Relationship of Depression, Impulsivity, Distress Intolerance and Coping Styles with Maladaptive Eating Patterns in Bariatric Candidates

doi:10.21203/rs.3.rs-1555125/v1

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Research Article

Relationship of Depression, Impulsivity, Distress Intolerance and Coping Styles with Maladaptive Eating Patterns in Bariatric Candidates

https://doi.org/10.21203/rs.3.rs-1555125/v1

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Purpose

The study aimed to investigate the problematic eating patterns, and understand their relationship to some psychological constructs including stress intolerance, coping mechanisms and impulsivity; and psychiatric symptoms among a group of bariatric surgery candidates.

Methods

The bariatric candidates were evaluated by psychiatric interview and standard scales assessing maladaptive eating behaviors (Eating Attitudes Test (EAT), Bulimia Investigatory Test-Edinburgh (BITE), Dutch Eating Behavior Questionnaire(DEBQ)), depression (Beck Depression Inventory (BDI)), psychiatric symptoms (Brief Symptom Inventory (BSI)), and psychological constructs (Distress Intolerance Index (DSI), Coping Styles Scale (CSS), UPPS Impulsive Behavior Scale(UPPS)).

Results

More than half (57.8%) of the sample had maladaptive eating behaviors, and 23.6% had binge eating behavior. Depression and anxiety were found to predict EAT, BITE and DEBQ emotional and external eating sub-scale scores; and distress intolerance, helpless coping style and impulsivity were also found to predict maladaptive eating behaviors in bariatric candidates.

Conclusion

Maladaptive eating patterns play an important role in failure to lose weight and regaining weight, and are found to be predicted by depression, anxiety and psychological constructs in this study. Evaluation of pathological trait characteristics besides discrete psychiatric syndromes should be recommended in the pre-operation process to plan relevant interventions in the long-term management of weight.

bariatric candidate

eating behavior

depression

stress intolerance

coping styles

impulsivity

Maladaptive eating styles and state characteristics such as impulsivity, distress intolerance and coping styles were studies in individuals with obesity, but this study is one of the few in bariatric surgery candidates. The relationship of pathological eating patterns and state psychological characteristics were investigated first in bariatric candidates.

What this study adds?

Findings in this study suggest that maladaptive eating behaviors are predicted by trait (impulsivity, stress intolerance and coping styles) characteristics in addition to state characteristics in extremely obese individuals applying for bariatric surgery; this shows that evaluation of trait characteristics should be an important part of pre-surgery psychiatric evaluation of bariatric candidates.

Bariatric surgery is an effective method in most of the obesity patients, however it is known that a substantial amount of the individuals fail to lose weight or regain a significant amount of the lost weight in a few years after the surgery [1].

There has been efforts to identify the possible factors for the failure to lose weight and sustain the weight loss in people with obesity. An important research area has been the problematic eating behaviors such as binge eating, and psychopathology, especially depression and impulsivity in obese patients. Although obesity is not classified as an eating disorder, various problematic eating behaviors including emotional eating, binge eating, and night eating syndrome have been documented in the obese individuals [2].

Considering the substantial portion of the bariatric patients had regained weight in the post-operative period, eating behaviors in bariatric candidates has been an area of interest in the last years, and bariatric surgery candidates have been found to have higher rates of eating problems compared to obese individuals seeking the traditional methods of weight loss [3].

Emotional eating is defined as the eating behavior emerging as a response to the negative emotions such as anxiety and irritability [4]. Few studies have examined the prevalence of emotional eating in large general populations, on the other hand the prevalence of this behavior was found to be between 25% and 38% in some bariatric candidate groups indicating that emotional eating is very common in this group [5].

Some other studies yet reported similar emotional eating rates between obese individuals who seek traditional weight-loss programs and bariatric surgery candidates [6].

The prevalence rates of binge eating disorder in the individuals with obesity varied substantially due to different methods to evaluate this behavior, but generally reported to be between 10 to 30% [7].

Some studies have shown that the binge eating behavior is related to the severity of obesity and also psychopathology [8]. Bariatric candidates were found to have more severe binge eating behaviors than obese individuals seeking non-surgical weight loss methods in many studies [3;9]. Patients with binge eating disorder were found to have other eating problems as well as depressive and anxiety disorders [10;11].

In addition to eating disorders, studies have revealed a relationship between obesity and other mental health problems. Depression is the most studied and most prevalent mental health problem in obese individuals [12]. The exact mechanisms linking obesity and depression were not understood clearly, but there have been many hypotheses on the issue. Depressed individuals could develop obesity through dysregulated stress systems or through unhealthy lifestyles and maladaptive eating behaviors such as emotional eating, on the other hand obesity could lead to the development of depression through its negative effects on self-image and self-esteem. One meta-analysis reported that obesity increased the risk of depression while depression was also a predictor of the obesity [13].

