Bariatric surgery procedures substantially alter the normal anatomy of the gastrointestinal (GI) tract, leading to significant changes in eating behavior. However, a number of bariatric surgery patients report problematic eating behaviors, as well as full and subthreshold eating disorders, both preoperatively and postoperatively, which have been associated with poor weight treatment outcomes (Conceição et al. 2013a, 2014). The notable heterogeneity in eating pathology documented in the literature and the lack of an identified nomenclature for these problems are serious challenges, and understanding disordered eating in candidates for bariatric surgery is important for clinicians attempting to devise and implement an effective therapeutic approach.
Currently, no diagnostic terms have been specifically developed to describe eating disorders and problematic eating in individuals before or after bariatric surgery. The criteria used for diagnosis in these populations have been the standard Diagnostic and Statistical Manual criteria, but important differences should be considered when assessing eating disorders and problematic eating behaviors in bariatric surgery patients, both preoperatively and in the postoperative period. In this chapter, we focus on the assessment of eating disorders before and after surgery and in the application of DSM-5 criteria for eating disorders in bariatric surgery patients (American Psychiatric Association 2013). We also address problematic eating behaviors and GI syndromes that play an important role in bariatric surgery outcomes, such as grazing, emotional eating, and dumping syndrome. Finally, we provide specific guidelines for the clinical assessment of eating disorders and problematic eating behaviors.
It is strongly recommended that mental health professionals assessing individuals before and after bariatric surgery possess specialized interest in and knowledge about obesity, weight control, and weight loss surgery. The clinical assessment of eating disorders and problematic eating behaviors in bariatric surgery patients requires not only specific knowledge of the different surgical procedures, the associated nutritional requirements, and the variations in eating that these patients must implement over time, but also attention to subsyndromal presentation of symptoms and atypical behaviors not often seen in nonbariatric surgery patients with eating disorders. Additionally, clinicians need to have open communication with the rest of the multidisciplinary bariatric team to exchange information particularly regarding adherence to nutritional requirements, as well as other factors affecting surgical outcomes. These factors may result in less weight loss or greater weight regain and also may dictate the need for additional clinical attention. The remainder of this chapter focuses on the specific types of information relevant to the assessment of eating disorders and problematic eating among individuals having bariatric surgery.
When a bariatric surgery candidate or postoperative patient is referred for evaluation, standard assessments for the DSM-5 diagnostic criteria for eating disorders should be used. The assessment of eating pathology is often intended to identify patients who are engaging in behaviors that may increase the risk for poor outcomes, including attenuated weight loss, excessive regain, or impaired psychological functioning. Because interviews typically occur during what is often a mandatory psychiatric assessment, there is a risk that participants will deny problematic behaviors to avoid delay or denial of surgery. With postsurgery patients, assessment should take place at critical postoperative time points, particularly after the weight loss nadir is reached at about 1-2 years after surgery, when eating behavior may potentially deteriorate (Magro et al. 2008). Like other individuals with symptoms of an eating disorder, post-bariatric surgery patients with anorexia- or bulimia-like symptoms may deny their problematic behaviors in the hope of achieving unrealistic weight goals. They may justify these behaviors as common sequelae of surgery, including the need to limit the amounts and types of foods ingested, and may attribute the occurrence of vomiting and/or dumping to the surgery even if those behaviors are self-induced. In such cases, the patients’ low level of commitment to change may be particularly challenging, and an empathic, nonjudgmental but firm approach will be needed to address the underlying motivation for these problematic behaviors. At all times, educating patients about the risks of certain eating behaviors or eating disorders and about how early detection of problematic symptoms may improve outcome of surgery and enhance psychological functioning will facilitate cooperation and openness.
Binge-eating disorder (BED), binge eating, and so-called loss-of-control eating are the most commonly reported eating disorder problems in patients before and after bariatric surgery. However, in bariatric surgery candidates, little is known about the prevalence of either full or subthreshold bulimia nervosa (BN), and anorexia nervosa (AN) is excluded because these patients do not meet the low-weight criteria. The development of classic eating disorders after bariatric surgery is now recognized, and although incidence rates are not well established, they appear to be very low. Nonetheless, in rare cases inpatient eating disorder treatment may be required (Conceição et al. 2013a). Presentations following surgery may be atypical because of age at onset (bariatric surgery patients are usually older), the difficulties in deciding what should be considered a normal or low body mass index (BMI), dissatisfaction with body image after massive weight loss, and some of the specific compensatory behaviors that are unique to this population.
