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1.  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
2.  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
3.  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
4.  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
5.  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
6.  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
7.  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
8.  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
9.  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
11.  Bariatric Surgery Patients Exhibit Improved Memory Function 12 Months Post-Operatively 
Obesity surgery  2013;23(10):1527-1535.
Introduction/Purpose
Previous work from our group demonstrated improved memory function in bariatric surgery patients at 12 weeks post-operatively relative to controls. However, no study has examined longer term changes in cognitive functioning following bariatric surgery.
Materials and Methods
A total of 137 individuals (95 bariatric surgery patients, 42 obese controls) were followed prospectively to determine whether post-surgery cognitive improvements persist. Potential mechanisms of change were also examined. Bariatric surgery participants completed self-report measurements and a computerized cognitive test battery prior to surgery and at 12-week and 12-month follow-up; obese controls completed measures at equivalent time points.
Results
Bariatric surgery patients exhibited cognitive deficits relative to well established standardized normative data prior to surgery, and obese controls demonstrated similar deficits. Analyses of longitudinal change indicated an interactive effect on memory indices, with bariatric surgery patients demonstrating better performance post-operatively than obese controls.
Conclusion
While memory performance was improved 12 months post-bariatric surgery, the mechanisms underlying these improvements were unclear and did not appear attributable to obvious post-surgical changes, such as reductions in BMI or co-morbid medical conditions. Future studies employing neuroimaging, metabolic biomarkers, and more precise physiological measurements are needed to determine the mechanisms underlying memory improvements following bariatric surgery.
doi:10.1007/s11695-013-0970-7
PMCID: PMC3773052  PMID: 23636994
obesity; cognitive function; bariatric surgery; longitudinal assessment
12.  Associations between Retrospective versus Ecological Momentary Assessment Measures of Emotion and Eating Disorder Symptoms in Anorexia Nervosa 
Journal of psychiatric research  2013;47(10):1514-1520.
This study examined the unique associations between eating disorder symptoms and two emotion-related constructs (affective lability and anxiousness) assessed via distinct methodologies in anorexia nervosa (AN). Women (N=116) with full or subthreshold AN completed baseline emotion and eating disorder assessments, followed by two weeks of ecological momentary assessment (EMA). Hierarchical regressions were used to examine unique contributions of baseline and EMA measures of affective lability and anxiousness in accounting for variance in baseline eating disorder symptoms and EMA dietary restriction, controlling for age, body mass index, depression, and AN diagnostic subtype. Only EMA affective lability was uniquely associated with baseline eating disorder symptoms and EMA dietary restriction. Anxiousness was uniquely associated with baseline eating disorder symptoms regardless of assessment method; neither of the anxiousness measures was uniquely associated with EMA dietary restriction. Affective lability and anxiousness account for variance in global eating disorder symptomatology; AN treatments targeting these emotion-related constructs may prove useful.
doi:10.1016/j.jpsychires.2013.06.021
PMCID: PMC3805055  PMID: 23880601
eating disorders; ecological momentary assessment; emotion; affective lability; anxiety; assessment
13.  Race/Ethnicity, Education, and Treatment Parameters as Moderators and Predictors of Outcome in Binge Eating Disorder 
Objective
Binge eating disorder (BED) is prevalent among individuals from minority racial/ethnic groups and among individuals with lower levels of education, yet the efficacy of psychosocial treatments for these groups has not been examined in adequately powered analyses. This study investigated the relative variance in treatment retention and post-treatment symptom levels accounted for by demographic, clinical, and treatment variables as moderators and predictors of outcome.
Method
Data were aggregated from eleven randomized, controlled trials of psychosocial treatments for BED conducted at treatment sites across the United States. Participants were N = 1,073 individuals meeting criteria for BED including n = 946 Caucasian, n = 79 African American, and n = 48 Hispanic/Latino participants. Approximately 86% had some higher education; 85% were female. Multi-level regression analyses examined moderators and predictors of treatment retention, Eating Disorder Examination (EDE) global score, frequency of objective bulimic episodes (OBEs), and OBE remission.
Results
Moderator analyses of race/ethnicity and education were non-significant. Predictor analyses revealed African Americans were more likely to drop out of treatment than Caucasians, and lower level of education predicted greater post-treatment OBEs. African Americans showed a small but significantly greater reduction in EDE global score relative to Caucasians. Self-help treatment administered in a group showed negative outcomes relative to other treatment types, and longer treatment was associated with better outcome.
