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1.  Improved Memory Function Two Years After Bariatric Surgery 
Obesity (Silver Spring, Md.)  2013;22(1):32-38.
Obesity is as an independent risk factor for poor neurocognitive outcomes, including Alzheimer’s disease. Bariatric surgery has recently been shown to result in improved memory at 12-weeks post-operatively. However, the long-term effects of bariatric surgery on cognitive function remain unclear.
Design and Methods
86 individuals (63 bariatric surgery patients, 23 obese controls) were recruited from a prospective study examining the neurocognitive effects of bariatric surgery. All participants completed self-report measurements and a computerized cognitive test battery prior to surgery and at 12-week and 24-month follow-up; obese controls completed measures at equivalent time points.
Bariatric surgery patients exhibited high rates of pre-operative cognitive impairments in attention, executive function, memory, and language. Relative to obese controls, repeated measures ANOVA showed improvements in memory from baseline to 12-weeks and 24-months post-operatively (p < .05). Regression analyses controlling for baseline factors revealed that a lower BMI at 24-months demonstrated a trend toward significance for improved memory (β = -.30, p = .075).
These findings suggest that cognitive benefits of bariatric surgery may extend to 24-months post-operatively. Larger prospective studies with extended follow-up periods are needed to elucidate whether bariatric surgery decreases risk for cognitive decline and possibly the development of dementia.
PMCID: PMC4054602  PMID: 23625587
Obesity; bariatric surgery; cognitive function; weight loss
2.  Weight Change and Health Outcomes at Three Years After Bariatric Surgery Among Patients with Severe Obesity 
Severe obesity (Body Mass Index, BMI ≥35) is associated with a broad range of health risks. Bariatric surgery induces weight loss and short-term health improvements but little is known about long term outcomes of these operations.
Report 3 year change in weight and select health parameters following common bariatric surgical procedures.
The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium is a multi-center observational cohort study at ten hospitals in six geographically diverse clinical centers in the United States.
Adults undergoing first-time bariatric surgical procedure as part of routine clinical care by participating surgeons were recruited between 2006 and 2009 and followed until September 2012. Participants completed research assessments utilizing standardized and detailed data collection prior to surgery and 6 months, 12 months, and then annually post-surgery.
Three years following Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) we assessed percent weight change from baseline and the percentage of patients with diabetes achieving HbA1c <6.5 or FPG < 126 mg/dL without pharmacologic therapy. Dyslipidemia or hypertension resolution at 3 years was also assessed.
At baseline, participants (n=2458) ranged in age from 18 to 78 years, 79% were women, the median BMI was 45.9 (interquartile range (IQR) 41.7–51.5) kg/m2 and median baseline weight was 129 (115, 147) kg. 1738 participants underwent RYGB, 610 LAGB, and 110 other procedures. At baseline, 774 (33%) had diabetes, 1252 (63%) dyslipidemia, and 1601 (68%) hypertension. 3 years post-surgery, the median actual weight loss for RYGB participants was 41 (IQR: 31, 52) kg corresponding to percent of baseline weight lost of 31.5% (IQR: 24.6%–38.4%). For LAGB participants, actual weight loss was 20 (IQR: 10, 29) kg which results in 15.9% (IQR: 7.8%–23.0%) weight loss. The majority of weight loss was evident one year post-surgery for both procedures. Five distinct weight change trajectory groups were identified for each procedure. 216(67.5%) of RYGB and 28(28.6%) of LAGB participants who had diabetes at baseline experienced partial remission at three years. The incidence of diabetes was 0.9% after RYGB and 3.2% following LAGB. Dyslipidemia resolved in 237 (61.9%) of RYGB and 39 (27.1%) of LAGB participants, remission of hypertension occurred in 269(38.2%) and 43(17.4%) of RYGB and LAGB participants, respectively.
Among patients with severe obesity, there was substantial weight loss 3 years following bariatric surgery with the majority experiencing maximum weight change during the first year. However, there was variability in the amount and trajectories of weight loss, and in diabetes, blood pressure, and lipid outcomes. NCT00465829,
PMCID: PMC3955952  PMID: 24189773
3.  Cognitive Function Predicts Weight Loss Following Bariatric Surgery 
Clinically significant cognitive impairment is found in a subset of patients undergoing bariatric surgery. These difficulties could contribute to reduced adherence to postsurgical lifestyle changes and decreased weight loss.
The current study is the first to prospectively examine the independent contribution of cognitive function to weight loss following bariatric surgery. Executive function/attention and verbal memory at baseline were expected to negatively predict percent excess weight loss (%EWL) and body mass index (BMI) at follow-up.
Three sites of the Longitudinal Assessment of Bariatric Surgery (LABS) parent project were used: Columbia, Cornell, and Neuropsychiatric Research Institute
Eighty-four individuals enrolled in the LABS project undergoing bariatric surgery completed cognitive evaluation at baseline. BMI and %EWL were calculated at 12-week and 12-month post-surgery follow-ups.
