Author's Accepted Manuscript

What is Grazing? Reviewing its Definition,

Frequency, Clinical Characteristics and Impact on
Bariatric Surgery Outcomes, and Proposing a
Standardized Definition
Eva Conceio PhD, James E. Mitchell MD, PhD,
Scott Engle PhD, Paulo P.P. Machado PhD, Kathryn
Lancaster BA, Stephen Wonderlich PhD

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PII: S1550-7289(14)00201-9
DOI: http://dx.doi.org/10.1016/j.soard.2014.05.002
Reference: SOARD1997

To appear in: Surgery for Obesity and Related Diseases

Cite this article as: Eva Conceio PhD, James E. Mitchell MD, PhD, Scott Engle PhD,
Paulo P.P. Machado PhD, Kathryn Lancaster BA, Stephen Wonderlich PhD, What is
Grazing? Reviewing its Definition, Frequency, Clinical Characteristics and Impact on
Bariatric Surgery Outcomes, and Proposing a Standardized Definition, Surgery for
Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2014.05.002

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 WHAT IS GRAZING? REVIEWING ITS DEFINITION, FREQUENCY, CLINICAL

CHARACTERISTICS AND IMPACT ON BARIATRIC SURGERY OUTCOMES, AND PROPOSING

A STANDARDIZED DEFINITION

Eva Conceio,a* PhD; James E Mitchell,b,c MD, PhD; Scott Engle,b,c PhD; Paulo PP

Machado,a PhD; Kathryn Lancaster,b BA; Stephen Wonderlich,b,c PhD

a
University of Minho, School of Psychology, Braga, Portugal
b
Neuropsyhciatric Research Institute, Fargo, ND, USA
c
University of North Dakota, School of Medicine and Health Sciences, Fargo, ND, USA

*Corresponding author: econceicao@psi.uminho.pt; Tel: +351 253604650; Fax: +351 253604224.

University of Minho, School of Psychology, Campus Gualtar, 4710-057, Braga, Portugal

Role of Funding Sources

This research was partially supported by a Fundao para a Cincia e a Tecnologia / Foundation

for Science and Technology, Portugal post-doctoral grant (SFRH/BPD/78896/2011) to Eva

Conceio; grant (PTDC/MHC-PCL/4974/2012) to Eva Conceio. FCT had no role in the

study design, collection, analysis or interpretation of the data, writing the manuscript, or the

decision to submit the paper for publication.

Acknowledgements

The authors wish to thank all the clinicians and researchers who responded to our survey and

revised the final version of this manuscript. They provided great information for discussion of

this concept and their input was crucial. A special thanks to Drs Leslie Heinberg; Ronna

Saunders; Martina de Zwaan; Carlos Grilo; Luca Busetto, Marney White; Michael Devlin;

Melissa Kalarchian; Marsha Marcus; Christie Zunker; Trisha Karr; Ana Vaz; Heather Simonich;

Athena Robinson; Debra Safer; Robin Masheb; Deborah Reas.

WHAT IS GRAZING? DEFINING THE CONCEPT

Background: Grazing, characterized by a repetitive eating pattern, has received

increased attention among bariatric surgery patients. However, different definitions and

terminology have been used, preventing the accurate measurement of this phenomenon

and comparison of data across studies.

Objective: To review existing definitions and associated clinical features of grazing

among different samples and to propose a standardized definition that will allow for

consistency in future work. Setting: University and Clinical Research Institute.

Methods: Of the 39 studies found, 9 provided an original definition and 12 provided

data of its association with weight outcomes. Six were studies of non-bariatric surgery

populations. Based on this literature review, the most common criteria used in previous

studies to define grazing were included in a survey that was sent to 24 individuals who

have published work in the field. These experts were asked to provide their opinion on

what should constitute grazing.

Results: Grazing is a frequent behavior in the bariatric surgery population as well as in

eating disordered and community samples. Its association with psychopathology is not

clear, but its negative impact on weight outcomes after bariatric surgery generally has

been supported. Survey data provided a consensus regarding the definition of grazing as

an eating behavior characterized by the repetitive eating (more than twice) of

small/modest amounts of food in an unplanned manner, with what we characterize as

compulsive and non-compulsive subtypes.

