ORIGINAL ARTICLE

Psychological effects and outcome predictors of three bariatricsurgery interventions: a 1-year follow-up study

Giovanni Castellini • Lucia Godini •

Silvia Gorini Amedei • Carlo Faravelli •

Marcello Lucchese • Valdo Ricca

Received: 21 December 2013 / Accepted: 1 April 2014 / Published online: 16 April 2014

� Springer International Publishing Switzerland 2014

Abstract

Purpose Weight loss surgery efficacy has been demon-

strated for morbid obesity. Different outcomes have been

hypothesized, according to specific bariatric surgery

interventions and psychological characteristics of obese

patients. The present study compared three different sur-

gery procedures, namely laparoscopic adjustable gastric

band (LAGB), Roux-en-Y gastric bypass (RYGB) and

biliopancreatic diversion (BPD), in terms of weight loss

efficacy and psychological outcomes.

Methods Eighty-three subjects seeking bariatric surgery

have been evaluated before and 12 months after surgery

intervention, by means of a clinical interview and different

self-reported questionnaires, including Eating Disorder

Examination Questionnaire, Emotional Eating Scale, Binge

Eating Scale, Beck Depression Inventory, Symptom

Checklist and State-Trait Anxiety Inventory.

Results BPD group (26 subjects) showed the greatest

weight loss, followed by RYGB (30 subjects), and LAGB

group (27 subjects). All the treatments were associated

with a significant improvement of anxiety, depression, and

general psychopathology, and a similar pattern of reduction

of binge eating symptomatology. BPD group reported a

greater reduction of eating disorder psychopathology,

compared to the other groups. Pre-treatment emotional

eating severity was found to be a significant outcome

modifier for the three treatment interventions.

Conclusions These results suggest that all the three types

of bariatric surgery significantly improved psychopathol-

ogy and eating disordered behaviors. They also support the

importance of a pre-treatment careful psychological

assessment in order to supervise the post-surgical outcome.

Keywords Bariatric surgery � Eating psychopathology �General psychopathology � Morbid obesity � Weight loss

Introduction

Morbid obesity is a severe medical condition characterized

by a poor outcome for dietary, pharmacological or psy-

chotherapeutic treatments [1].

Over the past 10 years different studies have supported a

good efficacy of weight loss surgery, as gastroplasty, gas-

tric bypass or biliopancreatic diversion seems to have an

important impact on weight loss outcome with high per-

centages of excess weight loss [2]. Furthermore, the effi-

cacy of bariatric surgery has been demonstrated also in the

improvement of frequent obesity comorbidities such as

diabetes, hyperlipidemia, hypertension and obstructive

sleep apnea, which were improved or completely resolved

after surgery in most of the patients [3].

G. Castellini � L. Godini � S. G. Amedei � V. Ricca

Psychiatric Unit, Department of Neuropsychiatric Sciences,

Florence University School of Medicine, Viale Morgagni 85,

50134 Florence, Italy

L. Godini � S. G. Amedei � M. Lucchese

Bariatric Surgery Unit, Careggi Hospital, Viale Morgagni 85,

50134 Florence, Italy

C. Faravelli

Department of Psychology, University of Florence, Via di San

Salvi 12, Complesso di San Salvi, Padiglione 26,

50135 Florence, Italy

V. Ricca (&)

Psychiatric Unit, Department of Neuropsychiatric Sciences,

Florence University School of Medicine, Largo Brambilla 3,

50134 Florence, Italy

e-mail: valdo.ricca@unifi.it

123

Eat Weight Disord (2014) 19:217–224

DOI 10.1007/s40519-014-0123-6

Obese subjects referring to bariatric surgery facilities

show high rates of current and lifetime Axis I mental dis-

orders [4], in particular affective, anxiety and binge eating

disorders [5]. Several evidences suggest that weight loss

surgery is associated with an improvement in psychologi-

cal condition; however, high psychiatric comorbidity

seems to last after the surgery interventions [5]. Further-

more, psychiatric comorbidities have been proposed as

significant outcome modifiers of bariatric surgery [5, 6]. In

particular, considering eating disorders symptoms, pre-

operative binge eating behavior seems to be associated

with more eating-related and general psychopathology and

low weight loss after surgery, whereas post-operative binge

eating behavior significantly predicts poorer post-surgical

weight loss and psychosocial outcomes [7]. Therefore,

patients reporting loss of control over eating, above all

after surgery, have been identified as a distinctive subgroup

with a less favorable outcome, including weight regain [8].

