https://doi.org/10.17795/ijpbs-2445

Comparison Between Marital Satisfaction and Self-Esteem Before and After Bariatric Surgery in Patients With Obesity

authors:

avatar Atefeh Ghanbari Jolfaei 1 , avatar Tahereh Lotfi 1 , avatar Abdolreza Pazouki 1 , avatar Azadeh Mazaheri Meybod 2 , * , avatar Fahimeh Soheilipour 1 , avatar Fatemeh Jesmi 1

Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, IR Iran
Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
Iranian Journal of Psychiatry and Behavioral Sciences: Vol.10, issue 3; e2445
published online: August 17, 2016
article type: Original Article
received: May 23, 2015
accepted: July 22, 2016

How To Cite Ghanbari Jolfaei A, Lotfi T, Pazouki A, Mazaheri Meybod A, Soheilipour F, et al. Comparison Between Marital Satisfaction and Self-Esteem Before and After Bariatric Surgery in Patients With Obesity. Iran J Psychiatry Behav Sci. 2016;10(3):e2445. https://doi.org/10.17795/ijpbs-2445.

Abstract

Background:

Obesity is one of the most common chronic diseases with important medical effects, as well as mental and social health problems. Bariatric surgery is one of the most effective treatments of morbid obesity.

Objectives:

Because of the possible psychological changes, and its effects on weight loss after surgery, the current study aimed to compare marital satisfaction and self-confidence in patients with obesity before and after bariatric surgery in Rasoul-e-Akram hospital in 2013.

Materials and Methods:

This prospective observational study was conducted on 69 candidates for bariatric surgery. Marital satisfaction and self-confidence were assessed before and six months after the surgery by Enrich marital satisfaction scale and Coopersmith self-esteem inventory. Descriptive statistics and T-tests were utilized to analyze data. Values of P ≤ 0.01 were considered statistically significant.

Results:

Despite the improvement of sexual relationship, marital satisfaction scores significantly decreased from141.26 ± 12.75 to 139.42 ± 12.52 six months after the surgery (P = 0.002). Satisfaction in scales of conflict resolution and communication showed a descending pattern (P < 0.001). No significant difference was found between self-esteem before and after the surgery (P = 0.321).

Conclusions:

Weight loss after bariatric surgery did not improve self-esteem and marital satisfaction six months post operatively; therefore, psychiatric assessment of patients before and after the surgery is crucial; since even if they are not associated with prognosis of the surgery, it is important to provide treatment for psychiatric problems. Prospective studies are recommended to assess post-operative changes of other psychological aspects.

1. Background

Today, obesity is one of the most common chronic diseases that affect the majority of people. It is estimated that about one-third of adults in the developed countries have obesity or overweight (1) and it is predicted that by the year 2040, more than 50% of people have overweight or obesity (2). Due to the lifestyle changes and eating patterns, the prevalence of obesity has also increased in Iran in the recent decades. Studies indicated that the prevalence of overweight and obesity among Iranian adults is 22% and 40%, respectively (3).Various factors including genetics, age, gender, diet, lack of exercise, eating disorders, psychiatric disorders and socioeconomic status can affect the weight and lead to obesity (4).

Besides important medical effects of obesity, including cardiovascular diseases, diabetes, hypertension, cancers, lung diseases, liver diseases, skeletal and joint diseases, mental and social health problems are also common in patients with obesity. Several studies show that obesity may be associated with mental disorders, and this relationship can be reciprocal (5-13).

Based on the side effects of obesity, researchers are continually seeking solutions to prevent and treat obesity (14). Non-surgical procedures such as diet therapy, medication, exercise, cognitive and behavior therapy and bariatric surgery are the current interventions to treat obesity (14-22).

Despite the growing research on the impact of bariatric surgery on medical conditions such as sleep apnea, diabetes and hypertension, the study on the impact of surgical interventions on mental health, social and psychological well-being of patients with obesity is limited. Some studies show an overall improvement in depressive symptoms, self-esteem, body image and health-related quality of life after the surgery. Findings were heterogeneous, i.e. in some studies a group of patients experienced post-operational (post-op) mental health benefits, while others reported some emotional problems after the surgery (23-31). A comprehensive research on 4047 Swedish obese subjects (SOS) demonstrated a significant reduction of depression and anxiety scores in the patients, one year after the surgery compared with those of the control group (32).

