Variables that Influence Psychological Well-Being following Significant Weight Loss Submitted by
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Introduction
The goal of therapies addressing weight loss is to decrease the risks for chronic diseases such as diabetes and hypertension, but also to ultimately increase positive feelings of well-being from physical improvements. Significant weight loss is accompanied by both positive and negative emotions and if the decrease in body mass is accompanying by negative feelings, maintenance is difficult. Therefore, psychological aspects to weight loss programs are an important consideration when determining the success of the therapy. Previous research concerning the psychological aspects of significant weight loss has made associations with the physical phenomenon, but has failed to indicate specific variables that are influential to the point of affecting weight loss maintenance and well-being. The purpose of this research project is to discover the influence of three specific variables on the well-being of individuals who have experienced significant weight loss. This information may prove valuable to health care providers in guiding therapeutic interventions toward improved psychological outcomes to weight loss.
Background of the Problem
The medical community has long been aware of the benefits of maintaining optimum body weight, but the importance of psychological aspects influencing the loss of significant weight and maintaining weight goals has not been properly emphasized. Diseases associated with obesity impact the mental well-being of patients as their general health and potentially decreased lifespan are affected. Obesity results in a mental state for many that are a result and often a cause of excessive weight gain. Whether the patient is considered to be overweight or is diagnosed as obese or even morbidly obese, research directed toward variables associated with excessive weight influence self-esteem and other components of well-being is important.
While numerous studies over the past decade have addressed the benefits of weight loss on physical health, more research is needed on the psychological changes that take place after significant weight loss. When treating obesity, psychological evaluations and interventions may be recommended (Collins & Bentz, 2009). Multiple studies have shown that losing significant amounts of weight may result in improved self-image, social relationships, and employment opportunities (Herpertz et al., 2003; van Hout, Boekestein, Fortuin, Pelle & van Heck, 2006). However, not all research shows positive psychological effects of the loss of significant amounts of weight. Studies by Jackson, Steptoe, Beeken, Kivimaki & Wardle (2014), Lasikiewicz, Myrissa, Hoyland, and Lawton (2014), and Bryan & Tiggemann (2001) reported no positive results concerning well-being, mixed results, or results that did not endure. The research measured components of well-being associated with weight loss, but not the variables influencing them.
Theoretical Foundations and Review of the Literature/Themes
Theoretical foundations/conceptual framework. It is not currently known the degree to which significant weight loss by an adult influences their feelings of well-being as described by personal perceptions of self-esteem, self-image, and self-worth, the impact on individual depression and the influence of variables that include body image, social environment, family support, and events such as job opportunities, but there are theories addressing the concept. Ryff (2014) constructed a model of psychological well-being as it relates to mental and physical well-being, incorporating the theories of Rogers’ fully functioning person (1961), Allport’s maturity theory (1961), Neugarten’s theory of executive processes of personality (1973), Buhler’s theory on basic life tendencies (1935), Maslow’s theory of self-actualization (1969), Erickson’s theory of personal development (1959), Frankl’s will to meaning theory (1959), Jahoda’s mental health theory (1958), and Jung’s theory of individuation (1933) to propose the core dimensions of psychological well-being are self-acceptance, purpose in life, autonomy, mastery of the environment, positive relationships, and personal growth.
The theoretical model will be adapted from Markowitz et al. (2008) and Napolitano et al. (2008) to address pre-existing psychological influences. The model shows the relationship between common mental disorders and obesity. Understanding the relationship between the two will help to determine how weight loss affects the mental health of people whose weight is influenced by mental disorders in that interventions may targeting both conditions, facilitating the implementation of interventions for the most positive outcome. The theory proposed by this study is that the variables of family support, personal relationships, body image, and employment opportunities have a significant bearing on patients following significant weight loss on whether they experience an improved sense of well-being. Since some patients who successful lose weight experience a decreased sense of well-being, it is theorized that these variables may be exerting an influence that does not result in negativity in patients reporting improved well-being.
Review of the literature/themes.
