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Surgery for Obesity and Related Diseases 12 (2016) 188–193
Integrated health original article
Psychological predictors of body image concerns 3 months after
bariatric surgery
Ashleigh A. Pona, B.S.
a
, Leslie J. Heinberg, Ph.D.
b,c
, Megan Lavery, Psy.D.
b,c
,
Yossef S. Ben-Porath, Ph.D.
d
, Julie Merrell Rish, Ph.D.
b,c,*
a
University of Missouri—Kansas City, Kansas City, Missouri
b
Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
c
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
d
Kent State University, Kent, Ohio
Received January 9, 2015; accepted May 14, 2015
Abstract Background: Although studies have associated postoperative weight loss with improvement in
body image dissatisfaction, some individuals continue to report body image concerns after bariatric
surgery. These concerns are linked to increased depressive symptoms and decreased self-esteem in
bariatric populations.
Objective: This study sought to explore preoperative factors that may predict early body image
concerns 3 months after bariatric surgery.
Setting: Academic medical center.
Method: Data were analyzed from 229 patients evaluated for bariatric surgery who completed a 3-
month postoperative psychology appointment and the Minnesota Multiphasic Personality Inventory,
Second Edition, Restructured Form (MMPI-2-RF). Scales measuring depression, persecution, self-
doubt, and inadequacy were examined. Medical records were reviewed for demographic charac-
teristics, psychotropic medication usage, history of psychological treatment, and current or lifetime
depression diagnosis.
Results: Patients who preoperatively scored higher on demoralization (F [1, 227] ¼35.40, Po
.001), low positive emotions (F [1, 227] ¼4.18, Po.05), ideas of persecution (F [1, 227] ¼15.24,
Po.001), self-doubt (F [1, 227] ¼27.47, Po.001), and inefficacy (F [1, 227] ¼21.34, Po
.001) were significantly more likely to report body image concerns 3 months after bariatric surgery.
Similarly, body image concerns were more common in patients with a preoperative depression
diagnosis (χ
2
¼8.76, Po.01), current psychotropic medication usage (χ
2
¼7.13, Po.01), and
history of outpatient therapy (χ
2
¼8.34, Po.01) and psychotropic medication (χ
2
¼9.66,
Po.001).
Conclusion: Bariatric surgery candidates with psychopathology and other psychological risk fac-
tors are more likely to report body image concerns early after bariatric surgery. Future research is
warranted to determine whether this association remains further out from surgery. (Surg Obes Relat
Dis 2016;12:188–193.) r2016 American Society for Metabolic and Bariatric Surgery. All rights
reserved.
Keywords: Bariatric surgery; Body image; Depression; Self-esteem; MMPI-2-RF
Patients who pursue bariatric surgery have been reported
to have higher rates of psychopathology compared with
normal weight and nonsurgical obese controls [1–4].
http://dx.doi.org/10.1016/j.soard.2015.05.008
1550-7289/r2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.
*
Correspondence: Julie Merrell Rish, Ph.D., 9500 Euclid Avenue/M61,
Cleveland, OH 44195.
E-mail: merrelj@ccf.org
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Mitchell et al. [2] found that approximately 34% of patients
received 1 or more current Axis I diagnoses and 69% met
criteria for a lifetime diagnosis. Sarwer et al. [4] also found that
approximately 25%–30% of bariatric patients reported clini-
cally significant depression. Patients diagnosed with a depres-
sive disorder had lower excess weight loss at 1, 3, 6, and 9
months and were more dissatisfied with their postoperative
weight loss than those without depression [5], which may result
in or contribute to body image concerns after surgery.
Previous studies that have examined the relationship
between bariatric surgery and body image have found
mixed results. Although a number of studies have associ-
ated postoperative weight loss with a marked improvement
in body image dissatisfaction, often to the normative range
[4,6,7], there are still some individuals who continue to feel
dissatisfied with their body image after bariatric surgery
[4,8,9]. Overall, bariatric surgery patients demonstrate
significant improvements in body image satisfaction and
quality of life in the first 2 years after surgery and these
improvements are correlated with percentage of weight loss
[6–8,10]. However, formerly obese individuals may experi-
ence “phantom fat”[11] by which they evidence a perceptual
disturbance regarding their weight, have concerns with
excess/redundant skin [9], and may retain a degree of body
dissatisfaction regardless of weight loss [12].
