clinical obesity
doi: 10.1111/cob.12080
Exploring the concept of eating dyscontrol in severely obese patients candidate to bariatric surgery A. Calderone1, M. Mauri2, P. F. Calabrò2, P. Piaggi3, G. Ceccarini1, C. Lippi1, P. Fierabracci1, A. Landi3, P. Vitti1 and F. Santini1
1
Obesity Center at the Endocrinology Unit,
Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy; 2Division of Psychiatry, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy; 3Department of Information Engineering, University of Pisa, Pisa, Italy
Received 13 June 2014; revised 28 August 2014; accepted 8 September 2014
Address for correspondence: Dr A Calderone, Obesity Center at the Endocrinology Unit, University Hospital of Pisa, Via Paradisa 2, Pisa 56124, Italy. Tel.: +39 050 995099; Fax +39 050 995639. E-mail: [email protected]
Summary Eating dyscontrol constitutes a potential negative predictor for the outcome of treatment strategies for obese patients. The aim of this study was to examine the qualitative characteristics of eating dyscontrol in obese patients who engage in binge eating (BE) compared with those who do not (NBE), and to analyse the relationship between eating dyscontrol and axis-I, axis-II, spectrum psychopathology using instruments that explore mood, panic–agoraphobic, social– phobic, obsessive–compulsive and eating disorders spectrum psychopathology (SCI-MOODS-SR, SCI-PAS-SR, SCI-SHY-SR, SCI-OBS-SR, SCI-ABS-SR). This was a cross-sectional study involving a clinical sample of adult obese patients with severe obesity (average body mass index = 45 ± 8 kg m−2) and candidate to bariatric surgery who were recruited between November 2001 and November 2010 at the Obesity Center of the Endocrinology Unit, University Hospital of Pisa. All participants completed a face-to-face interview, including a diagnostic assessment of axes-I and II mental disorders (using the Structured Clinical Interview for Manual of Mental Disorders, fourth edition [SCID]-I and SCID-II) and filled out self-report spectrum instruments. Among obese patients not affected by BE, eating dyscontrol was highly represented. Indeed, 39.7% (N = 177) of subjects endorsed six or more items of the Anorexia–Bulimia Spectrum SelfReport, lifetime version domain exploring this behaviour. The cumulative probability of having axis-I, axis-II and a spectrum condition disorder increased significantly with the number of eating dyscontrol items endorsed. In both BE and NBE obese subjects, eating dyscontrol may represent an independent dimension strongly related to the spectrum psychopathology and axes I/II disorders. A systematic screening for eating dyscontrol symptoms by means of self-report spectrum instruments may be valuable to assign specific treatment strategies. Keywords: Bariatric surgery, dyscontrol, obesity, spectrum psychopathology.
Introduction Bariatric surgery is an effective treatment for severe obesity, with sustained results in the long-term (1,2), and the demand for bariatric surgery is constantly increasing (3,4). 22
Likewise, obese patients candidate to bariatric surgery show high rates of binge eating disorder (BED) and psychiatric disorders in general (5–10). In this area, however, there are no guidelines concerning the contraindications to the surgical treatment, and it is not clear if the outcome or © 2015 World Obesity. clinical obesity 5, 22–30
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the degree of weight loss is different in patients with or without BE (11). The most reliable and accepted form of assessment of BED involves the use of a self-report questionnaire based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM) combined with a standardized interview. The prevalence of BED among obese individuals undergoing weight reduction programs ranges between 1.3% and 40% depending on the self-report and interview assessment methods employed (12–16). Research in the last decade comparing binge eaters (BE) and non-binge eaters (NBE) (17) has documented that BE have a significantly higher lifetime prevalence of mood, anxiety, substance abuse disorders and axis-II disorders (18,19). Moreover BE share important features with patients with binge drinking behaviours (20). Nevertheless, BED continues to pose challenges in terms of its definition, and a systematic review of the literature pointed to loss of control (LOC) as a core feature of this disease (21). The most commonly used definition of loss of control varies from the fear of not being empowered to stop eating voluntarily to a feeling of lack of control during the over-eating episode. Perceived eating LOC is an emotional and inherently subjective experience to rationalize. Colles et al. (22) found in a sample of bariatric surgery candidates that LOC related to eating dyscontrol was the factor most closely associated to psychological distress and the association was higher in those meeting full criteria of BED. Goldschmidt et al. (23) reported that in obese patients with BED a greater premeal self-reported LOC was associated with higher postprandial negative effect. Kalarchian et al. (24) in a cross-sectional study of bariatric surgery patients reported that self-report LOC over-eating was associated with rebound weight gain after gastric bypass. However, further assessment of LOC is warranted to further generalize these results while a better definition of the relationships among perceived control over food intake, psychological status and bariatric surgery outcome is needed (25,26). At present, there are few specific questions included in the Eating Disorder Examination questionnaire (EDE-Q) that explore the main features of LOC (27). These features are most likely represented along a continuum (28) and may influence the outcome of any bariatric surgery procedure. The aim of this work was to examine the qualitative characteristics of eating dyscontrol in obese patients candidate to bariatric surgery who engaged in BE compared with those who did not. The relationships between eating dyscontrol and axis-I, axis-II and spectrum psychopathology were also investigated. © 2015 World Obesity. clinical obesity 5, 22–30
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Methods Data were available from 494 obese subjects who were candidates for bariatric surgery; they were recruited and received a careful psychological assessment between November 2001 and November 2010 at the Obesity Research Center of the Endocrinology Unit, University Hospital of Pisa. Inclusion criteria included age of 18–65 years and a body mass index (BMI; kg m−2) of ≥35. Exclusion criteria were: life-threatening physical illness, mental retardation, illiteracy or poor knowledge of Italian language. The diagnostic assessment was conducted using the SCID-I (29) and the SCID-II (30) for DSM-IV-R diagnoses by psychiatrists trained and certified to the use of the interviews. The Ethics Committee of the University Hospital of Pisa approved the study protocol and the assessment procedures. All subjects provided a written informed consent to participate in the study. Five self-report questionnaires were administered to assess the spectrum psychopathology including: 1 The 2 The 3 The 4 The (35,36); 5 The
eating disorders spectrum (ABS-SR) (28); Panic–Agoraphobic Spectrum (PAS-SR) (31,32); Mood Spectrum (MOODS-SR) (33,34); Obsessive–Compulsive Spectrum (OBS-SR) Social Anxiety Spectrum (SHY-SR) (35,36).