To date, few studies have compared the clinical and

psychopathological outcomes of different types of bariatric

surgery interventions [5], and in most of the cases the

comparison included only patients treated with the vertical

banded gastroplasty or gastric bypass [8, 9]. Moreover,

some studies were conducted on relatively small samples

[10], with high drop-out rates at the post-operative

assessment points [9, 10], and without an adequate eating

psychopathology assessment at different time points [1].

The aim of the present study was to compare different

surgical interventions, in terms of weight loss, psycho-

pathological outcomes, and outcome predictors. In partic-

ular, we evaluated the effect of restrictive [laparoscopic

adjustable gastric banding (LAGB)], malabsorptive [bilio-

pancreatic diversion (BPD)], restrictive and malabsorptive

[Roux-en-Y gastric bypass (RYGB)] bariatric surgery

procedures.

Materials and methods

Participants

The present study was designed as a follow-up survey, and

was performed by the Psychiatric Unit of the University of

Florence (Italy) and the Bariatric Surgery Unit.

All the diagnostic procedures and the psychometric tests

were part of the routine clinical assessment for obese

patients performed at our clinics. Before the collection of

data, during the first routine visit, the procedures of the

study were fully explained; after that, the patients were

asked to provide their written informed consent to the

participation in the present study. The protocol was

approved by the Ethics Committee of the Institution.

The patients were recruited among a consecutive series

of overweight and obese subjects referring for the first

time to the Obesity Surgery Clinic of the University of

Florence (Italy) and candidates for bariatric surgery.

Patients were enrolled from September 2010 to December

2011. The inclusion criteria were age between 18 and

65 years, body mass index (BMI) [40 kg/m2 or BMI

[35 kg/m2 with severe obesity-related disease, over

5 years of obesity and failure in previous weight reduction

therapies, absence of previous bariatric intervention, and

the patient’s complete understanding of the surgical pro-

cedure and its risks. The exclusion criteria were illiteracy,

mental retardation, high surgical risk, current comorbid

severe mental disorders, such as bulimia nervosa and

vomiting behaviors, schizophrenia, bipolar disorder,

severe major depression, suicide ideation and psychoactive

substance dependence, assessed by means of the structured

clinical interview for diagnostic and statistical manual of

mental disorders (DSM-IV) [11].

Design of the study

Psychopathological, behavioral and sociodemographic

data were collected through a face-to-face interview on

the first day of admission (baseline T0; 21.2 ± 14.8 week

before surgery), and 1 year after the surgery treatment

(T1) by two expert psychiatrists who were unaware of the

kind of surgical procedure (LG, SGA) and had not

therapeutic relationship with any of the participants they

assessed. During the visits, BMI was calculated and the

psychopathological evaluation was performed. Further-

more, during the first visit, the patients were evaluated by

a dietitian and a surgeon. As already reported in a pre-

vious study by our group [12], patients choose by their

own initiative to address to the Bariatric Surgery Unit of

Florence. Patients were assessed at their first contact with

the clinic, before the evaluation of the inclusion/exclusion

criteria for starting a surgical or medical intervention.

The bariatric surgical procedure is determined after

completing all the assessments, composed by a psychi-

atric visit (a clinical interview and specific psychopath-

ological questionnaires), a dietitian visit and a surgical

visit. If the patient was evaluated as eligible to the sur-

gery, he/she received detailed information about the

treatment.

At T1, the patients were evaluated by the same psy-

chiatrists during a specialist control visit, and those sub-

jects who were not attending the clinic for control visits

were contacted by telephone and invited to the clinic for a

follow-up visit.

The three bariatric surgery procedures (LAGB, BPD,

RYGB) took place in exclusion.

218 Eat Weight Disord (2014) 19:217–224

123

Assessment

Anthropometric measurements were made using standard

calibrated instruments. Height (m) was measured using a

wall-mounted stadiometer and weight (kg) using electronic

scales with an upper weight limit of 300 kg. BMI was

calculated as weight in kilograms divided by the square of

height in meters.

