Relationships Between a History of Abuse,Changes in Body Mass Index,Physical Health,and Self-Reported Depression in Female Bariatric Surgery Patients

Abstract

Background/Objectives:

A history of physical and sexual abuse has been implicated in weight gain. Although bariatric surgery is effective for weight loss in severely obese individuals, we investigated whether bariatric surgery patients who self-report a history of physical and/or sexual abuse have differential outcomes regarding weight loss, body mass index (BMI), quality of life (SF-36), and depressive symptoms (Center for Epidemiologic Studies Depression [CESD]) compared with nonabused patients.

Materials and Methods:

Standardized assessments at baseline and follow-up visits were performed on 103 obese (BMI >35) female bariatric surgery patients (mean age: 44.11 years, standard deviation: 11.67 years).

Results:

In total 49.5% of participants reported abuse. Abused group had significantly higher BMI (p < 0.01) and depression scores (p < 0.01). After surgery, the BMI between the two groups was no longer significantly different, although the abused group remained significantly more depressed. Mixed models showed that abuse was associated with CESD scores (p < 0.01) and SF-36 mental composite scores (p = 0.03) after adjusting for smoking history.

Conclusion:

Bariatric surgery leads to a better weight loss in abused patients. Abuse history might be an additional factor for clinicians to consider when advising bariatric surgery, as our study suggests that women with history of abuse may have a higher weight loss benefit but less mental health improvement from the intervention.

Introduction

Owing to failure of other weight loss interventions,¹ bariatric surgery is commonly used by severely obese people with a history of abuse to achieve significant and sustainable weight loss. Current literature shows that childhood and adulthood physical and sexual abuse have drastic consequences on adult eating habits, and are highly correlated with excessive weight gain as well as destructive eating disorders, even when sociodemographic factors are taken into account.^2,3 Those with morbid obesity are also two to three times more likely to have been victims of physical and/or sexual abuse in the past.⁴ With the prevalence of abuse among adults in the United States estimated to be between 15% and 27%,⁵ it is important to explore the effect of bariatric surgery on patients with history of abuse.

There is accumulating evidence that depressive symptoms are associated with severe obesity in adults.⁶ The Swedish Obesity Study demonstrated that severely obese adults have increased rates of mood disorders and more severe self-reported depressive symptoms.⁷ This effect might be stronger in female patients with a history of abuse, as Roosa et al. suggested that there may be a link between history of abuse and depression in women.⁸ Obesity also has negative consequences on self-reported physical quality of life measured by SF-36 and other surveys.⁹

Sustained reductions in depressive symptoms have been reported after bariatric surgery.¹⁰ Major weight loss, achieved by improved diet, increased exercise, or bariatric surgery, is strongly associated with higher quality of life with respect to both physical and mental scores measured by the SF-36 assessment and body image for people with severe obesity.^11–13 Despite high prevalence of mental disease and history of abuse in the bariatric surgery patients,^4,14 there have been few studies analyzing the associations between a history of physical and/or sexual trauma in the past and quality of life after the surgery. This line of research is especially important considering that psychological and psychiatric issues may result in denial of bariatric surgery in ∼15% of patients.¹⁵

The purpose of this study was to examine associations between abuse histories and weight loss as well as the SF-36 mental and physical composite scores, and the severity of depressive symptoms (Center for Epidemiologic Studies Depression [CESD]) after bariatric surgery. These measures are both highly validated and commonly used.^16,17 This study would help to inform bariatric surgeons about change in body mass index (BMI), depressive symptoms, and quality of life among women with and without histories of abuse undergoing bariatric surgery.

Materials and Methods

Participants and settings

This study utilized data from two cohort studies of female bariatric surgery patients performed at Magee Womens Research Institute, which followed the same inclusion criteria.^18,19 These data sets were utilized because they included demographic information, health history, standardized surveys, and outcomes of the bariatric surgery patients collected in a standardized way using validated methods. A comparison of recruited participant characteristics and demographics by history of abuse is described in Table 1.

