brigid a[1]. wilson - final dissertation
TRANSCRIPT
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SELF-ESTEEM IN PREOPERATIVE
ROUX-EN-Y GASTRIC BYPASS WHITE WOMEN
AND THIER POSTOPERATIVE COUNTERPARTS
by
Brigid A. Wilson
CAROLYN ALLEN, Ph.D., Faculty Mentor and Chair
CHERRI LESTER, Ph.D., Committee Member
AMY DONOVAN, Ph. D., Committee Member
CHRISTOPHER CASSIRER, Ph.D, Dean, School of Human Services
A Dissertation Presented in Partial Fulfillment
of the Requirements for the Degree
Doctor of Philosophy
Capella University
August 2007
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Brigid Wilson, 2007
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Abstract
Interventions exist to counter obesity, yet only gastric bypass surgery has shown the
possibility of producing significant long-term weight loss results. Few studies have
examined the psychological affects of the surgical procedure, especially on the
hierarchical trait of self-esteem. This study used quantitative methodology to address
issues of self-esteem and the effect Roux-en-Y Gastric Bypass surgery has on adult
morbidly obese women. The objective was to examine hierarchical self-esteem in
preoperative RYGB morbidly obese White women and their two-or-more- years
postoperative counterparts. Research questions focused on discovering if a significant
difference between groups existed in physical, social, emotional, performance, and global
self-esteem. The researcher hypothesized that the postoperative group would positively
significantly differ in social, physical, performance, and global self-esteem but not differ
in emotional self-esteem. Empirical data was collected with the Customized Version of
the Modified Self-Rating Scale and analyzed through multiple variance analysis. The
analysis found a significant difference between groups existed in physical, social,
emotional, performance, and global self-esteem.
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Dedication
First and foremost, I would like to thank my dad for his undying financial and
psychological support. He is the ultimate father, best friend, and role model. He has
shown me the meaning of unconditional love. Along side my dad is his wonderful wife
Helen. Helen has been a true blessing since the day I met her. I thank Helen for all her
emotional and financial support. I would also like to thank my brother, Barry. Barry is the
reason I am able to enjoy the sunrise each morning. Thank you for truly being my
lifesaver and for assisting me with my various electronically orientated dilemmas. In
addition, I would like to thank some of the dear people whom I have worked with for
years. Their support and encouragement has persuaded me to carry on during my
numerous struggles when I felt defeated. Lastly, I thank my female friends for sharing
their positive attitudes and creative ideas. Without my female counterparts, success
would not have been achieved. Sisters in friendship, Regina, Leslie, and Karen are the
reason why this female believes she can successfully accomplish any goal.
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Acknowledgments
I would like to begin by thanking my dear friend, Asim Zulfiqar, for his constant
academic support, motivation, and sacrifices. His scholarly assistance was invaluable to
me, as it helped my successful completion of the dissertation. He is a genuine person.
Additionally, gratitude needs to be given to my assistants Francis and Jeanette Castillo
for their consistent hard work and dedication. The sisters were a tremendous assistance in
generating ideas, solving problems, and editing chapters. Additional assistants, Tania
Reyes and Bianca Smith, also deserve thanks for contributing ideas, time, and effort
towards dissertation improvement. Regina Garceau was my mentor in technical aspects,
such as writing, layout, and design issues. Much gratitude is given to her for sharing her
precious time and wonderful ides. Leslie Villars and Karen Craig were my formatting
experts, as they were able to answer all questions concerning the intricacies of the
Microsoft Word program. Dr. Adelman also needs to be thanked because she enhanced
my voice, message, and morale. Dr. Mansfield and Dr. Fetter are heroes to me, as they
helped make my empirical data manageable and meaningful.
Dr. Margaret M. Inman and her office assistant Colleen OBrien, from the
Meridian Surgical Group in Carmel Indiana, also need to be recognized for their interest
and support in helping the study come to fruition. Their cooperation enabled the
researcher to secure the collaboration agreement with St. Vincents Hospital, Bariatric
Weight Loss Center of Excellence in Carmel, Indiana. Ted Eads, bariatric center director,
needs to be acknowledged for his time and support in aiding the researcher to carry out
the study according to hospital regulations. Without his assistance, attaining a large
desired sample population would have been difficult.
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The dissertation process is complex, and therefore it cannot be successfully
accomplished without the guidance and expertise of knowledgeable committee members.
The committee members helped me to grow as a scholar and a researcher by making
poignant suggestions and pointing out weaknesses. To begin with, I need to thank Dr.
Carolyn Carter for her positive attitude and professional standards. She has been a terrific
role model, as she encouraged learning through constructive criticism and diverse
suggestions. Without her constant support, I would have not been able to survive the
trying times. In addition, I would like to thank Dr. Lester and Dr. Donovan for their
beneficial feedback that prompted problem solving and enhanced the dissertations
quality. All the committee members were genuine in their communications, and hence
they earned my utmost respect. Their dedication to the teaching profession was clearly
evident.
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Table of Contents
Acknowledgements..........................................................................................................iv
List of Tables ...................................................................................................................ix
CHAPTER 1: INTRODUCTION............................................................................................ 1
Obesity as a Disease......................................................................................................... 2
Prejudice and the Obese................................................................................................... 4
Background of the Study ................................................................................................. 6
Statement of the Problem............................................................................................... 18
Purpose of the Study ...................................................................................................... 19
Rationale ........................................................................................................................ 21
Research Questions/Hypotheses .................................................................................... 22
Nature of the Study ........................................................................................................ 25
Significance of the Study...............................................................................................28
Definition of Terms........................................................................................................ 29
Assumptions................................................................................................................... 31
Limitations ..................................................................................................................... 33
Conclusion ..................................................................................................................... 35
CHAPTER 2: LITERATURE REVIEW............................................................................... 37
Psychological Health of Obese and Morbidly Obese Individuals ................................. 38
Bariatric Surgical Procedures ........................................................................................ 51
Self-Esteem.................................................................................................................... 60
Conclusion...................................................................................................................... 64
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CHAPTER 3: METHODOLOGY......................................................................................... 67
Philosophy of Method Selection....................................................................................67
Theoretical Framework.................................................................................................. 68
Research Design............................................................................................................. 69
Sampling Design............................................................................................................ 70
Measures ........................................................................................................................ 74
The Customized Version of the Modified SRS Scale.................................................... 78
Data Collection .............................................................................................................. 80
Pilot Testing ................................................................................................................... 84
Data Analysis Procedures .............................................................................................. 94
Limitations of Methodology and Strategies................................................................... 97
Expected Outcomes ....................................................................................................... 99
Ethical Issues ............................................................................................................... 103
Timeline of Research Activity.....................................................................................105
Conclusion ....................................................................................................... ............106
CHAPTER 4: DATA ANALYSIS and RESULTS............... ...... 108
Sample Characteristics................................................................................................. 108
Descriptive Statistics of Self-Esteem Data .................................................................. 111
Group Differences is Self-Esteem Subscales.............................................................. .113
Group Difference in Global Self-Esteem..................................................................... 116
Conclusion ................................................................................................................... 117
CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS....................................... 118
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Discussion .................................................................................................................... 119
Conclusions .................................................................................................................. 121
Limitations ................................................................................................................... 129
Implications.................................................................................................................. 135
Future Research ............................................................................................................ 140
Summary.......................................................................................................................141
REFERENCES .................................................................................................................... 143
APPENDIX: CUSTOMIZED VERISION OF THE MODIFIEDSELF-RATING SCALE ................................................................................ 165
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List of Tables
Table 1. Principal Components Analysis of the Customized Version of theModified SRS............................................................................................................ 89
Table 2. Principal Components Analysis of the Rosenberg Scale......................................... 90
Table 3. Correlation between Modified SRS and Rosenberg Scale ...................................... 90
Table 4. Demographic Characteristics by RYGB Status.....................................................109
Table 5. Descriptive Statistics of Self-Esteem Components by RYGB Status.................... 112
Table 6. Adjusted Means for Self-Esteem Subscales by RYGB Status. ........................... ..116
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CHAPTER 1. INTRODUCTION
Obesity is the most prevalent, lethal, and rampant chronic illness of the 21st
century in the United States, increasing at an alarming rate that is only commonly
observed with infectious diseases (Downey, 2002). The illness is recognized as the
second leading cause of preventable death in America, preceded only by tobacco use
(American Obesity Association, 2002). The percentage of adult Americans who are
obese/overweight is three times as great as those who smoke (Hartwig & Wilkinson,
2004). The disease is believed to be caused by a combination of genetic, metabolic,
behavioral, environmental, cultural, and socioeconomic factors (Belluscio, 2005). It has
serious implications because it is associated with social prejudice and discrimination, as
well as physiological and psychological impediments (Wadden, Womble, Stunkard, &
Anderson, 2002). Harmful effects such as diabetes, cancer, heart disease, and stroke, can
be so great that they result in death (American Obesity Association, 2005). In the United
States, obesity is associated with 300,000 deaths per year or about 1,000 deaths each day
(Bancroft, 2003).
