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Psychological predictors of adherence to dietary recommendations after Roux-en-Y Gastric Bypass
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Integrated Health Oral Presentations / Surgery for Obesity and Related Diseases 12 (2016) S40–S47
74.2% of the sample were women. 66.2% were Caucasian, 19.7% were African American, and 14.1% were of another ethnicity. The mean age of participants was 46.75 years (SD¼11.63; Range 18 - 74). Patients' mean pre-surgical BMI was 49.14 kg/m2 (SD¼9.50 kg/m 2). Psychiatric diagnoses were obtained from a pre-surgical, semi-structured clinical interview and all participants were administered the MMPI-2-RF at their pre-surgical evaluations. BMIs were collected at 4 post-operative time points: 3-months (M¼38.59 kg/m 2, SD¼7.62) 6-months (M¼34.59 kg/m 2, SD¼7.24, 1-year (M¼32.42 kg/m2, SD¼7.63, and 5-years (M¼34.71 kg/m2, SD¼7.57). Percent missing at the 4 post-surgical time points were: 3-months (15.5%), 6-months (24.7%), 1-year (28.3%), and 5-years (52.2%). Correlations between demographic or psychological variables and attrition over time suggested that younger individuals evidenced higher amounts of missing data over time (r¼-.18).Statistical Analyses: Longitudinal structural equation modeling (SEM) was used for prediction analyses. Specifically, latent growth curves were used to model BMIreduction across time. Full Information Maximum Likelihood was used to handle missing data across time. Path analyses were used to estimate whether pre-surgical psychopathology predicted 5-year post-surgical BMIs as well as the rate of BMIchange over the 5-year trajectory. Diagnoses were tested first followed by the MMPI-2-RF scales by scale set. Results: A non-linear latent growth curve fit the outcome data best [χ2(7)¼12.36, p¼.09, RMSEA¼.041, CFI¼.98, SRMR¼.07], indicating that BMI-reduction across time was best modeled with a combination of linear and curvilinear trends. This non-linear trend implied that BMI-reduction was rapid from baseline through the one-year outcome. From one-year to fiveyears post-surgery, most patients evidenced a small increase in their BMIs. Age significantly predicted the rate of BMIreduction across time (β¼.20, p¼.005), such that older individuals evidenced a slower rate of change over time. When psychiatric diagnoses were introduced into the model, a presurgical diagnosis of Binge Eating Disorder predicted higher BMIs at the 5-year outcome (β¼.16, p¼.008). Patients who scored higher on the MMPI-2-RF scales Behavioral/Externalizing Dysfunction (β¼.11, p¼.030), Low Positive Emotions (β¼.13, p¼.032), and Hypomanic Activation (β¼.13, p¼.028) also evidenced higher BMIs at the 5-year outcome after controlling for age and Binge Eating Disorder. In regards to predicting variability in BMI-reduction over time, patients who scored higher on MMPI-2-RF scales Hypomanic Activation (β¼.24, p¼.002), Anger Proneness (β¼.16, p¼.004), and Activation (β¼.17, p¼.036) prior to surgery evidenced a slower rate of BMI-reduction over 5-years after controlling for age and Binge Eating Disorder. Discussion: As hypothesized, patients with higher pre-surgical levels of externalizing (e.g., impulse control) and internalizing (notably with difficulty feeling positive emotions) psychopathology had higher BMIs five years post-operatively compared to patients who did not evidence such elevations at the time of their pre-surgical evaluation. In addition, both age and psychopathology predicted slower post-operative BMI-reduction. This indicates that pre-operative indicators of psychopathology are important in predicting post-operative outcomes. A closer follow-up with patients who evidence pre-surgical problems, both before and after surgery, may help improve
outcomes. Post-operative psychological assessments may also enhance surgical outcomes.
