Bariatric Surgery and Suicide Risk in Patients With Obesity.

OBJECTIVE: In a large multisite cohort of Veterans who underwent Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy, we compared the 5-year suicidal ideation and attempt rates with matched nonsurgical controls. BACKGROUND: Bariatric surgery has significant health benefits but has also been associated with adverse mental health outcomes. METHODS: Five-year rates of suicidal ideation and suicide attempts of Veterans who underwent Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy from the fiscal year 2000-2016 to matched nonsurgical controls using sequential stratification using cumulative incidence functions (ideation cohort: n=38,199; attempt cohort: n=38,661 after excluding patients with past-year outcome events). Adjusted differences in suicidal ideation and suicide attempts were estimated using a Cox regression with a robust sandwich variance estimator. RESULTS: In the matched cohorts for suicidal ideation analyses, the mean age was 53.47 years and the majority were males (78.7%) and White (77.7%). Over 40% were treated for depression (41.8%), had a nonrecent depression diagnosis (40.9%), and 4.1% had past suicidal ideation or suicide attempts >1 year before index. Characteristics of the suicide attempt cohort were similar. Regression results found that risk of suicidal ideation was significantly higher for surgical patients (adjusted hazard ratio=1.21, 95% CI: 1.03-1.41), as was risk of suicide attempt (adjusted hazard ratio=1.62, 95% CI: 1.22-2.15). CONCLUSIONS: Bariatric surgery appears to be associated with a greater risk of suicidal ideation and attempts than nonsurgical treatment of patients with severe obesity, suggesting that patients need careful monitoring for suicidal ideation and additional psychological support after bariatric surgery.

Trajectories of Psychopathology and Dysregulation 2-4 Years following Adolescent Bariatric Surgery.

OBJECTIVE: This study examined psychopathology and weight over 4 years following bariatric surgery in adolescents with obesity, as compared to a nonsurgical group. The role of psychological dysregulation in relation to psychopathology in the 2-4 year "maintenance phase" following surgery was also examined. METHODS: Adolescent participants (122 surgical and 70 nonsurgical) completed height/weight and psychopathology assessments annually for 4 years, with dysregulation assessed at Year 2. Analyses examined the association of "High" and "Low" psychopathology with weight over time using logistic regression. Mediation analyses in the surgical group examined indirect effects of dysregulation on percent weight loss through Year 4 psychopathology. RESULTS: There were lower odds of "High" internalizing symptoms in the surgical group versus the nonsurgical group from baseline (presurgery) to Year 4 (OR = .39; p < .001; 42.3% "High" internalizing in surgical; 66.7% in nonsurgical) and during the 2-4 year maintenance phase (OR = .35, p < .05; 35.1% "High" internalizing in surgical; 60.8% in nonsurgical). There was a significant mediation effect in the surgical group: higher dysregulation was associated with greater Year 4 internalizing symptoms (ß = .41, p < .001) which in turn was associated with less Year 4 percent weight loss (ß = -.27, p < .05). CONCLUSIONS: While the surgical group was less likely to experience internalizing symptoms, internalizing psychopathology was related to less percent weight loss in this group. Internalizing symptoms mediated the relationship between dysregulation and percent weight loss in the surgical group. Postoperative mental health follow-up is needed for adolescents into young adulthood.

The Effect of Bariatric Surgery on Long-term Depression Treatment in Patients With Obesity.

