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Kaft Floor - Psychological Attachment in Obesity Final.pdf 1 24-04-14 14:45 Uitnodiging Floor - Psychological Attachment in Obesity (drukbestand).pdf 1 18-04-14 15:36
Psychological Attachment in Obesity
Significance for Bariatric Surgery
Floor Aarts
Psychological Attachment in Obesity. The Significance for Bariatric Surgery
Academic thesis, University of Amsterdam, Amsterdam, The Netherlands
ISBN 978-94-6108-685-3
Author Floor Aarts
Coverdesign Coen Siebenheller, 7Pixels Media, Arnhem, The Netherlands
Layout and print Gildeprint, Enschede, The Netherlands
© 2014 Floor Aarts, Amsterdam, The Netherlands
All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any
form or by any means, without written permission of the author.
Printing of this thesis was financially supported by: Stichting Klinisch Wetenschappelijk Onderzoek
Slotervaart Ziekenhuis, Academic Medical Center, Covidien, Novo Nordisk BV, Julius Clinical BV
te Zeist
Psychological Attachment in Obesity
Significance for Bariatric Surgery
ACADEMISCH PROEFSCHRIFT
ter verkrijging van de graad van doctor
aan de Universiteit van Amsterdam
op gezag van de Rector Magnificus
prof. dr. D.C. van den Boom
ten overstaan van een door het college voor promoties
ingestelde commissie,
in het openbaar te verdedigen in de Agnietenkapel
op dinsdag 10 juni 2014, te 12:00 uur
door
Floortje Kara Aarts
geboren te Arnhem
Promotiecommissie
Promotores: Prof. dr. D.P.M. Brandjes
Prof. dr. R. Geenen
Co-promotores: Dr. S.C.H. Hinnen
Dr. V.E.A. Gerdes
Overige leden: Prof. dr. P.M.M. Bossuyt
Dr. M. de Brauw
Prof. dr. E. Fliers
Prof. dr. R. Sanderman
Prof. dr. S. Visser
Content
Chapter 1 General introduction and Outline of this thesis 7
Chapter 2 The significance of attachment representations for obesity: 23
a systematic review
Submitted for Publication
PART I ATTACHMENT REPRESENTATIONS, OBESITY AND PREOPERATIVE
ASSESSMENT
Chapter 3 Psychologists’ evaluation of bariatric surgery candidates influenced 41
by patients’ attachment representations and symptoms of depression
and anxiety
Journal of Clinical Psychology in Medical Settings, 2014; 21(1).
Chapter 4 Coping style as a mediator between attachment and mental and 57
physical health in patients suffering from morbid obesity
International Journal of Psychiatry in Medicine, 2014; 47(1).
Chapter 5 Mental health care utilization in patients seeking bariatric surgery: 75
the role of attachment behavior
Bariatric Surgical Practice and Patient Care, 2013; 8(4).
PART II POSTOPERATIVE: ATTACHMENT REPRESENTATIONS AND EFFECT OF
FAMILY MEMBERS
Chapter 6 Attachment anxiety predicts poor adherence to dietary recommendations: 89
an indirect effect on weight change one year after gastric bypass surgery
Submitted for Publication
Chapter 7 The significance of attachment representations for quality of life one 105
year following gastric bypass surgery: a longitudinal analysis
Submitted for Publication
Chapter 8 Gastric bypass may promote weight loss in overweight partners in the 119
first year after surgery
Submitted for Publication
PART III SUMMARY AND APPENDICES
Summary 133
Samenvatting (Dutch Summary) 137
Dankwoord 143
PhD Portfolio 147
List of Publications 149
Curriculum Vitae 151
1General introduction and Outline of the thesis
Floor Aarts
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8 | Chapter 1
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General introduction and Outline of the thesis | 9
1Morbid obesity: definition and treatment
Obesity is a growing health problem and can be described as having disproportionately more
body weight in relation to body height.1, 2 The most common used classification for obesity is
Body Mass Index (BMI), defined as weight in kilograms divided by height in squared meters.
A person with a BMI above 25 kg/m2 is considered overweight, with a BMI above 30 kg/m2
obese and with a BMI above 40 kg/m2 morbid obese.3
After an increase in the past decades, worldwide more than 20% of the adults are overweight
and approximately 10% are obese.4 In The Netherlands in 2012, 48% of the population were
overweight, and 12% were obese.5 Some other European countries and the US show even higher
rates. The prevalence of overweight in the US in 2007–2008 was 68%, and the prevalence of
obesity in 2012 was 34.9%.6, 7 Although obesity rates remain high, the prevalence of obesity
remained relative stable the last years.7
Obesity is seen as a chronic disease. It is associated with several diseases and conditions such as,
type 2 diabetes mellitus, hypertension, dyslipidemia, coronary heart diseases, obstructive sleep
apnoea syndrome (OSAS), cancer, psychopathology and increased mortality.8, 9 Since obesity is
often combined with somatic and psychological problems, the overall health care costs related to
obesity are higher than for non-obese subjects.10
Dietary and exercise regimens are used as primary treatment for obesity. However, patients with
morbid obesity seem to respond poorly to this traditional form of treatment and therefore turn
to bariatric surgery.11 Bariatric surgery, which consists of several surgical weight loss procedures
is currently the treatment of choice for patients with morbid obesity when conservative regimens
have failed.12-14
A common type of bariatric surgery is the gastric bypass operation. This procedure combines two
alterations: restriction of gastric volume (limitation of food intake) and diversion of the ingested
nutrients away from the proximal small intestine.15 The gastric bypass procedure creates a small
gastric pouch via stapling (10-30 ml), and a limb of the jejunum (small intestine) is attached directly
to the pouch, which results in ingested food bypassing 90% of the stomach, the duodenum, and
the upper portions of the small intestine (Figure 1).16
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10 | Chapter 1
Before surgery After surgery
Figure 1. Gastric bypass procedure
Gastric bypass outcome
Several studies have reported long-term follow-up results of weight loss and quality of life in
patients after gastric bypass surgery. The majority of the patients lose 25-35% of their initial
body weight with gastric bypass surgery within one year after surgery.13 Although the majority of
patients benefit from a gastric bypass operation, there is still a small but considerable portion of
patients who are unable to benefit optimally from a gastric bypass operation in terms of weight
loss and quality of life.15, 17, 18 The amount of weight loss after gastric bypass surgery will to a
large extent depend on the degree to which the patient succeeds in adopting healthy dietary
behavior.19 Both being successful in adopting healthy dietary recommendations and a person’s
ability to bring about enduring changes in quality of life will be determined by psychological
factors.
Psychological aspects
A standard component of the clinical evaluation of candidates applying for bariatric surgery is
a pre-surgical psychological assessment to identify possible indicators of suboptimal adherence
and outcomes.20-22 A history of psychiatric problems and current psychiatric comorbidity (e.g.,
anxiety and depression) are among the factors assessed.8, 20-23 The importance of these factors is
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General introduction and Outline of the thesis | 11
1supported by studies showing that psychiatric comorbidity was associated with less weight loss
after the initial year of the gastric bypass operation.24-26 This relationship may be explained by
difficulties with adherence to dietary and/or exercise recommendations.27
The focus of this thesis is on attachment representations, habitual states of mind with respect
to interpersonal relations. It is expected that –in addition to and related to current and past
psychological problems– patients’ attachment representations will influence adherence to dietary
recommendations. Moreover, attachment theory is expected to be a relevant determinant of
preoperative and postoperative quality of life in the group of patients with morbid obesity.28, 29
Attachment theory
According to attachment theory, people internalize early childhood experiences that centre
around the interaction with primary caregivers resulting in enduring beliefs and expectations
(i.e., internal working models or schemes) about the self (e.g., as worthy of love and care) and
about others (e.g., as trustworthy and caring).30-33 These enduring expectations are referred to
as attachment representations and in adulthood have been conceptualized as a set of mental
states concerning anxiety about rejection and abandonment, and avoidance of intimacy and
interdependence.30, 31, 34 Attachment representations impact among other things the way people
regulate emotions and deal with stress.35, 36
Description of attachment representations
Figure 2 presents a two dimensional, four categorical model of adult attachment. Attachment
representations have been characterized by their position on two dimensions reflecting anxiety
and avoidance.37
Persons who are securely attached (i.e., those low on attachment anxiety and low on attachment
avoidance) have a positive view of the self and a positive view of others, are self-confident,
explorative (e.g. curious, problem solving) and are comfortable in seeking support when needed.38
They have a sense of social resiliency, that is, they dispose over psychosocial skills (e.g. social and
communicative competences) and are capable to use a broad range of coping strategies (e.g.
social support, active problem solving) in times of stress.39
Persons who are anxiously attached (i.e., those high on attachment anxiety) have a negative
view of the self and a positive view of others, feel fragile, unlovable and unworthy of care and
are hypervigilant for rejection or abandonment. Their sense of vulnerability and hypervigilance
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12 | Chapter 1
for threats results in high levels of perceived stress and distress.38 They have been found to make
stronger attempts to seek proximity in order to try and elicit increased attention and support from
others often to the point of being ‘clingy’ in order to regulate their emotions.40, 41 Despite their
strong desire for closeness and reassurance, research shows that support is hardly effective in
reducing distress in these people.42
Low Avoidance
High Avoidance
Low Anxiety High Anxiety
AnxiousSecure
Avoidant Disorganized
Figure 2. Two dimensional model of adult attachment related to the four attachment representations31
Persons who are avoidantly attached (i.e., those high on attachment avoidance), have a positive
view of the self and a negative view of others, perceive others as unavailable and unable to
provide adequate support when needed, and therefore value independency and self-reliance.43,
44 As a way to reinforce their self-sufficiency and to avoid relationships with others, they tend to
dismiss symptoms of distress and vulnerability.38 They deal with stressors by distancing, avoiding
and repressing negative emotions.45-48
Persons who are disorganized attached (i.e. those high on attachment anxiety and high on
attachment avoidance) are a mixture of both characteristics, the avoidant and anxious attachment
pattern.37 They have a negative view of both self and others. They are cautious, avoidant, and
distrustful and expect others to be harsh or rejecting and experience difficulties with assertiveness
(shy) and social inhibition (timid).49, 50 Although they may experience intense negative affect, they
rather suffer than seek help.51, 52
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General introduction and Outline of the thesis | 13
1Attachment as predictor of dietary adherence
Both attachment anxiety and attachment avoidance have been found to be related to poorer
adherence to medical regiments in chronically ill patients.53, 54
More anxiously attached patients have been consistently shown to be more prone to distress
when confronted with stressors.28 In stressful situations people high on attachment anxiety may
view themselves unable to deal with the stressors and they may rely on smoking, alcohol and
high caloric food to regulate their emotions.39, 55, 56 In accordance, attachment anxiety has been
found to be associated with obesity in both children and adults.56, 57 Due to their high levels of
distress and their tendency to rely on external and behavioural modulators of affect such as high
caloric food, more anxiously attached patients can be expected to find it more difficult to adhere
to dietary recommendations after bariatric surgery.
More avoidantly attached patients, on the other hand, stress the importance of independence
and self-reliance, are reluctant to seek support and feel uncomfortable trusting others, including
health care providers.43, 44 Due to their high level of self-reliance and low collaboration with health
care providers, it can be expected that they will be less adherent to dietary recommendations
after bariatric surgery as well.
Attachment as predictor for quality of life
The improvement in quality of life after bariatric surgery will in addition to the amount of
weight loss depend on individual characteristics58 such as one’s attachment representations.
Both attachment anxiety and attachment avoidance have been uniformly found to be associated
with impaired mental and physical functioning in healthy people,28, 29 chronically ill patients59
and morbidly obese patients.60 In a cross-sectional study in morbidly obese bariatric surgery
candidates an association between attachment avoidance and poor mental health quality of
life was observed,60 but it is as yet unknown whether attachment representations impact the
postoperative course of quality of life.
The effect of gastric bypass on family members
The development of obesity is multifactorial with a sedentary lifestyle and a hypercaloric
diet playing important roles.61 Parental weight has proven to be one of the most important
independent predictors of childhood obesity, and consequently of obesity in adulthood.62, 63 While
parents and children share both genetic and environmental factors, if one’s partner becomes
obese, the likelihood that the other partner will become obese is increased by 37%.64 Following
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14 | Chapter 1
gastric bypass, patients are instructed to implement diet and lifestyle changes which may lead to
partners and children mimicking the altered behaviours of the patients undergoing gastric bypass
surgery.65
Outline of this thesis
This thesis examines social and emotional aspects of bariatric surgery and obesity with a focus on
attachment representations. In this thesis we approached this subject on two levels: (1) the aim
of the first part is to examine the role of patients’ attachment representations in obesity and the
assessment before bariatric surgery (2) the second part focuses on the postoperative situation by
examining attachment representations as a predictor of the treatment outcome of gastric bypass
surgery for morbid obesity and the effect of gastric bypass surgery on weight and eating behavior
of family members. Chapter 2 presents a systematic review of the main topic of this thesis. Next,
the three preoperative cross-sectional studies are described in chapters 3, 4 and 5 and the three
postoperative longitudinal studies in chapters 6, 7 and 8 (Figure 3).
Part I: Attachment representations, obesity and preoperative assessment
It is now clear that the aetiology of many chronic diseases including obesity concerns not only
genetic and current environmental factors, but also the way in which early repeated interactions
with significant others results in enduring ways of reacting to stress and dealing with negative
affectivity. In chapter 2 we systematically evaluate the existing evidence on attachment
representations in relation to obesity.
The main focus of the next three chapters lies on the role of attachment on mental well being and
functioning in the group of patients referred for bariatric surgery.
Attachment may influence many aspects psychologists are likely to incorporate into their
evaluation, including the anxious and depressive symptoms patients’ experience. The aim of
Chapter 3 was to examine whether patients’ self-reported attachment representations and
levels of depression and anxiety were associated with psychologists’ evaluations of patients with
morbid obesity applying for bariatric surgery.
Chapter 4 examines in patients applying for bariatric surgery the association of attachment
representations and coping styles on the one hand with mental health and physical functioning
on the other. Less securely attached patients (those high on attachment anxiety or attachment
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General introduction and Outline of the thesis | 15
1avoidance) may use more ineffective coping strategies which in turn may increase the risk at
mental problems and limitations in physical functioning in patients suffering from morbid obesity.
Obesity may be a factor contributing to mental health problems in patients seeking bariatric
surgery. Whether or not a person uses mental health care for one’s psychological problems may
have its roots in attachment behaviour. In Chapter 5 attachment behavior is hypothesized to be
associated with mental health care utilization in morbidly obese patients seeking bariatric surgery.
Part II: Postoperative: attachment representations and effect on family members
There is a small but considerable proportion of patients who are unable to benefit optimally from a
gastric bypass operation in terms of weight loss. The final outcome of the operation will to a large
extent depend on the degree to which to which the patient succeeds in adopting healthy dietary
recommendations. Current and past psychological problems and attachment representations are
expected to be determinants of adherence to dietary recommendations.
In Chapter 6 we aimed to examine the mediating role of adherence to dietary recommendations
between on the one hand, current and past psychological problems, attachment anxiety and
attachment avoidance, and on the other hand, weight reduction one year after gastric bypass
surgery.
The main aim of Chapter 7 was to examine whether attachment anxiety and attachment
avoidance, independent of body mass index (BMI), predict the level and course of physical
functioning and mental well-being after gastric bypass surgery. The improvement in quality of
life after bariatric surgery will in addition to the amount of weight loss depend on individual
characteristics such as one’s attachment representations.
Chapter 8 describes a 1-year longitudinal study examining weight and eating behavior changes
in cohabitating family members of patients after gastric bypass surgery. Obesity is increasingly
recognized as a family trait, with family members imitating each other’s lifestyle. Following
bariatric surgery, patients are assumed to implement diet and lifestyle changes which are expected
to have a positive effect on the body weight of family members.
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16 | Chapter 1
Attachment representations
Gastric bypass
Weight & Quality of life
Family members
Chapter 3 & 4
Chapter 6 & 7 Chapter 8
Obesity
Chapter 2 & 5
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General introduction and Outline of the thesis | 17
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57. Anderson SE, Whitaker RC. Attachment security and obesity in US preschool-aged children. Arch Pediatr Adolesc Med 2011;165(3):235-242.
58. Loving TJ, Smets EM. Romantic relationships and health. In: Simpson JA, Campbell L, editors. The Oxford handbook of close relationships. New York: Oxford Univeristy Press: 2013:617-637.
59. Martin LA, Vosvick M, Riggs SA. Attachment, forgiveness, and physical health quality of life in HIV + adults. AIDS Care 2012;24(11):1333-1340.
60. Sockalingam S, Wnuk S, Strimas R, Hawa R, Okrainec A. The association between attachment avoidance and quality of life in bariatric surgery candidates. Obes Facts 2011;4(6):456-460.
61. Simopoulos AP. Characteristics of obesity: an overview. Ann N Y Acad Sci 1987;499:4-13.
62. Agras WS, Mascola AJ. Risk factors for childhood overweight. Curr Opin Pediatr 2005;17(5):648-652.
63. Keane E, Layte R, Harrington J, Kearney PM, Perry IJ. Measured parental weight status and familial socio-economic status correlates with childhood overweight and obesity at age 9. PLoS One 2012;7(8):e43503.
64. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med 2007;357(4):370-379.
65. Woodard GA, Encarnacion B, Peraza J, Hernandez-Boussard T, Morton J. Halo effect for bariatric surgery: collateral weight loss in patients’ family members. Arch Surg 2011;146(10):1185-1190.
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PART IAttachment representations, obesity and
preoperative assessment
2The significance of attachment representations
for obesity: a systematic review
Floor Aarts, Rinie Geenen, Victor E.A. Gerdes, Dees P.M. Brandjes, Chris Hinnen
Submitted for publication
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24 | Chapter 2
Abstract
Theoretical considerations and empirical results suggest that interpersonal patterns known as
attachment representations are of relevance to obesity. This paper systematically examines the
peer-reviewed evidence regarding the relationship between attachment representations and
obesity. Peer-reviewed literature published between 1990 and 2013 was derived from PubMed,
PsycINFO and reference lists of included papers. Ten studies met the selection criteria. Overall the
studies suggest a relationship between attachment insecurity and obesity. Particularly attachment
anxiety, (i.e. the anxiety about rejection and abandonment by others) was associated with current
and future obesity. Possible explanations for an impact of attachment insecurity on obesity can
be found in heightened physiological responses to stressful situations and the underdevelopment
of emotion-regulation, which is an issue for future inquiry. Despite the early stage of theory and
research in the field of obesity, there is potential in considering attachment representations in
obesity care.
Keywords: obesity; attachment; body mass index; child; adult; systematic review
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Significance of attachment for obesity | 25
2
Introduction
Obesity is a complex global health problem, which has proven difficult to prevent and to treat1
and is also affecting children.2 It is now clear that the aetiology of many chronic diseases including
obesity concerns not only genetic and current environmental factors, but also the way in which
early repeated interactions with significant others results in enduring ways of reacting to stress
and dealing with negative affectivity.3, 4 Problems with stress management and affect regulation
have been repeatedly linked to obesity in both children and adults.5, 6 One specific theoretical
framework that describes individual differences in dealing with stress and affect regulation based
on early childhood experiences is attachment theory.7
According to attachment theory, individuals internalize early childhood interactions with primary
caregivers in enduring beliefs and expectations about how others behave towards oneself and how
oneself behaves towards others.8-13 These enduring expectations are referred to as attachment
representations or internal working models and are thought to be the mechanisms by which
the influence of childhood experiences are sustained into adulthood.13 In adulthood, internal
working models of attachment are generally conceptualized as sets of global beliefs about the
self (e.g., as worthy of care and lovable) and about others (e.g., as trustworthy and caring).10, 14 In
terms of their affective –motivational characteristics, these global beliefs are referred to as anxiety
about rejection and abandonment and avoidance of intimacy and interdependence.13 These
two dimensions can be combined into four attachment styles– one secure and three insecure
subtypes: preoccupied, dismissing and fearful.10, 14
Individuals low on attachment anxiety and low on attachment avoidance (i.e., secure) have a sense
of social resiliency. That is, they dispose over psychosocial skills (e.g. social and communicative
competences) and are capable to use a broad range of coping strategies (e.g. social support, active
problem solving) in times of stress.4 Individuals high on attachment anxiety (i.e., preoccupied)
have a sense of vulnerability and hypervigilance for threats, resulting in high levels of perceived
stress and distress.15 They have been found to make stronger attempts to seek proximity in order
to try and elicit increased attention and support from others often to the point of being ‘clingy’
in order to regulate their emotions.16, 17 Despite their strong desire for closeness and reassurance,
research shows that social and emotional support is hardly effective in reducing distress in
these people.18 In contrast, individuals high on attachment avoidance (i.e., dismissing) tend to
dismiss symptoms of distress and vulnerability.19 They deal with stressors by distancing, avoiding
and repressing negative emotions.20-23 Consequently, more avoidantly attached patients may
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26 | Chapter 2
experience and report to be non-distressed while showing considerable biological distress (e.g.,
increased blood pressure, heart rate variability).24, 25 Individuals high on both attachment anxiety
and attachment avoidance (i.e., fearful) show a mixture of both preoccupied and dismissing
attachment patterns.14 Although they may experience intense negative affect, they rather suffer
than seek help.26, 27
Due to their prototypical ways of dealing with stress and affect regulation, eating has been
suggested to be a regulatory mechanism for more insecurely attached individuals to deal with
stressors.28 Therefore, several investigators expected higher levels of attachment anxiety and
attachment avoidance to be associated with obesity.
Insight into the relationship between attachment representations and obesity is important as
it may help to determine who is at risk of obesity as well as to develop person-customized
prevention and intervention programs. Therefore, in the present study we systematically reviewed
the literature on the association between attachment and obesity.
Materials and Methods
Document eligibility
We aimed to identify articles which covered any aspect of the relationship between attachment
representations -in both adults as children- and obesity, published between 1990 and 2013.
Dissertations were excluded.29 The study design and document type was unrestricted.
Search strategy and document selection
A systematic search was implemented in the following two bibliographic databases: PubMed
and PsycINFO. The search strategy included the following combination of key words/MeSH
terms: ‘attachment’ OR ‘relationship style’ AND ‘obesity’ OR ‘overweight’ OR ‘body weight’ OR
‘body mass index’ OR ‘waist-to-hip ratio’ OR ‘BMI’. In line with the document eligibility criteria,
publication date and human studies limits were applied. The search strategy is shown in Table 1.
First, titles and abstracts and, second, full-text version of records identified by the search strategies
were assessed by two authors (FA and CH) against document eligibility returned 350 articles
in PubMed and 86 articles in PsycINFO of which 421 articles remained after the removal of
duplicates.
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Significance of attachment for obesity | 27
2
Table 1. Search strategy
Database KeywordsPubMed (attachment[tiab] OR “relationship style”[tiab]) AND ((“obesity”[MeSH Terms] OR
“obesity”[tiab]) OR (“overweight”[MeSH Terms] OR “overweight”[tiab]) OR “body weight”[tiab] OR “body mass index”[tiab] OR BMI[tiab] OR “waist-hip ratio”[tiab] OR “waist-to-hip ratio”[tiab])
PsycINFO (exp Attachment behavior/ or relationship style.ti,ab. or emotional attachment.ti,ab) AND (exp Overweight/ or exp Obesity/ or exp Body Weight/ or exp Body Mass Index/ or obesity.ti,ab. or overweight.ti,ab. or body weight.ti,ab. or exp body weight/ or body mass index.ti,ab. or exp body mass/ or waist-hip ratio.ti,ab. or waist-to-hip ratio.ti,ab.)
Quality assessment
The Newcastle-Ottawa Scale (NOS) for assessing the quality of non-randomised studies in meta-
analyses was used as a guide to assess the quality of the observational studies.30 This scale assesses
three broad areas: (i) selection; (ii) comparability; (iii) outcome or exposure. Quality of the included
studies was assessed independently by the same two reviewers (FA and CH). No attempts to mask
for authorship, journal name or institution were made. Appendix 1 details the quality assessment
and scoring system.
Results
Characteristics of studies
A total of 10 articles met the inclusion criteria and were identified in this review. Table 2 depicts the
study characteristics and main results. Six studies were cross-sectional and four were longitudinal.
Six studies investigated an adult population whereas four studies investigated children. The
majority of the studies were performed in the general population with a prevalence of obesity
between 15%-20%.
Obesity and attachment measures
As a definition of obesity, BMI was used in the majority of studies; however, also waist-to-hip
ratio (WHR) was used in two studies.31, 32 In children an adjusted BMI score for youngsters was
used, or categories relative to the 2000 US growth reference were used.12, 33 For the evaluation
of attachment representations, nine methods were used comprising both categorical (e.g., RQ,
AHQ, AAPR) and dimensional measures of attachment (e.g., AQS, ECR-R, MAQ, IPPA-R, SC).
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28 | Chapter 2
Tab
le 2
. Ove
rvie
w o
f st
udie
s on
the
rel
atio
nshi
p be
twee
n at
tach
men
t an
d ob
esity
Stu
dy
Pop
ula
tio
nD
esig
nA
ttac
hm
ent
mea
sure
Ob
esit
y ch
arac
teri
zati
on
Ou
tco
me
Qu
alit
ySi
gn
ifica
nt
Coo
per
et
al. 44
145
youn
g w
omen
Cro
ss-
sect
iona
l A
HQ
-qu
estio
nnai
re17
.2 %
BM
I >25
Th
e su
bsca
le n
egat
ive
pare
ntal
dis
cipl
ine
was
ass
ocia
ted
with
BM
I Bet
a=.0
17 p
=
.02,
but
not
the
sub
scal
es s
ecur
e ba
se,
thre
ats
of s
epar
atio
n or
pee
r af
fect
iona
l su
ppor
t.
Low
Yes
for
pare
ntal
di
scip
line,
no
for
secu
re b
ase/
thre
ats
of
sepa
ratio
n/ a
ffec
tiona
l su
ppor
t
Wilk
inso
n et
al
. 46
200
stud
ents
C
ross
-se
ctio
nal
ECR-
R-
ques
tionn
aire
Mea
n BM
I 23.
0, r
ange
fro
m
17.4
- 4
1.1
(sd
= 3
.2)
Att
achm
ent
anxi
ety
and
BMI r
= .1
5 (p
<
.05)
; att
achm
ent
avoi
danc
e an
d BM
I w
ere
not
sign
ifica
ntly
cor
rela
ted.
Low
Yes
D’A
rgen
io e
t al
. 45
50 n
on-o
bese
150
obes
eC
ross
-se
ctio
nal
RQ-
ques
tionn
aire
Mea
n BM
I non
-obe
se h
ealth
y pa
rtic
ipan
ts 2
3.38
±2.
85M
ean
BMI o
bese
pa
rtic
ipan
ts=
41.3
3 (s
d=6.
80)
Mea
n BM
I obe
se p
artic
ipan
ts
with
cur
rent
psy
chia
tric
di
agno
sis=
38.2
7 (s
d=6.
69)
The
odds
for
obe
sity
was
1.2
3 (9
5% C
I, 1.
08-1
.41,
p =
.002
) hig
her
for
anxi
ous
vs. s
ecur
e at
tach
men
t
Med
ium
Yes
Kie
sew
ette
r at
al.
63, 6
9
44 o
bese
pa
tient
sC
ross
-se
ctio
nal
AA
PR-
inte
rvie
wM
ean
BMI=
37.3
(sd=
7.4)
Mea
n BM
I ins
ecur
e pa
tient
s=40
.6 (s
d=9.
1)M
ean
BMI s
ecur
e pa
tient
s=37
.2 (s
d=6.
4)
Mea
n w
eigh
t in
kg
inse
cure
pa
tient
s=11
6.0
(sd=
22.
3)M
ean
wei
ght
in k
g se
cure
pa
tient
s=10
4 (s
d= 2
3.7)
No
rela
tion
betw
een
atta
chm
ent
and
BMI a
t ba
selin
e.Se
cure
and
inse
cure
pat
ient
s di
d di
ffer
on
wei
ght
in k
g at
bas
elin
e p=
.03.
Low
Yes
for
wei
ght
in k
g,
no f
or B
MI
Bahr
ami e
t al
. 70
202
over
wei
ght
stud
ents
Cro
ss-
sect
iona
lIP
PA-R
-qu
estio
nnai
reM
ean
BMI 2
7.48
(sd
= 4
.81)
Att
achm
ent
qual
ity a
nd B
MI r
=-0
.27,
p=
.003
Low
Yes
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Significance of attachment for obesity | 29
2
Hin
tsan
en e
t al
. 32
1570
men
an
d w
omen
fr
om t
he
Car
diov
ascu
lair
Risk
Fin
ns s
tudy
Cro
ss-
sect
iona
lRQ
-qu
estio
nnai
reN
ot r
epor
ted
Fear
ful a
ttac
hmen
t an
d yo
uth
BMI
Beta
=.0
7, p
=.0
1Fe
arfu
l att
achm
ent
and
adul
thoo
d BM
I Be
ta=
.07,
p=
.007
Fear
ful a
ttac
hmen
t an
d W
HR
Beta
=.0
82, p
=.0
16Pr
eocc
upie
d at
tach
men
t an
d W
HR
Beta
=.1
32, p
=.0
02N
o as
soci
atio
ns b
etw
een
othe
r at
tach
men
t st
yles
and
BM
I wer
e fo
und.
Med
ium
Yes
for
preo
ccup
ied
atta
chm
ent
in m
en
and
for
fear
ful
atta
chm
ent,
and
no
for
othe
r at
tach
men
t st
yles
Goo
ssen
s et
al
. 33
601
prea
dole
scen
tsC
ross
-se
ctio
nal a
nd
long
itudi
nal
SC-
ques
tionn
aire
Base
d on
adj
uste
d BM
I sco
re
youn
gste
rs[(a
ctua
l BM
I/per
cent
ile 5
0 of
BM
I for
age
and
gen
der)
x
100]
71.
4% u
nder
wei
ght
(adj
uste
d BM
I≤85
) 83
% n
orm
al w
eigh
t (8
5<
adju
sted
BM
I<12
0)11
% o
verw
eigh
t (1
20≤
adju
sted
BM
I<14
0)2%
obe
se (a
djus
ted
BMI≥
140)
No
rela
tion
betw
een
atta
chm
ent
tow
ards
mot
her
and
base
line
BMI.
Att
achm
ent
inse
curit
y to
war
ds m
othe
r, -b
ut n
ot t
owar
ds f
athe
r- s
igni
fican
tly
pred
icte
d in
crea
se o
f BM
I one
yea
r la
ter
β=-.
07, p
<.0
1, a
djus
ted
for
base
line
BMI.
