Abstract
Emotional eating (EE) has been found to be associated with depression, anxiety, excessive weight, obesity, and unhealthy eating habits. EE could also be associated with recurrent weight gain. To date, the factors predicting success following bariatric surgery remain uncertain. In addition, there is a paucity of data regarding the associations between EE, percent of total weight loss (TWL), and depression after bariatric surgery. The aims of this study were to evaluate the relationship between EE behavior, depression, and TWL, and to identify other factors, such as the type of bariatric surgery, that may have an impact on EE, depression and TWL after bariatric surgery. A self-report questionnaire was administered to 253 patients who underwent bariatric surgery between 2014 and 2021 at the Department of General Surgery, Faculty of Medicine, Gazi University. In total, 115 patients agreed to participate and completed the questionnaire. The administered scales consisted of the Sociodemographic Data Form, Emotional Eating Scale (EES), and Beck Depression Inventory (BDI). The participants were divided into the Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) groups. The RYGB and SG groups included 79 (68.8%) and 36 (31.3%) patients, respectively. A significant difference was found in terms of age (P = .002) and gender (P = .033). The BDI scores (P = .499) and TWL (P = .068) did not differ significantly. The EES score was higher in the SG group (P = .020). Between the groups with and without EE, age (P = .004) and BDI scores (P = .004) were significantly different. In correlation analyses, EES score was related to BDI score(ρ = 0.402, P < .001) and age(ρ = −0.348, P = .002) in the RYGB group. In regression analyses, TWL was associated with age (β = −0.366, P < .001) and surgery type (β = −6.740, P < .001), EES score was associated with BDI score (β = 0.149, P = .009) and age (β = −0.154, P = .006), and BDI score was associated with EES score (β = 0.419, P = .009) and age (β = −195, P = .041). In patients with moderate-to-severe depression, TWL was higher than in those without depression (P = .025). The effect of emotional eating and depression on TWL was not detected. Emotional eating and depression trigger each other in the individuals who underwent bariatric surgery. Young individuals who undergo bariatric surgery are more vulnerable to emotional eating and depression than older patients.
Keywords: bariatric surgery, depression, emotional eating, TWL
1. Introduction
Worldwide, the incidence of obesity has nearly tripled since 1975. Obesity is estimated to affect more than 650 million people globally.[1] Surgery is the one of the preferred methods for morbid obesity. However, surgery does not yield equal results in every patient. To date, the factors predicting success following surgery have been an area of interest and still remain uncertain. Psychosocial functioning may not directly predict outcomes. However, it is important to determine the features that can be associated with the patient prognosis and to provide the necessary psychosocial interventions before and after surgery.[2]
Preoperative age, sex, and body mass index (BMI) have been found to be significant predictors of bariatric surgery outcomes. Therefore, they are taken into consideration during preoperative assessments.[3] Preoperative eating behavior is a major predictor of bariatric surgery outcomes.[4] Burgmer et al demonstrated that postoperative eating behavior played a significant role in determining the extent of weight loss following gastric restriction surgery.[5] However, some studies have shown that preexisting eating behavior disorders before surgery were not negative determinants of success following bariatric surgery.[6,7]
Emotional eating (EE), a behavior present in 38% to 59% of individuals indicated for bariatric surgery and one that holds intriguing implications within this patient population, has been described by Van Strien et al as the “propensity to overconsume food in response to negative emotions like anxiety or irritability.”[8] This form of eating behavior is frequently viewed as a potential risk factor for less favorable outcomes following surgery.[9]
Feelings of stress, depression, and anxiety could potentially influence eating habits, both diminished and heightened. Gade et al[10] found a connection between elevated EE tendencies and presence of anxiety and depression, similarly to Zijlstra et al[11] who pointed out an association between EE and unfavorable mood.
The main purpose of this study was to evaluate the relationship between EE behavior, depression, and percentage of total weight loss (TWL) in individuals who underwent RYGB and sleeve gastrectomy (SG). The secondary aim was to identify other factors, such as the type of bariatric surgery, that may have an impact on EE behavior, depression and TWL in a population who underwent bariatric surgery. This study may provide guidance on the necessary precautions and follow-ups for mental health problems in populations undergoing obesity surgery, which requires a multidisciplinary approach.