The United States is at risk of reversing the gains made in the treatment of heart
disease, cancer, hypertension, and other chronic problems if obesity continues to rise in
prevalence (Spence-Jones, 2003). Harmful psychological effects include low self-
confidence, depression, and a sense of isolation (Carpenter, Hasin, Allison, & Faith,
2000). Additionally, in the United States, 30% of people 18 years old and older are obese
and, within that population, about 5% are morbidly obese, defined as having a body mass
index (BMI) of 40 or more (Flegal, Carrol, Ogden, & Johnson, 2002). Thus,
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approximately five million people are afflicted with morbid obesity, the highest rate ever
recorded in the United States (National Institutes of Health [NIH], 2004) and this
population is expansive, as both genders, all ages, races, ethnicities, and socioeconomic
classes are afflicted (Wellman & Friedberg, 2002). However, not all populations are
affected equally. Women are twice as likely to be afflicted by obesity as men: 3.1% of
American men and 6.3% of American women suffer from this health problem, and adults
aged 30 to 59 have the highest incidence rate. Non-Hispanic Blacks have the highest
prevalence rate of obesity of all ethnic groups (American Obesity Association, 2005).
Obesity as a Disease
Obesitys incidence has expediently risen at such an alarming rate over the last 2
decades that the American government took legislative action in 2000 to counteract the
diseases widespread detrimental consequences (Encinosa, Bernard, Steiner, & Chen,
2005). In 2000, the Internal Revenue Service declared that taxpayers could deduct the
cost of weight-loss programs as medical expenses, including behavioral counseling,
nutrition advisement, pharmacology, and surgery, if the expenses account for more than
7% of an individuals adjusted gross income (Internal Revenue Service, 2005).
Subsequently, the U.S. government officially declared obesity a disease in 2004
(Gruman, 2004). Obesitys classification as a disease was monumental because it
mandated that insurance companies had to pay for obesity-related medical visits,
prescriptions, and surgeries (Hartwig & Wilkinson, 2004).
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The governments actions have had a dramatic affect on the number of weight-
loss treatments that Americans may choose to utilize. For example, the number of
bariatric surgical procedures performed in the United States increased from 26,700 in
2000 (Waraksa & Vinson, 2004) to over 140,000 in 2005, more than a five-fold increase
(American Society for Bariatric Surgery, 2001) in just 5 years. The increased popularity
of bariatric procedures is not only attributed to insurance coverage, but also to positive
media publicity surrounding celebrities who have undergone the treatment (Johns
Hopkins University, 2004), such as Al Roker, Carney Wilson, Sharon Osborne, and
Roseanne Barr. Furthermore, bariatric surgeries have become popular because they
appear to be a quick and effective method to lose weight, with the average person losing
approximately 30 to 40 pounds in the year following surgery (Duke Medical Center,
2006).
Due to the rising popularity of bariatric surgery, it is imperative that scholars
study the surgical procedure from diverse perspectives. These perspectives include
physiological, psychological, and financial viewpoints. Examining Roux-en-Y Gastric
Bypass surgery (RYGB), the most popular and effective form of bariatric surgery
(Buchwald et al., 2004), from multiple perspectives might provide a broader, more
overarching picture of how surgery affects all of these perspectives. When an individual
undergoes bariatric surgery, that individual experiences multiple lifestyle changes that
need to be contended with, because bariatric surgery is not an effortless, unproblematic
miracle cure for obesity (Park Nicollet Clinic, 2005).
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Prejudice and the Obese
Prejudice, a subjective attitude of a particular group developed from
preconceived, irrational convictions of anothers supposed distinctions from the group
(Mish, 1991), is so prevalent against overweight and obese individuals that it is not
surprising that individuals will undertake major surgery and risk possible health
complications to lose excess weight (Farber, 2003). A specific term was coined for this
damaging attitude towards the obese: weightism, also known as fatism (Winfield, 2002).
Weightism refers to the detrimental stereotypical beliefs many Americans possess
towards overweight individuals in virtually every aspect of life (Crocker & Garcia, 2004).
Weightism propagates the beliefs that obese individuals are weak-willed, ugly,
unmotivated, emotionally troubled, unclean, immoral, self-indulgent, and incompetent
(Schwartz & Brownell, 2004). Weightism in America is extremely common, as obese
individuals experience discrimination in almost all areas of life: education, employment,
social life, family relationships, housing, healthcare, public accommodations, and media
exposure (Wadden, Womble, et al., 2002). Wherever the individual travels, be it work, a
physicians office, or the grocery store, the obese individual encounters weightism.
Weightism is so prevalent and powerful that an obese individuals sense of self
may suffer permanent damage leading to the persons sense of well-being becoming
permanently impaired (Winfield, 2002). Obese individuals may possess a negative sense
of self due to their evaluation of self in relation to societal beliefs and values, and
therefore weightism exhibited by others can have tremendously detrimental
psychological affects for the obese individual. The obese individuals fragile sense of self
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becomes further weakened and, thus, weight often becomes an obsession for the obese
individual. Weight may develop into the only subject of concern, as other personal
attributes, like talent, wealth, and intelligence are discounted (Farber, 2003).
Mental health specialists consider weight infatuation detrimental, as it leads to
poor body image and low self-esteem (Fox, Taylor, & Jones, 2000). Poor body image
results from an obese individuals perception of self not correlating with the ideal
American body image (Schwartz & Brownell, 2004). Low self-esteem occurs because
individuals focus on self-perceived negative characteristics (obesity) rather than positive
attributes (Crocker & Park, 2004). Low self-esteem also occurs because individuals are
unsuccessful in losing a self-specified desired amount of weight and, therefore, feel as
though they are failures (Ginty, 2005).
Along with poor body image and low self-esteem, other documented
psychological effects of weightism include diminished self-efficacy, augmented
depression, anxiety, and social withdrawal (Belluscio, 2005). Diminished self-efficacy
occurs because obese individuals lose confidence in their abilities (Bandura, 1997;
Crocker & Garcia, 2004). Society bombards obese individuals with negativity and
reinforces an already present belief in low self-worth (Puhl & Brownell, 2003).
Moreover, depression occurs when obese individuals feel defeated by weightism because
the prejudicial attitude affects both their personal and professional life (Rogge,
Greenwald, & Golden, 2004). These individuals are left feeling that they cannot meet
anyones standards, including their own (Maranto & Stenoien, 2000). Some obese
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individuals consider their disease as a greater detriment than deafness, dyslexia, or
blindness (Wadden, Womble, et al., 2002).
Weightisms prevalence continues to increase in America, even though the
incidence of obesity has also continued to rise (Winfield, 2002) and more individuals
suffer from the disease. Scholars who adhere to the Attribution Theory state that
weightism is based on the Calvinist doctrine and the Protestant ethic that associates self-
discipline, hard work, perseverance, and successfulness (Crocker & Park, 2004; Seaman,
2003). Although the religious foundation of these beliefs has lessened in American
society, the majority of Americans continue to believe in the intrinsic worth of self-
discipline and hard work and judge success as a gauge of ones worth (Crocker & Park).
