing which variables are effective may help to improve the sleep quality and reduce the sleep disorders. In this research, we aimed to evaluate the effects of bariatric surgery on sleep disorders and sleep quality.
Methods
Research Model
The study was designed as a cross-sectional retrospective survey study. At first, sleep disturbances and sleep quality levels were measured by using a descriptive screening method from patients who underwent bariatric surgery and by filling out scales regarding their pre- and post-operative conditions. Then, symptoms of obstructive sleep apnea, insomnia, hypersomnia, restless legs syndrome and sleep quality after bariatric surgery were evaluated and analyzed using a relational screening model.
Patient Group
Patients with a diagnosis of morbid obesity who underwent bariatric surgery at least 6 months ago at the Üsküdar University Faculty of Medicine, Department of General Surgery, Hitit University Faculty of Medicine, Department of General Surgery, Ondokuz Mayıs University Faculty of Medicine, Department of General Surgery between January 2018 and June 2024 and also had sleep-related complaints were included in the study. Study data were collected by patients who had previously undergone bariatric surgery and who self-assessed their sleep quality before and after surgery. Patients self-reported their sleep quality both before and after bariatric surgery using self-report measures. The patients with mental retardation, dementia history or an ophthalmological disease that would prevent filling out the questionnaire, applying an additional treatment method to lose weight after bariatric surgery, being not able to lose weight or regain weight after bariatric surgery, unable to specify the characteristics of complaints related to sleep disorders before or after bariatric surgery and post-operative follow-up missing were excluded.
The socio-demographic characteristics of patients, symptoms for obstructive sleep apnea, restless legs syndrome, insomnia, excessive daytime sleepiness and also sleep quality were questioned before and six months after bariatric surgery using a Google survey form prepared by the researchers. Regardless of the bariatric surgery method chosen for the treatment of morbid obesity, the patient’s weight loss was considered sufficient. Those who underwent a different surgical, pharmacological or non-pharmacological treatment to lose weight after bariatric surgery were not included in the study.
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Data Collection Tools
Sleep quality was assessed by using the Pittsburg Sleep Quality Questionnaire [15], obstructive sleep apnea syndrome by Berlin Questionnaire [16], excessive daytime sleepiness by the Epworth Sleepiness Scale [7], restless legs syndrome (RLS) severity by RLS severity scale [18], and insomnia severity was assessed by using the Insomnia Severity Index [19] before and six months after the bariatric surgery.
Pittsburgh Sleep Quality Index (PSQI)
It is a frequently used self-report questionnaire that evaluates sleep quality over the past month. The scale was developed by Daniel Buysse et al. at the University of Pittsburgh in 1989. The Turkish validity and reliability study was conducted by Ağargün et al. [15].
The PSQI is a 19-item scale measuring various aspects of sleep, yielding seven component scores and one composite score. Each component of the PSQI is scored from 0 to 3, with 3 indicating the greatest impairment. The sum of the scores of the seven components produces an overall PSQI score ranging from 0 to 21. Higher scores indicate poorer sleep quality, and scores greater than 5 indicate significant sleep difficulties.
Berlin Sleep Questionnaire (BSQ)
It is a questionnaire designed for screening for Obstructive Sleep Apnea Syndrome. There are 10 questions in 3 categories. Each category is evaluated within itself, and if 2 or more categories are positive, the risk of OSAS is considered high. The Turkish validity and reliability study was conducted by Acar et al. [16].
Epworth Sleepiness Scale (ESS)
ESS is a self-administered questionnaire consisting of 8 questions developed by Johns MW. Participants are asked to rate the likelihood of falling asleep or dozing off while participating in eight different activities on a 4-point scale (0–3). The ESS score can range from 0 to 24. A total score of 10 or more indicates the presence of excessive daytime sleepiness. A higher ESS score indicates a higher degree of daytime sleepiness in daily activities. Turkish validity and reliability study was conducted by İzci et al. [17].