2. Methods
2.1. Participants
Between 2014 and 2021, a total of 615 patients underwent bariatric surgery at the Department of General Surgery, Gazi University Faculty of Medicine. The study was approved by the Ethics Committee of Ufuk University Faculty of Medicine (22.10.25.09/05). In power analysis; according to the correlation point biserial model analysis with 95% confidence (1-α), 80% test power (1-β) and d = 0.24 effect size, the number of samples to be taken in the group was determined as 103.[12] Then, self-report questionnaires were sent to 253 patients who continue their follow-up in our clinic. Of those who agreed to participate, 115 fully completed the questionnaires, without missing data and were included in the study.
2.2. Measurements
The Emotional Eating Scale (EES) was developed by Garaulet et al to assess EE behaviors in individuals with obesity and overweight.[13] The scale consisted of 10 items and 3 sub-dimensions (food dis-inhibition, types of food, and guilt feeling). The questions were answered on a 4-point Likert-type scale (“0” Never, “1” Sometimes, “2” Often, and “3” Always). The scale, which does not have reverse items, yielded scores ranging from a minimum of “0” to a maximum of “30.” Higher scores indicated a higher level of EE behavior.
Validity and reliability studies were conducted by Arslantaş et al for the Turkish version of the scale. Similar to the original version, the Turkish version also showed a 3-factor structure comprising “food dis-inhibition,” “types of food,” and “guilt feeling.” The corrected item–total score correlations were reported to be above 0.34. Moreover, the internal consistency coefficient of the total score was reported to be 0.84.[14]
Garaulet et al suggested that scores between “0–5” indicated “non-emotional eaters,” scores between “6–10” indicated “low-level emotional eaters,” scores between “11–20” indicated “emotional eaters,” and scores between “21–30” indicated “very emotional eaters.”13
The Beck Depression Inventory was developed by Beck et al in 1961.[15] This scale assessed the physical, emotional, and cognitive symptoms of depression. Hisli conducted a validity and reliability study of this scale in our country in 1989. The scale consisted of 21 items, each consisting of 4 self-assessment statements. The items were scored on a scale from 0 to 3. The total depression score was obtained by summing the scores of the items. A higher score indicated a higher level of depression symptoms. Based on the scoring, 0 to 9, 10 to 16, 17 to 29, and a score ≥ 30 were considered minimal or no depression, mild, moderate, and severe depression, respectively.[16]
2.3. Statistical analyses
Descriptive statistics were calculated for each variable. These included the median (minimum–maximum), mean (±standard deviation), frequencies, and percentages. Differences were analyzed to test the hypotheses. The Kolmogorov-Smirnov test was used for evaluating the normality of data distribution within the groups. In cases where the assumption of normal distribution was met, an independent samples t test was employed. Furthermore, in groups that did not adhere to a normal distribution, the Mann–Whitney U test was applied. Subsequently, bivariate correlations between the EE and depression were assessed. A 3-stage hierarchical multiple linear regression model was applied to examine the association between EES score, BDI score, TWL (continuous, dependent variable), as well as to test whether these associations were independent of other predictors and their effects on each other. IBM SPSS version 25.0 software (SPSS Inc., Chicago, IL, USA) was used for data analyses. Differences were considered statistically significant at P < .05.
3. Results
The mean age of the patients participating in the study was 39.19 (±10.77; minimum:18, maximum: 66). Among the patients, 83.5% (n = 96) were women and 73% (n = 84) were married. Additionally, 53.9% (n = 62) of the patients had an educational level of high school or higher. Moreover, 59.1% (n = 68) of the patients had a high-income level. In addition, 67% (n = 77) of the patients resided in metropolitan areas. Furthermore, 73.9% (n = 85) of the patients had at least one comorbidity. The most common comorbidities were diabetes mellitus (49.4%; n = 38), followed by psychiatric disorders (45.5%; n = 35). The least common comorbidity was chronic kidney disease accounting for 1.3% (n = 1). Determining indicators of weight change, TWL was determined to be 35.51 ± 9.62. The patients’ mean preoperative BMI was found to be 42.77 ± 6.3. The patients’ BMI at the time of data collection was 27.41 ± 4.85. The patients’ average EES scores were determined to be 20.85 ± 5.77 and average BDI score were determined to be 13.26 ± 9.40. Additionally, 50.4% of the patients were identified as emotional eaters (EE Group). The average BDI score of the patients was determined to be 13.26 ± 9.40. Additionally, 27.8% (n = 32) of the patients had moderate-to-severe depression, while 72.2% were within the normal range. A total of 68.7% (n = 79) of the patients underwent RYGB, while 31.3% (n = 36) underwent SG. When the 2 groups were compared, a significant difference was found in terms of age (P = .002), gender (P = .033) and number of children (P = .035). The BDI scores and TWL did not differ significantly between the SG and RYGB groups. The EES score was higher in the SG group than RYGB group (P = .020) (Table 1).