OBJECTIVE: In a large multisite cohort of Veterans who underwent Roux-en-Y gastric bypass (RYGB) or laparoscopic sleeve gastrectomy (LSG), initiation of (ie, incident) and persistence of (ie, continuation of preoperative) depression treatment are compared with matched nonsurgical controls. BACKGROUND: Bariatric surgery has been associated with short-term improvements in depression but less is known about longer term outcomes. METHODS: In a retrospective cohort study, we matched 1713 Veterans with depression treatment who underwent bariatric surgery in Veterans Administration bariatric centers from fiscal year 2001 to 2016 to 15,056 nonsurgical controls using sequential stratification and examined the persistence of depression treatment via generalized estimating equations. Incidence of depression treatment was compared using Cox regression models between 2227 surgical patients and 20,939 matched nonsurgical controls without depression treatment at baseline. RESULTS: In surgical patients with depression treatment at baseline, the use of postsurgical depression treatment declined over time for both surgical procedures, but postsurgical patients had greater use of depression treatment at 5 years [RYGB: odds ratio=1.24, 95% confidence interval (CI): 1.04-1.49; LSG: odds ratio=1.27, 95% CI: 1.04-1.56] compared with controls. Among those without depression treatment at baseline, bariatric surgery was associated with a higher incidence of depression treatment compared with matched controls (RYGB: hazard ratio=1.34, 95% CI: 1.17-1.53; LSG: hazard ratio at 1-5 years=1.27, 95% CI: 1.10-1.47). CONCLUSIONS: Bariatric surgery was associated with a greater risk of postoperative incident depression treatment and greater persistence of postoperative depression treatment. Depression may worsen for some patients after bariatric surgery, so clinicians should carefully monitor their patients for depression postoperatively.

Psychotropic Medications in Metabolic and Bariatric Surgery: Research Updates and Clinical Considerations.

PURPOSE OF REVIEW: We review evidence for assessing and monitoring psychotropic medications in metabolic and bariatric surgery (MBS) patients. We describe weight gain side effects, potential perioperative risks, pharmacokinetic changes that occur after MBS, and conclude with clinical recommendations. RECENT FINDINGS: Research on psychiatric medication use and post-MBS weight outcomes is lacking and inconsistent; however, there is consistent evidence that, though variable, psychiatric medication use is associated with weight gain. Several meta-analyses and reviews provide guidance on lowering risk when appropriate. Perioperative lithium toxicity and SSRI discontinuation syndrome also warrant consideration, as do potential post-operative pharmacokinetic changes. In the absence of data for each psychiatric drug classification, close symptom monitoring and, where appropriate, serum concentration monitoring are recommended. MBS patients are a psychiatrically vulnerable population, and many are on psychiatric medications. Given potential weight/metabolic side effects, perioperative complications, and post-operative pharmacokinetic changes that occur with psychotropic medication use, providers should stay well informed on psychiatric medication management considerations.

Machine learning enhances prediction of illness course: a longitudinal study in eating disorders.

BACKGROUND: Psychiatric disorders, including eating disorders (EDs), have clinical outcomes that range widely in severity and chronicity. The ability to predict such outcomes is extremely limited. Machine-learning (ML) approaches that model complexity may optimize the prediction of multifaceted psychiatric behaviors. However, the investigations of many psychiatric concerns have not capitalized on ML to improve prognosis. This study conducted the first comparison of an ML approach (elastic net regularized logistic regression) to traditional regression to longitudinally predict ED outcomes. METHODS: Females with heterogeneous ED diagnoses completed demographic and psychiatric assessments at baseline (n = 415) and Year 1 (n = 320) and 2 (n = 277) follow-ups. Elastic net and traditional logistic regression models comprising the same baseline variables were compared in ability to longitudinally predict ED diagnosis, binge eating, compensatory behavior, and underweight BMI at Years 1 and 2. RESULTS: Elastic net models had higher accuracy for all outcomes at Years 1 and 2 [average Area Under the Receiving Operating Characteristics Curve (AUC) = 0.78] compared to logistic regression (average AUC = 0.67). Model performance did not deteriorate when the most important predictor was removed or an alternative ML algorithm (random forests) was applied. Baseline ED (e.g. diagnosis), psychiatric (e.g. hospitalization), and demographic (e.g. ethnicity) characteristics emerged as important predictors in exploratory predictor importance analyses. CONCLUSIONS: ML algorithms can enhance the prediction of ED symptoms for 2 years and may identify important risk markers. The superior accuracy of ML for predicting complex outcomes suggests that these approaches may ultimately aid in advancing precision medicine for serious psychiatric disorders.