Much of the work about the relationship of obesity and psychopathology has focused on discrete psychiatric diagnoses such as depression and bipolar disorder, however shared features across diagnoses such as impulsivity, and trait psychological characteristics such as emotion dysregulation and the use of pathological coping mechanisms, might be contributing to the maladaptive eating behaviors and obesity as a result [14].

Lack of impulse control over food may contribute to the weight gain and obesity; impulsivity and disinhibited behavior are known to be common for mood disorders, binge eating and substance use disorders; this common construct may explain the relationship between obesity and mental health problems like eating disorders and mood disorders. Whether these psychological constructs were playing a role in bariatric surgery outcome was also investigated in a few studies. One of these studies has worked on subtyping bariatric candidates based on regulative temperament, emotion dysregulation and disinhibited eating and investigated the effect of these subtypes on bariatric outcome [15]. In this study, patients with pre-bariatric deficits in self and emotional control were found to have an increased risk for showing these deficits in post-operative period; however it was also found that neither pre- nor post-bariatric subtypes predicted the post-surgery weight loss. The conflicting evidence on the relationship of pre-operative psychopathology and post-surgery success has also been revealed in a meta-analysis [12].

Psychological stress has been suggested to be associated with disordered eating in many studies [16]. But some of the researchers have proposed that instead of stress alone, the maladaptive coping strategies used to deal with stress are among the factors contributing to the development of maladaptive eating behaviors [17].

Coping mechanisms are defined as the behavioral and cognitive strategies used to manage stressing conditions and crises. Coping skills are not considered inherently adaptive or maladaptive, as it depends in which context they are used. However, problem-focused coping is generally associated with better adjustment whereas emotion-focused and avoidant coping are generally conceptualized as maladaptive styles and associated with psychopathology, including eating disorders [18].

Generally it was found there was a difference between people with or without an eating disorder regarding the coping strategies used: individuals with eating disorders demonstrate more emotion-focused and avoidant coping responses than the individuals without problematic eating behavior, actually disordered eating may be viewed as an avoidant coping strategy [16]. Avoidant coping has also been proposed as a predictor of various eating disorders; the relationship between these maladaptive coping strategies and substance and eating disorders might be moderated by reward sensitivity, individuals using these strategies who also have higher reward sensitivity may be more likely to use substances or engage in maladaptive eating behavior to decrease their distress [19].

In sum, the pathological eating behaviors are common in bariatric candidates, and the pathological eating patterns could be related to some psychological constructs (trait characteristics) as well as discrete psychiatric diagnoses (state characteristics). Despite the rich literature on the relationship between eating disorders and those state and trait characteristics, the findings were mostly obtained from either adolescents from community or the individuals with obesity; the studies on bariatric candidates were very limited in this area. The aim of this study was to investigate the problematic eating patterns, and understand their relationship to some psychological constructs including impulsivity, stress coping mechanism and tolerance to emotional strain as well as psychiatric symptoms such as depression and anxiety among a group of bariatric surgery candidates. We hypothesized that depression and maladaptive coping behaviors, stress intolerance and impulsivity would be positively related to disordered eating behaviors in bariatric candidates.

Participants

The population of this retrospective study is composed of the patients who have applied for bariatric surgery and have been evaluated by the Bariatric Surgery Board of ……… University Hospitals between 2013–2020 and whose medical records were available for data extraction. As a rule all the bariatric candidates were evaluated by the Bariatric Surgery Board composed of the physicians from Departments of Internal Medicine- Endocrine Department, General Surgery, Thoracic Surgery, Cardiology and Psychiatry. For the board evaluation all bariatric surgery candidates were evaluated by two psychiatrists, a dietitian and a clinical psychologist to identify any psychiatric contraindications to the surgery such as active psychosis, severe depression and suicidal behavior, and active substance abuse. All of the bariatric candidates had undergone a brief psychoeducation on the dietary and behavioral challenges of the surgery. The candidates in need of a more advanced intervention were provided with psychiatric care (medication, brief psychotherapy for 3–6 months especially targeting maladaptive eating behaviors), before the approval.

A total of 465 participants’ hospital records were recruited. None of these candidates had an absolute contraindication to the surgery. After exclusion of the patients who left blank more than 10% of the items of any of the scales selected to collect data for the procedure, the study sample was composed of 410 patients; all of the statistics were done for this group except the presentation of sociodemographic data which includes whole participants. The study was approved by the ……….. University Ethics Committee.

