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Curr Opin Psychiatry. Author manuscript; available in PMC 2020 November 01.
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Published in final edited form as:

Curr Opin Psychiatry. 2019 November ; 32(6): 504–509. doi:10.1097/YCO.0000000000000549.

Disordered eating after bariatric surgery: clinical aspects,

impact on outcomes, and intervention strategies
Eva M. Conceição*,
School of Psychology, University of Minho

Andrea Goldschmidt
Department of Psychiatry & Human Behavior, Warren Alpert Medical School of Brown
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University/The Miriam Hospital

Abstract
Purpose of review: Disordered eating behaviors (DEBs) are associated with poor weight
outcomes following bariatric surgery. We describe DEBs most relevant to this population, their
associations with weight outcomes, and emerging data on interventions for DEBs.

Recent findings: Loss of control eating episodes and grazing have been the most well studied
DEBs in bariatric samples. Although DEBs often remit after surgery even without targeted
intervention, a subgroup of patients have persistent or newly developed DEBs post-operatively.
Pre-operative DEBs have little effect on weight outcomes, while pre-operative impulse control-
related features commonly associated with DEBs (e.g., inhibitory control) may have stronger
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predictive value. Post-operatively, DEBs appear to exert robust effects on concurrently measured
weight. Post-operative interventions hold promise for optimizing treatment outcomes.

Summary: We recommend the following to improve clinical care and move research forward: 1)
a common language for DEB constructs is needed to improve cross-talk among researchers and
care providers; 2) diagnostic schemes and assessment tools may require tailoring for the bariatric
population; 3) mechanisms underlying improvements in DEBs following surgery should be
clarified; 4) ongoing monitoring of DEBs in the post-operative period is warranted; and 5) a
stepped-care approach may improve weight outcomes in a cost-effective manner.

Keywords
Bariatric surgery; disordered eating behaviors; loss of control eating; binge eating; grazing
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Introduction
Bariatric surgery (BS) is currently the most effective treatment for obesity. Although most
patients experience marked weight loss following surgery, a subset present with suboptimal
weight loss and/or weight regain in the long-term [1]. Attempts to identify risk factors for
poor post-operative outcomes have focused on disordered eating behaviors (DEBs), which

*
Corresponding author: School of Psychology, University of Minho, Campus Gualtar, 4710-057, Braga, Portugal;
econceicao@psi.uminho.pt; +351 253 604 220.
3.Conflicts of interest: none.
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are relatively common in pre-surgery samples, often produce imbalances between energy
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intake and expenditure, and may be associated with post-operative onset of full-syndrome
eating disorders [2]. This review will provide an updated description of DEBs common to
the bariatric surgery population and their relation to weight outcomes; propose a clinical
management approach based on the latest empirical findings; and suggest priorities for
future research.

Clinical presentation
Anatomical alterations produced by surgery place several physiological constraints on eating
behavior. As a result, constructs, measures, and diagnostic categories originally developed
for non-bariatric eating disorder patients may not adequately address the clinical
presentation of DEBs among post-surgery patients [3]. Moreover, the eating disorders and
obesity fields are plagued by a lack of consistency when describing and labeling eating-
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related constructs, resulting in considerable overlap among constructs [e.g., food

“addiction,” compulsive eating, loss of control eating (LOCE)]. In addition to limiting cross-
study comparisons, this lack of consistency impedes recognition of DEBs and appropriate
referrals/continuity of care by clinicians.

Research on the development of eating disorders after surgery is scarce, and there are no
data on prevalence rates of eating disorders other than binge eating disorder (BED) in post-
operative samples. The published reports in this area suggest that a) post-bariatric patients
with eating disorders tend to be older than non-bariatric patients with these disorders which
may indicate that eating disorder symptoms/risk factors predate surgery; b) what constitutes
a “low” BMI in this population is debatable, as several post-surgical patients with anorexia
nervosa-like symptoms present with a BMI in the normal weight range despite extreme
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dietary restraint and substantial weight loss; and c) surgery-specific gastrointestinal

symptoms (e.g., vomiting or diarrhea experienced as “dumping” syndrome) may function as
compensatory behaviors to avoid weight gain [2].

BED involves recurrent episodes of objective binge eating (OBE; consumption of an

unambiguously large amount of food in a discrete time period, accompanied by LOCE) in
the absence of inappropriate compensatory behaviors [4]. Approximately 12.7% of pre-
surgery patients present with BED [5**], marking it the second most common psychiatric
disorder in this population [6**].

