Considerations in the Association between Eating Pathology and Bariatric Surgery

Published: October 2, 2013

As bariatric surgery has become a more commonplace treatment for obesity in recent years, interest has arisen in the extent to which eating pathology might affect surgical prognosis. No concrete conclusions have been reached regarding whether pre-existing eating pathology negatively or positively affects weight loss and quality of life outcomes after surgery—or if it has no effect at all. 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 post-surgical life is changed dramatically with regard to physical anatomy, lifestyle, and behavioral recommendations. The following represents important (but not exhaustive) insights about eating pathology in the management and study of bariatric patients.

  • Pre-surgical considerations
    • Binge eating is common among bariatric candidates with nearly 30% of obese adults who are seeking surgical intervention reporting binge eating.
      • Results are mixed with regard to how binge eating might affect post-surgical weight loss with some reporting greater weight loss (PMID: 15072655), some reporting less weight loss (PMID: 11361166; 15329189), and others reporting that binge eating was unrelated to weight loss outcomes (PMID: 10728171; 17194271).
  • While less common, a history of anorexia nervosa (AN) and bulimia nervosa (BN) are reported among 0.5% and 3.5% of bariatric candidates respectively (PMID: 16815322; 17267797).
  • Grazing (PMID: 18239603) and compulsive overeating/emotional eating (PMID: 18996769) are also commonly reported among bariatric candidates; however, it remains unclear how these behaviors might affect weight loss after surgery.
  • Post-surgical considerations
    • The literature is more conclusive about the negative prognostic indication of eating pathology after bariatric surgery.
      • Binge eating and loss of control eating are frequently associated with poorer weight loss outcomes. PMID: 18074498; 15479602; 19837012; 20168309; 23121796.
        • It is worth noting that “binge eating” is an elusive 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. Thus, no firm guidelines on the assessment and diagnosis of binge eating in post-bariatric patients have been established, and prevalence estimates remain unknown. Further research is certainly necessary to first define this construct for this patient population so that we can then assess the degree to which binge eating might still be prevalent after bariatric surgery.
    • Grazing (PMID: 18239603; 20168309), snacking (PMID: 18830780), and non-hungry eating (PMID: 18408982) have been associated with poorer weight loss after surgery.
  • Threshold clinical eating disorders are have been documented across several case studies of bariatric patients.
    • AN and BN have been reported among bariatric patients as both a re-occurrence of previous symptoms (prior to surgery) and as de novo cases.
    • Two excellent reviews and case studies of eating disorders and bariatric surgery have been published can be found here: PMID: 21495051 and PMID: 23600557.
  • The post-surgical recommendations regarding diet and exercise can prove to be challenging for patients and have the potential to contribute to disordered eating.
    • The post-surgical diet focuses on small meals, a restriction of carbohydrates and fats, and a limitation on overall calories consumed.
    • The post-surgical diet in combination with an almost exclusive focus on weight loss as the primary outcome measure can 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 and has thereby created 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 post-surgical period where 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

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