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Mood and Food: Pre-operative Affective State and Postoperative Weight Loss.


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Mood and Food:

Pre-operative affective state and postoperative weight loss


Raman Krimpuri, MD MBA, James Yokley, PhD, Eileen Seeholzer, MD MS, Ewald Horwath MD, Charles Thomas MA, Allison Griesmer, MA and Sergio Bardaro, MD FACS


Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio




Bariatric surgery research has for some time revealed mood state, particularly depression to be both a cause (e.g., emotional comfort eating) and a consequence (e.g., body image related self-dislike and self-criticism) of morbid obesity. Studies of pre-surgical depression reveal upwards of 40% of surgical patients have a lifetime history of major depression. Pre-surgical depressive disorder is associated with poorer outcome, higher probability of adverse events and can predict post-surgical depression. Depressive symptoms often re-emerge 1- 3 years after surgery (Mitchell et al., 2014) and post-surgical depression has been associated with less weight loss 24- 36 months after surgery (de Zwaan et. at. 2011). Other unwanted moods that can impact quality of life and bariatric surgery outcome include anxiety, anger and mood swings (e.g., Kalarchian, 2007). While few studies have examined depressive symptoms clusters, Recently Hawkins et. al. (2016) conducted a study showing that some symptom clusters within the depressive symptom spectrum are better predictors than others. Specifically, the cognitive-affective subset of depressive symptoms was found to be a better predictor of bariatric surgery outcome at 12 months.



The present study evaluated the predictive value of psychological testing of depression, anxiety, anger and mood swings on bariatric outcome with particular emphasis on attempting to replicate the predictive ability of cognitive-affective symptoms on bariatric outcome.



Subjects in the present IRB approved study, were 220 patients who underwent psychological evaluation for bariatric surgery clearance in an inner city academic hospital. Their mean age was 44, 84% were female, 57% were minorities (49% African-American, 5% Hispanic and 3% Other), 43% were Caucasians and 71% received Roux-en-Y Gastric Bypass (26% gastric sleeve and 3% lap band).  Bariatric affective state outcome predictor variables that were evaluated in the present study were depression (Beck Depression Inventory-II), anxiety (Beck Anxiety Inventory), anger (State-Trait Anger Expression Inventory) and mood swings (Mood Disorder Questionnaire). Cognitive-Affective items from the Beck Depression Inventory-II were selected from the study of Steer et. al. (1999) and are listed in Table 1. Post-operative BMI was the outcome variable measured at one-year follow-up. A general linear regression model (controlling for age, race, gender and preoperative BMI) was used to conduct a comparative evaluation of potential affective state predictors of postoperative outcome.



The results of the present study revealed that level of depression (i.e., total BDI-II score) was not a significant predictor of pre-operative or post-operative BMI but when test items were divided into cognitive-affective vs somatic symptoms, the cognitive-affective symptoms were significant predictors of BMI at 1 year after surgery.


When all four tests of affective state were evaluated comparatively, the same results were found. Specifically, total depression score (BDI-II) was not a significant outcome predictor of pre-operative or post-operative BMI but when broken down into cognitive-affective vs somatic symptoms, the cognitive-affective symptoms were again predictive of bariatric patient BMI at one year after surgery. Patients with a BDI-II cognitive-affective symptom score under 10 had a better outcome (i.e., lower BMI) one year after surgery (M= 34.8) than patients with cognitive-affective symptom scores greater than or equal to 10 (M= 38.0), t(216)= 1.935, p = 0.05.



The present evaluation of bariatric patient preoperative affective state (i.e., depression, anxiety, anger and mood swings) revealed that the cognitive-affective symptoms of depression appear to be promising predictors of bariatric surgery outcome.


Table 1. BDI-II Cognitive-Affective Items

Item Number

Item Content




Past Failure


Guilty Feelings


Punishment feelings






Suicidal thoughts








Changes in sleeping



de Zwaan, M., Enderle, J., Wagner, S., et. al. (2011). Anxiety and depression in bariatric surgery patients: A prospective, follow-up study using structured clinical interviews. Journal of Affective Disorders, 133(1-2), 61-68.


Hawkins, M., Williams, G. Duncan, J. et. al. (2016). Pre-surgical Depressive Symptom Clusters and Shirt-Term Post-Surgical Weight Loss Outcomes. Kalarchian, M. A., Marcus, M. D., Levine, M. D.,


Kalarchian, M. A., Marcus, M. D., Levine, M. D., et. al. (2007). Psychiatric disorders among bariatric surgery candidates: Relationship to obesity and functional health status. The American Journal of Psychiatry, 164(2), 328-334.


Mitchell, J. E., King, W. C., Chen, J.‐Y et. al. (2014). Course of depressive symptoms and treatment in the Longitudinal Assessment of Bariatric Surgery (LABS‐2) study.


Steer, R., Ball, R., Ranieri, W. & Beck, A. (1999). Dimensions of the Beck Depression Inventory-II in Clinically Depressed Outpatients. J. of Clinical Psychology, 55(1), 117- 128.



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