Genome-wide analysis of a model-derived binge eating disorder phenotype identifies risk loci and implicates iron metabolism.

Binge eating disorder (BED) is the most common eating disorder, yet its genetic architecture remains largely unknown. Studying BED is challenging because it is often comorbid with obesity, a common and highly polygenic trait, and it is underdiagnosed in biobank data sets. To address this limitation, we apply a supervised machine-learning approach (using 822 cases of individuals diagnosed with BED) to estimate the probability of each individual having BED based on electronic medical records from the Million Veteran Program. We perform a genome-wide association study of individuals of African (n = 77,574) and European (n = 285,138) ancestry while controlling for body mass index to identify three independent loci near the HFE, MCHR2 and LRP11 genes and suggest APOE as a risk gene for BED. We identify shared heritability between BED and several neuropsychiatric traits, and implicate iron metabolism in the pathophysiology of BED. Overall, our findings provide insights into the genetics underlying BED and suggest directions for future translational research.

An exploratory structural equation modelling (ESEM) of the Eating Disorders Examination Questionnaire (EDE-Q) in bariatric patients.

Several studies in clinical and non-clinical populations indicate differences between rationally and empirically derived subscales for the Eating Disorder Examination Questionnaire (EDE-Q), including samples of patients seeking bariatric surgery. This study aimed to use exploratory structural equation modelling (ESEM) to estimate the factor structure of the EDE-Q and assess for the additive value of alternative measurement of eating disorder symptoms. Adolescents and adults completed the EDE-Q and a psychiatric evaluation prior to bariatric surgery. Data from 330 participants were analysed using the original four-factor and modified three-factor structure of the EDE-Q using both confirmatory factor analysis (CFA) and exploratory structural equation modelling (ESEM). Age, ethnicity, and body mass index were examined as covariates in the best fitting model, and model subscales used to generate a predictive model of clinician screened DSM-5 eating disorder diagnoses for criterion validity. A CFA of the four-factor EDE-Q provided poor model fit for a pre-surgical bariatric population, but the three-factor EDE-Q and an ESEM of the four-factor EDE-Q provided excellent model fit. The Eating Concern subscale of the four-factor ESEM model significantly predicted eating disorder diagnosis and was positively correlated with age. Our results suggest the ESEM derived factors of the EDE-Q offered some improvements to the original empirically derived factor structure, as subscale scores based on the original items and cross-loading items yielded an adequate prediction of clinician diagnoses.

An Initial Test of the Efficacy of a Digital Health Intervention for Bariatric Surgery Candidates.

BACKGROUND: Rigorous research on smartphone apps for individuals pursuing bariatric surgery is limited. A digital health intervention was recently developed using standard behavioral weight loss programs with specific modifications for bariatric surgery. The current study evaluated this intervention for improving diet, exercise, and psychosocial health over 8 weeks prior to surgery in an academic medical center. METHODS: Fifty patients were randomized to receive either the digital intervention or treatment as usual prior to a surgical procedure. Measures of anxiety, depression, stress, quality of life, physical activity, and diet were administered at baseline and at 8-week follow-up. Statistical power of 80% estimated for N = 50 to detect ES = 0.68 with alpha = 0.05. RESULTS: Results of intent-to-treat (N = 50 baseline, N = 36 follow-up) analyses indicated significant moderate differences in stress and anxiety (ES = - 0.58 to - 0.62) favoring the digital intervention. Effects of the program on total daily calories consumed, body mass index, quality of life, and eating disorder symptoms were small (ES = - 0.24 to 0.33) and not significant. Given small effects for these domains, the sample size of the study likely affected the ability to detect significant differences. CONCLUSIONS: The digital health intervention appears to significantly impact several measures of physical activity and emotional functioning in candidates for bariatric surgery, which could augment surgical outcomes.

Lessons learned developing and testing family-based interoceptive exposure for adolescents with low-weight eating disorders.