Measures

Each bariatric surgery candidate referred to Psychiatry Department by the Bariatric Surgery Board of the hospital, was evaluated for their suitability for surgery, with a psychiatric interview, various clinical scales, and a personality inventory as recommended by the expert guidelines [20]. Besides the scales, a clinical data form questioning the patients' body mass index, knowledge and expectations about surgery, psychiatric history, current mental complaints, and a sociodemographic data form were also administered.

Within the scope of this study, each patient was evaluated with standard scales that assess eating attitudes and screen for abnormal eating behaviors and symptoms of various eating disorders. State and trait psychological characteristics thought to be related to eating attitudes and eating disorders were also evaluated by standard scales.

Eating Attitudes Test (EAT)

EAT-40 is a 4-point Likert-type scale, developed to evaluate eating behaviors and attitudes and to screen for possible abnormal eating behaviors in individuals [21], which is valid in Turkish [22]. The possible range of scores is 0-120, and an increase in scores indicates abnormality in eating attitudes.

Bulimia Investigatory Test, Edinburgh (BITE)

This is a self-report scale that aims to evaluate bulimic behaviors and binge eating symptoms [23] and valid in Turkish [24]. A score of 20 or more indicates binge eating syndrome, 10–19 indicates abnormal eating behavior, 0–10 indicates normal eating behavior.

Dutch Eating Behavior Questionnaire (DEBQ)

It consists of a total of 33 items and three sub-scales measuring Emotional, External and Restricted Eating Behaviours [25]. The scale was validated in Turkish [26].

Beck Depression Inventory (BDI)

This is a self-report scale consisting of 21 items in which physical, emotional, and cognitive symptoms observed in depression are evaluated and increasing values correspond to increasing severity [27]. The validity and reliability study of the Turkish version has been conducted [28].

Brief Symptom Inventory (BSI): This is a 53-item short form of the Symptom Check List (SCL-90) [29;30]. The total score obtained from the scale varies between 0 and 212. Turkish version consists of 5 sub-dimensions in total: anxiety, depression, negative self concept, somatization, and hostility [31]

The UPPS Impulsive Behavior Scale (UPPS)

The UPPS is a self-report scale with 1–4 Likert type scoring of 45 items [32]. Its four subscales are Urgency, Lack of Premeditation, Lack of Perseverance and Sensation Seeking. Higher scores indicate higher levels of impulsivity. The scale was adapted to Turkish [33].

Distress Intolerance Index (DII): The DII is a 10-item self-report measure designed to

assess the inability to tolerate negative states [34], with higher scores indicating greater distress intolerance. The index was adapted to Turkish [35].

Coping Style Scale (CSS)

The scale is designed [36] to measure the two main coping styles; effective style (problem-oriented) with 3 sub-dimensions of seeking social support, self-confident approach and optimistic approach and ineffective style (emotion-oriented) with 2 sub-dimensions of helpless approach and submissive approach. It was found that individuals who can cope effectively with stress often use the “self-confident” and “optimistic” approaches, whereas those who cannot cope with stress often use the “helpless” and “submissive” approaches. The Turkish validity and reliability study was conducted [37].

Statistical Analysis

All analyses were carried out with Statistical Package for the Social Sciences (SPSS) software version 18.0 (IBM Corp., Armonk, NY, USA). Normal distribution of the data was evaluated with analytical (Kolmogorov-Smirnov test) and visual (histograms, probability graphs) methods. Descriptive statistics were expressed with means, standard deviations, median and minimum-maximum values for continuous variables. Correlation analyses between variables, coefficients of correlation and statistical significance was calculated with Pearson Product-Moment Correlation Test.

Hierarchical multiple regression analyses were used to evaluate the independent effects of state and trait variables on the scores of the scales assessing eating attitudes and abnormal eating behaviours. The statistical significance was set as a p value < 0.05.

Sample characteristics

A total of 465 bariatric surgery candidates, 77.4% (n = 360) female and 22.6% (n = 105) male, were included in the study. A total of 71.6% of the sample had at least high school level of education. The majority was married (n = 284, 61.1%), 25.2% single, 9.3% (n = 43) was either widowed or divorced. The mean age of the participants was 37.78 (± 10.41, 18–67 ), mean BMI of the sample was 47.06 kg/m² (± 6.41, 35.00- 79.86). Eighteen (3.9%) of the bariatric candidates had a BMI value of 35- 39.99, 316 (%68) of them had a BMI value of 40.00- 49.99, 113 persons (%24.3) had a BMI value of 50.00- 59.99, and 18 (%3.9) had a BMI value of 60.00 and above.