Diagnosis of obesity (BMI [30 kg/m2) was performed

according to a single clinical criterion suggested by recent

clinical guidelines developed by the National Heart, Lung

and Blood Institute [13].

The results of bariatric surgery on body weight were

evaluated through the use of the percentage of the excess

BMI loss (%EBMIL = 100 9 [(initial BMI - final BMI)/

(initial BMI-25)] [14]. In order to assess the current and

lifetime prevalence of mental disorders, patients were

interviewed by two expert clinicians (LG, SGA) by means

of the structured clinical interview for DSM-IV [11].

Current eating attitudes and behaviors were specifically

investigated by means of the Eating Disorder Examination

Questionnaire (EDE-Q).

The self-reported EDE-Q consists of 38 items, assessing

the core psychopathological features of eating disorders,

and contains four subscales: dietary restraint, eating con-

cern, weight concern, and shape concern. The dietary

restraint subscale is an admixture of cognitions and

behaviors pertaining to dietary restriction. The three other

subscales evaluate the dysfunctional attitudes regarding

eating and overvalued thoughts regarding weight and

shape. The global score represents the mean of the four

subscale scores [15]. The EDE-Q has been reported to

show a good validity also in bariatric surgery candidates

[16].

In order to investigate the severity of binge eating, the

Binge Eating Scale (BES) was applied [17].

The BES has been proposed as a rapid screening

instrument for BED in obese patients, and it examines both

behavioral signs (eating large amounts of food) and feeling

or cognition during a binge episode (loss of control, guilt,

fear of being unable to stop eating) through 16 items. The

BES was already used in bariatric surgery populations

showing good psychometric properties [18, 19].

Emotional eating was assessed by means of the Emo-

tional Eating Scale (EES) [20], a 25-item self-report

questionnaire that indicates the extent to which specific

feelings lead a subject to feel an urge to eat. Each item

consists of an emotion term (e.g., jittery, angry, helpless),

and the 5-point scale used was anchored on ‘‘no desire to

eat’’ and ‘‘an overwhelming urge to eat,’’ with ‘‘a small

desire to eat,’’ ‘‘a moderate desire to eat,’’ and ‘‘a strong

desire to eat’’. The 25 items form 3 subscales, reflecting

eating in response to anger (anger/frustration), anxiety

(anxiety), and depressed mood (depression). For a further

characterization of the psychopathological features of the

patients, the Beck Depression Inventory (BDI) [21],

Symptom Checklist (SCL-90-R) [22] and State-Trait

Anxiety Inventory (STAI) [23] were also applied.

Treatment

At Bariatric and Metabolic Surgery Unit of University of

Florence (Italy), three main surgical options are performed:

LAGB as ‘‘restrictive’’ procedure, BPD as ‘‘malabsorp-

tive’’ procedure, and RYGB as ‘‘restrictive and malab-

sorptive’’ procedure.

LAGB is one of the most important types of bariatric

restrictive procedures. LAGB is a restrictive procedure and

consists on the limitation of the luminal diameter of the

stomach, without the exclusion of some segments of the

gastrointestinal tract. This procedure involves a foreign

material (the ‘‘band’’) that is an adjustable plastic and sil-

icone ring, placed around the proximal stomach just

beneath the gastroesophageal junction. An access present

in the subcutaneous area links to the band and it allows to

adjust the constriction level by the injection or withdrawal

of saline [24].

The BPD is a primarily malabsorptive procedure with

some restrictions. It consists of a partial gastrectomy where

a 200–500 mL proximal gastric pouch, a distal Roux and

proximal biliary limb are created by division of the small

bowel 250 cm proximal to the terminal ileum. The gastric

pouch is attached to the end of the Roux limb, and the

biliary limb is connected 50 cm proximal to the ileocecal

valve, thereby obtaining a very short common [24].

The RYGB consists of a malabsorbitive and restrictive

procedure. It determines the creation of a small, vertically

oriented gastric pouch (*30 mL) that is attached to a Roux

limb formed by division of the jejunum about 40–60 cm

from the ligament of Trietz. The biliary limb is anasto-

mosed to the Roux limb 150 cm from the gastrojejunos-

tomy [24].