Restless Legs Syndrome Severity Scale (RLS)
The scale was developed by the International Restless Legs Study Group. Turkish validity and reliability study was conducted by Ay et al. [18]. This scale consists of 10 questions, each graded from 0 to 4. 0–10 points are defined as mild, 11–20 points as moderate, 21–30 points as severe, and 31–40 points as very severe RLS. Increasing scores on the IRLSSG determine the severity of RLS symptoms.
Insomnia Severity Index
The insomnia severity index (ISI) used to indicate insomnia and sleep insufficiency consists of seven questions. Scale items are scored from 0 to 4 and total scores range from 0 to 28. The scale was developed by Bastien et al. and Turkish validity and reliability study was conducted by Boysan et al. [19, 20].
Ethical Approval
Ethics committee permission was obtained from the Health Sciences University Health Sciences University Erenköy Mental and Nervous Diseases Training and Research Hospital Scientific Research Ethics Committee with the decision numbered 5 and dated 09.01.2025. The participation of the patients in the survey was voluntary and all patients signed the patient consent form.
Statistical Methods
Nominal and ordinal data were described with frequency analysis, and measurement data were described with mean, standard deviation, median and variation ranges. Kolmogorov Smirnov test was performed for normality analysis of scale means. Wilcoxon Signed Rank test was used for difference analysis of paired scores. Fisher’s exact test was used for differences of nominal values. Pearson’s moments correlation was used for relational screening analysis of BMI difference. In regression analysis, Generalized Linear Model (Logit) analysis was performed to minimize linearization deviations [21, 22]. SPSS 25.0 for Windows program was used for all analyses with 95% confidence interval.
Results
Comorbidities and basic parameters of patients were given in the Table 1. Mean age of patients were 38.33 ± 9.98 with 20–71 age range. 345 female (76.0%) and 109 male (24.0%) patients were attempted to the study. BMI means were 43.67 ± 17.79 and 28.32 ± 5.81 before and after the operation. Most of patients were graduated from university (63.0%). Comorbidities were; hypertension (HT) 8.4%, diabetes mellitus (DM) 8.6%, hyperlipidemia 4.6%, thyroid disease 6.2%, chronic pain (fibromyalgia, etc.) 13.2%, gastrointestinal system disorders 3.3%, allergic diseases 7.7%, depression 7.7%, anxiety 11.5% and 45.6% of the patients had informed sleep problems (Table 1). Of the patients with sleep problems 31.4% were male, 68.6% were female with a mean age of 38.47 ± 12.04. Comorbidities in this group were 11.6% HT, 9.2% DM, 8.2% hyperlipidemia, 4.8% throid disease, 17.9% chronic pain disorders, 3.9% gastrointestinal problem, 10.6% allergic diseases, 11.6% depression, 16.4% anxiety (Table 1).
Table 1
Demographic features and comorbidities of patients and descriptive statistics results
Parameter
Total (n = 454)
Patients without sleep complaints (n = 247)
Pateints with sleep complaints (n = 207)
Age, years, Mean ± SD
Median (Minimum-Maximum)
38.33 ± 9.98
37.00 (20.00–71.00)
36.71 ± 10.59
36.00(0.00–71.00)
38.47 ± 12.04
39.00(0.00–70.00)
Gender, n (%)
Females
345 (76.0)
203 (82.2)
142 (68.6)
Males
109 (24.0)
44 (17.8)
65 (31.4)
Height, cm, Mean ± SD
