Surgery for Obesity and Related Diseases 17 (2021) 1510–1520

Review article

Disordered eating following bariatric surgery: a review of measurement

and conceptual considerations
Valentina Ivezaj, Ph.D.a,*, Meagan M. Carr, Ph.D.a, Cassie Brode, Ph.D.b,
Michael Devlin, M.D.c,d, Leslie J. Heinberg, Ph.D.e, Melissa A. Kalarchian, Ph.D.f,
Robyn Sysko, Ph.D.g, Gail Williams-Kerver, Ph.D.h, James E. Mitchell, M.D.i
a
Yale University School of Medicine, New Haven, Connecticut
b
West Virginia University School of Medicine, West Virginia
c
Columbia University Vagelos College of Physicians and Surgeons, New York, New York
d
New York State Psychiatric Institute, New York, New York
e
Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
f
Duquesne University School of Nursing, Pittsburgh, Pennsylvania
g
Icahn School of Medicine at Mount Sinai, New York, New York
h
Sanford Center for Biobehavioral Research, Fargo, North Dakota
i
University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota
Received 1 May 2020; accepted 13 March 2021

Abstract Eating disorders are associated with significant medical morbidity and mortality and serious psycho-
logical impairment. Individuals seeking bariatric surgery represent a high-risk group for evidencing
disordered eating and eating disorders, with some patients experiencing the persistence or onset of
disordered eating postsurgery. This review synthesizes the available literature on problematic or
disordered eating in the bariatric field, followed by a review of measurement and conceptual consid-
erations related to the use of eating disorder assessment tools within the bariatric population. (Surg
Obes Relat Dis 2021;17:1510–1520.) Ó 2021 American Society for Bariatric Surgery. Published by
Elsevier Inc. All rights reserved.

Keywords: Measurement; Bariatric surgery; Eating disorders; Obesity; Assessment

Individuals seeking bariatric surgery may report engaging
in certain types of disordered eating and meet eating disor-
der criteria. The current Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5) [1] recognizes
feeding disorders, including the eating disorder diagnoses
of (1) anorexia nervosa (AN); (2) bulimia nervosa (BN);
and (3) binge-eating disorder (BED), as well as 2 residual
categories in which the full diagnostic criteria for AN,
BN, or BED are not met: (4) other specified feeding or
* Correspondence: Valentina Ivezaj, Ph.D., Yale University School of
Medicine, Psychiatry, 300 George Street, Suite 901, New Haven, CT 06511.
E-mail address: valentina.ivezaj@gmail.com (V. Ivezaj).
https://doi.org/10.1016/j.soard.2021.03.008
1550-7289/Ó 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
eating disorder (OSFED); and (5) unspecified feeding or
eating disorders (USFED). Eating disorders are associated
with significant medical morbidity and mortality [2] and
serious psychological impairment [3], including a 5-fold
increased risk of suicide attempts [4]. According to the Lon-
gitudinal Assessment of Bariatric Surgery–3 (LABS-3)
study, 6.1% of participants seeking bariatric surgery met
DSM-IV diagnostic criteria for BED, while 1.2% met BN
criteria, exceeding rates reported in the general population
[5,6]. Disordered eating behaviors were also quite common
in the LABS-3 study: 40.4% reported loss-of-control (LOC)
eating, 30.5% reported binge eating, 16.5% reported night
eating, and 6.4% reported at least 1 compensatory behavior
during the prior 6 months [7]. Presurgical problematic
 Valentina Ivezaj et al. / Surgery for Obesity and Related Diseases 17 (2021) 1510–1520
eating behaviors, however, have had little prognostic signif-
icance for postsurgical weight outcomes [7–9]. Although
many of these behaviors improve after bariatric surgery,
disordered eating behaviors may persist, recur, or develop
de novo. In fact, studies suggest that various forms of
disordered eating after bariatric surgery are associated with
suboptimal weight loss trajectories and/or greater weight
regain [9]. Beyond weight outcomes, changes in disordered
eating may also have a cascade of effects on depression, qual-
ity of life, self-esteem, and body image [10,11].
Disordered eating behaviors (e.g., binge eating and LOC
eating) and cognitions (e.g., overvaluation of weight or
shape) that are clinically distressing and/or associated with
impairment, but do not meet full criteria for an eating disor-
der, are also concerning. For instance, recent research sug-
gests that LOC eating—that is, eating episodes occurring
with a concurrent subjective sense of feeling out of control,
regardless of the quantity of food consumed—is associated
with psychological impairment [12,13]. Regarding disor-
dered eating cognitions, overvaluation of weight or shape,
which describes a sense of personal worth based on one’s
weight or shape, is similarly associated with significant
negative sequalae (e.g., greater functional impairment and
depressive symptoms) [14,15].
