Susan Wnuk

The Association between Attachment Avoidance and Quality of Life in Bariatric Surgery Candidates

Objective: Patients presenting for bariatric surgery have high rates of psychiatric co-morbidity and reduced health-related quality of life (HRQOL) compared to the general population. In this study, we aimed to determine the relationship between insecure attachment styles and HRQOL in bariatric surgery candidates. Methods: We assessed depression, social support, attachment avoidance, attachment anxiety, HRQOL (SF-36), and eating disorder psychopathology in 70 consecutive patients assessed for bariatric surgery. SF-36 physical (PCS) and mental component scores (MCS) were compared to a normative sample and analyzed using t-tests. Predictors of HRQOL were analyzed using multiple linear regression analyses. Results: SF-36 PCS and MCS in this pre-bariatric surgery sample were significantly lower than in an age-matched reference population. Depression, attachment anxiety, attachment avoidance and eating disorder psychopathology scores were negatively correlated with SF-36 MCS. Depression was associated with lower SF-36 PCS (p = 0.015). SF-36 MCS were significantly predicted by BDI scores (p < 0.001) and attachment avoidance (p = 0.024) in our multiple regression model. Conclusion: This is the first study to demonstrate an association between attachment avoidance and poor mental HRQOL in bariatric surgery candidates. Future studies are needed to examine the effect of attachment avoidance on post-bariatric surgery outcomes.

Attachment style and emotional eating in bariatric surgery candidates: The mediating role of difficulties in emotion regulation

OBJECTIVE Difficulties with emotion regulation is a hypothesized mechanism through which attachment insecurity may affect emotional eating. No studies have yet investigated this effect in the bariatric population. Because many obese individuals engage in emotional eating, difficulty regulating emotion may be an important underlying mechanism through which attachment insecurity is linked to emotional eating in bariatric surgery candidates. METHODS In this cross-sectional study, 1393 adult bariatric surgery candidates from the Toronto Western Hospital were recruited to complete the Emotional Eating Scale (EES), Patient Health Questionnaire-9 (PHQ9), Generalized Anxiety Disorder-7 (GAD7), Difficulties in Emotion Regulation Scale (DERS), Eating Disorder Examination Questionnaire (EDE-Q), and the Experiences for Close Relationships 16-item Scale (ECR-16) in order to explore the mediating role of emotion regulation on the relationship between attachment insecurity and emotional eating. Path analysis within a structural equation modeling framework examined direct and indirect effects of attachment insecurity on emotional eating. RESULTS The indices of this overall model indicated that the specified set of direct and indirect pathways and corresponding correlations were a good fit with the data (RMSEA<.06, CFI=1.00; SRMR<.08). Moreover, tests of all of the possible indirect pathways between attachment style and emotional eating were significant. DISCUSSION Findings suggest that difficulties in emotion regulation may be an important mechanism to consider when examining the association between attachment insecurity and emotional eating in adult bariatric surgery candidates. Although causality cannot be concluded, these results shed light on the important role that emotion regulation may have in predicting problematic eating in bariatric patients.

Weight Loss Following Roux-en-Y Gastric Bypass Surgery: A Systematic Review of Psychosocial Predictors

Objective: Weight loss surgery has been heralded as a treatment alternative for patients with morbid obesity. Psychiatric disorders are highly prevalent in bariatric surgery candidates and a myriad of psychosocial variables has been explored to identify mediators of post-surgery weight loss. The following review aims to elucidate psychosocial predictors of weight loss outcomes specific to Roux-en-Y gastric bypass surgery (RYGBS). Methods: We searched PubMed for prospective trials evaluating psychosocial predictors for weight loss with RYGBS published between 2000 and 2010. Manual searches of references listed in review articles, case series and anecdotal reports supplemented our literature search. Additional literature on post-bariatric surgery psychosocial outcomes and management of psychiatric sequelae in bariatric surgery patients are discussed in this review. Results: A total of 20 prospective studies were identified. Our review found that few psychosocial factors have been studied and results were predominantly inconclusive. We observed heterogeneity amongst studies with respect to study duration and assessment methods. Binge eating disorder, mood disorders, and anxiety disorders have not reliably predicted weight loss in identified studies. Preliminary results suggest that psychosocial support is an important predictor of postoperative weight loss and highlight a likely role for pre- and post-surgery support groups. Conclusion: Social support, current or lifetime Axis I disorder, and post-operative loss of control over eating have been identified as important predictors of weight loss post-RYGBS. Larger, long-term studies are needed to further elucidate psychosocial risk factors for weight loss post-RYGBS

Prospective study of psychiatric illness as a predictor of weight loss and health related quality of life one year after bariatric surgery

