Eating pathology before and after bariatric surgery: a prospective study

Weight Regain After Bariatric Surgery: Scope of the Problem, Causes, Prevention, and Treatment

PURPOSE OF REVIEW

Although bariatric surgery is the most effective treatment of severe obesity, a proportion of patients experience clinically significant weight regain (WR) with further out from surgery. The purpose of this review is to summarize the prevalence, predictors, and causes of weight regain.

RECENT FINDINGS

Estimating the prevalence of WR is limited by a lack of consensus on its definition. While anatomic failures such as dilated gastric fundus after sleeve gastrectomy and gastro-gastric fistula after Roux-en-Y gastric bypass can lead to WR, the most common causes appear to be dysregulated/maladaptive eating behaviors, lifestyle factors, and physiological compensatory mechanisms. To date, dietary, supportive, behavioral, and exercise interventions have not demonstrated a clinically meaningful impact on WR, and there is limited evidence for pharmacotherapy. Future studies should be aimed at better defining WR to begin to understand the etiologies. Additionally, there is a need for non-surgical interventions with demonstrated efficacy in rigorous randomized controlled trials for the prevention and reversal of WR after bariatric surgery.

Gut-brain mechanisms underlying changes in disordered eating behaviour after bariatric surgery: a review

Bariatric surgery results in long-term weight loss and an improved metabolic phenotype due to changes in the gut-brain axis regulating appetite and glycaemia. Neuroendocrine alterations associated with bariatric surgery may also influence hedonic aspects of eating by inducing changes in taste preferences and central reward reactivity towards palatable food. However, the impact of bariatric surgery on disordered eating behaviours (e.g.: binge eating, loss-of-control eating, emotional eating and 'addictive eating'), which are commonly present in people with obesity are not well understood. Increasing evidence suggests gut-derived signals, such as appetitive hormones, bile acid profiles, microbiota concentrations and associated neuromodulatory metabolites, can influence pathways in the brain implicated in food intake, including brain areas involved in sensorimotor, reward-motivational, emotional-arousal and executive control components of food intake. As disordered eating prevalence is a key mediator of weight-loss success and patient well-being after bariatric surgery, understanding how changes in the gut-brain axis contribute to disordered eating incidence and severity after bariatric surgery is crucial to better improve treatment outcomes in people with obesity.

'In the night kitchen': A scoping review on the night eating syndrome

BACKGROUND

First described in 1955, night eating syndrome refers to an abnormal eating behavior clinically defined by the presence of evening hyperphagia (>25% of daily caloric intake) and/or nocturnal awaking with food ingestion occurring ⩾ 2 times per week.

AIMS

Although the syndrome is frequently comorbid with obesity, metabolic and psychiatric disorders, its etiopathogenesis, diagnosis, assessment and treatment still remain not fully understood.

METHODS

This review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines; PubMed database was searched until 31 October 2020, using the key terms: 'Night Eating Syndrome' AND 'complications' OR 'diagnosis' OR 'drug therapy' OR 'epidemiology' OR 'etiology' OR 'physiology' OR 'physiopathology' OR 'psychology' OR 'therapy'.

RESULTS

From a total of 239 citations, 120 studies assessing night eating syndrome met the inclusion criteria to be included in the review.

CONCLUSION

The inclusion of night eating syndrome into the Diagnostic and Statistical Manual of Mental Disorders-5 'Other Specified Feeding or Eating Disorders' category should drive the attention of clinician and researchers toward this syndrome that is still defined by evolving diagnostic criteria. The correct identification and assessment of NES could facilitate the detection and the diagnosis of this disorder, whose bio-psycho-social roots support its multifactorial nature. The significant rates of comorbid illnesses associated with NES and the overlapping symptoms with other eating disorders require a focused clinical attention. Treatment options for night eating syndrome include both pharmacological (selective serotonin reuptake inhibitors, topiramate and melatonergic drugs) and non-pharmachological approaches; the combination of such strategies within a multidisciplinary approach should be addressed in future, well-sized and long-term studies.

Evaluation of the impact of gastric bypass surgery on eating behaviour using objective methodologies under residential conditions: Rationale and study protocol

Gastric bypass surgery leads to significant and sustained weight loss and a reduction in associated health risks in individuals with severe obesity. While reduced energy intake (EI) is the primary driver of weight loss following surgery, the underlying mechanisms accounting for this energy deficit are not well understood. The evidence base has been constrained by a lack of fit-for-purpose methodology in assessing food intake coupled with follow-up studies that are relatively short-term. This paper describes the underlying rationale and protocol for an observational, fully residential study using covert, objective methodology to evaluate changes in 24-hr food intake in patients (n = 31) at 1-month pre-surgery and 3-, 12- and 24-months post-surgery, compared to weight-stable controls (n = 32). The main study endpoints included change in EI, macronutrient intake, food preferences, and eating behaviours (speed, frequency, and duration of eating). Other physiological changes that may influence EI and weight regulation including changes in body composition, circulating appetite hormones, resting metabolic rate, total energy expenditure and gastrointestinal symptoms were also evaluated. Understanding which mechanisms contribute to a reduction in EI and weight loss post-surgery could potentially help to identify those individuals who are most likely to benefit from gastric bypass surgery as well as those that may need more targeted intervention to optimise their weight loss post-surgery. Furthermore, clarification of these mechanisms may also inform targeted approaches for non-surgical treatments of obesity.

Chew and spit (CHSP) in bariatric patients: a case series

BACKGROUND

Studies into the disordered eating behaviour of chew and spit have alluded to several cohorts more likely to engage in the behaviour, one such group being bariatric surgery candidates and patients. Weight-loss surgery candidates have received little to no attention regarding engaging in chew and spit behaviour. Changes in pre- and post- surgery eating pathology related to chew and spit behaviour has yet to be explored and described in academic literature.

CASE PRESENTATION

The current study reports on three cases of individual women, aged 30, 35, and 62 respectively, who indicated engagement in chew and spit. All three cases underwent bariatric surgery (two underwent gastric bypass, one underwent vertical sleeve gastrectomy). Eating pathology-including chew and spit behaviour, anxiety and depression, and adherence to the Norwegian nutritional guidelines were examined pre-operatively and post-operatively (one and two-year follow-up). At baseline (pre-surgery), two participants reported that they engaged in chew and spit, compared to one patient post-surgery. All three cases reported that they, to at least some extent, adhered to dietary guidelines post-surgery. Subjective bingeing frequency appeared to be relatively low for all three cases, further declining in frequency at one-year follow-up. At baseline, one participant reported clinically significant depression and anxiety, with no clinically significant depression or anxiety reported at follow-ups in participants that chew and spit.