This review synthesizes the available literature on disor-
dered and problematic eating after bariatric surgery, fol-
lowed by a review of measurement and conceptual
considerations related to the use of eating disorder assess-
ment tools within the bariatric population. Although the
terms “problematic eating” and “disordered eating” are
sometimes used interchangeably in the literature, problem-
atic eating in this review refers to normative eating behav-
iors that are inconsistent with healthful weight loss goals
(e.g., overeating), whereas disordered eating refers to be-
haviors associated with eating disorders (e.g., LOC eating
or binge eating) or cognitions that do not meet full criteria
for a standalone DSM-5 eating disorder.
Eating behavior after bariatric surgery
Normative or recommended eating after bariatric surgery
Understanding normative eating after bariatric surgery is
essential to operationalize and identify postoperative prob-
lematic and disordered eating. In the early postoperative
period (first 6 mo), most patients are unable to consume
large amounts of food due to metabolic and anatomical
changes. Patients are expected to make significant lifestyle
changes as to how, what, and when they eat to tolerate
food intake and have progressive and sustained weight
loss. The American Society for Metabolic and Bariatric Sur-
gery has outlined nutritional guidelines for bariatric patients
[16,17]. Despite long-term weight loss success achieved by
many who undergo bariatric surgery [18,19], nonadherence
to recommended guidelines is common [20].
1511
Problematic and/or disordered eating after bariatric
surgery
Binge-eating and LOC eating
Objective binge episodes (OBEs) are defined as a discrete
period in which a person eats an unusually large quantity of
food and has a sense of losing control. OBEs, required for
the BED and BN diagnoses, are rarely physically possible
early after bariatric surgery, but such problems can recur
over time [12,21]. However, patients may still experience
a sense of LOC while eating an amount of food that is not
objectively large (i.e., subjective binge-eating episodes).
Such problems may be reported shortly after surgery, or af-
ter an interim period [22]. Those most at risk appear to be
patients who met BED criteria or engaged in OBEs prior
to surgery [19]. Studies [22,23] estimate that 10%–39% of
patients develop LOC eating by 2 years postsurgery,
although this problem may emerge as early as 4–6 months
postsurgery [13,23,24]. LOC eating is associated with other
postsurgical problems [23] (e.g., vomiting), as well as an
elevated risk for psychopathology (e.g., depression), less
weight loss, and greater weight regain [9]. In 7-year pro-
spective data obtained as part of the LABS-3 study using
structured assessment instruments, postsurgery LOC eating
was confirmed as a risk factor for less long-term weight loss
and greater weight regain [8].
Grazing/picking and nibbling
Grazing or picking and nibbling (P&N) is a frequent, albeit
difficult to define, problem postsurgery. Conceiç~ao and col-
leagues [25] surveyed 24 authors who had published research
on grazing and, based on the responses, concluded that char-
acteristics associated with the concept were highly variable
among these researchers. They proposed a composite defini-
tion of P&N: an eating behavior characterized by the repeti-
tive eating of small/modest amounts of food in an unplanned
manner and/or not in response to hunger/satiety [25,26]. A
difficulty with differentiating P&N from normative eating
behavior is that patients are often instructed to eat multiple
small meals throughout the day postsurgery. A differentiator,
however, may be that P&N is often engaged in without plan-
ning. To date, the literature suggests that P&N behavior after
surgery is common, affecting perhaps 18.6%–46.6% of pa-
tients [25,26], and is also linked to attenuated weight loss
[27]. Some patients develop new-onset P&N postsurgery
without a history of BED or OBE. Notably, P&N is widely
prevalent in obesity and eating disorders in general, suggest-
ing a considerable lack of specificity to those who have un-
dergone bariatric surgery [28].
Eating in the absence of hunger or beyond satiety
Similarly, eating in the absence of hunger (i.e., when not
hungry) or eating beyond satiety may have some negative
prognostic significance for weight loss after surgery [27].
Early in the postoperative period, hunger cues diminish;
1512 Valentina Ivezaj et al. / Surgery for Obesity and Related Diseases 17 (2021) 1510–1520
thus, eating in the absence of hunger might be normative
during that period, but become more problematic over
time. In addition, eating when not physically hungry is a
behavioral indicator of LOC eating. Yet, when this behavior
develops into disordered behavior after bariatric surgery is
unclear.
