Oesity Surgery, 15, 3-39 Helth-Relted Qulity of Life nd Symptoms of Depression in Extremely Oese Persons Seeking Britric Surgery Anthony N. Frictore, PhD; Thoms A. Wdden, PhD; Dvid B. Srwer, PhD; Myles S. Fith, PhD University of Pennsylvni School of Medicine, Deprtment of Psychitry, Phildelphi, PA, USA Bckground: Extreme oesity, defined y ody mss index (BMI) kg/m, is ssocited with incresed risk of depression nd with impirments in helthrelted qulity of life (HRQoL). This study exmined the reltionships mong BMI, HRQoL, nd symptoms of depression in persons with extreme oesity. Method: Prticipnts were 3 ptients who sought ritric surgery (men ± SD ge 3.±9. yers, BMI 5.±9.3 kg/m ) nd who completed questionnires to ssess symptoms of depression nd HRQoL prior to surgery. We defined HRQoL impirment s score 1 SD elow ntionl mens. Results: Impirments in HRQoL were common: >% of prticipnts scored in the impired rnges of physicl functioning, physicl role limittions, nd odily pin. Results of nlyses of vrince (ANOVAs) indicted tht impirments in HRQoL were significntly relted to symptoms of depression. Ptients with impired HRQoL scored ove the cut-off point for cliniclly significnt depression, while those without such impirment scored elow tht cut-off, regrdless of BMI. The contriution of BMI to depression ws not significnt in ny ANOVA. Conclusion: HRQoL is more strongly nd more directly relted to symptoms of depression thn is BMI. These findings highlight the need to ssess HRQoL in ptients with extreme oesity nd suggest tht interdisciplinry strtegies to ddress HRQoL impirments my e eneficil in this popultion. Key words: Morid oesity, ritric surgery, depression, qulity of life, SF-3 Reprint request to: Anthony N. Frictore, PhD, University of Pennsylvni School of Medicine, Deprtment of Psychitry, 3535 Mrket Street, Suite 3, Phildelphi, PA 19-339, USA. E-mil: frict@milmed.upenn.edu Introduction Extreme oesity, defined y ody mss index (BMI) kg/m, is risk fctor for psychosocil disturnce. 1, In study of oese individuls who sought weight loss, those who pursued ritric surgery (men BMI 5.7 kg/m ) reported greter symptoms of depression nd lower self-esteem thn less oese persons (men BMI 3. kg/m ) who sought ehviorl nd phrmcologicl tretments. 3 A community study similrly found incresed distress mong individuls with extreme oesity. Compred with persons of verge weight (BMI 1.5-.9 kg/m ), there were no elevtions in the risk of pstmonth depression in persons with BMIs of 3-3.9 kg/m or 35-39.9 kg/m. However, individuls with BMIs kg/m were nerly five times s likely s those of norml weight to hve experienced mjor depressive episode in the prior month. Incresing BMI lso is ssocited with poorer helth-relted qulity of life (i.e., the perception tht dily functioning is limited y helth conditions). 5 The reltionship etween BMI nd helth-relted qulity of life (HRQoL) holds whether the ltter is ssessed using generl or oesity-specific mesures.,7 Previous studies lso hve found tht impirments in HRQoL re relted to greter symptoms of depression, ut investigtors hve not exmined the reltive contriutions of impired HRQoL nd BMI to depression. The present study ssessed the contriutions of BMI nd impirments in HRQoL to symptoms of depression in lrge smple of extremely oese persons who sought ritric surgery. We determined 3 Oesity Surgery, 15, 5 FD-Communictions Inc.
