Identifying prebariatric subtypes based on temperament traits, emotion dysregulation, and disinhibited eating: A latent profile analysis

Self-regulation profiles reflecting distinct levels of eating disorder and comorbid psychopathology in the adult population: A latent profile analysis

OBJECTIVE

Previous research showed that individuals with eating disorders (EDs) can be subtyped by their levels of psychopathology and self-regulation abilities. However, nothing is known about whether self-regulation abilities are solely suited to depict the heterogeneity in ED and comorbid psychopathology in nonclinical samples. Therefore, this study sought to explore self-regulation profiles and their ability to discriminate ED, depression and anxiety disorders, and personality dysfunction in the adult population.

METHODS

Within a German representative sample, N = 2391 adults (18-92 years) were examined using latent profile analysis to identify profiles based on established cognitive and emotional self-regulation scales including attention control, cognitive reappraisal, and difficulties in identifying feelings. Profiles were validated with ED, depression, anxiety, and personality dysfunction measures.

RESULTS

The final solution selected as best balancing goodness of fit and interpretability included four profiles-High-Functioning, Moderate-Functioning, Dysregulated, and Alexithymic-with high explanatory power of R²  = .99. Profiles were characterized primarily by differences in difficulties in identifying feelings followed by differences in attention control and differed significantly regarding ED, depression and anxiety disorders, and personality dysfunction, with the Dysregulated profile showing the most unfavorable correlates.

CONCLUSIONS

This study uniquely revealed that low cognitive and emotional self-regulation were indicators for ED, depression, anxiety, and personality dysfunction in the adult population. Future research should investigate whether the identified profiles predict the development of ED and comorbid psychopathology longitudinally.

PUBLIC SIGNIFICANCE

Individuals with eating disorders present with difficulties in cognitive and emotional self-regulation, likely maintaining their symptoms. This representative study in the German adult population sought to build profiles based on cognitive and emotional self-regulation that differed in eating disorder and comorbid psychopathology. We discuss the potential to detect individuals with elevated eating disorder and comorbid psychopathology based on the identified profiles in nonclinical settings.

Binge Eating Before and After Bariatric Surgery

PURPOSE OF REVIEW

The purpose is to review the state of the literature of binge eating in the context of bariatric surgery including prevalence, conceptualization, assessment, course, and related sequela throughout the perioperative continuum, particularly highlighting new advancements and future directions.

RECENT FINDINGS

Accurate assessment of binge eating in bariatric samples is essential for optimization of patient outcomes. Binge eating is less prevalent after bariatric surgery; however, prevalence rates increase over time. Most studies do not find a relationship between pre-operative binge eating and suboptimal weight outcomes after surgery. Refinement in understanding and conceptualization of post-operative binge eating is needed; new conceptualizations have proposed such a definition. Emerging constructs relevant to binge eating for bariatric patients include food addiction and food insecurity. Despite the introduction of formal diagnostic criteria for binge eating disorder, many uncertainties regarding the prevalence, course, and effects of binge eating currently exist; varied assessment methods continue to be a barrier to research on binge eating in bariatric surgery samples. Consensus on operational definitions for post-operative binge eating and best practices for assessment are areas for future consideration.

Executive Functions of Adults with Binge-Eating Disorder: The Role of Weight Status and Psychopathology

Findings on executive functions (EFs) in binge-eating disorder (BED) are inconsistent and possibly biased by associated comorbidities. This study aimed to identify whether distinct levels of physical and mental comorbidity are related to EFs in BED. General and food-specific EFs in n = 77 adults with BED were compared to population-based norms and associations with weight status, depressive symptoms, and eating disorder psychopathology were analyzed. To detect within-sample patterns of EF performance, k-means clustering was applied. The results indicated that participants' general EFs were within the average range with slight deficits in alertness. While depression and eating disorder psychopathology were unrelated to EFs, weight status was associated with food-specific attentional bias that was significantly higher in obesity class 2 than in overweight/obesity class 1 and obesity class 3. Four meaningful clusters with distinct strengths and impairments in general and food-specific EFs but without differences in clinical variables were identified. Altogether, adults with BED showed few specific deficits compared to normative data. Performance was unrelated to depression and eating disorder psychopathology, while weight status was associated with food-specific EFs only. The results highlight the need for longitudinal studies to evaluate the relevance of EFs in BED development and maintenance in neurologically healthy adults.

