Beruflich Dokumente
Kultur Dokumente
Maria Sardari
N01186937
November 8, 2017
2
SURGERY
1. INTRODUCTION
significant problem for many individuals and the healthcare industry. Bariatric
surgery appears to be the most effective tool for significant weight loss that is
weight loss may be used, they are not as effective, create a significant burden on the
individual, and are often too lengthy for the safety of the individual, thus bariatric
surgery is a good option.1 Another issue for the patients afflicted by the condition is
obesity. Eating disorders such as binge eating, loss of control eating, maladaptive
eating, anorexia nervosa, and bulimia nervosa are a significant issue that could be life
who is obese or morbidly obese and involves the alteration of the gastrointestinal tract
are several issues associated with bariatric surgery such as the fact that 20-30% of all
bariatric surgery patient regain a significant amount of weight 18-24 months after
such as binge eating.2 Since an eating disorder may pose significant health and
3
psychological risk for the patients, it is important to understand the various forms of
The most prevalent eating disorders are binge eating (BE), disordered eating,
maladaptive eating, picking and nibbling, anorexia nervosa (AN), emotional eating,
and loss of control eating (LOC.) Binge eating disorder (BED) is described as the
consumption of an amount of food, over a distinct period, that is certainly larger than
most people would eat in the same period of time under regular circumstances.3,4
BED has been estimated at 15.7%-26.6% in those who have obesity and desire
bariatric surgery procedures.4 It is understood that those with BED eat compulsively
and may have addictive personalities.5 Another form of disordered or abnormal eating
behaviors and addictive tendencies that may result in increased total energy intake
and/or negative consequences for the individual, but does not fall under a defined
eating disorder.5,6 Picking and nibbling is the consumption of modest amounts of food
disorder usually associated with post and not pre-operative conditions, is anorexia
nervosa and is defined by the DSM-4 and 5, as the restriction of energy consumption
the framework of age, sex, developmental stage, and physical health.8 Emotional
eating, eating in response to emotional triggers, is not a classified eating disorder but
has been associated with risk factors associated with poor post-operative outcomes.9
Finally, loss of control eating is similar to BED but does not necessarily include the
conditions of impulsivity. 10 Due to the limitations of this review, not all types of
disordered eating are mentioned but the key categories are explored due to the
presence of research on the subject. Furthermore, eating disorders are not present in a
Some disordered eating causes proposed by current research in the field, are from
the patient or pre- and post-operative psychological evaluations.13 The causes are
various but the former are several theories associated with disordered eating and
bariatric patients with these conditions. Due to the risks involved, a proposition of the
Health professionals are key in the assessment and treatment of bariatric surgery
patients and are therefore in part responsible for the provision of adequate care and
prevention. The following are a compilation of actions that the healthcare field may
multifaceted approach and this paper will evaluate the current status of eating
disorders and bariatric surgery procedures. The primary question investigated in this
review is whether patients with disordered eating patterns prior to surgery show an
2. BODY
The relationship between eating disorders, obesity, and the election of bariatric
surgery is complicated, but in order to understand the significance of the issue and why
5
an obese individual may have an eating disorder we must evaluate the literature on the
potential causes of eating disorders. For example, Vartanian and Fardouly studied the
stigma associated with bariatric surgery which could prevent obese individuals from
undergoing the surgery or feeling excessive judgement for electing the procedure. In the
study, 275 randomly selected participants were shown a before and after weight loss
photograph of a woman and they were asked to rate the woman on a variety of traits after
reading the method by which the woman had lost weight.1 The study showed that
individuals who had lost weight through bariatric surgery were evaluated more negatively
than those who had lost the same weight through diet and exercise.1 Overall, the bariatric
weight loss option was rated in a statistically significant value of P < 0.001 as more lazy,
sloppy, less competent, and less sociable than the weight loss through diet and exercise
option.1 This indicates that there are significant social repercussions for individuals
undergoing bariatric surgery related to judgement and could potentially play a role in the
patterns. Lier et al. also focused on the presence of shame in a study of 87 bariatric
