Binge Eating Disorder (BED) is a highly prevalent psychological condition in obese bariatric surgery candidates and is associated with various forms of psychopathology , including symptoms of depression and anxiety disorders . The literature suggests also that eating problems, such as binge eating, persist after surgery care and could affect weight loss and its maintenance . However, the findings are not consistent across studies and a variated of methodological issues has been highlighted .
Overall, BED subjects have been found to report more disturbances in eating attitudes [5, 6], lower self-esteem and higher psychiatric comorbidity, as well as substance abuse disorders , when compared to obese patients undergoing bariatric surgery without BED. Riener and colleagues  found that patients with BED reported higher scores of disinhibited eating, unsatisfactory relationships and an earlier onset of obesity, usually during childhood, than subjects without this condition. There were no differences as regards to depression and mental stress between BED and non-BED groups. In this study, approximately 30% of participants were scheduled for surgical treatment. In another research , BED individuals, compared to obese control, showed higher scores on MMPI-2-RF internalizing and externalizing scales. Still, 13% of obese adolescent undergoing bariatric surgery met diagnostic criteria for Eating Disorder (ED) diagnoses and 27% reported a sense of loss of control (LOC) over eating. LOC eating was associated with impairments in weight-related quality of life and on psychosocial factors, such as depressive symptomatology .
Research on body image disturbance in pre-bariatric surgery patients is limited. Among extremely obese seeking gastric bypass surgery, women reported significantly higher levels of body dissatisfaction than men. In predicting body dissatisfaction, binge eating and a sense of inadequacy accounted for a significant amount of the variance. No significant associations were reported between Body Mass Index (BMI), ethnicity, the age of onset of overweight, childhood trauma and body dissatisfaction for both genders .
In terms of the BED occurrence among candidates for weight loss surgery, eating disturbances seem to be not significantly associated with demographic variables, such as sex, age, BMI [2, 6] or less education . While, depression and low self-esteem have been suggested to account for unique variance in binge eating in both Caucasian and African American women . Overall, research has supported the hypothesis that BED patients are inclined to experience difficulties with emotion regulation  and these difficulties account for unique variance in emotional overeating and general eating pathology . Negative mood predicts binge eating onset and maintaining in BED  and bulimia nervosa , although obese adults with BED seem to reveal less antecedent painful emotions than the bulimic group . Similarly, emotion regulation difficulties were found to mediate the relationship between attachment insecurity and emotional eating  and between weight bias internalization and dysfunctional eating behaviors  in bariatric surgery candidates.
1.1 The current study
In sum, dysfunctional eating behaviors are common in preoperative patients and may affect surgical outcome. Given this, the first purpose of the current study was to assess the prevalence of binge eating disorder and abnormal eating behaviors in bariatric surgery candidates and compare patients with and without BED as regards to eating disturbances, psychological characteristics, and health status. Furthermore, we sought to individuate which factors were significantly related to binge eating severity. The reason for examining these factors and relationships is to improve bariatric surgery outcomes.
2.1 Participants and procedures
Participants included 63 obese patients (17 males and 46 females) with a mean age of 35.17 years (SD=10.28), who were seeking surgical treatment at two centers for bariatric surgery in southern Italy from November 2017 to October 2018. They were informed of the nature of the study and only two individuals refused to take part to the study. All of them agreed to participate signed an informed consent form and completed the questionnaire within 3 days of their scheduled surgery date. All measures were administered in Italian and presented in randomized order for each participant. The diagnosis of BED was performed through a semi-structured interview according to the diagnostic criteria of the DSM V .
Individuals were ineligible if they had medical, cognitive or psychiatric impairment established through a preoperative psychological screening at admission.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the Ethic Board of the Department of Psychology and by the Ethic Committee of the School of Medicine, University of Campania “Luigi Vanvitelli”.
2.2.1 Demographic data
Participants were asked to fill in a form with information about age, gender, race/ethnicity, relationship status, education level, and age of onset of their obesity. Additional questions concerned about abuse/violence histories, substance use, and self-injurious behaviors.