Examining the roles of emotion dysregulation and impulsivity in the relationship between psychological trauma and substance abuse among women with bulimic-spectrum pathology.

Individuals with bulimia nervosa report elevated rates of childhood maltreatment, which appears to increase risk for co-occurring substance use problems and negatively impact clinical course. The current study sought to examine the mechanistic pathways by which specific forms of childhood maltreatment may give rise to substance use problems among individuals with bulimic-spectrum pathology. Women with bulimic-spectrum disorders (N = 204) completed measures of childhood trauma, emotion dysregulation, impulsivity, and substance use. Path analysis was used to examine emotion dysregulation and impulsivity as mediators of the relationship between distinct forms of childhood trauma (physical abuse, physical neglect, emotional abuse, emotional neglect, and sexual abuse) and the presence of problematic alcohol/drug use. In the full path model, significant pathways from childhood emotional abuse to emotion dysregulation, childhood emotional neglect to impulsivity, and emotion dysregulation to problematic substance use emerged. Further, emotion dysregulation significantly mediated the relationship between emotional abuse and substance use. Results indicate that emotion dysregulation may be an important mechanism linking a history of childhood emotional maltreatment to later eating and substance use problems, and therefore may be an important treatment target among individuals with co-occurring eating and substance use concerns.Childhood emotional abuse was related to greater emotion dysregulation.Childhood emotional neglect was related to greater impulsivity.Emotion dysregulation was related to greater problematic substance use.Emotional abuse may impact substance use through emotion dysregulation.Creating emotion dysregulation may improve substance and eating disorder symptoms.

Patient Behaviors and Characteristics Related to Weight Regain After Roux-en-Y Gastric Bypass: A Multicenter Prospective Cohort Study.

OBJECTIVE: To identify patient behaviors and characteristics related to weight regain after Roux-en-Y gastric bypass surgery (RYGB). BACKGROUND: There is considerable variation in the magnitude of weight regain after RYGB, highlighting the importance of patient-level factors. METHODS: A prospective cohort study of adults who underwent bariatric surgery in 6 US cities between 2006 and 2009 included presurgery, and 6-month and annual assessments for up to 7 years. Of 1573 eligible participants, 1278 (81%) with adequate follow-up were included (80% female, median age 46 years, median body mass index 46 kg/m). Percentage of maximum weight lost was calculated each year after weight nadir. RESULTS: Weight was measured a median of 8 (25th-75th percentile, 7-8) times over a median of 6.6 (25th-75th percentile, 5.9-7.0) years. ß coefficients, that is, the mean weight regain, compared with the reference, and 95% confidence interval, are reported. Postsurgery behaviors independently associated with weight regain were: sedentary time [2.9% (1.2-4.7), for highest vs lowest quartile], eating fast food [0.5% (0.2-0.7) per meal/wk], eating when feeling full [2.9% (1.2-4.5)], eating continuously [1.6% (0.1-3.1)], binge eating and loss-of-control eating [8.0% (5.1-11.0) for binge eating; 1.6 (-0.1 to 3.3) for loss of control, vs neither], and weighing oneself

Are the Criterion B binge-eating symptoms interchangeable in understanding binge-eating severity? An item response theory analysis.

OBJECTIVE: The Criterion B binge-eating symptoms represent five symptoms associated with binge eating. Any three out of five symptoms can be used to meet Criterion B. However, Criterion B symptoms may not be interchangeable in terms of how binge-eating severity is associated with each symptom. Item response theory (IRT) can test how endorsing each symptom relates to the overall level (i.e., severity) of binge-eating measured by Criterion B. We used IRT to identify (a) how each Criterion B symptom corresponded with binge-eating severity in a transdiagnostic binge-eating sample and (b) how well each symptom differentiated individuals with differing levels of severity. METHOD: Participants (N = 219) were adults (80.8% female) with a current ED that included objective binge-eating episodes assessed via semi-structured interview. A two-parameter logistic IRT model evaluated how endorsement of each Criterion B symptom corresponded with the level of latent binge-eating severity. RESULTS: "Eating large amounts when not hungry" and "eating alone" reflected the highest binge-eating severity. "Eating alone" was the best discriminator across different binge-eating severity levels, whereas "uncomfortably full" was the poorest discriminator across binge-eating severity levels. DISCUSSION: Criterion B symptoms were not interchangeable in terms of what level of binge-eating severity corresponded with symptom endorsement. "Eating large amounts when not hungry" or "eating alone" may signify elevated binge-eating severity, whereas "uncomfortably full" and "feeling disgusted/depressed/guilty" were not necessarily indicative of elevated severity. Results suggested that Criterion B may need to be revised to eliminate symptoms that are redundant with other binge-eating diagnostic criteria.

