The Association Between Body Esteem and Post-operative Outcomes in Adult Weight-loss Surgery Patients

Bariatric surgery (weight-loss surgery) remains the most effective long-term treatment for obesity, resulting in improved obesity-related comorbidities and increased life expectancy. There remains, however, a limited understanding of predictors and patientlevel factors associated with insufficient weight loss and psychological dysfunction. Body esteem, or feelings of self-worth about one’s body and appearance, is a significant concern for individuals undergoing weight-loss surgery, although the relationship between body esteem and weight loss is complex. Indeed, there is a subset of patients who experience suboptimal weight loss and poor psychological outcomes after undergoing bariatric surgery. This retrospective, longitudinal study examined the relationship between pre-operative body esteem and post-operative outcomes, including weight change, post-operative body esteem, depressive symptoms, and adherence to the post-operative diet and vitamin regimen, at one year. Results indicated that body esteem and depressive symptoms improve following weight-loss surgery, although level of preoperative body esteem did not predict weight change or adherence to the post-operative diet and vitamin regimen. This study did not directly connect body esteem to weight loss following surgery, although improved body esteem could be important for optimizing post-operative psychological health and weight loss. These findings may lend support to patient and provider decisions in clinical care for bariatric surgery and potentially improve post-surgical outcomes. BODY ESTEEM AND OUTCOMES IN WEIGHT-LOSS SURGERY PATIENTS 2 CHAPTER 1: INTRODUCTION Statement of the Problem Obesity is a global health problem that has reached epidemic proportions. Obesity, generally defined by a body mass index (BMI) ≥ 30 kg/m2, refers to excessive fat accumulation that results from a consistently greater energy intake than expenditure that presents a risk to health (Tsai, Carvajal, Egner, & Wadden, 2010). Currently, more than 39% of the world's population is overweight and approximately 13% lives with obesity (World Health Organization, 2015). In the United States, the prevalence of obesity has increased to over 39% in adults and is greatest among women and minority groups, namely those of African-American and Hispanic origin (Hales, Fryar, Carroll, Freedman, & Ogden, 2018). In fact, in 2013 the American Medical Association officially classified obesity as a disease (American Medical Association, 2013). Furthermore, the World Health Organization set obesity as one of its major global health targets in the 2013 World Health Assembly (World Health Organization, 2013). The etiology of obesity is complex and manifests from a combination of genetic, physiological, psychological, cultural, and socioeconomic factors. Its principle cause, however, is an interaction of genetic and environmental factors characterized by an energy imbalance, namely the excessive accumulation and storage of fat in the body that contributes to weight gain, secondary to excessive intake of calories (Plourde & Prud’homme, 2012). In American culture, a “toxic” food environment and exposure to high calorie, low nutrient, inexpensive foods that are readily accessible promotes dietary excess (Brownell, 2005). A progressively sedentary lifestyle among individuals in which there is a decrease in physical activity further contributes to obesity. BODY ESTEEM AND OUTCOMES IN WEIGHT-LOSS SURGERY PATIENTS 3 The negative impact of obesity on public health and related health care expenditure is considerable (Farran, Ellis, & Barron, 2013). The Centers for Disease Control and Prevention (2014) estimated that the annual medical cost of obesity in the United States is approximately $147 billion, which constitutes a severe societal and economic crisis. Obesity is a major risk factor for premature death and chronic conditions, such as hypertension, hypercholesterolemia, Type II diabetes, metabolic syndrome, osteoarthritis, obstructive sleep apnea, and depression, and is associated with diminished quality of life (Tsai et al., 2010; Plourde & Prud’homme, 2012). Consequently, the per capita medical costs are more than 40% higher for individuals with obesity compared to those of normal weight and are expected to increase (Finkelstein, Trogdon, Cohen, & Dietz, 2009). In 2012, the U.S. Preventive Services Task Force (USPSTF) updated its recommendation to screen all adults for obesity and directs clinicians to offer or refer patients with a BMI of ≥ 30 kg/m2 to intensive, multi-component behavioral interventions (Moyer, 2012). Effective behavioral treatment can be provided in primary care settings, specialized weight management clinics, community-based programs, or through referral to a nutritionist or evidence-based commercial program (Carvajal, Wadden, Tsai, Peck, & Moran, 2013). Generally, individuals with obesity are advised by health care professionals