Female bariatric surgery candidates who are young and
Caucasian with a history of childhood-onset obesity and a
history of binge eating disorder (BED) and/or weight
cycling are at greatest risk for body image dissatisfaction
after surgery [13]. Particularly among obese women, body
image dissatisfaction is associated with increased depressive
symptoms, decreased self-esteem, and a history of teasing
independent of the degree of obesity [14–16]. Additionally,
researchers have found that greater presurgical body image
dissatisfaction has been connected to psychological distress
1 year after bariatric surgery [8] and that lower percentage
of weight loss is related to worse postoperative body image
satisfaction [5,8]. Moreover, studies have examined the role
of unrealistic weight loss expectations on body image and
psychological distress after surgery [17,18]. These findings
suggests that patients may be disappointed with their
amount of weight loss after surgery and that their goals
may be driven more by body image ideals, rather than
health and quality-of-life benefits [18].
Psychological assessment is a widely utilized part of a
multidisciplinary assessment for bariatric surgery candidates
to assess suitability and plan pre- and postoperative
behavioral interventions [19–22]. Methods to assess bari-
atric surgery candidates include informal and structured
interviews, as well as self-report records of psychopathol-
ogy [23], such as the Minnesota Multiphasic Personality
Inventory, Second Edition, Restructured Form (MMPI-2-
RF) [24]. To date, there has been no known research
investigating MMPI-2-RF scores on body image concerns
after bariatric surgery. Most studies have focused on either
MMPI or MMPI-2 scores on weight loss as a dependent
measure. However, Wygant et al. [25] found correlates of
the Restructured Clinical Scales of the MMPI-2-RF to
include life dissatisfaction, history of psychiatric illness
and psychotropic medication usage, and obesity negatively
affecting self-image and quality of life (i.e., Demoralization,
Low Positive Emotions scales), in addition to a history of
being teased about weight (i.e., Ideas of Persecution scale).
Additionally, Tarescavage et al. [26] found scales measur-
ing emotional dysfunction (i.e., Demoralization, Low Pos-
itive Emotions, Self-Doubt, Inefficacy scales) to be
significantly related to poor insight and judgment, reported
negative effect of obesity on quality of life and self-image, a
history of psychotropic medication use, and moderate to
severe psychiatric illness [26]. Further research is needed to
adequately assess the MMPI-2-RF as a measure of predict-
ability in bariatric surgery outcome variables.
The link between depression, body image, self-esteem,
and bariatric surgery has been demonstrated. Although the
literature indicates that most patients’body image dissat-
isfaction improves after surgery, there is significant varia-
bility among patients. Thus, the aim of the present study
was to identify preoperative factors that may predict body
image concerns 3 months after bariatric surgery. Specifi-
cally, it was hypothesized that patients who self-reported
postoperative body image concerns would be more likely to
endorse preoperative psychological symptoms (i.e., depres-
sion diagnosis, history of outpatient therapy, psychotropic
medication use) and score higher on MMPI-2-RF scales
measuring depression (i.e., Demoralization, Low Positive
Emotions) and low self-esteem (i.e., Ideas of Persecution,
Self-Doubt, and Inefficacy) during preoperative psycholog-
ical testing. The MMPI-2-RF scales used in this study were
selected because they have been correlated with factors
affecting depression and self-esteem, such as a lack of
positive emotional experiences, feelings of inadequacy and
self-doubt, and a history of being teased about weight—
psychological symptoms that may serve as predictors of
body image concerns after bariatric surgery. Therefore,
using the MMPI-2-RF scales of Demoralization and Low
Positive Emotions as representations of depression and the
scales of Ideas of Persecution, Self-Doubt, and Inefficacy as
representations of self-esteem, we predicted that elevated
scores on the former and the latter would be associated with
body image concerns 3 months after bariatric surgery.
Materials and methods
Participants
Participants (n ¼229 out of 958) presenting for bariatric
surgery between March 2009 and November 2011 were
included in the present study if they had completed the
following requirements: (1) the initial preoperative semi-
structured psychodiagnostic interview; (2) the MMPI-2-RF
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[24] (only valid profiles were included); (3) bariatric surgery
(568 out of 958), and (4) a 3-month postoperative shared
psychological appointment and behavioral questionnaire.
