**4. Discussion**

The primary aim of the present study was to examine the contributions of emotional overload (depression and anxiety), emotion regulation, and impulsivity in female and male obese people with and without BED and seeking bariatric surgery. Moreover, this study aimed to examine the contribution of emotional overload (depression and anxiety), emotion regulation difficulties, and impulsivity to eating patterns observed in patients with BED. Our two main findings, discussed below, were as follows: (1) limited access to emotional regulation strategies and bulimic symptoms were significant predictors of BED; (2) emotional eating, external eating, the degree of binge eating symptoms and the severity of bingeing and purging behaviors in patients with BED were associated with specific dimensions of emotion regulation and impulsivity as well as anxiety and depression scores. To the best of our knowledge, our study is the first to assess these contributions in this population.

More anecdotal, in our sample, the prevalence of BED was of 22.31%, which is consistent with the prevalence reported by the literature [36,37].

#### *4.1. Emotional Overload, Emotion Regulation, and Impulsivity*

The findings showed that emotion dysregulation (i.e., limited access to emotional regulation strategies) was a significant predictor of BED. The DERS Strategies subscale reflects limited access to the flexible use of adaptive emotion regulation skills to modulate (vs. eliminate) the intensity and/or temporal features of emotional responses [12]. This finding is consistent with results reported in a review from Dingemans et al. (2017) [9]. These authors suggest that individuals with BED are more likely to engage in maladaptive emotional strategies (e.g., suppression, rumination) and less likely to engage in adaptive ones (e.g., acceptance, reappraisal). Moreover, in a prospective study, Svaldi et al. (2019) demonstrated that, in individuals with BED, rumination was a significant predictor of binge eating and that from a clinical perspective, ruminations were correlated with the probability of a binge episode by approximately 28% [38]. In the specific population of patients seeking bariatric surgery, Cella et al. (2019) reported that patients suffering from BED exhibited more emotional dysregulation, as assessed by the Eating Disorders Inventory-3 (EDI-3), than patients without BED [16]. Moreover, Gianini et al. (2013) reported that, in treatment-seeking obese adults with BED, limited access to emotion regulation strategies was strongly associated with emotional overeating [39].

When examining eating-related behaviors, as assessed by the BITE, only bulimic symptoms were associated with BED, which is not surprising as binge eating is the essential feature of this disorder [1]. The severity subscale score was not associated with BED. It outlines that individuals with BED, in our sample, as was logically expected, do not show marked or sustained dietary restriction designed to influence body weight and shape between binge eating episodes.

In our univariate analysis, patients with BED showed significantly higher levels of depression, anxiety, and impulsivity than patients without BED. We expected that these dimensions would also be significant predictors to BED in the multivariable analysis, but this was not the case. This result underlines, in our population, the major contribution of the emotional regulation dimension to the disorder.