Clinicians must distinguish between symptoms of an eating disorder and changes in behavior necessitated by alterations to the GI tract. After surgery, patients require a very restrictive diet and are instructed to limit meal size, to systematically follow an eating schedule, to weigh their food, and often to cut food into small pieces. They are also told to avoid certain foods that may be intolerable (e.g., red meat), to chew food extensively, and to monitor and control their weight. In fact, some level of patient self-responsibility and self-control regarding food intake is strongly encouraged by professionals caring for these patients to facilitate weight loss. These self-responsibility and self-control behaviors may resemble those expected in treatment of individuals with eating disorders. Thus, in evaluating such behaviors, the clinician needs to determine whether the patient’s behaviors result from excessive concerns about weight and shape or from the desire to strictly adhere to recommendations to avoid complications following surgery.
Similarly, episodic vomiting is frequent among patients following bariatric surgery (de Zwaan et al. 2010) and usually occurs in response to the ingestion of intolerable foods (e.g., red meat), eating too quickly, or chewing food insufficiently. At times, vomiting is used to reduce physical discomfort from plugging symptoms (problems with the small opening of the stomach becoming plugged with food) or from having eaten too much at one time. However, a minority of patients (12% in the study by de Zwaan et al. [2010]) also utilize vomiting as a means to control their weight.
Atypical compensatory behaviors also may emerge in patients following bariatric surgery. Dumping syndrome—the rapid movement of undigested food into the small bowel, causing abdominal cramps, nausea, and diarrhea—is a common GI event after surgery. Dumping syndrome has typically been described as an involuntary event, but dumping also is induced purposefully with the ingestion of specific foods by some patients to compensate for overeating or to enhance weight loss.
Additional concerns emerge when assessing low weight in post-bariatric surgery patients. It has not yet been determined what constitutes a low BMI for patients who were formerly severely obese and have lost massive amounts of weight following surgery. A BMI of 25 kg/m2 has been recommended as a useful line between overweight and so-called normal weight in the general population; however, there is little agreement on what should be regarded as a low or normal BMI in patients following bariatric surgery (Dixon et al. 2005). In reality, the majority of those who successfully lose weight postsurgery do not reach a BMI lower than 25 kg/m2, which would be difficult to achieve outside of severely restricting their food intake and risking malnutrition (Dixon et al. 2005). Moreover, postsurgery BMI is also affected by patients’ excess skin, which averages 4.8 kg but can account for up to 15 kg of weight following massive weight loss (Ortega et al. 2010). A detailed weight history and exploration of the patient’s expectations regarding weight may facilitate the evaluation of BMI in this population.
Among patients being assessed after surgery, the clinician should also assess the age at onset and duration of obesity, past history of weight loss and weight loss attempts, the patient’s view about his or her current weight, the patient’s ideal weight and desired weight after surgery, weight loss since surgery, and recent weight fluctuations and their impact on self-esteem and mood. Patients’ perspectives about their ideal weight, the weight they think they can achieve and maintain in a healthy way, fear of weight regain, coping strategies for weight stabilization, and behaviors to facilitate weight loss may help in deciding whether the weight goal is appropriate and whether it is being pursued or maintained with problematic or inappropriate eating behaviors.
Addressing weight or shape concerns in individuals who are undergoing massive changes in weight poses additional challenges. When addressing the role of body weight and body image in self-evaluation, the clinician should consider the fact that substantial weight loss facilitates many activities of daily living, improves perceived quality of life and social functioning, and is usually reinforced by others, which naturally results in weight being a salient aspect of self-evaluation (van Hout et al. 2006). Following surgery, individuals not only may have a realistic fear of weight regain, but excess loose skin, skin envelopes, and fat deposits also have a great impact on body image and may contribute to severe body dissatisfaction, as well as social embarrassment, despite weight loss (Odom et al. 2010). Weight concerns appear to peak when much of the expected weight loss has been achieved and patients reach a plateau in their rate of weight change (Conceição et al. 2013b). The slower weight loss rate at this time may trigger increased fears of weight regain (Conceição et al. 2013b) and greater efforts to control weight, resulting in overly restrictive eating behaviors that may result in malnutrition.