A176
PSYCHOLOGICAL PREDICTORS OF ADHERENCE TO DIETARY RECOMMENDATIONS AFTER ROUX-EN-Y GASTRIC BYPASS Irmelin Bergh; Ingela Kvalem; Tom Mala; University of Oslo, Oslo Oslo Background: Adherence to dietary recommendations can be challenging after bariatric surgery. Unhealthy eating habits have been described as a main factor for suboptimal outcomes. Selfregulation is essential for adopting new or improving health behaviors and depends on changes in a set of interrelated cognitions such as planning, self-efficacy and action control skills (i.e., self-monitoring). There is limited data on self-regulatory factors involved in postoperative dietary adherence. A few studies have shown that lower self-efficacy, less planning and higher degree of depressive and anxiety symptoms were associated with non-adherence. To further extend our knowledge of eating behavior after bariatric surgery, we aimed to identify selfregulatory predictors of dietary adherence one year after gastric bypass surgery. Methods: Measures of demographic variables, self-regulation variables (intention, planning, self-efficacy, action control), depressive and anxiety symptoms (Hospital anxiety and Depression scale, HADS) and adherence to dietary recommendations were taken one year after Roux-en-Y gastric bypass in 230 patients (78.3% women). All patients received pre- and postoperative education from clinical nutritionists regarding the dietary recommendations after surgery. Adherence to the recommendations was evaluated according to the Norwegian national guidelines for healthy diet. Patients were asked: 'You have received recommendations regarding how/what to eat after surgery. To what degree does it correspond with how/what you have eaten the last four weeks?' (1¼little, 7¼a lot), followed by six recommendations (e.g., 'I eat five portions of fruit and vegetables every day', 'I limit my intake of sugar and fat' etc.). Specific nutritional recommendations, e.g., consumption of at least 60g of protein daily, vitamin substitution etc. were not evaluated. Action control involved items about self-monitoring behavior, awareness of standard (keeping one's goals in mind) and effort to avoid selfregulation failure. Results: Mean (SD) body mass index (BMI) before and after surgery was 44.9 kg/m2 (6.0) and 30.6 kg/m2 (5.2), respectively. Total weight loss was 29.2% (8.2). There were no differences for any of the psychological variables depending on demographic groups (age, sex, marital status, education, employment) or initial BMI groups (o 40, 40-50, 4 50 kg/m2). The self-regulatory variables intention, self-efficacy, planning and action control showed moderate and positive correlations with dietary adherence (p o. 001), whereas depressive and anxiety symptoms showed small and negative correlations with the outcome measure (p o. 001). Adherence to the recommendations was not associated with postoperative weight loss. Based on the multivariate regression analysis more planning (β¼16.9, p o. 01), better action control skills (β¼27.2, p o. 001) and lower degree of depressive and
Integrated Health Oral Presentations / Surgery for Obesity and Related Diseases 12 (2016) S40–S47
anxiety symptoms (β¼-16.6, p o. 01) predicted dietary adherence, explaining 26.5% of total variance. Conclusions: This study adds to our understanding of selfregulatory variables involved in eating behavior after bariatric surgery. Action control was the strongest predictor of dietary adherence. To our knowledge this is the first time action control has been examined in this context. Our findings indicate that interventions targeting patients' self-regulation, and especially action control skills, might affect long-term outcomes after gastric bypass surgery.
