Associations between physical activity and mental health among bariatric surgical candidates

https://doi.org/10.1016/j.jpsychores.2012.11.010Get rights and content

Abstract

Objective

To examine associations between physical activity (PA) and mental health among adults undergoing bariatric surgery.

Methods

Cross sectional analysis was conducted on pre-operative data of 850 adults with ≥ class 2 obesity. PA was measured with a step activity monitor; mean daily steps, active minutes, and high-cadence minutes (proxy for moderate–vigorous intensity PA) were determined. Mental health functioning, depressive symptoms and treatment for depression or anxiety were measured with the Medical Outcomes Study 36-item Short Form, Beck Depression Inventory, and a study-specific questionnaire, respectively. Logistic regression analyses tested associations between PA and mental health indicators, controlling for potential confounders. Receiver operative characteristic analysis determined PA thresholds that best differentiated odds of each mental health indicator.

Results

Each PA parameter was significantly (p < .05) associated with a decreased odds of depressive symptoms and/or treatment for depression or anxiety, but not with impaired mental health functioning. After controlling for sociodemographics and physical health, only associations with treatment for depression and anxiety remained statistically significant. PA thresholds that best differentiated those who had vs. had not recently received treatment for depression or anxiety were < 191 active minutes/day, < 4750 steps/day, and < 8 high-cadence minutes/day. Utilizing high-cadence minutes, compared to active minutes or steps, yielded the highest classification accuracy.

Conclusion

Adults undergoing bariatric surgery who meet relatively low thresholds of PA (e.g., ≥ 8 high-cadence minutes/day, representative of approximately 1 h/week of moderate–vigorous intensity PA) are less likely to have recently received treatment for depression or anxiety compared to less active counterparts.

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

References (65)

  • SB Harvey et al.

    Psychiatric aspects of chronic physical disease

    Medicine

    (2008)
  • RK Dishman et al.

    Lessons in exercise neurobiology: the case for endorphins

    Mental Health and Physical Activity

    (2009)
  • AA Russo-Neustadt et al.

    Physical activity and antidepressant treatment potentiate the expression of specific brain-derived neurotrophic factor transcripts in the rat hippocampus

    Neuroscience

    (2000)
  • ES Becker et al.

    Obesity and mental illness in a representative sample of young women

    International Journal of Obesity and Related Metabolic Disorders

    (2001)
  • CU Onyike et al.

    Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey

    American Journal of Epidemiology

    (2003)
  • NM Petry et al.

    Overweight and obesity are associated with psychiatric disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions

    Psychosomatic Medicine

    (2008)
  • GE Simon et al.

    Association between obesity and psychiatric disorders in the US adult population

    Archives of General Psychiatry

    (2006)
  • JB Dixon et al.

    Depression in association with severe obesity: changes with weight loss

    Archives of Internal Medicine

    (2003)
  • R Pingitore et al.

    Gender differences in body satisfaction

    Obesity Research

    (1997)
  • EY Chen et al.

    Obesity stigma in sexual relationships

    Obesity Research

    (2005)
  • RM Puhl et al.

    Obesity stigma: important considerations for public health

    American Journal of Public Health

    (2010)
  • MV Roehling

    Weight-based discrimination in employment: psychological and legal aspects

    Personnel Psychology

    (1999)
  • MA Kalarchian et al.

    Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status

    The American Journal of Psychiatry

    (2007)
  • J Karlsson et al.

    Swedish obese subjects (SOS) — an intervention study of obesity. Two-year follow-up of health-related quality of life (HRQL) and eating behavior after gastric surgery for severe obesity

    International Journal of Obesity and Related Metabolic Disorders

    (1998)
  • C Rojas et al.

    Anxiety, depression and self-concept among morbid obese patients before and after bariatric surgery

    Revista Médica de Chile

    (2011)
  • HO Lier et al.

    Prevalence of psychiatric disorders before and 1 year after bariatric surgery: the role of shame in maintenance of psychiatric disorders in patients undergoing bariatric surgery

    Nordic Journal of Psychiatry

    (May 16 2012)
  • T Legenbauer et al.

    Depression and anxiety: their predictive function for weight loss in obese individuals

    Obesity Facts

    (2009)
  • JF Kinzl et al.

    Psychosocial predictors of weight loss after bariatric surgery

    Obesity Surgery

    (2006)
  • A Strohle

    Physical activity, exercise, depression and anxiety disorders

    Journal of Neural Transmission

    (2009)
  • VS Conn

    Depressive symptom outcomes of physical activity interventions: meta-analysis findings

    Annals of Behavioral Medicine

    (2010)
  • MP Herring et al.

    Effect of exercise training on depressive symptoms among patients with a chronic illness: a systematic review and meta-analysis of randomized controlled trials

    Archives of Internal Medicine

    (2012)
  • PJ Carek et al.

    Exercise for the treatment of depression and anxiety

    International Journal of Psychiatry in Medicine

    (2011)
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