Table 1.
Sociodemographic and clinical characteristics of the patients and comparison of Sleeve gastrectomy and Roux-en-Y gastric bypass groups.
| Total (n = 115) | Bariatric surgery type | P | ||
|---|---|---|---|---|
| Sleeve gastrectomy (n = 36, 31.30%) |
Roux-en-Y Gastric Bypass (n = 79, 68.70%) |
|||
| Age (yr) | 39.19 ± 10.76* | 30.50 (17–53)** | 41 (23–66)** | .002 a |
| Gender, N (%) | ||||
| Female | 96 (83.5%) | 34 (94.4%) | 62 (78.5%) | .033 b |
| Male | 19 (16.5%) | 2 (5.6%) | 17 (21.5%) | |
| Marital status, N (%) | ||||
| Maried | 84 (73.0%) | 23 (63.9%) | 61 (77.2%) | .288b |
| Single | 31 (27.0%) | 13 (36.1%) | 18 (22.8%) | |
| Education status, N (%) | ||||
| Primary education | 20 (17.4%) | 4 (11.1%) | 16 (20.3%) | .587b |
| High school | 33 (28.7%) | 11 (30.6%) | 22 (27.8%) | |
| Undergraduate and Above | 57 (53.9%) | 20 (55.6%) | 37 (46.8%) | |
| Income range, N (%) | ||||
| Low income (<2500 TL/month) | 4 (3.5%) | 1 (2.8%) | 3 (3.8%) | .569b |
| Medium income (2500–4500 TL/month) | 43 (37.9%) | 16 (44.4%) | 27 (34.2%) | |
| High level Income (>4500 TL/month) | 68 (59.1%) | 19 (52.8%) |
49 (62.0%) | |
| Preoperative pregnancy history, N (%) |
48 (42.5%) | 13 (63.9%) | 35 (44.3%) | .416c |
| Number of children* | 1.29 ± 1.12* | 1 (0–3)** | 1 (0–4)** | .035 a |
| Residantial locaiton, N (%) | ||||
| District | 23 (20.0%) | 7 (19.4%) | 16 (20.3%) | .883b |
| Province | 15 (13.0%) | 4 (11.1%) | 11 (13.9%) | |
| Metropolitan | 77 (67.0%) | 25 (69.5%) | 52 (65.8%) | |
| Smoking, N (%) | 43 (37.4%) | 11 (30.6%) | 30 (38.0%) | .531c |
| Alcohol, N (%) | 10 (8.7%) | 3 (8.3%) | 7 (8.9%) | .926b |
| Age of starting to weight gain (yr)* | 17.08 ± 11.35* | 14 (0–43)** | 16 (0–50)** | .446a |
| Comorbidites, N (%) | 85 (63.5%) | 27 (63.9%) | 58 (63.3%) | .858b |
| Hypertension | 23 (20.0%) | 8 (22.2%) | 15 (19.0%) | .802c |
| Diabetes Mellitus | 38 (33.0%) | 10 (27.8%) | 28 (35.4%) | .523c |
| Asthma/Bronchitis | 10 (8.7%) | 3 (8.3%) | 7 (8.9%) | .926c |
| Coronary artery Disease | 7 (6.1%) | 1 (2.8%) | 6 (7.6%) | .431c |
| Chronic kidney Disease | 1 (0.9%) | 0 (0.0%) | 1 (1.3%) | .498b |
| Sleep apnea | 19 (16.5%) | 6 (16.7%) | 13 (16.5%) | .977b |
| Orthopedic Disorder | 14 (12.2%) | 5 (13.9%) | 9 (11.4%) | .762c |
| Psychiatric Disorder | 35 (30.4%) | 10 (27.8%) | 25 (31.6%) | .827c |
| Preoperative body Mass Index (kg/m2) | 42.77 ± 6.30* | 41.83 ± 6.17* | 43.19 ± 6.35* | .204b |
| Follow-up (months) | 31.34 ± 12.91* | 29.5 (13–50)** | 30 (14–85)** | .172a |
| Body mass index (kg/m2) | 27.41 ± 4.85* | 27.90 ± 5.24* | 27.18 ± 4.68* | .461d |
| TWL | 35.49 ± 9.62* | 32.82 ± 11.18* | 36.71 ± 8.63* | .068d |
| Emotional eating Scale Score | 20.85 ± 5.77* | 22.69 ± 5.15* | 20.01 ± 5.88* | .020 d |
| Emotional eater, N (%) | 58 (50.4%) | 23 (63.9%) | 35 (44.3%) | .070c |
| Beck depression inventory score | 13.26 ± 9.40* | 10 (3–39)** | 12 (0–39)** | .499a |
| Modare-to-severe depression, N (%) | 32 (27.8%) | 8 (22.2%) | 24 (30.4%) | .501c |
Mean ± Standart Deviation,
Median (min-max).