BACKGROUND: Anorexia nervosa (AN) usually develops in early adolescence and is characterized by high rates of morbidity and mortality. Family-based therapy (FBT) is the leading evidence-based treatment for adolescents with AN, but not all patients experience sufficient improvement. The purpose of this manuscript is to describe the development and subsequent experience with a Family-Based Interoceptive Exposure (FBT-IE) for adolescents with a broader form of low-weight eating disorders. METHODS: The novel IE-based behavioral intervention is a six-session family-based treatment module designed to directly target and modify disgust by altering the prefrontal regulation of the insula response to aversive stimuli by decreasing visceral sensitivity (e.g., bloating). Each session teaches a new skill regarding tolerating distress to visceral sensations associated with disgust and an in-vivo "IE exercise," in which the family is provided with a meal replacement shake of unknown content and caloric density. RESULTS: In this novel treatment, the patient learns to tolerate disgust in the context of a challenging food stimulus as a way to increase consumption of restricted foods outside of session. CONCLUSION: We discuss successes and challenges executing this treatment with patients with low-weight eating disorders and propose future directions for the intervention.

Disordered eating following bariatric surgery: a review of measurement and conceptual considerations.

Eating disorders are associated with significant medical morbidity and mortality and serious psychological impairment. Individuals seeking bariatric surgery represent a high-risk group for evidencing disordered eating and eating disorders, with some patients experiencing the persistence or onset of disordered eating postsurgery. This review synthesizes the available literature on problematic or disordered eating in the bariatric field, followed by a review of measurement and conceptual considerations related to the use of eating disorder assessment tools within the bariatric population.

Mental health, loss of control eating, and cognitive functioning in adolescents undergoing bariatric surgery.

Bariatric surgery is an effective treatment for severe obesity in adolescence. Nevertheless, much remains to be understood regarding the impact of surgery on mental health, eating behaviors, and cognition. We review the findings related to mental health both before and after surgery as well as long-term changes in psychopathology, including suicide risk. Overall, adolescents with and without a history of psychopathology lose weight at similar rates. At the same time, there is an increased risk for suicide that requires further study. Regarding alcohol and substance use, this population reports lower rates of consumption than age related non-obese cohorts. Nevertheless the impact of altered anatomy and metabolism on alcohol ingestion in a population at risk for substance use is concerning. Eating behaviors, specifically loss of control eating, are discussed. Finally, we include discussion of the cognitive changes occurring perioperatively and considerations for adolescents with cognitive impairments. Clinical recommendations and suggestions for future research are discussed.

Adolescent Gastric Banding: a 5-Year Longitudinal Study.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is used to treat obesity in adults. Less is known about long-term results of the procedure in adolescents. OBJECTIVES: To evaluate LAGB 5-year outcomes in teenagers with severe obesity. SETTING: Children's hospital, USA. METHODS: Adolescents (14-18 years) underwent LAGB in an FDA-approved observational clinical trial. Outcomes including anthropometric measurements, comorbid conditions, complications, and band retention were collected through 60 months. RESULTS: One hundred thirty-seven subjects underwent LAGB (94 female, 43 male; 43% white, 37% Hispanic, 17% black; 4% other). Mean age and body mass index (BMI) pre-operatively were 17.0 + 1.2 years and 48.3 + 8.2 kg/m2, respectively. Comorbidities were present in 71%. Maximum weight loss occurred by 36 months (mean % excess weight loss (EWL) 40.6 + 35.2, mean % excess BMI loss (EBMIL) 41.6 + 34.9) and was maintained through 5 years for most subjects. There were no significant differences in weight loss by gender. Twenty-three (18%) of 127 adolescents reporting at 60 months achieved 50% excess weight loss. Postoperative heartburn and emesis occurred in 70% and 32%, respectively. Complications requiring additional surgery occurred 80 times in 63 patients. Thirty-three (26%) of 127 subjects contacted at 5 years had undergone band removal. CONCLUSION: In this study, fewer than 20% of adolescents with severe obesity lost > 50% of their excess weight following LAGB. Nearly 50% of patients required additional surgery. With reports of success following sleeve gastrectomy and gastric bypass, we believe that LAGB is not a preferred choice to treat adolescents with obesity.

Applying the disgust conditioning model of food avoidance: A case study of acceptance-based interoceptive exposure.