CONCLUSIONS

The current study provides a starting point for the exploration of chew and spit as a pathological symptom of disordered eating in bariatric patients. It highlights the need to further explore chew and spit before and after weight-loss surgery.

The Development of Feeding and Eating Disorders after Bariatric Surgery: A Systematic Review and Meta-Analysis

Background: Patients in the postoperative period following bariatric surgery are at risk of developing eating disorders. This study aims to analyze the relation between bariatric surgery and the development and recurrence of eating disorders. Material and methods: A literature review was carried out on 15 November 2020. Fourteen studies that met the eligibility criteria were included for qualitative synthesis, and 7 studies for meta-analysis. Results: The prevalence of eating disorders in the postoperative period was 7.83%, based on the 7 studies in the meta-analysis. Binge eating disorder alone was 3.81%, which was the most significant factor, and addressed in 6 of these studies. Conclusion: The investigated studies have significant methodological limitations in assessing the relation between bariatric surgery and eating disorders, since they mostly present data on prevalence. PROSPERO CRD42019135614.

Psychopathology and Adolescent Bariatric Surgery: A Topical Review to Support Psychologists in Assessment and Treatment Considerations

The rising rates of severe obesity among adolescents in the United States indicate a dire need for more intensive weight management strategies. While current evidence suggests that bariatric surgery is a safe and efficacious intervention for adolescents, the linkages with psychopathology before and after surgery are not well understood. Psychologists are an integral part of the interdisciplinary surgery team and play an important role in preparing youth for bariatric surgery as well as supporting adolescents post-surgery. The present manuscript reviews the literature on psychopathology in the context of adolescent bariatric surgery, discusses consideration of psychopathology as a contraindication for surgery, and provides recommendations on how psychologist members of the bariatric surgery team may balance attention to motivation and adherence to medical recommendations with assessment and treatment of psychopathology. Finally, the importance of continued research to confirm clinical consensus regarding decision-making and expansion of psychological resources within adolescent bariatric surgery programs are discussed.

Psychological Outcomes and Predictors of Weight Loss in Adolescents With Severe Obesity Following a Reversible Endoscopic Bariatric Procedure

Introduction: Adolescent and children obesity is a growing concern worldwide. Bariatric surgery is used as an effective treatment for adolescents with obesity and provides physical and mental health benefits. Application of alternative, minimally invasive, safe, and reversible endoscopic procedures, such as the Duodenojejunal bypass liner (DJBL), has been recently suggested as an effective treatment for adolescents with obesity. We explored specific psychological outcomes of adolescents with obesity during a year of follow-up after undergoing a reversible endoscopic bariatric procedure, and a year after removal. We were also interested in identifying psychological factors that could predict successful weight loss after the procedure. Methods: Nineteen adolescent with severe obesity undergoing DJBL procedure were psychologically assessed in an open-label, prospective clinical trial (NTC0218393), at the implantation of device and at the removal of device after 12 months. Control group of 26 adolescents with severe obesity were recruited from the same outpatient clinic undergoing only conservative treatment. In addition, adolescents from the intervention group were followed for 12 months after the removal of the device. The Youth Self Report (YSR) was used to assess adolescents' emotional and behavioural problems; The Multidimensional Body-Self Relations Questionnaire (MBSRQ) to assess body image and The Eating Disorder Examination Questionnaire (EDE-Q) to assess attitudes and behaviours related to eating disorder. Results: Significant improvements in somatic complain (F = 12.478, p = 0.001), emotional and behavioural problems (F = 7.169, p = 0.011) and food restraining (F = 9.605, p = 0.004) were found in the intervention group at device removal compared to the control group. Moreover, at the time of device removal compared to baseline, improvements in several psychological outcomes were found (F = 32.178 p = 0.000 for emotional and behavioural problems). Adolescents also became more satisfied with their appearance (F = 6.789, p = 0.019). Majority of observed changes remained stable at the next follow up a year after the device removal. Significant predictors of successful weight loss at device removal were fewer overeating episodes (B = 0.147, p = 0.022) and lower body satisfaction (B = 0.932, p = 0.013). Discussion: Following a reversible bariatric procedure, improvements of psychological (emotional and behavioural) factors were found in adolescents with severe obesity. Psychological predictors of successful weight loss were identified, showing the greatest importance of eating behaviour and body satisfaction in successful weight loss.

Relationship of personality characteristics and eating attitude with the success of bariatric surgery

Background: Obesity is a chronic disease that causes several medical and psychiatric complications. There are plenty of pharmacological and non-pharmacological therapies for obesity treatment. Bariatric surgery is one of the most efficient nonpharmacological treatment for morbid obesity; however, several psychological factors affect the success of bariatric surgery. This study aims to evaluate personality characteristics and eating attitude relationship with the success of bariatric surgery. Methods: This study was carried out on 75 patients with obesity who were candidates of bariatric surgery in the obesity clinic of Rasoul-e-Akram Hospital in Tehran. The patients were asked to fill the TCI and EAT-26 questionnaires before and after the surgery. Statistical analyses were performed using the SPSS-23 applying T-test, Mann-Whitney tests and Pearson and Spearman's correlation coefficient. The significance level was set at 0.05. Results: Seventy-five patients, including 13 men and 62 women, were assessed through this study. The mean of the BMI of the participants was 44.7 prior to the surgery and 30 after the operation. Personality characteristics and eating attitudes had no significant relationship with the success of bariatric surgery. Conclusion: Although the eating attitude and personal characteristics of the bariatric surgery candidates before the surgery was not related to the outcome of the surgery, they should be considered in post-operational psychological assessments.

