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1.  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.
doi:10.1002/erv.2273
PMCID: PMC4420157  PMID: 24347539
binge eating disorder; obesity; outcome
2.  Possible Risk Factors for Increased Suicide Following Bariatric Surgery 
Obesity (Silver Spring, Md.)  2013;21(4):665-672.
There is a growing research literature suggesting that there may be elevated risk of suicide following bariatric surgery. Most of the data reported thus far has been cross-sectional and observational, and very little is known about the possible specific causal variables involved. The purpose of this report is to review this literature and to review possible risk factors for increased suicidal risk following bariatric surgery, in order to delineate future research directions. First a variety of medical, biological, and genetic factors, including the persistence of recurrence of medical comorbidities after bariatric surgery, the disinhibition and impulsivity secondary to changes in the absorption of alcohol, hypoglycemia, as well as pharmacokinetic changes that may affect the absorption of various medications including antidepressant medications are reviewed. Also reviewed are possible mediating factors involving changes in various peptidergic systems such as GLP-1 and Ghrelin. A number of psychosocial issues that might be involved are discussed, including lack of improvement in quality of life after surgery, continued or recurrent physical mobility restrictions, persistence or recurrence of sexual dysfunction and relationship problems, low self-esteem, and a history of child maltreatment. Inadequate weight loss or weight regain are also discussed. Possible theoretical models involved and directions for research are suggested.
doi:10.1002/oby.20066
PMCID: PMC4372842  PMID: 23404774
3.  Biological Therapies for Eating Disorders 
Objective
To provide a comprehensive review of pharmacotherapy and other biological treatments for eating disorders.
Method
Literature on this topic was systematically reviewed.
Results
The bulimia nervosa literature underscores the utility of antidepressants, particularly SSRIs, in improving the symptoms of the disorder. The literature on binge eating disorder supports efficacy on reduction in binge eating frequency for a variety of compounds. However, such compounds have only modest effects on weight. Certain antiepileptic agents such as topiramate, if tolerated, are probably more useful in terms of weight loss. The number of controlled trials in patients with anorexia nervosa in particular has been quite small, and recent meta-analyses show disappointing results using atypical antipsychotics in anorexia nervosa.
Discussion
The pharmacological treatment of eating disorders remains an underdeveloped field although drug therapy clearly plays a role in the treatment of those with bulimia nervosa and binge eating disorder. Other biological therapies have not been adequately studied.
doi:10.1002/eat.22104
PMCID: PMC4372845  PMID: 23658094
anorexia nervosa; bulimia nervosa; binge eating disorder; pharmacotherapy; drug treatment
4.  Health Care Costs in Patients with Eating Disorders 
Objective
To examine health care costs among patients with eating disorders using the Blue Cross Blue Shield of North Dakota (BCBSND) claims database system.
Method
Four groups of individuals enrolled between 1999 and 2005 were identified: 1) a group diagnosed with eating disorders at the beginning of the study period, in 2000 or 2001; 2) a group diagnosed with eating disorders later in the study period, in 2004 or 2005; 3) a comparison group with depression; and 4) a non-eating disordered comparison group.
Results
Health care costs were high for patients diagnosed with an eating disorder during the period when the diagnosis was made but remained elevated in the years following. Such costs were consistently higher than those for the non-eating disordered comparison group, but similar to the depression comparison group.
Conclusion
Health care costs remained elevated after a diagnosis of an eating disorder for an extended period of time.
doi:10.1002/eat.20651
PMCID: PMC4205564  PMID: 19172600
5.  A Fine-Grained Analysis of Eating Behavior in Women with Bulimia Nervosa 
Objective
In the current study we were interested in developing a typology of eating in patients with bulimia nervosa based on the size of the eating episode, whether the episode was followed by self-induced vomiting, and the degree of loss of control self-reported by participants.
Method
Twenty-one adult women with bulimia nervosa, purging type, were evaluated using the Nutritional Data System for Research, the Eating Disorders Examination, and the Matrix.
Results
The most common type of episode resembled what might be termed “normal” eating which involved the consumption of less than 1000 kcal with no sense of loss of control and no vomiting. There was an increase in severity of self-assessed loss of control in objectively large eating episodes with vomiting. Self-reported hunger prior to eating episodes did not seem to be predictive of subsequent behavior. Most people were engaged in other behaviors while eating.
