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The Relationship Between Eating Disorders and Bariatric Surgery

Maria Sardari


November 8, 2017




Obesity is a nationwide epidemic in the United States and has become a

significant problem for many individuals and the healthcare industry. Bariatric

surgery appears to be the most effective tool for significant weight loss that is

available to obese and morbidly obese individuals.1 Although traditional methods of

weight loss may be used, they are not as effective, create a significant burden on the

individual, and are often too lengthy for the safety of the individual, thus bariatric

surgery is a good option.1 Another issue for the patients afflicted by the condition is

the co-occurrence of eating disorders or disordered eating patterns associated with

obesity. Eating disorders such as binge eating, loss of control eating, maladaptive

eating, anorexia nervosa, and bulimia nervosa are a significant issue that could be life

threatening. It is common for obese individuals to exhibit symptoms of such behavior

without diagnosis prior to and after bariatric operations.

Bariatric surgery, is defined as an operation that is performed on an individual

who is obese or morbidly obese and involves the alteration of the gastrointestinal tract

in a manner that results in a decrease of food intake, malabsorption, or both.1 There

are several issues associated with bariatric surgery such as the fact that 20-30% of all

bariatric surgery patient regain a significant amount of weight 18-24 months after

undergoing surgery.2 Weight regain is often attributed to maladaptive eating patterns

such as binge eating.2 Since an eating disorder may pose significant health and

psychological risk for the patients, it is important to understand the various forms of

disordered eating commonly encountered.

The most prevalent eating disorders are binge eating (BE), disordered eating,

maladaptive eating, picking and nibbling, anorexia nervosa (AN), emotional eating,

and loss of control eating (LOC.) Binge eating disorder (BED) is described as the

consumption of an amount of food, over a distinct period, that is certainly larger than

most people would eat in the same period of time under regular circumstances.3,4

According to the DSM-5, a manual for psychological diagnostic, the prevalence of

BED has been estimated at 15.7%-26.6% in those who have obesity and desire

bariatric surgery procedures.4 It is understood that those with BED eat compulsively

and may have addictive personalities.5 Another form of disordered or abnormal eating

is maladaptive eating, which is a broader term that encompasses compulsive eating

behaviors and addictive tendencies that may result in increased total energy intake

and/or negative consequences for the individual, but does not fall under a defined

eating disorder.5,6 Picking and nibbling is the consumption of modest amounts of food

in an unplanned and repetitious way, in the absence of loss of control.7 An eating

disorder usually associated with post and not pre-operative conditions, is anorexia

nervosa and is defined by the DSM-4 and 5, as the restriction of energy consumption

in relation to standard requirements which leads to a significantly low body weight in

the framework of age, sex, developmental stage, and physical health.8 Emotional

eating, eating in response to emotional triggers, is not a classified eating disorder but

has been associated with risk factors associated with poor post-operative outcomes.9

Finally, loss of control eating is similar to BED but does not necessarily include the

consumption of an excessively large amount of food but is related to psychological


conditions of impulsivity. 10 Due to the limitations of this review, not all types of

disordered eating are mentioned but the key categories are explored due to the

presence of research on the subject. Furthermore, eating disorders are not present in a

vacuum and necessitate an investigation of the potential causes of such conditions.

Some disordered eating causes proposed by current research in the field, are from

stigma,1 shame,11 depression and ineffectiveness,2 control,12 and lack of follow-ups of

the patient or pre- and post-operative psychological evaluations.13 The causes are

various but the former are several theories associated with disordered eating and

bariatric patients with these conditions. Due to the risks involved, a proposition of the

possible solutions will be explained.