2.2.2 Rosenberg Self Esteem Scale (RSES)
The RSES  is a 10-item self-report measure that assesses global self-esteem. Scores range from 0 to 30, with lower scores indicating lower self-esteem. Sample Cronbach’s alpha is .74.
2.2.3 Eating Disorders Inventory-3 (EDI-3)
The EDI-3  is a 91-item inventory exploring eating-related psychopathology. Three scales are specific for eating disorders (Drive for Thinness, Body Dissatisfaction, and Bulimia) and nine evaluate psychological aspects relevant for eating disorders (Low Self-esteem, Personal Alienation, Interpersonal Insecurity, Interpersonal Alienation, Interoceptive Deficits, Emotional Dysregulation, Perfectionism, Asceticism, and Maturity Fear). Sample Cronbach’s alpha ranges from .62 to .82.
2.2.4 Binge Eating Scale (BES)
The BES  is a 16-item self-report measure to assess the behavioral as well as the cognitive and emotional symptoms associated with binge eating. The score range is from 0 to 46 with higher scores indicating more severe binge eating problems. Sample Cronbach’s alpha is .83.
2.2.5 Binge Eating Disorder
The diagnosis of BED was performed through a semi-structured interview according to the diagnostic criteria of the DSM V  by a clinical psychologist with experience on eating disorders.
2.2.6 The General Health Questionnaire – 28 (GHQ-28)
The GHQ-28  is a 28-item measure of somatic symptoms, anxiety, social dysfunction, and depression. Sample Cronbach’s alpha ranges from .40 to .73.
2.2.7 Body Mass Index (BMI)
Each individual was weighed and measured in height.
2.3 Statistical analysis
Statistical analyses were carried out using SPSS 20 version. First, the Chi-square (χ2) test was conducted for categorical variables and the Mann-Whitney U test was conducted for comparisons between groups. Next, Pearson correlation coefficients were investigated to inspect associations among all of the study variables, and multiple regression was used to identify factors that were independently related to binge eating. Value of p less than or equal to .01 was considered statistically significant since the examined group was of small size.
3.1 Preliminary analyses
Preliminary univariate distributions of observed scores were examined for normality and multicollinearity. Values of Skewness and Kurtosis indicated that there wasn’t a violation of the normal distribution. Furthermore, there was no evidence of multicollinearity. All analyses were based upon available data.
3.2 Sample characteristics
The preliminary sample consisted of 68 bariatric surgery candidates. Of these, 5 individuals were excluded because returned incomplete questionnaires, so the final sample included 63 Caucasian patients, of whom 73% (N=46) women, with a mean age of 35.17 years (SD=10.28) and a mean BMI of 40.50 (SD=5.75). Thirty-seven (58.7%) were morbidly obese (defined as BMI>40 Kg/m2). Most patients (96.8%) held a diploma of higher education or less. About 82.5% of patients (N=52) were accepted for gastric bypass, 15.9% (N=10) for a laparoscopic sleeve gastrectomy and an additional patient for a laparoscopic gastric banding.
Demographic characteristics and personal background of the patients are shown in Table 1.
3.3 Prevalence of BED and abnormal eating behaviors
Overall, thirteen (21.3%) of the patients met DSM V criteria for BED.
Thirty (47.6%) participants reported regularly binge eating, 54.8% (N=17) feel out of control when eating, 65.4% (N=17) ate rapidly, over half (N=14) ate until uncomfortable, 61.5% (N=16) ate when not hungry, 50% (N=12) ate alone because embarrassed and the vast majority (89.3%, N=25) felt disgusted and distress after overeating. Over a third (N=12) of participants declared to adopt inappropriate compensatory behavior, such as purging, fasting or excessive exercise.