Hig
hYe
s, f
or a
ttac
hmen
t in
secu
rity
tow
ards
m
othe
r in
pre
dict
ing
BMI,
no f
or
atta
chm
ent
tow
ards
m
othe
r fo
r ba
selin
e BM
I or
tow
ards
fat
her
And
erso
n et
al
. 12
8750
chi
ldre
nLo
ngitu
dina
lO
bser
vatio
n of
the
m
othe
r-ch
ild
inte
ract
ion
with
the
TA
SS-
45 (m
odifi
ed
vers
ion
of A
QS
Prev
alen
ce o
besi
ty in
secu
re
23.1
%Pr
eval
ence
obe
sity
sec
ure
16.6
%O
besi
ty s
tatu
s at
4.5
yea
rs w
as
defin
ed r
elat
ive
to t
he 2
000
US
grow
th r
efer
ence
72.
The
odds
for
obe
sity
at
4.5
year
s w
as
1.30
(95%
CI,
1.05
-1.6
2) t
imes
hig
her
for
inse
cure
vs.
sec
ure
atta
chm
ent
(with
the
obs
erva
tion
of a
ttac
hmen
t at
24
mon
ths
of a
ge),
adju
sted
for
so
ciod
emog
raph
ic c
hara
cter
istic
s su
ch
as b
irth
wei
ght
Hig
hYe
s
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30 | Chapter 2
Stu
dy
Pop
ula
tio
nD
esig
nA
ttac
hm
ent
mea
sure
Ob
esit
y ch
arac
teri
zati
on
Ou
tco
me
Qu
alit
ySi
gn
ifica
nt
And
erso
n et
al
. 42
977
child
ren
Long
itudi
nal
Obs
erva
tion
of t
he
mot
her-
child
in
tera
ctio
n w
ith t
he A
QS
32.9
% “
secu
re”
of w
hich
13
.4 %
obe
se42
.7 %
“in
bet
wee
n gr
oup”
(n
ot s
ecur
e no
t in
secu
re) o
f w
hich
17.
5% o
bese
24.5
% “
inse
cure
” of
whi
ch
18.8
% o
bese
Ado
lesc
ent
obes
ity w
as
defin
ed a
s ge
nder
-spe
cific
BM
I ≥9
5th p
erce
ntile
of
the
Cen
ters
fo
r D
isea
se C
ontr
ol a
nd
Prev
entio
n gr
owth
ref
eren
ce 72
The
odds
for
ado
lesc
ent
obes
ity (w
ith
the
obse
rvat
ion
of a
ttac
hmen
t at
15
and
36 m
onth
s of
age
) was
1.2
9 (9
5%
CI,
0.85
-1.9
4) t
imes
hig
her
for
the
“in
betw
een
grou
p” v
s. “
secu
re”
and
1.23
(95%
CI,
0.75
-1.9
3) t
imes
hig
her
for
“ins
ecur
e” v
s. “
secu
re”,
aft
er
adju
stm
ent
for
gend
er a
nd b
irth
wei
ght
Hig
hYe
s
Mid
ei e
t al
. 3121
3 ad
oles
cent
sLo
ngitu
dina
lM
AQ
-qu
estio
nnai
reM
ean
WH
R=.7
9 (s
d=.0
5)M
ean
BMI=
22.7
(sd=
4.0)
Att
achm
ent
anxi
ety
vs. W
HR
(3 y
ears
af
ter
the
obse
rvat
ion
of a
ttac
hmen
t),
adju
sted
for
BM
I at
base
line
β=.1
15,
p=.0
6
Hig
hN
o
BMI=
body
mas
s in
dex
(kg/
m2 )
, W
HR=
Wai
st-t
o-hi
p ra
tio,
ECR-
R=ex
perie
nces
in c
lose
rel
atio
nshi
ps-r
evis
ed,
AH
Q=
atta
chm
ent
hist
ory
ques
tionn
aire
, RQ
=re
latio
nshi
p qu
estio
nnai
re,
IPPA
-R=
inve
ntor
y of
par
ent
and
peer
att
achm
ent-
revi
sed
vers
ion
for
child
ren,
MA
Q=
Mea
sure
men
t of
att
achm
ent
qual
ity,
SC=
Secu
rity
Scal
e,
AA
PR=
Adu
lt A
ttac
hmen
t Pr
otot
ype
Ratin
g, A
QS=
Att
achm
ent
Q-s
ort,
TA
SS-4
5=To
ddle
r A
ttac
hmen
t So
rt-4
5
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Significance of attachment for obesity | 31
2
The relationship questionnaire (RQ)14 is a single item measure made up for four short paragraphs,
each describing a prototypical attachment pattern as it applies in close adult peer relationships.
The RQ is relatively brief, has been implemented in multiple studies and demonstrated
independence from self-deceptive biases.34 A weakness, however, is that each attachment style is
measured with only one item, and therefore no internal consistency reliability can be determined.
The attachment history questionnaire (AHQ)35 provides self-report information about early
attachment-related events and peer relationships. It has 51 items, with responses rated on seven
point scales, which assess the frequency and intensity of behaviors by attachment figures. The
AHQ shows respectable reliability and validity, but the nature of the AHQ is relatively untested.
The adult attachment prototype rating (AAPR) is a measurement used during a semi-standardized
one- to two hour attachment interview and determines a patients’ attachment style. The AAPR
has demonstrated its reliability and validity in a variety of studies. The attachment Q-sort (AQS)
is used by a data collector during approximately 2 hours of observation of the mother-child
interaction. The data collector sorted 45 “cards” based on how well the behavior described
on the card applied to the mother-child interaction. From the AQS, a continuous measure of
attachment security was derived, which could range from -1 to 1, with higher values indicating
a secure child. IJzendoorn et al. showed that the AQS is a reliable an valid measure.36 The
Experiences in Close Relationships- Revised Scale (ECR-R) is a 36-item self-report measure of
adult attachment, which requires participants to reflect on their typical ways of relating in close/
romantic relationships. Reviews of self-report measures of adult attachment suggest that the
ECR-R has the best psychometric properties of the available measures.37 The measurement of
attachment quality (MAQ)38 is a 14-item, measure of attachment orientation. It has separate
scales to assess secure attachment tendencies and avoidant tendencies, and two scales reflecting
aspects of the anxious-ambivalent pattern. The inventory of parent and peer attachment-revised
version for children (IPPA-R),39 is a 28-item child report questionnaire measuring the quality of
attachment to parents (and peers) and how well they serve as a source of psychological secu rity.
The IPPA-R had good internal consistency and good convergent validity. However, it is possible
that children answer these ques tions in a more socially desirable manner as the questions are
more personalised. The security scale (SC)40 is a self-report questionnaire to measure attachment
toward mother and father. The SC has been found to be internally consistent and stable. Support
was found for the convergent and discriminant validity.41
Findings
The prevalence of obesity in insecurely attached children (23.1%, 95% CI, 19.9%-26.3%) and
securely attached children (16.6%, 95% CI, 15.3%-17.8%) was reported once.12
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32 | Chapter 2
Overall, the reviewed studies suggested a concurrent relationship between insecure attachment,
particularly attachment anxiety, and a higher BMI.12, 32, 33, 42-46 All longitudinal studies controlled
for baseline BMI or birth weight. The two longitudinal studies of Anderson et al.12, 42 that included
the largest study populations found an association between attachment insecurity at 2 years of
age and obesity two-an-a-half years later12 and in their adolescence.42 This was also confirmed in
a longitudinal study with 601 preadolescent children, in which attachment insecurity was found
to predict an increase of BMI one year later.33 No longitudinal studies were performed in adults.
Three studies reported mediational pathways between attachment and BMI.43, 44, 46 One study
suggested that the relationship between attachment and BMI was partially mediated by mood
(i.e., symptoms of anxiety and depression).44 Other studies indicated that eating self-efficacy43
and disinhibited eating46 were mediators of the relationship between attachment representations
and BMI.
However, not all studies observed a relation between attachment and BMI. One study did not
found a relation between attachment and waist-hip ratio (WHR).31
Quality of included studies
A detailed description of individual study quality is provided in Appendix 1. Four studies of high
quality and two studies of medium quality were identified. The other remaining studies were
considered of low quality.
Discussion
This paper reviewed empirical studies highlighting the association between attachment
representations and obesity. Both cross-sectional and longitudinal studies rather uniformly
suggest that individuals with more insecure attachment representations, in particular individuals
high on attachment anxiety, are at greater risk for obesity.
Although the three of the four reviewed longitudinal studies observed a temporal relationship
between early observations of attachment and later observations of obesity,12, 33, 42 solid
conclusions about causality cannot be inferred from observational longitudinal data. Moreover,
in two studies birth weight –but not body weight at the time of assessment of attachment– was
used as a control variable.12, 42 However, another study that controlled for earlier body weight
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Significance of attachment for obesity | 33
2
did also observe an association between attachment insecurity and an increase of body weight
one year later.33 Thus, although it cannot be excluded that the presence of obesity impacts on
attachment relationships or that both insecure attachment and obesity are influenced by a third
variable, the longitudinal studies do suggest that early attachment insecurity shows who is at risk
for later obesity.
Several complementary explanations for the association between attachment and obesity may
hold. One explanation is based on physiological responses to stress.24 Studies suggest that
attachment insecurity, and in particular attachment anxiety,47, 48 lead to hyperactivity of the
hypothalamic pituitary adrenal (HPA) axis and the release of glucocorticoids of which cortisol is the
most well-known.49 Hyperactivity of the HPA-axis can cause accumulation of depot fat in visceral
adipose tissues.50 This can alter glucose metabolism and promote insulin resistance which changes
the number of appetite-related hormones (e.g. leptin, ghrelin) and feeding neuropeptides. As a
result the secretion of Neuropeptide Y and ghrelin (hunger-stimulating hormone) may increase,
while the release of leptin (satiety-stimulating hormone) may decrease.51 By modifying glucose
metabolism and insulin sensitivity, eating and especially eating of high caloric food may reduce
the symptoms of stress.45, 46, 52, 53 Thus, in people with high attachment anxiety, the heightened
physical responses to stressors may have stimulated eating leading to obesity.
As stress responses not only depend on stressors but also on the appraisal of stressors and one’s
capability of dealing with stressors,54 a supplementary explanation for the association between
attachment representations and obesity can be found in the underdevelopment of emotion-
regulation processes. Confronted with a stressor, securely attached individuals seek proximity
to significant others. Previous studies suggest that satisfying interpersonal relationships may
reduce the impact of stressors on individuals’ health,55-57 in interaction with other mediators by
decreasing cortisol levels.58 Similarity high caloric foods may act to calm the stress-perceiving
areas of the brain as was shown in animal studies.59-61 That is, food intake, just as during satisfying
social interactions with significant others, leads to a release of oxytocin from the hypothalamus
which has an anxiolytic effect.62 Therefore, to compensate for poor emotion regulation skills, food
consumption may serve as a way of “self-medication” for more anxiously attached individuals by
releasing oxytocin and down-regulating negative affect.
A number of limitations to this review should be recognised. First, we reviewed 10 individual
studies, each of which with its own strengths, but also limitations such as small sample size or
representatives of the study population. Using the Newcastle-Ottawa Scale as a guide,30 only six
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34 | Chapter 2
of the ten studies were observed medium to high quality. Second a variety of measures were used
for attachment and obesity. Obesity was measured by BMI and waist-hip-ratio and attachment
was measured with nine different measures, which may have affected the results. However, the
relationship between attachment and obesity was rather uniformly observed, independent of
the attachment measure, which supports the strength of the association between attachment
representations and obesity. The assessment of attachment representations involved observation
of the child, the Adult Attachment Prototype Rating (AAPR) interview, and questionnaires
measuring attachment in a categorical or dimensional way. While categorical measures provide
clear textbook cases of the four prototypical attachment styles, dimensional measures describe
a two dimensional space which may be depicted linearly on a spectrum with attachment anxiety
at the one en and attachment avoidance at the other.63, 64 Both types of measures have their
advantages and disadvantages. Categorical measures often use responses to single items to
make classifications (e.g.65), which can lead to serious problems in conceptual analyses, statistical
power, and measurement precision,66 whereas dimensional measures do not guarantee that
measurement precision will be equally distributed across the domain of interest.67
One important step in future research will be to perform high quality longitudinal studies and
research on the predictive role of attachment on obesity. The prediction of adult attachment
behavior and obesity from attachment patterns in early childhood is needed to verify the
hypothesized etiological role of early attachment behavior. In these studies baseline assessments
of body weight should be included. Also the prediction of adult obesity from attachment in
adolescence is particularly useful, because adolescence is a significant period for the onset and
increase of obesity, especially among girls.68 Future studies employing a prospective design could
investigate the usefulness of interventions aimed at the guidance of more insecurely attached
patients both during weight loss treatment programs and during treatment of comorbidities.
The early stage of theory and research in the field of obesity indicates the potential importance
of considering attachment representations in obesity care. Implications can be twofold. On an
individual level attachment theory may guide us in indicating individuals at risk of obesity in order
to better customize prevention efforts to individual characteristics. At a wider level, attachment
theory can usefully contribute to finding an overall framework for future research and the
development of obesity care and services.
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Significance of attachment for obesity | 35
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37. Fraley RC, Waller NG, Brennan KA. An item response theory analysis of self-report measures of adult attachment. J Pers Soc Psychol 2000;78(2):350-365.
38. Carver C. Adult attachment and personality: Converging evidence and a new measure. Personality and Social Psychology 1997;23:865-883.
39. Gullone E, Robinson K. The Inventory of Parent and Peer Attachment-Revised (IPPA-R) for children: a psychometric evaluation investigation. Clinical Psychology and Psychotherapy 2005;12:67-79.
40. Kerns K, Klepac L, Cole A. Peer relationships and pre-adolescents’ perceptions of security in the child-mother relationship. Developmental Psychology 1996;32:457-466.
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42. Anderson SE, Gooze RA, Lemeshow S, Whitaker RC. Quality of early maternal-child relationship and risk of adolescent obesity. Pediatrics 2012;129(1):132-140.
43. Bahrami F, Kelishadi R, Jafari N, Kaveh Z, Isanejad O. Association of children’s obesity with the quality of parental-child attachment and psychological variables. Acta Paediatr 2013;102(7):e321-e324.
44. Cooper MJ, Warren L. The relationship between body weight (body mass index) and attachment history in young women. Eat Behav 2011;12(1):94-96.
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47. Jaremka LM, Glaser R, Loving TJ, Malarkey WB, Stowell JR, Kiecolt-Glaser JK. Attachment anxiety is linked to alterations in cortisol production and cellular immunity. Psychol Sci 2013;24(3):272-279.
48. Powers SI, Pietromonaco PR, Gunlicks M, Sayer A. Dating couples’ attachment styles and patterns of cortisol reactivity and recovery in response to a relationship conflict. J Pers Soc Psychol 2006;90(4):613-628.
49. Kidd T, Hamer M, Steptoe A. Examining the association between adult attachment style and cortisol responses to acute stress. Psychoneuroendocrinology 2011;36(6):771-779.
50. Bjorntorp P. Do stress reactions cause abdominal obesity and comorbidities? Obes Rev 2001;2(2):73-86.
51. Torres SJ, Nowson CA. Relationship between stress, eating behavior, and obesity. Nutrition 2007;23(11-12):887-894.
52. Nemeroff CB. Early-Life Adversity, CRF Dysregulation, and Vulnerability to Mood and Anxiety Disorders. Psychopharmacol Bull 2004;38 Suppl 1:14-20.
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54. Lazarus RS. Emotion and adaptation. New York: NY: Oxford University Press; 1991.
55. George LK, Blazer DG, Hughes DC, Fowler N. Social support and the outcome of major depression. Br J Psychiatry 1989;154:478-485.
56. Hibbard JH, Pope CR. The quality of social roles as predictors of morbidity and mortality. Soc Sci Med 1993;36(3):217-225.
57. Stadler G, Snyder KA, Horn AB, Shrout PE, Bolger NP. Close relationships and health in daily life: a review and empirical data on intimacy and somatic symptoms. Psychosom Med 2012;74(4):398-409.
58. Heffner KL, Kiecolt-Glaser JK, Loving TJ, Glaser R, Malarkey WB. Spousal support satisfaction as a modifier of physiological responses to marital conflict in younger and older couples. J Behav Med 2004;27(3):233-254.
59. Dallman MF, Pecoraro N, Akana SF et al. Chronic stress and obesity: a new view of “comfort food”. Proc Natl Acad Sci U S A 2003;100(20):11696-11701.
60. Pecoraro N, Reyes F, Gomez F, Bhargava A, Dallman MF. Chronic stress promotes palatable feeding, which reduces signs of stress: feedforward and feedback effects of chronic stress. Endocrinology 2004;145(8):3754-3762.
61. Peters A, Pellerin L, Dallman MF et al. Causes of obesity: looking beyond the hypothalamus. Prog Neurobiol 2007;81(2):61-88.
62. Onaka T, Takayanagi Y, Yoshida M. Roles of oxytocin neurones in the control of stress, energy metabolism, and social behaviour. J Neuroendocrinol 2012;24(4):587-598.
63. Hunter JJ, Maunder RG. Using attachment theory to understand illness behavior. Gen Hosp Psychiatry 2001;23(4):177-182.
64. Maunder RG, Hunter JJ. A prototype-based model of adult attachment for clinicians. Psychodyn Psychiatry 2012;40(4):549-573.
65. Hazan C, Shaver P. Romantic love conceptualized as an attachment process. J Pers Soc Psychol 1987;52(3):511-524.
66. Fraley RC, Waller NG. Attachment theory and close relationships. In: Simpson JA, Rholes WS, editors. Adult attachment patterns: A test of the typological model. New York: Guilford Press; 1998:77-114.
67. Fraley RC, Waller NG, Brennan KA. An item response theory analysis of self-report measures of adult attachment. J Pers Soc Psychol 2000;78(2):350-365.
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68. Harding S, Maynard MJ, Cruickshank K, Teyhan A. Overweight, obesity and high blood pressure in an ethnically diverse sample of adolescents in Britain: the Medical Research Council DASH study. Int J Obes (Lond) 2008;32(1):82-90.
69. Kiesewetter S, Kopsel A, Mai K et al. Attachment style contributes to the outcome of a multimodal lifestyle intervention. Biopsychosoc Med 2012;6(1):3.
70. Bahrami F, Kelishadi R, Jafari N, Kaveh Z, Isanejad O. Association of children’s obesity with the quality of parental-child attachment and psychological variables. Acta Paediatr 2013;102(7):e321-e324.
71. Van Winckel M, Van Mil E. Wanneer is dik té dik? [When is fat too fat?]. In: Braet C, Van Winckel M, editors. Behandelingsstrategieën bij kinderen met overgewicht [Treatmentstrategies in overweight children]. Houten/Diegem, The Netherlands: Bohn Stafleu Van Loghum; 2001:11-26.
72. Kuczmarski RJ, Ogden CL, Guo SS et al. 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat 11 2002;(246):1-190.
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Significance of attachment for obesity | 39
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Appendix 1
Main items of quality assessment and their scoring using the Newcastle-Ottawa Scale (NOS).30
Selection (Maximum 5 stars)
1) Representatives of sample (1 star for quality is given if the cohort consisted of patients
truly or somewhat comparable to the general population).
2) Ascertainment of exposure (2 stars are given if data was derived from medical records,
trough observation or by structured interview, 1 star is given by the use of validated
self-reported measurement tool and presenting cronbach’s alpha)
3) Sample size (1 star is given if justified and satisfactory)
4) Non-respondents (1 star is given if comparability between respondents and non-
respondents characteristics is established, and the response rate is satisfactory).
Comparability (Maximum 2 stars)
5) Confounding (2 stars are given as body weight at the start of the study was presented
and controlled for and if the study controls for the most important factors and 1 star is
given if the study controls for the most important factor or when a study controls for
any additional factor)
Outcome (Maximum 3 stars)
6) Statistical test (1 star is given if the statistical test used to analyze the data is clearly
described and appropriate, and the measurement of the association is presented,
including confidence intervals and the probability level).
7) Follow-up (1 star is given if study design is longitudinal)
8) Adequacy of follow up (1 star is given in case of complete follow-up, or subjects lost to
follow up unlikely to introduce bias - small number lost - > 30 % or description provided
of those lost)
A total of 8-10 stars was considered a high quality study; 5-7 stars a medium quality study; 4 stars
or less, a low quality study
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40 | Chapter 2
Table 1. Individual quality assessment of observational studies
First author
Repr
esen
tativ
enes
s
Asc
erta
inm
ent
of e
xpos
ure
Sam
ple
size
Non
-res
pond
ents
Con
foun
ding
Stat
istic
al t
est
Follo
w-u
p
Ade
quac
y of
fol
low
-up
Scor
e
Stud
y qu
ality
Cooper et al. 44 0 0 1 0 1 1 0 0 3 LowWilkinson et al. 46 0 1 1 0 1 1 0 0 4 LowD’Argenio et al. 45 1 1 1 0 1 1 0 0 5 MediumKiesewetter at al. 63, 69 0 2 0 0 1 1 0 0 4 LowBahrami et al. 70 0 1 1 0 0 1 0 0 3 LowHintsanen et al. 32 1 1 1 1 1 1 0 0 6 MediumGoossens et al. 33 1 1 1 1 2 1 1 1 9 HighAnderson et al. 12 1 2 1 0 2 1 1 1 9 HighAnderson et al. 42 1 2 1 1 2 1 1 1 10 HighMidei et al. 31 0 1 1 1 2 1 1 1 8 High
3Psychologists’ evaluation of bariatric surgery
candidates influenced by patients’ attachment
representations and symptoms of depression
and anxiety
Floor Aarts, Chris Hinnen, Victor EA Gerdes, Yair Acherman, Dees PM Brandjes
Published in Journal of Clinical Psychology in Medical Settings, 2014; 21 (1).
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42 | Chapter 3
Abstract
Background: This study examines whether patients self-reported attachment representations
and levels of depression and anxiety influenced psychologists’ evaluations of morbidly obese
patients applying for bariatric surgery.
Methods: A sample of 250 patients (mean age 44, 84% female) who were referred for bariatric
surgery completed questionnaires to measure adult attachment and levels of depression and
anxiety. Psychologists rated patients’ suitability for bariatric surgery using the Cleveland Clinic
Behavioural Rating System (CCBRS), unaware of the results of the completed questionnaires.
Results: Attachment anxiety (OR = 2.50, p = .01) and attachment avoidance (OR = 3.13, p = .001)
were found to be associated with less positive evaluations on the CCBRS by the psychologists,
and symptoms of depression and anxiety mediated this association.
Conclusion: This study strongly supports the notion that patients’ attachment representations
influence a psychologist’s evaluation in an indirect way by influencing the symptoms of depression
and anxiety patients report during an assessment interview. The clinical implications of these
findings are discussed.
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Psychologists' evaluation of bariatric surgery candidates influenced by adult attachment | 43
3
Introduction
The prevalence of morbid obesity is increasing worldwide.1,2 Currently, morbid obesity is seen
as a chronic disease and a risk factor for several medical conditions and increased mortality.3-5
Since patients with morbid obesity respond poorly to traditional dietary and exercise weight-loss
regimens, a gastric bypass operation is currently the most effective method of ensuring significant
and sustained weight loss, improved health and quality of life.6-9
In spite of these promising results, approximately 15% of the patients are unable to benefit
significantly from a gastric bypass operation in terms of weight loss and quality of life.10 These
suboptimal results may be more associated with psychological factors such as psychiatric
problems (e.g. anxiety and depression), eating habits, past success or failure with weight loss
attempts, behavioral compliance, availability of support, and motivation than with surgical factors
such as pouch size.11 Research shows that extensive psychiatric problems, motivation, and lack
of compliance preoperatively, are important factors that may negatively impact the results of a
gastric bypass operation.12-14 Since psychological factors may influence the long-term outcome of
a gastric bypass operation, a pre-surgical psychological assessment to identify possible indicators
of suboptimal outcomes and postoperative psychological problems is a standard component of
the evaluation of candidates applying for bariatric surgery.15-18 However, to date, no studies have
investigated whether psychological risk factors for suboptimal outcomes such as anxiety and
depressive symptomathology actually do influence psychologists’ evaluation of gastric bypass
candidates.
In addition to levels of anxiety and depression, patients’ attachment representations may also
influence the psychologists’ evaluation before bariatric surgery. In accordance with attachment
theory19, insecure attachment representations (indicated by high attachment anxiety and/or high
attachment avoidance) have been found to be associated with poorer mentalization (i.e., the
ability to understand behaviors of oneself and others in terms of mental representations such as
thoughts and feelings),20 less perceived support21, less adherence to lifestyle changes,22, 23 poorer
coping abilities24 as well as more extensive psychological problems throughout life.25-29 In other
words, attachment may influence many of the factors psychologists are likely to incorporate into
their evaluation, including the symptoms of depression and anxiety patients’ experience. If this is
the case, patients’ attachment representations may in part influence psychologists’ evaluations
through the influence attachment may have on levels of anxiety and depression.
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Based on the aforementioned literature, we hypothesized that insecure attachment representations
would be associated with less positive evaluations by psychologists. Moreover, we hypothesized
that the association between patients’ attachment representations and psychologists’ evaluation
of the patients would be mediated by patients’ symptoms of depression and anxiety.
Methods
Study sample
A group of 250 consecutively referred candidates for bariatric surgery assessed by the Slotervaart
bariatric surgery clinic in Amsterdam, the Netherlands between February 2012 and July 2012
participated in the study. To be eligible for bariatric surgery, patients must have a BMI ≥ 40 or
≥ 35 kg/m² with a co-morbid obesity-related condition such as hypertension, sleep apnoea or
diabetes mellitus.30 Since we were interested in the data of the patients who were referred to the
clinic, none of the candidates were excluded from this study based on BMI, a particular diagnosis
or co-morbidity.
Procedures
All patients referred to the Slotervaart bariatric surgery clinic received pre-surgical multidisciplinary
assessments. The assessment process involved examinations by a dietician, internist, surgeon
and a psychologist. Before meeting with the psychologist, patients received a ‘take-home
package’ designed to assess the preoperative diet and exercise habits, co-morbidities and
sociodemographics. Although in normal pre-surgical psychological assessments (interviews and
questionnaires) inquiries into aspects such as psychological symptomathology, social support and
coping abilities are made, no standardized instruments are used to assess adult attachment or
levels of anxiety and depression. For this study two questionnaires were added that assessed
adult attachment and symptoms of depression and anxiety. After signing informed consent, the
patients completed their questionnaires at home and returned them upon their first visit with one
of the psychologists. Since our psychologists were asked not to view the additional questionnaires
and all confirmed they had not done so, we are confident that these questionnaires did not
influence their clinical judgement. Patients that failed to return the questionnaires upon their visit
with the psychologist were asked to fill out the questionnaire in the waiting room immediately
before their visit and to leave them with the counter assistant when completed. For the screening
of patients, five trained psychologists were available and evaluated a comparable amount of
patients. All psychologists have obtained a bachelor’s and master’s degree in Psychology and
completed internal training for bariatric surgery.
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All questionnaires returned were treated strictly confidentially and received an identification
number through random allocation. The study was approved by the Medical Ethics Committee.
Measures
Adult attachment was assessed using the Experiences in Close Relationship Scale Revised (ECR-R).
Patients completed the 36-item ECR-R31 that assesses how individuals experience emotionally
intimate relationships. Assessing two broad dimensions, the ECR-R contains 18 items on
attachment anxiety (e.g., “I am afraid that I will lose the love of others” and “My desire to
be very close sometimes scares people away.”) and 18 items on attachment avoidance (e.g.,
“I prefer not to show others how I feel deep down” and “I am nervous when others get too
close to me.”) that theoretically underlie adult attachment.32, 33 Individuals rate how well each
statement describes their feelings in romantic relationships on a 5-point scale, ranging from
“strongly disagree” to “strongly agree.” Attachment anxiety and attachment avoidance are each
calculated as the mean score of 18 items. Individuals who score high on attachment anxiety
exhibit fear of rejection and abandonment and have feelings of unworthiness. Individuals
high in attachment avoidance are uncomfortable with intimacy and interdependence, have an
excessive need for self-reliance, and are reluctant to self-disclose. A combination of relatively
low attachment anxiety and low attachment avoidance is recognized as secure attachment. The
present data showed that Cronbach’s alpha for the attachment anxiety subscale was 0.88 and
Cronbach’s alpha for the attachment avoidance subscale was 0.90. Furthermore, both subscales
of the attachment measure are correlated, which means that there are obvious conceptual and
empirical commonalities between the two. However, a large part of the variance (66%) remains
as yet unexplained. In addition, the two scales were not designed to capture the same constructs
and are therefore treated as conceptually independent in analyses.
Psychologists’ evaluations were assessed using the Cleveland Clinic Behavioural Rating System
(CCBRS). Research shows that the multidimensional CCBRS is a reliable instrument in the
preoperative psychological evaluation of candidates for bariatric surgery.34, 35 The CCBRS
was developed to assess patients across the domains found to be important in preoperative
psychological assessments (consent, expectations, social support, mental health, substance use/
abuse/dependence, eating behaviors, adherence, coping/stressors and overall impression). The
CCBRS was completed by the evaluating psychologist immediately after the interview resulting
in an overall score ranging from 1 (poor) to 5 (excellent). The 5 ratings were operationalized as
follows: 5, excellent- no concerns and no psychological follow-up recommended unless future
problems develop; 4, good – if a problem is present, it is well managed and relative weaknesses
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46 | Chapter 3
or concerns may be addressed without significant intervention; 3, fair- concerns or risk factors are
present but reasonably well-controlled or managed, with a balance between the patient’s relative
strengths and weaknesses; 2, guarded- strongly recommend intervention before proceeding and
likely to require discussion in multidisciplinary rounds; and 1, poor – inappropriate with risks very
likely outweighing benefits (e.g., threatening or aggressive to staff; acutely psychotic). Results
suggest that the CCBRS is an instrument with very high internal consistency and internal-rater
reliability.34
The Hospital Anxiety and Depression Scale (HADS) consists of 14 items, divided into two subscales.
Seven items relate to anxiety (e.g., “I feel tense or wound up.” “I get sudden feelings of panic.”)
and seven items relate to depression (e.g., I have lost interest in my appearance.” “I feel as if
I am slowed down.”). Each item has four descriptive response options to be scored on a scale
of 0 to 3, with a value of 0 corresponding to “not exhibiting the symptom at all,” and a value
of 3 corresponding to “exhibiting the symptom to a high degree.” Scores for each of the two
sub-scales are derived by summation of its seven items. If one or more of its items were missing,
the subscale was disregarded. The lowest possible score for each subscale is 0 and the highest
possible score for each subscale is 21. The developers have suggested that aggregate sub-scale
scores of 0–7 represent non-cases, while scores of > 8 on the subscale indicate a current disorder
that would warrant clinical attention may be present.36 High internal consistency was found
for both subscales of the HADS in this study; HADS-anxiety Cronbach’s alpha = .85 and HADS-
depression Cronbach’s alpha = .79.
Statistical analysis
Statistical analyses were performed using the SPSS 19.0-software package. Descriptive statistics
were calculated for demographic variables and medical variables (see Table 1). Means (M)
and standard deviations (SD) were calculated for continuous variables with frequencies and
percentages used to describe categorical data.