The patients have been allocated to a specific surgical

option in relation to the BMI ([50 kg/m2) or metabolic

criteria. Subjects with BMI \45 kg/m2 underwent LAGB,

patients with BMI between 45 and 50 kg/m2 underwent

RYGB, and patients with BMI[50 kg/m2 underwent BPD.

Furthermore, if diabetes mellitus, blood lipid disorders,

impaired glucose tolerance or low resting metabolic rate

was present, RYGB or BPD was the procedure of choice.

Statistical analyses

Continuous variables were reported as mean ± standard

deviation (SD), whereas categorical variables were repor-

ted as percentages. Univariate analysis of variance

Eat Weight Disord (2014) 19:217–224 219

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(ANOVA, with Bonferroni post hoc test) and Chi square

(v2) were used for continuous and categorical variables,

respectively. Linear mixed models (ANOVA mixed model

with random intercept) were adopted for longitudinal data.

Linear mixed models are a proper method to analyze

repeated measures data because they take into account the

dependencies within the data. They are more flexible in

handling missing data than other methods, such as regres-

sion and ANOVA, and they are able to model within

subjects’ random effects, thereby allowing for individual

variation in intercepts and/or regression slopes. Linear

mixed models were used to study the variation (time effect)

of BMI and psychological variables from baseline to 1-year

follow-up. BMI and psychological variables were the

dependent variables for each model, and time was entered

as independent variable, together with age and BMI before

surgery as covariates. At first, we tested the between

treatment group effect (time by treatment interaction), and

subsequently we evaluated the time effect within each

treatment group (LAGB, BPD, RYGB). For each model,

we considered: random subject level effects, and time, age,

BMI before surgery as fixed effects.

Linear regression analyses were performed to evaluate

associations between psychological variables percentage

variation and excess of BMI loss, and between psycho-

logical variables at baseline and excess of BMI loss, in

order to identify moderators of weight loss outcome. All

analyses were performed using SPSS for windows 15.0

(Chicago Inc., USA).

Results

From the 133 consecutive patients initially included in the

follow-up study, 42 were excluded and 37 did not meet

inclusion criteria because of illiteracy (2), mental retarda-

tion (1), severe mental disorders (28) and medical contra-

indication (6), while 5 patients refused the surgical

treatment. Ninety-one patients were enrolled in the study:

30 were allocated to LAGB; 31 were allocated to RYGB

and 30 were treated with BPD, as reported in the consort

flow diagram of the study. Patients who were not available

at follow-up (three in the LAGB group, one in the RYGB

group and four in the BPD) were excluded from the

analyses.

The final sample consisted of 83 Caucasian outpatients

(75 women; 90.4 %) with a mean ± standard deviation age

of 45.3 ± 10.1 years. Twenty-seven subjects underwent

LAGB, 30 underwent RYGB and 26 BPD.

The main DSM-IV diagnoses observed at baseline were:

unipolar depression (20 subjects, 24.1 %), obsessive com-

pulsive disorder (5 subjects, 6.0 %), panic disorder (11

subjects, 13.3 %), and binge eating disorder (22 subjects,

26.5 %). No significant difference was found between

groups in terms of rates of the mentioned diagnoses.

No significant differences were found among the three

groups of patients in terms of sociodemographic, clinical

and psychopathologic variables at baseline (Table 1), with

the exception of BMI which was higher in RYGB and BPD

when compared with LAGB group. At 1-year follow-up

(Table 1), BMI was no longer different between the

groups. Other comparisons at follow-up were not signifi-

cant. As far as the excess of BMI loss is concerned (Fig. 1),

a different effect of treatment was found (F = 5.16;

p = 0.008), with RYGB and BPD groups reporting greater

weight loss compared with LAGB.

The different pattern of treatment effects on psycho-

logical variables was evaluated (Table 2). A slight effect of

group was found in terms of general psychopathology

change, and all the three groups showed a significant

reduction of SCL-90, BDI and STAI scores. LAGB group

showed a higher BDI reduction, as compared with the other

groups.

Considering eating disorder specific psychopathology,

all the groups showed a significant reduction in most of the

psychological measures taken into account, with the

exception of EDE-Q restraint.