Conclusions
Observed lower treatment retention among African Americans and lesser treatment effects for individuals with lower levels of educational attainment are serious issues requiring attention. Reduced benefit was observed for shorter treatment length and self-help administered in groups.
doi:10.1037/a0032946
PMCID: PMC4175452  PMID: 23647283
binge eating disorder; race; ethnicity; socioeconomic status; treatment outcome
14.  Patient reports of cognitive problems are not associated with neuropsychological test performance in bariatric surgery candidates 
Background
Recent work shows that cognitive deficits are common in bariatric surgery candidates and associated with reduced weight loss at 12 months post-operatively. As pre-operatively neuropsychological assessment is not available for all patients at all sites, many care providers ask patients to self-report their level of cognitive dysfunction. However, the accuracy of patient self-report of cognitive abilities has not been empirically examined.
Setting
Longitudinal Assessment of Bariatric Surgery (LABS), United States; Medical Center
Methods
Eighty-one bariatric surgery candidates completed self-report measures of cognitive functioning and neuropsychological tests of memory and other cognitive abilities.
Results
Analyses found no association between subjective report of cognitive function and objective performance on neuropsychological testing. However, persons with history of major depressive disorder reported experiencing greater cognitive deficits.
Conclusions
These findings suggest that bariatric surgery candidates have little insight into their current level of cognitive function. Future work is needed to confirm these findings and identify brief, objective measures of cognitive function that are sensitive to deficits in bariatric surgery candidates.
doi:10.1016/j.soard.2012.10.008
PMCID: PMC3610809  PMID: 23245496
Bariatric; Cognition; Self-report; Memory; Executive Function
15.  Reporting weight change: Standardized reporting accounting for baseline weight 
Background
Although it is recognized that a standardized approach to reporting weight change is essential to permit meaningful comparisons among cohorts and across studies, consensus is lacking.
Objective
Propose a method of reporting weight change allowing meaningful comparisons among studies of patients who underwent bariatric surgery and to demonstrate its utility using an example from the Longitudinal Assessment of Bariatric Surgery (LABS).
Methods
Relationships among several measures of weight change are described. Results from an observational, longitudinal cohort study of adults undergoing bariatric surgery and from simulation studies are used to illustrate the proposed method.
Setting
University Hospitals
Results
Baseline weight is a critical parameter when assessing weight change. Men undergoing a bariatric procedure other than gastric bypass or adjustable band tended to have greater weight loss twelve months after surgery than men undergoing gastric bypass when not accounting for baseline weight, but the opposite was found when results were adjusted for baseline weight. Simulation results show that with relatively modest sample sizes, the adjusted weight loss was significantly different between the two groups of men.
Conclusion
A consistent metric for reporting weight loss following bariatric surgery is essential to interpret outcomes across studies and among subgroups. The baseline weight adjusted % weight loss (A%WL) uses a standard population, e.g., the LABS cohort, to account for differences between cohorts with respect to baseline weight and its use can change the interpretation of results compared to an unadjusted measure.
doi:10.1016/j.soard.2012.11.006
PMCID: PMC3686891  PMID: 23337770
obesity; bariatric surgery; weight change
16.  Cognitive Function Predicts 24-Month Weight Loss Success Following Bariatric Surgery 
Background
Clinically significant cognitive impairment, particularly in attention/executive and memory function, is found in many patients undergoing bariatric surgery. These difficulties have previously been linked to decreased weight loss 12 months post-surgery, but more protracted examination of this relationship has not yet been conducted.
Objectives
The current study prospectively examined the independent contribution of cognitive function to weight loss 24 months following bariatric surgery. Given the rapid rate of cognitive improvement observed following surgery, postoperative cognitive function (i.e., cognition 12 weeks following surgery, controlling for baseline cognition) was expected to predict lower body mass index (BMI) and higher percent total weight loss (%WL) at 24-month follow-up.
Setting
Data were collected by three sites of the Longitudinal Assessment of Bariatric Surgery (LABS) parent project.
Methods
Fifty-seven individuals enrolled in the LABS project undergoing bariatric surgery completed cognitive evaluation at baseline, 12 weeks, and 24 months. %WL and BMI were calculated for 24-month postoperative follow-up.
