Psychological Correlates of Body Image Dissatisfaction Before and After Bariatric Surgery

Abstract

Purpose:

Identify psychological factors associated with body image dissatisfaction (BID) before, 3 months, and 6+ months after bariatric surgery.

Methods:

Bariatric patients (n = 444) completed a preoperative interview, 3 month and/or 6+ month postoperative psychology appointment, and Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF). Scales measuring generalized distress, depression, anxiety, and low self-esteem were examined. Medical records were reviewed for demographics and current psychiatric diagnoses.

Results:

Preoperative BID was associated with higher scores on MMPI-2-RF scales of Emotional/Internalizing Dysfunction, Demoralization, Low Positive Emotions, Dysfunctional Negative Emotions, Self-Doubt, Inefficacy, Anxiety, and Negative Emotionality/Neuroticism, in addition to a diagnosis of depression and eating disorder not otherwise specified. Patients who reported BID at 3 months scored higher on MMPI-2-RF scales of Emotional/Internalizing Dysfunction, Demoralization, Ideas of Persecution, Dysfunctional Negative Emotions, Self-Doubt, Inefficacy, and Negative Emotionality/Neuroticism, and were more likely to have a depression or anxiety diagnosis. No psychiatric diagnoses or MMPI-2-RF scales were predictive of BID 6+ months after bariatric surgery.

Conclusions:

Bariatric candidates experiencing symptoms of depression, anxiety, low self-esteem, and disturbed eating at preoperative evaluation are more likely to report BID before and after bariatric surgery. Future research should consider the limitations of long-term follow-up in this study to advance the field forward.

Introduction

Body image dissatisfaction (BID) is a well-established source of psychosocial distress in populations with obesity.^1–3 While previous research has yielded a large effect size (Cohen's d = 0.85) for the relationship between obesity and BID,² there is substantial body image heterogeneity within populations with obesity, and not all individuals with obesity are equally susceptible to BID.¹ Studies have identified risk factors associated with BID to help explain who in populations with obesity is most vulnerable. Schwartz and Brownell¹ identified several risk factors, including weight status, gender, binge eating, and appearance teasing, among others. Moreover, individuals with obesity are at high risk of experiencing psychological comorbidities such as depression, anxiety, and low self-esteem, which are strongly correlated with BID.^2,4

BID often serves as a motivator for seeking bariatric surgery among individuals with obesity.^5,6 Libeton et al.⁶ found that 32% of 208 bariatric candidates were primarily driven to seek surgery due to feeling distressed and embarrassed about their physical appearance and weight. Studies have also identified features that are associated with preoperative BID in bariatric patients. Rosenberg et al.⁵ found depression, self-esteem, and perfectionism accounted for 48% of variability in preoperative BID in a sample of female bariatric candidates. Grilo et al.⁷ found self-esteem and binge eating were significant predictors of preoperative BID, with self-esteem accounting for 56% and 33% of variability in preoperative BID in men and women, respectively.

Researchers have also assessed changes in BID from presurgery to postsurgery. Although postoperative weight loss has been linked to improvement in BID,^8–13 this improvement might not reach normative levels for all patients, and there are some individuals who continue to experience BID after bariatric surgery.^8–11,13,14 For example, concerns with excess/redundant skin after surgery is a common source of BID,¹⁵ and it is possible that these concerns become more prominent in later postoperative months. Individuals with former obesity may also experience “phantom fat,” whereby they evidence a perceptual disturbance regarding their weight and may retain a degree of BID regardless of weight loss.³ Moreover, the underlying mechanisms responsible for improvement in BID after surgery are unclear. Some researchers report improvement is linked to weight-related parameters,⁹ whereas others suggest it is connected to psychological factors.^10,11