Table 1.

Comparison of Demographic and Personal Characteristics by a History of Abuse

	Total (n = 103)	History of abuse		p
	Total (n = 103)	No (n = 51)	Yes (n = 50)	p
Age, mean ± SD	44.1 ± 11.7	44.8 ± 12.1	43.8 ± 11.4	0.67^a
Race, n (%)				0.67^b
Caucasian	80 (78)	39 (76.5)	40 (80)
African American	23 (22)	12 (23.5)	10 (20)
Education level, n (%)				0.37^b
High school or GED	53 (51)	24 (47.1)	28 (56)
College or higher	50 (49)	27 (52.9)	22 (44)
Employment status, n (%)				0.94^b
Unemployed/disabled	37 (36)	18 (35.3)	18 (36)
Employed	66 (64)	33 (64.7)	32 (64)
Smoking history, n (%)				<0.01^b
Never smoker	63 (61)	41 (80.4)	21 (42)
Former smoker	40 (39)	10 (19.6)	29 (58)
History of menopause, n (%)				0.83^b
No	67 (65)	33 (66)	32 (49)
Yes	35 (34)	17 (34)	18 (51)

Student's t-test.

Chi-square test.

GED, graduate equivalent diploma; SD, standard deviation.

In brief, 103 women, with class II (35–40 kg/m²) or class III obesity (>40 kg/m²), aged 18–72 (mean age: 44.11 years, standard deviation [SD]: 11.67 years) completed baseline and 6-month follow-up assessments. The inclusion criteria for the parent studies included confirmed approval for bariatric surgery (Roux-en-Y gastric bypass, laparoscopic gastric banding, or sleeve gastrectomy), life expectancy >3 years, and at least one ovary.^18–20 The exclusion criteria for the parent studies included refusal to sign informed consent, plans to become pregnant within a year, inability to attend the in-person visits for the study assessments, endometrial ablation, previous hysterectomy, severe inflammatory disease, recent surgery, or plans to change residence within a year. For the purpose of this investigation, inclusion criterion was completion of two study visits and completion of the abuse questionnaire. All participants signed informed consents. The University of Pittsburgh's Human Research Protection Office approved this study.

Outcome and predictor variables

Our primary outcomes (BMI, CESD score, and SF-36 physical and mental scores) were assessed before and after the bariatric surgery, and were used as repeated outcome variables in our mixed models.

Data on main predictor variables, including abuse and smoking history, were self-reported by participants using the Screening Questionnaire for General Health History. These validated questionnaires were previously used in both the SMART and PREFER studies, in which behavioral weight management was examined.^16,17 Abuse was self-reported as either present or not present in childhood and/or adulthood. Patient assessment visit (baseline and 6 months) was used as a predictor in mixed models.

Registered nurses and staff at the Clinical and Translational Research Center at Magee Womens Hospital of UPMC obtained anthropometric measurements 2–6 weeks before surgery. BMI (kg/m²) was determined using weights collected by a Tanita body composition analyzer (Model TBF-310; Tanita Corporation of America). Participants wore light clothing and no shoes during the measurements. BMI change was calculated by subtracting BMI value 6 months after the bariatric surgery from presurgery BMI. Percent excess weight loss (%EWL) was calculated as following: \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} \begin{align*} { \rm { \% EWL = \; } } { \frac { \left( { { \rm { presurgery \;BMI } } - { \rm { postsurgery \;BMI } } } \right) } { \left( { { \rm { presurgery \;BMI } } - { \rm { 25kg / } } { { \rm { m } } ^ { \rm { 2 } } } } \right) } } \times { \rm { 100 } } \end{align*} \end{document}

Depressive symptoms were assessed using the validated and widely used self-reported CESD short scale.²¹ A cutoff point was then used to determine whether the participant met the criteria for clinically elevated depressive symptoms (CESD score >16).²¹

Physical and mental composite scores were assessed using the self-reported Medical Outcomes Study Questionnaire Short Form 36 (MOS-SF-36, V2.9).²² SF-36 questionnaire contains eight subscales, including general health perception, change in health, physical functioning, physical roles, emotional roles, social functioning, bodily pain, mental health, and vitality scores.²² Physical and mental composite scores were calculated as functions of these eight subscales.