Conclusions: Given the clinical relevance of grazing among bariatric surgery patients, a

unique definition is crucial to better study its associated features and impact on different

populations.
 Key-words Grazing; picking and nibbling; bariatric surgery; eating disorders;

concept definition.
 Introduction

Bariatric surgery is usually an effective intervention for severe obesity, but

despite the substantial weight loss usually observed following such procedures, the long

term maintenance of weight loss is still considered a problem for some patients. Past

research has showed that eating behaviors may have a significant impact on weight

outcomes.(1-3) Traditionally eating disorders and disordered eating behavior such as loss

of control eating (LOC), binge eating disorder (BED) or night eating syndrome (NES)

have been the focus of attention in the study of behavioral predictors of successful

weight loss after bariatric surgery.(3-5)

Grazing behavior is one of the eating problems that has been associated with

less weight loss and eventually weight regain. It was originally defined as whether in

the past 6 months (the patients) had eaten small portions of food continuously or larger

amounts of food over an extended period of time.(6) Some authors considered it a

high-risk behavior that may compromise weight maintenance after bariatric surgery.(2,7)

A relationship between grazing behavior and binge eating has also been suggested.

Saunders(7, 8) and Colles(9) suggested that there can be a shift to grazing behavior at post-

surgery for some patients who have problems with binge eating before undergoing

surgery, concluding that it might serve a function similar to binge eating. Other authors

reported a new onset of a repetitive eating pattern on post-operative patients with no

association with previous eating disorders.(10) However, this behavior has only rarely

been reported and frequently neglected in clinical assessments and research, and little is

known about its prevalence and impact on treatment outcomes. Additionally, there is

little agreement across reports as to the definition of grazing behavior. The lack of a

consensus prevents accurate, comprehensive and standardized measurement of this

phenomenon and thus greatly limits cross-study comparisons.

 This paper aims to: a) review and contrast the definitions of grazing (or similar

concepts) used previously in the literature, b) review its association with weight

outcomes and psychological characteristics, and c) propose a standardized definition to

allow for consistency in future work.

Materials and Methods

For the literature review, a post-doctoral researcher conducted a web search on

PsychINFO, Pubmed, Scholar Google. The reference lists of the articles obtained were

searched for the period from January 1982 to March 2014. Key-words included were:

bariatric surgery; eating patterns; grazing; picking or nibbling; snack eating; snacking,

maladaptive eating patterns and bariatric surgery; weight outcomes and bariatric

surgery. Only articles written in English were considered.

A survey questionnaire was developed including the different criteria most

frequently reported in the literature. In order to achieve a consensus definition, the

authors then contacted 24 individuals via email who have published work in the field of

eating behaviors and/or bariatric surgery to gather their opinions. Each respondent was

asked to check a series of items, whether or not that item should be considered a core

criterion, or to indicate if they were not sure. Fourteen items/criteria were included

addressing different features of the behavior: repetitive; small/modest amount of

food; unplanned; results in excessive caloric intake; amount eaten unknown at

onset; sense of loss of control present/absent; (not) eating rapidly; eating alone;

associated sense of distress; (not) precipitated by strong emotions; other.

Additional questions on the preferred term among those used in the literature; whether
there was a need for subtypes and what they considered the minimum frequency to label

the behavior. The questionnaires were sent/responded to via e-mail.

Table 1 presents the list of citations located, included and excluded. Studies

were selected based on satisfying at least one of the following criteria: a) provide an

original definition of the eating behavior (grazing, snacking, picking or nibbling); b)

include statistical data on its prevalence/frequency; c) establish statistical association

with weight/psychological features. Studies not providing any information on at least

one of these aspects were excluded. Our literature review found 39 published papers

that mentioned grazing, picking or nibbling, or snack-eating. Of these, 9 provided

original definitions and descriptions of the target eating behaviors (see Table 2),(6,7,9,11-
16)
and the remaining papers used a description provided by previous reports. Only 12

out of the initial 39 included statistical data on the frequency, associated psychological

features or weight outcomes in bariatric surgery patients (see Table 3),(2,6,7,9,10,13,16-21)

and 6 studies were found with data on these eating behaviors in non-bariatric surgery

samples.(15,22-26) Seventeen studies were excluded because they mentioned grazing

without providing statistical data or a new definition of the behavior,(1,5,8,27-40) and one

study surveyed a group of bariatric patients on their ideas about the definition of

grazing.(41)

(Insert Table 1)

Defining the concept

Emergence of the concept: Grazing as eating-disordered behavior

The term grazing was first used in the literature in 1989 as an eating problem

with possible implications for insulin levels,(27) and later to describe an eating pattern
associated with failed dieting attempts,(28) poorer outcomes in binge eating treatment(29)

or gastric bypass surgery.(30) The first authors to suggest a definition for grazing

behavior were Saunders and colleagues.(6) Grazing was later associated with compulsive

eating when Saunders(8) suggested that grazing behavior was perceived as a binge eating

episode involving only small amounts of food. In 2004, Saunders(7) provided a

modified definition for grazing including the loss of control component and considering

it a sub-threshold eating disorder.