In the post-operative period, anatomical alterations induced by the surgical procedure,

resulting in limited gastric capacity, make it impossible for most patients to accommodate
large amounts of food. Thus, BED is rarely diagnosed after surgery since the primary
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criterion (ingestion of an unambiguously large amount of food in a discrete time period) is

physically unfeasible. As a result, there is evidence for a significant decrease in BED
diagnoses after surgery [5**], which suggests a post-operative improvement of eating
behavior. Nevertheless, several studies demonstrate that episodes involving LOCE over
smaller amounts of food (subjective binge eating – SBE) may continue or emerge shortly
after surgery, increasing in frequency with follow-up time [5**,7*,8]. Research suggests that
LOCE is a unique indicator of psychopathology, and that the amount of food eaten reflects

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the degree of LOCE experienced during the episode [9,10**]. Indeed, post-bariatric patients
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meeting the criteria for BED, except for endorsing SBE rather than OBE, show comparable
levels of eating-related and depressive symptomatology relative to non-BS individuals with
full-syndrome BED [7*]. Our group [10**] used a continuous rating scale to assess the
degree of LOCE in relation to four DEB, including OBE and SBE. We found that
psychopathology across the DEBs were more strongly related to the degree of LOCE than
amount of food eaten during eating episodes. At the same time, OBE and SBE are associated
with similar levels of psychopathology, while the degree of LOCE is highly correlated with
the amount of food eaten in laboratory tests [9].

Recent research indicates that LOCE among bariatric surgery patients may be present in the
context of eating behaviors outside of OBE or SBE episodes, including grazing [10**].
Grazing involves eating small/modest amounts of food in an unplanned and repetitious
manner, and not in response to hunger/satiety sensations. Researchers have described two
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subtypes of grazing, compulsive (related to one’s inability to resist eating) and non-
compulsive (related to the experience of mindless eating). These features, along with the
unplanned nature of grazing, suggest that a certain degree of LOCE may be present [11].

Our research suggests that OBE/SBE and compulsive/non-compulsive grazing among

bariatric patients could be conceptualized along a continuum of LOCE and eating-related
psychopathology, whereby non-compulsive grazing is associated with the lowest levels of
LOCE and psychopathology, and OBE with the highest (resulting in larger amounts of food
eaten during the episode) [9,10**]. Thus, assessing LOCE on a dimensional scale rather
than dichotomously (present/absent) may clarify different behavioral presentations of DEBs
in this population.
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Stability and course

Although DEBs typically decrease immediately following surgery, they may emerge or re-
appear as early as 4–9 months following surgery [7*], with rates continuing to increase over
follow-up [5**,12] and peaking at 3 years after surgery [5**]. Recent data from the large,
multisite Longitudinal Assessment of Bariatric Surgery (LABS) study showed that the
presence of BED and LOCE decreased from 12.7% and 35% pre-operatively, to 2.1% and
24% one year after surgery, respectively [5**], with remittance rates reaching 70% for BED
vs. only 27% for LOCE. Thus, LOCE may be more stable than full-syndrome BED. Indeed,
46.6% of those whose BED remitted continued to report sub-syndromal LOCE after surgery.
Notably, 4.8% and 25.6% of LABS participants reported post-operative BED and LOCE de
novo, respectively, indicating that while risk for post-surgical LOCE is highest for
individuals who engaged in DEBs prior to surgery, a small subset of patients evidence new
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onset of these behaviors after surgery. With respect to other DEBs, we reported that picking/
nibbling, an eating behavior resembling grazing, persists from pre- to post-surgery for
43.8% of the sample. Half of those whose LOCE remitted post-surgery engaged in picking/
nibbling two years after surgery [13], suggesting that transition among DEBs is not
uncommon.

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Impact on weight outcomes

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Identifying pre-surgical DEBs predictors of weight outcomes could help clinicians screen
patients at risk for poor outcomes and inform personalized care. Unfortunately, identification
of pre-surgical prognostic indicators has proved elusive [14], and recent research sustains the
mixed findings.

Recently, Marek and colleagues [15] found that pre-operative BED was associated with
higher post-operative BMI, but not BMI reduction over 5 years of follow-up. Similarly,
García-Ruiz-de-Gordejuela and colleagues [16] showed that patients with slower weight loss
trajectories in the year following surgery presented with more pre-operative
psychopathology, including DEBs. Another group showed that pre-operative emotional
eating was associated with lower weight loss one year after surgery, and “food addiction”
symptoms with lack of weight loss from 3 to 12 months post-surgery [17]. Unfortunately,
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none of these studies controlled for the presence of concurrent DEBs after surgery, such that
associations with weight outcomes may be accounted for by DEBs that persist among the
subset of patients who reported pre-surgery DEBs [5**,13].