Statistical analysis

Basic descriptive statistics were used to characterize the study populations. Demographic and personal characteristics were compared between abused and nonabused women using the Student's t-test and Wilcoxon Mann–Whitney U-test for continuous variables, and Chi-square test and Fisher's exact test for categorical variables. Linear mixed models, including repeated measures, were performed to compare the effects of bariatric surgery on in BMI and EWL, CESD score, SF-36 physical score, and mental composite scores. These models included time (baseline and 6 months) and abuse history, and were further adjusted for smoking history and interaction between effect of bariatric surgery and abuse. All statistical analyses were done with SAS version 9.4 (SAS Institute, Cary, NC). The alpha level was set at 0.05 and was two-sided.

Results

The comparisons of personal characteristics between the groups of abused and nonabused women are presented in Table 1. There were no significant differences in the basic characteristics of abused and nonabused women, except for smoking. More than half (58%) of the women in the abused group reported being former smokers compared with only one-fifth (19.6%) of the nonabused group (p < 0.01).

Table 2 shows the comparisons of BMI, CESD score, and SF-36 physical and mental health characteristics of the participants in the abused and nonabused groups at the assessments before and after the bariatric surgery. Women in the abused group had significantly higher BMI compared with nonabused women at both assessments (p = 0.01), but benefited more from the surgery, as the abused group had a larger decrease in BMI with an average decrease of 12.1 as opposed to 9.4 for the nonabused group. This resulted in the abused group having a BMI that was not significantly different from the nonabused group (p = 0.51) after bariatric surgery. %EWL was also not statistically significant between abused (58%) and nonabused (51.7%) groups (p = 0.18).

Table 2.

Comparison of Physical and Mental Health Characteristics by a History of Abuse

	Total (n = 103)	History of abuse		p
	Total (n = 103)	No (n = 51)	Yes (n = 50)	p
BMI, mean ± SD
Presurgery	45.3 ± 6.2	43.6 ± 4.5	46.8 ± 7.3	0.01^a
Postsurgery	34.5 ± 5.6	34.1 ± 5	34.8 ± 6.3	0.51^a
BMI change	10.8 ± 4.7	9.4 ± 4.4	12.1 ± 4.5	<0.01^a
Excess weight loss (%)	54.8 ± 23.5	51.7 ± 24.4	58 ± 22.4	0.18^a
Depression score, median (IQR)
Presurgery	10 (IQR 5,18)	8 (IQR 3,12)	15 (IQR 9,19)	<0.01^b
Postsurgery	8 (IQR 3,14)	5 (IQR 2,11)	9 (IQR 4,18)	0.02^b
Depression score change, mean ± SD	−1.8 ± 9.2	−1.2 ± 7.8	−2.7 ± 10.7	0.45^a
Clinical levels of depression, presurgery, n (%)				<0.01^c
No	73 (71)	44 (86.3)	28 (56)
Yes	30 (29)	7 (13.7)	22 (44)
Clinical levels of depression, postsurgery, n (%)				0.03^c
No	77 (75)	43 (88)	33 (70)
Yes	21 (20)	6 (12)	14 (30)
Physical composite score, median (IQR)
Presurgery	43.7 (IQR 34.4,50.1)	44 (IQR 35,51)	43 (IQR 34,48)	0.10^b
Postsurgery	52.8 (IQR 46.1,56.3)	53 (IQR 48,57)	53 (IQR 45,55)	0.46^b
Physical composite score change, median (IQR)	8.5 ± 10.2	7.2 ± 8.5	9.8 ± 12	0.23^a
Mental health composite score, median (IQR)
Presurgery	53.2 (IQR 42.2,57.2)	55 (IQR 48,58)	49 (IQR 41,56)	0.10^b
Postsurgery	53.8 (IQR 45.9,58.2)	56 (IQR 50,59)	53 (IQR 42,57)	0.04^b
Mental health composite score change, mean ± SD	9.5 ± 15.8	10.1 ± 16.4	9.1 ± 15.3	0.78^a

Student's t-test.