Roles of Family Stress, Maltreatment, and Affect Regulation Difficulties on Adolescent Mental Health During COVID-19

This study examines the indirect effects of affect dysregulation and suppression on the associations between family stress from confinement, maltreatment, and adolescent mental health during COVID-19. We examined both adolescent and caregiver perspectives to yield a more well-rounded understanding of these associations than afforded in previous research. Using both adolescent (N = 809, Mage = 15.66) and caregiver (N = 578) samples, family stress from confinement, exposure to physical and psychological maltreatment, affect dysregulation and suppression, and youth internalizing and externalizing symptoms were measured in the summer of 2020, following three months of stay-at-home orders due to COVID-19. Affect dysregulation partially accounted for the associations between family stress from confinement and psychological maltreatment on both internalizing and externalizing symptoms for youth and caregiver report. Suppression partially accounted for the associations between family stress and maltreatment on internalizing and externalizing symptoms in the youth sample, but only for internalizing symptoms in the caregiver sample. Understanding family predictors of adolescents' mental health concerns and their underlying mechanisms, affect dysregulation and suppression, can inform mental health interventions during and following the COVID-19 pandemic.

Food approach and avoidance appetitive traits in university students: A latent profile analysis

Eating behaviors are influenced by many factors including appetitive traits. Few studies have utilized latent profile analysis (LPA) to examine food approach and food avoidance appetitive traits. This study utilized LPA to define cluster profile groups based on appetitive traits in undergraduate and graduate/professional students at a large University in the southwest United States. Students completed a cross-sectional online survey in fall 2020 assessing demographic information, appetitive traits via the Adult Eating Behavior Questionnaire (AEBQ), and anxiety via the Generalized Anxiety Disorder Scale (GAD-7; higher scores indicate more severe anxiety symptoms). Appetitive traits were combined into eight scales (four food approach and four food avoidance traits). Latent profile analyses were conducted to identify homogenous subgroups of participants based on AEBQ scale scores. The final sample included 1243 students (mean age = 26.5 years, 73% female, 59% White, 57% undergraduates). LPA revealed four cluster profile groups: Cluster 1 (moderate eaters: lower than mean scores for food approach and avoidance traits), Cluster 2 (food seekers and avoiders: higher than mean scores for food approach and avoidance traits), Cluster 3 (food seekers: higher than mean scores for food approach traits), and Cluster 4 (food avoiders: higher than mean scores for food avoidance traits). Distribution of age, gender, race/ethnicity, and student status differed significantly between clusters. GAD-7 score was highest in Cluster 2 (food seekers and avoiders) and lowest in Cluster 1 (moderate eaters). Among the four LPA-defined cluster profile groups, students who endorsed both food approach and avoidance traits reported more severe anxiety symptoms compared to moderate eaters, food seekers, and food avoiders. It is useful to consider clusters of appetitive traits instead of individual appetitive traits when examining associations with physical and mental health.

Acceptability of technology-based physical activity intervention profiles and their motivational factors in obesity care: a latent profile transition analysis

OBJECTIVES

This study aimed to: (a) identify the acceptability profiles for three technology-based physical activity interventions (TbPAI) in obesity treatment (active video games, mobile applications, telehealth), (b) examine the issues of consistency or change in these profiles for the same individual across technologies, and (c) determine whether acceptability profiles are related to motivational factors.

METHODS

Three hundred and twelve women (M_age = 30.7, SD = 7.1 years; M_BMI = 34.5, SD = 7.8 kg/m²) using obesity services were recruited for this cross-sectional survey. They completed an online survey including sociodemographic data and measures related to physical activity: level, stage of change, motivation, and general causality orientations. The women read descriptions of the three technologies and rated their acceptability. We used a latent profile transition analysis (LPTA) approach.

RESULTS

A 2-class model (high and low acceptability) best described the profiles for each technology. Intra-individual analysis revealed that the profiles exhibited both changes and stability across TbPAI. Women with high scores on impersonal orientation were more likely to be in the high acceptability telehealth profile, whereas those reporting high scores on control orientation were more likely to be in the high acceptability active video games profile. Women with high scores on control orientation and low scores on impersonal orientation were more likely to be in the high acceptability mobile applications profile.