Carter and Jansen(14) described grazing as a target eating behavior for improving

psychological treatments for obesity, defining the concept as involving the repeated

consumption of smaller amounts of food over an extended period of time.

Recently, Lane and Szabo(15) attempted to assess grazing in a group of 248

undergraduate psychology students using a self-report questionnaire they developed,

defining grazing as the unplanned and repetitious eating of small amounts of food with

an accompanying sense of a lack of control over this eating.

Grazing distinguished from uncontrolled eating

Colles and colleagues(9) offered an adapted definition, describing grazing as the

consumption of smaller amounts of food continuously over an extended period of time,

eating more than the subjects consider best for them. In this study the authors

differentiated grazing from uncontrolled eating, considering that the latter would

include feelings of loss of control (LOC) during the consumption of either a

subjectively or objectively large amount of food.

 Similar Concepts

A similar concept, termed picking or nibbling, was proposed by Fairburn and

Cooper(12) in the Eating Disorder Examination Interview (EDE) Version 14.3, a semi-

structured interview developed for non-bariatric population. According to these authors,

the eating episode should be unplanned; the amount eaten should be uncertain at the

time that the episode was initiated; and the eating should have a repetitious element to

it. This definition considers that loss of control over eating (which is required for binge

eating episodes) should not be considered a criterion for picking or nibbling.

Another related eating pattern was reported by Brolin et al.(11) and later by Faria

et al..(21) This was termed snack-eating, and was defined as the consumption 150 kcal

or more per portion in the form of snacks in between meals. Also, Busetto and

colleagues(13) described the concept of nibbling as eating small quantities of foods

repeatedly between meals, typically triggered by inactivity and/or loneliness.

OConnor and colleagues(22) also studied a between-meals snacking behaviour and its

associations with daily hassles.

Table 2 summarizes the criteria used in each manuscript presenting new

definitions of the target behavior. Repetitive eating was the most common

characteristic. However, generally Table 2 demonstrates the inconsistency concerning

most of the criteria used to define these concepts, particularly in regards to the

presence/absence of loss of control; the amount eaten and frequency of the occurrence;

the association with emotional triggers; the unplanned character; and the association

with binge eating.

(Insert Table 2)

The impact of grazing on outcomes after bariatric surgery

Table 3 presents a summary of the studies that have reported the frequency of

grazing, picking or nibbling, and snack eating and their association with other

disordered eating, psychological characteristics, and weight outcomes. It highlights the

variability of methods and criteria used to assess this behavior that is reported with

frequency rates ranging from 18.6% to 59.8%, usually with increased rates after

bariatric surgery. Most of the studies (n=5) found an association between (pre- or

postoperative) grazing and poorer outcomes, but two studies failed to find this

relationship. Data regarding the association between grazing and BED, binge eating,

loss of control or eating disorders psychopathology were mixed. Negative feelings, poor

compliance with treatment and poor health related quality of life also were significantly

associated with grazing in 5 studies.

(Insert Table 3)

Grazing, picking or nibbling, and snack eating in other populations

Picking or nibbling has also been assessed in normal weight university

women,(24) community women,(25) and those with bulimia nervosa (BN), binge eating

disorder (BED) and anorexia nervosa (AN),(26) as well as in undergraduate psychology

students.(15) Despite the high prevalence rates, with up to 91%(24) of individuals in non-

clinical samples reporting this behavior, with reports of 44%(26) and 88%(25) in BED

patients, 34.3% in AN patients and 57.6% in BN patients.(26) Most studies found no

association with Body Mass Index (BMI), frequency of meals, binge eating, overeating,

dietary restraint, or shape, eating and weight concerns, or compensatory behaviors.(23-26)

However, grazing was inversely related to food avoidance, sensitivity to weight

regain,(24) and the frequency of morning and afternoon planned snacks.(25) Grazing,

included loss of control over eating in its definition, was assessed in undergraduate

psychology students, and was found to be associated with binge eating and other

measures of psychological distress (eg. anxiety, depression) and disordered eating (eg.,

emotional eating, external eating), but not with BMI.(15)

Proposing a standardized and consensual definition for grazing

Of the 24 researchers and clinicians contacted to answer the online survey, 16

responded and two additional researchers were invited by their colleagues to participate,

resulting in a total of 18 respondents. All responders had published work in the field and

were included in our analysis.