Discussion
The results of this study suggest a typology that included primarily four types of eating episodes. The results also suggest that when loss of control is assessed on a Likert-scale rather than as a dichotomous variable there is considerable variability in self-assessed degree of loss of control.
doi:10.1002/eat.20961
PMCID: PMC4201497  PMID: 21956763
bulimia nervosa; eating behavior; binge eating; vomiting; nutritional assessment
6.  The Role of Leptin, Melanocortin, and Neurotrophin System Genes on Body Weight in Anorexia Nervosa and Bulimia Nervosa 
Objective
Although low weight is a key factor contributing to the high mortality in anorexia nervosa (AN), it is unclear how AN patients sustain low weight compared with bulimia nervosa (BN) patients with similar psychopathology. Studies of genes involved in appetite and weight regulation in eating disorders have yielded variable findings in part due to small sample size and clinical heterogeneity. This study: (1) assessed the role of leptin, melanocortin, and neurotrophin genetic variants in conferring risk for AN and BN and (2) explored the involvement of these genes in body mass index (BMI) variations within AN and BN.
Method
Our sample consisted of 745 individuals with AN without a history of BN, 245 with BN without a history of AN, and 321 controls. We genotyped 20 markers with known or putative function among genes selected from leptin, melanocortin, and neurotrophin systems.
Results
There were no significant differences in allele frequencies among individuals with AN, BN, and controls. AGRP rs13338499 polymorphism was associated with lowest illness-related BMI in those with AN (p=0.0013), and NTRK2 rs1042571 was associated with highest BMI in those with BN (p=0.0018).
Discussion
To our knowledge, this is the first study to address the issue of clinical heterogeneity in eating disorder genetics and to explore the role of known or putatively functional markers in genes regulating appetite and weight in individuals with AN and BN. If replicated, our results may serve as an important first step toward gaining a better understanding of weight regulation in eating disorders.
doi:10.1016/j.jpsychires.2014.04.005
PMCID: PMC4191922  PMID: 24831852
anorexia nervosa; bulimia nervosa; candidate gene association; body weight; melanocortins; neurotrophins
8.  Daily Patterns of Anxiety in Anorexia Nervosa: Associations with Eating Disorder Behaviors in the Natural Environment 
Journal of abnormal psychology  2013;122(3):672-683.
The role of anxiety has been emphasized in etiological/maintenance models of anorexia nervosa. This study identified daily patterns of anxiety in anorexia nervosa and examined the likelihood of the occurrence of eating disorder behaviors in each trajectory, the daily temporal distribution of eating disorder behaviors in each trajectory, and the extent to which the tendency to exhibit particular anxiety trajectories was associated with baseline diagnostic and trait-level personality variables. Women with full or subthreshold anorexia nervosa (N = 118) completed a two-week ecological momentary assessment (EMA) protocol during which they reported on a variety of behavioral and affective variables, including anxiety and eating disorder behaviors. Using latent growth mixture modeling to classify EMA days (N = 1526) based on anxiety ratings, seven distinct daily anxiety trajectories were identified. Overall differences between trajectories were found for rates of binge eating, self-induced vomiting, body checking, skipping meals, and dietary restriction. Further, distinct daily temporal distributions of eating disorder behaviors were found across the trajectories, with peaks in the probability of behaviors frequently coinciding with high levels of anxiety. Finally, traits of personality pathology (affective lability, self-harm, social avoidance, and oppositionality) and the presence of a co-occurring mood disorder were both found to be associated with the tendency to experience particular daily anxiety trajectories (e.g., Stable High anxiety). Findings support the presence of within-person variability in daily anxiety patterns in anorexia nervosa and also provide evidence for an association between these anxiety patterns and eating disorder behaviors.
doi:10.1037/a0031823
PMCID: PMC4515356  PMID: 23647124
eating disorder; anxiety; ecological momentary assessment; latent growth mixture modeling; personality
9.  Therapeutic Factors Affecting the Cognitive Behavioral Treatment of Bulimia Nervosa via Telemedicine versus Face-to-Face Delivery 
Objective
Recently, Mitchell and colleagues (2008) conducted a randomized controlled trial of an empirically supported treatment for bulimia nervosa (BN) delivered face-to-face (FTF-CBT) or via telemedicine (TV-CBT). Results suggested that the TV-CBT and FTF-CBT were generally equivalent in effectiveness. The objective of the current study was to examine ratings of therapeutic alliance factors in TV-CBT and FTF-CBT.