Meanwhile, scholars who advance the Social Consensus Theory explain this paradoxical
phenomenon by arguing that obese individuals are trying to disassociate themselves from
a group of individuals whom they deem unpopular and associate with a group they
admirenormal-weight individuals (Rogge et al., 2004). From this theory, it is evident
that some obese individuals suffer from low self-esteem because of their own personal
belief system (Puhl & Brownell, 2003).
Background of the Study
Bariatric Surgery Physiological and Psychological Effects
Bariatric surgery is viewed as an extreme, yet often necessary, weight-loss
intervention for morbidly obese individuals (American Obesity Association, 2004).
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Bariatric surgery was first performed in the 1950s and the results were less than ideal
because of unpleasant and serious complications commonly experienced by patients
(Gordon, 2005). Not until the late 1960s was a surgeon able to perform the surgery with
few complications (Thompson, 2004). After the National Institutes of Health recognized
bariatric surgerys effectiveness in its 1991 Consensus Statement and established criteria
for who was eligible for the procedure, its popularity began to increase (NIH, 1991).
Bariatric surgery may be necessary because morbidly obese individuals suffer from
tremendous physiological problems such as hypertension, possible stroke, cardiovascular
disease, heart attacks, diabetes, gall bladder disease, sleep apnea, and osteoarthritis
(American Obesity Association, 2005). Bariatric surgery has proven results in weight
loss, with an average loss of 63% excess body weight (Cohn, 2003).
Gastric bypass surgical procedures began to receive extensive mass media
attention in the 21st century because of their increasing popularity, growing from 20,000
operations in 1995 to 40,000 in 2000 (Charatan, 2000), and their reported long-term
weight-loss effectiveness (Daniels, 2006). However, in 2005 attention surrounding gastric
bypass surgical procedures began to shift from positive to negative because of a study
reported in the Journal of the American Medical Association, which stated that the death
rate for bariatric surgery is closer to 5% instead of the previously reported 1% (Flum et
al., 2005). Other recent studies also reported that over one-third of bariatric patients
develop gallstones postoperatively and approximately 10% to 20% of bariatric patients
need additional surgeries to address complications that develop (American Obesity
Association, 2005). Besides these negative physiological effects, recent research has also
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shown that bariatric surgery may be correlated with harmful psychological conditions
such as depression, compulsive behaviors (Park Nicolett Clinic, 2005), suicide (Farber,
2003; Thompson, 2001), and eating disorders (Guisado et al., 2002).
Conversely, other studies have found that gastric surgery is associated with
positive psychological changes, such as a decrease in body-image disparagement, an
increase in self-esteem (Kral, Sjostrom, & Sullivan, 1992), enhanced self-confidence, and
elevated mood (Rand, MacGregor, & Hankskins, 1986). Furthermore, since bariatric
surgery is associated with improvements in comorbid conditions such as hypertension,
hyperlipidemia, type 2 diabetes, degenerative joint disease, asthma, and pseudotumor
cerebri (American Obesity Association, 2005; Daniels, 2006), its benefits are believed to
far outweigh its risks (American Obesity Association, 2004).
Differences between bariatric procedures. Surgical procedures have become a
viable treatment option for obese individuals since the late 1980s (American Society for
Bariatric Surgery, 2005). However, surgical treatments should be undergone only after
serious contemplation because they are major surgeries, which involve lifestyle
modifications and life-long medical visits to a physician. Since surgical treatments for
obesity are considered a drastic treatment option, they are not recommended for every
obese individual and are considered viable only for the following types of obese
individuals: morbidly obese individuals (BMI of 40 or more), individuals with a BMI of
35 to 39.9 who suffer from a critical medical condition (e.g., hypertension, high
cholesterol or blood pressure, diabetes), and individuals whose quality of life is so
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severely deteriorated that daily activities are impossible to perform (American Obesity
Association, 2005).
Three main general classifications of bariatric surgery presently exist and all of
them are capable of producing substantial weight loss (American Obesity Association,
2004). Gastric restrictive procedures produce significant weight loss by limiting food
consumption through diminishing stomach size (Mattison & Jensen, 2004). The stomach
pouch is normally reduced to 30mL or less (Latifi & Sugerman, 2003). A smaller
stomach results in a feeling of fullness occurring after a minimal portion of food is
ingested because a full digestive capacity has been quickly achieved with the smaller
gastric reservoir (American Obesity Association).
Three types of restrictive procedures are gastric stapling (Mattison & Jensen,
2004), laparoscopic adjustable silicone gastric banding and laparoscopic (vertical) banded
gastroplasty (Hell, Miller, Moorehead, & Norman, 2000). Gastric stapling was the first
restrictive procedure devised, and it involved creating a small stomach pouch through a
vertical or horizontal staple line. Surgeons rarely practice gastric stapling today because
of common stomach widening or staple line dehiscence (Mattison & Jensen).
Laparoscopic adjustable silicone gastric banding is more advanced than gastric
stapling because an upper section of the stomach is banded with adjustable silicone
elastic, rather than stapled. When stapling is used, surgical wounds have been known to
disease, or split open, and the stomach opening to widen again, defeating the purpose of
the surgery (Hell et al., 2000). The banding creates a small pouch that restricts the
passage of food the stomach can hold and decreases the speed at which food passes into
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the stomach (American Obesity Association, 2005). The band may be altered to fit an
individuals needs. Some individuals prefer the procedure because no permanent
alternation to the stomach occurs, and therefore the food digestion process is unaltered.
All food, which is consumed, is also absorbed with this surgery. Individuals typically lose
40 to 70% of excess weight within a 1-3 years (Hell et al.).
Laparoscopic (vertical) banded gastroplasty is another common type of restrictive
weight-loss surgical procedure (Hell et al., 2000). The surgical procedure entails the
upper region of the stomach being stapled and divided. A small pouch is formed which
limits the size of the stomach and hence the quantity of food it can hold. The outlet from
the pouch is restricted by an adjustable band that slows food passage and produces a
feeling of fast satiety when eating. Although the anatomy is permanently modified, all
food consumed is fully absorbed. The average weight loss is 50% to 70% during the first
13 years (Aurora Healthcare, 2006).
Malabsorptive weight-loss procedures are the other main type of bariatric surgery
(Hell et al., 2000). Malabsorptive procedures change the digestive process through
bypassing a significant section of the small intestines absorptive surface, and thus
altering food absorption. Food that is not completely absorbed is eliminated in the stool.
The most common type of malabsorptive procedure performed in the U.S. is the
jejunoileal bypass. The surgery enhances weight loss by reducing the absorptive surface
area of the small intestine and subsequently interrupting euterohepatic bile circulation
(Mattison & Jensen, 2004). The procedure is advantageous because weight loss is rapid
and a change in eating behavior is not necessary. However, it is rarely performed today
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due to the high incidence of metabolic complications like vitamin and protein deficiency,
kidney stones, and liver failure (Chand, Gugliotti, Schauer, & Steckner, 2006).
To capitalize on the strengths of both restrictive and malabsorptive procedures,
the third type of weight-loss procedure is a combined restrictive and malabsorptive
procedure approach (Mattison & Jensen, 2004). The benefit of these approaches is that
they result in greater weight loss than restrictive methods and have far fewer metabolic
complications than malabsorptive procedures (Latifi & Sugerman, 2003). Two main
types of combined restrictive and malabsorptive procedures are partial biliopancreatic
diversion (BPD), and RYGB (Mattison & Jensen).
Partial BPD is a surgical procedure treatment that creates a 200 to 500 mL gastric
pouch that connects to the distal 250 cm (98.4 in) of the small intestine. The proximal
small intestine, which receives biliary and pancreatic secretions, attaches to the final 50
cm of the small intestine (Mattison & Jensen, 2004). The result is that food and digestive
substances do not meet until the last 50 cm of the ileum. Gastric restriction and
malabsorption are both utilized, and hence significant weight loss should transpire (Joyal,
2004).
