HUN3800

Literature Review Paper

The Power of Counseling Related to Bariatric Patients and Eating Disorders

Acadia Wyckoff

N01242844

November 8, 2017
Introduction

Currently, 30 million people of all ages are suffering from some form of eating disorder in the

U.S. From those 30 million, 2.8% adults suffer from binge eating disorder (BED). [1] These

statistics seem startling when considering how many people actually suffer from an eating

disorder in general. In reality, these statistics are changing every day and continue to increase

due to the rise of obesity in our world. Not only is obesity rapidly increasing, the social construct

behind bariatric surgery is becoming more and more accepted. Those who are considered obese

and cannot lose weight in a conventional way are opting for a surgery that could force them into

the weight loss predicament that they want to take part in.

Background

Bariatric surgery is defined by Mayo Clinic as a “weight loss surgeries [that] make changes to

your digestive system to help you lose weight by limiting how much you can eat or by reducing

the absorption of nutrients, or both.” [2] This surgery is associated with people who cannot lose

weight conventionally or, more recently, those who have an eating disorder (such as binge eating

disorder (BED), loss of control eating (LOC), etc.) who need extra help in their recovery process

and weight loss goals. Eating disorders are defined by the National Eating Disorders

Collaboration as not solely a mental illness but associated with major and serious medical

complications that can alter major organs in the body. [3] These disorders can be serious,

especially when paired with a major life altering surgery such as bariatric surgery. This is why

the topic of eating disorders in bariatric patients is so relevant and important to investigate and

research.
 The most common studies found for these research topics include those that involve

questionnaires that patients can fill out regarding eating disorders and psychological functions

before and after surgery. The importance of these questionnaires lies in the fact that some

patients may lie about their current condition in fear that they will not receive the surgery. If

more research is done to evaluate this correlation, more can be done to prevent fall backs post-

surgery or even pre counseling could help alleviate issues before patients undergo bariatric

surgery. This paper focuses on pre and post-bariatric patients that have an existing eating

disorder that have had counseling or have had no counseling, and how they fared in their quest

for weight loss.

Body

Generally, when one thinks of bariatric surgery they imagine a person who is severely obese

and cannot lose weight in conventional ways such as exercise and dieting. This idea is true in the

fact that only those who are considered morbidly obese can have this surgery. In the past

bariatric surgery was seen as an extreme therapy for weight loss, but recently with the emergence

of higher rates of obesity, this form of weight loss is harder to attain. Since the option of bariatric

surgery is so sought after, only a minority of severely obese patients can undergo bariatric

surgery. [4] The general population that is associated with this surgery focuses on adults, but

surprisingly many adolescents aged 13-19 undergo bariatric surgery as well. There are many

forms of bariatric surgery but there are three main forms that will be discussed in this

background section of the paper. The first form of surgery is called laparoscopic gastric banding

(LGB) and it is the least invasive of all the surgery types. LGB does not require incisions or

removal/rerouting of the intestines and generally leads to the loss of 55-60% of excess weight in

the patient. The patient must learn to eat slowly and chew food for longer to avoid throwing up
after meals. The second surgical procedure is called roux-en-Y gastric bypass. This technique

connects the smaller stomach directly to the jejunum and passes the duodenum which reduces the

area of absorption. This form of bariatric surgery usually is very effective but can lead to

nutritional deficiencies which need to be carefully monitored. The last common bariatric surgery

technique is called sleeve gastrectomy (SG) which is new but is becoming more and more

popular. The stomach volume is reduced in this procedure by about 70-80% which forces the

patient to reduce their food intake significantly. SG does not affect the intestines and therefore

does not have the same problems with deficiencies as the other procedures do. [5]

Although these forms of bariatric surgery can be effective, the trouble lies in the pre and post

care patients receive. If a patient has an eating disorder before their surgery, they are more likely

to have that same disorder post-surgery if no intervention or guidance is given. Common eating

disorders seen in these type of patients includes binge eating disorder (BED), loss of control

eating (LOC), and night eating syndrome (NES). BED is when a person eats an excessive

amount of food at any given time, LOC is when a person is “unable to stop or control one’s

eating regardless of the type of amount of food being eaten” [6], and NES is when someone has

abnormal eating patterns at night. All three of these disorders are commonly researched when

looking at bariatric patients and weight loss/weight gain after surgery.