OBJECTIVE Despite a lack of evidence, there is an assumption that patients with more complex psychiatric histories (CPH) prior to bariatric surgery have poor post-surgical weight loss and worsening psychiatric symptoms following surgery. Consequently, those with CPH are excluded from bariatric surgery in many bariatric clinics. This study examines whether psychiatric illness affects post-surgical weight loss and HRQOL, focusing on patients with CPH. METHOD This prospective cohort study investigated 341 patients from a tertiary care centre bariatric surgery program who had surgery between September 2010 and October 2013. Patients were divided into CPH, other psychiatric disorder (OPD), or no psychiatric disorder (NPD) groups based on lifetime psychiatric diagnoses. Groups were compared one year post-surgery in regards to percent total weight loss (%TWL), mental and physical health related quality of life (HRQOL) using a Kruskal-Wallist test. Linear regression analysis was used to determine if mental illness group, gender, age, pre-op BMI, education, employment and relationship status predict change in %TWL and HRQOL. RESULTS There was no significant difference in %TWL or physical HRQOL across groups. The CPH group experienced a decrease in mental HRQOL (p=0.0003). Mental illness severity predicted mental HRQOL (p=0.002) but not physical HRQOL or %TWL. CONCLUSION Those with controlled CPH can achieve comparable weight loss compared to those with OPD or NPD. However, CPH may predict post-surgical decline in mental HRQOL. These findings demonstrate a need to reevaluate exclusion criteria to ensure equitable access to care, while continuing to monitor for psychiatric illness following surgery.

Psychosocial predictors of quality of life and weight loss two years after bariatric surgery: Results from the Toronto Bari-PSYCH study

OBJECTIVES Studies exploring the impact of pre-surgery psychiatric status as a predictor of health related quality of life (QOL) after bariatric surgery have been limited to short-term follow-up and variable use of psychosocial measures. We examined the effect of pre-operative psychiatric factors on QOL and weight loss 2-years after surgery. METHODS 156 patients participated in this prospective cohort study, the Toronto Bariatric Psychosocial Cohort Study, between 2010 and 2014. Patients were assessed pre-surgery for demographic factors, weight, psychiatric diagnosis using the MINI International Neuropsychiatric Interview and symptom measures for QOL, depression and anxiety at pre-surgery and at 1 and 2years post-surgery. RESULTS At 2-years post-bariatric surgery, patients experienced a significant decrease in mean weight (-48.43kg, 95% [-51.1, -45.76]) and an increase only in physical QOL (+18.91, 95% [17.01, 20.82]) scores as compared to pre-surgery. Multivariate regression analysis identified pre-surgery physical QOL score (p<0.001), younger age (p=0.005), and a history of a mood disorder as significant predictors of physical QOL. Only a history of a mood disorder (p=0.032) significantly predicted mental QOL (p=0.006). Pre-surgery weight (p<0.001) and a history of a mood disorder (p=0.047) were significant predictors of weight loss 2-years post-surgery. CONCLUSIONS Bariatric surgery had a sustained impact on physical QOL but not mental QOL at 2-years post-surgery. A history of mood disorder unexpectedly increased physical QOL scores and weight loss following surgery. Further research is needed to determine if these results are due to bariatric surgery candidate selection within this program.

Psychosocial Predictors of Cognition in Bariatric Surgery

BACKGROUND Obesity affects individuals worldwide and is currently the 5th leading cause of death according to the WHO. Bariatric surgery is an effective strategy that produces durable long-term weight loss. There is a bidirectional interplay between mental health and obesity; with higher depression and anxiety in the obese population as well as significant effects on weight loss for people with mental health disorders. OBJECTIVE Our cross-sectional study aimed to examine psychosocial predictors of cognition for the pre-operative bariatric surgery population and its effect on work productivity. METHODS Demographic data, perceived cognitive deficits (PDQ-5), depression scale (PHQ-9), anxiety (GAD-7), Quality of life (SF36) and work impairment (LEAPS) was collected from 302 pre-operative bariatric surgery candidates at their initial assessment. Multiple regression was conducted with perceived cognitive deficits as the dependent variable. A secondary analysis was done controlling for anxiety and depression. RESULTS Variables that were significantly associated with perceived cognition were anxiety, depression, work productivity and overall mental health quality of life. Perceived cognition was also significantly associated with work impairment independent of mood symptoms. DISCUSSION Anxiety and depression are prevalent in the pre-operative bariatric surgery population, significantly affecting cognition, and should be routinely screened. Work performance was also affected by cognition in our population but the link between obesity and cognition needs to be further explored. CONCLUSIONS We identified a significant association between perceived cognition and psychosocial factors in pre-operative bariatric surgery candidates. Further studies will be needed to better explore obesity and its impact on cognition.