Further, a battery of spectrum instruments were also administered including the Anorexia–Bulimia Spectrum (ABS-SR), the PAS-SR, the MOODS-SR, the OBS-SR and the SHY-SR.
Spectrum instruments The ABS-SR, lifetime Version (28) consists of 134 items coded as present or absent, and is structured into nine domains: ‘attitude and beliefs’ (seven items); ‘weight history’ (five items); ‘self-esteem and satisfaction’ (11 items); ‘phobias’ (25 items); ‘avoidant and compulsive behaviours’ (nine items); ‘weight maintenance’ (30 items); ‘eating dyscontrol’ (19 items); ‘associated features and consequences’ (20 items); and ‘interference and level of insight’ (eight items). The ABS-SR differs from other questionnaires typically used to assess eating disorders (such as eating attitude test (EAT) and eating disorder inventory 2nd version (EDI II)) because it assesses typical and atypical symptoms, behaviours, temperament traits pertaining to eating disorders, and their impact on everyday life. The concurrent validity of ABS-SR vs. EAT and EDI II ranged from 0.46 to 0.77; the ABS-SR proved to be able to discriminate patients with eating disorders from controls. In this study, we used the ‘eating dyscontrol’ domain, which includes 19 items exploring the lack of control over
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eating. Responses were coded in a dichotomous way (yes/ no), and the domain score was obtained by counting the number of positive responses thus ranging from 0 to 19. This domain proved to have an excellent internal consistency (Kuder–Richardson coefficient = 0.935) in the ABS-SR validation study (28). The PAS-SR (31,32) comprises symptoms, traits and behaviours considered to occur commonly in patients with panic disorder. DSM-IV criterion symptoms for panic disorder and agoraphobia are included, along with associated features found in the DSM-IV text and other symptoms, behavioural traits and interpersonal behaviours. The PAS-SR lifetime version consists of 114 items coded as present or absent grouped into eight domains: ‘separation sensitivity’ (15 items), ‘panic-like symptoms’ (27 items), ‘stress sensitivity’ (two items), ‘substance sensitivity’ (nine items), ‘anxious expectation’ (five items), ‘agoraphobia’ (25 items), ‘illness phobias’ (five items), and ‘reassurance orientation’ (26 items). The Mood Spectrum Self-Report Version (MOODS-SR) (33,34) allows for the simultaneous assessment of both overt and subtle components of depression and mania along a continuum of diverse psychopathological dimensions, different levels of mood dys-regulations. The MOODS-SR lifetime version consists of 161 items; seven impairment items (not calculated in the total score) and 154 items coded as present or absent organized into a depressive component (63 items), a manic component (62 items) and a rhythmicity/ vegetative function component (29 items). The OBS-SR Self-Report Version (35,36) explores the typical symptoms of obsessive–compulsive disorder (OCD) and a wide range of atypical and subthreshold traits and behaviours that surround the core symptomatology of the disorder. The OBS-SR lifetime version consists of 195 items grouped into seven domains: ‘childhood/adolescence experiences’ (22 items), ‘doubt’ (14 items), ‘hypercontrol’ (70 items), ‘attitude towards time’ (8 items), ‘perfectionism’ (18 items), ‘repetition and automation’ (12 items) and ‘specific items’ (51 items). The SHY-SR (35,36) is designed to assess symptoms of social phobia. The essential feature of social phobia is a marked and persistent fear of social or performance situations in which the subject may be exposed to unfamiliar persons or to the judgment of others. The SHY-SR lifetime version consists of 168 items coded as present or absent grouped into four domains and one appendix: ‘social phobic traits during childhood and adolescence’ (12 items), ‘interpersonal sensitivity’ (29 items) ‘behaviour inhibition and somatic symptoms’ (23 items) and ‘specific anxieties and phobic features’ (98 items). The appendix (six items) explores the use of psychoactive substances that is a frequent complication of social anxiety disorder. In the validation studies, including patients with the disorders of interest and controls, for each spectrum condition, a cut-off
score was obtained using Receiver Operating Characteristic (ROC) analysis. Subjects exceeding the threshold for any of the spectrum condition were considered as meeting the criteria for that specific spectrum.
Statistical analysis Spearman’s Rho was employed to assess correlation between eating dyscontrol and other ABS-SR domains in subjects with BED (BE) and in subjects without BED (NBE). Chi-squared test was used to evaluate differences between proportions of BE and NBE patients for each item of the eating dyscontrol questionnaire. The relationships between eating dyscontrol and the presence of any axis-I disorder, any axis-II disorder and any spectrum condition of psychopathology were evaluated by binary logistic regression models, using a forward selection algorithm based on Wald statistics; age, gender, BMI and the presence of BE disorder entered into the models as covariates to control for their effect. A P value less than 0.05 was considered statistically significant. Data are presented as mean ± standard deviation.
Results Study sample The study sample consisted of 494 subjects severely obese, according to the World Health Organization classification (37) of whom 388 were women (78.5%) with a mean age of 48 ± 11 years and mean BMI of 45 ± 8 kg m−2, and 106 men ( 21.5%) with a mean age 46 ± 12 years and mean BMI of 46 kg m−2 ± 7 (Table 1). Forty-eight subjects meeting the criteria for BED (BE) were compared with the rest of the sample (NBE) in the subsequent analyses.
Eating dyscontrol In the entire study population, eating dyscontrol was found to be unrelated to BMI (Spearman’s Rho =0.07, P = 0.13). The average score of items endorsed of eating dyscontrol domain was higher in BE subjects compared with NBE subjects (10.98 ± 5.9 vs. 5.73 ± 4.92, P < 0.001). The large majority (81.3%) of BE and 39.7% of NBE patients endorsed at least six items out of the 19 eating dyscontrol items; 14.3% of BE and 17.4% of NBE patients did not endorse any item of the dyscontrol domain (Fig. 1A–B). The distribution of eating dyscontrol in NBE was highly skewed to the right, with 177 out of 446 subjects (39.7%) endorsing six items or more. Furthermore, 15 items were endorsed more frequently by BE than NBE (P < 0.05, Table 2). These included the way food is consumed and ingested and the inability to control the sense of hunger. © 2015 World Obesity. clinical obesity 5, 22–30
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Table 1 Demographic characteristics of the obese population studied N = 494 (%) Gender Female Male Age (mean ± SD) Marital status Single Married Divorced Widowed Employment status Student Unemployed Employed Housewife Retired Educational level University degree High school Secondary school Primary school BMI (mean ± SD) Class I moderate Class II severe Class III very severe Any axis-I disorder (excluding BEDs) Any axis-II disorder Any spectrum condition BED
388 (78.0) 106 (22.0) 48 ± 11 115 (23.3) 342 (69.1) 31 (6.3) 6 (1.3) 26 (5.2) 23 (4.7) 307 (62.2) 104 (21.1) 34 (6.8) 44 (8.9) 209 (42.4) 186 (37.6) 55 (11.1) 45 ± 8.0 30 (6.1) 104 (21.1) 360 (72.9) 146 (29.5) 98 (19.8) 189 (38.3) 48 (9.7)
BED, binge eating disorder; BMI, body mass index; SD, standard deviation.