Autonomy in creating self-motivation. The theme is that weight loss is more successfully obtained and maintained if the individual is allowed appropriate control over his environment. Webber, Gabriele, Tate, & Dignan (2010) subscribe to the belief that promoting autonomous motivation is more beneficial to weight loss than controlled motivation. Their conclusion is that controlled motivation was more effective than behavioral loss intervention. Fuglestad, Jeffery, & Sherwood (2012) determined that subjects who used their own initiative to remove unhealthy food from their environment and incorporated exercise into their lifestyle were more successful at reaching weight loss goals.
Effect of weight loss on self-esteem. The impact of weight loss on self-esteem is determined by the influence of independent variables. Studies by Jackson, Steptoe, Beeken, Kivimaki & Wardle (2014), Lasikiewicz, Myrissa, Hoyland & Lawton (2014), and Kubik, Gill, Laffin and Karmali (2013) reported that improvements in self-esteem were dependent on individual variables relating to perception of success. Nnaemeka and Solomon (2014) and Oktan & Şahin (2010) drew a correlation between the well-being component of self-esteem with the variable of body image. Gruber (2014) and Samuel-Hodge et al. (2010) focused on the influence of the variable of family support.
Weight loss and perceived quality of life. For many patients, the health-related quality of life improves when weight is lost. This perception may be relevant to higher self-esteem, decreased depression, or a number of other possible influences. Studies by Warkentin, Das, Majumdar, Johnson, and Padwal (2013) and Osama & Shehab (2015) reported improvements in perceived quality of life with significant weight loss.
Effect of body weight on mental disorders. Bruch (1952) stated that unless the underlying cause of the excessive weight was discovered and modified, the weight would return. Yen, Huang, & Tai (2014) promote the inclusion of psychiatric evaluations with weight loss programs. Studies by Lin et al. (2013) and Hayden, Murphy, Brown, and O’Brien (2014) propose that obese patients do not exhibit any higher incidences of mental disorders than the general population.
Weight loss and improved depression. Weight loss may influence depression through other factors such as improved self-image, but it may also be related to the physical effects of obesity. Studies by Hamer, Batty & Kivimaki (2012) and Jackson, Steptoe, Beeken, Kivimaki & Wardle (2014) found obese patients are at higher risk of depression that people with normal body mass. Lasikiewicz, Myrissa, Hoyland & Lawton (2014) and Fabricatore et al. (2011) reported decreases in depression with weight loss. Petasne Nijamkin, Campa, Samiri Nijamkin, and Sosa (2013) felt that steps with behavioral or motivational psychotherapy might decrease symptoms of depression after bariatric surgery with a secondary effect of optimum weight loss.
Weight loss and suicide. The risk of suicide is significant following bariatric surgery due to and disappointment with the procedure, inadequate support from family, anxiety related to the responsibility to continue dietary and physical recommendations, and other forms of stress that may intensify already existing depression to the point where suicidal ideologies develop. Studies by Tindle et al. (2010) and Peterhänsel, Petroff, Klinitzke, Kersting, and Wagner (2013) confirm the statistics.
Weight loss and cognitive function. Cognitive function has been shown to be a strong determinant in weight loss maintenance and achievement. A patient who acknowledges increases in cognitive function has the potential to improve his sense of well-being secondary to the perception of increased mental functioning. Spitznagel, Galioto, Limbach, John Gunstad, and Leslie Heinberg (2013) associated decreases in cognitive function with lack of adherence to patient guidelines after bariatric surgery. Marques et al. (2014) reported that cognition in obese women improved until the point where their body weight was considered normal.
The role of emotional eating in regaining weight lost. Eating to relieve stress is a factor both in causing obesity and in maintaining weight loss. Emotional eating is related to depression, poor self-image, lack of environmental mastery, and other elements of well-being. Peacock & Zizzi (2012) found compliance in maintenance programs discouraged emotional eating and Chesler (2012) promotes cognitive behavior therapy as a post-weight loss option.
Problem Statement
There is a problem in the population of obese adults that despite numerous forms of weight loss programs available, obesity continues to be a growing health problem. The issue has negatively impacted millions of overweight individuals because of physical and mental health consequences. A possible cause is the influence of variables on the components of well-being. Perhaps further research investigating influencing variables on physical weight loss and maintenance could remedy the problem.