Methods
Data obtained from 116 adults who met criteria for BN or eating disorder—not otherwise specified (EDNOS) with binge eating or purging weekly and 6 doctoral-level psychologists who delivered the therapy were used in the analyses.
Results
Therapists generally endorsed greater differences between the treatment delivery methods than patients. Patients tended to make significantly higher ratings of therapeutic factors than therapists.
Discussion
TV-CBT is an acceptable method for the delivery of BN treatment compared to FTF-CBT, and TV-CBT is more easily accepted as a treatment delivery method by patients than therapists.
doi:10.1002/eat.20874
PMCID: PMC4496947  PMID: 22072405
10.  The Role of Cognitive Function in Postoperative Weight Loss Outcomes: 36 Month Follow-Up 
Obesity surgery  2014;24(7):1078-1084.
Introduction/Purpose
Cognitive dysfunction is associated with reduced postoperative weight loss up to two years following surgery, though the role of cognition at more extended follow-up is not yet understood. Thirty-six months following bariatric surgery, we retrospectively compared obese and non-obese patients on12-week postoperative cognitive performance. We hypothesized that early postoperative cognitive dysfunction would predict higher body mass index (BMI) and lower percent weight loss (%WL) in the total sample at 36 month follow-up.
Materials and Methods
Fifty-five individuals undergoing bariatric surgery completed cognitive testing at preoperative baseline and serial postoperative timepoints, including 12 weeks and 36 months. Cognitive test scores were normed for demographic variables. Percent weight loss (%WL) and body mass index (BMI) were calculated at 36-month follow-up.
Results
Adjusting for gender, baseline cognitive function, and 12-week %WL, 12-week global cognitive test performance predicted 36 month postoperative %WL and BMI. Partial correlations revealed recognition memory, working memory, and generativity were most strongly related to weight loss.
Conclusion
Cognitive function shortly after bariatric surgery is closely linked to extended postoperative weight loss at 36 months. Further work is necessary to clarify mechanisms underlying the relationship between weight loss durability and cognitive function, including contribution of adherence, as this may ultimately help identify individuals in need of tailored interventions to optimize postoperative weight loss.
doi:10.1007/s11695-014-1205-2
PMCID: PMC4047156  PMID: 24570090
memory; cognition; executive function; adherence
11.  Blood Alcohol Concentrations Rise Rapidly and Dramatically Following Roux-en-Y Gastric Bypass 
Background
This study provides new information on how rapidly and extensively alcohol is absorbed following Roux-en-Y Gastric Bypass (RYGB). Prior alcohol pharmacokinetic research in RYGB patients has not reported blood alcohol concentrations in this early time-period following ingestion.
Objectives
The objective of this study was to examine the rate and extent of alcohol absorption, particularly in the first ten minutes following a dose of alcohol.
Setting
The study was conducted at a nonprofit research organization within the United States.
Methods
Five female participants who had undergone RYGB three to four years prior completed the study. Participants were given 0.3 grams/kilogram of actual body weight of ethanol. Following the dose of alcohol, blood samples were collected through an indwelling intravenous catheter every minute for the first five minutes and at 7.5, 10, 20, and 60 minutes.
Results
The observed mean Cmax was 138.4 ± 28.6 mg/dl (range 98.0–170.0 mg/dl) and the observed mean Tmax was 5.4 ± 3.1 minutes (range 2–10 minutes) following alcohol consumption.
Conclusions
Within minutes following consumption of a beverage containing a modest amount of alcohol, post-RYGB patients achieve disproportionately high blood alcohol concentrations. All five patients in this study reached blood alcohol concentrations above 0.08%, the legal driving limit in the United States, within ten minutes following a dose of alcohol. Clinicians are encouraged to educate patients about the marked changes in alcohol pharmacokinetics that are they are likely to experience post-RYGB and to guide patients in making modifications to alcohol intake following surgery accordingly.
doi:10.1016/j.soard.2013.02.002
PMCID: PMC4487806  PMID: 23507629
alcohol; gastric bypass; pharmacokinetics; absorption
12.  Improved Serum Leptin and Ghrelin Following Bariatric Surgery Predict Better Postoperative Cognitive Function 
Background and Purpose
Bariatric surgery is associated with improved cognitive function, but the mechanisms underlying these gains remain poorly understood. Disturbed leptin and ghrelin systems are common in obese individuals and are associated with impaired cognitive function in other samples. Bariatric surgery has been shown to improve serum leptin and ghrelin levels, and these changes may underlie postoperative cognitive improvements.