However, a different pattern of response was found

between groups (time by treatment effect). BPD group

reported a higher reduction of EDE-Q total score, com-

pared with the other groups, while RYGB group reported

an intermediate effect. Only BPD was associated with a

reduction in all EDE-Q subscales scores. All the treatments

showed a significant reduction in BES scores with a lower

reduction in BPD subjects, while a reduction in EES total

score was found in RYGB and BPD, but not in LAGB

group.

EDE-Q total score variation rate [calculated as (EDE-Q

at baseline - EDE-Q at follow-up)/EDE-Q at baseline]

was found to be positively associated with excess of BMI

loss only in the RYGB group (R2 = 0.65; b = 0.80;

p = 0.015). This means that the higher rate of variation of

EDE-Q was associated with the higher BMI loss.

Other correlations were not significant

Finally, the effect of baseline psychological variables on

excess of BMI loss was calculated. Within all the psy-

chological variables only emotional eating at baseline was

found to be associated with the excess of BMI loss

(R2 = 0.08; b = -0.24; p = 0.03). In particular, the

higher baseline EES values were reported at baseline and

the lower was found to be the excess of BMI loss. The

analyses were performed for the whole sample and the

results were confirmed for each group of treatment

separately.

220 Eat Weight Disord (2014) 19:217–224

123

Discussion

To our knowledge, this is one of the few studies which

compared different bariatric surgery procedures, in terms

of weight loss and psychopathological outcomes. The

evaluation of bariatric surgery effects on general and eating

disorder specific psychopathology is of relevance, consid-

ering the increasing evidences of their role as potential

predictors of sustained weight loss in the long term after

surgery interventions [25].

According to our main results:

– The three types of bariatric surgical procedures showed

a different pattern of efficacy on weight loss, with BPD

group reporting the greatest weight loss;

– ‘‘Malabsorptive’’ and ‘‘restrictive and malabsorptive’’

procedures showed a higher reduction of eating disor-

der psychopathology as compared with the restrictive

intervention; however, all the treatments showed a

significant improvement in terms of binge eating

behaviors;

– A high emotional eating at baseline resulted to be

associated with a lower weight loss after surgery

interventions.

The different efficacy of surgical interventions in terms

of weight loss seems to support previous researches which

reported that weight loss outcomes strongly favor RYGB

over LAGB [26] and that RYGB is associated to a lower

%EWL (percentage of excess of weight loss) than BPD [2].

The mechanisms whereby RYGB and BPD produce

weight loss may be represented by malabsorption of

nutrients, decreased intake, food aversion, altered

Table 1 BMI and psychopathological variables at baseline (T0) and 1 year after surgery (T1)

Baseline 1 year after surgery

LAGB (n: 27) RYGB (n: 30) BPD (n: 26) ANOVA,

v2LAGB

(n: 27)

RYGB

(n: 30)

BPD (n: 26) ANOVA

Age (years) 43.85 ± 11.36 43.63 ± 9.83 48.84 ± 8.36 2.28

Gender (women) 23 (83.2 %) 28 (93.3 %) 24 (92.3 %) 1.24

BMI (kg/m2) 44.79 ± 5.3 49.49 ± 6.76 50.57 ± 6.55 6.26*** 34.91 ± 6.22 34.39 ± 7.14 32.5 ± 5.55 0.97

SCL-90 GSI 0.96 ± 0.58 1.28 ± 0.69 1.14 ± 0.5 1.88 0.65 ± 0.60 0.80 ± 0.52 0.92 ± 0.54 0.77

BDI 16 ± 11.07 18.34 ± 11.31 17.76 ± 12.06 0.28 6.66 ± 6.46 8.53 ± 6.45 9.88 ± 6.64 0.80

STAI 45.12 ± 9.18 44.68 ± 10.21 44.5 ± 11.32 0.01 36.14 ± 10.5 40.72 ± 6.49 38.00 ± 13.67 0.59

EES 46.25 ± 9.88 43.14 ± 12.43 46.76 ± 10.01 0.52 1.30 ± 1.03 0.75 ± 0.73 0.79 ± 0.51 1.69

EDE-Q total score 1.40 ± 0.93 1.64 ± 0.89 1.67 ± 0.91 0.50 1.80 ± 1.28 2.20 ± 1.18 1.2 ± 0.89 1.97