The most consistent endorsed criterion was repetitive, followed by

small/modest amount of food and unplanned. Least agreement was found for the

sense of loss of control present, with some respondents considering it a core

component, while others suggested that it should not be used to differentiate the

behavior from binge eating. Finally, important concerns were raised regarding the

differential diagnosis in relation to subjective binge eating episodes, how many times

it had to be repetitive, and the time limit between eating events.

Taking into consideration the suggestions provided by the different respondents,

we would like to offer a definition that captures the core features of this eating behavior,

and proposes two subtypes. We suggest grazing to be defined as an eating behavior

characterized by the repetitive eating of small/modest amounts of food in an unplanned

manner and/or not in response to hunger/satiety sensations. Repetitive should be

defined as engaging in more than two eating events in the same period of time; for
example, in the morning, afternoon, and evening, or consecutively during the day. There

should not be prolonged gaps between eating events (for example, no more than an

hour). We believe that two subtypes should be considered: a) a compulsive subtype

characterized by the sense that the person will not be able to resist eating, returning to

snack on food even if not intending to; and b) a non-compulsive subtype characterized

by eating in a distracted way over a long period. Appendix A provides a description and

examples of these behaviors. Grazing should be rated as the number of days in the

previous month that the behavior was present. Appendix B contains the 'script' for a

semi-structured interview and an 18 item self-report questionnaire to assess grazing

under the proposed classification system. The assessment measures we believe capture

the features suggested by the different responders to our survey and are currently under

validation.

A few associated features could be present in some, but not necessarily all

individual. The amount of food eaten may not be small in a cumulative sense, resulting

in excessive caloric intake overtime. Grazing could be precipitated by strong emotions

or boredom and not necessarily from hunger. It can result in moderate levels of distress.

Typically, grazing would occur over an extended period of time, such as over the course

of a morning, an afternoon, an evening, or throughout the day, but could happen in

shorter blocks of time (e.g. over the course of 1or 2 hours). In some cases, grazing can

include caloric drinks, such as sipping on a smoothie throughout the day.

Grazing should be distinguished from other eating episodes (see Appendix A). It

should be differentiated from the repetitive eating pattern often exhibited by bariatric

surgery patients who intentionally eat multiple small meals, as prescribed because of the

difficulty in accommodating the total kilocalories needed due to the physical restrictions

imposed by surgery. Also it should be distinguished from intentional overeating, which

would involve intentionally fractionating a larger snack and eating small portions

repeatedly to overcome the restrictions imposed by the small gastric pouch. In such

cases, the choice of food and the timing of ingestion would be planned/anticipated,

and/or to some extent controlled, or the eating might occur in response to hunger and

satiety sensations. Instead, grazing should include some level of lack of control and

distraction, craving or compulsion associated with eating.

Grazing should also be distinguished from subjective binge eating episodes,

which involve a sense that one will not be able to resist or stop eating; consuming, in a

circumscribed period of time, an amount of food that is not "large" but is viewed by the

individual as excessive. Appendix A presents a characterization of the different eating

episodes within different gradients of loss of control.

Discussion

Grazing, picking or nibbling, and snack eating have been increasingly reported

in the literature. Our findings, which considered different extant definitions throughout

the literature, found that grazing a relatively frequent behavior among non-clinical

samples, as well as among eating disordered (ED) and severely obese patients

undergoing or having undergone bariatric surgery. However, this review also draws

attention to the lack of consistency regarding the criteria used to assess the behavior.

Different researchers have used different definitions, preventing meaningful

comparisons of results across reports. In fact, the ambiguity of the concept has also

been stressed by Zunker and colleagues(41) who, based on patient input, used a

qualitative nominal group technique to attempt to provide a better understanding of

grazing. Nonetheless, similarities across the definitions that have been used emerged as
well: a) the repetitive characteristic of the behavior, and b) the rather small/modest

amounts of food eaten. On the contrary, less agreement is found for the presence or

absence of a sense of loss of control eating.