Chi-square tests and the one-way-ANOVA were used to test the associations between demo-
graphic variables (e.g., age, gender, marital status), medical variables (e.g., hypertension,
diabetes) and evaluation by different psychologists on the one hand and the outcome variable
(CCBRS overall rating) on the other, to see which variables should be included as covariates in
further analyses.
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To test our hypothesis the four criteria by Baron and Kenny (1986) should be met.37 The first
criterion states that attachment representations should be significantly associated with the
evaluation score by psychologists (i.e., CCBRS score). This association was tested using multinomial
logistic regression. Multinomial logistic regression is an extension of binary logistic regression. The
technique breaks up the regression analyses into a series of binary regressions comparing each
group of the CCBRS (poor/guarded and fair) to a baseline group (good).
The second criterion state that attachment anxiety and attachment avoidance should be
associated with symptoms of depression and anxiety. This association was tested with linear
regression analysis. The third criterion states that symptoms of depression and anxiety should
be associated with the evaluation score by psychologists. This association was also tested with
multinomial logistic regression. The fourth criterion states that after controlling for symptoms of
depression and anxiety the association between attachment anxiety and attachment avoidance,
on the one hand, and the evaluation score by psychologists on the other, should be reduced
or be no longer significant. This association was tested using multinomial logistic regression.
Sobel test38 was used to determine whether the reduction in the association between attachment
and the evaluation score by psychologists was significant. Findings support partial mediation
if the association between the independent variable (attachment) and the dependent variable
(CCBRS) is reduced but still significant, and full mediation if the mediated effect is no longer
significant. The criteria proposed by Baron and Kenny (1986) and the use of the Sobel tests are
well established.37, 38
Results
Our study sample included 250 patients, was predominantly female (84%), and the mean age
was 44 ± 10.9 years. More than half of the patients lived together with a partner (68%), and
only 19% had completed a Bachelor’s degree or higher. The majority of patients was currently
employed (65%). Median weight was 121.9 kg /299.83 lb (interquartile range 109.0 kg – 136.0
kg/ 240.3 lb – 299.83 lb) and median BMI was 42.4 (interquartile range 39.6 - 46.9).
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48 | Chapter 3
Table 1. Characteristics of patients (N =250)
Variable All patientsN (%)
CCBRSGuarded/Poor
N (%)
CCBRSFair
N (%)
CCBRSGoodN (%)
Mean age (SD) 43.9 (10.9) 37.9 (13.9) 43.3 (11.0) 46.2 (9.2)Mean BMI (SD) 43.6 (6.3) 46.2 (6.4) 44.1 (5.7) 42.8 (6.7)Mean weight kg (SD) 124.6 (24.6) 125.8 (21.4) 126.8 (23.1) 123.0 (22.1)Gender
Female 209 (83.6%) 27 (93.1%) 78 (83.0%) 85 (81.0%) Male 41 (16.4%) 2 (6.9%) 16 (17.0%) 20 (19.0%)
Marital status Married 166 (68.6%) 13 (44.8%) 60 (65.2%) 80 (79.2%) Single 50 (20.7%) 11 (37.9%) 21 (22.8%) 14 (13.9%) Divorced/Widow 26 (10.7%) 5 (17.2%) 11 (12.0%) 7 (6.9%)
Education Higher level of Education
(bachelor’s degree or higher)47 (19.0%) 4 (14.3%) 12 (12.9%) 28 (26.9%)
Medical comorbidities Diabetes 89 (35.6%) 12 (41.4%) 30 (31.9%) 41 (39.0%) Hypertension 105 (42.0%) 15 (51.7%) 34 (36.2%) 49 (46.7%) Arthralgia 160 (64.0%) 20 (69.0%) 63 (67.0%) 59 (56.2%) Sleep apnoea 51 (20.4%) 7 (24.1%) 23 (24.5%) 16 (15.2%)
Smoking 48 (19.2%) 13 (44.8%) 16 (17.0%) 15 (14.3%)Alcohol 20 (8.0%) 4 (13.8%) 9 (9.7%) 7 (6.7%)Drugs 4 (1.6%) 1 (3.4%) 2 (2.1%) 1 (1.0%)Job
Employed 163 (65.2%) 16 (55.2%) 62 (66.0%) 71 (67.6%)
Note: due to missing data the sum of N varies between 250 and 222
Pre-operative psychological assessment: CCBRS
Most candidates (87.3%, n = 199) were deemed psychologically acceptable for bariatric surgery,
with 41.2% (n = 94) rated as “fair”, and 46.1% (n = 105) rated as “good.” None of the patients
were deemed excellent. A significant subset (11.4%, n = 26) was considered guarded, and
additional treatment and/or requirements were deemed necessary before psychological clearance.
Only 1.3% (n = 3) of candidates were deemed “poor” and were evaluated as unable to achieve
the goals that would lead to clearance for surgery. Since only a small group of the patients were
rated poor by the specialized psychologists, we decided to combine the patients rated as poor
or guarded. Further analyses were performed with the CCBRS divided into three groups (poor/
guarded, fair and good).
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Table 1 presents demographic characteristics stratified by CCBRS group. Patients who were rated
by the psychologist as poor/guarded on the CCBRS were more likely to be smokers (x² = 14.14,
p = .001), to live without a partner (x² = 13.51, p = .009), to be younger, (F(2) = 7.2, p = .001),
to have a lower level of education (x² = 6.69, p = .035), and to have a higher BMI, (F(2) = 3.6,
p = .03) than patients who were rated fair or good on the CCBRS.
Table 2. Correlation matrix of the four predictors that are central in this study
1 2 3 Mean SD1. Attachment anxiety 1.99 .772. Attachment avoidance .58* 2.14 .763. HADS-anxiety .52* .41* 5.56 4.094. HADS-depression .41* .35* .69* 5.80 3.98
*Correlation is significant at the 0.01 level (2-tailed).
Therefore, we adjusted for smoking, marital status, age, education and BMI in further analyses, to
ensure that the effect of the predictors were independent of these variables. The CCBRS ratings
did not differ significantly based on gender, evaluation by different psychologists, comorbidities,
or alcohol and drug use and were excluded from further analyses. Coefficients are considered
significant if the respective p-values are less than α = 0.05. Table 2 shows the correlations between
the four predictors that are central in this study.
Association of adult attachment and CCBRS mediated by symptoms of depression and anxiety
We tested whether symptoms of depression and anxiety were potential mediators for the
association between adult attachment and independent CBBRS ratings by psychologists (Figure
1). Table 3 shows all beta coefficients and p-values of the analyses. The first criterion that should
be met for symptoms of depression and anxiety to influence the association between attachment
representations and the CCBRS is that attachment anxiety and attachment avoidance should
be significantly associated with the CCBRS. Multinomial logistic regression analyses between
attachment representations and the CCBRS showed that higher scores on attachment anxiety
(OR = 2.50, 95% [CI 1.25, 4.99]) and attachment avoidance (OR = 3.13, 95% CI [1.56, 6.29])
predicted lower scores on the CCBRS for the group evaluated as poor/guarded than for the group
evaluated as good. Moreover, higher scores on attachment anxiety (OR = 2.71, 95% CI [1.69,
4.33]) and attachment avoidance (OR = 1.64, 95% CI [1.03, 2.58]) were also associated with
lower scores in group fair vs. group good (Unmediated effect column of Table 3). Thus patients
with a higher score on attachment anxiety and/or attachment avoidance received a less positive
evaluation from the specialized psychologist.
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50 | Chapter 3
Tab
le 3
. Med
iatio
n of
att
achm
ent
on t
he C
CBR
S by
sym
ptom
s of
dep
ress
ion/
anxi
ety
Un
med
iate
d e
ffec
t
Β
p
Path
A
Β
p
Path
B
Β
p
Med
iate
d e
ffec
t
Β
p
Sob
el’s
Z (p
val
ue)
Β
p
Att
achm
ent
anxi
ety
-> H
AD
S-an
xiet
y ->
Po
or/ G
uard
ed v
s. G
ood
.916
(p =
.01)
2.63
8 (p
< .0
01)
.130
(p <
.05)
.776
(p =
.07)
a2.
13 (p
< .0
5)
Att
achm
ent
anxi
ety
-> H
AD
S-an
xiet
y ->
Fa
ir vs
. Goo
d.9
98 (p
< .0
01)
2.63
8 (p
< .0
01)
.125
(p <
.01)
.878
(p =
.001
)b2.
93 (p
< .0
1)
Att
achm
ent
avoi
danc
e ->
HA
DS-
anxi
ety
->Po
or/ G
uard
ed v
s. G
ood
1.14
2 (p
= .0
01)
2.15
1 (p
< .0
01)
.130
(p <
.05)
1.02
6 (p
< .0
1)b
2.08
(p <
.05)
Att
achm
ent
avoi
danc
e ->
HA
DS-
anxi
ety
->Fa
ir vs
. Goo
d.4
91 (p
< .0
5)2.
151
(p <
.001
).1
25(p
< .0
1).2
49 (p
= .3
2)a
2.81
(p <
.01)
Att
achm
ent
anxi
ety
-> H
AD
S-de
pres
sion
->
Poor
/ Gua
rded
vs.
Goo
d.9
16 (p
= .0
1)1.
842
(p <
.001
).1
70 (p
< .0
1).6
54 (p
= .0
8)a
2.44
(p =
.01)
Att
achm
ent
anxi
ety
-> H
AD
S-de
pres
sion
->
Fair
vs. G
ood
.998
(p <
.001
)1.
842
(p <
.001
).1
53 (p
= .0
01)
.843
(p =
.001
)b2.
97 (p
< .0
1)
Att
achm
ent
avoi
danc
e ->
HA
DS-
depr
essi
on -
>
Poor
/ Gua
rded
vs.
Goo
d1.
142
(p =
.001
)1.
671
(p <
.001
).1
70 (p
< .0
1).8
78 (p
< .0
5)b
2.37
(p <
.05)
Att
achm
ent
avoi
danc
e ->
HA
DS-
depr
essi
on -
>Fa
ir vs
. Goo
d.4
91 (p
< .0
5)1.
671
(p <
.001
).1
53 (p
= .0
01)
.277
(p =
.26)
a2.
86 (p
< .0
1)
a fu
ll m
edia
tion
b pa
rtia
l med
iatio
n
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Psychologists evaluationAdult attachment
Depressive and anxiety symptoms
path A path B
Unmediated effectFigure 1. Depression and anxiety symptoms as mediator of the effect of adult attachment on psychologists evaluation. Pathway values are reported in the results section.
The second criterion states that attachment representations should be significantly associated with
symptoms of depression and anxiety. Linear regression analyses showed that attachment anxiety
(β = 1.842, p < .001) and attachment avoidance (β = 1.671, p < .001) were associated with
symptoms of depression. Furthermore, attachment anxiety (β = 2.638, p < .001) and attachment
avoidance (β = 2.151, p < .001) were also associated with symptoms of anxiety. Thus, the second
criterion was also met (Path A column of Table 3).
Next, in accordance with the third criterion by Barron and Kenny, we investigated whether
symptoms of depression and anxiety were significantly associated with CCBRS. Multinomial
logistic regression analyses showed that higher scores on the depression scale (OR = 1.19, 95%
CI [1.05, 1.34]) and on the anxiety scale (OR = 1.14, 95% CI [1.02, 1.28]) predicted lower scores
on the CCBRS for the group evaluated as poor/guarded than for the group evaluated as good.
The analyses also showed that higher scores on the depression scale (OR = 1.17, 95% CI [1.07,
1.27]) and the anxiety scale (OR = 1.13, 95% CI [1.05, 1.23]) were significantly associated with
lower scores in the fair vs. the good group. In other words, having more symptoms of depression
and anxiety was associated with lower ratings on the CCBRS by the psychologist (Path B column
of Table 3).
Finally, the fourth criterion states that for symptoms of depression and anxiety to be mediators,
the association between attachment and CCBRS should be reduced or no longer be significant
when controlling for symptoms of depression or anxiety. As seen in the Mediated effect column
of Table 3, multinomial logistic regression analyses showed that the strength of the association
between attachment representations and the CCBRS decreased when symptoms of depression
or anxiety were taken into account as mediators. Sobel tests showed that the decreases in all
beta coefficients were significant (Sobel’s column of Table 3). Thus, the relationship between
attachment and the CCBRS is mediated by symptoms of depression and anxiety. The first row of
Table 3 is an example for full mediation, as the unmediated effect (p = .01) is significant and the
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52 | Chapter 3
mediated effect (when symptoms of depression or anxiety were taken into account) is no longer
significant (p = .07). The second row is an example for partial mediation, as the beta coefficients
of the mediated effect decreases (β = .878) with reference to the unmediated effect (β = .998),
but still is significant (p = .001).
Discussion
In accordance with our hypothesis, we found that for a group of 250 patients referred for bariatric
surgery, patients’ symptoms of depression and anxiety mediated the association between patients’
attachment representations and psychologists’ evaluation of the patients with the Cleveland
Clinic Behavioural Rating System (CCBRS).
Attachment anxiety as well as attachment avoidance was found to differentiate the psychologists’
evaluation of gastric bypass candidates. That is, higher scores on attachment anxiety and attachment
avoidance were associated with less positive evaluations by the specialized psychologists. To the
best of our knowledge, this has not been shown before. The results of our study confirmed that
both higher levels of attachment anxiety and attachment avoidance were significantly linked with
more symptoms of depression and anxiety. These results are in line with previous studies, which
show that an insecure attachment style may be viewed as a vulnerability factor in developing
psychological problems when confronted with stressors and illness.39-41 Significant differences in
the evaluation of gastric bypass candidates were also found to depend on patients’ symptoms
of depression and anxiety. That is, patients with more symptoms of depression and/or anxiety
were considered by the psychologist to be less suited for surgery. Finally, Sobel tests showed
that attachment anxiety and attachment avoidance were associated with more symptoms of
depression and anxiety, which in turn were associated with a less positive evaluation by the
psychologist. Thus, the effects of higher levels of attachment anxiety and attachment avoidance
on psychologists’ evaluation can be accounted for, in part and in some cases fully, by more
symptoms of depression and anxiety.
Very similar to other reports,13,42-45 most candidates were considered mentally suited for surgery,
with a very small percentage of patients requiring additional treatment and/or stabilization, and
an even smaller percentage of the patients were unable to receive clearance for surgery. None
of the patients were evaluated as excellent. This might indicate psychologists’ preference for less
extreme classifications or might be indicative of the frequency of at least minimal psychological
concerns in a bariatric population.
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Findings of this study are interesting for the psychological screening of patients applying for
bariatric surgery. That is, patients’ attachment representations seem to influence psychologists’
evaluations in an indirect way by influencing the symptoms of depression and anxiety patients
report during an assessment interview. This may, however, not be the only path through which
attachment informs psychologists’ evaluations. Other ways may be through patients’ patterns
in interpersonal behavior, their mentalization capabilities and the coherence of their stories.20
Moreover, more insecurely attached patients may also be perceived as more difficult, which may
in turn influence psychologists’ evaluation.46
These results should be interpreted in the context of a few study limitations. First, the cross-
sectional design precludes conclusions regarding cause and effect. Second, the attachment and
anxiety and depression data were obtained exclusively from self-report. Third, although five
different psychologists evaluated patients suitability for surgery, there was a possibility that the
different psychologists may have evaluated patients differently. Therefore, we tested for possible
confounding, and no association between evaluation by different psychologists and the CCBRS
scores were found. A further limitation is that we included patients from one bariatric surgery
clinic only, so results may not be generalizable to bariatric surgery patients as a whole. Future
research should further investigate through which factors patients’ attachment representations
may influence psychologists’ evaluation before bariatric surgery.
In summary, this is the first study to empirically document that patients’ attachment
representations influences psychologists’ evaluations before bariatric surgery while being blind
for the attachment measure. Whether a less positive evaluation of more insecurely attached
patients is pertinent should be investigated in future longitudinal studies showing the relationship
between attachment and post-operative outcomes.
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54 | Chapter 3
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5. Visscher TL, Seidell JC. The public health impact of obesity. Annu Rev Public Health 2001;22:355-375.
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10. Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res 2005;13(4):639-648.
11. Hsu LK, Benotti PN, Dwyer J et al. Nonsurgical factors that influence the outcome of bariatric surgery: a review. Psychosom Med 1998;60(3):338-346.
12. Bauchowitz AU, Gonder-Frederick LA, Olbrisch ME et al. Psychosocial evaluation of bariatric surgery candidates: a survey of present practices. Psychosom Med 2005;67(5):825-832.
13. Fabricatore AN, Crerand CE, Wadden TA, Sarwer DB, Krasucki JL. How do mental health professionals evaluate candidates for bariatric surgery? Survey results. Obes Surg 2006;16(5):567-573.
14. Fried M, Hainer V, Basdevant A et al. Interdisciplinary European guidelines for surgery for severe (morbid) obesity. Obes Surg 2007;17(2):260-270.
15. Ritz SJ. The bariatric psychological evaluation: a heuristic for determining the suitability of the morbidly obese patient for weight loss surgery. Bariat Nurs Surg Pat 2006;1:97-105.
16. Snyder AG. Psychological assessment of the patient undergoing bariatric surgery. Ochsner J 2009;9(3):144-148.
17. Wadden TA, Sarwer DB. Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach. Surg Obes Relat Dis 2006;2(2):171-179.
18. van Hout GC, Vreeswijk CM, van Heck GL. Bariatric surgery and bariatric psychology: evolution of the Dutch approach. Obes Surg 2008;18(3):321-325.
19. Bowlby J. Attachment and loss: retrospect and prospect. Am J Orthopsychiatry 1982;52(4):664-678.
20. Maunder RG, Hunter JJ. Assessing patterns of adult attachment in medical patients. Gen Hosp Psychiatry 2009;31(2):123-130.
21. Hinnen C, Schreuder I, Jong E, Duijn MV, Dahmen R, van Gorp EC. The contribution of adult attachment and perceived social support to depressive symptoms in patients with HIV. AIDS Care 2012.
22. Kiesewetter S, Kopsel A, Mai K et al. Attachment style contributes to the outcome of a multimodal lifestyle intervention. Biopsychosoc Med 2012;6(1):3.
23. Ciechanowski P, Russo J, Katon W et al. Influence of patient attachment style on self-care and outcomes in diabetes. Psychosom Med 2004;66(5):720-728.
24. Mikulincer M, Florian V, Weller A. Attachment styles, coping strategies, and posttraumatic psychological distress: the impact of the Gulf War in Israel. J Pers Soc Psychol 1993;64(5):817-826.
25. Doron G, Moulding R, Nedeljkovic M, Kyrios M, Mikulincer M, Sar-El D. Adult attachment insecurities are associated with obsessive compulsive disorder. Psychol Psychother 2012;85(2):163-178.
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26. Kobak RR, Sceery A. Attachment in late adolescence: working models, affect regulation, and representations of self and others. Child Dev 1988;59(1):135-146.
27. Maunder RG, Hunter JJ. Attachment and psychosomatic medicine: developmental contributions to stress and disease. Psychosom Med 2001;63(4):556-567.
28. Mikulincer M. Adult attachment style and individual differences in functional versus dysfunctional experiences of anger. J Pers Soc Psychol 1998;74(2):513-524.
29. Ward MJ, Lee SS, Polan HJ. Attachment and psychopathology in a community sample. Attach Hum Dev 2006;8(4):327-340.
30. Melissas J. IFSO guidelines for safety, quality, and excellence in bariatric surgery. Obes Surg 2008;18(5):497-500.
31. Mikulincer M, Shaver PR. An attachment perspective on psychopathology. World Psychiatry 2012;11(1):11-15.
32. Brennan KA, Clark CL, Shaver PR. Self-report measurement of adult attachment: An integrative overview. Attachment theory and close relationships. In J. A. Simpson & W. S. Rholes (1998) (Eds.) Attachment theory and close relationships:46-76. New York: Guilford Press.
33. Kurdek LA. On being insecure about the assessment of attachment styles. J Soc Pers Relat 2002;19:811-834.
34. Heinberg LJ, Ashton K, Windover A. Moving beyond dichotomous psychological evaluation: the Cleveland Clinic Behavioral Rating System for weight loss surgery. Surg Obes Relat Dis 2010;6(2):185-190.
35. Heinberg LJ, Ashton K, Windover A, Merrell J. Older bariatric surgery candidates: is there greater psychological risk than for young and midlife candidates? Surg Obes Relat Dis 2011.
36. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67(6):361-370.
37. Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986;51(6):1173-1182.
38. Sobel ME. Effect analysis and causation in lineair structural equation models. Psychometrika 1990;55:495-515.
39. Sockalingam S, Wnuk S, Strimas R, Hawa R, Okrainec A. The association between attachment avoidance and quality of life in bariatric surgery candidates. Obes Facts 2011;4(6):456-460.
40. Riggs SA, Vosvick M, Stallings S. Attachment style, stigma and psychological distress among HIV+ adults. J Health Psychol 2007;12(6):922-936.
41. Rodin G, Walsh A, Zimmermann C et al. The contribution of attachment security and social support to depressive symptoms in patients with metastatic cancer. Psychooncology 2007;16(12):1080-1091.
42. Pawlow LA, O’Neil PM, White MA, Byrne TK. Findings and outcomes of psychological evaluations of gastric bypass applicants. Surg Obes Relat Dis 2005;1(6):523-527.
43. Sadhasivam S, Larson CJ, Lambert PJ, Mathiason MA, Kothari SN. Refusals, denials, and patient choice: reasons prospective patients do not undergo bariatric surgery. Surg Obes Relat Dis 2007;3(5):531-535.
44. Tsuda S, Barrios L, Schneider B, Jones DB. Factors affecting rejection of bariatric patients from an academic weight loss program. Surg Obes Relat Dis 2009;5(2):199-202.
45. Walfish S, Vance D, Fabricatore AN. Psychological evaluation of bariatric surgery applicants: procedures and reasons for delay or denial of surgery. Obes Surg 2007;17(12):1578-1583.
46. Maunder RG, Panzer A, Viljoen M, Owen J, Human S, Hunter JJ. Physicians’ difficulty with emergency department patients is related to patients’ attachment style. Soc Sci Med 2006;63(2):552-562.
4Coping style as a mediator between attachment
and mental and physical health in patients
suffering from morbid obesity
Floor Aarts, Chris Hinnen, Victor EA Gerdes, Yair Acherman, Dees PM Brandjes
Published in International Journal of Psychiatry in Medicine 2014;47(1)
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58 | Chapter 4
Abstract
Background: The presence of mental health problems and limitations in physical functioning is
high in patients suffering from morbid obesity. The purpose of the current study was to examine
the mediating role of coping style in the relationship between attachment representations and
mental health and physical functioning in a morbidly obese population.
Methods: A total of 299 morbidly obese patients who were referred to the Slotervaart bariatric
surgery unit in Amsterdam, the Netherlands, completed self-report questionnaires assessing
adult attachment style (Experiences in Close Relationship – Revised Questionnaire), coping style
(Utrecht Coping List) and patients physical functioning and mental health (Short Form-36).
Results: Attachment anxiety (β = -.490, p < .001) and attachment avoidance (β = -.387, p < .001)
were both found to be related to mental health. In addition, attachment anxiety was also found
to be related to physical functioning (β = -.188, p < .001). Coping style partly mediated these
associations.
Conclusion: Findings suggest that coping mediates the association between attachment anxiety
and attachment avoidance on the one hand and mental health and physical functioning in
patients with morbid obesity on the other hand.
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Introduction
Morbid obesity has a negative impact on patients’ mental health and physical functioning,1
and has been shown to be related to physical and psychiatric co-morbidities such as diabetes,
hypertension, depression and eating disorders.2-4 Research shows that 35.6% of the morbidly
obese patients applying for bariatric surgery have diabetes, the lifetime prevalence of Axis I (DSM-
IV) clinical psychiatric diagnoses was 47.5%.5, 6 Patients suffering from morbid obesity often report
feelings of sadness and shame, lack of energy and limitations in self-care and mobility, which are
important reasons for people to consider bariatric surgery.7, 8 Although patients overweight may
account for these higher levels of mental health problems and limitations in physical functioning,
within the group of morbidly obese patients large differences exist which may in part be explained
by patients’ attachment style.
According to the attachment theory (Bowlby, 1969), internal working models of attachment are
the mechanisms by which the continuity of childhood experiences is thought to be maintained
over time and into adulthood.9 Bartholomew & Horowitz (1991) and Brennan et al. (1998)
demonstrated that these internal working models of attachment style can be categorized
as either attachment anxiety or attachment avoidance.10, 11 Individuals who score high on
attachment anxiety exhibit fear of rejection and abandonment, have feelings of unworthiness
and tend to turn to others in an anxious, clingy manner. Individuals high in attachment avoidance
are uncomfortable with intimacy and interdependence while maintaining a high sense of self-
worth 10, 11. Those low in attachment anxiety and attachment avoidance (i.e. secure attachment)
have been found to show self-confidence coupled with confidence about the availability and
responsiveness of others.12
Compared to more insecure attachment representations, more secure attachment representations
have been consistently found to be associated with better mental and physical functioning in
healthy people,13, 14 chronically ill patients15 and in morbidly obese patients.16 More securely
attached patients may have a more realistic view of the stressors and threats they are facing
and of their own resilience.17 Consequently, physical symptoms and complaints tend to be ‘real’
and connected to illness and injury.18 In contrast, patients high in attachment anxiety tend to
worry about health more than seems justified, are hypervigilant for threats and stressors and
report physical symptoms and complaints also when there is no indication for illness or injury.19, 20
Moreover, patients high in attachment avoidance try their best to suppress symptoms of distress
and may worry too little about their health.18
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60 | Chapter 4
In part, the association between attachment and mental and physical functioning may be
explained by differences in coping skills between more securely and more insecurely attached
patients. 9, 21 Kotler et al. (1994) and Wei et al. (2003) have found evidence for the mediating role
of coping between attachment representations and physical and mental functioning in student
samples.13, 21 However, no published studies have examined the association between attachment
style, various coping styles and mental and physical functioning in morbidly obese patients
seeking bariatric surgery. A complex patient population characterised by both physical as well as
psychiatric co-morbidities.
Coping, defined as the thoughts and actions we use to deal with stress, is found to be strongly
associated with mental health and physical functioning. Lazarus and Folkman (1984) classified
two types of coping responses: emotion focused coping and problem focused coping.22 The
seven coping strategies used in this study are derived from the Utrecht Coping List (UCL).23 The
coping strategies seeking social support, palliative reacting, avoiding, passive reacting, reassuring
thoughts and expression of emotions can be seen as emotion focused coping, whereas active
tackling can be seen as problem focused coping. In general, problem focused coping has been
found to be associated with better outcomes when dealing with situations where a high level
of control is perceived, while emotion focused coping seems more appropriate when stressors
are unalterable.24, 25 Moreover, passive ways of coping and expressing emotions is found to be
associated with lower mental and physical functioning, whereas a more active way of coping and
seeking support is shown to positively influence patients’ mental and physical functioning.26-28
Furthermore, individuals with more secure attachment representations (i.e., low on attachment
anxiety and attachment avoidance) who perceive others as available and responsive may not
only be comfortable seeking support but may also have learned that their own actions (active
tackling) are often effective in reducing distress and in solving problems.29, 30 On the other hand,
less securely attached patients (i.e., those who believe others will not be readily available) may
be more likely to feel overwhelmed and paralyzed (passive reacting) by problems and may
possibly cope by adopting external regulatory mechanisms (palliative reacting), such as smoking
and drinking.31, 32 Specifically, those people with more anxious attachment representations may
tend to express their fears and worries in a profound and clingy way (emotional expression) in
order to ensure support and care from others.33 This tendency is consistent with developmental
experiences where the primary caregiver was only helpful if the “signal” of neediness was strong
enough.14 As a consequence, these people learned to focus on and express negative emotions
while waiting for reassurance as the ability to sooth and distract oneself is underdeveloped.30
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Instead, they have become hyper-vigilant to distress which manifest itself through worrying
and thinking about negative experiences and emotions in a repetitive and passive way (passive
reacting). Furthermore, patients with more avoidant attachment representations have a habitual
way of coping with negative experiences and emotions by distancing, avoiding and repressing.34-37
They have most likely received consistently unresponsive care giving,38 maintaining a high sense
of self-worth by defensively denying the value of close relationships and stressing the importance
of independence and self-reliance39 and therefore may be reluctant to seek support.40, 41
The purpose of the current study was to examine the relationships between attachment
representations and coping styles on the one hand and mental health and physical functioning
on the other, in a morbidly obese population. Based on the aforementioned literature three
main hypotheses were formulated: (1) more attachment anxiety and attachment avoidance are
associated with worse mental health and physical functioning; (2) lower attachment anxiety
and lower attachment avoidance (i.e., attachment security) are associated with more support
seeking and active tackling, whereas attachment anxiety and attachment avoidant are associated
with more passive reacting and palliative reacting; and (3) the association between patients’
attachment representations on the one hand and physical and mental functioning on the other
are mediated by patients’ coping style.
Method
Study sample
This study took place in the Slotervaart bariatric surgery unit, Amsterdam, the Netherlands
between February and August 2012. The total sample included 299 morbidly obese patients
referred for bariatric surgery. Patients between the ages of 18 and 60 years are eligible for gastric
bypass surgery if IFSO criteria are met: BMI above 40 or a BMI above 35 combined co morbidity
such as hypertension, diabetes, obstructive sleep apnea syndrome or arthrosis, and if they have
made serious attempts at losing weight. 42
Procedures
All patients referred to the Slotervaart bariatric surgery unit received a pre-surgical multidisciplinary
assessment. During this assessment patients received questionnaires to complete at home. These
questionnaires assessed patients’ attachment style, coping styles, physical functioning and mental
health. Patients were asked to bring the completed questionnaire to their next visit at the bariatric
surgery unit.
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62 | Chapter 4
After random allocation all completed and returned questionnaires received an identification
number and information gathered was treated as strictly confidential. The study was approved by
the Medical Ethical Committee. Research participants provided informed consent.
Measures
Attachment styles were assessed using the Experiences in Close Relationships- Revised scale
(ECR-R). The ECR-R is a 36-item self-report measure of adult attachment style, which requires
participants to reflect on their typical ways of relating in close/romantic relationships. Reviews
of self-report measures of adult attachment suggest that the ECR-R has the best psychometric
properties of the available measures.43 The ECR consists of two subscales, attachment anxiety
(e.g., I’m afraid that I will lose my partner’s love) and attachment avoidance (e.g., I prefer not to
show a partner how I feel deep down) and both dimensions are assessed with 18 items. Answers
are on a 5-point scale ranging from ‘strongly disagree’(1) to ‘strongly agree’(5). The present data
showed that Cronbach’s alpha for subscale attachment anxiety was 0.88 and the Cronbach’s
alpha for subscale attachment avoidance was 0.90.
