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DEVELOPMENT AND VALIDATION OF A PSYCHOLOGICAL SCALE FOR BARIATRIC SURGERY: THE BARITEST

DESENVOLVIMENTO E VALIDAÇÃO DE ESCALA PSICOMÉTRICA PARA OS PACIENTES DE CIRURGIA BARIÁTRICA: O BARITEST

ABSTRACT

BACKGROUND:

It is recommended that bariatric surgery candidates undergo psychological assessment. However, no specific instrument exists to assess the psychological well-being of bariatric patients, before and after surgery, and for which all constructs are valid for both genders.

AIMS:

This study aimed to develop and validate a new psychometric instrument to be used before and after bariatric surgery in order to assess psychological outcomes of patients.

METHODS:

This is a cross-sectional study that composed of 660 individuals from the community and bariatric patients. BariTest was developed on a Likert scale consisting of 59 items, distributed in 6 constructs, which assess the psychological well-being that influences bariatric surgery: emotional state, eating behavior, quality of life, relationship with body weight, alcohol consumption, and social support. Validation of BariTest was developed by the confirmatory factor analysis to check the content, criteria, and construct. The R statistical software version 3.5.0 was used in all analyses, and a significance level of 5% was used.

RESULTS:

Adjusted indices of the confirmatory factor analysis model indicate adequate adjustment. Cronbach’s alpha of BariTest was 0.93, which indicates good internal consistency. The scores of the emotional state, eating behavior, and quality of life constructs were similar between the results obtained in the community and in the postoperative group, being higher than in the preoperative group. Alcohol consumption was similar in the preoperative and postoperative groups and was lower than the community group.

CONCLUSIONS:

BariTest is a reliable scale measuring the psychological well-being of patients either before or after bariatric surgery.

HEADINGS:
Bariatric Surgery; Psychometrics; Psychological Tests; Obesity

RESUMO

RACIONAL:

Recomenda-se que os candidatos à cirurgia bariátrica sejam submetidos a uma avaliação psicológica. Contudo, não existe nenhum instrumento específico para avaliar os pacientes bariátricos, e que todos os construtos sejam válidos para ambos os sexos.

OBJETIVOS:

Desenvolver e validar um novo instrumento psicométrico para avaliar o bem-estar psicológico dos pacientes antes e após a cirurgia bariátrica.

MÉTODOS:

O estudo foi transversal e composto por 660 indivíduos da comunidade e pacientes bariátricos. O BariTest foi desenvolvido numa escala Likert composta por 59 itens, distribuídos em seis construtos, que avaliam o bem-estar psicológico que influenciam a cirurgia bariátrica: estado emocional, comportamento alimentar, qualidade de vida, relação com o peso corporal, consumo de álcool, e suporte social. A validação do BariTest foi feita pela validação de conteúdo, critério e construto e utilizou-se análise fatorial confirmatória. O software estatístico R versão 3.5.0, foi utilizado em todas as análises, com um nível de significância de 5%.

RESULTADOS:

Os índices ajustados do modelo análise fatorial confirmatória indicam um ajustamento adequado. O alfa de Cronbach do BariTest foi 0,93, o que indica uma boa consistência interna. As pontuações de estado emocional, comportamento alimentar e qualidade de vida foram semelhantes na comunidade e no grupo pós-operatório, sendo mais elevados do que no grupo pré-operatório. O consumo de álcool foi semelhante nos grupos pré e pós-operatórios e foi inferior ao do grupo comunitário.

CONCLUSÕES:

O BariTest é uma escala confiável que mede o bem-estar psicológico dos pacientes antes e após a cirurgia bariátrica.

DESCRITORES:
Cirurgia Bariátrica; Psicometria; Testes Psicológicos; Obesidade

INTRODUCTION

Obesity is a chronic disease of multifactorial causes such as genetic, environmental, socioeconomic, endocrine, metabolic, and psychiatric1717 González-Muniesa P, Mártinez-González MA, Hu FB, Després JP, Matsuzawa Y, Loos RJF, et al. Obesity. Nat Rev Dis Primers. 2017;3:17034. https://doi.org/10.1038/nrdp.2017.34
https://doi.org/10.1038/nrdp.2017.34...
. When conventional treatments such as diet, medication, and physical exercise do not show any positive results and that obesity causes harm to the individual, bariatric surgery may be recommended2525 Lin Z, Qu S. Legend of weight loss: a crosstalk between the bariatric surgery and the brain. Obes Surg. 2020;30(5):1988-2002. https://doi.org/10.1007/s11695-020-04474-8
https://doi.org/10.1007/s11695-020-04474...
.

The candidates for bariatric surgery must have a body mass index (BMI) above 35 associated with a comorbidity (e.g., high blood pressure, diabetes, and hepatic steatosis, among others mentioned in Resolution No. 2,131/15 of the Federal Council of Medicine)99 Conselho Federal de Medicina. Resolução nº 2.131, de 12 de novembro de 2015. Altera o anexo da Resolução CFM nº1.942/10. Diário Oficial da União, 2015. Available at: https://www.in.gov.br/web/guest/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/22175085/do1-2016-01-13-resolucao-n-2-131-de-12-de-novembro-de-2015-22174970. Accessed: Jan. 25, 2021.
https://www.in.gov.br/web/guest/materia/...
or a BMI above 40, considered morbidly obese. The American Society for Metabolic and Bariatric Surgery (ASMBS)11 American Educational Research Association, American Psychological Association, National Council on Measurement in Education. Standards for educational and psychological testing. Washington: American Educational Research Association; 2014. recommends that the candidates for bariatric surgery be followed up by a multidisciplinary team. In this team, the psychologist’s objective is to assess the candidate’s mental aptitude in order to understand the surgical procedure and the psychological aspects that can influence the result of the operation3838 Sarwer DB, Allison KC, Wadden TA, Ashare R, Spitzer JC, McCuen-Wurst C, et al. Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery. Surg Obes Relat Dis. 2019;15(4):650-5. https://doi.org/10.1016/j.soard.2019.01.029
https://doi.org/10.1016/j.soard.2019.01....
,4242 Still C, Sarwer DB, Blankenship J. The ASMBS textbook of bariatric surgery: integrated health. New York: Springer Science; 2014. https://doi.org/10.1007/978-1-4939-1197-4
https://doi.org/10.1007/978-1-4939-1197-...
.

Wadden and Sarwer4646 Wadden TA, Sarwer DB. Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach. Obes Res. 2012;14(S53):53-64. https://doi.org/10.1038/oby.2006.283.
https://doi.org/10.1038/oby.2006.283...
suggested that in the psychological evaluation process, 70–90% of patients are unconditionally indicated for surgery, 15–30% are referred for psychological or nutritional treatment as a prerequisite for surgery, and the remaining patients are excluded due to psychiatric reasons such as psychosis, untreated severe depression, mood disorders, eating disorders, substance use disorder, psychosocial problems, or behavioral noncompliance.

Psychological treatment should be started in the preoperative phase because the candidates for bariatric surgery have a higher prevalence of mental disorders than the general population, and psychopathological abnormalities tend to impact both the evolution of obesity and the results of bariatric surgery2929 Mitchell JE, Zawaan M. Psychopathology and bariatric surgery. ASMBS. 2014;2(3):11-17. https://doi.org/10.1007/978-1-4939-1197-4_1
https://doi.org/10.1007/978-1-4939-1197-...
,3939 Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res. 2005;13(4):639-48. https://doi.org/10.1038/oby.2005.71
https://doi.org/10.1038/oby.2005.71...
. Caution is recommended to indicate bariatric surgery in patients with severe psychiatric disorders without treatment. This is suggested when there is an absence of social support in those who, due to emotional instability, may find it difficult to follow and obey postoperative dietary instructions, and in cases of abuse of illicit drugs and/or alcoholism99 Conselho Federal de Medicina. Resolução nº 2.131, de 12 de novembro de 2015. Altera o anexo da Resolução CFM nº1.942/10. Diário Oficial da União, 2015. Available at: https://www.in.gov.br/web/guest/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/22175085/do1-2016-01-13-resolucao-n-2-131-de-12-de-novembro-de-2015-22174970. Accessed: Jan. 25, 2021.
https://www.in.gov.br/web/guest/materia/...
,4141 Sociedade Brasileira de Cirurgia Bariátrica e Metabólica. Obesidade. 2014. Available at: http://www.sbcb.org.br/. Accessed: Feb. 14, 2021.
http://www.sbcb.org.br/...
.

A difficulty that professionals who make psychological assessment for bariatric surgery face is the lack of specific validated instruments for this population2222 Kalil-Filho FA, Pinto JSP, Borsato EP, Kuretzki CH, Ariede BL, Mathias JEF, et al. Multiprofessional electronic protocol for digestive surgery validation. ABCD Arq Bras Cir Dig. 2021;34(2):e1583. https://doi.org/10.1590/0102-672020210002e1583.
https://doi.org/10.1590/0102-67202021000...
. Psychologists vary in their methods of evaluating patients before and after bariatric surgery1010 Conselho Federal de Psicologia do Brasil. Resolução nº 009, de 25 de abril de 2018. Estabelece diretrizes para a realização de Avaliação Psicológica no exercício profissional da psicóloga e do psicólogo, regulamenta o Sistema de Avaliação de Testes Psicológicos – SATEPSI e revoga as Resoluções nº 002/2003, nº 006/2004 e nº 005/2012 e Notas Técnicas nº 01/2017 e 02/2017. Brasília, DF: CFP; 2018. Available at: https://satepsi.cfp.org.br/docs/ResolucaoCFP009-18.pdf. Accessed: Jan. 25, 2021.
https://satepsi.cfp.org.br/docs/Resoluca...
. They usually apply symptom inventories to screen for depression and eating disorders, and some psychopathology, personality, or cognitive function tests4646 Wadden TA, Sarwer DB. Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach. Obes Res. 2012;14(S53):53-64. https://doi.org/10.1038/oby.2006.283.
https://doi.org/10.1038/oby.2006.283...
. The most cited assessment instruments in the literature1616 Flores CA. Avaliação psicológica para cirurgia bariátrica: práticas atuais. Rev ABCD Arq Bras Cir Dig. 2014;27(Supl 1):59-62. https://doi.org/10.1590/S0102-6720201400S100015
https://doi.org/10.1590/S0102-6720201400...
are the Beck Depression Inventory (BDI), the Binge Eating Scale (BES), the Eating Disorder Examination, the Millon Behavioral Medicine Diagnostic (MBMD), and the Minnesota Multiphasic Personality Inventory (MMPI). These instruments were not developed with a focus on the bariatric population and the psychologist should avoid using several instruments because the patient’s tiredness may interfere in the accuracy of the answers2020 Hutz CS, Bandeira DR, Trentini CM. Psicometria. Porto Alegre: Artmed; 2015.. Among the instruments intended for bariatric surgery, there is only one psychological instrument validated for the bariatric population, i.e., the PsyBari, developed by David Mahony, PhD, a clinical psychologist at the Lutheran Medical Center, Brooklyn, New York2727 Mahony D. Psychological assessments of bariatric surgery patients. Development, reliability, and exploratory factor analysis of the PsyBari. Obes Surg. 2011;21(9):1395-406. https://doi.org/10.1007/s11695-010-0108-0
https://doi.org/10.1007/s11695-010-0108-...
. Despite being practical on a Likert scale and intended to assess bariatric patients before bariatric surgery, not all items of the test were valid for both genders. This is an important characteristic as there are two different test formats for each gender and it is questioned whether it is a single instrument or whether there are two distinct instruments, bringing unnecessary complexity. In addition, PsyBari validation was not performed with post-bariatric patients, and it is known that there is a significantly higher prevalence of alcohol consumption after bariatric surgery2323 King WC, Chen JY, Mitchell JE, Kalarchian MA, Steffen KJ, Engel SG, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA;2012;307(23):2516-25. https://doi.org/10.1001/jama.2012.6147
https://doi.org/10.1001/jama.2012.6147...
, and some patients have an aggravation of the psychiatric disorder, which may worsen the patient’s psychological well-being, despite weight loss3838 Sarwer DB, Allison KC, Wadden TA, Ashare R, Spitzer JC, McCuen-Wurst C, et al. Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery. Surg Obes Relat Dis. 2019;15(4):650-5. https://doi.org/10.1016/j.soard.2019.01.029
https://doi.org/10.1016/j.soard.2019.01....
. Furthermore, it is important to continue the psychological follow-up after bariatric surgery because some patients do not have a favorable outcome, which can lead to depression, use of alcoholic beverages, and weight regain88 Cambi MPC, Baretta GAP, Magro DO, Boguszewski CL, Riveiro IB, Jirapinyo P, et al. Multidisciplinary approach for weight regain-how to manage this challenging condition: an expert review. Obes Surg. 2021;31(1):1290-303. https://doi.org/10.1007/s11695-020-05164-1
https://doi.org/10.1007/s11695-020-05164...
,3232 Müller A, Hase C, Pommnitz M, De Zwaan M. Depression and suicide after bariatric surgery. Curr Psychiatry Rep. 2019;21(9):84. https://doi.org/10.1007/s11920-019-1069-1
https://doi.org/10.1007/s11920-019-1069-...
. Between 20 and 30% of patients experience suboptimal weight loss or significant weight regain within the first few postoperative years. The reasons for this involve physiological, behavioral, and psychological characteristics3838 Sarwer DB, Allison KC, Wadden TA, Ashare R, Spitzer JC, McCuen-Wurst C, et al. Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery. Surg Obes Relat Dis. 2019;15(4):650-5. https://doi.org/10.1016/j.soard.2019.01.029
https://doi.org/10.1016/j.soard.2019.01....
.