In contrast to the study by Carlson, a qualitative study showed an increase of psychological conflicts three, six and twelve months after the surgery. It was concluded that identity change, anger towards others and fear of losing food as a friend were the findings not reflected in the questionnaires in quantitative studies. Almost all the patients reported the increased post-op need of psycho-social support. The result of this study indicated that besides the psychological improvement, patients could have some psychological conflicts after bariatric surgery which should be considered (33).

2. Objectives

In regard to the importance of mental health and its possible changes and effects on weight loss after surgery (34), the current study aimed to assess marital satisfaction and self-confidence before and six months after undergoing bariatric surgery in patients with obesity.

3. Materials and Methods

It was a prospective observational study. All of the patients were admitted to the outpatient obesity clinic of Rasoul-e-Akram teaching hospital affiliated to Iran University of Medical Sciences from March 2012 to November 2013.

Patients were evaluated by two psychiatrist faculty members of Iran University of Medical Sciences with special interest in this area. The sampling method was convenient and all eligible patients, candidates for gastric bypass surgery, were selected to obtain a sample size of 69. The study was approved by the ethical committee of Iran University of Medical sciences, Tehran, Iran; it conforms to the provisions of the declaration of Helsinki (as revised in Edinburgh 2000) under the code 54163. Written informed consent was obtained from all subjects.

Excluding criteria were being unmarried, lack of interest to participate in the study, comorbidity of axis I psychiatric comorbidity and inability to complete the questionnaire because of cognitive problems or insufficient education.

In the current study, the following tools were used to collect data:

A) Enrich marital satisfaction questionnaire: Enrich scale is used to assess marital satisfaction of the subjects. The reliability and validity of original and Persian versions are reported in previous studies (35).

B) The Coopersmith self-esteem inventory: A measure of self-study, self-concept questionnaire. Previous studies demonstrated validity and reliability of the Persian version of the questionnaire (36).

C) The Persian structured clinical interview for DSM-IV axis I disorders (SCID-I): It is a diagnostic instrument which should be administered by a clinician. The Persian version had acceptable reliability, validity and feasibility on a large sample of Iranian patients; it was used to exclude the patients with major psychiatric comorbidities (37).

Descriptive statistics were utilized to determine the pre-surgical and post- surgical statuses of marital satisfaction and self-esteem. The changes of mentioned variables after surgery were assessed using T-tests. P values ≤ 0.01 were considered statistically significant.

4. Results

Sixty-nine patients with obesity were enrolled into the study; 63 patients (91.30%) were female. The mean age was 39.42 ± 8.87 years; 59 (85.5%) patients had high school diploma and others had higher educations.

The pre- and post-surgical body mass index (BMI) were 48.88 ± 4.7 and 29.3 ± 7.7, respectively (P = 0.0001). The pre- and post-surgical top scores of marital satisfaction were obtained on communication and sexual relationship scales, respectively. Compared with pre-surgical results, the scale of sexual relationship improved significantly (P = 0.0001) and satisfaction in scales of conflict resolution and communication showed a descending pattern post-surgically (P = 0.0001). Despite the improvement of sexual relationship, marital satisfaction scores significantly decreased six months after the surgery (P = 0.002).

The pre- and post-surgical scores of the other eight scales did not show a statistically significant difference (Table 1).

Also there was no significant difference between the pre- and post-operative scores of the Coopersmith self-esteem inventory (Table 2).

Table 1.

Marital Satisfaction of Patients Before and After the Surgery

VariablesBefore the Surgery, n = 69Six month After the Surgery, n = 69T ValuedfP Value
Spiritual beliefs13.52 ± 3.7913.26 ± 3.631.175680.244
Family and friends14.52 ± 3.4914.23 ± 3.021.297680.199
Sexual relationship15.37 ± 3.1918.65 ± 3.358.22168< 0.001
Children and parenting14.00 ± 2.4213.68 ± 2.541.518680.134
Conflict resolution16.51 ± 3.1614.78 ± 2.316.39068< 0.001
Financial management15.24 ± 2.7415.24 ± 2.700.106680.916
Leisure activities15.44 ± 3.0015.34 ± 2.630.47680.64
Personality issues16.54 ± 3.6716.37 ± 3.070.414680.680
Communication16.86 ± 3.7016.43 ± 4.913.98968< 0.001
Idealistic distortion13.90 ± 2.4113.72 ± 2.331.418680.143
Role relationship13.41 ± 3.7513.24 ± 3.471.183680.293
Marital satisfaction141.26 ± 12.75139.42 ± 12.523.149680.002
Table 2.

