Health Behaviors of Patients Qualified for Bariatric Surgery: The Role of Excess Body Weight,Age,and Depressive Symptoms

Abstract

Introduction:

Health behaviors exhibited by patients qualified for bariatric surgery has never been evaluated simultaneously with depressive symptoms.

Objectives:

To compare the health behaviors of obese patients with the general Polish population and establish their associations with demographic and clinical factors.

Subjects and Methods:

Proper nutrition habits, preventive behaviors, health practices, and positive mental attitude were evaluated with the Juczynski Health Behaviors. Inventory in 93 patients (66 females) qualified for bariatric surgery (44.2 ± 11.5 years, body mass index [BMI] = 44.3 ± 10.5, percent excess body weight [%EBW] = 81% ± 39%), and depressive symptoms were assessed with the Beck Depression Inventory.

Results:

Scores obtained are similar to those of the general Polish population. Women scored higher in the proper nutrition habit category than men (p = 0.02), but they scored lower in health practices and positive mental attitude than women in the general population. Higher severity of depressive symptoms negatively correlated with proper eating habits (R = −0.21; p = 0.04). Higher BMI and higher %EBW were correlated to higher scores in health practices (R > 0.24, p = 0.02), independent of age.

Conclusions:

Generally, associations between health behaviors, BMI, and %EBW are weakly positive or absent. Therefore, they either do not contribute to the development of obesity or they might be adopted by patients once the disease is underway.

Introduction

Health behaviors are the result of an attitude to health, which is acquired over the course of a lifetime. The role of behavioral factors in the genesis of obesity is today increasingly acknowledged.¹ Although the role of factors, such as poor eating habits, a sedentary lifestyle, and negative emotional states, are broadly documented,^2,3 little is known about the health-improving activities (such as placing emphasis on a balanced diet, avoiding food containing preservatives, eating vegetables, fruit, and wholegrain bread, as well as following health recommendations and seeing a doctor regularly) of morbidly obese patients qualified for bariatric surgery.

Nutritional habits, physical activity, and emotional states/stress are important aspects of people's lifestyles, which have an influence on health, morbidity, and mortality for a range of conditions.^2,3 Therefore, patterns of food consumption, and their relationship to mental health, have received some attention in research.⁴

Health behaviors are affected by multiple factors, such as age, sex, marital status, and socioeconomic status.⁵ Research shows that health behavior scores increase with age.^6,7 Furthermore, females obtain higher scores in health behavior questionnaires than males.^6,8

Earlier epidemiological studies on behavioral risk factors did not evaluate morbidly obese individuals. Regarding overweight and obese individuals, Kruger et al.⁹ found that being overweight or obese is associated with tobacco use, alcohol intake, a lower consumption of fruit and vegetables, and lower physical activity, after adjusting for demographics, measures of functional health, and various behavioral risk factors. In addition, a higher percentage of healthy weight or overweight men engaged in recommended levels of physical activity and strength training in their leisure time than obese men. Another epidemiological study of almost 45,000 participants¹⁰ demonstrated that obese women and overweight (but not obese) men were more prone to depressive mood than their nonoverweight counterparts; depressive mood was operationalized by whether or not the participant reported feeling sad, blue, or depressed for more than 7 days during the month before answering the questionnaire.

Higher body mass indices (BMIs)^11,12 and increased visceral fat¹³ are frequently reported to be associated with depression or depressive symptoms, for example, adults with current depression or a history of diagnosed depression or anxiety.¹¹ Obese people are at a higher risk of depression, but depression is also a predictor of weight gain and future obesity.^14,15 Higher scores on measures of depressive symptoms have been associated with lower diet quality in several population-based studies.^16,17 The prevalence of psychiatric comorbidities was reported to be higher among bariatric patients than in the general population.¹⁸