Night Eating Syndrome
Currently, there is limited research on Night Eating Syn-
drome (NES) after bariatric surgery [29]. Like P&N, the
field currently lacks an agreed-upon definition of NES.
Most often, NES is defined based on the timing of eating
rather than the size of eating episodes. The focus on an
eating pattern rather than the amount of food consumed
may increase the utility within bariatric populations, as
detailed above, for whom limited gastric capacity impacts
the quantity of food consumed at 1 time. One study sug-
gested that postoperative night eating symptoms improved
among patients who had a preoperative depressed mood
versus those without it [29], but the relationship between
mood and NES is complex; other factors, including sleep,
may also play a role [29,30].
Excessive dietary restriction
Very little is known regarding excessive dietary restric-
tion following bariatric surgery. Most studies have exam-
ined dietary restraint, which examines the intention to
restrict as opposed to actual restriction [8,31]. Although un-
common, a smaller percentage of individuals may develop
restrictive-type eating disorders, such as AN. In some cases,
patients present with a critically low body mass index (BMI)
and medical co-morbidities, whereas others may not have a
low BMI but nonetheless have lost excessive weight, evi-
dence starvation, and meet criteria for AN, except for the
criterion related to low weight [32,33]. Yet, there are no
prevalence data available on the development of such eating
disorders or other eating disorder classifications, including
OSFED and USFED, after bariatric surgery.
Surgically related behaviors
Bariatric procedures may result in surgery-specific be-
haviors that may or may not be a function of disordered
eating. To avoid over-pathologizing normative behaviors
or potential consequences of bariatric surgery, assessing
the cause and function of the behavior is key. For example,
“dumping syndrome,” which is characterized by dizziness,
diaphoresis, flushing, palpitations, and diarrhea, can occur
frequently after bariatric surgery due to postsurgical
behavior changes [34], and is more likely to occur in pa-
tients undergoing Roux-en-Y as compared with laparo-
scopic sleeve gastrectomy [35]. This is sometimes referred
to as early dumping, and such symptoms can be precipitated
by the ingestion of sweet, high-carbohydrate, or other foods,
and generally occurs in the first 30 minutes after eating. Late
dumping, probably better referred to as reactive
hypoglycemia, is also characterized by these symptoms, as
well as symptoms of neuroglycopenia, such as slurred
speech, tremor, and shaking [35]. This generally occurs later
after eating, is indicative of critically low blood glucose that
affects the brain, can be quite dangerous, and requires
appropriate care. Dumping, in and of itself, is not a form
of disordered eating, but a byproduct of the surgery. Howev-
er, if a patient decides to intentionally induce dumping to try
to eliminate food or calories through diarrhea, disordered
eating may be inferred. In a small case series study, 2 pa-
tients described dumping as an intentional form of purging
[36], although data in this area are scarce.
“Plugging,” or dysphagia, is characterized by a sense of
food getting “stuck” after eating, and may be cleared by
waiting or fluid ingestion [37]. This can be problematic
for patients, who may self-induce vomiting to alleviate the
sensation of plugging, but it is not a sign of disordered
eating per se. Notably, however, LOC eating occurring at
least once weekly was associated significantly with weekly
plugging in the LABS-3 consortium study [37].
Vomiting after surgery is another complex behavior with
multiple potential causes and functions. Spontaneous vom-
iting—that is, vomiting that is not self-induced—can occur
after bariatric surgery [38], but probably occurs less over
time. Vomiting that appears to be spontaneously caused by
bariatric surgery, however, may be due to intentional efforts
to eat food(s) that cause vomiting, with the desire to influ-
ence weight or shape. Intentional self-induced vomiting
may also occur in an attempt to influence weight or shape,
or to alleviate physical comfort. Differentiating between
various forms of vomiting is important; however, cases of
self-induced vomiting for weight control have rarely been
reported in the bariatric population [19].
Chewing and spitting food sometimes occurs, at times as a
means to taste foods that may not be tolerated if swallowed,
but also in other samples of patients with eating disorders, as
well as in the general population [39]. After bariatric surgery,
individuals might engage in chewing and spitting behavior to
avoid gaining weight, to influence shape, to get the sensation
or enjoyment from chewing, and/or to avoid physical
discomfort related to the surgery. Prevalence data on this
behavior after bariatric surgery are lacking.
Disordered eating assessment
Measurement
Rigorous assessment tools are needed to measure the
array of aforementioned eating behaviors to facilitate accu-
rate identification of eating disorders and disordered eating.