Clinical impairment in task performance was most prominent in tasks associated with verbal recall and recognition (14.3–15.5% of the sample) and perseverative errors (15.5%). After accounting for demographic and medical variables, baseline tests of attention/executive function and memory predicted BMI and %EWL at 12 months, but not at 12 weeks.
Results demonstrate that baseline cognition predicts greater %EWL and lower BMI 12 months following bariatric surgery. Further work is needed to clarify the degree to which cognition contributes to adherence, and the potential mediation of cognition on the relationship between adherence and weight loss in this group.
PMCID: PMC3294182  PMID: 22133580
memory; cognition; executive function
4.  The Role of Eating and Emotion in Binge Eating Disorder and Loss of Control Eating 
Binge eating, defined as the consumption of large amounts of food during which a sense of loss of control is experienced, is associated with negative affect. However, there are no data on the experience of loss of control after accounting for the effects of negative affect and caloric intake.
Nine adult patients with binge eating disorder (BED) and 13 obese non-BED (NBED) participants carried a palmtop computer for seven days, rating momentary mood and sense of loss of control multiple times each day. Electronic food logs were collected once daily.
After removing the effects of caloric intake and negative affect, a significant group difference was observed for ratings of loss of control between BED and NBED participants.
These findings suggest the experience of loss of control in adults with BED is a salient feature of binge episodes, beyond that explained by caloric intake and momentary affect.
PMCID: PMC3570734  PMID: 23109227
5.  Temporal Sequence of Comorbid Alcohol Use Disorder and Anorexia Nervosa 
Addictive behaviors  2012;38(3):1704-1709.
Women with eating disorders have a significantly higher prevalence of substance use disorders than the general population. The goal of the current study was to assess the temporal pattern of comorbid anorexia nervosa (AN) and alcohol use disorder (AUD) and the impact this ordering has on symptomatology and associated features. Women were placed into one of three groups based on the presence or absence of comorbid AUD and the order of AN and AUD onset in those with both disorders: (1) AN Only, (2) AN First, and (3) AUD First. The groups were compared on psychological symptoms and personality characteristics often associated with AN, AUD, or both using general linear models. Twenty-one percent of women (n = 161) with AN reported a history of AUD with 115 reporting AN onset first and 35 reporting AUD onset first. Women with binge-eating and/or purging type AN were significantly more likely to have AUD. In general, differences were found only between women with AN Only and women with AN and AUD regardless of order of emergence. Women with AN and AUD had higher impulsivity scores and higher prevalence of depression and borderline personality disorder than women with AN Only. Women with AN First scored higher on traits commonly associated with AN, whereas women with comorbid AN and AUD displayed elevations in traits more commonly associated with AUD. Results do not indicate a distinct pattern of symptomatology in comorbid AN and AUD based on the temporal sequence of the disorders.
PMCID: PMC3558554  PMID: 23254222
anorexia nervosa; alcohol use disorder; comorbidity; age of onset
6.  Moderators of Post-Binge Eating Negative Emotion in Eating Disorders 
Journal of psychiatric research  2012;47(3):323-328.
The purpose of this study was to test the impact of two variables on post-binge eating negative emotion in a combined sample of women with anorexia nervosa (AN; n = 47) and bulimia nervosa (BN; n = 121). Participants completed two weeks of an ecological momentary assessment protocol during which they provided multiple daily ratings of overall negative affect and guilt and reported eating disorder behaviors including binge eating and self-induced vomiting. The results indicate that both overall negative affect and guilt exhibited a statistically significantly decrease in the hour immediately following binge eating episodes. The decrease in guilt, but not overall negative affect, was moderated by eating disorder diagnosis and the tendency to engage in self-induced vomiting. Specifically, individuals with BN reported a greater reduction in guilt than those with AN, and individuals who did not typically engage in self-induced vomiting reported more decreases in guilt than those who typically engaged in self-induced vomiting. This study extends the existing literature on the relationship between negative affect and eating disorder behaviors, suggesting guilt as a potentially relevant facet of negative affect in the maintenance of binge eating. In addition, the findings indicate that two individual differences, eating disorder diagnosis and self-induced vomiting, may influence the trajectory of guilt following binge eating episodes.
PMCID: PMC3570645  PMID: 23245289
anorexia nervosa; bulimia nervosa; negative affect; guilt; ecological momentary assessment
7.  Trait-level and momentary correlates of bulimia nervosa with a history of anorexia nervosa 
Some investigators have suggested subtyping bulimia nervosa (BN) by anorexia nervosa (AN) history. We examined trait-level and momentary eating-related and psychosocial factors in BN with and without an AN history.
Interview, questionnaire, and ecological momentary assessment data of eating-related and psychological symptoms were collected from 122 women with BN, including 43 with (BN+) and 79 without an AN history (BN−).
