Appetite 91 (2015) 69–75

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Research report

Binge eating in bariatric surgery candidates: The role of insecure attachment and emotion regulation ☆ Sharry Shakory a, Jessica Van Exan b,*, Jennifer S. Mills a, Sanjeev Sockalingam b,c, Leah Keating a, Marlene Taube-Schiff b,c a

Department of Psychology, York University, 4700 Keele St, Toronto, ON M3J 1P3, Canada Psychosocial Bariatric Surgery Program, Toronto Western Hospital, 399 Bathurst St., Toronto, ON M5T 2S8, Canada c Department of Psychiatry, University of Toronto, 250 College St., Toronto, ON, M5T 1R8, Canada b

A R T I C L E

I N F O

Article history: Received 2 December 2014 Received in revised form 21 March 2015 Accepted 24 March 2015 Available online 28 March 2015 Keywords: Insecure attachment Binge eating Emotion regulation Bariatric surgery

A B S T R A C T

Binge eating has a high prevalence among bariatric patients and is associated with post-surgical weight gain. This study examined the potential mediating role of emotion regulation difficulties in the relation between attachment insecurity and binge eating among this population. Participants were 1388 adult pre-bariatric surgery candidates from an accredited bariatric surgery assessment centre in Toronto, Ontario. Participants completed measures of psychological functioning, including attachment style and emotion regulation. Mediation analyses revealed that difficulties with emotion regulation mediated a positive association between insecure-anxious attachment and binge eating. An insecure-avoidant attachment was found to have a non-significant association with binge eating when examining the total effect. However, when difficulties with emotion regulation were controlled for in the model to examine its role as a mediator, this association became significant, and emotion regulation difficulties also mediated the relationship between attachment avoidance and binge eating. These findings suggest that difficulties in emotion regulation may be an important clinical issue to address in order to reduce binge eating in adult bariatric surgery candidates. © 2015 Elsevier Ltd. All rights reserved.

Introduction Bariatric surgery is considered the most effective means for substantial and sustained weight loss and resolution of medical comorbidities (Buchwald et al., 2004) for morbidly obese individuals (BMI ≥ 40; Maggard et al., 2005). Adherence to a calorie-restricted and healthy post-surgical diet is required to maintain weight loss, and disordered eating (e.g., binge eating) can interfere with maintaining dietary recommendations long-term (Saunders, Johnson, & Teschner, 1998). Post-surgical binge eating has significantly predicted weight loss failure (Hsu, Sullivan, & Benotti, 1997; Livhits et al., 2010; Meany, Conceicao, & Mitchell, 2014) in terms of less excess weight loss (Kofman, Lent, & Swencionis, 2010) and greater weight regain (Colles, Dixon, & O’Brien, 2008; Hsu et al., 1997; Kofman et al., 2010; Mitchell et al., 2001). Binge eating is frequently reported among bariatric surgery candidates, and binge eating prior to surgery

☆ Acknowledgments: We would like to thank our patients who participated in the study. We would also like to thank our Toronto Western Hospital Bariatric Interdisciplinary team for their support and the Ministry of Health of Ontario and the Ontario Bariatric Network for their ongoing psychosocial program funding. Conflict of interest: The authors have no conflicts of interest related to this work. * Corresponding author. E-mail address: [email protected] (J. Van Exan).

http://dx.doi.org/10.1016/j.appet.2015.03.026 0195-6663/© 2015 Elsevier Ltd. All rights reserved.

is a risk factor for binge eating following surgery, which can emerge as late as two or more years post-surgery (Hsu et al., 1997; Niego, Kofman, Weiss, & Geliebter, 2007). Given that the reoccurrence of binge eating can undermine weight loss, delineating the psychological mechanisms involved in the development and maintenance of binge eating in bariatric candidates is necessary to better understand the aspects that need to be addressed to improve postsurgery outcomes. Insecure attachment styles have been found to be associated with both disordered eating (e.g., Tasca & Balfour, 2014) and emotion regulation difficulties (e.g., Han & Pistole, 2014). Thus, the current study examined whether the relationship between attachment insecurity and binge eating is mediated by emotion regulation difficulties in bariatric candidates. Emotion regulation and binge eating The negative affect model has received much support and suggests that binge eating is a maladaptive emotion regulation strategy that is triggered by negative emotions (Wiser & Telch, 1999). Negative affect has been found to precede binge eating episodes (e.g., Haedt-Matt & Keel, 2011; Stein et al., 2007), and negative emotional states have been found to be associated with higher rates of binge eating in binge-eating disorder (BED; Zeeck, Stelzer, Linster, Joos, & Hartmann, 2011). Support has also been shown for the

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association between emotion regulation difficulties and binge eating in both non-clinical (e.g., Whiteside et al., 2007) and clinical samples. Higher rates of emotion regulation difficulties have been found in individuals with BED (Svaldi, Griepenstroh, Tuschen-Caffier, & Ehring, 2012; Zeeck et al., 2011). These findings support the notion that binge eating functions as a behavioral means of managing negative affect.