Wilcoxon Mann–Whitney U-test.

Chi-square test.

BMI, body mass index; IQR, interquartile range; SD, standard deviation.

The depression score was significantly different between abused (15, interquartile range [IQR] 9,19) and nonabused women (8, IQR 3,12) (p < 0.01). The abused group had larger improvement in their depression scores (6 vs. 3 points), but the change was not statistically significant (p = 0.45). The abused group still had significantly higher depression scores after the surgery compared with the nonabused group (5 vs. 9 points) (p = 0.02). In addition, there was a significant difference between the two groups in the number of participants self-reporting clinical levels of depressive symptoms (CESD scores ≥16) with the abused group having significantly higher number (p < 0.01). At the 6-month assessment, the abused group still reported significantly high number of depressive symptoms (p = 0.03).

There were no significant differences in SF-36 physical score between abused and nonabused groups before and after bariatric surgery. The abused population also had significantly lower SF-36 mental health composite scores postsurgery (p = 0.04), even though there was no significant difference in this variable before surgery.

Linear mixed models showed that assessment visit was significantly associated with BMI, CESD score, and SF-36 physical composite score over time adjusting for abuse, smoking history, and interaction between abuse and visit (Table 3). Abuse and assessment time were significantly associated with BMI over time with abused women having a higher BMI by 2.57 (p < 0.01) before surgery compared with other women after adjusting for abuse and smoking history. Women in the abused group were more depressed (p < 0.01) compared with those in the nonabused group after adjusting for smoking history and abuse and visit interaction. A history of abuse was also significantly associated with SF-36 mental score, with the abused group having a lower score by 5.93 points (p = 0.03) than the nonabused group after adjusting for smoking history and abuse and assessment time interaction.

Table 3.

Mixed Models for Body Mass Index, Depression Score, Physical Composite Score, and Mental Composite Score Between Pre- and Postsurgery After Adjusting for Abuse, Smoking History, and Interaction Between Abuse and Visit

Variable	p	p	p	p
BMI
Visit	<0.01	<0.01	<0.01	<0.01
Abuse		0.14	0.27	0.19
Smoking history			0.52	0.51
Abuse × visit				<0.01
Depression score (CESD)
Visit	0.04	0.03	0.03	0.03
Abuse		<0.01	<0.01	<0.01
Smoking history			0.15	0.15
Abuse × visit				0.54
Physical composite score (SF-36)
Visit	<0.01	<0.01	<0.01	<0.01
Abuse		0.20	0.21	0.18
Smoking history			0.82	0.23
Abuse × visit				0.84
Mental composite score (SF-36)
Visit	0.14	0.12	0.11	0.11
Abuse		0.10	0.02	0.03
Smoking history			0.06	0.06
Abuse × visit				0.33

Mixed modeling was used to analyze each of the outcome models. Adjustments for abuse, smoking history, and interaction about abuse and visit were adjusted for, in that order.

CESD, Center for Epidemiologic Studies Depression Scale; SF-36, 36-Item Short Form Health Survey.

Discussion

This study is one of the first to explore the association between self-reported physical and/or sexual abuse and bariatric surgery outcomes. Half of the participants (49.5%) reported a history of abuse, which is slightly higher than that of other studies (∼25%).²³ Women in the abused group had significantly higher BMI before, but not after the surgery, lost significantly more weight, and were more depressed compared with nonabused women. Mixed models showed that depression and SF-36 composite mental scores were significantly worse in the abused group over time. This is consistent with prior literature that suggests high levels of psychological disturbances as well as psychiatric diagnoses possibly associated with a history of abuse in bariatric surgery candidates at baseline assessments.^24,25

The abused and nonabused groups were similar in their demographic characteristics except that the abused group was significantly more likely to have a history of smoking. Since there is evidence of a correlation between severe stress and smoking being used as a coping mechanism,²⁶ the correlation between former abuse and smoking is not surprising. Because smoking is linked to numerous health problems and leads to a decline in physical health over the long term, this factor should be further examined in the future studies. It is important to note that to qualify for the bariatric surgery at our institution, patients were not permitted to be current smokers. Therefore, there is a possibility that bariatric surgery patients underreported current tobacco use.