to reach and maintain a healthy weight. Behavioral weight-loss programs typically involve caloric restriction and increased physical activity (Jensen at al., 2014). Specifically, lifestyle interventions to influence behavior change target modification of diet and physical activity through strategies that may include elevating motivation, setting manageable weight-loss and nutrition goals, addressing barriers, BODY ESTEEM AND OUTCOMES IN WEIGHT-LOSS SURGERY PATIENTS 4 changing of beliefs and expectations, and providing guidance in the use of selfmonitoring skills (Teixeira et al., 2015). Pharmacological treatment of obesity may also be considered in patients with obesity, although drug therapies are typically recommended concomitantly with behavioral strategies, diet, physical activity, and psychological support (Fujioka, 2002; Pereira & Astorga, 2005). Research suggests there are systematic barriers that preclude use of pharmacological options and involve physician, patient, and health care system factors (Thomas, Mauer, Shukla, Rathi, & Aronne, 2016). More specifically, obstacles such as low recognition of obesity as a chronic disease that requires medical care, limited prescription coverage of obesity treatment (it is estimated that a third of health insurance plans do not reimburse obesity drugs at all), limited training of health care providers, weight bias toward patients with obesity, and a disconnect between expected and actual effectiveness of treatment may limit the adoption of pharmacotherapy in the treatment of obesity (Kyle & Stanford, 2016). Moreover, the medication may be ineffective or associated with adverse events or significant safety concerns and requires continual medical monitoring (Yanovski & Yanovski, 2014). Evidence suggests that if a patient does not lose at least 5% of excess weight after 12 weeks of appropriately dosed drug therapy, the costs of continuing pharmacological therapy may exceed the benefit to the patient (Yanovski & Yanovski, 2014). Lifestyle interventions are currently the first recommended strategies in obesity management of adults (Jensen et al., 2014). Most behavioral interventions include multiple behavioral management activities, such as individual or group sessions that strategize on maintaining lifestyle changes (Moyer, 2012). Research indicates that in the BODY ESTEEM AND OUTCOMES IN WEIGHT-LOSS SURGERY PATIENTS 5 short term (12 to 26 sessions), these programs are effective, with individuals losing approximately 6% of their baseline weight within the first year (Moyer, 2012). A 5% reduction in weight is considered clinically significant by the U.S. Food and Drug Administration (FDA) and demonstrates improvement in intermediate health outcomes, such as blood pressure, glucose tolerance, and weight circumference. Evidence suggests, however, that relatively little weight loss and associated health benefits achieved in most behavioral weight-loss programs is maintained beyond one year (Wing & Hill, 2001). When behavioral modification or pharmacological therapy for weight loss results in limited long-term efficacy, bariatric surgery (i.e., weight-loss surgery) may be considered for patients with severe obesity (BMI ≥ 40 kg/m2 or 35 kg/m2 with comorbidities). Bariatric surgery remains the most effective long-term treatment for patients with severe obesity (Sjöström, 2013). Despite the demonstrated effectiveness of bariatric surgery for weight loss, the reliability and predictability of weight loss in patients undergoing bariatric surgery remains uncertain. While many patients experience significant weight loss following surgery, some are unable to achieve, or sustain, weight loss (Courcoulas et al., 2014). Insufficient weight loss is a weight loss of less than 50% of excess weight (%EWL = [(Initial Weight) – (Post-op Weight)] / [(Initial Weight) – (Ideal Weight)]) (Brethauer et al., 2015) one year after surgery, while weight regain (there is no generally accepted definition) is an increase in weight after initially successful weight loss (Maleckas, Gudaitytė, Petereit, Venclauskas, & Veličkienė, 2016). It is estimated that approximately 20% to 30% of bariatric surgery patients regain some or all of their initial weight loss approximately two years after surgery (Wimmelmann, Dela, & Mortensen, 2014). This weight recidivism has important health consequences BODY ESTEEM AND OUTCOMES IN WEIGHT-LOSS SURGERY PATIENTS 6 including the recurrence of obesity-related comorbidities (Wimmelmann et al., 2014). Currently, there is a poor understanding of patient-level factors associated with insufficient weight loss over the long term (Courcoulas et al. 2013). The many life changes that occur around bariatric surgery pose unique social, psychological, and lifestyle challenges. Bariatric surgery is clinically proven to be an effective intervention for managing weight loss and associated comorbidities in individuals with obesity, although there remains limiting understanding of the impact on psychological health (Kubik, Gill, Laff