Eating Pathology and Bariatric Surgery: Important Implications
By Christine Peat, PhD
In recent years, the term bariatric (weight loss) surgery has become commonplace. Many of us have family members, friends, neighbors, or coworkers who have undergone these types of procedures. There are even entire television programs dedicated to chronicling the lives of people who elect to have these surgeries. Thus, collectively, our society has become accustomed to learning about bariatric surgery and the impact it has on a person’s physical health. There has also been considerable discussion about the impact these types of surgeries have on one’s mental health, including the role that eating disorders might play both before and after surgery. Extant literature indicates that eating pathology is not uncommon among bariatric candidates; however, there is less consensus about the impact these conditions might have on postsurgical outcomes.1,2 Clinicians and researchers should, however, be mindful of the potential for eating problems both before and after bariatric surgery. The latter is a particularly unique issue, as postsurgical life is changed dramatically with regard to physical anatomy, lifestyle, and behavioral recommendations.2 The following represents important (but not exhaustive) insights about eating pathology in the management and study of bariatric patients.
Binge eating is common among bariatric candidates, with up to 53 percent of individuals meeting threshold criteria for binge eating disorder (BED) and an even greater number reporting subthreshold symptoms.3 Given the association between weight-loss attempts and eating disorders,4–6 the prevalence of binge eating among bariatric candidates (who are required to have a history of dieting prior to undergoing surgery) is perhaps unsurprising. Research also suggests that the risk for BED increases with weight,7,8 which might also account for the association, given that many people seeking bariatric surgery are at their highest lifetime weight. Although less common, a history of anorexia nervosa (AN) and bulimia nervosa (BN) is reported among 0.5 percent and 3.5 percent of bariatric candidates, respectively.9 In addition, grazing10 and compulsive overeating/emotional eating11 are commonly reported among bariatric candidates; however, these conditions are studied less frequently, so prevalence estimates are less well-defined.
As reflected in the above, current evidence indicates that eating pathology prior to undergoing bariatric surgery is common. Thus, best practices recommend that bariatric candidates undergo a thorough mental health evaluation prior to undergoing surgery.12 During these evaluations, clinicians should be screening for the presence and/or history of eating pathology, and if there is any evidence of active eating disorder behaviors, clinicians are encouraged to refer patients to appropriate care.12 Although doing so is not a standardized component of mental health evaluations for weight-loss surgery, the savvy clinician might also discuss the extent to which weight stigma has affected each bariatric candidate. Ample evidence suggests that weight stigma itself can be an important factor that contributes to negative mental and physical health outcomes, including eating pathology.13,14 Bariatric candidates may be somewhat reluctant to discuss the extent to which they have faced weight stigma, particularly given its prevalence in health care settings; however, a careful discussion about the impact of this stigmatization may help patients achieve a better understanding of how these factors may influence their health both before and after surgery.
In contrast to the data on the impact of presurgical eating pathology, the literature is more conclusive about the negative prognostic indication of eating pathology after bariatric surgery. Postsurgical binge eating is frequently associated with adverse outcomes2; however, there are inherent challenges in both diagnosing and treating binge eating after bariatric surgery. First, “binge eating” is a challenging construct to define in post-bariatric patients. While loss of control (considered a crucial component of binge eating) is certainly reported among these individuals, the extent to which they can consume “an unusually large amount of food” is still debated.2 Thus, no firm guidelines on the assessment and diagnosis of binge eating in post-bariatric patients have been established, and firm prevalence estimates remain elusive. Furthermore, the treatment of binge eating in post-bariatric patients requires modifications to a standardized approach (e.g., cognitive behavioral therapy), given the dietary restrictions, frequency of meals, and possible food intolerances that might occur in this patient population. Such modifications to clinical practice are not always commonplace, and it can thus be difficult for patients to access the care they need. Further research is certainly necessary to first define the construct of binge eating so we can better determine its prevalence, and then also to determine best practices for its treatment.
In addition to binge eating, other forms of eating pathology can occur after surgery and have been associated with poorer surgical outcomes. Grazing (defined as a pattern of repeatedly eating smaller quantities of food over a long period of time with accompanying feelings of loss of control)10,15 and eating in the absence of hunger have both been associated with suboptimal outcomes in post-bariatric patients.10 Threshold eating disorders have also been documented across several case studies of bariatric patients.16,17 Although not a frequent outcome, AN and BN have been reported among post-bariatric patients as both a reoccurrence of previous symptoms (prior to surgery) and as de novo cases.16,17 In fact, many of the patients described in these reviews/case studies required inpatient hospitalization, which underscores the extent to which eating pathology can quickly become severe among post-bariatric patients. Similar to managing binge eating, the management of other forms of postsurgical eating pathology also requires a nuanced approach to treatment, given the differences in physical anatomy and associated dietary restrictions. The interested reader is encouraged to read two excellent reviews and case studies of eating disorders and bariatric surgery published by Marino and colleagues17 and Conceição et al.16
Vulnerability to Eating Pathology After Bariatric Surgery
The postsurgical recommendations regarding diet, exercise, and other lifestyle changes can prove to be challenging for patients and have the potential to contribute to eating pathology. The postsurgical diet focuses on small meals, a restriction of carbohydrates and fats, and a limitation on overall calories consumed. Most post-bariatric patients also experience a reduction of hunger during the initial postsurgical months, and this might lead to meal skipping (a factor that can increase the likelihood of a binge eating episode). In addition, postsurgical health care visits often focus exclusively on the amount of weight lost, and many individuals experience frequent comments about their weight and shape from family members and friends. Thus, collectively, there are several factors inherent in the post-bariatric lifestyle that might inadvertently create an environment that is hyper-focused on calorie restriction and weight loss—much like what is seen in patients with AN or BN. Evaluation of and treatment for eating pathology after bariatric surgery is often limited, thereby creating a critical gap in necessary patient care.