Both female and male participants were included in the
present study. The patients included in the present study were
primarily female (68.3%, n ¼155), with a mean age of
47.6 ⫾11.55 years (range 19–74), a mean preoperative body
mass index (BMI) of 51.1 ⫾10.17 kg/m
2
(range 34–92), and
an average of 13.9 ⫾2.25 years of education (range 9–23).
Assessments
On the day of the initial preoperative semistructured
psychodiagnostic interview, patients completed the MMPI-
2-RF [24]. The MMPI-2-RF is a 338-item test of person-
ality and psychopathology that uses a true/false format. It
includes reliable and empirically confirmed measures of
emotional, thought, behavioral, somatic, and interpersonal
dysfunction. Three of the 9 Restructured Clinical (RC)
scales were included in the analyses and have been reported
to have good internal consistency and discriminant validity
within a bariatric surgery sample (i.e., Demoralization [α¼
.89], Low Positive Emotions [α¼.70], Ideas of Persecution
[α¼.54]) [26]. Wygant et al. identified correlates of the
scales examined in the present study to include life
dissatisfaction, history of psychiatric illness and psycho-
tropic medication usage, and obesity negatively affecting
self-image and quality of life using the Demoralization and
Low Positive Emotions scales, in addition to a history of
being teased about weight using the Ideas of Persecution
scale [25]. Two of the Internalizing scales were also
included in the analyses and have been found to have good
internal consistency and discriminant validity within a
bariatric sample (i.e., Self-Doubt [α¼.72], Inefficacy
[α¼.69]) [26]. Profile invalidity was determined for
those with unscorable, cannot say responses of Z18, a
tscore of Z80 on variable response inconsistency, a tscore
of Z80 on true response inconsistency, and/or a tscore
of Z100 on infrequent psychopathology responses [27].
Three months after the bariatric procedure, patients
attended a follow-up appointment with a psychologist and
completed a self-report questionnaire asking them to
identify any psychosocial, physical, or medical complica-
tions they were experiencing after surgery. The question-
naire consisted of a predetermined list of items and patients
were instructed to check the items they were currently
experiencing. The outcome variable, body image concerns,
was listed as a psychosocial complication on the question-
naire and was coded as indicated or not indicated. The rate
of attendance for follow-up was 39.9%.
Procedures
The study was conducted as a retrospective chart review
and was approved by the Institutional Review Board.
Medical records were reviewed for demographic variables
(age, ethnicity, and education) and baseline BMI. The
following psychosocial risk variables were examined from
the preoperative semi-structured psychodiagnostic interview
and coded as yes or no to current and past psychotropic
medication usage, past outpatient therapy, and current or
lifetime depression diagnosis. Scores from the MMPI-2-RF
scales of Demoralization and Low Positive Emotions were
examined to measure depression, and scores from the Self-
Doubt, Inefficacy, and Ideas of Persecution scales were
examined to measure self-esteem. A follow-up self-report
questionnaire consisting of a predetermined list of psycho-
social, physical, and medical complications instructed
patients to indicate which complications they were currently
experiencing. The outcome variable, body image concerns,
which was listed as a psychosocial complication, was
examined from the follow-up questionnaire and coded as
indicated or not indicated.
Statistical analyses
Data were analyzed using SPSS Statistics, Version 19
[28].χ
2
analyses and 1-way analyses of variance were
conducted, testing the statistical significance between the
dichotomous and continuous psychosocial variables. A
series of χ
2
analyses and analyses of variance were
conducted to test for group differences on demographic
variables (age, ethnicity, education, surgical procedure, and
BMI) and clinical variables (psychotropic medication usage,
previous psychiatric treatment, depression diagnosis).
Results were considered significant with a Pr.05.
Results
The patients who endorsed body image concerns 3
months after bariatric surgery comprised 9.3% (n ¼20)
of the total sample, consisting of 75% women (n ¼15) and
25% men (n ¼5). Specifically, body image concerns
affected 9.6% of the female sample and 6.9% of the male
sample. Of those reporting postoperative body image
concerns, Caucasians comprised 65% (n ¼13), blacks
15% (n ¼3), and Latinos 5% (n ¼1); 15% (n ¼3) were
missing race/ethnicity data or were unidentified. The
majority of our study population received the Roux-en-Y
gastric bypass surgery (81.9%, n ¼152) followed by the
adjustable gastric banding (10.2%, n ¼19). The presence of
body image concerns at 3 months was not significantly
different based on BMI, gender, race, surgical procedure, or
education.