EDE-Q restraint 1.78 ± 1.4 1.96 ± 1.39 2.01 ± 1.49 0.17 1.61 ± 1.31 1.78 ± 1.59 0.88 ± 1.01 1.30

EDE-Q eating

concern

1.61 ± 1.52 2.09 ± 1.08 1.94 ± 1.85 0.53 1.18 ± 1.53 1.08 ± 1.49 0.25 ± 0.27 1.51

EDE-Q weight

concern

3.27 ± 1.2 3.43 ± 1.33 3.06 ± 1.45 0.54 1.87 ± 1.36 2.37 ± 1.22 1.42 ± 1.40 1.50

EDE-Q shape

concern

4.09 ± 1.4 4.42 ± 1.22 4.05 ± 1.57 0.59 2.53 ± 1.82 2.55 ± 1.13 2.29 ± 1.69 2.44

BES 15.5 ± 9.6 20.11 ± 9.51 16.11 ± 8.53 1.92 6.00 ± 6.43 6.13 ± 4.15 11.22 ± 9.93 2.10

Statistics—continuous variables are reported as mean ± standard deviation

BDI Beck Depression Inventory, BES Binge Eating Scale, BPD biliopancreatic diversion, BMI body mass index, EDE-Q Eating Disorder

Examination Questionnaire, EES Emotional Eating Scale Total Score, LAGB laparoscopic adjustable gastric band, RYGB Roux-en-Y gastric

bypass, STAI State-Trait Anxiety Inventory, SCL-90 GSI Symptom Checklist (SCL 90-R) global severity index

*** p \ 0.001

Fig. 1 Excess body mass index (BMI) loss: 100 9 [(initial BMI -

final BMI)/(initial BMI-25)]. LAGB laparoscopic adjustable gastric

band, BPD biliopancreatic diversion, RYGB Roux-en-Y gastric

bypass

Eat Weight Disord (2014) 19:217–224 221

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metabolism, or a combination of them [27]. Cummings

et al. showed that gastric bypass disrupts ghrelin secretion

by isolating ghrelin producing cells from direct contact

with ingested nutrients which normally regulate ghrelin

levels. This effect, associated to an adaptation in the levels

of other gut hormones (increase of peptide YY, glucagon-

like peptide 1, oxyntomodulin and reduction of leptin and

insulin) that promote satiety, may contribute to the efficacy

of the bariatric procedures in reducing weight [28, 29].

The greatest %EBMI loss in BPD group confirmed

results of previous studies [2], and it can be interpreted also

as the subjects who underwent BPD had a lower weight

regain during the first post-operative year, as compared

with other treatments.

Furthermore, a significant effect of treatment on general

psychopathology was found independently from bariatric

procedure, according to the previous researches demon-

strating a reduction of Axis I comorbidity after bariatric

surgery [30].

The significant decrease of depressive symptoms after

surgery [5] confirmed the existence of a complex rela-

tionship between obesity and depression [31]. Biological

mechanisms have been implicated, such as HPA-axis

dysregulation, as well as diabetes mellitus and insulin

resistance which have been found to increase the risk of

depression [31]. Furthermore, weight-related stigmatiza-

tion [32], increased body dissatisfaction and decreased self-

esteem might increase the risk of depression [31]. In gen-

eral, a significant reduction in weight has been frequently

associated with a post-operative improvement in all

patients’ psychopathologic parameters, given the reduced

perception of criticism and self-blame associated with

relevant weight loss after bariatric surgery [9].

As far as pathological eating behaviors are concerned,

we found that eating disorder specific psychopathology was

similarly present in the treatments groups, according to the

previous studies reporting that a substantial percentage of

bariatric surgery patients suffered from binge eating

symptoms [33]. All the considered surgical interventions

demonstrated to be efficacious in reducing pathological

eating behaviors, and eating disorder specific psychopa-

thology. Sanchez Zaldvar et al. [34] showed that after ba-

riatric surgery the impulse to thinness and corporal

dissatisfaction improved in patients with morbid obesity.

