Binge eating in the bariatric surgery population - Wiley Online Library

REVIEW ARTICLE

Binge Eating in the Bariatric Surgery Population: A Review of the Literature Sara H. Niego, MD1* Michele D. Kofman, PhD2 Jeffrey J. Weiss, PhD3 Allan Geliebter, PhD4

ABSTRACT Objective: This article reviews the status of the literature addressing clinically significant binge eating in the bariatric surgery patient. The goal is to provide a background that will guide patients, surgeons, and mental health practitioners toward the most successful longterm surgical outcome when binge eating is identified. Method: Pubmed and Medline search with subsequent reference list search of identified articles. We searched literature through April 2006 on the influence of binge eating (BE) on surgical outcome. Results: Those with pre-surgical BE are more likely to retain the eating pathology and, if they do, to have poorer weight loss outcome. Many people who binge ate prior to surgery report continued feelings of loss of control when eating small amounts of food after surgery. Studies that employed the DSM-IV defini-

Introduction In 1991, the National Institutes of Health Consensus Development Conference panel met to address obesity treatment in the context of increasing obesity prevalence and the failure of behavioral and pharmacological treatments to demonstrate sustained, long-term weight loss outcomes.1 The panel recommended that bariatric surgery be considered for well-informed, motivated, severely morbidly obese individuals with acceptable operative risks

Accepted 3 January 2007 *Correspondence to: Dr. Sara Niego, Hartford Hospital Institute of Living, Eating Disorders Program, 200 Retreat Avenue Braceland Building, Hartford, CT 06016. E-mail: [email protected] 1 Department of Psychiatry, Hartford Hospital Institute of Living, Hartford, Connecticut 2 Ferkauf Graduate School of Psychology, Albert Einstein College of Medicine, Yeshiva University, Bronx, New York 3 Department of Psychiatry, Mount Sinai School of Medicine, New York, New York 4 Department of Psychiatry, North-Shore Long Island Jewish Medical Center, Zucker Hillside Hospital, New Hyde Park, New York Published online 15 February 2007 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/eat.20376 C 2007 Wiley Periodicals, Inc. V

tion of a binge episode reported absence of BE after surgery, unlike those that modified binge criteria after surgery. Conclusion: Clinically significant BE is related to poorer surgical outcomes, and additional interventions may be needed to improve long term outcomes. Though surgery does alter body’s physiology, claims that the psychological aspects of BE are ‘‘cured’’ by obesity surgery must be viewed with caution. Researchers and practitioners must reach a consensus on how to define BE after gastric surgery so that future long-term prospective studies may further evaluate the effect of BE on surgical outcome and vice versa. C 2007 by Wiley Periodicals, Inc. V Keywords: Niego; Sara MD; bariatric surgery outcome; binge eating obesity surgery; obesity surgery outcome binge eating (Int J Eat Disord 2007; 40:349–359)

and for moderately obese individuals with highrisk comorbid conditions. The surgical techniques of gastric bypass (GBP) and vertical banded gastroplasty (VBG) were endorsed treatments.2 According to the American Society for Bariatric Surgery (ASBS), the number of people undergoing bariatric surgery procedures rose from 16,000 in 1992 to 170,000 in 2005.3 Bariatric surgery is currently the most effective treatment for morbid and clinically severe obesity, frequently resulting in significant weight loss.4,5 However, not long after the 1991 NIH recommendation, publications began to appear that questioned the long-term durability of the substantial weight loss following VBG and GBP surgeries. Specifically, at about the 1.5–2 year mark, weight loss from surgery stabilizes, and a substantial proportion of individuals begin to regain lost weight.6 Evidence began to build that continued maladaptive eating behaviors, such as binge eating, might be contributors to reduced or reversed success of bariatric surgery, further contributing to long-term medical and psychological morbidity. Binge eating disorder (BED) is one of the most common psychiatric disorders in patients presenting for obesity surgery,7 and can potentially affect

International Journal of Eating Disorders 40:4 349–359 2007—DOI 10.1002/eat

349

NIEGO ET AL.

