Health benefits of gastric bypass surgery after 6 years

CONTEXT

Extreme obesity is associated with health and cardiovascular disease risks. Although gastric bypass surgery induces rapid weight loss and ameliorates many of these risks in the short term, long-term outcomes are uncertain.

OBJECTIVE

To examine the association of Roux-en-Y gastric bypass (RYGB) surgery with weight loss, diabetes mellitus, and other health risks 6 years after surgery.

DESIGN, SETTING, AND PARTICIPANTS

A prospective Utah-based study conducted between July 2000 and June 2011 of 1156 severely obese (body mass index [BMI] ≥ 35) participants aged 18 to 72 years (82% women; mean BMI, 45.9; 95% CI, 31.2-60.6) who sought and received RYGB surgery (n = 418), sought but did not have surgery (n = 417; control group 1), or who were randomly selected from a population-based sample not seeking weight loss surgery (n = 321; control group 2).

MAIN OUTCOME MEASURES

Weight loss, diabetes, hypertension, dyslipidemia, and health-related quality of life were compared between participants having RYGB surgery and control participants using propensity score adjustment.

RESULTS

Six years after surgery, patients who received RYGB surgery (with 92.6% follow-up) lost 27.7% (95% CI, 26.6%-28.9%) of their initial body weight compared with 0.2% (95% CI, -1.1% to 1.4%) gain in control group 1 and 0% (95% CI, -1.2% to 1.2%) in control group 2. Weight loss maintenance was superior in patients who received RYGB surgery, with 94% (95% CI, 92%-96%) and 76% (95% CI, 72%-81%) of patients receiving RYGB surgery maintaining at least 20% weight loss 2 and 6 years after surgery, respectively. Diabetes remission rates 6 years after surgery were 62% (95% CI, 49%-75%) in the RYGB surgery group, 8% (95% CI, 0%-16%) in control group 1, and 6% (95% CI, 0%-13%) in control group 2, with remission odds ratios (ORs) of 16.5 (95% CI, 4.7-57.6; P < .001) vs control group 1 and 21.5 (95% CI, 5.4-85.6; P < .001) vs control group 2. The incidence of diabetes throughout the course of the study was reduced after RYGB surgery (2%; 95% CI, 0%-4%; vs 17%; 95% CI, 10%-24%; OR, 0.11; 95% CI, 0.04-0.34 compared with control group 1 and 15%; 95% CI, 9%-21%; OR, 0.21; 95% CI, 0.06-0.67 compared with control group 2; both P < .001). The numbers of participants with bariatric surgery-related hospitalizations were 33 (7.9%), 13 (3.9%), and 6 (2.0%) for the RYGB surgery group and 2 control groups, respectively.

CONCLUSION

Among severely obese patients, compared with nonsurgical control patients, the use of RYGB surgery was associated with higher rates of diabetes remission and lower risk of cardiovascular and other health outcomes over 6 years.

Development of a brief measure to assess quality of life in obesity

OBJECTIVE

Obesity researchers have a growing interest in measuring the impact of weight and weight reduction on quality of life. The Impact of Weight on Quality of Life questionnaire (IWQOL) was the first self-report instrument specifically developed to assess the effect of obesity on quality of life. Although the IWQOL has demonstrated excellent psychometric properties, its length (74 items) makes it somewhat cumbersome as an outcome measure in clinical research. This report describes the development of a 31-item version of the IWQOL (IWQOL-Lite).

RESEARCH METHODS AND PROCEDURES

IWQOLs from 996 obese patients and controls were used to develop the IWQOL-Lite. Psychometric properties of the IWQOL-Lite were examined in a separate cross-validation sample of 991 patients and controls.

RESULTS

Confirmatory factor analysis provided strong support for the adequacy of the scale structure. The five identified scales of the IWQOL-Lite (Physical Function, Self-Esteem, Sexual Life, Public Distress, and Work) and the total IWQOL-Lite score demonstrated excellent psychometric properties. The reliability of the IWQOL-Lite scales ranged from 0.90 to 0.94 and was 0.96 for the total score. Correlations between the IWQOL-Lite and collateral measures supported the construct validity of the IWQOL-Lite. Changes in IWQOL-Lite scales over time correlated significantly with changes in weight, supporting its sensitivity to change. Significant differences in IWQOL-Lite scale and total scores were found among groups differing in body mass index, supporting the utility of the IWQOL-Lite across the body mass index spectrum.

DISCUSSION

The IWQOL-Lite appears to be a psychometrically sound and clinically sensitive brief measure of quality of life in obese persons.