Coping styles were measured using the Utrecht Coping List (UCL), a 47-item, self-report
questionnaire that measures seven empirically derived subscales that assess ‘active tackling’
(7 items, e.g. ‘putting things in a row’, ‘seeking a way to solve a problem’), ‘seeking social
support’ (6 items, e.g. ‘discussing the problem with friends or family’ and ‘asking somebody for
help’), ‘palliative reacting’ (8 items, e.g. ‘looking for distraction’ and looking for good company’),
‘avoiding’ (8 items, e.g. ‘avoiding difficult situations’ and ‘letting things go’), ‘passive reacting’ (7
items, e.g. ‘being overwhelmed by problems’), ‘reassuring thoughts’ (5 items, e.g. ‘imagining that
things could be worse’) and ‘expression of emotions’ (3 items e.g. ‘showing anger to the person
who is responsible for the problem’). Answers are on a 4-point scale ranging from ‘seldom or
never’ to ‘very frequently’. Prior research has shown that the UCL is a valid and reliable instrument
for measuring coping strategies and that it has fairly good internal consistency.23 In the present
data the different coping scales showed good internal consistency, Cronbach’s alpha for active
tackling was .85, for seeking social support .89, for palliative reacting .63, for avoiding .74,
for passive reacting .74, for reassuring thoughts .67, with the exception of the expression of
emotions scale, Cronbach’s alpha is .57. This might be due to the small number of items in this
scale, whereas most other scales consisted of at least five or six items.23
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4
Physical functioning and mental health were evaluated using the SF-36, a widely used Health
Related Quality Of Life (HRQOL) measure. Its use in bariatric surgery patient populations is well-
established. For the domain physical functioning and mental health scores were coded, summed
up and transformed to a scale of 0 (worst health) to 100 (best health). The instrument has been
translated into Dutch and validated for the Dutch population.44 The physical functioning domain
and the mental health domain were used as outcome variables in the present study. The physical
functioning domain consists of 10 items (e.g. to what extent do you have limitations in lifting and
carrying groceries?) and answers are on a 3-point scale ranging from ‘extremely limited’ to ‘not
limited at all’. The mental health domain consists of 5 items ( e.g. in the last 4 weeks, how often
did you feel nervous?) and answers are on 6-point scale ranging from ‘constantly’ to ‘never’. The
present data showed that Cronbach’s alpha for physical functioning 0.88, and mental health
0.84, showed good internal consistency.
Statistical analyses
Statistical analyses were performed using SPSS 19.0. Independent T-tests and Pearson’s
correlations were used to explore possible confounding in the relationship between, on the
one hand, demographics (i.e., age, gender), BMI and education level, and, on the other hand,
coping styles, physical functioning and mental health. The mean scores on the SF-36 of physical
functioning and mental health were compared to age-matched Dutch general population norms
using t-tests.44
In order to determine whether coping styles are a mediator of attachment style, and physical
functioning and mental health, three regression equations were carried out: we first regressed
the mediator (coping style) on the independent variable (attachment style); second, we regressed
the dependent variable (physical functioning and mental health) on the independent variable
(attachment style); and third we regressed the dependent variable (physical functioning and
mental health) on both the independent variable (attachment style) and on the mediator (coping
styles). To establish mediation, we tested the three regression equations following the criteria
of Baron and Kenny (1986).45 All relationships that were found insignificant were excluded
from further analyses. Finally, we used unstandardized regression coefficients (B) and standard
errors for the approximate significance test of Sobel (1982) to test for the indirect effect of the
independent variable on the dependent variable via the mediator 45, 46. Standardized regression
coefficients (β) are presented in the text. The level of significance was set at p< .05. All tests were
two-tailed.
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64 | Chapter 4
Results
Descriptive statistics
A total of 299 patients seeking bariatric surgery were included in the study. Mean age of the
study population was 44 (SD = 11.0), and 85% of test subjects were women. Mean BMI was
44.1 (SD = 6.2) and only a small part of the patients had followed a higher education (20.5%).
Pearson’s correlations showed that age was not associated with most of the coping styles except
for palliative reacting (r = -.162, p = .006). Women (M = 2.47, SD = .62) reported to seek more
social support than men (M = 2.15, SD = .66), t(291) = 3.06, (p = .002), 95% CI: .11 - .51.
Women (M = 2.54, SD = .49) were also found to use more reassuring thoughts than men (M
= 2.30, SD = .45), t(292) = 3.11, (p = .002), 95% CI:.09;.40. Patients with a higher education
used more active tackling, t(285) = -3.51, (p = .001), 95% CI: -.41;- .11, and sought more social
support, t(289) = -2.16, (p = .032), 95% CI:-.38;-.02, than patients with a lower education.
Furthermore, patients’ BMI was not associated with one of the different coping styles.
Independent t-test showed gender differences for physical functioning t(297) = -1.981, (p =
.048). Similarly, significant differences in physical functioning t(295) = -2.820, (p = .005), 95%
CI:-15.69; -2.79, were found between patients with a higher and a lower education level.
Pearson correlation showed that both age (r = -.125, p = .030) and BMI (r = -.132, p = .023) were
associated with physical functioning. In other words women, patients with a lower education,
older patients and patients with a higher BMI scored lower on physical functioning than men,
patients with a higher education, younger patients and patients with a lower BMI. Table 1 shows
the correlations between the main study variables. No correlations between demographics and
mental health were found.
Mean scores for physical functioning (present study M = 55.0, norm M = 83.0, P < .001) and
for mental health (present study M = 71.3, norm M = 76.8, P = .001) were significantly lower
compared to those of persons of comparable age in the general Dutch population.44
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Attachment and mental and physical health | 65
4
Tab
le 1
. Cor
rela
tion
mat
rix o
f th
e m
ain
stud
y va
riabl
es.
2
34
56
78
910
111.
Att
ach
men
t an
xiet
y.5
86**
-.40
6**
.121
*.2
21**
-.27
5**
.532
**.1
20*
-.00
5-.
495*
*-.
210*
*2.
Att
ach
men
t av
oid
ance
1
-.29
3**
.115
.262
**-.
570*
*.4
57**
.027
-.08
4-.
379*
*-.
065
3. A
ctiv
e ta
cklin
g1
.110
-.38
7**
.327
**-.
480*
*-.
100
.310
**. 3
97**
.181
**4.
Pal
liati
ve r
eact
ing
1.1
89**
.216
**.2
19**
.110
.411
**-.
103
-.02
15.
Avo
idin
g
1-.
220*
*.4
63**
.023
.096
-.22
4**
-.07
16.
See
kin
g s
oci
al s
up
po
rt1
-.21
1**
.183
**.2
57**
.210
.093
7. P
assi
ve r
eact
ing
1
.256
**.0
04-.
657*
*-.
216*
*8.
Exp
ress
ion
of
emo
tio
ns
1.0
31-.
123*
.042
9. R
eass
uri
ng
th
ou
gh
ts1
.023
-.04
010
. Men
tal h
ealt
h1
.340
**11
. Ph
ysic
al f
un
ctio
nin
g1
Cor
rela
tion
is s
igni
fican
t at
the
0.0
5 le
vel (
2-ta
iled)
. **
Cor
rela
tion
is s
igni
fican
t at
the
0.0
1 le
vel (
2-ta
iled)
.
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66 | Chapter 4
Attachment, Coping and Health
We tested whether coping was a potential mediator for the effect of adult attachment and
mental and physical health (Figure 1). The first criterion that should be met for a coping style
to mediate the association between attachment anxiety and attachment avoidance on the one
hand and mental health and physical functioning on the other stipulates that attachment should
be significantly associated with mental health and physical functioning. The unmediated effect in
Table 2 shows that, after controlling for age, gender, education and BMI, a significant negative
association was found between attachment anxiety and physical functioning (β = -.188, p < .001)
and between attachment anxiety and mental health (β = -.490, p < .001). Furthermore, we also
found a strong relation between attachment avoidance and mental health (β = -.387, p < .001).
AttachmentAttachment anxiety
Attachment avoidance
HealthPhysical functioning
Mental health
CopingActive tackling
Seeking social support
Palliative reacting
Avoiding
Passive reacting
Reassuring thoughts
Expression of emotions
Unmediated effect
Path A Path B
Figure 1. Coping as mediator of the effect of adult attachment on health outcomes. Pathway values are reported in the Table 2.
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Attachment and mental and physical health | 67
4
Tab
le 2
. C
opin
g st
yle
as m
edia
tor
betw
een
atta
chm
ent
styl
e an
d th
e de
pend
ent
varia
bles
men
tal h
ealth
and
phy
sica
l fun
ctio
ning
, ad
just
ed f
or a
ge,
gend
er,
educ
atio
n an
d BM
I
Pred
icto
r ->
Med
iato
r ->
Ou
tco
me
Un
med
iate
d e
ffec
tB
p
Path
AB
p
Path
BB
p
Med
iate
d e
ffec
tB
p
Sob
el’s
Z
(p v
alu
e)B
p
Att
achm
ent
anxi
ety
-> A
ctiv
e ta
cklin
g->
• Ph
ysic
al f
unct
ioni
ng-5
.422
(p<
.001
)-.
266
(p<
.001
)5.
642
(p <
.05)
-.4.
857
(p <
.05)
-2.0
96 (p
< .0
5)•
Men
tal h
ealth
-10.
696
(p <
.001
)-.
266
(p<
.001
)12
.663
(p<
.001
)-8
.523
(p <
.001
)-4
.954
(p <
.001
)A
ttac
hmen
t av
oida
nce
-> A
ctiv
e ta
cklin
g->
• M
enta
l hea
lth-8
.632
(p <
.001
)-.
197
(p <
.001
)12
.663
(p <
.001
)-6
.694
(p <
.001
)-4
.063
(p <
.001
)A
ttac
hmen
t an
xiet
y ->
Avo
idin
g->
• M
enta
l hea
lth-1
0.69
6 (p
< .0
01)
.122
(p <
.001
)-7
.994
(p =
.001
)-1
0.34
8 (p
< .0
01)
-2.5
11 (p
< .0
5)A
ttac
hmen
t av
oida
nce
->A
void
ing-
>•
Men
tal h
ealth
-8.6
32 (p
< .0
01)
.148
(p <
.001
)-7
.994
(p =
.001
)-7
.951
(p <
.001
)-3
.089
(p <
.05)
Att
achm
ent
anxi
ety
-> S
eeki
ng s
ocia
l sup
port
->
• M
enta
l hea
lth-1
0.69
6 (p
< .0
01)
-.21
8 (p
< .0
01)
6.46
5 (p
< .0
01)
-10.
122
(p <
.001
)-2
.902
(p <
.05)
Att
achm
ent
avoi
danc
e ->
See
king
soc
ial s
uppo
rt -
>•
Men
tal h
ealth
-8.6
32 (p
< .0
01)
-.46
0 (p
< .0
01)
6.46
5 (p
< .0
01)
-8.7
64 (p
< .0
01)
-3.8
40 (p
< .0
01)
Att
achm
ent
anxi
ety
-> P
assi
ve r
eact
ing-
>•
Phys
ical
fun
ctio
ning
-5.4
22 (p
< .0
01)
.315
(p <
.001
)-9
.637
(p =
.001
)-2
.945
(p =
.130
)-3
.311
(p <
.001
)•
Men
tal h
ealth
-10.
696
(p <
.001
).3
15 (p
< .0
01)
-23.
901
(p <
.001
)-4
.265
(p <
.001
)-8
.343
(p <
.001
)A
ttac
hmen
t av
oida
nce
-> P
assi
ve r
eact
ing-
>•
Men
tal h
ealth
-8.6
32 (p
< .0
01)
.274
(p <
.001
)-2
3.90
1 (p
< .0
01)
-2.5
62 (p
< .0
5)-7
.219
(p <
.001
)A
ttac
hmen
t an
xiet
y ->
Exp
ress
ion
of e
mot
ions
• M
enta
l hea
lth-1
0.69
6 (p
< .0
01)
.076
(p <
.05)
-4.6
45 (p
< .0
5)-1
0.43
9 (p
< .0
01)
-1.5
12 (p
= .1
29)
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68 | Chapter 4
These results show that the first criterion for mediation was met for all the associations, except
for attachment avoidance and physical functioning.
The second criterion stipulates that attachment representations should be significantly associated
with coping style. Path A in table 2 shows that a lower score on attachment anxiety and
attachment avoidance are found to be associated with more active tackling and social support
seeking. A higher score on attachment anxiety and/or attachment avoidance are found to be
associated with more avoidance, passive reacting and palliative coping. Moreover, a higher score
on attachment anxiety is found to be associated with more emotional expression. The coping
style reassuring thoughts, was not associated with any attachment style and therefore excluded
from further analyses.
Next, in accordance with the third criterion, we investigated whether the different coping styles
were significantly associated with mental health and physical functioning. Regression analyses
showed that active tackling was positively and passive reacting negatively associated with
both physical functioning and mental health (see Path B Table 2). Moreover, social support was
positively associated with mental health, while avoidance and expression of emotions were both
negatively associated. Thus, the third criterion was also met.
Finally, the fourth criterion for coping style to be a mediator, requires the association between
attachment style and physical functioning or mental health to be reduced or to no longer be
significant after controlling for a specific coping style. The mediated effect in Table 2 shows that
this final criterion was also met. The strength of the association between attachment anxiety or
attachment avoidance and mental health and physical functioning, decreased when the specific
coping style was taken into account as a mediator. The Sobel test confirmed these findings and
showed that the decrease in all beta coefficients was significant (Table 2). The beta coefficients
of attachment anxiety and attachment avoidance in all relations decreased, but remained in
almost all mediating analyses significant when coping style was controlled for. This indicates
that the association between attachment style and mental health or physical functioning was
partly mediated by the mentioned coping styles. In contrast, a full mediation model was found
to describe the association between attachment anxiety and physical functioning, and the beta
coefficient was no longer significant when controlling for passive reacting.
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4
Discussion
Although previous studies identified relations between attachment and mental health and physical
functioning,13, 15 our results extends these findings by suggesting that attachment representations
influences mental health and physical functioning through various coping styles in morbidly obese
patients seeking bariatric surgery. A population who constantly has to cope with the different
aspects of morbid a obesity, a chronic life threatening and limiting disease often combined with
complex psychological and medical problems (e.g. diabetes).
Our results suggest that more securely attached morbidly obese patients (i.e., those with lower
levels of attachment anxiety and attachment avoidance) reported more active problem solving
strategies as well as a willingness to seek support when needed. These findings confirm our
expectations and may reflect an adequate balance between two sides of a continuum as described
by Maunder and colleagues.14, 47 This continuum stretches from autonomy and confidence in one’s
own ability to solve problems to dependency and the need to trust others for support and care.
While more securely attached patients are able to integrate both sides, more insecurely attached
patients (i.e., those with higher levels of attachment anxiety and attachment avoidance) discard
one side of the continuum (either autonomy in the case of attachment anxiety or dependency
in the case of attachment avoidance) in favour of the other side. This is reflected by their coping
style, which, in this and other studies,30 was found to be characterised by not knowing what to
do and by feeling overwhelmed in stressful situations (i.e., avoidance and passive coping).
Active problem solving coping as well as support seeking were in the present study, as well as
in previous studies28 found to be associated with better mental health. Hence, these coping
strategies seem to help more securely attached patients maintain a positive outlook despite their
overweight. In contrast, avoidance coping, passive coping and expression of emotions were
found to be associated with worse mental health. This may help explain why more insecurely
attached patients may experience more mental problems than more securely attached patients.
Although we did not find any association between attachment avoidance and palliative reacting,
we did find an association for attachment anxiety.
Moreover, in the present study we also found that more anxiously attached patients (i.e., those
scoring higher on attachment anxiety) reported worse physical functioning. This was not true for
more avoidant attached patients (i.e. those scoring higher on attachment avoidance). This finding
is in accordance with the idea that more anxiously attached patients may respond to a stressor in
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70 | Chapter 4
a hypervigilant way, that they focus on physical complaints and that they may express their fears
and worries more eagerly in an attempt to guarantee the availability and responsiveness of those
needed as much as possible.14 More anxiously attached patients have been found to report more
(un)explained physical symptoms and to use the health care system more regularly.48
In the present study active as well as passive coping were not only found to be associated with
mental functioning but also with physical functioning. That is, more active coping and less passive
coping were found to be associated with better physical functioning These findings are in line
with other studies.27 An explanation for these findings might be that due to their passive way
of coping patients develop more stress-related physical symptoms (e.g. back pain), which in
turn may lead to worse physical functioning.48 Moreover, patients with a less active coping style
may tend to focus more on bodily sensations, which in turn may also result in more physical
complaints. Alternatively patients with more physical problems may be forced to use more passive
coping strategies, due to their physical complaints.
Furthermore, patients with morbid obesity were found to report more impaired physical
functioning and mental health compared to the general Dutch population.49, 50 We found that
more securely attached patients exhibited better mental health and physical functioning than
more insecurely attached patients. While the physical functioning scores of the more securely
attached patients were still lower than those of the general population, the scores for mental
health of more securely attached patients were comparable to those of the general population.
These results indicate that more secure attachment representations may serve as a buffer for
mental health of morbidly obese patients. In contrast, more insecure attachment representations
may exacerbate the impact of obesity on mental health and physical functioning.
These results should be interpreted in the context of limitations. As we only included patients
from the Slotervaart bariatric surgery unit, the results may not be generalizable to all patients
seeking bariatric surgery and the general population as a whole. In addition all data is gathered
through self-reported measurements. Determining the mediating role of coping styles in the
relation between attachment representations and mental health and physical functioning
could therefore benefit from the inclusion of clinical interviews. Furthermore, this study has a
cross-sectional design which prevents us from drawing conclusions about causality. Therefore
longitudinal studies are needed to evaluate our findings.
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Attachment and mental and physical health | 71
4
Despite these limitations, the value of our study lies in that it is the first to investigate the
relationship between attachment representations and mental health and physical functioning
in patients seeking bariatric surgery and how this is mediated by patients’ coping styles. In
considering bariatric surgery for patients, specialists currently use patients’ quality of life as an
important criterion, as they expect that patients’ quality of life will improve after the operation.
Although post-operative improvements in quality of life (including physical functioning and
mental health) are expected, our findings suggest that BMI predicts only a small part of the
differences in physical functioning and mental health. Therefore, our study argues in favour of
a greater consideration of patients’ attachment representations and coping behaviors when
considering physical functioning and mental health. Findings suggest not only that it is important
to consider attachment anxiety or attachment avoidance in understanding mental health and
physical functioning in patients with morbid obesity but also that coping style plays an important
role in these relationships. Future studies are needed to investigate whether patients attachment
representations and coping behaviors can predict physical functioning and mental health after
the surgery.
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72 | Chapter 4
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2. Guh DP, Zhang W, Bansback N, Amarsi Z, Birmingham CL, Anis AH. The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health 2009;9:88.
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5. Campos GM, Ciovica R, Rogers SJ et al. Spectrum and risk factors of complications after gastric bypass. Arch Surg 2007;142(10):969-975.
6. Halmi KA, Long M, Stunkard AJ, Mason E. Psychiatric diagnosis of morbidly obese gastric bypass patients. Am J Psychiatry 1980;137(4):470-472.
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9. Bowlby J. Attachment and Loss. Attachment. New York: Basic Books;1969.
10. Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol 1991;61(2):226-244.
11. Brennan KA CCSP. Self-report measurement of adult attachment: An integrative overview. In: Simpson JA, Rholes WS (eds). Attachment theory and close relationships. New York: Guilford Press 1998:46-76.
12. Cooper ML, Shaver PR, Collins NL. Attachment styles, emotion regulation, and adjustment in adolescence. J Pers Soc Psychol 1998;74(5):1380-1397.
13. Kotler T, Buzwell S, Romeo Y, Bowland J. Avoidant attachment as a risk factor for health. Br J Med Psychol 1994;67 ( Pt 3):237-245.
14. Hunter JJ, Maunder RG. Using attachment theory to understand illness behavior. Gen Hosp Psychiatry 2001;23(4):177-182.
15. Martin LA, Vosvick M, Riggs SA. Attachment, forgiveness, and physical health quality of life in HIV + adults. AIDS Care 2012;24(11):1333-1340.
16. Sockalingam S, Wnuk S, Strimas R, Hawa R, Okrainec A. The association between attachment avoidance and quality of life in bariatric surgery candidates. Obes Facts 2011;4(6):456-460.
17. Ciechanowski P, Katon WJ. The interpersonal experience of health care through the eyes of patients with diabetes. Soc Sci Med 2006;63(12):3067-3079.
18. Maunder RG, Hunter JJ. Assessing patterns of adult attachment in medical patients. Gen Hosp Psychiatry 2009;31(2):123-130.
19. Ciechanowski PS, Katon WJ, Russo JE, Dwight-Johnson MM. Association of attachment style to lifetime medically unexplained symptoms in patients with hepatitis C. Psychosomatics 2002;43(3):206-212.
20. Stuart S, Noyes R, Jr. Attachment and interpersonal communication in somatization. Psychosomatics 1999;40(1):34-43.
21. Wei M, Heppner PP, Mallinckrodt B. Perceived Coping as a Mediator Between Attachment and Psychological Distress: A Structural Equation Modeling Approach. J Couns Psych 2003;50(4):434-447.
22. Lazarus RS, Folkman S. Stress, appraisal and coping. New York: Springer Publishing company; 1984.
23. Schreurs P, van de Willige G, Tellegen B, Brosschot J. Handleiding Utrechtse Coping Lijst: UCL. Swets & Zeitlinger, Lisse, 1988.
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24. Folkman S. Lifespan developmental psychology: Perspectives on stress and coping. In: Cummings EM, Greene AL, Karraker KH, editors. Coping across the lifespan: Theoretical issues. Erlbaum, Hillsdale, NJ: 1991:3-19.
25. Folkman S. Personal coping: Theory, research, and application. In: Carpenter BN, editor. Making the case for coping. Praeger, Westport, CT: 1992:31-46.
26. Hopman-Rock M, Kraaimaat FW, Bijlsma JW. Quality of life in elderly subjects with pain in the hip or knee. Qual Life Res 1997;6(1):67-76.
27. Scharloo M, Kaptein AA, Weinman J, Bergman W, Vermeer BJ, Rooijmans HG. Patients’ illness perceptions and coping as predictors of functional status in psoriasis: a 1-year follow-up. Br J Dermatol 2000;142(5):899-907.
28. van der Have M, Minderhoud IM, Kaptein AA et al. Substantial impact of illness perceptions on quality of life in patients with Crohn’s disease. J Crohns Colitis 2012.
29. Simpson JA, Rholes WS, Nelligan JS. Support seeking and support giving within couples in an anxiety-provoking situation: The role of attachment styles. Journal of Personality and Social Psychology 1992;62(3):434-446.
30. Mikulincer M, Florian V, Weller A. Attachment styles, coping strategies, and posttraumatic psychological distress: the impact of the Gulf War in Israel. J Pers Soc Psychol 1993;64(5):817-826.
31. Ciechanowski P, Russo JE, Katon WJ et al. Influence of patient attachment style on self-care and outcome in diabetes. Psychosomatic Medicine 2004;66:720-728.
32. Maunder RG, Hunter JJ. Attachment and psychosomatic medicine: Developmental cotributions to stress and disease. Psychosomatic Medicine 2001;63:556-567.
33. Mikulincer M, Florian V, Tolmacz R. Attachment styles and fear of personal death: A case study of affect regulation. Journal of Personality and Social Psychology 1990;58(2):273-280.
34. Mikulincer M, Orbach J. Attachment style and repressive defensiveness: The accessibility and architecture of affective memories. Journal of Personality and Social Psychology 1995;68(5):917-925.
35. Turan B, Osar Z, Turan JM, Ilkova H, Damci T. Dismissing attachment and outcome in diabetes: The mediating role of coping. Journal of Social and Clinical Psychology 2003;22(6):607-626.
36. Fraley RC, Shaver PR. Adult attachment and the suppression of unwanted thoughts. Journal of Personality and Social Psychology 1997;73(5):1080-1091.
37. Vetere A, Myers LB. Repressive coping style and adult romantic attachment style: is there a relationship. Personality and Individual Differences 2002;32:799-807.
38. Mikail SF, Henderson PR, Tasca GA. An interpersonally based model of chronic pain: An application of attachment theory. Clinical Psychology Review 1994;14(1):1-16.
39. Mikulincer M. Adult attachment style and affect regulation: Strategic variations in self-appraisals. Journal of Personality and Social Psychology 1998;75(2):420-435.
40. Florian V, Mikulincer M, Bucholtz I. Effects of adult attachment style on the perception and search for social support. The Journal of Psychology 1995;129(6):665-676.
41. Priel B, Shamai D. Attachment style and perceived social support: effects on affect regulation. Personality and Individual Differences 1995;19(2):235-241.
42. Melissas J. IFSO guidelines for safety, quality, and excellence in bariatric surgery. Obes Surg 2008;18(5):497-500.
43. Fraley RC, Waller NG, Brennan KA. An item response theory analysis of self-report measures of adult attachment. J Pers Soc Psychol 2000;78(2):350-365.
44. Aaronson NK, Muller M, Cohen PD et al. Translation, validation, and norming of the Dutch language version of the SF-36 Health Survey in community and chronic disease populations. J Clin Epidemiol 1998;51(11):1055-1068.
45. Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986;51(6):1173-1182.
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46. Sobel ME. Effect analysis and causation in lineair structural equation models. Psychometrika 1990;55:495-515.
47. Maunder RG, Hunter JJ. A prototype-based model of adult attachment for clinicians. Psychodyn Psychiatry 2012;40(4):549-573.
48. Maunder RG, Hunter JJ, Lancee WJ. The impact of attachment insecurity and sleep disturbance on symptoms and sick days in hospital-based health-care workers. J Psychosom Res 2011;70(1):11-17.
49. Algul A, Ates MA, Semiz UB et al. Evaluation of general psychopathology, subjective sleep quality, and health-related quality of life in patients with obesity. Int J Psychiatry Med 2009;39(3):297-312.
50. Lier HO, Biringer E, Hove O, Stubhaug B, Tangen T. Quality of life among patients undergoing bariatric surgery: associations with mental health- A 1 year follow-up study of bariatric surgery patients. Health Qual Life Outcomes 2011;9:79.
5Mental Health Care Utilization in Patients
Seeking Bariatric Surgery:
the Role of Attachment Behavior
Floor Aarts, Chris Hinnen, Victor EA Gerdes, Dees PM Brandjes, Rinie Geenen
Published in Bariatric Surgical Practice and Patient Care 2013;8(4)
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76 | Chapter 5
Abstract
Obesity may be a factor contributing to mental health in patients seeking bariatric surgery.
Whether a person uses mental health care for one’s psychological problems may have its roots in
attachment behavior. The present study (N = 260) identified that attachment anxiety was associated
with more mental health care visits (OR = 1.86, 95% CI = 1.11-2.54, p = .02), present use of
medication (OR = 2.30, 95% CI = 1.43-3.68, p = .001) and previously prescribed medication (OR
= 2.01, 95% CI = 1.13-3.57, p = .02). Furthermore, the use of previously prescribed medication
was especially prevalent in patients with high attachment anxiety and low attachment avoidance
(OR = 2.96, 95% CI = 1.35-6.50, p = .007). The observation that attachment anxiety is associated
with mental health care utilization indicates that it should be recognized and considered by health
care providers working with patients with morbid obesity for therapeutic and economic reasons.
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Attachment behavior and mental health care utilization | 77
5
Introduction
Obesity has been recognized as a growing public health problem and it is associated with physical
problems such as type II diabetes and hypertension as well as mental problems such as depressed
mood.1, 2 Mental problems are particularly high among patients with morbid obesity seeking
bariatric surgery,3-7 and mental health care utilization has also been found to be high.8 Some
patients with mental problems are given mental health counseling prior to bariatric surgery
to improve their mental health status.9 The present study focuses on the association between
attachment behavior and mental health care utilization.
Attachment behavior -the habitual way of relating to other persons- plays a role in the etiology
of mental problems, and may influence the risk of individuals becoming obese and the probability
of individuals using mental health services. According to attachment theory,10-13 early interactions
with attachment figures influence how people think, feel and behave in adulthood.14 Anxiously
attached people seek support from others through amplifying distress, while avoidantly attached
people evade dependency on others.15 Confronted with a stressor, people with anxious attachment
representations have been found to increase caloric intake and physiological responses relevant
to eating (e.g. cortisol).6, 16, 17 Moreover, insecure attachment has been found to be associated
with obesity in both child- and adulthood18, 19 and with poor self-efficacy of eating management 20. In addition, insecure attachment was shown to be a vulnerability factor for mental health
problems in the general population21 and in bariatric surgery candidates.22
Mental health care may be used by patients with morbid obesity as a one-off after crisis,23
throughout life in case of chronic psychiatric comorbidity,9 as a preoperative psychological
intervention for bariatric surgery patients with significant psychological problems,24 and as pre-
treatment for bariatric surgery.9 Based on observations in the general population for health care
utilization,25-28 attachment anxiety in bariatric surgery patients is hypothesized to predict mental
health care utilization of any kind. Individuals with anxious attachment representations are
expected to use more mental care, because they have a negative view of the self are hypervigilant
to stressors, have little faith in their own ability to manage and tend to rely on others.29 In
contrast, individuals with avoidant attachment representations have a positive view of the self
and a negative view of others, have fear for intimacy, and have been found to be self-reliant,29
and are therefore expected to use less mental health care. Finally, although individuals with secure
attachment representations believe that they are worthy of care and attention, are comfortable
in seeking support and are confident that health care providers are capable and willing to provide
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78 | Chapter 5
care,29 we expect their use of mental health care to be low because they have a low risk at mental
disorders.27
Thus, the aim of our study was to examine the association between attachment representations
and mental health care use in patients with morbid obesity applying for bariatric surgery.
Materials and Methods
Study sample
Patients with morbid obesity between the ages of 18 and 60 referred to the Department of
Bariatric Surgery of the Slotervaart Hospital, Amsterdam, the Netherlands between February and
August 2012 were included in this study. Patients are eligible for gastric bypass surgery if they
have a Body Mass Index (BMI) above 40 kg/m2 or a BMI above 35 kg/m2 and co-morbidity such as
hypertension, diabetes, obstructive sleep apnea syndrome (OSAS) or osteoarthritis. Furthermore,
patients should have made serious attempts at losing weight.30 A total of 299 patients from the
Slotervaart bariatric surgery unit completed the questionnaires. Of these 299 patients, the 260
patients with complete datasets on variables needed in this study were included in analyses.
Procedures
Data were obtained from questionnaires filled out by patients during their pre-surgical
multidisciplinary assessment. Questionnaires consisted of questions on demographics, adult
attachment and mental health care utilization. After random allocation all questionnaires received
an identification number and information gathered was treated confidentially. The study was
approved by the Medical Ethical Committee of the Slotervaart hospital. Research participants
provided informed consent.
Instruments
Adult attachment was measured with the Experiences in Close Relationship scale Revised (ECR-R),
a continuous measurement of attachment.21, 31 The ECR-R comprises 36 items to assess how
individuals experience intimate relationships emotionally by employing two broad dimensions,
attachment anxiety (18 items) and attachment avoidance (18 items). Items were rated on a
5-point Likert scale, ranging from ‘strongly disagree’ to ‘strongly agree’. The present data showed
good internal consistency for both subscales, Cronbach’s alphas for attachment anxiety and
attachment avoidance subscale were 0.88 and 0.90.