surgical outcome. An estimated 30% of obese individuals seeking bariatric surgery have been reported to meet criteria for BED, when compared with just 2% in the general population.8 BED is defined in the DSM-IV as binge eating (BE) (the consumption over a discrete period of time of an amount of food that is ‘‘definitely larger’’ than most people would eat in the same period of time under similar circumstances), while feeling a sense of loss of control over eating, at least 2 days per week for 6 months, followed by feelings of self-recrimination and distress but not by compensatory behaviors.9 Although the majority of surgeons indicate that they screen pre-surgically for BE and BED, practice varies widely regarding in how carefully these are identified and in the decisions made and subsequent management when these behaviors are identified.10 This lack of consensus reflects in part the absence of adequate empirical data on the impact of clinically significant eating disorders on bariatric surgery outcome. This article will review research on the prevalence of BE and BED among patients seeking surgery for obesity. It will also review what is known about how BE changes after surgery and what impact BE has on post-surgical weight, eating behaviors, and general surgical outcome. One aim is to help clarify whether clinically significant binge eating, either pre- or post-surgical, adversely affects surgical outcome. This will enable practitioners and bariatric surgery patients, when BE is identified, to focus on possible interventions to improve outcome. Additionally, in this article, we will address the methodological limitations of the existing published data and the unique challenges in assessing of BE and its impact in the bariatric surgery population. We will then discuss research directions that emerge as key areas of focus from this review. Although literature reviews of factors that influence outcome of bariatric surgery have been published, and have included eating behaviors as part of a larger psychosocial picture, we did not find any review published since 1998 that focused specifically on how clinically significant BE alters, or is altered by, obesity surgery.

Method We searched the English language literature between 1995 and 2006 in Medline and Pubmed using the following terms: Bariatric surgery, obesity surgery, bariatric surgery/ obesity surgery outcome, binge eating (BE) and bariatric surgery, BE and obesity surgery, binge eating disorder

350

(BED) and bariatric surgery outcome. In addition, the reference lists of all identified publications were searched for relevant articles. The search was completed in April, 2006. Included in this review were all controlled and noncontrolled studies with either a prospective, retrospective, or cross-sectional design published between 1995 and 2006. Several different diagnostic tools and criteria were used in studies to characterize BE and BED (see Table 2). This review included all studies of BE and BED. Studies of BED were those that specifically diagnosed BED according to the DSM-IV criteria described above. However, patients who binge eat regularly but do not meet the frequency criteria for BED (2 times per week for 6 months) are still often functionally impaired and at risk for obesity. Many experience psychological distress as a result of frequent episodes of eating amounts of food, although not unusually large, while feeling out of control11 (‘‘subjective binge episodes’’ on EDE) and are also considered binge eating. Therefore, studies that assessed some, but not all, DSM-IV criteria for BED were considered to concern clinically significant BE. We did not attempt a meta-analysis in this review, given the wide variation in study approach, method of data collection, sample statistics provided, and various study limitations, which will be discussed further at the end of this review.

Results Using the selection criteria described above, 32 studies were identified that focused on BE in the bariatric surgery patient. Of these, 14 were crosssectional, 14 were prospective, and 4 were retrospective. Table 1 provides a summary of the essential features of the reviewed articles. Pre-surgical Binge Eating

In the studies that assessed pre-surgical prevalence, the rates of DSM-IV defined BED ranged from 2% to 49%. For studies that assessed BE of any kind the prevalence ranged from 6% to 64%. The four studies that inquired about BED retrospectively found prevalence rates ranging from 37.5% to 49%. Seventeen studies were identified that included post-surgical binge data. Although 14 of these studies included both pre- and postsurgical data, only a handful specifically focused on the relationship between pre- and post-surgical binge eating. Those that did found that post-surgical BE was primarily observed in patients who binge ate prior to surgery and rarely seen in those who did not. Table 2 details studies reporting outcome data relating to binge eating.


BINGE EATING IN THE BARIATRIC SURGERY POPULATION TABLE 1.