Body mass index (kg/m2) was lower in BN+ than BN− (p=.001). Groups did not differ on trait-level anxiety, shape/weight concerns, psychiatric comorbidity, or dietary restraint; or on momentary anxiety, dietary restriction, binge eating, purging, or exercise frequency, or affective patterns surrounding binge/purge behaviors. Negative affect increased prior to exercise and decreased thereafter in BN+ but not BN−, although groups did not statistically differ.
Results do not support formally subtyping BN by AN history. Exercise in BN+ may modulate negative affect, which could have important treatment implications.
PMCID: PMC3570735  PMID: 22987478
eating disorders; bulimia nervosa; history of anorexia nervosa; subtyping; classification; exercise
8.  Associations between physical activity and mental health among bariatric surgical candidates 
Journal of psychosomatic research  2013;74(2):161-169.
This study aimed to examine associations between physical activity (PA) and mental health among adults undergoing bariatric surgery.
Cross sectional analysis was conducted on pre-operative data of 850 adults with ≥ class 2 obesity. PA was measured with a step activity monitor; mean daily steps, active minutes, and high-cadence minutes (proxy for moderate-vigorous intensity PA) were determined. Mental health functioning, depressive symptoms and treatment for depression or anxiety were measured with the Medical Outcomes Study 36-item Short Form, Beck Depression Inventory, and a study-specific questionnaire, respectively. Logistic regression analyses tested associations between PA and mental health indicators, controlling for potential confounders. Receiver operative characteristic analysis determined PA thresholds that best differentiated odds of each mental health indicator.
Each PA parameter was significantly (P<.05) associated with a decreased odds of depressive symptoms and/or treatment for depression or anxiety, but not with impaired mental health functioning. After controlling for sociodemographics and physical health, only associations with treatment for depression and anxiety remained statistically significant. PA thresholds that best differentiated those who had vs. had not recently received treatment for depression or anxiety were <191 active minutes/day, <4750 steps/day, and <8 high-cadence minutes/day. Utilizing high-cadence minutes, compared to active minutes or steps, yielded the highest classification accuracy.
Adults undergoing bariatric surgery who meet relatively low thresholds of PA (e.g., ≥ 8 high-cadence minutes/day, representative of approximately one hour/week of moderate-vigorous intensity PA) are less likely to have recently received treatment for depression or anxiety compared to less active counterparts.
PMCID: PMC3556899  PMID: 23332532
anxiety; bariatric surgery; depressive symptoms; exercise; Roux-en-Y gastric bypass; severe obesity
9.  Psychopathology Prior to Surgery in the Longitudinal Assessment of Bariatric Surgery-3 (LABS-3) Psychosocial Study 
Current and prior psychopathology in bariatric surgery candidates is believed to be common. Accurate prevalence estimates, however, are difficult to obtain given that bariatric surgery candidates often wish to appear psychiatrically healthy when they are undergoing psychiatric evaluation prior to being approved for the surgery. Also, structured diagnostic assessments have been utilized infrequently.
This report concerns the 199 patients who were enrolled in the Longitudinal Assessment of Bariatric Surgery (LABS) study who also participated in the LABS-3 Psychopathology sub-study. All were interviewed independent of the usual preoperative psychosocial evaluation process. Patients were explicitly told that the data would not be shared with the surgical team unless certain high risk behaviors such as suicidality that could lead to adverse peri-operative outcomes were reported.
The majority of the sample was female (82.9%) and Caucasian (non-white 7.6%, Hispanic 5.0%). The median age was 46.0 years with a median body mass index (BMI) of 44.9 kg/m2; 33.7% had at least one current Axis I disorder and 68.8% at least one lifetime Axis I disorder. Of note, 38.7% had a lifetime history of major depressive disorder, and 33.2% had a lifetime diagnosis of alcohol abuse or dependence, all much higher than population-based prevalence rates obtained for this age group in the National Comorbidity Survey--Replication Study. With respect to binge eating disorder, 13.1% had a lifetime diagnosis, while 10.1% had a current diagnosis.
Current and lifetime rates of psychopathology are high in bariatric surgery candidates, and lifetime rates of affective disorder and alcohol use disorders are particularly prominent. Binge eating disorder is present in approximately 1 in 10 bariatric surgery candidates.
PMCID: PMC3584713  PMID: 22920965
Psychopathology; Eating Disorders; Binge Eating Disorder
10.  Posttraumatic Stress Disorder as a Moderator of the Association Between Negative Affect and Bulimic Symptoms: An Ecological Momentary Assessment Study 
Comprehensive psychiatry  2012;54(1):61-69.
The purpose of this study was to examine the potential moderating effect of posttraumatic stress disorder (PTSD) on the emotion-behavior relationship in individuals with bulimia nervosa (BN).