The latest reports from LABS [18] found that pre-surgery eating disorder diagnoses were not
associated with weight change over 7 years of follow-up. In addition, patients presenting
with pre-surgical LOCE had similar 7-year variations in weight loss relative to those with no
pre- or post-surgical LOCE [12]. In their investigation of weight trajectories over 2 years
following surgery among patients who underwent primary or reoperative surgery [19], Pinto-
Bastos and colleagues found that none of the pre-operative disordered eating constructs
(eating-related psychopathology, grazing, or OBE/SBE) was a significant predictor of
weight loss or regain. Using latent class analysis, Schäfer and colleagues identified different
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disordered eating subtypes among bariatric surgery candidates, none of which differed in
terms of weight loss [20]. Finally, our research showed that patients presenting with pre-
operative DEBs did not differ in weight loss trajectories across 30 months of follow-up [13].
A recent literature review found that pre-operative grazing was not associated with post-
operative outcomes [21]. Together, these data highlight the limited prognostic value of pre-
operative eating disorder diagnoses or subclinical DEBs in relation to weight loss after
surgery.

In response to the lack of support for pre-operative DEBs as predictors of post-surgical

weight outcomes, several investigators have suggested that personality features [22] such as
impulsivity [6**] may account for overlap among DEBs, and may have greater utility as
outcome predictors than specific behaviors [22]. Indeed, pre-operative inhibitory control has
been shown to predict variability in BMI as early as 6 months after surgery [23], although it
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is unclear whether effects are mediated by changes in self-regulation of eating [24]. Future
research should investigate how impulse control constructs vary across time, and clarify
mechanisms of action by which these constructs impact post-operative eating and weight
outcomes.

The literature has been far more consistent regarding the impact of post-operative DEBs on
weight outcomes. Post-operative eating-related psychopathology has been associated with

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weight loss and regain, and post-operative grazing with weight regain for primary and
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reoperative patients [19]. In addition, evidence suggests an association between post-

operative grazing and weight loss/regain, gastrointestinal symptoms and compliance with a
healthy lifestyle [21].

With respect to other DEBs, we showed that weight loss trajectories were poorer for patients
presenting with versus without post-operative DEBs (OBE, SBE, picking/nibbling), with
differences observed by 18 months following surgery [13]. Furthermore, data from a
subsample of LABS participants suggest a prospective effect of DEBs on weight outcomes,
such that LOCE at one year follow-up predicts subsequent weight loss at two years [12]. On
the contrary, more recent data on the full LABS sample found no evidence for a prospective
(LOCE at previous assessments) or cumulative (total number of LOCE endorsements over
time) effect of LOCE on weight outcomes over 7 years of follow-up. However, LOCE was
concurrently associated with weight outcomes assessed at the same time point [4]. Thus,
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past history of DEBs may not be as prognostically meaningful as current DEBs in predicting
weight outcomes.

Clinical management
To summarize, there is significant heterogeneity in the timing and impact of DEBs after
surgery. A subgroup of patients with pre-operative BED presents with subthreshold LOCE
post-operatively, while another subgroup remits. A considerable percentage of patients
develop new onset BED, LOCE, and/or grazing post-operatively; these behaviors may
appear relatively early after surgery, but tend to impact weight only after a year following
surgery. Finally, prospective effects of post-operative DEBs on weight outcomes are
inconsistent, but there is strong evidence for a concurrent effect. The latest findings should
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be considered to inform clinical management of DEBs in the context of surgery.

Screening and assessment.

Pre- and post-operative assessment should focus on early detection of DEBs and
psychological/personality characteristics that may persist after surgery and/or increase the
risk for poor weight outcomes. A systematic assessment battery incorporating measures that
have been validated in the bariatric population should be used throughout the post-operative
period to identify high-risk behaviors before they significantly impact weight.

Prevention and treatment.

Given limited evidence for effects of pre-operative DEBs on post-surgical DEB and weight
outcomes, it may be most expedient to target interventions towards the post-surgical period.
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Importantly, pre-operative interventions may not generalize to patient’s post-operative needs,

and patients who develop DEBs post-operatively may not retain skills learned by the time
their application is necessary. Moreover, bariatric surgery itself may achieve more robust
impacts on weight-related and psychological outcomes than psychological/behavioral
interventions, although head-to-head comparisons are needed [25**]. Indeed, there appears
to be no effect of insurance-mandated pre-operative weight management on rates of
readmission/reoperation, follow-up visits, or weight loss one year after surgery [26], and

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pre-surgical cognitive behavioral therapy seems have no impact on DEBs or BMI at one and
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at four years after surgery despite showing post-intervention effects [25**]. Of note, in the
study reporting an association between pre-operative BED and higher BMI post-surgery
[15], patients with pre-operative BED received pre-surgery intervention.