Study features

Authors

Type of Study

Includes Pre-surgical Binge Data

Adami et al., 1995 Adami et al., 1999 Allison et al., 2006 Boan et al., 2004 Burgmer et al, 2005 Busetto et al. 2005 Busetto et al., 1996 De Zwaan et al., 2002 De Zwaan et al., 2003 Dymek et al., 2001 Glinski, et al., 2001 Green et al., 2004 Guisado et al., 2001 Hsu et al., 1996 Hsu et al., 1997 Hsu et al., 2002 Kalarchian et al., 1999 Kalarchian et al., 2000 Kalarchian et al., 2002 Lang et al., 2002 Larsen et al., 2004 Latner et al., 2004 Malone and Alger-Mayer, 2004 Mitchell et al., 2001 Pekkarinen et al., 1994 Powers et al., 1999 Sabbioni et al., 2001 Sanchez-Johnsen et al., 2003 Sarwer et al., 2004 Saunders, 1999 Saunders, 2004 Wedden et al., 2001

Cross-sectional Prospective Cross-sectional Prospective Prospective Prospective Cross-sectional Cross-sectional Prospective Cross-sectional Prospective Cross-sectional Retrospective Retrospective Cross-sectional Cross-sectional Prospective Cross-sectional Prospective Cross-sectional Prospective Prospective Retrospective Retrospective Prospective Prospective Cross-sectional Cross-sectional Cross-sectional Prospective Cross-sectional Prospective

x x x x x x x x x x x x — x x x x x — x x x x x — x x x x x x x

Hsu et al. found that 4 of 9 patients who binge ate prior to surgery continued to do so, whereas only one patient developed new BED following surgery.24 A later study by the same group noted that that pre-surgical eating disturbances (including BED, BN, night eating syndrome) predicted postsurgical eating disturbance status 2 or more years after surgery but not in the first 2 years following surgery.25 Specifically, 6 of 9 patients who had an eating disturbance pre-surgically still had one at 2 or more years post compared with zero of the five who did not have an eating disorder pre-surgery. The group difference was statistically significant (p < .05). Mitchell et al. found that 14 of 38 patients (37%) who recalled BE prior to surgery continued to feel out of control when eating, ate rapidly, ate until uncomfortable, ate when not hungry, ate alone, and felt disgusted and distressed for eating this way as long as 15 years postsurgery.26 Comparing the eating behaviors of 66 patients before and 1 year after lap band surgery, Lang and colleagues reported that, of patients who reported BE prior to surgery, 24.2% continued to report binge eating.27 By

% BE þ BED Pre-surgery 68 52 5.6 30 20.1 34 12.5 49 39 43 10 51 37 48 25 39 44 64 56 48 52 49 52 43 40 42 61 60 42

Includes Post-surgical Binge Data — x — x — — x — x — — x x — — x x x x x x x x x x — — — x —

% BE þ BED Post-surgery

0 0

11.5 0

21 26 0 46 29 2 yrs: 37 0 0 12 37 0 5

48 BE þ graze

contrast, of those who did not report BE prior to surgery, only 4.5% reported new binge eating. In a descriptive study, Saunders found that 80% of 64 patients who endorsed BE or ‘‘grazing’’ behavior with loss of control pre-surgically reported that this re-emerged 6 months after surgery and continued to worsen over time after that. Many of the study participants reported that they considered their grazing episodes to be binge behavior after surgery.28 Seven studies found that the surgical reduction in stomach capacity led to a complete absence of BE behavior post-surgery. Interestingly, all seven studies employed the DSM-IV ‘‘large amount of food’’ criteria in the assessment of BE after surgery. Powers and colleagues followed 72 patients who endorsed presurgical BE for a mean of 5.5 years after surgery.29 Of these, no subjects endorsed BE post-surgically. These patients reported being unable to binge eat because they became too full. To assess features of BED following surgery in the presence of a modified stomach, 5 studies omitted the criteria of consuming an unusually large amount of food, 9 used the ‘‘large amount’’ criteria, and 2 used both and compared findings.


351

352

1996

2003

2001

2004

DeZwaan et al.,

Dymek et al.,

Green et al.,

2005

Burgmer et al,

Busetto et al.

2004

Boan et al.,

2005

1999

Adami et al.,

Busetto et al.

Year

Prospective

Prospective

Prospective

Prospective

Prospective

Prospective

Prospective

Prospective

Type of Study

N¼65, female¼48, ma¼39.3 (SD 9.9).RYGBP

Pre-op gp:n¼110, female f¼96, ma¼39.6,RYGBP. Post-op gp:n¼78, female ¼65, ma¼54.1, RYGBP. N¼32, female¼26, ma¼39.1 (SD 8.47).RYGBP

Total n¼379: BED n¼130, 102 f¼102, ma¼36.0 Non-BED n¼249, 178 f¼178, ma¼38, LAGB N¼80, female¼57, ma¼36, adjustable silicon gastric banding (ASGB)

5–7 mos

6 mos

13.8 yr avg (range 12.5–15.6)

12 mos

5 yr

Avg 14 (SD 1.5)

6 mos

N ¼ 40, female ¼ 34, ma¼41 (SD 9.1).RYGBP

n¼149, f¼ 102, avg age¼38.8, VBG or AGB

3 yr

Length of follow-up

N ¼ 53, female ¼ 48, ma¼38 (range 19–61), Biliopancreatic diversion

Sample Size, Gender Distribution, Mean Age(ma),Type of Surgery

Main features of outcome studies

Author

TABLE 2.