The Mean Difference Between the Pre- and Post-Operative Self-Esteem

VariableTimeMean ± SDdfT ValueP Value
Self-EsteemBefore surgery43.65 ± 4.9268-1.00.321
After Surgery43.53 ± 4.88

5. Discussion

The current study did not show a positive change in marital satisfaction six months after bariatric surgery.

Perhaps one of the reasons was the shortness of the follow-up interval. It is supposed that associations between weight and bio psychosocial status affecting quality of life could become more significant after long term fallow-up; since before the surgery patients had a common problem of morbid obesity, the heterogeneity of sample was low. During the first months after bariatric surgery, patients had common problems of fast weight loss, losing food as a friend and adjustment with new life, but after that the heterogeneity increased; therefore, the analysis of correlations was well founded. Some studies concluded that the duration of follow-up after bariatric surgery can affect the impact of bariatric surgery on psychological improvement (24). The result of some studies, such as that of Cooper and Wells on patients with obesity before and after gastric bypass surgery showed that after even three months nearly 69% of the patients had an increase in their marital satisfaction (38).

Results of a study by Bond et al. on 102 females who were candidates for bariatric surgery showed that 61% of them had problems in sexual desire, sexual arousal and orgasm (39).

Consistent with this study, another study on 54 females before and six months after bariatric surgery demonstrated a considerable improvement in sexual functioning of the subjects. From 63% of patients who complained of sexual problems before surgery and 68% reported improvement of sexual functioning six months after bariatric surgery. This improvement was not associated with the quantity of weight loss and the type of surgery (39). Dano and Hahn-Pedersen also reported that patients experienced a lower rate of sexual problems post-operatively (27).

In the current study, despite the improvement of sexual relationship, marital satisfaction scores, especially the score of conflict resolution, decreased after surgery. In contrast to this, in a study on 54 females one year after bariatric surgery, 52% of the patients reported improvement of marital satisfaction. They also reported post-op improvement of social life, sexual function and self-esteem (40). Rand et al. considered an increased rate of divorce after the surgery and reported that happy marriages had the same or even better situations before the surgery compared with that of after the surgery; in another words, the surgery had a negative effect on pre-surgically conflictual relationships (40).

A study on 69 married females before and 12 months after bariatric surgery by Hafner revealed decrease in the post-op affection feeling/behavior scale of the marital attitudes questionnaire. After the surgery, the females evaluated themselves more social and attractive and their husbands described their wives’ social contacts excessive (41). Hafner et al. also found marital problems were centered on issues of control and power. On the other hand, the role of changes and power struggle between the couples after the weight loss could deteriorate the marriage and lead to marital discord (41).

Concurring with this study, Crisp et al. reported that although 46% of the married patients reported a post-operative enhancement in sexual desire; only 2 of 10 patients stated the improvement of their marriage (26). These results could be explained by decrease of submissiveness of patients with obesity after losing weight and increase of self-confidence and autonomy. These results could show the importance of further psycho-social support for the couple after bariatric surgery. As a result, assessment of marital satisfaction and offer of psychological intervention, if needed, is strongly suggested pre- and post-surgically.

The post-surgical changes in patients’ self-esteem is noteworthy, since poor self-esteem can deteriorate their prognosis and increase the risk of post-op weight regain according to the study by Georgiadis (42). In the current study, there was no significant difference between the pre- and post-operative scores of self-esteem. The relationship between self-esteem in patients with obesity before and after the surgery is fairly complicated. Meanwhile, some studies showed the relationship between obesity and poor self-esteem, and concluded that the weight loss could lead to increased self-esteem; some studies showed that obesity after childhood was not correlated with lower self-esteem scores (43).

In contrast to the current study, some studies showed a significant increase in the subjects’ self-esteem after the surgery (26).

The results of the current study indicated no significant increase in self-esteem scores, six months after the surgery. Maybe, since the candidates for bariatric surgery had more mental health issues and poorer self-esteem in comparison with other patients with obesity, improvement of their mental health cannot be achieved in short time or only after losing weight and psychological interventions are needed (44-48). Besides, sagging and loose skin after a considerable weight loss is observed in majority of the patients and this could affect their post-op body image satisfaction and their self-esteem (49, 50).

The small number of sample size and the short-term follow-up were limitations of the current study. Prospective studies with long-term follow-up, which consider other psychosocial variables influencing the marital satisfaction such as quality of life, socioeconomic characteristics and marital satisfaction of patients, are recommended.

References

  • 1.