A177
PRE-SURGICAL DEPRESSIVE SYMPTOM CLUSTERS AND SHORT-TERM POST-SURGICAL WEIGHT LOSS OUTCOMES AMONG BARIATRIC SURGERY PATIENTS Misty Hawkins1; Gail Williams2; Jennifer Duncan3; Christina Rummell3; 1Oklahoma State University, Stillwater OK; 2 Kent State University, Kent OH; 3Summa Health, Akron OH Background: Depression is common among bariatric surgery candidates, but the impact of different depressive symptom clusters on surgical outcomes is currently unclear. Thus, the current study examined whether the depressive symptoms clusters (e.g., somatic vs. cognitive/affective symptoms) were differentially and/or uniquely related to pre-surgical weight or short-term post-surgical weight loss outcomes. Methods: Depressive symptoms were assessed using the Beck Depression Inventory (BDI-II) as part of a bariatric pre-surgical evaluation in 335 candidates. The total BDI score and the somatic and cognitive/affective cluster subscale scores were calculated as well as a categorical variable of clinically depressed (BDI 412) or not (BDI o 12). Continuous scores were examined in relation to pre-surgical body mass index (BMI; kg/m2). Analyses examining the BDI total and subscale scores as predictors of
S47
percentage excess weight loss (%EWL) was also conducted in subsamples of individuals with 6-month (N¼244, 73%) and 12month (N¼217, 65%) short-term post-surgical follow-up data. The somatic and cognitive/affective scores were entered together in a simultaneous model to ascertain their unique impact on the dependent variables. Covariates included: age, sex, and race-ethnicity. Results: Nearly 30% of the total pre-surgical sample endorsed moderate or severe depressive symptoms (BDI score 420). Regression results indicate that the total BDI score was unrelated to pre-surgical BMI (β¼.025, p¼.650), adjusting for covariates. In simultaneous-entry models, neither cluster subscale was related to pre-surgical BMI (β¼-.072, p¼.351 for somatic cluster; β¼.091, p¼.233 for cognitive/affective cluster). Similarly, the total BDI score failed to predict %EWL at 6 or 12 months (all ps 4.174) although t-tests comparing clinically depressed to non-depressed persons indicated that depressed persons had higher %EWL at 6 months (t(246)¼2.13, p¼.034) and 12 months (t(219)¼1.94, p¼.054) (see Figure 1). In the simultaneous-entry models for the subscales, greater endorsement of cognitive/affective cluster symptoms predicted higher %EWL at 6 (β¼.194, p¼.025) and at 12 months (β¼.200, p¼.027). The somatic cluster was unrelated to %EWL (all ps 4.170). Conclusions: Results indicate that, while 30% of bariatric surgical candidates in this sample endorsed moderate or severe depressive symptoms, the cognitive/affective cluster (e.g., self-dislike, anhedonia) may have a stronger prognostic influence on short-term post-surgical outcomes than the somatic symptoms (e.g., fatigue, appetite changes). Somatic symptoms of depression may not be predictive of weight outcomes given that they overlap with common side effects of obesity. Another potential explanation is that individuals with higher levels of cognitive/affective symptoms are more psychologically distressed and may be more motivated to adhere to strategies that promote successful weight loss postsurgery. These possibilities should be examined in future studies with longer follow-up periods.
Integrated Health Oral Presentations / Surgery for Obesity and Related Diseases 12 (2016) S40–S47
74.2% of the sample were women. 66.2% were Caucasian, 19.7% were African American, and 14.1% were of another ethnicity. The mean age of participants was 46.75 years (SD¼11.63; Range 18 - 74). Patients' mean pre-surgical BMI was 49.14 kg/m2 (SD¼9.50 kg/m 2). Psychiatric diagnoses were obtained from a pre-surgical, semi-structured clinical interview and all participants were administered the MMPI-2-RF at their pre-surgical evaluations. BMIs were collected at 4 post-operative time points: 3-months (M¼38.59 kg/m 2, SD¼7.62) 6-months (M¼34.59 kg/m 2, SD¼7.24, 1-year (M¼32.42 kg/m2, SD¼7.63, and 5-years (M¼34.71 kg/m2, SD¼7.57). Percent missing at the 4 post-surgical time points were: 3-months (15.5%), 6-months (24.7%), 1-year (28.3%), and 5-years (52.2%). Correlations between demographic or psychological variables and attrition over time suggested that younger individuals evidenced higher amounts of missing data over time (r¼-.18).Statistical Analyses: Longitudinal structural equation modeling (SEM) was used for prediction analyses. Specifically, latent growth curves were used to model BMIreduction across time. Full Information Maximum Likelihood was used to handle missing data across time. Path analyses were used to estimate whether pre-surgical psychopathology predicted 5-year post-surgical BMIs as well as the rate of BMIchange over the 5-year trajectory. Diagnoses were tested first followed by the MMPI-2-RF scales by scale set. Results: A non-linear latent growth curve fit the outcome data best [χ2(7)¼12.36, p¼.09, RMSEA¼.041, CFI¼.98, SRMR¼.07], indicating that BMI-reduction across time was best modeled with a combination of linear and curvilinear trends. This non-linear trend implied that BMI-reduction was rapid from baseline through the one-year outcome. From one-year to fiveyears post-surgery, most patients evidenced a small increase in their BMIs. Age significantly predicted the rate of BMIreduction