Qulity of Life nd Depression the presence of impired HRQoL in three res physicl functioning, role limittions due to physicl prolems, nd odily pin nd compred men depression scores of those with nd without these impirments cross three BMI ctegories (i.e., - 9.9 kg/m, 5-59.9 kg/m, nd kg/m ). We hypothesized tht prticipnts with impirments in HRQoL would report greter symptoms of depression thn those without these impirments, regrdless of their BMI. Method Prticipnts Prticipnts were 3 consecutively enrolled ptients who sought ritric surgery t the University of Pennsylvni. The smple included women with men (± stndrd devition [SD]) ge of 3.3 ± 9. yers nd BMI of 51. ±.7 kg/m. The 5 men hd men ge of 5. ±.1 yers nd BMI of 5. ±. kg/m. Of the prticipnts, % were Cucsin, 13% were Africn Americn, nd 1% were Hispnic or Asin Americn. Procedure Surgery pplicnts completed severl questionnires efore meeting with psychologist who determined whether they hd ny ehviorl contrindictions to surgery (see ref. 3). Administrtion of the questionnires ws pproved y the University of Pennsylvni's Institutionl Review Bord. Mesures Depression. Symptoms of depression were ssessed using the Beck Depression Inventory, Second Edition (BDI). 9 Totl scores on the 1-item scle rnge from to 3, with higher scores indicting greter symptoms of depression. Scores of -13 suggest miniml symptoms of depression, while vlues of -19, -, nd 9-3 reflect mild, moderte, nd severe symptomtology, respectively. 9 HRQoL. The Medicl Outcomes Study 3-item Short-Form Helth Survey (SF-3) ws used to ssess HRQoL. The SF-3 is comprised of eight scles four relted to physicl helth nd four to mentl helth nd hs fvorle psychometric properties. 11 Scores on ll SF-3 scles rnge from to, with lower scores indicting greter impirments in HRQoL. For the present study, we limited our exmintion to three of the SF-3's four physicl scles: 1) physicl functioning, which ssesses ility to complete ctivities of dily living; ) role limittions due to physicl prolems (physicl role limittions), which mesures physicl limittions in fulfilling socil nd occuptionl roles; nd 3) odily pin, which mesures oth the frequency nd severity of physicl pin. The fourth physicl scle, generl helth perception, ws not included in these nlyses. The decision to exclude tht scle ws mde priori, ecuse it represents n overll cognitive pprisl of helth sttus, s opposed to functionl ilities or limittions. The mentl helth scles were excluded ecuse previous studies hve found inconsistent reltionships etween them nd BMI. Weight nd Height. On the dy of their ehviorl evlution, 3 prticipnts were weighed in light clothing on n electronic scle. They reported their height. All mesures were completed efore surgery. Sttisticl Anlyses A preliminry multivrite nlysis of vrince (MANOVA) ws conducted to determine whether men nd women differed significntly in symptoms of depression or HRQoL. They did not nd, thus, their dt were comined in susequent nlyses. Prticipnts were divided into three BMI ctegories s follows: 1) -9.9 kg/m ; ) 5-59.9 kg/m ; nd 3) kg/m. Individuls who scored t lest one stndrd devition elow the ntionl men for HRQoL vrile 11 were clssified s impired on tht spect of HRQoL. Thus, ptients who scored <.9 on physicl functioning, <.9 on physicl role limittions, nd <51.5 on odily pin were considered to hve impirment in those res, respectively. A 3 (BMI ctegory: -9.9 kg/m ; 5-59.9 kg/m ; nd kg/m ) X (impirment sttus: impired; not impired) fctoril nlysis of vrince (ANOVA) ws conducted for ech HRQoL scle (i.e., physicl functioning, physicl role limi- Oesity Surgery, 15, 5 35