Special considerations and specific probe questions for the assessment eating disorder criteria in bariatric surgery patients are summarized in Table 5–1.
An objective binge-eating episode, as defined by DSM-5, is determined by two characteristics: 1) a sense of loss of control over eating, or not being able to resist eating or stop eating once started, and 2) ingestion of an excessively large amount of food in a discrete period of time (see Chapter 10, “Use of the Eating Disorder Assessment for DSM-5”). Assessing binge eating prior to bariatric surgery poses challenges similar to those faced in the assessment of this behavior in any overweight individual (see Chapter 4, “Eating Problems in Individuals With Overweight and Obesity”). Considerations include 1) evaluating the presence of loss of control, which is often not as distinct among obese individuals as among individuals with BN, because feelings of loss of control may not be as intense and disorganizing for severely obese individuals and for BN patients and many of these patients may feel that they “gave up” trying to control or limit the amount of food they eat because of unsuccessful previous attempts; 2) deciding what constitutes a large amount of food in the context of eating episodes may be challenging because it may not be as distinctively different from other non-binge meals as it is in BN patients; and 3) the absence of inappropriate compensatory behaviors, such as vomiting at the termination of an eating episode, as is seen in BN, possibly making occurrences more difficult to recognize as episodes of binge eating.
Required for DSM-5 diagnosis |
Criterion |
Special considerations after surgery |
Specific probe questions (to be used in addition to the questions concerning formal eating disorder diagnosis) |
AN |
Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health |
A highly restrictive diet is prescribed in the initial months after surgery. The amount of food tolerated is limited. There are no clear rules for defining underweight in postoperative patients. Considering the weight loss trajectory and physical health are particularly important. |
Could you describe your regular eating patterns for me? What is the prescribed nutritional plan for your follow-up? Do you avoid any foods, not because of the physical discomfort they may cause you but because you believe they will have an impact on your weight? Have you experienced any symptoms of starvation (e.g., cold intolerance, hypotension)? Do you have a problem with excess hanging skin? |
Intense fear of gaining weight or becoming fat and persistent behaviors to control weight |
Fear of weight gain is to some extent realistic and based on past experience. |
What strategies do you use to control your weight? Do you count calories? Do you avoid any food or nutritional supplements that were recommended to you? Do you limit the amount of food you eat at each meal? How often do you weigh yourself? How would you feel if you regained 5 pounds? 10 pounds? |
|
AN, BN, BED |
Undue influence of body weight or shape on self-evaluation |
Aesthetic alterations characterized by loose skin, skin envelopes, and fat deposits have important impacts on body image, causing dissatisfaction and social embarrassment. |
What areas of your body are affected by extra hanging skin? What activities do you avoid because of excess skin? What types of clothing do you avoid? |
BN, BED |
Recurrent episodes of binge eating |
Assessing the amount of food requires knowledge about the nutritional needs of each patient in their stage of treatment, the gastric capacity, and the type of surgery. Loss of control may be the only feature present in postoperative bariatric patients. |
How is the amount of food eaten in a binge-eating episode different from the regular amount of food you eat in your typical meals? Do you often have the feeling of plugging from the food in your stomach? Do you experience dumping syndrome? Do you keep eating even though you know food will feel plugged, you will vomit, or you will experience dumping? |
BN |
Recurrent inappropriate compensatory behaviors in order to prevent weight gain |
Spontaneous or voluntary vomiting is commonly associated with the ingestion of intolerable foods or with eating too rapidly, or is secondary to physical discomfort after eating, and is not necessarily influenced by body weight or shape concerns. Atypical compensatory behaviors such as dumping may emerge. |
What are your motives for vomiting and/or dumping? Does episodic vomiting happen because you feel plugged or physically uncomfortable with the food eaten? Did you overeat because you knew you would easily vomit or compensate through dumping? |
Note. AN=anorexia nervosa; BED=binge-eating disorder; BN=bulimia nervosa.