Attachment theory and emotion regulation Attachment theory provides a valuable framework for understanding eating pathology, as difficulties with emotion regulation can reflect individual differences in early attachment organization (Shaver, Mikulincer, & Chun, 2008; Tasca & Balfour, 2014). During early interactions with primary caregivers, children develop an internal cognitive-affective schema that organizes expectations of both self and others and that informs and directs subsequent behaviour (Bowlby, 1982; Shaver et al., 2008; Waters, Merrick, Treboux, Crowell, & Albersheim, 2000). These behaviours comprise attachment patterns which can be secure or insecure, and which are fairly stable across the lifetime; longitudinal research has indicated a stability rate of 72% between ages 12 months and 20 years (Waters et al., 2000). A secure attachment organization is characterized by a tendency to seek proximity from others and to effectively manage emotional distress, while insecure attachment styles (e.g., avoidant and anxious) are characterized by an overdependence on or avoidance of relationships with others to regulate attachment concerns (Shaver et al., 2008). Specifically, individuals high in attachment avoidance tend to exhibit deactivating strategies, in which emotions are suppressed and regulated through an overreliance on self. In contrast, individuals high in attachment anxiety demonstrate hyper-activating strategies such that they often become preoccupied by emotional distress and over-reliant on others to manage negative emotional responses (Hunter & Maunder, 2001; Shaver et al., 2008; Tasca & Balfour, 2014). These insecure patterns are thought to emerge as a result of interacting with unresponsive, insensitive, or inconsistent caregivers (Shaver et al., 2008). These early experiences then serve as a template for future relationships (Shaver et al., 2008). Considerable research with both children (e.g., Panfile & Laible, 2012) and adults (e.g., Gentzler, Kerns, & Keener, 2010) supports the notion that attachment insecurity is associated with greater difficulties with emotion regulation.

Attachment, emotion regulation and eating pathology Impaired emotion regulation strategies are associated with attachment insecurity and may manifest in maladaptive behaviours, such as eating disorder symptoms (Tasca & Balfour, 2014). The research to date supports this notion (Burns, Fischer, Jackson, & Harding, 2012; Han & Pistole, 2014; Keating, Tasca, & Hill, 2013; Tasca et al., 2009; Ty & Francis, 2013). Specifically, emotion regulation difficulties have been found to mediate the relationship between high attachment insecurity and disordered eating (Ty & Francis, 2013) and binge eating in non-clinical samples (Han & Pistole, 2014). These findings have also been extended to other correlates of eating pathology (Tasca et al., 2009), such as low body esteem (Keating et al., 2013) in women with eating disorders. Findings regarding the mediating role of emotion regulation in the relation between anxious attachment and disordered eating are particularly consistent. In contrast, the results are mixed for the role of emotion regulation in the relation between avoidance attachment and disordered eating (Tasca et al., 2009; Ty & Francis, 2013). Given that binge eating may be more related to under-controlled, as opposed to over-controlled emotion regulation, one could speculate that individuals who are high in avoidant attachment would be more inclined to engage in restrictive dietary behaviour than in binge eating (Tasca & Balfour, 2014). However, limited research has examined the different dimensions of attachment insecurity, and only one study has focused on binge eating specifically (Han & Pistole, 2014). There are also no known studies to date that have examined these associations in a bariatric population. The current study investigated whether emotion regulation difficulties mediate the relationship between attachment insecurity and binge eating in pre-surgical bariatric candidates. As such, the current study sought to extend research by Ty and Francis (2013) and by Han and Pistole (2014) using a sample of bariatric surgery candidates. It was hypothesized that there would be a significant positive relationship between insecure-anxious attachment and binge eating, and that this relationship would be mediated by difficulties with emotion regulation. A similar model was examined for the avoidant attachment style. However, it was hypothesized that there would be no significant association with binge eating, since deactivating strategies are more common in individuals high in avoidance (Hunter & Maunder, 2001; Tasca & Balfour, 2014) and since the relationship between over-controlled emotion regulation strategies and binge eating remains unclear. Method