Psychological outcomes following surgical and endoscopic bariatric procedures: A systematic review

Obesity is a leading global epidemic. Bariatric surgery is the only treatment demonstrating substantial long-term weight loss and medical benefits. However, there is limited research on the psychological outcomes following surgery. Therefore, the primary aim of this study was to systematically review depression, anxiety, and binge eating outcomes at different time points following bariatric surgery and identify whether bariatric surgery significantly reduces psychological symptoms over time. These outcomes were also examined among endoscopic bariatric procedures as a secondary aim. Forty-eight studies met inclusion criteria. Findings suggested that most patients experience a short-term reduction in anxiety and depression symptoms from pre-surgery. Over time, however, these symptoms increase and may even return to pre-surgery levels. Furthermore, while binge eating was uncommon after surgery, other disordered eating patterns may emerge. Binge eating may also restart over time as the stomach enlarges again. Overall, the complex psychological difficulties faced by individuals with obesity continue after surgery and may contribute to longer-term weight recidivism. More comprehensive and standardised psychological assessment procedures, including clinical interviews and longer-term follow-up, may provide insight into the psychological mechanisms maintaining weight management issues, and may serve as a starting point for improving the long-term success of patients with obesity.

Oral Hydration, Food Intake, and Nutritional Status Before and After Bariatric Surgery

BACKGROUND AND AIMS

Bariatric surgery is considered to be the most effective treatment of morbid obesity. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGBP) are the most popular procedures. We evaluated nutritional status, micro- and macronutrient intake, and oral hydration in patients before and regularly during 1 year after RYGBP and SG.

METHODS

All patients that had been through bariatric surgery with at least 1-year post-surgery were retrospectively included in the study. All participants were evaluated once during the 2 months before the surgery and at 1, 3, 6, and 12 months after surgery. Clinical and biological evaluations as well as dietary investigations were performed.

RESULTS

Fifty-seven patients were included in this study (28 RYGBP and 29 SG). Patients in the RYGBP group had significantly higher body weight (132.3 ± 22 versus 122.2 ± 22.2 kg, p = 0.039) than patients in the SG group. Before surgery, total energy intake, oral hydration, and vitamin and mineral intakes were not different between the two groups. RYGBP and SG induced significant similar excess weight loss 1 year after surgery, 48.6 29.8% and 57.6 27.6% of body weight respectively. Energy intake significantly decreased 1 month after surgery and slightly increased from 1 to 12 months without reaching baseline intake levels. Macronutrient repartition did not change during follow-up. Oral hydration significantly decreased after RYGBP (- 58%) and showed a trend to be decreased after SG (- 49%). Sixty-five percent of patients still had vitamin D deficiency 1 year after surgery. Whatever the type of surgery, more than 20% had some vitamin deficiency 1 month after surgery.

CONCLUSIONS

Calories intake decreases after bariatric surgery, whatever the type of procedure. In addition, the prevalence of vitamin deficiency is high after bariatric surgery. Lastly, oral hydration is importantly decreased after bariatric surgery, especially after RYGBP.

Consequences of Circadian Disruption in Shift Workers on Chrononutrition and their Psychosocial Well-Being

The workers and employees in various institutions are subjected to different shifts and work schedules. The employees work not only at daytime but also during odd hours at night. The biological clock of an individual is often altered during night shifts. This affects the psychosocial well-being and circadian nutritional intake of the worker. Disturbance in circadian rhythm results in the development of metabolic disorders such as hypertension, dyslipidemia, dysglycemia, and abdominal obesity. In the present review, we discuss the nature of shift work, sleep/wake cycle of an individual, chrononutrition, dietary habits, and meal changes with regard to timing and frequency, related to shift work. We also discuss the relationship between nutritional intake and psychosocial well-being among shift workers. The review may be beneficial for prevention of metabolic disorders and maintaining sound psychological condition in shift workers.

BARIATRIC SURGERY AND BINGE EATING DISORDER: SHOULD SURGEONS CARE ABOUT IT? A LITERATURE REVIEW OF PREVALENCE AND ASSESSMENT TOOLS

BACKGROUND

Eating pathologies among bariatric surgery candidates are common and associated with adverse surgical outcomes, including weight regain and low quality of life. However, their assessment is made difficult by the great variety and inconsistent use of standardized measures.

OBJECTIVE

The purpose of this review was to synthesize current knowledge on the prevalence of binge eating disorder (BED) in presurgical patients and to make a critical appraisal of assessment tools for BED.

METHODS

A search was conducted on PubMed, Scopus, and Web of Science databases from January 1994 to March 2017. Data were extracted, tabulated and summarized using a narrative approach.

RESULTS

A total of 21 observational studies were reviewed for data extraction and analysis. Prevalence of BED in bariatric populations ranged from 2% to 53%. Considerable variation in patient characteristics and in BED assessment measures was evident among the studies. In addition, several methodological weaknesses were recognized in most of the studies. Ten different psychometric instruments were used to assess BED. Clinical interviews were used in only 12 studies, though this is the preferred tool to diagnose BED.

CONCLUSION

Study heterogeneity accounted for the variability of the results from different centers and methodological flaws such as insufficient sample size and selection bias impaired the evidence on the magnitude of BED in surgical settings. For the sake of comparability and generalizability of the findings in future studies, researchers must recruit representative samples of treatment-seeking candidates for bariatric surgery and systematically apply standard instruments for the assessment of BED.

Perceived Social Support for Exercise and Weight Loss in Adolescents Undergoing Sleeve Gastrectomy

OBJECTIVES

Bariatric surgery is an effective treatment for youth with severe obesity. However, outcomes are variable and there remains sparse understanding of predictors of weight loss following surgery. The current study examines the role of adolescent-reported pre-operative social support around exercise, binge eating, and exercise to predict excess body mass index (EBMI) loss from 3 to 12 months post-surgery.

METHOD

Participants were 101 adolescents ages 12-21 (M age = 16.6, SD = 1.8). Pre-operative body mass index (BMI) ranged from 35 to 87 (M = 50.3, SD = 8.6). Structural equation modeling (SEM) was used to evaluate a model of the association of adolescent report of perceived social support for exercise with less binge eating (items from the Eating Disorder Diagnostic Scale) and more self-reported exercise (items from the Youth Risk Behavior Surveillance System). The model was used to predict EBMI loss at 3, 6, 9, and 12 months post-surgery.

RESULTS

Social support significantly predicted exercise and demonstrated a trend for predicting binge eating, such that more social support was associated with more exercise and a trend for less binge eating. Binge eating was associated with less EBMI loss. However, there was no association of exercise with EBMI loss.