OBJECTIVE: The current case report details the treatment of a 16-year-old adolescent with anorexia nervosa utilizing a novel adjunct, acceptance-based interoceptive exposure, prior to family-based treatment (FBT) for eating disorders. METHOD: The exposure-based module focused particularly on the tolerance of disgust. For six sessions, the clinician taught the client skills that could be used to tolerate distress to visceral sensations associated with disgust. These skills were to be used during in- and between-session exposures. Each session included exposure to physical sensations that occurred while drinking a milkshake. RESULTS: Across six sessions, the client reported improvement in symptoms in addition to gaining weight. Additionally, she consumed more calories of a test meal following the intervention. Within broader FBT, the client reached an established weight goal, was able to return to physical activity, and reported an increased ability to manage distress. DISCUSSION: Given the client's improvement on the Eating Disorders Examination-Questionnaire (EDE-Q) within six sessions, we believe IE may be a useful adjunct to FBT. Interoceptive exposure may augment the efficacy of FBT for anorexia nervosa as it provides clients with skills to utilize during the refeeding phase of treatment.

Suicidal Ideation and Behaviours Among Adolescents Receiving Bariatric Surgery: A Case-Control Study.

OBJECTIVE: This study examined the prevalence and correlates of suicidal ideation and behaviour (SI/B) among adolescents receiving bariatric surgery. METHOD: Charts of 206 adolescents receiving bariatric surgery were reviewed. Cases with SI/B (current/lifetime reported at baseline or event occurring in the programme n = 31, 15%) were case matched on gender, age and surgery type to 31 adolescents reporting current or past psychiatric treatment and 31 adolescents denying lifetime SI/B or psychiatric treatment. RESULTS: Before surgery, adolescents with SI/B reported significantly lower total levels of health-related quality of life (p = 0.01) and greater depressive symptoms (p = 0.004) in comparison with candidates who never received psychiatric treatment. No significant differences were found between groups for the change in depressive symptoms or body mass index following surgery. CONCLUSIONS: As in studies of adults, a notable subset of adolescents receiving bariatric surgery indicated pre-operative or post-operative SI/B. It is critical that clinicians evaluate and monitor adolescent patients undergoing bariatric surgery for risk of SI/B.

Adolescent laparoscopic adjustable gastric banding (LAGB): prospective results in 137 patients followed for 3 years.

BACKGROUND: Evidence supports weight loss surgery as an effective long-term weight reduction therapy in adults. METHODS: Few adolescent obesity surgery series report outcomes for laparoscopic gastric banding (LAGB). We studied a population of morbidly obese teenagers who underwent LAGB to evaluate its safety and effectiveness in this age group. Three hundred and six morbidly obese adolescent candidates for LAGB were screened. Enrollees were evaluated monthly by the nutritionist and the surgical team to monitor compliance with recommended changes in diet and exercise. Patients also underwent psychiatric and endocrine evaluations. Those who made good changes in eating and exercise habits over a 6-month period were offered LAGB. The setting was a university hospital in the United States. RESULTS: One hundred thirty-seven adolescent patients underwent LAGB. The mean weight gain between enrollment and LAGB was 4.7 kg. Mean preoperative weight, body mass index (BMI), and excess BMI were 136.1 kg, 48.3 kg/m2, and 23.6 kg/m2, respectively. Mean BMI at 6, 12, 18, 24, and 36 months was 43.8, 41.6, 41.5, 40.5, and 39.3. Excess BMI loss was 28.4%, 35.9%, and 41.1% at 1, 2, and 3 years postop. Co-morbid conditions improved or resolved with weight loss after LAGB. Thirty patients (22%) underwent one or more additional operations for complications. Twenty-seven patients (20%) converted to other weight loss procedures or had their bands removed. CONCLUSION: LAGB is a safe weight loss operation in adolescents. Morbidly obese adolescents can lose weight successfully and experience health improvement following LAGB, but the role of LAGB in the younger population requires long-term evaluation.

Predictors and correlates of follow-up visit adherence among adolescents receiving laparoscopic adjustable gastric banding.

BACKGROUND: Adherence behaviors have not been examined among adolescents undergoing laparoscopic adjustable gastric banding (LAGB). In addition, studies of youth receiving bariatric surgery have not considered the influence of psychopathology on postoperative adherence. The purpose of this study was to evaluate predictors and correlates of adherence to post-surgery visits among a sample of adolescents undergoing LAGB. METHODS: Postoperative visits with surgical staff were analyzed over the 2 years after surgery (n = 101 adolescents). Growth mixture modeling examined trends in adherence. RESULTS: A 3-class solution provided the best fit to the data. The classes from the final model were characterized by class 1 (61.6%) demonstrating high levels of adherence over the 24 months after LAGB, class 2 (28.5%) showing a more gradual decline in adherence, and class 3 (9.9%) with an accelerated decline in adherence. Higher levels of preoperative depressive symptoms and more preoperative episodes of loss of control overeating decreased the likelihood of adherence. Class 3 adolescents had significantly higher estimated 24-month body mass indices than classes 1 or 2. CONCLUSION: Variable patterns of follow-up visit adherence were identified among adolescents receiving LAGB, which were predicted by depressive symptoms and loss of control overeating. The trajectory characterized by a rapid decline in adherence to follow-up visits was also associated with less weight loss.

