Eating Disorders Awareness and Prevention Eating Disorders Before and After Bariatric Surgery By Lauren Muhlheim, PsyD, CEDS Lauren Muhlheim, PsyD, CEDS Facebook LinkedIn Twitter Lauren Muhlheim, PsyD, is a certified eating disorders expert and clinical psychologist who provides cognitive behavioral psychotherapy. Learn about our editorial process Updated on May 01, 2020 Medically reviewed Verywell Mind articles are reviewed by board-certified physicians and mental healthcare professionals. Medical Reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. Content is reviewed before publication and upon substantial updates. Learn more. by Rachel Goldman, PhD, FTOS Medically reviewed by Rachel Goldman, PhD, FTOS Facebook LinkedIn Twitter Rachel Goldman, PhD FTOS, is a licensed psychologist, clinical assistant professor, speaker, wellness expert specializing in eating behaviors, stress management, and health behavior change. Learn about our Medical Review Board Print Table of Contents View All Table of Contents What It Is Considerations The Relationship Eating Disorders After Surgery Other Post Surgery Behaviors Getting Help Bariatric surgery is often recommended for people who struggle with obesity. While obesity is not the same as an eating disorder, there is an intersection between the two. A sizable number of people considering bariatric surgery may have an eating disorder. An existing eating disorder can make the outcome of bariatric surgery worse. Furthermore, the surgery itself may create conditions that cause or mimic eating disorders or disordered eating. What Is Bariatric Surgery? Bariatric surgery, also known as weight loss surgery, refers to a range of procedures that physically alter the structure of the body in order either to restrict the volume of food that can be consumed or to cause nutrient malabsorption in order to produce weight loss. Restrictive Procedures Restrictive procedures limit food intake by reducing the stomach’s capacity. Such procedures include: Laparoscopic adjustable gastric banding: Placing an adjustable band around the upper part of the stomach to create a small pouch to hold foodSleeve gastrectomy (gastric sleeve): Permanently and surgically removing approximately 80% of the stomach, leaving a tube-shaped stomach about the size and shape of a banana Vertical banded gastroplasty: Using a band and staples to create a small stomach pouch Malabsorptive Procedures Malabsorptive procedures shorten the length of the functional small intestine and include procedures such as: Biliopancreatic diversion, a procedure in which portions of the stomach are surgically removed. The small pouch that remains is connected directly to the final segment of the small intestine, entirely bypassing the upper part of the small intestines, and a shared channel remains in which bile and pancreatic digestive juices mix prior to entering the colon. Weight loss occurs because most of the calories and nutrients are routed into the colon and are not absorbed.Jejunoileal bypass, a procedure that was primarily in the 1960s and 1970s that involved surgically bypassing about 90% of the small intestine to short-circuit nutrient absorption; it is no longer performed due to causing severe malnutrition and death. Combination Procedures Finally, some procedures combine restriction with malabsorption. One such procedure is the Roux-en-Y gastric bypass (RYGB), in which the upper section of the stomach is stapled off, leaving a small gastric pouch that limits oral intake. This pouch is then attached directly to part of the small intestine called the Roux limb, bypassing the rest of the stomach and the upper part of the small intestine, which further causes mild malabsorption. Today, the gastric sleeve and the RYGB are the most commonly performed bariatric procedures in the U.S. It is estimated that in 2017, 228,000 total gastric surgeries were performed, 59% of which were gastric sleeve and 18% RGBY. Important Considerations If you have an eating disorder or struggle with disordered eating and are considering bariatric surgery, it is important to understand that the surgery is not likely to solve the eating disorder or eating issues; in fact, it may make it worse. There is no guarantee it will permanently solve your weight issues either. It is imperative your doctor prepares you for all possible risks and potential outcomes of the procedure. Forced Diet Critics say that bariatric surgery is merely a forced diet—the various techniques are designed to reduce your stomach’s capacity to hold food or to damage your organs so that they cannot absorb as many nutrients. In short: induced malnutrition. Post-surgical nutritional deficiencies