Patient responses on the substantive scales of the MMPI-
2-RF were significantly related to body image concerns 3
months after surgery. Specifically, patients who reported
body image concerns 3 months after bariatric surgery had
scored higher preoperatively on the MMPI-2-RF Restruc-
tured Clinical Scales measuring Demoralization (RCd) (F
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[1,227] ¼35.40, Po.001), Low Positive Emotions (RC2)
(F [1, 227)] ¼4.18, Po.05), and Ideas of Persecution
(RC6) (F [1,227] ¼15.24, Po.001) (Table 1). Addition-
ally, these patients scored higher preoperatively on the
MMPI-2-RF Specific Problems Scales measuring Self-
Doubt (SFD) (F [1,227] ¼27.47, Po.001) and Inefficacy
(NFC) (F [1,227] ¼21.34, Po.001). (Table 1 contains
means, standard deviations, F statistics, and Pvalues.)
The patients who reported body image concerns were
also significantly more likely to have a preoperative lifetime
or current depression diagnosis (78% versus 22%; χ
2
¼
8.76, Po.01, ϕ¼.32) and currently use psychotropic
medication (70% versus 30%; χ
2
¼7.13, Po.01, ϕ¼.18)
based on the medical record review and present at the time
of the initial preoperative semi-structured psychodiagnostic
interview. In addition, a lifetime history of outpatient
therapy (75% versus 25%; χ
2
¼8.11, Po.01, ϕ¼.19)
and psychotropic medication management (90% versus
10%; χ
2
¼9.66, Po.001, ϕ¼.21) were more common
among patients who endorsed body image concerns 3
months after bariatric surgery.
Discussion
The current investigation sought to identify preoperative
factors that relate to body image concerns 3 months after
bariatric surgery. Consistent with our hypotheses and the
findings of others [29–32], this study found body image
concerns to be associated with a history of and/or current
depression, as demonstrated by preoperative elevated scores
on the MMPI-2-RF scales measuring demoralization and
low positive emotions, and also by a preoperative depres-
sion diagnosis. Patients concerned with their body image
were also more likely to have a history of and current
psychotropic medication usage in addition to a history of
outpatient therapy, perhaps further exemplifying a relation-
ship between depression and body image concerns.
Furthermore, consistent with our hypotheses and pre-
vious reports [15,31,32], postoperative body image con-
cerns were associated with low self-esteem preoperatively,
as indicated by preoperative elevated scores on the MMPI-
2-RF scales measuring ideas of persecution, self-doubt, and
inefficacy. These results are consistent with Grilo et al.’s
[15] finding that low self-esteem in adulthood is signifi-
cantly associated with body image dissatisfaction among
obese men and women seeking bariatric surgery. Addition-
ally, Wygant et al. [25] identified correlates of the MMPI-2-
RF scale measuring ideas of persecution and found that
elevated scores on this scale may represent feelings of
mistreatment due to obesity (e.g., weight-related teasing,
stigmatization, etc.). Perhapsthissubsetofoursamplehas
experienced more critical comments, teasing, and bullying as
a result of their weight and thus may require more time for
their body image to improve, regardless of weight loss. It is
also possible that these patients may continue to struggle with
body image concerns despite continued weight loss.
Overall, the results of this study are consistent with
previous studies that have concluded that depression and
self-esteem serve as important correlates of body image
dissatisfaction in both male and female obese bariatric
candidates [15,31]. Bariatric surgery candidates with a
history of psychopathology and other psychological risk
factors may be more vulnerable to body image concerns
after bariatric surgery. Past research has confirmed that the
body image of severely obese patients seeking bariatric
surgery can be impaired and that, compared with normal
weight individuals, obese persons are more likely to be
dissatisfied with their physical appearance [33,34].
Based on former descriptive studies, weight reduction
does not guarantee a “normal”body image. It is important
for patients to be educated that bariatric surgery is not a
quick fix to resolve co-morbid psychological conditions that
occur with obesity. Rather, it is a powerful tool that should
be used in conjunction with other factors, such as psycho-
social interventions found to improve psychiatric co-
morbidity such as body image [35].