Attachment style and eating pathology

Participants

Higher rates of attachment insecurity have been reported among eating disordered women compared to women without eating disorders (O’Shaughnessy & Dallos, 2009; Troisi, Massaroni, & Cuzzolaro, 2005; Zachrisson & Skarderud, 2010), and higher attachment anxiety is associated with greater severity of eating disorder symptoms (Tasca & Balfour, 2014). Attachment insecurity has also been found to be associated more specifically with disinhibited eating (Wilkinson, Rowe, Bishop, & Brunstrom, 2010) and binge eating (Han & Pistole, 2014) in non-clinical samples of university students. There has been limited research examining the role of attachment insecurity in bariatric samples. In pre-bariatric surgery candidates, attachment insecurity has been found to be associated with poorer mental quality of life (Aarts, Hinnen, Gerdes, Acherman, & Brandjes, 2014; Sockalingam, Wnuk, Strimas, Hawa, & Okrainec, 2011) and high attachment avoidance has been found to be associated with postbariatric surgery non-attendance (Sockalingam, Cassin, Hawa et al., 2013). The relationship between attachment insecurity and binge eating has not yet been examined in bariatric patients.

Participants were 1388 morbidly obese patients who were being assessed in terms of their candidacy for bariatric surgery at Toronto Western Hospital (TWH) in Toronto, Ontario. TWH is an adult bariatric surgery assessment centre that has been accredited by the American College of Surgeons as a Level 1A bariatric surgery Centre of Excellence. The pre-surgery assessment process has been described in previous studies (Pitzul et al., 2014; Sockalingam, Cassin, Crawford et al., 2013). Procedure The current study utilized cross-sectional data collected from presurgical bariatric candidates in the Bariatric Surgery Program at TWH between May 2010 and August 2013. These data were collected as part of a larger study evaluating psychosocial outcomes of bariatric surgery. This study was approved by the University Health Network research ethics review board. To be eligible for the program, patients must have a BMI ≥40 or ≥35 with a comorbid obesity-related

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medical condition. All patients receive the Roux-en-Y gastric bypass (RYGB) surgical procedure unless a sleeve gastrectomy is surgically indicated. Recruited patients completed the psychosocial questionnaires during the pre-surgery assessment process.

Measures

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Table 1 Bivariate correlations between variables. Variable

1

2

3

4

1. Attachment anxiety 2. Attachment avoidance 3. Emotion regulation difficulties 4. Binge eating

–

.39* –

.58* .50* –

.33* .19* .44* –

* p < .01.

Sociodemographic data A demographics questionnaire was used to obtain information about participants’ age, gender, BMI (objective), race/ethnicity, relationship status, educational status, and employment status.

Attachment style The Experiences in Close Relationships scale (ECR-M16; Lo et al., 2009) is a modified 16-item version of the ECR-M36. It is comprised of two 8-item subscales that measure attachment in close relationships: anxiety (fear of rejection and abandonment) and avoidance (discomfort with closeness and dependence on others). Items are rated on a 7-point Likert scale and scores for each subscale range from 8 to 56, with higher scores representing higher attachment insecurity. The ECR-M16 has been validated against the longer version (Lo et al., 2009) and has been used in a sample of bariatric surgery candidates (Sockalingam et al., 2011). In the current sample, the internal consistency was high (Cronbach alpha values were .89 and .85 for the anxiety and avoidance subscales, respectively).

Difficulties with emotion regulation The Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) is a 36-item self-report measure developed to assess difficulties with emotion regulation and items are rated on a 5-point Likert scale, with higher scores indicating greater difficulty with emotion regulation. The total score was used in the current study and internal consistency was high in the current sample (Cronbach’s alpha = .95). The DERS has been validated for use with obese adults with BED (Gianini, White, & Masheb, 2013; Gratz & Roemer, 2004).

