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Psychosocial predictors of problematic eating in young adults who underwent adolescent bariatric surgery

Abstract Introduction This study examined problematic eating and eating‐related psychopathology among young adults who underwent adolescent bariatric surgery including concurrent and prospective associations with psychosocial factors and weight change. Methods VIEW point is a 6‐year follow‐up study within a prospective observational study series observing adolescents with severe obesity who had bariatric surgery (n = 139) or who presented to nonsurgical lifestyle modification programs (n = 83). Participants completed height/weight measurements, questionnaires, and diagnostic interviews. Regression analyses compared problematic eating across groups and examined Year 6 correlates (i.e., psychosocial factors and weight change) and baseline predictors (i.e., psychosocial factors) of eating‐related psychopathology. Results Compared to the nonsurgical group, the surgical group reported lower eating‐related psychopathology, objective binge eating, and grazing at Year 6. While chewing/spitting out and vomiting for weight/shape‐related reasons were very infrequent for the surgical group, self‐induced vomiting for other reasons (e.g., avoid plugging) was more common. For the surgical group, lower self‐worth, greater internalizing symptoms, and higher weight‐related teasing in adolescence predicted increased eating‐related psychopathology in young adulthood. Year 6 eating‐related psychopathology was concurrently associated with lower percent weight loss for the surgical group and greater percent weight gain for the nonsurgical group. Conclusion Undergoing adolescent bariatric surgery appears to afford benefit for problematic eating and eating‐related psychopathology. Current findings suggest that the clinical intervention related to problematic eating and associated psychosocial concerns may be needed for young adults with obesity, regardless of surgical status.


| INTRODUCTION
Problematic eating behaviors such as overeating and binge eating are common among youth with higher weight 1 and may persist and increase from adolescence to young adulthood. 2 These behaviors can detrimentally impact physical and psychosocial functioning 3 including increasing risk for development of full-syndrome eating disorders, 4 which impact 55.5 million individuals worldwide. 5 In the United States, adolescent severe obesity (7.7% prevalence, body mass index [BMI] >120% of the sex-specific 95th percentile) 6 and associated health conditions are of high public health concern as they are typically carried into young adulthood 7 without successful intervention. While bariatric surgery is a highly effective treatment for improved health and quality of life for adolescents with severe obesity, 8 problematic eating behaviors may attenuate surgery benefits. Unfortunately, we know little about the impact of such behaviors in these uniquely high-risk clinical populations, young adults who underwent bariatric surgery and those with persistent, severe obesity.
Presurgery prevalence of problematic eating behaviors (e.g., loss of control [LOC] eating, binge eating) among adolescents in the United States 9,10 appear similar to rates among nonsurgical samples of youth with overweight or obesity 1 but higher than the general adolescent population. 2 Early research among adolescents who underwent laparoscopic adjustable gastric banding highlighted that presurgical LOC eating was associated with poorer postsurgical BMI change 11 and early dropout from postsurgical treatment. 12 Recent work from prospective longitudinal cohorts in the United States (Teen Longitudinal Assessment of Bariatric Surgery [Teen-LABS]) 9,13 and Sweden (Adolescent Morbid Obesity Study [AMOS]) 14 has indicated that problematic eating behaviors (e.g., LOC, binge eating) decreased dramatically from pre to postsurgery (4-6 years) and postsurgical problematic eating was associated with poorer weight loss outcomes. 9,14 This prior work provides invaluable insight into patients' experiences of LOC, binge eating, and eating-related psychopathology both presurgery and across time. 9,11,12,14 Measuring problematic eating using semi-structured diagnostic interviews would advance this literature, which has largely relied on self-report questionnaires.
While research with adults who underwent bariatric surgery has measured problematic eating using semi-structured diagnostic interviews, 15 which is recommended as a more rigorous assessment method for this population than questionnaires, 16 no studies have incorporated such measurement among young adults who underwent surgery while also examining associations with novel psychosocial factors.
Utilizing a prospective observational design, we aimed to examine relevant problematic eating behaviors (i.e., objective binge eating, objective overeating, and grazing) and eating-related psychopathology (e.g., eating restraint and eating/weight/shape concerns) that may adversely impact health outcomes 9,14,17 in a sample of young adults (ages [19][20][21][22][23][24] in the United States who had bariatric surgery as adolescents (aged [13][14][15][16][17][18]. A comparator group who did not undergo surgery provide critical developmental context regarding the psychosocial trajectory of adolescents with severe obesity as they transition to young adulthood. This study aimed at (Aim 1) describing and comparing problematic eating behaviors and eating-related psychopathology at presurgery/baseline and Year 6 postsurgery/follow-up.
We hypothesized that groups would have similar rates of problematic eating behaviors and eating-related psychopathology at presurgery/ baseline, and that the surgical group would have lower rates at Year 6.
Additionally, we described Year 6 eating behaviors unique to patients undergoing surgery and those that are historically low frequency (e.g., vomiting). Within surgical and nonsurgical groups, we examined (Aim 2) concurrent correlates and (Aim 3) presurgery/baseline predictors of Year 6 eating-related psychopathology, including internalizing symptoms, self-worth, weight-related teasing, and weight-related quality of life (WRQOL). For Aims 2 and 3, increased internalizing symptoms, decreased self-worth, increased weightrelated teasing, and poorer WRQOL were hypothesized to be associated with increased eating-related psychopathology. Finally, we examined (Aim 4) concurrent associations between problematic eating behaviors, eating-related psychopathology, and percent weight change at Year 6. We hypothesized that increased problematic eating behaviors and eating-related psychopathology at Year 6 would be associated with lower percent weight loss (surgical) and higher percent weight gain (nonsurgical).