Nowadays, no psychometric scale has been identified for which all of the instrument assesses both genders, before and after surgery, regardless of the surgical technique, focusing to assess the psychological well-being that can influence the outcome of the operation, such as severe depression, mood disorders, substance use disorder, eating disorders, psychosocial problems, or behavioral noncompliance3838 Sarwer DB, Allison KC, Wadden TA, Ashare R, Spitzer JC, McCuen-Wurst C, et al. Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery. Surg Obes Relat Dis. 2019;15(4):650-5. https://doi.org/10.1016/j.soard.2019.01.029
https://doi.org/10.1016/j.soard.2019.01....
. Considering the six main psychological aspects that can influence the result of the operation3838 Sarwer DB, Allison KC, Wadden TA, Ashare R, Spitzer JC, McCuen-Wurst C, et al. Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery. Surg Obes Relat Dis. 2019;15(4):650-5. https://doi.org/10.1016/j.soard.2019.01.029
https://doi.org/10.1016/j.soard.2019.01....
, BariTest was developed to compare the outcomes of psychological well-being that will emerge from bariatric surgery2020 Hutz CS, Bandeira DR, Trentini CM. Psicometria. Porto Alegre: Artmed; 2015.,3838 Sarwer DB, Allison KC, Wadden TA, Ashare R, Spitzer JC, McCuen-Wurst C, et al. Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery. Surg Obes Relat Dis. 2019;15(4):650-5. https://doi.org/10.1016/j.soard.2019.01.029
https://doi.org/10.1016/j.soard.2019.01....
.

The BariTest is a patient-reported outcome measures (PROM) psychometric scale which assesses the psychological well-being, before and after the bariatric surgery99 Conselho Federal de Medicina. Resolução nº 2.131, de 12 de novembro de 2015. Altera o anexo da Resolução CFM nº1.942/10. Diário Oficial da União, 2015. Available at: https://www.in.gov.br/web/guest/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/22175085/do1-2016-01-13-resolucao-n-2-131-de-12-de-novembro-de-2015-22174970. Accessed: Jan. 25, 2021.
https://www.in.gov.br/web/guest/materia/...
,3838 Sarwer DB, Allison KC, Wadden TA, Ashare R, Spitzer JC, McCuen-Wurst C, et al. Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery. Surg Obes Relat Dis. 2019;15(4):650-5. https://doi.org/10.1016/j.soard.2019.01.029
https://doi.org/10.1016/j.soard.2019.01....
,4242 Still C, Sarwer DB, Blankenship J. The ASMBS textbook of bariatric surgery: integrated health. New York: Springer Science; 2014. https://doi.org/10.1007/978-1-4939-1197-4
https://doi.org/10.1007/978-1-4939-1197-...
, and is composed of six constructs:

  1. emotional state;

  2. eating behavior;

  3. alcohol consumption;

  4. social support;

  5. relationship with body weight;

  6. quality of life

These constructs are represented in 59 items answered by PROM, on a four-point Likert scale: 0= Never, 1= Rarely, 2= Sometimes, 3= Often, 4= Always (Table 1). The preparation and validation of BariTest was carried out through content, construct, and criterion validity, as suggested by Erthal1515 Erthal TC. Manual de psicometria. São Paulo: Zahar; 1987., Hutz2020 Hutz CS, Bandeira DR, Trentini CM. Psicometria. Porto Alegre: Artmed; 2015., Pasquali3535 Pasquali L. Psicometria: teoria dos testes na psicologia e na educação. 5th ed. São Paulo: Vozes; 2013., and American Educational Research Association11 American Educational Research Association, American Psychological Association, National Council on Measurement in Education. Standards for educational and psychological testing. Washington: American Educational Research Association; 2014..

Table 1
BariTest: psychometric scale to bariatric patients.

METHODS

Participants

This is a cross-sectional BariTest validation study, approved by the Research Ethics Committee of the Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil, under number CAAE: 12476019.3.0000.0020. This study involved 660 people. Of these, 598 were awaiting consultation (preoperative or postoperative) at the bariatric surgery. In addition, for validation purposes, BariTest was applied to 48 nonobese subjects in the community, who had not undergone and did not intend to undergo bariatric surgery (Table 2). The instrument was also evaluated by a focus group (validity of content), selected as a convenience sample, composed of 10 bariatric patients who analyzed the semantic understanding of the item. Four patients did not respond to the questionnaire and were excluded from the analysis.

Table 2
Sociodemographic data of the participants in the BariTest validation.

Validation of BariTest

The BariTest validation process was carried out through content, construct, and criterion validity. In addition, the instrument’s reliability was analyzed, and the instrument’s correction and interpretation table was elaborated.

After conducting a literature review and expert discussions, a preliminary version of the BariTest scale was developed. BariTest items were prepared by the authors, based on tests and scales: Bipolar Depression Rating Scale (BDRS), Eating Attitudes Test (EAT-26), Binge Eating Scale (BES), BDI-II, BAI, BIS-11, AUDIT, SF-36, World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), HADS, ETC-R, the Eating Disorder Examination, and the MMPI.

Initially, the instrument had 99 items. Content validity was performed by assessing seven specialists in bariatric surgery or psychology, and all items were evaluated (Appendix 1). The anonymity of the evaluators was maintained, and each committee member individually determined their agreement on whether each item should remain in BariTest, using a four-point Likert scale: 0= Very Bad, 1= Bad, 2= More or less, 3= Good, 4= Great. At the end of this assessment, the experts carried out a qualitative analysis and offered suggestions for improvements. Items that had a mean of less than 3.5, or that were considered irrelevant to the objective by at least two members of the expert committee, were removed from the instrument (Appendix 3). Thus after this analysis, 40 items were excluded and BariTest completed with 59 items (Table 1). Also a focal group analyzed the understanding of each item, and no items were excluded by this group.

The validity of construct was performed by confirmatory factor analysis (CFA) (Appendix 2). The fitted CFA model was evaluated through the indices66 Brown TA. Confirmatory factor analysis for applied research. New York: Guilford publications; 2015.,77 Byrne BM. Structural equation modeling with AMOS: basic concepts, applications, and programming. New York: Routledge; 2001. https://doi.org/10.4324/9780203805534
https://doi.org/10.4324/9780203805534...
,1818 Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. SEM. 1999;6(1):1-55. https://doi.org/10.1080/10705519909540118
https://doi.org/10.1080/1070551990954011...
,4343 Tucker LR, Lewis C. A reliability coefficient for maximum likelihood factor analysis. Psychometrika.1973;38:1-10. https://doi.org/10.1007/BF02291170
https://doi.org/10.1007/BF02291170...
,4747 Xia Y, Yang Y. RMSEA, CFI, and TLI in structural equation modeling with ordered categorical data: the story they tell depends on the estimation methods. Behav Res Methods. 2019;51(1):409-28. https://doi.org/10.3758/s13428-018-1055-2
https://doi.org/10.3758/s13428-018-1055-...
such as standardized root mean squared residual (SRMR), root mean of the squares of the errors of approximation (RMSEA), comparative fit index (CFI), and Tucker-Lewis index (TLI).

