OBJECTIVE:While loss of control (LOC) eating is associated with poor outcomes following metabolic and bariatric surgery (MBS), the mechanisms driving it are less understood. This study used momentary, naturalistic data to examine glucose as a biological correlate of LOC eating after Roux-en-Y gastric bypass (RYGB). METHOD:Participants (45 adults one-year post-RYGB) completed 10 days of ecological momentary assessment (EMA) while wearing a continuous glucose monitor (CGM). Eating episodes reported in EMA were time-matched to CGM readings 3 hours before and after eating episodes. Four CGM metrics (mean, variability, time in hyper- and hypo-glycaemia) were used in multilevel models to test whether glucose functioning was a significant antecedent and/or consequence of LOC eating. RESULTS:Greater mean glucose levels and variability each significantly predicted engagement in an eating episode, while more time spent in hyperglycemia predicted the absence of eating. Significantly higher mean glucose was observed after eating. No glucose metric specifically predicted engagement in LOC eating; however, LOC eating resulted in significantly greater glucose variability. CONCLUSIONS:Glucose level and variability predicted subsequent eating, but not LOC eating. However, LOC eating was associated with subsequent glucose variability, which might help explain how LOC eating is associated with poorer outcomes following RYGB.

BACKGROUND:Affect regulation models suggest high negative and low positive affect may drive binge eating and purging in bulimia nervosa (BN). While ecological momentary assessment (EMA) studies often support these theories, inconsistent outcomes in affect-targeted interventions suggest causal relations vary across individuals. This study applied causal discovery analysis (CDA) to EMA data to characterize such heterogeneity in person-specific causal models for BN. METHODS:EMA data from 118 adult women with BN, collected over 14 days, assessed momentary negative affect, positive affect, binge eating, and self-induced vomiting. Using the Greedy Fast Causal Inference algorithm, we derived individual causal models and estimated effect sizes via structural equation modeling. Heterogeneity was evaluated by the proportion of participants with affect as a causal factor for BN behaviors. RESULTS:Causal patterns were highly heterogeneous. Elevated negative affect was causal for binge eating in 16.9% of participants, vomiting in 18.6%, and either behavior in 27.1%. Low positive affect was causal for binge eating in 8.5%, vomiting in 11.0%, and either behavior in 15.3%. Behavior-behavior causality was also common: vomiting caused binge eating in 26.3% of participants, and binge eating caused vomiting in 22.0%. CONCLUSIONS:CDA revealed marked heterogeneity in causal factors underlying BN behaviors, with some models showing affect-driven behaviors and others indicating behavior-driven patterns. Ultimately, this work indicates that the link between momentary affect and BN behaviors is highly individualized, underscoring the need for precision-targeted interventions rather than one-size-fits-all treatments.

Background Emotion regulation plays an important role in primary restrictive eating disorders, and preliminary evidence suggests that individuals with avoidant/restrictive food intake disorder (ARFID) exhibit deficits in emotion regulation. However, this research is exclusively cross-sectional and has not tested the time-directed associations between discrete emotions and ARFID behaviors, or if there are specific emotions that prospectively predict engagement in ARFID behaviors. The current study used ecological momentary assessment data and network analysis to test hypotheses that negative emotions would predict engagement in ARFID behaviors, and that emotion-behavior associations would vary according to ARFID profile. Methods Participants ( N = 20; M age =26.2) completed the Positive/Negative Affective Schedule and behavior constructs (i.e., Pica, ARFID, and Rumination Disorder Interview) eight times a day for 12 days (mean EMA compliance = 80%). Results Group-level networks showed that feeling ashamed was a core emotion (i.e., had the highest number of outgoing connections with other symptoms), which predicted ARFID behaviors at the next timepoint (e.g., missing a meal, not finishing a meal ; p s<.05). Further, engagement in ARFID behaviors predicted reductions in negative emotions (e.g., feeling nervous ) at the next timepoint. Individual networks demonstrated unique emotion-behavior associations according to ARFID profile—anxiety predicted fear-driven food avoidance, while shame predicted low appetite-driven food restriction. Conclusions Results suggest that negative emotions play a central and directed role in maladaptive behaviors in the daily lives of adults with ARFID, and that these behaviors may be negatively reinforcing. Further, these temporal processes differed according to ARFID profile, findings that may guide future longitudinal research and ultimately inform treatment development.