Binge eating The Binge Eating Scale (BES; Gormally, Black, Daston, & Rardin, 1982) is a widely-used 16-item self-report measure of binge eating severity in obese individuals. Each item is rated on either a 3- or 4-point scale and the total scores are used (range from 0 to 46). Total scores that are below 17 indicate absent or minimal binge-eating, scores between 18 and 26 suggest moderate binge eating severity, and scores at or above 27 indicate a high severity of binge eating (Hood, Grupski, Hall, Ivan, & Corsica, 2013). There is empirical support for the use of the BES among bariatric surgery candidates (Mazzeo, Saunders, & Mitchell, 2005) and the Cronbach’s alpha was .86 in the current sample.

Eating disorder symptoms The Eating Disorder Examination Questionnaire (EDE-Q 6.0; Fairburn & Beglin, 1994) is a 28-item questionnaire version of the interview based EDE, which measures disordered eating in the past month using a 7-point Likert scale. The EDE-Q is a valid and reliable instrument for evaluating eating disorder symptoms in bariatric surgery candidates (Hrabosky et al., 2008). There was considerable between-subject variability in terms of participants’ level of severity of general disordered eating, including dietary restraint, weight concern, and other variables typically related to binge eating. Therefore, global disordered eating was controlled for statistically by including the EDE-Q as a covariate (see Table 2). In the current sample, Cronbach’s alpha was .83.

Statistical analysis All analyses were performed using SPSS software version 21.0 for Windows. The data were screened for data entry errors, missing values, and multivariate assumptions. Less than 15% of responses to all items were missing, and missing value analysis indicated that the data were missing at random. To circumvent potential biases arising from casewise deletion (Schafer & Graham, 2002), multiple imputation with five imputations was conducted for missing subscale and total scores. Skewed variables were transformed using logarithmic or square root transformations. There were three univariate and four multivariate outliers for which less extreme scores were assigned (Tabachnick & Fidell, 2007). Pearson product-moment correlation coefficients were computed to examine correlations between variables. To test the hypothesis that the relationship between insecure anxious attachment and binge eating is mediated by emotion regulation difficulties, bootstrapping was conducted with bias-corrected confidence intervals using the Indirect Macro for SPSS (Preacher & Hayes, 2008). Five thousand samples were taken with replacement. The indirect effect is determined to be significant when zero is not contained in the 95% confidence interval (Preacher & Hayes, 2004). This procedure has lower Type I and Type II error rates and higher power than both the Sobel test and the Baron and Kenny (1986) test for mediation (Fritz & MacKinnon, 2007). In this analysis, attachment anxiety or avoidance was the predictor variable, difficulties with emotion regulation was the mediator variable, and binge eating was the outcome variable. Given the moderate correlation between the two attachment dimensions (Table 1), mediation analysis of each attachment model was performed while controlling for the effect of the other. Global disordered eating was controlled for using the EDE-Q global score. Gender, age, and BMI were not controlled for as they were not significantly correlated with the variables of interest. Results Participant characteristics The sample was predominately female (79.3%) with a mean age of 44.69 (SD = 10.59; Range = 17–74) and a mean BMI of 49.00 kg/ m 2 (SD = 8.67; Range = 32.4–109.10). The most common selfidentified ethnicity was White (84.8%, n = 754), followed by Black (5.2%, n = 46), Asian (4.2%, n = 37), Hispanic (3.6%, n = 32), and Other (2.2%, n = 20). In terms of relationship status, 52.8% (n = 515) were married, 8.8% (n = 86) were common-law, 22.8% (n = 222) were single, 7.9% (n = 77) were divorced, 6.1% (n = 59) were separated, and 1.6% (n = 16) were widowed. Regarding educational background, 28.7% (n = 269) reported a high school education or less, 12.0% (n = 112) attended some college, 4.4% (n = 41) attended some university, 36.3% (n = 340) had a college diploma, 13.9% (n = 130) had a bachelor’s degree, and 4.7% (n = 44) had a graduate degree. In terms of employment status, 59.2% (n = 572) were full-time, 8.8% (n = 85) were part-time, 9.4% (n = 91) were unemployed, 6.0% (n = 58) were retired, 3.0% (n = 29) were on social assistance, and 13.6% (n = 131) were on disability.