Daily and momentary mood and stress are associated with binge eating and vomiting in bulimia nervosa patients in the natural environment

The relation of mood and stress to binge eating and vomiting in the natural environments of patients with bulimia nervosa (BN) was examined using real-time data collection. Women (n = 131; mean age = 25.3 years) with BN carried a palmtop computer for 2 weeks and completed ratings of positive affect (PA), negative affect (NA), anger/hostility (AH), and stress (STRS); they also indicated binge or vomit episodes (BN-events) 6 times each day. Mixed models were used to compare mood and STRS between and within days when BN-events occurred. Between-days analyses indicated that binge and vomit days both showed less PA, higher NA, higher AH, and greater STRS than days with no BN-events. Within-day, decreasing PA, and increasing NA and AH, reliably preceded BN-events. Conversely, PA increased, and NA and AH decreased following BN-events. Demonstration of the temporal sequencing of affect, STRS, and BN-events with a large BN sample may help advance theory and clinical practice, and supports the view that binge and purge events hold negatively reinforcing properties for women with BN.

An examination of the food addiction construct in obese patients with binge eating disorder

OBJECTIVE

This study examined the psychometric properties of the Yale food addiction scale (YFAS) in obese patients with binge eating disorder (BED) and explored its association with measures of eating disorder and associated psychopathology.

METHOD

Eighty-one obese treatment-seeking BED patients were given the YFAS, structured interviews to assess psychiatric disorders and eating disorder psychopathology, and other pathology measures.

RESULTS

Confirmatory factor analysis revealed a one-factor solution with an excellent fit. Classification of "food addiction" was met by 57% of BED patients. Patients classified as meeting YFAS "food addiction" criteria had significantly higher levels of depression, negative affect, emotion dysregulation, eating disorder psychopathology, and lower self-esteem. YFAS scores were also significant predictors of binge eating frequency above and beyond other measures.

DISCUSSION

The subset of BED patients classified as having YFAS "food addiction" appear to represent a more disturbed variant characterized by greater eating disorder psychopathology and associated pathology.

Parental monitoring: association with adolescents' risk behaviors

CONTEXT

Contemporary threats to adolescents' health are primarily the consequence of risk behaviors and their related adverse outcomes. Identifying factors associated with adolescents' risk behaviors is critical for developing effective prevention strategies. A number of risk factors have been identified, including familial environment; however, few studies have examined the impact of parental monitoring.

OBJECTIVE

To examine the influence of less perceived parental monitoring on a spectrum of adolescent health-compromising behaviors and outcomes. Design. Survey.

SETTING

A family medicine clinic. Participants. To assess eligibility, recruiters screened a sample of 1130 teens residing in low-income neighborhoods. Adolescents were eligible if they were black females, between the ages of 14 and 18 years, sexually active in the previous 6 months, and provided written informed consent. Most teens (n = 609) were eligible, with 522 (85.7%) agreeing to participate.

MAIN OUTCOME MEASURES

Variables in 6 domains were assessed, including: sexually transmitted diseases, sexual behaviors, marijuana use, alcohol use, antisocial behavior, and violence.

RESULTS

In logistic regression analyses, controlling for observed covariates, adolescents perceiving less parental monitoring were more likely to test positive for a sexually transmitted disease (odds ratio [OR]: 1.7), report not using a condom at last sexual intercourse (OR: 1.7), have multiple sexual partners in the past 6 months (OR: 2.0), have risky sex partners (OR: 1.5), have a new sex partner in the past 30 days (OR: 3.0), and not use any contraception during the last sexual intercourse episode (OR: 1.9). Furthermore, adolescents perceiving less parental monitoring were more likely to have a history of marijuana use and use marijuana more often in the past 30 days (OR: 2.3 and OR: 2.5, respectively); a history of alcohol use and greater alcohol consumption in the past 30 days (OR: 1.4 and OR: 1.9, respectively); have a history of arrest (OR: 2.1); and there was a trend toward having engaged in fights in the past 6 months (OR: 1.4).

CONCLUSIONS

The findings demonstrate a consistent pattern of health risk behaviors and adverse biological outcomes associated with less perceived parental monitoring. Additional research needs to focus on developing theoretical models that help explain the influence of familial environment on adolescent health and develop and evaluate interventions to promote the health of adolescents.

Psychometric properties of the eating disorder examination-questionnaire: factor structure and internal consistency

OBJECTIVE

The purpose of this investigation was to evaluate the factor structure and the internal consistency of the Eating Disorder Examination-Questionnaire (EDE-Q).

METHOD

The EDE-Q was administered to 203 women with bulimic symptoms, who were recruited from five Midwestern communities.