Taken together, there is limited support for the efficacy of pre-operative interventions.
However, we believe that undergoing bariatric surgery should follow an informed decision-
making process in which patients are fully aware of the need for lifestyle changes, treatment
requirements, and risks of suboptimal response. Thus, we propose that pre-operative
interventions should be geared towards psychoeducation with the intent of informing
patients about their role as active agents in the treatment process, changes they will
experience, importance of having a strong support system [27,28], and risk for re-emergence
of DEBs and possible impacts on weight.
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In contrast, there is growing support for the need to address risk behaviors in the post-
operative period to optimize weight outcomes. Clinical approaches should consider the
variability of weight loss trajectories across individuals, and the limited public health
resources to meet demands of an increasing number of patients. Research should investigate
how to optimize the allocation of resources in a cost-effective manner, and identify when
and whom needs additional treatment [29*]. A stepped-care approach may hold promise as a
strategy for more adaptive and personalized care [29*]. For example, low-intensity strategies
such as self-monitoring of weight and food intake may be offered first as a preventive
strategy for weight regain, before moving on to more intense interventions, such as
behavioral/psychological treatment or pharmacotherapy for weight loss. Such an approach
should pivot from systematic and ongoing monitoring of key risk behaviors to screen
patients as they develop needs for more intense clinical attention.
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Alternative delivery methods can improve access to specialized care while utilizing fewer
human resources. New technologies [30] and telephone-based interventions [31] offer novel
platforms for contacting the patients without the caveats associated with face-to-face care
[32]. These platforms allow for frequent monitoring of risk behaviors and delivery of “real
time” intervention content [32], while supporting a greater number of patients at reduced
cost [33]. Indeed, pilot data suggest that an Internet-based behavioral intervention may be an
acceptable and effective for weight regain and eating-related problems after surgery [30],
with high rates of retention (70%) and satisfaction. Other technology-based approaches,
such as just-in-time adaptive interventions, should be tested as well [34].

Conclusion
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There is strong support for an association between post-operative DEBs and weight
outcomes following BS, and growing data suggest that intervening in the post-surgical
period may improve patient outcomes. Yet, several gaps in our understanding of DEBs and
surgery outcomes need to be addressed through future research. First, researchers from
different fields (e.g., eating disorders, obesity, personality) should consider the ways in
which different DEBs overlap and develop a common language for DEB constructs to
improve cross-study comparisons and screening/intervention. Relatedly, existing diagnostic

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schemes and assessment protocols may need to be tailored for the post-bariatric population.
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Second, an improved understanding of the mechanisms by which bariatric surgery improves

DEBs should be undertaken to inform both surgical and non-surgical treatment options for
these behaviors [35]. Third, considering the marked heterogeneity of the bariatric population
[36], optimal modalities, timing, and delivery formats of interventions should be identified
[32], with a focus towards cost-effectiveness, given the growing demand for surgical
procedures. In this era of personalized medicine, a stepped-care approach based on
systematic screening of risk behaviors seems like a reasonable strategy to deliver care for
patients in need. Rigorous trials with large samples, state-of-the-art assessment tools, and
ability to dismantle critical intervention components and their cost are essential to address
the burden of obesity on patients and public health.

Acknowledgements
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2. Financial support and sponsorship: This research was partially conducted at Psychology Research Centre (PSI/
01662), University of Minho, through support from the Portuguese Foundation for Science and Technology and the
Portuguese Ministry of Science, Technology and Higher Education through national funds/co-financed by FEDER
through COMPETE2020 under the PT2020 Partnership Agreement (POCI-01–0145-FEDER-007653), by grants to
Eva Conceição (IF/01219/ 2014 and POCI-01–0145-FEDER-028209), and by the National Institute of Diabetes and
Digestive and Kidney Disease (K23-DK105234) to Andrea Goldschmidt.

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Key-points
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1. Although DEBs often remit after surgery even without targeted intervention, a
subgroup of patients have persistent or newly developed DEBs post-
operatively

2. Pre-operative DEBs have little effect on weight outcomes.

3. A concurrent effect, rather than prospective or cumulative effect, of DEBs on

weight outcomes yields the stronger predictive value.

4. Post-operative stepped-care interventions hold promise for optimizing

treatment outcomes in a cost-effective manner.

5. Diagnostic schemes and assessment tools may require tailoring for the
bariatric population.
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Author Manuscript
Author Manuscript

Curr Opin Psychiatry. Author manuscript; available in PMC 2020 November 01.