The presence of loss of control over eating is a necessary component of binge

eating episode, and is usually rated as present/absent.(42) However some authors have

suggested that not all episodes are evaluated by patients in a dichotomous fashion,(43),

and that gradients of LOC are observed across individuals when reported continuously

rather than dichotomously. The same clinical impression was expressed in relation to

the repetitive eating behavior we are discussing: the absence of loss of control over

eating (as measured dichotomously) does not necessarily imply that the person feels in

complete control of their eating behavior, and that these grazing events happen

repetitively and on the spur of the moment, suggests that there is no intentional

control over the amount of food eaten, and that it is not a response to hunger cues. Thus,

some level of lack of control, which could be captured in a continuous rating scheme,

would probably be reported in association with grazing (for both subtypes), but would

not be as clinically significant as the loss of control observed in traditional eating

disorders.

Some discussion also rose regarding the sense of distress associated with the

event. In our survey, several respondents suggested that the behavior should be

accompanied by a sense of distress, since psychological disorders require some degree

of psychological impairment.(44) Studies considering loss of control as a core component

of grazing suggested an association with increased psychological impairment,(2,9,15,17)

which may suggest that the core psychopathologic component is the sense of loss of

control. Nonetheless, studies excluding loss of control suggested other results,(10,24-26)

indicating that the sense of distress may be secondary to other features, such as the
presence/absence of the compulsive element or guilt after eating, and should not be

considered as a core criterion. Moreover, psychological disorders generally require a

level of psychological distress associated that highly compromise general functioning.

However, some authors believe that some psychological states, such as experiencing

negative emotions, boredom, loneliness, or inactivity may precipitate grazing.(7,13)

There is little evidence that grazing itself leads to clinically significant

psychological distress, or that it necessarily should be considered as a type of disordered

eating behavior. In fact, with frequency rates up to 59.8% in the bariatric population,

and rates as high as 89.8%(25) in clinical samples or 91% in community samples,(24)

there is considerable doubt whether this is really a non-normative eating behavior, but a

rather common eating behavior associated with maladaptive eating habits, with

important weight implications for a subgroup of individuals. Additionally, in support of

a non-disordered eating behavior, different studies failed to find an association between

grazing or picking or nibbling and eating disorders psychopathology or compensatory

behaviors, suggesting that it may falls outside the spectrum of eating disorders, and may

have limited interest when working with eating disorder patients.(24,26) Thus, the

evidence points to this being a rather common eating behavior that tends to interfere

with weight control in specific populations, but there are no clear data to suggest that it

should be considered a psychopathological behavior. Thus, the definition proposed in

this work may prompt future research to establish the clinical importance of this eating

behavior, allowing for the assessment and comparison of the compulsive and a non-

compulsive definitions and their impact on psychopathology and weight outcomes.

There is, however, growing support for an association between grazing and

poorer outcomes after the bariatric surgery. These data also imply that this behavior

may be of clinical significance to bariatric surgery patients, particularly because

following such procedures the physical restriction essentially prevents the occurrence of

objective overeating episodes. The question remains as to whether this behavior would

have a similar impact on patients undergoing non-surgical weight loss programs. Since

this definition was developed based on the criteria used in the assessment of different

samples (bariatric and non-bariatric; clinical and non-clinical), we suggest that our

proposed definition of grazing may be suitable for both clinical and research purposes in

bariatric or non-bariatric, clinical or non-clinical populations.

Future research

Additional research is still required to better define some of the core criteria of

the behavior. First, the concept of repetitive should be investigated. We provide initial

guidelines based on our survey, but it is important to study the utility of these

guidelines, to better establish the number of eating events and what should be the time

limit in between eating events in order to demarcate a grazing episode. Second, research

should provide guidelines for what constitutes a small/modest amount of food. On one

hand, the importance of an upper limit for the amount of food eaten should be

investigated. On the other hand, the amount of food consumed should not be so small

that the total amount of caloric intake is not necessarily substantially increased,

considering the clinical context of the patient. Third, empirical research should

investigate/confirm the validity of the two subtypes (compulsive/non-compulsive) and

statistical techniques such as factor analysis, latent class analysis, or latent profile

analysis may be particularly helpful in investigating the validity of the proposed criteria

across different populations. Additional research is necessary to investigate the clinical

validity of the compulsive component associated with grazing. In particular, research

should investigate if compulsive grazing is related to significantly more distress,

precedes binge eating behaviors, is associated with increased weight regain, or requires

specific therapeutic strategies. Some loss of control eating episodes begin with the

ingestion of rather small amounts of food during a controlled eating event. It would be

important to investigate whether grazing is a risk behavior for the eventual occurrence

of binge eating.

Finally, additional longitudinal research is required to study the frequency and

duration of grazing for it to be considered a risk behavior for weight gain or

psychological distress in both clinical and non-clinical samples. Longitudinal data is

also necessary to investigate the association between eating behavior, particularly

compulsive eating, before bariatric surgery and the onset of grazing postoperatively.