Median (Minimum-Maximum)
167.23 ± 9.37
166.00 (147.00–196.00.00.00)
166.54 ± 9.05
165.00(147.00–195.00.00.00)
168.05 ± 9.69
167.50(148.00–196.00.00.00)
Weight preop, kg, Mean ± SD
Median (Minimum-Maximum)
120.52 ± 23.78
116.00 (78.00–272.00.00.00)
118.63 ± 24.25
113.00(82.00–272.00.00.00)
122.78 ± 23.06
120.00(78.00–191.00.00.00)
Weight, kg, Mean ± SD
Median (Minimum-Maximum)
79.59 ± 19.03
76.00 (46.00–205.00.00.00)
78.17 ± 19.70
75.00(50.00–205.00.00.00)
81.28 ± 18.10
80.00(46.00–145.00.00.00)
BMI preop, kg/m2, Mean ± SD
Median (Minimum-Maximum)
43.67 ± 17.79
41.81 (28.01–391.60)
42.53 ± 7.15
41.41(30.85–99.91)
43.34 ± 6.25
42.16(28.01–63.69)
BMI postop, kg/m2, Mean ± SD
Median (Minimum-Maximum)
28.32 ± 5.81
27.57 (18.34–70.52)
28.04 ± 6.29
26.85(18.42–70.52)
28.65 ± 5.17
28.29(18.34–50.06)
Education, n (%)
Primary school
50 (11.0)
26 (10.5)
24 (11.6)
High school
118 (26.0)
67 (27.1)
51 (24.6)
University
286 (63.0)
154 (62.3)
132 (63.8)
HT, n (%)
38 (8.4)
14 (5.7)
24 (11.6)
DM, n (%)
39 (8.6)
20 (8.1)
19 (9.2)
Hyperlipidemia, n (%)
21 (4.6)
4 (1.6)
17 (8.2)
Thyroid disease, n (%)
28 (6.2)
18 (7.3)
10 (4.8)
Chronic pain disorders, n (%)
60 (13.2)
23 (9.3)
37 (17.9)
Gastrointestinal system disorders, n (%)
15 (3.3)
7 (2.8)
8 (3.9)
Allergic diseases, n (%)
35 (7.7)
13 (5.3)
22 (10.6)
Depression, n (%)
35 (7.7)
11 (4.5)
24 (11.6)
Anxiety, n (%)
52 (11.5)
18 (7.3)
34 (16.4)
SD Standard Deviation, BMI Body Mass Index, HT Hypertension, DM Diabetes Mellitus
After the bariatric surgery, the mean scores of RLS, ISI, ESS, ISI, BSQ category 1 and category 2 were significantly reduced in patients (p < 0.01) (Table 2). All dimensions of sleep quality except habitual sleep efficiency were also found to be better 6 months after surgery compared before surgery (p < 0.01) (Table 2).
Table 2
Differences of sleep scale scores between before and after bariatric surgery
Mean ± SD
Median (Minimum-Maximum)
Before operation
After operation
p value
BSQ total
5.06 ± 1.92
5.00 (0.00–9.00)
0.72 ± 1.31
0.00 (0.00–9.00)
0.000a
BSQ category 1
2.16 ± 1.32
2.00 (0.00–4.00)
0.26 ± 0.71
0.00 (0.00–5.00)
0.000a
BSQ category 2
2.04 ± 0.88
2.00 (0.00–4.00)
0.25 ± 0.69
0.00 (0.00–4.00)
0.000a
RLS
20.30 ± 9.14
20.00 (0.00–40.00)
17.26 ± 8.64
17.00 (4.00–40.00)
0.001a
ESS
8.83 ± 5.24
8.00 (0.00–24.00)
6.48 ± 4.80
5.50 (0.00–24.00)
0.000a
ISI
16.02 ± 5.81
16.00 (2.00–28.00)
6.54 ± 5.78
5.00 (0.00–28.00)
0.000a
PSQI subjective sleep quality
0.60 ± 1.04
0.00 (0.00–3.00)
0.29 ± 0.79
0.00 (0.00–3.00)
0.000a
PSQI sleep latency
1.77 ± 0.92
2.00 (0.00–3.00)
0.81 ± 0.87
1.00 (0.00–3.00)
0.000a
PSQI habitual sleep efficiency
0.63 ± 0.80
0.00 (0.00–3.00)
0.72 ± 0.96
0.00 (0.00–3.00)
0.396a
PSQI sleep disorder
1.76 ± 0.75
2.00 (0.00–3.00)
0.96 ± 0.59
1.00 (0.00–3.00)
0.000a
PSQI sleep drug
0.60 ± 1.04
0.00 (0.00–3.00)
0.29 ± 0.79
0.00 (0.00–3.00)
0.000a
PSQI daytime dysfunction
2.18 ± 1.80
2.00 (0.00–6.00)
0.56 ± 1.14
0.00 (0.00–6.00)
0.000a
a. Wilcoxon Signed Rank Test, SD Standard Deviation, BSQ Berlin Sleep Questionnaire, OSAS Obstructive Sleep Apnea Syndrome, RLS Restless Leg Syndrome, ESS Epworth Sleepiness Scale, PSQI Pittsburg Sleep Quality Index, ISI Insomnia Severity Index
All scores of scale means were significantly decreased after surgery, and BSQ-OSAS had highest decrease among other scales (Fig. 1).