The validity of criterion was performed to ascertain the accuracy of the instrument, by means of stability in equivalent forms of different tests4444 Urbina S. Fundamentos da testagem psicológica. Porto Alegre: Artmed; 2007.. To determine responsiveness, an analysis of the receiving operating characteristic (ROC) curve was performed, verifying accuracy through sensitivity and specificity (Figure 2). At the time of applying BariTest, 175 patients also received two other questionnaires: the WHODAS 2.0 (Annex 1 Annex 1 Complementary Scales: WHODAS 2.0 – 36 items WHODAS 2.0 WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0 36-item version, self-administered This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please circle only one response. In the past 30 days, how much difficulty did you have in: Understanding and communicating D1.1 Concentrating on doing something for ten minutes? None Mild Moderate Severe Extreme or cannot do D1.2 Remembering to do important things? None Mild Moderate Severe Extreme or cannot do D1.3 Analyzing and finding solutions to problems in day-to-day life? None Mild Moderate Severe Extreme or cannot do D1.4 Learning a new task, for example, learning how to get to a new place? None Mild Moderate Severe Extreme or cannot do D1.5 Generally understanding what people say? None Mild Moderate Severe Extreme or cannot do D1.6 Starting and maintaining a conversation? None Mild Moderate Severe Extreme or cannot do Getting around D2.1 Standing for long periods such as 30 min? None Mild Moderate Severe Extreme or cannot do D2.2 Standing up from sitting down? None Mild Moderate Severe Extreme or cannot do D2.3 Moving around inside your home? None Mild Moderate Severe Extreme or cannot do D2.4 Getting out of your home? None Mild Moderate Severe Extreme or cannot do D2.5 Walking a long distance such as a kilometer [or equivalent]? None Mild Moderate Severe Extreme or cannot do In the past 30 days, how much difficulty did you have in: Self-care D3.1 Washing your whole body? None Mild Moderate Severe Extreme or cannot do D3.2 Getting dressed? None Mild Moderate Severe Extreme or cannot do D3.3 Eating? None Mild Moderate Severe Extreme or cannot do D3.4 Staying by yourself for a few days? None Mild Moderate Severe Extreme or cannot do Getting along with people D4.1 Dealing with people you do not know? None Mild Moderate Severe Extreme or cannot do D4.2 Maintaining a friendship? None Mild Moderate Severe Extreme or cannot do D4.3 Getting along with people who are close to you? None Mild Moderate Severe Extreme or cannot do D4.4 Making new friends? None Mild Moderate Severe Extreme or cannot do D4.5 Sexual activities? None Mild Moderate Severe Extreme or cannot do Life activities D5.1 Taking care of your household responsibilities? None Mild Moderate Severe Extreme or cannot do D5.2 Doing most important household tasks well? None Mild Moderate Severe Extreme or cannot do D5.3 Getting all the household work done that you needed to do? None Mild Moderate Severe Extreme or cannot do D5.4 Getting your household work done as quickly as needed? None Mild Moderate Severe Extreme or cannot do If you work (paid, non-paid, self-employed) or go to school, complete questions D5.5–D5.8, below. Otherwise, skip to D6.1. Because of your health condition, in the past 30 days, how much difficulty did you have in: D5.5 Your day-to-day work/school? None Mild Moderate Severe Extreme or cannot do D5.6 Doing your most important work/school tasks well? None Mild Moderate Severe Extreme or cannot do D5.7 Getting all the work done that you need to do? None Mild Moderate Severe Extreme or cannot do D5.8 Getting your work done as quickly as needed? None Mild Moderate Severe Extreme or cannot do Participation in society In the past 30 days: D6.1 How much of a problem did you have in joining in community activities (e.g., festivities, religious, or other activities) in the same way as anyone else can? None Mild Moderate Severe Extreme or cannot do D6.2 How much of a problem did you have because of barriers or hindrances in the world around you? None Mild Moderate Severe Extreme or cannot do D6.3 How much of a problem did you have living with dignity because of the attitudes and actions of others? None Mild Moderate Severe Extreme or cannot do D6.4 How much time did you spend on your health condition, or its consequences? None Mild Moderate Severe Extreme or cannot do D6.5 How much have you been emotionally affected by your health condition? None Mild Moderate Severe Extreme or cannot do D6.6 How much has your health been a drain on the financial resources of you or your family? None Mild Moderate Severe Extreme or cannot do D6.7 How much of a problem did your family have because of your health problems? None Mild Moderate Severe Extreme or cannot do D6.8 How much of a problem did you have in doing things by yourself for relaxation or pleasure? None Mild Moderate Severe Extreme or cannot do H1 Overall, in the past 30 days, how many days were these difficulties present? Record number of days ______ H2 In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition? Record number of days ______ H3 In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition? Record number of days ______ This completes the questionnaire. Thank you. Annex 2 Complementary Scales: Brazilian version of the Obesity-related Problems Scale (OP) How do you feel about your weight or your body shape in the following situations? OP1. Receiving friends at home OP2. Visiting the home of relatives or friends OP3. Going to restaurants OP4. Doing activities in the community (courses etc.) OP5. Holidaying away from home OP6. Trying on and buying clothes OP7. Bathing in public places (beach, pool etc.) OP8. Intimate relationships (kiss, sex, etc.) OP items are represented by the acronym “OP” followed by their ordering number. All of them must be answered on a Likert scale as follows: “It bothers me a lot.” “It bothers me more or less.” “It bothers me a little.” “It doesn’t bother me.” Appendix 1 Evaluation of the version of BARITEST by the Committee of Experts. Items Agreement index 1. When I’m eating, I feel like I’m losing control and I end up eating too much. 3.6 2. I think about food most of the day. 3.6 3. I eat sparingly in front of others, but then I make up for it when I’m alone. 4 4. I have a habit of eating when distracted by the TV, cell phone, computer. 3.6 5. I eat small amounts of food for several hours in a row (Pinch Habit). 3.7 6. When I feel sad or anxious or idle I have a habit of compensating with food and overeating. 3.7 7. I chew my food well and eat my meals calmly. 3.6 8. I eat few times a day, but when I eat, I overdo it. 3.6 9. I have difficulty in distinguishing between hunger and the desire to eat. 3.9 10. I have crises of eating a lot until I am full. 3.1 11. I have a habit of eating “fast food” (Snacks). 3.8 12. I am a candy eater. 3.5 13. When I feel the urge to eat, it is difficult to control myself. 3.9 14. I intend to eat just a little, but when I see it, I eat a lot more than I want to. 3.4 15. I notice that I eat more at night. 3.9 16. I wake up in the early hours to eat something. 3 17. When I go on a diet, I manage to stop eating some foods that I love, without any problem. 3.3 18. My behavior towards food causes me a lot of suffering. 3.9 19. When I have emotional problems, I use food to relieve tension or to bring me joy. 3.9 20. When I feel like eating a treat, I eat without delaying and/or depriving myself. 3.7 21. I have difficulty leaving food on the plate at the end of a meal. 3.9 22. The next morning, after drinking, I wake up with a hangover (If you don’t drink, mark 0). 3.6 23. I drink alcohol on weekends. 3.1 24. I drink alcohol during the week. 3.4 25. People tell me that I am drinking too much. (If you don’t drink, mark “never”). 3.5 26. I am in the habit of using alcohol to relax and be happy. (If you don’t drink, mark “never”). 3.9 27. After drinking alcohol, I missed or was late for an appointment the next day. (If you don’t drink, mark “never”). 3.6 28. I don’t like going to social events that don’t have alcohol. 3.9 29. I perform leisure activities. 3.7 30. I stop going to social settings (parties, meetings,.) due to my physical appearance or health limitations. 3.9 31. I believe I have problems with my work because of my weight. 3.6 32. I feel pain in my body. 3.6 33. I am satisfied with myself. 3.4 34. I feel happy. 3 35. I like the way I relate to people. 3.6 36. I am satisfied with my sex life. 3.5 37. I am satisfied with the support I receive from my friends/family. 3.6 38. I have negative feelings, such as: bad mood, despair, anxiety and/or depression. 3 39. I feel ashamed because of my weight. 3.5 40. I have quality sleep. 3.9 41. The physical environment (home or work) that I frequent is stressful (pollution, noise, traffic, arguing). 3.4 42. Religion is part of my life and/or I have a higher belief. 2.3 43. I find it difficult to perform my personal hygiene because of my weight. 3.5 44. I avoid places until I know if there will be a place where I can sit. 3.5 45. I believe I have quality of life. 3.9 46. I perform physical activity. 3.7 47. I find myself sulking and irritated for no reason. 3.5 48. There are times when I sleep a lot and times when I sleep little. 3 49. I believe I talk too much. 3.1 50. There are days when I wake up extremely excited and on others I barely feel like getting out of bed. 3.7 51. I feel very sad and/or unhappy. 3 52. I believe that there is nothing to achieve in my future. 3.1 53. I feel discouraged and hopeless. 3.5 54. I believe that I am a disappointment to my family and/or friends. 3.6 55. There are times when I feel like dying. 3.6 56. I think about ending my life. 3.3 57. There are times when I cry a lot. 3.6 58. I have or have had some type of auditory hallucination (heard voices). 2.7 59. I find myself much more interested in sex than usual. 3.1 60. There are phases that I work too much and produce a lot, and in other phases I don’t feel like working, and my work doesn’t produce. 3.5 61. I find that I get distracted or lose focus on what I’m doing very easily. 3.4 62. I feel that there are people following me and/or watching me. 3.1 63. I talk too much or speak much faster than normal. 3.5 64. Standing still causes me anxiety. 3.1 65. I have a feeling of regret for the things I do/say. 3.5 66. I feel so nervous that I have shortness of breath. 3.3 67. I have a tremor in my hands. 2.9 68. I feel more nervous than other people, with some everyday situations. 3.1 69. People say that I am anxious. 3.9 70. I find it difficult to fall asleep because I feel very agitated and/or with rapid thoughts at night. 3.6 71. I have bouts of tachycardia, despair and the feeling that I am going to die. 3.6 72. I believe that I do things impulsively. 3.9 73. I do and/or say things without thinking. 3.5 74. I can focus on just one thing for a long time. 3 75. I buy things on impulse, without really needing them. 3.4 76. There are situations where I think I’m going to lose control and go after someone. 3.4 77. I consider myself an optimistic person and I have positive thoughts. 3.8 78. I have self-control. 2.7 79. My family/friends are offended if I refuse any food. 3.6 80. My family/friends insist that I eat more. 3.5 81. In my family, people are in the habit of eating (includes meals, snacks and sweets) in front of the TV. 3.6 82. I have family/friends support to facilitate my health care (e.g., taking care of children when I have an appointment, taking care of the house when I need help). 4 83. My family has a healthy lifestyle (food and physical activity). 3.7 84. I feel supported and valued as a person. 3.9 85. I have people I can talk to or talk about issues related to my health, obesity and/or weight loss. 4 86. My family members acquired a healthier lifestyle to help me with the weight loss process. 3.5 87. I believe that the people who live with me would love me more if I were not obese. 3.5 88. I believe I have people with whom I can vent or talk about issues related to my health, obesity and/or weight loss. 3.7 89. I usually wait for things to work out over time. 2.9 90. I panic when difficulties arise. 2.9 91. To deal with difficulties, I make an action plan and try to apply it. 3.1 92. I know what I have to do and I redouble my efforts to achieve it. 3.4 93. I try to see the positive and/or make the best of situations. 3.2 94. When I have problems/difficulties, I face the situation. 3.3 95. I forget about my problems by denying and/or taking medication. 3.4 96. When I have a problem, I feel guilty. 2.9 97. When I have a problem, I distance myself from others. 3.2 98. When I have a problem, I don’t do anything, because I think I won’t be able to solve it. 3.1 99. I feel angry at the people who caused me a problem. 3.4 Version of BariTest with 99 items, assessed qualitatively and quantitatively (five-point Likert scale: 0= Very bad, 1= Bad, 2= More or less, 3= Good, 4= Great), by the expert committee. The questions that had an average below 3.5 or a critic in the qualitative analysis were removed from the instrument. Appendix 2 Confirmatory factor analysis of BariTest. Dimension Item Factorial loading Standard error Construct coefficient BariTest general coefficient Emotional state 1 10.000 0.0000 17.652 0.3273 2 0.9204 0.0285 16.248 0.3013 3 10.015 0.0298 17.678 0.3278 4 10.849 0.0311 19.152 0.3551 5 10.709 0.0309 18.904 0.3505 6 0.9410 0.0288 16.611 0.3080 7 0.8879 0.0280 15.674 0.2906 8 0.8556 0.0275 15.103 0.2800 9 0.8764 0.0278 15.471 0.2869 10 11.378 0.0320 20.085 0.3724 11 0.8203 0.0270 14.480 0.2685 12 10.167 0.0300 17.947 0.3328 13 10.668 0.0308 18.831 0.3492 14 0.9734 0.0293 17.182 0.3186 15 0.5087 0.0231 0.8980 0.1665 Eating behavior 16 10.000 0.0000 19.187 0.3638 17 10.166 0.0253 19.505 0.3698 18 0.9094 0.0238 17.449 0.3308 19 0.8733 0.0233 16.757 0.3177 20 10.719 0.0261 20.567 0.3899 21 0.7578 0.0219 14.539 0.2756 22 0.6526 0.0206 12.521 0.2374 23 0.8907 0.0236 17.089 0.3240 24 0.6337 0.0204 12.159 0.2305 25 0.9807 0.0248 18.816 0.3567 26 0.6276 0.0204 12.043 0.2283 27 0.7742 0.0221 14.855 0.2816 28 0.8943 0.0236 17.158 0.3253 29 0.5849 0.0199 11.222 0.2127 30 0.5985 0.0201 11.483 0.2177 31 0.7635 0.0219 14.649 0.2777 Quality of life 32* 10.000 0.0000 35.401 0.5531 33* 0.9617 0.0346 34.046 0.5320 34* 10.095 0.0355 35.738 0.5584 35* 0.8073 0.0317 28.578 0.4465 36* 0.6471 0.0290 22.909 0.3579 37* 0.4676 0.0266 16.555 0.2587 38 0.6006 0.0283 21.261 0.3322 39* 0.9824 0.0350 34.779 0.5434 40* 0.5856 0.0281 20.731 0.3239 Relationship with body weight 41 10.000 0.0000 44.830 0.7285 42 10.660 0.0336 47.791 0.7766 43 0.8484 0.0298 38.032 0.6180 44 10.146 0.0327 45.486 0.7391 45 0.7663 0.0285 34.352 0.5582 46 0.8813 0.0303 39.508 0.6420 Alcohol consumption 47 10.000 0.0000 52.100 0.9226 48 0.9320 0.0465 48.556 0.8599 49 11.566 0.0548 60.259 10.671 50 0.9126 0.0459 47.546 0.8420 51 0.7973 0.0422 41.539 0.7356 52 10.000 0.0000 28.210 0.3644 Social support 53 11.017 0.0737 31.079 0.4014 54 0.5297 0.0551 14.944 0.1930 55* 12.046 0.0778 33.981 0.4389 56* 10.015 0.0699 28.253 0.3649 57* 0.9904 0.0695 27.938 0.3609 58* 12.749 0.0806 35.966 0.4646 59* 17.592 0.1017 49.628 0.6410 This table contains the confirmatory factor analysis with the factorial loading and standard error of each item of BariTest. * Items 32, 33, 34, 35, 36, 37, 39, 40, 55, 56, 57, 58, and 59 had the score reversed so that all domains point in the same direction of assessing psychological well-being. Calculation for correction of BariTest obtained through confirmatory factor analysis. Appendix 3 Reference levels for interpreting the BariTest result. Percentile Group Postop: 18–30 Postop: 31–45 Postop: 46+ Preop: F:18–30 Preop: F:31–45 Preop: F:46+ Preop: M:18–30 Preop: M:31–45 Preop: M:46+ 2.5 6.087 5.462 0.580 20.054 17.081 11.480 18.479 14.233 8.013 5 9.728 8.533 4.024 23.199 20.302 14.861 21.158 17.426 11.371 10 13.926 12.074 7.994 26.825 24.016 18.759 24.247 21.107 15.242 15 16.759 14.463 10.673 29.272 26.521 21.389 26.331 23.591 17.854 20 19.010 16.362 12.802 31.217 28.513 23.479 27.988 25.565 19.929 25 20.941 17.991 14.629 32.885 30.221 25.272 29.409 27.259 21.710 30 22.675 19.453 16.269 34.383 31.756 26.882 30.685 28.780 23.309 35 24.282 20.809 17.789 35.771 33.177 28.374 31.868 30.189 24.791 40 25.807 22.095 19.232 37.088 34.526 29.790 32.990 31.526 26.198 45 27.283 23.340 20.627 38.363 35.832 31.160 34.076 32.820 27.558 50 28.735 24.565 22.000 39.617 37.116 32.509 35.144 34.093 28.897 55 30.187 25.789 23.374 40.871 38.401 33.857 36.212 35.367 30.236 60 31.662 27.034 24.769 42.146 39.706 35.227 37.298 36.660 31.597 65 33.187 28.320 26.212 43.463 41.055 36.643 38.420 37.998 33.003 70 34.794 29.676 27.732 44.851 42.477 38.135 39.603 39.407 34.485 75 36.529 31.139 29.372 46.350 44.011 39.745 40.879 40.928 36.084 80 38.460 32.768 31.199 48.018 45.719 41.538 42.300 42.621 37.865 85 40.711 34.666 33.328 49.962 47.711 43.628 43.956 44.595 39.941 90 43.543 37.055 36.007 52.409 50.216 46.258 46.041 47.079 42.552 95 47.741 40.596 39.977 56.035 53.930 50.156 49.130 50.760 46.423 97.5 51.382 43.668 43.421 59.180 57.151 53.537 51.809 53.953 49.781 Preop.: preoperative; Postop.: postoperative; M: Male; F: Female. ), which is a self-administered questionnaire that measures functionality and disability related to any disease or health status, avoiding the researcher’s bias, and the Obesity — related Problems Scale (OP) (Annex 2), which is a scale of outcomes reported by patients that measures the impact of excess weight on psychosocial functioning. These instruments were chosen because they have been validated44 Brasil AMB, Brasil F, Maurício AA, Vilela RM. Adaptação transcultural e validação para o Brasil da Obesity-related Problems Scale. Einstein. 2017, 15(3):327-33. https://doi.org/10.1590/S1679-45082017AO4004
https://doi.org/10.1590/S1679-45082017AO...
,55 Brasil F, Brasil AMB, Correr CJ. Validation of the Brazilian version of WHODAS 2.0 in patients with mental disorders: should the 12-Item Scale be an Alternative to 36-Item Scale in DSM-5? Neuropsychiatry (London). 2018;8(2):719-26. https://doi.org/10.4172/Neuropsychiatry.1000397
https://doi.org/10.4172/Neuropsychiatry....
for the Brazilian population with obesity to measure psychological well-being.