The fact that some individuals continue to experience BID after surgery,^8–11,13,14 despite successful weight loss, is concerning and indicates a need for further examination of the factors predictive of postoperative BID in bariatric patients. To our knowledge, only one study has identified preoperative predictors of BID early after bariatric surgery. Pona et al.¹⁶ examined scales from the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF)^17,18 measuring depression (e.g., Demoralization and Low Positive Emotions) and low self-esteem (e.g., Self-Doubt, Ideas of Persecution, Inefficacy) and found patients who scored higher on these scales more likely to report BID 3 months after bariatric surgery. BID was also more common in patients with a preoperative depression diagnosis, history of outpatient therapy, and current or historical use of psychotropic medication.¹⁶

This study sought to extend the findings of Pona et al.¹⁶ by identifying correlates of BID before, 3 months, and 6+ months after bariatric surgery using MMPI-2-RF scales and psychiatric diagnoses. We examined the MMPI-2-RF scales used in the original Pona et al.¹⁶ study, as well as five additional scales that are closely related to those initially used, including Emotional/Internalizing Dysfunction, Dysfunctional Negative Emotions, Anxiety, Negative Emotionality/Neuroticism–Revised, and Introversion/Low Positive Emotionality–Revised. We also examined psychiatric diagnoses, including depression, anxiety, and eating disorder not otherwise specified (EDNOS), the latter two of which were not examined in the previous investigation. We hypothesized that the variables predictive of 3-month BID in the original study, as well as the additional MMPI-2-RF scales and psychiatric diagnoses, would be predictive of BID before, 3 months, and 6+ months after bariatric surgery.

Materials and Methods

Participants

Data were collected between March 2009 and July 2012. The preliminary sample consisted of 444 consecutive and consented bariatric patients who completed a preoperative interview and 3 and/or 6+ month postoperative psychology appointment, had a valid MMPI-2-RF profile,¹⁸ and had surgery. The sample consisted of 74.48% women, with a mean age of 46.54 (standard deviation [SD] = 11.83) years, preoperative body mass index of 50.56 kg/m² (SD = 10.61), and 14.03 (SD = 2.33) years of education. Ethnicity breakdowns were as follows: 63.10% white, 21.20% black, and 15.30% other ethnicities. The patients obtained the following types of bariatric surgery: Roux-en-Y Gastric Bypass (80.00%), Adjustable Gastric Band (8.15%), Sleeve Gastrectomy (9.88%), Jejunectomy (0.49%), and Revision (1.48%).

Measures

Semi-Structured Psychodiagnostic Intake Interview

Patients completed a semi-structured intake interview, conducted by a doctoral-level psychologist, following a template produced by the clinic. Information used in this study included an evaluation of diagnostic and statistical manual of mental disorders (4th ed., text rev.; DSM-IV-TR; American Pscychiatric Association, 2000) diagnoses, including EDNOS (mostly binge eating, but could include night eating and graze eating), demographic information, and presence of BID. Body image was self-reported at the initial interview and coded by the psychologist as distorted, dissatisfied, within normal limits, or positive. Due to limited variability, body image ratings were collapsed into two groups: dissatisfied and positive. Data were coded through a retrospective chart review by a trained research assistant. Diagnoses and BID were dummy coded (1 = Present; 0 = Absent).

Minnesota Multiphasic Personality Inventory-2-Restructured Form

The MMPI-2-RF^17,18 is a 338-item self-report inventory that has demonstrated good reliability and validity coefficients across multiple bariatric samples.^19,20 The test has published normative data for bariatric patients, and scores derived from the instrument are not demographically biased when used in bariatric settings.^18,21 The items are scored on 9 measures of protocol validity (i.e., measures that detect noncredible, overreporting, or underreporting response styles) and 42 substantive scales that assess personality and psychopathology-related constructs related to emotional, thought, and behavioral dysfunction, interpersonal difficulties, and somatic/cognitive complaints. Scales used in the current investigation are outlined in Table 1.

Table 1.