    Berrington de Gonzalez A, Hartge P, Cerhan JR, Flint AJ, Hannan L, MacInnis RJ, et al. Body-mass index and mortality among 1.46 million white adults. N Engl J Med. 2010;363(23):2211-9. [PubMed ID: 21121834]. https://doi.org/10.1056/NEJMoa1000367.

  • 2.

    Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293(15):1861-7. [PubMed ID: 15840860]. https://doi.org/10.1001/jama.293.15.1861.

  • 3.

    Rashidi A, Mohammadpour-Ahranjani B, Vafa MR, Karandish M. Prevalence of obesity in Iran. Obes Rev. 2005;6(3):191-2. [PubMed ID: 16045632]. https://doi.org/10.1111/j.1467-789X.2005.00174.x.

  • 4.

    Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB. Annual deaths attributable to obesity in the United States. JAMA. 1999;282(16):1530-8. [PubMed ID: 10546692].

  • 5.

    Preston SH. Deadweight?--The influence of obesity on longevity. N Engl J Med. 2005;352(11):1135-7. [PubMed ID: 15784667]. https://doi.org/10.1056/NEJMe058009.

  • 6.

    Gluck ME, Geliebter A, Satov T. Night eating syndrome is associated with depression, low self-esteem, reduced daytime hunger, and less weight loss in obese outpatients. Obes Res. 2001;9(4):264-7. [PubMed ID: 11331430]. https://doi.org/10.1038/oby.2001.31.

  • 7.

    James WP, Caterson ID, Coutinho W, Finer N, Van Gaal LF, Maggioni AP, et al. Effect of sibutramine on cardiovascular outcomes in overweight and obese subjects. N Engl J Med. 2010;363(10):905-17. [PubMed ID: 20818901]. https://doi.org/10.1056/NEJMoa1003114.

  • 8.

    Henderson KE, Brownell KD. The toxic environment and obesity: contribution and cure. Handbook of eating disorders and obesity. New York: Wiley and Sons; 2004. p. 339-48.

  • 9.

    Jiao L, Berrington de Gonzalez A, Hartge P, Pfeiffer RM, Park Y, Freedman DM, et al. Body mass index, effect modifiers, and risk of pancreatic cancer: a pooled study of seven prospective cohorts. Cancer Causes Control. 2010;21(8):1305-14. [PubMed ID: 20383573]. https://doi.org/10.1007/s10552-010-9558-x.

  • 10.

    Sutin AR, Costa PT, Chan W, Milaneschi Y, Eaton WW, Zonderman AB, et al. I know not to, but i can't help it: weight gain and changes in impulsivity-related personality traits. Psychol Sci. 2013;24(7):1323-8. [PubMed ID: 23630223]. https://doi.org/10.1177/0956797612469212.

  • 11.

    Sanchez-Villegas A, Pimenta AM, Beunza JJ, Guillen-Grima F, Toledo E, Martinez-Gonzalez MA. Childhood and young adult overweight/obesity and incidence of depression in the SUN project. Obesity (Silver Spring). 2010;18(7):1443-8. [PubMed ID: 19875985]. https://doi.org/10.1038/oby.2009.375.

  • 12.

    Oreopoulos A, Padwal R, McAlister FA, Ezekowitz J, Sharma AM, Kalantar-Zadeh K, et al. Association between obesity and health-related quality of life in patients with coronary artery disease. Int J Obes (Lond). 2010;34(9):1434-41. [PubMed ID: 20386551]. https://doi.org/10.1038/ijo.2010.73.

  • 13.

    Li C, Ford ES, Zhao G, Croft JB, Balluz LS, Mokdad AH. Prevalence of self-reported clinically diagnosed sleep apnea according to obesity status in men and women: National Health and Nutrition Examination Survey, 2005-2006. Prev Med. 2010;51(1):18-23. [PubMed ID: 20381517]. https://doi.org/10.1016/j.ypmed.2010.03.016.

  • 14.

    Grudell AB, Sweetser S, Camilleri M, Eckert DJ, Vazquez-Roque MI, Carlson PJ, et al. A controlled pharmacogenetic trial of sibutramine on weight loss and body composition in obese or overweight adults. Gastroenterology. 2008;135(4):1142-54. [PubMed ID: 18725220]. https://doi.org/10.1053/j.gastro.2008.07.009.

  • 15.

    Perri MG, Corsica JA. Improving the maintenance of weight lost in behavioral treatment of obesity, Handbook of obesity treatment. 1. New York, NY, US: Guilford Press; 2002. p. 357-79.

