Psychometric properties of the eating loss of control scale among postbariatric patients

BackgroundAssessing the complexities of eating behaviors in patients who undergo bariatric surgery is challenging. The Eating Loss of Control Scale (ELOCS), a measure of loss-of-control (LOC) eating, has not yet been evaluated psychometrically among bariatric surgery patients.ObjectiveThis study presents a psychometric examination of the ELOCS in postoperative bariatric surgery patients.SettingAcademic medical center in the United States.MethodsOne hundred seventy-one postbariatric treatment-seeking adults (82.5% female, 52.4% white) with LOC eating completed the ELOCS and measures assessing eating psychopathology and mood. Confirmatory factor analysis (CFA) was used to test fit for a 1-factor solution. Exploratory factor analysis (EFA) examined alternative factor structures.ResultsCFA revealed poor fit for a 1-factor structure (χ² = 220.375, degrees of freedom = 135, P < .001, comparative fit index = .917, Tucker-Lewis index = .906, root mean square error of approximation = .067). EFA data suggested an alternative factor solution (χ² = 157.76, degrees of freedom = 118, P = .009, comparative fit index = .965, Tucker-Lewis index = .955, root mean square error of approximation = .047). Factor 1 (α = .88) reflected behavioral aspects and factor 2 (α = .92) reflected cognitive/emotional aspects of LOC eating. Bivariate correlations with measures of eating and other psychopathology suggested good construct validity for factors.ConclusionsFindings suggest possible differences in the construct validity of the ELOCS among postbariatric patients. The 1-factor solution previously supported in clinical and nonclinical groups demonstrated poor fit. EFA revealed a possible alternative 2-factor solution that aligns with emerging literature, suggesting that LOC eating presents differently in postbariatric patients. Researchers interested in LOC eating among bariatric patients should consider use of the ELOCS and testing the proposed alternative factor structure.     

Brief,four-session group CBT reduces binge eating behaviors among bariatric surgery candidates

BackgroundThe objective of this study was to evaluate the effectiveness of a brief, 4-session cognitive behavioral, group psychotherapy for binge eating among bariatric surgery candidates at an academic medical center. Binge eating behaviors have been linked to poorer outcomes among bariatric surgery patients, and binge eating disorder have be considered a contraindication in surgery programs, some of which have mandated preoperative binge eating treatment. However, no previous studies have examined whether a preoperative binge eating intervention could successfully reduce binge eating behaviors among severely obese bariatric surgery candidates.MethodsA total of 243 bariatric surgery candidates completed a brief cognitive behavioral group treatment for binge eating behaviors and were administered the Binge Eating Scale and reported the number of weekly binge eating episodes at the initial psychological evaluation and again after the group sessions. The study used a pre–post intervention design.ResultsThe results suggested significant reductions in both binge eating behaviors and cognitions and binge eating episodes after the group intervention. The intervention's effectiveness did not differ according to gender or ethnicity (black versus white).ConclusionA brief cognitive behavioral intervention can reduce binge eating behaviors among bariatric surgery candidates. Given the potential influence of binge eating on outcomes, bariatric surgery programs could benefit by treating binge eating before surgery.     

Eating expectancies before bariatric surgery: assessment and associations with weight loss trajectories

BackgroundWhile presurgical eating behaviors have demonstrated limited prognostic value, cognitions regarding the effects of eating may serve as important predictors of weight loss outcomes after bariatric surgery. The Eating Expectancies Inventory (EEI) is a commonly used, self-report measure of expected consequences of eating; however, its psychometric and predictive properties have not yet been evaluated among bariatric surgery patients.ObjectivesThis study sought to examine the factor structure and internal consistency of the EEI among bariatric surgery candidates, to examine relationships between EEI factors and measures of eating psychopathology, and to explore the effects of eating expectancies on postsurgical weight loss.SettingData originated from an interdisciplinary bariatric surgery center in the Midwest United States.MethodsTwo hundred sixty-two women completed self-report questionnaires before bariatric surgery. Presurgical data and available postsurgical weights (at 6, 12, and 18 mo) were obtained from medical records.ResultsAnalyses indicated that the original 5-factor model was a good-to-excellent fit for the EEI data. All EEI factors demonstrated good reliability and were significantly associated with eating disorder symptoms and behaviors at baseline. Higher scores on EEI Factor 1 (negative affect) and Factor 5 (alleviates boredom) predicted poorer weight loss at 18 months postsurgery (n = 132).ConclusionsFindings support the reliability and validity of the EEI among female bariatric candidates. Presurgical eating expectancies were linked to pathologic eating patterns and also predicted postsurgical weight loss trajectories, suggesting that eating expectancies may have prognostic value as predictors of bariatric surgery outcomes.     