CONCLUSIONS

Pre-operative binge eating should be a target for identification and treatment prior to sleeve gastrectomy in adolescents. Although not directly or indirectly associated with EBMI loss, perceived social support around exercise was associated with increased exercise, which may make it a consideration for a target for intervention as well.

Long-Term Effect of Gastric Bypass and Sleeve Gastrectomy on Severe Obesity: Do Preoperative Weight Loss and Binge Eating Behavior Predict the Outcome of Bariatric Surgery?

BACKGROUND

Few studies have examined weight loss sustainability after sleeve gastrectomy (SG). The purpose of this study was to determine long-term outcome after SG and gastric bypass (GBP) and learn whether preoperative weight loss and binge eating behavior can be used to predict outcome.

MATERIALS AND METHODS

Together, 257 patients (64 % women) were operated, 163 by GBP and 94 by SG. Binge eating was assessed by binge eating scale (BES) and preoperative weight loss was advised to all, including very low-calorie diet for 5 weeks. Postoperative visits took place at 1 and 2 years, and long-term outcome was at median 5 years (range 2.29-6.85). Multivariate linear regression analysis was used to predict outcome at 2-year and long-term control.

RESULTS

Median age was 48 years, weight 141.1 kg, and BMI 48.2 kg/m(2). Preoperative weight loss was median 4.9 % before GBP and 3.8 % before SG, P = 0.04. Total weight loss at year one was 24.1 % in GBP and 23.7 % in SG (P = 0.40), at year two 24.4 and 23.4 % (P = 0.26), and at long-term control 23.0 and 20.2 % (P = 0.006), respectively. Weight was analyzed in 93, 88, and 89 % of those alive, respectively. BES did not predict weight outcome, but larger preoperative weight loss predicted less postoperative weight loss at 2 years.

CONCLUSION

On long term, weight loss was better maintained after GBP compared with SG. Binge eating behavior was not a significant predictor, but larger preoperative weight loss predicted less postoperative weight loss for the next 2 years.

Cirurgia bariátrica e transtornos alimentares: uma revisão integrativa

RESUMO Objetivo Realizar revisão sobre transtornos alimentares e comportamentos alimentares transtornados relacionados à cirurgia bariátrica. Métodos Revisão integrativa da literatura nas bases de dados PubMed, Lilacs, Bireme, portal SciELO com descritores indexados com critérios de inclusão: oferecer dado sobre a presença ou frequência de transtorno alimentar e/ou comportamentos alimentares disfuncionais previamente e/ou após a cirurgia. Resultados Foram selecionados 150 estudos (14 nacionais e 136 internacionais): 80,6% eram com avaliação de pacientes pré-/pós-cirúrgicos; 12% eram estudos de caso e 7,3% eram estudos de revisão. Diferentes instrumentos foram usados para avaliação, principalmente o Questionnaire on Eating and Weight Patterns, a Binge Eating Scale e Eating Disorders Examination Questionnaire. A compulsão alimentar foi o comportamento mais avaliado, com frequências/prevalências variando de 2% a 94%; no caso do transtorno da compulsão alimentar as frequências/prevalências variaram de 3% a 61%. Houve também a descrição de anorexia e bulimia nervosa, síndrome da alimentação noturna e comportamento beliscador. Alguns estudos apontam melhora dos sintomas no pós-cirúrgico e/ou seguimento enquanto outros apontam surgimento ou piora dos problemas. Conclusão Apesar da variabilidade entre métodos e achados, comportamentos alimentares disfuncionais são muito frequentes em candidatos à cirurgia bariátrica e podem ainda surgir ou piorar após a intervenção cirúrgica. Profissionais de saúde devem considerar de maneira mais cuidadosa tais problemas neste público, dadas às consequências para o resultado cirúrgico e qualidade de vida.

Changes in problematic and disordered eating after gastric bypass, adjustable gastric banding and vertical sleeve gastrectomy: a systematic review of pre-post studies

Despite differences in their mechanisms and outcomes, little is known about whether postsurgical changes in eating behaviours also differ by bariatric procedure. Following a systematic search, 23 studies on changes in binge eating disorder (BED) and related behaviours, bulimia nervosa and related behaviours, night eating syndrome, grazing and emotional eating after Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB) and vertical sleeve gastrectomy (VSG) were reviewed. Significant methodological problems and a dearth of literature regarding many behaviours and VSG were seen. Regarding BED and related behaviours, although later re-increases were noted, short to medium-term reductions after RYGB were common, and reported changes after AGB were inconsistent. Short to medium-term reductions in emotional eating, and from a few studies, short to long-term reductions in bulimic symptoms, were reported after RYGB. Reoccurrences and new occurrences of problem and disordered eating, especially BED and binge episodes, were apparent after RYGB and AGB. Further conclusions and comparisons could not be made because of limited or low-quality evidence. Long-term comparison studies of changes to problematic and disordered eating in RYGB, AGB and VSG patients are needed. It is currently unclear whether any bariatric procedure leads to long-term improvement of any problematic or disordered eating behaviours.

Patients' long-term experiences following obesity surgery with a focus on eating behaviour: A qualitative study

This study explored long-term consequences of obesity surgery. Interpretative phenomenological analysis was used to analyse transcripts of 10 interviews with patients who underwent surgery 8 or more years ago. Experiences were described under three broad themes: eating behaviours, relationship with food and quality of life. Although patients described variability within these themes, describing different patterns of change, analysis revealed associations between themes and outcomes. In particular, those who reported successful weight loss also described the functionalization of food, the development of new coping strategies and a process of positive reinvention creating a new sense of self.

Poor diet quality and postoperative time are independent risk factors for weight regain after Roux-en-Y gastric bypass

OBJECTIVE

In this study, multivariate analyses was used to investigate factors associated with weight regain long after Roux-en-Y gastric bypass.

METHODS

This retrospective study comprised 80 patients (88.8% female) with at least 24 mo of postoperative time. Weight regain was defined as an increase of at least 10% of the lowest postoperative weight. The following data were collected: demographic characteristics, eating behavior, food intake, diet quality measured by the Healthy Eating Index, level of physical activity, follow-up visit attendance, anthropometric history, and postoperative time. Multivariate logistic regression generated a controlled analysis, followed by calculation of the odds ratio (OR).

