Obesity Surgery

, Volume 23, Issue 10, pp 1703–1710 | Cite as

Adherence and Weight Loss Outcomes in Bariatric Surgery: Does Cognitive Function Play a Role?

  • Rachel GaliotoEmail author
  • John Gunstad
  • Leslie J. Heinberg
  • Mary Beth Spitznagel
New Concept


Although bariatric surgery is the most effective intervention for severe obesity, a significant minority of participants fail to achieve or maintain optimal weight loss at extended follow-up. Accumulating evidence suggests that adherence to prescribed postoperative recommendations, including attendance at follow-up appointments and dietary and physical activity, is related to improved weight loss outcomes. However, adherence to these guidelines presents a significant challenge for many patients, potentially due in part to deficits in cognitive function. In this paper, we briefly examine current literature of adherence on postoperative weight loss outcomes, and review emerging evidence that the cognitive dysfunction present in a subset of obese individuals is related to weight loss outcomes following bariatric procedures. We then extend these findings, positing a role for cognitive function in moderating the relationship between adherence and postoperative outcomes.


Adherence Memory Cognition Executive function Bariatric surgery 


  1. 1.
    Sjöström L, Lindroos AK, Peltonen M, et al. Swedish Obese Subjects Study Scientific Group. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351(26):2683–93.PubMedCrossRefGoogle Scholar
  2. 2.
    Melton GB, Steele KE, Schweitzer MA, et al. Suboptimal weight loss after gastric bypass surgery: correlation of demographics, comorbidities, and insurance status with outcomes. J Gastrointest Surg. 2008;12(2):250–5. Epub 2007 Dec 11. PMID: 18071836.PubMedCrossRefGoogle Scholar
  3. 3.
    Karlsson J, Taft C, Ryden A, et al. Ten year trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obes (Lond). 2007;31(8):1248–61. PMID: 17356530.CrossRefGoogle Scholar
  4. 4.
    Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA. 2012;308(11):1122–31.PubMedCrossRefGoogle Scholar
  5. 5.
    Branson R, Potoczna N, Brunotte R, et al. Impact of age, sex and body mass index on outcomes at four years after gastric banding. Obes Surg. 2005;15(6):834–42. PMID: 15999426.PubMedCrossRefGoogle Scholar
  6. 6.
    Ortega E, Moringo R, Flores L, et al. Predictive factors of excess body weight loss 1 year after laparoscopic bariatric surgery. Surg Endosc. 2012;26(6):1744–50. PMID: 22234587.PubMedCrossRefGoogle Scholar
  7. 7.
    Chevallier JM, Paita M, Rodde-Dunet MH, et al. Predictive factors of outcome after gastric banding: a nationwide survey on the role of center activity and patients’ behavior. Ann Surg. 2007;246(6):1034–9. PMID: 18043107.PubMedCrossRefGoogle Scholar
  8. 8.
    Busetto L, Segato G, De Marchi F, et al. Outcome predictors in morbidly obese recipients of an adjustable gastric band. Obes Surg. 2002;12(1):83–92. PMID: 11868035.PubMedCrossRefGoogle Scholar
  9. 9.
    Larsen JK, Geenen R, Maas C, et al. Personality as a predictor of weight loss maintenance after surgery for morbid obesity. Obes Res. 2004;12(11):1828–34. PMID: 15601979.PubMedCrossRefGoogle Scholar
  10. 10.
    Renquist KE, Mason EE, Tang S, et al. Pay status as a predictor of outcome in surgical treatment of obesity. Obes Surg. 1996;6(3):224–32. PMID: 10729863.PubMedCrossRefGoogle Scholar
  11. 11.
    Toussi R, Fujioka K, Coleman KJ. Pre- and postsurgery behavioral compliance, patient health, and postbariatric surgical weight loss. Obesity (Silver Spring). 2009;17(5):996–1002. Epub 2009 Jan 22. PMID: 19165167.CrossRefGoogle Scholar
  12. 12.
    Korenkov M, Kneist W, Heintz A, et al. Laparoscopic gastric banding as a universal method for the treatment of patients with morbid obesity. Obes Surg. 2004;14(8):1123–7. PMID: 15479604.PubMedCrossRefGoogle Scholar
  13. 13.