3.4 Group comparisons of study variables
As shown in tables 2, there were no significant differences between BED and non-BED (NBED) groups as regards to respective demographic variables, such as sex (p=.664),
age (p=.341), BMI (p=.218) and the onset of obesity (p=.681). Compared to those without BED, individuals with BED reported lower self-esteem (p=.010), scored significantly higher on Binge Eating Scale (p=.000) and on all EDI-3 scale (p<.010), except for Body Dissatisfaction (p=.378), Interpersonal Alienation (p=.117) and Perfectionism (p=.022). Non-BED and BED did not differ significantly in GHQ-28 scales (p>.01). Differences were found regarding substance use (p=.008) and self-injury behaviors (p=.006).
Prior to conducting regression analyses, bivariate correlations were run to ensure there were significant associations among the variables of interest (demographic variables, eating disturbances, psychological characteristics, and health status). Correlation analysis showed significant relationships between BES score, RSES self-esteem (p=.002), GHQ-28 anxiety (p=.003), EDI-3 Drive for Thinness (p=.010), EDI-3 Bulimia (p=.000), EDI-3 Interoceptive Deficit (p=.002), EDI-3 Emotional Dysregulation (p=.000) and EDI-3 Asceticism (p=.000) (Table 3). These variables were selected to be included in the regression analyses except for Bulimia. This scale assesses the tendency to think about and to engage in binge-eating . Thus, the use to predict BES score seemed duplicative.
Binge eating was not significantly associated with demographic variables of sex (r=.016, p=.899), age (r=.078, p=.541) and BMI (r=-.069, p=.589). Accordingly, these variables were not used as covariates in the analyses.
3.6 Predictors of Binge Eating Symptoms
Specifically, the contribution of self-esteem, anxiety, drive for thinness, interoceptive deficits, emotional dysregulation, and asceticism was assessed through a linear regression analysis performed on BES score. For regression equations using six or more predictors, an absolute minimum of 10 participants per predictor variable is appropriate . Multiple regression analyses revealed that only EDI-3 Emotional Dysregulation scale (B=.469, p=.001), significantly predicted binge eating (Table 4). The total variability of the variable explained by the model was 37% (Adjusted R2=.370, F=6.300, p=.000).
The findings of this study show how BED and disordered eating, such as episodes of binge eating, sense of lack of control over eating and inappropriate compensatory behaviors, appear common in patients undergoing for weight loss surgery and are mainly associated with low self-esteem, emotional dysfunction, impulse behaviors, including substance use and self-injury behaviors, self-destructiveness, distress and reticence in social situations.
Overall, the prevalence of BED in surgery candidates ranges from 2% to 49% , depending on the method of assessment and the criteria employed. As such, our finding
of 21% is congruent with those reported by the literature, although it was much lower than the 48% assessed following the criteria of the DSM V by Vinai and colleagues  among Italian obese patients seeking bariatric surgery.
In line with other studies, gender, age, and BMI were not different between the groups [2, 6]. While, when compared to obese patients without BED, BED subjects reported lower self-esteem and greater preoccupation with weight, the tendency to think about and to engage in episodes of uncontrollable overeating and more difficulties with emotion regulation, including being able to clearly identify emotional states. These latter results confirm the findings of Vinai and colleagues , although in the current research a difference in the measure of body dissatisfaction was not found. One reason for this may be that severely obese patients have an already higher level of body dissatisfaction, which is not further aggravated by the presence of BED. This is in agreement with evidence that the mean score on this EDI-3 scale for both two groups was over 27, a number which is very similar to that seen among eating disordered individuals . However, research on body dissatisfaction in obese bariatric surgery candidates has received limited attention in the literature and future empirical studies should investigate this suggestion.
Additionally, our findings have shown that pre-bariatric surgery patients with BED report more distress and reticence in social situations. This datum probably reflects the decreased social and interpersonal functioning indicated by Hsu and colleague  and partially supports the evidence that patients with BED experience more stressful relationships .