32% BED pre-op; no pts with BED at f/u. Pre-op non-binge eaters lost significantly (p < .012) more wt then BE Compared to non-binge eaters (NBE), BE had higher BMIs (p < .06), and lost lower % excess wt at f/u (p < .05)

QEWP-Rf,TFEQ,BES

ED-SCIDI,QEWP-R

M-FEDd,QEWPe

clinical interview using DSM-IV binge criteria, food/vomiting record review

clinical interview using DSM-IV binge criteria, on eating behaviour/ patterns

TFEQ (German version), SIABc

TFEQa,BESb

In all patients sharp wtloss toward normalization was maintained by 3rd post op yr.Pre-surgically 43% met BED criteria. BY 3rd post-op yr all of these pts had stopped binge eating Baseline BES score was significant (p ¼.03) positive predictor of percent wt loss at follow-up. 100% of BE prior to surgery was absent was absent at 6mos. Post-operative, but not pre-operative dimensions of eating (cognitive restraint, disinhibition, hunger) were predicted wt loss at 1 yr Pts with pre-surgical BED had similar wt outcomes to non-BED pts but required more aggressive post-surgical medical management. Percent of pts with high vomiting frequency at follow-up higher in pts with pre-surgical BED. Neostoma stenosis more frequent in pre-surgical BE than non BE Post-op group: 6.4% met BED criteria; 11.5% met criteria when ‘‘large amount of food’’ criteria dropped; BED pts had higher BMI at f/u.

BE Findings

Structured clinical interview using DSM-IV criteria for BED

Binge Eating Behavior Assessment Measures

short-term f/u

Small sample size, reliance on self-report, short-term follow-up

Cross-sectional nature, reliance on telephone interview and self-report data, retrospective

No standardized eating assessment tool used. Lacks post-surgical binge data. Pts with BED had pre-op treatment Lacks post-surgical binge data. Reliance on 24 hr dietary, recall, retrospective

short-term f/u, no post-surgical BE/graze data; no analysis of BE in relation to outcome

short term follow-up reliance on self-report measures

Biliopancreatic diversion (BPD) procedure only

Study Limitations

NIEGO ET AL.


Year

2002

1997

1996

2002

1999

2002

2004

2004

2004

Guisado et al.,

Hsu et al.,

Hsu et al.,

Kalarchian et al,

Kalarchian et al,

Lang et al.,

Larsen et al.,

Latner et al.,

Malone and Alger-Mayer,

continued

Author

TABLE 2.


Prospective

Prospective

Cross-sectional comparison of 3 groups: Prospective (I)

Prospective comparison of 2 gps:I binge eaters (BE) and II non-binge caters (NBE) Prospective

Cross-sectional comparison of 2 groups:I: BE:IIBE

Cross-sectional retrospective

Cross-sectional retrospective

Cross-sectional, post-Surgery;

Type of Study

N¼109,female¼91, ma¼45 RYGBP

Group I: n¼93, F¼77, ma: 39 (range 22-59) Group II: n¼48, F¼42, ma: 40 (range 24-61) Group III: n¼109, F¼102,ma: 41 (range 22-55) N¼65,female¼65, ma¼39.5, RYGBP

N¼66,female¼57, ma¼38.1 (SD 11.2),LAGB

Group I: n¼22, f¼13, Group II: n¼28, f¼25

1 yr

Mean 16.4 mos

GroupII:8–24mos GroupIII:25–

12 mos

3.84 mos (SD.89)

EDE-Qh, TFEQ

I: n ¼44, F ¼31 ma:40.4 (SD 10.2)52, F¼46 ma:42.8 (SD 11.2)SD 1.5) II:4 yrs (SD 1.4)

BES

EDE(abridged with supplemental questions regarding BED)

D-BES(Dutch version), D-EDE,DEBQi.