Moreover, we found that bariatric surgery was effective in

reducing the severity of binge eating (BES scores),

according to the previous studies [34] which suggested that

the gastric restrictive procedures make physiologically

very difficult to binge eat. However, it is of note that

RYGB and BPD were associated with a higher reduction in

EDE-Q scores and emotional eating. A possible explana-

tion could be that in RYGB patients obtained a higher

weight loss after surgery, and a more relevant weight loss

outcome determined a better outcome in terms of eating

disorder specific psychopathology. The positive correlation

between EDE-Q reduction and excess of BMI loss seems to

support such hypothesis. Alternatively, we may hypothe-

size that a higher reduction of eating pathology in RYGB

and BPD group may be one of the mechanisms favoring the

weight loss [8].

Finally, our data showed that emotional eating prior to

undergo bariatric surgery was associated with different

pattern of weight loss after intervention, since higher pre-

treatment emotional eating levels predicted lower excess of

BMI loss, for all the three treatment groups. Previous

studies demonstrated that emotional eating was a main-

taining factor of binge eating [35], and an important

Table 2 Treatment effects on BMI and psychopathological variables

Treatment

by time

effect (F)

Treatment

effect of

gastric

banding

Treatment

effect of

gastric

bypass

Treatment

effect of

biliopancreatic

diversion

Time effect

(b)

Time

effect (b)

Time effect (b)

BMI 62.2*** 0.65*** 0.73*** 0.82***

SCL-90

GSI

2.86* 0.26* 0.36* 0.23*

STAI 2.70 0.48** 0.24* 0.27*

BDI 7.46*** 0.44** 0.46** 0.38*

BES 11.6*** 0.49** 0.68*** 0.34*

EDE-Q

total

score

7.08** 0.31* 0.38** 0.62***

EDE-Q

restraint

1.08 0.01 0.04 0.36*

EDE-Q

eating

concern

3.59* 0.09 0.31* 0.44*

EDE-Q

weight

concern

9.64*** 0.41* 0.47** 0.61**

EDE-Q

shape

concern

7.52*** 0.32* 0.39** 0.58**

EES 4.43** 0.03 0.46** 0.48**

Statistical analyses—data reported in the table represent the F and bvalues for linear mixed models assessing the variation (time effect) of

BMI and psychological variables from baseline to 1-year follow-up.

The first column reports the F values for differences in treatment

effects (time by treatment interaction), and the other columns report

the b values for the time effects within different treatment groups.

Data are age and baseline BMI adjusted

BDI Beck Depression Inventory, BES Binge Eating Scale, BMI body

mass index, SCL-90 GSI Symptom Checklist (SCL 90-R) global

severity index, STAI State-Trait Anxiety Inventory, EDE-Q Eating

Disorder Examination Questionnaire, EES Emotional Eating Scale

Total Score

* p \ 0.05; ** p \ 0.01; *** p \ 0.001

222 Eat Weight Disord (2014) 19:217–224

123

outcome modifier in psychological treatments [36]. Our

findings support the importance of this psychopathological

dimension, which seems to play a relevant role even in

obese patients who underwent bariatric surgery, and stress

the importance of a careful assessment of different psy-

chological variables in obese subjects attending different

bariatric surgery interventions, in order to identify potential

outcome predictors for weight loss.

However, it is important to note that even if emotional

eating was associated with %EBML, it accounts for a

limited proportion of its variance in the model. Therefore,

it is possible that in sever obese subjects, weight loss

depends on several other clinical variables than

psychopathology.

One limitation of the current data set is that it

included a limited number of patients. Therefore, the

results of the present study should be confirmed by

larger studies. However, it is important to note that,

despite the relatively small sample size, significant dif-

ferences were found between treatment groups. A second

limitation is that some important psychological data of

this study were obtained by means of self-reported

questionnaires, thus possibly determining potential sub-

jective bias. Errors or memory biases could have affected

the retrospectively collected data. Finally, the follow-up

length of this study is very short (only 12 months);

indeed, considering that the weight loss curves observed

after LAGB, RYGB and DBP (with the LAGB having a

slower a more prolonged weight loss phase) show dif-

ferent slopes and duration, at the end of 1 year only a

part of the long-term effects of these different procedures

can be captured. Therefore, further studies with longer

follow-up period are needed.

Conclusion

In conclusion, our results support the importance of a

careful assessment of different psychological variables in

obese subjects attending different bariatric surgery inter-

ventions, in order to supervise the post-surgical outcome.

Conflict of interest The authors declare that they have no conflict

of interest.

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