Self-care model and body image in adults after a bariatric surgery

Abstract Objective: the aim of the present article was to test a self-care model explained by the relationship between self-efficacy, body image, obsessive-compulsive disorder, and depression in people with bariatric surgery in the city of Tijuana, Baja California, Mexico. Method: this was a correlational cross-sectional study carried out between August and December 2020. Validated instruments were administered to 102 participants to measure their self-care capacity, general self-efficacy, psychopathological symptoms, and body image perception and satisfaction. The variables of interest were analyzed using descriptive statistics and the Pearson and Spearman correlation coefficients were used to develop a model using path analysis. Result: a significant model was obtained with adequate goodness-of-fit indicators (chi-square χ2 (8) = 11.451, p = .177; root mean square error of approximation (RMSEA)= 0.000; goodness-of-fit index (GFI)= 0.965; comparative fit index (CFI)= 0.985; parsimonious normed fit index (PNFI)= 0.509, and Akaike information criterion (AIC)= 37.451). Self-efficacy (Zβ=0.294) and body image dissatisfaction (So= -0.376) were shown to influence self-care abilities while psychopathological symptoms influenced body dissatisfaction: obsessive-compulsive disorder (Zβ=0.370) and depression (Zβ=0.320). Conclusion: adequate levels of self-efficacy and body satisfaction predict a high capacity for self-care.


Introduction
In recent years, the increase in morbid obesity has gone hand in hand with the growth in the number of bariatric procedures, which have become the main treatment of this disease, with more and more people wanting to undergo this type of intervention (1) . According to the International Federation for Surgery for Obesity and Metabolic Disorders (IFSO), the United States performs the highest number of procedures (335,124 in 2019) (2) . About 28,000 people undergo bariatric surgery (BS) annually in Latin America, with rapid growth in the number of cases. This is attributed to the high obesity rates in the region (3) , coupled with the fact that Latin Americans who live in the United States and have obesity (4) sometimes decide to return to their countries of origin to undergo this type of treatment, since Latin America has been a leader in bariatric surgery of comparable quality at a lower cost (5) .
The success of bariatric surgery is explained because it allows for sustained long-term weight loss, achieving a decrease in morbidity and mortality and risk factors, in addition to optimizing anthropometric parameters and improving quality of life (6) . However, accelerated weight loss requires patients to be able to cope with and adapt quickly to their new body image (BI), with no time to reconstruct their own body representation. This leads to changes in how they relate to their environment.
It has been observed that, in the early stages of the postoperative period, patients experience problems with the organization of their BI (7) .
Body image is a mental representation that each individual constructs in terms of feelings, attitudes and behaviors concerning their own body. It is a multidimensional construct that includes different components, such as perception (body size and silhouette), subjectivity (cognitive aspects and affective connection with the evaluation of one's own body, resulting in satisfaction/ dissatisfaction) and behavior (exposure, avoidance), where people with obesity have greater body image dissatisfaction (BID) than those without obesity (8) .
Body image dissatisfaction is a consequence of the discrepancy that results from the importance put on physical appearance by setting high beauty standards and evaluating one's appearance as less attractive (9) .
Bariatric patients often report an improvement in their BI; however, this is not the case for everyone, because for some, BI perception does not improve after surgery, with individuals expressing dissatisfaction with the aesthetic results of BS related to excess skin (10)(11) .
This dissatisfaction has a negative effect on emotions, generating distress or psychological discomfort such as depression because of the constant desire to achieve an unrealistic ideal figure that can even turn into obsessive-compulsive disorder (OCD) (12) . These emotions and thoughts can be damaging to levels of general self-efficacy and self-care ability, influencing patients to make decisions that put their health at risk, such as lack of adherence to prescribed treatment, which includes a balanced diet, moderate physical activity, consumption of bariatric multivitamin supplements, and follow-up visits (13)(14) .
According to Bandura's social cognitive theory, perceived self-efficacy is defined as "people's judgments of their capabilities to organize and execute courses of action required to attain designated types of performance." Bandura postulated that "a high sense of self-efficacy facilitates information processing and cognitive performance in diverse contexts, including decisionmaking" (15) .
Self-efficacy levels are of great importance because they can increase or decrease motivation, which has been observed in health behaviors such as chronic disease management, exercise, weight loss, and in the ability to recover from health problems or avoid potential risks (16) .
In these cases, patients with high perceived self-efficacy have a greater capacity for self-care (17) .
Self-care is the conceptual axis of Orem's theory (18) , who defined it as "the set of actions that mature (or maturing) individuals carry out in the interest of staying alive and healthy, and continuing with personal development and well-being". According to Orem, those who provide their own care have specialized skills, which were named "self-care capabilities", which allow individuals to acquire new behaviors when they identify lifestyle imbalances that do not lead to an optimal level of self-care.
According to this theory, individuals exercise their self-care capabilities ("self-care agency") by taking responsibility for their own care to maintain and improve a state of well-being and quality of life. Therefore, the "self-care agent" (patient) has the power to commit to a course of action and to perform activities to meet the ongoing requirements of self-care, which is known as "treatment self-management".
According to the above, a possible limitation of "treatment self-management" (19) in bariatric patients is the lack of preparation and acceptance of their new BI. Previous studies have shown a correlation between positive BI and adequate self-care capacity (20) or a high level of self-efficacy (21) . According to the literature review, there is no scientific evidence that has studied these three constructs together in the bariatric population, which is of utmost importance because, as described, bariatric patients can feel unprepared for extreme psychosocial and lifestyle changes after surgery (22) . Therefore, the present study aimed to test a self-care model based on the relationship between self-efficacy, www.eerp.usp.br/rlae