BACKGROUND:Hypoglycemia (i.e., low blood glucose) is a potential complication following metabolic and bariatric surgery (MBS) that can ultimately result in severe and deadly consequences. However, the symptoms typically associated with hypoglycemia (e.g., dizziness, anxiety) can be nonspecific, which impairs effective monitoring. OBJECTIVES:This study utilized a unique combination of naturalistic assessments to compare the subjective self-report of hypoglycemic symptoms measured via ecological momentary assessment (EMA) with objectively-collected data from continuous glucose monitoring (CGM). SETTING:Private Hospital, United States. METHODS:Participants were 44 adults who completed 10 days of EMA and CGM 1 year after undergoing Roux-en-Y gastric bypass. Multiple times per day during the EMA protocol, participants identified how many of 18 hypoglycemic symptoms they had experienced since they were last signaled several hours earlier. RESULTS:CGM data showed that ∼66% of participants experienced at least one possible daytime hypoglycemic event (range = 1-23 episodes/person). The total number of hypoglycemic symptoms endorsed via EMA did not correspond with the occurrence of a possible hypoglycemic event captured by CGM (P = .145). However, multilevel models revealed that participants were more likely to report feeling "shaky", "lightheaded", and "coordination problems/clumsiness" (false discovery rate corrected P values < .05) during periods of time coinciding with possible hypoglycemic events identified by CGM. CONCLUSIONS:Many patients are at risk for low blood glucose post-MBS. In the absence of objective assessment, several subjective symptoms may serve as indicators of possible hypoglycemic events following MBS.

Social Media use among individuals pre- and post- metabolic and bariatric surgery (MBS) has dramatically increased in recent years, yet the benefits and risks to patients remain unclear. This systematic review sought to synthesize the literature on social media use among individuals pre-and post-MBS. Objectives were to: 1) explore the patterns of social media use in this population, 2) identify the benefits and risks of MBS-focused social media use and, 3) inform clinicians and patients about strategies to more effectively engage with MBS-focused social media. This systematic review was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analysis and was registered with PROSPERO (CRD42023473191). Studies which included a retrospective or prospective examination of social media and MBS were included. A comprehensive search was performed and published scientific articles were examined by three independent reviewers, resulting in 24 full text articles meeting inclusion criteria based on pre-specified selection criteria. Results are reported by social media platform including Facebook, YouTube, Online Forums/Websites, X (formerly “Twitter”), Instagram, and TikTok. Findings indicate that social media use among individuals pre-and post-MBS is high and Facebook is the preferred platform. Several benefits of social media use were identified including easier access to large peer support communities, inspiration and encouragement, and health information. Possible downsides to social media use include problems with the accuracy of MBS content on social media. Given these findings, MBS clinicians can use this information to inform their patients about strategies to promote benefits and reduce potential risks of social media use.