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Attachment behavior and mental health care utilization | 79
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Mental health care utilization of patients was measured with the question: Have you ever been
in contact with a social worker, psychologist or psychiatrist for professional help? Previously
prescribed medication was measured with: Have you ever used medication for mental problems
in the past? The question to measure current medication use was: Do you use medication
for mental problems currently? Questions could be answered by yes or no. Medication use at
presentation was retrieved from the electronic patient files.
Statistical analyses
Descriptive statistics were used to summarize demographics, attachment, and mental health care
utilization. Means (M) and standard deviations (SD) were calculated for continuous variables.
Frequencies and percentages were used to describe categorical data. Differences between patients
with and without complete datasets regarding demographics were investigated using one-way
analysis of variance and Pearson χ2. Logistic regression analysis was used to predict mental health
care visits, previously prescribed medication and present use of medication for mental problems
from attachment anxiety, attachment avoidance and the interaction between attachment anxiety
and attachment avoidance. Also the possible prediction of age, gender, BMI and education level
of the patient (person characteristics) was examined. However, only those demographic variables
that significantly correlated (p < .10) with at least one of the three variables indicating mental
health care use were included in the regression model.
In step 1 of the logistic regression, demographic variables (i.e. gender, age) were entered. In
step 2, attachment anxiety and attachment avoidance were entered. In step 3, we examined the
interaction term between attachment anxiety and attachment avoidance. Attachment anxiety and
attachment avoidance were centred on their grand mean (i.e., the overall mean was subtracted
from the values of a variable). To probe a significant interaction effect, logistic regression analyses
were repeated including only patients with score below and above the median on attachment
anxiety and attachment avoidance, respectively. Statistical analyses were performed using SPSS
19.0 software package. The level of significance was set at p < .05. All tests were two-tailed.
Results
Description of the sample
The mean age of the study population was 44 years (SD = 10.8); 84% of the research participants
was female, mean BMI was 44 kg/m2 (SD = 6.2) and 20% of the patients had followed higher
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80 | Chapter 5
education (bachelor’s degree or higher). Mean attachment anxiety was 2.01 (SD = .79) and mean
attachment avoidance was 2.13 (SD = .79).
No statistically significant differences were found between the patients with missing data and
those with complete datasets regarding age, gender, BMI or education level (data not shown).
Personal characteristics, attachment style and mental health utilization
In our sample of patients seeking bariatric surgery, 53% of the patients had ever been in contact
with a mental health care provider, 60 patients (23%) had ever used prescribed medication
for mental problems, and 29 patients (11%) currently used prescribed medication for mental
problems. Most of the patients with current medication (n = 23) used antidepressants and two
patients used antipsychotics. Furthermore, six patients used antidepressants or antipsychotics
combined with benzodiazepines.
Table 1 shows the results of logistic regression analysis. In step 1, neither age nor gender
were found significantly associated with the outcome variables. Almost significant (p < 0.10)
observations were that previously prescribed medication use was higher in older than younger
patients (p = .07) and that mental health care visits (p = .06), previously prescribed medication use
(p = .06) and present use of medication (p = .07) were higher for women than men. Step 2 showed
that attachment anxiety was associated with more mental health care visits (OR = 1.86, 95%
CI = 1.11-2.54, p = .02), previously prescribed medication (OR = 2.30, 95% CI = 1.43-3.68,
p = .001), and present use of medication (OR = 2.01, 95% CI = 1.13-3.57, p = .02). No significant
associations were found between attachment avoidance and mental health care utilization. In
step 3, the interaction of attachment anxiety and attachment avoidance predicted a significant
proportion of individual differences in previously prescribed medication (OR = .56, 95% CI = .33-
.94, p = .03). In the prediction of previously prescribed medication, neither the odds ratios for
attachment avoidance in patients below the median on attachment anxiety (OR = 1.32, 95% CI =
0.59-2.96, p = .51) or above (OR = 0.73, 95% CI = 0.42-1.25, p = .25) the median on attachment
anxiety were significant, nor the odds ratio for attachment anxiety in patients scoring high on
attachment avoidance (OR = 1.47, 95% CI = 0.89-2.42, p = .13). However, previously prescribed
medication was significantly predicted by attachment anxiety in patients with attachment
avoidance below the median (OR = 2.96, 95% CI = 1.35-6.50, p = .007) indicating that previously
prescribed medication was especially prominent in patients scoring high on attachment anxiety
and low on attachment avoidance.
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Attachment behavior and mental health care utilization | 81
5
Tab
le 1
. Re
gres
sion
ana
lyse
s pr
edic
ting
men
tal h
ealth
car
e vi
sits
, pr
evio
usly
pre
scrib
ed m
edic
atio
n an
d pr
esen
t us
e of
med
icat
ion
for
men
tal p
robl
ems
from
pe
rson
cha
ract
eris
tics
(ste
p 1)
att
achm
ent
anxi
ety,
att
achm
ent
avoi
danc
e (s
tep
2) a
nd t
he in
tera
ctio
n te
rm (s
tep
3)
Men
tal h
ealt
h c
are
visi
tsPr
evio
usl
y p
resc
rib
ed m
edic
atio
nPr
esen
t u
se o
f m
edic
atio
nSt
ep 1
OR
95%
CI
OR
95%
CI
OR
95%
CI
Age
1.01
(.99-
1.04
)1.
03*
(.99-
1.06
)1.
03(.9
9-1.
07)
Gen
der
(0=
fem
ale,
1=
mal
e).5
3*(.2
7-1.
04)
.38*
(.14-
1.03
).1
5*(.0
2-1.
17)
Step
2 A
ge1.
01(.9
9-1.
04)
1.03
*(.9
9-1.
02)
1.03
(.99-
1.07
) G
ende
r (0
=fe
mal
e, 1
=m
ale)
.49*
*(.2
5-.9
9).3
7*(.1
4-1.
02)
.16*
(.02-
1.20
) A
ttac
hmen
t an
xiet
y1.
68**
(1.1
1-2.
54)
2.30
***
(1.4
3-3.
68)
2.01
**(1
.13-
3.57
) A
ttac
hmen
t av
oida
nce
1.09
(.73-
1.64
).7
9(.4
8-1.
31)
.71
(.37-
1.37
)St
ep 3
Age
1.01
(.99-
1.04
)1.
03*
(.99-
1.06
)1.
03(.9
9-1.
07)
Gen
der
(0=
fem
ale,
1=
mal
e).4
9**
(.25-
.98)
.36*
(.13-
1.00
).1
6*(.0
2-1.
19)
Att
achm
ent
anxi
ety
1.77
***
(1.1
6-2.
73)
2.66
***
(1.6
4-4.
29)
2.22
***
(1.2
4-3.
96)
Att
achm
ent
avoi
danc
e1.
09(.7
3-1.
63)
.90
(.55-
1.47
).8
(.41-
1.56
)
Att
achm
ent
anxi
ety
* A
ttac
hmen
t
avo
idan
ce.8
0(.5
2-1.
21)
.56*
*(.3
3-.9
4).6
3(.3
2-1.
25)
*p<
.10,
**p
<.0
5, *
**p<
.01
OR=
odds
rat
io; C
I=co
nfide
nce
inte
rval
; BM
I=Bo
dy M
ass
Inde
x
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82 | Chapter 5
Discussion
Our study shows that more than half of the 260 patients (53%) referred for bariatric surgery has
ever been in contact with a mental health care provider. In addition, 1 out of every 4 to 5 patients
(23%) has ever used prescribed medication for mental problems, and 1 out of 9 patients (11%)
currently uses such medication.
The results of this study demonstrate that the use of mental health care is greatest in more
anxiously attached patients and that the use of previously prescribed medication is especially
prevalent in patients scoring high on attachment anxiety and low on attachment avoidance.
These findings are in agreement with attachment theory and may reflect that patients with more
anxious attachment representations seek mental care more often because they rely more for
support and care on others in combination with being more vulnerable for developing mental
problems and experiencing higher levels of negative affect.29 On the other hand, attachment
avoidance was not found to be associated with mental health care, which may reflect preference
to be self-reliant and reluctance to become interdependent. Although patients with avoidant
attachment representations may show considerable biological distress (e.g. increased blood
pressure), they appear calm and subjectively feel and report to be not distressed.21
Furthermore, previous research showed that more secure attachment representations are
associated with resilience and good psychological health.32 Although patients with morbid obesity
who are more securely attached may not be free of mental problems, they might possess more
effective psychosocial skills (e.g. social and communicative competences) and coping strategies
(e.g. social support, active problem solving).32 These skills and strategies may prevent them from
needing mental health care. In our study, more secure attachment representations might be
reflected in the combination of low scores on attachment anxiety and low scores on attachment
avoidance. This interaction was not associated with low or high mental health care use, perhaps
because psychiatric disorders were low in this group and in case of psychiatric disorders these
patients are comfortable in seeking support and are confident that health care providers are
capable and willing to provide support.29 The most use of mental health care was made by
patients scoring high on attachment anxiety and low on attachment avoidance. These patients
may have relatively high mental problems or even psychopathology and are dependent without
being reluctant to accept help form others.
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Attachment behavior and mental health care utilization | 83
5
Although the association between higher health care utilization and attachment anxiety has been
described in previous studies,26, 27 the present study adds to this literature by focusing specifically
on mental health care utilization in a population seeking bariatric surgery. Some aspects of this
study require comment. The main limitation of this study is its retrospective, cross-sectional
design preventing conclusions about the direction or prospective relation between variables.
Furthermore, our findings do not generalize beyond the population of patients with morbid
obesity seeking bariatric surgery or to other variables not rooted in attachment that may affect
obesity and the use of health care. We cannot exclude that a proportion of the patients may have
had a visit with a psychologist or psychiatrist as part of an earlier weight loss program instead
of treatment for mental problems. A final limitation is that we used self-reports of health care
utilization. Future prospective studies should include questions about the number and reasons of
visits at the different mental health care providers and should verify these visits with mental health
care providers. While this study provide descriptive information on which patients seems to utilize
the most mental health care, future studies are required to examine who needs and benefits from
mental health care on pre- and post-surgical level.
Conclusions
Overall, the results suggest that attachment behavior plays a role in mental health care utilization
of patients with morbid obesity who apply for bariatric surgery. Therefore, it is important for
health care providers working with patients with morbid obesity to have knowledge of the
attachment theory, to recognize anxious attachment representations and to be aware of these
patients’ desire of close relationships and hypervigilance for rejection as well as of the mental
vulnerability of this group. Anticipation on attachment representations may help prevent
unnecessary delay and may increase throughput of patients needing psychological treatment to
improve their mental health before they are allowed to receive bariatric surgery. The implication
is twofold. First of all, more anxiously attached patients may actually need more mental health
care than securely attached patients, and, secondly, their emotionally dependency on caregivers
and fear of rejection and abandonment may lead to unnecessary mental health care visits and
high costs. To deal with both problems regularly scheduled frequent brief visits or telephone
calls with health care providers may be required for these patients.29, 33 If a health care provider
–responsive to concerns34– is available at these scheduled moments before the patient asks for
it and independently of symptoms, anxiously attached patients may become less compulsive in
care-seeking outside these moments. Patients may experience that support occurs regardless
of whether or not they communicate to have symptoms.29 Furthermore, it is important for the
patients that they experience enough support and empathy from the health care provider as
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84 | Chapter 5
well as from more accessible resources such as family, friends or religion.35 Conclusively, the
observation that attachment anxiety is associated with mental health care utilization in morbidly
obese patients seeking bariatric surgery indicates that it should be recognized and considered by
health care providers for therapeutic and economic reasons.
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Attachment behavior and mental health care utilization | 85
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Reference List
1. Lawrence VJ, Kopelman PG. Medical consequences of obesity. Clin Dermatol 2004;22(4):296-302.
2. Visscher TL, Seidell JC. The public health impact of obesity. Annu Rev Public Health 2001;22:355-375.
3. Martinez EP, Gonzalez ST, Vicente MM, van-der Hofstadt Roman CJ, Rodriguez-Marin J. Psychopathology in a sample of candidate patients for bariatric surgery. Int J Psychiatry Clin Pract 2012.
4. Zijlstra H, Larsen JK, Wouters EJM, van RB, Geenen R. The Long-Term Course of Quality of Life and the Prediction of Weight Outcome After Laparoscopic Adjustable Gastric Banding: A Prospective Study. Bariatr Surg Pract Patient Care 2013;8(1):18-22.
5. Fitzgibbon ML, Stolley MR, Kirschenbaum DS. Obese people who seek treatment have different characteristics than those who do not seek treatment. Health Psychol 1993;12(5):342-345.
6. Jaremka LM, Glaser R, Loving TJ, Malarkey WB, Stowell JR, Kiecolt-Glaser JK. Attachment anxiety is linked to alterations in cortisol production and cellular immunity. Psychol Sci 2013;24(3):272-279.
7. Wuehlhans B, Horbach T, de ZM. Psychiatric disorders in bariatric surgery candidates: a review of the literature and results of a German prebariatric surgery sample. Gen Hosp Psychiatry 2009;31(5):414-421.
8. Keating CL, Moodie ML, Bulfone L, Swinburn BA, Stevenson CE, Peeters A. Healthcare utilization and costs in severely obese subjects before bariatric surgery. Obesity (Silver Spring) 2012;20(12):2412-2419.
9. Sarwer DB, Cohn NI, Gibbons LM et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg 2004;14(9):1148-1156.
10. Bowlby J. Attachment and Loss: Vol 1. Attachment. New York: Basic Books;1969.
11. Bowlby J. Attachment and Loss, Vol 2. Separation, Anxiety and Anger. New York: Basic Books;1973.
12. Bowlby J. Attachment and Loss, Vol 3. Loss, Sadness and Depression. New York: Basic Books;1980.
13. Levy KN, Ellison WD, Scott LN, Bernecker SL. Attachment style. J Clin Psychol 2011;67(2):193-203.
14. Bowlby J. A secure base: clinical applications of attachment theory. Londen: Routledge; 1988.
15. Mikulincer M, Shaver PR. Adult attachment and affect regulation. In: Cassidy J, Shaver PR, editors. Handbook of attachment: Theory, research and clinical implications. New York: Guilford Press; 2008:503-531.
16. Maunder RG, Hunter JJ. Attachment and psychosomatic medicine: developmental contributions to stress and disease. Psychosom Med 2001;63(4):556-567.
17. Torres SJ, Nowson CA. Relationship between stress, eating behavior, and obesity. Nutrition 2007;23(11-12):887-894.
18. Anderson SE, Whitaker RC. Attachment security and obesity in US preschool-aged children. Arch Pediatr Adolesc Med 2011;165(3):235-242.
19. Wilkinson LL, Rowe AC, Bishop RJ, Brunstrom JM. Attachment anxiety, disinhibited eating, and body mass index in adulthood. Int J Obes (Lond) 2010;34(9):1442-1445.
20. Bahrami F, Kelishadi R, Jafari N, Kaveh Z, Isanejad O. Association of children’s obesity with the quality of parental-child attachment and psychological variables. Acta Paediatr 2013;102(7):e321-e324.
21. Mikulincer M, Shaver PR. An attachment perspective on psychopathology. World Psychiatry 2012;11(1):11-15.
22. Sockalingam S, Wnuk S, Strimas R, Hawa R, Okrainec A. The association between attachment avoidance and quality of life in bariatric surgery candidates. Obes Facts 2011;4(6):456-460.
23. Wiltink J, Weber MM, Beutel ME. Mental co-morbidity, health care utilization and illness behaviour in overweight and obese subjects--results from a representative German community survey. Psychother Psychosom Med Psychol 2007;57(11):428-434.
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24. Friedman KE, Applegate KL, Grant J. Who is adherent with preoperative psychological treatment recommendations among weight loss surgery candidates? Surg Obes Relat Dis 2007;3(3):376-382.
25. Caspers KM, Yucuis R, Troutman B, Spinks R. Attachment as an organizer of behavior: implications for substance abuse problems and willingness to seek treatment. Subst Abuse Treat Prev Policy 2006;1:32.
26. Ciechanowski P, Sullivan M, Jensen M, Romano J, Summers H. The relationship of attachment style to depression, catastrophizing and health care utilization in patients with chronic pain. Pain 2003;104(3):627-637.
27. Ciechanowski PS, Walker EA, Katon WJ, Russo JE. Attachment theory: a model for health care utilization and somatization. Psychosom Med 2002;64(4):660-667.
28. Feeney JA, Ryan SM. Attachment style and affect regulation: relationships with health behavior and family experiences of illness in a student sample. Health Psychol 1994;13(4):334-345.
29. Hunter JJ, Maunder RG. Using attachment theory to understand illness behavior. Gen Hosp Psychiatry 2001;23(4):177-182.
30. Melissas J. IFSO guidelines for safety, quality, and excellence in bariatric surgery. Obes Surg 2008;18(5):497-500.
31. Brennan KA, Clark CL, Shaver PR. Self-report measurement of adult attachment: An integrative overview. In: Simpson JA, Rholes WS (eds). Attachment theory and close relationships. New York: Guilford Press 1998:46-76.
32. Hooper LM, Tomek S, Newman CR. Using attachment theory in medical settings: implications for primary care physicians. J Ment Health 2012;21(1):23-37.
33. Maunder RG, Hunter JJ. A prototype-based model of adult attachment for clinicians. Psychodyn Psychiatry 2012;40(4):549-573.
34. Thompson D, Ciechanowski PS. Attaching a new understanding to the patient-physician relationship in family practice. J Am Board Fam Pract 2003;16(3):219-226.
35. Adler HM. The sociophysiology of caring in the doctor-patient relationship. J Gen Intern Med 2002;17(11):874-881.
PART IIPostoperative: attachment representations
and effect on family members
6Attachment anxiety predicts poor adherence
to dietary recommendations:
an indirect effect on weight change one year
after gastric bypass surgery
Floor Aarts, Rinie Geenen, Victor E.A. Gerdes, Arnold van de Laar,
Dees P.M. Brandjes, Chris Hinnen
Submitted for publication
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90 | Chapter 6
Abstract
Introduction: Weight-loss after gastric bypass surgery depends on the adoption of healthy dietary
recommendations, which may be influenced by psychological problems and patients’ attachment
representations (habitual states of mind with respect to interpersonal relations). The present study
examines 1) the association of psychological problems and attachment representations with
dietary adherence, 2) the association between dietary adherence and weight-loss, and 3) dietary
adherence as mediator of the relation of psychological problems and attachment representations
with weight reduction after gastric bypass surgery.
Materials and Methods: This longitudinal study included 105 patients who had a laparoscopic
Roux-en-Y gastric bypass operation. Current and past psychological problems and attachment
representations were assessed before surgery. Dietary adherence was assessed 6 and 12 months
after surgery. Patients’ weight and height were collected from medical records. Multiple linear and
logistic regression analyses and mediation analyses using bootstrapping resampling procedures
were conducted.
Results: Of all examined predictor variables, attachment anxiety, i.e. fear of social rejection and
abandonment, was most strongly associated with low dietary adherence at both 6 months (p
= .009) and 12 months (p = .006) post-surgery. Dietary adherence 6 months post-surgery was
associated with weight-loss 1 year after the operation (p = .003). Dietary adherence at 6 months
(B = .51; 95% CI = .19 to 1.04) mediated the association between preoperative attachment
anxiety and postoperative weight-loss.
Conclusion: The results suggest that more anxiously attached patients are less adherent to
dietary recommendations 6 months after gastric bypass surgery, influencing weight-loss in a
negative way during the first year after surgery.
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Attachment anxiety, adherence and weight loss | 91
6
Introduction
Bariatric surgery is the weight loss treatment of choice for patients with morbid obesity.1 The
majority of the patients lose 25-35% of their initial body weight within one year after gastric
bypass surgery.2 However, there is a small but considerable proportion of patients who are unable
to benefit optimally from a gastric bypass operation in terms of weight loss.3, 4
The amount of weight loss after gastric bypass surgery will depend to a large extent on the
degree to which the patient succeeds in adopting healthy dietary recommendations.4 Patients
who underwent gastric bypass surgery typically receive a number of diet recommendations such
as to limit snacking and drinking soda.3 Patients who fail to adhere to these recommendations
will lose less weight after a gastric bypass surgery and may regain more weight on the long-term.
For example, preoperative and postoperative binge eating or grazing have been shown to be
associated with poorer weight loss one year following gastric bypass surgery.5
Therefore, identifying factors that could influence adherence to dietary recommendations after
a gastric bypass operation is important. It may help to optimize the results of the operation. In
accordance, a standard component of the clinical evaluation of candidates applying for bariatric
surgery is a pre-surgical psychological assessment to identify possible indicators of suboptimal
adherence and outcomes.6-9 A history of psychological problems and current psychological
problems (e.g., symptoms of anxiety and depression) are among the preoperatively assessed
variables.6, 10 Psychological problems have been found to be associated with a less positive
evaluation of the eligibility of bariatric surgery candidates by psychologists11 and with less weight
loss after the initial year of the gastric bypass operation.12-14 These relationships may be explained
by the level of adherence to dietary recommendations, as those who were less adherent were
found to have more psychological problems than those who did follow dietary recommendations
more stringently.15
In addition to past and current psychological problems, different individual characteristics
such as one’s attachment representations may help explain differences in adherence to dietary
recommendations. According to attachment theory, early childhood experiences that centre around
the interaction with primary caregivers result in enduring expectations about the availability and
responsiveness of others.16 These attachment representations are conceptualized in adulthood as
mental states concerning anxiety about rejection and abandonment, and avoidance of intimacy
and interdependence.12-14 Attachments representations not only impact intimate relationships but
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92 | Chapter 6
also the relationship with more distant social sources such as one’s physician.17 Both attachment
anxiety and attachment avoidance have been found to be related to poorer adherence to medical
regiments in chronically ill patients.18, 19
More anxiously attached patients have been consistently shown to be more prone to distress
when confronted with stressors.20 In stressful situations people with high levels of attachment
anxiety may view themselves unable to deal with the stressors and may rely on smoking, alcohol
and high caloric food to regulate their emotions.21-23 In accordance, attachment anxiety has been
found to be associated with obesity in both children and adults.23, 24 Due to their high levels of
distress and their tendency to rely on external and behavioral modulators of affect such as high
caloric food, more anxiously attached patients can be expected to find it more difficult to adhere
to dietary recommendations after bariatric surgery.
More avoidantly attached patients, on the other hand, tend to dismiss symptoms of distress and
vulnerability.25 They stress the importance of independence and self-reliance, are reluctant to seek
support and feel uncomfortable trusting others, including health care providers.26, 27 Due to their
high level of self-reliance and low collaboration with health care providers, it can be expected that
they will be less adherent to dietary recommendations after bariatric surgery as well.
The present study has three objectives. First, we aim to get insight into determinants of individual
differences in adherence to dietary recommendations after a gastric bypass operation. We expect
current and past psychological problems as well as attachment anxiety and attachment avoidance
to be associated with poor adherence to dietary recommendations. Second, we aim to examine
the association between dietary adherence and weight loss in the first year after surgery. We
expect that poorer dietary adherence is associated with less weight reduction. Finally, we aim to
examine the mediating role of adherence to dietary recommendations between on the one hand,
current and past psychological problems, attachment anxiety and attachment avoidance, and on
the other hand, weight reduction one year after gastric bypass surgery.
Materials and Methods
Study sample
Included in analyses were 105 patients with morbid obesity between 18-60 years of age who
applied for a laparoscopic Roux-en-Y gastric bypass operation in Slotervaart hospital between
February and August 2012. The inclusion flow chart is presented in Figure 1. Of the 310 patients
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Attachment anxiety, adherence and weight loss | 93
6
who applied for bariatric screening, 190 were operated between April and December 2012 and
131 of these patients agreed to participate in this study. Eventually, 105 patients completed the
study and 26 were lost to follow-up.
Patients applying for bariatric screening
(n=310)
Not operated during study inclusion period
(n=68)
Not eligible for operation(n=44)
Operated(n=190)
Decided not to have surgery (n=8)
Agreed to participate in the study
(n=131)
Declined participation in the study(n=59)
Completed the study(n=105)
Dropped-out(n=26)
Figure 1. Flowchart
Procedures
All patients referred to the Slotervaart bariatric surgery clinic received pre-surgical multidisciplinary
assessments by a dietician, internist, surgeon and a psychologist including self-report
questionnaires, semi-structured interviews, and assessments of weight and height (BMI, Body
Mass Index), preoperative diet and exercise habits, co-morbidity and sociodemographics.
For this study, questionnaires to assess patients’ attachment representations and previous and
current psychological problems were added to the standard set of preoperative measures. At 6
and 12 months postoperatively, adherence to dietary recommendations and BMI were assessed.
The study was conducted according to the guidelines of the Declaration of Helsinki and approved
by the Medical Ethical Committee of the Slotervaart Hospital. Informed consent was obtained
from all participants.
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Instruments
Patients’ height and weight (without shoes) were measured in the hospital. Weight was measured
at the approximately same time of the day, with the same pair of scales and rounded off to the
nearest 0.1 kg. BMI was calculated by weight in kilograms divided by the square of the height in
meters (kg/m2).
Adherence with dietary recommendations was assessed using a single item with three possible
responses: a) “I generally followed the dietary recommendations”, b) “I almost followed the
dietary recommendations” or c) “I did not follow dietary recommendations”.
Past psychological problems was assessed with a single item: “Have you ever been in contact with
a social worker, psychologist or psychiatrist for professional help?” Response alternatives were
“yes” and “no”.
Current psychological problems were measured with the Hospital Anxiety and Depression Scale
(HADS), which consists of 14 items divided into two subscales. Seven items relate to anxiety (e.g.,
“I feel tense or wound up.”) and seven items relate to depression (e.g., “I have lost interest in
my appearance.”). Each item has four descriptive response options to be scored on a scale of 0
to 3, with a value of 0 corresponding to “not exhibiting the symptom at all,” and a value of 3
corresponding to “exhibiting the symptom to a high degree.” Scores for each of the two sub-
scales are derived by summation of its seven items. If one or more of its items were missing,
the subscale was disregarded. The lowest possible score for each subscale is 0 and the highest
possible score for each subscale is 21. The developers have suggested that aggregate sub-scale
scores of 0–7 represent non-cases, while scores of > 8 on the subscale indicate that a current
disorder warranting clinical attention may be present.28 High internal consistency was found for
both subscales of the HADS in this study; HADS-anxiety Cronbach’s alpha = .85 and HADS-
depression Cronbach’s alpha = .79.
Adult attachment representations were assessed using the Experiences in Close Relationships-
Revised Scale (ECR-R). The ECR-R is a 36-item self-report measure of adult attachment, which
requires participants to reflect on their typical ways of relating in close relationships. Reviews
of self-report measures of adult attachment suggest that the ECR-R has the best psychometric
properties of the available measures.29 The ECR consists of two continues subscales, attachment
anxiety (e.g., “I’m afraid that I will lose my partner’s love”) and attachment avoidance (e.g., “I
prefer not to show a partner how I feel deep down”). Both dimensions are assessed with 18
items. Answers are on a 5-point scale ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (5).
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In the present study, Cronbach’s alpha for subscale attachment anxiety was 0.88 and for subscale
attachment avoidance 0.90.
Medical variables (e.g., hypertension, diabetes) were collected from patients’ medical records.
Demographic variables (e.g., age, gender, marital status) at the first assessment were self-reported
by the patients.
Statistical analyses
Continuous variables are presented as means (M) and standard deviations (SD) and categorical
data as frequencies and percentages. Assumptions of normality were checked for the dependent
variables. Missing items in psychometric rating scales were substituted by the individual
respondent’s mean score on the respective scales, when missing items did not constitute more
than half of the answered items.30
Independent samples t-tests, Pearson correlations and Chi-square tests were used to determine
which covariates had to be controlled for. The variables age, gender, marital status (married: yes/
no), education level (bachelors’ degree or higher: yes/no), comorbidities, type of operation (i.e.
gastric bypass or redo), were correlated with BMI at baseline and dietary adherence at 6 and 12
months after surgery. A variable was considered a potential covariate in case of a correlation
significant at p < .10.
Preliminary analysis showed that no patients reported not to have followed the dietary advices
at all. Therefore, logistic regression analyses were performed with the outcomes: “I generally
followed the dietary recommendations” and “I almost followed the dietary recommendations”.
In order to test the hypotheses concerning the association between current and past
psychological problems and attachment anxiety and attachment avoidance, on the one hand,
and adherence to dietary recommendations at 6 and at 12 months after bariatric surgery, on
the other hand, univariate logistic regression analyses were used. In order to determine which
variable predicted dietary adherence the most forward logistic repression analyses were used.
To test the hypothesis concerning the association between, on the one hand, dietary
recommendations at 6 and 12 months and, on the other hand, BMI at 12 months multiple
linear regression analyses were used, adjusted for baseline BMI. The percentage total weight loss
(%TWL) was calculated as (100x (baseline BMI - BMI at 12 months) / baseline BMI).
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Finally, to examine dietary adherence as a potential mediator of the association between the
strongest predictor(s) of dietary adherence and weight loss (BMI at 12 months following surgery
adjusted for baseline BMI) (Figure 2), a bootstrapping resampling method with bias-corrected
confidence estimates was done.31, 32 In the present study, the 95% bootstrap confidence interval
of the indirect effects was calculated based on 5000 bootstrap resamples 33, 34. If the confidence
interval does not overlap zero, the effect is said to be statistically significant. In all analyses,
significance levels were set at p < .05. Data were analyzed using SPSS 19.
Unmediated effectAttachmentanxiety
Adherence to dietary recommendations
Weight loss one year following gastric bypass
surgery
Figure 2. Dietary adherence at 6 months as mediator of the effect of attachment anxiety on weight loss one year following gastric bypass surgery. Pathway values are reported in the results section.
Results
Characteristics
Independent samples t-test showed that patients who dropped-out (n = 26) –as compared
to those who completed the study– scored higher on attachment anxiety [t(124) = -11.979,
(p < .001), 95% CI: -2.34; - 1.66] and attachment avoidance [t(126) = -3.139, (p = .002), 95% CI:
-.83; - 1.19]. Drop-outs did not differ significantly on any other variables in this study.
Our study sample included 105 patients, predominantly female (81%), with a mean age of 45 ±
9.1 years. Most patients lived with a partner (84%) and were employed (76%); about a quarter
of the sample (27%) had received higher education (bachelors’ degree or higher). Before surgery,
mean weight was 123.7 ± 19.7 kg and mean BMI was 42.7 (6.1) kg/m2. Most of the patients
underwent primary gastric bypass surgery (86%) and 14% of the patients had a revision gastric
bypass surgery with removal of gastric banding during the same operation. All patients were
operated laparoscopically.
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Pearson correlations showed that the p-value of the correlation between BMI at baseline and a
younger age was < .10: r = -.18, p = .06. BMI was not significantly related to gender, diabetes,
marital status, level of education and type of operation; these variables were excluded from
further analyses.