Reliability

Reliability was calculated using the instrument’s internal consistency. Cronbach’s alpha33 Bland JM, Altman DG. Statistics notes: cronbach’s alpha. BMJ.1997;314(7080):572-88. https://doi.org/10.1136/bmj.314.7080.572
https://doi.org/10.1136/bmj.314.7080.572...
was calculated for the six dimensions of BariTest, assessed in four situations, i.e., considering the entire sample, only patients in the preoperative period, only in the postoperative period, and separating by gender (Table 3).

Table 3
Reliability of BariTest’s items, considering the entire bariatric sample and separating by gender.

Standardization of BariTest

To correct BariTest, it was necessary to multiply the response of each item by its respective general BariTest coefficient (Appendix 2) and calculate the average. The factorial loads were previously staggered so that each patient achieved a minimum of zero and a maximum of 100 points. It is important to note that some items had the score reversed; thus, items 32, 33, 34, 35, 36, 37, 39, 40, 55, 56, 57, 58, and 59 had the inverted correction, whereby 4=0, 3=1, 2=2, 1=3, and 0=4.

To interpret the score obtained, it was necessary to use the reference levels table (Appendix 3), calculated through the standard score (percentile). The characteristics of the patient were considered when they answered the BariTest (preoperative or postoperative phase, age, and gender) to check the percentile corresponding to that score. The purpose of this subdivision was to compare the score obtained with that of another similar subject3535 Pasquali L. Psicometria: teoria dos testes na psicologia e na educação. 5th ed. São Paulo: Vozes; 2013.. The higher the score, the more the unwanted behaviors related to the construct.

Data Analysis

The results were expressed as mean and standard deviation when the scores were normally distributed. Differences between groups were assessed using the t- or F-test when the normality assumption holds, and the Mann-Whitney or Kruskal-Wallis test, otherwise. CFA was performed based on polychoric correlations, since they are indicated1212 Drasgow F. Polychoric and polyserial correlations. In: Kotz S, Balakrishnan N, Read CB, Vidakovic B, editors. Encyclopedia of statistical sciences. New York: John Wiley; 1986. p. 68-74. instead of the usual Pearson linear correlations when data are expressed on an ordinal scale (Likert). In addition, data imputation based on proportional chance regression models was used to fill the missing values. Patients who did not respond to most questions were excluded from the analysis. All conclusions were based on a significance level of 5%. The statistical software R3636 R Core Team (2020). R: a language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2018. version 3.5.0 was used in all analyses. The Psych library3737 Revelle WR. Psych: procedures for personality and psychological research. Evanston: Northwestern University; 2019. Available at: https://cran.R-project.org/package=psychVersion=1.9.12.19.
https://cran.R-project.org/package=psych...
was used to obtain the Cronbach’s alpha, while the Lavaan library4848 Yves R. Lavaan: an R package for structural equation modeling. J Stat Software. 2012;48(2):1-36. https://doi.org/10.18637/jss.v048.i02.
https://doi.org/10.18637/jss.v048.i02...
was used for the CFA.

RESULTS

BariTest

The BariTest psychometric scale was elaborated (Table 1).

Sociodemographic data

This is a cross-sectional study; therefore, the three groups are composed of different people (Table 2).

Validity of BariTest

For validation of BariTest, CFA (Appendix 2) was performed. The correlation between the items that make up each domain is shown in Figure 1. The factor loadings show how much the item is representative of construct. The more intense color tone shows a strong correlation; in contrast, the lower correlation level shows a weaker tone. The purple color represents a positive correlation, i.e., the answers point in the same direction, and the red represents a negative correlation, in which the answers point to the opposite of what that domain intends to prove. The variation ranges from 1 to −1, and the closer to 1 (purple color) means greater correlation between items. Therefore, the six BariTest factors show for the most part, strong and positive correlation.

Figure 1
Correlations of the BariTest instrument items in their respective constructs.

The results of quality of the fit model are as follows: RMSEA of 0.064 (0.062; 0.066) and SRMR of 0.073 indicate an adequate fit, while the CFI of 0.926 and TLI of 0.923 indicate an acceptable fit4747 Xia Y, Yang Y. RMSEA, CFI, and TLI in structural equation modeling with ordered categorical data: the story they tell depends on the estimation methods. Behav Res Methods. 2019;51(1):409-28. https://doi.org/10.3758/s13428-018-1055-2
https://doi.org/10.3758/s13428-018-1055-...
.

