Associations between physical activity and mental health among bariatric surgical candidates
Introduction
Mental disorders, such as depression and anxiety, have become the leading cause of disability in the developing world [1]. National survey results indicate that adults with obesity, and in particular severe obesity (body mass index [BMI]≥40 kg/m2), are disproportionately affected [2], [3], [4], [5], [6], [7], [8]. This is especially true for women [2], [7], [9], [10], who appear to suffer more psychological consequences from obesity, such as body image dissatisfaction, stigmatization, and discrimination [11], [12], [13], [14].
Studies of clinical populations suggest that a sizeable portion of adults seeking bariatric surgery, the majority of whom are severely obese females, have current depression or anxiety disorders. For example, Kalarchian and colleagues, who assessed Axis I disorders (i.e., mood, anxiety, eating and substance disorders) with structured interviews independent of the surgery approval process in consecutive bariatric surgery cases (n=288), reported that 10.4% of preoperative patients had current major depressive disorder (42.0% lifetime), while almost a quarter (24.0%) had a current anxiety disorder (37.5% lifetime) [15]. In comparison, using similar assessment methods Muhlhans and colleagues (n=146) reported a higher rate of major depressive disorder (25.3%; 50.7% lifetime), but a lower rate of anxiety disorders (15.1%; 21.5% lifetime) [16]. These estimates straddle the prevalence of current major depressive disorder and anxiety disorders (13.3% and 19.6%, respectively) reported in a national sample of adults with severe obesity, and are almost two-fold higher than in normal weight adults (7.2% and 10.2%, respectively) [6].
There is evidence to suggest that depressive symptoms and the prevalence of major depressive disorder decrease after bariatric surgery [10], [17], [18]. However, the same has not been consistently shown for symptoms of anxiety and anxiety disorders [17], [18], [19]. In addition, preoperative depression and anxiety increase risk of their counterpart postoperative conditions [18], [20], and have been shown to have a negative impact on long-term surgically induced weight loss [18], [21], [22]. These findings underscore the importance of providing appropriate mental health care to pre- and post-operative patients with depression and anxiety disorders.
Typical management of depression and anxiety by clinical professionals involves counseling and/or antidepressant or anti-anxiety medication [23]. In the past decade research has focused on whether physical activity (PA) may also help in the prevention or treatment of depression and anxiety. Recent meta-analyses and systematic reviews have concluded that exercise 1) is effective as a standalone treatment in reducing depressive symptoms among adults without clinical depression [24]; 2) reduces depressive symptoms among patients with chronic illness [25]; 3) compares favorably to antidepressant medications as a first-line treatment for mild to moderate depression [26]; 4) alleviates depressive symptoms among adults with major depression [27], with comparable results to psychotherapy or antidepressant medications [28], [29], [30]; and 5) improves depressive symptoms when used as an adjunct to medication [26]. However, only a handful of studies have investigated whether exercise improves depressive symptoms in obese adults, with mixed results [31], [32], [33], and to our knowledge there are no published studies testing PA interventions to treat depression or anxiety in adults with severe obesity.
In recent years, a few studies have examined associations between PA and mental health in severely obese adults, and more specifically in bariatric surgery patients. In 2006, Bond et al. administered the International Physical Activity Questionnaire-Short Form (IPAQ-S) and the Medical Outcomes Study 36-item Short-Form (SF-36) to adults seeking Roux-en-Y gastric bypass (RYGB). No difference in mental health functioning, as assessed with the Mental Component Summary (MCS) score, or any of the SF-36 mental domain scores, was found between adults who reported sufficient PA (defined as reporting at least 30 min of moderate intensity PA for at least 5 days in the past week; n=31) vs. those who reported less PA (n=58) [34]. In 2009, Bond et al. found some support for a relationship between postoperative PA participation, assessed with the IPAQ-S, and a change in mental health functioning following RYGB. Specifically, improvement in the MCS score from pre- to 1 year postoperative was significantly higher among those who were active (defined in this study as reporting at least 200 min of moderate intensity PA in the past week) pre- and post-operative (n=68) or only postoperative (n=83), compared to those who reported less PA pre- and postoperative (n=39) [35]. However, there was not a significant correlation between change in the self-reported PA and change in the SF-36 MCS score from pre- to 1 year postoperative, making interpretation of results difficult. More compelling evidence for a link between PA and mental health among bariatric patients was reported by Rosenberger et al. in 2011 [36]. Based on the 4-item Godin Leisure Time Questionnaire, PA frequency and intensity 1 year post-RYGB were independently associated with better mental health functioning, as measured by the SF-36 MCS score, and fewer depressive symptoms, as measured with the Beck Depression Inventory (BDI), at that same time point, after controlling for sex, age, ethnicity, preoperative body mass index, and preoperative SF-36 and BDI scores (n=131) [36]. Similarly, Larson et al. found a significant association between a composite physical exercise score from the Sport Index of the Baecke Questionnaire, and mental health functioning (SF-36 MCS score) in 157 adults who were 1 to 6 years post-laparoscopic adjustable gastric banding [37]. While these studies provide some evidence of a link between PA and mental health among bariatric surgery patients, they all rely on self-reported PA and do little to inform preoperative PA recommendations.