A total of 119 women with BN were involved in the study. Participants were divided into two groups: those with BN and PTSD (n = 20), and those with BN only (n = 99). Ecological momentary assessment (EMA) procedures were utilized for the examination of affect, frequency of bulimic behaviors, and the relationship of affect and bulimic behavior over time. The Structured Clinical Interview for DSM-IV Axis I Disorders was conducted for the diagnosis of BN, PTSD, mood disorders, anxiety disorders, and substance use disorders. Mood disorders, anxiety disorders, and substance use disorders functioned as covariates in all analyses.
Statistical models showed that those in the PTSD group reported a greater daily mean level of negative affect and a greater daily frequency of bulimic behaviors than those in the BN only group. Moderation was found for the association between negative affect and time in that the PTSD group showed a faster acceleration in negative affect prior to purging and faster deceleration in negative affect following purging. The association between positive affect and time was also moderated by group, indicating that the PTSD group had a faster acceleration in positive affect after purging than the BN only group.
These findings highlight the importance of recognizing PTSD when interpreting the emotion-behavior relationship in individuals with BN.
PMCID: PMC3473110  PMID: 22789761
Posttraumatic stress disorder; Bulimia nervosa; Palm top computers
11.  Moderators of the Association Between Exercise Identity and Obligatory Exercise Among Participants of an Athletic Event 
Body image  2012;10(1):70-77.
Previous research has connected exercise identity with obligatory exercise, yet to date no empirical studies have identified moderator variables of this association. The current study included participants of an athletic event (full marathon, n = 582; half marathon, n = 1,106; shorter distance, n = 733) who completed questionnaires about exercise behaviors, obligatory exercise, and internalization of both the thin-ideal and athletic-ideal body shapes. General linear model analyses were conducted to examine the exercise identity-obligatory exercise relationship; moderator variables included gender, internalization of the thin-ideal body shape, and internalization of the athletic-ideal body shape. After controlling for the effects of body mass index, age, and distance group, the three-way interaction of exercise identity, gender, and internalization of the athletic-ideal body shape predicted obligatory exercise. Findings suggest that women who report high identification with exercise and high value on having an athletic physique may be vulnerable to obligatory exercise.
PMCID: PMC3534926  PMID: 23092850
exercise identity; obligatory exercise; internalization
12.  DSM-IV-Defined Anorexia Nervosa Versus Subthreshold Anorexia Nervosa (EDNOS-AN) 
Eating disorder not otherwise specified (EDNOS) is the most prevalent eating disorder, yet its heterogeneity begs less reliance on this broad diagnostic category. The purpose of this study was to compare women with anorexia nervosa (AN) and EDNOS, AN type (EDNOS-AN) from a multisite study on eating-related and general psychopathology measures.
One hundred eighteen participants (n = 59 with DSM-IV AN, n = 59 with EDNOS-AN) completed structured interviews, questionnaires and a physical examination at baseline. In addition, participants carried a handheld palm pilot computer for two weeks to provide ecological momentary assessment (EMA) information about mood and eating disorder behaviors.
No significant differences between AN and EDNOS-AN were found on the self-report and interview measures, or on the EMA mood assessments. The only differences to emerge were that participants with AN reported higher rates of binge eating and purging on EMA compared to those with EDNOS-AN, while EDNOS-AN reported higher rates of checking thighs and joints on EMA compared to those with AN. For the physiological parameters, AN presented with lower white blood cell counts compared to EDNOS-AN.
Findings highlight the clinical significance of EDNOS-AN, and support a closer look at the definition of AN as proposed by DSM-5.
PMCID: PMC3715616  PMID: 22847947
Anorexia nervosa; EDNOS; classification
13.  Subjective and Objective Binge Eating in Relation to Eating Disorder Symptomatology, Negative Affect, and Personality Dimensions 
The International journal of eating disorders  2012;46(1):10.1002/eat.22066.
The current study explored the clinical meaningfulness of distinguishing subjective (SBE) from objective binge eating (OBE) among individuals with threshold/subthreshold bulimia nervosa (BN). We examined relations between OBEs and SBEs and eating disorder symptoms, negative affect, and personality dimensions using both a group comparison and a continuous approach.
Participants were 204 adult females meeting criteria for threshold/subthreshold BN who completed questionnaires related to disordered eating, affect, and personality.
Group comparisons indicated that SBE and OBE groups did not significantly differ on eating disorder pathology or negative affect, but did differ on two personality dimensions (cognitive distortion and attentional impulsivity). Using the continuous approach, we found that frequencies of SBEs (not OBEs) accounted for unique variance in weight/shape concern, diuretic use frequency, depressive symptoms, anxiety, social avoidance, insecure attachment, and cognitive distortion.
SBEs in the context of BN may indicate broader areas of psychopathology.
PMCID: PMC3832259  PMID: 23109272
subjective binge eating; objective binge eating; affect; personality; bulimia nervosa
14.  Momentary Affect Surrounding Loss of Control and Overeating in Obese Adults With and Without Binge Eating Disorder 
Obesity (Silver Spring, Md.)  2011;20(6):10.1038/oby.2011.286.