After surgery, physical restriction greatly limits the amount of food that can fit into a small gastric pouch/stomach created by bariatric surgery. However, it is still possible for individuals to report feeling a loss of control over eating, although the amount of food eaten is not objectively large (Colles et al. 2008). Therefore, the decision as to what constitutes a large amount of food eaten by individuals following bariatric surgery is not always straightforward, and emerging data suggest that this distinction may not be as important as the feature of loss of control over eating (Fitzsimmons-Craft et al. 2014; Niego et al. 1997). In fact, research with different patient samples showed that those presenting with subjective binge eating (loss of control over amounts of food not “large” but viewed by the individual as excessive) were similar to those reporting objective binge eating on eating disorder features, general psychopathology, and negative affect (Brownstone et al. 2013; Palavras et al. 2013). Additionally, subjective binge eating seems to be associated with depressive symptoms, anxiety, social avoidance, insecure attachment, and cognitive distortion (Brownstone et al. 2013; Fitzsimmons-Craft et al. 2014).
A number of studies have evaluated the presence of binge eating prior to bariatric surgery in an attempt to identify eating behaviors that might be predictive of attenuated weight loss after surgery, but research has failed to consistently demonstrate a significant relationship between preoperative binge eating and outcome. Some studies have found an association with poorer weight outcomes, whereas other studies have found no association or even greater weight loss (Livhits et al. 2012; Meany et al. 2014). However, the presence of binge eating prior to surgery can be associated with the risk of postsurgical binge eating or loss-of-control eating, both of which have been more consistently associated with less weight loss and/or increased weight regain over time (Meany et al. 2014; White et al. 2010). Binge eating prior to surgery has been related to increased psychological distress and other eating-disordered symptoms (Colles et al. 2008). Therefore, assessing binge eating prior to surgery plays an important role in screening for a subgroup of patients who may pose additional challenges following surgery.
Other problematic eating behaviors, such as grazing and emotional eating, have also been associated with loss-of-control eating (Allison et al. 2010; Conceição et al. 2014) and ultimately with risk of increased weight regain (Colles et al. 2008). See Table 5–1 for the special considerations that must be taken into account when assessing eating disorders in post-bariatric surgery patients.
Night eating syndrome, listed in DSM-5 as one of the other specified feeding or eating disorders, is characterized by evening/nocturnal hyperphagia and associated emotional distress (Allison et al. 2010). With a wide range of prevalence rates reported, the prevalence of night eating syndrome is estimated to be as high as 55% among obese patients seeking surgical treatment (Colles and Dixon 2006). No consistent relationship has been observed between presurgery night eating syndrome and presurgery psychological distress or postsurgery weight loss, loss-of-control eating, grazing, or night eating syndrome (Colles and Dixon 2006). However, preoperative night eating syndrome has been associated with BED, lower cognitive restraint, increased social eating, eating when tired, and less consumption of protein, which can be highly problematic for patients following bariatric surgery (Colles and Dixon 2006; Colles et al. 2008). Thus, night eating syndrome seems to be part of a disorganized, high-risk eating pattern that may require treatment before or after bariatric surgery. Night eating syndrome should be distinguished from sleep-related eating disorder, a rare condition often related to the use of certain sedatives or hypnotics and associated with other sleep disorders such as restless legs syndrome (Colles and Dixon 2006). Sleep-related eating disorder is characterized by partial arousal from sleep, reduced levels of awareness, and impaired recall.
Different definitions of the term grazing have been employed in the literature, which has led to some confusion. Recently, with our colleagues, we proposed that grazing be defined as the repetitive eating (more than twice in the same period of time without prolonged gaps between) of small or modest amounts of food in an unplanned manner and/or not in response to sensations of hunger or satiety (Conceição et al. 2014). Two subtypes were also suggested: 1) compulsive grazing—trying to resist but not being able to, returning repetitively to snack on food, and 2) noncompulsive grazing— repetitively eating in a distracted and mindless way (Conceição et al. 2014). Constructs similar to grazing that have been described in the literature include picking, nibbling, and repetitive snack eating; however, there is little research regarding the extent to which these behaviors overlap.