Health professionals are key in the assessment and treatment of bariatric surgery

patients and are therefore in part responsible for the provision of adequate care and

prevention. The following are a compilation of actions that the healthcare field may

implement to alleviate the risks of eating disorders on bariatric surgery: reduction of

stigma,1 cognitive behavioral therapy,14,15 planning and intention,3 evaluation and

treatment of addictive behaviors.5 The problem is complex and requires a

multifaceted approach and this paper will evaluate the current status of eating

disorders and bariatric surgery procedures. The primary question investigated in this

review is whether patients with disordered eating patterns prior to surgery show an

improvement in eating habits and positive weight loss following surgery.


The relationship between eating disorders, obesity, and the election of bariatric

surgery is complicated, but in order to understand the significance of the issue and why

an obese individual may have an eating disorder we must evaluate the literature on the

potential causes of eating disorders. For example, Vartanian and Fardouly studied the

stigma associated with bariatric surgery which could prevent obese individuals from

undergoing the surgery or feeling excessive judgement for electing the procedure. In the

study, 275 randomly selected participants were shown a before and after weight loss

photograph of a woman and they were asked to rate the woman on a variety of traits after

reading the method by which the woman had lost weight.1 The study showed that

individuals who had lost weight through bariatric surgery were evaluated more negatively

than those who had lost the same weight through diet and exercise.1 Overall, the bariatric

weight loss option was rated in a statistically significant value of P < 0.001 as more lazy,

sloppy, less competent, and less sociable than the weight loss through diet and exercise

option.1 This indicates that there are significant social repercussions for individuals

undergoing bariatric surgery related to judgement and could potentially play a role in the

retention or acquisition of psychological disturbances leading to disordered eating

patterns. Lier et al. also focused on the presence of shame in a study of 87 bariatric

patients.11 The researchers found that high pre-operative shame scores resulted in high

post-operative shame scores with a P = 0.007. 11Furthermore, Beck et al. found that

patients with depression, ineffectiveness, and anxiety symptoms following bariatric

surgery encountered less weight loss and more problematic eating than controls from the

Danish normal population. 2 In the study, 45 patients who underwent surgical

interventions were evaluated for eating disorder symptoms using the Eating Disorder

Inventory, an altered BED questionnaire, the Hospital Anxiety and Depression scale for

screening mood disorders, and current weight. 2 To understand the relationship between

weight status and psychological variables, a multiple linear regression analysis was

performed along with p < .05 considered as statistically significant.3 It was found that

27% of the patient experienced BED after surgery, 35% had loss of control, and 37% felt

shame after eating, 2 Due to the high scores on BED with a value of -0.29 and

ineffectiveness with a value of -0.37 which are statistically significant, it was understood

that after plotting on a linear regression analysis, there was less weight loss associated

with these symptoms.2 Therefore, it can be concluded that BED negatively affected

outcomes for some patients even after surgery. Additionally, another study by Lent and

Swencionis agreed with Lier et al. findings of associations between psychological

disturbances and the persistence of poor health outcomes in bariatric patients. Lent and

Swencionis found that overeating scores were associated with the Addiction Scale at

p<.001 values. 5 Moreover, those who exhibited BE had significantly higher addiction

scores (Z = -3.26; p=0.001) than the female norm.5 Conceicao et al. also found that

weight regain was significantly associated with Picking and Nibbling (p<0.001) and that

the regain was positively associated with psychological distress .7 Several additional

factors appeared to show comorbidity with obesity and election of bariatric surgery such

as emotional eating,9 pressure to maintain the thin ideal,8 emphasis on restrictive

behaviors,12 and underreporting of eating pathologies before and after surgery.13 The

emphasis on the thin ideal by culture and the restrictive manner of the diet imposed on

post-surgery patients, may have contributed to potentially anorexia type restrictive

behaviors in 7 out of 12 patients studied by Conceicao et al. 8 Based on the above

findings, it may be concluded that there is a significant prevalence of disordered eating

patterns, psychological disorders, and negative outcomes associated with these symptoms

in bariatric patients. Now that potential causes were mentioned, the prevalent eating

disorders may be further elucidated


Throughout the literature, the most common problematic eating patterns were: binge

eating and loss of control eating,4,610maladaptive eating, food addiction and emotional

eating, 5,7,9 and anorexia nervosa and restrictive type disorders.8 Chao et al. in a study of