Research suggests that loss of control (LOC) while eating (the sense that one cannot control what or how much one is eating) is a more salient feature of binge eating than the amount of food consumed. This study examined the unique contributions of LOC and episode size to negative affect surrounding eating episodes in binge eating disorder (BED) and obesity. Twenty-two obese adults with (n = 9) and without (n = 13) BED completed daily records of eating patterns and mood using ecological momentary assessment (EMA). Linear mixed modeling revealed that across groups, greater premeal self-reported LOC was associated with higher premeal negative affect independent of episode size. For individuals with BED, greater premeal self-reported LOC was associated with higher postmeal negative affect, regardless of the amount of food eaten, whereas for obese controls, the combination of LOC and consumption of large amounts of food was associated with lower postmeal negative affect. Results indicate that LOC, but not the quantity of food consumed, is associated with momentary distress related to aberrant eating in BED. Findings also highlight the need for further research investigating the emotional context surrounding aberrant eating in obese individuals without BED.
PMCID: PMC3816927  PMID: 21938073
15.  Adding Chemoprophylaxis to Sequential Compression May Not Reduce the Risk of Venous Thromboembolism in Bariatric Surgery Patients 
Anticoagulation, the use of sequential compression devices on lower extremities peri-operatively, and early ambulation are thought to reduce venous thromboembolism (VTE) postoperatively and are recommended to reduce VTE risk. However, the evidence upon which this recommendation is based is not particularly strong. We demonstrate that even a large, multi-center cohort with carefully collected prospective data is inadequate to provide sufficient evidence to support, or refute, this recommendation.
The Longitudinal Assessment of Bariatric Surgery (LABS) participants from 10 centers in the United States who underwent their first bariatric surgery between March, 2005 and December, 2007 comprise the study group. We examined the ability to address the question of whether anti-coagulation therapy, in addition to sequential compression, reduces the 30 day incidence of VTE or death sufficiently to recommend the use of prophylactic anticoagulation, a therapy that is not without risk.
Of 4416 patients, 396 (9.0%) received sequential compression alone, while the others also received anticoagulation therapy. The incidence of VTE within 30 days of surgery was small (0.25% among those receiving sequential compression alone, 0.47% when anticoagulation therapy was added), and the 30 days incidence of death was also small (0.25% vs. 0.34%, p = 0.76, for sequential compression alone vs. sequential compression plus anticoagulation therapy). Estimates of the number of cases required to address the question of whether there is a difference in outcome related to VTE chemoprophylaxis, or whether the outcome rates are equivalent, range from 13,680 to at least 35,760 patients, depending upon whether superiority or equivalence is being analyzed.
Sufficient evidence from a clinical trial study to determine whether prophylactic anticoagulation added to compression devices further prevents VTEs is not available and such a trial is likely to be impractical. The data presented are insufficient to make a final recommendation concerning prophylactic treatment to prevent VTE in the 30 days following bariatric surgery.
PMCID: PMC3498574  PMID: 22963819
bariatric surgery; thromboembolism; pulmonary emboli; chemoprophylaxis; deep vein thrombosis; sequential compression
16.  The Safety and Efficacy of Bariatric Surgery: The Longitudinal Assessment of Bariatric Surgery (LABS) 
Obesity is a leading health concern in the United States. Since traditional treatment approaches for weight loss are generally unsuccessful long-term 1, bariatric surgical procedures are increasingly being performed to treat extreme obesity. To facilitate research in this field, the National Institute of Diabetes and Digestive and Kidney Diseases responded to this knowledge gap by establishing the Longitudinal Assessment of Bariatric Surgery (LABS) consortium.
A competitive NIDDK grant process resulted in the creation of a group of investigators with expertise in bariatric surgery, internal medicine, endocrinology, behavioral science, outcomes research, epidemiology, biostatistics and other relevant fields who have worked closely to plan, develop, and conduct the LABS study. The LABS consortium protocol is a prospective, multi-center observational cohort study of consecutive patients undergoing bariatric surgery at six clinical centers. LABS includes an extensive database of information systematically collected pre-operatively, at surgery, and perioperatively during the 30 day post-operative period, and longer term.
The LABS study is organized into three phases. LABS-1 includes all patients at least 18 years of age who undergo bariatric surgery by LABS-certified surgeons with the goal to evaluate the short-term safety of bariatric surgery. LABS-2, a subset of approximately 2400 LABS-1 patients, evaluates the relationship of patient and surgical characteristics to longer-term safety and efficacy of bariatric surgery. LABS-3 involves a subset of LABS-2 subjects who undergo detailed studies of mechanisms involved in weight change. The rationale, goals, and approach to study bariatric surgery are detailed in this report along with a description of the outcomes, measures, and hypotheses utilized in LABS-1 and -2.