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Table 2 Descriptive statistics (N = 1388). Variable

Range

M

SD

Attachment anxiety Attachment avoidance Emotion regulation difficulties Binge eating Global disordered eating

8–56 8–56 40–147 0–43 0.13–6

26.78 24.06 76.69 17.56 3.31

11.89 10.12 22.16 8.35 1.00

Correlational analyses Pearson product moment correlations among the variables of interest are presented in Table 1. Correlations among difficulties with emotion regulation, anxious attachment, avoidant attachment, and binge eating were all significant and positive, suggesting that the mediation analysis was appropriate (Baron & Kenny, 1986). The ranges, means, and standard deviations for all of the variables of interest are presented in Table 2. For the BES, the mean was in the minimal–to mild range and according to suggested cut-off scores, 53% reported minimal binge-eating (scores < 17; Gormally et al., 1982), 32% reported mild- moderate binge-eating (scores between 18 and 26) and 15% reported high binge eating severity (scores > 27). Compared to the bariatric sample reported in Hood et al. (2013), this sample had lower rates of minimal binge eating and higher rates for both mild-to moderate and high binge-eating severity.

Fig. 2. Unstandardized regression coefficients for the paths between avoidant attachment, emotion regulation difficulties, and binge eating. The coefficients in parentheses represent the direct path from avoidant attachment to binge eating when the mediator was controlled for in addition to the covariates (anxious attachment and global disordered eating symptoms); *p < .01, **p < .001.

difficulties in emotion regulation was significant, with a point estimate of 0.08 (SE = .011) and a 95% CI of 0.06 to 0.12. Furthermore, the direct effect of avoidant attachment on binge eating (controlling for emotion regulation difficulties) was significant (B = −0.10, t(1386) = −3.99, p = .006), but in the opposite direction than the indirect effect, suggesting competitive mediation. That is, both the indirect effect and the direct effect were significant but point in opposite directions, suggesting the likelihood of an omitted mediator (Zhao et al., 2010). Figure 2 displays these results.

Mediation analyses Exploratory analyses In the first mediation model tested, anxious attachment was the predictor variable, binge eating was the outcome variable, and difficulties with emotion regulation were the mediating variable. The indirect effect of attachment anxiety on binge eating through emotion regulation difficulties was significant, with a point estimate of 0.01 (SE = .001) and a 95% CI of 0.008 to 0.012. In addition, although the total effect (where the mediator is not controlled for) was significant (B = 0.02, t(1386) = 6.36, p = .001), the direct effect of anxious attachment on binge eating became non-significant (B = 0.01, t(1386) = 1.94, p = .112) when controlling for difficulties in emotion regulation, suggesting a strong mediation effect. Figure 1 displays these results. In the second mediation model tested, avoidant attachment was the predictor variable, binge eating was the outcome variable, and difficulties with emotion regulation was the mediating variable. The total effect (where the mediator is not controlled for) was not significant (B = −0.02, t(1386) = −0.82, p = .354). However, researchers have indicated that the only requirement to demonstrate mediation is a significant indirect effect (Zhao, Lynch, & Chen, 2010). The indirect effect of attachment avoidance on binge eating through

Although the proposed mediation model implies a causal relationship among the variables, the current study was cross-sectional in design, limiting the ability to make causal inferences. Therefore, while the present study explored one possible pathway, other pathways may be possible. For example, it may be that attachment insecurity leads to binge eating (through an alternative pathway), and emotion regulation difficulties increase in response to binge eating. An exploratory analysis was investigated in order to explore this alternative reversed mediational model in which binge eating is the mediator variable, attachment insecurity is the predictor variable, and emotion regulation difficulties are the outcome variable. As shown in Fig. 3, the indirect effect of attachment anxiety on emotion regulation difficulties through binge eating was significant, with a point estimate of 0.0004 (SE = .0001) and a 95% CI of 0.0003 to 0.0005. Furthermore, the total effect of anxious attachment on emotion regulation difficulties was significant (B = 0.004, t(1386) = 17.30, p = .001), and the direct effect of anxious attachment on emotion regulation difficulties was significant (B = 0.004,

Fig. 1. Unstandardized regression coefficients for the paths between anxious attachment, emotion regulation difficulties, and binge eating. The coefficients in parentheses represent the direct path from anxious attachment to binge eating when the mediator was controlled for in addition to the covariates (avoidant attachment and global disordered eating symptoms); **p < .001.

Fig. 3. Unstandardized regression coefficients for the paths between anxious attachment, binge eating, and emotion regulation difficulties. The coefficients in parentheses represent the direct path from anxious attachment to emotion regulation difficulties when the mediator was controlled for in addition to the covariates (avoidant attachment and global disordered eating symptoms); **p < .001.