59 bariatric surgery (BS) patients compared the weight outcomes at two years after

surgery. The results demonstrated that there were statistically significant differences

between BED patients and non-BED patients, with 18.6% versus 23.9% weight loss

respectively. 4 Besides weight loss attenuation, Horvath et al. found that 31.9% of those

undergoing BS had depression and felt more compulsive and many had a greater energy

intake from carbohydrates and lower intake of fatty acids which could result in additional

negative effects outside of weight.6 When it comes to loss of control eating, the findings

are similarly discouraging, according to Meany et al loss of control eating is often a

varied form of BE and generally leads to less weight loss over time. 10 Other forms of

poor eating such as maladaptive eating, food addiction, and emotional eating are also

common within the literature evaluating bariatric surgery comorbidities. Lent and

Swencionos found that addiction plays a major role in maladaptive eating patterns. Their

study found that as addictive personality scores increase, overeating behaviors intensify.5

Conceicao et al. also demonstrated that maladaptive eating is associated with weight

regain and significant psychological distress.7 Likewise, psychology played a significant

role according to Chesler’s extrapolation that emotional eating is an untreated risk factor

following BS. 9 According to Chesler, conscious and reflexive emotional eating (EE) is a

behavior in response to emotion that involves food consumption that is rather different

than BED because it is not as severe and is considered subclinical, yet weight loss for

those undergoing EE is often lower than controls.9 The risks associated with insignificant

weight loss are great and unresolved conditions such as emotional eating could be

preventing substantial weight loss in patients. Although the primary problems are

generally associated with insignificant weight loss outcomes in BS patients, there is

another type of eating disorder that could be just as problematic in regard to health for BS

patients. Anorexia nervosa is characterized by severe restriction and may lead to too

much weight loss, leading to an increased risk of death. In a report by Conceicao, out of

12 patients evaluated, four reported a BMI below 18 which placed them within the

severely underweight category indicative of anorexia nervosa(AN). 8 What was even

more alarming, was the presence of AN symptoms in ten out of the twelve BS patients

prior to surgery even when weight was not categorized as being underweight.9 In the

evaluation, 4 patients were readmitted to a clinic several times over 4 years following the

BS due to eating disorder symptoms.9 The reoccurrence of these symptoms and

readmission is indicative of a significant psychological and physical burden associated

with the presence of an eating disorder, thus making it crucial for the implementation of

psychological treatment for pre and post-operative conditions.

Unfortunately, the negative side effects associated with the presence of eating

disorders associated with BS patients may expand beyond overweight status or normal

post-surgery complications such as lower quality of life, depressive symptoms,

persistently extreme BMI, weight regain, higher fat mass, malnutrition, and excessive

weight loss. Most patients electing bariatric surgery do so in order to increase quality of

life or resolve health related problems. Contrary to the former, the presence of eating

disorders before the surgery may result in deteriorating psychological conditions.

Vartanian and Fardouly have already demonstrated that those undergoing BS are judged

more harshly such as less competent (p<0.001) and less competent (p<0.001) than the

diet and exercise weight loss group. 1 Such judgements may increase shame associated

with BS surgery and decrease the quality of life of the afflicted individual. Additionally,

less %BMI loss was associated with feelings of ineffectiveness and binge eating

symptoms (p<0.05). 2 The feelings of ineffectiveness could contribute to negative

psychological effects in the patients electing BS. Lier et al. unveiled an association

between the presence of pre-operative psychological disturbances and post-operative

conditions, in the study 18% of those with pre-operative psychiatric disorders maintained

the condition even after BS. 11 One report exposed that one patient acquired a post-

operative syndrome, a year after surgery. 11 Such results signify risks associated with BS

that are not standard since they are mostly psychological rather than direct physical