Unexpectedly, BED patients scored significantly higher on the EDI-3 asceticism scale. This finding is surprising and it is not yet described by other investigators. Asceticism implies the pursuit of spiritual ideals such as self-denial, control of bodily sensations, and sacrifice . In addition to the rejection for weakness, overall it refers to the tendency to consider pleasure as shameful, and it involves not only fasting but also other practices of renunciation, including sexual abstinence and various forms of bodily flagellation. From this viewpoint, self-restrictions could only be part of a more general theme of renouncing physical gratifications to the detriment of the body. Feelings of anger and a self-destructive impulse are, indeed, considered some of the features strongly implicated in ascetic behaviors . Consistently with the issue, self-injurious behaviors frequently are reported in EDs , and angry feelings and excessive control over anger were found characterized anorectic patients scoring high on EDI-2 asceticism scale . In this study, the asceticism resulted also strongly associated with ineffectiveness, interoceptive awareness and impulsiveness scales of EDI-2. However, the authors did not investigate if and how these variables interact with others in explaining ED onset. Similarly, of the EDI-2 scales, only interoceptive awareness and asceticism scales were found to differentiate a group of bulimic patients from a general psychiatric control group . There is not literature encouraging a theoretical rationale for the relationship between asceticism and BED, and it may even seem contradictory. In our opinion, the link could be found in a self-destructive impulse underlying and in the pursuit of mortification of the body through self-denial and suffering. In this sense, emotional dysregulation is a key psychopathological element of binge eating disturbances, relates to “mood instability, impulsivity, anger, and self-destructiveness” . Accordingly, the study confirms the association between substance use and BED. Further studies on this construct would be very useful.
In contrast with some studies , BED than non-BED patients did not differ in terms of levels of anxiety and depressive symptoms. One reason for this may be caused by small sample size or may be due to an inadequate assessment. Furthermore, results could have been confused by exclusionary criteria for which individuals were ineligible if they had severe psychiatric conditions. However, other studies did not support the relationship between binge eating disorder and health status .
Finally, another important contribution of this research was individuated which factors were significantly related to binge eating. In line with findings from other researchers , our results revealed that difficulty in impulse regulation (not specifically in relation to eating behavior) is the strongest predictor of binge eating. This is consistent with the idea that difficulty in impulse control regarding emotional states is one of the prominent features strongly implicated in BED occurrence as well as in the maintenance of the disorder, and it might represent the root of the pathology. However, this study was based on small sample sizes and thus further investigation in this area should deepen this datum.
Within eating disorder literature, self-esteem  and interoceptive awareness [32, 33] are considered very important vulnerability factors in the development of these diseases. In the present study, they hadn’t a direct effect on binge eating. There are several possible explanations for such results. In our opinion, one potential mean by which these variables are related to binge eating vulnerability is through their effects on impulse regulation difficulties. In this regard, identification of internal emotional states has been shown to be an essential prerequisite for emotion regulation [34, 35]. Future empirical studies should investigate this suggestion.
The results of the present study have noteworthy implications for obesity treatment. In our opinion, the recognition of potential factors involved in the development and maintenance of disordered eating in bariatric patients may support the choice of particular therapeutic strategies and improve bariatric surgery outcome. Specifically, emotion regulation difficulties may be to address both pre- and post-surgery in order to reduce binge eating and to improve health outcomes . Furthermore, this study presents a unique contribution to the literature by illustrating the pursuit of mortifying own body through self-denial and suffering of patients seeking bariatric surgery. This issue should be taken into account when assessing bariatric surgery candidates and further studies on the role of asceticism in emotion regulation difficulties and BED vulnerability would be useful.
Several limitations necessitate being considered when interpreting the findings of the present study. First of all, these results need to be further tested on a larger sample and must include a control group. The sample is very heterogeneous: adolescents, young adults, and adults have different contexts and life goals. Moreover, the cross-sectional design precludes a final conclusion with regard to directionality. Longitudinal studies are necessary to establish the direction of the relationship identified. These limitations should be addressed in further studies.
Appreciation is expressed to Dr. Giuseppina Antonia Silvestro Crispo and Dr. Doriana Elia for their help with data collection.