    Dixon JB, O’Brien PE. Selecting the optimal patient for LAP-BAND placement. Am J Surg. 2002;184(6B):17S–20S. PMID: 12527345.PubMedCrossRefGoogle Scholar
  14. 14.
    Powers PS, Rosemurgy A, Boyd F, et al. Outcome of gastric restriction procedures: weight, psychiatric diagnoses, and satisfaction. Obes Surg. 1997;7(6):471–7. PMID: 9730503.PubMedCrossRefGoogle Scholar
  15. 15.
    Kinzl JF, Schrattenecker M, Traweger C, et al. Psychosocial predictors of weight loss after bariatric surgery. Obes Surg. 2006;16(12):1609–14. PMID: 17217637.PubMedCrossRefGoogle Scholar
  16. 16.
    Durkin AJ, Bloomston M, Murr MM, et al. Financial status does not predict weight loss after bariatric surgery. Obes Surg. 1999;9(6):524–6. PMID: 10638475.PubMedCrossRefGoogle Scholar
  17. 17.
    Garb J, Welch G, Zagarins S, et al. Bariatric surgery for the treatment of morbid obesity: a meta-analysis of weight loss outcomes for laparoscopic adjustable gastric banding and laparoscopic gastric bypass. Obes Surg. 2009;19(10):1447–55. PMID: 19655209.PubMedCrossRefGoogle Scholar
  18. 18.
    Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122(3):248–56. PMID: 19272486.PubMedCrossRefGoogle Scholar
  19. 19.
    Perugini RA, Mason R, Czerniach DR, et al. Predictors of complication and suboptimal weight loss after laparoscopic Roux-en-Y gastric bypass: a series of 188 patients. Arch Surg. 2003;138(5):541–5. PMID: 12742960.PubMedCrossRefGoogle Scholar
  20. 20.
    Júnior WS, do Amaral JL, Nonino-Borges CB. Factors related to weight loss up to 4 years after bariatric surgery. Obes Surg. 2011;21(11):1724–30.PubMedCrossRefGoogle Scholar
  21. 21.
    Beck NN, Mehlsen M, Stoving RK. Psychological characteristics and associations with weight outcomes two years after gastric bypass surgery: postoperative eating disorder symptoms are associated with weight loss outcomes. Eat Behav. 2012;13(4):394–7. PMID: 23121796.PubMedCrossRefGoogle Scholar
  22. 22.
    Kalarchian MA, Marcus MD, Wilson GT, et al. Binge eating among gastric bypass patients at long-term follow-up. Obes Surg. 2002;12(2):270–5. PMID: 11975227.PubMedCrossRefGoogle Scholar
  23. 23.
    Green AE, Dymek-Valentine M, Pytluk S, et al. Psychosocial outcome of gastric bypass surgery for patients with and without binge eating. Obes Surg. 2004;14(7):975–85. PMID: 15329189.PubMedCrossRefGoogle Scholar
  24. 24.
    Kalarchian MA, Wilson GT, Brolin RE, et al. Effects of bariatric surgery on binge eating and related psychopathology. Eat Weight Disord. 1999;4(1):1–5. PMID: 10728171.PubMedGoogle Scholar
  25. 25.
    Odom J, Zalesin KC, Washington TL, et al. Behavioral predictors of weight regain after bariatric surgery. Obes Surg. 2010;20(3):392–56. PMID: 19554382.CrossRefGoogle Scholar
  26. 26.
    van Hout G, van Heck G. Bariatric psychology, psychological aspects of weight loss surgery. Obes Facts. 2009;2(1):10–5. Epub 2009 Feb 3. PMID: 20054199.PubMedGoogle Scholar
  27. 27.
    van Hout GC, Verschure SK, van Heck GL. Psychosocial predictors of success following bariatric surgery. Obes Surg. 2005;15(4):552–60. PMID: 15946437.PubMedCrossRefGoogle Scholar
  28. 28.
    Livhits M, Mercado C, Yermilov I, et al. Preoperative predictors of weight loss following bariatric surgery: systematic review. Obes Surg. 2012;22(1):70–89. PMID: 21833817.PubMedCrossRefGoogle Scholar
  29. 29.
