Vol.

11: 126-132, September 2006

ORIGINAL
RESEARCH Decision-making in obesity: A study
PAPER using the Gambling Task
R. Pignatti*,**, L. Bertella*,**,***, G. Albani****,*****, A. Mauro****,*****,
E. Molinari*,******, and C. Semenza*,**
*Laboratory of Psychology, Istituto Auxologico Italiano IRCCS, Piancavallo (VB), **Department of
Psychology, University of Trieste, Italy, *** Unit of Neuropsychology and Logopedy, Hildebrand Clinic,
Brissago, TI, Switzerland, ****Department of Neurology and Neuro-Rehabilitation, Istituto Auxologico Italiano
IRCCS, Piancavallo (VB), *****Department of Neurosciences, University of Turin, and ******Department of
Psychology, Catholic University of the Sacred Heart, Milan, Italy

ABSTRACT. The present study addresses the issue of whether a “decision-making disorder”
could account for the behavioral problems of severely obese patients (BMI score >34) who
are not classified by traditional psychiatric Eating Disorder tests. The neuropsychological test
employed, the Gambling Task (GT), is not directly related to the food domain, but it is sensi-
tive to failure in making long-term advantageous choices. A comparison was made of 20
obese subjects (OS) and 20 normal-weight subjects (NWS) matched in age, education and IQ.
The subjects' personalities and food behavior were assessed from psychological question-
naires, and then the Gambling Task was administered. The number of “good” choices made
by the two groups during GT performance differed significantly, and the OS did not learn to
maximize advantageous choices like the NWS did. OS behavior could be consistent with a
prefrontal cortex defect that implies difficulties in inhibition of excessive food intake.
(Eating Weight Disord. 11: 126-132, 2006). ©2006, Editrice Kurtis

INTRODUCTION upsurges in psychometric tests relative to

Key words:
Obesity, Gambling Task (GT),
decision-making,
neuropsychological
assessment.
Correspondence to:
Riccardo Pignatti
Unità di Neuropsicologia
Istituto Auxologico Italiano
Ospedale “San Giuseppe”
di Piancavallo
Via Cadorna 90
28924 Oggebbio (VB)
E-mail: pignatti@virgilio.it.
Received: September 1, 2005
Accepted: February 1, 2006
Simple obesity is included in the
International Classification of Diseases
(ICD) (1) as a general medical condition, but
does not appear in the Diagnostic and
Statistical Manual of Mental Disorders
(DSM-IV) (2) because it has not been estab-
lished that it is consistently associated with
a psychological or behavioral syndrome.
However, when there is evidence that psy-
chological factors are of importance in the
etiology or course of a particular case of
obesity, this can be indicated by noting the
presence of Psychological Factors Affecting
Medical Condition. This “lack of specific
categorization” is due to the poor under-
standing of the association between simple
obesity and psychological and/or behav-
ioral problems. Indeed the role of psychi-
atric factors in obesity is rather equivocal,
and it is still a matter of much debate
whether an individual's overweight condi-
tion is the cause, or the consequence, of
emotional and behavioral disturbances. For
example, authors like Telch and Agras (3)
described minimal and controversial psy-
chopathological differences between obese
and non-obese subjects, while other scien-
tists reported Obese Subjects (OS) showing
depression, hysteria, hypochondria, impul-
siveness and anxiety (4-7). This controversy
concerning psychopathology and obesity
led some clinicians (8) to hypothesize that
some degree of psychopathology in obesity
cases should be attributed to the prejudice
and discrimination suffered by OS, rather
than just physical obesity itself being
responsible for the condition.
A number of studies on the relationship
between personality traits and obesity, with
or without Binge Eating Disorders (BED),
simply report that the greater the degree of
overweight, the greater would be the ten-
dency to show depression, anxiety and
impulsiveness (9). Furthermore frequent
findings included feelings of ineffectiveness,
strong perfectionist attitudes, low self-
esteem, poor interoceptive awareness (10)
and increased sensitivity to environmental
stress factors (11). Recently, Mela (12) put
forward the hypothesis that difficulties in
controlling weight could also reflect prob-
lems, giving cues and motivation to eat,
rather than just be the result of heightened
pleasure derived from eating. Paradoxically,
individuals who are highly concerned about
their food intake and weight control can be
particularly susceptible to thoughts, emo-