RESULTS

Acceptable levels of internal consistency were observed for the EDE-Q total score (alpha = .90) and subscales: Restraint (alpha = .70), Eating Concern (alpha = 0.73), Shape Concern (alpha = 0.83) and Weight Concern (alpha = 0.72). Exploratory factor loadings using Principal Axis Analysis supported the Eating Concern and Restraint subscales. Most of the Shape Concern and Weight Concern items loaded on one factor, with the exception of the items focusing on the importance of weight and shape in self-evaluation and preoccupation with shape and weight.

CONCLUSION

The results of this study provide support for the internal consistency of the EDE-Q and indicate a need for further examination of the factor structure of this instrument.

Precise localization of the autonomic nerves from the pelvic plexus to the corpora cavernosa: a detailed anatomical study of the adult male pelvis

The anatomical location of the branches of the pelvic plexus that innervate the corpora cavernosa has been identified previously in stillborn male neonates and fetuses. Based upon these observations, the techniques of radical retropubic prostatectomy and cystectomy have been modified to avoid injury to the autonomic innervation of the corpora cavernosa. However, the exact anatomical relationships of these nerves to the prostate, urethra and other pelvic structures in adults are unclear, since the initial anatomical studies of the pelvic plexus were performed in stillborn neonates in whom the accompanying vessels and fascia had been removed. Because these nerves are microscopic in size and can only be identified by their association with other pelvic structures, it was believed that a more refined understanding of the anatomy was necessary. In an effort to identify precisely the relationship of the cavernous branches of the pelvic plexus to the lateral pelvic fascia and the branches of the prostatovesicular arteries and veins, the following study was performed. Shortly after death a 60-year-old man was perfused completely with Bouin's fixative solution. The entire bladder, prostate, urethra, penis, corpora cavernosa, rectum, and pelvic sidewall fascia and musculature were removed en bloc. The specimen was serially sectioned transversely at 10 mu thickness, and every tenth section was stained with hematoxylin and eosin. An anatomical reconstruction in 3 dimensions was performed and illustrated. Thus, the specific location of the nerves that innervate the corpora cavernosa and their important relationships to the urethra, prostatic capsule, Denonvilliers' fascia and pelvic floor vasculature have been identified.

The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25-27, 2007

Sleeve gastrectomy is a rapid and less traumatic operation, which thus far is showing good resolution of comorbidities and good weight loss if a narrower channel is constructed than for the duodenal switch. There are potential intraoperative complications, which must be recognized and treated promptly. Like other bariatric operations, there are variations in the technique used. The laparoscopic sleeve gastrectomy (LSG) is being performed for super-obese and high-risk patients, but its indications have been increasing. A second-stage bariatric operation may be performed if necessary, with increased safety. Long-term results of LSG and further networking are anxiously awaited.

Psychometric evaluation of the impact of weight on quality of life-lite questionnaire (IWQOL-lite) in a community sample

The short form of impact of weight on quality of life (IWQOL)-Lite is a 31-item, self-report, obesity-specific measure of health-related quality of life (HRQOL) that consists of a total score and scores on each of five scales--physical function, self-esteem, sexual life, public distress, and work--and that exhibits strong psychometric properties. This study was undertaken in order to assess test-retest reliability and discriminant validity in a heterogeneous sample of individuals not in treatment. Individuals were recruited from the community to complete questionnaires that included the IWQOL-Lite, SF-36, Rosenberg self-esteem (RSE) scale, Marlowe-Crowne social desirability scale, global ratings of quality of life, and sexual functioning and public distress ratings. Persons currently enrolled in weight loss programs or with a body mass index (BMI) of less than 18.5 were dropped from the analyses, leaving 341 females and 153 males for analysis, with an average BMI of 27.4. For test-retest reliability, 112 participants completed the IWQOL-Lite again. ANOVA revealed significant main effects for BMI for all IWQOL-Lite scales and total score. Females showed greater impairment than males on all scales except public distress. Internal consistency ranged from 0.816 to 0.944 for IWQOL-Lite scales and was 0.958 for total score. Test-retest reliability ranged from 0.814 to 0.877 for scales and was 0.937 for total score. Internal consistency and test-retest results for overweight/obese subjects were similar to those obtained for the total sample. There was strong evidence for convergent and discriminant validity of the IWQOL-Lite in overweight/obese subjects. As in previous studies conducted on treatment-seeking obese persons, the IWQOL-Lite appears to be a reliable and valid measure of obesity-specific quality of life in overweight/obese persons not seeking treatment.