Methods
Eighty-four patients completed a computerized cognitive test battery prior to bariatric surgery and at 12 months postoperatively. Participants also submitted to an 8-hour fasting blood draw to quantify serum leptin and ghrelin concentrations at these same time points.
Results
Baseline cognitive impairments and disturbed leptin and ghrelin levels improved at the 12-month follow-up compared to presurgery. Higher leptin levels were associated with worse attention/executive function at baseline; no such findings emerged for ghrelin. Regression analyses controlling for baseline factors and demographic characteristics showed that both decreased leptin and increased ghrelin following surgery was associated with better attention/executive function at the 12-month follow-up. These effects diminished after controlling for the postoperative change in body mass index (BMI); however, BMI change did not predict 12-month cognitive function.
Conclusions
Improvements in leptin and ghrelin levels following bariatric surgery appear to contribute to postoperative cognitive benefits. These gains may involve multiple mechanisms, such as reduced inflammation and improved glycemic control. Future studies that employ neuroimaging are needed to clarify the underlying mechanisms and determine whether the effects of bariatric surgery on leptin and ghrelin levels can attenuate adverse brain changes and/or risk of dementia in severely obese individuals.
doi:10.3988/jcn.2015.11.1.48
PMCID: PMC4302179  PMID: 25628737
obesity; bariatric surgery; cognitive function; leptin; ghrelin
13.  Cognitive Function Following Bariatric Surgery: Evidence for Improvement 3 Years Post-Surgery 
American journal of surgery  2013;207(6):870-876.
Background
Bariatric surgery is associated with improved cognition and it is possible that such improvements are found at extended follow-ups. We hypothesized that cognitive improvement would be maintained 3 years post-bariatric surgery.
Methods
Fifty bariatric patients were recruited from the Longitudinal Assessment of Bariatric Surgery parent project. Participants completed a computerized cognitive test battery to assess cognitive function at 12-weeks, 12-months, 24-months, and 36-months post-surgery.
Results
Repeated measures revealed main effects for attention, executive function, and memory. Attention improved up to 24-months and then slightly declined, though still fell within the average range at 36-months. Improvements in executive function reached its peak at 36-months post-surgery. Short-term improvements in memory were maintained at 36-months. No main effect emerged for language.
Conclusion
Bariatric surgery may lead to lasting improvements in cognition. Prospective studies with extended follow-ups (e.g., 10 years) should examine whether bariatric surgery can attenuate cognitive decline in severely obese persons.
doi:10.1016/j.amjsurg.2013.05.018
PMCID: PMC3983172  PMID: 24119892
Bariatric surgery; obesity; cognitive function; weight loss
14.  Latent profile analysis of eating episodes in anorexia nervosa 
Background
Despite being characterized primarily by disturbances in eating behavior, relatively little is known about specific eating behaviors in anorexia nervosa (AN) and how they relate to different emotional, behavioral, and environmental features.
Methods
Women with AN (n=118) completed a 2-week ecological momentary assessment (EMA) protocol during which they reported on daily eating- and mood-related patterns. Latent profile analysis was used to identify classes of eating episodes based on the presence or absence of the following indicators: loss of control; overeating; eating by oneself; food avoidance; and dietary restraint.
Results
The best-fitting model supported a 5-class solution: avoidant eating; solitary eating; binge eating; restrictive eating; and loss of control eating. The loss of control and binge eating classes were characterized by high levels of concurrent negative affect and a greater likelihood of engaging in compensatory behaviors. The restrictive eating class was associated with the greatest number of concurrently-reported stressful events, while the avoidant and solitary eating episode classes were characterized by relatively few accompanying stressful events. Body checking was least likely to occur in conjunction with restrictive eating behaviors.
Conclusions
Results support the presence of discrete types of eating episodes in AN that are associated with varying degrees of negative affect, stress, and behavioral features of eating disorders. Loss of control and dietary restriction may serve distinct functional purposes in AN, as highlighted by their differing associations with negative affect and stress. Clinical interventions for AN may benefit from targeting functional aspects of eating behavior among those with the disorder.
doi:10.1016/j.jpsychires.2014.02.019
PMCID: PMC4011391  PMID: 24630466
Anorexia nervosa; eating behavior; ecological momentary assessment; negative affect; binge eating; dietary restriction
15.  The Mini-Mental State Exam (MMSE) is not Sensitive to Cognitive Impairment in Bariatric Surgery Candidates 
Background
Cognitive dysfunction is common among bariatric surgery candidates and associated with poorer weight loss outcomes. Identification of a brief screening measure to detect cognitive impairment in this population is needed, as comprehensive neuropsychological evaluations may not be available in all clinical settings.