The Eating Disorder Examination (EDE) interview [40] is
the most commonly used semi-structured interview to assess
disordered eating behaviors, cognitions, and general eating
disorder psychopathology. The EDE was originally devel-
oped for AN and BN, but was adapted for the rigorous
LABS-3 psychosocial study into what is referred to as the
 Valentina Ivezaj et al. / Surgery for Obesity and Related Diseases 17 (2021) 1510–1520
Bariatric Surgery Version (EDE-BSV) [19]. The EDE-BSV
includes the original EDE items and assesses rich clinical
data, including items which might help differentiate behav-
iors that are disordered from behaviors that are expected af-
ter bariatric surgery. The EDE-BSV also incorporates other
self-report measures, such as the Night Eating Scale [41],
into an interview format. A single study investigated the
interrater reliability of the EDE-BSV, with strong support
for the traditional EDE subscales and for the newly defined
bariatric overeating and LOC eating episodes [42]. Agree-
ment was less robust (k 5 .60) for bariatric overeating epi-
sodes as compared to LOC eating episodes. Notably, the
BSV items were not examined, and other psychometric
data of the EDE-BSV are largely unavailable [42]. In addi-
tion, because the interview requires extensive training and
time, many researchers and clinics elect to use self-report
measures instead.
Table 1 summarizes the most commonly used eating dis-
order self-report measures in the bariatric field, with
detailed descriptions (e.g., psychometric properties, admin-
istration time, and costs) of each measure (see Parker et al.
[43] for a systematic review of these measures at the pre-
bariatric phase). Importantly, very few studies have evalu-
ated the psychometric properties of these measures at the
pre- or postoperative bariatric stage. At the preoperative
stage, comparisons between the EDE interview and the
self-report questionnaire version (EDE-Q) [44] suggest
lower levels of agreement between the 2 assessment tools
than those previously observed in other clinical populations
[45]. Furthermore, the limited literature does not support the
use of the original factor structures of many measures at the
pre- or postsurgical phase [43]. Without a valid factor struc-
ture, components like subscale scores are not meaningful.
Failure to replicate factor structures suggests that the bariat-
ric surgery population may have unique characteristics that
are distinct from those of traditional eating disorder sam-
ples. Indeed, in the first set of studies examining the factor
structure of the EDE-Q among individuals seeking bariatric
surgery, the original factor structures were not supported;
rather, alternative factor structures were found [46]. Parker
and colleagues [47] replicated and extended these findings
at the pre- and postsurgical stages; analyses did not support
the original factor structures of widely used eating disorder
measures, including the EDE, EDE-Q, and Three-Factor
Eating Questionnaire (TFEQ) [48]. Importantly, however,
these findings were based on individuals who had undergone
the laparoscopic adjustable gastric banding procedure [47].
Only 1 study has examined the factor structure of an eating
disorder measure in the postoperative phase following
sleeve gastrectomy. Carr and colleagues [49] found that
among individuals with LOC eating following laparoscopic
sleeve gastrectomy, the Eating Loss of Control Scale
(ELOCS) [50] generated 2 factors, instead of the traditional
1 factor supported in nonbariatric populations [50]. To our
knowledge, no study has examined the factor structures of
1513
eating disorder measures among individuals who underwent
Roux-en-Y gastric bypass.
The scarcity of psychometric data negatively impacts
both the clinical utility of measures and the generalizability
of findings. Two general concepts, reliability and validity,
help determine the quality of the measures used and, ulti-
mately, the research findings. Reliability refers to the consis-
tency of a measure [51], and it includes internal consistency
(degree to which all items measure the same construct) and
test–retest (consistency across time or raters) [52]. Within
the bariatric field, internal consistency is inconsistently re-
ported. Estimates range from weak (.38) [53] to excellent
(.98) consistency [47]. Caution is warranted when using
scales that demonstrate weak internal consistency, as the
single scale (or subscale) is likely not measuring a single
unitary construct. In some cases, revised scales developed
using bariatric samples have shown improvements in reli-
ability, including revised versions of the EDE-Q [47]. To
our knowledge, the test–retest reliability of eating disorder
measures in the bariatric literature has been completely un-
tested. This suggests that we do not know whether the eating
disorder measures would produce similar findings if a given
measure was repeated [52]. The evidence suggests that
testing the reliability of most measures used within the bar-
iatric field is warranted.
Validity refers to the degree to which the underlying latent
construct is the cause of the item scores, and it conceptually
reflects whether or not the measure is assessing what it pur-
ports to measure [52]. The most common forms of validity
include content validity, criterion validity, and construct val-
idity. Content validity refers to the degree to which a scale
adequately samples from the universe of possible items.