BariTest’s responsivity (accuracy) was verified in a comparative manner with the WHODAS 2.0 and OP scores (Annexes 1 Annex 1 Complementary Scales: WHODAS 2.0 – 36 items WHODAS 2.0 WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0 36-item version, self-administered This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please circle only one response. In the past 30 days, how much difficulty did you have in: Understanding and communicating D1.1 Concentrating on doing something for ten minutes? None Mild Moderate Severe Extreme or cannot do D1.2 Remembering to do important things? None Mild Moderate Severe Extreme or cannot do D1.3 Analyzing and finding solutions to problems in day-to-day life? None Mild Moderate Severe Extreme or cannot do D1.4 Learning a new task, for example, learning how to get to a new place? None Mild Moderate Severe Extreme or cannot do D1.5 Generally understanding what people say? None Mild Moderate Severe Extreme or cannot do D1.6 Starting and maintaining a conversation? None Mild Moderate Severe Extreme or cannot do Getting around D2.1 Standing for long periods such as 30 min? None Mild Moderate Severe Extreme or cannot do D2.2 Standing up from sitting down? None Mild Moderate Severe Extreme or cannot do D2.3 Moving around inside your home? None Mild Moderate Severe Extreme or cannot do D2.4 Getting out of your home? None Mild Moderate Severe Extreme or cannot do D2.5 Walking a long distance such as a kilometer [or equivalent]? None Mild Moderate Severe Extreme or cannot do In the past 30 days, how much difficulty did you have in: Self-care D3.1 Washing your whole body? None Mild Moderate Severe Extreme or cannot do D3.2 Getting dressed? None Mild Moderate Severe Extreme or cannot do D3.3 Eating? None Mild Moderate Severe Extreme or cannot do D3.4 Staying by yourself for a few days? None Mild Moderate Severe Extreme or cannot do Getting along with people D4.1 Dealing with people you do not know? None Mild Moderate Severe Extreme or cannot do D4.2 Maintaining a friendship? None Mild Moderate Severe Extreme or cannot do D4.3 Getting along with people who are close to you? None Mild Moderate Severe Extreme or cannot do D4.4 Making new friends? None Mild Moderate Severe Extreme or cannot do D4.5 Sexual activities? None Mild Moderate Severe Extreme or cannot do Life activities D5.1 Taking care of your household responsibilities? None Mild Moderate Severe Extreme or cannot do D5.2 Doing most important household tasks well? None Mild Moderate Severe Extreme or cannot do D5.3 Getting all the household work done that you needed to do? None Mild Moderate Severe Extreme or cannot do D5.4 Getting your household work done as quickly as needed? None Mild Moderate Severe Extreme or cannot do If you work (paid, non-paid, self-employed) or go to school, complete questions D5.5–D5.8, below. Otherwise, skip to D6.1. Because of your health condition, in the past 30 days, how much difficulty did you have in: D5.5 Your day-to-day work/school? None Mild Moderate Severe Extreme or cannot do D5.6 Doing your most important work/school tasks well? None Mild Moderate Severe Extreme or cannot do D5.7 Getting all the work done that you need to do? None Mild Moderate Severe Extreme or cannot do D5.8 Getting your work done as quickly as needed? None Mild Moderate Severe Extreme or cannot do Participation in society In the past 30 days: D6.1 How much of a problem did you have in joining in community activities (e.g., festivities, religious, or other activities) in the same way as anyone else can? None Mild Moderate Severe Extreme or cannot do D6.2 How much of a problem did you have because of barriers or hindrances in the world around you? None Mild Moderate Severe Extreme or cannot do D6.3 How much of a problem did you have living with dignity because of the attitudes and actions of others? None Mild Moderate Severe Extreme or cannot do D6.4 How much time did you spend on your health condition, or its consequences? None Mild Moderate Severe Extreme or cannot do D6.5 How much have you been emotionally affected by your health condition? None Mild Moderate Severe Extreme or cannot do D6.6 How much has your health been a drain on the financial resources of you or your family? None Mild Moderate Severe Extreme or cannot do D6.7 How much of a problem did your family have because of your health problems? None Mild Moderate Severe Extreme or cannot do D6.8 How much of a problem did you have in doing things by yourself for relaxation or pleasure? None Mild Moderate Severe Extreme or cannot do H1 Overall, in the past 30 days, how many days were these difficulties present? Record number of days ______ H2 In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition? Record number of days ______ H3 In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition? Record number of days ______ This completes the questionnaire. Thank you. Annex 2 Complementary Scales: Brazilian version of the Obesity-related Problems Scale (OP) How do you feel about your weight or your body shape in the following situations? OP1. Receiving friends at home OP2. Visiting the home of relatives or friends OP3. Going to restaurants OP4. Doing activities in the community (courses etc.) OP5. Holidaying away from home OP6. Trying on and buying clothes OP7. Bathing in public places (beach, pool etc.) OP8. Intimate relationships (kiss, sex, etc.) OP items are represented by the acronym “OP” followed by their ordering number. All of them must be answered on a Likert scale as follows: “It bothers me a lot.” “It bothers me more or less.” “It bothers me a little.” “It doesn’t bother me.” Appendix 1 Evaluation of the version of BARITEST by the Committee of Experts. Items Agreement index 1. When I’m eating, I feel like I’m losing control and I end up eating too much. 3.6 2. I think about food most of the day. 3.6 3. I eat sparingly in front of others, but then I make up for it when I’m alone. 4 4. I have a habit of eating when distracted by the TV, cell phone, computer. 3.6 5. I eat small amounts of food for several hours in a row (Pinch Habit). 3.7 6. When I feel sad or anxious or idle I have a habit of compensating with food and overeating. 3.7 7. I chew my food well and eat my meals calmly. 3.6 8. I eat few times a day, but when I eat, I overdo it. 3.6 9. I have difficulty in distinguishing between hunger and the desire to eat. 3.9 10. I have crises of eating a lot until I am full. 3.1 11. I have a habit of eating “fast food” (Snacks). 3.8 12. I am a candy eater. 3.5 13. When I feel the urge to eat, it is difficult to control myself. 3.9 14. I intend to eat just a little, but when I see it, I eat a lot more than I want to. 3.4 15. I notice that I eat more at night. 3.9 16. I wake up in the early hours to eat something. 3 17. When I go on a diet, I manage to stop eating some foods that I love, without any problem. 3.3 18. My behavior towards food causes me a lot of suffering. 3.9 19. When I have emotional problems, I use food to relieve tension or to bring me joy. 3.9 20. When I feel like eating a treat, I eat without delaying and/or depriving myself. 3.7 21. I have difficulty leaving food on the plate at the end of a meal. 3.9 22. The next morning, after drinking, I wake up with a hangover (If you don’t drink, mark 0). 3.6 23. I drink alcohol on weekends. 3.1 24. I drink alcohol during the week. 3.4 25. People tell me that I am drinking too much. (If you don’t drink, mark “never”). 3.5 26. I am in the habit of using alcohol to relax and be happy. (If you don’t drink, mark “never”). 3.9 27. After drinking alcohol, I missed or was late for an appointment the next day. (If you don’t drink, mark “never”). 3.6 28. I don’t like going to social events that don’t have alcohol. 3.9 29. I perform leisure activities. 3.7 30. I stop going to social settings (parties, meetings,.) due to my physical appearance or health limitations. 3.9 31. I believe I have problems with my work because of my weight. 3.6 32. I feel pain in my body. 3.6 33. I am satisfied with myself. 3.4 34. I feel happy. 3 35. I like the way I relate to people. 3.6 36. I am satisfied with my sex life. 3.5 37. I am satisfied with the support I receive from my friends/family. 3.6 38. I have negative feelings, such as: bad mood, despair, anxiety and/or depression. 3 39. I feel ashamed because of my weight. 3.5 40. I have quality sleep. 3.9 41. The physical environment (home or work) that I frequent is stressful (pollution, noise, traffic, arguing). 3.4 42. Religion is part of my life and/or I have a higher belief. 2.3 43. I find it difficult to perform my personal hygiene because of my weight. 3.5 44. I avoid places until I know if there will be a place where I can sit. 3.5 45. I believe I have quality of life. 3.9 46. I perform physical activity. 3.7 47. I find myself sulking and irritated for no reason. 3.5 48. There are times when I sleep a lot and times when I sleep little. 3 49. I believe I talk too much. 3.1 50. There are days when I wake up extremely excited and on others I barely feel like getting out of bed. 3.7 51. I feel very sad and/or unhappy. 3 52. I believe that there is nothing to achieve in my future. 3.1 53. I feel discouraged and hopeless. 3.5 54. I believe that I am a disappointment to my family and/or friends. 3.6 55. There are times when I feel like dying. 3.6 56. I think about ending my life. 3.3 57. There are times when I cry a lot. 3.6 58. I have or have had some type of auditory hallucination (heard voices). 2.7 59. I find myself much more interested in sex than usual. 3.1 60. There are phases that I work too much and produce a lot, and in other phases I don’t feel like working, and my work doesn’t produce. 3.5 61. I find that I get distracted or lose focus on what I’m doing very easily. 3.4 62. I feel that there are people following me and/or watching me. 3.1 63. I talk too much or speak much faster than normal. 3.5 64. Standing still causes me anxiety. 3.1 65. I have a feeling of regret for the things I do/say. 3.5 66. I feel so nervous that I have shortness of breath. 3.3 67. I have a tremor in my hands. 2.9 68. I feel more nervous than other people, with some everyday situations. 3.1 69. People say that I am anxious. 3.9 70. I find it difficult to fall asleep because I feel very agitated and/or with rapid thoughts at night. 3.6 71. I have bouts of tachycardia, despair and the feeling that I am going to die. 3.6 72. I believe that I do things impulsively. 3.9 73. I do and/or say things without thinking. 3.5 74. I can focus on just one thing for a long time. 3 75. I buy things on impulse, without really needing them. 3.4 76. There are situations where I think I’m going to lose control and go after someone. 3.4 77. I consider myself an optimistic person and I have positive thoughts. 3.8 78. I have self-control. 2.7 79. My family/friends are offended if I refuse any food. 3.6 80. My family/friends insist that I eat more. 3.5 81. In my family, people are in the habit of eating (includes meals, snacks and sweets) in front of the TV. 3.6 82. I have family/friends support to facilitate my health care (e.g., taking care of children when I have an appointment, taking care of the house when I need help). 4 83. My family has a healthy lifestyle (food and physical activity). 3.7 84. I feel supported and valued as a person. 3.9 85. I have people I can talk to or talk about issues related to my health, obesity and/or weight loss. 4 86. My family members acquired a healthier lifestyle to help me with the weight loss process. 3.5 87. I believe that the people who live with me would love me more if I were not obese. 3.5 88. I believe I have people with whom I can vent or talk about issues related to my health, obesity and/or weight loss. 3.7 89. I usually wait for things to work out over time. 2.9 90. I panic when difficulties arise. 2.9 91. To deal with difficulties, I make an action plan and try to apply it. 3.1 92. I know what I have to do and I redouble my efforts to achieve it. 3.4 93. I try to see the positive and/or make the best of situations. 3.2 94. When I have problems/difficulties, I face the situation. 3.3 95. I forget about my problems by denying and/or taking medication. 3.4 96. When I have a problem, I feel guilty. 2.9 97. When I have a problem, I distance myself from others. 3.2 98. When I have a problem, I don’t do anything, because I think I won’t be able to solve it. 3.1 99. I feel angry at the people who caused me a problem. 3.4 Version of BariTest with 99 items, assessed qualitatively and quantitatively (five-point Likert scale: 0= Very bad, 1= Bad, 2= More or less, 3= Good, 4= Great), by the expert committee. The questions that had an average below 3.5 or a critic in the qualitative analysis were removed from the instrument. Appendix 2 Confirmatory factor analysis of BariTest. Dimension Item Factorial loading Standard error Construct coefficient BariTest general coefficient Emotional state 1 10.000 0.0000 17.652 0.3273 2 0.9204 0.0285 16.248 0.3013 3 10.015 0.0298 17.678 0.3278 4 10.849 0.0311 19.152 0.3551 5 10.709 0.0309 18.904 0.3505 6 0.9410 0.0288 16.611 0.3080 7 0.8879 0.0280 15.674 0.2906 8 0.8556 0.0275 15.103 0.2800 9 0.8764 0.0278 15.471 0.2869 10 11.378 0.0320 20.085 0.3724 11 0.8203 0.0270 14.480 0.2685 12 10.167 0.0300 17.947 0.3328 13 10.668 0.0308 18.831 0.3492 14 0.9734 0.0293 17.182 0.3186 15 0.5087 0.0231 0.8980 0.1665 Eating behavior 16 10.000 0.0000 19.187 0.3638 17 10.166 0.0253 19.505 0.3698 18 0.9094 0.0238 17.449 0.3308 19 0.8733 0.0233 16.757 0.3177 20 10.719 0.0261 20.567 0.3899 21 0.7578 0.0219 14.539 0.2756 22 0.6526 0.0206 12.521 0.2374 23 0.8907 0.0236 17.089 0.3240 24 0.6337 0.0204 12.159 0.2305 25 0.9807 0.0248 18.816 0.3567 26 0.6276 0.0204 12.043 0.2283 27 0.7742 0.0221 14.855 0.2816 28 0.8943 0.0236 17.158 0.3253 29 0.5849 0.0199 11.222 0.2127 30 0.5985 0.0201 11.483 0.2177 31 0.7635 0.0219 14.649 0.2777 Quality of life 32* 10.000 0.0000 35.401 0.5531 33* 0.9617 0.0346 34.046 0.5320 34* 10.095 0.0355 35.738 0.5584 35* 0.8073 0.0317 28.578 0.4465 36* 0.6471 0.0290 22.909 0.3579 37* 0.4676 0.0266 16.555 0.2587 38 0.6006 0.0283 21.261 0.3322 39* 0.9824 0.0350 34.779 0.5434 40* 0.5856 0.0281 20.731 0.3239 Relationship with body weight 41 10.000 0.0000 44.830 0.7285 42 10.660 0.0336 47.791 0.7766 43 0.8484 0.0298 38.032 0.6180 44 10.146 0.0327 45.486 0.7391 45 0.7663 0.0285 34.352 0.5582 46 0.8813 0.0303 39.508 0.6420 Alcohol consumption 47 10.000 0.0000 52.100 0.9226 48 0.9320 0.0465 48.556 0.8599 49 11.566 0.0548 60.259 10.671 50 0.9126 0.0459 47.546 0.8420 51 0.7973 0.0422 41.539 0.7356 52 10.000 0.0000 28.210 0.3644 Social support 53 11.017 0.0737 31.079 0.4014 54 0.5297 0.0551 14.944 0.1930 55* 12.046 0.0778 33.981 0.4389 56* 10.015 0.0699 28.253 0.3649 57* 0.9904 0.0695 27.938 0.3609 58* 12.749 0.0806 35.966 0.4646 59* 17.592 0.1017 49.628 0.6410 This table contains the confirmatory factor analysis with the factorial loading and standard error of each item of BariTest. * Items 32, 33, 34, 35, 36, 37, 39, 40, 55, 56, 57, 58, and 59 had the score reversed so that all domains point in the same direction of assessing psychological well-being. Calculation for correction of BariTest obtained through confirmatory factor analysis. Appendix 3 Reference levels for interpreting the BariTest result. Percentile Group Postop: 18–30 Postop: 31–45 Postop: 46+ Preop: F:18–30 Preop: F:31–45 Preop: F:46+ Preop: M:18–30 Preop: M:31–45 Preop: M:46+ 2.5 6.087 5.462 0.580 20.054 17.081 11.480 18.479 14.233 8.013 5 9.728 8.533 4.024 23.199 20.302 14.861 21.158 17.426 11.371 10 13.926 12.074 7.994 26.825 24.016 18.759 24.247 21.107 15.242 15 16.759 14.463 10.673 29.272 26.521 21.389 26.331 23.591 17.854 20 19.010 16.362 12.802 31.217 28.513 23.479 27.988 25.565 19.929 25 20.941 17.991 14.629 32.885 30.221 25.272 29.409 27.259 21.710 30 22.675 19.453 16.269 34.383 31.756 26.882 30.685 28.780 23.309 35 24.282 20.809 17.789 35.771 33.177 28.374 31.868 30.189 24.791 40 25.807 22.095 19.232 37.088 34.526 29.790 32.990 31.526 26.198 45 27.283 23.340 20.627 38.363 35.832 31.160 34.076 32.820 27.558 50 28.735 24.565 22.000 39.617 37.116 32.509 35.144 34.093 28.897 55 30.187 25.789 23.374 40.871 38.401 33.857 36.212 35.367 30.236 60 31.662 27.034 24.769 42.146 39.706 35.227 37.298 36.660 31.597 65 33.187 28.320 26.212 43.463 41.055 36.643 38.420 37.998 33.003 70 34.794 29.676 27.732 44.851 42.477 38.135 39.603 39.407 34.485 75 36.529 31.139 29.372 46.350 44.011 39.745 40.879 40.928 36.084 80 38.460 32.768 31.199 48.018 45.719 41.538 42.300 42.621 37.865 85 40.711 34.666 33.328 49.962 47.711 43.628 43.956 44.595 39.941 90 43.543 37.055 36.007 52.409 50.216 46.258 46.041 47.079 42.552 95 47.741 40.596 39.977 56.035 53.930 50.156 49.130 50.760 46.423 97.5 51.382 43.668 43.421 59.180 57.151 53.537 51.809 53.953 49.781 Preop.: preoperative; Postop.: postoperative; M: Male; F: Female. and 2), by analysis of the areas under the ROC curves. Bariatric surgery causes changes in the psychological well-being of patients undergoing the procedure. The results showed that WHODAS 2.0 has 65% accuracy, OP has 72%, and BariTest has 78% (Figure 2), being. therefore, superior to the others to identify the chances of psychological well-being of the patient with obesity.