For dietary adherence at 6 and 12 months after surgery, Chi-square tests showed that patients
with diabetes (χ2=4.1, p = .04) were less adherent to dietary recommendations. No other variables
were found to be related to dietary adherence. At 6 months after surgery 70% and at 12 months
58% of the patients reported to be adherent to their dietary recommendations. Table 1 shows
the correlations between the five predictors in this study. Low to moderate correlations were
observed between attachment representations and psychological problems.
Table 1. Pearson correlations between of the five predictors in the study
1 2 3 41. Past psychological problems2. Current anxiety symptoms .133. Current depressive symptoms .10 .64***4. Attachment anxiety .44*** .24* .34***5. Attachment avoidance .27** .37*** .37** .49***
*p<.05, **p<.01, ***p<.001
Psychological problems, attachment and dietary adherence
Univariate logistic regression analyses, controlled for diabetes, showed that past psychological
problems (OR = 5.04, p = .007), current anxiety symptoms (OR = 1.16, p = .03), current depressive
symptoms (OR = 1.18, p = .02), attachment anxiety (OR = 4.76, p < .001) –but not attachment
avoidance (OR = 1.63, p = .13)– were associated with dietary adherence at 6 months (path A,
Figure 2). Similarly, past psychological problems (OR = 3.29, p = .01) current anxiety symptoms
(OR = 1.17, p = .008), current depressive symptoms (OR = 1.14, p = .04), attachment anxiety
(OR = 2.38, p = .009) –but not attachment avoidance (OR = 1.18, p = .56)– were associated
with dietary adherence at 12 months. Forward logistic regression analyses showed that of these
variables, attachment anxiety was the strongest predictor of dietary adherence at both 6 months
(Nagelkerke R2 = .30, OR = 4.92, p = .009) and 12 months (Nagelkerke R2 = .13, OR = 2.61,
p=.006).
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Diet adherence and weight loss
Multiple linear regression analyses, controlled for age and for baseline BMI, showed that poorer
adherence to dietary recommendations at 6 months (β = .23, p = .003) (path B, Figure 2), was
associated with less weight loss 12 month after surgery explaining 58% of the variance. Patients
who were adherent at 6 months showed a %TWL of 30.5 ± 6.5, while the patients who were less
adherent to dietary recommendations showed a %TWL of 24.7 ± 6.5 in the first year following
surgery. In contrast no association was found between adherence to dietary recommendations at
12 months (β = .09, p = .243) and weight loss at 12 months.
Mediation analysis attachment anxiety, dietary adherence and weight loss
Attachment anxiety, the strongest predictor of dietary adherence, was examined in mediation
analysis using the bootstrapping resampling method. Analyses adjusted for age and baseline
BMI showed that dietary adherence at 6 months mediated the association between attachment
anxiety and BMI (B = .51; 95% CI = .19 to 1.02). Since there was no relationship between dietary
adherence at 12 months and weight loss at 12 months, no mediating effect was found for dietary
adherence at 12 months.
Conclusion
Attachment anxiety was observed to be a main predictor of poor dietary adherence. In addition,
poor dietary adherence in the first 6 months after surgery showed an association with the amount
of weight loss 1 year after the operation. Overall we found support for the indirect effect of
attachment anxiety on weight loss in the year following a gastric bypass operation, mediated by
difficulty with adherence to dietary recommendations at 6 months.
Of the predictors that were examined in this study (past psychological problems, current
psychological problems, attachment anxiety, and attachment avoidance), attachment anxiety
was found to be the strongest predictor of poor adherence to dietary recommendations. A
possible explanation for this association can be found in the tendency of more anxiously attached
individuals to experience high levels of distress and to have problems with down-regulating
their negative affect.35 Eating may function as an emotion regulatory mechanism which may be
especially difficult to give up for more anxiously attached patients.36 This notion is in accordance
with previous studies showing an association between inadequate emotion regulation strategies
and eating disorders.37-40 A physiological mechanism may explain eating in response to stress and
distress. Animal studies have shown that the consumption of high caloric foods acts to calm the
stress-perceiving areas of the brain41-43 possibly by the release of oxytocin from the hypothalamus
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which has an anxiolytic effect.44 Thus, high caloric foods may help especially more anxiously
attached individuals to down-regulate their high levels of distress, thereby obstructing adherence
to dietary recommendations after gastric bypass surgery.
In contrast to expectations, no relationship was found between attachment avoidance and
adherence to dietary recommendations. This may be explained by a differential way of coping
between more anxious and more avoidantly attached individuals. While more anxiously attached
patients respond to stressors in a hypervigilant manner, more avoidantly attached patients tend to
respond by distancing, avoiding and repressing negative emotions.45-48 Perhaps for some of them
negative emotions occur less often, or their self-reliant way of coping sometimes even helps them
to follow dietary recommendations. Previous studies showing low adherence to medical regiment
by more avoidantly attached patients took the quality of the patient-physician relationship
into account.19 That is, more avoidantly attached patients may show to be less adherent only
when the relationship with the healthcare professional is less satisfying. Thus, although in some
circumstances attachment avoidance may obstruct healthy eating behavior, our results suggest
that attachment avoidance per se is not a vulnerability factor to low dietary adherence after
gastric bypass surgery.
Although there is no doubt that gastric bypass surgery is an effective treatment for the majority of
patients with morbid obesity, our results indicate that the amount of weight loss after surgery will
to some extent depend on the degree to which the patient succeeds in adopting healthy dietary
recommendations in the first 6 months after surgery, which is in agreement with other reports.4,
5 However, no relationship was found between adherence to dietary recommendations at 12
months and postoperative weight reduction. This finding suggests that adherence to dietary
recommendations is more predictive of future weight loss than of current weight loss. A future
study with a design using more repeated measurements during a longer time interval is needed
to examine this hypothesis.
A methodological asset of this study is the prospective design, but some weaker points should also
be indicated. First, our data of attachment and dietary adherence were obtained by self-report.
Second, dietary adherence was measured with single items which may have lead to problems in
measurement precision.49 Therefore, future studies should use more objective measures for dietary
adherence. Third, dietary recommendations were not controlled in this study, that is, patients
who showed more and less weight reduction postoperatively may have received more and less
dietary advice. Fourth, results do not necessarily generalizable to bariatric surgery patients as a
whole or to patients subjected to other operations or with a still higher weight before surgery.
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Fifth, selection bias is suggested as drop-out rates in this study were higher for more anxiously
and more avoidantly attached patients. Sixth, patients with a redo surgery were included as they
failed in terms of successful weight loss after laparoscopic adjustable gastric banding. However,
we did not find an association between type of surgery and weight loss or adherence to dietary
recommendations in this study.
Finally, while a dimensional and self-report measure of attachment has theoretical and statistical
advantages, the use of a categorical measure would have had clinical advantages 50. In future
studies a categorical measure based on a more thorough investigation such as the adult attachment
interview51 may be considered.52 A categorical measure makes it possible to further determine the
relevance of considering attachment when designing interventions aimed at optimizing the result
of a gastric bypass surgery.
In summary, in the year following a gastric bypass operation more anxiously attached patients are
indicated to have greater difficulty to adhere to dietary recommendations and consequently are
at greater risk of not being able to profit fully from a gastric bypass operation.
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3. Elkins G, Whitfield P, Marcus J, Symmonds R, Rodriguez J, Cook T. Noncompliance with behavioral recommendations following bariatric surgery. Obes Surg 2005;15(4):546-551.
4. Karmali S, Brar B, Shi X, Sharma AM, de Gara C, Birch DW. Weight recidivism post-bariatric surgery: a systematic review. Obes Surg 2013;23(11):1922-1933.
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6. Ritz SJ. The bariatric psychological evaluation: a heuristic for determining the suitability of the morbidly obese patient for weight loss surgery. Bariatr Surg Pract Patient Care 2006; 1: 97-105.
7. Snyder AG. Psychological assessment of the patient undergoing bariatric surgery. Ochsner J 2009;9(3):144-148.
8. Wadden TA, Sarwer DB. Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach. Surg Obes Relat Dis 2006;2(2):171-179.
9. van Hout GC, Vreeswijk CM, van Heck GL. Bariatric surgery and bariatric psychology: evolution of the Dutch approach. Obes Surg 2008;18(3):321-325.
10. Fabricatore AN, Crerand CE, Wadden TA, Sarwer DB, Krasucki JL. How do mental health professionals evaluate candidates for bariatric surgery? Survey results. Obes Surg 2006;16(5):567-573.
11. Aarts F, Hinnen C, Gerdes VEA, Acherman Y, Brandjes DPM. Psychologists’ evaluation of bariatric surgery candidates influenced by patients’ attachment representations and symptoms of depression and anxiety. J Clin Psychol Med Set 2014; 21(1):116-123.
12. Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol 1991;61(2):226-244.
13. Brennan KA, Clark CL, Shaver PR. Self-report measurement of adult attachment: An integrative overview. Attachment theory and close relationships. In: J. A. Simpson & W. S. Rholes, eds. Attachment theory and close relationships: 46-76. New York: Guilford Press 1998.
14. Crowell JA, Fraley RC, Shaver PR. Measures of individual differences in adolescent and adult attachment. In: J. Cassidy & P. R. Shaver, eds. Handbook of attachment: Theory, research, and clinical applications: 434-465. New York: Guilford Press 1999.
15. Gorin AA, Raftopoulos I. Effect of mood and eating disorders on the short-term outcome of laparoscopic Roux-en-Y gastric bypass. Obes Surg 2009;19(12):1685-1690.
16. Bowlby J. Attachment and Loss: retrospect and prospect. Am J Orthopsych 1969; 52(4), 664-678.
17. Consedine NS, Magai C. Attachment and emotion experience in later life: the view from emotions theory. Attach Hum Dev 2003;5(2):165-187.
18. Bennett JK, Fuertes JN, Keitel M, Phillips R. The role of patient attachment and working alliance on patient adherence, satisfaction, and health-related quality of life in lupus treatment. Patient Educ Couns 2011;85(1):53-59.
19. Ciechanowski PS, Katon WJ, Russo JE, Walker EA. The patient-provider relationship: attachment theory and adherence to treatment in diabetes. Am J Psychiatry 2001;158(1):29-35.
20. Hunter JJ, Maunder RG. Using attachment theory to understand illness behavior. Gen Hosp Psychiatry 2001;23(4):177-182.
21. Maunder RG, Hunter JJ. Attachment relationships as determinants of physical health. J Am Acad Psychoanal Dyn Psychiatry 2008;36(1):11-32.
22. Maunder RG, Hunter JJ. Attachment and psychosomatic medicine: developmental contributions to stress and disease. Psychosom Med 2001;63(4):556-567.
23. Wilkinson LL, Rowe AC, Bishop RJ, Brunstrom JM. Attachment anxiety, disinhibited eating, and body mass index in adulthood. Int J Obes (Lond) 2010;34(9):1442-1445.
24. Anderson SE, Whitaker RC. Attachment security and obesity in US preschool-aged children. Arch Pediatr Adolesc Med 2011;165(3):235-242.
25. Maunder RG, Hunter JJ. Assessing patterns of adult attachment in medical patients. Gen Hosp Psychiatry 2009;31(2):123-130.
26. Florian V, Mikulincer M, Bucholtz I. Effects of adult attachment style on the perception and search for social support. The Journal of Psychology 1995;129(6):665-676.
27. Priel B, Shamai D. Attachment style and perceived social support: effects on affect regulation. Personality and Individual Differences 1995;19(2):235-241.
28. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67(6):361-370.
29. Fraley RC, Waller NG, Brennan KA. An item response theory analysis of self-report measures of adult attachment. J Pers Soc Psychol 2000;78(2):350-365.
30. Schafer JL, Graham JW. Missing data: our view of the state of the art. Psychol Methods 2002;7(2):147-177.
31. Preacher KJ, Hayes AF. SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behav Res Methods Instrum Comput 2004;36(4):717-731.
32. MacKinnon DP, Lockwood CM, Williams J. Confidence Limits for the Indirect Effect: Distribution of the Product and Resampling Methods. Multivariate Behav Res 2004;39(1):99.
33. Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods 2008;40(3):879-891.
34. Hayes AF. Beyond Baron and Kenny: Statistical Mediation Analysis in the New Millennium. Communication Monographs 2009;76(4):408-420.
35. Maunder RG, Lancee WJ, Nolan RP, Hunter JJ, Tannenbaum DW. The relationship of attachment insecurity to subjective stress and autonomic function during standardized acute stress in healthy adults. J Psychosom Res 2006;60(3):283-290.
36. Raynes E, Auerbach C, Botyanski NC. Level of object representation and psychic structure deficit in obese persons. Psychol Rep 1989;64(1):291-294.
37. Evers C, Marijn Stok F, de Ridder DT. Feeding your feelings: emotion regulation strategies and emotional eating. Pers Soc Psychol Bull 2010;36(6):792-804.
38. Spoor ST, Bekker MH, Van Strien T, van Heck GL. Relations between negative affect, coping, and emotional eating. Appetite 2007;48(3):368-376.
39. Vandewalle J, Moens E, Braet C. Comprehending emotional eating in obese youngsters: the role of parental rejection and emotion regulation. Int J Obes (Lond) 2013.
40. Zijlstra H, van MH, Devaere L, Larsen JK, van RB, Geenen R. Emotion processing and regulation in women with morbid obesity who apply for bariatric surgery. Psychol Health 2012;27(12):1375-1387.
41. Dallman MF, Pecoraro N, Akana SF et al. Chronic stress and obesity: a new view of “comfort food”. Proc Natl Acad Sci U S A 2003;100(20):11696-11701.
42. Pecoraro N, Reyes F, Gomez F, Bhargava A, Dallman MF. Chronic stress promotes palatable feeding, which reduces signs of stress: feedforward and feedback effects of chronic stress. Endocrinology 2004;145(8):3754-3762.
43. Peters A, Pellerin L, Dallman MF et al. Causes of obesity: looking beyond the hypothalamus. Prog Neurobiol 2007;81(2):61-88.
44. Onaka T, Takayanagi Y, Yoshida M. Roles of oxytocin neurones in the control of stress, energy metabolism, and social behaviour. J Neuroendocrinol 2012;24(4):587-598.
45. Mikulincer M, Orbach J. Attachment style and repressive defensiveness: The accessibility and architecture of affective memories. Journal of Personality and Social Psychology 1995;68(5):917-925.
46. Turan B, Osar Z, Turan JM, Ilkova H, Damci T. Dismissing attachment and outcome in diabetes: The mediating role of coping. Journal of Social and Clinical Psychology 2003;22(6):607-626.
47. Fraley RC, Shaver PR. Adult attachment and the suppression of unwanted thoughts. Journal of Personality and Social Psychology 1997;73(5):1080-1091.
48. Vetere A, Myers LB. Repressive coping style and adult romantic attachment style: is there a relationship. Personality and Individual Differences 2002;32:799-807.
49. Fraley RC, Waller NG. Attachment theory and close relationships. In: Simpson JA, Rholes WS, editors. Adult attachment patterns: A test of the typological model. New York: Guilford Press; 1998:77-114.
50. Maunder RG, Hunter JJ. A prototype-based model of adult attachment for clinicians. Psychodyn Psychiatry 2012;40(4):549-573.
51. Heinicke CM, Levine MS. Clinical applications of the adult attachment interview. New York: 2008.
52. van IJzendoorn MH. Adult attachment representations, parental responsiveness, and infant attachment: a meta-analysis on the predictive validity of the Adult Attachment Interview. Psychol Bull 1995;117(3):387-403.
7The significance of attachment representations
for quality of life one year following gastric
bypass surgery: a longitudinal analysis
Floor Aarts, Rinie Geenen, Victor E.A. Gerdes, Dees P.M. Brandjes, Chris Hinnen
Submitted for publication
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Abstract
Objective: Quality of life after bariatric surgery may among other things depend on patients’
attachment representations such as anxiety about rejection and abandonment (attachment
anxiety) and avoidance of intimacy and interdependence (attachment avoidance). The aim of
this study was to examine whether attachment representations, independent of body mass index
(BMI), are associated with the level and course of physical functioning and mental well-being
after gastric bypass surgery.
Methods: This longitudinal study included 105 patients applying for a Roux-en-Y gastric bypass
operation. Patients’ attachment representations (ECR-R) were measured before surgery and
quality of life dimensions (physical functioning and mental well-being, SF-36) were measured
before surgery and 1, 3, 6 and 12 months following surgery. Linear mixed effect models were
used in analyses.
Results: Physical functioning (p < .001) improved and mental well-being worsened (p = .002)
in the postoperative interval. Both attachment anxiety (p = .005) and attachment avoidance
(p < .001) were associated with a lower level of mental well-being, but not with the postoperative
course of quality of life.
Conclusion: Our study suggests that bariatric surgery leads to improvement in physical
functioning but not mental well-being. Results highlight that patients with insecure attachment
representations should be protected against unrealistic expectations regarding improvement of
mental well-being after surgery.
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Introduction
Gastric bypass surgery is the weight loss treatment of choice for obese individuals with a body
mass index (BMI) of more than 35 kg/m2 in the presence of weight-related comorbidities.1 Several
studies indicated improvement in quality of life following gastric bypass surgery.2-4 In the present
study we propose that improvement in quality of life after bariatric surgery may in addition to the
amount of weight loss, depend on individual difference characteristics5 such as one’s attachment
representations.
Attachment theory describes the significance of attachment representations, i.e. the enduring
beliefs and expectations about the availability and responsiveness about the self (e.g., as
worthy of love and care) and about others (e.g., as trustworthy and caring).6 In adulthood these
beliefs and expectations are conceptualized as a set of mental states concerning anxiety about
rejection and abandonment, and avoidance of intimacy and interdependence.6-8 Patients high on
attachment anxiety have a sense of vulnerability and hypervigilance for threats, resulting in high
levels of perceived stress and distress.9 Despite their strong desire for closeness and reassurance,
research shows that support is hardly effective in reducing distress in these people.10 In contrast,
patients high on attachment avoidance feel uncomfortable in close relationships, perceive
others as unavailable and unable to provide adequate support when needed, and therefore
value independency and self-reliance.11, 12 The importance of attachment theory is supported
by the finding that both attachment anxiety and attachment avoidance have been found to
be associated with impaired quality of life in healthy people13, 14 and chronically ill patients.15 In
a cross-sectional study in morbidly obese bariatric surgery candidates an association between
attachment avoidance and poor mental health quality of life was observed.16 It is as yet unknown
whether attachment representations might impact the postoperative level and course of quality
of life. Quality of life takes into account patients’ physical functioning and mental well-being,
which are the main elements of health.
The aim of the present longitudinal study was to investigate whether attachment anxiety and
attachment avoidance, independent of the course of body mass index (BMI), are associated with
the level and course of physical functioning and mental well-being in the first year after a gastric
bypass operation.
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Methods
Study sample
Included in analyses were 105 patients with morbid obesity between 18-60 years of age who
had undergone Roux-en-Y gastric bypass operation in Slotervaart hospital, Amsterdam between
February and August 2012. The flow chart is presented in Figure 1. Of the 310 patients who
applied for bariatric screening, 190 were operated between April and December 2012 and 131
of these patients agreed to participate in this study. Eventually, 105 patients completed the study
and 26 were lost to follow-up.
Patients applying for bariatric screening
(n=310)
Not operated during study inclusion period
(n=68)
Not eligible for operation(n=44)
Operated(n=190)
Decided not to have surgery (n=8)
Agreed to participate in the study
(n=131)
Declined participation in the study(n=59)
Completed the study(n=105)
Dropped-out(n=26)
Figure 1. Flowchart
Procedures
All patients referred to the Slotervaart bariatric surgery clinic received pre-surgical multidisciplinary
assessment by a dietician, internist, surgeon and a psychologist including self-report questionnaires,
semi-structured interviews, and assessments of body weight and height (BMI, body mass index),
preoperative diet and exercise habits, co-morbidity and sociodemographics.
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For this study questionnaires were added to the standard set of preoperative measures assessing
patients’ attachment representations preoperatively and quality of life both pre- as postoperatively.
The study was conducted according to the guidelines of the Declaration of Helsinki and approved
by the Medical Ethical Committee of the Slotervaart Hospital. Informed consent was obtained
from all participants.
Instruments
Quality of life was measured using the SF-36.17 The physical component summary (as a reflection
of physical functioning) and mental component summary (as a reflection of mental well-being)
of the SF-36 were used as outcome variables in the present study.18 The validity of the Dutch
version of SF-36 has been tested and has good construct validity, high internal consistency, and
high test-retest stability; norm data were obtained from the Dutch Health Survey in community
and chronic disease populations.19
Adult attachment was assessed using the Experiences in Close Relationships-Revised Scale (ECR-R).
The ECR-R is a 36-item self-report measure of adult attachment, which requires participants to
reflect on their typical ways of relating in close/romantic relationships. Reviews of self-report
measures of adult attachment suggest that the ECR-R has the best psychometric properties of
the available measures.20 The ECR consists of two continuous subscales, attachment anxiety
(e.g., “I’m afraid that I will lose my partner’s love”) and attachment avoidance (e.g., “I prefer
not to show a partner how I feel deep down”). Both dimensions are assessed with 18 items.
Answers are on a 5-point scale ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (5). In the
present study, Cronbach’s alpha for subscale attachment anxiety was 0.88 and for the subscale
attachment avoidance 0.90.
Body weight and height as well as medical variables (e.g., hypertension, diabetes) were acquired
from patients’ medical records. Demographic variables (e.g., age, gender, marital status) at the
first assessment were self-reported by the patients.
Statistical analyses
Continuous variables are presented as means and standard deviations and categorical data
as frequencies and percentages. Assumptions of normality were checked for the dependent
variables. The score distributions of the quality of life dimensions were sufficiently normal to allow
parametric tests. Missing items in psychometric rating scales were substituted by the individual
respondent’s mean score on the respective scales, when missing items did not constitute more
than half of the answered items.21
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To examine which variables should be included as covariates in further analyses, independent
samples t-tests and Pearson correlations were used to test the associations between demographic
variables (i.e., age, gender, marital status, level of education), medical variables (i.e., hypertension,
diabetes, osteoarthritis, sleep apnoea, type of operation) on the one hand and the outcome
variables (i.e., physical functioning and mental well-being) at baseline on the other hand.
Linear mixed model analyses were used to examine whether the level and course of physical
functioning and mental well-being after the gastric bypass operation were predicted by
preoperative levels of attachment anxiety and attachment avoidance. Maximum likelihood
estimation was selected and a random intercept was added to all models to take account of
and maintain individual differences in baseline values. Three models were specified and tested
separately for both domains of quality of life.
In Model 1, linear mixed models examined the effect of time, that is, the change in outcome
measurements across baseline and the one, three, six and twelve month follow-ups after
surgery. Besides time, no other variables were added to this model.
Model 2 tested the main effect of attachment scores, that is, whether attachment anxiety and
attachment avoidance were associated with levels of physical functioning and mental well-being.
In this model, covariates that correlated with the dependent variable and the level of BMI over
time were included to adjust for these variables.
Since previous studies have shown that the course of BMI is associated with the course of quality
of life, we included the interaction term of BMI by time reflecting the course of BMI in model
3.22 In this way we adjusted for the course of BMI. Moreover, covariates that correlated with
the dependent variable were included in the model to adjust for these variables. Thus, model 3
tested whether attachment anxiety and attachment avoidance were associated with the course
of quality of life across the repeated measurements. This was done by predicting the quality
of life dimension from the interaction term of the attachment dimension by time. Significant
interactions were probed by plotting regression lines for individuals with low (-1 SD) and high (+1
SD) levels on the two interaction terms while filling out mean values for all the other variables.23
All analyses were performed with SPSS, version 19.0 (for Windows). The level of significance was
set at p < .05. All tests were two-tailed.
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Results
Independent samples t-tests showed that patients who dropped-out (n = 26) and those who
completed the study differed on attachment anxiety t(124) = -11.80, (p < .001), 95% CI: -2.34,
- 1.66 and attachment avoidance t(126) = -3.14, (p = .002), 95% CI: -.83, - 1.19. That is, more
anxiously and more avoidantly attached patients dropped-out of the study. Drop-outs did not
differ significantly on any other variables in this study.
Our study sample included 105 patients, who were predominantly female (81%) and had a mean
age of 45 years ± 9.1 years. Most patients lived with a partner (84%) and about a quarter of the
sample (27%) had received high education (bachelors’ degree or higher). The majority of patients
were employed (76%). Before the operation, the mean weight was 123.7 ± 19.7 kg and mean
BMI was 42.8 ± 6.1 kg/m2. Most of the patients had gastric bypass surgery for the first time
(86%) and 14% of the patients had a redo surgery (gastric bypass and removal of gastric band).
Table 1. Pearson correlations between of the five main variables in the study
1 2 3 41. Attachment anxiety2. Attachment avoidance .49**3. Physical functioning -.13 -.074. Mental well-being -.42** -.42** -.055. BMI .05 .00 -.21* .06
*p<.05, **p<.01
Table 1 shows the correlations between the main study variables. Independent samples t-test
showed that being a woman t(99) = -3.27, (p = .001), 95% CI: -12.33, -3.02, not having diabetes
t(99) = 3.15, (p = .002), 95% CI: 2.29, 10.11, having osteoarthritis t(99) = -5.486, (p < .001),
95% CI: -13.18, -6.18 and not having a partner t(99) = -2.02, (p = .046), 95% CI: -8.84, -.07
were associated with poorer physical functioning. Furthermore, having a lower education level
t(98) = -2.39, (p = .02), 95% CI: -7.36, -.69 and not having a partner t(99) = -2.12, (p = .04), 95%
CI: -7.50, -.25 were associated with poorer mental well-being. Thus, in model 2 and 3, tests of
physical functioning included the covariates gender, diabetes, osteoarthritis, and marital status,
and tests of mental well-being included the covariates education level and marital status.
Table 2 shows the means and standard deviations of the attachment variables, quality of life
dimensions, and BMI at the repeated assessments.
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Table 2. Means and standard deviations of the attachment variables, quality of life dimensions, and BMI at
the repeated assessments.
Baseline
M (SD)
1 month AfterM (SD)
3 months AfterM (SD)
6 months AfterM (SD)
1 year AfterM (SD)
Attachment anxiety 1.9 (.7) -- -- -- -- -- -- -- --Attachment avoidance 2.1 (.76) -- -- -- -- -- -- -- --Physical functioning 37.6 (9.5) 46.1 (8.3) 51.6 (8.4) 53.2 (7.6) 54.6 (7.1)Mental well-being 51.9 (7.8) 48.3 (8.7) 50.8 (8.9) 50.9 (8.7) 49.7 (9.3)BMI 42.8 (6.1) 38.0 (5.6) 34.8 (5.1) 33.5 (5.4) 30.1 (4.7)
Figure 2 shows the mean scores of the quality of life dimensions over time. Model 1 of the
linear mixed model analyses showed that physical functioning improved across the five repeated
measurements (F = 128.6, p < .001), while mental well-being worsened between baseline and
1 month (p < .001) and between baseline and one year after surgery (F = 4.28, p = .01). The
postoperative levels of physical functioning and mental well-being after surgery were close to the
norm of 50 as seen in the general population.19
Physical functioningMental well-beingbefore 37,58 51,881 month 46,14 48,283 months 51,56 50,756 months 53,15 50,91-yr after 54,62 49,73
30
40
50
60
before 1 month 3 months 6 months 1-yr after
Qua
lity
of L
ife
Operation
Physicalfunctioning
Mental well-being
Figure 2. Mean scores of the quality of life dimensions, physical functioning and mental well-being before gastric bypass surgery, and 1, 3, 6 and 12 months following surgery
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Model 2 examined whether baseline assessments of attachment anxiety and attachment avoi-
dance, controlled for covariates and the main effect of the level BMI over time, were associated
with the level of quality of life across repeated measurements. The level of BMI over time was
associated with the level of physical functioning (F = 14.43, p < .001) but not with the level
of mental well-being (F = .22, p = .639). Both attachment anxiety (F = 8.34, p = .005) and
attachment avoidance (F = 13.74, p < .001) were associated with the level of mental well-being
but neither attachment anxiety (F = .38, p = .537) nor attachment avoidance (F = .46, p =
.498) were associated with the level of physical functioning. Regarding the relation between
attachment representations and mental well-being, for each unit a patient scored higher on
attachment anxiety, the average level of mental well-being across repeated measurements was
2.5 units lower (CI: -4.27, .81). Moreover, for each unit a patient scored higher on attachment
avoidance, the average level of mental well-being across repeated measurements was 3.3 units
lower (CI: -5.05, -1.53).
Model 3 examined whether attachment representations were associated with the course of the
quality of life dimensions by testing the interaction between the attachment representations and
the repeated measurements at the quality of life dimensions. Analyses showed that attachment
representations were not associated with the course of physical functioning or mental well-being.
However, we did find that the postoperative course of physical functioning was predicted by the
interaction between BMI and time (F = 16.34, p < .001). The interaction is shown in Figure 3. As
compared to patients with a lower mean BMI (-1 SD in this sample), patients with a high mean
BMI (+1 SD in this sample) improved towards a similar level of physical functioning one year after
the operation despite their clearly lower level of physical functioning before the operation.
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low BMI high BMIbefore 46,02 38,561-yr after 55,35 56,42
30
40
50
60
before 1-yr after
Phys
ical
func
tioni
ng
Operation
low BMI
high BMI
Figure 3. Physical functioning as predicted from having a low vs. high average body mass index (BMI) and time of measurement (before vs. 1-yr after the operation)
Discussion
This study showed significant improvement in physical functioning but not in mental well-being
within the first year after a gastric bypass operation. Both attachment anxiety and attachment
avoidance were associated with a lower level of postoperative mental well-being. We did not find
an association between attachment anxiety and attachment avoidance and the postoperative
level of physical functioning. Also no association between attachment representations and the
postoperative course of physical functioning and mental well-being was found.
The finding that patients benefit more in terms of physical functioning than mental well-being is in
accordance with previous studies.22, 24 Mental well-being seems to be a rather constant factor that
is not easily influenced by weight reduction. As shown in a meta-analysis, physical functioning
deviates far more from normal in bariatric surgery candidates than mental well-being, and the
level of mental well-being is hardly dependent on body weight.25 In line with the results of this
meta-analysis, our study showed that a loss of body weight was associated with an improvement
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of physical functioning. However, the present study extends these results by indicating that to
improve mental well-being a focus on processes related to attachment representations may be
more important than a reduction of body weight. That is, insecurely attached patients reported
lower levels of mental well-being before bariatric surgery and remained more dissatisfied after
bariatric surgery than more securely attached patients.
The prospective design is an asset of this study, but a weaker point is that the study might be
biased towards patients with relatively good attachment representations, because patients with
poorer attachment representations dropped out. Future studies should examine the significance
of attachment representations for quality of life on the longer-term, as adult attachment may be
helpful in the selection of patients for surgery and the guidance of patients after surgery.