After surgery, owing to reduced gastric capacity, most patients must eat multiple small meals in order to consume a sufficient amount of food. This behavior should not be considered grazing, because this eating pattern demonstrates appropriate control. Grazing should also be distinguished from intentional overeating, a behavior in which individuals fractionate and eat smaller portions of a large amount over an extended time in order to purposefully overeat. The planned nature of intentional overeating distinguishes it from grazing. Grazing should also be differentiated from binge eating with moderate amounts of food (subjective binge eating), because grazing does not involve the sense that one cannot stop or resist eating in a circumscribed period of time.
Episode |
Sense of control |
Description |
Normal |
0 |
Eating behavior that is planned, controlled, and mindful of hunger and satiety. Repetitive eating of small amounts of food in order to accommodate the required daily amounts. |
Deliberate overeating |
0 |
Plan to fractionate and repeatedly eat small amounts to intentionally overeat and accommodate the amount of food desired (e.g., dessert). No sense of loss of control. |
Grazing, noncompulsive subtype |
1 |
“Mindless” and distracted eating of whatever is available. Not planned. |
Grazing, compulsive subtype |
2 |
Attempting to resist but returning repeatedly to eat small/modest portions of tempting foods; associated with cravings for food. |
Binge eating; loss of control |
3 |
Eating in a circumscribed period of time with a sense that one cannot resist eating or stop eating. |
Source. Adapted from Conceição et al. 2014.
Grazing may be characterized by some level of lack of control that is clinically different from the loss of control experienced in binge-eating episodes and that might be captured with a more flexible rating scheme. Some have advocated the use of a continuous rating scale for loss of control (see example in Table 5–2) instead of the more typical dichotomous (present/absent) nomenclature (Conceição et al. 2014; Mitchell et al. 2012).
Little is known about the clinical importance or prevalence of grazing prior to surgery, but the emergence of grazing postoperatively has been the focus of some research. Postoperative grazing has been suggested to serve the same function as presurgery binge eating, which is no longer possible because of the anatomical changes (Saunders 2004). Also, the unplanned, repetitive nature of the behavior may result in excessive caloric intake and ultimately less weight loss and/or greater weight regain. Grazing behavior after bariatric surgery may also be associated with binge eating and/or loss-of-control eating, and the overall combined pattern may lead to increased weight regain (Conceição et al. 2014). Although inconsistent, initial evidence points to an association between grazing and depressive symptoms, emotional eating, mindless eating, and poorer mental health and quality of life (Colles et al. 2008; Kofman et al. 2010). Although there is no clear evidence to argue that grazing is necessarily a psycho-pathological eating behavior in the general population, it does seem that grazing may compromise weight outcomes after bariatric surgery.
Although a standardized definition of emotional eating is lacking, the phenomenon has been described as “the tendency to eat in response to emotional distress and during stressful life situations” (Canetti et al. 2009, p. 109). Before surgery, emotional eating has been associated with higher levels of depression and binge eating and with more frequent eating in response to external cues (Fischer et al. 2007). Emotional eating is thought to be common among bariatric surgery candidates and postoperative patients and has been associated with binge eating (Pinaquy et al. 2003), grazing, uncontrolled eating, and snack eating (Chesler 2012). Additionally, some authors have considered emotional eating to be a risk factor for poorer outcomes after surgery, although data addressing this issue are quite limited (e.g., Canetti et al. 2009; Chesler 2012). Although emotional eating has been suggested to play a mediating role in treatment outcomes, including weight loss and quality of life (Canetti et al. 2009), contradictory results have been reported about the impact of emotional eating on weight outcomes after surgery (Fischer et al. 2007).
Dumping syndrome refers to a constellation of GI and vasomotor symptoms associated with the consumption of foods containing high concentrations of carbohydrates or sugar and/or with eating excessively following bariatric surgery (Deitel 2008). Dumping syndrome is estimated to occur in about three-quarters of patients undergoing malabsorptive bariatric procedures (Mechanick et al. 2013), typically develops 10-30 minutes postprandially, and has been referred to as early dumping by some authors. The syndrome occurs following rapid gastric emptying, leading to a hyperosmolar load in the intestine and subsequent fluid shifts (Deitel 2008), which are accompanied by an autonomic vasomotor response.