The goal of the LABS consortium is to accelerate clinical research and understanding of extreme obesity and its complications by evaluating the risks and benefits of bariatric surgery. LABS investigators use standardized definitions, high fidelity data collection, and validated instruments to enhance the ability of clinicians to provide meaningful evidence-based recommendations for patient evaluation, selection for surgery, and follow-up care.
PMCID: PMC3805365  PMID: 17386392
Bariatric Surgery; Obesity
17.  Distribution of 10-Year and Lifetime Predicted Risk for Cardiovascular Disease Prior to Surgery in the Longitudinal Assessment of Bariatric Surgery-2 Study 
The American journal of cardiology  2012;110(8):1130-1137.
Primary prevention guidelines recommend calculation of lifetime cardiovascular disease (CVD) predicted risk among individuals who may not meet criteria for high short-term (10-year) ATP-III risk for coronary heart disease (CHD). Both extreme obesity and bariatric surgery are more common among women, who often have low short-term predicted CHD risk. The distribution and correlates of lifetime CVD predicted risk, however, have not yet been evaluated among bariatric surgery candidates. Using established 10-year (ATP-III) CHD and lifetime CVD risk prediction algorithms and pre-surgery risk factors, participants from the Longitudinal Assessment of Bariatric Surgery-2 study without prevalent CVD (n=2070) were stratified into 3 groups: low 10-year (<10%)/low lifetime (<39%) predicted risk, low 10-year (<10%)/high lifetime (≥39%) predicted risk, and high 10-year (≥10% predicted risk or diagnosed diabetes.) Participants were predominantly white (86%), women (80%), with a median age of 45 years and median BMI of 45.6 kg/m2. High 10-year CHD predicted risk was common (36.5%), and associated with diabetes, male sex and older age, but not with higher BMI or hs-c-reactive protein. Most (76%) participants with low 10-year predicted risk had high lifetime CVD predicted risk, which was associated with dyslipidemia and hypertension, but not with BMI, waist circumference, HDL cholesterol or hs-C-reactive protein. In conclusion, bariatric surgery candidates without diabetes or existing CVD are likely to have low short-term, but high lifetime CVD predicted risk. Current data support the need for long-term monitoring and treatment of elevated CVD risk factors among bariatric surgery patients, to maximize lifetime CVD risk reduction.
Clinical Trial Registration
Long-term Effects of Bariatric Surgery, #NCT00465829,
PMCID: PMC3462227  PMID: 22742719
Cardiovascular disease; extreme obesity; bariatric surgery; lipids
18.  An Assessment of Daily Food Intake in Participants with Anorexia Nervosa in the Natural Environment 
To examine the caloric intake in women with anorexia nervosa (AN) and how it varies by day as a function of the presence or absence of binge eating and/or purging behaviors.
Female participants with AN (n = 84, mean age = 24.4, range 18–51) were recruited from three different sites. Data on food intake were obtained through the use of 24-h dietary recall using the Nutritional Data Systems for Research, and data on binge eating and purging behaviors were collected on palmtop computers using an ecological momentary assessment paradigm. Daily macronutrient intake was compared on days during which binge eating and/or purging behaviors did or did not occur.
On days during which binge eating and purging behaviors both occurred, participants reported significantly greater kilocalorie intake when compared with days when neither behavior occurred, or when only binge eating or purging occurred. Binge eating episodes were only modest in size on days when purging did not occur. Energy intake overall was higher than expected.
Intake on days where binge eating occurred varied dramatically based on whether or not purging occurred. Whether markedly increased binge eating intake was causally related to purging is unclear. Nonetheless eating episodes were at times quite large and equivalent to those reported by participants with bulimia nervosa in other research.
PMCID: PMC3584709  PMID: 19040266
AN; binge eating; compensatory behaviors; caloric intake
19.  Pre- to Post-operative Changes in Physical Activity: Report from the Longitudinal Assessment of Bariatric Surgery-2 
Numerous studies report that bariatric surgery patients report more physical activity (PA) after surgery than before, but the quality of PA assessment has been questionable.
The Longitudinal Assessment of Bariatric Surgery-2 is a 10-center longitudinal study of adults undergoing bariatric surgery. Of 2458 participants, 455 were given an activity monitor, which records steps/minute, and an exercise diary before and 1 year after surgery. Mean step/day, active minutes/day, and high-cadence minutes/week were calculated for 310 participants who wore the monitor at least 10 hours/day for at least 3 days at both time points. Pre- and post-surgery PA were compared for differences using the Wilcoxon signed-rank test. Generalized Estimating Equations identified independent pre-operative predictors of post-operative PA.