Third International Summit: Current status of sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been performed for morbid obesity in the past 10 years. LSG was originally intended as a first-stage procedure in high-risk patients but has become a stand-alone operation for many bariatric surgeons. Ongoing review is necessary regarding the durability of the weight loss, complications, and need for second-stage operations.

METHODS

The first International Summit for LSG was held in October 2007, the second in March 2009, and this third in December 2010. There were presentations by experts, and, to provide a consensus, a questionnaire was completed by 88 attendees who had >1 year (mean 3.6 ± 1.5, range 1-8) of experience with LSG.

RESULTS

The results of the questionnaire were based on 19,605 LSGs performed within 3.6 ± 1.5 years (228.8 ± 275.0 LSGs/surgeon). LSG had been intended as the sole operation in 86.4% of the cases; in these, a second-second stage became necessary in 2.2%. LSG was completed laparoscopically in 99.7% of the cases. The mean percentage of excess weight loss at 1, 2, 3, 4, and 5 years was 62.7%, 64.7%, 64.0%, 57.3%, and 60.0%, respectively. The bougie size was 28-60F (mean 36F, 70% blunt tip). Resection began 1.5-7.0 cm (mean 4.8) proximal to the pylorus. Of the surgeons, 67.1% reinforced the staple line, 57% with buttress material and 43% with oversewing. The respondents excised an estimated 92.9% ± 8.0% (median 95.0%) of fundus (i.e., a tiny portion is maintained lateral to the angle of His). A drain is left by 57.6%, usually closed suction. High leaks occurred in 1.3% of cases (range 0-10%); lower leaks occurred in .5%. Intraluminal bleeding occurred in 2.0% of cases. The mortality rate was .1% ± .3%.

CONCLUSION

According to the questionnaire, presentations, and debates, the weight loss and improvement in diabetes appear to be better than with laparoscopic adjustable gastric banding and on par with Roux-en-Y gastric bypass. High leaks are infrequent but problematic.

Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy

BACKGROUND

LSG has been increasingly performed. Long-term follow-up is necessary.

METHODS

During the Fourth International Consensus Summit on LSG in New York Dec. 2012, an online questionnaire (SurveyMonkey®) was filled out by 130 surgeons experienced in LSG. The survey was submitted directly to the statisticians.

RESULTS

The 130 surgeons performed 354.9 ± SD 453 LSGs/surgeon (median 175), for a total of 46,133 LSGs. The LSGs had been performed over 4.9 ± 2.7 year (range 1-10). Of the 46,133 LSGs, 0.2 ± 1.0 % (median 0, range 0-10 %) were converted to an open operation. LSG was intended as the sole operation in 93.1 ± 14.8 %; in 3.0 ± 6.3 %, a second stage became necessary. Of the 130 surgeons, 40 (32 %) use a 36F bougie, which was most common (range 32-50F). Staple-line is reinforced by 79 %; of these, 57 % use a buttress and 43 % over-sew. Mean %EWL at year 1 was 59.3 %; year 2, 59.0 %; year 3, 54.7 %; year 4, 52.3 %; year 5, 52.4 %; and year 6, 50.6 %. If a second-stage operation becomes necessary, preference was: RYGB 46 %, duodenal switch 24 %, re-sleeve 20 %, single-anastomosis duodenoileal bypass 3 %, sleeve plication 3 %, minigastric bypass 3 %, non-adjustable band 2 %, and side-to-side jejunoileal anastomosis 1 %. Complications were: high leak 1.1 %, hemorrhage 1.8 %, and stenosis at lower sleeve 0.9 %. Postoperative gastroesophageal reflux occurred in 7.9 ± 8.2 % but was variable (0-30 %). Mortality was 0.33 ± 1.6 %, which translates to ≈ 152 deaths. Eighty-nine percent order multivitamins (including vitamin D, calcium, and iron) and 72 % order B12. A PPI is ordered by 29 % for 1 month, 29 % for 3 months, and others for 1-12 months depending on the case.

CONCLUSIONS

LSG was relatively safe. Further long-term surveillance is necessary.

Longitudinal associations between binge eating and overeating and adverse outcomes among adolescents and young adults: does loss of control matter?

OBJECTIVE

To investigate the association between overeating (without loss of control) and binge eating (overeating with loss of control) and adverse outcomes.

DESIGN

Prospective cohort study.

SETTING

Adolescents and young adults living throughout the United States.

PARTICIPANTS

Sixteen thousand eight hundred eighty-two males and females participating in the Growing Up Today Study who were 9 to 15 years old at enrollment in 1996.

MAIN EXPOSURE

Overeating and binge eating assessed via questionnaire every 12 to 24 months between 1996 and 2005.