Abnormal eating behaviors

The total and sub-scale scores of the 3 eating scales (DEBQ, BITE, EAT) and the scores of scales for state and trait characteristics are presented in Table 1. A total of 92 persons (23.1%) was found to have scores of 30 and above which implies abnormal eating behavior from EAT. Seventy five participants (18.6%) had scores of 0–9 from BITE, while 233 participants (57.8%) had scores of 10–19 which shows abnormal eating behavior and finally 95 participants (23.6%) had scores of 20 and above from this test which implies binge eating.

Table 1

The Descriptive Statistics of the Variables (N = 410)
Variables	Min.-Max.	Mean	Standard deviation
BDI	0–43	11.12	7.35
BSI sub-scales
Anxiety	0–37	6.66	7.05
Depression	0–43	9.24	9.10
Negative self concept	0–41	7.33	8.11
Somatization	0–30	5.28	5.09
Hostility	0–21	4.96	4.35
DII total	0–40	14.35	8.82
UPPS sub-scales
Lack of premeditation	11–44	36.11	4.77
Urgency	13–48	33.99	6.31
Lack of perseverance	14–40	30.38	4.25
Sensation seeking	14–46	32.57	6.19
CSS sub-scales
Self-confident approach	7–28	23.47	3.82
Optimistic approach	6–20	15.42	2.97
Helpless approach	8–31	16.36	4.86
Submissive approach	6–22	11.46	3.19
Seeking social support	4–16	11.38	2.16
EAT total score	5.13–62.86	23.03	11.23
DEBQ sub-scales
Restricting	10–48	27.77	7.83
Emotional	13–65	30.08	13.54
External	12–50	29.93	7.44
DEBQ total score	39- 139.44	87.82	17.50
BITE	2–27	14.82	5.66
Note: BDI: Beck Depression Inventory; BSI: Brief Symptom Inventory; DII: Distress Intolerance Index; UPPS: The UPPS Impulsive Behavior Scale; CSS: Coping Styles Scale; EAT: Eating Attitudes Test, DEBQ: Dutch Eating Behaviors Questionnaire; BITE: Bulimia Investigatory Test, Edinburgh

Relations Between Eating Behaviors and State and Trait Characteristics

Beck Depression Inventory mean scores were found as 11.42 ± 7.46 for the whole sample; 96 participants (23.4%) were found to have BDI scores of 17 and above, indicating clinical depression.

Pearson Product-Moments Correlation Coefficients between eating behavior scales and state characteristics’ tests (BDI and BSI) are presented in Table 2 and the correlation coefficients between eating behaviors scales and trait characteristics’ scales (COPE, DII, and UPPS) are presented in Table 3.

Table 2

Correlations Between Eating Behavior Tests and State Characteristics
	BDI	BSI anxiety	BSI negative self concept	BSI somatization	BSI hostility	BSI total
DEBQ restricting sub-scale	-0.04	-0.09	-0.10	0.01	-0.09	-0.08
DEBQ emotional sub-scale	0.28*	0.40**	0.32**	0.32**	0.37**	0.42**
DEBQ external sub-scale	0.22*	0.24**	0.25**	0.16**	0.23**	0.27**
DEBQ total score	0.29*	0.37**	0.33**	0.32**	0.34**	0.41**
BITE total score	0.40*	0.40**	0.37**	0.30**	0.36**	0.42**
EAT total score	0.38*	0.26**	0.26**	0.27**	0.24**	0.29**
p < 0.05 *p < 0.001
Note: BDI: Beck Depression Inventory; BSI: Brief Symptom Inventory, DEBQ: Dutch Eating Behavior Questionnaire, BITE: Bulimia Investigatory Test, Edinburgh; EAT: Eating Attitudes Test

Table 3

Correlations Between Eating Behavior Tests and Trait Characteristics
	CSS self-confident approach	CSS optimistic approach	CSS helplessapproach	CSS submissive approach	CSS seeking social support	DII	UPPS lack of premeditation	UPPS urgency	UPPS Lack of perseverance	UPPS Sensation seeking	UPPS total
DEBQ restricting sub-scale	0.07	0.08	-0.02	-0.06	-0.07	0.02	0.16**	0.17**	0.07	-0.10*	0.11*
DEBQ emotional sub-scale	-0.19*	-0.19**	0.26**	0.07	0.07	0.27**	-0.07	-0.37**	-0.09	0.04	-0.21**
DEBQ external sub-scale	-0.09	-0.14**	0.19**	0.17*	0.11*	0.12*	-0.01	-0.26**	-0.06	0.04	-0.12*
DEBQ total score	-0.15*	-0.17**	0.28**	0.08	0.07	0.26**	0.01	-0.32**	-0.07	0.00	-0.17**
BITE total score	-0.24*	-0.28**	0.36**	0.11*	0.07	0.34**	-0.11*	-0.41**	-0.10*	-0.02	-0.27**
EAT total score	0.05	-0.01	0.30**	0.14**	0.14**	0.33**	0.03	-0.21**	0.07	-0.01	-0.06
p < 0.05 *p < 0.001
Note: CSS: Coping Styles Scale
DII: Distress Intolerance Index
UPPS: UPPS Impulsive Behavior Scale
DEBQ: Dutch Eating Behavior Questionnaire
BITE: Bulimic Behavior Inventory-Edinburgh
EAT: Eating Attitudes Test