TFEQ, BSQi( German versions.)

Pts with post-surgical BE reported greater weight regain then NBE despite comparable initial wt loss EDE,TFEQ

48% of pts BED pre-surgically and 0% post-surgically; frequent binge eating, greater initial BMI, post-op length and exercise predicted greater BMI loss Most severe binge eaters pre-surgically had most improvements in binge eating and depressive symptoms

No BE reported post-surgery. Surgery had strongly positive effect on depressive symptoms, attitudes toward eating and weight that were more pronounced in those with pre-surgical BE 39.4% of pts ceased previous binge eating after surgery, 24.2% continued to report binge eating and 4.5% reported new onset binge eating. Changes were significant (p < 001) Pts with binge eating post-operatively showed worse outcome

Both post-op eating disturbance status and wt regain were predicted by interaction of pre-surgical ED status and time since surgery Pts with pre-surgical BED were more likely to retain their ED. Post-surgical ED was significantly associated with wt regain. Pre-surgical ED did not predict post-surgical wt regain. Reliance on self-report, Cross-sectional design, high % did not respond to questionnaires

EDEh with supplemental questions re:fluid intake and Night Eating Syndrome (NES) EDE with supplement questions

Up to 36 post-op

Up to 42 mos post-op

Pts with greater wt loss scored lower on global EDI

BE Findings

EDIB


18 mos

Length of follow-up

N¼24, all female, ma: 39.7 (SD 8.6)

N¼100, female¼85, ma¼40.5 (SD 11.15).VBG n¼27, all female, ma:40.4


Relatively short-term f/u, BES identified by authors as inadequate tool comp to EDE

Follow-up data retrospective via telephone, no males in, study; done on low-income, inner city population

Cross-sectional design Reliance on self report,

Self-report data, short term follow-up

Very short-term follow-up

Cross-sectional, retrospective self-report, small sample size, BED/BN combined in analysis

Pre-surgical ED assessed by recall, small sample size, ‘‘eating disturbance’’ widely defined

Cross-sectional design, binge data not reported

Study Limitations

BINGE EATING IN THE BARIATRIC SURGERY POPULATION

353

354

Prospective

Prospective

Prospective

Retrospective

Retrospective

Type of Study

N¼64,f¼unk, ma¼unk, GBP

N¼82,f¼68, ma¼40.8 (range 18-70),VBG

N¼116,f¼96, ma¼39.6 (SD 9.3), "gastric restrictive surgery"

N¼27,f¼19, ma¼36 (range 22-48),VBG

N¼78,female¼65, ma¼56.8 (range 31-77).RYGBP


12 wk 12 moþ

Mean 21.55 mo(max

Average 5.5 yr (range 5–10.5 yr)

Mean 5.4 yr(range 2–10)

13–15 yr

Length of follow-up

No instrument used: BE defined as "large amount of food, short period of time with loss of control" and recorded present/absent Pre-surg:QEWP, BES, Post-surg: self report quest developed to assess BE/grazing beh, loss of control

EDQl,BES,EATm

BES,BITEk(both modified to assess binge given postsurgical stomach capacity)

M-FED


80% of pts with pre-surgical BE/grazing reported reappearance of these starting 6mo post-surgically, pts with pre-surgical BE/grazing reported grazing þ loss of control/dysphoria at f/u

6.4% of pts met DSM-IV BED criteria; when ‘‘large amt of food’’ criteria dropped 12% med BED criteria; pts who had BED at f/u had regained more wt 10 pts classified as BE at f/u; Post-op BE was main predictor of poor wt loss at 1 yr was same between BE and non BE pts but longer term BE pts had more regain (p < .01) No significant difference in BMI at f/u between pts with pre-surgical BE & BED found; 33% pts vomiting at least weekly at fu, no significant difference between pre-surgical BE/BED and post-surgical vomiting At f/u, significant (no p value given) increase in postprandial vomiting, significant decrease in BE.