Hunger mediates the relationship between food insecurity and binge eating among bariatric surgery candidates

BackgroundThe food insecurity–obesity paradox suggests that people lacking access to adequately nutritious foods are more susceptible to disordered eating. However, the mechanisms underlying the relationship between food insecurity and binge eating are not well understood.ObjectivesThis study sought to assess the role of eating behaviors (i.e., cognitive restraint, disinhibition, and hunger) as mediators between food insecurity and binge eating among a sample of preoperative bariatric candidates.SettingUniversity hospital in the Appalachian region of the United States.MethodsA total of 369 adults seeking bariatric surgery were included in this cross-sectional study. Patients completed validated measures of food insecurity and eating behaviors as part of a routine psychological evaluation prior to bariatric surgery.ResultsFood insecurity was significantly related to binge eating symptoms (r[369] = .14, P < .01) and hunger (r[369] = .11, P < .05). Hunger mediated the relationship between food insecurity and binge eating (b = 1.23, standard error = .62, 95% confidence interval .08–2.54). Food insecurity was not associated with restraint (r[369] = .06, P = .27) or disinhibition (r[369] = .02, P = .69).ConclusionsFood insecurity presents a unique pathway to binge eating that has several implications for intervention prior to bariatric surgery. Identification of food insecurity and the subsequent effects on eating behaviors is crucial to understanding the factors relevant to disordered eating prior to bariatric surgery.     

When is the best time to deliver behavioral intervention to bariatric surgery patients: before or after surgery?

BackgroundMany comprehensive bariatric surgery programs have implemented preoperative behavioral interventions for patients presenting with problematic eating behaviors in an effort to enhance postoperative weight loss and improve psychosocial adjustment. However, it is unknown whether these interventions are best delivered pre- or postoperatively. The purpose of this study was to determine when bariatric surgery patients are most receptive to a behavioral intervention, before or after surgery.MethodsA total of 32 pre- and postoperative patients were referred to a 10-week intervention designed to reduce eating behaviors associated with postoperative weight gain (e.g., loss of control while eating, grazing). The sample was 78.1% female and 84.4% white, with an average age of 49.43 ± 9.13 years and a body mass index of 44.22 ± 6.48 kg/m². Of the 32 patients, 21 were referred preoperatively and 11 were referred postoperatively (5.63 ± 2.91 months after surgery). These patients were tracked prospectively to determine whether pre- or postoperative patients were more likely to attend and complete the behavioral intervention.ResultsCompared with the preoperative patients, the postoperative patients were more likely to follow-up with their referral and initiate treatment [χ²(1) = 10.06, P = .002]. Of the postoperative patients, 100% attended the first intervention session compared with only 43% of preoperative patients. The postoperative patients also attended more intervention sessions [t(18) = 2.51, P = .02] and were more likely to complete the intervention [χ²(1) = 7.21, P = .007]. Only 14% of the preoperative referral patients completed the program compared with 91% of the postoperative patients.ConclusionComprehensive bariatric surgery programs ought to consider balancing the needs of the preoperative patients presenting with maladaptive eating behavior with the likelihood of them participating in a behavioral intervention before surgery.     

Maternal child feeding practices and eating behaviors of women with extreme obesity and those who have undergone bariatric surgery