PA increased significantly (p<.0001) pre- to post-operative for all PA measures. Median values pre- and post-operative were: 7563 and 8788 steps/day; 309 and 340 active minutes/day; and 72 and 112 high-cadence minutes/week, respectively. However, depending on the PA measure, 24–29% of participants were at least 5% less active post-operative than pre-operative. Controlling for surgical procedure, sex, age and BMI, higher PA preoperative independently predicted higher PA post-operative (p<.0001, all PA measures). Less pain, not having asthma and self-report of increasing PA as a weight loss strategy pre-operative also independently predicted more high-cadence minutes/week post-operative (p<.05).
The majority of adults increase their PA level following bariatric surgery. However, most remain insufficiently active and some become less active. Increasing PA, addressing pain and treating asthma prior to surgery may have a positive impact on post-operative PA.
PMCID: PMC3248952  PMID: 21944951
Physical activity; exercise; activity monitor; bariatric surgery; severe obesity
20.  The Genetics of Anorexia Nervosa Collaborative Study: Methods and Sample Description 
Supported by National Institute of Mental Health (NIMH), this 12-site international collaboration seeks to identify genetic variants that affect risk for anorexia nervosa (AN).
Four hundred families will be ascertained with two or more individuals affected with AN. The assessment battery produces a rich set of phenotypes comprising eating disorder diagnoses and psychological and personality features known to be associated with vulnerability to eating disorders.
We report attributes of the first 200 families, comprising 200 probands and 232 affected relatives.
These results provide context for the genotyping of the first 200 families by the Center for Inherited Disease Research. We will analyze our first 200 families for linkage, complete recruitment of roughly 400 families, and then perform final linkage analyses on the complete cohort. DNA, genotypes, and phenotypes will form a national eating disorder repository maintained by NIMH and available to qualified investigators.
PMCID: PMC3755506  PMID: 18236451
anorexia nervosa; eating disorders; bulimia nervosa; psychiatric disorders; genetics; linkage analysis; genomics
21.  Prevalence of Adverse Intraoperative Events during Obesity Surgery and Their Sequelae 
Adverse intraoperative events (AIEs) during surgery are a well-known entity. A better understanding of the incidence of AIEs and their relationship with outcomes is helpful for surgeon preparation and preoperative patient counseling. The goals of this study are to describe the incidence of AIEs during bariatric surgery and examine their impact on major adverse complications.
The study included 5,882 subjects who had bariatric surgery in the Longitudinal Assessment of Bariatric Surgery study between March 2005 and April 2009. Prospectively collected AIEs included organ injuries, anesthesia-related events, anastomotic revisions, and equipment failure. The relationship between AIEs and a composite end point of 30-day major adverse complications (ie, death, venous thromboembolism, percutaneous, endoscopic, or operative reintervention and failure to be discharged from the hospital within 30 days from surgery) was evaluated using a multivariable relative risk model adjusting for factors known to influence their risk.
There were 1,608 laparoscopic adjusted gastric banding, 3,770 laparoscopic Roux-en-Y gastric bypass operations, and 504 open Roux-en-Y gastric bypass operations. Adverse intraoperative events occurred in 5% of the overall sample and were most frequent during open Roux-en-Y gastric bypass (7.3%), followed by laparoscopic Roux-en-Y gastric bypass (5.5%) and laparoscopic adjusted gastric banding (3%). The rate of composite end point was 8.8% in the AIE group compared with 3.9% among those without an AIE (p < 0.001). Multivariable analysis revealed that patients with an AIE were at 90% greater risk of composite complication than those without an event (relative risk = 1.90; 95% CI, 1.26–2.88; p = 0.002), independent of the type of procedure (open or laparoscopic).
Incidence of an AIE is not infrequent during bariatric surgery and is associated with much higher risk of major complication. Additional study is needed to assess the association between specific AIEs and short-term complications.
PMCID: PMC3569521  PMID: 22634116
22.  Cognitive Function in Morbidly Obese Individuals With and Without Binge Eating Disorder 
Comprehensive Psychiatry  2011;53(5):490-495.
Obesity is associated with poorer cognitive function and impulsivity, which may contribute to binge eating disorder (BED). The objective of this study was to compare cognitive function in morbidly obese individuals with and without BED.
A total of 131 morbidly obese individuals (41 with past or present BED, 90 with no BED history) completed a computerized battery of cognitive tests including executive, memory, language, and attention.
Both groups of participants evidenced high rates of cognitive impairment, however, no significant differences emerged between persons with and without BED on cognitive testing. Comparison of persons without BED, current BED, and past BED also yielded no differences.
In the present sample, morbidly obese individuals with and without BED were clinically indistinguishable on tests of cognitive function. Our findings suggest that obesity, rather than binge eating, may be more directly related to cognition. Future studies should further examine this relationship, as it might provide greater insight into the neural mechanisms for this BED.
PMCID: PMC3321396  PMID: 22036317
23.  Prevalence of alcohol use disorders before and after bariatric surgery 
Anecdotal reports suggest bariatric surgery may increase the risk of alcohol use disorders (AUD), but prospective data are lacking.
