Helping patients to feel more worthy and reinforcing their beliefs about their own competences could lead to higher engagement with healthy lifestyle and adherence to treatment protocols, ultimately helping patients to achieve their goals for bariatric surgery, according to researcher from the Netherlands. The findings were reported in the paper, ‘Attachment style and post-bariatric surgery health behaviours: the mediating role of self-esteem and health self-efficacy’, published in BMC Psychology.
Although there are numerous reasons that patients do not achieve satisfactory weight loss or experience weight recurrence after bariatric surgery, attachment avoidance and anxiety have been linked to overweight and poor health behaviours, yet the mechanisms that underpin the relationship between attachment and health behaviours are not fully understood. Issues around self-esteem and self-efficacy have been found to differ between attachment styles, rendering these variables potential mediators of the relationship.
This longitudinal study investigated the serial mediation between preoperative attachment and two-year post-operative health behaviours through self-esteem and health self-efficacy. The study recruited 263 bariatric surgery patients (75.7% females, aged 47.7 ± 10.4 years, BMI 38.9 ± 3.6 kg/m2) who assessed before the operation and again one and two years after the surgery. Patients completed the Experiences for Close Relationships Brief Scale (measuring attachment style), Rosenberg Self-esteem scale (to assess person’s global evaluation of him/herself), Weight Efficacy Lifestyle Questionnaire (to assess participants’ self-efficacy for controlling their eating behaviour in specific situations), Bariatric Surgery Self-Management Questionnaire (adherence to the eating recommendations during the past week), Exercise Self-Efficacy Scale (capability to perform regular physical exercise) and the Exercise Behaviour Scale (the time spent on various forms of exercise in the past week).
Outcomes
Prior to surgery, the mean BMI was 38.98 (± 3.61) kg/m2 and mean weight 115.02 (± 14.928) kg. Patients lost on average 32.9 kg 2 years after the surgery (t(260)= -53.93, p < .001), which corresponded to 43.3%AWL and 28.7%TWL. The most common surgical method was laparoscopic- Roux-en-Y Gastric Bypass, performed on 235 patients (89.4%), whereas 22 patients underwent laparoscopic-omega loop- gastric bypass and six patients underwent a sleeve gastrectomy.
Attachment anxiety, avoidance and dietary adherence
Preoperative attachment anxiety and avoidance predicted poorer post-operative self-esteem (p<0.001) one year after bariatric surgery and explained 28% of the variance in self-esteem. Higher self-esteem, in turn, significantly predicted better self-efficacy for eating (p=0.003), which further predicted better diet adherence (p<0.001). Attachment anxiety predicted lower self-efficacy to control eating behaviours significantly (p=0.010) whereas attachment avoidance did not (p=0.301). When the mediators were not included in the model, neither attachment anxiety nor attachment avoidance significantly predicted post-operative diet adherence (total effects for anxiety p=0.417 and for avoidance p=0.853). Attachment anxiety and avoidance alone accounted for 0.9% of the variance in post-operative dietary adherence. When attachment anxiety and avoidance and both mediators were included in the model, they explained 8.1% of the variance in dietary adherence, and the model was significant (p<0.001).
Direct and indirect effects
When both mediators were included in the model, the direct effect between attachment anxiety and diet adherence became significant (p=0.043), and significant indirect relationships through self-efficacy to control eating, and through self-esteem and self-efficacy to control eating were evident. The total indirect effect of attachment anxiety to dietary adherence through the two mediators was significant.
Conversely, they reported a direct relationship between attachment avoidance and diet adherence was not significant when the mediators included in the model (p=0.877). Further, only the serial mediation between attachment avoidance and diet adherence through self-esteem and self-efficacy was significant.
Attachment anxiety, avoidance and physical activity
The serial mediation models between preoperative attachment anxiety (and attachment avoidance as a covariate) and two years post-operative physical activity through self-esteem and self-efficacy for exercise behaviours. Neither attachment anxiety nor avoidance predicted self-efficacy to be physically active (ps >0.05) two years after the surgery. When the mediators were not included in the model, attachment anxiety and avoidance (p=0.188) did not predict physical activity two years after the surgery (total effects). Without self-esteem and self-efficacy to be physically active in the model, attachment anxiety and avoidance explained 0.9% of variance in post-operative physical activity. When attachment anxiety and avoidance and both mediators were included in the model, they explained 13.3% of the variance in physical activity, and the model was significant (p<.001).
Direct and indirect effects
The direct relationship between attachment anxiety and physical activity was significant when mediators were included in the model (p=.048). As the researchers hypothesised, attachment anxiety had an indirect effect on physical activity through self-esteem and self-efficacy to exercise, while the indirect effects via each mediator separately were not significant (i.e., serial mediation only).
Attachment avoidance did not predict two-year post-operative physical activity when the mediators were included in the model (p=0.213). Similarly, only the serial mediation between attachment avoidance and two-year post-operative physical activity through self-esteem and self-efficacy to exercise was significant.
In other words, preoperative attachment anxiety predicted lower one-year post-operative self-esteem (p<0.001), as did preoperative attachment avoidance (p=.005). Higher self-esteem predicted better self-efficacy to be physically active two years after operation (p<0.001), which, in turn, predicted more frequent physical activity (p<0.001).
The researchers explained that their findings shed new light on the role of adult attachment in health behaviours and the potential of self-esteem in promoting health self-efficacy among bariatric surgery patients. Their results suggest that helping patients feel more worthy and reinforcing their beliefs about their own competences could lead to higher engagement with healthy lifestyle, better weight management skills, and adherence to treatment protocols, ultimately helping patients to achieve their bariatric surgery goals.
“The study contributes to our understanding of the mechanism between attachment and health behaviours, and suggests a potential pathway through self-esteem and self-efficacy,” the authors concluded. “Promoting post-operative self-esteem may support patients’ ability to control their eating and exercise behaviours, which could be important for enhancing post-operative diet adherence and physical activity, especially among patients with high attachment anxiety or avoidance.”
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