RESULTS

The mean postoperative time was 47.0 ± 18.0 mo. The mean pre- and postoperative body mass indexes were 49.8 ± 9.3 kg/m(2) and 33.6 ± 7.2 kg/m(2), respectively. Despite satisfactory postoperative weight loss, 23.7% of the patients regained weight. After controlling for confounders, only postoperative time (OR 1.08; P < 0.01) and Healthy Eating Index (OR 0.95; P = 0.04) remained associated with weight regain.

CONCLUSION

Patients with long-term obesity and poor diet quality were at high risk of weight regain. These results suggest the need of nutritional monitoring during the late postoperative period, paying special attention to eating patterns.

Eating Disorders and Problematic Eating Behaviours Before and After Bariatric Surgery: Characterization, Assessment and Association with Treatment Outcomes

Accumulating evidence suggests that bariatric surgery candidates are likely to present with eating disorders (EDs) and/or problematic eating behaviours (EBs), and research suggests that these problems may persist or develop after bariatric surgery. While there is growing evidence indicating that EDs and EBs may impact bariatric surgery outcomes, the definitions and assessment methods used lack consensus, and findings have been mixed. The aims of this paper were (1) to summarize the existing literature on pre‐operative and post‐operative EDs and problematic EBs; (2) to discuss the terms, definitions and assessment measures used across studies; and (3) to consider the extent to which the presence of these problems impact surgery outcomes. We highlight the importance of investigators utilizing consistent definitions and assessment methodologies across studies. © 2015 The Authors. European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd.

Measurement of disordered eating following bariatric surgery: a systematic review of the literature

Disordered eating is elevated in bariatric surgery patients and is a risk factor for poor surgical outcomes. A systematic review evaluated the definitions and measurement methods used to identify and assess disordered eating in patients following bariatric surgery. One hundred articles were identified featuring 35 questionnaires and 23 interviews. There were numerous variations to diagnostic criteria and amendments to measures to account for the post-surgical eating context. Only 20% of questionnaires and 4% of interviews had reported psychometric evaluation in post-surgery samples. Results highlight the need for a consistent definition of disordered eating and for current assessment measures to be (a) adapted to account for the altered gastrointestinal system in patients following surgery and (b) psychometrically evaluated in bariatric surgery patients.

The eating-related behaviours, disorders and expectations of candidates for bariatric surgery

It is important that clinicians and researchers understand the possible eating-related difficulties experienced by pre-bariatric surgery candidates, as well as their expectations of how their eating and hunger will change after surgery. This review examines English-language publications related to the eating-related behaviours, disorders and expectations of bariatric candidates. Seventy-five articles related to binge eating disorder, grazing, night eating syndrome, emotional eating, food cravings and addiction, and pre-surgical expectations of post-surgical eating in this population were critically reviewed. A variety of often problematic eating behaviours appear more common in bariatric candidates than in non-obese populations. The literature suggests that 4-45% of candidates may have binge eating disorder, 20-60% may graze, 2-42% may have night eating syndrome, 38-59% may engage in emotional eating and 17-54% may fit criteria for food addiction. Binge eating may also be more prevalent in bariatric candidates than in similarly obese non-surgical individuals. Expectations of surgery are high, with pre-surgical candidates believing their bariatric procedure will virtually guarantee significantly improved eating behaviours. Study replications are needed, and further investigation into prevalence, impacts and candidate characteristics related to disordered eating behaviours, as well as candidates' expectations of eating after surgery, will be important. Further comparisons of bariatric candidates to similarly obese non-bariatric populations will be important to understand eating-related characteristics of candidates beyond those related to their weight. Future research may be improved by the use of validated measures, replicable methodologies, minimization of data collected in circumstances where respondents may been motivated to 'fake good', use of prospective data and consistent definitions of key terminology.

Effects of Theodore Millon's Teaching, Mentorship, Theory, and Scientific Contributions on Health Psychology and Behavioral Medicine Research and Practice

This article summarizes the impact of Theodore Millon's work on the disciplines of health psychology and behavioral medicine over the past 5 decades spanning from the late 1960s to present. The article is written from my perspectives as a graduate student mentored by Millon on through my faculty career as a collaborator in test construction and empirical validation research. Several of the most recent entries in this summary reflect projects that were ongoing at the time of his passing, revealing the innovation and visionary spirit that he demonstrated up until the end of his life. Considering that this summary is restricted to Millon's contributions to the disciplines of health psychology and behavioral medicine, this work comprises only a small portion of his larger contribution to the field of psychology and the areas of personality theory and psychological assessment more broadly.

Chronic subordination stress induces hyperphagia and disrupts eating behavior in mice modeling binge-eating-like disorder

Background: Eating disorders are associated with physical morbidity and appear to have causal factors like stressful life events and negative affect. Binge-eating disorder (BED) is characterized by eating in a discrete period of time a larger than normal amount of food, a sense of lack of control over eating, and marked distress. There are still unmet needs for the identification of mechanisms regulating excessive eating, which is in part due to the lack of appropriate animal models. We developed a naturalistic murine model of subordination stress-induced hyperphagia associated with the development of obesity. Here, we tested the hypotheses that the eating responses of subordinate mice recapitulate the BED and that limiting hyperphagia could prevent stress-associated metabolic changes.

Methods: Adult male mice were exposed to a model of chronic subordination stress (CSS) associated with the automated acquisition of food intake and we performed a detailed meal pattern analysis. Additionally, using a pair-feeding protocol we tested the hypothesis that the manifestation of obesity and the metabolic syndrome could be prevented by limiting hyperphagia.

Results: The architecture of feeding of subordinate mice was disrupted during the stress protocol due to disproportionate amount of food ingested at higher rate and with shorter satiety ratio than control mice. Subordinate mice hyperphagia was further exacerbated in response to either hunger or to the acute application of a social defeat. Notably, the obese phenotype but not the fasting hyperglycemia of subordinate mice was abrogated by preventing hyperphagia in a pair-feeding paradigm.

Conclusion: Overall, these results support the validity of our CSS to model BED allowing for the determination of the underlying molecular mechanisms and the generation of testable predictions for innovative therapies, based on the understanding of the regulation and the control of food intake.