Setting
Longitudinal Assessment of Bariatric Surgery (LABS), United States; Medical Center
Methods
The current study examined the utility of the Mini-Mental State Examination (MMSE) for detecting cognitive impairment in 30 bariatric surgery candidates by comparing impairment on the MMSE (at varying cutoffs) to impairment on a comprehensive neuropsychological test battery.
Results
Results indicated that the MMSE showed low sensitivity and specificity in identifying impairment, even at the more stringent MMSE cutoffs of 27 and 28.
Conclusions
These findings suggest that the MMSE is a poor screener for cognitive impairment in bariatric surgery candidates. Future research is needed to identify or develop cognitive screeners for use in this population.
doi:10.1016/j.soard.2013.09.010
PMCID: PMC3962514  PMID: 24355321
Bariatric surgery; Cognitive function; Neuropsychological testing; Cognitive screening
16.  Nutritional Adequacy of Dietary Intake in Women with Anorexia Nervosa 
Nutrients  2015;7(5):3652-3665.
Understanding nutrient intake of anorexia nervosa (AN) patients is essential for the treatment. Therefore, estimates of total energy and nutrient consumption were made in a group of young women (19 to 30 years) with restricting and binge purge subtypes of AN participating in an ecological momentary assessment study. Participants completed three nonconsecutive 24-hour diet recalls. Mean nutrient intakes were stratified by subtype and by quartiles of energy intake and compared to the age specific Dietary Reference Intake (DRI) levels, as well as to the reported intakes from the What We Eat In America (WWEIA) dietary survey 2011–2012. Reported intake was determined for energy, macronutrients, and micronutrients. The mean body mass index (BMI) for all participants was 17.2 ± 0.1 kg/m2. Reported nutrient intake was insufficient for participants in quartiles 1–3 of both AN subtypes when compared to the DRIs. Intake reported by participants in quartile 4 of both subgroups met requirements for most nutrients and even met or exceeded estimated energy needs. Counseling of AN patients should be directed to total food consumption to improve energy intake and to reduce individual nutritional gaps.
doi:10.3390/nu7053652
PMCID: PMC4446771  PMID: 25988761
anorexia nervosa; dietary intake; WWEIA; NHANES 2011–2012
17.  Psychopathology in Bariatric Surgery Candidates: A Review of Studies Using Structured Diagnostic Interviews 
Comprehensive psychiatry  2013;55(2):248-259.
Psychiatric disorders are not uncommon among severely obese patients who present for bariatric surgery. This paper (1) reviews the results of the published studies using the structured interviews to assess psychopathology in bariatric surgery candidates; (2) compares the prevalence rates of psychiatric disorders across these studies with the data from other population samples; and (3) assesses whether sociodemographic variables appear to affect these prevalence rates. We searched online resources, PubMed, PsychINFO and reference lists of all the relevant articles to provide an overview of evidence so far and highlight some details in the assessment and comparisons of different samples in different countries. The prevalence estimates in the non- treatment obese group did not appear to differ substantially from the general population group in the US or the Italian population samples, although they were relatively higher for the German population. However, the rates of psychopathology in the bariatric surgery candidates were considerably higher than the other two population groups in all the samples. Overall, the most common category of lifetime Axis I disorders in all the studies was affective disorders, with anxiety disorders being the most common category of current Axis I disorders. Certain demographic characteristics are also associated with higher rates of psychopathology, such as, female gender, low socioeconomic status, higher BMI. Overall, methodological and sociodemographic differences make these studies difficult to compare and these differences should be taken into account when interpreting the results.