Studies from several countries show that around 40% of all bariatric surgery patients have had at least one psychiatric diagnosis. Depressive disorders (i.e., dysthymic disorder and major depressive disorder), anxiety disorders (i.e., generalized anxiety disorder), and eating disorders (i.e., binge eating disorder) are the three most common psychiatric diagnoses.¹⁹ A recent review article by Brandao et al.²⁰ revealed that 20–56% of preoperative bariatric patients have a current psychiatric diagnosis. Moreover, the authors pointed out that major depressive disorder is the most frequent condition, followed by social phobia, anxiety disorders, somatization, hypochondria, and obsessive compulsive disorder.²⁰ These psychiatric comorbidities, together with acknowledged metabolic comorbidities such as type 2 diabetes, exert an additional burden on the patient. However, it was also demonstrated that being seriously ill improves health-related behaviors, for example, some patients make necessary lifestyle modifications before surgery as a result of preheart failure conditions, such as coronary heart disease, hypertension, or type 2 diabetes. In Poland, higher BMI values were found to be correlated to lower scores of health behaviors.^6,21 However, patients treated for obesity obtained higher scores than their untreated counterparts.²¹ A recent study by Oved et al.²² demonstrated a high occurrence of unhealthy eating habits and a nonactive lifestyle among Israeli patients before laparoscopic sleeve gastrectomy. However, no healthy control group was used in this study, and therefore, it is impossible to compare these findings to the general Israeli population.

In summary, only a few studies have evaluated health-related behaviors exhibited by patients qualified for bariatric surgery. To the best of our knowledge, none of those studies evaluated health behaviors as a function of the severity of depressive symptoms. We hypothesized lower scores of health behaviors among bariatric patients than in the general Polish population and that lower scores are correlated to higher BMI, larger excess body weight, being male, and to more severe depressive symptoms.

It is predicted that by 2025, 177 million people worldwide will be suffering from morbid obesity (www.worldobesity.org/resources/world-map-obesity). Therefore, it is obvious to us that our results are important not only for the Polish population. Therefore, we decided to publish the results of our study in an international journal.

Methods

Subjects

We retrospectively analyzed data collected prospectively from 93 consecutive patients (66 females, 27 males) who were qualified for and underwent bariatric surgery at the Department of General Surgery of the Military Institute of Aviation Medicine (MIAM) in Warsaw, Poland. We used standard criteria for bariatric surgery: BMI >40 or BMI >35 with comorbidities. There were no psychiatric contraindications to bariatric surgery. All patients were medically approved before surgery according to Interdisciplinary European guidelines on metabolic and bariatric surgery.²³ Their average age was 44.2 ± 11.5 years (range 18–67). The mean BMI value was 44.3 ± 10.5 (range 35.2–94.2), and the mean percent excess body weight (%EBW) was 81% ± 39%. We found no differences between females and males in these parameters. Thirty-three patients (35%) suffered from obesity class II° (BMI 35.0–39.9) and 60 patients (65%) suffered from obesity class III° (BMI ≥40.0). No patient reported a diagnosis of any psychiatric disease (including major depressive disorder) or the use of any psychiatric medications. The Commission for Bioethics at the Military Institute of Aviation Medicine in Warsaw, Poland gave us permission to analyze the data retrospectively.

Behavioral assessments

The patterns of health behaviors were assessed using the Health Behavior Inventory (HBI), developed and standardized for the Polish population by Juczynski.^24,25 This is a Polish language questionnaire widely used in studies conducted in Poland.^26–28 The HBI is a self-report questionnaire, which consists of 24 statements describing different behaviors related to health. Patients rate these behaviors on a 5-point scale, where 1 represents the lowest intensity of the behavior and 5 represents the highest. Therefore, the general index ranges from 24 to 120. The HBI scores are grouped into the following four categories: (1) “proper nutrition habits” focusing on the types of food consumed by the patient (wholemeal bread and eating significant amounts of fruit and vegetables); (2) “prophylactic behaviors” associated with disease prevention, defined as adherence to doctor's recommendations, regular medical check-ups, receiving medical information; (3) “health practices” assessing sleep quality, rest, exercise, monitoring body weight; and (4) “positive mental attitude” focusing on the avoidance of situations that might cause a depressed mood and the avoidance of strong emotions, anger, and anxiety. The results for the categories were calculated as the mean number of points obtained for answers to the questions belonging to a particular category. The mean results obtained by male and female patients for each category were compared with the reference values for the general Polish population. The intensity of particular health related behaviors, as well as the general index, was categorized into high level, medium level, and low level. We used the Beck Depression Inventory (BDI)²⁹ to assess the level of depressive symptoms. The BDI test is a 21-item self-report questionnaire which uses a 4-point scale ranging from 0 (symptom not present) to 3 (symptom very intense.) The standard cutoff scores are as follows: 0–9 indicates minimal depression; 10–18 indicates mild depression; 19–29 indicates moderate depression; and 30–63 indicates severe depression. Higher total scores indicate more severe depressive symptoms in this questionnaire.