The four items that did not discriminate BE from NBE were those exploring the difficulty in maintaining a steady weight, or to comply with the diet and eating before going to bed and during the night.
Dyscontrol and anorexia–bulimia spectrum The pattern of correlations of eating dyscontrol with the other ABS-SR domains was different between obese individuals with or without BE. In obese with BE, eating dyscontrol was strongly related with impairment and insight (Spearman’s Rho = 0.68, P < 0.01), self-esteem (Rho = 0.63, P < 0.01), attitudes and beliefs (Rho = 0.59, P < 0.01), associated features and consequences (Rho = 0.58, P < 0.01), weight history (Rho = 0.57, P < 0.01), avoidant and compulsive behaviours domains (Rho = 0.49, P < 0.01) and moderately related with phobias domain (Rho = 0.31, P = 0.03). No significant correlation was found between eating dyscontrol and the weight maintenance domain (Rho = 0.22, P > 0.05). In obese individuals without BE, eating dyscontrol was strongly associated with associated features and conse© 2015 World Obesity. clinical obesity 5, 22–30
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quences (Rho = 0.58, P < 0.01), impairment and insight (Rho = 0.55, P < 0.01), weight maintenance (Rho = 0.53, P < 0.01), phobias (Rho = 0.52, P < 0.01), self-esteem (Rho = 0.49, P < 0.01), avoidant and compulsive behaviours (Rho = 0.46, P < 0.01), attitudes and beliefs (Rho = 0.40, P < 0.01), and weight history (Rho = 0.25, P < 0.01) domains. In conclusion, NBE patients showed a stronger association than BE between eating dyscontrol and weight maintenance domain, which explores dietary habits (0.53 vs. 0.22, P < 0.05), but a lower correlation with weight history domains (0.25 vs. 0.57, P < 0.05), which explores the impact of weight during childhood.
Eating dyscontrol and psychopathology The relationship between eating dyscontrol and psychopathology was examined in three distinct logistic models. The presence of any lifetime axis-I disorder, any axis-II disorder and any spectrum condition was used as a dependent variable in the logistic models. Figure 2 summarizes the results of this analysis. The cumulative probability of having an axis-I disorder increased linearly with the number of eating dyscontrol items endorsed (odds ratio [OR] = 1.077, 95% confidence interval [CI]: 1.039–1.116, P < 0.01) and exceeded 50% at 10 items endorsed. The cumulative probability of having an axis-II disorder increased by 11.7% for each eating dyscontrol item endorsed (OR = 1.089, 95% CI: 1.046–1.133, P < 0.01). The probability of having at least one spectrum condition increased over 50% at 10 items endorsed (OR = 1.199, 95% CI: 1.152–1.247, P < 0.01). Furthermore, the relationship between eating dyscontrol and each of the four spectrum conditions was examined using four distinct models. Figure 3 shows that the higher the number of eating dyscontrol items endorsed, the higher was the probability of having a depressive spectrum (OR = 1.253, 95% CI: 1.192–1.317, P < 0.01), a panic-agoraphobic spectrum (OR = 1.141, 95% CI: 1.096–1.188, P < 0.01), a social anxiety spectrum (OR = 1.213, 95% CI: 1.157–1.272, P < 0.01) and an OBS-SR (OR = 1.187, 95% CI: 1.129– 1.247, P < 0.01). For each logistic model mentioned earlier (the presence of any lifetime axis-I/axis-II disorder and any spectrum condition as a dependent variable), the correction for age, gender and BMI as covariates did not modify the results of the statistical significance with the exception for the model with the spectrum condition in which women showed a higher risk of having at least a spectrum disorder (OR = 1.792, 95% CI: 1.063–3.021, P < 0.05). Similarly, BE patients showed a greater chance of having at least one spectrum condition, regardless of the number of eating
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a
b
Figure 1 (a) Shows the percentage of non-binge eaters (NBE) and binge-eating (BE) patients who endorsed various eating dyscontrol items. (b) Shows the mean values (with 95% confidence interval) of eating dyscontrol scores for BE and NBE emphasizing the continuum between the two groups.
dyscontrol items endorsed (OR = 2.199, 95% CI: 1.067– 4.530, P < 0.05). Moreover, the probability of any spectrum condition increased over 50% at six and 11 items endorsed for BE and NBE patients, respectively. In conclusion, eating dyscontrol was found to be significantly related to the presence of an axis-I or II disorder, regardless of age and BMI; moreover, sub-threshold psychiatric disorders were significantly associated to eating dyscontrol and to gender, with women showing a greater risk than men.