| Design and participants
VIEWpoint is a 6-year follow-up study within TeenVIEW, a prospective observational study series observing adolescents with severe obesity into young adulthood who either underwent bariatric surgery (e.g., surgical group) or presented for nonsurgical lifestyle modification programs (e.g., nonsurgical group). TeenVIEW was not designed as a comparative intervention trial as its parent study, Teen-LABS (NCT00474318), is conducting first generation safety and efficacy observation of adolescent bariatric surgery outcomes. As such, Teen-VIEW added a comparator group and aimed to illuminate psychosocial benefits and risks associated with adolescent bariatric surgery relative to a more "natural course" for adolescent severe obesity similar to an approach taken by the AMOS Study 14 conducted during the same time period. As an ancillary study to Teen-LABS study (N = 242, recruitment 546 -DECKER ET AL. age 13 to ≤19 years), 8 adolescents were either a subgroup of Teen-LABS participants enrolled within 30 days prior to surgery or a group of demographically similar (i.e., sex, race, and �6 months in age) adolescents with severe obesity in nonsurgical lifestyle modification programs across the five Teen-LABS sites in the United States. Initial eligibility criteria and enrollment procedures have been previously reported. 8,18 Consistent with national bariatric surgery trends, 19 Teen-LABS adolescents self-identified predominantly as non-Hispanic white females, with fewer teens identifying with other racial and ethnic groups (e.g., non-Hispanic Black). Efforts were made to match nonsurgical to surgical adolescents by race and ethnicity. While groups were statistically similar when comparing non-Hispanic white to all other racial and ethnic groups (Table 1)

| Procedures
Written assent/consent was obtained at each time point. At presurgery/baseline, research personnel measured heights/weights and administered paper/pencil questionnaires to adolescents in person at Teen-LABS sites. At Year 6, young adults completed self-report questionnaires via a secure web-based portal onsite or at home and structured clinical interviews via phone with a trained clinician.
For surgical participants, height/weight were either measured on-site during their Teen-LABS visit (n = 92), by trained field examiners at home visits (n = 29), or via self-report (n = 7). 8 Height/weight for nonsurgical participants was measured at a Quest Diagnostics TM location closest to their home (n = 50) or via self-report (n = 13).

Eating Disorder Examination-Bariatric Surgery Version
The Eating Disorder Examination-Bariatric Surgery Version (EDE-BSV) 15 was adapted from the EDE, a well-established semi-structured clinical interview used to assess eating-related behaviors and cognitions and diagnose eating disorders. 20 The present study assessed

Questionnaire on Eating and Weight Patterns-Revised
The Questionnaire on Eating and Weight Patterns-Revised (QEWP-R) is a self-report measure of problematic eating behaviors 21 with adequate reliability and validity 22

Internalizing symptoms
The Youth Self-Report 23 Internalizing subscale assessed depression and anxiety symptoms at presurgery/baseline. It has good psychometric properties, and higher T-scores indicate greater symptomology. 23 At Year 6, internalizing symptoms were assessed using the Structured Clinical Interview for DSM-IV-TR, 24 a widely used semistructured, diagnostic interview of psychiatric disorders. Meeting diagnostic criteria for at least one anxiety and/or depressive disorder was coded as 1 and not meeting criteria for as 0.