Frictore et l ttions, odily pin). Symptoms of depression were the dependent vrile, nd BMI ctegory nd impirment sttus were etween-sujects fctors in ech ANOVA. Prtil et squred (η ), which is rtio of the etween-groups sum of squres nd the totl sum of squres, ws clculted s mesure of effect size. Post-hoc comprisons were mde using Tukey's honestly significnt difference test. Dt were nlyzed using SPSS, version 11.5. Results Nerly hlf of prticipnts (%, n = ) hd BMI of -9.9 kg/m, 3% (n = 5) BMI of 5-59.9 kg/m, nd 19% (n = 59) vlue kg/m. HRQoL impirments (i.e., defined s score 1 SD elow ntionl mens) were common: 7%, 5%, nd 5% of prticipnts scored in the impired rnges of physicl functioning, physicl role limittions, nd odily pin, respectively. Results of three fctoril ANOVAs re summrized in Tle 1. These nlyses reveled tht impirment on ech of the three HRQoL vriles ws significntly relted to symptoms of depression: 1) physicl functioning (P <.1, η =.); ) physicl role limittions, (P <.1, η =.13); nd 3) odily pin, (P <.1, η =.). By contrst, BMI ws not relted to depression nd the interction of BMI nd HRQoL impirment ws not significnt in ny of the fctoril ANOVAs. Figures 1-3 show men BDI scores plotted y BMI ctegory nd HRQoL impirment. Figure presents BDI scores sed on the three clsses of oesity lone. Correltions mong vriles re presented in Tle. Significnt negtive reltionships, rnging from -.1 to -.3, were found etween BMI nd physicl functioning, physicl role limittions, nd odily pin, indicting tht higher BMI ws ssocited with lower physicl qulity of life. Correltion coefficients mong HRQoL vriles rnged from. to.59. BDI scores were significntly nd negtively relted to physicl functioning, physicl role limittions, nd odily pin, with coefficients rnging from -.3 to -.. Thus, poorer physicl qulity of life ws correlted with greter symptoms of depression. BMI correlted wekly, ut significntly, with symptoms of depression (r =.11, P =.5). A multiple regression nlysis with stepwise entry indicted tht physicl role limittions nd odily pin ech contriuted significntly to symptoms of depression. These predictors ccounted for 15.9% nd.3% of the vrince in depression, respectively. Physicl functioning nd BMI ech explined <1% of the remining vrince, s shown in Tle 3. Discussion Helth-cre providers who ssess or tret individuls with extreme oesity should e wre tht these Tle 1. Results of ANOVA testing effects of BMI ctegory nd HRQoL impirment on symptoms of depression HRQoL Vrile BMI -9.9 BMI 5-59.9 BMI Totl ANOVA F men SD men SD men SD men SD BMI Impired BMI X Impired Physicl Functioning.7 5.**.5 - Not Impired. 5.9..9. 9.. 5. - Impired..9. 7.. 11.3. 9. Physicl Role Limittions 1..3** 1. - Not Impired 9.5 7.7 9.5.3 9. 7.1 9.5 7.1 - Impired. 9...5 1.5 11.9. 9.9 Bodily Pin 1.3 5.**. - Not Impired 9.5 7. 9.5.7. 9.7 9.7 7.7 - Impired 15. 9.3 13..1 17. 11.5 15.3 9. Totl.1 9. 11.7 7.7 15. 11.. 9. **P<.1. 3 Oesity Surgery, 15, 5
Qulity of Life nd Depression 1 Physicl Functioning: -9.9 5-59.9 + Not Impired Impired Figure 1. Men symptoms of depression cross groups defined y BMI nd whether the ptient scored in the impired rnge on the physicl functioning scle of the SF-3. The Ns for the six ctegories, from left to right, were 5, 97, 19,, 5 nd 5, respectively. Error rs represent stndrd errors. Brs with different letters differ significntly from ech other s determined y Tukey's honestly significnt difference comprison (P<.5). BDI 1 Bodily Pin: -9.9 5-59.9 + Not Impired Impired Figure 3. Men symptoms of depression cross groups defined y BMI nd whether the ptient scored in the impired rnge on the odily pin scle of the SF-3. The Ns for the six ctegories, from left to right, were 77, 5, 51, 5, 19 nd, respectively. Error rs represent stndrd errors. Brs with different letters differ significntly from ech other s determined y Tukey's honestly significnt difference comprison (P<.5). ptients re t incresed risk for depression. 