This is conceptually difficult to establish, but review by ex-
perts can increase confidence in content validity [52]. Within
the bariatric field, the majority of measures were developed
by eating disorder experts broadly. Although limited,
measures such as the EDE-BSV and the Repetitive Eating
Questionnaire (RepEAT-Q) were developed by bariatric ex-
perts, which increases confidence in the content validity.
Criterion-related validity describes an empirical association
between the measure of interest and related and well-
validated measures [52]. For measures intended to diagnose
types of eating disorders, establishing the level of agreement
is a form of criterion validity. Based on the studies reviewed,
only the Questionnaire on Eating and Weight Patterns [54]
has available estimates of criterion validity. Construct validity
refers to the degree to which the underlying latent construct is
the cause of item scores, and it can include a range of psycho-
metric properties, such as a replicated factor structure. Like
reliability, untested or poor replication of a factor structure
can seriously undermine confidence in findings.
Finally, in addition to the measurement issues specific to
bariatric surgery populations, measurement within the field
suffers from some of the main limitations observed in
self-report measurement broadly (e.g., evidence to support
Table 1

1514
Available psychometric properties and administration information for commonly used eating disorder measures in the bariatric field
Scale Items Description Available psychometric properties Administration information
Internal Test–retest Factor structure Means/SD, cut Time to Cost to use Requires
consistency points complete, permission
min to use
Binge Eating Scale 16 Assesses binge-eating behaviors and binge- .83–.90 [68–73] Not reported Not tested Means/SD 5 No No
(BES) [82] related feelings and cognitions (Pre/Post)
Each item consists of 4 multiple-choice Validated cut
statements reflecting a range of severity scores (Pre)

Valentina Ivezaj et al. / Surgery for Obesity and Related Diseases 17 (2021) 1510–1520
(score 0–3) [71]
Clinical cutoff scores are provided
Dutch Eating 33 Assesses aspects of eating behavior Not reported Not reported Not tested Means/SD 10 No No
Behavior Items are assessed on a 5-point Likert scale (Pre/Post)
Questionnaire Includes 2 factors: (1) eating in response to
(DEBQ) [89] specific emotions and (2) eating in response
to diffuse emotional states
Includes 3 subscales: (1) Restrained Eating, (2)
Emotional Eating, and (3) External Eating
Eating Disorder 22 Assesses DSM-4-TR criteria for AN, BN and .86 [74] Not reported Not tested None 5–10 No No
Diagnostic Scale BED
(EDDS) [90] Consists of a combination of Likert scores,
dichotomous scores, frequency scores, and
open-endedquestions (e.g., height and
weight)
Eating Disorder 28–41 Adapted from the Eating Disorder Original Not reported Original not Means/SD 5–15 No No
Examination or 7* Examination (EDE) semi-structured .60–.89 supported (Pre/Post)
Questionnaire interview [46,56,75–77] [46,47,56,78]
(EDE-Q) [44] Assesses frequency of each listed behavior Revised/
over the last 28 days. Alternative
Includes 4 subscales: Restraint, Weight .69–.98
Concern, Shape Concern, and Eating [46,47,56,78]
Concern
Eating Disorder 64 Assesses psychological and behavioral traits .38–.88 [53,79] Not reported Not tested Means/SD 20 Yes No
Inventory (EDI) common in AN and BN (Pre/Post)
[91] Items are assessed on a 6-point Likert scale Inferential
Includes 8 subscales: Drive for Thinness, comparisons
Bulimia, Body Dissatisfaction, Bariatric (Post) to
Ineffectiveness, Perfectionism, general and ED
Interpersonal Distrust, Interoceptive sample [97]
Awareness, and Maturity Fears
Eating Loss of Control 18 Assesses frequency and severity of loss-of- .88–.92 [49] Not reported Original not Means/SD 10 No No
Scale (ELOCS) control eating supported (Post)
[50] Items include frequency counts and other [49]
questions, rated on an 11-point Likert scale
(continued on next page )
Table 1 (continued )
Scale Items Description Available psychometric properties Administration information
Internal Test–retest Factor structure Means/SD, cut Time to Cost to use Requires
consistency points complete, permission
min to use
Emotional Eating 25 Assesses desire to eat in response to 25 .72–.92 Not reported Not tested Mean/SD 5 No No
Scale (EES) [92] negative affective states [77,80,81] (Pre/Post)
Items are measured on an 5-point Likert scale Means for upper/
Includes 3 subscales: Anger/Frustration, lower quartile
Anxiety, and Depression (Pre) [80]

Valentina Ivezaj et al. / Surgery for Obesity and Related Diseases 17 (2021) 1510–1520
Night Eating 14 Assesses the behavioral and psychological .80 [82] Not reported Not tested Mean/SD 5–10 No No
Questionnaire symptoms of night eating syndrome (Pre/Post)