Optimal management of night eating syndrome: challenges and solutions

Night Eating Syndrome (NES) is a unique disorder characterized by a delayed pattern of food intake in which recurrent episodes of nocturnal eating and/or excessive food consumption occur after the evening meal. NES is a clinically important disorder due to its relationship to obesity, its association with other psychiatric disorders, and problems concerning sleep. However, NES often goes unrecognized by both health professionals and patients. The lack of knowledge regarding NES in clinical settings may lead to inadequate diagnoses and inappropriate treatment approaches. Therefore, the proper diagnosis of NES is the most important issue when identifying NES and providing treatment for this disorder. Clinical assessment tools such as the Night Eating Questionnaire may help health professionals working with populations vulnerable to NES. Although NES treatment studies are still in their infancy, antidepressant treatments and psychological therapies can be used for optimal management of patients with NES. Other treatment options such as melatonergic medications, light therapy, and the anticonvulsant topiramate also hold promise as future treatment options. The purpose of this review is to provide a summary of NES, including its diagnosis, comorbidities, and treatment approaches. Possible challenges addressing patients with NES and management options are also discussed.

Review article: The nutritional and pharmacological consequences of obesity surgery

BACKGROUND

Obesity surgery is acknowledged as a highly effective therapy for morbidly obese patients. Beneficial short-term effects on common comorbidities are practically undisputed, but a growing data pool from long-term follow-up reveals increasing evidence of potentially severe nutritional and pharmacological consequences.

AIMS

To assess the prevalence, causes and symptoms of complications after obesity surgery, to elucidate and compare therapy recommendations for macro- and micronutrient deficiencies, and to explore surgically-induced effects on drug absorption and bioavailability, discussing ramifications for long-term therapy and prophylaxis.

METHODS

PubMed, Embase and MEDLINE were searched using terms including, but not limited to, bariatric surgery, gastric bypass, obesity surgery and Roux-en-Y, coupled with secondary search terms, e.g. anaemia, micronutrients, vitamin deficiency, bacterial overgrowth, drug absorption, pharmacokinetics, undernutrition. All studies in English, French or German published January 1980 through March 2014 were included.

RESULTS

Macro- and micronutrient deficiencies are common after obesity surgery. The most critical, depending on surgical technique, are hypoalbuminemia (3-18%) and deficiencies of vitamins B1 (≤49%), B12 (19-35%) and D (25-73%), iron (17-45%) and zinc (12-91%). Many drugs commonly administered to obese patients (e.g. anti-depressants, anti-microbials, metformin) are subject to post-operative and/or PPI-associated changes affecting bioavailability and absorption.

CONCLUSIONS

Complications are associated with pre-operative and/or post-operative malnutrition or procedure-related changes in intake, absorption and drug bioavailability. The high prevalence of nutrient deficiencies after obesity surgery makes life-long nutritional monitoring and supplementation essential. Post-operative changes to drug absorption and bioavailability in bariatric patients cast doubt on the validity of standard drug dosage and administration recommendations.

Psychological assessment of candidates for bariatric surgery

Objectives: National Institute of Clinical Excellence guidelines indicate that pre-surgical assessment of patients wishing to undergo bariatric surgery should include consideration of psychological factors. This paper describes the psychological characteristics of a cohort of 59 patients.

Method: Patients were interviewed and completed the following psychometric assessments: the Hospital Anxiety and Depression Scale, the Dieting Belief Scale, the Binge Eating Scale, the Emotional Eating Scale, the Generalised Self Efficacy Scale, and the Social Support Questionnaire.

Results: High levels of psychological distress and binge eating were reported. Men more commonly reported a history of alcohol misuse. There was evidence to suggest that psychological distress predated obesity in the majority of cases.

Conclusion: Compulsive eating leading to obesity appears to be both a consequence and a cause of psychological distress. Replacing compulsive eating represents a major post-surgical challenge in the majority of cases. Psychological assessment and follow-up should be offered to each patient.

Depression and Disordered Eating in the Obese Person

Three mental health problems commonly associated with obesity are major depression, binge eating disorder (BED), and Night Eating Syndrome (NES). Evidence from both cross-sectional and longitudinal studies support independent relationships between obesity and depression, and between obesity and binge eating. These problems are most prevalent in severely obese individuals (Class III obesity; a body mass index (BMI) of >40kgm(2)), many of whom seek bariatric surgery, and we briefly review whether the presence of pre-operative depression, BED or NES affects post-operative outcomes. Historically depressed individuals have been screened out of weight loss trials due to concerns of worsening mood with weight loss. Such practices have precluded the development of effective treatments for depressed, obese individuals, leaving large numbers of people without appropriate care. We present recent advances in this area, and attempt to answer whether depressed individuals can lose clinically significant amounts of weight, show improvements in mood, and adhere to the demands of a weight loss intervention.

The Treatment of Night Eating Syndrome: A Review and Theoretical Model

The treatment of night eating syndrome, a disorder characterized by evening hyperphagia, morning anorexia, and insomnia, continues to gain attention with its inclusion in the DSM-V. Known treatments for NES include pharmacological, phototherapy, weight loss and dietary, and psychological interventions, which, together with the syndrome's clinical characteristics, support a treatment guiding biobehavioral model. The biobehavioral model proposes that a genetic predisposition, coupled with stress, enhances midbrain serotonin transporter (SERT) binding, which results in lower post-synaptic serotonin, dysregulating circadian rhythms and decreasing satiety. Selective serotonin reuptake inhibitors should therefore decrease SERT binding, increase postsynaptic serotonin, and restore circadian function and satiety regulation. Psychological interventions may be used to decrease stress as well as address insomnia and circadian rhythm disruptions. Dietary and behavioral interventions may produce beneficial changes in satiety as well as dysregulated eating. Avenues for future treatment outcome studies, including alternative pharmacological and combination therapies, are discussed.

Binge eating, binge eating disorder and loss of control eating: effects on weight outcomes after bariatric surgery

There is increasing evidence that patients who have problems with binge eating (BE) or BE disorder (BED) are quite common among the severely obese, including bariatric surgery candidates. The literature suggests that in many cases such eating behaviours improve after bariatric surgery, although this is not uniformly true. The current paper reviews the data on the development of BE, BED and loss of control (LOC) eating after bariatric surgery and the impact of these problems on long-term weight outcome. A search was made of various databases regarding evidence of BE, BED and LOC eating post-operatively in bariatric surgery patients. The data extracted from the literature suggests that 15 research studies have now examined this question. Fourteen of the available 15 studies suggest that the development of problems with BE, BED or LOC eating post-bariatric surgery is associated with less weight loss and/or more weight regain post-bariatric surgery. These data suggests that it is important to identify individuals at high risk for these problems, to follow them post-operatively, and, if appropriate interventions can be developed if such behaviours occur in order to maximize weight loss outcomes.