MAIN OUTCOME MEASURES

Risk of becoming overweight or obese, starting to binge drink frequently, starting to use marijuana, starting to use other drugs, and developing high levels of depressive symptoms. Generalized estimating equations were used to estimate associations. All models controlled for age and sex; additional covariates varied by outcome.

RESULTS

Among this large cohort of adolescents and young adults, binge eating was more common among females than males. In fully adjusted models, binge eating, but not overeating, was associated with incident overweight/obesity (odds ratio, 1.73; 95% CI, 1.11-2.69) and the onset of high depressive symptoms (odds ratio, 2.19; 95% CI, 1.40-3.45). Neither overeating nor binge eating was associated with starting to binge drink frequently, while both overeating and binge eating predicted starting to use marijuana and other drugs.

CONCLUSIONS

Although any overeating, with or without loss of control, predicted the onset of marijuana and other drug use, we found that binge eating is uniquely predictive of incident overweight/obesity and the onset of high depressive symptoms. These findings suggest that loss of control is an important indicator of severity of overeating episodes.

Ten-year follow-up of anorexia nervosa: clinical course and outcome

The clinical course and outcome of anorexia nervosa are presented in a 10-year follow-up study of 76 severely ill females with anorexia nervosa who met specific diagnostic criteria and had participated in a well-documented hospital treatment study. Information was obtained on 100% of the subjects. A comprehensive assessment was made in 93% of the living subjects in specific categories of weight, eating and weight control behaviours, menstrual function, anorexic attitudes, and psychological, sexual, social and vocational adjustment. Five subjects had died, which gives a crude mortality rate of 6.6%. Standardized mortality rates demonstrated an almost 13-fold increase in mortality in the anorexia nervosa subjects. Only eighteen (23.7%) were fully recovered. Sixty-four per cent developed binge-eating at some time during their illness, 57% at least weekly. Twenty-nine (41%) were still bulimic at follow-up. The high frequency and chronicity of the bulimic symptoms plus the high rate of weight relapse (42% during the first year after hospital treatment) suggest that intensive intervention is needed to help anorexics restore and maintain their weight within a normal range and to decrease abnormal eating and weight control behaviours.

Eating disorders and personality: A methodological and empirical review

Methodological approaches utilized to evaluate models of the relationship between personality and eating disorders, as well as empirical support for each model, are reviewed. Limited prospective research suggests that negative emotionality, perfectionism, drive for thinness, poor interoceptive awareness, ineffectiveness, and obsessive-compulsive personality traits are likely predisposing factors. Limited family study research suggests that obsessive-compulsive personality disorder (OCPD) and anorexia nervosa share a common familial liability. Potential pathoplastic personality factors include Cluster B personality disorders and OCPD, which predict a poorer course and/or outcome, and histrionic personality traits and self-directedness, which predict a more favorable course and/or outcome. Future research should focus upon sophisticated prospective and family study research in order to best evaluate competing models of the eating disorder-personality relationship.

Health-related quality of life varies among obese subgroups

OBJECTIVE

To compare the health-related quality of life (HRQOL) of overweight/obese individuals from different subgroups that vary in treatment-seeking status and treatment intensity.

RESEARCH METHODS AND PROCEDURES

Participants were from five distinct groups, representing a continuum of treatment intensity: overweight/obese community volunteers who were not enrolled in weight-loss treatment, clinical trial participants, outpatient weight-loss program/studies participants, participants in a day treatment program for obesity, and gastric bypass patients. The sample was large (n = 3353), geographically diverse (subjects were from 13 different states in the U.S.), and demographically diverse (age range, 18 to 90 years; at least 14% African Americans; 32.6% men). An obesity-specific instrument, the Impact of Weight on Quality of Life-Lite questionnaire, was used to assess health-related quality of life (HRQOL).

RESULTS

Results indicated that obesity-specific HRQOL was significantly more impaired in the treatment-seeking groups than in the nontreatment-seeking group across comparable gender and body mass index (BMI) categories. Within the treatment groups, HRQOL varied by treatment intensity. Gastric bypass patients had the most impairment, followed by day treatment patients, followed by participants in outpatient weight-loss programs/studies, followed by participants in clinical trials. Obesity-specific HRQOL was more impaired for those with higher BMIs, whites, and women in certain treatment groups.

DISCUSSION

There are differences in HRQOL across subgroups of overweight/obese individuals that vary by treatment-seeking status, treatment modality, gender, race, and BMI.