Mann–Whitney U test,
Chi-squared test,
Fisher exact test,
Independent—Samples T Test.
When the EE and Non-EE groups were compared, a significant difference was detected in terms of age (P = .004), number of children (P = .006) and age of starting to gain weight (P = .044). The BDI scores in EE Group (EES score = 13) were higher compared with Non-EE Group (EES score = 8) (P = .004). No statistically significant difference was observed in TWL based on EE tendencies (Table 2).
Table 2.
Comparison of participants without and with Emotional Eating.
| Emotional eating | P | ||
|---|---|---|---|
| Without EE group (n = 57, %49.6) | With EE group (n = 58, %50.4) | ||
| Age (yr)* | 42.08 ± 10.53 | 36.34 ± 10.30 | .004 a |
| Gender, N (%) | |||
| Female | 47 (82.5%) | 49 (84.5%) | .806b |
| Male | 10 (17.5%) | 9 (15.5%) | |
| Marital status, N (%) | |||
| Maried | 43 (75.4%) | 41 (70.7%) | .819c |
| Single | 14 (24.6%) | 17 (29.3%) | |
| Education status, N (%) | |||
| Primary education | 14 (24.6%) | 6 (10.3%) | .184c |
| High school | 17 (29.8%) | 16 (27.6%) | |
| Undergraduate and Above | 26 (45.6%) | 36 (62.1%) | |
| Income range, N (%) | |||
| Low income (<2500 TL/month) | 2 (3.5%) | 2 (3.4%) | .436b |
| Medium income (2500–4500 TL/month) | 18 (31.6%) | 25 (43.1%) | |
| High level income (>4500 TL/month) | 37 (64.9%) | 31 (53.4%) | |
| Preoperative pregnancy history, N (%) |
24 (42.1%) | 24 (42.9%) | .936c |
| Number of children** | 2 (0–4) | 1 (0–4) | .006 d |
| Residantial locaiton, N (%) | |||
| District | 9 (15.8%) | 14 (24.1%) | .356b |
| Province | 9 (15.8%) | 6 (10.3%) | |
| Metropolitan | 39 (68.4%) | 38 (65.5%) | |
| Smoking, N (%) | 15 (26.3%) | 26 (44.8%) | .051b |
| Alcohol, N (%) | 6 (10.5%) | 4 (6.9%) | .528d |
| Age of starting to weight gain (yr)** | 18 (0–50) | 13 (0–40) | .044 d |
| Comorbidites, N (%) | 42 (73.7%) | 43 (74.1%) | .956c |
| Hypertension | 13 (22.8%) | 10 (17.2%) | .492b |
| Diabetes mellitus | 21 (36.8%) | 17 (29.3%) | .432b |
| Asthma/bronchitis | 6 (10.5%) | 4 (6.9%) | .528b |
| Coronary artery disease | 5 (8.8%) | 2 (3.4%) | .272b |
| Chronic kidney disease | 1 (1.8%) | 0 (0.0%) | .496b |
| Sleep apnea | 9 (15.8%) | 10 (17.2%) | .834c |
| Orthopedic disorder | 10 (17.5%) | 4 (6.9%) | .094b |
| Psychiatric disorder | 19 (33.3%) | 16 (27.6%) | .547b |
| Preoperative body mass Index (kg/m2)* | 42.47 ± 5.21 | 43.05 ± 7.25 | .625a |
| Bariatric surgery type, N (%) | |||
| Sleeve gastrectomy | 13 (22.8%) | 23 (39.7%) | .070b |
| Roux-en-Y gastric Bypass | 44 (77.2%) | 35 (60.3%) | |
| Follow-up time (mo)* | 31.64 ± 14.55 | 31.05 ± 11.20 | .805a |
| Body mass index (kg/m2)** | 26.6 (19.5–43.2) | 27.05 (16.7–40.9) | .819d |
| TWL* | 35.42 ± 9.96 | 35.56 ± 9.36 | .934a |
| Beck depression inventory score** | 8 (0–39) | 13 (1–39) | .004 d |
| Modare-to-severe depression, N (%) | 10 (17.5%) | 22 (37.9%) | .021 b |
Mean ± Standart Deviation,
Median (min-max),
Independent—Samples T Test,
Fisher exact test,
Chi-squared test,
Mann–Whitney U test, TL: Turkish Lira.