Figure 2
Illustration of BariTest’s responsivity (accuracy).

Reliability

BariTest’s reliability showed a Cronbach’s alpha of 0.93 (95%CI, 0.92–0.94). The reliability of each construct was analyzed, considering the entire bariatric sample, and was separated by gender (Table 3). The similarity of the results showed1919 Hulley SB, Cumming SR, Browner WS, Grady DG, Hearst NB, Newman TB. Delineando a pesquisa clínica: uma abordagem epidemiológica. 4th ed. São Paulo: Artmed; 2015. that all of the instrument is valid for both genders.

Results of BariTest

The analysis between the constructs and groups (Figure 3) was adjusted for the results by the Bonferroni correction factor, to guarantee the significance level of 5%. The constructs Emotional state, Eating behavior, and Quality of life show a similarity between the results obtained in the community and postoperative groups and better than the preoperative group.

Figure 3
Comparison of the results of BariTest obtained between the preoperative, postoperative, and community.

The community in general revealed to have more social support compared with obesity patients (preoperative and postoperative). Relationship with body weight differed in the three groups, possibly because the questions are specific to the bariatric population and the community was unable to answer.

Alcohol consumption was similar in the preoperative and postoperative groups and lower than the community group, indicating that people in the community consume more than the bariatric population. Five of the six constructs obtained p<0.001, with Social support being p=0.0204.

DISCUSSION

There are numerous advantages for the psychologist to use BariTest, as it is a validated and complementary tool for psychological assessment that measures the psychological well-being of bariatric surgery patients. This instrument is valuable as a systematic procedure to collect, quantify, and evaluate the patient’s behavior and compare the psychological outcomes of the surgery2020 Hutz CS, Bandeira DR, Trentini CM. Psicometria. Porto Alegre: Artmed; 2015.,4444 Urbina S. Fundamentos da testagem psicológica. Porto Alegre: Artmed; 2007.. The instrument was also applied in the community to nonobese subjects, with the sole purpose of verifying whether bariatric patients are distinct from the general population. Thus, BariTest proved that it is specific for the bariatric population, since the results obtained with candidates or patients who have already undergone bariatric surgery are different from the findings with the nonobese community.

The Emotional state construct consists of items that assess mood, anxiety, and impulsivity. Patients with obesity may have some cognitive difficulties, especially in the area of executive function responsible for planning, organizing, and controlling impulses3838 Sarwer DB, Allison KC, Wadden TA, Ashare R, Spitzer JC, McCuen-Wurst C, et al. Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery. Surg Obes Relat Dis. 2019;15(4):650-5. https://doi.org/10.1016/j.soard.2019.01.029
https://doi.org/10.1016/j.soard.2019.01....
,4040 Smith E, Hay P, Campbell L, Trollor JN. A review of the association between obesity and cognitive function across the lifespain: implications for novel approaches to prevention and treatment. Obesity Research. 2011;12(9):740-55. https://doi.org/10.1111/j.1467-789X.2011.00920.x
https://doi.org/10.1111/j.1467-789X.2011...
. The weight loss after bariatric surgery reduces neuroinflammation to rescue some aspects of defects in cognition and behavior2424 Li P, Shan H, Nie B, Liu H, Dong G, Guo Y, et al. Sleeve gastrectomy rescuing the altered functional connectivity of lateral but not medial hypothalamus in subjects with obesity. Obes Surg. 2019;29(7):2191-99. https://doi.org/10.1007/s11695-019-03822-7
https://doi.org/10.1007/s11695-019-03822...
. Anxiety is the most common psychiatric disorder in patients with obesity who are awaiting bariatric surgery1414 Edwards-Hampton SA, Madan A, Wedin S, Borckardt JJ, Crowley N, Byrne KT. A closer look at the nature of anxiety in weight loss surgery candidates. Int J Psychiatry Med. 2014;47(2):105-13. https://doi.org/10.2190/PM.47.2.b
https://doi.org/10.2190/PM.47.2.b...
,2121 Kalarchian MA, Marcus MD, Levine MD, Courcoulas AP, Pilkonis PA, Ringham RM, et al. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiat. 2007;164(2):328-34. https://doi.org/10.1176/ajp.2007.164.2.328
https://doi.org/10.1176/ajp.2007.164.2.3...
.

The Emotional state score is similar between the postoperative period 29.7 (SD±16) and the community 27.1 (SD±13.8), but lower than the group that has not yet undergone surgery 37.8 (SD±15.5). This finding corroborates with the literature1111 De Zwaan M, Hilbert A, Swan-Kremeier L, Simonich H, Lancaster K, Howell LM, et al. Comprehensive interview assessment of eating behavior 18-35 months after gastric bypass surgery for morbid obesity. Surg Obes Relat Dis. 2010;6(1):79-85. https://doi.org/10.1016/j.soard.2009.08.011
https://doi.org/10.1016/j.soard.2009.08....
,3131 Motta AKF, Gomes KKA, Macedo MGD, Negreiros LN. Bariatric Surgery Program: therapeutic group post surgical as instrument of interdisciplinary intervention. Rev Hosp Univ Getúlio Vargas. 2011;10(2):21-4.,3232 Müller A, Hase C, Pommnitz M, De Zwaan M. Depression and suicide after bariatric surgery. Curr Psychiatry Rep. 2019;21(9):84. https://doi.org/10.1007/s11920-019-1069-1
https://doi.org/10.1007/s11920-019-1069-...
,3434 Nasirzadeh Y, Kantarovich K, Wnuk S, Okrainec A, Cassin SE, Hawa R, et al. Binge eating, loss of control over eating, emotional eating, and night eating after bariatric surgery: results from the Toronto Bari-psych Coort Study. Obes Surg. 2018;28(7):2032-9. https://doi.org/10.1007/s11695-018-3137-8
https://doi.org/10.1007/s11695-018-3137-...
that shows the prevalence of depressive disorders being lower than in patients who have already undergone bariatric surgery and that patients who are in the preoperative period of bariatric surgery demonstrate more critical levels of depression, higher than those observed in the general population. In addition, worsening depression is associated with weight gain, which in turn leads to worse depression outcomes22 Arhi CS, Dudley R, Moussa O, Ardissino M, Scholtz S, Purkayastha S. The complex association between bariatric surgery and depression: a national nested-control study. Obes Surg. 2021;31(5):1994-2001. https://doi.org/10.1007/s11695-020-05201-z
https://doi.org/10.1007/s11695-020-05201...
.

The preoperative patients scored in BariTest’s Eating behavior (Figure 3), an average of 51.3 (SD±18.1), which was the highest average of all constructs, demonstrating that the candidate for bariatric surgery does not have a healthy relationship with food. It is important to assist the patient from the preoperative period, since studies have shown that the prevalence of binge eating symptoms in patients who are the candidates for bariatric surgery is 39–50% and is related to a suboptimal weight loss result after bariatric surgery88 Cambi MPC, Baretta GAP, Magro DO, Boguszewski CL, Riveiro IB, Jirapinyo P, et al. Multidisciplinary approach for weight regain-how to manage this challenging condition: an expert review. Obes Surg. 2021;31(1):1290-303. https://doi.org/10.1007/s11695-020-05164-1
https://doi.org/10.1007/s11695-020-05164...
,1313 Dymek-Valentine M, Rienecke-Hoste R, Alverdy J. Assessment of binge eating disorder in morbidly obese patients evaluated for gastric by-pass: SCID versus QEWP-R. EWD. 2004;9(3):211-6. https://doi.org/10.1007/bf03325069
https://doi.org/10.1007/bf03325069...
,2828 Meany G, Conceição E, Mitchel JE. Binge eating, binge eating disorder and loss of control eating: effects on weight outcomes after bariatric surgery. Eur Eat Disord Rev. 2014;22(2):87-91. https://doi.org/10.1002/erv.2273
https://doi.org/10.1002/erv.2273...
,4545 Wadden TA, Faulconbridge LF, Jones-Corneille LR, Sarwer DB, Fabricatore AN, Graham-Thomas J, et al. Binge eating disorder and the outcome of bariatric surgery at one year: a prospective, observacional study. Obes. 2011;19(6):1220-8. https://doi.org/10.1038/oby.2010.336.
https://doi.org/10.1038/oby.2010.336...
.