Patients who reported a history of abuse also had significantly higher BMIs before surgery. However, they also lost significantly more weight 6 months after surgery such that there was no significant difference between the groups' BMI after bariatric surgery, thus normalizing the abused population. Previous weight loss research reported mixed results, with some studies suggesting that prior abuse has no correlation with success in weight loss,^23,27,28 whereas another reports positive correlations with weight loss as a result of surgery.²⁹ Since previous research demonstrates that surgical weight loss results in better psychological functioning after bariatric surgery compared with other weight loss interventions,³⁰ one might anticipate that individuals with a history of abuse may particularly benefit from bariatric surgery.

CESD scores showed marked improvement from the baseline to 6-month assessment for both groups (Table 2), which is consistent with prior studies dealing with mental health for female bariatric surgery candidates and quality of life.^31–33 However, CESD scores of the abuse group demonstrated higher levels of depressive symptomatology for both the baseline and 6-month visits. Thus, those who reported abuse still exhibited more self-reported markers of poor mental health, despite losing a similar, or in some cases, more weight. Research performed at another large medical center corroborates this finding, suggesting that initial weight and weight loss is not directly correlated with mental health score improvements.³⁴ This is particularly concerning, as poor mental health and more depressive symptoms have been closely linked to eating disorders and weight gain in the first place.³⁵

In concordance with previously published literature, we have found that bariatric surgery had positive effects on BMI, CESD score, and SF-36 physical composite score adjusting for abuse, smoking history, and interaction between abuse and assessment time (baseline and 6 months). Mixed models also showed that the abused group had higher BMI at baseline compared with the nonabused group, which aligns with published reports.^36,37 Although bariatric surgery decreased depressive symptoms in both abused and nonabused women, abused women were still significantly more depressed than nonabused women, postsurgery. However, women in the abused group showed better improvement of the absolute change in the depression score suggesting that they benefit from the surgery.

Only female bariatric surgery candidates were included in the study; therefore, we do not know if our results can be generalized to men. Many studies on bariatric surgery do not dichotomize based on gender,^38,39 but because men and women react to abuse differently,⁴⁰ such analysis is necessary to provide a complete picture in future research.

One of the strengths of the study is that the ethnic breakdown of our research sample closely mirrors the general population breakdown in the United States and Allegheny County where the study was conducted. According to the most recent census, African Americans and European Americans represent 13.3% and 77.1% of the population of the United States, respectively.⁴¹ Similar breakdown is observed in Allegheny County.⁴²

Another strength is the robust methodology, including the use of standardized SF-36 and CESD surveys, which are validated and commonly used instruments for this type of research.

There were limitations to this study, one of which was the modest sample size. A larger cohort might reveal more subtle associations. Another potential limitation is the fact that that we were not able to analyze the data by the type of bariatric surgery. It has been reported that laparoscopic gastric band surgery induces the slowest weight loss, whereas the gastric sleeve surgery leads to the fastest weight loss.⁴³ This limitation will need to be addressed in future investigations with larger sample sizes.

Finally, since the questionnaires were self-reported, one limitation is the potential for response bias. Because participants may have wanted to present themselves in a favorable light, they may have underreported problems, which could potentially affect the CES-D and SF-36 scores.