Regression analyses

Eating test scores and state characteristics

The predicting effects of the state characteristics first and then the trait characteristics on the eating attitudes were examined separately for each of the eating tests and their sub-scales using multiple regression analyses while statistically controlling for the sex and the age of the participants. Therefore, these two variables were entered in the equation at the first step to control for their possible confounding effect on the predictors.

A series of hierarchical multiple regression analyses were executed as the eating test scores assigned as the dependent variable (criterion) and the state characteristics BDI total and BSI sub-scale scores assigned as the independent variable (predictor) while statistically controlling for the sex and the age of the participants at the first step. BDI score was secondly entered into the regression in all the analyses due to its being an established and well-known variable related to depression, obesity and abnormal eating behaviors from many studies. The 4 sub-scale scores of BSI except depression sub-score, were entered into the regression at the next step as together. Regression analysis results are presented in Table 4.

Table 4

Hierarchical regression analysis of state characteristics on the eating test scores
EAT total score		Beta unstandardized	R²_change	F _change
1. step	Sex and Age		0.01	2.2
2. step	BDI score	0.63**	0.17	73.95**
3. step	BSI anxiety	0.06
	BSI negative self-concept	0.04
	BSI somatization	0.08
	BSI hostility	0.06
DEBQ emotional eating sub-scale
1. step	Sex and Age		0.02	2.9
2. step	BDI score	0.52**	0.08	30.44**
3. step
	BSI anxiety	0.73**	0.09	40.72**
	BSI negative self-concept	-0.10
	BSI somatization	0.02
	BSI hostility	0.11
DEBQ external eating sub-scale
1. step	Sex and Age		0.004	0.64
2. step	BDI score	0.22**	0.05	19.80**
3. step
	BSI negative self-concept	0.19**	0.03	12.06**
	BSI anxiety	0.07
	BSI somatization	-0.02
	BSI hostility	0.08
BITE total score
1. step	Sex and Age		0.005	0.83
2. step	BDI score	0.33**	0.18	79.25**
3. step
	BSI anxiety	0.22**	0.05	23.73**
	BSI negative self-concept	-0.02
	BSI somatization	-0.06
	BSI hostility	0.05
Note: p < 0.05, *p < 0.001; EAT: Eating Attitudes Test; DEBQ: Dutch Eating Behaviors Questionnaire; BITE: Bulimic Behavior Inventory, Edinburgh

As can be seen from the table, after controlling for sex and age of the participants, BDI scores were found to significantly predict the EAT score as the dependent variable (R² = 0.17, F _{(1, 191)} = 73.95, p < 0.001). The other variables entered into the regression at the third step were found to not have a predictive power on EAT scores.

BDI scores entered into the regression at the second step were found to predict DEBQ emotional sub-scale scores (the dependent variable) significantly at 8% level (R² = 0.08, F _{(1, 365)} = 30.44, p < 0.05). Only the BSI anxiety sub-scale score which was entered into the regression at the third step was found to predict significantly DEBQ emotional sub-scale scores beyond BDI scores (R²_change = 0.09, FΔ _{(2, 365)} = 40.72, p < 0.001).

For the regression analysis of DEBQ external eating sub-scale assigned as the dependent variable, BDI score entered into the regression at the second step was found to predict the dependent variable significantly at 5% level (R² = 0.05, FΔ _{(1, 365)} = 19.80, p < 0.001). Only the negative self-concept sub-scale score of BSI which was entered the regression at the third step was found to predict DEBQ external eating scores significantly beyond depression scores’ contribution (R²_change = 0.03, FΔ _{(2, 364)} = 12.06, p < 0.001).

In regression analyses with BITE score as the dependent variable, BDI scores were found to predict the dependent variable significantly at 18% level (R²_change = 0.18, FΔ _{(1, 363)} = 79.25, p < 0.001); at the third step only the BSI anxiety sub-scale score was found to predict BITE scores significantly beyond BDI scores (R²_change = 0.22, FΔ _{(2, 362)} = 23.73, p < 0.001), and the other sub-scale scores were found to have no predictive power at all on BITE scores.