are common. Fatalities Death is another real possibility. Reported mortality rates for people undergoing bariatric surgery are as high as 5% of patients dying within a year—the actual rate may be even higher due to underreporting. One investigative report found that deaths attributable to gastric bypass were not accounted for and recorded as deaths from other causes. Other complications are likely and encompass all bodily systems. Effectiveness Most of the research on bariatric surgery focuses on outcomes during the first year after surgery; data on long term outcomes is limited. Most studies report outcomes for less than 80% of the patients, omitting those who may have dropped out of the study due to poor results and the shame that comes with them. And few studies track results beyond two years post-surgery. That said, more recently, the Longitudinal Assessment of Bariatric Surgery (LABS) study looked at both the short-term and longer-term outcomes of bariatric surgery. The seven-year post-operative data revealed that most participants maintained much of their weight loss, although variable weight fluctuations were seen over the long-term. These issues significantly bias the reported results, as noted by Puzziferri: “Substantial risks exist for arriving at overly optimistic conclusions regarding the effect of a weight-loss intervention when follow-up is incomplete. Because of incomplete follow-up, most bariatric surgery studies may report overly optimistic estimates for these operations’ effects.” While many patients are successful at maintaining weight loss post-surgery and many no longer need to take many of the medications they were taking before, including those for hypertension, hyperlipidemia, and diabetes, other data suggests the surgery may offer only temporary relief from the medical issues that it is meant to treat and that weight may be gradually regained. Following surgery, many patients are still large, though less so, and may not have significantly improved health outcomes. Some may never be able to eat regularly again or may be limited to eating small amounts and avoiding certain foods. Eating Disorders and Bariatric Surgery Research suggests that eating disorders and problematic eating behaviors are common in those seeking bariatric surgery, possibly because they may have engaged in repeated dieting which can be a precursor to disordered eating. Existing disorders can significantly impact surgery outcomes. Unfortunately, researchers believe that eating disorder and problematic eating behaviors are likely minimized or underreported by patients electing to have these procedures. They may fear that they will not be approved for surgery if they admit to an eating disorder or disordered eating. Binge eating disorder (BED), which is characterized by episodes of eating large amounts of food while feeling out of control, is the most common eating disorder reported in patients seeking bariatric surgery. Prevalence rate estimates of BED vary greatly due to the use of different criteria and varied assessment methods and range from 4% to 49%. But these may not be accurate as explained above. Impact of Eating Disorders on Bariatric Surgery Outcomes The impact that having an existing eating disorder has on the success of the surgery has proven difficult to study. Some studies suggest that a diagnosis of BED prior to surgery is associated with eating disorder symptoms after surgery and less weight loss or more weight regain. Unfortunately, patients with eating disorders prior to surgery may be inadequately evaluated and treated. Individual bariatric surgery programs use their own assessment procedures. There is no universally accepted or recommended practice. Most of the criteria for bariatric surgery focus on a patient having a body over a certain size (measured by body mass index, BMI), having a history of failed weight loss attempts, and a lack of psychological contraindications, which are not well-defined. Eating disorder symptoms may not be adequately assessed. Body Mass Index (BMI) is a dated, biased measure that doesn’t account for several factors, such as body composition, ethnicity, race, gender, and age. Despite being a flawed measure, BMI is widely used today in the medical community because it is an inexpensive and quick method for analyzing potential health status and outcomes. Eating Disorders After Surgery Eating disorders after bariatric surgery are difficult to assess and may be under-reported. Complications from the surgery can include medical problems and symptoms that can mimic eating disorder behaviors or symptoms, such as vomiting, constipation, and decreased appetite. Other symptoms related to