Determine the prevalence of pre- and postoperative AUD, and independent predictors of postoperative AUD.
Design, Setting, Participants
Longitudinal Assessment of Bariatric Surgery-2 is a prospective cohort study of adults who underwent bariatric surgery at 10 U.S. hospitals. Of 2458 participants, 1945 (78.8% female, 87.0% white, median age=47 years, median body mass index=45.8 kg/m2) completed pre- and postoperative (1 and/or 2 years) assessments between 2006–2011.
Main Outcome measure
Past year AUD symptoms determined with the Alcohol Use Disorders Identification Test (indication of ‘alcohol-related harm,’ ‘alcohol dependence symptoms,’ or score ≥8).
The prevalence of AUD did not significantly differ from pre- to 1 year postoperative (7.6% vs. 7.3%; p=.98), but was significantly higher at 2 years (9.6%; p<.01). Male sex (adjusted odds ratio [OR], 2.1; 95% confidence interval [CI], 1.5–3.0; p<.0001), younger age (OR, 1.3; CI, 1.03–1.7 per 10 years younger with pre-op AUD; p=.03; OR, 2.0; CI, 1.7–2.3 per 10 years younger without pre-op AUD; p<.0001), smoking (OR, 2.6; CI, 1.2–5.6; p=.02), regular alcohol consumption (OR, 6.4; CI, 4.2–9.7; p<.0001), AUD (e.g., OR, 11.1; CI, 7.7–16.1 at age 45; p<.0001), recreational drug use (OR, 2.4; CI, 1.4–4.1; p<.01) and lower ‘belonging’ interpersonal support (OR, 1.1; CI, 1.04–1.2; p<.01) preoperatively, and undergoing a Roux-en-Y gastric bypass (OR, 2.1; CI, 1.4–3.1; p<.001; reference=adjustable gastric band) were independently related to an increased odds of AUD postoperatively.
In this cohort, the prevalence of AUD was greater in the second postoperative year than preoperatively or in the first postoperative year, and was associated with preoperative AUD and regular alcohol consumption, and undergoing Roux-en-Y gastric bypass.
PMCID: PMC3682834  PMID: 22710289
24.  Racial/Ethnic Differences in Adults in Randomized Clinical Trials of Binge Eating Disorder 
Recent studies suggest that binge eating disorder (BED) is as prevalent among African American and Hispanic Americans as among Caucasian Americans; however, data regarding the characteristics of treatment-seeking individuals from racial and ethnic minority groups are scarce. The purpose of this study was to investigate racial/ethnic differences in demographic characteristics and eating disorder symptoms in participants enrolled in treatment trials for BED.
Data from 11 completed randomized, controlled trials were aggregated in a single database, the Clinical Trials of Binge Eating Disorder (CT-BED) database, which included 1,204 Caucasian, 120 African American, and 64 Hispanic participants assessed at baseline. Age, gender, race/ethnicity, education, body mass index (BMI), binge eating frequency, and Eating Disorder Examination (EDE) Restraint, Shape, Weight, and Eating Concern subscale scores were examined.
Mixed model analyses indicated that African American participants in BED treatment trials had higher mean BMI than Caucasian participants, and Hispanic participants had significantly greater EDE shape, weight, and eating concerns than Caucasian participants. No racial or ethnic group differences were found on the frequency of binge eating episodes. Observed racial/ethnic differences in BED symptoms were not substantially reduced after adjusting for BMI and education. Comparisons between the CT-BED database and epidemiological data suggest limitations to the generalizability of data from treatment-seeking samples to the BED community population, particularly regarding the population with lower levels of education.
Further research is needed to assess alternative demographic, psychological, and culturally specific variables to better understand the diversity of treatment-seeking individuals with BED.
PMCID: PMC3668439  PMID: 22201327
binge eating; eating disorders; treatment; health disparities; ethnicity
25.  The Significance of Repetitive Hair-Pulling Behaviors in Eating Disorders 
Journal of clinical psychology  2011;67(4):391-403.
We studied the relation between intrusive and repetitive hair-pulling, the defining feature of trichotillomania, and compulsive and impulsive features in 1453 individuals with anorexia nervosa and bulimia nervosa. We conducted a series of regression models examining the relative influence of compulsive features associated with obsessive compulsive disorder; compulsive features associated with eating disorders; trait features related to harm avoidance, perfectionism and novelty seeking; and self harm. A final model with a reduced sample (n=928) examined the additional contribution of impulsive attributes. One out of 20 individuals endorsed hair-pulling. Evidence of a positive association with endorsement of compulsive behavior of the obsessive compulsive spectrum emerged. Hair-pulling may be more consonant with ritualistic compulsions than impulsive urges in those with eating disorders.
PMCID: PMC3664303  PMID: 21365638
eating disorders; trichotillomania; hair-pulling; anorexia nervosa; bulimia nervosa; impulsivity; compulsivity

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