Many of the research papers that will be discussed look at the effect that counseling has on

bariatric patients. Some common counseling options that patients have available to them were

generated in a study conducted by Cairns et al. and included counseling strategies such as

assessments, rapport-building, educational, and/or behavior-change. Under these headings of

specific counseling strategies, there were subgroups of different strategies used in this study to

determine which combination seemed to work best with certain sets of bariatric patients. [7]
Along with these strategies, another form of counseling is focusing on mindful eating. In a

randomized controlled pilot trial conducted by Chacko et al. a mindful based intervention was

conducted with bariatric patients. This research was conducted to help reduce binge eating and

emotional eating. This study was performed over a 10-week time and was compared to a

standard intervention program. The end findings deduced that a mindful based intervention was

highly accepted by bariatric patients and was effective in reducing emotional and binge eating

episodes. This proves that counseling in some way, even in post bariatric patients, can reduce the

risk of weight regain and help them to adopt a healthier mindset and eating pattern. Overall, the

study concluded with the need for further study and investigation into mindful eating initiatives

amongst bariatric patients. [8]

If a counseling treatment such as mindful eating intervention could influence the way post

bariatric patients look at themselves and at food, what would happen if intervention and

counseling happened earlier in the process? Sadly, most obese individuals that seek bariatric

surgery do not mention an existing eating disorder when consulting a bariatric surgeon. This

misinformation can lead to a person undergoing a surgery that may or may not help the situation

they are in. A study by Kalarchian et al. focused on the best approach for diagnosis for eating

disorders in pre-surgical patients. In this study they assessed how people classified their eating

disorder in an interview versus a questionnaire. Patients who took the questionnaire were quite

honest with their symptoms but were more likely to self-diagnose themselves with an eating

disorder even though they didn’t have one. This study proves that pre-counseling could also be

beneficial in the fact that specific diagnoses could be made to help a patient have the most

success post-surgery. [9] The reality is that once a bariatric surgery is completed there is a

common failure rate of 20%, which can show up 1-2 years’ post-surgery. [8,10] A large cohort
study conducted by Mitchell, MD et al. focused on eating disorders among adults before they

underwent bariatric surgery. Their focus was on self-reported eating disorders and not clinically

diagnosed disorders. Throughout the study, many participants reported having some sort of

eating disorder that lead them to the path of bariatric surgery as a final option. Some even

reported taking medications for their psychiatric or emotional situation as well as symptoms of

alcoholism and low self-esteem. A higher number of individuals that admitted to having an

eating disorder of some kind were those with a college degree or higher. The study concluded by

mentioning that pre surgery BED (or another form of eating disorder) was not associated with a

predicted amount of weight loss post-surgery. There was a correlation however with the number

of people having an eating disorder before surgery and also having an eating disorder after

surgery. This correlation suggests that those who undergo this surgery do not automatically

revert to healthier alternatives when losing weight via bariatric surgery and need counseling of

some sort to guide them into a healthier lifestyle. [11] Another study conducted by Greenburg et

al. focused on how psychological factors influence eating disorders among bariatric patients and

how those being diagnosed early could impact the success rate of a patient who undergoes

bariatric surgery. Self-report of LOC eating was related to weight gain post-surgery and was

found to be an important target for intervention pre and post-surgery. Those who self-reported

having an eating disorder, depression, anxiety, and personality disorders were more likely to

regain weight post-surgery. This study was concluded with the idea of treatment before surgery

which could help patients forgo the surgery in the long run or have a more successful post-

surgery experience where they lose the weigh intended without gaining it back. [12]

Although it is nice to assume that pre-surgical counseling and guidance would be beneficial,

the option is not always available to some. Many studies have been conducted regarding the
intervention of programs after bariatric surgery. One such study was conducted by Sallet, MD,

PhD et al. and discussed eating behaviors after gastric bypass surgery (a form of bariatric

surgery). The purpose of this study was to see if the eating disorders had any effect on weight

loss after surgery. Overall they found that there was no difference in weight loss between those

who were only diagnosed with a slight eating disorder and those who were diagnosed with BED.