the surgery can lead patients to engage in compensatory behaviors to relieve uncomfortable feelings from having eaten too much or having eaten food that is difficult to tolerate. Bariatric surgery patients experience anatomical and physiological changes that significantly alter their diet and eating behaviors. As a result, eating an objectively large amount of food in one sitting, as required for a diagnosis of BED, may be physically impossible, at least for a period following the surgery. Thus existing diagnostic criteria for eating disorders may not adequately reflect the presentation seen in patients after bariatric surgery. Patients may not technically meet criteria for BED even when assessed even if they have clinically significant eating pathology. Reported prevalence rates of eating disorders in the post-bariatric surgery population may, therefore, be artificially low. Post-Surgery Loss of Control Eating However, the experience of loss of control while eating over smaller amounts of food appears to be commonly reported among patients post-surgery. Evidence indicates that the experience of loss of control, regardless of the amount of food eaten, may be the most defining feature of binge eating. Researchers have proposed a diagnosis of “bariatric binge-eating disorder” to describe those patients who fulfill DSM-5 criteria for binge eating disorder except for the “unusually large” criterion for binge eating episodes. Preliminary research supports the “presence of an eating disorder very much like binge-eating disorder among a significant subgroup of patients” after bariatric surgery. Loss of control eating is common among bariatric patients. It is found in 13% to 61% of patients prior to surgery and in 17% to 39% of patients post-surgically. Post-Surgery Anorexia Nervosa, Bulimia Nervosa, and OSFED While little is known about rates of bulimia nervosa before or after surgery, case reports of bulimia nervosa after bariatric surgery have been reported. Similarly, rates of anorexia nervosa prior to surgery are not reported, and not often diagnosed in patients in larger bodies due to DSM-5 diagnostic criteria. But among patients who have had bariatric surgery, several case reports describe patients with atypical anorexia, referring to people who meet all the criteria for anorexia nervosa except for the objectively low weight. This points further to evidence that bodies are naturally diverse and that extreme weight loss can be detrimental. Night eating syndrome, a proposed diagnosis that is currently classified as a type of "other specified feeding or eating disorder (OSFED)," is characterized by episodes of awake nighttime overeating and a disrupted circadian rhythm, has also been documented in patients after bariatric surgery with prevalence rates ranging from 2% to 18%. Problematic Behaviors Post Surgery Bariatric surgery patients are instructed to change their eating behaviors after surgery. They are instructed to limit meal size and to chew food extensively. They are asked to follow strict schedules, weigh and measure their food, and avoid specific foods. In the general population, these exact behaviors are often diagnosed as symptoms of eating disorders. In fact, the preoccupation with maintaining the weight loss and avoiding weight regain prescribed for bariatric surgery patients is incredibly similar to what is observed in an eating disorder. This may lead one to wonder if bariatric surgery is just teaching people how to have a more restrictive eating disorder. Vomiting Episodic vomiting appears to be relatively common after bariatric surgery. Individuals may vomit deliberately or spontaneously after eating certain intolerable foods or after eating too quickly or chewing inadequately. Some doctors may encourage periodic vomiting to relieve uncomfortable physical symptoms. Even when it occurs spontaneously at first, patients may eventually learn to do it deliberately, believing it will help control their weight. Frequent vomiting, however, can cause electrolyte imbalances which can lead to cardiac arrhythmia that can cause sudden death. Dumping Dumping—the failure of food to digest, bringing increased fluid into the small intestine and causing extreme diarrhea—occurs post-surgery for many after consuming sweets or large quantities of food. Patients will often complain about lightheadedness and sweating after eating a high-glucose meal or consuming a large meal. This is extremely uncomfortable and accompanied by intense fatigue. Dumping is another post-surgery behavior that is sometimes used deliberately for weight loss or to try to compensate for food eaten. Grazing Grazing—the repetitive eating of small amounts of