doi:10.1016/j.comppsych.2013.08.021
PMCID: PMC3985130  PMID: 24290079
18.  Psychopathology Prior to Surgery in the Longitudinal Assessment of Bariatric Surgery-3 (LABS-3) Psychosocial Study 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1016/j.soard.2012.07.001
PMCID: PMC3584713  PMID: 22920965
Psychopathology; Eating Disorders; Binge Eating Disorder
19.  Primary Amenorrhea in Anorexia Nervosa: Impact on Characteristic Masculine and Feminine Traits 
Animal studies indicate gonadal hormones at puberty have an effect on the development of masculine and feminine traits. However, it is unknown whether similar processes occur in humans. We examined whether women with anorexia nervosa (AN), who often experience primary amenorrhea, exhibit attenuated feminization in their psychological characteristics in adulthood due to the decrease/absence of gonadal hormones at puberty. Women with AN were compared on a number of psychological characteristics using General Linear Models based on the presence/absence of primary amenorrhea. Although women with primary amenorrhea exhibited lower anxiety scores than those without primary amenorrhea, in general, results did not provide evidence of attenuated feminization in women with AN with primary amenorrhea. Future research should utilize novel techniques and direct hormone measurement to explore the effects of pubertal gonadal hormones on masculine and feminine traits.
doi:10.1002/erv.2263
PMCID: PMC4266542  PMID: 24123541
Organizational effects; sex differences; amenorrhea; pubertal timing; anorexia nervosa
20.  Hard Exercise, Affect Lability, and Personality Among Individuals with Bulimia Nervosa 
Eating behaviors  2013;14(4):10.1016/j.eatbeh.2013.07.004.
The current study explores the personality traits of compulsivity (e.g., sense of orderliness and duty to perform tasks completely) and restricted expression (e.g., emotion expression difficulties) as potential moderators of the relation between affect lability and frequency of hard exercise episodes in a sample of individuals with bulimic pathology. Participants were 204 adult females recruited in five Midwestern cities who met criteria for threshold or subthreshold bulimia nervosa (BN). Compulsivity was found to significantly moderate the relation between affect lability and number of hard exercise episodes over the past 28 days, such that among those with high compulsivity, level of affect lability was associated with the number of hard exercise episodes; whereas, among those with low compulsivity, affect lability was not associated with the number of hard exercise episodes. The same pattern of findings emerged for restricted expression; however, this finding approached, but did not reach statistical significance. As such, it appears that affect lability is differentially related to hard exercise among individuals with BN depending upon the level of compulsivity and, to a more limited extent, restricted expression. These results suggest that, for individuals with BN with either compulsivity or restricted expression, focusing treatment on increasing flexibility and/or verbal expression of emotions may help them in the context of intense, fluctuating affect.
doi:10.1016/j.eatbeh.2013.07.004
PMCID: PMC3832258  PMID: 24183126
exercise; emotion regulation; bulimia nervosa; affect lability; compulsivity; emotion expression
21.  Examining Duration of Binge Eating Episodes in Binge Eating Disorder 
Objective
The primary goal of this paper is to examine and clarify characteristics of binge eating in individuals with binge eating disorder (BED), particularly the duration of binge eating episodes, as well as potential differences between individuals with shorter compared to longer binge eating episodes.
Method
Two studies exploring binge eating characteristics in BED were conducted. Study 1 examined differences in clinical variables among individuals (N = 139) with BED who reported a short (< 2 hours) versus long (≥ 2 hours) average binge duration. Study 2 utilized an ecological momentary assessment (EMA) design to examine the duration and temporal pattern of binge eating episodes in the natural environment in a separate sample of nine women with BED.
Results
Participants in Study 1 who were classified as having long duration binge eating episodes displayed greater symptoms of depression and lower self-esteem, but did not differ on other measures of eating disorder symptoms, compared to those with short duration binge eating episodes. In Study 2, the average binge episode duration was approximately 42 minutes, and binge eating episodes were most common during the early afternoon and evening hours, as well as more common on weekdays versus weekends.
Discussion
Past research on binge episode characteristics, particularly duration, has been limited to studies of binge eating episodes in BN. This study contributes to the existing literature on characteristics of binge eating in BED.
doi:10.1002/eat.22164
PMCID: PMC3889648  PMID: 23881639
22.  Restrictive Eating Behaviors are a Non-Weight-Based Marker of Severity in Anorexia Nervosa 
Objective
The purpose of this study was to compare the type and frequency of restrictive eating behaviors across the two subtypes of anorexia nervosa (AN; restricting [ANr] and binge eating/purging [ANbp]) using ecological momentary assessment (EMA) and to determine whether subtype differences in restrictive eating behaviors were attributable to severity of the disorder or the frequency of binge eating.