In Spearmen correlations between emotional eating and depression, in the RYGB group, the EES score was moderately and positively correlated with BDI scores and negative correlated with age (ρ = 0.402 and −0.348; P < .001 and 0.002, respectively). However, in the SG group, no relationship between EES score and BDI score was found (Table 3). The patients with moderate-to-severe depression had higher TWL compared with those without depression (P = .025) (Table 4).
Table 3.
Bivariate Spearman correlations between emotional eating and depression, age, TWL.
| Beck depression inventory score | Age | TWL | |||||
|---|---|---|---|---|---|---|---|
| ρ* | p | ρ* | P | ρ* | P | ||
| Roux en Y Gastric Bypass (n = 78) |
Emotional Eating Scale Score | 0.402** | ≤0.001 | −0.348** | .002 | .001 | .990 |
| Sleeve Gastrectomy (n = 36) |
Emotional Eating Scale Score | 0.106 | 0.538 | −0.078 | .651 | 0.005 | .979 |
Spearman rho.
Correlation is significant at the 0.01 level (2-tailed).
Table 4.
Evaluation of the Effect of Patients’ Depression Status on TWL.
| No depression (n = 83) | Moderate-severe depression (n = 32) | Test statistic | P | |||
|---|---|---|---|---|---|---|
| Mean (SD) | Median (min-max) | Mean (SD) | Median (min-max) | |||
| TWL | 34.3 ± 9.8 | 35.5 (10.2–53.8) | 38.7 ± 8.4 | 39.1 (25.5–53.9) | −2.3 | .025 |
Independent Samples T Test.
%TWL = total weight loss; min, minimum; max, maximum, SD = standard deviation.
The regression model with overall EES and BDI scores revealed that age and bariatric surgery type were significant predictors for TWL (P < .001, β = −0.366, 95% CI [−0.533, −0.198] and P < .001, β = −6.740, 95% CI [−10.406, −3.074], respectively) after adjusting for covariates (Table 5). When EES score is applied as a dependent variable, BDI score and age were significant predictors for EES score (P = .009, β = −0.149, 95% CI [0.039, 0.259] and P = .006, β = −0.154, 95% CI [−0.264, −0.045], respectively) (Table 6). When BDI score is applied as a dependent variable, EES score and age were significant predictors for EES score (P = .009, β = 0.419, 95% CI [0.109, 0.729] and P = .041, β = −0.195, 95% CI [−0.382, −0.008], respectively) (Table 7)
Table 5.
Multiple linear regression analysis for predictors of TWL.
| Roux-en-Y gastric bypass | Sleeve gastrectomy | All participants | ||||
|---|---|---|---|---|---|---|
| Beta coefficient | P value | Beta coefficient | P value | Beta coefficient | P value | |
| Model 1 | ||||||
| Emotional Eating Scale Score | −0.035 | .828 | 0.096 | .798 | −0.073 | .634 |
| Model 2 | ||||||
| Emotional Eating Scale Score | −0.042 | .813 | 0.044 | .904 | −0.148 | .358 |
| Beck Depression Inventory Score | 0.011 | 0.922 | 0.365 | .068 | 0.150 | .126 |
| Model 3 | ||||||
| Emotional Eating Scale Score | −0.181 | .302 | −0.251 | .458 | −0.217 | .158 |
| Beck Depression Inventory Score | −0.067 | .530 | 0.196 | .276 | 0.020 | .826 |
| Age | −0.311 | .002 | 0.390 | .021 | −0.366 | <.001 |
| Gender | −1.808 | .409 | −13.01 | .106 | −2.963 | .183 |
| Bariatric Surgery Type | - | - | −6.740 | <.001 | ||
Table 6.