(NEQ) [41] Items are assessed on a 15-pointLikert scale
Provides cutoff scores for probable night-
eating syndrome
Questionnaire on 28 Assesses the presence or absence of binge- Not reported Not reported Not tested Proportion BED/ 5 No No
Eating and Weight eating episodes, the frequency of such LOC
Patterns (QEWP) episodes, and additional (Pre/Post)
[54] required features for the diagnosis of DSM-4 Agreement
BED criteria (Kappa) with
Items include both dichotomous queries and other Dx
frequency assessments measures
(Pre) [58,93,94]
3-Factor Eating 51 Assesses cognitive restraint, disinhibition, and .73–.87 Not reported Original not Mean/SD 20 No No
Questionnairey hunger responsiveness [47,78,83] supported (Pre/Post)
(TFEQ) [48] Items are presented in both True–False and 5- [47,78]
point Likert response formats
Yale Food Addiction 25 25-item instrument assessing eating behavior .82–.94 Not reported Original factor Mean/SD 10 No No
Scale (YFAS) [95] in relation to highly palatable foods (i.e., [55,81,84–89] structure (Pre/Post)
high-sugar and/or high-fat foods) replicated
Majority of items provide a Likert response [55,90]
format of increasing frequency
Can be scored in 2 ways: (1) A symptom count
version indicating the number of
dependence symptoms experienced in the
past 12 mo; and (2) a diagnostic threshold
version determining whether 3 or more
symptoms are present and whether there is
clinically significant impairment or distress
SD 5 standard deviation; DSM-4 5 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; DSM-4-TR 5 Diagnostic and Statistical Manual of Mental Disorders, Forth Edition Text Revi-
sion; AN 5 anorexia nervosa; BN 5 bulimia nervosa; BED 5 binge-eating disorder; ED 5 eating disorder; LOC 5 loss-of-control; Dx 5 diagnosis.
* The 7-item version of this scale has different subscales than those included in the description.
y
Measure was later revised and re-named to “Eating Inventory” [96].

1515
1516 Valentina Ivezaj et al. / Surgery for Obesity and Related Diseases 17 (2021) 1510–1520
use of the measures in heterogenous samples). Whether con-
structs such as body image concerns or other cognitive
symptoms of eating disorder psychopathology differ across
age, gender, and racial and ethnic groups in those undergo-
ing bariatric surgery remains unknown. In order to better
characterize either similarities or dissimilarities across
groups, more information is needed related to the validity
of self-report measurements within diverse bariatric
samples.
Taken together, relatively few studies have examined psy-
chometric properties of eating disorder measures in the bar-
iatric field, particularly after bariatric surgery, when eating
behaviors are nuanced and potentially more complex
compared to other populations that do not have an altered
gastrointestinal anatomy. There is limited psychometric
testing of disordered eating measurement tools and limited
support of original factor structures in the bariatric field.
Indeed, of the 12 commonly used self-report measures listed
in Table 1, factor analyses were conducted for only 4 mea-
sures (EDE-Q, ELOCS, TFEQ, and Yale Food Addiction
Scale [YFAS]); only 1 study with 1 of these measures—
the YFAS, which is a controversial construct not clearly
defined as disordered eating—replicated the original factor
structure [55]. Future studies with large and diverse sample
sizes are needed to appropriately and accurately examine
factor structures, and greater rigor in reporting psychometric
properties (i.e., various forms of reliability and validity, as
well as means and standard deviations for the overall partic-
ipant group and subgroups as appropriate) is warranted.
Based on the limited psychometric literature to date, the
use of the EDE-Q [47,56] and TFEQ with alternative factor
structures is recommended to examine eating disorder psy-
chopathology prior to bariatric surgery, while the ELOCS
with 2 factors is recommended to examine LOC eating after
bariatric surgery [49]. Importantly, however, the authors
note the need for replication of the structure within indepen-
dent bariatric samples.
Conceptual considerations
In addition to psychometric limitations of eating disorder
measures in the bariatric field, a discussion of conceptual
measurement issues is warranted for this population. The
majority of disordered eating examined among bariatric
populations has included eating behaviors thought to pro-
mote suboptimal weight outcomes, such as LOC eating. Lit-
tle is known about the entire spectrum of disordered eating,
including more restrictive disordered eating behaviors and
cognitions (e.g., preoccupation with weight/shape), which
can be impairing. This is likely because the original eating
disorder diagnostic criteria were not developed with bariat-
ric surgery in mind and are not well suited to characterize a
full range of eating pathology in postsurgery patients.