Results
Better cognitive function 12 weeks following surgery predicted higher %WL and lower BMI at 24 months, and specific domains of attention/executive and memory function were robustly related to decreased BMI and greater %WL at 24 months.
Conclusions
Results demonstrate that cognitive performance shortly after bariatric surgery predicts greater long-term %WL and lower BMI 24 months following bariatric surgery. Further work is needed to clarify the degree to which this relationship is mediated by adherence to postoperative guidelines.
doi:10.1016/j.soard.2013.04.011
PMCID: PMC3788845  PMID: 23816443
memory; cognition; executive function; adherence
17.  Predicting group cognitive-behavioral therapy outcome of binge eating disorder using empirical classification 
Behaviour research and therapy  2013;51(9):10.1016/j.brat.2013.05.001.
The purpose of this study was to use empirical classification based on Latent Profile Analysis to identify subgroups of binge eating disorder (BED) and to evaluate the extent to which these subgroups were predictive of treatment outcome in group cognitive–behavioral therapy (CBT). The Eating Disorder Examination (EDE), Structured Clinical Interview for DSM-IV, and Inventory of Depressive Symptomatology-Self-Report were administered to 259 participants at baseline in a 15-session CBT trial (190 of whom received active treatment). The best fitting model included three profiles: dietary restraint only (DRO; n = 96; 51%); low dietary restraint (LDR; n = 52; 27%); and dietary restraint plus psychopathology (DRP; n = 42; 22%). Regression analyses revealed that after controlling for baseline score and treatment condition, EDE Global scores were lower for the DRO compared to the LDR profile at one year follow-up (p = .047). Class assignment was not predictive of EDE binge eating frequency or abstinence at end of treatment or follow-up. These results suggest that meaningful empirical classes based on eating disorder symptoms, psychopathology, dietary restraint, and BMI can be identified in BED and that these classes may be useful in predicting long-term group CBT outcome.
doi:10.1016/j.brat.2013.05.001
PMCID: PMC3813468  PMID: 23820157
Binge eating; Cognitive–behavioral therapy; Empirical classification; Prognosis
18.  Personality-Based Subtypes of Anorexia Nervosa: Examining Validity and Utility Using Baseline Clinical Variables and Ecological Momentary Assessment 
Behaviour research and therapy  2013;51(8):512-517.
Objective
This study sought to empirically derive and validate clinically relevant personality-based subtypes of anorexia nervosa (AN).
Methods
Women (N=116) with full or subthreshold AN completed baseline measures of personality, clinical variables, and eating disorder (ED) symptoms, followed by two weeks of ecological momentary assessment (EMA). A latent profile analysis was conducted to identify personality subtypes, which were compared on baseline clinical variables and EMA variables.
Results
The best-fitting model supported three subtypes: underregulated, overregulated, and low psychopathology. The underregulated subtype (characterized by high stimulus seeking, self-harm, and oppositionality) displayed greater baseline ED symptoms, as well as lower positive affect and greater negative affect, self-discrepancy, and binge eating in the natural environment. The overregulated subtype (characterized by high compulsivity and low stimulus seeking) was more likely to have a lifetime obsessive-compulsive disorder diagnosis and exhibited greater perfectionism; levels of negative affect, positive affect, and self-discrepancy in this group were intermediate between the other subtypes. The low psychopathology subtype (characterized by normative personality) displayed the lowest levels of baseline ED symptoms, co-occurring disorders, and ED behaviors measured via EMA.
Conclusions
Findings support the validity of these personality-based subtypes, suggesting the potential utility of addressing within-diagnosis heterogeneity in the treatment of AN.
doi:10.1016/j.brat.2013.05.007
PMCID: PMC3721308  PMID: 23792181
eating disorders; personality; ecological momentary assessment; affect; empirical classification; latent profile analysis
19.  The Role of Affect in the Maintenance of Anorexia Nervosa: Evidence from a Naturalistic Assessment of Momentary Behaviors and Emotion 
Journal of abnormal psychology  2013;122(3):709-719.