126

tions, and situational cues that prompt overeat-
ing, and thus undermine any attempt to restrain
eating. In fact, repeated dieting, marked fluctua-
tions in the day-to-day food intake, and
attempts to enforce a very rigid control over
eating, all seem counterproductive to weight
control efforts, and could disrupt a more appro-
priate food choice behavior. Indeed, this
hypothesis appears to have been indirectly con-
firmed by a recent study of Fassino et al. (13)
who, using the Temperament and Character
Inventory (TCI) on 120 obese women, with or
without BED, found that the psychometric
scales of “Harm Avoidance” and “Self-
Directedness” of both patient groups differed
significantly from those of non-obese people.
Thus “defect in decision-making” could be a
plausible explanation for overeating behavior.
However, no studies so far have specifically
evaluated the role decision-making could play
in OS. Even so the above investigations clearly
suggest that it could be an important compo-
nent of behavior leading to obesity. Indeed, a
number of defects could, in principle, be
responsible for decision-making difficulties;
for instance, difficulty in understanding the sit-
uation, poor cognitive ability and, at a subtler
level, failure to see adverse consequences or to
govern impulse. From a neuropsychological
perspective, the common denominator of all
these problems is poor frontal lobe function-
ing. In a recent work, Bechara and Martin (14)
measured decision-making in substance
abusers, namely abusers of alcohol, drugs and
gambling. They used the Gambling Task (GT)
and observed that the poor performance of the
abusers could be attributed to the overall exec-
utive process of the frontal lobes (switching
and response inhibition components), rather
than to the memory storage process.
Moreover, poor working memory capacity
does not necessarily explain all the instances of
“myopia” substance abusers can have towards
future events.
Aims of the study
The aim of the present study was to ascertain
whether a decision-making disorder could
account for the problems of severely obese
patients who could not be classified into Eating
Disorders or other psychiatric categories via
traditional tests. To test such hypothesis we
used, for our investigation, the GT created by
Bechara et al. (15, 16). This task detects impair-
ment in personal and social decision-making.
Failure to make long-term advantageous choic-
es was evidenced in patients with pre-frontal
cortex damage (17-20), in regular poker
machine players (21), and in substance (alcohol
Decision-making in obesity
and drugs) abusers (14, 22-24). Data from these
studies suggest the existence of a link between
pathological gambling and other conditions
like drug addiction and obsessive-compulsive
disorder. Subjects with such disorders com-
monly have a diminished ability to evaluate
future consequences, and this can, in part, be
explained by an abnormal functioning of the
orbito-frontal cortex (25, 26). However other
studies have revealed poorer decision-making
and less impulsiveness in obsessive-compulsive
patients and schizophrenics (27, 28) than in
pathological gamblers. Nevertheless it would
seem that all three groups are over-stimulated
by an immediate need for reward, and appear
unable to manage this need and make the right
decisions even when the subjects know their
behavior can produce future economical
and/or physical damage.
In the present study it was also assumed that
an “aseptic” test such as GT, developed origi-
nally for neuropsychological purposes, could
help identify some basic lack in OS awareness
of harm avoidance, even though the subjects'
psychometrical test scores for behavior
towards food were within average limits. One
obvious advantage of GT over tests focussed
on pathological eating behavior is the lack of
any direct relationship between eating and the
food domain. Thus the GT test could help
bypass the patient resistance that occurs when
questions concerning nutrition cognition
and/or behavior are asked; in fact, question-
naires on eating behavior itself inevitably stim-
ulate such resistance.
MATERIALS AND METHODS
Subjects
Twenty OS (six males and 14 females)
responding to the undermentioned criteria
were selected from patients admitted to the
Istituto Auxologico Italiano at Piancavallo
(Verbania, Italy), a hospital specialized in the
treatment of obesity and eating behavior disor-
ders. The control participants were 20 normal-
weight subjects (NWS) (10 males and 10
females) matched on the basis of age, educa-
tion, and IQ (Table 1); their selection was made
at random from among hospital patients whose
medical records reported no history whatsoev-
er of psychiatric disorders, alcohol or drug
abuse, or sexual addictions.
Identification of OS group
We involved in our study OS from patients
responding to the following characteristics: a
BMI-score over 34 kg/m2 (moderate to severe
Eating Weight Disord., Vol. 11: N. 3 - 2006 127