Interestingly, 9.3% of the sample in this study endorsed
body image concerns after surgery (i.e., 6.9% of men, 9.6%
of women), which is lower than national prevalence studies
that indicate estimates ranging from 11%–72% for women
and 8%–61% for men [36] and survey results ranging from
13%–32% for women and from 9%–28% for men [37].
Similar to limitations of the present study, these studies are
limited by an inconsistent definition and assessment of body
image dissatisfaction [36]. It is possible that the lower levels
found in this study are due to asking whether participants
have experienced body image concerns as a psychological
complication since surgery rather than asking more broadly
if they experienced body image dissatisfaction before or
after surgery. Future research should replicate this study
adding a standardized measure of body image dissatisfac-
tion before and after surgery.
Table 1
Results from analyses of variance examining the difference between body
image concerns indicated versus not indicated on preoperative MMPI-2-RF
scale scores
Body image concerns
indicated (n ¼21)
Body image concerns not
indicated (n ¼208)
MMPI-2-RF
scale
Mean (SD) Mean (SD) F
Demoralization 61.81 (11.27) 49.04 (9.17) 35.40
*
Low Positive
Emotions
56.62 (14.56) 51.36 (10.86) 4.18
†
Ideas of
Persecution
57.60 (10.60) 49.07 (9.43) 15.24
*
Self-Doubt 61.20 (13.11) 49.51 (9.35) 27.47
*
Inefficacy 57.08 (13.81) 46.71 (9.33) 21.34
*
MMPI-2-RF ¼Minnesota Multiphasic Personality Inventory, Second
Edition, Restructured Form.
*
Significant at Po.001.
†
Significant at Po.05.
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A number of components of this study make it novel in
comparison to previous literature. First, most studies on
obesity and body image have focused on women, simply
because being a woman or girl in Western culture is a risk
factor for body image dissatisfaction and a large number of
obese women seek weight loss surgery [12,13,16,32]. The
present study included a male sample in addition to a
female sample. The inclusion of a male sample in a bariatric
setting is important because men may also be at risk for
experiencing body image concerns [8,15]. This is also the
first study to investigate MMPI-2-RF scale scores as
predictors of body image concerns. Most studies that have
examined body image in bariatric populations have used
other self-report measures to predict body image, such as
the Body Shape Questionnaire [8,15] or the Multidimen-
sional Body-Self Relations Questionnaire [7,9].
It is important to note several limitations in interpreting
our findings. This study is limited by its reliance on
retrospective chart review and patient’s self-reported body
image concerns. It is possible that patients did not report
symptoms or minimized their intensity. A second limitation
is that body image concerns were coded as indicated versus
not indicated on the 3-month follow-up questionnaire. As a
result, the type, severity, and interference of the concerns
are unknown. A third limitation is that preoperative body
image was not assessed. Therefore, it is unknown if body
image worsened, stayed the same, or even improved
compared with baseline. This study is also limited in that
diagnosis of depression was coded as presence or absence
based on the semi-structured presurgical psychodiagnostic
interview; however, it failed to include severity of symp-
toms (mild, moderate, severe) or whether symptoms were in
full or partial remission. Thus, it is possible that a diagnosis
of depression could reflect current symptoms or symptoms
in partial or full remission. Additionally, 60.1% of our
patient population failed to follow up at 3 months after
surgery. It is possible that the participants in this study may
not be representative of the larger bariatric surgery pop-
ulation. Future research is warranted examining the impact
of preoperative body image on postoperative body image
concerns. A final limitation of the present study is that body
image concerns were only assessed at a 3-month follow-up.
Future research should further replicate this study and
determine whether the association among depression, self-
esteem, and body image remains further out from surgery
(e.g., 1 year, 2 years). Future research should also examine
presurgical intervention and impact on postoperative body
image concerns as well as the relationship between presur-
gical disordered eating behaviors and pre- and postoperative
body image concerns.
Conclusion
Bariatric surgery candidates with psychopathology and
other psychological risk factors may be more vulnerable to
body image concerns early after bariatric surgery. Although
patients may have lost weight, a subset of patients continues
to report body image concerns, which may be an indication
for treatment. Future research is warranted to determine
whether this association remains further out from surgery.
Disclosures
An author of this study is a paid consultant to the MMPI-
2-RF publisher, the University of Minnesota, and distrib-
utor, Pearson. As co-author of the MMPI-2-RF, he receives
royalties on sales of the test.
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