RYGB is the most common weight-loss surgical procedure performed in the
United States (Maggard et al., 2005). During the procedure, the upper stomach is stapled
and a small pouch is created which is completely distinct from the remainder of the
stomach. The pouch bypasses the duodenum and upper portion of the small intestine and
is connected directly to the lower portion of the small intestine. The procedure results in
superior weight loss when compared to other bariatric procedures, 60% to 80% in 13
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years, because of the malabsorption caused by bypassing a majority of the stomach and
approximately two feet of the small intestine (Duke Medical Center, 2006). Since
malabsorption does occur due to the bodys abnormal digestive pattern, individuals must
consume vitamins for a lifetime. Although RYGB is deemed the gold standard of
bariatric surgical procedures (Aurora Healthcare, 2006), it is not to be perceived as a
miracle cure for all of the health complications caused by obesity. The procedure can
directly aid physical health complications when the patient follows special postoperative
instructions, but it does not address the mental health issues that have arisen from a life
spent contending with self-esteem issues (Wadden et al., 2001).
Self-Esteem
Since bariatric surgery is a major surgical procedure that alters ones appearance
and physical health, it has been perceived to have an effect on self-esteem (Herpertz et
al., 2003). Self-esteem is an important psychological construct to analyze when
examining any special population because the concept has been associated with
psychological happiness, healthiness, and productive living (Branden, 1994), and low
self-esteem has been linked to depression, shyness, loneliness, and alienation (Heatherton
& Wyland, 2003). Consequently, self-esteem seems an essential construct of
psychological health. Although self-esteem has been a widely studied construct, there is a
lack of consensus as to its exact meaning, as illustrated by the numerous definitions,
models, and measures that exist (Tafarodi & Milne, 2002). Specifically, defining self-
esteem is crucial if the construct is to possess scientific utility (Marsh & Craven, 2006).
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Some researchers confuse self-esteem with self-concept, which is the sum of
cognitive ideas that people have about themselves inclusive of uncontaminated self-
descriptions (Heatherton & Wyland, 2003). However, self-esteem is a term distinct from
self-concept because it involves self-appraisal, which self-concept does not
(Coopersmith, 1967). Self-esteem can be defined as the emotional reaction that
individuals experience when they ponder and appraise different aspects of themselves
(Fleming & Courtney, 1984). Some scholars label self-esteem as a stable trait because it
steadily develops over time through because of personal experiences. Self-esteem
fluctuates around a steady baseline, but the fluctuations are minimal due to enhanced
sensitivity about specific situations or tasks (Fleming & Courtney). However, other
scholars believe that self-esteem is not stable individual-differences construct because it
does not possess long-term stability (Fleming & Courtney). Self-esteem is believed to be
reactive to social evaluation and thus alters according to external feedback (Leary &
Baumeister, 2000). Furthermore, self-esteem stability is thought to decrease from
adulthood to old age due to the dramatic life changes and transforming social
circumstances that are representative of later adulthood and old age (Tiggeman &
Stevens, 1999). For example, empty nest syndrome, retirement, death of loved ones, and
dependency on others can drastically alter self-esteem. Additionally, self-esteem may
change according to the critical self-appraisals of life experiences and accomplishments
that individuals commonly partake in as they reach middle age (Trzesniewski, Donnellan,
& Robins, 2003).
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Discord also surrounds self-esteem because of the debate over whether it is a
singular trait or a multidimensional trait (Fleming & Watts, 1980; Marx & Winnie, 1978;
Shavelson & Bolus, 1982). If self-esteem is viewed as a singular trait, then it must be
perceived as an overall self-attitude that affects all facets of a persons life (Dunbar, Ford,
Hunt, & Der, 2000). When scholars define self-esteem as a multidimensional trait, it is
seen as a hierarchical construct that can be broken down into constituent parts that
represent specific competencies. When the constituent parts are summed, they equate to
global or general self-esteem and, hence, global self-esteem is dependent on its lower
order constructs (Fleming & Courtney, 1984).
When self-esteem is viewed as a hierarchical multifaceted construct, scholars
diverge on the quantity and type of constructs that it possesses. For example, Heatherton
and Polivy (1991) proposed a self-esteem model that consists of three major components
comprising a global self-esteem. The three major components are performance, social,
and physical self-esteem. Performance self-esteem measures the broad competence of an
individuals intellectual, academic, and employment performance interrelating with self-
efficacy concerning task completion. High performance self-esteem equates to
individuals believing that they are intelligent and capable of achievement. Social self-
esteem represents how individuals judge others to perceive them and this perception is
vital because it is what constitutes the persons reality. If a person possesses high social
self-esteem, the person will believe that others value and respect who that person is. Last,
physical self-esteem assesses how individuals view the physical body and includes
athletic talent, physical desirability, and body image. Physical self-esteem also sees the
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physical image as structured by race and ethnicity. If a person has high physical self-
esteem then there is a belief that the body is attractive and that physical skills are
adequate.
Somewhat similar to Heatherton and Polivys (1991) self-esteem model is the
hierarchical facet model proposed by Shavelson, Hubner, and Stanton (1976). The
hierarchical facet model posits that self-esteem is composed of four subcomponents that
comprise global self-esteem: emotional, social, physical, and academic. The emotional,
social, and physical components are clearly conceptualized and, being nonacademic, are
not related to intellectual capabilities. The components of physical and social self-esteem
are quite similar to the identically named constructs in the Heatherton and Polivy model
and no significant difference exists. Performance and academic self-esteem are also
similar to Heatherton and Polivys physical and performance concepts in that both focus
around accomplishing tasks. However, the Shavelson et al. model is centered on children
and academic self-esteem concentrates on school performance. Emotional self-esteem is
the only component that is distinct from Heatherton and Polivys model and refers to the
self-esteem surrounding how one perceives control of emotions. If an individual
possesses high emotional self-esteem, then that person perceives the self as having
control of emotions and not being classified as moody (Shavelson et al.).
This researcher contends that self-esteem must be examined as a
multidimensional trait if true precision is to be attained. Which specific model to employ
is dependent on the subgroup being studied and the studys objectives. The Heatherton
and Polivy model (1991) is appropriate for use with all ages, as every individual
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possesses social, physical, and performance self-esteem. However, if a study solely
concentrates on children and educational experiences, then the Shavelson et al. (1976)
model might be most appropriate. Regardless of which model is employed, or if a
combination of the models is used, this researcher contends that self-esteem should be
viewed as a multidimensional trait, because studying specific self-esteems should provide
more effective predictors of the emotional response to the self than lone general self-
esteem (Pelham, 1995). Heatherton and Polivy state that self-esteem is a higher-order
construct that is supported by numerous factors and thus research must assess all of its
components to attain a holistic picture.
The Shavelson et al. model (1976) regarding self-esteem (indistinguishable from
self-concept) is hierarchical and multidimensional. The model was based on self-esteem
(also known as self-concept) which is defined as a persons perception of himself or
herself. The perception was developed through interpretation and experience with the
environment. The construct was particularly impacted by assessments made from loved
ones, reinforcements, and attributions for ones own behavior. A persons sense of self is
developed through multiple sources and situations (Marsh, 1993).
Self-concept is elucidated by seven main principles (Byrne, 2001). Self-concept is
organized around the way individuals categorize the mass array of information they
ascertain about themselves and relate the categories to each other. Self-concept is
multifaceted and the facets represent a self-referent classification system developed by a
specific individual (Watkins, Fleming, & Alfon, 1989). In addition to being multifaceted,
it is also hierarchical. Perceptions of personal behavior at the base move to inferences
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about self in sub-areas and subsequently to the more general self. Stability is another
characteristic of self-concept, though self-concept can be minimally affected by situation.
Although self-concept, which is deemed a stable trait, does alter throughout an
individuals life cycle because it is believed to develop in complexity from infancy to
adulthood (Marsh, 1993).