1-,13 The results of the present study suggest tht, within this t-risk popultion, impirments in HRQoL occur frequently nd further increse the risk of mood disturnce. On verge, ptients with impired HRQoL reported symptoms of depression tht exceeded the 1 Physicl Role Limittions: Not Impired -9.9 5-59.9 + Impired Figure. Men symptoms of depression cross groups defined y BMI nd whether the ptient scored in the impired rnge on the physicl role limittions scle of the SF-3. The Ns for the six ctegories, from left to right, were 9, 5, 57,, 1 nd 3, respectively. Error rs represent stndrd errors. Brs with different letters differ significntly from ech other s determined y Tukey's honestly significnt difference comprison (P<.5). c c BDI s cut-off for likely clinicl significnce (i.e., score of ). 9 BDI scores of ptients without impirments in HRQoL fell well elow the cut-off, even if BMIs exceeded kg/m. These findings suggest tht impired HRQoL my e mechnism through which extreme oesity increses the risk of depression. Such pthwy is intuitive, sed on findings tht incresing BMI is relted to greter impirments in HRQoL which, in turn, re relted to greter symptoms of depression. 1-9.9 5-59.9 + Figure. Men symptoms of depression cross BMI ctegories. The Ns for the three ctegories, from left to right, were, 5, nd 59, respectively. Error rs represent stndrd errors. Tukey's honestly significnt difference comprison showed no significnt differences mong mens. Oesity Surgery, 15, 5 37
Frictore et l Tle. Descriptive sttistics nd correltions mong vriles (N = 3) Vrile Men + SD 3 5 1. (kg/m ) 5. ± 9. -.3** -.1** -.3**.11*. Physicl Functioning (SF-3). ±..5**.59** -.3* 3. Role Limittions due to Physicl Prolems (SF-3). ± 1..** -.**. Bodily Pin (SF-3) 51.9 ±. -.37** 5. Symptoms of Depression (BDI). ± 9. *P.5, **P.1. Tle 3. Regression nlysis summry for ody mss index nd helth-relted qulity of life vriles predicting symptoms of depression ( N = 3) Vrile B SEB β R Step 1 Physicl Role Limittions -.9.1 -..159** Step Bodily Pin -.9. -.3.3** Step 3 Physicl Functioning -.. -.. Step -..5 -.. ** P.1. B = unstndrdized regression coefficient. SEB = Stndrd error of B. β = stndrdized regression coefficient. R = portion of vrince in depression ccounted for y vrile. Direct empiricl support for this hypothesis, however, would e dependent on meeting the following ssumptions: 1) oesity precedes nd cuses the onset of HRQoL impirments; nd ) HRQoL impirments precede nd cuse the onset of depression. Although prospective studies hve yet to estlish those temporl reltionships definitively, t lest one longitudinl study found tht the onset of oesity occurred efore tht of depression. Roerts nd collegues found in community smple of middle-ged nd older dults tht oesity t one time incresed the risk of developing depression t lter time. Correltionl nlyses reveled tht symptoms of depression incresed, nd HRQoL decresed, with incresing BMI. These findings re consistent with previous reserch. 7,15 The mgnitude of the reltionship etween BMI nd symptoms of depression, however, ws quite smll (r =.11), nd the men BDI score did not exceed the cut-off for likely clinicl significnce until the BMI reched. kg/m. Even mong ptients in the highest BMI ctegory, the men BDI score (15. ± 11.) suggested only mild symptoms of depression. We emphsize this point to illustrte tht extreme oesity nd depression re not strongly ssocited. While extremely oese individuls my hve higher prevlence of depression thn do persons of verge weight, it is inccurte to ssume tht significnt dysphori is n inevitle consequence of extreme oesity. Evidence of mood disturnce ws found only in those individuls who reported significnt