Eating Behaviors 15 (2014) 670–672
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Eating Behaviors
Associations between relationship stability, relationship quality, and weight loss outcomes among bariatric surgery patients☆ Shannon M. Clark a,⁎, Karen K. Saules a, Leslie M. Schuh b, Joseph Stote b, David B. Creel b a b
Eastern Michigan University, Ypsilanti, MI, United States St. Vincent Carmel Bariatric Center of Excellence, Carmel, IN, United States
a r t i c l e
i n f o
Article history: Received 18 May 2014 Accepted 17 September 2014 Available online 28 September 2014 Keywords: Bariatric surgery Relationship satisfaction Weight loss outcomes
a b s t r a c t After weight loss surgery (WLS), psychosocial functioning, including the quality of social relationships, generally improves, but for a minority, relationships worsen. We examined how changes in relationship stability and quality from pre- to post-WLS relate to long-term weight loss outcomes. Postoperative patients (N = 361) completed surveys which queried relationship changes and weight loss. The sample was 95.9% Caucasian, 80.1% female, averaged 7.7 years post-WLS, with a mean age at surgery of 47.7 years (range 21–72); 87.3% had a Roux-en-Y gastric bypass. Four relationship status groups were created: Not in a relationship at surgery or follow-up (No-Rel, n = 66; 18.2%); Post-WLS relationship only (New-Rel, n = 23; 6%); Pre-WLS relationship only (Lost-Rel, n = 17; 5%); and Pre–Post Relationship (Maintainer, n = 255; 70.6%). Current BMI was 34.5 for No-Rel; 40.5 for New-Rel; 37.4 for Lost-Rel; 33.3 for Maintainers (p b .05 for Maintainers and No-Rel vs. New-Rel). These same group differences were significant for weight loss, which was not associated with gender, time since surgery, or age at time of surgery, but was associated with pre-WLS BMI (lower pre-WLS BMI was associated with greater %EWL). Analyses were repeated with pre-WLS BMI as a covariate; group differences remained significant [F (3, 355) = 3.09, p = .03], as did pre-WLS BMI, [F (1, 355) = 9.12, p = .003]. Among Maintainers, relationship quality was associated with weight loss outcomes: those with improved relationships post-WLS had significantly greater %EWL [F (2, 234) = 15.82, p b 0.000; p b .05 for Improved N (Stayed Same = Got Worse)]. Findings support the importance of assessing relationship stability and quality in pre-WLS candidates, as healthy and stable relationships may support improved long-term outcomes. Interventions to improve relationships preand post-WLS may increase both quality of life and weight loss outcomes. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Bariatric surgery, also referred to as Weight Loss Surgery (WLS), is the most effective weight loss treatment for clinically severe or morbid obesity (BMI ≥ 40 kg/m2; NIH, 2000). Surgical techniques have advanced in recent years, with associated risks decreasing as a function of increases in the use of minimally invasive laparoscopic procedures. In the US, the Roux-en-Y gastric bypass procedure is most commonly performed, followed by adjustable gastric banding (Buchwald & Oien, 2009) and the newer gastric sleeve procedure. In a meta-analysis of 164 bariatric outcome studies, Chang et al. (2013) concluded that sleeve gastrectomy and gastric bypass procedures had comparable long-term weight loss outcomes, and both resulted in greater weight loss than ☆ Preparation of this manuscript was supported by the Eastern Michigan University Department of Psychology and the EMU Graduate School. Data presented in this manuscript were included in a preliminary report presented at the Annual Meeting of the Obesity Society (Obesity.org, November 2013). ⁎ Corresponding author at: Wayne State University, Department of Psychology, 5057 Woodward Ave., 7th Floor, Detroit, MI 48202, United States. Tel.: +1 313 577 2800; fax: +1 313 577 7636. E-mail address:
[email protected] (S.M. Clark).