across time (β¼.20, p¼.005), such that older individuals evidenced a slower rate of change over time. When psychiatric diagnoses were introduced into the model, a presurgical diagnosis of Binge Eating Disorder predicted higher BMIs at the 5-year outcome (β¼.16, p¼.008). Patients who scored higher on the MMPI-2-RF scales Behavioral/Externalizing Dysfunction (β¼.11, p¼.030), Low Positive Emotions (β¼.13, p¼.032), and Hypomanic Activation (β¼.13, p¼.028) also evidenced higher BMIs at the 5-year outcome after controlling for age and Binge Eating Disorder. In regards to predicting variability in BMI-reduction over time, patients who scored higher on MMPI-2-RF scales Hypomanic Activation (β¼.24, p¼.002), Anger Proneness (β¼.16, p¼.004), and Activation (β¼.17, p¼.036) prior to surgery evidenced a slower rate of BMI-reduction over 5-years after controlling for age and Binge Eating Disorder. Discussion: As hypothesized, patients with higher pre-surgical levels of externalizing (e.g., impulse control) and internalizing (notably with difficulty feeling positive emotions) psychopathology had higher BMIs five years post-operatively compared to patients who did not evidence such elevations at the time of their pre-surgical evaluation. In addition, both age and psychopathology predicted slower post-operative BMI-reduction. This indicates that pre-operative indicators of psychopathology are important in predicting post-operative outcomes. A closer follow-up with patients who evidence pre-surgical problems, both before and after surgery, may help improve
outcomes. Post-operative psychological assessments may also enhance surgical outcomes.
A176
PSYCHOLOGICAL PREDICTORS OF ADHERENCE TO DIETARY RECOMMENDATIONS AFTER ROUX-EN-Y GASTRIC BYPASS Irmelin Bergh; Ingela Kvalem; Tom Mala; University of Oslo, Oslo Oslo Background: Adherence to dietary recommendations can be challenging after bariatric surgery. Unhealthy eating habits have been described as a main factor for suboptimal outcomes. Selfregulation is essential for adopting new or improving health behaviors and depends on changes in a set of interrelated cognitions such as planning, self-efficacy and action control skills (i.e., self-monitoring). There is limited data on self-regulatory factors involved in postoperative dietary adherence. A few studies have shown that lower self-efficacy, less planning and higher degree of depressive and anxiety symptoms were associated with non-adherence. To further extend our knowledge of eating behavior after bariatric surgery, we aimed to identify selfregulatory predictors of dietary adherence one year after gastric bypass surgery. Methods: Measures of demographic variables, self-regulation variables (intention, planning, self-efficacy, action control), depressive and anxiety symptoms (Hospital anxiety and Depression scale, HADS) and adherence to dietary recommendations were taken one year after Roux-en-Y gastric bypass in 230 patients (78.3% women). All patients received pre- and postoperative education from clinical nutritionists regarding the dietary recommendations after surgery. Adherence to the recommendations was evaluated according to the Norwegian national guidelines for healthy diet. Patients were asked: 'You have received recommendations regarding how/what to eat after surgery. To what degree does it correspond with how/what you have eaten the last four weeks?' (1¼little, 7¼a lot), followed by six recommendations (e.g., 'I eat five portions of fruit and vegetables every day', 'I limit my intake of sugar and fat' etc.). Specific nutritional recommendations, e.g., consumption of at least 60g of protein daily, vitamin substitution etc. were not evaluated. Action control involved items about self-monitoring behavior, awareness of standard (keeping one's goals in mind) and effort to avoid selfregulation failure. Results: Mean (SD) body mass index (BMI) before and after surgery was 44.9 kg/m2 (6.0) and 30.6 kg/m2 (5.2), respectively. Total weight loss was 29.2% (8.2). There were no differences for any of the psychological variables depending on demographic groups (age, sex, marital status, education, employment) or initial BMI groups (o 40, 40-50, 4 50 kg/m2). The self-regulatory variables intention, self-efficacy, planning and action control showed moderate and positive correlations with dietary adherence (p o. 001), whereas depressive and anxiety symptoms showed small and negative correlations with the outcome measure (p o. 001). Adherence to the recommendations was not associated with postoperative weight loss. Based on the multivariate regression analysis more planning (β¼16.9, p o. 01), better action control skills (β¼27.2, p o. 001) and lower degree of depressive and
Integrated Health Oral Presentations / Surgery for Obesity and Related Diseases 12 (2016) S40–S47
anxiety symptoms (β¼-16.6, p o. 01) predicted dietary adherence, explaining 26.5% of total variance. Conclusions: This study adds to our understanding of selfregulatory variables involved in eating behavior after bariatric surgery. Action control was the strongest predictor of dietary adherence. To our knowledge this is the first time action control has been examined in this context. Our findings indicate that interventions targeting patients' self-regulation, and especially action control skills, might affect long-term outcomes after gastric bypass surgery.