 R. Pignatti, L. Bertella, G. Albani, et al.
TABLE 1
Demographic variables. Age, Education, IQ mean (SD)
scores according to the Wechsler Adult Intelligence Scale (WAIS-R),
and body mass index (BMI) for both groups and the results
of the t-test (two-tailed) analyses.
NWS OS (BMI> 34) p (two-tailed)
Number of subjects 20 (10 M/10 F) 20 (6 M/14 F)
Age (years) 46.65 (16.33) 43.40 (8.13) NS
Education (years) 11.70 (3.79) 10.20 (3.27) NS
IQ (WAIS-R) 101.33 (2.47) 102.77 (3.28) NS
BMI (kg/m2) 22.16 (1.83) 42.17 (6.00) <0.001
NWS=Normal Weight Subjects; OS=Obese Subjects; NS=Not Significant.
obesity), a history of weight increase from
childhood, no request whatsoever for either
psychological support, or a psychiatric diagno-
sis of any kind during or before hospitalization,
an IQ score classified as “average” according to
the Wechsler Adult Intelligence Scale-Revised
(WAIS-R), no abnormality (no scores under
cut-off) in all sub-tests of the following psycho-
logical scales:
Eating Disorder Inventory-2 (EDI-2): The
EDI-2 (24, 29, 30) is a widely used, standardized
test which is based on the self-reported mea-
surements of psychological symptoms com-
monly associated with anorexia nervosa,
bulimia nervosa and other eating disorders.
The psychological profile provided by the EDI-
2 is consistent with the understanding that eat-
ing disorders can be considered as multi-deter-
mined and heterogeneous syndromes. The
EDI-2 has 11 subscales, derived from 91 items,
presented in a six-point, forced choice, format
that requires the respondent to answer
whether each item applies “always”, “usually”,
“often”, “sometimes”, “rarely” or “never”.
Three of the subscales are designed to assess
attitudes and behavior concerning eating,
weight and shape: Drive for Thinness, Bulimia,
Body Dissatisfaction, and the remaining eight
relate to more general organizing constructs or
psychological traits clinically relevant to eating
disorders: Ineffectiveness, Perfection,
Interpersonal Distrust, Interoceptive
Awareness, Maturity Fears, Asceticism,
Impulse Regulation and Social Insecurity.
Auto evaluation Scale (SCL-90-R): The SCL-
90-R (31) is a 90-item self-report system
designed to reflect the psychological symptom
patterns of community, medical and psychi-
atric respondents. Each item is rated on a five-
point scale of distress (0-4) ranging from “not
at all” to “extremely”. The nine primary symp-
128 Eating Weight Disord., Vol. 11: N. 3 - 2006
tom dimensions are labeled as: somatization;
obsessive-compulsive; interpersonal sensitivi-
ty; depression; anxiety; hostility; phobic anxi-
ety; paranoid ideation; and psychoticism; a
General Symptomatic Index is a résumé of all
dimensions.
Bulimic Investigatory Test Edinburgh (BITE):
The BITE (32) is a brief self-report question-
naire for the detection and description of
binge-eating behavior. The scale has 33
Symptoms and Severity (frequency) measure-
ment items typical of bulimia, like binge-eating
and inappropriate compensatory behavior.
Body Uneasiness Test (BUT): The BUT (33) is
a self-report scale originally developed in Italy.
It explores a subject's uneasiness with regard
to body and weight, and indexes the avoiding
or checking of compulsive behavior, deperson-
alization of feelings, and excessive care of spe-
cific parts or body functions. The scale consists
of 34 clinical items and has a list of 37 body
parts. The output scores identify five main psy-
chological indexes: Weight-Phobia, Body
Image Concerns, Avoidance, Compulsive Self-
Monitoring, and Depersonalization, and give
three global indexes: Global Severity Index,
Positive Symptom Total and Positive Symptom
Distress Index .
Mild upsurges in the scores of two sub-tests,
Body Dissatisfaction from the EDI-2 and
Somatization from the SCL-90-R, were consid-
ered acceptable as they fit the description of
the feelings commonly associated with obesity
(34). Indeed, vis-à-vis these observations, it
appears reasonable to expect higher levels of
body dissatisfaction. However, unlike other
alterations in these scales, such problems are
not necessarily connectable to psychiatric dis-
turbances. At the time of evaluation our sample
presented no medical complications or resis-
tance to treatment.
Measures
GT: We used a PC-implemented version of
GT (DOS version made at the University of
Iowa in 1997) and scrupulously followed the
original procedures described by Bechara et al.
(15). The participants, seated before a PC-
screen, see four decks of identical cards
(labeled A, B, C and D), and are given a loan of
$2000 in facsimile. The only information given
is that the game requires a long series of card
selections and that the cards represent invest-
ments that can lead to win or loss. They are
requested to try to maximize a profit on the
$2000 by uncovering one card at a time from
any of the four decks, selecting the cards until
told to stop, and are warned that the values of
the decks vary, some carrying lower values