In light of these considerations, it behooves both clinicians and researchers to be cognizant of how eating pathology may present prior to and after surgery. For clinicians, it is imperative that eating pathology be carefully assessed, particularly in the postsurgical period, when patients may be the most vulnerable to disordered eating behaviors. For researchers, longitudinal studies are needed to more fully evaluate the impact of eating pathology on bariatric outcomes, including weight loss, health markers (e.g., metabolic parameters), and quality of life. Such information has the potential to improve the ability of patients to obtain more permanent and successful treatment that minimizes the risk of eating pathology and enhances global well-being.
About the author:
Dr. Christine Peat is the Director of the National Center of Excellence for Eating Disorders (NCEED) and an Associate Professor of Psychiatry at the University of North Carolina at Chapel Hill. She completed her undergraduate training in psychology at the University of Arizona and earned her master’s degree and doctorate in clinical psychology at the University of North Dakota. Her internship was in behavioral medicine at West Virginia University, after which she went on to complete her postdoctoral fellowship in eating disorders research at the University of North Carolina under the directorship of Dr. Cynthia Bulik. As the Director of NCEED, Dr. Peat is focused on broadly disseminating education and training on eating disorders to healthcare providers across a variety of disciplines. Her research centers on eating pathology across the spectrum, but with a distinct focus on binge-eating disorder. She is particularly interested in the intersection between obesity, bariatric surgery, and eating pathology and investigating physiological comorbidities associated with eating disorders.
Dr. Peat is also a licensed psychologist in North Carolina and as such, treats eating disorders across the spectrum, with a primary focus on binge eating. Given her background in behavioral medicine, she has also established clinical services in GI Surgery where she provides both psychotherapy and behavioral medicine interventions to this patient population. In addition to her clinical and research responsibilities, Dr. Peat is also a clinical supervisor for pre-doctoral psychology interns, psychiatry residents, and mentors undergraduate students.
- Devlin MJ, King WC, Kalarchian MA, Hinerman A, Marcus MD, Yanovski SZ, et al. Eating pathology and associations with long-term changes in weight and quality of life in the longitudinal assessment of bariatric surgery study. International Journal of Eating Disorders. 2018 Dec;51(12):1322-30.
- Williams-Kerver GA, Steffen KJ, Mitchell JE. Eating pathology after bariatric surgery: An updated review of the recent literature. Current Psychiatry Reports. 2019/08/13;21(9):86.
- Tess BH, Maximiano-Ferreira L, Pajecki D, Wang YP. Bariatric surgery and binge eating disorder: Should surgeons care about it? A literature review of prevalence and assessment tools. Archives of Gastroenterology. 2019 May 20;56(1):55-60.
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- Kessler RC, Berglund PA, Chiu WT, Deitz AC, Hudson JI, Shahly V, et al. The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biological Psychiatry. 2013 May 1;73(9):904-14.
- Kalarchian MA, Marcus MD, Levine MD, Courcoulas AP, Pilkonis PA, Ringham RM, et al. Psychiatric disorders among bariatric surgery candidates: Relationship to obesity and functional health status. American Journal of Psychiatry. 2007 Feb;164(2):328-34.
- 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, Md.). 2008 Mar;16(3):615-22.
- Jantz EJ, Larson CJ, Mathiason MA, Kallies KJ, Kothari SN. Number of weight loss attempts and maximum weight loss before Roux-en-Y laparoscopic gastric bypass surgery are not predictive of postoperative weight loss. Surgery for Obesity and Related Diseases: Official Journal of the American Society for Bariatric Surgery. 2009 Mar-Apr;5(2):208-11.
- Sogg S, Lauretti J, West-Smith L. Recommendations for the presurgical psychosocial evaluation of bariatric surgery patients. Surgery for Obesity and Related Diseases: Official Journal of the American Society for Bariatric Surgery. 2016 May;12(4):731-49.
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- Tomiyama AJ, Carr D, Granberg EM, Major B, Robinson E, Sutin AR, et al. How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Medicine. 2018 2018/08/15;16(1):123.
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- Marino JM, Ertelt TW, Lancaster K, Steffen K, Peterson L, de Zwaan M, et al. The emergence of eating pathology after bariatric surgery: A rare outcome with important clinical implications. International Journal of Eating Disorders. 2012 Mar;45(2):179-84.