Perceived Responsibility for Bariatric Surgery,Eating,and Exercise Behaviors Among Adolescent Bariatric Surgery Candidates

Abstract

Background:

Adolescents’ perceived responsibility for weight management behaviors has yet to be studied in relation to bariatric surgery. The current study examined perceived responsibility to pursue bariatric surgery and engage in specific weight management behaviors among adolescents seeking bariatric surgery and its associations with demographic, family support, and eating disorder symptoms.

Methods:

Data were collected using retrospective chart review of adolescent bariatric surgery candidates presenting to a tertiary interdisciplinary clinic. Data included demographics and adolescents’ self-report of (1) perceived responsibility (i.e., primarily adolescent; primarily parent; shared) for the decision to pursue bariatric surgery and weight management behaviors, (2) family support for eating and exercise behaviors, and (3) eating disorder symptoms. Analyses included one-way analysis of covariance, chi-squared tests, and Kruskal–Wallis tests.

Results:

Participants reporting primarily teen or shared responsibility for seeking bariatric surgery were older than those reporting primarily parent responsibility (p = 0.023). Teens perceiving primary responsibility for their own healthy eating reported less family encouragement for healthy eating (p = 0.011) and more eating disorder symptoms (p = 0.002) than those reporting primarily parent or shared responsibility. Teens reporting primary responsibility for exercise reported less family encouragement for healthy eating (p = 0.012) compared with those reporting shared responsibility.

Conclusions:

This study is the first to provide a description of health behavior responsibilities in a sample of adolescents with severe obesity seeking bariatric surgery. Not only will these insights improve our understanding of this population, but it can also inform presurgical discussions with adolescents and their parents.

Introduction

The prevalence of bariatric surgery among adolescents is increasing, driven by rising rates of severe obesity and endorsements of surgical interventions from the American Academy of Pediatrics (AAP).¹ In 2023, the AAP updated their recommendations for obesity treatment in adolescents, focusing on early and intensive treatment.² The new guidelines recommend intensive health behavior and lifestyle treatment and family-based treatment for any child aged 2 years or older with obesity. For adolescents aged 13 and older with severe obesity [i.e., sex-specific body mass index (BMI) for age ≥120% of the 95th percentile], bariatric surgery is recommended in addition to intensive health behavior and lifestyle treatment.² Given that both family-based interventions and bariatric surgery are recommended for adolescents with severe obesity, it is important to understand the role that adolescents play in making decisions about pursuing bariatric surgery and responsibility for changing weight-related health behaviors.

One way that adolescent responsibility for decision-making can be measured is with assessments of perceived responsibility.³ Perceived responsibility is defined as the degree to which parents or adolescents, or both, are perceived as responsible for making decisions about behaviors, and is particularly salient during adolescence given the complex biopsychosocial transition that occurs during this developmental period.⁴ Given that teens are beginning to experience—or are expected to develop—more autonomy and independence related to their health, examining perceived responsibility in the context of complex and demanding medical conditions or procedures is important.⁵ For example, there are substantial short- and long-term lifestyle changes that are required after bariatric surgery to decrease the risk of weight regain and improve the efficacy of the surgery itself.⁶ These include following a liquid diet immediately after surgery, a pureed and soft food diet up to 2 months after surgery and long-term dietary guidelines focused on smaller portioned meals high in protein and low in fat and sugar.⁷ Understanding who primarily is responsible for the decision to pursue surgery [is it the adolescent, the parent, or a shared decision?] and who is primarily responsible for the teen engaging in healthy eating and exercise behaviors has important implications for the implementation and success of early and intensive interventions, such as bariatric surgery. Yet, there is a lack of research on perceived responsibility for surgery and weight-related behaviors, which may have an impact on long-term outcomes in adolescents who are considering bariatric surgery.