The role of affect in the maintenance of anorexia nervosa: evidence from a naturalistic assessment of momentary behaviors and emotion

The current study examines the relationship of affect and eating disorder behavior in anorexia nervosa (AN) using ecological momentary assessment. Participants were 118 adult females recruited at three sites from eating disorder treatment centers and community advertisements. All participants met full Diagnostic and statistical manual of mental disorders (4th ed.) criteria or subthreshold criteria for AN. Participants were provided handheld computers and asked to report positive affect, negative affect, loss of control (LOC) eating, purging, exercise, drinking fluids to curb appetite, and weighing one's self multiple times per day as well as dietary restriction once daily over a 2-week interval. Mixed-effects models were used to examine the extent to which affective states predict dietary restriction. In addition, we used two analytic approaches to compare affect before and after other eating disorder behaviors. We found that higher daily ratings of negative affect were associated with a greater likelihood of dietary restriction on subsequent days. When examining the single rating immediately before and after behaviors, we found that negative affect increased significantly after LOC eating, purging, the combination of LOC and eating/purging, and weighing of one's self. Using this same analytic approach, we also found negative affect to decrease significantly after the consumption of fluids to curb appetite and exercise. When examining the covariation of AN behaviors and negative affect assessed multiple times in the hours and minutes before the behaviors, we found negative affect significantly increased before LOC eating, purging, the combination of LOC eating/and purging, and weighing behavior. Negative affect also significantly decreased after the occurrence of these behaviors. These findings are consistent with the idea that that negative affect is potentially a critical maintenance mechanism of some AN symptoms, but that the analytic approach used to examine affect and behavior may have significant implications on the interpretation of findings.

Long-term outcome of anorexia nervosa: Results from a large clinical longitudinal study

OBJECTIVE

Assessment of the long-term outcome of anorexia nervosa (AN) in a very large sample of inpatients (N = 1,693) and identification of predictors for poor outcome.

METHOD

Over 25 years (mean 10 years), consecutively admitted inpatients of a specialized hospital were followed. A subsample of 112 patients with 20-year follow-up was defined. Bivariate comparisons and logistic regression analysis identified risk factors of poor outcome.

RESULTS

Body mass index (BMI) increased during the follow-up period. Eating behavior as well as general psychopathology improved but did not reach the level of healthy controls. Remission was found in 30% (total sample) and in 40% (20-year follow-up subsample). Crossover from AN to binge-eating disorder or obesity was rare. The predictors of a negative course of illness included lower BMI at admission; a higher score on the Eating Disorder Inventory Maturity Fears subscale at admission; fewer follow-up years; and higher age at admission. The main diagnostic crossover occurred from AN to eating disorder not otherwise specified. Motherhood was related to better outcome.

DISCUSSION

Many patients with very severe AN recover from their illness but AN also shows considerable long-term negative consequences. Over long time periods, survivors show improvement but better treatments for severe cases are still needed. Predictors of outcome included symptom severity, chronicity, and length of follow-up but not psychiatric comorbidity.

Screening for eating disorders in primary care: EDE-Q versus SCOFF

OBJECTIVE AND METHODS

The comparative validity of the Eating Disorder Examination Questionnaire (EDE-Q) (22 items) and SCOFF (five items) in screening for cases of the more commonly occurring eating disorders was examined in a primary care sample of young adult women (n=257). Diagnoses were confirmed in a sub-group of interviewed participants (n=147).

RESULTS

Twenty-five cases, primarily variants of bulimia nervosa (BN) not meeting formal diagnostic criteria, were identified in the interviewed sample. An EDE-Q global score of >or= 2.80 yielded the optimal trade-off between sensitivity (Se) (0.80) and specificity (Sp) (0.80) (positive predictive value (PPV)=0.44), whereas a score of two or more positive responses on the SCOFF was optimal (Se=0.72, Sp=0.73, PPV=0.35). Validity coefficients for both measures varied as a function of participants' age and body weight, although these effects were more pronounced for the SCOFF.

CONCLUSIONS

Both measures performed well in terms of their ability to detect cases and to exclude non-cases of the more commonly occurring eating disorders in a primary care setting. The EDE-Q performed somewhat better than the SCOFF and was more robust to effects on validity of age and weight. These findings need to be weighed against the advantage of the SCOFF in terms of its brevity.

A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa

CONTEXT

Evidenced-based treatment trials for adolescents with bulimia nervosa are largely absent.

OBJECTIVE

To evaluate the relative efficacy of family-based treatment (FBT) and supportive psychotherapy (SPT) for adolescents with bulimia nervosa.

DESIGN

Randomized controlled trial.

SETTING

The University of Chicago from April 1, 2001, through June 30, 2006.

