Brigid a[1]. Wilson - Final Dissertation

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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-moreyears

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

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