By Dr. Elisha Carcieri, Ph.D., Psychologist at Eating Disorder Therapy LA
Approximately 200,000 people elect to undergo bariatric surgery each year. Many are encouraged by their doctors to undergo surgery with the hope of improving physical health outcomes like diabetes, and many are hoping that this will be the final answer to a lifetime struggle with their weight. This is a decision that should not be taken lightly, especially for those who have suffered from disordered eating patterns or a diagnosable eating disorder prior to surgery. While most people who undergo gastric bypass will lose weight and maintain this weight loss, bariatric surgery represents a unique challenge to those individuals with disordered eating patterns.
It is crucial to note here that not all people with obesity have an eating disorder, and that obesity is not an eating disorder. However, binge eating disorder (BED), which involves consuming large amounts of food in a discrete period of time with a sense of loss of control, is more prevalent among people who are obese than the general population. BED is especially common among people with obesity seeking weight loss surgery. Some prevalence estimates of BED among people seeking surgery range are as high as 50%. Night eating syndrome (NES) also appears to be common and other eating disorders including bulimia are observed among people who are obese.
There are various types of bariatric surgery, but all surgeries result in weight loss via restriction of gastric capacity resulting in eating less, or restriction combined with bypassing a portion of the intestine which results in malabsorbtion (interrupting the amount of calories that are absorbed). Most people have “successful” surgeries resulting in relatively rapid weight loss over the first 12-36 months followed by sustained and stabilized weight loss. Up to 20% will experience a “failed” surgery, meaning that their weight loss is considered inadequate (less than 50% of excess weight lost) or they gained a significant amount of weight back following initial weight loss. Being labeled as a “surgery failure” can be devastating, especially when surgery is often presented as a quick, easy, and final fix for obesity. It is unclear how many patients who fail to lose weight or regain weight do not present to their medical team for follow up due to shame or embarrassment.
In addition to the common risks associated with having a major surgery, bariatric surgery can result in certain food intolerances, such as red meat or white bread, and can result in vitamin deficiency (more common with surgeries involving malabsorbtion). Additional eating-related problems that do not necessarily constitute an eating disorder commonly develop related to surgery include:
- Involuntary nausea and/or vomiting – usually from eating too quickly or consuming too much food too quickly; vomiting can also be voluntary to relieve discomfort.
- “Plugging” – a sensation described as food being stuck in the upper digestive tract.
- “Dumping syndrome” lightheadedness, sweating, palpitations, cramps, and diarrhea occurring in response to the consumption of too much sugary food, such as ice cream or cake, at one time.
- “Chewing and spitting” – This pattern of eating may develop to avoid plugging.
- “Grazing” – Frequent (often unplanned) snacking or nibbling, mindless eating
With regard to the development of eating disorders, it is rare that a full-blown classic eating disorder will develop post-surgery. A more common occurrence is the development of eating disorder symptoms that may not qualify as a diagnosable eating disorder but are distressing to the patient. These symptoms may begin as a common eating problem associated with surgery such as plugging or dumping. The continuation of BED or engaging in binge eating episodes is not uncommon following surgery, but may take a different form as it may be physically impossible for an individual to consume an objectively large amount of food post-surgery. Episodes of binge eating post-surgery may instead be described as subjectively large and may be characterized by a sense of loss of control eating. Also of note, it may be possible to binge on larger amounts of food further out from surgery as the capacity to consume more food in one sitting grows over time. This increased capacity may result in binge eating episodes involving objectively large amounts of food years after surgery.
Although reports of the development of bulimia following bariatric surgery are rare, for many patients, it may become unclear whether vomiting to relieve discomfort or “plugging” is simply an episodic habit associated with post-surgical life or an eating disorder behavior. In this case, it is important to consider the motivation behind vomiting: whether it is solely to relieve discomfort (likely an eating problem related to surgery) or to control weight and/or shape (better described as compensatory vomiting associated with eating disorders).
The diagnostic requirement that an individual maintain a below-normal weight to have anorexia nervosa (AN) means that most pre- or post-bariatric patients cannot be diagnosed with AN. However, the accelerated weight loss and dietary restriction that is characteristic of bariatric surgery, coupled with the common and somewhat expected preoccupation with food intake as a result of surgery may pose as risk factors for the development of a restrictive eating disorder like anorexia. Patients may maintain a weight that is still considered to be in the “normal range,” but is well below expected or recommended weight loss. An intense fear of gaining weight and disturbances in their self-perception of weight or body size or shape can also develop post-surgery which can be associated with a restrictive eating disorder. Additional distress related to body image may develop in response to the presence of loose skin following weight loss.
“Failure” to meet expected weight loss outcomes post surgery, significant weight regain, subjective binging or grazing, eating less than recommended amounts, and weight loss well beyond the recommendation of the medical team can be indicators of disordered eating post-surgery. Voluntary vomiting can also be an indicator, though this is difficult to determine given how common it is to vomit for relief and discomfort associated with “plugging.”
The development of surgery-related eating problems or disordered eating patterns following weight loss surgery can be extremely distressing. Patients who hoped that surgery would end a lifetime of dieting and obsession over food and eating may be surprised to find that they are thinking about it more than ever before. Those with history of an eating disorder may find that their doctor’s post-surgery dietary recommendations that encourage restriction and rule-based eating sound a lot like the voice of their eating disorder that has either been silenced in recovery or continues to lurk among every day thoughts.
Needless to say, all bariatric surgery candidates should be thoroughly screened and provided with support and resources prior to and following surgery. And while history of an eating disorder or a current eating disorder should not preclude an individual from surgery, these patients should be especially mindful of the potential for continuation of an eating disorder, or a relapse in response to surgery-related diet recommendations and eating-related problems.
Our staff members have experience working with clients both pre- and post-bariatric surgery.
American Society for Metabolic and Bariatric Surgery. https://asmbs.org
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Sarwer, D. B., Wadden, T. A., & Fabricatore, A. N. (2005). Psychosocial and behavioral aspects of bariatric surgery. Obesity research, 13(4), 639-648