Fig. 1
Differences of scale scores between before and after surgery. BSQ: Berlin Sleep Questionnaire, OSAS: Obstructive Sleep Apnea Syndrome, RLS: Restless Leg Syndrome, ESS: Epworth Sleepiness Scale, PSQI: Pittsburg Sleep Quality Index, ISI: Insomnia Severity Index
Sleep related problems as sweating, sexual dysfunction, reflux, clenching teeth, dry mouth, headache, toilet wake up and day time asleep were significantly reduced in patients after bariatric surgery (p<0.05) (Table 3).
Table 3
Sleep related symptoms and health problems before and after surgery
n (%)
Before operation
After operation
p value
Sweating
142 (31.3)
15 (3.3)
0.000a
Sexual dysfunction
73 (16.1)
20 (4.4)
0.000a
Reflux
132 (29.1)
33 (7.3)
0.000a
Clenching teeth
116 (25.6)
53 (11.7)
0.000a
Dry mouth
173 (38.1)
72 (15.9)
0.000a
Morning headache
128 (28.2)
39 (8.6)
0.000a
Toilet wake up
141 (31.1)
69 (15.2)
0.000a
Day time asleep
180 (39.6)
52 (11.5)
0.000a
a. Fisher’s Exact Test
Spearman’s rho correlation between BMI difference and sleep related scale scores results showed that BMI difference was significantly correlated with BSQ-OSAS total (r=−0.143; p<0.05), RLS (r=−0.410; p<0.05) and PSQI sleep latency (r=0.174; p<0.05) pos-bariatric surgery. However, correlation between BMI difference with ESS, PSQI and ISI were statistically insignificant (p>0.05) (Table 4).
Table 4
Spearman’s rho correlation between BMI difference and sleep related scale scores
BMI difference
r
p
BSQ total
−0.143*
0.048
BSQ category 1
0.001
0.988
BSQ category 2
0.134
0.064
RLS
−0.410*
0.014
ESS
−0.052
0.716
ISI
−0.090
0.197
PSQI subjective sleep quality
0.112
0.109
PSQI sleep latency
0.174*
0.027
PSQI habitual sleep efficiency
0.084
0.253
PSQI sleep disorder
0.005
0.943
PSQI sleep pill
0.112
0.109
PSQI daytime dysfunction
0.033
0.633
*p < 0.05, BSQ Berlin Sleep Questionnaire, OSAS Obstructive Sleep Apnea Syndrome, RLS Restless Leg Syndrome, ESS Epworth Sleepiness Scale, PSQI Pittsburg Sleep Quality Index, ISI Insomnia Severity Index
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Generalized Linear Model (Logit) for effects of BMI difference on BSQ-OSAS showed that effect of BMI difference on BSQ-OSAS was statistically significant (OR=−0.041; p<0.05). Effects of BMI difference (OR=−0.490; p<0.05) and having thyroid comorbidity (OR=−24.752; p<0.01) on RLS severity were also statistically significant (Table 5).