Eating test scores and trait characteristics

A series of hierarchical multiple regression analyses were executed as the eating tests’ scores assigned as dependent variable (criterion) and DII, CSS sub-scales’ and UPPS sub-scales’ scores assigned as independent variables (predictor) while statistically controlling for the sex and the age of participants at the first step and the results are presented in Table 5.

Table 5

Multiple regression analysis of trait characteristics on the eating test scores
EATtotal-score		Beta unstandardized	R² _change	F _change
1. step	Sex and Age		0.01	1.48
2. step	CSS- helpless approach	0.64**	0.08	26.38**
	UPPS-lack of perseverance	0.43*	0.03	8.20*
	DII	0.24*	0.03	8.48*
DEBQ emotional eating sub-scale
1. step	Sex and Age		0.01	1.78
2. step	UPPS- urgency	-0.67**	0.09	30.15**
	CSS-helpless approach	0.38*	0.01	4.52*
DEBQ external eating sub-scale
1. step	Sex and Age		0.001	0.22
2. step	UPPS- urgency	-0.33**	0.08	24.82**
	UPPS- lack of premeditation	0.20*	0.01	4.56*
BITE total score
1. step	Sex and Age		0.006	0.84
2. step	UPPS- urgency	-0.34**	0.14	49.07**
	CSS-helpless approach	0.27**	0.04	14.80**
Note: p < 0.05, *p < 0.001; EAT: Eating Attitudes Test; DII: Distress Intolerance Index; DEBQ: Dutch Eating Behaviors Questionnaire; BITE: Bulimic Investigatory Test, Edinburgh; UPPS: UPPS Impulsive Behavior Scale; CSS: Coping Styles Scale
Trait characteristics found to have no significant contribution to the predictive power are not included in the table.

As seen from the table, in the analyses with EAT scores as the dependent variable while controlling for sex and age of participants, CSS- helpless approach (R² = 0.08, FΔ _{(3, 295)} = 26.38, p < 0.001), UPPS- lack of perseverance sub-scale (R² = 0.03, FΔ _{(2, 296)} = 8.20, p < 0.01) and DII (R² = 0.03, FΔ _{(1, 297)} = 8.48, p < 0.01), were found to predict the dependent variable significantly.

In the analyses with DEBQ emotional eating sub-scale as the dependent variable, UPPS- urgency sub-scale (R² = 0.09, FΔ _{(1, 304)} = 30.15, p < 0.001) and CSS- helpless approach sub-scale (R² = 0.01, FΔ _{(2, 303)} = 4.52, p < 0.05) were found to predict the dependent variable in negative and positive directions subsequently.

In regression analyses with DEBQ- external eating sub-scale as the dependent variable, UPPS- urgency sub-scale (R² = 0.08, FΔ _{(1, 304)} = 24.82, p < 0.001) and UPPS- lack of premeditation sub-scale scores (R² = 0.01, FΔ _{(2, 303)} = 4.56, p < 0.05) were found to have a statistically significant predictive power on the dependent variable in negative and positive ways subsequently.

In analyses with BITE assigned as the dependent variable, the UPPS- urgency subscale score was found to predict the dependent variable in a negative way (R² = 0.14, FΔ _{(1, 301)} = 49.07, p < 0.001) and CSS- helpless approach was found to predict the dependent variable positively (R² = 0.4, FΔ _{(2, 300)} = 14.80, p < 0.001).

The goal of this study was to investigate the relationship of maladaptive eating patterns with the psychological constructs including coping styles, stress intolerance and impulsivity beyond discrete psychiatric diagnoses in a group of bariatric surgery candidates. As expected and found in the literature, a quarter of the sample had scores which implies binge eating and more than half of the sample had scores pointing to the maladaptive eating behavior from the Bulimic Investigatory Test, Edinburgh (BITE). Many bariatric surgery programs require a pre-bariatric evaluation in order to determine the eligibility of the candidates through evaluating the maladaptive eating behaviors as suggested in the guidelines [38;39]. It is believed that some patients engage in “impression management” or “faking good” during pre-operative evaluations, minimizing or hiding symptoms of psychopathology intentionally or non-intentionally in order to be seen in a favorable light and to avoid the rejection of surgery by the mental health professionals; thus the prevalence of maladaptive eating behaviors could be found lower than expected in this population [40], we still found very high numbers of candidates had problematic eating behaviors in our sample.