  • 16.

    Goodpaster BH, Delany JP, Otto AD, Kuller L, Vockley J, South-Paul JE, et al. Effects of diet and physical activity interventions on weight loss and cardiometabolic risk factors in severely obese adults: a randomized trial. JAMA. 2010;304(16):1795-802. [PubMed ID: 20935337]. https://doi.org/10.1001/jama.2010.1505.

  • 17.

    Cigaina V. Gastric pacing as therapy for morbid obesity: preliminary results. Obes Surg. 2002;12(1):12S-6S.

  • 18.

    Bays HE. Current and investigational antiobesity agents and obesity therapeutic treatment targets. Obes Res. 2004;12(8):1197-211. [PubMed ID: 15340100]. https://doi.org/10.1038/oby.2004.151.

  • 19.

    Gallagher D, Heymsfield SB, Heo M, Jebb SA, Murgatroyd PR, Sakamoto Y. Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index. Am J Clin Nutr. 2000;72(3):694-701. [PubMed ID: 10966886].

  • 20.

    Deitel M, Shikora SA. Introduction. Gastric pacing for obesity. Obes Surg. 2002;12 Suppl 1:2S. [PubMed ID: 11969105].

  • 21.

    Statement on morbid obesity and its treatment. Obes Surg. 1997;7(1):40-1. [PubMed ID: 9730537].

  • 22.

    Dieting and the development of eating disorders in overweight and obese adults. Arch Intern Med. 2000;160(17):2581-9. [PubMed ID: 10999971].

  • 23.

    Balsiger BM, Kennedy FP, Abu-Lebdeh HS, Collazo-Clavell M, Jensen MD, O'Brien T, et al. Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity. Mayo Clin Proc. 2000;75(7):673-80. [PubMed ID: 10907381]. https://doi.org/10.4065/75.7.673.

  • 24.

    Larsen JK, Geenen R, van Ramshorst B, Brand N, de Wit P, Stroebe W, et al. Psychosocial functioning before and after laparoscopic adjustable gastric banding: a cross-sectional study. Obes Surg. 2003;13(4):629-36. [PubMed ID: 12935367]. https://doi.org/10.1381/096089203322190871.

  • 25.

    van Hout GC, Boekestein P, Fortuin FA, Pelle AJ, van Heck GL. Psychosocial functioning following bariatric surgery. Obes Surg. 2006;16(6):787-94. [PubMed ID: 16756745]. https://doi.org/10.1381/096089206777346808.

  • 26.

    Crisp AH, Kalucy RS, Pilkington TR, Gazet JC. Some psychosocial consequences of ileojejunal bypass surgery. Am J Clin Nutr. 1977;30(1):109-20. [PubMed ID: 831433].

  • 27.

    Dano P, Hahn-Pedersen J. Improvement in quality of life following jejunoileal bypass surgery for obesity. Scand J Gastroenterol. 1977;12(7):769-74. [PubMed ID: 594647].

  • 28.

    van Hout G. Psychosocial effects of bariatric surgery. Acta Chir Belg. 2005;105(1):40-3. [PubMed ID: 15790201].

  • 29.

    Bocchieri LE, Meana M, Fisher BL. A review of psychosocial outcomes of surgery for morbid obesity. J Psychosom Res. 2002;52(3):155-65. [PubMed ID: 11897234].

  • 30.

    Herpertz S, Kielmann R, Wolf AM, Langkafel M, Senf W, Hebebrand J. Does obesity surgery improve psychosocial functioning? A systematic review. Int J Obes Relat Metab Disord. 2003;27(11):1300-14. [PubMed ID: 14574339]. https://doi.org/10.1038/sj.ijo.0802410.

  • 31.

    Batsis JA, Clark MM, Grothe K, Lopez-Jimenez F, Collazo-Clavell ML, Somers VK, et al. Self-efficacy after bariatric surgery for obesity. A population-based cohort study. Appetite. 2009;52(3):637-45. [PubMed ID: 19501761]. https://doi.org/10.1016/j.appet.2009.02.017.

  • 32.

    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):113-26. [PubMed ID: 9504319].

  • 33.

    Magdaleno R, Chaim EA, Turato ER. Psychological recommendations in the massive weight loss for patients after bariatric surgery in public service outpatient in Southeast Brazil. Euro Psychia. 2011;1(26).

  • 34.