Conclusion

Despite the clinical interest in assessing grazing behavior when studying post-

surgical outcomes, different definitions and associated criteria have been used,

preventing meaningful comparison, and compromising interpretation of data published

on its frequency and impact on weight and associated features. This work is the first to

tentatively provide a consensual definition of grazing based on the collective opinion of

a group of researchers and clinicians who work in the field. The consistent use of a

single definition is crucial, and future research on the impact of grazing in weight loss

treatments and associated eating behavior or psychological characteristics is warranted.

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Table 1 List of Citations Located, Included and Excluded.

Author Type of Sample Concept Offers Include Includes Inclu

s Study Denomin Origin s Data Associati ded in
(year) ation al on on with This
Defini Prevale Weight Revie
tion nce/ or w
Freque Psycholo
ncy gical
Features
Calles- Observat Non- Grazing ____ ____ ____ Exclu
Escand ional insulin- ded
on, et dependent
al(27) Diabetes M
(1989) ellitus and
Controls
Wittig Interview General Grazing ____ ____ ____ Exclu
& techniqu ded
Wittig(2 es
8)

(1993)
Harvey, Treatmen Binge Grazing ____ ____ ____ Exclu
et al(29) t Eating ded
(1994) outcomes Males
Brolin, Longitud Bariatric Snack- 9 ____ Table
et al(11) inal Surgery eating _ 2
(1994) Patients _
_
_
Saunder Cross- Bariatric Grazing 9 9 9 Table
s, et al(6) sectional Surgery 2/3
(1998) Candidates
Cook & Cross- Post- Grazing/ ____ ____ ____ Exclu
Edward sectional bariatric snacking ded
s(30) Patients
(1999)
Saunder Cross- Bariatric Grazing ____ 9 9 Table
s(17) sectional Surgery 2/3
(1999) Candidates
Fairbur ____ ____ Picking/ 9 ____ ____ Table
n& nibbling 2
Cooper
(12)

(2000)
Nicklas, Review Individuals Nibbling; ____ ____ ____ Exclu
et al(31) with grazing d
(2001) Obesity e
d
Saunder Observat Post- Grazing ____ ____ ____ Exclu
s(8) ional bariatric ded
(2001) (anecdot Patients
al
informati
on)
Bocchie Review Bariatric Grazing ____ ____ ____ Exclu
ri et Surgery d
at(32) Patients e
(2002) d
Busetto, Transver Post- Nibbling 9 9 9 Table
et al(13) sal, bariatric 2/3
(2002) analytica Patients
l and
descripti
ve
Lang, et Longitud Bariatric Grazing ____ ____ ____ Exclu
al(33) inal Surgery ded
(2002) Patients
de Cross- Pre-surgery Grazing; ____ ____ ____ Exclu
zwaan, sectional Bariatric Frequent d
et al(34) Patients Snacking e
(2003) d
Saunder Descripti High-risk Grazing 9 9 9 Table
s(7) ve Post- 2/3
(2004) Bariatric
Patients
Tanofsk Perspecti Individuals Grazing ____ ____ ____ Exclu
y-Kraff ve paper with d
& Obesity e
Yanovs d
ki(35)
(2004)
Ogden, Cross- Bariatric Grazing ____ ____ ____ Exclu
et al(36) sectional Surgery d
(2005) Patients e
d
Burgme Longitud Bariatric Grazing ____ 9 9 Table
r,et inal Surgery 3
al(18) Patients
(2005)
Busetto, Longitud Bariatric Nibbling _ 9 9 Table
et al(19) inal Surgery _ 3
(2005) Patients _
_
Poole, Group Post- ____ 9 9 Table
et al(20) comparis bariatric 3
(2005) on Surgery
Patients
Kinzl, Cross- Post- Grazing ____ ____ ____ Exclu
et al(37) sectional bariatric ded
(2006) Surgery
 Patients
Niego, Review Bariatric Grazing ____ ____ ____ Exclu
et al(5) Surgery d
(2007) Patients e
d
Colles, Prospecti Bariatric Grazing 9 9 9 Table
et al(9) ve Surgery 2/3
(2008) observati Patients
onal
OConn Multilev Adults Between- ____ ____ 9 9
or, et el diary (non- meals
al(22) design clinical Snacking
(2008) sample)
Ashton, Effective Post- Graze ____ ____ ____ Exclu
et al(38) ness bariatric Eating d
(2009) Surgery pattern e
Patients d
Faria, et Cross- Post- Snack- ____ 9 9 Table
al(21) sectional bariatric eating 3
(2009) descripti Surgery
ve Patients
de Longitud Post- Picking or ____ 9 9 Table
Zwaan inal bariatric Nibbling 3
et al(10) design Surgery
(2010) Patients
Kofman Cross- Post- Grazing 9 9 Table
, et al(2) sectional bariatric ___ 3
2010 Surgery _
Patients
Masheb Community Picking or ____ 9 9 9
et al(23) Women Nibbling
(2011)
Marino Review Post- Grazing ____ ____ ____ Exclu
et al(39) bariatric d
(2011) Surgery e
Patients d
Sarwer( Review Post- ____ ____ ____ Exclu
1)
bariatric d
(2011) Surgery e
Patients d
Welch(4 Cross- Post- Grazing ____ ____ ____ Exclu
0)
sectional bariatric d
(2011) Surgery e
Patients d
Carter Review ____ Grazing 9 ____ ____ Tabl
& e2
Jansen(1
4)