A quarter of the sample had BDI scores of 17 and above which indicates depression, this was also compatible with many studies finding increased prevalence of depressive disorders in bariatric surgery candidates [41]. The detection of the psychopathology also varies based on the methods used, as well as the candidates’ willingness to admit that they are experiencing some mental health issues. Bariatric candidates may also underreport depression or other psychiatric symptoms to avoid the exclusion from the bariatric surgery procedure. In our study the psychiatric interview by the mental health professionals and the psycho-educational approach during the evaluation period might have played a role in decreasing the defensive attitudes to admit the problems experienced by the candidates.

We found positive correlations between depression scores and all the eating test scores except DEBQ restricting sub-scale, meaning that maladaptive eating behaviors are correlated with depressive symptoms. Similarly all the eating test scores except DEBQ restricting sub-scale, were found as correlated with BSI sub-scale scores anxiety, negative self-concept, somatization, and hostility and the total BSI score. Depression was found to predict all of the pathological eating behaviors except restrictive eating behavior. There are studies showing that the relationship between obesity and mental disorders is stronger among the individuals with more severe obesity, especially bariatric candidates are known to have a higher prevalence of depressive syndromes [42]. Anxiety was also found in our study to predict emotional eating and binge eating significantly. Anxiety was less well studied compared to depression and other affective states in obesity and bariatric surgery literature, it is one of the important findings in our study that anxiety is a predictive factor in pathological eating behaviors. However the direction of the relationship of depression and other psychiatric diagnoses such as anxiety, and the maladaptive eating behaviors are not well understood until today. Depression and anxiety may cause maladaptive eating patterns, as well as pathological eating behavior might trigger depressive symptoms as a result of obesity and related problems. This uncertainty has inspired us that the long-term psychological constructs such as stress intolerance, coping styles, and impulsivity inherent in psychopathological conditions should be investigated beyond discrete psychological diseases.

Distress intolerance was shown to be positively correlated with emotional eating, binge eating and generally maladaptive eating behaviors in this study. Individuals with poor distress tolerance are characterized by a low threshold for negative emotional experiences and may have difficulty to regulate emotion, and this leads to the inability to cope in a healthy way with emotions [43]. In a longitudinal study, the combined effect of high internalizing symptoms and high distress intolerance was found to be early risk factors for future development of eating disorder attitudes [44]. In another longitudinal study evaluating both pre and post-bariatric surgery individuals, low distress tolerance was found to be associated with disordered eating behaviors and high BMI, and patients with higher level of distress tolerance were more likely to undergo bariatric surgery [45]. Distress intolerance was also found to be a predictive factor on maladaptive eating behaviors in our study, thus being a trait characteristic to be worked on in obese individuals. Despite evidence supporting relationships among stress tolerance, coping styles and pathologic eating behaviors, most of these studies have a cross-sectional design, from which conclusions regarding causal relationships cannot be drawn. Some longitudinal research showed significant relationships between stress intolerance and maladaptive eating behavior but an opposite direction for prediction; Rosen et al (1993) found that eating disorder symptoms in a group of adolescent girls predicted later stress in a 4-month period [46]. Similarly a longitudinal study assessed stress, coping and eating behavior in a 6-month period in a large sample of young women and found that the disordered eating predicted the perceived stress weakly [47]. Despite these findings, these studies still used short periods of time to assess stress tolerance and coping strategies, were mostly limited to adolescents or young women and had lower sample sizes. Stress tolerance may be a transient and relatively short-time construct which could be affected from disordered eating, whereas coping styles are long-term constructs used to deal with stress throughout a life-time, making the causal direction from coping styles to the maladaptive eating patterns more reasonable. Also these studies had recruited healthy samples and young individuals, however morbidly obese patients and bariatric candidates represent a different population, caution is needed on generalising these results to the individuals with obesity seeking help from medical authorities.

