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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


    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


    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



    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).



    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


    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


    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


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