OBJECTIVE:Limited research has examined the function or consequences of dietary restriction among individuals for whom it may serve differential purposes, such as those with food insecurity. Indeed, food insecurity may uniquely relate to differential functions for engaging in dietary restriction, which may relate to subsequent changes in mood; this study sought to assess these associations. METHOD:A subsample of 77 young adults from the Minnesota-based EAT (Eating and Activity over Time) cohort with food insecurity (Mage = 25.2 ± 1.8 years; Women = 72.7%; Black = 18.2%; Latinx = 19.5%; Asian = 18.2%; White = 27.3%) reported on state-level functions for dietary restriction (financial only, weight-control only, or both) versus no restriction, and state-level mood, via ecological momentary assessment (EMA). Demographics-adjusted linear mixed models were conducted to examine the function of dietary restriction since the last EMA signal and current mood. RESULTS:Across a 14-day EMA period, 29.9% of observations involved dietary restriction due to financial functions only, 6.2% involved dietary restriction due to both financial and weight-control functions, and 3.0% involved restriction for weight-control functions only. Compared to instances of no dietary restriction, overall negative mood was higher after engaging in dietary restriction for both functions (B = 0.43; p = 0.002), but not for financial (B = 0.12; p = 0.14) or weight-control (B = 0.30; p = 0.06) functions only. DISCUSSION:These findings suggest dual-purpose dietary restriction (i.e., for both financial and weight-control) is common in young adults with food insecurity and may influence mood; thus, it may be an important intervention target.

ABSTRACTIntroductionStudies have shown that early weight gain in family‐based treatment (FBT) predicts treatment response in adolescents with anorexia nervosa (AN); however, research examining factors associated with early weight gain in FBT is limited. This study tested the feasibility and acceptability of ecological momentary assessment (EMA) in early FBT, particularly to capture momentary data on family climate during mealtimes.MethodsUsing multiple methods, quantitative (EMA) and qualitative (interviews) data were collected in the first 4 weeks of FBT. Participants (11 families; 9 adolescents, 19 parents/caregivers) completed EMA assessments daily on the emotional climate during meals, parental strategies and confidence/agreement in renourishment. Qualitative interviews obtained technological and procedural data using EMA. Completion rates and markers of change were explored using repeated measures ANOVA. Interviews were analyzed using reflexive thematic analysis.ResultsThe EMA completion rate for all family members was 78%: 84% for adolescents, 83% for mothers, 64% for fathers. Results demonstrated changes in caregivers' use of renourishment strategies and in the emotional climate (decreased anger) at mealtimes. No changes were observed in caregiver confidence/agreement in renourishment. Qualitative analyses revealed factors interfering with and facilitating the use of EMA.DiscussionEMA is an acceptable and feasible tool for use with adolescents and their families in early FBT, particularly to capture momentary data on family climate during mealtimes. Future research is needed with larger sample sizes to examine the mechanisms of change in early FBT, and the utility of EMA as a clinical tool in FBT.

Background: A bidirectional association between shape and weight concerns (SWC) and physical activity (PA) has been previously documented. This relationship may be particularly salient among youth with overweight/obesity, given that social marginalization of larger bodies has been associated with elevated SWC and barriers to PA. This pilot study explores reciprocal relationships between momentary SWC and accelerometer-assessed PA behavior.Methods: Youth with overweight/obesity (N = 17) participated in a 14-day ecological momentary assessment protocol, during which they were prompted to respond to questions about SWC several times per day. They also continuously wore Actiwatch 2 accelerometers to capture light and moderate-to-vigorous PA behavior.Results: Hierarchical linear modeling revealed a unidirectional association between SWC and PA, whereby after engaging in a higher duration of PA, participants reported lower SWC. SWC did not predict subsequent PA.Conclusion: The findings support a negative temporal relationship between PA and SWC. While further work is needed to replicate and extend these preliminary findings, they may suggest that PA acutely benefits SWC among youth with overweight and obesity.