Multiple linear regression analysis for predictors of EES.
| Roux-en-Y gastric bypass | Sleeve gastrectomy | All participants | ||||
|---|---|---|---|---|---|---|
| Beta coefficient | P value | Beta coefficient | P value | Beta coefficient | P value | |
| Model 1 | ||||||
| Beck Depression Inventory Score | 0.258 | .828 | 0.041 | .657 | −0.185 | .001 |
| Model 2 | ||||||
| Beck Depression Inventory Score | 0.258 | .813 | 0.038 | .705 | 0.191 | .001 |
| TWL | −0.018 | .922 | 0.010 | .904 | −0.052 | .358 |
| Model 3 | ||||||
| Beck Depression Inventory Score | 0.203 | .302 | 0.025 | .796 | 0.149 | .009 |
| TWL | −0.081 | .530 | −0.071 | .458 | −0.085 | .158 |
| Age | −0.189 | .002 | −0.036 | .700 | −0.154 | .006 |
| Gender | −1.468 | .409 | −8.200 | .054 | 0.324 | .816 |
| Bariatric Surgery Type | - | - | - | - | 1.293 | .291 |
Table 7.
Multiple linear regression analysis for predictors of Beck Depression Inventory Score.
| Roux-en-Y gastric bypass | Sleeve gastrectomy | All participants | ||||
|---|---|---|---|---|---|---|
| Beta coefficient | P value | Beta coefficient | P value | Beta coefficient | P value | |
| Model 1 | ||||||
| Emotional Eating Scale Score | 0.665 | <.001 | 0.142 | .657 | 0.495 | .001 |
| Model 2 | ||||||
| Emotional Eating Scale Score | 0.665 | <.001 | 0.117 | .705 | 0.505 | .001 |
| TWL | 0.012 | .922 | 0.266 | .068 | 0.139 | .126 |
| Model 3 | ||||||
| Emotional Eating Scale Score | 0.553 | .003 | 0.087 | .796 | 0.419 | .009 |
| TWL | −0.081 | .530 | 0.194 | .276 | 0.022 | .826 |
| Age | −0.185 | .110 | −0.153 | .383 | −0.195 | .041 |
| Gender | −2.860 | .234 | 0.622 | .940 | −2.100 | .369 |
| Bariatric Surgery Type | - | - | - | - | −3.351 | .102 |
4. Discussion
Previous research has found the effects of emotional eating and depression as predictors of weight loss outcomes after bariatric surgery controversial. The purpose of this study was to (1) investigate the relationship between emotional eating, depression, and TWL; (2) was to evaluate other factors affecting these 3 in patients undergoing bariatric surgery.
When we compared the patients who underwent sleeve gastrectomy and Roux-en-Y gastric bypass, we found significant differences in terms of age (P = .002), gender (P = .033) and emotional eating scores (P = .020) in both groups. Although there was no difference in the BDI scores (P = .499). Then, when we compared those with and without emotional eating, age (P = .004) and BDI scores (P = .004) were significantly different between the 2 groups. In the regression analyses we subsequently performed, after correcting for multiple covariates, younger age (P = .006) and higher BDI scores (P = .009) were associated with higher EES score. No effect of surgery type and gender on EES score was detected. When these findings were combined, we concluded that the significant EES score difference between the SG and RYGB groups was due to the younger age of the SG group. The relationship between EE and age has not been clearly established in the literature. While Konttinen et al did not find a relationship between EE and age and gender, Samuel et al reported that EE behavior decreased with increasing age.[17,18] Increased EES and BDI scores in young patients suggest that detailed evaluation of emotional eating should be performed in young individuals before bariatric surgery.