Perceived responsibility is well-researched in other areas of pediatric psychology, such as type 1 diabetes (T1D), and this condition may be an appropriate analog to pediatric bariatric surgery.³ Similar to the complex and long-term dietary changes required after bariatric surgery, T1D requires the lifelong daily execution of complex health behaviors, such as blood glucose monitoring and careful calculation of insulin dosage.³ Adolescent responsibility for diabetes care is associated with older age, male sex, higher self-efficacy, higher executive functioning, and intrinsic motivation.³ When adolescents assume primary responsibility for diabetes care at a developmentally appropriate time, it can lead to psychological and physical benefits, including improved metabolic control and quality of life.³ Adolescents assuming primary responsibility for their diabetes care can also come with risks, though, if they are not sufficiently equipped to manage their care, including difficulty maintaining stable blood glucose levels.⁸ The same may be true for adolescent candidates seeking bariatric surgery. Teens transitioning to being responsible for their own bariatric surgery and the associated weight management behaviors may engage in disordered eating behaviors. Although granting teens autonomy over their health behaviors can be developmentally appropriate and lead to positive outcomes when introduced at the right time, it can also be associated with unintended health risk behaviors.³

Only two studies to date have examined perceived responsibility in relation to severe obesity and/or bariatric surgery. A qualitative study by Roberts and colleagues reported that in a sample of adolescents with severe obesity, parents and adolescents often have conflicting views of perceived responsibility for initiating and maintaining exercise.⁹ Although adolescents reported wanting more parental involvement in their exercise routines, parents expressed the belief that adolescents should transition to being independent and exercise alone. Ryder and colleagues examined differences in retrospective reports of family health responsibilities between adolescents who maintained weight loss after bariatric surgery and those who regained weight within the first year following surgery.¹⁰ Interestingly, the results showed no differences in perceived responsibility between groups. The differences in these findings may be due to age and developmental differences in the samples, the populations recruited, and the methods used. Adolescents in the qualitative study by Roberts and colleagues were early adolescents (M age = 12.9 years) with severe obesity in a weight management program who were not pursuing bariatric surgery. Adolescents in the quantitative study by Ryder and colleagues were late adolescents (M age = 17.1 years) who had completed bariatric surgery 5 years before the study and were retrospectively reporting on perceived responsibility after surgery. Given that successful health behavior changes before surgery have been directly linked to more positive outcomes after bariatric surgery, it is important to understand who is responsible for weight-related health behaviors before surgery.¹¹

To address the limited research in this area, the current study aimed to describe perceived health behavior responsibilities in a sample of adolescents with severe obesity seeking bariatric surgery. This study had two aims. First, we sought to describe adolescents’ reports of teen versus shared versus parent responsibility with respect to the decision to pursue bariatric surgery, the teen’s healthy eating behavior, and the teen’s exercise behavior among teens seeking bariatric surgery. Second, we examined whether there were differences across perceived responsibility categories (i.e., primarily adolescent, shared, and primarily parent) for these behaviors with respect to demographic factors, BMI, family support for healthy eating and exercise, and number of eating disorder symptoms. Given the limited research on perceived responsibility in adolescent bariatric surgery, hypotheses were informed by the pediatric T1D literature. In particular, it was hypothesized that adolescents reporting primary responsibility for the decision to pursue bariatric surgery and for maintaining healthy eating and exercise behaviors would be older and male.

Methods

Participants and Procedures

Data were collected using retrospective electronic medical record (EMR) review of adolescents presenting to an interdisciplinary bariatric surgery clinic at a large teaching hospital in the southeastern United States between 2015 and 2020. Of the 127 EMRs reviewed, 63 adolescents had completed a comprehensive psychosocial intake packet that included measures of perceived responsibility for bariatric surgery and eating and exercise behaviors and family support for eating and exercise behaviors. See Table 1 for sample demographics. This study was reviewed and deemed exempt by the hospital and university’s independent Institutional Review Boards.

Table 1.