food in an unplanned manner and/or not in response to hunger—is a newly recognized behavior. To be repetitive, it must occur twice in the same period during the day (i.e., morning). It is suggested that there are two types: compulsive with a loss of control and non-compulsive (distracted and mindless but without loss of control). Grazing is distinguished on the one hand from binge-eating episodes by the amount of food eaten, and on the other hand from loss of control eating by its lack of a circumscribed period of time. Grazing may be a natural response to the shrunken capacity of the stomach as the person may not be able to take in the amount of food they require at a single meal. Grazing is estimated to occur in up to 47% of patients after surgery. Picking or nibbling—patterns of repetitive and unplanned eating—are similar to grazing. Some patients may also engage in chewing and spitting. Understanding Chewing and Spitting in Eating Disorders Body Image Issues Loose skin, which is common after surgery, can increase body dissatisfaction. A cruel irony is that the dissatisfaction with body size that existed before the surgery may not be alleviated but instead replaced by concern over the loose skin. Getting Help Post-operative loss of control eating and binge eating are both associated with less weight loss and more psychosocial problems. Unfortunately, post-surgical psychological support is not uniformly provided. There are no established treatments specifically for patients with eating disorders or problematic eating post-bariatric surgery. Cognitive behavioral therapy (CBT) is the psychological treatment with the most support for adults with eating disorders including BED and bulimia nervosa and thus might be helpful for patients with post-bariatric eating disorders and disordered eating. People in larger bodies may feel desperate to have surgeries that they believe will improve health and solve their lifelong struggles with their weight. Indeed, weight stigma and dislike of fat people is commonplace. Doctors will often encourage surgery. However, people undergoing bariatric procedures are facing serious medical complications and often exchanging one problem—large body size—for others like permanent health problems and a potential eating disorder. Patients should be better informed about the potential risks. What Weight Stigma Is and Why You Should Care A Word From Verywell If you have an eating disorder and are contemplating bariatric surgery, it would be best to first receive eating disorder treatment, ideally from a therapist who practices from a Health at Every Size approach and does not have a vested interest in your surgery decision. If you’ve had bariatric surgery and are experiencing any of the above symptoms, you are strongly encouraged to seek help from an eating disorder specialist. If you or a loved one are coping with an eating disorder, contact the National Eating Disorders Association (NEDA) Helpline for support at 1-800-931-2237. For more mental health resources, see our National Helpline Database. 7 Sources Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Puzziferri N, Roshek TB, Mayo HG, Gallagher R, Belle SH, Livingston EH. Long-term follow-up after bariatric surgery: A systematic review. JAMA. 2014;312(9):934–42. doi:10.1001/jama.2014.10706 Conceição E, Orcutt M, Mitchell J, et al. Eating disorders after bariatric surgery: A case series. Int J Eat Disord. 2013;46(3):274–279. doi:10.1002/eat.22074 Marino JM, Ertelt TW, Lancaster K, et al. The emergence of eating pathology after bariatric surgery: A rare outcome with important clinical implications. Int J Eat Disord. 2012;45(2):179-84. doi:10.1002/eat.20891 Meany G, Conceição E, Mitchell JE. Binge eating, binge eating disorder and loss of control eating: effects on weight outcomes after bariatric surgery. Eur Eat Disord Rev. 2014;22(2):87-91. doi:10.1002/erv.2273 Ivezaj V, Kessler EE, Lydecker JA, Barnes RD, White MA, Grilo CM. Loss-of-control eating following sleeve gastrectomy surgery. Surg Obes Relat Dis. 2017;13(3):392-398. doi:10.1016/j.soard.2016.09.028 Mitchell JE, King WC, Courcoulas A, et al. Eating behavior and eating disorders in adults before bariatric surgery. Int J Eat Disord. 2015;48(2):215-22. doi:10.1002/eat.22275 Pizato N, Botelho PB, Gonçalves VSS, Dutra ES, de Carvalho KMB. Effect of grazing behavior on weight regain post-bariatric surgery: A systematic review. Nutrients. 2017;9(12):1322. doi:10.3390/nu9121322 By Lauren Muhlheim, PsyD, CEDS Lauren Muhlheim, PsyD, is a certified eating disorders expert and clinical psychologist who provides cognitive behavioral psychotherapy. 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