Table 5
Generalized linear model (Logit) for effects of BMI difference on BSQ and RLSSS
Parameter
OR
Std. Error
95% Wald Confidence Interval
Hypothesis Test
Lower
Upper
Wald X2
df
p value
BSQ-OSAS
(Intercept)
1.927
1.178
−0.383
4.237
2.673
1
0.102
Gender
−0.114
0.208
−0.523
0.294
0.301
1
0.584
HT
0.228
0.324
−0.407
0.862
0.495
1
0.482
DM
−0.165
0.332
−0.816
0.485
0.248
1
0.619
Hyperlipidemia
0.400
0.363
−0.311
1.112
1.217
1
0.270
Thyroid disease
−0.292
0.437
−1.150
0.565
0.447
1
0.504
Chronic pain disorders
−0.018
0.280
−0.566
0.530
0.004
1
0.949
Gastrointestinal system disorders
−0.176
0.554
−1.262
0.909
0.102
1
0.750
Allergic diseases
0.001
0.336
−0.657
0.660
0.000
1
0.997
Depression
−0.101
0.320
−0.729
0.527
0.099
1
0.753
Anxiety
−0.146
0.266
−0.668
0.376
0.301
1
0.583
Age
−0.007
0.008
−0.023
0.010
0.632
1
0.427
BMI difference
−0.041
0.018
−0.077
−0.005
4.915
1
0.027
(Scale)
1.649
0.169
1.349
2.015
RLS
(Intercept)
55.130
15.519
24.712
85.547
12.619
1
0.000
Gender
−2.017
2.851
−7.604
3.570
0.501
1
0.479
HT
3.589
4.413
−5.062
12.239
0.661
1
0.416
DM
−2.707
3.729
−10.016
4.602
0.527
1
0.468
Thyroid
−24.752
7.728
−39.900
−9.605
10.257
1
0.001
Chronic pain
−3.077
4.033
−10.982
4.828
0.582
1
0.446
Digestive system
1.864
4.512
−6.980
10.708
0.171
1
0.679
Allergy
−0.107
4.679
−9.277
9.063
0.001
1
0.982
Depression
0.731
3.367
−5.868
7.330
0.047
1
0.828
Anxiety
−1.352
3.051
−7.332
4.627
0.196
1
0.658
Age
−0.126
0.120
−0.362
0.109
1.103
1
0.294
BMI difference
−0.490
0.250
−0.980
0.001
3.827
1
0.049
(Scale)
42.726
10.213
26.743
68.260
OR Odds Ratio, HT Hypertension, DM Diabetes Mellitus, BSQ Berlin Sleep Questionnaire, OSAS Obstructive Sleep Apnea Syndrome, RLSSS Restless Leg Syndrome Severity Scale
Discussion
Obesity is an important public health problem [1] leading to several diseases [2‐4]. Studies in the literature have revealed the relationship between obesity and sleep quality and sleep disorders [11‐14]. Though surgical methods have begun to be used as effective treatments in the last decades, studies on the sleep quality and sleep disorders after bariatric surgery are relatively limited. Pinto et al [23] reported that bariatric surgery has positive contributions on the sleep quality and excessive daytime sleepiness. Toor et al reported that both the duration and quality of sleep increased significantly after bariatric surgery [24], besides in another study it was reported that this should be supported by physical activity [25]. A positive effect of surgery was also found on sleep patterns in adolescents with severe obesity [26]. In our study we have found that sleep quality was significantly improved in patients on postoperative follow-ups. Especially daytime dysfunction subgroups of PSQI were found to be very lower compared with the scores before surgery.
Obstructive sleep apnea (OSA) and obesity have a bidirectional relationship. Obesity, being one of the risk factors of OSA, can also be worsened by the accompaniance of OSA. Haines et al [27] have observed a statistically significant decrease in sleep apnea syndrome after bariatric surgery. In a meta-analysis, significant and positive contributions of bariatric surgery, especially in sleep apnea and sleep quality were reported [28].
Restless legs syndrome (RLS), being a sleep-related movement disorder, is also found to be related with obesity with a female predominance [29, 30]. But in a recently published study, BMI was found to be in a significant association with RLS in males but not in females [31]. Treatment of obesity has a beneficial effect on RLS symptoms. In a study, 12 of 14 obese patients with RLS who underwent LSG for obesity have discontinued medical therapy for RLS in one year of follow-up [32]. In our study, 190 patients among 207 patients (91.8%) had symptoms of RLS. On follow-up at sixth month RLS severity scale scores were found to be significantly decreased.