than others. Thus, if possible, these “poorer
return” decks are best avoided. The subjects
are totally unaware of when the task stops
(after 100 choices) or of the number of cards in
a deck (40 cards).
When the subjects turn the cards they some-
times receive “money”: immediately after
selecting the card a smiling face with the
amount “won” appears on the screen; other
times the subjects receive money but are asked
to pay a penalty: in this case the screen shows
a sad face and the payment to be made. The
penalty varies with both the deck and the posi-
tion in the deck, according to a schedule
unknown to the subjects. The cards from decks
A and B yield a larger short-term payoff (mean
of $100 per card) than the cards from decks C
and D (mean of $50 per card). Decks A and B
are equivalent in terms of overall net loss over
the trials. The difference is that the cards in
deck A penalize frequently for a small amount,
whereas in deck B they penalize less often but
for a greater amount. Also decks C and D are
equivalent in terms of overall net gain. In deck
C the penalty is frequent and of small amount
while in deck D the penalty is less frequent but
a bigger amount. In the long run a continued
choice from either deck C or D leads to a net
gain ($250/10 cards), whereas choosing from
decks A or B leads to a net loss (-$250/10
cards). Thus, each card choice requires a judg-
ment to assess relative risk. With each choice
the subjects receive perhaps only a reward
(shown by the smile) or perhaps a reward plus
an unavoidable penalty (a sad face). Needless
to say the smiling face is always a “winner” but
also the sad face can be a winner in that the
reward can be far greater than the penalty.
For this reason the subject, throughout the
task, needs to calculate also the figures associ-
ated with the sad face. In order to favor the
comprehension of the task, the examiner invit-
ed the subjects to calculate each effective win
or loss until such time they encountered the
first punishment; after that, no further help
was given. Thus the overall size of the loss can
be minimized in subsequent choices. To per-
form the task well the participants must dis-
cover that decks C and D are “advantageous”
(in the long term, the rewards will outweigh
the losses), whilst decks A and B are “disad-
vantageous” (they provide some immediate
high reward, but long-term losses).
Statistics
GT performance was measured in two ways
following a methodology traditionally used in
previous studies (14, 15, 35-37). In one measure-
ment protocol the overall result was the net
Decision-making in obesity
score of the cards, calculated by subtracting the
total number of cards selected from the advan-
tageous decks minus those from the disadvanta-
geous decks for all 100 selections: (C+D)-(A+B).
Thus, lower net scores represent poorer perfor-
mance, and negative net scores indicate a pref-
erence for choosing from the low yield decks. A
one-way analysis of variance (ANOVA) was
used to assess the GT performance differences
in the two groups. Then, as some possible fac-
tors characterizing groups would take decision-
making results into account, an additional one-
way ANOVA for sex differences was carried out
for both groups. Also correlation analysis
(Pearson's ρ) for the two groups was carried
out, taking into consideration the net scores
from the GT and the demographic factors (age
and education). In the second measurement
protocol, a 2 (group) X 5 (block) ANOVA was
carried out on the net sub-scores of the GT (see
above) obtained after 20 consecutive choosings
of cards, for a total of five blocks of 20 cards
each. When permitted, post hoc Newman-Keuls
tests were performed to ascertain if NWS and
OS, separately or combined, differed in perfor-
mance in particular sectors of the task.
RESULTS
A one-way ANOVA conducted on the net
scores of all 100 selections revealed a signifi-
cant, and predominating, effect of group, F(1,
38)=5.0, p<0.04, supporting the prediction that
the performance of the OS in the GT would be
worse than that of the NWS. No sex differences
were revealed from ANOVA for both OS and
NWS. The correlation of age, education and GT
net scores was not significant for both OS and
NWS, not even when combined.
A 2 (group) X 5 (block) ANOVA on the net
scores revealed significant main effects of both
group and block, F(1, 38)=9.3, p<0.003 and F(4,
190)=5.7, p<0.0003, respectively. The first result
confirmed the poorer performance of the OS
group. No significant interaction was found.
Instead, on comparing the net post hoc
Newman-Keuls test scores from the combined
scores of OS and NWS, it was found that there
were significantly increasing higher scores for
the second (p<0.01), third (p<0.003), fourth
(p<0.0004) and fifth blocks (p<0.0001) with
respect to the first block of cards. This indicates
that all subjects understood the task and could
therefore improve performance, even if the two
groups showed a different overall perfor-
mance. Table 2 shows the means and the
Standard Deviation (SD) of the GT net scores