BackgroundBariatric surgery is the most effective treatment of extreme obesity. Few studies, however, have explored some of the lifestyle behaviors (i.e., grocery shopping and cooking methods) thought to contribute to postoperative weight maintenance. To date, the child feeding practices of women who have undergone bariatric surgery have not been explored. The study setting was a university in the United States.MethodsA total of 41 women awaiting bariatric surgery were assessed preoperatively; an additional 23 women who had undergone bariatric surgery (6–24 mo previously) were also assessed. The participants had to be responsible for feeding a child (age range 2–16 yr) in their home. Self-report measures assessed demographics, maternal child feeding practices, eating behaviors, and available household foods. Bivariate correlations were used to investigate the relationships among the measures. Independent sample t tests assessed group differences, and 1-way analysis of variance and concepts of linear progression and regression were used to determine whether the findings remained statistically significant after controlling for demographic variables.ResultsWomen who had undergone surgery, compared with those awaiting surgery, reported more frequent modeling of healthy eating for their child (P = .009), significantly greater levels of cognitive restraint (P = .001), and lower levels of disinhibition (P = .019). Some between-group differences were found in grocery shopping frequency (P = .093) and in select foods available in the home (P = .101 to P = .151), which approached statistical significance.ConclusionMothers who had undergone bariatric surgery demonstrated healthy eating for their child and were engaged in healthier eating behaviors themselves compared with women awaiting surgery. Intervening with mothers who are undergoing bariatric surgery could present a unique opportunity for modifying the home food environment and promoting healthy eating among other family members, especially those children at risk of extreme obesity.     

Parent-based prevention after parental weight loss surgery: a pilot case-series trial

BackgroundOvereating and obesity are elevated in children of parents who have undergone weight loss surgery. Parents who have undergone weight loss surgery often report their personal history of obesity interferes with their knowledge, skills, and self-efficacy in developing their children’s healthy habits, thus reducing the likelihood of addressing obesogenic environmental factors.ObjectivesThis study examines whether a 6-session parent-based prevention after bariatric surgery online intervention is feasible and acceptable for parents. The study also explores the program’s signal of efficacy in improving short-term outcomes related to decreased long-term risks for obesity by examining short-term impact on targeted parental cognitions, feeding practices, and child eating behaviors and physical activity habits.SettingUniversity Hospital, United States.MethodsParents were recruited using flyers, clinician referrals, and social media. Measures assessed parental feeding practices, children’s eating behaviors, daily hours of screen time, and outdoor play.ResultsTen families enrolled and 7 completed the study. Parents found the intervention relevant and suitable for addressing their parenting concerns. Parental feeding behaviors, such as restriction and pressure to eat, reduced while tracking of sweets and high-fat snacks increased. Children reduced both emotional overeating and undereating. Children’s daily hours of screen time reduced as well as their outdoor play time.ConclusionsParent-based prevention after bariatric surgery aimed at helping parents who have undergone weight loss surgery engineer healthier family lifestyles is feasible, acceptable, and associated with reduced obesogenic risk factors.     

Comprehensive interview assessment of eating behavior 18–35 months after gastric bypass surgery for morbid obesity

BackgroundWeight loss surgery induces a marked change in eating behavior. However, not much work has been done characterizing the eating behavior after weight loss surgery. We conducted a detailed analysis of patients' eating behavior 18–35 months after Roux-en-Y gastric bypass surgery, determined whether preoperative eating disorders might be associated with non-normative postoperative eating, and examined the association of such eating behaviors with weight loss and psychopathology.MethodsA sample of 59 patients who had undergone Roux-en-Y gastric bypass was interviewed in person after surgery about a range of eating behaviors, including binge eating, chewing and spitting out food, picking at and nibbling food, and nocturnal eating and compensatory behaviors such as vomiting and laxative and diuretic misuse. An established semistructured interview was used. The prevalence of preoperative eating disorders was assessed retrospectively. The eating-related and general psychopathology and quality of life were assessed using self-report questionnaires before and after surgery.ResultsSubjective bulimic episodes were reported by 25% and vomiting for weight and shape reasons by 12% of the participants, on average, 2 years after surgery. Subjective bulimic episodes were significantly associated with a preoperative binge eating disorder, with more eating-related and general psychopathology after surgery, and with less weight loss.ConclusionA substantial subgroup of patients with a preoperative eating disorder will develop binge eating after surgery that might be associated with less weight loss. A subsample will start vomiting for weight and shape reasons after bariatric surgery. Clinicians must probe carefully for these behaviors postoperatively to identify patients in need of treatment of pathological eating behaviors.     