    Buchwald H. Consensus conference statement bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. Surg Obes Relat Dis. 2005;371–381. PMID: 16925250.Google Scholar
  30. 30.
    Poole NA, Al Atar A, Kuhanendran D, et al. Compliance with surgical after-care following bariatric surgery for morbid obesity: a retrospective study. Obes Surg. 2005;15(2):261–5. PMID: 15802071.PubMedCrossRefGoogle Scholar
  31. 31.
    El Chaar M, McDeavitt K, Richardson S, et al. Does patient compliance with preoperative bariatric office visits affect postoperative excess weight loss? Surg Obes Relat Dis. 2011;7(6):743–8. Epub 2010 Dec 8. PMID: 21256092.PubMedCrossRefGoogle Scholar
  32. 32.
    Gould JC, Beverstein G, Reinhardt S, et al. Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass. Surg Obes Relat Dis. 2007;3(6):627–30. discussion 630. Epub 2007 Oct 18. PMID: 17950045.PubMedCrossRefGoogle Scholar
  33. 33.
    Pontiroli AE, Fossati A, Vedani P, et al. Post-surgery adherence to scheduled visits and compliance, more than personality disorders, predict outcome of bariatric restrictive surgery in morbidly obese patients. Obes Surg. 2007;17(11):1492–7. PMID: 18219777.PubMedCrossRefGoogle Scholar
  34. 34.
    Bobbioni-Harsch E, Huber O, Morel P, et al. Factors influencing energy intake and body weight loss after gastric bypass. Eur J Clin Nutr. 2002;56(6):551–6. PMID: 1203265639.PubMedCrossRefGoogle Scholar
  35. 35.
    Brolin RL, Robertson LB, Kenler HA, et al. Weight loss and dietary intake after vertical banded gastroplasty and Roux-en-Y gastric bypass. Ann Surg. 1994;220(6):782–90. Dec. 8.PubMedCrossRefGoogle Scholar
  36. 36.
    Colles SL, Dixon JB, O’Brien PE. Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obesity (Silver Spring). 2008;16(3):615–22. Epub 2008 Jan 17. PMID: 18239603.CrossRefGoogle Scholar
  37. 37.
    Kofman MD, Lent MR, Swencionis C. Maladaptive eating patterns, quality of life, and weight outcomes following gastric bypass: results of an internet survey. Obesity (Silver Spring). 2010;18(10):1938–43. Epub 2010 Feb 18. PMID: 20168309.CrossRefGoogle Scholar
  38. 38.
    Sarwer DB, Wadden TA, Moore RH, et al. Preoperative eating behavior, postoperative dietary adherence, and weight loss after gastric bypass surgery. Surg Obes Relat Dis. 2008;4(5):640–6. Epub 2008 Jun 30. PMID: 18586571.PubMedCrossRefGoogle Scholar
  39. 39.
    Bond D, Evans RK, Wolfe LG, et al. Impact of self-reported physical activity participation on proportion of excess weight loss and BMI among gastric bypass surgery patients. Am Surg. 2004;70(9):811–4. PMID: 15481300.PubMedGoogle Scholar
  40. 40.
    Evans RK, Bond DS, Demaria EJ, et al. Initiation and progression of physical activity after laparoscopic and open gastric bypass surgery. Surg Innov. 2004;11(4):235–9. PMID: 15756392.PubMedCrossRefGoogle Scholar
  41. 41.
    Evans RK, Bond DS, Wolfe LG, et al. Participation in 150 min/wk of moderate or higher intensity physical activity yields greater weight loss after gastric bypass surgery. Surg Obes Relat Dis. 2007;3(5):526–30. PMID: 17903772.PubMedCrossRefGoogle Scholar
  42. 42.
    Rosenberger PH, Henderson KE, White MA, et al. Physical activity in gastric bypass patients: associations with weight loss and psychosocial functioning at 12-month follow-up. Obes Surg. 2011;21(10):1564–9. PMID: 20890771.PubMedCrossRefGoogle Scholar
  43. 43.