In summary, we found significant improvements in physical functioning −but not mental well-
being− one year following gastric bypass surgery. While weight and weight loss are predictors of
physical functioning, attachment representations predict levels of mental well-being.
In order to improve mental well-being in insecurely attached patients with morbid obesity other
strategies than weight reduction should be considered. A recent review provides preliminary
evidence that psychotherapy may be effective in promoting well-being in insecurely attached
patients by reframing and reappraising past interpersonal experiences.26 Also, rather than
changing attachment representations which may be an intensive and time consuming task,
attachment tailored care by healthcare workers may also promote well-being and prevent
an unnecessary increase in distress and turmoil.27 All patients, especially those with insecure
attachment representations, should be protected against unrealistic expectations of improvement
in mental well-being after surgery.
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Reference List
1. Adams TD, Davidson LE, Litwin SE et al. Health benefits of gastric bypass surgery after 6 years. JAMA 2012;308(11):1122-1131.
2. Karlsson J, Taft C, Ryden A, Sjostrom L, Sullivan M. 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(8):1248-1261.
3. Suter M, Donadini A, Romy S, Demartines N, Giusti V. Laparoscopic Roux-en-Y gastric bypass: significant long-term weight loss, improvement of obesity-related comorbidities and quality of life. Ann Surg 2011;254(2):267-273.
4. Aftab H, Risstad H, Sovik TT et al. Five-year outcome after gastric bypass for morbid obesity in a Norwegian cohort. Surg Obes Relat Dis 2013.
5. Loving TJ, Smets EM. Romantic relationships and health. In: Simpson JA, Campbell L, editors. The Oxford handbook of close relationships. New York: Oxford Univeristy Press: 2013:617-637.
6. Bowlby J. Attachment and Loss: retrospect and prospect. Am J Orthopsych 1969; 52(4), 664-678.
7. Crowell JA, Fraley RC, Shaver PR. Measures of individual differences in adolescent and adult attachment. In: J. Cassidy & P. R. Shaver, eds. Handbook of attachment: Theory, research, and clinical applications: 434-465. New York: Guilford Press 1999.
8. Griffin D BK. Models of the self and other: Fundamental dimensions underlying measures of adult attachment. Journal of personality and social psychology. J Pers Soc Psychol 1994; 67(3): 430–445.
9. Maunder RG, Hunter JJ. Assessing patterns of adult attachment in medical patients. Gen Hosp Psychiatry 2009;31(2):123-130.
10. George C, West M. The development and preliminary validation of a new measure of adult attachment: the adult attachment projective. Attach Hum Dev 2001;3(1):30-61.
11. Florian V, Mikulincer M, Bucholtz I. Effects of adult attachment style on the perception and search for social support. J Psychol 1995;129(6):665-676.
12. Priel B, Shamai D. Attachment style and perceived social support: effects on affect regulation. Personality and Individual Differences 1995;19(2):235-241.
13. Kotler T, Buzwell S, Romeo Y, Bowland J. Avoidant attachment as a risk factor for health. Br J Med Psychol 1994;67 ( Pt 3):237-245.
14. Hunter JJ, Maunder RG. Using attachment theory to understand illness behavior. Gen Hosp Psychiatry 2001;23(4):177-182.
15. Martin LA, Vosvick M, Riggs SA. Attachment, forgiveness, and physical health quality of life in HIV + adults. AIDS Care 2012;24(11):1333-1340.
16. Sockalingam S, Wnuk S, Strimas R, Hawa R, Okrainec A. The association between attachment avoidance and quality of life in bariatric surgery candidates. Obes Facts 2011;4(6):456-460.
17. VanderZee KI, Sanderman R, Heyink JW, de HH. Psychometric qualities of the RAND 36-Item Health Survey 1.0: a multidimensional measure of general health status. Int J Behav Med 1996;3(2):104-122.
18. Ware JE, Kosinski M, KSD. SF-36 physical and mental health summary scales: A user’s manual. Boston, MA: The Health Institute 1994.
19. Aaronson NK, Muller M, Cohen PD et al. Translation, validation, and norming of the Dutch language version of the SF-36 Health Survey in community and chronic disease populations. J Clin Epidemiol 1998;51(11):1055-1068.
20. Fraley RC, Waller NG, Brennan KA. An item response theory analysis of self-report measures of adult attachment. J Pers Soc Psychol 2000;78(2):350-365.
21. Schafer JL, Graham JW. Missing data: our view of the state of the art. Psychol Methods 2002;7(2):147-177.
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22. Karlsson J, Sjostrom L, Sullivan M. Swedish obese subjects (SOS)--an intervention study of obesity. Two-year follow-up of health-related quality of life (HRQL) and eating behavior after gastric surgery for severe obesity. Int J Obes Relat Metab Disord 1998;22(2):113-126.
23. Aiken LS, West SG. Multiple regression: Testing an interpreting interactions. Newbury Park: CA: Sage; 1991.
24. Julia C, Ciangura C, Capuron L et al. Quality of life after Roux-en-Y gastric bypass and changes in body mass index and obesity-related comorbidities. Diabetes Metab 2013;39(2):148-154.
25. van Nunen AM, Wouters EJ, Vingerhoets AJ, Hox JJ, Geenen R. The health-related quality of life of obese persons seeking or not seeking surgical or non-surgical treatment: a meta-analysis. Obes Surg 2007;17(10):1357-1366.
26. Taylor P, Rietzschel J, Danquah A, Berry K. Changes in attachment representations during psychological therapy. Psychother Res 2014.
27. Maunder RG, Hunter JJ. Assessing patterns of adult attachment in medical patients. Gen Hosp Psychiatry 2009;31(2):123-130.
8Gastric bypass may promote weight loss in
overweight partners the first year after surgery
Floor Aarts, Nalini N.E. Radhakishun, Mariska van Vliet, Rinie Geenen, Ines A. von Rosenstiel,
Chris Hinnen, Jos H. Beijnen, Dees P.M. Brandjes, Michaela Diamant, Victor E.A. Gerdes
Submitted for publication
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120 | Chapter 8
Abstract
Introduction: Both obesity and eating behavior clusters in families, with family members
imitating each others’ lifestyle. Following bariatric surgery, patients are expected to implement
diet and lifestyle changes. We hypothesize that cohabitating family members will lose weight and
improve their eating behavior within one year after surgery.
Materials and Methods: In this observational prospective study, repeated assessments were
taken in 92 morbidly obese patients who had gastric bypass surgery and their family members
(88 partners, 20 children >18 years and 25 children between 12-17 years) who lived in the same
household. Family members were asked to assess their weight and height before and three, six
and twelve months following bariatric surgery of the patient, and filled out the Dutch Eating
Behavior Questionnaire (DEBQ).
Results: Between baseline and one year following surgery, 49 (66.2%) partners of patients who
underwent gastric bypass surgery lost weight, 6 (8.1%) remained stable and 19 (25.7%) gained
weight. Using linear mixed model analysis, body mass index (BMI) of partners (p = .002), particular
of overweight (p < .001) partners –but not children– showed a small, significant decrease over
time. No significant changes in eating behavior for partners or children were found.
Discussion: The study indicates that gastric bypass surgery may have a ripple effect with body
weight in partners of patients decreasing over time. However, there is considerable variation in
the postoperative weight loss of partners.
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Introduction
The development of obesity is multifactorial with an important role for sedentary lifestyle,
hypercaloric diet and family factors.1 Parental weight has proven to be one of the most important
independent predictors of childhood obesity (17.9% increased risk for obesity with overweight
parents vs. 7.9% with normal weight parents),2 and consequently of obesity in adulthood.3, 4 While
parents and children share both genetic and environmental factors, data from the Framingham
Heart Study showed that if one’s partner becomes obese, the likelihood that the other partner
will become obese is increased by 37%.5
For patients with morbid obesity gastric bypass surgery is one of the most reliable and effective
treatments when previous interventions for achieving and maintaining weight loss have been
unsuccessful.6 The benefits of a gastric bypass operation include weight loss and reduction
of comorbidities and overall mortality.6, 7 Following gastric bypass, patients are instructed to
implement diet and lifestyle changes which may lead to partners and children mimicking the
altered behaviors of the patients undergoing gastric bypass surgery.8
Although some studies have been performed in partners and children of patients who underwent
gastric bypass surgery,9, 10 only one paper examined changes in weight and health behavior in
patients and their family members in the interval before and one year after the operation.8 This
study did find a decrease in weight in obese adult family members (n=50), but did not detect
significant differences in obese children, perhaps due to a small sample size (n=15). Furthermore,
family members received lifestyle counselling (e.g., dietary advice, multivitamins, physical exercise
advice) which will have influenced the effect of the gastric bypass operation on family members.
The present study adds to findings in previous studies by only monitoring weight change of
family members of patients undergoing gastric bypass surgery without adding an intervention
aimed to reduce weight loss in partners, by including twice as many partners and children, by
also investigating the change in eating behavior of family members, and by taking measurements
preoperatively and at three time points postoperatively.
We hypothesized that cohabitating family members of patients undergoing gastric bypass surgery
will lose weight and improve their eating behavior during the first year after the operation.
Therefore we set out a prospective observational study to evaluate weight, height and eating
behavior of the family members of patients undergoing gastric bypass surgery both before, as
well as three, six and twelve months after the operation.
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Materials and Methods
Study sample
Patients who underwent gastric bypass surgery in the Slotervaart Hospital (Amsterdam, The
Netherlands), and their cohabitating family members (partner and/or children, (12-85 years)) were
asked to participate in the study. Partners and children were excluded in case of not holding a
pair of scales or height measurement equipment (n = 0), an endocrine disorder (n = 2), treatment
with medications that may cause significant weight gain or loss such as glucocorticoids (n = 4),
participation in an organized weight reduction program (n = 0), participation in a clinical trial
within the last three months prior to screening (n = 0), previous surgical treatment for obesity
(n = 8), history of depressive disorder or other psychiatric disorders (n = 0), pregnancy (n = 1),
language barrier (n = 1) or mental incapacity (n = 0).
Study design
The design was an observational prospective study with repeated measurements before the
operation and three, six and twelve months postoperatively. Figure 1 shows the flowchart of the
inclusion process. At baseline, 177 families were eligible for participation in the study, of which
92 families agreed to participate. One year after bariatric surgery, 80 families of patients who had
gastric bypass surgery (77 partners, 20 children > 18 years and 19 children between 12-17 years)
completed the study and 4 families were lost to follow-up.
The patients’ weight and height were retrieved from the electronic patient files before surgery
and 1 year after the surgery. Family members’ weight and height were self-recorded at home and
participants were asked to fill out eating behavior questionnaires before and three, six and twelve
months postoperatively. Families were contacted by telephone to remind them of and instruct
them about the measurements and questionnaires.
The study was conducted according to the guidelines of the Declaration of Helsinki and approved
by the Ethics Review Board of the hospital. Written informed consent was obtained from all
participants, and, if between 12-17 years, also from their parents/guardians.
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Assessed for eligibility
n=177
Agreed to participate in the study
n=92
Not interested n=69
Excluded n=16
3 months
Missing: 21
Lost to follow up: 3
n=68
6 months
Missing: 23
Lost to follow up: 4
n=65
12 months
Missing: 8
Lost to follow up: 4
n=80
Figure 1. Study flowchart
Eating Behavior Questionnaire
Individual’s eating behavior was assessed using the validated Dutch Eating Behavior Questionnaire
(DEBQ).11 The questionnaire includes 13 items on emotional eating (e.g., ‘‘Does worrying make
you feel like eating?’’), 10 items on external eating (e.g.,‘‘Does walking past a candy store make
you feel like eating?’), and 10 items on restrained eating (e.g.,‘‘Do you intentionally eat food
that helps you lose weight?’’). The questionnaire has a five point Likert rating format, ranging
from 1 (never) to 5 (very often). The questionnaire has shown to possess fair internal consistency,
satisfactory test-retest stability and adequate construct and discriminant validity.11 In the current
study, Cronbach’s alpha for emotional eating was .95, for external eating .76 and for restrained
eating .94. The theoretical value of alpha varies from zero to 1. An alpha between .6 and .7 is
represents acceptable internal consistency, between .7 and .9 good internal consistency, and an
alpha ≥ .9 represents excellent internal consistency.
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Weight and height
Height was measured by participants at home without shoes, at approximately the same time
of the day, with their back against the wall looking straight ahead. Participants were instructed
to measure weight at home with an empty bladder, without shoes, only wearing light clothing,
at approximately the same time of the day, with the same pair of scales. BMI was calculated as
weight divided by squared height (kg/m²) for adults. Normal weight was defined as BMI < 25 kg/
m², overweight as BMI ≥ 25 and < 30 kg/m² obesity as BMI ≥30 kg/m².
For children BMI was standardized using z-scores according to Dutch reference values. A z-BMI
from 1.1 to 2.3 was classified as overweight and a z-BMI of 2.3 or higher as obese.12 The amount
of weight loss was calculated by subtracting baseline weight of the weight measured at one
year following surgery. Then three groups were defined: 1) a stable group showing no changes
in body weight, 2) a group losing weight (> -0.1 kg) and 3) a group gaining weight (> +0.1 kg).
Statistical analysis
Descriptive statistics were computed for demographics, weight and eating behavior. Means and
standard deviations were calculated for continuous variables; frequencies and percentages were
used to describe categorical data. Results were stratified by type of family member (partners,
children >18 years, children 12-17 years). The score distributions of the dependent variables, BMI
and eating behavior (emotional eating, external eating and restrained eating) were sufficiently
normal to allow parametric tests. Variables with a positively skewed distribution were log-
transformed or square root transformed before analysis. The univariate correlation between age,
sex and outcome variables (z-BMI and eating behavior) were examined. Demographic variables
that significantly correlated with the outcome variables were included in the model.
Linear mixed models analyses with random slopes were used to assess the change in outcome
measurements at baseline and three, six and twelve months after gastric bypass surgery for BMI,
emotional eating, external eating and restrained eating. A p-value of < 0.05 was considered
significant. All analyses were performed with SPSS, version 19.0 (for Windows).
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8
Results
Baseline characteristics are presented in Table 1. Complete data was obtained of 83 partners and
47 children (26 children > 18 years, 21 children between 12-17 years) of patients who underwent
gastric bypass surgery. Partners were predominantly male (80.7%) with a mean age of 49.3 years.
The percentage of boys was nearly 50% (48.1% in children > 18 and 47.6% in children between
12 and 17 years of age) of all children.
Table 1. Baseline characteristics stratified by family member
Patients Partners Children >18 Children 12-17N 88 83 26 21Male (%) 16 (18.2%) 67 (80.7%) 12 (46.2) 10 (47.6%)Age (years) 47.3±8.4 49.3±9.4 22.6±4.2 15.1±1.4Height (m) 1.71±.08 1.78±.09 1.78±.13 1.69±.06Weight (kg) 127.9±20.2 90.6±18.8 82.9±20.9 61.3±11.9BMI (kg/m2) 43.7±5.9 28.4±5.4 25.9±4.8 -- --Z-BMI -- -- -- -- -- -- .84±.96Emotional eating -- -- 1.6±.59 2.0±.87 1.8±.62External eating -- -- 2.7±.47 2.7±.56 2.6±.56Restrained eating -- -- 2.5±.91 2.4±1.1 2.1±.79Overweight (%) 0 40 (48.2) 9 (34.6) 1 (4.8)Obese (%) 88 (100) 24 (28.9) 5 (19.2) 1 (4.8)
BMI - body mass index. overweight adults: BMI ≥ 25 kg/m² & < 30 kg/m²overweight children Z-BMI > 2.1 & < 2.30, obese adults: BMI ≥30 kg/m²; obese children: Z-BMI > 2.3 corresponding to ≥ 95th percentile for age and gender.
Pearson’s correlations showed that for partners higher age was associated with restrained eating
(r = .26, p < .05) and that a higher BMI was associated with emotional, external (both r = .26,
p < .05) and restrained eating (r = .30, p < .01). For children > 18 years, a higher age was
associated with BMI (r = .57, p < .001) but no correlations between BMI and eating behaviors
were found. Furthermore, for children between 12 and 17 years z-BMI was correlated with both
external (r = .56, p < .05) and restrained eating (r = .48, p = .05). No sex-related differences were
noted in adults or children.
At baseline, 72.5% of adult family members (≥ 18 years) were either overweight (45.0%) or
obese (27.5%) which are higher rates as seen in the general Dutch population (37% overweight,
11% obese).13 In children between 12-17 years, 9.6% was overweight (4.8%) or obese (4.8%)
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which is more comparable to the Dutch population (10% overweight, 3% obese).13 Furthermore,
emotional eating, external eating and restrained eating of partners and children were comparable
with the general Dutch population.11
In total, 49 (66.2%) partners of patients who underwent gastric bypass surgery lost weight one
year after the operation, 6 (8.1%) remained stable and 19 (25.7%) gained weight. Ten (50%)
children with an age > 18 years lost weight one year after the operation, none remained stable
and 10 (50%) gained weight. Furthermore, 6 (33.3%) children with an age of 12-17 years lost
weight, none remained stable and 12 (66.7%) gained weight.
Table 2 shows the means and standard deviations of BMI and eating behavior over time for the
family members. Mixed model analyses showed that body weight (p = .002) and BMI of partners
(p = .002) decreased significantly over time. Both body weight (all ps < .01) and BMI (all ps < .05)
improved significantly between all time points. Between the baseline assessment and the 1-year
postoperative follow-up, the median BMI decrease was .41 kg/m2, interquartile range (IQR) 1.39,
total range -5.25 kg/m2 to +5.26 kg/m2 and there was a median weight loss in kg of 1.3 kg, IQR
4.38, range -12.00 kg to +16.30 kg in partners one year after surgery.
When divided by weight status (normal weight, overweight and obese), mixed model analyses
showed that body weight (M = 87.32 SD = 11.74 before surgery, M = 85.62 SD = 11.61 one year
after surgery, p < .001) and BMI (M = 27.43 SD = 1.53 before surgery, M = 26.76 SD = 1.74 one
year after surgery, p < .001) of overweight partners decreased significantly over time between all
time points (all ps < .01). No significant improvements were found for normal weight and obese
partners (data not shown).
Changes in body weight and BMI in children > 18 years of age were not significant over time.
In children between 12-17 years of age, there was no significant change in z-BMI over time. No
significant changes were found for emotional, external or restrained eating, for partners, or for
children.
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Table 2. Changes over time for family members of patients who underwent gastric bypass surgery.
BaselineM (SD)
3 months M (SD)
6 months M (SD)
1 year M (SD)
P (over time)
PartnersBody weight (kg) 90.58 (18.78) 88.72 (18.51)* 90.21 (16.3)* 88.87 (16.69)* <.01BMI (kg/m2) 28.49 (5.40) 27.68 (5.40)* 28.03 (4.86)* 28.00 (5.72)* <.01Eating behavior
emotional eating 1.64 (.59) 1.61 (.67) 1.60 (.56) 1.69 (.67) .623 external eating 2.68 (.47) 2.59 (.48) 2.56 (.54) 2.61 (.54) .410
restrained eating 2.50 (.91) 2.64 (.95) 2.55 (.82) 2.62 (.85) .244Children > 18 yearsBody weight (kg) 82.88 (20.87) 83.65 (19.23) 86.56 (19.62) 80.90 (16.42) .206BMI (kg/m2) 25.86 (4.79) 25.10 (4.33) 25.98 (5.39) 24.99 (3.67) .176Eating behavior
emotional eating 2.02 (.87) 2.18 (.95) 1.79 (.69) 2.14 (.87) .492 external eating 2.72 (.55) 2.79 (.68) 2.76 (.49) 2.87 (.56) .765
restrained eating 2.41 (1.05) 2.64 (1.06) 2.30 (1.11) 2.44 (1.11) .115Children 12-17 yearsBody weight (kg) 61.31 (11.95) 60.10 (11.36) 62.74 (13.86) 64.45 (13.77) <.05Z-BMI (kg/m2) .84 (.96) .57 (.87) .51 (1.32) .60 (1.23) .191Eating behavior
emotional eating 1.81 (.62) 1.62 (.25) 1.86 (.89) 1.48 (.39) .225 external eating 2.57 (.56) 2.57 (.55) 2.79 (.46) 2.64 (.42) .765
restrained eating 1.95 (.79) 1.80 (.75) 1.88 (.92) 1.84 (.69 .802
M= Means, SD= standard deviations, *p<.05 compared to baseline value. BMI- body mass index, Z-BMI: standard deviation score of BMI according to Dutch reference values. Eating behavior assessed by the Dutch Eating Behavior Questionnaire.
Conclusion
This study shows a positive change in the body weight in 2 out of every 3 partners living with
patients who underwent gastric bypass surgery. At baseline, almost half of the adult family
members in our cohort were overweight and one third obese, which, as expected, is significantly
higher than seen in the general Dutch population. A small but significant reduction in BMI of
partners, and in particular overweight partners, one year after bariatric surgery was observed.
This is in concordance with a previous study also observing no change in the weight in lean
partners.8 However, they did find significant weight loss in 21 obese partners (106 to 103 kg,
p < .01), but, in contrast to our results, not in overweight partners.8 However, another study
observed a mean increase of weight in 30 obese partners of patients who underwent gastric
bypass surgery.9 They hypothesized that a so called “garbage can effect” could cause this: due to
the limited oral intake of the partner who had gastric bypass surgery, the food that is left is eaten
by the partner causing an increase in weight.9 In our cohort, 66.2% of the partners lost weight,
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128 | Chapter 8
8.1% remained stable and 25.7% gained weight one year after gastric bypass of the partner. The
weight increase in a quarter of the partners in our cohort could be caused by this effect as well.
However, our data give more support to the hypothesis that the overweight partners mimicked
the more healthy eating behavior of the patient who underwent gastric bypass resulting in a
significant weight decrease over time.
Comparable to the only available study addressing this question,8 we found no difference in
z-BMI or eating behavior in children, aged 12-17 years. This could be due to the physiological
i.e. a higher energy need due to the puberty-related growth spurt or psychological development
of children going through puberty; i.e. they undergo progressive individualization, accompanied
by newly derived independence, which may leave the adolescents less sensitive to family-guided
behavioral changes; instead children’s eating behavior is affected by eating behavior of peers
proximate to the child.14
Indeed, we could not detect a change in eating behavior over time in children or partners of
patients who underwent gastric bypass surgery. In contrast, a previous study showed in 24 adult
family members of gastric bypass patients an improvement in uncontrolled and emotional eating
one year after surgery (p < .05).8 This discrepancy in outcome could not be explained in our study;
perhaps it is caused by differences in sample characteristics or the eating behavior questionnaire
used.
Although changes in body weight of partners9 and children8 of patients who underwent gastric
bypass surgery have been described in previous studies, the present study adds to this literature
by including twice as many family members and performing measurements at four different time
points; an interesting aspect of any weight loss intervention. Nevertheless, some limitations are
to be acknowledged. First, family members knew that they were participating in a study and had
to monitor their weight, which may have had impact on the family members’ weight loss. The
periodical contact by telephone to remind them and instruct them about the measurements and
questionnaires may have promoted their cooperation and weight loss. Second, comparable to a
previous study,9 weight, height and eating behavior of family members were obtained through
self-assessment. Although family members received extensive instructions regarding these
measurements, this may still have caused measurement bias, in particular for children in the age
between 12 and 17 who may still be growing. From the literature is known that in self-reports
individuals overestimate their height and underestimate their weight,15, 16 but since we were
interested in BMI change over time, measurement bias may not have influenced our results to a
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8
large extent. Third, the follow up of the study was one year, even though the trend of weight loss
seams stable, it would be preferable to extend the follow-up period to examine if this effect is
permanent. Finally, we did not include a control group also being monitored in terms of weight,
which precludes strong interference of our observational results.
In conclusion, partners of patients after gastric bypass surgery showed a decrease of weight in
the one year postoperative interval. Considering their higher than normal weight, the group of
partners may be a target group for weight loss interventions in the future. Prospective studies
with a control group that also monitors weight but with partners who did not have bariatric
surgery are needed to verify whether the bariatric surgery was the cause of weight loss in partners
of gastric bypass patients.
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Reference List
1. Simopoulos AP. Characteristics of obesity: an overview. Ann N Y Acad Sci 1987;499:4-13.
2. Davis MM, McGonagle K, Schoeni RF, Stafford F. Grandparental and parental obesity influences on childhood overweight: implications for primary care practice. J Am Board Fam Med 2008;21(6):549-554.
3. Agras WS, Mascola AJ. Risk factors for childhood overweight. Curr Opin Pediatr 2005;17(5):648-652.
4. Keane E, Layte R, Harrington J, Kearney PM, Perry IJ. Measured parental weight status and familial socio-economic status correlates with childhood overweight and obesity at age 9. PLoS One 2012;7(8):e43503.
5. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med 2007;357(4):370-379.
6. Christou NV, Sampalis JS, Liberman M et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg 2004;240(3):416-423.
7. Adams TD, Gress RE, Smith SC et al. Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357(8):753-761.
8. Woodard GA, Encarnacion B, Peraza J, Hernandez-Boussard T, Morton J. Halo effect for bariatric surgery: collateral weight loss in patients’ family members. Arch Surg 2011;146(10):1185-1190.
9. Madan AK, Turman KA, Tichansky DS. Weight changes in spouses of gastric bypass patients. Obes Surg 2005;15(2):191-194.
10. Watowicz RP, Taylor CA, Eneli IU. Lifestyle behaviors of obese children following parental weight loss surgery. Obes Surg 2013;23(2):173-178.
11. van Strien T, Frijters JER, Bergers GPA, Defares PB. The Dutch eating behaviour questionnaire (DEBQ) for assessment of restrained, emotional, and external eating behaviour. International Journal of Eating Disorders, 1986;5, 295-315.
12. Fredriks AM, van BS, Wit JM, Verloove-Vanhorick SP. Body index measurements in 1996-7 compared with 1980. Arch Dis Child 2000;82(2):107-112.
13. van Hilten O, Voorrips LE. Gezondheid en zorg in beeld. In: Centraal Bureau voor statistiek (CBS), editor. In Gezondheid en Zorg in Cijfers. Den Haag/Heerlen: 2012.
14. Wouters EJ, Larsen JK, Kremers SP, Dagnelie PC, Geenen R. Peer influence on snacking behavior in adolescence. Appetite 2010;55(1):11-17.
15. Pursey K, Burrows TL, Stanwell P, Collins CE. How Accurate is Web-Based Self-Reported Height, Weight, and Body Mass Index in Young Adults? J Med Internet Res 2014;16(1):e4.
16. Connor Gorber S, Tremblay M, Moher D, Gorber B. A comparison of direct vs. self-report measures for assessing height, weight and body mass index: a systematic review. Obes Rev 2007;8(4):307-326.
PART IIISummary and Appendices
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Summary | 133
Summary
The aim of this thesis was to examine social and emotional aspects of bariatric surgery and
obesity. Particular attention was given to the role of patients’ attachment representations. It
describes in two parts, the role of patients’ attachment representations preoperatively and the
postoperative situation by examining attachment representations as a predictor of the treatment
outcome of gastric bypass surgery for morbid obesity and the effect of gastric bypass surgery on
weight and eating behavior of cohabitating family members.
The first study described in Chapter 2 is a systematic review focusing on the relationship between
attachment representations and obesity. Peer-reviewed literature published between 1990 and
2013 was derived from PubMed, PsycINFO and reference lists of included papers. Ten studies
met the selection criteria. Six studies investigated an adult population whereas four studies
investigated children. For the evaluation of attachment representations, nine different methods
were used comprising both categorical and dimensional measures of attachment. Overall the
reviewed studies suggested a relationship between obesity and attachment insecurity, particularly
attachment anxiety, the anxiety about rejection and abandonment by others. Currently, less claims
can be made with regard to attachment avoidance. Possible reasons for an impact of attachment
representations on obesity are heightened physiological responses to stressful situations and the
underdevelopment of emotion-regulation. However, more research is needed to come to solid
conclusions. Despite the early stage of research and understanding in the field of obesity, there
may be a potential in considering attachment theory in obesity care.
Part I: Attachment representations, obesity and preoperative assessment
Chapter 3 is a cross-sectional study, examining whether patients’ self-reported attachment
representations and levels of depression and anxiety influenced psychologists’ evaluations of
morbidly obese patients applying for bariatric surgery. A group of 250 consecutively referred
candidates for bariatric surgery were assessed by the Slotervaart bariatric surgery clinic in
Amsterdam, the Netherlands between February 2012 and July 2012. Attachment anxiety (OR
= 2.50, p = .01) and attachment avoidance (OR = 3.13, p = .001) were found to be associated
with less positive psychological evaluations by psychologists, and symptoms of depression and
anxiety mediated this association. Findings of this study are useful for the psychological screening
of patients applying for bariatric surgery. That is, patients’ attachment representations influence
a psychologist’s evaluation in an indirect way by influencing the symptoms of depression and
anxiety patients report during an assessment interview.
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134 | Summary
Chapter 4 examined the mediating role of coping styles in the relation between attachment
and mental health and physical functioning in patients applying for bariatric surgery. The study
consisted of 299 patients referred for bariatric surgery to the Slotervaart bariatric surgery unit,
Amsterdam, the Netherlands between February and August 2012. Attachment anxiety (β = -.490,
p < .001) and attachment avoidance (β = -.387, p < .001) were found to be related to mental
health. In addition, attachment anxiety was also found to be related to physical functioning
(β = -.188, p < .001). Coping style were indicated to partly mediate these associations. Findings
suggest not only that it is important to consider attachment anxiety or attachment avoidance in
understanding mental health and physical functioning in patients with morbid obesity but also
that coping style plays a role in these relationships.
In Chapter 5 we investigated the association between attachment representations and mental
health care use in patients with morbid obesity applying for bariatric surgery. This study (N =
260) identified that attachment anxiety was associated with more mental health care visits (OR
= 1.86, 95% CI = 1.11-2.54, p = .02), present use of medication (OR = 2.30, 95% CI = 1.43-
3.68, p = .001) and previously prescribed medication (OR = 2.01, 95% CI = 1.13-3.57, p = .02).
Furthermore, the use of previously prescribed medication was especially prevalent in patients
with high attachment anxiety and low attachment avoidance (OR = 2.96, 95% CI = 1.35-6.50,
p = .007). In conclusion, the results of this study suggest that attachment behavior plays a role
in mental health care utilization of patients with morbid obesity who apply for bariatric surgery.
Therefore, it is important for health care providers working with patients with morbid obesity to
have knowledge of the attachment theory, to recognize anxious attachment representations and
to be aware of these patients’ desire of close relationships and hypervigilance for rejection as well
as of the mental vulnerability of this group.
