Author: Ya-Ke (Grace) Wu, PhD, RN

Note to readers: This blog deals with an important topic, namely bariatic surgery. Accordingly, it addresses topic such as weight loss and weight loss goals. If these topics make you uncomfortable, we suggest caution in deciding whether this blog post is for you.

Bariatric surgery (or weight loss surgery) is a commonly recommended procedure for people who live in higher weight bodies. Although these procedures are typically discussed in primary care offices or with endocrinologists, it is important to recognize the potential impact that eating pathology may play in the outcomes from these surgeries. For example, disordered eating behaviors are frequently reported among patients seeking bariatric surgery and may continue even after surgery.1 This blog post briefly introduces what bariatric surgery is, what are two common types of bariatric surgery, and how to assess binge eating after bariatric surgery.

What is bariatric surgery and what are two common types of bariatric surgery? “Bariatric surgery” refers to the surgical procedures performed to manage obesity.2 To date, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most common surgical procedures for weight loss. RYGB involves creating a small pouch from the top portion of the stomach and attaching that pouch directly to the small intestine, part of which is also removed during surgery.3 RYGB is designed to both restrict the amount of food a person ingests and limit the amount of nutrients absorbed from the food due to the removal of part of the intestine.3 SG is a less invasive procedure that reduces the stomach’s capacity by removing about 80% of the stomach to limit food intake.4 In 2018, more than 250,000 patients received bariatric surgery in the United States and Canada, with 61.4% undergoing SG, and 17.0% undergoing RYGB.5

After RYGB and SG, patients typically experience rapid weight loss for 6-12 months then lose weight more slowly over the next 18-24 months.6 However, a significant minority of patients report losing less weight than expected after surgery or having regained lost weight. In the bariatric field, “suboptimal weight loss” after bariatric surgery is defined as losing less than 50% of one’s excess weight.7 Weight regain after bariatric surgery is broadly defined as an increase in weight after initially successful weight loss.7 There is no specific definition of the amount of weight regain that constitutes weight regain. About 20-35% of patients who undergo RYGB and 5-10% of patients who undergo SG reported that they did not lose the expected 50% of excess weight or regained weight after 18–24 months post-surgery.8-10

Binge eating after bariatric surgery

Binge eating is defined as the consumption of a large amount of food in a short period of time with a sense of loss of control over eating.11 The prevalence of binge eating is higher among patients seeking bariatric surgery (15.7%) compared to the general population (2.6%).1 Even after surgery, binge eating has been shown to persist in a significant minority of patients (1.3-4.5%).12 Given the structural change of the stomach after bariatric surgery, the amount of food that patients actually can eat after surgery is restricted by the smaller stomach volume. Therefore, being able to accommodate an unusually large quantity of food (compared with non-surgical patients) is uncommon after the surgery.13 However, there is some debate that it may be more appropriate to determine an “unusually large amount of food” by comparing the amount eaten with other bariatric patients.11 Importantly, some patients report having a sense of loss of control when eating post-surgery, even in the absence of eating a large volume of food. “Loss of control over eating” is defined as feeling that one cannot stop eating, or cannot control how much one is eating once eating has started.14 Given that the size of a binge changes by necessity after bariatric surgery, clinicians have suggested that it may be more important to focus on the loss of control feature to determine whether binge eating may be occurring.

Given that binge eating is commonly reported among both pre-surgical candidates and post-surgical patients, it is critically important for individuals to undergo a comprehensive evaluation prior to bariatric surgery that includes a review of eating disorder behaviors. This can help guide pre-surgery preparation and post-surgery interventions to assist with developing healthy post-surgery eating behaviors and avoid disordered eating traps. In fact, a pilot study showed that cognitive-based behavioral therapy reduced loss of control over eating and other disordered eating symptoms post-surgery among patients who received RYGB.15 Such intervention may help to ensure binge eating is adequately addressed in this at-risk population.

