January 2014 Issue

BED, Bulimia in Bariatric Surgery Patients
By Kathryn Hillstrom, EdD, CDE, RD, and Nicole M. Avila, BS
Today’s Dietitian
Vol. 16 No. 1 P. 12

Learn about the prevalence, surgical complications, and strategies to counsel patients effectively.

Terry, 45, had a history of physical and substance abuse. To cope with the feelings of guilt and shame associated with her childhood and drug dependency, she often turned to food for comfort. For years, she frequently ate large quantities of food in one sitting that often exceeded 3,000 kcal. As a result, she became overweight and eventually morbidly obese. Her weight ballooned to 405 lbs, and her BMI reached 58.

Desperate to lose weight, Terry underwent Roux-en-Y gastric bypass surgery. Within three years following the procedure, she lost 220 lbs and achieved a healthier BMI of 27. When her weight loss stalled, however, she engaged in self-induced vomiting and took laxatives after meals in an attempt to lose more weight.

Later, Terry was hospitalized because of cardiac arrhythmias, an electrolyte imbalance, esophageal inflammation, dehydration, and constipation. Once her condition improved, she was transferred to an eating disorder treatment center where she was diagnosed retrospectively with binge-eating disorder (BED) before surgery and now with bulimia nervosa after surgery.

For unknown reasons, a physician didn’t diagnose Terry with BED before her weight-loss surgery. If a proper diagnosis had been made, it’s uncertain whether she would have been treated for the eating disorder first or allowed to have the procedure.

All health care professionals, including dietitians, who work with patients before and after gastric bypass surgery must be aware of the prevalence of eating disorders in this population and their symptoms, associated complications, and treatment strategies.

Prevalence Before and After Surgery
As the prevalence of obesity has increased, so have gastric bypass surgeries.1 Based on data from the 2000-2010 National Hospital Discharge Survey, an annual probability sample of discharged patients from nonfederal, short-stay, noninstitutional hospitals, 220,000 bariatric surgeries were performed in 2009 in the United States.2

Recognized as the most effective treatment for severe obesity, gastric bypass surgery decreases the stomach’s size, thereby reducing the amount of food an individual can consume. By decreasing the amount of food in the stomach, weight loss usually occurs. In addition to weight loss, improvements are seen in obesity-related health problems such as hypertension, hypercholesterolemia, type 2 diabetes, and sleep apnea.3

Unfortunately, gastric bypass surgery doesn’t cure the psychological aspects of overeating or binge eating linked to morbid obesity, such as depression, anxiety, lack of control, impulsivity, and difficulty coping with stress. According to Evelyn Attia, MD, director of the Center for Eating Disorders at NewYork-Presbyterian Hospital, “Bariatric surgery is rapidly becoming an accepted form of intervention for significant obesity, but this intervention cannot stand alone. Careful assessment of eating behaviors and nutrition counseling are important elements of successful surgical outcomes. Individuals who have a history of formal eating disorders, such as BED or bulimia nervosa, or those who develop abnormal eating behaviors in the context of postsurgical weight loss, likely need management for these symptoms if they’re to develop healthful eating [patterns] and a healthful weight following surgery."

Eating disorders are considered psychological problems, fueled by guilt, shame, and low self-esteem, and they’re prevalent among obese patients. In a sample of nearly 300 obese individuals qualifying for gastric bypass surgery, 66% had a lifetime history of an eating disorder, and 48% met the diagnostic criteria for BED at the time of their preoperative evaluation for bariatric surgery. Of the 48% diagnosed with BED presurgery, 28.8% developed bulimia nervosa postsurgery.4

In a similar study with fewer patients, only 12% reported self-vomiting as a means to control weight postsurgery. However, it has been widely suggested that eating disorders following gastric bypass surgery likely are underreported and misidentified in clinical settings, leading to the lower incidence of bulimia nervosa than what currently is recognized.5 If individuals use food for comfort to manage emotions, stress, or a traumatic event, which is common with BED, following gastric bypass surgery, the relationship with food would need to be altered as well to accommodate their new lifestyle.6

At this time, it’s unknown why BED before bariatric surgery transitions to bulimia nervosa after weight-loss surgery. However, thorough screening and follow-up are imperative.

Pre- and Postsurgery Differences
Eating disorders are diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). While the DSM-5 doesn’t make a distinction between pre- and postoperative BED and bulimia nervosa, diagnostic differences do exist.

The DSM-5 defines BED as consuming large quantities of food in a discrete time period.7 However, because of the stomach’s smaller size following gastric bypass surgery, the amount of food consumed substantially decreases.