Not all body image constructs are created equal: Predicting eating disorder outcomes from preoccupation, dissatisfaction, and overvaluation.

OBJECTIVE: Diverse terminology has been used to operationalize body image disturbance in eating disorders. However, the differential validity of these terms and their underlying constructs to predict outcomes among heterogeneous eating disorders is unknown. This study evaluated the validity of body image constructs to predict eating disorder and negative psychological symptoms concurrently and prospectively over 2 years in a transdiagnostic clinical sample. METHODS: Women with heterogeneous eating disorder diagnoses (n = 448) completed assessments at baseline, 12-month, and 24-month follow-up. Cross-sectional and cross-lagged generalized linear models examined effects of three body image constructs (i.e., weight and shape preoccupation, overvaluation, and dissatisfaction) on concurrent and subsequent outcomes (i.e., global eating disorder symptoms, binge eating, purging, fasting, self-esteem, and depression). RESULTS: In concurrent analyses, preoccupation was significantly associated with all outcomes (ps = .01 to <.001), overvaluation with all outcomes (ps = .01 to <.001) except binge eating (p = .06), and dissatisfaction with all outcomes (ps < .001) except purging (p = .38). In prospective analyses, preoccupation predicted Eating Disorder Examination global (p = .003) and fasting (p < .001), overvaluation predicted binge eating (p = .01), and body dissatisfaction did not predict any outcomes. DISCUSSION: Preoccupation, overvaluation, and dissatisfaction are differentially related to eating disorder and psychiatric outcomes, indicating that no one body image construct can capture clinical risk in eating disorders. Preoccupation was the most consistent concurrent and longitudinal predictor; this construct may warrant further attention in assessment and diagnosis. Further investigation of these constructs in diverse samples is encouraged.

Comparing integrative cognitive-affective therapy and guided self-help cognitive-behavioral therapy to treat binge-eating disorder using standard and naturalistic momentary outcome measures: A randomized controlled trial.

OBJECTIVE: Innovative treatments and outcome measures are needed for binge-eating disorder (BED). This randomized controlled trial compared Integrative Cognitive-Affective Therapy (ICAT-BED), an individual psychotherapy targeting momentary behavioral and emotional precipitants of binge eating, with an established cognitive-behavioral guided self-help (CBTgsh) treatment using standard and ecological momentary assessment (EMA) outcome measures. METHOD: A total of 112 participants were randomized to 17 weeks of treatment (21 sessions for ICAT-BED and 10 sessions for CBTgsh). Binge-eating frequency was assessed with the Eating Disorder Examination (EDE) as well as EMA using cell phone-based real-time, naturalistic assessment at end of treatment (EOT) and 6-month follow-up. Hypothesized maintenance mechanisms were assessed using self-report questionnaires. RESULTS: Binge-eating frequency as measured by the EDE and real-time assessment showed significant reductions at EOT and follow-up, with no significant differences between treatments. Hypothesized maintenance mechanisms, including emotion regulation, cognitive self-discrepancy, self-directed style, as well as measures of associated eating disorder psychopathology, depression, anxiety, impulsivity, and negative affect, showed similar improvement at EOT and follow-up with no differences between treatments. Abstinence rates at EOT (ICAT-BED: 57.1%; CBTgsh: 42.9%) and 6-month follow-up (ICAT-BED: 46.4%; CBTgsh: 42.9%) were not significantly different. Treatment retention was significantly higher for ICAT-BED (87.5%) than CBTgsh (71.4%). DISCUSSION: These findings suggest that ICAT-BED and CBTgsh were associated with similar improvements in binge eating, psychopathology, and putative maintenance mechanisms as measured by traditional self-report and momentary, naturalistic assessments and that these changes were generally sustained at 6-month follow-up.