The role of body appreciation,weight bias internalization,and disordered eating behaviors among presurgical bariatric patients

BackgroundBody appreciation and internalized weight bias have consistently been associated with eating behaviors. However, research has yet to examine the role of these variables among presurgical bariatric patients.ObjectivesThe present study sought to assess the relationships between body appreciation and weight bias internalization, binge eating, disinhibited eating, and symptoms of depression and anxiety among a sample of presurgical bariatric patients. The study also sought to examine the extent to which body appreciation and weight bias internalization account for unique variance in disordered eating even when controlling for depression and anxiety.SettingAcademic medical center in the United States.MethodsData were collected on body appreciation, weight bias internalization, eating behaviors, depression, and anxiety as part of a standard presurgical psychological evaluation for bariatric surgery (n = 319). Pearson correlations were used to assess relationships between all study variables. Multiple regressions were conducted to assess the roles of body appreciation and weight bias internalization on disordered eating.ResultsSignificant associations were found between low levels of body appreciation and high levels of weight bias internalization, disordered eating, and symptoms of depression and anxiety. Results indicated that body appreciation and weight bias internalization each significantly accounted for unique variance in symptoms of binge eating and disinhibited eating. Depressive symptoms were also statistically significant in all analyses.ConclusionFindings indicate the importance of conducting future positive body image research, as well as continuing to examine weight-related constructs, such as internalized weight bias, among bariatric surgery patients.     

Spiritual practices are associated with improved weight management following bariatric surgery

BackgroundResearch shows that spirituality and religiosity may positively impact various health outcomes, but little is known about their role in supporting weight management efforts, particularly in the context of bariatric surgery.ObjectiveThis study examined spiritual practices and health-related behaviors of bariatric surgery patients 1–2 years postoperatively.SettingLarge bariatric center in the Midwest of the United States.MethodsPatients (n = 152) completed questionnaires 1–2 years postoperatively examining weight, physical activity, eating behaviors, and spiritual practices and experiences related to bariatric surgery.ResultsParticipants were primarily married (59.2%), Caucasian (81.6%), and female (84.2%) who had undergone Roux-en-Y gastric bypass (64.5%) or sleeve gastrectomy (32.9%) 17.3 months previously. Most participants (71%) believed their spirituality did or could impact weight loss after surgery. Practices including connecting with nature, art and music, meditation, yoga, and attending spiritual or religious-based activities were positively correlated with weight loss, healthy eating, or exercise participation.ConclusionFindings provide preliminary evidence for the benefits of spirituality in bariatric patients making lifestyle changes after surgery.     

Compulsive Eating and Gastric Bypass Surgery: What does Hunger have to do with It?

Background: Binge eating and other patterns of disordered eating in obese patients need further investigation. In a previous study by this author, one-third of patients presenting for bariatric surgery met strict criteria for Binge Eating Disorder. It is important to clarify the role of such eating behaviors on outcome of surgery to determine whether treatments targeted specifically at these behaviors and associated psychological issues can improve surgical outcome. The aim of this paper is to raise awareness of the range of disordered eating patterns in bariatric patients, describe an approach used, and discuss issues reported by patients after surgery. Methods: Patients completed questionnaires before surgery (QWEP, BES, BDI) and were seen for a pre-surgery mental health evaluation. High risk patients were identified and invited to attend a postsurgery group (CBT approach) as a preventive measure to help them deal with eating patterns as well as emotional adjustment. Results: Disordered eating patterns can persist after surgery. While surgery may decrease actual physical hunger and reduce physical capacity for food, it is still possible to eat compulsively,although the patterns may change somewhat due to the surgical procedure. Conclusion: Since long-term weight maintenance depends on post-operative changes in eating behaviors, it is important to identify patients at risk for a range of disordered eating patterns so that a comprehensive treatment plan that targets the eating disturbances and associated psychological components can be implemented.     

Eating Behaviors Post-Bariatric Surgery: A Qualitative Study of Grazing

Background

Eating behaviors after bariatric surgery play an important role in postoperative outcomes. The purpose of this study was to explore eating behaviors among post-bariatric surgery patients, including developing a better understanding of the term ??grazing??, as interpreted by patients.

Methods

This study was conducted at a research institute with a community-based sample. Structured focus groups using the nominal group technique were conducted with five groups of post-bariatric patients (n?=?29). All patients were over 18?years old and reported having bariatric surgery at least 1?year prior to participation. Participants were asked to produce responses to the question: ??What does grazing mean to you??? Then, they were instructed to rank their responses to the questions: ??What is grazing??? and ??How does grazing affect you???