CONCLUSIONS

Results showed that the causality orientations were factors related to the TbPAI acceptability profiles, suggesting that clinicians should consider these psychological characteristics in TbPAI counseling.

The Clinical Obesity Maintenance Model: A Theoretical Framework for Bariatric Psychology

Ranked highly in its association with serious medical comorbidities, obesity, a rapidly growing epidemic worldwide, poses a significant socio-economic burden. While bariatric procedures offer the most efficacious treatment for weight loss, a subset of patients risk weight recidivism. Due to the heterogeneity of obesity, it is likely that there are phenotypes or sub-groups of patients that require evidence-based psychological support to produce more sustainable outcomes. So far, however, characteristics of patients have not led to a personalized treatment algorithm for bariatric surgery. Maintenance of weight loss following bariatric surgery requires long-term modification of eating behaviors and physical activity. A recent Clinical Obesity Maintenance Model (COMM) proposed a conceptual framework of salient constructs, including the role of habit, behavioral clusters, emotion dysregulation, mood, health literacy, and executive function as interconnected drivers of obesity maintaining behaviors relevant to the field of bariatric psychology. The primary aim of this concise review is to bring together emerging findings from experimental and epidemiological studies relating to the COMM constructs that may inform the assessment and follow up of bariatric surgery. We also aim to explain the phenotypes that need to be understood and screened prior to bariatric surgery to enable better pre-surgery intervention and optimum post-surgery response.

Decreased emotional eating behavior is associated with greater excess weight loss five years after gastric banding

While significant weight loss has been observed in the first two years following adjustable gastric banding (AGB), research on the long-term effectiveness of gastric restriction (e.g., 5 years) both on weight loss and eating behavior changes is scarce. The present study examined obese patients' changes in eating behavior preoperatively and 5 years after AGB and examined their associations with excess weight loss (EWL). Specifically, we focused on the association between the modification of three eating behavior profiles (i.e., restrained eating, emotional eating and external eating) and %EWL at 5 years. Among the 197 participants who underwent AGB, 136 completed the clinical assessments (weight, depression with the BDI, eating behavior with the DEBQ) before surgery, and after 5 years. Resultsshowed that the mean percentage of EWL was 47% after 5 years. Moreover, patients reported lower emotional eating and external eating after 5 years in comparison to the baseline, whereas there were no differences concerning restrained eating. Importantly, patients who presented higher %EWL at 5 years also reported a greater decrease in emotional eating between the two sessions than those with low %EWL. Our study underlines that eating behaviors are major variables involved in weight loss after gastric restriction. Results showed that emotional and external eating decreased significantly at 5 years whereas restrained eating behaviors did not vary between the pre- and postoperative stages. Moreover, the data suggest that a decrease in emotional eating accounts for the extent of EWL.

The Cards and Lottery Task: Validation of a New Paradigm Assessing Decision Making Under Risk in Individuals With Severe Obesity

BACKGROUND

A growing body of research demonstrated impaired executive functions in individuals with severe obesity, including increased sensitivity to reward and impulsive decision making under risk conditions. For the assessment of decision making in patients with severe obesity, studies widely used the Iowa Gambling Task (IGT) or the Delay Discounting Task (DDT), which cover short-term or long-term consequences of decisions only. A further development originating from the field of addiction research is the Cards and Lottery Task (CLT), in which each decision made has conflicting immediate and long-term consequences at the same time. The present study aimed to validate the CLT in individuals with severe obesity.

METHODS

Patients with severe obesity (N = 78, 67% women, 42.9 ± 10.4 years old, body mass index of 48.1 ± 8.3 kg/m²) were included. Convergent validity was evaluated using the computerized Delay Discounting Task and well-established self-report questionnaires assessing different aspects of impulsivity. For discriminant validity, CLT performance was compared between symptom groups characterized by high versus low impulsivity. The task's clinical validity was evaluated based on associations with general and eating disorder psychopathology, and body mass index. Test-retest reliability was determined by administering the CLT in n = 31 participants without weight-loss treatment one year later. The task's sensitivity to change due to weight loss was evaluated by retesting n = 32 patients one year after receiving obesity surgery.