Quality of life and Relationship with body weight were constructs of BariTest which revealed a worse score in preoperative than postoperative and community. These data corroborate the prospective cross-sectional study by Moraes et al.3030 Moraes JM, Caregnato RCA, Schneider DS. Qualidade de vida antes e após a cirurgia bariátrica. Acta Paul Enferm. 2014, 27(2):157-64. https://doi.org/10.1590/1982-0194201400028
https://doi.org/10.1590/1982-01942014000...
who analyzed quality of life before and after bariatric surgery, reporting that 25% of patients considered quality of life and health to be poor or very bad before bariatric surgery, and after the procedure all patients rated it as good or very good.

The BariTest Social support construct revealed that bariatric patients (preoperative and postoperative) have less social support than the community and it is known that social support is associated with greater adherence to treatment and consequently successful outcomes2626 Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, et al. Is social support associated with greater weight loss after bariatric surgery? A systematic review. Obes Res. 2011;12(2):142-8. https://doi.org/10.1111/j.1467-789X.2010.00720.x
https://doi.org/10.1111/j.1467-789X.2010...
.

BariTest showed that the bariatric sample had an alcohol consumption lower than that of the general population. This finding was different from the study by King et al.2323 King WC, Chen JY, Mitchell JE, Kalarchian MA, Steffen KJ, Engel SG, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA;2012;307(23):2516-25. https://doi.org/10.1001/jama.2012.6147
https://doi.org/10.1001/jama.2012.6147...
and it is known that there is a significantly higher prevalence of alcohol consumption after bariatric surgery. It is believed that patients who are undergoing evaluation for bariatric surgery report a lower consumption of alcohol, since it is a contraindication for surgery. Furthermore, to have a low alcohol consumption in the postoperative period is important due to preventing alcoholism and weight regain3333 Murray SM, Tweardy S, Geliebter A, Avena NM. A longitudinal preliminary study of addiction-like responses to food and alcohol consumption among individuals undergoing weight loss surgery. Obes Surg. 2019;29(8):2700-3. https://doi.org/10.1007/s11695-019-03915-3
https://doi.org/10.1007/s11695-019-03915...
.

The results of the present study suggest that BariTest is a psychometric instrument capable of evaluating the psychological well-being of patients of both genders, before and after bariatric surgery (Table 3).

Even though BariTest has been validated with a significant number of patients, this study was cross sectional, because the aim of this study was to elaborate and validate this psychometric scale. Therefore after this stage, a longitudinal study would be very interesting to understand the changes that the surgery provides and perhaps predict the most suitable psychological profile for bariatric surgery. Sarwer et al.3838 Sarwer DB, Allison KC, Wadden TA, Ashare R, Spitzer JC, McCuen-Wurst C, et al. Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery. Surg Obes Relat Dis. 2019;15(4):650-5. https://doi.org/10.1016/j.soard.2019.01.029
https://doi.org/10.1016/j.soard.2019.01....
emphasize the importance of these studies to improve patient selection, improve psychoeducation and preoperative interventions, in addition to developing intervention strategies for patients who are unable to achieve the expected result after the procedure.

CONCLUSION

BariTest is an instrument that makes it possible to measure and analyze psychological well-being and directs the necessary psychological interventions, before and after bariatric surgery, contributing to the psychological assessment. BariTest was developed as recommended in the scientific literature and proved all of the instrument was valid and reliable (α=0.93), measuring the psychological well-being of bariatric patients, regardless of gender, before and after bariatric surgery.

  • Financial source: None
  • Central Message
    Caution is recommended to indicate bariatric surgery in patients with severe psychiatric disorders without treatment. This is suggested when there is an absence of social support in those who, due to emotional instability, may find it difficult to follow and obey postoperative dietary instructions, and in cases of abuse of illicit drugs and/or alcoholism.
  • Perspectives
    BariTest is an instrument that makes it possible to measure and analyze psychological well-being and directs the necessary psychological interventions, before and after bariatric surgery, contributing to the psychological assessment.

REFERENCES

  • 1
    American Educational Research Association, American Psychological Association, National Council on Measurement in Education. Standards for educational and psychological testing. Washington: American Educational Research Association; 2014.
  • 2
    Arhi CS, Dudley R, Moussa O, Ardissino M, Scholtz S, Purkayastha S. The complex association between bariatric surgery and depression: a national nested-control study. Obes Surg. 2021;31(5):1994-2001. https://doi.org/10.1007/s11695-020-05201-z
    » https://doi.org/10.1007/s11695-020-05201-z
  • 3
    Bland JM, Altman DG. Statistics notes: cronbach’s alpha. BMJ.1997;314(7080):572-88. https://doi.org/10.1136/bmj.314.7080.572
    » https://doi.org/10.1136/bmj.314.7080.572
  • 4
    Brasil AMB, Brasil F, Maurício AA, Vilela RM. Adaptação transcultural e validação para o Brasil da Obesity-related Problems Scale. Einstein. 2017, 15(3):327-33. https://doi.org/10.1590/S1679-45082017AO4004
    » https://doi.org/10.1590/S1679-45082017AO4004
  • 5
    Brasil F, Brasil AMB, Correr CJ. Validation of the Brazilian version of WHODAS 2.0 in patients with mental disorders: should the 12-Item Scale be an Alternative to 36-Item Scale in DSM-5? Neuropsychiatry (London). 2018;8(2):719-26. https://doi.org/10.4172/Neuropsychiatry.1000397
    » https://doi.org/10.4172/Neuropsychiatry.1000397
  • 6
    Brown TA. Confirmatory factor analysis for applied research. New York: Guilford publications; 2015.
  • 7
    Byrne BM. Structural equation modeling with AMOS: basic concepts, applications, and programming. New York: Routledge; 2001. https://doi.org/10.4324/9780203805534
    » https://doi.org/10.4324/9780203805534
  • 8
    Cambi MPC, Baretta GAP, Magro DO, Boguszewski CL, Riveiro IB, Jirapinyo P, et al. Multidisciplinary approach for weight regain-how to manage this challenging condition: an expert review. Obes Surg. 2021;31(1):1290-303. https://doi.org/10.1007/s11695-020-05164-1
    » https://doi.org/10.1007/s11695-020-05164-1
  • 9
    Conselho Federal de Medicina. Resolução nº 2.131, de 12 de novembro de 2015. Altera o anexo da Resolução CFM nº1.942/10. Diário Oficial da União, 2015. Available at: https://www.in.gov.br/web/guest/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/22175085/do1-2016-01-13-resolucao-n-2-131-de-12-de-novembro-de-2015-22174970 Accessed: Jan. 25, 2021.
    » https://www.in.gov.br/web/guest/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/22175085/do1-2016-01-13-resolucao-n-2-131-de-12-de-novembro-de-2015-22174970
  • 10
    Conselho Federal de Psicologia do Brasil. Resolução nº 009, de 25 de abril de 2018. Estabelece diretrizes para a realização de Avaliação Psicológica no exercício profissional da psicóloga e do psicólogo, regulamenta o Sistema de Avaliação de Testes Psicológicos – SATEPSI e revoga as Resoluções nº 002/2003, nº 006/2004 e nº 005/2012 e Notas Técnicas nº 01/2017 e 02/2017. Brasília, DF: CFP; 2018. Available at: https://satepsi.cfp.org.br/docs/ResolucaoCFP009-18.pdf Accessed: Jan. 25, 2021.
    » https://satepsi.cfp.org.br/docs/ResolucaoCFP009-18.pdf
  • 11
    De Zwaan M, Hilbert A, Swan-Kremeier L, Simonich H, Lancaster K, Howell LM, et al. Comprehensive interview assessment of eating behavior 18-35 months after gastric bypass surgery for morbid obesity. Surg Obes Relat Dis. 2010;6(1):79-85. https://doi.org/10.1016/j.soard.2009.08.011
    » https://doi.org/10.1016/j.soard.2009.08.011
  • 12
    Drasgow F. Polychoric and polyserial correlations. In: Kotz S, Balakrishnan N, Read CB, Vidakovic B, editors. Encyclopedia of statistical sciences. New York: John Wiley; 1986. p. 68-74.
  • 13
    Dymek-Valentine M, Rienecke-Hoste R, Alverdy J. Assessment of binge eating disorder in morbidly obese patients evaluated for gastric by-pass: SCID versus QEWP-R. EWD. 2004;9(3):211-6. https://doi.org/10.1007/bf03325069
    » https://doi.org/10.1007/bf03325069
  • 14
    Edwards-Hampton SA, Madan A, Wedin S, Borckardt JJ, Crowley N, Byrne KT. A closer look at the nature of anxiety in weight loss surgery candidates. Int J Psychiatry Med. 2014;47(2):105-13. https://doi.org/10.2190/PM.47.2.b
    » https://doi.org/10.2190/PM.47.2.b
  • 15
    Erthal TC. Manual de psicometria. São Paulo: Zahar; 1987.
  • 16
    Flores CA. Avaliação psicológica para cirurgia bariátrica: práticas atuais. Rev ABCD Arq Bras Cir Dig. 2014;27(Supl 1):59-62. https://doi.org/10.1590/S0102-6720201400S100015
    » https://doi.org/10.1590/S0102-6720201400S100015
  • 17
    González-Muniesa P, Mártinez-González MA, Hu FB, Després JP, Matsuzawa Y, Loos RJF, et al. Obesity. Nat Rev Dis Primers. 2017;3:17034. https://doi.org/10.1038/nrdp.2017.34
    » https://doi.org/10.1038/nrdp.2017.34
  • 18
    Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. SEM. 1999;6(1):1-55. https://doi.org/10.1080/10705519909540118
    » https://doi.org/10.1080/10705519909540118
  • 19
    Hulley SB, Cumming SR, Browner WS, Grady DG, Hearst NB, Newman TB. Delineando a pesquisa clínica: uma abordagem epidemiológica. 4th ed. São Paulo: Artmed; 2015.
  • 20
    Hutz CS, Bandeira DR, Trentini CM. Psicometria. Porto Alegre: Artmed; 2015.
  • 21
    Kalarchian MA, Marcus MD, Levine MD, Courcoulas AP, Pilkonis PA, Ringham RM, et al. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiat. 2007;164(2):328-34. https://doi.org/10.1176/ajp.2007.164.2.328
    » https://doi.org/10.1176/ajp.2007.164.2.328
  • 22
    Kalil-Filho FA, Pinto JSP, Borsato EP, Kuretzki CH, Ariede BL, Mathias JEF, et al. Multiprofessional electronic protocol for digestive surgery validation. ABCD Arq Bras Cir Dig. 2021;34(2):e1583. https://doi.org/10.1590/0102-672020210002e1583
    » https://doi.org/10.1590/0102-672020210002e1583
  • 23
    King WC, Chen JY, Mitchell JE, Kalarchian MA, Steffen KJ, Engel SG, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA;2012;307(23):2516-25. https://doi.org/10.1001/jama.2012.6147
    » https://doi.org/10.1001/jama.2012.6147
  • 24
    Li P, Shan H, Nie B, Liu H, Dong G, Guo Y, et al. Sleeve gastrectomy rescuing the altered functional connectivity of lateral but not medial hypothalamus in subjects with obesity. Obes Surg. 2019;29(7):2191-99. https://doi.org/10.1007/s11695-019-03822-7
    » https://doi.org/10.1007/s11695-019-03822-7
  • 25
    Lin Z, Qu S. Legend of weight loss: a crosstalk between the bariatric surgery and the brain. Obes Surg. 2020;30(5):1988-2002. https://doi.org/10.1007/s11695-020-04474-8
    » https://doi.org/10.1007/s11695-020-04474-8
  • 26
    Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, et al. Is social support associated with greater weight loss after bariatric surgery? A systematic review. Obes Res. 2011;12(2):142-8. https://doi.org/10.1111/j.1467-789X.2010.00720.x
    » https://doi.org/10.1111/j.1467-789X.2010.00720.x
  • 27
    Mahony D. Psychological assessments of bariatric surgery patients. Development, reliability, and exploratory factor analysis of the PsyBari. Obes Surg. 2011;21(9):1395-406. https://doi.org/10.1007/s11695-010-0108-0
    » https://doi.org/10.1007/s11695-010-0108-0
  • 28
    Meany G, Conceição E, Mitchel JE. Binge eating, binge eating disorder and loss of control eating: effects on weight outcomes after bariatric surgery. Eur Eat Disord Rev. 2014;22(2):87-91. https://doi.org/10.1002/erv.2273
    » https://doi.org/10.1002/erv.2273
  • 29
    Mitchell JE, Zawaan M. Psychopathology and bariatric surgery. ASMBS. 2014;2(3):11-17. https://doi.org/10.1007/978-1-4939-1197-4_1
    » https://doi.org/10.1007/978-1-4939-1197-4_1
  • 30
    Moraes JM, Caregnato RCA, Schneider DS. Qualidade de vida antes e após a cirurgia bariátrica. Acta Paul Enferm. 2014, 27(2):157-64. https://doi.org/10.1590/1982-0194201400028
    » https://doi.org/10.1590/1982-0194201400028
  • 31
    Motta AKF, Gomes KKA, Macedo MGD, Negreiros LN. Bariatric Surgery Program: therapeutic group post surgical as instrument of interdisciplinary intervention. Rev Hosp Univ Getúlio Vargas. 2011;10(2):21-4.
  • 32
    Müller A, Hase C, Pommnitz M, De Zwaan M. Depression and suicide after bariatric surgery. Curr Psychiatry Rep. 2019;21(9):84. https://doi.org/10.1007/s11920-019-1069-1
    » https://doi.org/10.1007/s11920-019-1069-1
  • 33
    Murray SM, Tweardy S, Geliebter A, Avena NM. A longitudinal preliminary study of addiction-like responses to food and alcohol consumption among individuals undergoing weight loss surgery. Obes Surg. 2019;29(8):2700-3. https://doi.org/10.1007/s11695-019-03915-3
    » https://doi.org/10.1007/s11695-019-03915-3
  • 34
    Nasirzadeh Y, Kantarovich K, Wnuk S, Okrainec A, Cassin SE, Hawa R, et al. Binge eating, loss of control over eating, emotional eating, and night eating after bariatric surgery: results from the Toronto Bari-psych Coort Study. Obes Surg. 2018;28(7):2032-9. https://doi.org/10.1007/s11695-018-3137-8
    » https://doi.org/10.1007/s11695-018-3137-8
  • 35
    Pasquali L. Psicometria: teoria dos testes na psicologia e na educação. 5th ed. São Paulo: Vozes; 2013.
  • 36
    R Core Team (2020). R: a language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2018.
  • 37
    Revelle WR. Psych: procedures for personality and psychological research. Evanston: Northwestern University; 2019. Available at: https://cran.R-project.org/package=psychVersion=1.9.12.19
    » https://cran.R-project.org/package=psychVersion=1.9.12.19
  • 38
    Sarwer DB, Allison KC, Wadden TA, Ashare R, Spitzer JC, McCuen-Wurst C, et al. Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery. Surg Obes Relat Dis. 2019;15(4):650-5. https://doi.org/10.1016/j.soard.2019.01.029
    » https://doi.org/10.1016/j.soard.2019.01.029
  • 39
    Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res. 2005;13(4):639-48. https://doi.org/10.1038/oby.2005.71
    » https://doi.org/10.1038/oby.2005.71
  • 40
    Smith E, Hay P, Campbell L, Trollor JN. A review of the association between obesity and cognitive function across the lifespain: implications for novel approaches to prevention and treatment. Obesity Research. 2011;12(9):740-55. https://doi.org/10.1111/j.1467-789X.2011.00920.x
    » https://doi.org/10.1111/j.1467-789X.2011.00920.x
  • 41
    Sociedade Brasileira de Cirurgia Bariátrica e Metabólica. Obesidade. 2014. Available at: http://www.sbcb.org.br/ Accessed: Feb. 14, 2021.
    » http://www.sbcb.org.br/
  • 42
    Still C, Sarwer DB, Blankenship J. The ASMBS textbook of bariatric surgery: integrated health. New York: Springer Science; 2014. https://doi.org/10.1007/978-1-4939-1197-4
    » https://doi.org/10.1007/978-1-4939-1197-4
  • 43
    Tucker LR, Lewis C. A reliability coefficient for maximum likelihood factor analysis. Psychometrika.1973;38:1-10. https://doi.org/10.1007/BF02291170
    » https://doi.org/10.1007/BF02291170
  • 44
    Urbina S. Fundamentos da testagem psicológica. Porto Alegre: Artmed; 2007.
  • 45
    Wadden TA, Faulconbridge LF, Jones-Corneille LR, Sarwer DB, Fabricatore AN, Graham-Thomas J, et al. Binge eating disorder and the outcome of bariatric surgery at one year: a prospective, observacional study. Obes. 2011;19(6):1220-8. https://doi.org/10.1038/oby.2010.336
    » https://doi.org/10.1038/oby.2010.336
  • 46
    Wadden TA, Sarwer DB. Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach. Obes Res. 2012;14(S53):53-64. https://doi.org/10.1038/oby.2006.283
    » https://doi.org/10.1038/oby.2006.283
  • 47
    Xia Y, Yang Y. RMSEA, CFI, and TLI in structural equation modeling with ordered categorical data: the story they tell depends on the estimation methods. Behav Res Methods. 2019;51(1):409-28. https://doi.org/10.3758/s13428-018-1055-2
    » https://doi.org/10.3758/s13428-018-1055-2
  • 48
    Yves R. Lavaan: an R package for structural equation modeling. J Stat Software. 2012;48(2):1-36. https://doi.org/10.18637/jss.v048.i02
    » https://doi.org/10.18637/jss.v048.i02