Clinical Questions, Hypotheses, and Variables
The phenomenon to be studied is the influence of four variables on four components of well-being. The clinical question is, “What influence do the variables of family influence, job opportunities, body image, and personal relationships have on the well-being components of self-esteem, self-image, self-worth, and levels of depression?”. The variables that impact self-esteem and positive psychological well-being are interrelated with each other and individual psychology. Therefore, to promote individual weight loss and maintenance of the decrease in body mass, it is important to understand the impact of variables on individual perceptions.
Recognition of influencing variables is only the first step toward using them in promoting optimum body weight. Some variables are important to some patients while the same variables are not important to others. Identification of influencing variables requires the additional step of assigning a value of importance to each person in order to place proper emphasis during therapy.
The hypothesis of the study is that the significant majority of the participants will experience improvement in psychological well-being as determined by measurements of self-esteem, self-image, self-worth, and levels of depression acquired through test methods, interviewing, and self-reporting. The current study will attempt to answer the following research questions to explain the phenomenon.
R1: Do levels of depression as an element of well-being decrease after
participation in the program?
R2: Does self-esteem as an element of well-being increase after completion of the
program?
R3: Does self-image as an element of well-being improve after completion of the
program?
R4: Do feelings of self-worth improve as an element of well-being after completion of
the program?
R5: Does the support of family as an influencing variable negatively or positively impact
the studied elements of well-being?
R6: Does body image as an influencing variable negatively or positively impact the
studied elements of well-being?
R7: Do personal relationships as an influencing variable negatively or positively impact
the studied elements of well-being?
R8: Have employment opportunities as an influencing variable negatively or positively
impacted the studied elements of well-being?
R9: Have unexpected influences become apparent that may be included in future
research?
Significance of the Project:
The purpose of the study is significant for enhancing the psychological well-being of people losing weight by identifying the variables that exert influence on the outcome. The connection between obesity and being overweight and psychological well-being is bidirectional (Jackson et al., 2014). The study results have implications for practice, particularly the construction of weight loss programs. Research has promoted health care professionals to include the psychological effects of obesity when dealing with their clients and co-morbidity with mental disorders should be taken into account. Improved well-being is part of the motivation for seeking a weight loss program as obesity and psychological well-being are bidirectional and if patient satisfaction with the result is not adequate, the long-term outcome may be at risk.
Rationale for Methodology
The proposed research methodology for the study is the qualitative research method. This approach allows researchers to use descriptions to create complicated pictures, perform word analysis, and form intricate viewpoints of the study participants (Zucker et al., 2011). By moving from general logic to specific (inductive) and analyzing data as it is collected, a qualitative research design also allows for recognition of possible patterns and associations understand the meaning of the subjective data, allowing understanding of a mental process through evaluation several perspectives, and using interpretation.
Nature of the Project Design
The study will use the qualitative research design to answer the research questions because it is the best method for recognizing the relationship between the independent variable of psychological state after weight loss and the dependent variables of participant-perceived levels of body image, personal relationships, family support, and employment opportunities that determine the success of the program (Khan, 2014). In addition, open-ended questions are asked to allow responses involving unexpected variables that may arise in the course of the research that might be considered for future study.
The use of a qualitative research design is appropriate when there is not sufficient insight into the research, as in this case (Jackson, 2016). In addition, this form of design promotes understanding of factors in health care that involve emotion, perceptions, and experience in addition to physically measurable data.
Purpose of the Project
The purpose of this descriptive qualitative study is to promote understanding of types of psychological changes prompted by the significant weight loss in overweight and obese adults and how different styles of variables influence them. The research design used for this research will be a phenomenological study, following 15 participants over a three-month period of time with continuous monitoring of predetermined variables at a commercial weight loss center in New York City.
