Elsevier

Journal of Nutrition Education and Behavior

Volume 45, Issue 6, November–December 2013, Pages 620-626
Journal of Nutrition Education and Behavior

Research Article
Comprehensive Behavioral-Motivational Nutrition Education Improves Depressive Symptoms Following Bariatric Surgery: A Randomized, Controlled Trial of Obese Hispanic Americans

https://doi.org/10.1016/j.jneb.2013.04.264Get rights and content

Abstract

Objective

To evaluate the effect of 2 post-bariatric support interventions on depressive symptoms of Hispanic Americans treated with gastric bypass for morbid or severe obesity.

Design/Setting

Prospective randomized, controlled trial conducted in a laparoscopic institution.

Participants/Interventions

During the Phase 1 clinical trial (from preoperative evaluation to 6 months after surgery), all participants received standard care. During Phase 2 (6–12 months after surgery), participants were randomly assigned to receive either standard care (n = 72) or comprehensive support (n = 72). Comprehensive group participants received 6 educational sessions focused on behavior change strategies and motivation with nutrition counseling.

Main Outcome Measures

Depression scores and weight change over time.

Analysis

Independent samples t tests and regression analysis assessed relationships among depression scores and excess weight loss.

Results

Participants receiving behavioral-motivational intervention scored significantly lower on Beck's Depression Inventory questionnaire scores than those receiving standard care. For those with depressive symptoms at randomization, 24% of participants who received the comprehensive intervention reported no depressive symptoms at 12 months after surgery, compared with 6% of those who received standard care (P < .001). Patients' depressive mood improvement was significantly and positively associated with excess weight loss and attendance at educational sessions (P < .001).

Conclusions and Implications

Findings support the importance of post-bariatric comprehensive behavioral-motivational nutrition education for decreasing risk for depression and improving weight loss.

Introduction

Obesity and depression are leading contributors to the global burden of disease affecting populations of different backgrounds.1, 2 There is wide consensus in the scientific literature about the positive association between obesity and depression.3, 4, 5, 6 Individuals with obesity (body mass index [BMI] calculated as weight in kilograms divided by height in squared meters ≥ 30) are approximately 25% more likely to experience depressive symptoms compared with non-obese individuals,5 a relationship strongly affected by body dissatisfaction regardless of education level.7 Recent studies have confirmed a reciprocal link between obesity and depression.8, 9

Weight loss surgery (ie, bariatric surgery) is considered the most effective treatment for patients with morbid or severe obesity (BMI ≥ 40 or BMI ≥ 35 with associated obesity-related health condition such as type 2 diabetes, hypertension, or sleep apnea).10 Those seeking bariatric surgery are often emotionally vulnerable individuals experiencing increased psychiatric comorbidity.11, 12, 13 Depression is the most prevalent lifetime psychiatric disorder among bariatric patients, and accounts for approximately 50% of all mental health conditions.14

There is conflicting evidence regarding the effect of bariatric surgery on patients' depressive mood. Several short- and long-term studies have reported significant reduction, or low prevalence, of depressive symptoms after surgery.15, 16, 17, 18, 19 Other studies have shown a substantial increase in the rate of suicide occurring among bariatric patients.20 Furthermore, the use of antidepressants was mostly unchanged after surgery for those under medical treatment for depression.21 This highlights the importance of psychological monitoring after bariatric surgery, and the need to educate patients about the possibility of depressive symptoms postoperatively and strategies for self-esteem improvement.

Some findings indicate that patients with depression before and after surgery tended to lose less excess body weight (EBW) than those without underlying depression.22 Although depression does not appear to negatively affect weight loss, its occurrence may predict attenuated progress.23, 24 Others reported that patients treated with anti-depressive medications before and after surgery did not differ in weight loss significantly from those without pre-operatory depression.25

The incidence of bariatric procedures among Hispanic Americans is rising, because the obesity epidemic increasingly affects them due to cultural and socioeconomic factors.26, 27 Moreover, depression is a highly prevalent condition among ethnic minorities28 and Hispanic Americans seeking bariatric surgery.12 However, there is a lack of randomized, controlled studies on interventions addressing the effect of bariatric surgery and rapid weight loss on depressive moods of Hispanic Americans.

This study aimed to prospectively evaluate the effect of 2 post-bariatric support interventions on depressive symptoms of Hispanic Americans treated with Roux-en-Y gastric bypass surgery for morbid or severe obesity. It was hypothesized that patients receiving comprehensive support intervention (6 educational sessions focused on behavior change strategies and motivation along with nutrition counseling) would have greater improvement in depression scores compared with those receiving the usual standard care. Also examined was whether improvement in participants' depressive symptoms was associated with either greater EBW loss and/or attendance at comprehensive educational sessions.

Section snippets

Study Design and Procedures

This prospective study was conducted over 18 months in a bariatric laparoscopic institution in South Florida, an area with a high population of Hispanic Americans. Participants were enrolled in a 2-phase clinical trial. During Phase 1 (from the preoperative evaluation to 6 months after surgery) all participants received standard intervention. At the beginning of Phase 2 (month 6 after surgery), participants were randomly assigned to a 6-month clinical trial that compared 2 post-bariatric

Study Participants

A total of 307 participants were enrolled in Phase 1, 144 of whom (46.9%) met Phase 2 entry criteria (Figure). The randomized sample consisted of 144 obese Hispanic American adults, primarily women (83%). Mean age was 44.5 ± 13.5 years. Of the participants, 49% (n = 71) were Cuban-born, 46% were married (n = 66), 57% were employed (n = 82), and 52% were bilingual (n = 75). Participants were well educated (13.7 ± 2.7 mean years of education). There were no statistically significant differences

Discussion

The study findings provide new evidence of the depressive mood status of obese Hispanic American adults throughout the first year post-bariatric surgery. Consistent with the literature, depressive mood was prevalent (56%) among this cohort of preoperative bariatric patients,14 and decreased significantly over time along with EBW reduction.15, 16, 17, 18, 19

This study supports the feasibility of implementing a post-bariatric comprehensive support intervention (6 educational sessions focused on

Acknowledgments

The authors thank Claudio and Ariela Nijamkin for assistance with the study. This study was conducted as part of a PhD dissertation research project.

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