Statistical analysis

The results were analyzed using the statistical package STATISTICA 12.0 (StatSoft, Tulsa). Differences between female and male patients were assessed with the Mann–Whitney U test. Spearman correlation coefficients were used for correlational analysis. p-Values <0.05 were considered to be statistically significant.

Results

The majority of the patients obtained a low (36%) or an average (44%) HBI score. Only 20% of the studied population demonstrated a high level of health-related behaviors. The average HBI score was 80.2 ± 12.2. Patients obtained 3.28 ± 0.77 points for proper nutrition habits, 3.37 ± 0.75 points for prophylactic behavior, 3.29 ± 0.66 points for health practices, and 3.42 ± 0.66 for the positive mental attitude category, showing average intensities for these behaviors. The study group did not differ from the general Polish population in their average HBI score and in each HBI category (Table 1). Female patients obtained higher average HBI scores than their male counterparts (81.5 ± 12.5 vs. 76.6 ± 10.7, p = 0.04), similar to those observed in the Polish population.²⁴ Females scored significantly higher for the proper nutrition habit category than males (3.40 ± 0.76 vs. 3.01 ± 0.74, p = 0.02). The females under investigation had lower scores on both health practices and positive mental attitude than females in the general Polish population (3.30 ± 0.71 vs. 3.53 ± 0.78, p = 0.03 and 3.46 ± 0.70 vs. 3.74 ± 0.79, p = 0.001, respectively, Table 1). No such differences were found for males.

Table 1.

Average Results for Each Category of Health Behavior Inventory in the Study Group

Health behaviors	All patients (n = 93)	General Polish population (n = 496)	Men: study group (n = 27)	Men: general Polish population (n = 235)	Women: study group (n = 66)	Women: general Polish population (n = 261)
HBI score	80.2 ± 12.2	81.8 ± 14.2	76.6 ± 10.7^#	78.5 ± 14.0	81.5 ± 12.5^#	84.0 ± 14.2
Proper nutrition habits	3.3 ± 0.8	3.2 ± 0.8	3.0 ± 0.7	2.8 ± 0.8	3.4 ± 0.8	3.6 ± 0.7
Preventive behavior	3.4 ± 0.7	3.4 ± 0.8	3.2 ± 0.7	3.3 ± 0.8	3.4 ± 0.7	3.5 ± 0.8
Health practices	3.3 ± 0.7	3.4 ± 0.8	3.3 ± 0.5	3.0 ± 0.9	3.3 ± 0.7^*	3.5 ± 0.8^*
Positive mental attitude	3.4 ± 0.7	3.5 ± 0.7	3.3 ± 0.5	3.2 ± 0.7	3.5 ± 0.7^**	3.7 ± 0.8^**

p = 0.01; ^*p = 0.03; ^#p = 0.04.

HBI, health behavior inventory.

The mean BDI score of the patients was 13.8 ± 9.7 (range 0–43), with no differences between females and males. Based on BDI, there were no depressive symptoms among 44% of the studied patients, 32% of the patients demonstrated a mild level of depressive symptoms, 10% a moderate level, and 14% a severe level. The level of depressive symptoms did not correlate with the HBI score. However, the severity of depressive symptoms was weakly negatively correlated with proper eating habits (R = −0.21; p = 0.04). A positive correlation was found between age and all categories of health behaviors: proper nutrition habits (R = 0.38, p = 0.001 for all patients, or R = 0.43, p < 0.001 for females, Fig. 1a and R = 0.50, p = 0.009 for males, Fig. 1b), prophylactic behaviors (R = 0.26; p = 0.01), health practices (R = 0.27; p = 0.01), and positive mental attitude (R = 0.24; p = 0.02), independent of sex.