Associations Between Minnesota Multiphasic Personality Inventory-2-Restructured Form Scales and Body Image Dissatisfaction

	Preoperative BID							3 Month BID							6+ Month BID
	n = 204^a							n = 405							n = 39
	BID		NBID					BID		NBID					BID		NBID
	n = 144		n = 60		Inferential statistics			n = 35		n = 370		Inferential statistics			n = 11		n = 28		Inferential statistics
Self-report measures	M	SD	M	SD	t(df)	p	d	M	SD	M	SD	t(df)	p	d	M	SD	M	SD	t(df)	p	d
Emotional/internalizing dysfunction	52	11	47	9	3.01 (202)	0.003	0.50	58	12	46	11	4.76 (403)	<0.001	1.04	50	17	47	11	0.58 (37)	0.567	0.21
Demoralization	53	10	48	8	3.28 (202)	0.001	0.55	59	10	50	9	5.73 (403)	<0.001	0.95	52	14	50	10	0.64 (37)	0.527	0.16
Low positive emotions	54	11	50	9	2.57 (202)	0.011	0.40	55	12	52	11	1.30 (403)	0.193	0.26	52	16	50	12	0.41 (37)	0.683	0.14
Ideas of persecution	50	10	49	9	0.74 (202)	0.461	0.11	54	11	49	9	3.38 (403)	0.001	0.50	51	9	49	9	0.56 (37)	0.582	0.22
Dysfunctional negative emotions	47	10	44	8	2.59 (202)	0.010	0.33	52	11	45	9	4.68 (403)	<0.001	0.70	48	13	45	9	0.70 (37)	0.486	0.27
Self-doubt	53	12	48	9	2.73 (202)	0.010	0.47	60	13	50	10	5.55 (403)	<0.001	0.86	55	17	51	11	0.98 (37)	0.332	0.28
Inefficacy	50	12	47	9	1.03 (202)	0.007	0.28	55	14	47	10	4.40 (403)	<0.001	0.66	46	10	47	11	0.17 (37)	0.865	0.10
Anxiety	50	10	46	5	2.69 (202)	0.008	0.51	54	12	47	8	4.71 (403)	<0.001	0.69	56	16	49	9	1.78 (37)	0.083	0.54
Negative emotionality/neuroticism	50	10	47	7	2.26 (202)	0.025	0.35	53	12	48	9	3.59 (403)	<0.001	0.47	49	16	47	10	0.52 (37)	0.607	0.15
Introversion/low positive emotionality	55	11	52	9	1.74 (202)	0.083	0.30	55	12	52	10	1.22 (403)	0.224	0.27	49	17	50	12	0.34 (37)	0.733	0.07

Please note that the sample size varied in the total population due to missing data in the data set.

BID, Body Image Dissatisfaction; MMPI-2-RF, Minnesota Multiphasic Personality Inventory-2-Restructured Form; M, mean; NBID, No Body Image Dissatisfaction; SD, standard deviation.

Psychology Postoperative Questionnaire (Unpublished)

The Psychology Postoperative Questionnaire consists of items used by program psychologists to guide follow-up sessions, including common medical complications, psychological complications, behavioral adherence items, benefits of surgery, and future goals. The questionnaire was administered at 3 and 6+ month follow-up sessions. Patients were able to endorse if BID was a problem for them in the following item: “Did you have any psychological complications? Circle all that apply. (Body Image Problems).” The BID item was dummy coded (1 = Present; 0 = Absent).

Procedures

The study was conducted as a retrospective chart review and approved by the Institutional Review Board. Demographic information, MMPI-2-RF scale scores, psychiatric diagnoses, and endorsement/denial of BID were obtained through the chart review. At intake, a semi-structured interview was given by a doctoral-level psychologist to every patient, in addition to the MMPI-2-RF. Patients were automatically scheduled for a 3 month follow-up visit with a psychologist on the team. The 6+ month follow-up sessions were not mandatory or automatically scheduled. At each postoperative visit, the Psychology Postoperative Questionnaire was administered. Diagnoses were combined based on DSM organization to increase statistical power. For example, depression-related disorders such as Major Depression Disorder, Depression Not Otherwise Specified, and Dysthymia were collapsed into one depression variable.