for each group of participants.
Eating Weight Disord., Vol. 11: N. 3 - 2006 129
 R. Pignatti, L. Bertella, G. Albani, et al.
TABLE 2
Means (SD) of the Gambling Task net scores.
Details for each block of cards are provided.
Cards Subjects Net Scores Means (SD)
All selections (cards 1-100) NWS 17.3 (23.5)
OS 1.6 (20.8)
First block (cards 1-20) NWS -0.6 (6.3)
OS -4.6 (5.4)
Second block (cards 21-40) NWS 2.8 (6.6)
OS 0.5 (5.8)
Third block (cards 41-60) NWS 2.7 (9.6)
OS 2.0 (8.1)
Fourth block (cards 61-80) NWS 6.7 (8.2)
OS 0.2 (6.7)
Fifth block (cards 81-100) NWS 5.7 (8.3)
OS 3.5 (6.6)
NWS=Normal Weight Subjects; OS=Obese Subjects.
DISCUSSION
This study addressed the issue of potential
neurocognitive mechanisms underlying obesi-
ty, and utilized knowledge gained from studies
on patients with frontal lobe disorders.
Neuropsychological status has been investi-
gated in OS (38), however no investigation with
a relatively novel test, the GT, has been used to
assess the prefrontal mechanisms in decision-
making. Indeed, such mechanisms could play a
significant role at a lower level by controlling
automatically driven behavior, and at the high-
er cortical level by responding to inherently
rewarding stimuli like food. Our results con-
firm the findings of previous studies that sug-
gest that there is no relationship between
demographic factors (including sex) and GT
performance (14, 23, 35, 36). Obesity is howev-
er a complex phenomenon and there are sever-
al intermediates in its causal pathway.
Until now most researchers have been more
focussed on physiological aspects or on the
part of cognition that deals with the mecha-
nisms of food reward, i.e. why food is so
rewarding. Instead, in our study, we looked at
the prefrontal systems that enable a subject to
have “will power” to control behavior. At the
same time, other neuropsychological studies
conducted on bulimia nervosa (BN) showed BN
patients' poor performance in tests assessing
executive functions (39-41): these findings sug-
gested that BN frequent impulsive behaviors
(such as urge to binge) may be mediated by an
inadequate inhibition of impulses. Indeed, it
has been suggested that “stimulus-bound”
behavior could be related to a defect in
130 Eating Weight Disord., Vol. 11: N. 3 - 2006
inhibitory control played by dorsolateral pre-
frontal cortex (42).
We found that the obese participants per-
formed more poorly than the NWS in the GT,
just as in the study by Grant et al. (37) conduct-
ed using GT to investigate the decision making
of drug abusers. Data of both our study and
that of other authors support the validity of the
GT as a model to study critical behavioral
aspects that lead subjects to drug addiction or
the excessive use of food, i.e., persistence of
rewarded behavior despite adverse conse-
quences. Thus decision-making, which is not
generally assessed in eating disorders, seems to
be significantly deficient in OS, even in the
absence of clear psychiatric problems. However
it must be acknowledged that, given the com-
mon state of depression, anxiety and impulsive-
ness in OS, it would be premature at this stage
to conclude that poor decision-making ability is
directly related to the obesity condition.
It is important to note that the hospital in
which the experiment was carried out does not
admit patients in a state of acute illness. In fact,
most admitted patients are suffering from
chronic diseases connected to obesity and/or
eating disorders; during hospitalization these
patients undergo various analyses and partici-
pate in a period of rehabilitation (about 40
days) that usually involves dietary restrictions,
physical activities, informative meetings on ali-
mentation and, when prescribed, psychological
support. Our sample was taken from this hos-
pital population. Thus, despite the smallness of
the sample, it can be argued that the behavior
demonstrated by our OS subjects could be rep-
resentative of the general population with a
similar degree of obesity. This study, though
preliminary, indicates just how important it can
be to lack a specific cognitive ability, and such
a lack goes a long way towards explaining OS
insensitivity to the real-life long-term conse-
quences of certain behavior. If the frontal cor-
tex is involved in sustaining the normal flexibil-
ity of behavior by imposing volitional restric-
tions on cues selected by attention at each
given moment, therapists must realize that the
loss of flexibility may not necessarily be re-
instated just by providing nutritional guidance
or a new set of rational regulations. Indeed OS
behavior could be consistent with a dorsolater-
al prefrontal cortex defect that implies difficul-
ties in the inhibition of excessive food intake.
ACKNOWLEDGEMENTS
The authors wish to thank Fiorenza Garzoli and Ileana
Mori for their patience and technical support during

all the phases of the study. We also thank Barbara
Carey for the linguistic revision. The study was sup-
ported by a MIUR research grant awarded to Carlo
Semenza.
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