http://dx.doi.org/10.1016/j.eatbeh.2014.09.003 1471-0153/© 2014 Elsevier Ltd. All rights reserved.
adjustable gastric banding. Across surgery types, after WLS, patients lose, on average, over 60% of excess body weight (Buchwald et al., 2004). In addition, health care utilization and associated costs decrease after WLS (Cremieux, Buchwald, Shikora, et al., 2008), largely due to cost offsets conferred by reductions in obesity-related conditions including diabetes, hyperlipidemia, hypertension, and sleep apnea (Buchwald et al., 2004; Padwal et al., 2014). In addition to improvements in physical health and health-related quality of life (Aftab et al., 2014), many studies also show strong support for improvements in psychological health and well-being, with the magnitude of these gains typically associated with the amount of weight lost and the maintenance of that weight loss (Kubik, Gill, Laffin, & Karmali, 2013). With respect to the quality and stability of intimate relationships, however, an early report suggested that WLS patients experienced high rates of marital discord (Neill et al., 1978), and more recent reports indicate high rates of sexual dysfunction among WLS candidates (Bond et al., 2011; Sarwer et al., 2013). On the other hand, research supports that psychosocial functioning and the quality of social relationships generally improve after WLS. In particular, relationship and sexual satisfaction generally improve after WLS (Applegate & Friedman,
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2008; Sarwer et al., 2014). To our knowledge, the connection between relationship satisfaction and post-surgical weight loss has not been explored. Therefore, we examined how the stability and quality of intimate relationships from pre- to post-WLS relate to long-term weight loss outcomes. We hypothesized that better long-term weight loss outcomes would be associated with greater relationship satisfaction. 2. Method 2.1. Participants A total of 361 participants provided complete data for the primary analysis of relationship change status and weight loss. The sample was 95.9% Caucasian, 80.1% female, averaged 7.7 years post-WLS, with a mean age of 47.7 years (range 21–72); 87.3% had a Roux-en-Y gastric bypass. 2.2. Procedures Patients of the St. Vincent Carmel Bariatric Center of Excellence who underwent bariatric surgery between January 1, 1999 and June 30, 2005 were recruited by Center staff to complete a survey examining medical and psychological outcomes. All patients were contacted by Bariatric Center staff via telephone or at a scheduled Bariatric Center visit regarding their interest in participating in a study on long-term bariatric surgery outcomes. Patients completed a survey via mail, online, or telephone that assessed a host of medical and psychological variables, with the present study focusing on relationship status and satisfaction variables. A total of 808 surveys were mailed or emailed to patients, and 419 were returned, for a 52% response rate. Those who returned surveys were entered into a drawing for a Visa gift card, with one $400 gift card and five $50 cards available in the raffle. All survey data were kept separate from the patients' medical records unless they explicitly requested that it be shared with other St. Vincent health care professionals. The study was approved by the St. Vincent Institutional Review Board. Patients completed a survey that assessed a host of variables pertinent to bariatric surgery outcomes, but the present study focused only on variables pertaining to weight loss, relationship status, and relationship satisfaction. Participants were asked if they were currently “in a relationship” and whether they were in a relationship at the time of surgery. Based on answers to these two questions, four relationship status groups were created: Not in a relationship at surgery or currently (No-Rel, n = 66; 18.2%); Post-WLS relationship only (New-Rel, n = 23; 6%); Pre-WLS relationship only (Lost-Rel, n = 17; 5%); and Pre–Post Relationship (Maintainer, n = 255; 70.6%). Those who were in a relationship both before surgery and at present (i.e., the Maintainers, n = 255) were asked whether their relationship had changed since surgery. This item ranged from “Extremely Worse” (0) to “Extremely Better” (10). Current percent excess weight loss (%EWL) was calculated from self-reported height and weight with ideal weight defined as a BMI of 25.0 kg/m2.