patients.11 The researchers found that high pre-operative shame scores resulted in high
post-operative shame scores with a P = 0.007. 11Furthermore, Beck et al. found that
surgery encountered less weight loss and more problematic eating than controls from the
interventions were evaluated for eating disorder symptoms using the Eating Disorder
Inventory, an altered BED questionnaire, the Hospital Anxiety and Depression scale for
screening mood disorders, and current weight. 2 To understand the relationship between
weight status and psychological variables, a multiple linear regression analysis was
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performed along with p < .05 considered as statistically significant.3 It was found that
27% of the patient experienced BED after surgery, 35% had loss of control, and 37% felt
shame after eating, 2 Due to the high scores on BED with a value of -0.29 and
ineffectiveness with a value of -0.37 which are statistically significant, it was understood
that after plotting on a linear regression analysis, there was less weight loss associated
with these symptoms.2 Therefore, it can be concluded that BED negatively affected
outcomes for some patients even after surgery. Additionally, another study by Lent and
disturbances and the persistence of poor health outcomes in bariatric patients. Lent and
Swencionis found that overeating scores were associated with the Addiction Scale at
p<.001 values. 5 Moreover, those who exhibited BE had significantly higher addiction
scores (Z = -3.26; p=0.001) than the female norm.5 Conceicao et al. also found that
weight regain was significantly associated with Picking and Nibbling (p<0.001) and that
the regain was positively associated with psychological distress .7 Several additional
factors appeared to show comorbidity with obesity and election of bariatric surgery such
behaviors,12 and underreporting of eating pathologies before and after surgery.13 The
emphasis on the thin ideal by culture and the restrictive manner of the diet imposed on
patterns, psychological disorders, and negative outcomes associated with these symptoms
in bariatric patients. Now that potential causes were mentioned, the prevalent eating
Throughout the literature, the most common problematic eating patterns were: binge
eating and loss of control eating,4,610maladaptive eating, food addiction and emotional
eating, 5,7,9 and anorexia nervosa and restrictive type disorders.8 Chao et al. in a study of
59 bariatric surgery (BS) patients compared the weight outcomes at two years after
surgery. The results demonstrated that there were statistically significant differences
between BED patients and non-BED patients, with 18.6% versus 23.9% weight loss
respectively. 4 Besides weight loss attenuation, Horvath et al. found that 31.9% of those
undergoing BS had depression and felt more compulsive and many had a greater energy
intake from carbohydrates and lower intake of fatty acids which could result in additional
negative effects outside of weight.6 When it comes to loss of control eating, the findings
varied form of BE and generally leads to less weight loss over time. 10 Other forms of
poor eating such as maladaptive eating, food addiction, and emotional eating are also
common within the literature evaluating bariatric surgery comorbidities. Lent and
Swencionos found that addiction plays a major role in maladaptive eating patterns. Their
study found that as addictive personality scores increase, overeating behaviors intensify.5
Conceicao et al. also demonstrated that maladaptive eating is associated with weight
role according to Chesler’s extrapolation that emotional eating is an untreated risk factor
following BS. 9 According to Chesler, conscious and reflexive emotional eating (EE) is a
behavior in response to emotion that involves food consumption that is rather different
than BED because it is not as severe and is considered subclinical, yet weight loss for
those undergoing EE is often lower than controls.9 The risks associated with insignificant
weight loss are great and unresolved conditions such as emotional eating could be
8
preventing substantial weight loss in patients. Although the primary problems are
another type of eating disorder that could be just as problematic in regard to health for BS
patients. Anorexia nervosa is characterized by severe restriction and may lead to too
much weight loss, leading to an increased risk of death. In a report by Conceicao, out of
12 patients evaluated, four reported a BMI below 18 which placed them within the
more alarming, was the presence of AN symptoms in ten out of the twelve BS patients
prior to surgery even when weight was not categorized as being underweight.9 In the
evaluation, 4 patients were readmitted to a clinic several times over 4 years following the
with the presence of an eating disorder, thus making it crucial for the implementation of
Unfortunately, the negative side effects associated with the presence of eating
disorders associated with BS patients may expand beyond overweight status or normal