Psychotropic medication use in treatment-seeking youth with eating disorders.

OBJECTIVE: Psychotropic medication use in youth with eating disorders (EDs) is poorly understood despite high co-occurrence of psychiatric disorders. This study examined characteristics associated with medication use in treatment-seeking youth with EDs. METHOD: Youth up to age 18 reported on medication use when presenting to an academic medical center outpatient ED service in the United States. Data presented were collected between 1998-2015. RESULTS: The sample (N = 604) was predominantly female (90.6%) with a mean age of 15.3 years (SD = 2.3). Approximately one-third (30%, n = 173) were taking psychotropic medications (40%, n = 70, were taking multiple medications). Antidepressant use was most common (26%, n = 152), followed by atypical antipsychotics (8%, n = 43). Adjusting for co-occurring psychiatric disorders, non-Hispanic Whites who had received prior treatment (psychotherapy, hospitalization) were significantly more likely to be using medication. Longer illness duration and prior treatment were associated with greater antidepressant use. For atypical antipsychotics, prior hospitalization was associated with greater use. CONCLUSIONS: Findings confirm moderate psychotropic medication use among young patients with EDs despite a lack of clarity regarding optimally effective pharmacologic interventions in this population. Pharmacological trials examining the efficacy of medications for young patients with EDs are warranted to inform future prescribing practice.

Serum biomarkers of inflammation and adiposity in the LABS cohort: associations with metabolic disease and surgical outcomes.

BACKGROUND: The utility of serum biomarkers related to inflammation and adiposity as predictors of metabolic disease prevalence and outcomes after bariatric surgery are not well-defined. METHODS: Associations between pre- and post-operative serum levels of four biomarkers (C-reactive protein (CRP), cystatin C (CC), leptin, and ghrelin) with baseline measures of adiposity and metabolic disease prevalence (asthma, diabetes, sleep apnea), and weight loss and metabolic disease remission after bariatric surgery were studied in the Longitudinal Assessment of Bariatric Surgery (LABS) cohort. RESULTS: Baseline CRP levels were positively associated with the odds of asthma but not diabetes or sleep apnea; baseline CC levels were positively associated with asthma, diabetes, and sleep apnea; baseline leptin levels were positively associated with asthma and negatively associated with diabetes and sleep apnea; baseline ghrelin levels were negatively associated with diabetes and sleep apnea. Increased weight loss was associated with increased baseline levels of leptin and CRP and decreased baseline levels of CC. Remission of diabetes and asthma was not associated with baseline levels of any biomarker. A higher likelihood of asthma remission was associated with a greater decrease in leptin levels, and a higher likelihood of diabetes remission was predicted by a lesser decrease in CC. Bariatric surgery was associated with decreased post-operative CC, CRP, and leptin levels, and increased post-operative ghrelin levels. CONCLUSION: This is the largest study to date of serum biomarkers of inflammation and adiposity in a bariatric surgery cohort. Biomarker levels correlate with metabolic disease prevalence prior to bariatric surgery, and with weight loss but not metabolic disease remission after surgery. Bariatric surgery regulates serum biomarker levels in a manner consistent with anti-inflammatory and compensatory orexigenic effects. These data contribute to our understanding of the mechanisms underlying the biologic effects of bariatric surgery.

Eating Pathology After Bariatric Surgery: an Updated Review of the Recent Literature.