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Sleep duration and patterns of sleep timing may be in an association with obesity. Short sleep duration and having an evening chronotype may play roles on the development of obesity [33, 34]. Even in childhood, poor and short sleep was found to be a risk factor for developing obesity [33]. Poor sleep may have effects on leptin, ghrelin and cortisol levels, on glucose metabolism and insulin sensitivity, all of which are risk factors leading to obesity [35]. Short sleep duration was mainly found to be in association of BMI [36]. In our study group 190 patients had symptoms suggesting insomnia and imsomnia severity index scores were significantly low in comparison before surgery.
Excessive daytime sleepiness was found to be in association with obesity especially in patients with a high circumference of waist [36, 37]. Lack of physical activity was suspected to be the reason for obesity but no significant relationship was found [36]. It may also accompany OSA [38]. Surgical treatment of obesity was reported to have more beneficial effects on daytime sleepiness than nonsurgical procedures [39]. In our study 164 patients (79.2%) had >10 patients on ESS, pointing an excessive daytime sleepiness before surgery and the scores were significantly decreased six months following surgery.
Studies in literature reported whether symptomatic or causative relation between thyroid and RLS. Tan et al [40] reported that RLS symptoms are more common in thyroid patients, but not significantly difference was found. Geng et al [41] reported that serum thyroid hormon levels were higher in RLS patients. Pereira et al [42] argued that thyroid hormone imbalance may cause for RLS. Sönmez et al [43] reported that RLS was more common in Hashimoto’s thyroiditis. In our study, thyroid comorbidity on RLS were found to be statistically significant.
Sleep related problems as sweating, sexual dysfunction, reflux, clenching teeth, dry mouth, headache, toilet wake up and day time asleep were also significantly reduced in patients. BMI difference was significantly correlated with BSQ- and severity of RLS. Effect of BMI difference on BSQ and having a thyroid comorbidity on RLS were found to be statistically significant. However, correlation between BMI difference with ESS, PSQI and ISI were not found be statistically significant.
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While the prevalence and incidence of obesity are increasing daily, definitions can also differ. In many countries, a BMI <25 is considered overweight rather than obesity. However, the WHO guidelines were generally used as the basis for this study.
Limitations of the Study
The most important limitation of the study is the difficulties in patient follow-up after bariatric surgery and the difficulty in remembering their thoughts about their sleep quality before surgery. Since this study retrospectively measured sleep disorders symptomatically using scales and patient reports, insufficient research was conducted into the causes of sleep disorders. This is a significant limitation of the study, and future studies could benefit from more comprehensive prospective studies that include the causes of sleep disorders.
Although diagnosing sleep apnea is a much more detailed medical process, our study and previous studies on obesity and sleep apnea evaluated sleep apnea as symptomatic. This is another important limitation of the study. Potential confounders like CPAP use, hypnotics, among others, were not reported in patient files. Due to nature of the retrospective study, cofounders were limited. In future prospective researches, potential cofounders may be considered for further analysis.
Strength of the Study and Contributions to the Field and Clinical Practice
The strength of our study is the high number of patients describing sleep problems who underwent bariatric surgery and followed up at least 6 months.The most important contribution of the study to the literature is that it comprehensively analyzes sleep disorders and sleep quality after bariatric surgery in a multicenter and multi-scale manner. In addition, the study points to more than one sleep quality scale in the literature, allowing comparison of measurement tools, and the research is one of the first studies comparing scales.
The contribution of the study to clinical practice is that physicians should definitely question patients about sleep. Bariatric surgery methods can be considered in these diseases that seriously reduce the quality of life of individuals and can affect their daily lives.
Conclusion
There was a statistically significant improvement in symptoms of obstructive sleep apnea and restless leg syndrome after bariatric surgery. Bariatric surgery has a positive and beneficial effect on sleep apnea and restless leg syndrome. Further advanced and multidisciplinary studies are needed to justify the findings and develop them based on evidence.
Declarations
Ethical Approval
Ethics committee permission was obtained from the XXXX Research Ethics Committee with the decision numbered 5 and dated 09.01.2025.
Consent for Publication
Not applicable.
Patient Consent
The participation of the patients in the survey was voluntary and all patients signed the patient consent form.
Clinical Trial Number
Not applicable.
Competing Interests
The authors declare no competing interests.
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