Vinai P., Da Ros A., Speciale M., Gentile N., Tagliabue A., Vinai, P., et al., Psychopathological characteristics of patients seeking for bariatric surgery, either affected or not by binge eating disorder following the criteria of the DSM IV TR and of the DSM 5, Eat Behav., 2015, 16,1-4; CrossrefPubMedWeb of ScienceGoogle Scholar
Jones-Corneille L.R., Wadden T.A., Sarwer D.B., Faulconbridge L.F., Fabricatore A.N., Stack R.M., et al., Axis I psychopathology in bariatric surgery candidates with and without binge eating disorder: results of structured clinical interviews, Obes Surg., 2012, 22, 389-97; CrossrefPubMedWeb of ScienceGoogle Scholar
Kalarchian M.A., Marcus M.D., Levine M.D., Courcoulas A.P., Pilkonis P.A., Ringham R.M., et al., Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status, Am J Psychiatry, 2007, 164, 328-34; CrossrefPubMedWeb of ScienceGoogle Scholar
Hsu L.K., Mulliken B., McDonagh B., Krupa Das S., Rand W., Fairburn C.G., et al., Binge eating disorder in extreme obesity, Int J Obes Relat Metab Disord., 2002, 26, 1398–1403; CrossrefPubMedGoogle Scholar
Mitchell J.E., King W.C., Courcoulas A., Dakin G., Elder K., Engel S., et al., Eating behavior and eating disorders in adults before bariatric surgery, Int J Eat Disord., 2015, 48, 215-22; CrossrefWeb of SciencePubMedGoogle Scholar
Marek R.J., Ben-Porath Y.S., Ashton K., Heinberg L.J., Minnesota multiphasic personality inventory-2 restructured form (MMPI-2-RF) scale score differences in bariatric surgery candidates diagnosed with binge eating disorder versus BMI-matched controls, Int J Eat Disord., 2014, 47, 315-9; CrossrefPubMedWeb of ScienceGoogle Scholar
Utzinger L.M., Gowey M.A., Zeller M., Jenkins T.M., Engel S.G., et al., Loss of control eating and eating disorders in adolescents before bariatric surgery, Int J Eat Disord., 2016, 49, 947-952; CrossrefPubMedWeb of ScienceGoogle Scholar
Mazzeo S.E., Saunders R., Mitchell K.S., Binge eating among African American and Caucasian bariatric surgery candidates, Eat Behav., 2005, 6, 189-196; https://doi.org/10.1016j.eatbeh.2004.12.001 PubMedCrossrefGoogle Scholar
Leehr E.J., Krohmer K., Schag K., Dresler T., Zipfel S., Giel K.E., Emotion regulation model in binge eating disorder and obesity-a systematic review, Neurosci Biobehav Rev., 2015, 49,125-34; CrossrefWeb of SciencePubMedGoogle Scholar
Gianini L.M., White M.A., Masheb R.M, Eating pathology, emotion regulation, and emotional overeating in obese adults with Binge Eating Disorder, Eat Behav., 2013, 14, 309-13; CrossrefPubMedWeb of ScienceGoogle Scholar
Stein R.I., Kenardy J., Wiseman C.V., Zoler Dounchis J., Arnow B. A., Wilfley D.E., What’s driving the binge in binge eating disorder?: A prospective examination of precursors and consequences, Int J Eat Disord., 2007, 40, 195–203; CrossrefWeb of SciencePubMedGoogle Scholar
Smyth J.M., Wonderlich S.A., Sliwinski M.J., Crosby R.D., Engel S.G., Mitchell J.E., Calogero R.M., Ecological momentary assessment of affect, stress, and binge-purge behaviors: day of week and time of day effects in the natural environment, Int J Eat Disord., 2009, 42, 429–436; CrossrefWeb of SciencePubMedGoogle Scholar
Hilbert A., Tuschen-Caffier B., Maintenance of binge eating through negative mood: a naturalistic comparison of binge eating disorder and bulimia nervosa, Int J Eat Disord., 2007, 40, 521–530; CrossrefWeb of ScienceGoogle Scholar
Taube-Schiff M., Van Exan J., Tanaka R., Wnuk S., Hawa R., Sockalingam S., Attachment style and emotional eating in bariatric surgery candidates: The mediating role of difficulties in emotion regulation, Eat Behav., 2015, 18, 36-40; CrossrefPubMedWeb of ScienceGoogle Scholar
