Weight Loss Surgery and Eating Disorders

As rates of obesity in the United States rise, weight loss surgery (commonly known as bariatric surgery), is gaining popularity as a weight loss alternative. Many medical professionals recommend bariatric surgery to assist patients in managing their weight and improve health problems attributed to obesity. Although many people who undergo bariatric surgery lose weight, people with an eating disorder are at increased risk physically and psychologically. An eating disorder can complicate the potential effectiveness of weight loss surgery.

A high number of patients seeking weight loss surgery suffer from Binge Eating Disorder (BED). BED is characterized by eating a large amount of food in a small time period with loss of control. Of note, not all people who have BED are obese, nor is obesity an eating disorder. BED is one of the most common psychiatric disorders in patients presenting for weight loss surgery (Sarwer et al. 2004).

Weight Loss Surgery and Eating Disorders

A psychiatric evaluation to screen for an eating disorder is a mandatory part of the pre-surgical evaluation. However, many patients may not accurately self-report symptoms for fear of being excluded from surgery. Additionally, there is great variability in screening methods and how symptoms are addressed if reported. Even when an eating disorder is diagnosed in the preliminary examination, comprehensive treatment addressing factors maintaining the eating disorder and symptom reduction do not always occur before a patient is cleared for surgery.

It is important for patients with an eating disorder to receive comprehensive and effective treatment before considering weight loss surgery. Although weight loss commonly occurs post-surgery and patients can experience improved health, gastric bypass surgery doesn’t cure the psychological aspects of overeating or binge eating such as depression, anxiety, lack of control, impulsivity, and difficulty coping with stress. When individuals use food for comfort to manage painful emotions and experiences, as is common with BED, the relationship with food needs to be altered prior to surgery. To prevent surgical complications and enjoy full health, the eating disorder must be treated. To do this effectively, patients should receive multidisciplinary treatment including psychotherapy, nutritional counseling, and medical management prior to surgery. If weight loss surgery occurs, it is important a comprehensive treatment plan addressing effective coping skills, managing new dietary restrictions, and emotional adjustment post-surgery is in place.

Weight loss surgeries work in the following ways:

  • Restriction: Surgery shrinks the stomach size and slows down the process of digestion. Restrictive surgeries reduce the amount of food your stomach can hold, thus limiting caloric intake. These techniques are known as gastric banding or gastric stapling.
  • Malabsorption: Surgery limits the absorption of foods in the intestinal tract by “bypassing” a portion of the small intestine.
  • A combination of restriction and malabsorption techniques. This technique is commonly known as gastric bypass surgery.

Weight Loss Surgery and Eating Disorders

Physical Side Effects

Procedures involving malabsorption tend to have greater side effects than restrictive surgeries. Possible side effects of malabsorption include protein, vitamin, and mineral malnutrition.

Complications that may occur when patients do not eat as prescribed post-surgery include:

  • Dumping syndrome: Nausea, sweating, palpitations, cramping, and diarrhea after eating too much sugary food too quickly.
  • Nausea and vomiting from eating too quickly or eating too much food in a short period of time. Some patients report self-induced vomiting to relieve discomfort. For others, (estimate of 11.9% post-surgery patients) vomiting can occur involuntarily.
  • Plugging: Experience of food being stuck in the digestive tract.

Research has shown that these behaviors are common amongst post-bariatric patients. They are often in response to eating too quickly, eating large amounts, or ingesting foods that have become intolerable. They are not formal eating disorder symptoms. However, disordered patterns of eating such as chewing and spitting food (but not swallowing it) and “grazing” throughout the day can develop in order to avoid the physical discomfort of dumping and plugging. Some research has suggested that these common gastrointestinal symptoms might facilitate the development of eating disorder behaviors, and possibly trigger the onset of an eating disorder in a subgroup of patients.

Eating Disorders Post-Surgery

Many patients with a previous history of an eating disorder continue to have disordered eating patterns following weight loss surgery. In fact, weight loss outcomes are poorer among this group. Although some may not binge on a large amount of food due to reduced stomach capacity, many still experience a loss of control over eating and grazing patterns. Both symptoms are distressing and clinically significant. If underlying issues contributing to the eating disorder are not effectively addressed and behavioral interventions are not in place to manage eating disorder symptoms prior to the surgery, patients often learn to work around restrictions of surgery to continue eating disorder behaviors. Overall, there is a lack of adequate data regarding impact of eating disorders on bariatric surgery outcome. However, some findings suggest 4 out of 9 patients who binge ate prior to surgery continued to do so post-surgery (Hsu et al. 1998). Many more report symptoms of feeling out of control when eating, eating secretively, eating until uncomfortable, rapid eating, eating when not hungry and feelings of disgust and shame associated with eating habits.

Eating disorder clinicians are reporting an increase in patients seeking help following weight loss surgery. Patients presenting with the need for specialized treatment are experiencing a range of eating disorder symptoms associated with binge eating, bulimia, and anorexia nervosa. Often, eating disorder symptoms can be triggered by previously mentioned side effects of weight loss surgery such as plugging. Additionally, experienced anxiety and fear of gaining weight post-surgery can trigger disordered eating patterns that can reach clinical significance.

As the number of patients who undergo bariatric surgery continues to increase, it is important for clinicians to be alert of the range of complications that can be develop. Eating disorders have not been widely recognized in bariatric surgery patients, but a number of patients seem to present with symptoms that warrant eating disorder diagnoses and require specialized treatment. There is a significant need for specialized screening and comprehensive treatment before and after weight loss surgery.

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About The Author

Dr. Kristine Vazzano is a clinical Psychologist that specializes in eating disorders. Her private practice is located in Bloomfield Hills, Michigan.

References

Conceição, E., Orcutt, M., Mitchell, J., Engel, S., LaHaise, K., Jorgensen, M., Wonderlich, S. (2013). Characterization of Eating Disorders After Bariatric Surgery: A Case Series Study. The International Journal of Eating Disorders, 46(3), 274–279.

Dawes A.J., Maggard-Gibbons M., Maher A.R., et al. (2016), Mental Health Conditions Among Patients Seeking and Undergoing Bariatric Surgery: A Meta-Analysis. The Journal of the American Medical Association, 315(2), 150-163.

Hsu, L.K., Benotti, P.N., Dwyer, J., Roberts, S.B., Saltzman, E., Shikora, S., Rolls, B.J., Rand, W. (1998) Nonsurgical Factors that Influence the Outcome of Bariatric Surgery: A Review. Psychosomatic Medicine 60(3), 338-346.

Kalarchin, M.A., Marcus, M.D., Courcoulas, H.D., (2008). Eating Disorders Review 19(4).

Niego, S.H., Kofman, M.D., Weiss, J.J. and Geliebter, A. (2007), Binge eating in the bariatric surgery population: A review of the literature. The International Journal of Eating Disorders, 40: 349–359.

Sarwer, D.B., Wadden, T.A. and Fabricatore, A.N. (2005), Psychosocial and Behavioral Aspects of Bariatric Surgery. Obesity Research,13: 639–648.

Written – 2016