PARTICIPANTS

Eighty patients, aged 12 to 19 years, with a DSM-IV diagnosis of bulimia nervosa or a strict definition of partial bulimia nervosa.

INTERVENTIONS

Twenty outpatient visits over 6 months of FBT or SPT. Participants were followed up at 6 months posttreatment.

MAIN OUTCOME MEASURES

Abstinence from binge-and-purge episodes as measured by the Eating Disorder Examination. Secondary outcome measures were Eating Disorder Examination binge-and-purge frequency and Eating Disorder Examination subscale scores.

RESULTS

Forty-one patients were assigned to FBT and 39 to SPT. Categorical outcomes at posttreatment demonstrated that significantly more patients receiving FBT (16 [39%]) were binge-and-purge abstinent compared with those receiving SPT (7 [18%]) (P = .049). Somewhat fewer patients were abstinent at the 6-month follow-up; however, the difference was statistically in favor of FBT vs SPT (12 patients [29%] vs 4 patients [10%]; P = .05). Secondary outcome assessment, based on random regression analysis, revealed main effects in favor of FBT on all measures of eating pathological features (P = .003 to P = .03 for all).

CONCLUSIONS

Family-based treatment showed a clinical and statistical advantage over SPT at posttreatment and at 6-month follow-up. Reduction in core bulimic symptoms was also more immediate for patients receiving FBT vs SPT.

The relationship between health-related quality of life and weight loss

OBJECTIVE

This is a report of health-related quality of life (HRQOL) changes in obese patients completing at least 1 year of outpatient treatment in a weight reduction program combining phentermine-fenfluramine and dietary counseling.

RESEARCH METHODS AND PROCEDURES

Participants were 141 women (87.6%) and 20 men (12.4%) who had an average body mass index at intake of 41.1 kg/m(2) (SD = 7.0, range = 29.5 to 67.0 kg/m(2)) and an average age of 44.9 years (SD = 9.3, range = 23 to 65 years). HRQOL was assessed at intake and at 1-year follow-up using the Impact of Weight on Quality of Life (IWQOL)-Lite questionnaire. The relationship between HRQOL changes and weight loss was examined using Pearson correlations. Clinically meaningful change in HRQOL was defined as a 1.96 SEM reduction in IWQOL-Lite total score.

RESULTS

On average, participants lost 20.2 kg or 17.6% of their weight over the 1-year period. Of the participants, 15.5% lost <10% of their weight, 24.2% lost 10% to 14.9%, 23.6% lost 15% to 19.9%, and 36.6% lost 20% or more. All five IWQOL-Lite scales and total score showed statistically significant improvement over the 1-year period. Changes in IWQOL-Lite scores from intake to 1 year showed statistically significant correlations with percentage of weight loss for all subscales and total score. Subscale correlations with weight loss ranged from 0.166 (Public Distress) to 0.396 (Physical Function) and was 0.370 for the total score. Forty-four percent of participants losing <10% met the criterion of clinically meaningful change, compared with 51.3% losing 10% to 14.9%, 55.3% losing 15% to 19.95%, and 76.3% losing >20%. For total score and for three of the five IWQOL-Lite scales (Physical Function, Self-Esteem, and Sexual Life), the relationship between weight loss and clinically meaningful change was linear and was significant at p < 0.05. Physical Function and Self-Esteem were most strongly affected by weight loss.

DISCUSSION

HRQOL changes, as measured by an obesity-specific instrument (IWQOL-Lite), are strongly related to weight reduction.

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

BACKGROUND

Weight loss surgery induces a marked change in eating behavior. However, not much work has been done characterizing the eating behavior after weight loss surgery. We conducted a detailed analysis of patients' eating behavior 18-35 months after Roux-en-Y gastric bypass surgery, determined whether preoperative eating disorders might be associated with non-normative postoperative eating, and examined the association of such eating behaviors with weight loss and psychopathology.

METHODS

A sample of 59 patients who had undergone Roux-en-Y gastric bypass was interviewed in person after surgery about a range of eating behaviors, including binge eating, chewing and spitting out food, picking at and nibbling food, and nocturnal eating and compensatory behaviors such as vomiting and laxative and diuretic misuse. An established semistructured interview was used. The prevalence of preoperative eating disorders was assessed retrospectively. The eating-related and general psychopathology and quality of life were assessed using self-report questionnaires before and after surgery.

RESULTS

Subjective bulimic episodes were reported by 25% and vomiting for weight and shape reasons by 12% of the participants, on average, 2 years after surgery. Subjective bulimic episodes were significantly associated with a preoperative binge eating disorder, with more eating-related and general psychopathology after surgery, and with less weight loss.