Discussion The prevalence of BED in our sample, evaluated using the standardized diagnostic assessment (SCID-I/-II), was comparable with previous reports by us and others (5,9). Our study showed that, although ‘eating dyscontrol’ prevalence was higher in BE compared with NBE, the distributions of the score on this domain in the two groups
overlapped. As eating dyscontrol is a criterion symptom of BED and bulimia nervosa, it has rarely been studied in NBE obese patients. One research provided preliminary evidence that eating dyscontrol may not yield a useful distinction between BE and NBE patients. Eating dyscontrol, in fact, seems not to be related to the frequency of binge (38), that is the main criterion for the diagnosis of BED or bulimia nervosa according to DSM-IV-R. When we examined the qualitative differences between BE and NBE on eating dyscontrol, we found that all but four of the 19 items included in this domain were endorsed more frequently by BE subjects. One of these nondiscriminating items included the weight cycling phenomenon. While previous research showed that BE is strongly associated with weight cycling (39), our results suggest that this feature may be associated with all forms of obesity. The other two items, ‘felt that you couldn’t go to bed without eating something’ and ‘. . . had to wake up in the middle of the night to eat?’, describe the core behavioural symptoms © 2015 World Obesity. clinical obesity 5, 22–30
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Table 2 Frequency of endorsement of eating dyscontrol items in the study groups ITEMS
NBE N = 446 (%)
BE N = 48 (%)
Chi-square, P
88. . . . ate an amount of food in a short period (for example, two hours) that was definitely larger than most people would eat in the same time, under similar circumstances? 89. . . . ate continuously throughout the day, so that you ingested an amount of food that was definitely larger than most people usually eat? 90. . . . ate with a feeling of lack of control? 91. . . . ate much more rapidly than normal? 92. . . . ate until feeling uncomfortably full? 93. . . . ate large amounts of food when not feeling physically hungry? 94. . . . ate alone because of being embarrassed by how much you were eating? 95. . . . ate and then felt disgusted with yourself, depressed, or very guilty right after over-eating? 96. . . . hoarded or hidden food? 97. . . . had difficulty staying on a diet? 98. . . . spent a large portion of your pay-check on food or going to ‘gourmet’ restaurants? 99. . . . had a lot of problems maintaining a steady weight, so that your weight went up and down like a yo-yo? 100. . . . experienced a continuous sense of hunger? 101. . . . needed to eat something even if you just had a meal? 102. . . . felt that you couldn’t go to bed without eating something? 103. . . . had to wake up in the middle of the night to eat? 104. . . . found it difficult to resist food or beverages offered to you? 105. . . . felt you were unable to stop eating until you had finished a pack of candies or chocolate? 106. . . . eaten quickly, or swallowed food without chewing it?
100 (22.4)
23 (47.9)
13.73, P < 0.001
103 (23.1)
28 (58.3)
25.84, P < 0.001
90 (20.2) 168 (37.7) 134 (30.0) 105 (23.5) 82 (18.4) 119 (26.7)
29 (60.4) 34 (70.8) 35 (72.9) 33 (68.7) 30 (62.5) 36 (75.0)
36.20, 18.37, 33.51, 41.77, 45.62, 44.77,
47 (10.5) 285 (63.9) 56 (12.5)
12 (25.0) 37 (77.1) 19 (39.6)
7.298, P = 0.007 2.763, P = 0.096 22.53, P < 0.001
221 (49.5)
31 (64.6)
3.340, P = 0.067
143 (32.1) 136 (30.5) 107 (24.0) 44 (9.8) 114 (25.6) 108 (24.2)
30 (62.5) 30 (62.5) 18 (37.5) 9 (18.7) 23 (47.9) 27 (56.2)
16.33, 18.49, 3.501, 2.704, 9.720, 20.81,
137 (30.7)
34 (70.8)
29.07, P < 0.001
Figure 2 Shows the probability, estimated by logistic regression analysis, of having any axis-I disorder axis-II disorder or spectrum condition as a function of the eating dyscontrol score.
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P < 0.001 P < 0.001 P < 0.001 P < 0.001 P < 0.001 P < 0.001
P < 0.001 P < 0.001 P = 0.061 P = 0.100 P = 0.002 P < 0.001
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Figure 3 Shows the probability, estimated by logistic regression analysis, of having Obsessive–Compulsive Spectrum (OBS-SR), Panic–Agoraphobic Spectrum (PAS-SR), Social Anxiety Spectrum (SHY-SR) or Mood Spectrum (MOODS-SR) conditions as a function of the eating dyscontrol score.
of night eating syndrome (NES), introduced by Stunkard et al. (40). Our results pointed out that these symptoms were equally distributed among BE and NBE. In fact, the overlap between BE and NES is modest in obese patients, in agreement with other reports (41,42) thus emphasizing that they are different constructs (43). The last non-discriminating item explores the difficulty to adhere to dietary programs. The role of dieting on the development of eating disorder is controversial and has been implicated as a potential contributor in exacerbating BED. Overall, the relationship between dietary restraint and BE appears to be complex (44). Our results showed the same degree of compliance to dietary programs for BE and NBE patients. When we examined the psychopathology correlates of eating dyscontrol, we found that the higher the number of items endorsed, the more likely subjects have axis-I and II disorders. Of note, even the experience of few aspects related to eating dyscontrol increases the likelihood of having a spectrum condition in particular for female patients. We speculate that the impact of the eating dyscontrol on lifetime situations, like pregnancy and family management, might play an important role. The development and validation of spectrum instruments has been conducted in the last few years, and the relationship between eating dyscontrol and spectrum symptomatology has been investigated only recently. One study has
already underlined that panic spectrum is higher in obese patients with BED compared with lean subjects (45). In our sample, eating dyscontrol domain correlated significantly with other domains exploring the characteristics of subthreshold eating disorders. Subjects NBE showed a greater correlation with the domain of weight maintenance (which explores dietary habits) and lower with the domain referring to the history of weight (which explores the impact of weight during childhood). We can speculate that in NBE patients the dyscontrol was associated with multiple dietary attempts but had less interference on weight, dieting and criticism during childhood. Several results from the literature highlight the importance of sub-threshold psychopathology, in particular obsessive compulsive traits (46), depressive symptomatology, psychological disturbance (22,47) and panic agoraphobia spectrum (45) in BE patients. However, our analysis extends these results to non-binge NBE subjects, emphasizing a correlation with eating dyscontrol. In conclusion, eating dyscontrol may represent an independent dimension strongly related to the spectrum psychopathology, bridging between non-binge and binge obese patients. The administration of the spectrum instruments to obese patients in routine clinical practice might offer the advantage of identifying subjects who may or may not benefit from specific treatment strategies with particular attention to bariatric surgery procedures. © 2015 World Obesity. clinical obesity 5, 22–30
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Limits of the study It is important to underline that our results refer to a clinical sample composed by a highly selected group of severe obese patients. Patients with eating dyscontrol in the spectrum but without axis-I diagnosis of BED can be addressed to not appropriate surgical intervention. It could be important to assess the impact on body weight, on compliance and on clinical outcome in the post-operative period, which we propose to do in the continuation of this study.
Conflict of Interest Statement No conflict of interest was declared.