To address shortcomings in the literature, this study sought to determine whether objectively-measured PA was associated with mental health in a large (n=850) cohort of adults undergoing bariatric surgery. Specifically, we examined associations between ambulatory PA and three mental health indicators: impaired mental health functioning, depressive symptoms, and treatment for depression and/or anxiety. We aimed to determine whether associations 1) differed by various parameters of PA (i.e., active minutes, an inverse to sedentary time, high-cadence minutes, a proxy for minutes of moderate–vigorous intensity PA, and steps, a measure of total ambulatory PA), and 2) were independent of the effects of sociodemographics and physical illness and disability. In addition, we attempted to determine the thresholds of PA that best differentiated mental health status.
Section snippets
Sample
The Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) is an observational study designed to assess the risks and benefits of bariatric surgery [38]. Between February, 2006 and February, 2009 patients at least 18 years old seeking bariatric surgery by participating surgeons at ten hospitals throughout the United States were asked to participate if they had not had previous weight loss surgery. By the study enrollment closure (April 2009), 2458 participants attended a research visit prior to
Description of the sample
Characteristics of the analysis sample (n = 850) are shown in Table 1. LABS-2 participants who were excluded from the analysis (n = 1608) were similar (p>.05) for the most part. However, a greater proportion of the analysis sample was younger (median age 45 vs. 46 years; p = .01), Caucasian (88.6% vs. 84.4%; p < .01), employed full-time (74.1% vs. 65.6%; p < .0001), and had a household income ≥ $25,000 (86.0% vs. 79.2%; p < .0001), while fewer participants had impaired mental health functioning (19.7% vs.
Key findings
The results of this LABS-2 study confirm and extend previous research by demonstrating an inverse association between PA and indicators of poor mental health, in a large cohort of adults with class 2 and class 3 (i.e., severe) obesity prior to undergoing bariatric surgery. Specifically, individuals who were active for more minutes each day, who accumulated more daily steps, and who achieved more high-cadence minutes, had a lower odds of depressive symptoms and a lower odds of recent treatment
Conclusion
This study revealed an inverse association between rather modest levels of PA and depressive symptoms and recent treatment for depression or anxiety, in a large cohort of adults with class 2 and class 3 obesity undergoing bariatric surgery at one of 10 hospitals throughout the U.S. Although causality cannot be established, our findings are encouraging and should leverage further investigation of the role of PA in the prevention and treatment of depression and anxiety in adults with class 2 and
Funding
The LABS-2 study was funded by a cooperative agreement by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Grant numbers: Data Coordinating Center — U01 DK066557; Columbia–Presbyterian — U01-DK66667 (in collaboration with Cornell University Medical Center CTSC, Grant UL1-RR024996); University of Washington — U01-DK66568 (in collaboration with CTRC, Grant M01RR-00037); Neuropsychiatric Research Institute — U01-DK66471; East Carolina University — U01-DK66526;
Role of the sponsor
NIDDK scientists contributed to the design and conduct of the study, which included collection, and management of data. The Project Scientist from NIDDK served as a member of the Steering Committee, along with the Principal Investigator from each clinical site and the Data Coordinating Center (DCC). The DCC housed all data during the study and performed data analyses according to a pre-specified plan developed by the DCC biostatistician and approved by the steering committee and independent
Competing interest statement
All authors have completed the Unified Competing Interest Form at http://www.icmje.org/coi_disclosure.pdf and have no competing interests to report.
Acknowledgments
LABS personnel contributing to the study include: Columbia University Medical Center, New York, NY: Paul D. Berk, MD, Marc Bessler, MD, Amna Daud, Harrison Lobdell IV, Jemela Mwelu, Beth Schrope, MD, PhD, Akuezunkpa Ude, MD; Cornell University Medical Center, New York, NY: Michelle Capasso, BA, Ricardo Costa, BS, Greg Dakin, MD, Faith Ebel RD, MPH, Michel Gagner, MD, Jane Hsieh BS, Alfons Pomp, MD, Gladys Strain, PhD; Mt. Sinai Medical Center, New York, NY: W. Barry Inabnet, MD; East Carolina
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2014, Pain Medicine (United States)Citation Excerpt :As an extension of the cognitive theory of depression, preoperative depressive symptoms have been associated with increased morbidity and mortality after surgery [43,63]. Although the exact mechanism remains unclear, it is possible that depression related weight gain and physical inactivity hinders rehabilitation and promotes worse outcomes [63–65]. The self-medication hypothesis may extend to the surgical population.