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ORIGINAL ARTICLES |
From the Health Care Research Unit (A.R., J.K., M.S., C.T.) and the Department of Body Composition and Metabolism (J.S.T.), Institute of Internal Medicine, Sahlgrenska University Hospital, Göteborg University, Sweden.
Address reprint requests to: Anna Rydén, Health Care Research Unit, Institute of Internal Medicine, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden. Email: anna.ryden{at}medicine.gu.se
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: We used the Obesity Coping (OC) scale measuring emotion-focused, maladaptive coping (Wishful Thinking) and problem-focused, adaptive coping (Social Trust and Fighting Spirit). We also used the Obesity Distress (OD) scale (Intrusion and Helplessness) and the Hospital Anxiety and Depression (HAD) scale. A total of 1146 surgical candidates and 1085 conventionally treated patients completed the OC and OD before treatment and after 24 months.
RESULTS: Weight gainers reduced their use of both problem- and emotion-focused coping, thus leaving distress levels unchanged. All participants who lost weight decreased in emotion-focused coping and distress. Participants losing 20 kg or more also increased in problem-focused coping, resulting in even greater improvements regarding distress.
CONCLUSIONS: Two years after starting treatment, the pattern and magnitude of change in coping and distress was the same irrespective of type of treatment and was, instead, related to the amount of weight change (the more weight change the greater the changes in coping and distress). Increases in problem-focused coping required major weight reduction, whereas minor weight gain led to a decrease. Emotion-focused coping decreased irrespective of direction of weight change, suggesting a general intervention effect of receiving professional help and support. These results have implications concerning behavior-based interventions of obese patients.
Key Words: coping • distress • severe obesity • clinical trial • treatment outcome
Abbreviations: BMI = body mass index;; CI = confidence interval;; GFI = goodness-of-fit indices;; HAD = Hospital Anxiety and Depression;; OC = Obesity Coping;; OD = Obesity Distress;; RMSEA = root mean square error adjusted;; SEM = structural equation modeling;; SOS = Swedish obese subjects.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Coping is defined as cognitive and behavioral efforts to manage stress that are appraised as taxing one’s resources (11). A distinction is made between two approaches of coping: basic and specific. Basic coping assumes that individuals have relatively stable coping traits and is therefore interested in how people generally react to stress. A problem with assessing basic coping is that items are often not relevant to individuals in specific situations or with specific conditions. Specific coping regards coping as a dynamic process sensitive to the special type of situation in question, and the interest is in how people react with regard to a specific stressor. This makes generalization, for instance, between samples with different disabilities more difficult, but it better enables comparison between groups facing the same specific condition or situation.
Two major ways of coping have been identified: problem-focused and emotion-focused (11, 12). Problem-focused coping seeks to reduce stress by cognitively reconceptualizing a problem, by minimizing its effects or by solving it. Emotion-focused coping seeks to reduce stress by responses such as daydreaming, self-preoccupation, or emotional regulation.
We have previously developed obesity-related instruments and explored the interactive relation between specific coping and distress in the SOS study (8). Three major coping strategies were identified: Social Trust, Fighting Spirit (both problem-focused), and Wishful Thinking (emotion-focused). Social Trust and Fighting Spirit proved adaptive, ie, greater use of these strategies was associated with lower levels of distress. The emotion-focused strategy Wishful Thinking was maladaptive, ie, positively associated with distress. This is in line with previous studies showing problem-focused coping to be either unrelated or linked to improved mental health and emotion-focused coping linked to increased distress (12, 13). Compared with those who preferred conventional treatment, candidates choosing surgery displayed lower levels of problem-focused coping, higher levels of emotion-focused coping and, consequently, more distress (8).
Data from the SOS study has previously shown that improvements in health-related quality of life after surgically induced weight loss were related to the magnitude of weight loss (7). An important question is whether weight reduction also produces changes in coping strategies and distress levels. The purpose of this study was to examine if weight change affects perceived problem- and emotion-focused coping and distress 2 years posttreatment. We also wanted to explore if there is a correspondence between magnitude of weight change and changes in coping and distress and if treatment modality has an effect.
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METHODS |
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34 kg/m2 for men and 38 kg/m2 for women). All subjects undergo an extensive health examination at study start and complete a battery of questionnaires (on, for example, socio-demographics, psychological variables, eating behavior) at regular intervals. More detailed descriptions of the SOS study design, recruitment, and assessment procedures have been reported previously (2, 14). The ethical committees of all medical faculties in Sweden approved the study and informed consent was obtained from all patients.
Participants
The present study is based on data from 2350 intervention patients examined at 480 primary healthcare centers and 25 departments of surgery in 18 urban and rural counties all over Sweden. The sample consisted of the first 1236 surgical patients followed for 2 years and 1114 conventionally treated controls. The difference in number between the two groups is due to logistic reasons. Because the primary interest in this study was to examine obesity-related coping and distress, 44 surgically treated patients that 2 years postoperation had a BMI less than 25 (cutoff for overweight) (1) and also reported perceiving themselves as no longer overweight were excluded from the analysis. The follow-up rate in both treatment groups was high (96.1% and 97.4%, respectively), leaving a total of 1146 surgically treated patients and 1085 conventionally treated patients having completed the questionnaires at baseline as well as follow-up. In both groups more than two-thirds were females (71.5%) and the mean age at baseline was 47.5 (95% CI, 47.2–47.8) years in the surgical group and 48.7 (95% CI, 48.3–49.1) years for controls.
