Proefschrift Aarts

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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 20072008 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 persons

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

stat