persistently extreme BMI, weight regain, higher fat mass, malnutrition, and excessive
weight loss. Most patients electing bariatric surgery do so in order to increase quality of
life or resolve health related problems. Contrary to the former, the presence of eating
Vartanian and Fardouly have already demonstrated that those undergoing BS are judged
more harshly such as less competent (p<0.001) and less competent (p<0.001) than the
diet and exercise weight loss group. 1 Such judgements may increase shame associated
9
with BS surgery and decrease the quality of life of the afflicted individual. Additionally,
less %BMI loss was associated with feelings of ineffectiveness and binge eating
psychological effects in the patients electing BS. Lier et al. unveiled an association
conditions, in the study 18% of those with pre-operative psychiatric disorders maintained
the condition even after BS. 11 One report exposed that one patient acquired a post-
operative syndrome, a year after surgery. 11 Such results signify risks associated with BS
that are not standard since they are mostly psychological rather than direct physical
consequences due to BS procedures. On the other hand, Lent and Swencionis did not find
but rather that BED contributed to lower quality of life post operatively. 5 These findings
may mean that eating disorders could result in social and affective disruptions not
expected simply from bariatric surgery. Besides psychological issues, eating disorder
may lead to health risks related to weight. In a study by Horvath, BE resulted in higher
higher fat mass.6 Within the health field, it is generally understood that higher fat mass
may lead to cardiovascular complications such as arterial blockages which may even be
fatal. Thus BED, is related to severe health risks. Likewise, four other studies found that
eating disorders led to less weight loss and higher weight regain compared to controls,
representative of a real risk for BS patients. 4,7,9,10 Although, weight regain risks are an
issue, weight loss and malnutrition may be just as dangerous. Three studies mentioned
Conceicao et al. recorded a patient as reaching a BMI of 13.1 which requires specialized
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treatment in order to avoid death8 and other reports showed two patients with overly-
restrictive dieting and compulsive exercise.12 Marino et al. also found that a significant
number of patients practiced AN behaviors and even refused to eat. 13 Following this
review, it may be understood that eating disorders in BS patients are a significant pre-
operative and post-operative risk and must be addressed if weight loss and continued
Finally, several implemented programs have shown some success and should be
mentioned. Three studies emphasized that intention, planning, and cognitive behavioral
therapy (CBT) are useful tools for the alleviation of addiction, maladaptive eating, binge
eating, and restrictive behaviors in BS patients. 3,5,7,9,14,15 Wood and Ogden focused on
the predictors of decreased binge eating in a Health Action Process Approach model.3 In
the model, 24 participants met the criteria for BE disorder prior to surgery but only three
reported BED after surgery.3 Overall, the presence of “intention” revealed a significant
association with a decrease in binge eating after surgery. 3 Two studies demonstrated that
CBT, a psychological therapy that deals with cognition and active change of behavior,
aided with dysfunctional eating in patients.14,15 Gade et al. found that at follow-up, the
individuals who received CBT therapy before and after surgery experienced significant
those who did not undergo CBT.14 Abiles et al. also found that in a study of 110 BS
These results are promising because it indicates that there are potential solutions for
3. CONCLUSION
improvement in eating habits and positive weight loss after surgery? Following the
review, it is possible to state that there are issues related to BS that are not resolved
disorders even after BS and there is not enough psychological treatment. Therefore,
quite effective in regard to weight loss but does not appear to be an effective
treatment for psychologically associated disorders such as emotional eating and other
The implication of the review for the health field is significant. It is clear that
dietitians and doctors must receive more education on disordered eating and that more
and disordered eating. The issue is rather complex and may not be completely
understood due to the limitations of the above review. The limited scope of the
review does not detract from the importance of promoting further research on the
topic. Programs involving CBT and other therapies should be provided to BS patients
before and after surgery in order to decrease the risks associated with disordered
eating in the context of weight loss surgery. Healthcare professionals should receive
comprehensive education about the risks of untreated eating disorders and guidance
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