We identified effective factors for BDI scores as EES score and decreasing age. A relationship with gender and bariatric surgery type could not be demonstrated. Previous studies have shown that emotional eating and depression trigger each other and obesity.[17,19] In a study by Fischer et al, those identified as highly emotional eaters demonstrated a stronger inclination towards depression, binge eating, and eating prompted by external cues before bariatric surgery.[20] Our results are consistent with the literature on this subject.
TWL was higher in the RYGB group than SG group (36.71 ± 8.63 kg/m2 vs 32.81 ± 11.81 kg/m2). The difference was not statistically significant in T test (P = .068). However, in our regression analyses, we found that TWL was higher in younger patients (P < .001) and in patients undergoing RYGB (P < .001). The effect of EES and BDI scores on TWL could not be shown in regression analyses. However, when we compared patients without depression and patients with moderate-to-severe depression, TWL was significantly higher in the group with depression (P = .025). This result and the higher TWL in the young group with higher EES and BDI scores are noteworthy. There may be 2 possible reasons why this situation occurred in our study. First, patients with emotional eating and depression symptoms are monitored more closely by their surgeons, dietitians, and psychiatrists, and this closer follow-up may provide a better TWL. The other is the cross-sectional structure, which is a limitation of our study. Previous studies have reported that bariatric surgery improves depression.[21–23] However, there are also publications reporting that it may worsen depression in the long term.[24] There are also publications both for and against of the effect of depression on bariatric surgery outcomes.[25,26] BDI score may have changed depending on various postoperative factors such as follow-up time, psychosocial support, side effects and complications in our study participants. However, a better TWL can be achieved with close follow-up in patients with high EES and BDI scores.
Findings in the literature regarding the effect of emotional eating on TWL are contradictory.[6,12,27–32] Monpellier et al,[27] and Romeijn et al[33] did not find a relationship between emotional eating and TWL whereas Miller-Matero et al[12] and Castellini et al[28] reported that emotional eating was associated with low TWL. In our study, no relationship was found between EES score and TWL (P = .158).
Interestingly, we obtained different results for the relationship between EE and depression in our SG and RYGB groups. The EES score were moderately positively correlated with BDI scores in the RYGB group (P < .001), whereas such a correlation was not observed in the SG group (Table 3). The same result was obtained in regression analyses. The lack of a relationship between EE and depression in the SG group with higher EE tendencies could suggest that these individuals might have engaged in eating behaviors as a coping strategy for dealing with depression symptoms. As a result, when we prevent coping strategies, such as eating during post-bariatric surgery procedures, these individuals might become more susceptible to depression.
This study has several limitations. The study was retrospective-cross-sectional in nature. Pre- and postoperative depression and EE could not be directly compared. Although there is no clear consensus, the healing effect of bariatric surgery on emotional eating and depression may have affected our results. This study was considered a preliminary study with available data. The cognitive processes that explained these results needed to be evaluated.
In conclusion, bariatric surgery is an effective treatment method for obesity. In our study, the effect of emotional eating and depression on TWL was not detected. However, the hypothesis that emotional eating and depression trigger each other is also valid for the patient group who underwent bariatric surgery. It has been observed that young patients who undergo bariatric surgery are more vulnerable to emotional eating and depression than older patients. Careful evaluation for emotional eating and depression should be made in the young patient group undergoing bariatric surgery. More further studies are needed on the effect of different types of bariatric surgery on emotional eating.
Acknowledgments
I would like to thank to Dr Kayikçi (psychiatric evaluation), Assoc. Prof Dikmen (Statistical Analyses) and Prof Bedirli (Primary surgeon of some patients) for their support.
Author contributions
Conceptualization: Çağri Büyükkasap.
Data curation: Çağri Büyükkasap.
Supervision: Çağri Büyükkasap.
Writing – original draft: Çağri Büyükkasap.
Writing – review & editing: Çağri Büyükkasap.
Abbreviation:
- BDI
- Beck Depression Inventory
- BMI
- body mass index
- EE
- emotional eating
- EES
- Emotional Eating Scale
- RYGB
- Roux-en-Y gastric bypass
- SG
- sleeve gastrectomy
- TWL
- percent of total weight loss
The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.
The authors have no funding and conflicts of interest to disclose.
How to cite this article: Büyükkasap Ç. Assessing how bariatric surgery, emotional eating, and depression could affect each other: A cross-sectional study. Medicine 2023;102:48(e36409).
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