(2012)
Reas, et Normal Picking or ____ 9 9 9
al(23) Weight Nibbling
(2012) University
Women
Zunker Focus Post- Grazing ____ ____ ____ 9
et al(41) Group bariatric
(2012) Surgery
Patients
Masheb Binge Picking or ____ 9 9 9
, et al(25) Eating Nibbling
(2013) Disorder
Sample
Concei Anorexia, Picking or ____ 9 9 9
o, et Bulimia, Nibbling
al(26) Binge
(2013) Eating
Disorder
Patients
Lane & University Grazing 9 9 9 Table
Szab(15 Students 2
)

(2013)
Robinso Post- Grazing 9 9 9 Table
n et bariatric 2
al(16)
Surgery /
(2014)
Patients 3
Table 2 Criteria Used by Different Authors to Define the Eating Pattern Characterized by the Repetitive Ingestion
of Food.

Brolin, Saunders, Fairburn, Busetto, Saunders Colles, et Carter & Lane & Robinson
et al et al et al et al (2004)(6) al Jansen Szab et al(16)
(1994) (1998) (6) (2000)(12) (2002)(13) (2008) (9) (2012)(14) (2013)(15) (2014)
(11)

Denominatio Snack- Picking/ Grazing

Grazing Nibbling Grazing Grazing Grazing Grazing
eating Nibbling
Duration ----
---- 6 months 6 months ---- ---- 6 months ---- ----
(presence)
Frequency ----
---- ---- ---- ---- ---- ---- ---- ----
(days/week)
Duration Extended Continuous Extended Extended
Extended Extended
(episode) ---- period of ---- ---- period of parts of the period of
period of time period of time day time
time time
Repetitive ---- yes yes yes yes yes yes yes Yes
Between Yes
Yes ---- Yes yes ---- ---- yes
Meals
Unplanned ---- ---- yes ---- ---- ---- yes Yes
Loss of ----
Control ---- ---- no ---- Yes no yes
Trigger Feelings of
deprivation, late afternoon or
disappointment evening
Inactivity, are high risk
---- ---- ---- suppressed ---- times but can
---- ----
loneliness
emotions, body occur at any
image time
dissatisfaction
Amount of Not trivial;
Small, but
Food >150 Small or uncertain Small at
small Small Small high caloric yes
kcal large at the outset
foods
beginning
Individuals
Perception ----
---- ---- no ---- yes yes ---- Small
of
Overeating
Binge ---
Eating ---- ---- no ---- yes no ---- yes
Similarity
Table 3 Frequency of Grazing/Picking or Nibbling/Snack Eating in Bariatric
Surgery Patients and Its Relation to ED Symptomatology, Psychological Features and
Weight Outcomes.