Means, Standard Deviations, and Frequencies of Sample Demographics and the Variables of Interest

Construct	N	Mean (SD)/frequency	Min–max
Age	63	17.29 (2.23)	11.67–21.67
Body mass index	63	49.84 (10.22)	31.75–84.39
Sex
Female	63	40
Male		23
Race/ethnicity
Non-Hispanic	34
White		20
Black/African American		10
Native American/Alaska Native		1
Asian		2
Other race		1
Hispanic
White	28	19
Black/African American		1
Multi-racial		1
Other race		7
Family encouragement for healthy eating	62	16.67 (4.46)	6–23
Family discouragement of healthy eating	62	10.73 (4.44)	5–21
Family participation in exercise	60	22.96 (8.51)	9–44
Eating disorder symptoms	63	23.33 (15.24)	3–71
Responsibility for bariatric surgery
Parent	49	6
Shared		29
Teen		14
Responsibility for healthy eating
Parent	58	16
Shared		16
Teen		26
Responsibility for exercise
Parent	56	12
Shared		5
Teen		39

One patient did not report either race or ethnicity. Two individuals reported Puerto Rican race and one individual reported Cuban race. These were recoded into “Other race.”

Measures

Demographic and anthropometrics

Participants’ date of birth, date of intake appointment, sex, race (White, Black or African American, Asian, Native Hawaiian or Pacific Islander, Native American or Alaska Native, More than one race, Other), ethnicity (Hispanic/Latino or Not Hispanic/Latino), and anthropometric data were extracted from the EMR. Age was calculated by subtracting the patient’s date of birth from the date of their intake appointment. Height and weight were measured at the intake appointment and BMI was calculated as kg/m². Participants self-reported their race and/or ethnicity.

Perceived responsibility

Three items were adapted from the Diabetes Family Responsibility Questionnaire (DFRQ).¹² Participants responded to the following three questions: “Who took responsibility for the decision to pursue bariatric surgery?”; “Who takes responsibility for deciding what types of food you should eat?”; “Who takes responsibility for deciding how much and what type of exercise you should do?” Response options ranged from 1 (Mostly Parent) to 5 (Mostly Teen), with 3 labeled as Parent and Teen Share Equally. Consistent with the DFRQ, response options were collapsed to reflect three options for analyses: primarily parent responsible (responses of 1 and 2), shared responsibility (responses of 3), and primarily teen responsible (responses of 4 and 5).

Family social support for eating and exercise

The 23-item family support version of the Social Support for Diet and Exercise Behaviors (SSDEB) measured family support for health-related eating [e.g., “My family (or members of my household) reminded me not to eat high fat, high salt foods.”] and exercise behaviors (e.g., “My family or members of my household gave me encouragement to stick with my exercise program.”) over the past 3 months.¹³ The 5-item Encouragement and 5-item Discouragement subscales of the Eating Habits portion of the measure and the 10-item Family Participation subscale of the Exercise portion of the survey were used in the present study. Response options ranged from 1 (None) to 5 (Very Often), with the option to indicate 8 (Does not apply). Responses of 8 are recoded to 1 and items are summed. All subscales demonstrated acceptable internal consistency in the current sample (α_Enc = 0.67; α_Disc = 0.78; α_FamSupp = 0.89).

Eating disorder symptoms

The 23-item self-report Eating Disorder Diagnostic Scale (EDDS) for the Diagnostic and Statistical Manual of Mental Disorders, 5th Editions (DSM-5) measured eating disorder symptoms over the past 3 months based on diagnostic criteria.¹⁴ The EDDS provides an overall diagnostic symptom count and specific diagnoses of anorexia nervosa, bulimia nervosa, binge eating disorder (BED), and other specified feeding and eating disorders (OSFED; i.e., low frequency/subthreshold diagnoses). The EDDS demonstrates accuracy of diagnosis when compared with clinical interview (i.e., the proportion of individuals for whom the diagnosis generated by the EDDS matched the clinical interview; 0.87–0.93) and has been used with adult bariatric surgery samples.^15,16 The overall symptom count was used in the present study.

Data Analytic Plan

All analyses were conducted in SPSS v28. Owing to a survey programming error, the last item of the SSDEB was excluded from the survey. The Family Participation subscale of the SSDEB Exercise survey was calculated without this item. To maximize sample size, person-mean imputation was used for the SSDEB when missing responses were <10% within person (Shrive et al., 2006; N = 8, 5.2%–10.5%).

Listwise deletion was employed for all models. One participant was missing data for sex and self-reported sex from the EDDS was used. Three participants were missing data for Family Participation in Exercise. One participant was missing data for Family Encouragement and Family Discouragement of Health Eating Behaviors. Fourteen participants were missing data for Responsibility to Pursue Bariatric Surgery. Five participants were missing data for Responsibility for Eating Behaviors. Seven participants were missing data for Responsibility for Exercise Behaviors.