Indeed, many of the well-known eating disorder measures
may not conceptually apply to postoperative bariatric
patients. For example, the EDE interview and self-report
versions include items designed to capture disordered die-
tary restraint. The primary dietary restraint items ask:
“have you been consciously trying to restrict the amount
of food you eat, whether or not you succeeded?”; “have
you been consciously trying to avoid certain foods, whether
or not you succeeded?”; and “have you been trying to follow
certain definite rules regarding your eating?” Higher scores
are indicative of greater eating-disorder psychopathology.
However, one would expect individuals to endorse such
items after bariatric surgery. In fact, scoring higher might
be suggestive of greater adherence to postoperative dietary
guidelines and may be adaptive in some instances, at least
conceptually. Similarly, a higher score on weight dissatis-
faction is considered more severe or problematic, given
the original intention of this measure with more restrictive
eating disorders. For individuals seeking bariatric surgery,
however, higher scores of weight dissatisfaction might not
be problematic or might not capture the same construct as
originally intended among individuals with extremely low
weights.
The field also lacks consensus on how to define an OBE in
a postbariatric population. According to the DSM-5, the
amount of food eaten is objectively larger than most others
in a similar circumstance would eat. In this circumstance or
context (having undergone bariatric surgery), defining “an
unusually or objectively large” amount of food is complex
and is a matter of debate [57]. “Unusually or objectively
large” might be influenced greatly by the duration since hav-
ing the operation. This has important implications, because
rates of OBEs postsurgery could be higher if “unusually
large” is defined based on what constitutes a portion size
for someone who has undergone bariatric surgery as
opposed to someone without a bariatric surgery history.
Cognitive features of eating disorders are often over-
looked in the bariatric literature. For example, measure-
ments of eating disorder psychopathology among bariatric
surgery patients would be incomplete without at least a brief
assessment of overvaluation of weight and shape. Several
existing measures commonly used among bariatric surgery
patients (e.g., EDE and EDE-Q) include 2 applicable
Likert-scale questions (i.e., “has your weight influenced
how you think about [judge] yourself as a person?” and
“has your shape influenced how you think about [judge]
yourself as a person?”), and questions similar in content
and brevity would likely benefit future eating disorder mea-
surement development efforts among this population. Simi-
larly, other cognitive constructs, such as preoccupation with
food/eating or weight/shape, might shed light on important
risk factors or maintenance mechanisms of disordered
eating after bariatric surgery.
Although the existing adolescent research suggests paral-
lels to the adult literature—namely, general decreases in
eating disorder pathology following surgery—there are still
outstanding questions. For example, it is not clear whether
 Valentina Ivezaj et al. / Surgery for Obesity and Related Diseases 17 (2021) 1510–1520
the self-report measures that exist for younger populations are
developmentally appropriate [11]. Additional research on a
wider breadth of behaviors with larger samples of adolescents
would be important to help answer outstanding questions
about the presentation of youth receiving bariatric surgery.
Gaps and future research implications
Taken together, while reviewing current and future
research in this area, it is important to keep in mind the
following limitations. First, the majority of disordered
eating examined among bariatric populations has included
eating behaviors thought to promote suboptimal weight out-
comes, such as LOC eating. Little is known about the entire
spectrum of disordered eating, including more restrictive
disordered eating behaviors, compensatory behaviors, and
cognitive features of disordered eating. Second, the original
eating disorder diagnostic criteria were not developed with
bariatric surgery in mind and are not well suited to charac-
terize eating pathology in postsurgery patients. Third, cur-
rent eating disorder measures used in bariatric surgery
research were developed with nonbariatric patients, many
of which included predominantly White women presenting
with restrictive eating. As such, the nuances of disordered
eating behavior after bariatric surgery may not be captured
fully by the field’s current assessment instruments.
With these limitations in mind, we offer the following
recommendations. First, efforts should be made to study
the psychometric properties of existing measures at multiple
time points (before surgery, acute postsurgery, and long-
term follow-up). For example, psychometric testing of the
EDE and EDE-BSV is needed to determine the utility of
both instruments before and after bariatric surgery. Second,
efforts should be made to develop new reliable and valid
measures specifically for bariatric surgery. There are a few
noteworthy examples of this approach in assessing health-
related quality of life among bariatric patients, including
the Bariatric and Obesity Specific Surgery [59] and the
Quality of Life for Obesity Surgery [60] instruments.