Body image data were collected at three different time points: preoperative evaluation, 3 month, and 6+ month follow-up. Although all patients completed a preoperative evaluation, only 46% had body image data available at this time point because the interview was modified after data collection had already begun to include a preoperative body image variable. Statistical analyses were thus treated as cross-sectional rather than longitudinal. Three separate analyses were run for each time point and aimed to identify correlates of BID at each respective time point. The number of patients with BID data at each time point was as follows: preoperative evaluation (n = 204), 3 month (n = 405), and 6+ month follow-up (n = 39).

Statistical analyses

Percents of BID endorsement were calculated for each time point. Chi-square tests for categorical demographic information as well as preoperative psychiatric diagnoses were computed between patients who did and did not report BID at all three time points. Results were considered statistically significant if alpha was below 0.05. In addition, phi coefficients were calculated as measures of effect size (0.10 = small, 0.30 = medium, and 0.50 = large).²² Means, standard deviations, results of t-tests, and effect sizes were calculated for continuous demographic variables and each of the hypothesized MMPI-2-RF scales between patients who did and did not endorse BID across all three time points. To be deemed statistically and clinically significant, p-values had to be below 0.05 and yield a meaningful effect size (Cohen's d ≥ 0.20).

Results

Our study had 48.43% follow-up at 3 months and 4.38% at 6+ months. BID endorsement rates at each time point were as follows: preoperative evaluation (70.59%; 144/204), 3 month (8.60%; 35/405), and 6+ month follow-up (28.20%; 11/39). The percentages of men and women who endorsed BID at each time point were as follows: 65% and 72% before surgery, 8% and 9% at 3 months, and 50% and 26% at 6+ month follow-up, respectively. No demographic variables were significantly associated with BID at any of the three time points.

The presence of BID at preoperative evaluation was significantly and positively associated with a diagnosis of depression (χ²(1) = 3.86, p = 0.049, and φ = 0.14) and EDNOS (χ²(1) = 7.79, p = 0.005, and φ = 0.20), but not anxiety. The presence of BID at 3 month follow-up was significantly and positively associated with a diagnosis of depression (χ²(1) = 13.21, p < 0.001, and φ = 0.18) and anxiety (χ²(1) = 8.54, p = 0.003, and φ = 0.15), but not EDNOS. There were no diagnoses predictive of BID at 6+ month follow-up.

Table 1 reports the means, standard deviations, and inferential statistics of the hypothesized MMPI-2-RF scales. Patients who reported BID at preoperative evaluation scored statistically and meaningfully higher on Emotional/Internalizing Dysfunction, Demoralization, Low Positive Emotions, Dysfunctional Negative Emotions, Self-Doubt, Inefficacy, Anxiety, and Negative Emotionality/Neuroticism–Revised on the MMPI-2-RF. Patients who reported BID at 3 month follow-up scored higher on Emotional/Internalizing Dysfunction, Demoralization, Ideas of Persecution, Dysfunctional Negative Emotions, Self-Doubt, Inefficacy, and Negative Emotionality/Neuroticism–Revised on the MMPI-2-RF. Patients who reported BID at 6+ month follow-up tended to score higher on Emotional/Internalizing Dysfunction, Ideas of Persecution, Self-Doubt, Dysfunctional Negative Emotions, and Anxiety (d's ≥ 0.20) on the MMPI-2-RF; however, these trends did not reach statistical significance.

Discussion

This study sought to identify correlates of BID before, 3 months, and 6+ months after bariatric surgery. Consistent with our hypotheses and the findings of others, this study found preoperative BID to be associated with depressive symptoms,⁵ low self-esteem,^5,7 anxiety,⁵ and eating disorders.⁷ Patients who reported preoperative BID were more likely to produce higher scores on MMPI-2-RF scales of Emotional/Internalizing Dysfunction, Demoralization, and Low Positive Emotions, and have a current depression diagnosis. They were also more likely to score higher on MMPI-2-RF scales of Self-Doubt, Anxiety, Dysfunctional Negative Emotions, and Negative Emotionality/Neuroticism, and meet criteria for EDNOS.