One-way analysis of variance was used to compare primary responsibility across age, BMI, Family Encouragement for Healthy Eating, Family Discouragement for Healthy Eating, and Family Participation in Exercise. Welch’s test was interpreted for all continuous dependent variables given the smaller sample size, and the Games–Howell post-hoc tests were used when the omnibus test was significant. Adjusted Ω is reported as the effect size with 0.01 = small, 0.06 = medium, and 0.14 = large effects. Kruskal–Wallis tests were used to compare primary responsibility across eating disorder symptom count. Eta-squared based on the H statistic is reported as the effect size with 0.04 = weak, 0.16 = moderate, and 0.64 = strong effects. Chi-square likelihood ratio test was used to compare primary responsibility across sex and Cramer’s V is reported as the effect size with 0.1 = small, 0.30 = medium, and 0.50 = large effects. Data are available on request.

Results

Preliminary Descriptives

Descriptive statistics of the constructs of interest are presented in Table 1. Different patterns of responsibility were observed across the decision to pursue bariatric surgery, healthy eating, and exercise. Just over 20% of participants reported teen responsibility for the decision to pursue bariatric surgery (N = 14; 22.2%), 41.3% (N = 26) reported teen responsibility for healthy eating, and 61.9% (N = 39) reported teen responsibility for exercise.

Responsibility for Bariatric Surgery

Differences of large effect were observed for age (p = 0.023; adjusted Ω = 0.14). Participants reporting primarily teen or shared responsibility for seeking bariatric surgery were older than those reporting primarily parent responsibility. No other differences were observed (p > 0.159). See Table 2.

Table 2.

Differences in Demographics and Family Correlates across Primary Responsibility for the Decision to Pursue Bariatric Surgery

Construct	Responsibility for bariatric surgery			p	Effect size
Construct	Primarily parent (N = 6)	Shared (N = 29)	Primarily teen (N = 14)	p	Effect size
Age (N = 49)	15.00 ^a (1.84)	17.41 ^a,b (1.78)	17.88 ^b (1.89)	.023	.14
Body mass index (N = 49)	51.90 (18.17)	49.68 (8.65)	49.73 (8.53)	.962	-.04
Sex (% female; N = 49)	33.3%	69.0%	71.4%	.211	.25
Family encouragement for healthy eating (N = 48)	12.14 (6.27)	17.43 (3.47)	17.92 (4.03)	.167	.04
Family discouragement of healthy eating (N = 48)	8.28 (3.17)	11.18 (4.87)	11.23 (4.02)	.159	.04
Family participation in exercise (N = 46)	22.17 (11.55)	22.67 (7.29)	23.26 (10.93)	.979	-.04
Eating disorder symptoms^c (N = 49)	31.50	16.00	26.50	.231	.02

Welch’s robust test of equality of means reported.

Median reported. Bold values indicate statistically significant omnibus test. Adjusted omega-squared reported as effect size for Welch’s test with 0.01 = small, 0.06 = medium, and 0.14 = large. Cramer’s V reported as effect size for chi-squared test with 0.1 = small, 0.30 = medium, and 0.50 = large effects. Eta-squared based on the H statistic reported for Kruskal–Wallis test with 0.04 = weak, 0.16 = moderate, and 0.64 = strong. Different superscripts indicate significant mean differences based on Games–Howell post-hoc testing.

Responsibility for Healthy Eating

Differences of large effect were observed for family encouragement of healthy eating (p = 0.011, adjusted Ω = 0.13) and of moderate to large effect for eating disorder symptom count (p = 0.002, η² = 0.20). Participants who reported primarily teen responsibility for their own healthy eating reported less family encouragement for healthy eating compared with participants who reported shared responsibility or primarily parent responsibility for the teen’s healthy eating. In addition, participants who reported primarily teen responsibility reported more eating disorder symptoms compared with those who reported primarily parent or shared responsibility. No other differences were observed (p > 0.330). See Table 3.

Table 3.