Research on psychosocial outcomes after bariatric surgeries suggests that patients' lives typically follow the grounded theory methodology, in which patients experience a “rebirth” or “transformation”.^24,44 Often, such patients characterize the two periods of before and after surgery as clearly dichotomous with more positive aspects associated with the after stage.⁴⁵ However, not all surgeries result in sustained weight loss, with some patients gaining most or even more of the weight back within a few years or simply having unrealistic expectations of the surgery.⁴⁶ Because the current data deal only with baseline and 6-month assessments, it would be interesting to examine whether there are any marked differences between the formerly abused and nonabused groups for a longer follow-up time, which will be the focus of our future research.

Given the high cost of bariatric surgery and the possibility of complications, ensuring the best possible treatment plan customized to patients' personal characteristics is very important. Finally, if a history of abuse is predictive of outcomes, the most effective type of clinical intervention needs to be determined by future research. In an era where precision medicine is rapidly becoming the norm,⁴⁷ such research could aid in the development of new protocols, such as Adapted Motivational Interviewing,⁴⁸ to treat such patients and potentially achieve better outcomes. Ultimately, the goal of such research is not to deter future patients from the surgery but rather to educate and perhaps provide interventions and recommendations to ensure the best possible outcomes of the surgery.

Conclusion

This study is one of the first to examine the correlation between a history of prior physical and sexual abuse in bariatric surgery patients and the results of bariatric surgery. Those who self-reported abuse tended to lose more weight 6 months postoperatively, but had worse mental health profiles both before and 6 months after the surgery.

Footnotes

Acknowledgments

The study's authors acknowledge the following funding sources: the American Cancer Society (MRSG-1-079-01-CPRB), Scaife Foundation Award at the University of Pittsburgh School of Medicine, and the National Institutes of Health Grants ULIRR024153 and ULITR 000005. They also acknowledge the critical contributions of all the individuals who participated in the study.

Author Disclosure Statement

No competing financial interests exist.

References

Fujioka

, Yan

, Wang

H-J

, Li

. Evaluating preoperative weight loss, binge eating disorder, and sexual abuse history on Roux-en-Y gastric bypass outcome. Surg Obes Relat Dis, 2008; 4:137–143.

Johnson

, Cohen

, Kasen

, Brook

. Childhood adversities associated with risk for eating disorders or weight problems during adolescence or early adulthood. Am J Psychiatry, 2002; 159:394–400.

Afifi

, MacMillan

, Boyle

, Cheung

, Taillieu

, Turner

, et al. Child abuse and physical health in adulthood. Health Rep, 2016; 27:10–18.

Grilo

, Masheb

, Brody

, Toth

, Burke-Martindale

, Rothschild

. Childhood maltreatment in extremely obese male and female bariatric surgery candidates. Obes Res, 2005; 13:123–130.

Chiu

, Lutfey

, Litman

, Link

, Hall

, McKinlay

. Prevalence and overlap of childhood and adult physical, sexual, and emotional abuse: a descriptive analysis of results from the Boston Area Community Health (BACH) survey. Violence Vict, 2013; 28:381–402.

Jantaratnotai

, Mosikanon

, Lee

, McIntyre

. The interface of depression and obesity. Obes Res Clin Pract, 2017; 11:1–10.

Ryden

, Karlsson

, Sullivan

, Torgerson

, Taft

. Coping and distress: what happens after intervention? A 2-year follow-up from the Swedish Obese Subjects (SOS) study. Psychosom Med, 2003; 65:435–442.

Roosa

, Reinholtz

, Angelini

. The relation of child sexual abuse and depression in young women: comparisons across four ethnic groups. J Abnorm Child Psychol, 1999; 27:65–76.

Kushner

, Foster

. Obesity and quality of life. Nutrition, 2000; 16:947–952.

10.

Dixon

, Dixon

, O'Brien

. Depression in association with severe obesity: changes with weight loss. Arch Intern Med, 2003; 163:2058–2065.

11.

Song

, Patel

, Gunther

, Li

, Liu

, Lee

, et al. Body image & quality of life: changes with gastric bypass and body contouring. Ann Plast Surg, 2016; 76 Suppl 3:S216–S221.

12.

Lemstra

, Rogers

. Improving health-related quality of life through an evidence-based obesity reduction program: the Healthy Weights Initiative. J Multidiscip Healthc, 2016; 9:103–109.