A177
PRE-SURGICAL DEPRESSIVE SYMPTOM CLUSTERS AND SHORT-TERM POST-SURGICAL WEIGHT LOSS OUTCOMES AMONG BARIATRIC SURGERY PATIENTS Misty Hawkins1; Gail Williams2; Jennifer Duncan3; Christina Rummell3; 1Oklahoma State University, Stillwater OK; 2 Kent State University, Kent OH; 3Summa Health, Akron OH Background: Depression is common among bariatric surgery candidates, but the impact of different depressive symptom clusters on surgical outcomes is currently unclear. Thus, the current study examined whether the depressive symptoms clusters (e.g., somatic vs. cognitive/affective symptoms) were differentially and/or uniquely related to pre-surgical weight or short-term post-surgical weight loss outcomes. Methods: Depressive symptoms were assessed using the Beck Depression Inventory (BDI-II) as part of a bariatric pre-surgical evaluation in 335 candidates. The total BDI score and the somatic and cognitive/affective cluster subscale scores were calculated as well as a categorical variable of clinically depressed (BDI 412) or not (BDI o 12). Continuous scores were examined in relation to pre-surgical body mass index (BMI; kg/m2). Analyses examining the BDI total and subscale scores as predictors of
S47
percentage excess weight loss (%EWL) was also conducted in subsamples of individuals with 6-month (N¼244, 73%) and 12month (N¼217, 65%) short-term post-surgical follow-up data. The somatic and cognitive/affective scores were entered together in a simultaneous model to ascertain their unique impact on the dependent variables. Covariates included: age, sex, and race-ethnicity. Results: Nearly 30% of the total pre-surgical sample endorsed moderate or severe depressive symptoms (BDI score 420). Regression results indicate that the total BDI score was unrelated to pre-surgical BMI (β¼.025, p¼.650), adjusting for covariates. In simultaneous-entry models, neither cluster subscale was related to pre-surgical BMI (β¼-.072, p¼.351 for somatic cluster; β¼.091, p¼.233 for cognitive/affective cluster). Similarly, the total BDI score failed to predict %EWL at 6 or 12 months (all ps 4.174) although t-tests comparing clinically depressed to non-depressed persons indicated that depressed persons had higher %EWL at 6 months (t(246)¼2.13, p¼.034) and 12 months (t(219)¼1.94, p¼.054) (see Figure 1). In the simultaneous-entry models for the subscales, greater endorsement of cognitive/affective cluster symptoms predicted higher %EWL at 6 (β¼.194, p¼.025) and at 12 months (β¼.200, p¼.027). The somatic cluster was unrelated to %EWL (all ps 4.170). Conclusions: Results indicate that, while 30% of bariatric surgical candidates in this sample endorsed moderate or severe depressive symptoms, the cognitive/affective cluster (e.g., self-dislike, anhedonia) may have a stronger prognostic influence on short-term post-surgical outcomes than the somatic symptoms (e.g., fatigue, appetite changes). Somatic symptoms of depression may not be predictive of weight outcomes given that they overlap with common side effects of obesity. Another potential explanation is that individuals with higher levels of cognitive/affective symptoms are more psychologically distressed and may be more motivated to adhere to strategies that promote successful weight loss postsurgery. These possibilities should be examined in future studies with longer follow-up periods.