Measurement of disordered eating in bariatric surgery candidates: a systematic review of the literature

Symptoms of disordered eating are common among patients seeking bariatric surgery, and assessment of eating pathology is typical in pre-surgical evaluations. A systematic review was conducted to evaluate the definitions, diagnostic criteria and measures used to assess disordered eating in adults seeking bariatric surgery. The review identified 147 articles featuring 34 questionnaires and 45 interviews used in pre-surgical assessments. The Questionnaire on Eating and Weight Patterns Revised and the Structured Clinical Interview for DSM were the most frequently used questionnaire and interview respectively. Variations to pre-surgical diagnostic criteria included changes to the frequency and duration criteria for binge eating, and inconsistent use of disordered eating definitions (e.g., grazing). Results demonstrate a paucity of measures designed specifically for an obese sample, and only 24% of questionnaires and 4% of interviews used had any reported psychometric evaluation in bariatric surgery candidates. The psychometric data available suggest that interview assessments are critical for accurately identifying binge episodes and other diagnostic information, while self-report questionnaires may be valuable for providing additional information of clinical utility (e.g., severity of eating, shape and weight-related concerns). Findings highlight the need for consensus on disordered eating diagnostic criteria and psychometric evaluation of measures to determine whether existing measures provide a valid assessment of disordered eating in this population. Consistent diagnosis and the use of validated measures will facilitate accurate identification of disordered eating in the pre-surgical population to enable assessment of suitability for surgery and appropriate targeting of treatment for disordered eating to optimise treatment success.

A computational hypothesis for allostasis: delineation of substance dependence, conventional therapies, and alternative treatments

The allostatic theory of drug abuse describes the brain's reward system alterations as substance misuse progresses. Neural adaptations arising from the reward system itself and from the antireward system provide the subject with functional stability, while affecting the person's mood. We propose a computational hypothesis describing how a virtual subject's drug consumption, cognitive substrate, and mood interface with reward and antireward systems. Reward system adaptations are assumed interrelated with the ongoing neural activity defining behavior toward drug intake, including activity in the nucleus accumbens, ventral tegmental area, and prefrontal cortex (PFC). Antireward system adaptations are assumed to mutually connect with higher-order cognitive processes occurring within PFC, orbitofrontal cortex, and anterior cingulate cortex. The subject's mood estimation is a provisional function of reward components. The presented knowledge repository model incorporates pharmacokinetic, pharmacodynamic, neuropsychological, cognitive, and behavioral components. Patterns of tobacco smoking exemplify the framework's predictive properties: escalation of cigarette consumption, conventional treatments similar to nicotine patches, and alternative medical practices comparable to meditation. The primary outcomes include an estimate of the virtual subject's mood and the daily account of drug intakes. The main limitation of this study resides in the 21 time-dependent processes which partially describe the complex phenomena of drug addiction and involve a large number of parameters which may underconstrain the framework. Our model predicts that reward system adaptations account for mood stabilization, whereas antireward system adaptations delineate mood improvement and reduction in drug consumption. This investigation provides formal arguments encouraging current rehabilitation therapies to include meditation-like practices along with pharmaceutical drugs and behavioral counseling.

Predictors of decreased binge eating following laparoscopic adjustable gastric banding using the Health Action Process Approach model

The current study aimed to examine predictors of reduced binge eating in patients undergoing laparoscopic adjustable gastric banding (LAGB) for severe obesity. Participants were 49 patients (13 males and 36 females) who completed measures of binge eating, behavioural intentions, planning and self-efficacy two weeks prior and three months after their operation. Reduced binge eating following surgery was predicted by behavioural intentions. Planning and volitional self-efficacy were unable to predict a significant amount of variance over and above intentions. The results highlight how the role of intentions must not be overlooked when investigating the prediction of health behaviour change and challenge the notion that post-intentional constructs that translate intentions into action are more important. Interventions aiming to increase preoperative levels of intention to follow the post-operative eating guidelines in patients presenting with binge eating might be a useful way of decreasing this behaviour in patients opting for LAGB surgery in order to achieve weight loss and physical well-being.

Preoperative nutritional interventions in morbid obesity: impact on body weight, energy intake, and eating quality

BACKGROUND

Although the benefits of preoperative weight loss and adequacy of dietary patterns in bariatric surgery is well-recognized, the nutritional strategies in the preoperative period have been scarcely investigated. We aimed to evaluate the impact of intensive and standard nutritional interventions on body weight, energy intake, and eating quality.

METHODS

This is a retrospective study in which 32 patients undergoing intensive nutritional intervention, with low-calorie diet (10 kcal/kg) and biweekly visits, were pair-matched by age, sex, and body mass index with 32 patients under a standard nutritional intervention, based on a general dietary counseling. Twenty-four-hour food recall was used to assess energy intake and to derive healthy eating index (HEI). The follow-up preoperative period varied from 8 to 16 weeks.

RESULTS

Weight loss was observed in 72% of the patients from the intensive intervention group and 75% of the patients from the standard intervention group. According to the mixed model analysis, time effect on weight loss in both groups was significant (P = 0.0002); however, no difference was found between the intervention groups (P = 0.71). The time effect was significant in both groups for energy intake reduction as well (P < 0.0001), but no difference was found between the intervention groups (P = 0.25). Improvement of eating quality was expressed by the nutrient score of the HEI that increased significantly overtime (P = 0.02), also without distinction between the groups (P = 0.61).

CONCLUSION

Both intensive and standard nutritional interventions promoted weight loss, energy intake reduction, and improvement of eating quality in morbidly obese patients during preoperative period.

Examining the Binge Eating Scale in screening for binge eating disorder in bariatric surgery candidates. Obes Surg. 2013;23:1-6. [PMID: 23104387 DOI: 10.1007/s11695-011-0537-4]

BACKGROUND

This study assessed the utility of the Binge Eating Scale (BES) as a measure of binge eating disorder (BED) in a bariatric surgery-seeking population by (a) determining the optimal BES cut score for predicting BED, (b) calculating concordance statistics, and (c) determining the predictive value of each BES item.