OBJECTIVE:Emerging research indicates that skills acquisition may be important to behavior change in cognitive behavior therapy (CBT) for eating disorders. This study investigated whether skills use assessed in real time during the initial 4 weeks of CBT-based day treatment was associated with momentary eating disorder behavior change and rapid response to treatment. METHODS:Participants with DSM-5 bulimia nervosa or purging disorder (N = 58) completed ecological momentary assessments (EMA) several times daily for the first 28 days of treatment. EMA assessed skills use, the occurrence of binge eating and/or purging, and state negative affect. Rapid response was defined as abstinence from binge eating and/or purging in the first 4 weeks of treatment. RESULTS:Greater real-time skills use overall, and use of "planning ahead," "distraction," "social support," and "mechanical eating" skills in particular, were associated with a lower likelihood of engaging in binge eating or purging during the same period. After controlling for baseline group differences in overall difficulties with emotion regulation, rapid and non-rapid responders did not differ in overall skills use, or skills use at times of higher negative affect, during the EMA period. DISCUSSION:Momentary use of skills appears to play an important role in preventing binge eating and purging, and certain skills appear to be particularly helpful. These findings contribute to the literature elucidating the processes by which CBT treatments for eating disorders work by providing empirical evidence that skills use helps to prevent binge eating and purging behaviors. PUBLIC SIGNIFICANCE:Individuals with eating disorders learn new skills during treatment to help them improve their symptoms. This study shows that for people with eating disorders, using skills helps prevent eating disorder behaviors in the moment. Certain skills may be particularly helpful, including planning ahead, distracting activities, support from others, and focusing on eating meals and snacks regardless of how one is feeling. These findings help us better understand how treatments work.

Overweight and obesity affect >40% of adolescents. Family-based behavioral treatment (FBT) is the most efficacious behavioral treatment for weight management among youth and consists of nutrition and physical activity education, behavior change skills, and parent skills training. However, the efficacy of FBT decreases for youth as they get older. Increased emotional lability and limited emotion regulation skills may contribute to the reduced efficacy of FBT for adolescents. To date, there are no treatments for overweight or obesity specifically adapted for the needs of adolescents. We developed a treatment that integrates components from Dialectical Behavior Therapy and Emotion Focused Therapy with FBT (FBT+ER or FBT-ER) to address the specific needs of adolescents. The current study randomized 166 adolescents (BMI = 32.8; 14.3 years; 57% female; 32% Hispanic, 50% Non-Hispanic White, 18% Non-Hispanic and Non-White) and one of their parents (BMI = 32.9; 45.3 years; 85% female; 27% Hispanic, 57% Non-Hispanic White, 16% Non-Hispanic and Non-White) to 6 months of either standard FBT or FBT+ at 2 sites. Assessments were conducted at baseline, mid-treatment (month 3), post-treatment (month 6), 6-month follow-up (month 12) and 12-month follow-up (month 18). Primary outcomes are adolescent weight (BMIz/%BMIp95), emotion regulation skills, and emotional eating behaviors. Given the public health concern of adolescent obesity, FBT+ could prove extremely useful to provide more targeted and effective intervention for adolescents with overweight or obesity. Clinical trials: # NCT03674944

OBJECTIVE:Dysregulated eating is common among youth and is associated with trait-level negative affect and emotion regulation difficulties. Despite the transient nature of affect, momentary associations among affect and eating behavior are unclear, which limits development of more impactful treatment tools, such as "just-in-time" intervention approaches (JITAI). The current study (N = 62) drew from two ecological momentary assessment (EMA) studies involving children and adolescents who endorsed loss of control (LOC) eating symptoms during a two-week assessment period. METHOD:Intensive time series network analysis tested concurrent and prospective relationships across six specific affective states (i.e., upset, guilty, scared, tired, excited, attentive) and four eating-related experiences (e.g., LOC, overeating, hunger, craving) in real time. Additionally, we repeated these models within demographic subgroups of the sample based on age, race, and sex. RESULTS:In the full-sample models, contemporaneously assessed guilt was associated with craving and LOC eating, and tiredness was associated with LOC eating. In the prospective analysis, tiredness was negatively predicted by LOC eating and positively predicted by overeating at the previous timepoint, and attentiveness positively predicted craving. Differences in affect-eating relationships were identified across teens and preteens as well as male and female participants. DISCUSSION:These results suggest that specific affective states are associated with dysregulated eating-related experiences in real time among youth, and associations may differ depending on demographic characteristics. Findings may be used to inform the development and tailoring of momentary interventions.