Though not widely used, both measures include eating
behavior subscales and demonstrate psychometric strengths,
including estimates of internal consistency [59,60], test–
retest reliability [59], improved content validity [59,60],
and a supported factor structure among bariatric patients
[59,60]. In addition to considering health-related quality
of life, new measures are needed to understand eating-
disordered cognitions and behaviors and the bio-
psychosocial factors that motivate patients to initiate and
maintain these behaviors before and after bariatric surgery.
More research is also needed to characterize normative
eating after surgery, which will inform assessments of prob-
lematic or disordered eating after surgery.
In addition to investigating existing self-report measures
and developing new ones, attention should be paid to
methods that might reduce the limitations associated with
1517
traditional self-report measures, including recall bias and
social desirability/approval bias [61]. Methods such as daily
diaries can reduce recall biases and may have improved
ecological validity, though some data suggest the impact
of recall bias is less for people with eating disorders as
compared with other clinical groups [62,63]. Photographic
food records have shown some promise [64,65]. Further-
more, laboratory-based feeding paradigms would be useful
to help gain a better understanding of normative and disor-
dered eating before and after bariatric surgery. Emerging
technology, such as sensors and other objective measures,
have the potential to assess patterns of eating behavior
[66]. Early evidence, however, suggests problems with
adherence that would need to be addressed before wide-
spread adoption could be achieved [67,68].
Conclusions
To date, disordered eating is common among individuals
seeking bariatric surgery and tends to decrease significantly
following surgery. Existing literature suggests that postsur-
gical disordered eating is associated with attenuated weight
loss or weight regain following bariatric surgery. Relatively
few data, however, are available on the full spectrum of
disordered eating, including more restrictive eating and di-
agnoses. Further, our current eating-disorder classification
system and assessment tools are limited for pre- and postop-
erative bariatric surgery populations. The current tools,
which were originally designed for individuals with more
restrictive, low-weight eating disorders, might not accu-
rately or reliably capture complex and nuanced eating after
bariatric surgery. Thus, despite the proliferation of research
in this area over the past 2 decades, results should be inter-
preted with caution due to the lack of psychometric data of
many of these measures among bariatric samples. Future
research should examine comprehensive psychometric
properties (i.e., various reliability and validity indices) of
commonly used eating-disorder measures at preoperative
and postoperative phases to develop greater confidence in
the extant data and provide future measurement directions.
Without appropriate psychometric testing, it is unclear
whether new measures are needed for this population.
Importantly, however, even with psychometric testing of
current measures, it will be important to consider whether
current measures miss specific disordered-eating character-
istics after bariatric surgery. Future research should consider
rigorous scale-development techniques for disordered
eating that are unique to bariatric surgery, which would ul-
timately aid in early detection of problematic features and
inform treatment development and recommendations.
Moreover, individuals with disordered eating may have
unique needs in the postoperative period; more research is
needed examining the temporal relationships between disor-
dered eating and psychosocial sequalae postsurgery, utiliz-
ing tools that are validated for use with bariatric surgery
1518 Valentina Ivezaj et al. / Surgery for Obesity and Related Diseases 17 (2021) 1510–1520
patients. Objective methods of measuring disordered eating,
along with complementary self-report measures, may eluci-
date our understanding of the unique needs of individuals
undergoing bariatric surgery. Finally, mixed methods,
including qualitative methods, are needed to assess disor-
dered eating following bariatric surgery.
Acknowledgments
We acknowledge Rachel Allio, MS, RD, LD, Division of
Bariatric Surgery, West Virginia University, for her contri-
bution to nutritional guidelines.
Disclosures
Drs. Ivezaj, Devlin, Heinberg, Kalarchian, Sysko,
Williams-Kerver, and Mitchell report no conflicts of interest.
Dr. Ivezaj reports broader interests, including honoraria for
a journal editorial role and lectures, and was supported, in
part, by National Institutes of Health (NIH) grant R01
DK098492. The NIH played no role in the content of this pa-
per. Dr. Heinberg reports broader interests, including hono-
raria for lectures, and was supported by the National
Institutes of Health Grant R01 DK112585-01. Dr. Brode
was supported by the National Institute of General Medical
Sciences, 5U54GM104942-03. Dr. Carr was supported by
the National Institute of Drug Abuse Training Grants [grant
number T32 DA019426 and T32 DA007238]. Dr. Sysko was
supported by the NIH grant R44DK116370. The content is
solely the responsibility of the authors and does not neces-
sarily represent the official views of the NIH.
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