13.

Gomes-Neto

, Araujo

, Junqueira

, Oliveira

, Brasileiro

, Arcanjo

. Comparative study of functional capacity and quality of life among obese and non-obese elderly people with knee osteoarthritis. Rev Bras Reumatol Engl Ed, 2016; 56:126–130.

14.

Dawes

, Maggard-Gibbons

, Maher

, et al. Mental health conditions among patients seeking and undergoing bariatric surgery: a meta-analysis. JAMA, 2016; 315:150–163.

15.

Walfish

, Vance

, Fabricatore

. Psychological evaluation of bariatric surgery applicants: procedures and reasons for delay or denial of surgery. Obes Surg, 2007; 17:1578–1583.

16.

Burke

, Choo

, Music

, Warziski

, Styn

, Kim

, et al. PREFER study: a randomized clinical trial testing treatment preference and two dietary options in behavioral weight management—rationale, design and baseline characteristics. Contemp Clin Trials, 2006; 27:34–48.

17.

Burke

, Styn

, Glanz

, Ewing

, Elci

, Conroy

, et al. SMART trial: a randomized clinical trial of self-monitoring in behavioral weight management-design and baseline findings. Contemp Clin Trials, 2009; 30:540–551.

18.

Kaiyrlykyzy

, Freese

, Elishaev

, Bovbjerg

, Ramanathan

, Hamad

, et al. Endometrial histology in severely obese bariatric surgery candidates: an exploratory analysis. Surg Obes Relat Dis, 2015; 11:653–658.

19.

Goughnour

, Thurston

, Althouse

, Freese

, Edwards

, Hamad

, et al. Assessment of hot flushes and vaginal dryness among obese women undergoing bariatric surgery. Climacteric, 2016; 19:71–76.

20.

Linkov

, Goughnour

, Ma

, Xu

, Edwards

, Lokshin

, et al. Changes in inflammatory endometrial cancer risk biomarkers in individuals undergoing surgical weight loss. Gynecol Oncol, 2017; 147:133–138.

21.

Radloff

. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas, 1977; 1:385–401.

22.

Ware

Jr. , Sherbourne

. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care, 1992; 30:473–483.

23.

Gabert

, Majumdar

, Sharma

, Rueda-Clausen

, Klarenbach

, Birch

, et al. Prevalence and predictors of self-reported sexual abuse in severely obese patients in a population-based bariatric program. J Obes, 2013; 2013:374050.

24.

Glinski

, Wetzler

, Goodman

. The psychology of gastric bypass surgery. Obes Surg, 2001; 11:581–588.

25.

Batayyah

, Sharma

, Aminian

, Romero-Talamas

, Zelisko

, Ashton

, et al. The role of the multidisciplinary conference in the evaluation of bariatric surgery candidates with a high-risk psychiatric profile. Bariatr Surg Pract Patient Care, 2015; 10156–159.

26.

Dedert

, Hicks

, Dennis

, Calhoun

, Beckham

. Roles of inter-individual differences and intra-individual acute elevations in early smoking lapse in people with posttraumatic stress disorder. Addict Behav, 2016; 60:171–176.

27.

Hensel

, Grosman Kaplan

, Anvari

, Taylor

. The impact of history of exposure to abuse on outcomes after bariatric surgery: data from the Ontario Bariatric Registry. Surg Obes Relat Dis, 2016.

28.

Koball

, Himes

, Sim

, Clark

, Collazo-Clavell

, Mundi

, et al. Distress tolerance and psychological comorbidity in patients seeking bariatric surgery. Obes Surg, 2016; 26:1559–1564.

29.

Hulme

, McBride

, Kupzyk

, French

. Pilot study on childhood sexual abuse, diurnal cortisol secretion, and weight loss in bariatric surgery patients. J Child Sex Abus, 2015; 24:385–400.

30.

Karlsson

, Taft

, Ryden

, Sjostrom

, Sullivan

. Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obes (Lond), 2007; 31:1248–1261.