Baldofski S., Rudolph A., Tigges W., Herbig B., Jurowich C., Kaiser S., et al., Weight bias internalization, emotion dysregulation, and non-normative eating behaviors in prebariatric patients, Int J Eat Disord., 2016, 49, 180-5; CrossrefPubMedWeb of ScienceGoogle Scholar
American Psychiatric Association, American Psychiatric Association, DSM-5 task force. Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, Va: American Psychiatric Association, 2013 Google Scholar
Rosenberg M., Society and the adolescent self-image, Princeton, Princeton University Press, 1965 Google Scholar
VanVoorhis C., Morgan B., Statistical rules of thumb:what we don’t want to forget about sample sizes, Psy Journal, 2001, 6, 139-141 Google Scholar
Niego S.H., Kofman M.D., Weiss J.J., Geliebter A., Binge eating in the bariatric surgery population: A review of the literature, Int J Eat Disord., 2007, 40, 349–359; CrossrefPubMedWeb of ScienceGoogle Scholar
Menninger K., Man against himself. Nueva York: Harcourt, Brace & World Inc, 1938 Google Scholar
Iannaccone M., Cella S., Manzi A.S., Visconti L., Manzi F., Cotrufo P., My body and me: self-injurious behaviors and body modifications in eating disorders. Preliminary results, Eat Disord., 2013, 21, 130-139; CrossrefPubMedWeb of ScienceGoogle Scholar
Fassino S., Pierò A., Gramaglia C., Abbate-Daga G., Gandione M., Rovera G.G., Bartocci G., Clinical, psychological, and personality correlates of asceticism in anorexia nervosa: from saint anorexia to pathologic perfectionism, Transcult Psychiatry, 2006, 43, 600-14; CrossrefPubMedGoogle Scholar
Monell E., Clinton D., Birgegård A., Emotion dysregulation and eating disorders—Associations with diagnostic presentation and key symptoms, Int J Eat Disord., 2018, 1–10; doi:10.1002/eat.22925 Google Scholar
Cella S., Cipriano A., Iannaccone M., Cotrufo P., Identifying predictors associated with the severity of eating concerns in females and eating disorders, RIPPPO, 2017, 20(1), 91-99; doi:10.4081/ripppo.2017.199 Google Scholar
Racine S.E., Wildes J.E., Emotion dysregulation and symptoms of anorexia nervosa: the unique roles of lack of emotional awareness and impulse control difficulties when upset, Int J Eat Disord., 2013, 46, 713-20; CrossrefPubMedWeb of ScienceGoogle Scholar
Füstös J., Gramann K., Herbert B.M., Pollatos O., On the embodiment of emotion regulation: interoceptive awareness facilitates reappraisal, Soc Cogn Affect Neurosci, 2012, 8, 911-7; CrossrefWeb of SciencePubMedGoogle Scholar
Shakory S., Van Exan J., Mills J.S., Sockalingam S., Keating L., Taube-Schiff M., Binge eating in bariatric surgery candidates: The role of insecure attachment and emotion regulation, Appetite, 2015, 91, 69-75; CrossrefPubMedWeb of ScienceGoogle Scholar
About the article
Published Online: 2019-06-07
Contributors: Cella and Cotrufo designed the study and wrote the protocol. All authors conducted literature searches and provided summaries of previous research studies. Cella, Fei, D’Amico, Giardiello, and Allaria assisted with data collection. Cella conducted the statistical analysis and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Funding: No funding was received.
Conflict of Interest: The authors declare that they have no conflicts of interest.
Citation Information: Open Medicine, Volume 14, Issue 1, Pages 407–415, ISSN (Online) 2391-5463, DOI: https://doi.org/10.1515/med-2019-0043.
© 2019 Stefania Cella et al., published by De Gruyter. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License. BY-NC-ND 4.0