impirments in HRQoL. The principl limittion of this study is the crosssectionl nture of the dt. Only prospective studies cn estlish the temporl reltionships necessry to conclude whether impirments in HRQoL ccount for the reltionship etween extreme oesity nd depression. Another limittion is the use of self-report inventory rther thn structured clinicl interview to ssess mood disturnce. Thus, dignoses of mjor depression nd other mood disorders could not e mde. This study furthers understnding of the ssocition etween extreme oesity nd depression. It ppers tht impirments in completing ctivities of dily living, difficulties fulfilling socil nd occuptionl roles, nd the experience of significnt pin re stronger determinnts of mood disturnce thn is the severity of oesity. Thus, clinicins re dvised to ssess HRQoL when evluting persons with extreme oesity. Tretment recommendtions my include interventions tht trget not only weight (i.e., ritric surgery), ut lso functionl ilities. For exmple, physicl nd occuptionl therpy cn help to improve ptients' rnge of motion nd ilities to complete ctivities of dily 3 Oesity Surgery, 15, 5
Qulity of Life nd Depression living. Voctionl rehilittion my e le to help extremely oese ptients find nd mintin employment tht is consistent with their physicl cpilities. Approprite medicl consulttion should e sought to reduce weight-relted pin. We elieve tht interdisciplinry collortion cn significntly improve the qulity of cre provided to persons with extreme oesity. Preprtion of the mnuscript ws supported in prt y grnts U1-DK57135- nd K-DK51- to Dr. Wdden nd grnt K3-DK3-3 to Dr. Srwer. References 1. Herpertz S, Kielmnn R, Wolf AM et l. Does oesity surgery improve psychosocil functioning? A systemtic review. Int J Oes 3; 11:13-.. Srwer DB, Wdden TA, Frictore AN. Psychosocil nd ehviorl spects of ritric surgery. Oes Res (in press). 3. Wdden TA, Srwer DB, Womle LG et l. Psychosocil spects of oesity nd oesity surgery. Surg Clin North Am 1; 1:1-.. Onyike CU, Crum RM, Lee HB et l. Is oesity ssocited with mjor depression? Results from the third Ntionl Helth nd Nutrition Exmintion Survey. Am J Epidemiol 3; 15: 1139-7. 5. Hn TS, Tijhuis MAR, Len MEJ et l. Qulity of life in reltion to overweight nd ody ft distriution. Am J Pulic Helth 199; : 1-.. Doll HA, Petersen SEK, Stewrt-Brown SL. Oesity nd physicl nd emotionl well-eing: Associtions etween ody mss index, chronic illness, nd the physicl nd mentl components of the SF-3 questionnire. Oes Res ; : -7. 7. Kolotkin RL, Crosy RD, Willims GR. Helthrelted qulity of life vries mong oese sugroups. Oes Res ;:7-5.. Dixon JB, Dixon ME, O Brien PE. Depression in ssocition with severe oesity: Chnges with weight loss. Arch Intern Med 3; 3: 5-5. 9. Beck AT, Steer RA, Brown BK. Beck Depression Inventory Mnul, nd edn Sn Antonio (TX): Psychologicl Corportion, 199.. Wre JE, Sherourne CD. The MOS 3-item Short- Form Helth Survey (SF-3): I. Conceptul frmework nd item selection. Med Cre 199;3:73-3. 11.Wre JE, Kosinski M, Keller SK. SF-3 physicl nd mentl helth summry scles: A user's mnul. Boston (MA): The Helth Institute 199..Pedhuzer EJ, Pedhuzer-Schmelkin L. Mesurement, design, nd nlysis: An integrted pproch. Hillsdle, NJ: Lwrence Erlum 1991. 13.Srwer DB, Cohn NI, Gions LM et l. Psychitric dignoses nd psychitric tretment mong ritric surgery cndidtes. Oes Surg ; : 1-5..Roerts RE, Deleger S, Strwridge WJ et l. Prospective ssocition etween oesity nd depression: Evidence from the Almed County Study. Int J Oes 3; 7: 5-1. 15.Wdden TA, Womle LG, Stunkrd AJ et l. Psychosocil consequences of oesity nd weight loss. In: Wdden TA, Stunkrd AJ, eds. Hndook of Oesity Tretment. New York: Guilford : -9. (Received Octoer, ; ccepted Jnury, 5) Oesity Surgery, 15, 5 39