    Josbeno DA, Kalarchian M, Sparto PJ, et al. Physical activity and physical function in individuals post-bariatric surgery. Obes Surg. 2011;21(8):1243–9. PMID: 21153567.PubMedCrossRefGoogle Scholar
  44. 44.
    Colles SL, Dixon JB, O’Brien PE. Hunger control and regular physical activity facilitate weight loss after laparoscopic adjustable gastric banding. Obes Surg. 2008;18(7):833–40. Epub 2008 Apr 12. PMID: 18408982.PubMedCrossRefGoogle Scholar
  45. 45.
    Welch G, Wesolowski C, Piepul B, et al. Physical activity predicts weight loss following gastric bypass surgery: findings from a support group study. Obes Surg. 2008;18(5):517–24. PMID: 18365295.PubMedCrossRefGoogle Scholar
  46. 46.
    Silver HJ, Torquati A, Jensen GL, et al. Weight, dietary and physical activity behaviors two years after gastric bypass. Obes Surg. 2006;16(7):859–64. PMID: 16839483.PubMedCrossRefGoogle Scholar
  47. 47.
    Elkins G, Whitfield P, Marcus J, et al. Noncompliance with behavioral recommendations following bariatric surgery. Obes Surg. 2005;15(4):546–51. PMID: 15946436.PubMedCrossRefGoogle Scholar
  48. 48.
    Wheeler E, Prettyman A, Lenhard MJ, et al. Adherence to outpatient postoperative appointments after bariatric surgery. Surg Obes Relat Dis. 2008;4(4):515–20. Epub 2008 Jun 30. PMID: 18586576.PubMedCrossRefGoogle Scholar
  49. 49.
    Moroshko I, Brennan L, O’Brien P. Predictors of attrition in bariatric aftercare: a systematic review of the literature. Obes Surg. 2012;22(10):1640–7. PMID: 22696275.PubMedCrossRefGoogle Scholar
  50. 50.
    Schweiger C, Weiss R, Keidar A. Effect of different bariatric operations on food tolerance and quality of eating. Obes Surg. 2010;20(10):1393–9. PMID: 20680506.PubMedCrossRefGoogle Scholar
  51. 51.
    Brunault P, Jacobi D, Leger J, et al. Observations regarding ‘quality of life’ and ‘comfort with food’ after bariatric surgery: comparison between laparoscopic adjustable gastric banding and sleeve gastrectomy. Obes Surg. 2011;21(8):1225–31. PMID: 21533881.PubMedCrossRefGoogle Scholar
  52. 52.
    Franco JV, Ruiz PA, Palermo M, et al. A review of studies comparing three laparoscopic procedures in bariatric surgery: sleeve gastrectomy, Roux-en-Y gastric bypass and adjustable gastric banding. Obes Surg. 2011;21(9):1458–68. PMID: 21455833.PubMedCrossRefGoogle Scholar
  53. 53.
    Hawkins LA, Kilian S, Firek A, et al. Cognitive impairment and medication adherence in outpatients with heart failure. Heart Lung. 2012;41(6):572–82. Epub 2012 Jul 10. PMID: 22784869.PubMedCrossRefGoogle Scholar
  54. 54.
    Barclay TR, Hinkin CH, Castellon SA. Age-associated predictors of medication adherence in HIV-positive adults: health beliefs, self-efficacy, and neurocognitive status. Health Psychol. 2007;26(1):40–9. PMID: 17209696.PubMedCrossRefGoogle Scholar
  55. 55.
    Feil DG, Pearman A, Victor T, et al. The role of cognitive impairment and caregiver support in diabetes management of older outpatients. Int J Psychiatry Med. 2009;39(2):199–214. PMID: 19860078.PubMedCrossRefGoogle Scholar
  56. 56.
    Woods SP, Moran LM, Carey CL, et al. Prospective memory in HIV infection: Is “remembering to remember” a unique predictor of self-reported medication management? Arch Clin Neuropsychol. 2008;23(3):257–70. Epub 2008 Feb 19. PMID: 18243645.PubMedCrossRefGoogle Scholar
  57. 57.
    Kakos LS, Szabo AJ, Gunstad J, et al. Reduced executive functioning is associated with poorer outcome in cardiac rehabilitation. Prev Cardiol. 2010;13(3):100–3. PMID: 20626663.PubMedGoogle Scholar
  58. 58.