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Fig. 4. Unstandardized regression coefficients for the paths between avoidant attachment, binge eating, and emotion regulation difficulties. The coefficients in parentheses represent the direct path from avoidant attachment to emotion regulation difficulties when the mediator was controlled for in addition to the covariates (anxious attachment and global disordered eating symptoms); **p < .001.

t(1386) = 15.98, p = .001). In other words, binge eating does appear to have a mediating role in the relation between anxious attachment and emotion regulation difficulties, suggesting that this is also a plausible pathway. However, in examining the total effect and the direct effect, it appears that binge eating is a weak mediator given that the strength and magnitude of the relationship between anxious attachment and emotion regulation difficulties remains the same even when controlling for binge eating. In the second reversed mediation model tested (Fig. 4), the indirect effect of attachment avoidance on emotion regulation difficulties through binge eating was not significant, with a point estimate of 0.0005 (SE = .0006) and a 95% CI of −0.002 to 0.001. The total effect of attachment avoidance on emotion regulation difficulties was significant (B = 0.03, t(1386) = 13.34, p = .001), and the direct effect of attachment avoidance on emotion regulation difficulties was also significant (B = 0.03, t(1386) = 13.97, p = .001). In other words, binge eating does not appear to be a mechanism by which avoidant attachment is linked to emotion regulation difficulties. These results support the notion that avoidant attachment and binge eating are associated through difficulties in emotion regulation, as noted in the original mediation model. Discussion The current study examined whether difficulties in emotion regulation mediate the relation between attachment insecurity and binge eating in bariatric surgery candidates. Many studies have provided support for the conceptualization of binge eating as a maladaptive emotion regulation strategy that is triggered by negative affect (e.g., Gianini et al., 2013; Svaldi et al., 2012; Whiteside et al., 2007). Preliminary research findings have noted the role of difficulties with emotion regulation in mediating the positive relationship between attachment insecurity and disordered eating symptoms (Ty & Francis, 2013) as well as between attachment insecurity and binge eating more specifically (Han & Pistole, 2014). The results of the current analyses were consistent with the literature in that difficulty with emotion regulation was found to mediate the relationship between both avoidant and anxious attachment styles and binge eating in bariatric surgery candidates. This was true even after accounting for the influence of global eating pathology (e.g., dietary restraint, weight concern) on binge eating symptoms. These results suggest that emotion regulation difficulties are an important aspect of understanding how attachment-related difficulties affect binge eating. The current study’s findings not only replicate findings in a sample of bariatric surgery candidates (Han & Pistole, 2014; Ty & Francis, 2013), but are also unique in that the current study exclusively focused on binge eating in relation to different dimensions of attachment insecurity.

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Regarding attachment insecurity, the current study hypothesized that the role of emotion regulation would be different based on the type of insecure attachment pattern. More specifically, it was expected that attachment anxiety would demonstrate a positive association with binge eating but that individuals high in avoidant attachment would demonstrate a negative association, since emotion deactivating strategies are commonly associated with this attachment style. This hypothesis was partially supported. Difficulties with emotion regulation mediated the positive association between an insecure-anxious attachment style and binge eating. Difficulties with emotion regulation, and hyper-activating strategies in particular, are common among individuals high in attachment anxiety (Hunter & Maunder, 2001; Shaver et al., 2008; Tasca & Balfour, 2014). The results from the current study are consistent with this finding in that individuals with high attachment anxiety reported increased binge eating through greater difficulty regulating emotions. Consistent with the hypothesis that avoidant attachment would not be associated with binge eating, the mediation analyses revealed that the total relationship between avoidant attachment and binge eating was non-significant, when controlling for attachment anxiety and global disordered eating in this bariatric sample. These variables were not controlled for in conducting the Pearson moment correlations, which may explain the discrepancy in the direction and significance of the associations found between these two methods of analyses (i.e., a significant positive association between avoidant attachment and binge eating was found for the Pearson moment correlations, but a non-significant negative association was found from the correlations computed with bootstrapping). Individuals high in attachment avoidance have a tendency to down-regulate their emotions with the denial and repression of negative emotions (Hunter & Maunder, 2001; Shaver et al., 2008; Tasca & Balfour, 2014). On the other hand, when emotion regulation difficulties are accounted for, the direct effect is significant and negative such that greater avoidance is associated with less binge eating; however, the mediation effect is positive suggesting that attachment avoidance is positively associated with emotion regulation difficulties, which in turn is positively associated with binge eating. That is, these results suggest that while there is an indirect effect of attachment avoidance on binge eating through emotion regulation difficulties, a unique aspect of attachment avoidance which is not subsumed by emotion regulation difficulties is negatively associated with binge eating. These findings therefore suggest that attachment avoidance is a multifaceted construct; while one aspect may be associated with binge eating through maladaptive attempts to suppress and deactivate one’s emotions, other components of this construct may be negatively linked to binge eating through other mediators which have yet to be determined (e.g., over-control over one’s emotions and behaviours). Few research studies have looked at attachment avoidance separately from attachment anxiety (Han & Pistole, 2014) and further research is needed to elucidate these relationships. Clinical implications These findings point to the importance of understanding attachment patterns and emotion regulation processes in the development and maintenance of binge eating in bariatric surgery candidates. The current findings suggest that addressing underlying emotion regulation difficulties may be helpful in reducing binge eating behaviour in those with more insecure attachment patterns. Given that attachment style and emotion regulation are likely to persist after surgery, it would be important to assess whether these factors are also associated with binge-eating that re-emerges post-surgery. It would be important to consider attachment style and emotion regulation when assessing patients’ readiness for surgery, and patients would likely benefit from treatments (e.g.,