Differences in Demographics and Family Correlates across Primary Responsibility for the Teen’s Healthy Eating

Construct	Responsibility for healthy eating			p	Effect size
Construct	Primarily parent (N = 16)	Shared (N = 16)	Primarily teen (N = 26)	p	Effect size
Age (N = 58)	16.87 (2.43)	17.27 (2.45)	17.59 (1.96)	.617	-.02
Body mass index (N = 58)	50.82 (11.16)	49.12 (8.78)	50.18 (10.80)	.883	-.03
Sex (% female; N = 58)	50.0%	75.0%	65.4%	.330	.20
Family encouragement for healthy eating (N = 57)	18.72^a (3.97)	17.84^a (3.62)	14.62 ^b (4.62)	.011	.13
Family discouragement of healthy eating (N = 57)	9.57 (4.35)	11.74 (4.56)	10.95 (4.62)	.403	.00
Family participation in exercise (n = 55)	24.49 (9.19)	24.00 (9.19)	20.92 (8.09)	.382	.00
Eating disorder symptoms^c (N = 58)	20.0^a	15.0^a	30.5 ^b	.002	.20

Bold values indicate statistically significant omnibus test.

Welch’s robust test of equality of means reported.

a,b

Different superscripts indicate significant mean differences (p < .05) based on Games—Howell post-hoc testing.

Median reported.

Adjusted omega-squared reported as effect size for Welch’s test with 0.01 = small, 0.06 = medium, and 0.14 = large.

Cramer’s V reported as effect size for chi-squared test with 0.1 = small, 0.30 = medium, and 0.50 = large effects.

Eta-squared based on the H statistic reported for Kruskal—Wallis test with 0.04 = weak, 0.16 = moderate, and 0.64 = strong.

Responsibility for Exercise

Differences of moderate to large effect were observed for family encouragement for healthy eating (p = 0.012, adjusted Ω = 0.15) and family participation in exercise (p = 0.024, adjusted Ω = 0.14). Participants reporting primarily teen responsibility for engaging in exercise reported less family encouragement for healthy eating compared with participants reporting shared responsibility. Although there was a significant omnibus test for family participation in exercise, post-hoc testing did not suggest statistically significant mean differences (p > 0.052). Qualitative examination of the means suggested that participants reporting primarily teen responsibility for engaging in exercise reporter lower levels of family participation in exercise compared with those who reported shared or primarily parent responsibility. No other differences were observed (ps > 0.057). See Table 4.

Table 4.

Differences in Demographics and Family Correlates across Primary Responsibility for the Teen’s Exercise

Construct	Responsibility for exercise			p	Effect size
Construct	Primarily parent (n = 12)	Shared (n = 5)	Primarily teen (n = 39)	p	Effect size
Age (n = 56)	16.00 (2.12)	15.92 (3.57)	17.85 (1.69)	.057	.10
Body mass index (n = 56)	49.48 (10.12)	49.43 (13.64)	50.38 (10.37)	.961	-.04
Sex (% female; n = 56)	50.0%	80.0%	64.1%	.473	.16
Family encouragement for healthy eating (n = 55)	17.57^a ^,b (4.51)	19.80^b (1.92)	15.80^a ^,c (4.55)	.012	.15
Family discouragement of healthy eating (n = 55)	9.83 (4.06)	10.10 (3.58)	11.35 (4.86)	.543	-.01
Family Participation in exercise⁺ (n = 53)	26.07 (8.71)	28.80 (5.81)	20.06 (8.03)	.024	.14
Eating disorder symptoms^d (n = 56)	24.0	12.0	25.0	.224	.02

Bold values indicate statistically significant omnibus test.

Welch’s robust test of equality of means reported.

a,b,c

Different superscripts indicate significant mean differences (p < .05) based on Games—Howell post-hoc testing. + = Games—Howell post-hoc testing did not generate significant differences at p < 0.05.

Median reported. Adjusted omega-squared reported as effect size for Welch’s test with 0.01 = small, 0.06 = medium, and 0.14 = large.

Cramer’s V reported as effect size for chi-squared test with 0.1 = small, 0.30 = medium, and 0.50 = large effects.