Statistical Methods
Descriptive statistics with 95% CI were calculated according to standard procedures. Differences between groups were tested with the Mann-Whitney U test (p = .05) and analysis of covariance. Differences within groups were tested with the Wilcoxon paired signed rank test and given the large number of statistical comparisons, Bonferroni adjustment was applied within each set of responses in order to guard against type I errors. Thus, the p level was set at 0.01 (0.05/5). SEM was applied to analyze relations between coping and distress.
Anthropometric Measures
Body weight was measured to the nearest 0.1 kg using calibrated balances or electronic scales. Height was measured to the nearest 0.01 m. BMI was calculated by dividing body weight by height (2) (kg/m2).
Mental Health Measures
Coping.
Coping was measured by the OC scale. It consists of 16 statements on a four-point response scale ranging from "Do not agree at all" to "Agree totally." Items are grouped into three factors: Social Trust, Fighting Spirit, and Wishful Thinking. Social Trust reflects how people are regarded as potential helpers, eg, "I find it easy talking to others about my weight problems." Fighting Spirit reflects how problems are regarded as challenges to be solved, emphasizing things still possible to do, eg, "It is important thinking of everything I can do despite my overweight." Wishful Thinking reflects dreams and fantasies of losing weight and its benefits, eg, "I enjoy thinking of everything I would do if I were slimmer." Social Trust and Fighting Spirit are measures of problem-focused coping and Wishful Thinking of emotion-focused coping. A mean score is calculated for each factor. Score ranges are between 1 to 4, where higher scores represent more use of coping. Item content, psychometric properties, and descriptive statistics have been presented previously (8).
Distress.
The OD scale measures obesity-related distress. It consists of 13 statements on a four-point response scale ranging from "Do not agree at all" to "Agree totally." These items are grouped into two factors labeled Intrusion and Helplessness. Intrusion is a measure of how dominated and restricted life is due to the obesity, eg, "I think a lot of all the problems due to my overweight." Helplessness is a measure of feeling out of control and not knowing how to deal with various situations, eg, "I often feel at a loss without knowing what to do." A mean score is calculated for each factor, scores range between 1 to 4, with higher scores representing more distress. Item content, psychometric properties, and descriptive statistics have been presented previously (8).
The HAD scale measures general distress. It consists of 14 items on a four-point response scale that are summed up to separate scores on anxiety and depression. Each person is also grouped according to a clinically tested classification of psychiatric morbidity. A scale score of less than 8 is in the normal range, a score 8 to 10 indicates a possible case, and a score greater than 10 indicates a probable mood disorder. The Swedish version has been documented in several studies (2).
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RESULTS |
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Weight Change, Coping, and Distress
As seen in Table 1, surgical candidates weighed significantly more than the controls at baseline, had significantly lower levels of Social Trust and Fighting Spirit, and higher levels of Wishful Thinking. They also experienced significantly more distress. At 2-year follow-up, the surgically treated group had lost on average 27.1 kg (95% CI, 26.3–27.8) which equals on average 21% of original body weight, with only eight persons losing no weight at all. In contrast, the conventionally treated group lost on average 0.3 kg (95% CI, -0.8–0.2). The surgical group improved on all coping factors and the distress factor Helplessness to levels comparable with those of the conventionally treated group. Both groups improved regarding the distress factor Intrusion, although the conventionally treated group still displayed significantly lower levels.
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Surgical treatment.
Participants were grouped into four categories of weight loss: <10.0 kg (group 1); 10.0 to 19.9 kg (group 2); 20.0 to 29.9 kg (group 3); and 30.0 kg (group 4) (Table 2). At baseline, all groups differed significantly regarding weight except groups 1 and 2. Group 2 reported more use of Helplessness than group 4 (p = .024). At 2 years posttreatment, all groups still differed in weight but now in the opposite direction. Group 1 reported decreased use of maladaptive coping (Wishful Thinking) and improvement on one distress factor (Intrusion). Group 2 decreased more on Wishful Thinking and improved on both distress factors. Group 3 and 4 improved significantly on all coping factors and reported even greater reductions in distress.
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0.1 kg (group 1); weight loss 0.0 to 9.9 kg (group 2); 10.0 to 19.9 kg (group 3); and 20.0 kg (group 4) (Table 3). At baseline, all groups varied significantly in weight except groups 2 and 3. Group 1 and 2 also reported more use of Social Trust than group 4 (p = .0185, p = .041). At 2 years posttreatment, all groups still differed in weight but now in the opposite direction. Group 1 (weight gain) had significantly decreased their use of both adaptive and maladaptive coping. No difference in distress was found. Groups 2 and 3 decreased their use of maladaptive (Wishful Thinking) coping and reported lower distress. Group 4 reported significantly higher levels of adaptive (Social Trust) and lower levels of maladaptive (Wishful Thinking) coping and improved more than the other groups on distress. It should be noted that the improvement in Wishful Thinking concerning group 4 was not significant (p = .02), but the magnitude of change was greater than in the other groups.