Part II: Postoperative: attachment representations and effect on family members
The primary aim of Chapter 6 was to examine whether the association between on the one hand
current and past psychological problems, attachment anxiety and attachment avoidance, and on
the other hand weight reduction one year after gastric bypass surgery is explained by patients’
adherence to dietary recommendations. This longitudinal study included 105 patients applying
for a Roux-en-Y gastric bypass operation. Although there is no doubt that gastric bypass surgery
is an effective treatment for the majority of patients with morbid obesity, our results indicate that
the amount of weight loss one year after surgery will to some extent depend on the degree to
which the patient succeeds in adopting healthy dietary recommendations at 6 months. Of all
examined predictor variables, attachment anxiety was most strongly associated with low dietary
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Summary | 135
adherence at both 6 months (p = .009) and 12 months (p = .006) post-surgery. Mediation analyses
using resampling procedures indicated that in the year following a gastric bypass operation more
anxiously attached patients have greater difficulty with adherence to dietary recommendations at
6 months and consequently lose less weight.
Chapter 7 is a longitudinal cohort study, examining whether attachment anxiety and attachment
avoidance, independent of body mass index (BMI), predict the level and course of physical
functioning and mental well-being after gastric bypass surgery. This longitudinal study included
the same 105 patients applying for a Roux-en-Y gastric bypass operation as described in Chapter
6. Analyses showed significant improvement of quality of life for physical functioning (M = 37.6
SD = 9.5 before surgery, M = 54.6 SD = 7.1 one year after surgery, F = 128.6, p < .001), but
not for mental well-being (M = 51.9 SD = 7.8 before surgery, M = 49.7 SD = 9.3 after surgery,
F = 4.28, p = .01) within the first year after a gastric bypass operation. Both attachment anxiety
and attachment avoidance were associated with a lower level of mental well-being, but not with
the postoperative course of mental well-being and physical functioning. Our study suggests that
surgery and weight loss lead to improvement in physical functioning but not mental well-being
that is associated more clearly with attachment representations. Results highlight that patients
with weak attachment representations should be protected against unrealistic expectations
regarding improvement of mental well-being after surgery.
Chapter 8 describes a observational longitudinal study examining weight and eating behavior
changes in cohabitating family members of patients who underwent gastric bypass surgery during
the first year after the operation. In this study 92 morbidly obese patients undergoing gastric
bypass surgery and their cohabitating family members were followed (88 partners, 20 children
> 18 years and 25 children between 12-17 years). Results showed that between baseline and
one year following surgery, 49 (66.2%) partners of patients who had gastric bypass surgery lost
weight, 6 (8.1%) remained stable and 19 (25.7%) gained weight. Furthermore, body weight and
body mass index (BMI) of partners (p = .002), and in particular overweight partners (body weight
M = 87.32 SD = 11.74 before surgery, M = 85.62 SD = 11.61 one year after surgery, p < .001, and
BMI M = 27.43 SD = 1.53 before surgery, M = 26.76 SD = 1.74 one year after surgery, p < .001) –
but not children– showed a small, significant decrease over time. No significant changes in eating
behavior for partners or children were found. Gastric bypass surgery showed a ripple effect, as
weight and BMI of partners of patients decreased over time. However, there was a considerable
variation in the effect on partners. The results indicate that overweight family members may
be a target group for weight loss interventions in the future. Larger prospective studies with
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136 | Summary
standardized measurements in a case-control design are needed to assess the characteristics of
the group partners (of gastric bypass patients) that lose weight after the surgery.
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Samenvatting (Dutch Summary) | 137
Nederlandse samenvatting
Inleiding
Obesitas is een groot gezondheidsprobleem in welvarende landen en wordt gekenmerkt door
extreme vetophoping in het lichaam. Obesitas gaat vaak gepaard met andere ziektes zoals
diabetes, hart- en vaatziekten en psychische problematiek, en een verhoogde kans op vroegtijdig
overlijden. De meest gebruikte classificatie van obesitas voor volwassenen is BMI (Body Mass
Index); het lichaamsgewicht (kg) gedeeld door het kwadraat van de lichaamslengte in meters (kg/
m2). Een BMI tussen de 19-25 kg/m2 duidt op een normaal gewicht, tussen de 25-30 kg/m2 op
overgewicht, tussen de 30-40 kg/m2 op obesitas en een BMI van 40 kg/m2 of meer op morbide
obesitas.
Omdat dieet- en beweegprogramma’s weinig effectief lijken te zijn voor mensen met morbide
obesitas, richt deze groep zich na een aantal serieuze afvalpogingen vaak tot bariatrische
chirurgie. Bariatrische chirurgie (operatieve behandeling met als doel gewicht te verliezen) is
op dit moment de meest effectieve en aangewezen behandeling voor mensen met morbide
obesitas. Eén van de meest toegepaste vormen van bariatrische chirurgie is een gastric bypass
operatie (maagverkleining), waarbij de maag operatief wordt verkleind en verbonden met de
dunne darm, die op deze wijze functioneel wordt ingekort.
Drie kwart van de patiënten die een gastric bypass operatie ondergaat lijkt te profiteren van een
operatie in de zin van gewichtsverlies en kwaliteit van leven. Echter, bij één op de vier patiënten
blijft het gewichtsverlies en de verbetering van kwaliteit van leven achterwege terwijl de operatie
technisch goed gelukt is. De uitkomst van de operatie hangt niet alleen af van het slagen van de
operatie, maar ook van de mate waarin de patiënt in staat is zich dieetadviezen eigen te maken
en kwaliteit van leven te veranderen.
Naast psychologische problematiek verwachten we dat de gehechtheid van de patiënt van invloed
kan zijn op het wel dan niet kunnen volgen van dieetadviezen. Ook verwachten we dat inzicht in
gehechtheid helpt om kwaliteit van leven van de patiënt te kunnen voorspellen.
In de hechtingstheorie, ontwikkeld door John Bowlby, gaat men er vanuit dat mensen een
aangeboren behoefte hebben om de nabijheid van hun naasten te zoeken (hechtingsfiguren) in
bedreigende of stressvolle situaties. De nabijheid van anderen zorgt ervoor dat er een vorm van
veiligheid en rust wordt gecreëerd waardoor er met de dreiging en stress kan worden omgegaan.
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138 | Samenvatting (Dutch Summary)
Eerdere ervaringen die mensen hebben met de aanwezigheid en responsiviteit van anderen leiden
tot bepaalde gedachten en verwachtingen (interne werkmodellen) van zichzelf (zoals het waard
zijn om liefde en zorg te ontvangen) en anderen (zoals de verwachting dat anderen te vertrouwen
zijn en voor me zullen zorgen). Wanneer iemand vertrouwen heeft in zichzelf en in anderen, en
goed kan omgaan met stressvolle situaties, dan is waarschijnlijk sprake van veilige gehechtheid. Is
het natuurlijke hechtingsproces verstoord en de emotionele behoefte tijdens eerdere ervaringen
niet vervuld, dan raak iemand onveilig gehecht. Vaak gebeurt dit al in de kindertijd, wanneer de
opvoeder niet in staat is geweest om op emotioneel gebied voor het kind te zorgen, waardoor
het kind bijvoorbeeld voortdurend vernederd, genegeerd of afgewezen werd. Mensen verliezen
hierdoor het vertrouwen in zichzelf en richten zich daardoor sterk op anderen en raken onveilig
angstig gehecht, of verliezen het vertrouwen in anderen, onderdrukken de behoefte aan de
nabijheid van anderen en hebben het idee alleen te kunnen vertouwen op zichzelf en raken
onveilig vermijdend gehecht. Onderzoek heeft uitgewezen dat onveilig gehechte mensen (angstig
of vermijdend) eerder stress ervaren en minder goed in staat zijn om met negatieve gedachten en
emoties om te gaan dan veilig gehechte mensen.
Het doel van dit proefschrift is ten eerste om beter inzicht te krijgen in de rol van gehechtheid
in patiënten die zich aanmelden voor bariatrische chirurgie, ten tweede om te onderzoeken of
gehechtheid kan voorspellen waarom er verminderde uitkomsten optreden bij patiënten na een
gastric bypass operatie en ten derde om in beeld te brengen of er een indirect effect is van een
gastric bypass operatie op het gewicht en eetgedrag van de familieleden van de patiënt.
Samenvatting
Dit proefschrift is opgebouwd uit twee delen: een deel met onderzoeken voor de operatie en
een deel met onderzoeken na de operatie. Het eerste deel beschrijft de rol van gehechtheid bij
patiënten die zich aanmelden voor bariatrische chirurgie, het tweede deel beschrijft gehechtheid
als mogelijke voorspeller voor de uitkomst van de gastric bypass operatie, en het mogelijke effect
van een gastric bypass operatie op het eetgedrag en gewicht van familieleden.
Hoofdstuk 1 geeft een inleiding van het proefschrift en bestaat uit een overzicht van het
onderzoek in dit proefschrift en achtergrondinformatie over obesitas en de hechtingstheorie.
Hoofdstuk 2 geeft een systematisch overzicht van onderzoek naar het verband tussen gehechtheid
en obesitas. De databases PubMed en PsycINFO werden doorzocht om alle gepubliceerde
artikelen tussen 1990 en 2013 die dit verband onderzochten te verzamelen. Uiteindelijk zijn
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Samenvatting (Dutch Summary) | 139
10 onderzoeken meegenomen voor dit overzicht. Over het algemeen vonden we dat onveilige
gehechtheid en met name angstige gehechtheid samenhangen met obesitas. Mogelijke redenen
waarom gehechtheid samenhangt met obesitas kunnen gevonden worden in de aanwezigheid
van verhoogde fysiologische reacties op stressvolle situaties en de onderontwikkeling van emotie-
regulatie. Alleen wanneer in de toekomst goed uitgevoerde longitudinale studies worden gedaan,
kan de relevantie van onze bevindingen, vooral in termen van preventie en behandeling van
obesitas, worden vastgesteld.
Deel I: Preoperatief
Hoofdstuk 3 betreft een onderzoek waarbij het verband tussen gehechtheid van de patiënt en
de beoordeelding door de psycholoog voor de mate van geschiktheid voor bariatrische chirurgie
in beeld werd gebracht. Vervolgens is onderzocht in hoeverre de beoordeling van de psycholoog
verklaard werd door de aanwezigheid van symptomen van angst en depressie bij de patiënt. De
onderzoekgroep bestond uit 250 patiënten die waren doorverwezen voor bariatrische chirurgie
in het Slotervaartziekenhuis. De resultaten lieten zien dat patiënten die werden gekenmerkt
door onveilige gehechtheid door de psycholoog werden beoordeeld als minder geschikt voor de
operatie. Ook vonden we aanwijzingen dat dit deels te verklaren was door de symptomen angst
en depressie die de patiënt die door de psycholoog worden opgepikt.
In Hoofdstuk 4 onderzochten we of de manier van omgaan met tegenslag (coping) een rol
speelt in het verband tussen gehechtheid en mentale gezondheid en fysiek functioneren bij
patiënten die waren doorverwezen voor bariatrische chirurgie in het Slotervaartziekenhuis. We
legden 299 patiënten vragenlijsten voor over de relatie met hun naasten, omgang met tegenslag,
en fysiek en mentaal functioneren. De resultaten lieten zien dat meer onveilig gehechte patiënten
een minder goede mentale gezondheid hadden dan meer veilig gehechte patiënten en dat meer
angstig gehechte patiënten ook veel meer fysieke beperkingen ervoeren, wat deels te verklaren is
door de manier van omgang met tegenslag. Onze bevindingen laten niet alleen het belang zien
van de rol van gehechtheid in de mentale en fysieke gezondheid van de patiënt, maar ook dat de
coping stijl een rol zou kunnen spelen.
In Hoofdstuk 5 onderzochten we het verband tussen hechtingsgedrag en het gebruik
van mentale gezondheidzorg. De onderzoeksgroep bestond uit 260 patiënten die waren
doorverwezen voor bariatrische chirurgie in het Slotervaartziekenhuis. We vonden dat meer
angstig gehechte patiënten in het verleden vaker psychologische hulp kregen en vaker gebruik
maakten van psychofarmaca en dat ook het huidige gebruik van psychofarmaca aanzienlijk
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140 | Samenvatting (Dutch Summary)
hoger was in meer angstig gehechte patiënten dan in veilig of vermijdend gehechte patiënten.
Omdat gehechtheid een rol lijkt te spelen in het gebruik van geestelijke gezondheidszorg, is het
nuttig dat behandelend professionals goede kennis hebben over de hechtingstheorie, zodat ze
angstige gehechtheid kunnen herkennen, en zich bewust worden van de behoeften van deze
patiëntengroep. Ook is het belangrijk dat ze zich bewust zijn van de overgevoeligheid bij deze
patiënten voor afwijzing en de kwetsbaarheid voor de ontwikkeling van psychische problemen.
Deel II: Postoperatief
Het hoofddoel van Hoofdstuk 6 was te onderzoeken in hoeverre het verband tussen enerzijds
psychologische problemen in verleden en heden en gehechtheid en anderzijds gewichtsverlies
verklaard kan worden door het in meer of mindere mate trouw zijn aan dieetadviezen.
In totaal deden 105 patiënten die waren doorverwezen voor bariatrische chirurgie in het
Slotervaartziekenhuis mee in de studie. Hoewel er geen twijfel is dat een gastric bypass operatie
effectief is voor het grootste gedeelte van de patiënten met morbide obesitas, bieden onze
resultaten een aanwijzing dat de mate van gewichtsverlies na een jaar samenhangt met het
in meer of mindere mate volgen van dieetadviezen op 6 maanden. Van alle voorspellende
variabelen in dit onderzoek was angstige gehechtheid de sterkste voorspeller voor het minder
goed volgen van dieetadviezen. Toen we dit vervolgens in een medierend model analyseerden
vonden we dat meer angstig gehechte patiënten meer moeite lijken te hebben met het volgen
van dieetadviezen, wat vervolgens leidt tot minder gewichtsverlies postoperatief.
Hoofdstuk 7 is een longitudinaal onderzoek, waarbij in beeld werd gebracht in hoeverre
gehechtheid, onafhankelijk van het lichaamsgewicht (body mass index,BMI), samenhangt met het
niveau en verloop van kwaliteit van leven een jaar na de gastric bypass operatie. In totaal deden
105 patiënten mee aan het onderzoek; zij waren doorverwezen voor bariatrische chirurgie in het
Slotervaartziekenhuis deden mee aan het onderzoek. We vonden een significante verbetering
in kwaliteit van leven voor lichamelijk functioneren maar niet voor emotioneel welbevinden een
jaar na de operatie. Zowel angstig als vermijdende gehechtheid hingen samen met een lager
postoperatief niveau van emotioneel welbevinden. Echter, we vonden geen verband tussen
gehechtheid en het postoperatieve niveau van lichamelijk functioneren en gehechtheid en het
verloop van lichamelijk functioneren en emotioneel welbevinden. Terwijl gewicht en gewichtsverlies
voorspellers zijn voor lichamelijk functioneren, lijkt gehechtheid vooral emotioneel welbevinden
te voorspellen. Dit onderzoek benadrukt dat onveiligere gehechte patiënten beschermd moeten
worden tegen onrealistische verwachtingen over verbeterd emotioneel welbevinden na de
operatie.
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Samenvatting (Dutch Summary) | 141
Hoofdstuk 8 beschrijft een observationele longitudinale studie waarbij we een jaar lang
veranderingen in gewicht en eetgedrag bij familieleden van patiënten die een gastric bypass
operatie hebben ondergaan in beeld brachten. In totaal deden 92 patiënten en hun familieleden
die deel uit maakten van hetzelfde huishouden mee aan de studie. Deze familieleden betreffen
88 partners, 20 kinderen van 18 of ouder en 25 kinderen tussen de 12-17 jaar. Resultaten
lieten zien dat een jaar na de operatie 49 (66.2%) partners van patiënten die een gastric bypass
operatie hadden ondergaan een gewichtsafname hadden, 6 (8.1%) stabiel bleven in gewicht
en 19 (25.7%) aankwamen. Verder zagen we dat het lichaamsgewicht (BMI) van de partners
(p=.002) en met name partners met overgewicht (p<.001) –maar niet kinderen– een kleine daling
gedurende het jaar na de operatie liet zien. Geen significante verschillen werden gevonden voor
eetgedrag. Concluderend, partners van patiënten die een gastric bypass operatie ondergaan
vormen wellicht een interessante doelgroep voor een interventie voor gewichtsverlies. Voordat
we deze conclusie kunnen trekken zijn grotere prospectieve studies nodig die gebruik maken van
gestandaardiseerde meetinstrumenten en een controlegroep om de kenmerken van partners die
gewichtsverlies laten zien in kaart te brengen.
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142 | Dankwoord
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Dankwoord | 143
Dankwoord
Aangezien dit het eerst en meest gelezen hoofdstuk van mijn proefschrift zal zijn, wil ik graag
deze ruimte gebruiken om degene te bedanken die direct dan wel indirect –door er voor me te
zijn- betrokken waren bij de totstandkoming van mijn proefschrift.
Allereerst wil ik mijn twee promotoren prof. dr. Dees Brandjes en prof. dr. Rinie Geenen
bedanken. Beste Dees, zonder jou was mijn functie er wellicht niet (meer) geweest. Hoewel je
gedurende mijn promotieperiode je met name bezig hebt moeten houden met ‘de redding’ van
het Slotervaartziekenhuis, gaf je me toch vaak het gevoel dat je over mijn schouder meekeek
door het vertrouwen dat je in me had. Ik waardeer het dat we het samen toch nog voor elkaar
hebben weten te krijgen dat ik in juni kan promoveren. Beste Rinie, jou heb ik helaas pas in de
loop van mijn promotietraject als promotor aan boord gehaald. Direct nam je met jouw rustige
beschouwende maar kritische blik bij de interpretatie van de resultaten en het schrijven van de
artikelen een belangrijke rol in. Ik heb enorme bewondering voor jouw vermogen om in chaotische
stukken tekst orde te creëren. Je kritische blik zorgde keer op keer weer voor verfijning. Dank
voor deze prettige samenwerking!
Dr. Chris Hinnen en dr. Victor Gerdes beiden dank voor de begeleiding, de leerzame tijd en de
balans tussen de Psychologie en Geneeskunde. Beste Chris, wat heb ik het getroffen met jou als
co-promotor. Ik bewonder je bevlogenheid en kennis op het gebied van de psychologie. Jouw
vlotte respons op mijn e-mails werkte als een katalysator en hebben ervoor gezorgd dat het
tempo dat ik er graag in houd op hoog niveau bleef. Beste Victor, ik vond het mooi dat ik jouw
interesse in de psychologie als clinicus zag groeien gedurende mijn promotie. Jij durfde het aan
om met mij als promovenda dit promotietraject op te starten. Je gaf mij de ruimte om zelfstandig
te werken en hield me scherp. In het bijzonder was het prettig om zo nu en dan mijn hart bij je
te kunnen luchten, waarna mijn zorgen als wolken voor de zon verdwenen.
De leden van de promotiecommissie en de gastopponenten wil ik bedanken dat zij zitting
hebben willen nemen in mijn promotiecommissie en mijn proefschrift hebben beoordeeld op
wetenschappelijke waarde.
In het bijzonder wil ik alle patiënten die mee hebben gedaan aan de in dit proefschrift beschreven
studies ontzettend bedanken, zonder hun medewerking hadden deze onderzoeken niet plaats
kunnen vinden.
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144 | Dankwoord
Alle co-auteurs die hebben meegeschreven aan mijn stukken, Yair Acherman, Arnold van de Laar,
Mariska van Vliet, Ines von Rosenstiel, Jos Beijnen, Michaela Diamant en Nalini Radhakishun heel
erg bedankt. Lieve Nalini, wat heb ik het getroffen om samen met jou het ‘familieledenonderzoek’
te mogen uitvoeren. Jouw positieve benadering en gezelligheid hebben het onderzoek nog
leuker gemaakt.
Ook gaat mijn dank uit naar de psychologen van de medische psychologie van het
Slotervaartziekenhuis die hebben bijgedragen aan de inclusie van de patiënten voor het gros
van de studies. En in het bijzonder, Madelon Groenteman, Sanne Koemans, Willemijn Dekker
en Liedeke Duijverman. Kees, ook jij bedankt voor je hulp bij de inclusie en je interesse in het
onderzoek. Ook het ondersteunend personeel van het Slotervaartziekenhuis, zoals de postkamer,
secretaresses, en de centrale, dank voor jullie hulp. Jacqueline, jij bedankt voor het binnen halen
van mij bij de interne geneeskunde. Mede door jou ben ik van secretaresse uitgebloeid tot
onderzoeker. Beste Winnie, jou wil ik bedanken voor de artikelen die je telkens weer binnen no-
time voor me hebt opgezocht en de assistentie bij zoekopdrachten en het werken met Reference
Manager. Heel erg fijn!
Hoewel we altijd met een gezellig klein clubje aan promovendi op 9B in het Slotervaartziekenhuis
zaten, was het toch altijd wel een komen en gaan van onderzoekers. Mijn eerste onderzoeksmaatjes,
Danka en Patrick. Wat een top tijd had ik met jullie op ons kleine kamertje en wat een gemis toen
jullie beide gepromoveerd waren en het pand hadden verlaten. Lieve Marein/Marinus! SCALE-
maatje, maar ook gezellig ski- borrel- en dinermaatje. Lief en leed konden worden gedeeld. Erg
jammer dat je, met goed geluk, nog maar één keer per week in het SLZ was te vinden. Lieve
Laura, wat was ik blij toen jij na een aantal eenzame maanden onze kamer kwam bezetten. Dank
voor de gezelligheid en steuntjes in de rug die we elkaar konden geven. Thomas, een goede
aanwinst in ons onderzoeksteam die gedurende lange tijd alleen nog maar bestond uit vrouwen.
Mede dankzij jou, fungerend als mijn chauffeur naar het provinciale zuiden, heeft mijn promotie
toch nog in juni plaats kunnen vinden. ‘I’ll owe you big time’ –onbeperkt drank gedurende het
feest voor jou! Ook Funda, Maaike en Noëlle dank dat we er voor elkaar waren op de leuke
maar ook minder leuke momenten tijdens ons promoveren en niet te vergeten onze toch bijna
maandelijkse etentjes. Onderzoekers, het was gezellig!
Ook zijn er nog een aantal andere mensen in het Slotervaartziekenhuis die ik graag wil bedanken.
De internisten en arts-assistenten van 9B die in tijden van mijn promotie op de afdeling werkte.
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Dankwoord | 145
Dank voor de leuke sfeer op 9B en de gezellige uitjes, zoals het zeilen, de borrels en niet te
vergeten de ski-trip naar Sauze d’Oulx. Dames van de researchpoli, lieve Olga en Monique.
Hoewel ik nooit met jullie heb hoeven samen te werken bevonden we ons toch regelmatig met
onze research werkzaamheden op dezelfde verdieping. Dank voor jullie gezellige praatjes, de
kopjes thee en jullie brede interesse. Derk-Jan jij ook bedankt voor de gezelligheid en grappen en
grollen wanneer je even spontaan bij ons langskwam.
Mijn lieve vrienden en vriendinnen, ontzettend veel dank dat jullie mij de afgelopen jaren hebben
bijgestaan. Lieve Indra, wij gaan echt ‘way back’ en hopelijk ook nog jaren ‘way forward’!! Wij
begrijpen elkaar met een blik of een half woord. Dank voor je trouwe vriendschap, je bent me
veel waard. Lieve Mirte, lieve Janneke wat heb ik samen met jullie genoten van het Amsterdamse
leven, maar ook van het leven daarbuiten, de geweldige verre reizen die we gemaakt hebben
en de gedeelde “bodemloze sushi behoefte”. Lieve Maj, jij ook bedankt voor je gezelligheid,
luisterend oor en creatieve uitjes. Lieve dierbare vriendinnetjes uit Arnhem, Inger & Astrid,
Pauline, Claudia, Famke en Britt, ook al zijn we uitgewaaierd over het land (en het buitenland)
het blijft altijd heerlijk als vanouds met jullie. Lieve HBO-v vriendinnetjes, Marjo en Maaike. Die
maandelijkse etentjes in het voor ons centraal gelegen Utrecht houden we erin! Heerlijk dineren
terwijl we onze belevenissen van de gehele maand aan elkaar vertellen, altijd veel te gezellig en
veel te weinig tijd! Lieve Annet en alle andere Amsterdamse bootcamp- en hardloopmatties,
dank voor het samen ‘tot het gaatje’ gaan en de oh zo gezellige derde helft!! Merlijn dank voor
het lezen van een aantal van mijn stukken als ‘native speaker’ en Coen jij enorm bedankt voor het
ontwerpen van de kaft mijn proefschrift! Lieve Remy, dat ik jou nou nog in mijn laatste maanden
van mijn promotie heb mogen ontmoeten! Ik kijk uit naar alle momenten die we samen nog
mogen delen.
Lieve pap en mam, dank jullie wel voor jullie eeuwige steun en liefde, het loslaten en de oneindige
interesse. Altijd staan jullie voor me klaar! Lieve Arnout, grote broer, dank voor je droge humor,
je interesse en gezelligheid. Het was een pittig jaar voor ons vieren, waar we ons met elkaar goed
doorheen hebben weten te slaan. Wat ben ik ontzettend dankbaar, lieve pap, voor je goede
herstel. Dat we nog vele gezonde jaren en mooie momenten met elkaar als familie mogen delen.
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146 | PhD Portfolio
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PhD Portfolio | 147
PhD portfolioECTS
General courses
2011 Good Clinical Practice 0,9
2011 Electronic Data Capture training 0,9
2011 Training peripheral infusion 0,5
2012 Introductory biostatistics for researchers, Julius Centre Utrecht 2,9
Presentations
2011 The Influence of Psychological Factors on the Outcome of Gastric Bypass
Operation – Protocol presentation. Scientific meeting, Slotervaartziekenhuis.
0,5
2012 The evaluation of bariatric surgery candidates by psychologists. Scientific
meeting, Slotervaartziekenhuis, Amsterdam.
0,5
2013 Psychologists’ evaluation of bariatric surgery candidates influenced by patients’
attachment representations and symptoms of depression and anxiety.
Association for Researchers in Psychology and Health (ARPH) conference.
0,5
2013 Attachment representations: the gastric bypass patient. Internal Medicine,
Slotervaartziekenhuis Researchdag.
0,5
2014 Psychological attachment in obesity. The significance for bariatric surgery.
Internal Medicine, Slotervaartziekenhuis Researchdag.
0,5
Conferences
2012 the 30th Obesity Society Annual Scientific Meeting, Texas. 1,5
2012 23th symposium of the Netherlands Association for the Study of Obesity
(NASO), AMC, Amsterdam
0,25
2013 2nd annual conference of the Association for Researchers in Psychology and
Health (ARPH)
0,5
Other
1-2014 Trial nurse, SCALE-study, effect of liraglutide on body weight in non-diabetic
obese subjects or overweight subject with co-morbidities
10
1-2014 Trial nurse, CAPITA-study, Community-Acquired Pneumonia Immunization
Trial in Adults
2
Total ECTS 21,45
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148 | List of Publications
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List of Publications | 149
List of Publications
Aarts F, Geenen R, Gerdes VEA, Brandjes DPM, Hinnen C. The significance of attachment
representations for obesity: a systematic review. Submitted.
Aarts F, Hinnen C, Gerdes VEA, Acherman Y, Brandjes DPM. Psychologists’ evaluation of bariatric
surgery candidates influenced by patients’ attachment representations and symptoms of
depression and anxiety. J Clin Psychol Med Set 2014; 21(1):116-123.
Aarts F, Hinnen C, Gerdes VEA, Acherman Y, Brandjes DPM. Coping style as a mediator between
attachment and mental and physical health in patients suffering from morbid obesity. Int J
Psychiatry Med 2014;47(1):75-91.
Aarts F, Hinnen C, Gerdes VEA, Brandjes DPM, Geenen R. Mental Health Care Utilization in
Patients Seeking Bariatric Surgery: the Role of Attachment Behavior. Bariatr Surg Pract Patient
Care 2013;8(4):134-138.
Aarts F, Geenen R, Gerdes VEA, Van de Laar A, Brandjes DPM, Hinnen C. Attachment anxiety
predicts poor adherence to dietary recommendations: an indirect effect on weight change one
year after gastric bypass surgery. Submitted.
Aarts F, Geenen R, Gerdes VEA, Brandjes DPM, Hinnen C. The significance of attachment
representations for quality of life one year following gastric bypass surgery: a longitudinal analysis.
Submitted.
Aarts F, Radhakishun NNE, Van Vliet M, Geenen R, Von Rosenstiel IA, Hinnen C, Beijnen JH,
Brandjes DPM, Diamant M, Gerdes VEA. Gastric bypass may promote weight loss in overweight
partners the first year after surgery. Submitted.
Hoek W, Aarts F, Schuurmans J, Cuijpers P. Who are we missing? Non-participation in an Internet
intervention trial for depression and anxiety in adolescents. Eur Child Adoles Psy 2012;21(10):593-
595.
Celik F, Squizzato A, Aarts F, Groote ME, Fugazzola C, Gerdes VE. Imaging for the diagnosis of
pulmonary embolism in very obese patients; a survey among internists and radiologists in Italy
and the Netherlands. Thromb Res. 2013;131(4):189-190.
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Curriculum Vitae
Floor Aarts werd op 4 juni 1986 geboren als dochter van Aad Aarts en Fenna Aarts - van Heek
en zusje van de vier jaar oudere Arnout. Van 1999 tot 2004 genoot zij het Hoger Algemeen
Voorgezet Onderwijs aan het Lorentz Lyceum in Arnhem. Hierna startte zij haar verpleegkunde
opleiding aan de Hogeschool van Arnhem en Nijmegen, die in 2008 met goed succes werd
afgerond. Alvorens te gaan werken besloot zij haar horizon verder te verbreden, en begon aan
haar premaster Gezondheidswetenschappen. In 2010 slaagde zij voor haar master Prevention
and Public Health aan de Vrije Universiteit van Amsterdam. Na een jaar van reizen en werken,
begon zij in juni 2011 aan haar promotie traject in het Slotervaartziekenhuis onder begeleiding
van prof dr. Dees Brandjes, prof dr. Rinie Geenen (Universiteit van Utrecht), dr. Chris Hinnen en dr.
Victor Gerdes, waarvan dit proefschrift het eindresultaat is.
Floor Aarts was born on June 4th 1986 as the daughter of Aad Aarts and Fenna Aarts - van Heek,
and sister of the four years older Arnout. From 1999 till 2004 she followed secondary school
at Lorentz Lyceum in Arnhem. In 2004 she started her Bachelors in Nursing at the University of
Applied Sciences of Arnhem and Nijmegen, and graduated in 2008. Before starting the working
life, Floor decided to broaden her horizon and started her Premaster in Health Sciences. In 2010
she graduated for her Master’s degree in Prevention and Public Health at the Free University of
Amsterdam. After a year of travelling and working, she started her PhD thesis in the Slotervaart
Hospital in Amsterdam in June 2011, under the supervision of prof dr. Dees Brandjes, prof dr.
Rinie Geenen (University of Utrecht), dr. Chris Hinnen and dr. Victor Gerdes, of which this thesis
is the final result.
Kaft Floor - Psychological Attachment in Obesity Final.pdf 1 24-04-14 14:45 Uitnodiging Floor - Psychological Attachment in Obesity (drukbestand).pdf 1 18-04-14 15:36
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