Study design
This was a cross-sectional correlational study.

Sampling location
A private bariatric center in the city of Tijuana, B.C.,

Period
This study was conducted between August and December 2020.

Population
The sample included individuals who had undergone bariatric surgery.

Selection criteria
People of both sexes from 18 to 65 years old, with more than six months of having been operated with gastric sleeve techniques or Roux-en-Y gastric bypass, residents of the city of Tijuana, Mexico. People outside the age range, with other bariatric techniques and who had less than six months of surgery were excluded.

Sample definition
The sample size was non-probabilistic, extracted from a database of n= 250 patients from a private bariatric medical center. After careful revision, those who met the inclusion criteria were contacted by phone by their surgeon, who was not part of the research team, to be invited to participate in the study. N= 180 patients met the inclusion criteria, of which n=22 could not be located and n=56 did not agree to participate. Therefore, the final sample consisted of n=102 people.

Variables
Exogenous variables were sex, age, surgical technique, date of surgery, self-efficacy and distress or psychological discomfort represented by depression and OCD. Body dissatisfaction and self-care capacity were included as endogenous variables.

Data collection instruments
To collect sociodemographic and clinical data, a personal identification card was designed, whereas validated instruments were used to collect the variables of interest. The degree of distress or psychological discomfort was measured using the Symptom Checklist-90-Revised (SCL-90-R), created in 1977 (23) and modified in 1994.
In 2005, it was translated into Spanish and validated for the Mexican population (24) , with a Cronbach's alpha of >0.7-0.85. The Spearman range correlation values showed that, except for one item, all obtained a higher correlation value with their corresponding dimension: for 72%, the correlation was high (r>0.5) and for 26%, it was moderate (r>0.25 and <0.5).
The scale consists of 90 items with Likert-type answer options ranging from 0 to 4 (0 = never; 1 = rarely; 2 = sometimes; 3 = frequently; 4 = always), where the patient responds to each item depending on the discomfort they have experienced in the week before the questionnaire, including the day of its administration. General self-efficacy was measured using the Self-Efficacy Test, which measures a person's perception about their ability to handle different stressful situations in their daily life. (28) . It has been validated in Spanish by various www.eerp.usp.br/rlae The questionnaire consists of 10 items with Likerttype answers that indicate how a person perceives each item in terms of their ability at the time of the test: false (1 point); barely true (2 points); somewhat true (3 points) or true (4 points), with a minimum score of 10 and a maximum of 40 points. The higher the score, the greater perceived general self-efficacy, with scores divided into two categories: low and high, with 28 points as the cut-off point (31) . The instrument showed good internal consistency in this sample (α 0.864, p<0.001) and according to previous studies, it has good validity, explaining 65.85% of the accumulated variance (32) .
Body image was assessed using two measurement instruments, the Body Shape Questionnaire (BSQ) and the Body Image Assessment for Obesity (BIA-O), respectively.
The BSQ was developed as a measure of preoccupations with body size and shape (33) and consists of 34 items with Likert answer options: never=1, rarely=2, sometimes=3, often=4, very often=5 and always=6. The score ranges from 34 to 204, and body dissatisfaction is defined as a score greater than 110 (34) .  (38)(39) .

Data collection
The patients were invited to participate voluntarily in the project and gave their written consent. The researchers collected their sociodemographic information and administered the instruments to measure the variables of interest in a single one-hour session.