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doi: 10.1111/cob.12080
Exploring the concept of eating dyscontrol in severely obese patients candidate to bariatric surgery A. Calderone1, M. Mauri2, P. F. Calabrò2, P. Piaggi3, G. Ceccarini1, C. Lippi1, P. Fierabracci1, A. Landi3, P. Vitti1 and F. Santini1
1
Obesity Center at the Endocrinology Unit,
Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy; 2Division of Psychiatry, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy; 3Department of Information Engineering, University of Pisa, Pisa, Italy
Received 13 June 2014; revised 28 August 2014; accepted 8 September 2014
Address for correspondence: Dr A Calderone, Obesity Center at the Endocrinology Unit, University Hospital of Pisa, Via Paradisa 2, Pisa 56124, Italy. Tel.: +39 050 995099; Fax +39 050 995639. E-mail: [email protected]
Summary Eating dyscontrol constitutes a potential negative predictor for the outcome of treatment strategies for obese patients. The aim of this study was to examine the qualitative characteristics of eating dyscontrol in obese patients who engage in binge eating (BE) compared with those who do not (NBE), and to analyse the relationship between eating dyscontrol and axis-I, axis-II, spectrum psychopathology using instruments that explore mood, panic–agoraphobic, social– phobic, obsessive–compulsive and eating disorders spectrum psychopathology (SCI-MOODS-SR, SCI-PAS-SR, SCI-SHY-SR, SCI-OBS-SR, SCI-ABS-SR). This was a cross-sectional study involving a clinical sample of adult obese patients with severe obesity (average body mass index = 45 ± 8 kg m−2) and candidate to bariatric surgery who were recruited between November 2001 and November 2010 at the Obesity Center of the Endocrinology Unit, University Hospital of Pisa. All participants completed a face-to-face interview, including a diagnostic assessment of axes-I and II mental disorders (using the Structured Clinical Interview for Manual of Mental Disorders, fourth edition [SCID]-I and SCID-II) and filled out self-report spectrum instruments. Among obese patients not affected by BE, eating dyscontrol was highly represented. Indeed, 39.7% (N = 177) of subjects endorsed six or more items of the Anorexia–Bulimia Spectrum SelfReport, lifetime version domain exploring this behaviour. The cumulative probability of having axis-I, axis-II and a spectrum condition disorder increased significantly with the number of eating dyscontrol items endorsed. In both BE and NBE obese subjects, eating dyscontrol may represent an independent dimension strongly related to the spectrum psychopathology and axes I/II disorders. A systematic screening for eating dyscontrol symptoms by means of self-report spectrum instruments may be valuable to assign specific treatment strategies. Keywords: Bariatric surgery, dyscontrol, obesity, spectrum psychopathology.
Introduction Bariatric surgery is an effective treatment for severe obesity, with sustained results in the long-term (1,2), and the demand for bariatric surgery is constantly increasing (3,4). 22
Likewise, obese patients candidate to bariatric surgery show high rates of binge eating disorder (BED) and psychiatric disorders in general (5–10). In this area, however, there are no guidelines concerning the contraindications to the surgical treatment, and it is not clear if the outcome or © 2015 World Obesity. clinical obesity 5, 22–30
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the degree of weight loss is different in patients with or without BE (11). The most reliable and accepted form of assessment of BED involves the use of a self-report questionnaire based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM) combined with a standardized interview. The prevalence of BED among obese individuals undergoing weight reduction programs ranges between 1.3% and 40% depending on the self-report and interview assessment methods employed (12–16). Research in the last decade comparing binge eaters (BE) and non-binge eaters (NBE) (17) has documented that BE have a significantly higher lifetime prevalence of mood, anxiety, substance abuse disorders and axis-II disorders (18,19). Moreover BE share important features with patients with binge drinking behaviours (20). Nevertheless, BED continues to pose challenges in terms of its definition, and a systematic review of the literature pointed to loss of control (LOC) as a core feature of this disease (21). The most commonly used definition of loss of control varies from the fear of not being empowered to stop eating voluntarily to a feeling of lack of control during the over-eating episode. Perceived eating LOC is an emotional and inherently subjective experience to rationalize. Colles et al. (22) found in a sample of bariatric surgery candidates that LOC related to eating dyscontrol was the factor most closely associated to psychological distress and the association was higher in those meeting full criteria of BED. Goldschmidt et al. (23) reported that in obese patients with BED a greater premeal self-reported LOC was associated with higher postprandial negative effect. Kalarchian et al. (24) in a cross-sectional study of bariatric surgery patients reported that self-report LOC over-eating was associated with rebound weight gain after gastric bypass. However, further assessment of LOC is warranted to further generalize these results while a better definition of the relationships among perceived control over food intake, psychological status and bariatric surgery outcome is needed (25,26). At present, there are few specific questions included in the Eating Disorder Examination questionnaire (EDE-Q) that explore the main features of LOC (27). These features are most likely represented along a continuum (28) and may influence the outcome of any bariatric surgery procedure. The aim of this work was to examine the qualitative characteristics of eating dyscontrol in obese patients candidate to bariatric surgery who engaged in BE compared with those who did not. The relationships between eating dyscontrol and axis-I, axis-II and spectrum psychopathology were also investigated. © 2015 World Obesity. clinical obesity 5, 22–30
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Methods Data were available from 494 obese subjects who were candidates for bariatric surgery; they were recruited and received a careful psychological assessment between November 2001 and November 2010 at the Obesity Research Center of the Endocrinology Unit, University Hospital of Pisa. Inclusion criteria included age of 18–65 years and a body mass index (BMI; kg m−2) of ≥35. Exclusion criteria were: life-threatening physical illness, mental retardation, illiteracy or poor knowledge of Italian language. The diagnostic assessment was conducted using the SCID-I (29) and the SCID-II (30) for DSM-IV-R diagnoses by psychiatrists trained and certified to the use of the interviews. The Ethics Committee of the University Hospital of Pisa approved the study protocol and the assessment procedures. All subjects provided a written informed consent to participate in the study. Five self-report questionnaires were administered to assess the spectrum psychopathology including: 1 The 2 The 3 The 4 The (35,36); 5 The
eating disorders spectrum (ABS-SR) (28); Panic–Agoraphobic Spectrum (PAS-SR) (31,32); Mood Spectrum (MOODS-SR) (33,34); Obsessive–Compulsive Spectrum (OBS-SR) Social Anxiety Spectrum (SHY-SR) (35,36).