Background: Disordered eating is a concern for patients seeking metabolic and bariatric surgery (MBS), but little is known about how these behaviors are reflected in typical dietary intake prior to surgery. Objectives: This study examined the relationships between disordered eating behavior and the content and context of typical dietary intake among patients seeking MBS using an innovative combination of rigorous self-report and interview assessments. Setting: Participants were recruited from two academic medical centers in the United States. Methods: Adults were enrolled prior to MBS. Participants completed the Eating Disorder Examination-Bariatric Surgery Version (EDE-BSV) and then reported details of their dietary intake for three consecutive days using a validated 24-hour dietary recall system. Results: Among the sample (n 5 140), objective overeating (OOE) was prevalent and related to greater daily energy and macronutrient intake. Individuals engaging in recurrent OOE were also more likely to consume meals past 8 PM Findings failed to identify significant associations between other disordered eating behaviors, such as objective binge eating (OBE), and contextual factors related to dietary intake. Conclusions: The timing of eating may play a greater role in recurrent overeating than social and physical aspects of the environment. Individuals reporting frequent OOE before MBS may benefit from targeted education and intervention aimed at reducing OOE and subsequently promoting better adherence to dietary recommendations. (Surg Obes Relat Dis 2024;20:1381-1387.) (c) 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

We examined whether perceived stress, anhedonia, and food insecurity were associated with dietary adherence during a 6-week intervention. Sixty participants (23 m; 53 ± 14 y) completed psychosocial measures and were provided with full meals. Individuals with obesity were randomized to a weight-maintaining energy needs (WMENs) (n = 18; BMI 33 ± 4) or a 35% calorie-reduced diet (n = 19; BMI 38 ± 9); normal-weight individuals (n = 23; BMI 23 ± 2) were assigned to a WMENs diet. Adherence scores were determined via weekly assessments and daily ecological momentary assessments (EMAs) of real-time behavior in a natural environment. Perceived stress and anhedonia were associated with % body fat (all r-values > 0.25, all p-values < 0.05), but food insecurity and adherence were not. Higher perceived stress (r = −0.31, p = 0.02), anhedonia (r = −0.34, p = 0.01), and food insecurity (r = −0.27, p = 0.04) were associated with lower adherence scores, even after adjusting for age, sex, and % body fat. In all adjusted models, % body fat was not associated with adherence. Higher measures of stress, anhedonia, and food insecurity predicted lower adherence independently of body fat, indicating that psychosocial factors are important targets for successful adherence to dietary interventions, regardless of body size.

OBJECTIVE:Negative urgency (i.e., acting rashly when experiencing negative affect; NU), is a theorised maintenance factor in binge-eating type eating disorders. This study examined the association between trait NU and eating disorder severity, momentary changes in state NU surrounding episodes of binge eating, and the momentary mechanistic link between affect, rash action, and binge-eating risk. METHODS:Participants were 112 individuals with binge-eating disorder (BED). Baseline measures included the UPPS-P Impulsive Behaviour Scale to assess trait NU and the Eating Disorders Examination to assess binge-eating frequency and global eating disorder severity. Ecological momentary assessment captured real-time data on binge eating, negative affect, and state NU. RESULTS:Multiple regression analysis revealed a strong association between trait NU and eating disorder severity. Generalised estimating equations showed that state NU increased before and decreased after binge-eating episodes, and that this pattern was not moderated by trait-level NU. Finally, a multilevel structural equation model indicated that increases in rash action mediated the momentary relationship between states of high negative affect and episodes of binge eating. CONCLUSION:These findings underscore the importance of both trait and state NU in binge-eating type eating disorders, and suggest NU as a potential key target for intervention.