Consistent with the findings from the original Pona et al. study,¹⁶ 3 month BID was found to be linked with a depression diagnosis and elevations on MMPI-2-RF scales of Demoralization, Ideas of Persecution, Self-Doubt, and Inefficacy. Patients who reported BID at 3 months in this study were also more likely to exhibit elevations on scales measuring anxiety (e.g., Dysfunctional Negative Emotions and Negative Emotionality/Neuroticism) and general emotional and internalizing difficulties (e.g., Emotional/Internalizing Dysfunction). With a larger sample size, Low Positive Emotions did not reach statistical significance. Though the mean scores for this scale increased slightly for both those who did and did not report 3 month BID in this study, the range of scores decreased for individuals with BID and stayed the same for individuals without BID. Thus, the effect size (and corresponding confidence intervals) of this difference was smaller in this study, which may be reflective of range restriction in scores in individuals who reported BID at 3 month follow-up.

No psychiatric diagnoses or MMPI-2-RF scales were predictive of BID 6+ months after bariatric surgery. This is likely due to the small sample size (n = 39), which resulted in lack of statistical power to detect true long-term effects. As mentioned earlier, while patients were automatically scheduled for 3 month follow-up visit, 6+ month follow-up sessions were not mandatory or automatically scheduled. It is possible that patients who scheduled 6+ month visits were experiencing psychiatric or medical complications and may not be representative of the larger bariatric population. Nonetheless, it is important to note that 28.2% of patients who did attend a 6+ month follow-up session reported BID and tended to score higher on scales measuring general emotional and internalizing difficulties (e.g., Emotional/Internalizing Dysfunction), low self-esteem (e.g., Ideas of Persecution and Self-Doubt), and anxiety (e.g., Dysfunctional Negative Emotions and Anxiety). These initial, but important findings suggest that a subset of patients continue to struggle with BID despite weight loss after bariatric surgery, which provides information for clinicians to be aware of in terms of bariatric aftercare, and reaffirms the importance of long-term follow-up research.

There are a number of reasons why BID may continue to exist or even onset after successful weight loss. One reason may be the experience of loose, sagging skin that can result after massive weight loss.²³ Indeed, Kinzl et al.²⁴ found as many as 70% of bariatric surgery patients to report BID related to sagging skin after surgery, even though 90% reported being pleased with their overall appearance. Furthermore, patients who reported greater postsurgical body satisfaction had actually lost less weight than their dissatisfied counterparts, which further supports the idea that this group may have experienced less pronounced negative skin changes.²⁴

A second reason for residual BID after bariatric surgery may be due to unrealistic expectations for surgical outcomes, which could be related to weight loss, body appearance, or body perception. For example, some research groups have noted a significant difference between the amounts of postsurgical weight loss that clinicians consider successful versus the weight loss that bariatric candidates expect to achieve.^25,26 Price et al.²⁶ found female bariatric surgery candidates' body shape expectations to be thinner than clinically expected for typical postsurgical weight loss after surgery. Furthermore, bariatric surgery patients may also experience “phantom fat,” whereby they continue to perceive themselves as obese regardless of weight loss.³

A third reason for residual BID postbariatric surgery may be due to the multidimensionality of the BID construct. For example, De Panfilis et al.²⁷ found some aspects of BID (including body image overconcern, related avoidance behaviors, compulsive self-monitoring, and overall severity of BID) to improve following bariatric surgery, while other aspects (including weight phobia, depersonalization, and uneasiness toward body parts) did not. Similarly, while some patients will seek body contouring after massive weight loss to help with sagging skin, Song et al.¹⁵ found an improvement in overall BID after body contouring, but an onset of dissatisfaction with other parts of the body. This finding suggests that body expectations or ideals may shift as patients get closer to their ideal.¹⁵