Results

The mean age of the sample was 47, mean body mass index was 29.0?kg/m², and the majority of the participants were women (93?%). The group members generated a total of 105 responses, which were categorized into 17 themes. Common responses included eating frequently all through the day, out of control eating, and eating due to boredom, not hunger. Results suggest that grazing has a number of unique interpretations, including mindful and mindless behaviors.

Conclusions

Post-bariatric surgery patients seem to view grazing as a healthy eating behavior characterized by mindful food choices that are consumed in small amounts frequently throughout the day. However, grazing may also be viewed as an unhealthy eating pattern when it is perceived as unplanned, mindless, continuous food consumption.     

Interrater reliability and internal consistency of the eating disorder examination in the longitudinal assessment of bariatric surgery study

BackgroundPsychometric studies of eating disorder measures within bariatric surgery populations are limited.ObjectivesTo examine the interrater reliability and internal consistency of the Eating Disorder Examination (EDE) among patients before and after bariatric surgery.SettingThree clinical centers of the Longitudinal Assessment of Bariatric Surgery Research Consortium.MethodsThe EDE-Bariatric Surgery Version was administered and audio-recorded by trained interviewers before and at annual assessments after bariatric surgery. Approximately 20% of interviews were randomly selected for rating by a second interviewer. Reliability of the original and brief EDE subscales was examined.ResultsInterrater reliability of the EDE subscales ranged from .86–.97 for the original subscales and .83–.95 for brief subscales before surgery, and .90–.98 for the original subscales and .92–.97 for brief subscales after bariatric surgery. Interrater agreement (based on kappa) was almost perfect for overeating and binge-eating behaviors and substantial for loss-of-control eating before surgery. Similar interrater agreements (based on kappa) were observed after surgery for subjective overeating and binge-eating episodes. Internal consistency of the subscale and global scores was variable, ranging from .41–.97.ConclusionFindings provide support of the interrater reliability of the EDE, albeit with variable internal consistency, before and after bariatric surgery. Despite support for trained raters to reliably assess EDE constructs, variability in internal consistency suggests that further psychometric testing and rigorous scale development of disordered eating may be needed for the bariatric surgery population.     

Interrater reliability of the Eating Disorder Examination among postbariatric patients

BackgroundClinical assessment of eating behaviors with patients who undergo bariatric surgery is challenging because of the complexity of symptom presentation postoperatively. The Eating Disorder Examination (EDE) is a widely-used semistructured clinical interview of eating-disorder psychopathology, yet no studies have examined the interrater reliability among postoperative bariatric surgery patients.ObjectivesThe present study aimed to examine the interrater reliability of the EDE, and an alternative classification of size-specific thresholds of binge-eating episodes in a postoperative bariatric surgery sample.SettingUniversity School of Medicine, United States.MethodsParticipants interviewed were a randomly selected subset (n = 20) from a consecutive series of adults seeking treatment for eating concerns after bariatric surgery. Audio-taped interviews were rated independently by 1 of 4 expert raters. Interrater reliability was assessed using intraclass correlation coefficients (ICC) and kappa statistic.ResultsICCs for the original 4 EDE subscales were excellent, ranging from .88 to .98. ICCs for the alternative brief 3 subscales were also excellent, with a range of .78 to .97. ICCs for bariatric loss-of-control eating episodes were in the good to excellent range, with a range of .66 to .99. Kappa agreement for bariatric overeating episodes was moderate (.60).ConclusionsThese findings, based on 4 expert raters, suggest that complex eating-disorder psychopathology, as well as the newly proposed eating behavior with size thresholds relevant to bariatric patients, can be reliably assessed. To our knowledge, this is the first study to provide initial evaluation and support for the interrater reliability of the original EDE with additional modified eating categories developed for postbariatric surgery patients.     