The current study examines the relationship of affect and eating disorder behavior in anorexia nervosa (AN) using ecological momentary assessment. Participants were 118 adult females recruited at three sites from eating disorder treatment centers and community advertisements. All participants met full DSM-IV criteria or sub-threshold criteria for AN. Participants were provided handheld computers and asked to report positive affect, negative affect, loss of control (LOC) eating, purging, exercise, drinking fluids to curb appetite, and weighing one's self multiple times per day as well as dietary restriction once daily over a two-week interval. Mixed-effects models were used to examine the extent to which affective states predict dietary restriction. Additionally, we used two analytic approaches to compare affect prior to and after other eating disorder behaviors. We found that higher daily ratings of negative affect were associated with a greater likelihood of dietary restriction on subsequent days. When examining the single rating immediately before and after behaviors, we found that negative affect increased significantly following LOC eating, purging, the combination of LOC and eating/purging, and weighing of one's self. Using this same analytic approach we also found negative affect to decrease significantly following the consumption of fluids to curb appetite and exercise. When examining the covariation of AN behaviors and negative affect assessed multiple times in the hours and minutes before the behaviors, we found negative affect significantly increased prior to LOC eating, purging, the combination of LOC eating/and purging, and weighing behavior. Negative affect also significantly decreased following the occurrence of these behaviors. These findings are consistent with the idea that that negative affect is potentially a critical maintenance mechanism of some AN symptoms, but that the analytic approach used to examine affect and behavior may have significant implications on the interpretation of findings.
doi:10.1037/a0034010
PMCID: PMC3997111  PMID: 24016011
anorexia nervosa; ecological momentary assessment (EMA); negative affect; positive affect; restriction
20.  A Naturalistic Examination of Body Checking and Dietary Restriction in Women with Anorexia Nervosa 
Behaviour research and therapy  2013;51(8):507-511.
Body checking has been conceptualized as a behavioral manifestation of the core overvaluation of eating, shape, and weight concerns underlying eating disorder psychopathology. Cognitive-behavioral theories suggest that body checking behaviors may function to maintain dietary restriction. The current study examined the association between body checking frequency and dietary restriction among women with anorexia nervosa (AN) in the natural environment. Women (N = 118) with full or partial AN completed baseline clinical interviews and a two-week ecological momentary assessment protocol, during which they reported on body checking behaviors (i.e., checking whether one’s thighs touch; checking joints/bones for fat) and dietary restriction (i.e., 8 waking hours without eating; consuming less than 1200 calories per day). Average daily body checking frequency was positively associated with baseline eating disorder symptoms and body mass index. Daily body checking frequency was associated with both forms of dietary restriction on the same day, as well as the following day. Results support the theorized association between body checking and overvaluation of shape and weight, and suggest that targeting such behaviors in treatment may have utility in reducing dietary restriction.
doi:10.1016/j.brat.2013.05.004
PMCID: PMC3733328  PMID: 23792180
anorexia nervosa; body checking; dietary restriction; ecological momentary assessment
21.  Improved Memory Function Two Years After Bariatric Surgery 
Obesity (Silver Spring, Md.)  2013;22(1):32-38.
Objective
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.
Results
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).
Conclusion
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.
doi:10.1002/oby.20494
PMCID: PMC4054602  PMID: 23625587
Obesity; bariatric surgery; cognitive function; weight loss
22.  Weight Change and Health Outcomes at Three Years After Bariatric Surgery Among Patients with Severe Obesity 
IMPORTANCE
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.
OBJECTIVE
Report 3 year change in weight and select health parameters following common bariatric surgical procedures.
DESIGN and SETTING
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.
PARTICIPANTS and EXPOSURE
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.
MAIN OUTCOMES
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.
RESULTS
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.
CONCLUSIONS and RELEVANCE
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, ClinicalTrials.gov
doi:10.1001/jama.2013.280928
PMCID: PMC3955952  PMID: 24189773
23.  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
24.  Cognitive Function Predicts Weight Loss Following Bariatric Surgery 
Background
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.
Objectives
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.
Setting
Three sites of the Longitudinal Assessment of Bariatric Surgery (LABS) parent project were used: Columbia, Cornell, and Neuropsychiatric Research Institute
Methods
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.
Results
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.
Conclusions
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.
doi:10.1016/j.soard.2011.10.008
PMCID: PMC3294182  PMID: 22133580
memory; cognition; executive function
25.  The Role of Eating and Emotion in Binge Eating Disorder and Loss of Control Eating 
Objective
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.
Method
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.
Results
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.
Discussion
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.
doi:10.1002/eat.22061
PMCID: PMC3570734  PMID: 23109227

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