Annex 1 Complementary Scales: WHODAS 2.0 – 36 items

WHODAS 2.0 WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0

36-item version, self-administered

This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs.

Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please circle only one response.

In the past 30 days, how much difficulty did you have in: Understanding and communicating D1.1 Concentrating on doing something for ten minutes? None Mild Moderate Severe Extreme or cannot do D1.2 Remembering to do important things? None Mild Moderate Severe Extreme or cannot do D1.3 Analyzing and finding solutions to problems in day-to-day life? None Mild Moderate Severe Extreme or cannot do D1.4 Learning a new task, for example, learning how to get to a new place? None Mild Moderate Severe Extreme or cannot do D1.5 Generally understanding what people say? None Mild Moderate Severe Extreme or cannot do D1.6 Starting and maintaining a conversation? None Mild Moderate Severe Extreme or cannot do Getting around D2.1 Standing for long periods such as 30 min? None Mild Moderate Severe Extreme or cannot do D2.2 Standing up from sitting down? None Mild Moderate Severe Extreme or cannot do D2.3 Moving around inside your home? None Mild Moderate Severe Extreme or cannot do D2.4 Getting out of your home? None Mild Moderate Severe Extreme or cannot do D2.5 Walking a long distance such as a kilometer [or equivalent]? None Mild Moderate Severe Extreme or cannot do
In the past 30 days, how much difficulty did you have in: Self-care D3.1 Washing your whole body? None Mild Moderate Severe Extreme or cannot do D3.2 Getting dressed? None Mild Moderate Severe Extreme or cannot do D3.3 Eating? None Mild Moderate Severe Extreme or cannot do D3.4 Staying by yourself for a few days? None Mild Moderate Severe Extreme or cannot do Getting along with people D4.1 Dealing with people you do not know? None Mild Moderate Severe Extreme or cannot do D4.2 Maintaining a friendship? None Mild Moderate Severe Extreme or cannot do D4.3 Getting along with people who are close to you? None Mild Moderate Severe Extreme or cannot do D4.4 Making new friends? None Mild Moderate Severe Extreme or cannot do D4.5 Sexual activities? None Mild Moderate Severe Extreme or cannot do Life activities D5.1 Taking care of your household responsibilities? None Mild Moderate Severe Extreme or cannot do D5.2 Doing most important household tasks well? None Mild Moderate Severe Extreme or cannot do D5.3 Getting all the household work done that you needed to do? None Mild Moderate Severe Extreme or cannot do D5.4 Getting your household work done as quickly as needed? None Mild Moderate Severe Extreme or cannot do

If you work (paid, non-paid, self-employed) or go to school, complete questions D5.5–D5.8, below. Otherwise, skip to D6.1.

Because of your health condition, in the past 30 days, how much difficulty did you have in: D5.5 Your day-to-day work/school? None Mild Moderate Severe Extreme or cannot do D5.6 Doing your most important work/school tasks well? None Mild Moderate Severe Extreme or cannot do D5.7 Getting all the work done that you need to do? None Mild Moderate Severe Extreme or cannot do D5.8 Getting your work done as quickly as needed? None Mild Moderate Severe Extreme or cannot do
Participation in society In the past 30 days: D6.1 How much of a problem did you have in joining in community activities (e.g., festivities, religious, or other activities) in the same way as anyone else can? None Mild Moderate Severe Extreme or cannot do D6.2 How much of a problem did you have because of barriers or hindrances in the world around you? None Mild Moderate Severe Extreme or cannot do D6.3 How much of a problem did you have living with dignity because of the attitudes and actions of others? None Mild Moderate Severe Extreme or cannot do D6.4 How much time did you spend on your health condition, or its consequences? None Mild Moderate Severe Extreme or cannot do D6.5 How much have you been emotionally affected by your health condition? None Mild Moderate Severe Extreme or cannot do D6.6 How much has your health been a drain on the financial resources of you or your family? None Mild Moderate Severe Extreme or cannot do D6.7 How much of a problem did your family have because of your health problems? None Mild Moderate Severe Extreme or cannot do D6.8 How much of a problem did you have in doing things by yourself for relaxation or pleasure? None Mild Moderate Severe Extreme or cannot do H1 Overall, in the past 30 days, how many days were these difficulties present? Record number of days ______ H2 In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition? Record number of days ______ H3 In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition? Record number of days ______ This completes the questionnaire. Thank you.
Annex 2
Complementary Scales: Brazilian version of the Obesity-related Problems Scale (OP)
How do you feel about your weight or your body shape in the following situations?
  1. “It bothers me a lot.”

  2. “It bothers me more or less.”

  3. “It bothers me a little.”

  4. “It doesn’t bother me.”

Appendix 1
Evaluation of the version of BARITEST by the Committee of Experts.
Appendix 2
Confirmatory factor analysis of BariTest.
Appendix 3
Reference levels for interpreting the BariTest result.

Publication Dates

  • Publication in this collection
    09 Sept 2022
  • Date of issue
    2022

History

  • Received
    29 May 2022
  • Accepted
    22 June 2022
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