Method
Participants (N = 118) were women at least 18 years of age with full (n = 59) or sub-threshold (n = 59) AN who participated in a two week (EMA) protocol.
Results
General estimating equations revealed that individuals with ANbp generally reported more frequent restrictive eating behaviors than individuals with ANr. These differences were mostly accounted for by greater severity of eating psychopathology, indicating that the presence and frequency of restrictive eating behaviors in AN may be non-weight-based markers of severity. Binge eating frequency did not account for these findings.
Discussion
The present findings are especially interesting in light of the weight-based severity rating in the DSM-5.
doi:10.1002/eat.22163
PMCID: PMC4001723  PMID: 23868197
Anorexia nervosa; subtypes; dietary restriction; severity
23.  Picking and nibbling: Frequency and associated clinical features in bulimia nervosa, anorexia nervosa and binge eating disorder 
Picking and nibbling (P&N) is a newly studied eating behavior characterized by eating in an unplanned and repetitious manner in between meals and snacks. This behavior seems to be related to poorer weight loss outcomes after bariatric surgery for weight loss in severely obese patients, but clarification is still required regarding its value in other clinical samples.
Objective:
The purpose of this study was to investigate the frequency of P&N across different eating disorder samples, as well as to examine its association with psychopathological eating disorder features.
Methods:
Our sample included treatment-seeking adult participants, recruited for five different clinical trials: 259 binge eating disorder (BED); 264 bulimia nervosa (BN) and 137 anorexia nervosa (AN). Participants were assessed using the Eating Disorders Examination interview before entering the clinical trials.
Results:
P&N was reported by 44% of the BED; 57.6% of the BN and 34.3% of the AN participants. No association was found between P&N and BMI, the presence of compensatory behaviors, binge eating or any of the EDE subscales.
Discussion:
This study suggests that P&N behavior is highly prevalent across eating disorder diagnoses. Our findings suggest that P&N is not associated with psychopathology symptoms or other eating disordered behaviors.
doi:10.1002/eat.22167
PMCID: PMC4009470  PMID: 23922133
Picking and nibbling; eating behaviors;  eating disordered behaviors
24.  An Assessment of Daily Food Intake in Participants with Anorexia Nervosa in the Natural Environment 
Objective
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.
Method
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.
Results
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.
Discussion
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.
doi:10.1002/eat.20628
PMCID: PMC3584709  PMID: 19040266
AN; binge eating; compensatory behaviors; caloric intake
25.  Sexual Functioning and Sex Hormones in Persons with Extreme Obesity and Seeking Surgical and Non-Surgical Weight Loss 
Background
Many individuals with obesity are motivated to lose weight to improve weight-related comorbidities or psychosocial functioning, including sexual functioning. Few studies have documented rates of sexual dysfunction in persons with obesity.
Objectives
This study investigated sexual functioning, sex hormones, and relevant psychosocial constructs in individuals with obesity who sought surgical and non-surgical weight loss.
Setting
University based health systems.
Methods
One hundred forty-one bariatric surgery patients (median BMI [25th percentile, 75th percentile] 44.6 [41.4, 50.1]) and 109 individuals (BMI = 40.0 [38.0, 44.0]) who sought nonsurgical weight loss participated. Sexual functioning was assessed by the Female Sexual Function Index (FSFI) and International Index of Erectile Function (IIEF). Hormones were assessed by blood assay. Quality of life, body image, depressive symptoms and marital adjustment were assessed by validated questionnaires.
Results
Fifty-one percent of women presenting for bariatric surgery reported a sexual dysfunction; 36% of men presenting for bariatric surgery reported erectile dysfunction (ED). This is in contrast to 41% of women who sought nonsurgical weight loss and reported a sexual dysfunction and 20% of men who sought nonsurgical weight loss and reported ED. These differences were not statistically significant. Sexual dysfunction was strongly associated with psychosocial distress in women; these relationships were less strong and less consistent among men. Sexual dysfunction was unrelated to sex hormones, except for sex hormone binding globulin (SHGB) in women.
Conclusion
Women and men who present for bariatric surgery, as compared to individuals who sought non-surgical weight loss, were not significantly more likely to experience a sexual dysfunction. There were few differences in reproductive hormones and psychosocial constructs between candidates for bariatric surgery and individuals interested in non-surgical weight loss.
doi:10.1016/j.soard.2013.07.003
PMCID: PMC3864660  PMID: 24120985
Sexual Functioning; Quality of Life; Obesity

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