An important finding from our study was that men and women did not differ in their endorsement of BID at any of the three time points. These rates are mostly consistent with national prevalence studies that report estimates ranging from 11% to 72% for women and 8% to 61% for men,²⁸ and survey results ranging from 13% to 32% for women and 9% to 28% for men.²⁹ Furthermore, these results indicate that men are at risk for experiencing BID, which is consistent with previous findings,^7,8,16 as well as suggest that men experience BID at equal proportions to women both before and after bariatric surgery.

A diagnosis of EDNOS was found to be associated with BID only before surgery, but not after. A possible explanation for this is that patients who met criteria for EDNOS at the initial psychological evaluation were required to complete a four-session cognitive behavioral therapy group intervention³⁰ before they were cleared for bariatric surgery. Patients learned skills to eliminate disordered eating (e.g., binge eating) and reduce negative thoughts and emotions associated with eating and body image. Patients were reevaluated at the end of intervention and their symptoms were determined to be subclinical at the time of surgery. Perhaps this brief treatment resulted in improved BID in patients who met criteria for EDNOS, such that their disturbed eating was no longer a significant predictor of BID after bariatric surgery. Given the strong association between eating disorders and BID,^1,7 future research should examine postoperative BID in patients with untreated EDNOS.

This study has a number of strengths. It included a male sample in addition to a female sample and found that BID does not differ between the two. This suggests that men are also at risk for experiencing BID, which reaffirms the importance of including a male sample in both bariatric and body image research.^7,8,16 This is also the first study to investigate preoperative psychiatric diagnoses and MMPI-2-RF scale scores as correlates of BID before and 6+ months after bariatric surgery, although we did investigate predictors of 3 month BID in our original study.

A limitation is that a dichotomous variable was used to measure BID, which is a multidimensional construct. It is possible that this study measured generalized distress related to BID as body image has been found to encompass multiple facets. Panfilis et al.¹⁰ found that certain aspects of BID improved after bariatric surgery (i.e., overconcern about body image and related avoidance behaviors, compulsive self-monitoring, and overall severity of BID), while other aspects did not improve (i.e., weight phobia, depersonalization, and uneasiness toward body parts). Furthermore, the preoperative interview was modified after data collection began to include a body image variable, which is why some patients only had postoperative BID data. Future research should replicate this study using a consistent, multidimensional body image assessment administered across time. This will allow researchers to examine changes in body image over time, both before and after bariatric surgery. Another area for future research is to consider whether postoperative BID at 6+ months is related to body changes after surgery, such as the appearance of excess skin.

Another limitation was the small sample size at 6+ months and attrition to follow-up after surgery, which is mostly consistent with reported bariatric aftercare attrition rates of 49–89%.^31,32 In our program, patients were automatically scheduled follow-up appointments at 3 months, but not at 6+ months, which likely impacted attrition. It is possible that this subset is not representative of the larger population given they self-selected to follow-up with psychology after surgery, potentially due to struggling with psychological and/or medical symptoms. Nonetheless, this subset reported an alarming rate of BID, indicating additional research is necessary to further clarify reasons for BID after bariatric surgery. A final limitation is that our study was cross-sectional rather than longitudinal. Future research should consider our limitations of long-term follow-up to advance the field forward.

Conclusions

Bariatric candidates with psychopathology and other psychological risk factors may be more vulnerable to BID before and up to 6 months after bariatric surgery. Although patients may have lost weight, a subset of patients continues to struggle with BID, which provides important information for clinicians to be aware of in terms of bariatric aftercare. Future research should consider our limitations of long-term follow-up to advance the field forward.

Footnotes

Acknowledgments

This article was presented at the 32nd Annual Meeting of the American Society for Metabolic and Bariatric Surgery in Los Angeles, California, on November 3, 2015.

Author Disclosure Statement

No competing financial interests exist.

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