PURPOSE OF REVIEW: The goal of this paper was to extend the prior literature on eating pathology following bariatric surgery by highlighting themes in data published over the past 3 years and identifying limitations and future directions for research. RECENT FINDINGS: Changes in eating pathology after bariatric surgery remain consistent with previous research. Specifically, diagnostic prevalence rates and incidence of related behaviors generally decrease following surgery. However, some research supports that these factors increase and/or remit over time following surgery, and that they subsequently have a negative impact on weight loss outcomes. While recent findings have extended knowledge on eating pathology following bariatric surgery, the overall body of literature is still relatively limited. Additional research is needed, including work focusing on the standardization of eating pathology definitions, development/validation of standardized eating pathology instruments for bariatric surgery patients, and predictors of risk for continued or new onset eating pathology following surgery.

Changes in Alcohol Use after Metabolic and Bariatric Surgery: Predictors and Mechanisms.

PURPOSE OF REVIEW: This review synthesized the literature on predictors and mechanisms of post-bariatric alcohol problems, in order to guide future research on prevention and treatment targets. RECENT FINDINGS: Consistent evidence suggests an elevated risk of developing problems with alcohol following bariatric surgery. While there is a paucity of empirical data on predictors of problematic alcohol use after bariatric surgery, being male, a younger age, smoking, regular alcohol consumption, pre-surgical alcohol use disorder, and a lower sense of belonging have predicted alcohol misuse post-operatively. This review synthesizes potential mechanisms including specific bariatric surgical procedures, peptides and reinforcement/reward pathways, pharmacokinetics, and genetic influences. Finally, potential misperceptions regarding mechanisms are explored. Certain bariatric procedures elevate the risk of alcohol misuse post-operatively. Future research should serve to elucidate the complexities of reward signaling, genetically mediated mechanisms, and pharmacokinetics in relation to alcohol use across gender and developmental period by surgery type.

Buying-shopping disorder-is there enough evidence to support its inclusion in ICD-11?

The phenomenon of buying-shopping disorder (BSD) was described over 100 years ago. Definitions of BSD refer to extreme preoccupation with shopping and buying, to impulses to purchase that are experienced as irresistible, and to recurrent maladaptive buying excesses that lead to distress and impairments. Efforts to stop BSD episodes are unsuccessful, despite the awareness of repeated break-downs in self-regulation, experiences of post-purchase guilt and regret, comorbid psychiatric disorders, reduced quality of life, familial discord, work impairment, financial problems, and other negative consequences. A recent meta-analysis indicated an estimated point prevalence of BSD of 5%. In this narrative review, the authors offer a perspective to consider BSD as a mental health condition and to classify this disorder as a behavioral addiction, based on both research data and on long-standing clinical experience.

Effect of Bariatric Surgery on CKD Risk.

Obesity is linked to the development and progression of CKD, but whether bariatric surgery protects against CKD is poorly understood. We, therefore, examined whether bariatric surgery influences CKD risk. The study included 2144 adults who underwent bariatric surgery from March of 2006 to April of 2009 and participated in the Longitudinal Assessment of Bariatric Surgery-2 Study cohort. The primary outcome was CKD risk categories as assessed by the Kidney Disease Improving Global Outcomes (KDIGO) consortium criteria using a combination of eGFR and albuminuria. Patients were 79% women and 87% white, with a median age of 46 years old. Improvements were observed in CKD risk at 1 and 7 years after surgery in patients with moderate baseline CKD risk (63% and 53%, respectively), high baseline risk (78% and 56%, respectively), and very high baseline risk (59% and 23%, respectively). The proportion of patients whose CKD risk worsened was ≤10%; five patients developed ESRD. Sensitivity analyses using year 1 as baseline to minimize the effect of weight loss on serum creatinine and differing eGFR equations offered qualitatively similar results. Treatment with bariatric surgery associated with an improvement in CKD risk categories in a large proportion of patients for up to 7 years, especially in those with moderate and high baseline risk. These findings support consideration of CKD risk in evaluation for bariatric surgery and further study of bariatric surgery as a treatment for high-risk obese patients with CKD.

Eating pathology and associations with long-term changes in weight and quality of life in the longitudinal assessment of bariatric surgery study.