Sources of Data
The most common sources of qualitative data collection include questionnaires, surveys, observations, interviews, and secondary accounts such as those from family members. The self-reporting from the participants and interviews allow for subjective information that is not measurable by direct observation or physical measurements. On the other hand, objective data collection such as physical measurements and evaluation of medications that may affect mood, physical conditions, or both provide information for analysis of influences on mental state. Data analysis will begin after the first collection rather than waiting until all the information is gathered and will continue until the study is complete (Corbin & Strauss, 2008). Analysis is used with written notes, transcripts of interviews, coding of the interview responses, and discussions with the interviewer and the research team. Transcribed interviews will be imported into an MAXQDA software program, chosen for the ability to address variable functions and to data in text, bibliographic, video, and image files (MAXQDA, 2016).
Data Collection Procedures
The target population is obese adults in the New York City. The sample study is 15 obese adults enrolled in a weight loss program in New York City. The only characteristics addressed in this study is the age of participants as being over 18 years and no chronic illnesses that would influence a positive attitude based on weight loss. Since a measurement of the levels of depression is included as a variable to be evaluated, individuals with a diagnosis of depression were not eliminated from the study.
Giacomini, Cook and the Evidence-Based Medicine Working Group (2000) suggest there are four critical components when using qualitative analysis. First, the selection of study participants requires careful consideration of their common trait which is to be researched; in the case of this study, it is a history of obesity that has prompted enrollment in a weight loss program. Second, the method of collecting data must take into account the location and objectives of the study. The data collection will include both physical measurements, existing tools for psychological evaluation, interviews, and subjective self-reporting by questionnaires. Third, the process of collecting data must be adequate to provide comprehensive descriptions of the events influencing the problem. Finally, proper analysis of the data and corroboration from multiple sources is necessary. The research design of this study meets these criteria. The use of more than one person to collect and analyze the raw data is needed with a member of the research team determining that an adequate interpretation of the information obtained from the study participants is obtained.
Data Analysis Procedures
The data collected for the study on the impact of weight loss on the variables of psychological well-being will be analyzed using non-parametric inferential statistical methods which do not function with assumptions concerning the probability distributions of the influencing variables. The squared ranks test will demonstrate equality of the four tested influencing variables in two or more of the samples. Associations between the psychosocial constructs and changes in weight will use Pearson correlation. Variables will be expressed by the residuals of the final value regressed on the scores obtained during baseline measurements. This process allows the creation of a value that intersects the scores obtained at baseline, demonstrating change measurement when compared with subtraction after therapy. To facilitate interpretation of the correlational results, the scores for depression and body image were reversed so higher scores for every tests showed more desirable outcomes.
The steps taken for statistical analysis include: 1) clean the data for accuracy and to determine if missing values are clearly identified missing data, 2) become familiar with the data by making lists of small sets of data, producing descriptive statistics such as minima/maxima for variables, standard-deviations, and means, 3) produce composed scales by identification of variables or a single variable, 4) create tables or graphs to illustrate patterns or relationships, 5) measure the strengths and structure of the patterns or relationships by calculating coefficients, 6) describe the percentage of the variance determined by calculating coefficients, and 7) compute the significance level, which should be around the range of 5 percent.
Ethical Considerations
Each participant of the sample population for the study is enrolled in the same weight loss program. As clients of the company, utmost care will be taken to protect the business from liability associated with the study. Contact with the study participants will be kept to a minimum to decrease the possibility of contamination of data. Evaluations, measurements, and questionnaires will be administered by the employees of the business who will come into contact with the participants on a regular basis. Their ignorance of the methods of statistical analysis, research design, supportive research, and other aspects of the study will assist in avoidance of data contamination. To protect the research, the business, and associated entities, each participant will sign a consent form which will be witnessed and retained in the records of the study; the consent form will also contain a section that allows the information gathered to be used in a way that protects the confidentiality of the participant.
In order to conform with standards of HIPPA (HHS.gov, 2008) and confidentiality regulations of the weight loss company, the data for each participant will be assigned to a code with identifiers to patient charts. On completion of the study and verification of data, the codes will be altered to avoid the possibility of coordinating the original identifiers with company records. At no point will there be any contact with outside entities concerning measurements, evaluations, or individual results in conjunction with the study.
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Appendix
Qualitative Studies