Fig. 1. Percentage of excess weight loss (%EWL) to present time as a function of relationship status for long-term post-WLS patients who were not in a romantic relationship at surgery or follow-up (No-Rel), started a new relationship since WLS (New-Rel), ended a relationship since WLS (Lost-Rel), or maintained a relationship from pre- to post-WLS (Maintainer). p b .10;**p b .01; ***p b .001.
to pre-WLS BMI, with lower pre-WLS BMI associated with greater %EWL. ANCOVA analyses including pre-WLS BMI as a covariate revealed relationship status group differences in %EWL remained significant, F (3, 355) = 3.09, p = .03, as did the pre-WLS BMI covariate, F (1, 355) = 9.12, p = .003. As shown in Fig. 2, for Maintainers, relationship quality moderated weight loss outcomes in that those with improved relationships postWLS had significantly greater %EWL, F (2, 234) = 15.82, p b 0.001; p b .05 for Improved N (Stayed Same = Got Worse). 4. Discussion As expected, most of our sample did not change their relationship status. Specifically, over 70% of pre-WLS patients who were in romantic relationships at the time of surgery were also in such relationships at roughly 8 years post-WLS. The survey, however, did not specifically query whether the current relationship was the same relationship as prior to surgery. Given that ambiguity, it can only be concluded that ongoing involvement in a relationship – particularly a satisfying one – is associated with improved weight loss outcomes. Overall, most participants reported the quality of their relationship as stable or improving, and, among those who maintained relationships, long-term weight loss maintenance and relationship satisfaction were strongly associated, suggesting that relationship quality may
3. Results 3.1. Participants Current BMI (M ± SD) was 34.5 ± 9.3 for No-Rel; 40.5 ± 8.2 for New-Rel; 37.4 ± 10.5 for Lost-Rel; and 33.3 ± 7.4 for Maintainers (p b .05 for both Maintainers and No-Rel vs. New-Rel). As shown in Fig. 1, %EWL differed as a function of relationship status group, with the lowest weight loss for the “New Relationship” group, which differed significantly from the No-Rel and Maintainer groups; New-Rel trended (p b .10) towards differing from the Lost-Rel group. With respect to documented predictors of weight loss, %EWL was not associated with gender, time since surgery, or age at time of surgery, but it was related
Fig. 2. Percentage of excess weight loss (%EWL) to present time as a function of relationship satisfaction change from pre- to post-WLS among relationship maintainers (n = 237). *p b .05.
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be important for maintaining health behaviors related to weight management. Findings are consistent with recent reports of reduced female sexual dysfunction (Bond et al., 2011) and overall improved sexual functioning among both women (Sarwer et al., 2014) and men (Hammoud et al., 2009) after bariatric surgery. This study was not without some limitations, most notably that the sample was limited to long-term patients for whom the surgery center had current contact information. As such, these patients may be relatively stable and continuing to focus on maintaining WLS outcomes, limiting generalizability to WLS patients more broadly. Generalizability may also be limited by virtue of patients being drawn from a single surgery center in the Midwest. Finally, because we lacked fine grained assessment of relationship status onset and offset, we cannot disentangle whether it is the continuity of relationships or simply the ongoing source of interpersonal support Nonetheless, findings support the importance of assessing relationship stability and quality in pre-WLS candidates, as healthy and stable relationships may support improved long-term outcomes. Future research should explore whether interventions to improve relationships pre-and post-WLS may increase both quality of life and weight loss outcomes.
Role of funding sources No external funding was provided.
Contributors Authors Clark and Saules designed the study and wrote the protocol. Authors Schuh, Stote and Creel participated in data collection. Author Clark conducted literature searches and provided summaries of previous research studies. Authors Clark and Saules conducted the statistical analysis. Authors Clark and Saules wrote the first draft of the manuscript and Authors Schuh, Stote and Creel contributed to and have approved the final manuscript.
Conflict of interest All other authors declare that they have no conflicts of interest.
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