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Summary of consequences of weight change.
The pattern and magnitude of change in coping and distress in relation to weight change was the same irrespective of treatment. Figure 1 shows the changes in coping and distress between baseline and follow-up for all subjects. Due to the significant differences previously reported (Table 2 and 3), and for illustrative purposes, we grouped them into those who gained weight, lost <20 kg, or lost 20 kg. Weight gainers reduced their use of the maladaptive strategy Wishful Thinking but reported the smallest improvement. However, because an increase in weight also was associated with abated levels of problem-focused, adaptive coping, this counterbalanced the decrease in Wishful Thinking, leaving distress unchanged. All participants who lost weight decreased their use of emotion-focused, maladaptive coping and reported lower levels of distress. The greater the weight reduction, the greater the decrease in Wishful Thinking and the greater the reduction in distress. Participants who had managed to lose 20 kg or more also increased in problem-focused coping, resulting in even more radical improvements in distress. However, at a weight reduction of 30 kg or more, only minor additional improvements were noted for all coping and distress factors (see Table 2).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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All groups, irrespective of treatment and weight change, decreased their use of Wishful Thinking. This suggests a general intervention effect of participating in the study and receiving professional help and support. By enrolling in a clinical trial, persons may feel less stressed because they have actually taken active steps to do something about their conditions. Decreases in the use of Wishful Thinking were associated with decreases in distress, especially Intrusion, which reflects thoughts of how life is dominated and restricted by obesity and worries about the future. Only the weight gainers did not improve on Intrusion. In this group, distress did not decrease because the decrease in the use of Wishful Thinking was offset by a corresponding decrease in the use of problem-focused coping.
The adaptive strategies Social Trust and Fighting Spirit were less responsive to weight change than Wishful Thinking. Only large weight reductions were associated with significant improvements in these strategies, whereas a relatively small weight gain led to a decrease. An explanation for the inertia in improvement regarding Social Trust may be that the least likely response to weight problems is to ask a friend, spouse, or family member for help (17). If and to whom obese persons turn for help may depend on their past experiences in seeking help, characteristics of the supporter and the patients’ own feelings of self-blame. On the other hand, it might be speculated, that the obese person who succeeds in losing weight can take credit for this and, because the weight problem is now both diminished and less guilt provoking, it may be easier to turn to others. Fighting Spirit was more strongly inversely associated with distress, especially Helplessness, but was also the most stable.
In a review of the impact of coping interventions among seven other chronic disease types, de Ridder and Schreurs (18) concluded that, although improvements were in evidence, they were mostly limited to one or two coping strategies, particularly problem-focused strategies. The differences between their findings and ours may be partly due to differences in study design. In our study, no intentional coping intervention was given nor was organized or structured advice offered on how to deal mentally with being obese. The aim of intervention was to reduce what was perceived as the source of stress, ie, the obesity. Moreover, comparison between other chronic disease groups and the obese should be made with caution. Not only do the obese in general tend to suffer from comorbid conditions, they are also a unique group in the sense that very few other patient groups are so guilt-ridden and widely regarded as having only themselves to blame for their condition. However, we do agree with de Ridder and Schreurs that greater attention should be paid to which coping strategies are most useful under particular circumstances, irrespective of chronic disease.
We were also interested in whether the type of treatment patients underwent would affect coping and distress differently. However, we found no differences concerning changes in coping or distress between subjects within the same weight change class. The failure to find differences between treatment groups may be explained by the long follow-up period (2 years), enabling adaptation to a new psychological and somatic situation. During this period it is possible that more short-term differences were erased. Although some might consider conventional diet a more difficult way of losing weight, eg, requiring more willpower, it should be noted that surgical treatment also has its drawbacks and practical demands. To avoid vomiting, food intolerance, and the "dumping syndrome" (sweating, palpitations, light-headedness, nausea) one must change eating habits, eg, eat more often but only very small portions and avoid certain foods. Lifelong medical surveillance is also necessary, thus surgery implies a radical change of lifestyle.
Our results show that, among the obese seeking treatment, greater use of emotion-focused coping is associated with higher distress, but this strategy is also most easily improved. On the other hand, greater use of problem-focused coping, particularly Fighting Spirit, is associated with lower distress but is most difficult to improve. Our results also show that the greater the weight reduction, the greater the improvements in coping, distress, and mood disorders. These results should be taken into consideration in the planning and assessment of behavior-based interventions of obese patients. Coping could also be an important parameter in relation to the hypothesis that an inability to efficiently handle stress might be one factor leading to hypersensitivity in the hypothalamic-pituitary-adrenal (HPA) axis, eventually setting off neuroendocrine and metabolic disturbances (19–21). Such disturbances may cause hormonal changes leading to greater central fat distribution that, in turn, is a large risk factor for cardiovascular disease and diabetes. The relation between obesity-related coping and physiological stress is the aim of a future study.
Received for publication March 1, 2002.
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