METHODS

Four hundred seventy-three patients presented for a psychological evaluation prior to Roux-en-Y gastric bypass surgery. The BES and the SCID semi-structured interview for BED were administered.

RESULTS

Receiver operating characteristic curve analyses identified an optimal BES cut score of 17, which correctly classified 78% of patients with BED. A cut score of 27 improved this statistic, but significantly increased the number of false negatives, which is undesirable for a screening assessment. Discriminant function analyses revealed that nearly all BES items significantly predicted BED.

CONCLUSIONS

The BES is a valid screener of BED for patients seeking bariatric surgery; however, false positives can be expected. Administering the BES as part of a comprehensive psychological evaluation can help improve the assessment and treatment of patients presenting for bariatric surgery.

Night eating syndrome: implications for severe obesity

Night eating syndrome (NES) was first identified in 1955 by Stunkard, a psychiatrist specialising in eating disorders (ED). Over the last 20 years considerable progress has been made in defining NES as a significant clinical entity in its own right and it has now been accepted for inclusion in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) due for publication in 2013. NES is considered a dysfunction of circadian rhythm with a disassociation between eating and sleeping. Core criteria include a daily pattern of eating with a significantly increased intake in the evening and/or night time, as manifested by one or both of the following: at least 25% of food intake is consumed after the evening meal or at least two episodes of nocturnal eating per week. An important recent addition to core criteria includes the presence of significant distress and/or impairment in functioning. Stunkard's team recommend further investigation on the pathogenesis of NES, in particular its relationship with traumatic life events, psychiatric comorbidity, the age of onset of NES and course of NES over time. The relationship between NES and other ED also requires further clarification as night-eaters exhibit some features of other ED; previous guidance to separate NES from other ED may have hindered earlier characterisation of NES. Evidence from European and American studies suggests NES features strongly in populations with severe obesity. The complex interplay between depression, impaired sleep and obesity-related comorbidity in severely obese individuals makes understanding NES in this context even more difficult. This review examines evidence to date on the characterisation of NES and concludes by examining the applicability of current NES criteria to individuals with severe obesity.

Gastric Bypass in a Low-Income, Inner-City Population: Eating Disturbances and Weight Loss

OBJECTIVE

To examine the prevalence of eating disturbances and psychiatric disorders among extremely obese patients before and after gastric bypass surgery and to examine the relationship between these disturbances and weight outcomes.

RESEARCH METHODS AND PROCEDURES

Sixty-five women patients (ages 19 to 67) with a mean BMI of 54.1 were assessed by semistructured psychiatric interview before surgery and by telephone interview after surgery (mean follow-up: 16.4 months) to determine psychiatric status, eating disturbances, and weight and health-related variables.

RESULTS

Patients lost a mean of 71% of their excess BMI, with significantly poorer weight loss outcomes among African Americans. Psychiatric disorders remained prevalent before (37%) and after (41%) surgery. In contrast, binge eating disorder dropped from 48% to 0%. Psychiatric diagnosis did not affect weight outcomes. Instead, more frequent preoperative binge eating, along with greater initial BMI, follow-up length, and postoperative exercise, predicted greater BMI loss. Postsurgical health behaviors (exercise and smoking) and nocturnal eating episodes were also linked to weight loss. Exercise frequency increased and smoking frequency tended to decrease after surgery.

DISCUSSION

These findings indicated that eating and psychiatric disturbances did not inhibit weight loss after gastric bypass and should not contraindicate surgery. Prior binge eating, eliminated after surgery, predicted BMI loss and, thus, may have previously been a maintaining factor in the obesity of these patients. The association between health behaviors and outcome suggests possible targets for intervention to improve surgical results. Poorer outcomes among African Americans indicate that these patients should be closely monitored and supported after surgery.

Sleep problems are associated with binge eating in women

OBJECTIVE

We examined the association among current self-reported sleep problems, lifetime binge eating (BE), and current obesity in women from the Swedish Twin study of Adults: Genes and Environment.

METHOD

Logistic regression analyses were used to evaluate these associations in 3,790 women aged 20-47 years.

RESULTS

BE was reported by 244 (6.4%) women and was positively associated with not getting enough sleep (p < .015), sleeping poorly (p < .001), problems falling asleep (p < .001), feeling sleepy during work or free time (p < .001), and disturbed sleep (p < .001). These same sleep variables, as well as napping and being a night person, were also significantly associated with obesity. The associations between BE and sleep remained after accounting for obesity.

DISCUSSION

This investigation offers empirical support for an independent association between sleep problems and BE, which is likely due to complex psychological, biological, neuroendocrine, and metabolic factors.

Escitalopram for treatment of night eating syndrome: a 12-week, randomized, placebo-controlled trial

The primary objective of this study was to examine the short-term effects of escitalopram on symptoms of night eating syndrome (NES) in a randomized controlled clinical trial. A total of 40 patients with NES were randomly assigned to double-blind treatment with escitalopram 20 mg (n = 20) or placebo (n = 20) for 12 weeks. Escitalopram was started at 10 mg/d with a dosage increase to 20 mg/d after 4 weeks; placebo dosing was identical. The primary end point was a mean change in total score of the Night Eating Questionnaire (NEQ). At 12 weeks, mean (SE) change in NEQ total score was -13.0 (1.6) and -10.6 (2.2) in the escitalopram and placebo groups, respectively (F(1,37) = 2.5, P = 0.124). There was a marginal interaction effect between response to escitalopram and race (F(1,34) = 4.0, P = 0.052), with a favorable effect for white patients (F(1,20) = 6.0, P = 0.024) but not for black patients (F(1,13) = 0.6, P = 0.453). Seven patients in the escitalopram group, compared with 6 patients in the placebo group, showed a 50% NEQ score reduction (P = 0.736). Sixteen patients in the escitalopram group and 12 patients in the placebo group no longer met NES criteria (P = 0.168). Twelve patients in the escitalopram group were classified as responders according to the Clinical Global Impression Improvement scale compared with 7 patients in the placebo group (P = 0.113). No significant between-group differences were found for weight, mood ratings, or adverse events. We conclude that escitalopram treatment for 12 weeks was not superior to placebo in reducing NES symptoms as measured by the NEQ.