    Alosco ML, Spitznagel MB, van Dulmen M, et al. Cognitive function and treatment adherence in older adults with heart failure. Psychosom Med. 2012;74(9):965–73. Epub 2012 Oct 31. PMID: 23115344.PubMedCrossRefGoogle Scholar
  59. 59.
    Andrade AS, Deutsch R, Celano S, et al. Relationships among neurocognitive status, medication adherence measured by pharmacy refill records, and virologic suppression in HIV-infected persons. J Acquir Immune Defic Syndr. 2012 Nov 29. [Epub ahead of print]. PMID: 23202813Google Scholar
  60. 60.
    Insel K, Morrow D, Brewer B, et al. Executive function, working memory, and medication adherence among older adults. J Gerontol B Psychol Sci Soc Sci. 2006;61(2):P102–7. PMID: 16497953.PubMedCrossRefGoogle Scholar
  61. 61.
    Gunstad J, Paul RH, Cohen RA, et al. Obesity is associated with memory deficits in young and middle-aged adults. Eat Weight Disord. 2006;11(1):e15–19. PMID: 16801734.PubMedGoogle Scholar
  62. 62.
    Gunstad J, Paul RH, Cohen RA, et al. Elevated body mass index is associated with executive dysfunction in otherwise healthy adults. Compr Psychiatry. 2007;48(1):57–61. Epub 2006 Jun 30. PMID: 17145283.PubMedCrossRefGoogle Scholar
  63. 63.
    Lokken KL, Boeka AG, Yellumahanthi K, et al. Cognitive performance of morbidly obese patients seeking bariatric surgery. Am Surg. 2010;76(1):55–9. PMID: 20135940.PubMedGoogle Scholar
  64. 64.
    Gunstad J, Strain G, Devlin M, et al. Improved memory function 12 weeks after bariatric surgery. Surg Obes Rel Dis. 2011;7(4):465–72. Epub 2010 Oct 30. PMID : 21145295.CrossRefGoogle Scholar
  65. 65.
    Gold SM, Dziobek I, Sweat V, et al. Hippocampal damage and memory impairments as possible early brain complications of type 2 diabetes. Diabetologia. 2007;50(4):711–9. Epub 2007 Feb 14. PMID: 17334649.PubMedCrossRefGoogle Scholar
  66. 66.
    Hajjar I, Quach L, Yang F, et al. Hypertension, white matter hyperintensities, and concurrent impairments in mobility, cognition, and mood: the Cardiovascular Health Study. Circulation. 2011;123(8):858–65. Epub 2011 Feb 14. PMID: 212321150.PubMedCrossRefGoogle Scholar
  67. 67.
    Redline S, Strauss ME, Adams N, et al. Neuropsychological function in mild sleep-disordered breathing. Sleep. 1997;20(2):160–7. PMID: 9143077.PubMedGoogle Scholar
  68. 68.
    Alfonsson S, Parling T, Ghaderi A. Screening of adult ADHD among patients presenting for bariatric surgery. Obes Surg. 2012;22(6):918–26. PMID: 22161256.PubMedCrossRefGoogle Scholar
  69. 69.
    Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294(15):1909–17. PMID : 16234497.PubMedCrossRefGoogle Scholar
  70. 70.
    Spitznagel MB, Garcia S, Miller LA, Strain G, Devlin M, Wing R, Cohen R, Paul R, Crosby R, Mitchell JE, Gunstad J. Cognitive function predicts weight loss after bariatric surgery. Surg Obes Relat Dis. 2011 Oct 29. [Epub ahead of print]. PMID: 22133580Google Scholar
  71. 71.
    Spitznagel MB, Alosco M, Strain G, et al. Cognitive function predicts 24-month weight loss success after bariatric surgery. Surg Obes Relat Dis. 2013. doi: 10.1016/j.soard.2013.04.011.
  72. 72.
    Lezak MD. Neuropsychological assessment. 4th ed. New York: Oxford University Press; 2004.Google Scholar
  73. 73.