General self is the core of the model and it is divided into academic and
nonacademic self-concepts at the next level. Academic self-concept is broken down into
particular subject areas like reading and science. Nonacademic self-concept is subdivided
into three distinct areas: social self-concept, the relationships one has with colleagues and
loved ones; emotional self-concept that is based on physical ability; and physical
appearance. Additional components of self-concept are hypothesized although the base of
the model consists of specific self-concepts that are closely linked to particular behavior
(Shavelson et al., 1976).
The Shavelson et al. (1976) model of self-esteem is advantageous because it
enables researchers to focus either selectively on a single specific self-concept construct
or globally on numerous domains and assess how the domains are structured and related
hierarchical (Fox, 1990). Self-esteem cannot be adequately understood if its
multidimensions are ignored (Marsh & Craven, 2006).
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Statement of the Problem
Past obesity research concerning bariatric surgery, which has primarily been
carried out over the last 15 years, has mainly focused on the physiological affects of
morbidly obese individuals (Byrne, 2001; Gordon, 2005; Rabner & Greenstein, 1991). In
particular, most research studied bariatric surgerys impact on weight loss, postoperative
mortality outcome, diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea
(Buchwald et al., 2004). These research topics are rational and compulsory because
bariatric surgery is a major surgical procedure, which can result in serious medical
complications (Gordon), and basic defining and exploratory research was needed in the
area (Star-Ledger Report, 2005).
Since RYGB involves dramatic weight loss, with a mean and average loss of
68.2% of total body weight (Buchwald et al., 2004), psychological changes necessarily
accompany physiological changes. However, bariatric surgery research focusing on
psychological affects has not been extensive (Wald, 2001), even though many patients
list social, rather than medical reasons as the basis for having the surgery (Farber, 2003).
Bariatric surgery research concerning psychological well-being post-surgery has mainly
pertained to the issues of body image (Schwartz & Brownell, 2004), eating disorders
(Guisado et al., 2002), depression (Greenberg, Perna, Kaplan, & Sullivan, 2005), and
self-esteem (Bocchieri, Meana, & Fisher, 2002).
Self-esteem has been linked with advantageous health and focuses on the self-
assessment of qualities judged valuable (Rosenberg, 1979), therefore, it is natural that the
construct has been studied in conjunction with body mass. The belief that the physical
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self is a significant component of self-esteem has prevailed since the predominant
theories of self-esteem in the 1950s (James, 1950). More recently, the focus has been on
how possessing a body weight, which differs from societal norms, affects the self (Miller
& Downey, 1999). Numerous theoretical perspectives contend that overweight
individuals possess low self-esteem due to the vast amount of stigmatization which they
face in societal, educational, and employment settings (Friedman & Brownell, 1995;
Miller & Turnbull, 1986), while other researchers believe that heavy weight is not
associated with low self-esteem (White, ONeil, Kolotkin, & Byrne, 2004). Because of
these conflicting opinions, debate exists as to how bariatric surgery affects a morbidly
obese individuals self-esteem.
Although self-esteem has been studied in respect to bariatric surgery, it has
typically been examined in terms of short-term effects and as a global construct (Hell, et
al., 2000) as opposed to studying it as a multidimensional hierarchical trait with
independent subcomponents (Heatherton & Wyland, 2003). Therefore, the hierarchical
construct of self-esteem has yet to be comprehensively examined in morbidly obese
individuals undergoing bariatric surgery (Jambekar, Quinn, & Crocker, 2001).
Purpose of the Study
As a result of the increasing popularity of bariatric surgical procedures and
conflicting research findings concerning their psychological benefit, a quantitative study
was designed to examine self-esteem in morbidly obese White women aged 18 years and
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older (body mass index [BMI] 40 kg/m2) prior to RYGB surgery. Simultaneously, the
study examined self-esteem in their 2-or-more-years postoperative counterparts. The
study was developed to gain a better understanding of the relationship between RYGB
surgery and self-esteem. Numerous studies state that RYGB is overwhelmingly the most
effective weight-loss treatment for morbidly obese individuals (Pories & Beshay, 2002;
Woznicki, 2005), and, with the rapid increase in the numbers of the surgeries, scholars
must try to better comprehend the procedures impact on psychological functioning and
self-esteem. Self-esteem is a critical psychological construct to examine because it
symbolizes an individuals appraisal of self-worth (Blascovich & Tomaka, 1991).
Self-esteem was examined as a multidimensional hierarchical trait that possesses
the independent sub-constructs of emotional, social, physical, and performance
components (Fleming & Courtney, 1984). To ascertain the global construct of self-
esteem, the independent subcomponents were independently measured because self-
esteem is a composite of components that are hierarchically structured and intricately
related (Guindon, 2002). Understanding the changes in self-esteem in morbidly obese
individuals undergoing bariatric surgery was deemed crucial because self-esteem is a
vital component of psychological health (Heatherton & Wyland, 2003). Researchers have
also found that bariatric surgery, to some unknown degree, affects self-esteem (Wadden
et al., 2001). Consequently, the study may help discern whether bariatric surgery
negatively or positively affects obese White womens self-esteem and, if modification
occurs, what specific subcomponents of self-esteem are altered.
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Rationale
Great debate exists within the field of obesity research as to whether or not obese
individuals can be characterized as having low self-esteem (Adami et al., 1994; Wadden,
Womble, et al., 2002). This researcher contended that the debate is irrelevant, as
discussion should focus on understanding the relationship between the multidimensional
trait of self-esteem and obesity before focusing on whether or not obese individuals can
be characterized in a particular manner. Discovery of whether the assorted components of
self-esteem are affected by bariatric surgery should be paramount because large fractions
of obese individuals undergo bariatric surgery for psychological as well as physiological
reasons (Wald, 2001).
The multidimensional concept of self-esteem was based on the hierarchical facet
model by Shavelson, Hubner, and Stanton (1976) and was developed because self-esteem
was believed to exist as both a global construct and as separate distinguishable entities
(Blascovich & Tomaka, 1991). If that was indeed the case, separate distinguishable
components of self-esteem were thought critical to understand because they are better
predictors of specific behavior than global self-esteem. If self-esteem is analyzed too
broadly, it loses its scientific significance (Fleming & Courtney, 1984).
During the last decade, a steadily increasing number of Americans have become
obese. The prevalence of adult obese Americans in 2001 was 20.9% a 74% increase
since 1991 (Centers for Disease Control, 2005). Not only has the incidence rate of obesity
in American adults increased, but also the number of American adults who are morbidly
obese has risen. In 2000, eight million Americans were morbidly obese, almost a 50%
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increase from 1994 (American Obesity Association, 2005). The statistics involving
morbid obesity are frightening because premature death is a serious danger (Buchwald et
al., 2004).
Desperate Americans have been turning to RYGB for a cure to their disease.
The procedure is the most common bariatric procedure performed as an obesity
intervention, accounting for 84.7% of all gastric bypass procedures in the United States
(Encinosa et al., 2005). Therefore, it is necessary that scholars learn as much as possible
about the procedures effects, both physiological and psychological.
Although positive physiological changes have been repeatedly associated with
RYGB, research on the psychological modifications has produced conflicting results
(Ryden et al., 2004). Initial self-esteem and self-esteem changes brought about by the
bariatric procedure are vital psychological issues to comprehend, because self-esteem is a
critical construct dictating behavior (Fleming & Courtney, 1984) and the massive weight
losses resulting from the procedure will most likely alter an individuals self-esteem.
White women were identified as the target population for the study because this is the
largest ethnic group undergoing RYGB surgery for weight loss (Livingston & Ko, 2004).
Research Questions/Hypotheses
A quantitative postpositivism study was developed to examine multifaceted
hierarchical self-esteem in two distinct groups of native English speaking White women:
morbidly obese preoperative RYGB and 2-or-more-years postoperative RYGB. The two
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distinct groups of women were compared utilizing the following criteria, which include
the covariates of age, education level, preoperative BMI, and procedural type of RYGB
performed. The principle research questions were:
1. To what extent does social self-esteem of preoperative RYGB morbidly obeseWhite women significantly differ from the social self-esteem of Whitewomen who are 2-or-more-years postoperative RYGB?