Predictors of surgical intervention for those seeking bariatric surgery

BackgroundBariatric surgery has been found to be effective in the treatment of severe obesity. Studies have shown that the majority of eligible patients do not undergo surgery.ObjectivesIt is important to identify variables that may impact patient decision making and potentially lead to the disproportionate underutilization of bariatric surgery.SettingThe study was conducted at one academic medical center in central Pennsylvania.MethodsBariatric patients who participated in a preoperative psychological assessment from 2017 to early 2020 completed comprehensive self-report questionnaires addressing sociodemographic variables, health history, psychopathology, and eating behaviors. Body mass index was calculated based on clinical measurements of each patient at the start of the preoperative program. Sociodemographic variables and self-report instrument scores were compared between those who completed surgery and those who did not.ResultsOf the 1234 participants, significant differences were found between the compared variables. All minority groups were less likely to undergo surgery than White patients. Participants reporting higher impairment were less likely to progress to surgery. Impairments across 3 behavioral eating assessments were associated with a lower likelihood of surgery.ConclusionThere are multiple factors that contribute to patient progression to surgery, and ultimately whether the patient undergoes bariatric surgery. Results show a need for further investigation surrounding the sociodemographic and psychosocial variables that influence the patient’s advancement to surgery. Both providers and patients could benefit from a deeper understanding of potential barriers to utilization of bariatric surgery.     

Ecological momentary assessment of gastrointestinal symptoms and risky eating behaviors in Roux-en-Y gastric bypass and sleeve gastrectomy patients

BackgroundGastrointestinal symptoms (GIS) are common after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). However, little is known about frequencies of GIS and their co-occurrence with risky eating behaviors.ObjectivesCompare RYGB and SG on GIS and risky eating behaviors, and test associations between GIS and behaviors.SettingTwo university hospitals in Northeastern United States.MethodsRYGB (n = 18) and SG (n = 53) patients completed smartphone-based ecological momentary assessment of GIS and risky eating behaviors at 4 semi-random times daily for 10 days preoperatively and at 3, 6, and 12 months postoperatively. Study objectives were evaluated using generalized linear mixed-effects models.ResultsAll available data from each assessment were included in the analysis: participant attrition was 18%, 30%, and 38% at 3, 6, and 12 months. All GIS were reduced at 12 months postoperative. Bloating decreased consistently whereas cramping, dehydration, and dumping first increased at 3 to 6 months then decreased to 12 months. Diarrhea, nausea, reflux, and vomiting decreased to 12 months for RYGB, but first increased at 3 to 6 months then decreased to 12 months for SG. Consumption of carbonated and sugar-sweetened beverages, fatty meats, and sweets decreased to 6 months then rebounded at 12 months. Eating past the first sign of fullness, drinking liquids with meals, not starting meals with protein, and fried foods consumption decreased to 6 months and then rebounded for RYGB only at 12 months. Alcohol consumption did not change. Sweets consumption and eating past the first sign of fullness were most consistently associated with GIS for both RYGB and SG patients.ConclusionGIS and risky eating behaviors improved postoperatively, although patterns of change were variable and occasionally differed between RYGB and SG. Pending replication, patients may benefit from intervention to limit risky behaviors that are tailored to their surgery type.     

Factor structure and predictive utility of the Binge Eating Scale in bariatric surgery candidates

BackgroundScreening for binge eating before bariatric surgery is a component of the recommended clinical practice for bariatric surgery candidates. The Binge Eating Scale (BES) is 1 of the most commonly used self-report measures of eating behaviors in preoperative evaluations; however, the factor structure of this measure has not been evaluated in the bariatric population. The aims of the present study were to report the mean, standard deviation, and reliability of the BES for patients seeking bariatric surgery; to evaluate the 2-factor structure of the BES using confirmatory factor analysis; and to investigate the association between the BES and its factors with surgical weight loss. The setting was an academic medical center.MethodsA total of 530 patients completed the BES as a component of their psychological evaluation before undergoing Roux-en-Y gastric bypass surgery.ResultsApproximately one third of patients reported at least mild to moderate binge eating, with 9% of patients reporting severe binge eating on the BES. The BES demonstrated good internal consistency. The results of the confirmatory factor analysis indicated that a 2-factor structure, consisting of feelings/cognitions related to binge eating and behavioral manifestations of binge eating, was the best fit to the data. Nonsignificant correlations were found between the BES and its 2 factors with short-term postoperative weight loss.ConclusionThe BES measures 2 aspects of binge eating in bariatric surgery candidates, feelings/cognitions and behavioral manifestations of binge eating. Consideration of these factors in patients presenting for bariatric surgery could allow for a more detailed understanding of binge eating in this population.