OBJECTIVE: This study examines the course of eating pathology and its associations with change in weight and health-related quality of life following bariatric surgery. METHOD: Participants (N = 184) completed the eating disorder examination-bariatric surgery version (EDE-BSV) and the medical outcomes study 36-Item short form health survey (SF-36) prior to and annually following Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) for up to 7 years. RESULTS: The prevalence of ≥ weekly loss of control (LOC) eating, picking/nibbling, and cravings declined post-RYGB and remained lower through 7 years (LOC: 5.4% at Year-7 vs. 16.2% pre-RYGB, p = .03; picking/nibbling: 7.0% vs. 32.4%, p < .001; and cravings: 19.4% vs. 33.6%, p = .02). The prevalence of picking/nibbling was significantly lower 7 years following LAGB vs. pre-LAGB (29.4% vs 45.8%, p = .049), while cravings (p = .13) and LOC eating (p = .95) were not. EDE-BSV global score and ratings of hunger and enjoyment of eating were lower 7 years following both RYGB and LAGB versus pre-surgery (p's for all <.05). LOC eating following RYGB was associated with less long-term weight loss from surgery (p < .01) and greater weight regain from weight nadir (p < .001). Higher post-surgery EDE-BSV global score was associated with less weight loss/greater regain (both p < .001) and worsening/less improvement from surgery in the SF-36 mental component summary scores (p < .01). DISCUSSION: Initial improvements in eating pathology following RYGB and LAGB were sustained across 7 years of follow-up. Individuals with eating pathology post-RYGB, reflected by LOC eating and/or higher EDE-BSV global score, may be at risk for suboptimal long-term outcomes.

A preliminary study of momentary, naturalistic indicators of binge-eating episodes in adults with obesity.

OBJECTIVES: Binge eating is common in adults with obesity. The Diagnostic and Statistical Manual for Psychiatric Disorders describes five indicators of binge eating (eating more rapidly than usual; eating until uncomfortably full; eating large amounts of food when not physically hungry; eating alone because of embarrassment over how much one is eating; and feeling disgusted with oneself, depressed, or very guilty after overeating), but their validity is unclear. METHOD: We examined preliminary associations between the five indicators and binge versus nonbinge episodes among 50 adults with obesity via ecological momentary assessment. RESULTS: Generalized linear models revealed that, relative to nonbinge episodes, self-reported binge episodes were associated with lower pre-episode hunger (p = .004), higher postepisode fullness (p < .001), a greater likelihood of reporting moderate to extreme shame prior to eating in conjunction with eating alone (p < .001), and a greater likelihood of reporting moderate to extreme disgust, depression, and/or guilt after eating (p < .001), but not with eating more rapidly than usual (p = .85). DISCUSSION: Results support the validity of most binge-eating indicators, although the utility of the rapid eating criterion is questionable. Future research should examine whether modifying these indicators in binge-eating interventions would reduce the occurrence of loss of control and/or overeating.

Examining a momentary mediation model of appearance-related stress, anxiety, and eating disorder behaviors in adult anorexia nervosa.

PURPOSE: Appearance-related stress may result from appearance-focused events such as seeing one's reflection, seeing media images, and shopping for clothes. The purpose of this study was to examine the prospective association between momentary appearance-related stress and eating disorder (ED) behaviors (i.e., binge eating and vomiting) among women with anorexia nervosa (AN) using ecological momentary assessment (EMA). We hypothesized that appearance-related stress at Time 1 would predict binge eating and vomiting at Time 2, and that this prospective association would be mediated by momentary anxiety at Time 2 (controlling for anxiety at Time 1). METHODS: Women with AN completed a 2-week EMA protocol involving repeated daily assessments of experiences and behaviors. RESULTS: Momentary appearance-related stress preceded binge eating and vomiting, and momentary anxiety mediated the prospective association between appearance-related stress and ED behaviors. CONCLUSIONS: Targeted momentary interventions delivered in the natural environment that address appearance-related stress may have utility in the treatment of ED behaviors.