Similar to stress intolerance, coping styles were found to be correlated to the maladaptive eating behaviors in our study. The self-confident approach and optimistic approach which reflects effective coping styles were found to be negatively correlated with BITE scores and DEBQ total and sub-scale scores except restricting sub-scale, implying that the bariatric candidates using effective coping styles are less likely to engage in maladaptive eating behaviors. On contrary, helpless approach reflecting an ineffective style of coping was found to be positively correlated with all of the eating tests’ scores except DEBQ restricting sub-scale score, indicating that the surgery candidates using ineffective coping styles are more likely to have maladaptive eating patterns. The literature shows similar results for relationship of coping styles and eating behavior. A group of adolescents with binge eating behavior were shown to use avoidant coping strategies more compared to the group without binge eating [48]. Using avoidant coping strategies have also been found to be related to maladaptive eating behaviors in a group of young women [47]. In our study, helpless approach was found to predict the general maladaptive eating behavior strongly and also emotional eating and binge eating significantly in bariatric candidates. There is only one cross-sectional study on coping styles and disordered eating among bariatric candidates in literature, and this study also reported that avoidance coping (an ineffective coping style) predicted more disordered eating in bariatric candidates, and remained a relevant predictor even in regression models including depression and anxiety [49]. The same study has also reported similar results with our study that bariatric candidates with depression and anxiety symptoms had more maladaptive eating behaviors. Thus ineffective coping behavior together with depression and anxiety could be accepted as an important predictor on disordered eating in bariatric candidates with morbid obesity levels. A longitudinal study who followed up obese patients after treatment (either with surgery or conventional methods), found that weight gainers reduced their use of problem and emotion focused coping while those who lost weight decreased in emotion focused coping and had lower distress levels in 2 years after treatment [50]. Follow-up of bariatric candidates after surgery would give more information about the coping characteristics and their role in eating behavior in the future studies.

In this study, only the urgency sub-scale of UPPS Impulsivity Scale was found to be correlated with pathological eating behaviors, implying that as the impulsivity increased the maladaptive eating behavior also increased in bariatric candidates. The urgency was found to be a strong predictor of emotional eating, external eating and also binge eating, whereas lack of perseverance was found as a strong predictor of general maladaptive eating. Loss of control over eating (dietary disinhibition) was shown to play a role in the development of obesity [51]. Similarities between substance use disorders and binge eating disorder regarding the loss of control over the consumption of substance or food were hypothesized, and the facets of impulsivity are thought to represent a common trans-disease process underlying these maladaptive behaviors, contributing to the development of obesity [52]. Impulsivity was also shown to predict response to bariatric surgery [53]. It is obvious that impulsivity traits are important in the development of obesity, and the success of the bariatric surgery.

Our findings suggest that maladaptive eating behaviors are predicted by both state (depression and anxiety) and trait (impulsivity, stress intolerance and coping styles) characteristics in extremely obese individuals applying for bariatric surgery. Maladaptive eating patterns could play an important role in failure to lose weight and regaining weight in the post-operative era, these characteristics should be considered in pre-surgery assessments of bariatric candidates. If interventions targeting pathological trait characteristics together with maladaptive eating patterns are planned in the pre-operation process in relevant patients, these individuals could benefit more from the bariatric interventions in long term.

Strength and Limits

A range of limitations and strenghts exist in this study. This is a cross-sectional study. A longitudinal evaluation of trait and state characteristics before and after surgery would be better for demonstrating the causal directions between these variables and obesity as well as the success of bariatric surgery. Another limitation is the lack of a control group; patients applying for conventional treatment of obesity, especially with lower BMI values, would be a suitable comparison group. Bariatric candidates were a substantially homogeneous group regarding the BMIs and age in our sample, and some important relationships regarding age, sex and BMI levels could not be evaluated in this study. The detailed psychiatric interview carried out for all of the bariatric candidates was the strong part; the individuals diagnosed with discrete eating disorders such as binge eating disorder, or defined as having certain maladaptive eating behaviors were offered a brief intervention including dietary control and brief cognitive and behavioral therapy; the candidates diagnosed with depression or anxiety disorders during the interview were also treated with both medications and brief psychotherapy before accounted to be eligible for surgery.

Declaration of Interest Statement

We wish to confirm that the authors have no relevant financial or non-financial interests to disclose

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript

Author contributions

Ş Özlem Erden Aki, M İrem Yıldız and G Zuhal Kamış contributed to the study conception and design. Material preparation and data collection were performed by G Zuhal Kamış, Aslı Aytulun and Ş Özlem Erden Aki. Data analyses were performed by Jale Karakaya, Sedat Işıklı, M İrem Yıldız and Ş Özlem Erden Aki. The first draft of the manuscript was written by Ş Özlem Erden Aki, and all authors contributed and commented on this manuscript. All authors read and approved the final manuscript.

Data availability

The datasets generated during and analysed during the current study are available from the corresponding author on reasonable request.

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Relationship of Depression, Impulsivity, Distress Intolerance and Coping Styles with Maladaptive Eating Patterns in Bariatric Candidates

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Abstract

Purpose

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Results

Conclusion

What Is Already Known On This Subject?

What this study adds?

Introduction

Material And Methods

Participants

Measures

Statistical Analysis

Results

Sample characteristics

Abnormal eating behaviors

Relations Between Eating Behaviors and State and Trait Characteristics

Regression analyses

Eating test scores and state characteristics

Eating test scores and trait characteristics

Discussion

Strength and Limits

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