    Dubovsky SL, Haddenhorst A, Murphy J, Liechty RD, Coyle DA. A preliminary study of the relationship between preoperative depression and weight loss following surgery for morbid obesity. Int J Psychiatry Med. 1985;15(2):185-96. [PubMed ID: 4055255].

  • 35.

    Fowers BJ, Olson DH. Predicting marital success with PREPARE: A predictive validity study. J Marital and Family Therapy. 1986;12(4):403-13.

  • 36.

    Ahadi B. Relationship between personality and marital satisfaction. Contemporary psychology. 2008;2(2):31-6.

  • 37.

    Sharifi V, Assadi SM, Mohammadi MR, Amini H, Kaviani H, Semnani Y, et al. A Persian translation of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: psychometric properties. Compr Psychiatry. 2009;50(1):86-91. [PubMed ID: 19059520]. https://doi.org/10.1016/j.comppsych.2008.04.004.

  • 38.

    Cooper KM, Wells M. Effects of bariatric surgery on marital satisfaction. Surg Obes Relat Dis. 2006;2(3):334. https://doi.org/10.1016/j.soard.2006.04.152.

  • 39.

    Bond DS, Vithiananthan S, Leahey TM, Thomas JG, Sax HC, Pohl D, et al. Prevalence and degree of sexual dysfunction in a sample of women seeking bariatric surgery. Surg Obes Relat Dis. 2009;5(6):698-704. [PubMed ID: 19733514]. https://doi.org/10.1016/j.soard.2009.07.004.

  • 40.

    Rand CS, Kowalske K, Kuldau JM. Characteristics of marital improvement following obesity surgery. Psychosomatics. 1984;25(3):221-3. 226. [PubMed ID: 6709811]. https://doi.org/10.1016/S0033-3182(84)73064-7.

  • 41.

    Hafner RJ. Morbid obesity: effects on the marital system of weight loss after gastric restriction. Psychother Psychosom. 1991;56(3):162-6. [PubMed ID: 1758960].

  • 42.

    Georgiadis MM. Motivation for weight-loss diets: A clustering, longitudinal field study using self-esteem and self-determination theory perspectives. Health Education J. 2006;65(1):53-72. https://doi.org/10.1177/0017896906066067.

  • 43.

    French SA, Story M, Perry CL. Self-esteem and obesity in children and adolescents: a literature review. Obes Res. 1995;3(5):479-90. [PubMed ID: 8521169].

  • 44.

    Fabricatore AN, Wadden TA, Sarwer DB, Faith MS. Health-related quality of life and symptoms of depression in extremely obese persons seeking bariatric surgery. Obes Surg. 2005;15(3):304-9. [PubMed ID: 15826461]. https://doi.org/10.1381/0960892053576578.

  • 45.

    Dixon JB, Dixon ME, O'Brien PE. Depression in association with severe obesity: changes with weight loss. Arch Intern Med. 2003;163(17):2058-65. [PubMed ID: 14504119]. https://doi.org/10.1001/archinte.163.17.2058.

  • 46.

    Grilo CM, Reas DL, Brody ML, Burke-Martindale CH, Rothschild BS, Masheb RM. Body checking and avoidance and the core features of eating disorders among obese men and women seeking bariatric surgery. Behav Res Ther. 2005;43(5):629-37. [PubMed ID: 15865917]. https://doi.org/10.1016/j.brat.2004.05.003.

  • 47.

    Sarwer DB, Cohn NI, Gibbons LM, Magee L, Crerand CE, Raper SE, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg. 2004;14(9):1148-56. [PubMed ID: 15527626]. https://doi.org/10.1381/0960892042386922.

  • 48.

    de Zwaan M, Mitchell JE, Howell LM, Monson N, Swan-Kremeier L, Crosby RD, et al. Characteristics of morbidly obese patients before gastric bypass surgery. Compr Psychiatry. 2003;44(5):428-34. [PubMed ID: 14505305]. https://doi.org/10.1016/S0010-440X(03)00092-0.

  • 49.

    Hall JC, Horne K, O'Brien PE, Watts JM. Patient well-being after gastric bypass surgery for morbid obesity. Aust N Z J Surg. 1983;53(4):321-4. [PubMed ID: 6577847].

  • 50.

    Magdaleno R, Chaim EA, Turato ER. P02-138 - Body contouring following bariatric surgery: emotional meanings for patients of a public outpatient service in the Southeast Brazil. Europ Psychia. 2011;26:734. https://doi.org/10.1016/s0924-9338(11)72439-7.