31.

Ball

, Burton

, Brown

. A prospective study of overweight, physical activity, and depressive symptoms in young women. Obesity (Silver Spring), 2009; 17:66–71.

32.

Linkov

, Burke

, Komaroff

, Edwards

, Lokshin

, Styn

, et al. An exploratory investigation of links between changes in adipokines and quality of life in individuals undergoing weight loss interventions: possible implications for cancer research. Gynecol Oncol, 2014; 133:67–72.

33.

Freese

, Althouse

, Ramanathan

, Edwards

, Bovbjerg

, Linkov

. Presurgery weight loss goals, depressive symptoms, and weight loss among women undergoing bariatric surgery. Bariatr Surg Pract Patient Care, 2017; 12:67–71.

34.

Wedin

, Byrne

, Morgan

, Lepage

, Goldman

, Crowley

, et al. Presurgical weight is associated with pain, functional impairment, and anxiety among gastric bypass surgery patients. Pain Res Treat, 2012; 2012:412174.

35.

Capuron

, Lasselin

, Castanon

. Role of adiposity-driven inflammation in depressive morbidity. Neuropsychopharmacology, 2017; 42:115–128.

36.

Richardson

, Dietz

, Gordon-Larsen

. The association between childhood sexual and physical abuse with incident adult severe obesity across 13 years of the National Longitudinal Study of Adolescent Health. Pediatr Obes, 2014; 9:351–361.

37.

Hodge

, Stemmler

, Nandy

. Association between obesity and history of abuse among American Indians in rural California. J Obes Weight Loss Ther, 2014; 4:pii:1000208.

38.

Brissman

, Ekbom

, Hagman

, Marild

, Gronowitz

, Flodmark

, et al. Physical fitness and body composition two years after Roux-en-Y gastric bypass in adolescents. Obes Surg, 2017; 27:330–337.

39.

Devlin

, King

, Kalarchian

, White

, Marcus

, Garcia

, et al. Eating pathology and experience and weight loss in a prospective study of bariatric surgery patients: 3-year follow-up. Int J Eat Disord, 2016; 49:1058–1067.

40.

Schumacher

, Feldbau-Kohn

, Smith Slep

, Heyman

. Risk factors for male-to-female partner physical abuse. Aggression Violent Behav, 2001; 6:281–352.

41.

US Census Quick Facts: USA Government;. 2015. Available at www.census.gov/quickfacts/table/PST045215/00 (last accessed October 19, 2018).

42.

Allegheney Census Demographics: PA Census;. 2016. Available at www.pacenterofexcellence.pitt.edu/counties/allegheny/demographics_allegheny.html (last accessed October 19, 2018).

43.

Lee

, Nguyen

, Le

. Comparative effectiveness of 3 bariatric surgery procedures: roux-en-Y gastric bypass, laparoscopic adjustable gastric band, and sleeve gastrectomy. Surg Obes Relat Dis, 2016.

44.

Wolfe

, Terry

. Expectations and outcomes with gastric bypass surgery. Obes Surg, 2006; 16:1622–1629.

45.

Mitchell

, King

, Chen

, Devlin

, Flum

, Garcia

, et al. Course of depressive symptoms and treatment in the longitudinal assessment of bariatric surgery (LABS-2) study. Obesity (Silver Spring), 2014; 22:1799–1806.

46.

Homer

, Tod

, Thompson

, Allmark

, Goyder

. Expectations and patients' experiences of obesity prior to bariatric surgery: a qualitative study. BMJ Open, 2016; 6:e009389.

47.

Kim

, Goossens

, Hoshida

. Use of big data in drug development for precision medicine. Expert Rev Precis Med Drug Dev, 2016; 1:245–253.

48.

David

, Sockalingam

, Wnuk

, Cassin

. A pilot randomized controlled trial examining the feasibility, acceptability, and efficacy of Adapted Motivational Interviewing for post-operative bariatric surgery patients. Eat Behav, 2016; 22:87–92.