The role of cognitive function in postoperative weight loss outcomes: 36-month follow-up.

BACKGROUND: Cognitive dysfunction is associated with reduced postoperative weight loss up to 2 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 on 12-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.

Mental Health Evaluations for Adolescents Prior to Bariatric Surgery: A Review of Existing Practices and a Specific Example of Assessment Procedures.

OBJECTIVE: Best practice guidelines for adolescents considering bariatric surgery recommend a pre-operative mental health evaluation. However, only general information about these assessments appears in the literature, which makes consistency of administration challenging. This review proposes a specific empirically-derived format for pre-surgical mental health evaluations and summarizes currently available data on the psychiatric functioning of adolescents seeking bariatric surgery. DESIGN: Studies of mental health evaluations for adults preparing for bariatric surgery are reviewed, as is the limited literature relevant to adolescent evaluations. A specific and detailed example of an evaluation (clinical interview, self-report questionnaires, cognitive assessment) used for younger patients at a major metropolitan hospital center is presented, followed by data from an initial group of adolescents completing this evaluation. SUBJECTS: 200 adolescents (n=139 female; age: 14-18 y, BMI: 35.4-83.3 kg/m2) presenting for bariatric surgery. RESULTS: A notable subset of adolescents reported current Axis I conditions (31.5%) and current mental health treatment (29.5%), but reports of current illicit drug use (1.5%) and regular alcohol use (0.5%) were relatively rare. Procedures for using the completed evaluation and post-surgery monitoring of psychosocial issues are discussed. CONCLUSIONS: Adolescents considering weight loss surgery should receive comprehensive pre-surgical mental health evaluations, but additional data are needed to develop specific recommendations the use of these evaluations in post-operative care.

Hormonal responses and test meal intake among obese teenagers before and after laparoscopic adjustable gastric banding.

BACKGROUND: Relatively little is known about changes in eating behavior or hormonal responses to food after bariatric surgery in adolescents. OBJECTIVE: This study compared eating behavior and hormones among adolescents in a bariatric surgery program with those in nonoverweight control adolescents and evaluated changes before and after laparoscopic adjustable gastric banding (LAGB). DESIGN: Fasting leptin, peptide YY (PYY), and ghrelin concentrations were obtained, and postprandial ghrelin and PYY area under the curve (AUC) were assessed after a single-item breakfast. Intake from an ad libitum lunchtime multi-item meal was measured. RESULTS: Compared with controls (n = 9), all presurgical candidates (n = 20) had significantly greater fasting leptin, lower fasting ghrelin, and lower AUC ghrelin but similar PYY and AUC PYY. Preoperative candidates did not differ from controls in total energy consumed during the test meal. Postoperatively, among the 11 participants with data both before and after surgery, BMI (in kg/m(2)) decreased by 3.5 (P < 0.001), significantly less energy was consumed in the test meal, and a smaller number of foods were selected. AUC ghrelin and PYY did not significantly change before or after LAGB. CONCLUSIONS: Few significant short-term changes were observed in appetitive hormones after LAGB. It is unclear whether objective measures of eating behavior will prove useful in evaluating the impact of bariatric surgery on outcomes. This trial was registered at clinicaltrials.gov as CT00764127.

School and cognitive functioning problems in adolescent bariatric surgery candidates.