This shows that even with pre-diagnosis of a slight eating disorder (which may seem

insignificant), there is still a risk of having as little amount of weight loss as someone with a

clinically diagnosed eating disorder such as BED. [13] The most interesting study had to do with

post-surgery follow-ups and this study was conducted by Wadden, PhD et al. It focused on one-

year post-bariatric surgery. This study focused on those patients who had a reported issue with an

eating disorder and/or had potential to obtain an eating disorder after surgery. They compared

those who had an eating disorder (BED in this case) with those who did not have an eating

disorder pre-surgery. The patients with BED lost 22.1% of their excess body weight compared to

those without an eating disorder that lost 24.2% of their excess body weight. They also compared

those with BED and bariatric surgery with those who opted for a lifestyle modification method

of weight loss. The results for this comparison showed that those with preoperative BED lost

twice the amount of weight than those who participated in the lifestyle modification method.

Based on their results, it can be concluded that BED by itself should not be cause enough to

persuade patients to choose a different method of weight loss just because it has been shown as

slightly ineffective without counseling before or after bariatric surgery. This implies that

counseling, even after surgery can be beneficial to patients due to the fact that weight loss was

more significant after surgery than with a lifestyle modification approach. [14]
Application to Field

All of these studies have a similar goal in mind: to provide more resources and help to those

who are searching for a weight loss method that will work for them. It may be bariatric surgery

which some studies have found help the most. It could also be a mindful eating intervention

approach. It could also be a combination of the two or other options not mentioned in this paper

as well. Either way, the application that can be made from this to the field of dietetics is that

counseling before and/or after bariatric surgery can be extremely beneficial to the patients

involved and help their success rate regarding weight loss and overall health. Those patients who

do not meet with a dietitian after bariatric surgery are at a greater risk for regaining lost weight.

Regular consultation should be scheduled one, three, six, nine, and 12 months’ post-surgery and

then once every year to make sure that common eating disorder habits are not taking over again.

[4] In general, those who undergo bariatric surgery have the greatest amount of weight loss over

the first six months and will gradually lose more and more over an 18-month period but past that

will begin to regain weight. This pattern has been seen in patients that have weekly BED, BED

in general, or NES. [15] Based on these statistics, those who have bariatric surgery are more

likely to plateau or regress back to old habits without guidance and counseling from a source that

is reputable. In this case, dietitians have one step up on the others in the fact that we can help

guide a person after their surgery to make healthier lifestyle choices and food choices that will

benefit them in the long run.

Future Improvements

Some future improvements that can be made in this area include finding out what strategies

will work best for this general population in regards to diagnoses of eating disorders and

counseling based off of these disorders. By diagnosing disorders like this early on in the surgery
process there could be improvements in how many people need bariatric surgery in the first place

and also how successful post-surgery could be for these patients. If dietitians take one step

further, there could be a decrease in unhealthy and obese individuals. Intervention practices early

on in life could reduce the number of people who need this form of surgery which could create a

healthier future for future generations.

Conclusion

In conclusion, the best method for diagnosing and preventing bariatric surgery is counseling

and intervention programs. This would only be a reality if a potential patient had not undergone

bariatric surgery. In most cases though there may need to be counseling services that are aimed

more so at weight loss help or weight maintenance after bariatric surgery to prevent a person

from regaining weight post-surgery. Based on the statistics stated above when it comes to weight

regain, there is a greater need for follow-up counseling. Bariatric surgery is a great alternative for

those who cannot lose weight efficiently through traditional methods, but can be done in a

smarter way. Counseling can be done before surgery which could include a discussion between a

patient and a doctor/surgeon, making sure that surgery is a last resort. If surgery is eventually

needed, the discussion should turn to post-surgical counseling and the importance of those

follow-up appointments. The risks should be given to those who have an existing eating disorder

on how weight regain is possible for them and how they should follow-up when recommended to

get the best guidance and results from their surgery. All in all, counseling can be a helpful tool

and resource for those who are obese and want to fix this with bariatric surgery, but the first step

is being diagnosed for potential obstacles such as eating disorders and then intervention to help.

The studies mentioned above explain the importance of counseling and follow-ups post-bariatric

surgery.
 Work Cited

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