Eta-squared based on the H statistic reported for Kruskal—Wallis test with 0.04 = weak, 0.16 = moderate, and 0.64 = strong.

Discussion

This study was one of the first to describe adolescents’ presurgical perceptions of responsibility for the decision to pursue bariatric surgery and engage in specific weight management behaviors and how this perceived responsibility is associated with demographic, family, and eating disorder symptoms. Hypotheses generally were supported and results were consistent with developmental theory and findings from the pediatric T1D literature.^3,4 Though no sex differences in responsibility were observed, older teens reported greater responsibility and greater teen responsibility was associated with less family support for healthy eating and more eating disorder symptoms.

Although older age was associated with greater likelihood of teen responsibility for the decision to pursue bariatric surgery, age was not associated with teens’ perceptions of responsibility for eating or exercise behaviors. Findings are partially consistent with work suggesting that older adolescents report greater responsibility for the decision to lose weight using nonsurgical approaches and greater ability to self-manage different aspects of their health.^17–19 In the general population, adolescent involvement in food preparation is associated with healthier eating behavior, whereas parent involvement appears to be unrelated to adolescents’ eating behavior.²⁰ Research is needed to understand the extent to which age may be an important predictor of responsibility for exercise and eating behaviors among adolescents seeking bariatric surgery, and whether adolescents reporting responsibility for these behaviors have better surgical and weight outcomes. In addition, counter to previous research in the pediatric TID literature, sex differences in perceived responsibility were not observed. Further investigation is needed to determine if this finding is due to the relatively lower proportion of males in this sample (35%) or if adolescents’ perceived responsibility within the context of bariatric surgery is truly unrelated to sex.

Adolescents who reported responsibility for their own healthy eating and exercise reported less family involvement in these behaviors. Self-determination theory may provide a model for understanding factors involved in teen (autonomous) versus parent responsibility for weight-related health behaviors.²¹ When internal forces—as opposed to external forces (e.g., parent encouragement or participation)—are driving motivation, it may enhance autonomous decision-making and increase intrinsic motivation. Indeed, studies have shown that weight loss is primarily self-initiated by adolescents when motivation for the weight loss was associated with intrinsic (e.g., desire for better health) as opposed to extrinsic motivation (e.g., parent encouragement).^22,23 In addition, health motivation for weight loss, conceptualized as autonomous (intrinsic) motivation, was associated with healthier eating habits among adolescents with obesity (i.e., less fast food and salty/sugary snack consumption) and successful weight management practices.²⁴ These findings may indicate that adolescents who experience less parental encouragement and participation in their eating and exercise behaviors experience more intrinsic motivation to make healthier decisions.

Clinically, findings support the inclusion of assessing perceived responsibility for eating and exercise behaviors as part of presurgical assessments. Consistent with the T1D literature suggesting that adolescent responsibility for health behaviors can be associated with poor health management, adolescents reporting primary responsibility for eating behaviors reported more eating disorder symptoms.⁸ The American Society for Metabolic and Bariatric Surgery Pediatric Committee guidelines state that loss of control (LOC) eating “should be assessed, treated, and closely monitored before and after [metabolic and bariatric surgery],” but that it should not be considered a contraindication because it is “treatable.”²⁵ Although binge and LOC eating behaviors are the most commonly measured behaviors among individuals seeking bariatric surgery, both adolescents and adults seeking bariatric surgery report the full spectrum of disordered eating behaviors (e.g., restricting behaviors, compensatory behaviors, and LOC/binge eating behaviors).¹⁶ Pre-existing disordered eating behaviors have important surgery implications. Although some studies indicate that disordered eating can improve after bariatric surgery, others suggest that disordered eating may continue or take on a new or different form after surgery.^26,27 For example, a presurgical diagnosis of BED has been associated with LOC eating either shortly after surgery or after an interim (e.g., 2 years after surgery) and in other work documents the development of purging behaviors, such as vomiting.^28,29 Most studies demonstrate that preoperative disordered eating is associated with suboptimal surgery and weight loss outcomes highlighting the importance of both assessing for the full spectrum of disordered eating behaviors, as well as potential proxies or risk factors for disordered eating behaviors before surgery.²⁷ These outcomes raise questions about the ethical aspects of bariatric surgery for adolescents with eating disorder symptoms, beyond the ethics of conducting bariatric surgery in adolescents more generally.³⁰ Providers must carefully weigh the potential risks and benefits when contemplating bariatric surgery in adolescents endorsing eating disorder symptoms.