    Maayan L, Hoogendorn C, Sweat V, et al. Disinhibited eating in obese adolescents is associated with orbitofrontal volume reductions and executive dysfunction. Obesity (Silver Spring). 2011;19(7):1382–7. Epub 2011 Feb 24. PMID: 21350433.CrossRefGoogle Scholar
  74. 74.
    Teirian T, Jensen C, Lewis C, et al. Laparoscopic gastric bypass at a large academic medical center: lessons learned from the first 1000 cases. Am Surg. 2008;74(10):962–6. PMID: 18942623.Google Scholar
  75. 75.
    Bond D, Phelan S, Leahey T, et al. Weight-loss maintenance in successful weight losers: surgery vs. non-surgical methods. Int J Obes (Lond). 2009;33(1):173–80. Epub 2008 Dec 2. PMID: 19050676.CrossRefGoogle Scholar
  76. 76.
    Niemeier HM, Phelan S, Fava JL, et al. Internal disinhibition predicts weight regain following weight loss and weight loss maintenance. Obesity (Silver Spring). 2007;15(10):2485–94. PMID: 17925475.CrossRefGoogle Scholar
  77. 77.
    van Hout GCM, Jakimowicz JJ, Fortuin FA, et al. Weight loss and eating behavior following vertical banded gastroplasty. Obes Surg. 2007;17(9):1226–34. PMID: 18074499.PubMedCrossRefGoogle Scholar
  78. 78.
    Madan AK, Tichansky DS, Taddeucci RJ. Postoperative laparoscopic bariatric surgery patients do not remember potential complications. Obes Surg. 2007;17(7):885–8. PMID: 17894146.PubMedCrossRefGoogle Scholar
  79. 79.
    Testa R, Bennet P, Ponsford J. Factor analysis of nineteen executive function tests in a healthy adult population. Arch Clin Neuropsychol. 2012;27(2):213–24. Epub 2012 Feb 7. PMID: 22314610.PubMedCrossRefGoogle Scholar
  80. 80.
    Spitznagel MB, Galioto R, Limbach K, et al. Cognitive function is linked to adherence to bariatric postoperative guidelines. Surg Obes Relat Dis. 2013;9(4):580–5.Google Scholar
  81. 81.
    Mechanick JI, Kushner RF, Sugerman HJ, et al. American Society for Metabolic & Bariatric Surgery. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring). 2009 Apr; 17 Suppl 1: S1-70. PMID: 19319140Google Scholar
  82. 82.
    Thomas JG, Bond DS, Sarwer DB, et al. Technology for behavioral assessment and intervention in bariatric surgery. Surg Obes Relat Dis. 2011;7(4):548–57. PMID.PubMedCrossRefGoogle Scholar
  83. 83.
    Sarwer DB, Dilks RJ, West-Smith L. Dietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success. Surg Obes Relat Dis. 2011;7(5):644–51. PMID: 21962227.PubMedCrossRefGoogle Scholar
  84. 84.
    Wadden TA, Berkowitz RI, Womble LG, et al. Randomized trial of lifestyle modification and pharmacotherapy for obesity. N Engl J Med. 2005;353(20):2111–20. PMID: 16291981.PubMedCrossRefGoogle Scholar
  85. 85.
    Wing RR, Tate DF, Gorin AA, et al. A self-regulation program for maintenance of weight loss. N Engl J Med. 2006;355(15):1563–71. PMID: 17035649.PubMedCrossRefGoogle Scholar
  86. 86.
    Harper J, Madan AK, Ternovits CA, et al. What happens to patients who do not follow-up after bariatric surgery? Am Surg. 2007;73(2):181–4. PMID: 17305299.PubMedGoogle Scholar
  87. 87.
    Herman CP, Polivy J. From dietary restraint to binge eating attaching causes to effects. Appetite. 1990;14(2):123–5. PMID: 2337336 discussion 142–3.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Rachel Galioto
    • 1
    Email author
  • John Gunstad
    • 1
  • Leslie J. Heinberg
    • 2
  • Mary Beth Spitznagel
    • 1
  1. 1.Department of PsychologyKent State UniversityKentUSA
  2. 2.Cleveland Clinic Lerner College of MedicineClevelandUSA

Personalised recommendations