FIG. 1.

(a) Proper nutrition habit scores as a function of patient's age for females. (b) Proper nutrition habit scores as a function of patient's age for males.

We did not find any correlations between BMI or %EBW and total HBI score for the entire study group, irrespective of sex and most HBI categories (p > 0.12). Only health practices were weakly positively correlated with higher BMI and higher %EBW (R > 0.24, p = 0.02, Fig. 2).

FIG. 2.

Health practices as a function of percent excess body weight.

Discussion

The majority of morbidly obese patients who were qualified for bariatric surgery obtained low to average scores in the health behavior questionnaire, similar to that observed in the Polish adult population. Being female, being older, and having less depressive symptoms were associated with a higher level of health-related behaviors, consistent with previous studies.^6,7 Finally, higher BMI and higher %EBW were correlated to higher scores in health practices, contrary to our hypotheses.

Our results confirm that females exhibit a higher level of health behaviors than males, which is reflected by higher scores on the Juczynski test, and similar to that observed in the general Polish population, as well as consistent with our hypotheses and other studies.^6,7 Similarly, we have shown that age had a positive effect on the level of health behaviors, consistent with published research, except for Kawalec et al. who reported a negative correlation between age and proper eating habits among overweight and obese patients.²¹ The weak positive or the lack of associations between higher BMI, larger %EBW, and higher scores in health practices found in our study does not support our hypotheses that poor adherence to good health behaviors is associated with obesity. These results are consistent with a study by Kawalec et al., where patients who were treated pharmacologically for obesity scored better on a health behavior questionnaire than untreated obese adults.²¹ Therefore, our results may be interpreted as an indication that a higher health behavior score reflects an adaptation process in the progress of obesity. Even so, the health behavior score probably did not have an influence on the weight of patients. Conceivably, this potential improvement in health behavior score may have influenced the decision of patients to undergo bariatric surgery.

Depressive symptoms and mood disorders are commonly seen among severely obese adults. In our study 24% of patients reported moderate-to-severe depressive symptoms. This is slightly lower than the 30% reported among morbidly obese patients in the United States³⁰ and the 35% reported in Germany.³¹ The mean BDI score of 13.8 in our study was also lower than reported in two Australian studies, 17.7³² and 17.0.³³

Our results show that more severe depressive symptoms are correlated to poorer eating habits. This result is consistent with several population-based studies which demonstrated that higher scores on measures of depressive symptoms were associated with lower diet quality.^16,17 Excess body weight may negatively affect self-esteem and lead to a negative self-image, facilitating the development of mood disorders.³⁴ The severity of depressive symptoms can vary substantially across individuals and may have an influence on eating and physical activity.^35,36

It may appear that the use of the Juczynski HBI is a limitation of our study due to difficulties in making direct comparisons with the results of other studies. However, our choice of this questionnaire was intentional. We decided to assess HBI among morbidly obese patients with the Juczynski HBI because we were able to compare the results of our group with the results obtained for the general population of our country, unlike other studies, which were not able to do so.

In summary, our study demonstrated no differences in health behaviors between morbidly obese patients and the general population, except for health practices and a positive mental attitude among females. The abovementioned differences did not affect the health behavior score among females. However, depressive symptoms among morbidly obese patients who were qualified for bariatric surgery were weakly negatively correlated with proper eating habits. In general, associations between health behaviors, BMI, and %EBW are weakly positive or absent. Therefore, unhealthy behaviors in accordance with our study do not appear to be a cause of obesity, or healthy behaviors might be adopted by patients when the disease is already under way.

Footnotes

Acknowledgments

The study was partially supported by Polish National Science Centre (NCN) for partial support under grant 2013/09/B/NZ7/03763.

Author Disclosure Statement

No competing financial interests exist.

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