Currently, there’s no criteria quantifying what constitutes a large amount of food following gastric bypass surgery,6 although patients often report eating too much food for their new stomach size. According to the Khalili Center for Bariatric Care in Los Angeles, a medical practice dedicated to weight-loss surgery, meal plan guidelines recommend patients eat approximately 350 kcal/meal following gastric bypass surgery.8

For a postsurgery patient, a 600-kcal binge is significantly more than what’s appropriate for a single meal. However, according to the DSM-5, this may not be considered a binge in the traditional sense. In this case, defining a binge as loss of control rather than quantity consumed would be more appropriate for this population.4

The difference between pre- and postsurgery bulimia nervosa is the definition of the purging. Bulimia nervosa is defined as episodes of binging followed by purging, which involves self-induced vomiting, laxative use, or both, and/or exercise to compensate for the calories consumed during a binge.7

Because of the condition called dumping syndrome, often characterized by vomiting or diarrhea after ingesting foods high in fat or sugar or both, clinicians must determine whether the vomiting is self-induced or the result of eating these foods to make the proper diagnosis. A possible new diagnosis, known as postsurgical eating avoidance disorder, may capture the specifics of these subsyndromal diagnostic characteristics.9

Surgical Complications
Just as there are differences in the presentation of BED and bulimia nervosa before and after gastric bypass surgery, there are differences in the level of risk of developing surgical complications. Among the most common complications associated with gastric bypass surgery are nutritional deficiencies due to the malabsorption of nutrients resulting from the gut manipulation. And unfortunately, patients with bulimia nervosa experience greater nutrient deficiencies than those who don’t have the eating disorder.

The nutrients that are commonly malabsorbed postsurgery include protein, calcium, iron, and vitamins B12 and D, prompting the need for nutritional supplementation. The more severe the nutrient deficiency in eating disorder patients, the more likely they’ll develop additional complications, such as anemia, fatigue, neuropathy, pica, cognitive impairment, osteoporosis, and osteopenia.3

The purging associated with bulimia nervosa can cause electrolyte imbalances and cardiac arrhythmias, which can lead to heart attack or sudden death.10 Dehydration, which is common in postsurgery patients without eating disorders because of the stomach’s reduced capacity, is twice as likely to occur in those with bulimia nervosa.10

To treat dehydration, physicians recommend patients consume fluids between meals to avoid feeling overly full during meals. Fluids should be discontinued 30 minutes before a meal and only resumed 30 to 60 minutes after a meal, which leaves less time for adequate fluid intake.8

Because of excessive purging, some individuals may develop a narrowing of the connection between the new, smaller stomach and the large intestine, known as stomal stenosis. The narrowing may result in food intolerance, nausea, and difficulty swallowing. To remedy the problem, patients must stop purging or undergo additional surgeries to repair the stomal stenosis.2

Treatment Postsurgery
Ultimately, to prevent surgical complications and promote long-term weight loss and healthful behaviors, the eating disorder must be treated. To do this effectively, patients must receive nutrition counseling, adequate nutrition, medical care, and follow-up as well as individual, group, and family therapy.11 If a patient doesn’t receive a multidisciplinary approach to treatment, it’s likely the eating disorder will go untreated.

During individual and group therapy sessions, the root cause or causes of the eating disorder, which may include depression, trauma, and anxiety, must be uncovered and worked through. Otherwise, the eating disorder will persist.11

“Binging is a way for patients to cope with their emotional struggles, soothe and numb their emotions, or distract them from their emotional pain,” explains Farnaz Rahmani, an eating disorder specialist and licensed marriage and family therapist at The Bella Vita, an eating disorder clinic in Los Angeles. "Until they learn healthful coping mechanisms and effective emotion regulation, they will still rely on food to cope. As a result, even after gastric bypass surgery, their addiction and dependence on food still continues and they may rely on purging to avoid the physical ramifications of binging.”

In a seven-year follow-up study, Steffen and colleagues introduced a multidisciplinary approach to post–bariatric surgery, which reduced comorbidities and the incidence of eating disorders. The intensive follow-up included regular visits to an obesity specialist and required weekly participation in therapy groups dedicated to lifestyle changes and nutrition education.11 Individual therapy also was included but not required. The combination of group, individual, and medical nutrition therapy reduced unhealthful weight-loss behaviors, comorbidities, and eating disorders.

 According to a study by Kruseman and colleagues, eating behavior shouldn’t be screened only during the psychological assessment before surgery but also periodically after surgery, as these disorders are frequent and can occur at any time, making continuous group therapy, individual therapy, and nutrition support crucial for success.12

RDs’ Key Role
The American Society for Metabolic and Bariatric Surgery has published suggested guidelines for conducting a presurgical psychological assessment, which seeks to identify disordered eating behaviors such as BED and bulimia nervosa in gastric bypass candidates.13

Researchers have reported that BED is associated with impaired weight loss following surgery, leading some health care professionals to recommend patients with BED receive preoperative behavioral counseling.1,5,13,14 However, it isn’t against protocol for patients to refuse behavioral counseling and move forward with surgery.5,9,10

It’s common for RDs to meet with gastric bypass surgery candidates before the procedure to assess current eating habits and explain preoperative eating restrictions. If the dietitian suspects the patient has an eating disorder, the dietitian would refer the patient to a physician for further assessment.