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Group Psychodynamic Interpersonal Therapy; Maxwell, Tasca, Ritchie, Balfour, & Bissada, 2013, and Dialectical Behavior Therapy; Linehan, 1993; Safer, Robinson, & Booil, 2010) that can target these difficulties both pre- and post-surgery. Limitations and future directions Results of the current study must be considered in light of some study limitations. First, the study involves a cross-sectional design and correlational analyses. It is therefore not possible to infer causal or temporal relationships. One alternative model was tested for each attachment style, and this alternative model was less supported by the data. It would be important to look at these variables longitudinally to understand how these psychological processes impact binge eating over the long-term, as limited research has identified predictors of binge-eating post-surgery and this would further delineate the temporal ordering of these variables. Future studies with a prospective longitudinal design, as well as controlled studies examining binge eating with experimentally-induced negative emotions in individuals with attachment insecurity, are needed to replicate and extend the current findings. Additionally, the patients in the current sample were not screened for BED and the mean severity of binge eating in the current sample was minimal-mild. Therefore, these findings may not extend to patients with BED or a higher severity of binge-eating. Further research looking at these associations in clinical samples of BED is warranted. This study’s reliance on self-report measures involves the potential for response bias; examining these relationships using structured interviews such as the Adult Attachment Interview (AAI; Main, Goldwyn, & Hesse, 2003) would be beneficial (Tasca, Ritchie, & Balfour, 2011). Finally, the generalizability of these findings is unknown, as our sample consisted of pre-surgical bariatric candidates who were predominately White women. White women comprise 80–90% of patients in bariatric surgery studies and our sample matches those of previous studies (e.g., Kofman et al., 2010; Mitchell et al., 2001). However, the comparatively smaller number of men in the sample may have limited the statistical power of these analyses to detect significant differences between genders. Conclusions The present study extends the existing literature on eating pathology and attachment, and suggests that difficulties in emotion regulation explains the relationship between anxious and avoidant attachment and binge eating in pre-surgical bariatric candidates. These findings point to the importance of not only identifying binge eating prior to bariatric surgery, but recognizing psychosocial factors, such as attachment insecurity and emotion regulation difficulties which may contribute to binge eating. Identifying and addressing these issues prior to and/or after bariatric surgery might help to improve health outcomes. References Aarts, F., Hinnen, C., Gerdes, V. E., Acherman, Y., & Brandjes, D. P. (2014). Coping style as a mediator between attachment and mental and physical health in patients suffering from morbid obesity. International Journal of Psychiatry in Medicine, 47(1), 75–91. Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social psychological research. Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173–1182. Bowlby, J. (1982). Attachment and loss. Vol. 1. Attachment (2nd ed.). New York: Basic Books. Buchwald, H., Avidor, Y., Braunwald, E., Jensen, M. D., Pories, W., Fahrbach, K., et al. (2004). Bariatric surgery. A systematic review and meta-analysis. Journal of the American Medical Association, 292, 1724–1737. Burns, E. E., Fischer, S., Jackson, J. L., & Harding, H. G. (2012). Deficits in emotion regulation mediate the relationship between childhood abuse and later eating disorder symptoms. Child Abuse & Neglect, 36, 32–39.

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