Dumping usually involves diarrhea, and there are anecdotal reports of patients using dumping as a compensatory behavior, relying on this GI consequence to compensate for overeating or binge eating. Thus, clinicians need to be aware that dumping is not only a frequent problem in the initial months after surgery, particularly until patients learn to eat slowly and to avoid foods that trigger these symptoms, but also an inappropriate method to compensate for eating and to regulate weight. Uncontrolled severe dumping can also result in a fear of certain foods or of eating, resulting in accentuated weight loss and even malnutrition (Lin and Hasler 1995).
Some patients have reported another condition similar to dumping that has been termed by some authors late dumping, as opposed to the early dumping that corresponds to dumping syndrome. Despite the similarity of symptoms reported by patients (dizziness, fatigue, diaphoresis, and weakness), the physiological mechanism underlying these conditions is not the same, and they should be considered distinct conditions. Late dumping occurs about 1-3 hours after a meal because of an exaggerated insulin response to hyperglycemia, resulting in subsequent reactive hypoglycemia (Ceppa et al. 2012; Deitel 2008); when intense and recurrent, this may result in blackouts, seizures, and other severe complications, including death as a rare outcome (Ceppa et al. 2012). Whereas early dumping usually develops shortly after surgery, late dumping typically develops a year to several years later. Clinicians should assess for dumping syndromes and educate patients about common triggers and consequences. Patients who experience late dumping may require dietary modifications to reduce carbohydrate intake, may need to take medications, or, in rare treatment-resistant cases, may require pancreatic resection.
To perform a comprehensive evaluation of a patient’s current eating behaviors, the clinician should inquire about the frequency and content of meals and snacks, problematic eating behaviors, and GI problems. Important concerns include the following:
In addition to assessing current eating behaviors and related symptoms, the clinician needs to assess whether a patient has had prior clinically significant eating problems. For example, a history of intensive dietary restriction and low weight because of AN may indicate that a patient is more likely to subscribe to rigid, inflexible attitudes regarding eating and weight and to have these attitudes reinforced by the extreme weight loss and the facilitation of control over eating that surgery permits. A past history of BN, BED, or night eating may be informative regarding the potential for loss-of-control eating and the prior use of compensatory behaviors (e.g., vomiting, dumping) that may reemerge because they are facilitated by the surgery. Finally, information about past treatments and responses to them may be useful in anticipating what may be most helpful in the future.
Providers may use the general guidelines provided in this chapter in conducting clinical interviews but may also consider the use of structured diagnostic assessment instruments. Table 5–3 provides a brief summary of clinical interviews and self-report measures to assess disordered eating behavior among individuals following bariatric surgery (see also Part 3, “Assessment Tools,” in this volume).
As part of the clinical interview, in addition to soliciting the information relevant to eating disorders, providers should also assess other past and co-occurring psychiatric conditions of particular relevance for bariatric surgery patients.
Among bariatric surgery candidates, the presence of BED has been associated with current or past history of both mood and anxiety disorders. Although significant improvement often occurs after surgery, postoperative BED or loss of control has also been associated with continued anxiety and depression and ultimately poorer outcomes (de Zwaan et al. 2011).
Impulse-control disorders such as skin-picking disorder, compulsive buying, or intermittent explosive disorder have been estimated to occur in up to 19% of bariatric surgery candidates (Schmidt et al. 2012).
Although presurgery binge eating has not been found to be a significant predictor of postsurgery alcohol abuse (King et al. 2012), individuals with eating disorders are at increased risk of alcohol abuse (Ferriter and Ray 2011). Extant evidence suggests that bariatric surgery patients have a greater sensitivity to the intoxicating effects of alcohol after surgery and are vulnerable to the development of alcohol use disorder, particularly following gastric bypass (King et al. 2012).