At the University of North Carolina Memorial Hospital at Chapel Hill, all bariatric surgery candidates undergo a comprehensive evaluation by clinical psychologists from the UNC Health Care System. You can visit the UNC Bariatric Surgery Program to learn more about first steps for bariatric surgery: https://www.uncmedicalcenter.org/uncmc/care-treatment/bariatric-surgery/first-steps/

References 1. Mitchell, J.E., King, W.C., Courcoulas, A., Dakin, G., Elder, K., Engel, S., …Wolfe, B. (2015). Eating behavior and eating disorders in adults before bariatric surgery. International Journal of Eating Disorders, 48(2), 215-222. doi: 10.1002/eat.22275 2. National Institute of Diabetes and Digestive and Kidney Diseases. (2016). Definition & facts for bariatric surgery. Retrieved from https://www.niddk.nih.gov/health-information/weight-management/bariatric-surgery/definition-facts 3. Lim, C. H., Jahansouz, C., Abraham, A. A., Leslie, D. B., & Ikramuddin, S. (2016). The future of the Roux-en-Y gastric bypass. Expert Review of Gastroenterology & Hepatology, 10(7), 777-784. doi:10.1586/17474124.2016.1169921 4. Chung, A. Y., Thompson, R., Overby, D. W., Duke, M. C., & Farrell, T. M. (2018). Sleeve gastrectomy: Surgical tips. Journal of Laparoendoscopic & Advanced Surgical Techniques, 28(8), 930-937. doi:10.1089/lap.2018.0392 5. American Society for Metabolic and Bariatric Surgery. (2018). Estimate of bariatric surgery numbers, 2011-201. Retrieved from https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers 6. Ritz, P., Caiazzo, R., Becouarn, G., Arnalsteen, L., Andrieu, S., Topart, P., & Pattou, F. (2013). Early prediction of failure to lose weight after obesity surgery. Surgery for Obesity and Related Diseases, 9(1), 118-121. doi:10.1016/j.soard.2011.10.022 7. Maleckas, A., Gudaityte, R., Petereit, R., Venclauskas, L., & Velickiene, D. (2016). Weight regain after gastric bypass: Etiology and treatment options. Gland Surgery, 5(6), 617-624. doi:10.21037/gs.2016.12.02 8. Elnahas, A. I., Jackson, T. D., & Hong, D. (2014). Management of failed laparoscopic Roux-en-Y gastric bypass. Bariatric Surgical Practice and Patient Care, 9(1), 36-40. doi:10.1089/bari.2013.0012 9. Karmali, S. (2013). The sleeve gastrectomy and how and why it can fail? Surgery: Current Research, 04(03). doi:10.4172/2161-1076.1000180 10. Saliba, C., El Rayes, J., Diab, S., Nicolas, G., & Wakim, R. (2018). Weight regain after sleeve gastrectomy: A look at the benefits of re-sleeve. Cureus, 10(10), e3450. doi:10.7759/cureus.3450 11. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. 12. Smith, K. E., Orcutt, M., Steffen, K. J., Crosby, R. D., Cao, L., Garcia, L., & Mitchell, J. E. (2019). Loss of Control Eating and Binge Eating in the 7 Years Following Bariatric Surgery. Obesity Surgery, 29(6), 1773-1780. doi:10.1007/s11695-019-03791-x 13. Lydecker, J. A., Ivezaj, V., & Grilo, C. M. (2019). Secretive eating and binge eating following bariatric surgery. International Journal of Eating Disorders, 52(8), 935-940. doi:10.1002/ eat.23089 14. Devlin, M. J., King, W. C., Kalarchian, M. A., White, G. E., Marcus, M. D., Garcia, L., . . . Mitchell, J. E. (2016). Eating pathology and experience and weight loss in a prospective study of bariatric surgery patients: 3-year follow-up. International Journal of Eating Disorders, 49(12), 1058-1067. doi:10.1002/eat.22578 15. Himes, S. M., Grothe, K. B., Clark, M. M., Swain, J. M., Collazo-Clavell, M. L., & Sarr, M. G. (2015). Stop regain: A pilot psychological intervention for bariatric patients experiencing weight regain. Obesity Surgery, 25(5), 922-927. doi:10.1007/s11695-015-1611-0