consequences due to BS procedures. On the other hand, Lent and Swencionis did not find

addictive personalities as having an association between social and affective disturbances

but rather that BED contributed to lower quality of life post operatively. 5 These findings

may mean that eating disorders could result in social and affective disruptions not

expected simply from bariatric surgery. Besides psychological issues, eating disorder

may lead to health risks related to weight. In a study by Horvath, BE resulted in higher

mid-upper arm circumference (p=0.047) compared to overweight control, indicative of

higher fat mass.6 Within the health field, it is generally understood that higher fat mass

may lead to cardiovascular complications such as arterial blockages which may even be

fatal. Thus BED, is related to severe health risks. Likewise, four other studies found that

eating disorders led to less weight loss and higher weight regain compared to controls,

representative of a real risk for BS patients. 4,7,9,10 Although, weight regain risks are an

issue, weight loss and malnutrition may be just as dangerous. Three studies mentioned

anorexia nervosa and malnutrition as a problem following BS, most importantly,

Conceicao et al. recorded a patient as reaching a BMI of 13.1 which requires specialized

treatment in order to avoid death8 and other reports showed two patients with overly-

restrictive dieting and compulsive exercise.12 Marino et al. also found that a significant

number of patients practiced AN behaviors and even refused to eat. 13 Following this

review, it may be understood that eating disorders in BS patients are a significant pre-

operative and post-operative risk and must be addressed if weight loss and continued

weight maintenance is to be attained.

Finally, several implemented programs have shown some success and should be

mentioned. Three studies emphasized that intention, planning, and cognitive behavioral

therapy (CBT) are useful tools for the alleviation of addiction, maladaptive eating, binge

eating, and restrictive behaviors in BS patients. 3,5,7,9,14,15 Wood and Ogden focused on

the predictors of decreased binge eating in a Health Action Process Approach model.3 In

the model, 24 participants met the criteria for BE disorder prior to surgery but only three

reported BED after surgery.3 Overall, the presence of “intention” revealed a significant

association with a decrease in binge eating after surgery. 3 Two studies demonstrated that

CBT, a psychological therapy that deals with cognition and active change of behavior,

aided with dysfunctional eating in patients.14,15 Gade et al. found that at follow-up, the

individuals who received CBT therapy before and after surgery experienced significant

improvements(p<0.001) in dysfunctional eating, anxiety, and depression compared to

those who did not undergo CBT.14 Abiles et al. also found that in a study of 110 BS

patients who were treated with CBT preoperatively, experienced a significant

improvement (p<0.05) in symptoms regardless of the presence of BE disorder or not. 15

These results are promising because it indicates that there are potential solutions for

eating and psychological disorders available to BS patients.



So, do patients with disordered eating prior to bariatric surgery show an

improvement in eating habits and positive weight loss after surgery? Following the

review, it is possible to state that there are issues related to BS that are not resolved

by bariatric surgery alone. There appears to be a continuous prevalence of eating

disorders even after BS and there is not enough psychological treatment. Therefore,

an implementation of CBT and intention on the part of the patient must be

emphasized to alleviate the problem. Of course, it is evident that bariatric surgery is

quite effective in regard to weight loss but does not appear to be an effective

treatment for psychologically associated disorders such as emotional eating and other

forms of disordered eating stemming from psychological disturbances.

The implication of the review for the health field is significant. It is clear that

dietitians and doctors must receive more education on disordered eating and that more

research is necessary to understand the connection between bariatric surgery, obesity,

and disordered eating. The issue is rather complex and may not be completely

understood due to the limitations of the above review. The limited scope of the

review does not detract from the importance of promoting further research on the

topic. Programs involving CBT and other therapies should be provided to BS patients

before and after surgery in order to decrease the risks associated with disordered

eating in the context of weight loss surgery. Healthcare professionals should receive

comprehensive education about the risks of untreated eating disorders and guidance

on the early detection of maladaptive eating in potential bariatric surgery recipients.



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