Attachment style and post-bariatric surgery health behaviours: the mediating role of self-esteem and health self-efficacy

Johanna Eveliina Pyykkö*, Chris Hinnen, Ömrüm Aydin, Max Nieuwdorp, L. Maurits De Brauw, Sjoerd C. Bruin, Nienke van Olst, Victor E.A. Gerdes, Robbert Sanderman, Mariët Hagedoorn

*Corresponding author for this work

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Background: Attachment avoidance and anxiety have been linked to overweight and poor health behaviours, yet the mechanisms that underpin the relationship between attachment and health behaviours are not fully understood. Self-esteem and self-efficacy have been found to differ between attachment styles, rendering these variables potential mediators of the relationship. This longitudinal study investigated the serial mediation between preoperative attachment and 2-year post-operative health behaviours through self-esteem and health self-efficacy. Methods: Participants were 263 bariatric surgery patients (75.7% females, aged 47.7 ± 10.4 years, BMI 38.9 ± 3.6 kg/m2) assessed before the operation and again one and two years after the surgery. Patients completed the Experiences for Close Relationships Brief Scale, Rosenberg Self-esteem scale, Weight Efficacy Lifestyle Questionnaire, Bariatric Surgery Self-Management Questionnaire, Exercise Self-Efficacy Scale and the Exercise Behaviour Scale. Results: Higher preoperative attachment anxiety and avoidance were associated with lower self-esteem one year after bariatric surgery and poorer health self-efficacy two years after the surgery. Self-esteem and health self-efficacy mediated the relationships between preoperative anxious and avoidant attachment and 2- year post-operative diet adherence and physical activity. Conclusions: Helping patients to feel more worthy and reinforcing their beliefs about their own competences could lead to higher engagement with healthy lifestyle and adherence to treatment protocols, ultimately helping patients to achieve their goals for bariatric surgery. Clinical trial registration: BARIA: Netherlands Trial Register: NL5837 (NTR5992) . Diabaria: identifier (NCT number): NCT03330756.

Original languageEnglish
Article number248
Number of pages13
JournalBMC Psychology
Publication statusPublished - 25-Aug-2023


  • Attachment style
  • Bariatric surgery
  • Diet adherence
  • Exercise
  • Self-efficacy
  • Self-esteem

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