Page 123 - The efficacy and effectiveness of psychological treatments for eating disorders - Elske van den Berg

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with over-evaluation of weight and shape. The higher presence of avoidant behavior in the suboptimal weight loss group compared to the successful group in our study could be a result of possible disappointment with the amount of weight lost, lead- ing to body avoidance. The direction of this relationship remains unclear due to the lack of pre-operative data in our study. There is no consensus in the literature about what relationships exist between weight loss after BS and body image [25]. In the review by Bertoletti and colleagues (2019) concerns about body image were related to depressive symptoms, loss of control over eating and experiences of social discrim- ination and bullying. Further, this review reports that improvement in body image was associated with a decrease in compulsive eating symptoms, reduction of BMI and increase in percentage excess weight loss in some studies, but that other studies did not find an association between body image and weight loss after BS. However, the assessment of weight and shape concerns is complicated in post-operative bariat- ric patients, since shape concerns in the population of bariatric patients are different than in other populations [55]. Weight loss is frequently accompanied with loose skin which is associated with higher body dissatisfaction and depressive symptoms [56].
Impulsivity is a central factor in disordered eating behaviors and obesity and can contribute to the experience of suboptimal outcomes after BS [57]. In our study we found that impulsivity (i.e. poorer concentration and thought intrusions) is associated with poorer weight loss after BS. The research by Schag and colleagues [15] suggests that impulsivity has an indirect impact on weight loss after BS that is mediated by depression and transferred through disordered eating behaviors. The disinhibition observed in people with obesity and loss of control over eating, and the emotional dysregulation associated with mood disorders, all likely share common- alities that may be associated with suboptimal weight loss after BS. Another possible explanation could be that higher levels of impulsivity make it difficult to comply with the recommendations after BS. Facets of impulsivity may represent a transdiagnostic process that underlies multiple health-related behaviors, including physical activity, diet and adherence to treatment regiments [58].
In the review of Herpertz and colleagues (2004) was found that earlier studies have generated conflicting results about the post-operative presence of depressive symptoms and weight loss [18]. The difference in level of depression in our study must be interpreted with caution. The direction of this relationship is unclear due to the lack of pre-operative data. A different study design would be needed to clarify the direction of the relationship. The finding of mild depressive symptoms in partici- pants with suboptimal weight loss may be related to disappointment that weight loss has been less than expected.
In addition, we found in our study that previous psychological treatment is asso- ciated with suboptimal weight loss. A history of psychopathology seems to be associated