CONCLUSION

A substantial subgroup of patients with a preoperative eating disorder will develop binge eating after surgery that might be associated with less weight loss. A subsample will start vomiting for weight and shape reasons after bariatric surgery. Clinicians must probe carefully for these behaviors postoperatively to identify patients in need of treatment of pathological eating behaviors.

Parent-adolescent communication and sexual risk behaviors among African American adolescent females

OBJECTIVE

To examine associations between parent-adolescent communication about sex-related topics and the sex-related communication and practices of African American adolescent females with partners, as well as their perceived ability to negotiate safer sex.

DESIGN

A theory-guided survey and structured interview were administered to 522 sexually active African American females 14 to 18 years old. Recruitment sites were neighborhoods with high rates of unemployment, substance abuse, violence, and sexually transmitted diseases. Multivariate analyses, controlling for observed covariates, were used to identify the association of less frequent parent-adolescent communication with multiple assessed outcomes.

RESULTS

Less frequent parent-adolescent communication (scores below the median) was associated with adolescents' non-use of contraceptives in the past 6 months (adjusted odds ratio [AOR] = 1.7) and non-use of contraceptives during the last 5 sexual encounters (AOR = 1.6). Less communication increased the odds of never using condoms in the past month (AOR = 1.6), during the last 5 sexual encounters (AOR = 1.7), and at last intercourse (AOR = 1.7). Less communication was also associated with less communication between adolescents and their sex partners (AOR = 3.3) and lower self-efficacy to negotiate safer sex (AOR = 1.8).

CONCLUSIONS

The findings demonstrate the importance of involving parents in human immunodeficiency virus/sexually transmitted disease and pregnancy prevention efforts directed at female adolescents. Pediatricians and other clinicians can play an important role in facilitating parent-adolescent communication about sexual activity.

Factor structure and construct validity of the Eating Disorder Examination-Questionnaire in college students: further support for a modified brief version

OBJECTIVE

The Eating Disorder Examination-Questionnaire (EDE-Q) is widely used in research studies across clinical and nonclinical groups. Relatively little is known about psychometric properties of this measure and the available literature has not supported the proposed scale structure. This study evaluated the factor structure and construct validity of the EDE-Q in a nonclinical study group of young adults.

METHOD

Participants were 801 young adults (573 females and 228 males) enrolled at a large public university in the Midwestern United States who completed the EDE-Q and a battery of behavioral and psychological measures.

RESULTS

Confirmatory factor analysis (CFA) revealed an inadequate fit for the original EDE-Q structure but revealed a good fit for an alternative structure suggested by recent research with predominately overweight/obese samples. CFA supported a modified seven-item, three-factor structure; the three factors were interpreted as dietary restraint, shape/weight overvaluation, and body dissatisfaction. Factor loadings and item intercepts were invariant across sex and overweight status. The three factors had less redundancy than the original EDE-Q scales and demonstrated improved convergent and discriminant validity in relation to relevant other measures.

DISCUSSION

These factor-analytic findings, which replicate findings from studies with diverse predominately overweight/obese samples, supported a modified seven-item, three-factor structure for the EDE-Q with improved psychometric characteristics. The findings provide further empirical support for the distinction between body dissatisfaction and overvaluation and have implications for assessment and research. These findings need to be replicated in samples of persons with eating-disorder psychopathology including those with anorexia nervosa, bulimia nervosa, and allied states.

Facets of negative affect prior to and following binge-only, purge-only, and binge/purge events in women with bulimia nervosa

Ecological momentary assessment (EMA) data suggest that global negative affect (NA) increases prior to and decreases following episodes of binge eating and purging, providing support for the affect regulation model of BN. The current study examined whether facets of NA are differentially related to bulimic behaviors. Women with bulimia nervosa (BN; n = 133) completed a 2-week EMA protocol. Momentary assessments of 4 facets of NA (Fear, Guilt, Hostility, and Sadness) were derived from the PANAS subscales. Trajectories of the NA facets were modeled prior to and following binge-only, purge-only, and binge/purge events. Fear, Guilt, Hostility, and Sadness increased prior to and decreased following binge-only and binge/purge events. The same results were found for purge-only events, with the exception that Hostility did not increase significantly prior to purging. Notably, ratings of Guilt were higher than those of Fear, Hostility, and Sadness at the time of binge-only and binge/purge events. Furthermore, post hoc analyses demonstrate that Guilt increased prior to and decreased following the 3 behavior types, even after controlling for Fear, Hostility, and Sadness. These results provide further support for the affect regulation model of BN and also suggest that guilt may be particularly important to the pathology of BN.