2. To what extent does the emotional self-esteem of preoperative RYGBmorbidly obese White women significantly differ from the emotional self-esteem of White women who are 2-or-more-years postoperative RYGB?
3. To what extent does the physical self-esteem of preoperative RYGB morbidlyobese White women significantly differ from the physical self-esteem ofWhite women who are 2-or-more-years postoperative RYGB?
4. To what extent does the performance self-esteem of preoperative RYGBmorbidly obese White women significantly differ from the performance self-esteem of White women who are 2-or-more-years postoperative RYGB?
5. To what extent does the global self-esteem of preoperative RYGB morbidlyobese White women significantly differ from the global self-esteem of Whitewomen who are 2-or-more-years postoperative RYGB?
Based on the above research questions, the study was guided by five hypotheses as
indicated below. The null hypothesis is followed by the alternative hypothesis.
1. H0: The social self-esteem of preoperative RYGB morbidly obese Whitewomen will not be significantly different from their 2-or-more-yearspostoperative counterparts.
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H1: The social self-esteem of preoperative RYGB morbidly obese Whitewomen will be significantly lower from their 2-or-more-years postoperativecounterparts.
2. H0: The emotional self-esteem of preoperative RYGB morbidly obese Whitewomen will be significantly different from their 2-or-more-yearspostoperative counterparts.
H2: The emotional self-esteem of preoperative RYGB morbidly obese Whitewomen will not be significantly different from their 2-or-more-yearspostoperative counterparts.
3. H0: The physical self-esteem of preoperative RYGB morbidly obese White
women will not be significantly different from their 2-or-more-yearspostoperative counterparts.
H3: The physical self-esteem of preoperative RYGB morbidly obese Whitewomen will be significantly lower than their 2-or-more-years postoperativecounterparts.
4. H0: The performance self-esteem of preoperative RYGB morbidly obeseWhite women will not be significantly different from their 2-or-more-years postoperative counterparts.
H4: The performance self-esteem of preoperative RYGB morbidly obeseWhite women will be significantly lower than their 2-or-moreyears postoperative counterparts.
5. H0: The global self-esteem of preoperative RYGB morbidly obese Whitewomen will not be significantly different from their 2-or-more-yearspostoperative counterparts.
H5: The global self-esteem of preoperative RYGB morbidly obese Whitewomen will be significantly lower from their 2-or-more-years postoperativecounterparts.
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Nature of the Study
The study was designed according to the postpositivism paradigm, which
possesses the central tenet that the truth can never be fully comprehended due to the
human minds limited abilities to conceptualize phenomenon (Mertens, 2005). As a
result, knowledge can only be ascertained through careful observation and empirical
measurements of small occurrences (Creswell, 2003). Even then, results obtained are
accurate only at a specific level of probability and only according to the conditions
present at the time of the study (Leedy & Ormond, 2005). A studys subject matter
should be narrow, easily defined, and capable of being empirically tested in a precise,
objective manner (Neuman, 2003). Postpositivisms methodical assumption is that social
research should be facilitated to analyze laws and theories and determine if modification
needs to occur, which is decided through continuous observation and experimentation
(Creswell). Consequently, the study used the Hierarchical Facet Model (Shavelson et al.,
1976) as a conceptual model and employed a modified version of the established and
validated Self-Rating Scale (Fleming & Courtney, 1984).
Theory guided this researcher in developing an apt research design that tested the
present body of knowledge on the topic and, if the phenomenon was accurately studied,
the findings should aid in determining the relationship between the independent and
dependent variables (Neuman, 2003), allowing the causes which most probably
determined the effects to be deciphered (Benton & Craig, 2001). The study attempted to
discover the effect the independent variable of RYGB surgery had on the dependent
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variables comprised of the multidimensional trait of self-esteem in morbidly obese White
women.
Positivism also holds the ontological assumption that the absolute truth is not
possible to ascertain because of human limitations of conceptualization that prevent a
comprehensive picture of a phenomenon from being realized (Glicken, 2003). However,
research findings are still deemed valuable because they can attest to that which is most
likely (Creswell, 2003). The study acknowledged this dichotomy and therefore this write-
up details study design limitations.
The epistemological assumption of postpositivism avows that research originates
with theory and, subsequently, data collected either supports or refutes the theory
(Neuman, 2003). The epistemological assumption also avows that knowledge is
quantifiable, and quantitative measurement is necessary because it is perceived to be
more precise and controllable than qualitative measures (Trochim, 2002). The study
exemplified these beliefs because the research problems and hypotheses were clearly
stated.
Postpositivisms axiological assumptions are that research should involve values
and that researchers can control the degree to which their values interfere with outcomes
and interpretations of the research. The studys principal researcher understood that, in
order for the studys findings to be accurate, objectivity must be present. As a result,
research was conducted in a specific and exacting manner, with precise notes concerning
procedures and instrumentation being recorded. Data was collected according to a
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systematic mail survey approach and analyzed in as accurate and factual manner as
possible through careful attention to detail and peer verification (Creswell, 2003).
Postpositivism is an appropriate paradigm to employ with the topic of self-esteem
because self-esteem is a subjective construct, perception, rather than reality (Blascovich
& Tomaka, 1991). Since self-esteem is a subjective construct, it mandates objective
measurement in order to possess scientific utility (Dunbar et al., 2000). If self-esteem is
allowed to be a too broadly defined construct, then its meaning could overlap similar
constructs such as self-concept and self-consciousness (Heatherton & Wyland, 2003).
Postpositivism was, thus, the appropriate framework for the study because it enabled the
researcher to discover the relationship between the various independent subcomponents
of self-esteem and global self-esteem and RYGB surgery (Heatherton & Polivy, 1991).
The study utilized quantitative methods and employed a survey to ascertain associations.
The study was exploratory in nature due to the studys cross-sectional research
design and the lack of research concerning bariatric surgery and multidimensional self-
esteem. As stated above, the studys purpose was not to solve the problem of obesity, but
rather to add an additional piece to the puzzle that comprises the total Gestalt of obesity
(Neuman, 2003). The study aids in forming a more comprehensive understanding of the
psychological impact that RYGB has on morbidly obese White women, the largest sub-
population of obese individuals undergoing gastric bypass surgery (American Society for
Bariatric Surgery, 2001; Livingston & Ko, 2004). From the studys results, hypotheses
may be generated which would form the basis for changing current psychosocial
interventions and direct further research (Creswell, 2003).
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Significance of the Study
Obesity is a fatal health problem, which has garnered myriad media publicity and
scholarly attention in the last decade, although safe and effectual interventions for the
general population have yet to be found (American Obesity Association, 2004).
Presently, the only intervention that has demonstrated long-term effective results is major
gastric surgical procedures (American Obesity Association, 2005). Morbidly obese
individuals, especially White women, are speedily signing up for these surgeries because
they have insurance, the ability to self-pay, or both, believing it will solve all their
physiological and psychological health problems (Farber, 2003). However, bariatric
surgeries cannot cure all health problems associated with obesity because obesity is
associated with psychological as well as physiological affects and, to be effective, any
treatment must take both of these dimensions into account and include major lifestyle
changes (Byrne, 2001). The study expanded upon the existing body of obesity research
by exploring how RYGB affects the multidimensional trait of self-esteem.
Self-esteem modifications are essential to understand in this context, as self-
esteem has a direct affect on behavior (Heatherton & Wyland, 2003). If surgerys weight
loss is to be permanent, then self-esteem must be addressed in a positive and realistic
manner both pre- and postoperatively (Wald, 2001). Without changing those behaviors
that contributed to the persons morbid obesity, postoperative success for RYGB will be
lessened and could even lead to eventual return of much, if not all, the weight lost
because of the surgery (Thompson, 2001).