At the Khalili Center for Bariatric Care, a multidisciplinary team meets with patients before their surgery, according to Misti Gueron, MS, RD. If the team suspects the patient has an eating disorder, surgery is postponed until further evaluation. “Sometimes as a result of the surgery, an eating disorder from previous years may resurface,” she says. “Or, in some cases, an eating disorder may surface after the patient already has had surgery. However, in facilities like the Khalili Center, the patient’s physical and psychological stability are strongly evaluated before surgery. Furthermore, weekly support group meetings and nutrition education sessions the patients attend provide ongoing and comprehensive support.”

As part of the multidisciplinary health care team, dietitians provide nutrition counseling postsurgery. It’s during this time that RDs can discuss lifestyle changes, meal planning, weight-loss goals and expectations, and strategies to prevent weight regain.15 Often, patients consider gastric bypass surgery as the cure-all for their weight-loss struggles,15 so it’s imperative that dietitians stress the importance of lifestyle changes and adherence to postoperative dietary guidelines to weight loss and maintenance. If poor self-image is at the root of a patient’s eating disorder, learning to keep the weight off in a healthful manner may improve body image and prevent the transition from presurgery BED to postsurgery bulimia nervosa or another eating disorder.

The dietary guidelines that RDs discuss with patients after gastric bypass surgery encourage them to completely chew their food before swallowing, cut food into small pieces, and eat small scheduled meals throughout the day consisting of lean protein, fruit, vegetables, limited carbohydrates, and low-fat foods. Food volume gradually is increased, and fluids should be consumed before or after meals to limit fullness or stretching of the pouch. These eating behaviors help prevent stomach upset, dumping syndrome, dehydration, and electrolyte imbalances, but patients often may have difficulty adhering to them.15

“There’s an inherent obstacle in asking a gastric bypass patient to practice this level of mindfulness after surgery,” says Karen David, MS, RD, director of nutrition services at The Bella Vita. “Being aware of chewing, small bites, and taking one’s time while eating is very different from the type of eating behavior that leads to needing gastric bypass. When asking a client to be mindful, we also need to incorporate an attitude of compassion so the individual can connect with themselves and their food in a healthful, balanced way. If these elements are present and practiced while eating, the client can begin to heal physically and emotionally.”

Normalizing Satiety Cues
Part of the physical healing process is the patient’s ability to detect subtle satiety cues. Because patients may use binge eating and purging as coping mechanisms that help distract them from thoughts and behaviors that produce guilt and shame, they can’t discern the natural feeling of fullness. Postsurgery patients with bulimia nervosa may be more likely to experience satiety based on visual cues rather than physical ones after a high-volume meal, suggesting that they respond only to external cues, such as a full plate of food or multiple servings of a meal.16 This observation indicates that there’s a strong dissociation during meals, leaving patients unable to respond to subtle satiety cues physical discomfort as an indicator of satiety.16

Postsurgery patients who continue to strive for physical discomfort following a meal likely will experience dumping syndrome, self-induced vomiting, other complications, or even weight regain. Satiety feedback mechanisms will begin to normalize if patients adhere to an RD-provided postsurgery meal plan. Dietitians should instruct patients to record their dietary intake, including any episodes of vomiting and dumping syndrome, the types and quantities of food consumed, and internal factors such as thoughts and feelings, to better assess meal plan compliance and the extent of the eating disorder behavior.15

More Education and Research Needed
With gastric bypass surgery on the rise, there’s an increasing need for RDs to educate themselves about eating disorders to better identify symptoms before and after surgery. Further research on implementing psychological treatment for BED before surgery may develop new protocols for patients who qualify for the procedure.

Currently, standardized assessments to detect postoperative eating behaviors are lacking, and there’s a need for new tools to fully characterize the range of eating disorders that can develop.13 These tools ideally would improve postsurgery weight loss, decrease the risk of comorbidities, and prevent BED from transitioning to bulimia nervosa.

As nutrition professionals, it’s important to keep abreast of the latest research and information about eating disorder treatments in relation to weight-loss surgery and educate patients to help them follow dietary guidelines so they can maintain long-term weight loss.

In the end, the more precautions an interdisciplinary health care team takes before and after surgery, the greater the likelihood gastric bypass surgery patients will enjoy long-term success and won’t continue to suffer from eating disorders.

— Kathryn Hillstrom, EdD, CDE, RD, is an assistant professor of nutrition at California State University, Los Angeles, who specializes in family weight management and diabetes education.

— Nicole M. Avila, BS, is a graduate student at California State University, Los Angeles, pursuing a master’s degree in nutrition science. She’s a dietetic intern for the university’s coordinated dietetics program and recently has worked with the eating disorder population as a diet technician.


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