Self-worth
Global self-worth, or how happy an individual feels with themselves and their life, was assessed at baseline using Harter's Self-Perception Profile for Adolescents 25 and at Year 6 using the college student version. 26 This measure has good psychometric properties, 25,26 and higher scores indicate greater self-worth.

Weight-related Quality of Life
The impact of weight on quality of life was used to assess Weightrelated Quality of Life (WRQOL) at baseline (Kids version) 27 and at Year 6 (Lite version). 28 Total raw scores were transformed (0-100 scale) with higher scores indicating better WRQOL. These measures have strong psychometric properties. 27,28 Weight-related teasing At presurgery/baseline, frequency of self-reported weight-related teasing was assessed using the perception of teasing scale, which has good reliability and validity. 29 Items were summed and higher scores indicated greater frequency of weight-related teasing.

| Young adult eating and weight change
Separate regressions were conducted to examine concurrent (Year 6) associations of problematic eating behaviors and eating-related psychopathology with weight change outcomes while controlling for covariates (see Table 2). For the surgical group, eating-related psychopathology, objective overeating, and objective binge eating were associated with lower percent weight loss (p's < 0.001). For the nonsurgical group, eating-related psychopathology was associated with higher percent weight gain (p < 0.001).    Table 3. Chewing and spitting out, rumination, and vomiting for weight-and shape-related reasons were very low (<1%-2%). More common were plugging, dumping, and vomiting for non-weight-and shape-related reasons.

| Concurrent associations with young adult eating-related psychopathology
Concurrent associations between psychosocial variables (i.e., internalizing symptoms, self-worth, and WRQOL) and eating-related psychopathology were examined at Year 6 (see Table 4). While controlling for covariates and baseline problematic eating behaviors, lower WRQOL and global self-worth were associated with higher eatingrelated psychopathology for the surgical and nonsurgical groups (p < 0.001).

| Predictive associations of young adult eatingrelated psychopathology
The associations between pre-surgery/baseline psychosocial factors (internalizing symptoms, self-worth, weight-related teasing, and WRQOL) and eating-related psychopathology at Year 6 were examined. For the surgical group, lower self-worth (p < 0.001), greater internalizing symptoms (p = 0.03), and higher weight-related teasing (p = 0.04) predicted increased eating-related psychopathology at Year 6 (p < 0.001) after controlling for covariates (see Table 4).
For the nonsurgical group, no significant baseline psychosocial factors were identified.

| DISCUSSION
The present study is the first to examine problematic eating behaviors, eating-related psychopathology, and associated psychosocial factors across time among both surgical and nonsurgical treatment-seeking youth with severe obesity. As expected, young adults in the nonsurgical group reported greater Year 6 objective binge eating, grazing, and eating-related psychopathology than those who had bariatric surgery.
Previous research has shown improvement in problematic eating behaviors following surgery, 9,14 and while not designed as a comparative trial, the present findings highlight potential benefits associated with adolescent bariatric surgery in the context of a more "natural course" for severe obesity among peers who did not undergo surgery.
While anatomical changes (e.g., reduced stomach capacity) from bariatric surgery likely impact problematic eating behaviors and contribute to group differences, eating-related psychopathology differences are less likely to be an artifact of anatomical differences given that the EDE-BSV explicitly excludes surgery-motivated eating behaviors (e.g., restrictive eating to avoid plugging) from the score.
Additionally, this study is the first to describe bariatric surgerymotivated eating behaviors among young adults. Future research should explore the function (e.g., adaptive vs. pathological) and impact F I G U R E 1 Differences in problematic eating behaviors between surgical and nonsurgical groups at baseline and Year 6 550 -DECKER ET AL. -551 of these behaviors and ensure that assessment is appropriately tailored and accurately estimating symptomology for this unique group. 31 Although concurrent associations between psychosocial factors and eating-related psychopathology in young adulthood yielded congruent trends across groups, differences emerged in predictive  36  In conclusion, young adults who had adolescent bariatric surgery reported higher problematic eating than nonsurgical peers during adolescence but reported lower engagement in young adulthood. For those who had bariatric surgery, poorer presurgical psychosocial functioning was associated with problematic eating 6 years postsurgery, which was concurrently associated with lower percent weight loss. Undergoing bariatric surgery during adolescence appears to afford benefit for problematic eating and eating-related psychopathology. As problematic eating may detrimentally impact treatment benefit, continued assessment and treatment is important throughout postoperative life.