Further, a battery of spectrum instruments were also administered including the Anorexia–Bulimia Spectrum (ABS-SR), the PAS-SR, the MOODS-SR, the OBS-SR and the SHY-SR.
Spectrum instruments The ABS-SR, lifetime Version (28) consists of 134 items coded as present or absent, and is structured into nine domains: ‘attitude and beliefs’ (seven items); ‘weight history’ (five items); ‘self-esteem and satisfaction’ (11 items); ‘phobias’ (25 items); ‘avoidant and compulsive behaviours’ (nine items); ‘weight maintenance’ (30 items); ‘eating dyscontrol’ (19 items); ‘associated features and consequences’ (20 items); and ‘interference and level of insight’ (eight items). The ABS-SR differs from other questionnaires typically used to assess eating disorders (such as eating attitude test (EAT) and eating disorder inventory 2nd version (EDI II)) because it assesses typical and atypical symptoms, behaviours, temperament traits pertaining to eating disorders, and their impact on everyday life. The concurrent validity of ABS-SR vs. EAT and EDI II ranged from 0.46 to 0.77; the ABS-SR proved to be able to discriminate patients with eating disorders from controls. In this study, we used the ‘eating dyscontrol’ domain, which includes 19 items exploring the lack of control over
clinical obesity
24 Eating dyscontrol in bariatric surgery A. Calderone et al.
eating. Responses were coded in a dichotomous way (yes/ no), and the domain score was obtained by counting the number of positive responses thus ranging from 0 to 19. This domain proved to have an excellent internal consistency (Kuder–Richardson coefficient = 0.935) in the ABS-SR validation study (28). The PAS-SR (31,32) comprises symptoms, traits and behaviours considered to occur commonly in patients with panic disorder. DSM-IV criterion symptoms for panic disorder and agoraphobia are included, along with associated features found in the DSM-IV text and other symptoms, behavioural traits and interpersonal behaviours. The PAS-SR lifetime version consists of 114 items coded as present or absent grouped into eight domains: ‘separation sensitivity’ (15 items), ‘panic-like symptoms’ (27 items), ‘stress sensitivity’ (two items), ‘substance sensitivity’ (nine items), ‘anxious expectation’ (five items), ‘agoraphobia’ (25 items), ‘illness phobias’ (five items), and ‘reassurance orientation’ (26 items). The Mood Spectrum Self-Report Version (MOODS-SR) (33,34) allows for the simultaneous assessment of both overt and subtle components of depression and mania along a continuum of diverse psychopathological dimensions, different levels of mood dys-regulations. The MOODS-SR lifetime version consists of 161 items; seven impairment items (not calculated in the total score) and 154 items coded as present or absent organized into a depressive component (63 items), a manic component (62 items) and a rhythmicity/ vegetative function component (29 items). The OBS-SR Self-Report Version (35,36) explores the typical symptoms of obsessive–compulsive disorder (OCD) and a wide range of atypical and subthreshold traits and behaviours that surround the core symptomatology of the disorder. The OBS-SR lifetime version consists of 195 items grouped into seven domains: ‘childhood/adolescence experiences’ (22 items), ‘doubt’ (14 items), ‘hypercontrol’ (70 items), ‘attitude towards time’ (8 items), ‘perfectionism’ (18 items), ‘repetition and automation’ (12 items) and ‘specific items’ (51 items). The SHY-SR (35,36) is designed to assess symptoms of social phobia. The essential feature of social phobia is a marked and persistent fear of social or performance situations in which the subject may be exposed to unfamiliar persons or to the judgment of others. The SHY-SR lifetime version consists of 168 items coded as present or absent grouped into four domains and one appendix: ‘social phobic traits during childhood and adolescence’ (12 items), ‘interpersonal sensitivity’ (29 items) ‘behaviour inhibition and somatic symptoms’ (23 items) and ‘specific anxieties and phobic features’ (98 items). The appendix (six items) explores the use of psychoactive substances that is a frequent complication of social anxiety disorder. In the validation studies, including patients with the disorders of interest and controls, for each spectrum condition, a cut-off
score was obtained using Receiver Operating Characteristic (ROC) analysis. Subjects exceeding the threshold for any of the spectrum condition were considered as meeting the criteria for that specific spectrum.
Statistical analysis Spearman’s Rho was employed to assess correlation between eating dyscontrol and other ABS-SR domains in subjects with BED (BE) and in subjects without BED (NBE). Chi-squared test was used to evaluate differences between proportions of BE and NBE patients for each item of the eating dyscontrol questionnaire. The relationships between eating dyscontrol and the presence of any axis-I disorder, any axis-II disorder and any spectrum condition of psychopathology were evaluated by binary logistic regression models, using a forward selection algorithm based on Wald statistics; age, gender, BMI and the presence of BE disorder entered into the models as covariates to control for their effect. A P value less than 0.05 was considered statistically significant. Data are presented as mean ± standard deviation.
Results Study sample The study sample consisted of 494 subjects severely obese, according to the World Health Organization classification (37) of whom 388 were women (78.5%) with a mean age of 48 ± 11 years and mean BMI of 45 ± 8 kg m−2, and 106 men ( 21.5%) with a mean age 46 ± 12 years and mean BMI of 46 kg m−2 ± 7 (Table 1). Forty-eight subjects meeting the criteria for BED (BE) were compared with the rest of the sample (NBE) in the subsequent analyses.
Eating dyscontrol In the entire study population, eating dyscontrol was found to be unrelated to BMI (Spearman’s Rho =0.07, P = 0.13). The average score of items endorsed of eating dyscontrol domain was higher in BE subjects compared with NBE subjects (10.98 ± 5.9 vs. 5.73 ± 4.92, P < 0.001). The large majority (81.3%) of BE and 39.7% of NBE patients endorsed at least six items out of the 19 eating dyscontrol items; 14.3% of BE and 17.4% of NBE patients did not endorse any item of the dyscontrol domain (Fig. 1A–B). The distribution of eating dyscontrol in NBE was highly skewed to the right, with 177 out of 446 subjects (39.7%) endorsing six items or more. Furthermore, 15 items were endorsed more frequently by BE than NBE (P < 0.05, Table 2). These included the way food is consumed and ingested and the inability to control the sense of hunger. © 2015 World Obesity. clinical obesity 5, 22–30
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Table 1 Demographic characteristics of the obese population studied N = 494 (%) Gender Female Male Age (mean ± SD) Marital status Single Married Divorced Widowed Employment status Student Unemployed Employed Housewife Retired Educational level University degree High school Secondary school Primary school BMI (mean ± SD) Class I moderate Class II severe Class III very severe Any axis-I disorder (excluding BEDs) Any axis-II disorder Any spectrum condition BED
388 (78.0) 106 (22.0) 48 ± 11 115 (23.3) 342 (69.1) 31 (6.3) 6 (1.3) 26 (5.2) 23 (4.7) 307 (62.2) 104 (21.1) 34 (6.8) 44 (8.9) 209 (42.4) 186 (37.6) 55 (11.1) 45 ± 8.0 30 (6.1) 104 (21.1) 360 (72.9) 146 (29.5) 98 (19.8) 189 (38.3) 48 (9.7)
BED, binge eating disorder; BMI, body mass index; SD, standard deviation.