RESULTS

The number of advantageous decisions in the CLT was significantly positively associated with delay discounting and effortful control, and significantly negatively correlated with behavioral impulsivity. CLT performance differed significantly between individuals with and without symptoms of attention-deficit/hyperactivity disorder and between samples with severe obesity and healthy controls. Clinically, CLT performance was significantly associated with general, but not eating disorder psychopathology. The CLT showed moderate test-retest reliability after one year in weight-stable individuals and was sensitive to change in those undergoing obesity surgery.

CONCLUSIONS

This study identified the CLT to be a highly promising, new complex measure of short- and long-term decision making with good reliability and validity in individuals with severe obesity. Future studies should assess its association with the IGT and predictive value for real-life health behavior.

Investigating phenotypes of emotional eating based on weight categories: A latent profile analysis

OBJECTIVE

We aimed to investigate the phenotypes of individuals with emotional eating (EE) based on their levels of positive and negative EE, body mass index (BMI), and preoccupation with weight, and to assess differences in eating pathology and emotion regulation (ER) difficulties among them.

METHOD

A community sample of 605 women (mean age = 29.8 years, SD = 9.6; mean BMI = 23.4 kg/m² , SD = 4.7) filled out the Positive-Negative Emotional Eating Scale, Eating Disorders Assessment Scale, and Difficulties in Emotion Regulation Scale. Data of BMI, positive EE, negative EE, and preoccupation with body weight were submitted to a latent profile analysis.

RESULTS

A four-profile model was discovered with normal weight individuals without EE (63%), normal weight individuals with EE (23%), overweight individuals without EE (9%), and obese individuals with EE (5%). A five-profile model was also included, as a class of normal weight individuals with positive EE was found. Obese and normal weight individuals with EE showed the highest level of ER difficulties and eating pathology. Overweight individuals without EE showed moderate levels of eating pathology and low levels of ER difficulties, suggesting that high BMI itself might not be related to eating disorder (ED) psychopathology. Normal weight individuals with positive EE showed low levels of eating pathology, but moderate levels of ER difficulties.

DISCUSSION

Our results suggest that negative EE could be an important risk factor for disordered eating, independent of BMI. Further, individuals with EE could benefit from learning adaptive ER strategies to prevent the onset or maintenance of ED or weight gain.

A dual-process psychobiological model of temperament predicts liking and wanting for food and trait disinhibition

A dual-process model of temperament, incorporating the Behavioural Inhibition System (BIS), Behavioural Activation System (BAS) and effortful control (EC), may help to predict hedonic responses to palatable food and trait disinhibition.

PURPOSE

This study aimed to determine if the BIS, BAS and EC predicted liking and wanting for high-fat, sweet foods in adults with overweight and obesity, and if collectively, these variables predicted the eating behaviour trait of Disinhibition.

METHODS

168 adults (104 females, mean BMI = 33.3 kg/m²) completed the Three Factor Eating Questionnaire, the Carver and White BIS/BAS scales, the Adult Temperament Questionnaire-Effortful Control Scale - Short Form and the Leeds Food Preference Questionnaire. The strength of the BIS, BAS and EC in predicting wanting and liking for high-fat sweet foods, and trait Disinhibition was assessed using hierarchical multiple regression.

RESULTS

Both the BIS and EC predicted liking, F (6, 161) = 5.05, p < .001, R² = 0.16, and EC inversely predicted wanting, F (6, 161) = 3.28, p = .005, R² = 0.11. The BIS, EC and liking predicted, F (8, 159) = 11.0, p < .001, R² = 0.36, and explained 36% of Disinhibition. The BAS did not predict wanting, liking or Disinhibition.

CONCLUSIONS

These results demonstrate that a sensitive BIS and a lower level of effortful control predicts food reward and Disinhibition in overweight and obese adults. Consequently, interventions that aim to increase effortful control and reduce BIS reactivity may be beneficial for reducing hedonically motivated, disinhibited eating behaviour.

Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery

Outcomes of bariatric surgery, while frequently impressive, are not universal and vary between patients and across surgical procedures. Between 20% and 30% of patients experience suboptimal weight loss or significant weight regain within the first few postoperative years. The reasons for this are not fully understood, but likely involve both physiologic processes, behavioral factors, and psychological characteristics. Evidence suggests that preoperative psychosocial status and functioning can contribute to suboptimal weight losses and/or postoperative psychosocial distress. Much of this work has focused on the presence of recognized psychiatric diagnoses and with particular emphasis on mood disorders as well as binge eating disorder. Several studies have suggested that the presence of preoperative psychopathology is associated with suboptimal weight losses, postoperative complications, and less positive psychosocial outcomes. Contemporary psychological theory suggests that it may be shared features across diagnoses, rather than a discrete diagnosis, that better characterizes psychopathology. Mood and substance use disorders as well as binge eating disorder, share common features of impulsivity, although clinicians and researchers often use complementary, yet different terms, such as emotional dysregulation or disinhibition (i.e., loss of control over eating, as applied to food intake), to describe the phenomenon. Impulse control is a central factor in eating behavior and extreme obesity. It also may contribute to the experience of suboptimal outcomes after bariatric surgery, including smaller than expected weight loss and psychosocial distress. This paper reviews the literature in these areas of research and articulates a direction for future studies of these complex relationships among persons with extreme obesity.

Gender-related patterns of psychiatric disorder clustering among bariatric surgery candidates: A latent class analysis

BACKGROUND

Psychiatric disorders tend to distribute unevenly in women and men with severe obesity. The current research aimed to identify homogeneous clusters of concurrent psychiatric disorders among patients seeking bariatric surgery, by gender.

METHODS

We recruited a consecutive sample of 393 candidates with obesity (311 women and 82 men) in a university-based bariatric center. Trained clinicians assessed psychiatric disorders through the Structured Clinical Interview for DSM-IV (SCID). Latent class analysis categorized pre-surgical patients into uniform clusters of co-occurring psychiatric disorders.

RESULTS

For both genders, the 3-class psychopathological clustering was the best-fitting solution. Among women, the latent classes were: (1) "oligosymptomatic", wherein 42% of patients showed low probability of psychiatric disorders; (2) "bipolar with comorbidities", in 33%; and (3) "anxiety/depression", in 25%. Among men, (1) "bipolar with comorbidities" was found in 47% of patients; (2) "oligosymptomatic", in 40%; and (3) "anxiety/depression", in 13%. For both genders, the probability of presenting eating disorders was higher in both "bipolar" and "anxiety/depression" classes. Substance use disorders was prominent among "bipolar" men. In comparison with "oligosymptomatic" class, the likelihood of higher BMI was observed among "bipolar" men and poorer work attainment among men with "anxiety/depression".

LIMITATION

Participants was cross-sectionally drawn from a single bariatric center.

CONCLUSIONS

Pre-surgical men and women with severe obesity were distributed in three comorbidity profiles and revealed analogous psychopathological patterns. The class of "bipolar disorders" most likely presented comorbidity with eating and substance use disorder. This natural clustering of psychiatric disorders among bariatric patients suggests gender-related therapeutic approaches and surgical outcomes.

Pre- and Postbariatric Subtypes and Their Predictive Value for Health-Related Outcomes Measured 3 Years After Surgery

BACKGROUND

Although bariatric surgery is the most effective treatment for severe obesity, a subgroup of patients shows insufficient postbariatric outcomes. Differences may at least in part result from heterogeneous patient profiles regarding reactive and regulative temperament, emotion dysregulation, and disinhibited eating. This study aims to subtype patients based on these aspects before and 2 years after bariatric surgery and tests the predictive value of identified subtypes for health-related outcomes 3 years after surgery.

METHODS

Within a prospective multicenter patient registry, N = 229 bariatric patients were examined before bariatric surgery, 2 and 3 years postoperatively via clinical interviews and self-report questionnaires. Pre- and postbariatric subtypes were differentiated by temperament, emotion dysregulation, and disinhibited eating using latent profile analyses (LPA). The predictive value of pre- and postbariatric subtypes for surgery outcomes measured 3 years postoperatively was tested via linear regression analyses.

RESULTS

LPA resulted in five prebariatric and three postbariatric subtypes which were significantly associated with different levels of general and eating disorder psychopathology. Post- versus prebariatric subtypes explained more variance regarding eating disorder psychopathology, depression, and quality of life assessed 3 years postoperatively, whereas neither pre- nor postbariatric subtypes predicted postbariatric weight loss. Patients with prebariatric deficits in self- and emotional control had an increased risk for showing these deficits postoperatively.

CONCLUSIONS

A re-evaluation of patients' psychological status after bariatric surgery is recommended to detect patients with potential risk for adverse psychological surgery outcomes in the long term.