|
Measure (authors) |
Type of measure |
Description |
Examples of studies on bariatric surgery patients |
Eating disorders |
EDQ (Mitchell 2005) |
Self-report |
Designed to collect comprehensive data about disordered eating symptoms (current and lifetime); psychosocial, medical, and psychiatric history; and weight history. |
NA |
EDE–Bariatric Surgery Version (Fairburn et al. 2008; modified by de Zwaan et al. 2010) |
Semistructured interview |
45- to 75-minute interview. Assesses eating-disordered behaviors and symptomatology and gastrointestinal problems. Generates global score and four subscores: Restraint, Eating Concerns, Shape Concern, and Weight Concern. Also addresses behaviors specific to bariatric surgery patients. |
Kalarchian et al. 2000 |
|
EDE-Q (Fairburn and Beglin 2008) |
Self-report |
Self-report version of EDE. Assesses eating-disordered behaviors and symptomatology. Generates global score and four subscores: Restraint, Eating Concern, Shape Concern, and Weight Concern. |
||
BES (Gormally et al. 1982) |
Self-report |
16-item questionnaire with a total score reflecting severity of binge-eating behaviors. |
||
DEBQ (van Strien et al. 1986) |
Self-report |
33-item questionnaire assessing three patterns of eating, resulting in three subscores: Restrained Eating, Emotional Eating, and External Eating. |
||
Grazing |
Rep(eat) (Conceição et al. 2014) |
Semistructured interview |
15- to 45-minute interview. Assesses eating behaviors including grazing and allows decision on the presence/absence and characterization of grazing behavior. |
(Conceição et al., work in progress) |
Rep(eat)-Q (Conceição et al. 2014) |
Self-report |
15-item questionnaire. Assesses grazing and generates a total score reflecting levels of associated symptomatology. |
(Conceição et al., work in progress) |
|
Night eating syndrome |
NEQ (Allison et al. 2008) |
Self-report |
14-item questionnaire. Assesses behavioral and psychological symptoms of night eating syndrome. Generates a total score reflecting levels of associated symptomatology. |
|
Emotional eating |
EES (Arnow et al. 1995) |
Self-report |
25-item scale. Assesses tendency to eat in response to emotional triggers. Generates three subscores: Depression, Anxiety, and Anger. |
|
Dumping |
Sigstad’s Clinical Diagnostic Index (Sigstad 1970) |
Self-report |
Generates an index score based on the weight of 16 symptoms of dumping. A score of 7 or more points is suggestive of dumping. |
Note. BES=Binge-Eating Scale; DEBQ=Dutch Eating Behavior Questionnaire; EDE–Bariatric Surgery Version=Eating Disorder Examination–Bariatric Surgery Version; EDE-Q=Eating Disorder Examination Questionnaire; EDQ=Eating Disorder Questionnaire; EES=Emotional Eating Scale; NA=none available; NEQ=Night Eating Questionnaire; Rep(eat)=Repetitive Eating Interview; Rep(eat)-Q=Repetitive Eating Questionnaire.
Disordered eating behaviors in patients who have undergone bariatric surgery may have physical consequences that require medical attention. Disordered eating behaviors may be associated with compromised intake of vitamins and minerals, such as vitamin B12, calcium, vitamin D, thiamine, folic acid, iron, zinc, and magnesium (Malone 2008). Deficiency secondary to surgery and/or due to lack of compliance with replacement regimens should be addressed, as should dumping syndrome and recurrent vomiting.
Assessment of eating disorders and problematic eating behaviors in bariatric candidates poses challenges to both clinicians and researchers attempting to improve the support provided to these patients and to enhance weight outcomes. Particularly in the postoperative period, the subsyndromal presentations of eating disorders and the fact that some compensatory behaviors may be facilitated by the surgical procedures make the line between normative and problematic behaviors difficult to establish. Further, problematic eating behaviors that do not constitute DSM diagnoses should also be assessed as they may compromise weight maintenance in the long term.
Research has been proliferating in the development and validation of assessment instruments, and there are a variety of semistructured interviews and self-report measures validated to assess eating behaviors and problematic eating in both preoperative and postoperative bariatric surgery patients. However, despite the growing evidence that eating behaviors are predictors of outcomes, it seems that it is the long-term presentation of problematic eating that best predicts poor weight loss or weight regain, shedding light on the importance of longitudinal assessment of these patients.
Key Clinical Points
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