The four items that did not discriminate BE from NBE were those exploring the difficulty in maintaining a steady weight, or to comply with the diet and eating before going to bed and during the night.
Dyscontrol and anorexia–bulimia spectrum The pattern of correlations of eating dyscontrol with the other ABS-SR domains was different between obese individuals with or without BE. In obese with BE, eating dyscontrol was strongly related with impairment and insight (Spearman’s Rho = 0.68, P < 0.01), self-esteem (Rho = 0.63, P < 0.01), attitudes and beliefs (Rho = 0.59, P < 0.01), associated features and consequences (Rho = 0.58, P < 0.01), weight history (Rho = 0.57, P < 0.01), avoidant and compulsive behaviours domains (Rho = 0.49, P < 0.01) and moderately related with phobias domain (Rho = 0.31, P = 0.03). No significant correlation was found between eating dyscontrol and the weight maintenance domain (Rho = 0.22, P > 0.05). In obese individuals without BE, eating dyscontrol was strongly associated with associated features and conse© 2015 World Obesity. clinical obesity 5, 22–30
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quences (Rho = 0.58, P < 0.01), impairment and insight (Rho = 0.55, P < 0.01), weight maintenance (Rho = 0.53, P < 0.01), phobias (Rho = 0.52, P < 0.01), self-esteem (Rho = 0.49, P < 0.01), avoidant and compulsive behaviours (Rho = 0.46, P < 0.01), attitudes and beliefs (Rho = 0.40, P < 0.01), and weight history (Rho = 0.25, P < 0.01) domains. In conclusion, NBE patients showed a stronger association than BE between eating dyscontrol and weight maintenance domain, which explores dietary habits (0.53 vs. 0.22, P < 0.05), but a lower correlation with weight history domains (0.25 vs. 0.57, P < 0.05), which explores the impact of weight during childhood.
Eating dyscontrol and psychopathology The relationship between eating dyscontrol and psychopathology was examined in three distinct logistic models. The presence of any lifetime axis-I disorder, any axis-II disorder and any spectrum condition was used as a dependent variable in the logistic models. Figure 2 summarizes the results of this analysis. The cumulative probability of having an axis-I disorder increased linearly with the number of eating dyscontrol items endorsed (odds ratio [OR] = 1.077, 95% confidence interval [CI]: 1.039–1.116, P < 0.01) and exceeded 50% at 10 items endorsed. The cumulative probability of having an axis-II disorder increased by 11.7% for each eating dyscontrol item endorsed (OR = 1.089, 95% CI: 1.046–1.133, P < 0.01). The probability of having at least one spectrum condition increased over 50% at 10 items endorsed (OR = 1.199, 95% CI: 1.152–1.247, P < 0.01). Furthermore, the relationship between eating dyscontrol and each of the four spectrum conditions was examined using four distinct models. Figure 3 shows that the higher the number of eating dyscontrol items endorsed, the higher was the probability of having a depressive spectrum (OR = 1.253, 95% CI: 1.192–1.317, P < 0.01), a panic-agoraphobic spectrum (OR = 1.141, 95% CI: 1.096–1.188, P < 0.01), a social anxiety spectrum (OR = 1.213, 95% CI: 1.157–1.272, P < 0.01) and an OBS-SR (OR = 1.187, 95% CI: 1.129– 1.247, P < 0.01). For each logistic model mentioned earlier (the presence of any lifetime axis-I/axis-II disorder and any spectrum condition as a dependent variable), the correction for age, gender and BMI as covariates did not modify the results of the statistical significance with the exception for the model with the spectrum condition in which women showed a higher risk of having at least a spectrum disorder (OR = 1.792, 95% CI: 1.063–3.021, P < 0.05). Similarly, BE patients showed a greater chance of having at least one spectrum condition, regardless of the number of eating
26 Eating dyscontrol in bariatric surgery A. Calderone et al.
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a
b
Figure 1 (a) Shows the percentage of non-binge eaters (NBE) and binge-eating (BE) patients who endorsed various eating dyscontrol items. (b) Shows the mean values (with 95% confidence interval) of eating dyscontrol scores for BE and NBE emphasizing the continuum between the two groups.
dyscontrol items endorsed (OR = 2.199, 95% CI: 1.067– 4.530, P < 0.05). Moreover, the probability of any spectrum condition increased over 50% at six and 11 items endorsed for BE and NBE patients, respectively. In conclusion, eating dyscontrol was found to be significantly related to the presence of an axis-I or II disorder, regardless of age and BMI; moreover, sub-threshold psychiatric disorders were significantly associated to eating dyscontrol and to gender, with women showing a greater risk than men.