Results
The sociodemographic data of the sample indicated that 90.2% of the participants were women, with an average age of M= 39.77, SD= 10.05, and 9.8% were men, with an average age of M= 40.9, SD= 5.64. 84.3% had undergone the gastric sleeve technique while the rest were subjected to Roux-en-Y gastric bypass. Regarding postoperative time, 50% had been operated one to three years prior to the study, followed by 27.5%, who had had the surgery six months to one year prior to the study, and 22.5%, with over three years, ranging between 6 months and 2 days to 16 years and 23 days.
Descriptive results are presented in   As mentioned in the methodology, BI was measured using two scales. Regarding the BIA-O (Figure 1), the body image dissatisfaction (BID) scores indicated that a high percentage of the participants presented dissatisfaction and the desire to be thinner (62%  Finally, the explained variance of BID was 44.3%, and that of self-care, 22.8%. Table 3 Table 3.

Discussion
The sample was represented mainly by women, which can be attributed to the beauty standards that promote thinness, through the continuous exposure of models with this aesthetic standard. The impact of this "culture of thinness" can produce BID in people, especially women, since they tend to care more about their BI and therefore undergo weight-loss surgery more often to try to "fit" into social beauty standards (44) . In turn, this could explain the high prevalence of BID as measured by the BSQ in the sample and the desire of most of the sample to be thinner, as indicated by the BIA-O. a new BI, they also need to carry out treatment selfmanagement to maintain a healthy weight (45) and adhere to the prescribed treatment (46) , as this allows them to maintain well-being in health and avoid long-term complications.
Body image satisfaction has been associated with well-being, which is why there are proposals to include it in interventions to attempt to improve thoughts and feelings about weight through strategies that promote self-care (47) . In the present study, BI was a direct and negative predictor that explained self-care in the sample of patients who underwent BS: increased negative attitudes towards BI resulted in decreased self-care.
A possible strategy to promote self-care in these patients is to identify individuals who present negative psychosocial changes, especially those caused by BID.
This should be addressed by trained health professionals, highlighting the importance of quality of life and mental well-being over physical appearance through preoperative guidance and continuous follow-up (48) .
Some studies have evaluated the BI of people after having undergone a bariatric intervention (49) and have found negative attitudes associated, among other variables, with symptoms of depression and lack of functionality due to excess "redundant" skin. The present study found that depression (in a significant association with the characteristics of OCD) explains the presence of greater negative BI attitudes among the participants.
In this sense, the high figures of dissatisfaction with BI found in the sample participants are striking. Only a small proportion wished to larger (people who perceived themselves to be too thin) and a larger percentage of people wished to be thinner, which was probably due to dissatisfaction with the excess of "redundant" skin, and lack of BI reorganization and redefinition demanded by their new physical appearance (50) and the desire for a muscular slim silhouette among men and defined slim silhouette with salient breasts and buttocks among Mexican women (51) . The influence of OCD characteristics on negative BI has been observed in young people (52) , and the same behavior of variables was observed in the sample of adult participants in the present study. In people with body dysmorphia, obsessive thoughts are associated with body appearance (such as the idea of having a larger body and face size); while compulsions consist of behaviors such as mirror avoidance, constantly checking one's appearance, and frequently touching up makeup (53) . Among the general population, problems with BI have been related to low self-esteem, obsessive thoughts about appearance, and depression (54) .
The classical scientific literature has identified a neurological relationship between OCD disorders and depression (55) , and similarly, this study corroborates these findings with a strong significant association between symptoms of OCD and depression in people who have undergone bariatric surgery. These disorders tend to occur more frequently in women who have undergone bariatric surgery (56) , so the percentage of participants with high scores on these scales can be explained by the of surgical techniques, as these can influence the brain's reward system, and therefore the BI self-evaluation and satisfaction (57) . Furthermore, it is advisable to evaluate the effect of surgery on body image satisfaction.

Conclusion
The present study produced relevant results, because knowledge of the interaction between psychopathological symptoms (OCD and depression), BI and self-efficacy in the explanation of self-care among the bariatric population can help guide the development of interventions focused on promoting physical and mental health through positive changes in patient behavior, with the aim of improving BI perception, self-esteem, and self-care capacity.
Finally, the data reported in this study point to a strong association between symptoms of OCD and depression that function as predictors of negative BI attitudes. Self-efficacy in collaboration with BI explains self-care in people who have undergone bariatric surgery.