Autho Type of Sample (a) n Frequency Relation Relation

rs study / Type Assessme with with
(year) of nt Time; Disordered Weight
Surger (b) Eating Outcome
y Assessme Symptomat s
nt ology and
Measures Psychologic
al Features
Cross- Bariatri (a) Pre- 12 Pre-surgery: (1) Not
Saunder sectiona c surgery; 5 59.8%. Positively specified.
s, et al(6) l Surgery (b) Self- related with
(1998); Candid Binge
report
Saunder ates Eating Scale
s(17) scores and
(1999); severe binge
eating
problems;
(2) Impact
on diet
compliance.
Busett Longitu Bariatri (a) Pre- 26 Pre-operative: Not Not
o et dinal c surgery; 0 42.7%. specified. associate
al(13) Surgery (b) d with
(2002) Candid Clinical weight
ates / Interview. loss,
Gastric weight
Band regain or
surgical
complicat
ions.
Saunde Descript High- (a) >=6 64 Common (1) Shift Not
rs(7) ive, risk month Pattern with from pre- specified
(2004) Anecdot Post- after Average surgery
* al bariatri Surgery; Frequency of binge eating
c (b) Self- 3-5 Times a to post-
Patients report Week. surgery
/ Questionn grazing. (2)
Gastric aire; Re-
Bypass Anecdotal emergence
Informatio of grazing
n from by the 6th
Group post-surgery
Support. month; (3)
Grazing
triggered by
feelings of
 disappointm
ent with
eating
pattern; (4)
Less
compliance
with follow-
up
appointment
s.
Burgm Longitu Bariatri (a) Pre and 14 (1) Pre- Not Not
er, et dinal c 12 Months 9 surgery: specified associate
al(18) Surgery Post- 19.5%; d with
(2005) Candid Surgery; (2) Lifetime: weight
ates/ (b) 24.2%. loss.
Gastric Structured
Band Clinical
Interview .
Busett Longitu Bariatri (a) 5 years 37 (1) Pre- (1) Not
o, dinal c after 9 surgery Associated specified
et al(19) Surgery Surgery; Within BED: with BED.
(2005) Candid (b) 49.2%;
ates/ Clinical (2) Pre-
Gastric Interview. surgery
Band Within Non-
BED: 32.5%.
Poole, Case Post- (a) > 1 18 Not specified (1) Not
et al(20) Control bariatri year; Associated specified
(2005) (compli c (b) Review with
ants vs Patients of Case negative
non- / Notes affect;
complia Gastric (2)
Retrospect
nts) Band Associated
ively. with poor
compliance
with follow-
up
appointment
s and
modification
of eating
behavior.
Colles, Longitu Bariatri (a) Pre- 12 (1) Pre- (1) Baseline
et al(9) dinal c surgery 9 surgery: Associated and
(2008) Surgery and 12 26.4%; with lower postopera
Candid (2) Post- dietary tive
Months
ates/ surgery: 38%. restraint, grazing
Gastric Postoperat higher are
Band ively; (b) dietary predictors
Self-report disinhibitio of
and n and less
Confirmat hunger; w
 ory Semi- more daily ei
structured eating g
Clinical episodes; ht
(2) Pre- lo
Interview.
surgery ss
grazing: .
associated
with
postoperativ
e overeating
in response
to
emotional
triggers; eat
behind
satiation;
(3)
Postoperativ
e grazing:
associated
with
depression;
poorer
mental
health;
gastrointesti
nal
symptoms;
preoperative
BED and
grazing;
(4) Shift
from pre-
surgery
binge eating
to post-
surgery
grazing; (5)
Overlap
between
grazing and
loss of
control.
Faria, Cross- Post- (a) >=12 75 Post-surgery: (1) Highest Associate
et al(21) sectiona surgery Months; 18.6%. daily caloric d with
(2009) l Patients (b) 4-day intake; (2) less
/ Food Highest weight
Gastric Intake number of loss.
By-pass Record. daily meals.
de Cross- Post- (a) 18-35 59 Post-surgery: Not Not
Zwaan, sectiona surgery Months 32.2%. associated associate
et al(10) l Patients Post- with d with
(2010) / surgery; preoperative weight
Gastric (b) Semi- eating loss.
By-pass structured disorders.
Clinical
Interview.
Kofma Cross- Post- (a) 3-10 49 Post-surgery: Associated Associate
n, sectiona surgery Years after 7 46.6%. with poorer d with
et al(2) l Patients Surgery; health- more
(2010) / (b) Online related weight
Gastric Survey; quality of regain
By-pass Self-report life. and less
weight
loss.
Robins Cross- Post- (1) 2-12 27 Post-surgery: Associated (1)
on et sectiona surgery Years 4 Never: 4%; with: post- Grazing
al(16) l Patients Post-op; <1/month: surgery > once
(2014) / (2) 7.7%; OBE; per day
Gastric Emailed ~1/month: anhedonia; associate
By-pass Link/Onlin 8.4%; depressed d with
e Survey. ~1/week:16.8 mood; increased
%; emotional rates of
Several/week: eating post- surgical
24.8%; surgery; failure.
Daily:20.4%; mindless
>1/day: eating.
17.9%.