BACKGROUND: Prior studies have reported that students with overweight and obesity have impairments in performance IQ and executive function and worse school functioning in comparison with peers of normal weight. The present study assessed school and cognitive functioning in a sample of adolescents with severe obesity being evaluated for laparoscopic adjustable gastric banding. METHODS: Eligible candidates for bariatric surgery were referred for psychiatric evaluation, which included a semistructured clinical interview measuring school functioning and the vocabulary and matrix reasoning subtests of the Wechsler Abbreviated Scale of Intelligence (WASI). RESULTS: Self-reported school problems were common, with 55.5% of adolescents failing a grade or subject, 38.7% attending summer school, and 17.8% failing a citywide examination. A significant relationship was observed between body mass index, estimated WASI IQ (r = -.250; P = .005), and the vocabulary subtest (r = -.241; P = .006), but not matrix reasoning (r = -.126; P = NS). CONCLUSION: Even among a sample of adolescents with severe obesity, increased body mass index was associated with lower WASI IQ and vocabulary subtest scores. Increasing awareness of potential cognitive and school problems in bariatric candidates among teachers, school counselors, and other mental health providers is an important first step to improving academic support and educational systems deficiencies for students with overweight and obesity.

Psychological outcomes and predictors of initial weight loss outcomes among severely obese adolescents receiving laparoscopic adjustable gastric banding.

OBJECTIVE: Elevated rates of psychopathology are noted among severely obese youth presenting for weight loss surgery. The role of mental health providers in this population is not well defined, and the selection of candidates is often the result of clinical judgment alone. The purpose of this study was to comprehensively evaluate psychiatric symptoms among a large sample of adolescents receiving laparoscopic adjustable gastric banding (LAGB) by (1) examining changes in depressive symptoms and quality of life in the year following surgery; (2) evaluating the interaction between patterns of change in depression, quality of life, and weight postsurgery; and (3) identifying presurgical psychological predictors of initial weight change. METHOD: Participants were 101 severely obese adolescents aged 14 to 18 years receiving LAGB at the Center for Adolescent Bariatric Surgery at the Morgan Stanley Children's Hospital of New York Presbyterian/Columbia University Medical Center between August 2006 and December 2009. Measures of height, weight, depressive symptoms, and quality of life were obtained in the first year following surgery. Changes in the Beck Depression Inventory (BDI), Pediatric Quality of Life Inventory (PedsQL), and body mass index were analyzed using latent growth curve modeling. RESULTS: Short-term changes in psychiatric symptoms and weight were analyzed using latent growth curve modeling. Significant changes in total BDI (ßslope = -0.885, SE = 0.279, P < .01; ßquadratic = 0.054, SE = 0.021, P < .001) and PedsQL (ßslope = -0.885, SE = 0.279, P < .001) scores were observed following LAGB, and comparable postoperative changes between psychosocial variables and body mass index were also noted (BDI: covariance [COV] = 0.21, SE = 0.06, P < .001; PedsQL: COV = -0.41, SE = 0.10, P < .01). Two variables (family conflict/loss of control eating) were found to be significant predictors of weight change over the year following surgery (P < .05). CONCLUSIONS: Adolescents experienced notable improvements in initial depressive symptoms and quality of life after LAGB, and measures of preoperative binge eating and family conflict affected postsurgery body mass index among youth. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01045499.

Clinical correlates of the weight bias internalization scale in a sample of obese adolescents seeking bariatric surgery.

The aim of this study was to evaluate psychometric properties and clinical correlates of the Weight Bias Internalization Scale (WBIS) in a sample of obese adolescents seeking bariatric surgery. Sixty five adolescents enrolled in a bariatric surgery program at a large, urban medical center completed psychiatric evaluations, self-report questionnaires including the WBIS and other measures of psychopathology and physical assessments. The WBIS had high internal consistency (Cronbach's α = 0.92). As in previous research with adults, the one underlying factor structure was replicated and 10 of the original 11 items were retained. The scale had significant partial correlations with depression (r = 0.19), anxiety (r = 0.465), social, and behavioral problems (r = 0.364), quality of life (r = -0.480), and eating (r = 0.579), shape (r = 0.815), and weight concerns (r = 0.545), controlling for BMI. However, WBIS scores did not predict current or past psychiatric diagnosis or treatment or past suicidal ideation. Overall, the WBIS had excellent psychometric properties in a sample of obese treatment-seeking adolescents and correlated significantly with levels of psychopathology. These findings suggest that the WBIS could be a useful tool for healthcare providers to assess internalized weight bias among treatment-seeking obese youth. Assessment of internalized weight bias among this clinical population has the potential to identify adolescents who might benefit from information on coping with weight stigma, which in turn may augment weight loss efforts.