If the current findings replicate in other samples of adolescents seeking bariatric surgery, this may indicate that assessment of perceived responsibility may be a brief and nonface valid way of identifying adolescents who should undergo a more thorough assessment for an eating disorder and/or disordered eating behaviors more generally. Assessing perceived responsibility also can help bariatric surgery teams to develop tailored counseling to families about the division of responsibility for healthy eating and exercise behaviors, particularly if adolescents are exhibiting signs of an eating disorder or reporting disordered eating behaviors. It will be important for future research to investigate whether there are different patterns of perceived responsibility for healthy eating behaviors based on pre-existing disordered eating patterns, the utility of perceived responsibility as a predictor of eating disorder risk in this population, and to what extent and how perceived responsibility and disorder eating behaviors impact surgery and weight outcomes.

This study had a number of strengths, including the racial/ethnic diversity of the sample, the broad theoretical basis for the study, and the novelty of the question. Nonetheless, several limitations should be considered. This study focused on a small sample of adolescents seeking bariatric surgery. Findings are limited to describing adolescents pre-surgery and do not describe postoperative outcomes. In addition, there are a number of measurement considerations. Data were limited to adolescents’ perceptions of responsibility. Having data from both adolescent and parent reports of perceived responsibility will provide important information about the interaction between family members and to the extent to which there is concordance between adolescents and parents and whether concordance is important in adolescents’ surgery and long-term weight loss outcomes. Further, the items used to measure perceived responsibility were adapted from a measure that is specific to diabetes and additional reliability and validity testing of these items is merited. Last, the study used an eating disorder symptom count generated from a self-report measure intended to measure DSM-5 eating disorder diagnostic criteria and generate a likely eating disorder diagnosis.¹⁴ Future research would benefit from measuring specific disordered eating behaviors to better capture frequency and severity of distinct behaviors (e.g., binge or LOC eating, compensatory behaviors).

Investigating the role of culture on perceived responsibility is also merited, as perceived responsibility may differ based on cultural background. Investigating perceived responsibility in families with various cultural backgrounds could have important clinical implications such as informing presurgical conversations about roles and responsibilities with teens and their caregivers. The sample size was relatively small and some confidence intervals were relatively large. Future research would benefit from replicating the present study with a larger sample and following those individuals to understand the extent to which presurgical perceived responsibility predicts surgical, weight, and psychosocial outcomes.

Despite these limitations, to our knowledge, this is the first study to provide a comprehensive description of perceived health behavior responsibilities in a sample of adolescents with severe obesity seeking bariatric surgery. Preliminary evidence suggests measuring perceived responsibility before surgery could be useful for facilitating discussions about the significant lifestyle changes that are required after bariatric surgery and may be a nonface valid way to identify adolescents who are engaging in disordered eating behaviors. It will be important for subsequent research to examine how presurgical health behavior responsibilities are associated with presurgical functioning and postsurgical outcomes. This study is a first step toward understanding perceived responsibility in an adolescent bariatric population and the results highlight the complex process and consequences of teens taking more autonomy and having more independence with respect to their health.⁵

Impact Statement

This study explores adolescents’ perceived responsibility for pursuing bariatric surgery and engaging in healthy weight management behaviors. Adolescents claiming primary responsibility are older, experience less family support for healthy eating, and report more eating disorder symptoms. Implications underscore assessing adolescents’ perceived responsibility and eating disorder symptoms in presurgical evaluations.

Footnotes

Authors’ Contributions

Conceptualization: A.C., D.R., M.M., R.K., and A.W. Data curation: D.R.; Formal Analysis: D.R.; Methodology: D.R., R.K., and A.W.; Writing—Original draft: M.M. and D.R.; Write—Review and Editing: A.C., M.M., D.R., R.K., and A.W.

Author Disclosure Statement

No interests to disclose.

Funding Information

No funding was received for this article.

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