Discussion The prevalence of BED in our sample, evaluated using the standardized diagnostic assessment (SCID-I/-II), was comparable with previous reports by us and others (5,9). Our study showed that, although ‘eating dyscontrol’ prevalence was higher in BE compared with NBE, the distributions of the score on this domain in the two groups
overlapped. As eating dyscontrol is a criterion symptom of BED and bulimia nervosa, it has rarely been studied in NBE obese patients. One research provided preliminary evidence that eating dyscontrol may not yield a useful distinction between BE and NBE patients. Eating dyscontrol, in fact, seems not to be related to the frequency of binge (38), that is the main criterion for the diagnosis of BED or bulimia nervosa according to DSM-IV-R. When we examined the qualitative differences between BE and NBE on eating dyscontrol, we found that all but four of the 19 items included in this domain were endorsed more frequently by BE subjects. One of these nondiscriminating items included the weight cycling phenomenon. While previous research showed that BE is strongly associated with weight cycling (39), our results suggest that this feature may be associated with all forms of obesity. The other two items, ‘felt that you couldn’t go to bed without eating something’ and ‘. . . had to wake up in the middle of the night to eat?’, describe the core behavioural symptoms © 2015 World Obesity. clinical obesity 5, 22–30
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Table 2 Frequency of endorsement of eating dyscontrol items in the study groups ITEMS
NBE N = 446 (%)
BE N = 48 (%)
Chi-square, P
88. . . . ate an amount of food in a short period (for example, two hours) that was definitely larger than most people would eat in the same time, under similar circumstances? 89. . . . ate continuously throughout the day, so that you ingested an amount of food that was definitely larger than most people usually eat? 90. . . . ate with a feeling of lack of control? 91. . . . ate much more rapidly than normal? 92. . . . ate until feeling uncomfortably full? 93. . . . ate large amounts of food when not feeling physically hungry? 94. . . . ate alone because of being embarrassed by how much you were eating? 95. . . . ate and then felt disgusted with yourself, depressed, or very guilty right after over-eating? 96. . . . hoarded or hidden food? 97. . . . had difficulty staying on a diet? 98. . . . spent a large portion of your pay-check on food or going to ‘gourmet’ restaurants? 99. . . . had a lot of problems maintaining a steady weight, so that your weight went up and down like a yo-yo? 100. . . . experienced a continuous sense of hunger? 101. . . . needed to eat something even if you just had a meal? 102. . . . felt that you couldn’t go to bed without eating something? 103. . . . had to wake up in the middle of the night to eat? 104. . . . found it difficult to resist food or beverages offered to you? 105. . . . felt you were unable to stop eating until you had finished a pack of candies or chocolate? 106. . . . eaten quickly, or swallowed food without chewing it?
100 (22.4)
23 (47.9)
13.73, P < 0.001
103 (23.1)
28 (58.3)
25.84, P < 0.001
90 (20.2) 168 (37.7) 134 (30.0) 105 (23.5) 82 (18.4) 119 (26.7)
29 (60.4) 34 (70.8) 35 (72.9) 33 (68.7) 30 (62.5) 36 (75.0)
36.20, 18.37, 33.51, 41.77, 45.62, 44.77,
47 (10.5) 285 (63.9) 56 (12.5)
12 (25.0) 37 (77.1) 19 (39.6)
7.298, P = 0.007 2.763, P = 0.096 22.53, P < 0.001
221 (49.5)
31 (64.6)
3.340, P = 0.067
143 (32.1) 136 (30.5) 107 (24.0) 44 (9.8) 114 (25.6) 108 (24.2)
30 (62.5) 30 (62.5) 18 (37.5) 9 (18.7) 23 (47.9) 27 (56.2)
16.33, 18.49, 3.501, 2.704, 9.720, 20.81,
137 (30.7)
34 (70.8)
29.07, P < 0.001
Figure 2 Shows the probability, estimated by logistic regression analysis, of having any axis-I disorder axis-II disorder or spectrum condition as a function of the eating dyscontrol score.
© 2015 World Obesity. clinical obesity 5, 22–30
P < 0.001 P < 0.001 P < 0.001 P < 0.001 P < 0.001 P < 0.001
P < 0.001 P < 0.001 P = 0.061 P = 0.100 P = 0.002 P < 0.001
28 Eating dyscontrol in bariatric surgery A. Calderone et al.
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Figure 3 Shows the probability, estimated by logistic regression analysis, of having Obsessive–Compulsive Spectrum (OBS-SR), Panic–Agoraphobic Spectrum (PAS-SR), Social Anxiety Spectrum (SHY-SR) or Mood Spectrum (MOODS-SR) conditions as a function of the eating dyscontrol score.
of night eating syndrome (NES), introduced by Stunkard et al. (40). Our results pointed out that these symptoms were equally distributed among BE and NBE. In fact, the overlap between BE and NES is modest in obese patients, in agreement with other reports (41,42) thus emphasizing that they are different constructs (43). The last non-discriminating item explores the difficulty to adhere to dietary programs. The role of dieting on the development of eating disorder is controversial and has been implicated as a potential contributor in exacerbating BED. Overall, the relationship between dietary restraint and BE appears to be complex (44). Our results showed the same degree of compliance to dietary programs for BE and NBE patients. When we examined the psychopathology correlates of eating dyscontrol, we found that the higher the number of items endorsed, the more likely subjects have axis-I and II disorders. Of note, even the experience of few aspects related to eating dyscontrol increases the likelihood of having a spectrum condition in particular for female patients. We speculate that the impact of the eating dyscontrol on lifetime situations, like pregnancy and family management, might play an important role. The development and validation of spectrum instruments has been conducted in the last few years, and the relationship between eating dyscontrol and spectrum symptomatology has been investigated only recently. One study has
already underlined that panic spectrum is higher in obese patients with BED compared with lean subjects (45). In our sample, eating dyscontrol domain correlated significantly with other domains exploring the characteristics of subthreshold eating disorders. Subjects NBE showed a greater correlation with the domain of weight maintenance (which explores dietary habits) and lower with the domain referring to the history of weight (which explores the impact of weight during childhood). We can speculate that in NBE patients the dyscontrol was associated with multiple dietary attempts but had less interference on weight, dieting and criticism during childhood. Several results from the literature highlight the importance of sub-threshold psychopathology, in particular obsessive compulsive traits (46), depressive symptomatology, psychological disturbance (22,47) and panic agoraphobia spectrum (45) in BE patients. However, our analysis extends these results to non-binge NBE subjects, emphasizing a correlation with eating dyscontrol. In conclusion, eating dyscontrol may represent an independent dimension strongly related to the spectrum psychopathology, bridging between non-binge and binge obese patients. The administration of the spectrum instruments to obese patients in routine clinical practice might offer the advantage of identifying subjects who may or may not benefit from specific treatment strategies with particular attention to bariatric surgery procedures. © 2015 World Obesity. clinical obesity 5, 22–30
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Limits of the study It is important to underline that our results refer to a clinical sample composed by a highly selected group of severe obese patients. Patients with eating dyscontrol in the spectrum but without axis-I diagnosis of BED can be addressed to not appropriate surgical intervention. It could be important to assess the impact on body weight, on compliance and on clinical outcome in the post-operative period, which we propose to do in the continuation of this study.
Conflict of Interest Statement No conflict of interest was declared.
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