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Thus, the studys findings may aid scholars in developing pre- and postoperative
bariatric counseling programs that address areas of self-esteem that may have negative
impact on achieving a positive, self-confident, and healthy state of well-being for the
patient. These programs principal objectives could be to assist postoperative individuals
in developing a well-rounded multifaceted sense of self, building on personal strengths,
and addressing preoperative self-esteem issues (Buchwald et al., 2004).
Definition of Terms
To understand fully the studys purpose, design, and findings, it is essential that
key terms be clearly defined. Key terms are words or phrases that need to be concretely
explicated to avoid confusion and enhance comprehension. Thus, various health and
psychological terms were operationalized for the study.
Academic self-esteem. Academic self-esteem consists of components concerning
the academic disciplines of English, history, mathematics, and science.
Bariatric Surgery. A bariatric surgical procedure is any surgical procedure in
which the size of an individuals gastric reservoir (stomach) is reduced for the sole
purpose of inducing weight loss (American Society for Bariatric Surgery, 2001).
Emotional self-esteem. Emotional self-esteem is concerned with how the self
perceives specific emotional states (Fleming & Courtney, 1984) or how the self perceives
its emotional well-being and what constitutes an appropriate emotional reaction for a
given situation.
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Global self-esteem. Global self-esteem, also known as total self-esteem, is an
individuals overall attitude of the self (Guindon; Rosenberg, Schooler, Schoenbach, &
Rosenberg, 1995). Global self-esteem is composed of several components including,
academic, social, emotional, and physical self-esteem, which comprise the global self-
esteem concept (Guindon).
Hierarchical Self-Esteem Model. The Hierarchical Multifaceted Model (HMFM)
is a model of self-esteem developed by Shavelson et al. (1976) that depicts self-esteem
(defined below) as a hierarchical, multifaceted construct that has general self-esteem at
the acme of the hierarchy and is supported by increasingly specific constructs as the
hierarchy descends. Construct specificity correlates with downward movement, as the
most situation-specific self-perceptions are located at the models bottom (Fleming &
Courtney, 1984).
Morbid obesity. Morbid obesity, also known as severe obesity, is a label given to
any individual who is more than 100 pounds overweight or has a BMI 40 kg/m2 (NIH).
Normal weight. Normal weight is a term that applies to any individual who
possesses a body mass index (BMI) in the 1924.9 kg/m2 range, and is not overweight.
Obese. Obese is a term that applies to any individual who possesses a BMI in the
3039.9 kg/m2 range.
Overweight. Overweight is a term which applies to any individual who possesses
a BMI in the 2529.9 kg/m2 range (NIH, 2004) and excess weight visibly protrudes from
a persons body frame but does not severely imperil normal functioning.
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Performance self-esteem. Performance self-esteem is a persons perception of
general competence and includes intellectual capabilities, employment skills, self-
efficacy, and self-confidence (Fleming & Courtney; Heatherton & Wyland).
Physical self-esteem. Physical self-esteem concerns how individuals perceive
their physical bodies, especially features such as athletic skills, physical attractiveness,
and body image (Heatherton & Wyland).
Roux-en-Y Gastric Bypass surgery. Roux-en-Y Gastric Bypass surgery is a
specific type of gastric bypass surgical procedure in which the stomach size is decreased,
food intake is limited to 10 to 30 mL in the proximal pouch, and sections of the small
intestine, including the antrum, duodenum, and proximal jejum are bypassed (Gordon,
2005).
Self-concept. Self-concept is a self construct that is an individuals perception of
self that develops through an individuals experiences and interpretations of his or her
environment (Shavelson et al., 1976).
Social self-esteem. Social self-esteem regards how individuals believe others such
as peers, significant others, and coworkers judge them (Heatherton & Wyland, 2003).
Assumptions
Since the study originated from the postpositivism paradigm, its design
exemplified the beliefs that one knowable reality exists within probability and that the
discovery process could be facilitated with empirical assessments (Mertens, 2005). From
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these beliefs, three underlying assumptions were conceived. Due to the paradigms
conviction concerning reality, it was assumed that the studys findings are generalizable
to a larger population. It was also assumed that the adult White female participants were
similar pre- and postoperatively in psychological composition prior to RYGB surgery.
The assumption was based on the facts that all participants had a preoperative BMI >40,
and normal psychological functioning prior to surgery. Normal psychological functioning
was determined through a complete mental health assessment given by the bariatric
center prior to consideration for bariatric surgery. The mental health assessments
determined each participant had no psychopathology and hence normal psychological
functioning before the participant was accepted as a patient for bariatric surgery (C.
OBrien, personal communication, July 17, 2006). The assumption was necessary to
conduct a comparison of the two groups, given the limitations of the studys design (A.
Mansfield, personal communication, May 4, 2006).
Beliefs pertaining to empirical assessments and their validity led to the
assumption that the findings are the genuine result of participant responses that were
given independently, honestly, and to the best of each participants abilities. Another
related assumption was that a mailed questionnaire was a valid and reliable method of
conducting research for the study and that it produced the desired information solicited
on self-esteem (Neuman, 2003). Lastly, it was assumed that all participants interpreted
the questionnaires items in the same manner and as the researcher intended.
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Limitations
Although the research design closely adhered to the postpositivism paradigm, it
possessed several recognized limitations. There was only one instrument employed in the
study, a self-reporting assessment, Modified Version of the Self-Rating Scale. The
instrument required individuals to self-report on personal demographic characteristics of
age, education level, preoperative BMI, RYGB date, as well as the personal construct of
self-esteem. A self-reporting assessment was beneficial because it obtained meaningful
personal data that was inaccessible to others (Leedy & Ormond, 2005). However, this
type of assessment was also limiting, because it is an inherently flawed source of data due
to the possibility of semantic misunderstandings and context-uncertainty that could result
in major differences in findings (Schwarz, 1999).
The instruments design, which necessitated that individuals self-report on the
personal construct of self-esteem, was also limiting because it relied on individuals to
report their attitudes and feelings without demonstrating biases (Leedy & Ormond, 2005).
The instrument was especially vulnerable to participant deception because individuals
may have falsified answers because of self-presentational and inherent self-esteem issues
(Fleming & Courtney, 1984). To minimize participant deception due to self-
presentational issues, the survey did not utilize personally identifiable information such
as names or addresses. Numerical codes were used to differentiate between the assorted
surveys (details of the process are explained further in Chapter 3). The scale was also
restrictive because the standardized items limited assessment to fixed hypotheses (Dunbar
et al., 2000), as participants responded to items by selecting a predetermined response. As
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a result, spontaneous responses were excluded and accurate participant viewpoints were
not obtained (Fleming & Courtney).
Employing the postal method to collect data also presented specific limitations.
Mailed surveys were hindering because of the generally low response rates and the
researchers uncertainty as to who was completing the survey. Additionally, mail surveys
were restrictive because they are prone to items with missing or inappropriate responses.
Therefore, some of the data collected was incomplete and not fully comprehensive
(Neuman, 2003). Data from mailed surveys was also flawed because the researcher was
unable to ensure that participants had a complete understanding of items due to lack of
opportunities to clarify semantics, elucidate directions, define item wordings, or explain
response choices (Mertens, 2005).
Other limitations existed because the studys cross-sectional design involved a
preoperative group that did not consist of the same individuals comprising the 2-or-more-
years postoperative group. Consequently, the sample groups were not identical on all
variables except those that were specifically being identified and measured and, as a
result, every variable that could possibly account for a change in self-esteem during the
minimum 2-year postoperative RYGB time period was not assessed. Thus, extraneous
variables other than the RYGB might have been responsible for modifications in self-
esteem which were recorded, meaning a cause-and-effect relationship was not
determined, only an association (Patten, 2005). Nonetheless, the study was beneficial as a
starting point in determining if future, more extensive studies are needed on this
population.