Background Loss of control eating is more likely to occur in the evening and is uniquely associated with distress. No studies have examined the effect of treatment on within-day timing of loss of control eating severity. We examined whether time of day differentially predicted loss of control eating severity at baseline (i.e. pretreatment), end-of-treatment, and 6-month follow-up for individuals with binge-eating disorder (BED), hypothesizing that loss of control eating severity would increase throughout the day pretreatment and that this pattern would be less pronounced following treatment. We explored differential treatment effects of cognitive-behavioral guided self-help (CBTgsh) and Integrative Cognitive-Affective Therapy (ICAT).Methods Individuals with BED (N = 112) were randomized to receive CBTgsh or ICAT and completed a 1-week ecological momentary assessment protocol at baseline, end-of-treatment, and 6-month follow-up to assess loss of control eating severity. We used multilevel models to assess within-day slope trajectories of loss of control eating severity across assessment periods and treatment type.Results Within-day increases in loss of control eating severity were reduced at end-of-treatment and 6-month follow-up relative to baseline. Evening acceleration of loss of control eating severity was greater at 6-month follow-up relative to end-of-treatment. Within-day increases in loss of control severity did not differ between treatments at end-of-treatment; however, evening loss of control severity intensified for individuals who received CBTgsh relative to those who received ICAT at 6-month follow-up.Conclusions Findings suggest that treatment reduces evening-shifted loss of control eating severity, and that this effect may be more durable following ICAT relative to CBTgsh.

Disordered eating behavior has been linked to suboptimal weight outcomes following metabolic and bariatric surgery (MBS), thereby threatening the most efficacious treatment for severe obesity. While up to 40% of patients may experience loss of control (LOC) eating following MBS, mechanisms driving this behavior are not fully understood. Preliminary evidence suggests that high levels of negative affect (NA) in the moment prompt LOC eating post-MBS; however, it remains unclear whether this momentary relationship is stable or changes over the first several years following surgery. Consequently, this study examined differences in the prospective relationship between NA and LOC eating severity over time post-MBS using three waves of ecological momentary assessment data collection. Participants (n = 143, 87% female), were asked to rate momentary levels of NA and LOC eating severity on their smartphone ≥5 times/day for 7 days at 1-, 2-, and 3-years post-MBS. Both NA and LOC eating were rated on a 1-5 Likert scale, with higher scores indicating more severe symptoms. NA was within- and between-person centered and used as a prospective predictor of LOC eating severity. Analyses evaluated if time post-MBS moderated the relationship. A generalized linear mixed model demonstrated that higher NA predicted more severe LOC eating at the next signal when centered within- and between-subjects. Time post-MBS moderated the within-NA to LOC eating severity effect, such that the relationship remained unchanged between years 1 and 2, but strengthened between years 2 and 3. Findings suggest that momentary NA becomes a more powerful predictor of LOC eating severity as time passes post-MBS, which has important implications for interventions aimed at reducing LOC eating and promoting optimal weight outcomes in the post-surgical period.

Background While bariatric surgery results in substantial weight loss, one negative side effect of surgery is that patients often experience more rapid and intense intoxication effects after consuming alcohol. Objectives Given that alcohol use has been associated with impaired cognitive functioning in the general population, this study examined whether acute alcohol consumption after bariatric surgery immediately led to impaired cognitive control, and whether this effect was impacted by baseline levels of cognitive control. Setting Nonprofit teaching hospital, United States. Methods Participants were 34 adults who attended a laboratory visit before and 1 year after Roux-en-Y gastric bypass surgery, wherein they consumed a weight-based dose of alcohol and completed cognitive testing over the course of 3 hours. Results A series of generalized mixed-effect models demonstrated that performance on the cognitive task generally improved over time, likely due to practice effects. However, following bariatric surgery, individuals with impaired cognitive control before consuming alcohol experienced greater commission errors immediately afterward. Conclusions These findings suggest that alcohol use after bariatric surgery may produce immediate deficits in inhibitory control among individuals who are already vulnerable to impaired cognitive control. Clinicians should seek to educate bariatric surgery candidates on this possible effect, as deficits in inhibitory control may ultimately lead to risky behaviors and poor adherence with postsurgical medical recommendations.