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The studys nonprobability, convenience sampling technique also produced
limitations. These limitations arose because the sample could misrepresent the larger
population since all participants were voluntarily participating, assessed preoperatively as
having normal psychological functioning, and primarily from the Midwest region of the
United States. Furthermore, susceptibility to participant bias and systematic errors existed
due to nonrandom sample selection.
Conclusion
The prevalence of morbid obesity in the American population is steadily growing
and weight-loss interventions have gained great scholarly attention in the last 2 decades.
Presently, the only effective long-term weight-loss intervention, as determined by
research, for morbidly obese individuals is gastric bypass surgery (American Obesity
Association, 2004). Although the surgical procedures effectiveness on weight loss and
physiological problems has been widely documented, its effect on an individuals
psychological well-being is still unclear (Cohn, 2003). Studies have been conducted on
psychological well-being, yet few studies have focused solely on self-esteem (Wald,
2001). When self-esteem has been a principal variable in a study, it has been mainly
viewed as a single comprehensive construct, not a multifaceted hierarchical construct
(Baumeister, Campbell, Krueger, & Vohs, 2003). Thus, a gap in the literature exists (see
Chapter 2) as to understanding the effect which gastric bypass surgery has on a morbidly
obese individuals multifaceted self-esteem.
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CHAPTER 2. LITERATURE REVIEW
This chapter will contain a review of current peer-reviewed, published, English
language literature regarding the issues discussed in Chapter 1, with the central goal of
gaining a more enhanced comprehension of obese individuals psychological health, with
particular emphasis on the construct of self-esteem and the effects of bariatric surgery.
Importance will be placed on the obese subgroup of women, as they were the focus of the
study and their psychological health has been found to differ significantly from that of
men (Carpenter et al., 2000; Fabricatore & Wadden, 2003; Marlowe, Schneider, &
Nelson, 1996). Furthermore, since obese White females were the studys lone sample
population, special attention will be placed on literature relevant to the way in which their
unique cultural environment affects psychological functioning (Kolotkin, Crosby, &
Williams, 2002; Lancaster, 2004) and, hence, participation in gastric bypass surgical
treatment (Fabricatore & Wadden).
The literature review will commence by comparing the personality characteristics
of obese and morbidly obese individuals with that of normal weight individuals.
Subsequently, the psychological functioning of obese and morbidly obese individuals
will be analyzed to discover if patterns of psychopathology are prevalent. An
examination of the psychological functioning of obese women, White obese women, and
morbidly obese White women will follow, as these obese subgroups display a high
obesity incidence rate and distinct psychological functioning (Carryer, 2001).
Research on bariatric surgery, an increasingly popular weight-loss intervention,
will then be explored in an attempt to comprehend its diverse effects on psychological
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functioning. In this section, surgical procedures will be compared, and the psychological
health of pre- and postoperative bariatric patients will be compared. Subsequently, the
particular psychological construct of self-esteem in obese and morbidly obese individuals
as it relates to women and aging will be elucidated. This exploration of self-esteem is
deemed critical because of its hypothesized association with body weight (Crocker &
Garcia, 2004) and its significant impact on emotional well-being (Heatherton & Wyland,
2003). Finally, the chapter will conclude with a comprehensive summation.
Psychological Health of Obese and Morbidly Obese Individuals
Due to the various physiological and psychological health problems associated
with obesity and morbid obesity, physical and mental healthcare professionals are
interested in studying the diseases effects. The physical health consequences of obesity
have been well established and include the following conditions: arthritis, back and lower
extremity weight-bearing degenerative problems, cancers of the breast, colon, kidney,
pancreas, and uterus, cardiovascular disease, hyperlipidemia, hypertension, sleep apnea,
stroke, and type 2 diabetes (Daniels, 2006; Mokdad, Bowman, & Ford, 2001; World
Health Organization, 2002). However, the psychosocial consequences of obesity are less
well understood (Cohn, 2003; Wadden, Brownell, & Foster, 2002). To gain a better
understanding of how obesity and mental health are interrelated, a literature review was
conducted on the personality characteristics and psychological well-being of obese
individuals.
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While the literature review was being performed, a pattern was revealed regarding
publication dates for studies examining the obese population and psychological
functioning. An abundant number of studies were conducted in the late 1970s through the
early 1990s, and then a lull occurred throughout most of 1990s until 2000. The lull is
hypothesized to be the result of insufficient funding for research in this field (Brownell &
Wadden, 1992) and lack of new, effective interventions created or discovered in the
1990s (Wadden, Womble, et al., 2002). Not until the late 1990s was the first popular
weight-loss drug, Redux, approved by the Food and Drug Administration, with BMI
emerging as the standard measure used to characterize obesity (Star-Ledger Report,
2005). As a result, obesity and its treatment gained increased public attention in the late
1990s and early 2000s. In the early 2000s, the majority of studies concerning
psychological well-being and obese individuals concentrated on either preoperative
bariatric patients or comparisons of pre- and postoperative bariatric patients (Cohn, 2003;
Wald, 2001).
Psychological and Personality Characteristics of Obese Individuals
Obesity began to garner noticeable attention from the research community during
the late 1970s because its occurrence was becoming more commonplace (Star-Ledger
Report, 2005). As its prevalence increased, scholars focused on its causation. Some
researchers, in the 1970s through the 1990s, studied the psychology of being overweight
(Grana, Coolidge, & Merwin, 1989; Johnson, Swenson, & Gastineau, 1976; Svanum,
Lantz, Lauer, Wampler, & Madura, 1981) and some were particularly interested in
discovering if personality characteristics could be associated with obesitys causation
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(Grana et al., 1989; Mills 1995). Quantitative studies were designed to examine this
possibility (Leon & Roth, 1977; McReynolds, 1982; Mills, 1994). A substantial number
of these studies employed the closed-ended instrument, the Minnesota Multiphasic
Personality Inventory (MMPI), and compared the personality characteristics of obese
individuals to normal weight individuals. These studies reached a common conclusion:
obese individuals do not tend to have a significantly different personality profile than
normal weight individuals (Fitzgibbon, Stolley, & Kirschenbaum, 1993). The MMPI
clearly showed that obese individuals scores were typically within normal limits on all
psychological issues, such as hypochondriasis, depression, hysteria, and social
introversion (Grana et al.). Other studies (Hill & Williams, 1998; Stunkard & Wadden,
1992) that employed different quantitative measurement instruments attained similar
results. Moreover, Moore, Standard, and Srole (1996) conducted a study of 1,660 obese
individuals in midtown Manhattan and found that obese individuals actually had lower
levels of psychopathology than normal weight individuals. Consequently, it would appear
that even though obese individuals suffer personal and societal tribulations (Wadden,
Womble, et al., 2002), their personalities are typical of the general population.
Some clinical studies (Mattlar, Salminen, & Alanen, 1989; Mills, 1995; Stein,
1987) have associated negative personality characteristics with obese individuals. These
researchers have found passive dependency, self-consciousness, low assertiveness, and
low self-esteem to be evident in obese individuals personality. Obese individuals also
have been found to have more internal anxiety and depression than non-obese individuals
(Klesges, 1984; Mattlar et al., 1989). These results sharply contradict the aforementioned
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results, and thus it would appear that discord exists in research pertaining to the
personality characteristics of obese individuals; however, the discrepancies found among
the studies examining the psychological well-being of obese individuals may exist
because of diverse sample populations being examined (Fabricatore & Wadden, 2003).
The studies that found obese individuals to have normal functioning possessed samples
comprised of non-weight-loss treatment-seeking individuals, whereas the studies that
found obese individuals with damaging personality characteristics or psychopathology
possessed samples of weight-loss treatment-seeking individuals. As a result, clinical
samples may exhibit selection bias (Williamson & ONeil, 2005).
Inconsistent findings also may have materialized because of methodological
inconsistencies such as small convenience samples versus sizeable and nationally
representative samples, assessment instruments that produce clinical diagnoses versus
self-assessment surveys, and suitable control groups versus inadequate control groups
(Fabricatore & Wadden, 2003). With these considerations in mind, the remainder of this
chapter will discuss the current state of research in obesity and psychological fu