BE Findings

Descriptive study; findings partially anectdotal; newly developed f/u assessment

BE assessment by self-report as present/absent only

Follow up wt and psychological measures reported by mail or over phone

Retrospective nature of study small sample size,

Retrospective assessment of data from 13-15yrs ago

Study Limitations

Mean, standard deviation data are listed in table. a Three Factor Eating Questionnaire (TFEQ)12: A 51 item questionaire that measures dictary restraint, disinhibition of dietary control and perceived hunger. Has been shown to have good internal consistency, validity and test-retest reliability. b Binge eating Scale (BES)13: A 16-item Binge Eating Scale describing both behavioral features manifestations (e.g., eating large amounts of food) and feelings/cognitions surrounding a binge eating episode (e.g., guilt, fear of being unable to stop eating) A score of 17 on the BES is considered to indicate binge eating. c Structured Interview for Anorexia and Bulimia (SIAB)14,15,16: The SIAB is a structured interview with well-documented reliability and validity in patients with eating disorders. d M-FED14,15,17: An interview designed to collect longitudinal data during follow-up assessments on eating behaviors and psychopathology. e QEWP18: This 28 item instrument provides decision rules for diagnosing BED. QEWP-R is a revised format. f Structured Clinical Interview for DSM IV Disorders (SCID) is the most widely used and established diagnostic interview to assess current and lifetime Axis 1 psychiatric disorders. The SCID, which is continually updated to reflect classification changes, can be used to assess each of the DSM-IV eating disorder categories (including BED). Eating Disorders Module SCID (ED-SCID) is a structured clinical interview used to assess for a past or present eating disorder diagnosis using according to DSM-IV. g Eating Disorder Inventory (EDI)19: A 64 item scale which assesses specific eating/weight pathology and the psychological features associated with eating disorders. considered an index of global eating disturbance A lower global score indicates less severe binge eating. h Eating Disorder Examination (EDE)14,15: The EDE, employs a semistructured interview for assessing eating disorders and is regarded as a gold standard for diagnosis of BED The EDE provides clinicians and research workers with a detailed and comprehensive profile of the psychopathological features of patients with eating disorder. EDE-Q is a 41 item self-report measure adapted from the EDE. i Binge Scale Questionnaire (BSQ)20: A 9 -item self-report instrument that assesses frequency.intensity, and accompanying feelings and perceptions of binge eating episodes. j Dutch Eating Behavior Questionnaire (DEBQ)14,21: Consists of 3 subscales: emotional,external and restrained eating. Found to be valid and reliale instrument for evaluating eating behavior in obese subjects. k Bulimic Inventory Test, Edinburgh (BITE)12: A self-rating scale designed to detect patients who binge eat and purge.Has been validated with a semi-structured interview. l Eating Disorders Questionnaire (EDQ)22: Eicils epidemiological and clinical data including specific questions about different eating disorders. m Eating Attitudes Test (EAT)14,23: A 40-item self-repord questionnaire that measures symptoms of anorexia nervose.

2004

1999

powers et al.,

Saunders

1994

Pekkarinen et al.,

2001

2001

Mitchell et al.,

Sabbioni et al.,

Year

continued

Author

TABLE 2.

NIEGO ET AL.



Using the modified criteria, Hsu, Betancourt and Sullivan found that 5 of the 24 (21%) female patients at follow-up reported frequent loss of control when eating and a sense of remorse for eating out of control. These patients reported that they would have eaten more if they could.24 Mitchell et al. reported that 6.4% of patients met full criteria for BED 13–15 years after surgery but 12.0% exhibited BED symptoms if the criterion for consumption of large amounts of food was removed. Kalarchian, Wilson, Brolin and Bradley observed that 4 months after surgery, 2 of 50 patients (4%) reported consuming a subjectively large quantity of food at least once per week.30 In a separate study of 96 patients, Kalarchian and colleagues found that 44 patients (46%) were classified as binge eaters, as defined by an episode of feeling loss of control while eating at least once a week, in the past 4 weeks, 2–7 years after GBP surgery.31 When DeZwaan et al. assessed patients an average of 13.8 years after GBP, they found 5.4% met DSM-IV BED criteria, but this number rose to 11.5% when the ‘‘large amount of food’’ criteria was eliminated.32 Binge Eating and Weight Outcome

Studies that have examined the relationship between presurgical eating disturbances and weight loss outcomes have shown mixed results. Five studies found no difference in weight loss outcomes between patients with and without pre-surgical BE at time points ranging from 6 months to 5 years.29,33–36 Two studies found that presurgical binge eaters lost a significantly smaller percentage of excess body weight (determined by subtracting ideal body weight from current) after 6 months than non-binge eaters (41% vs. 47% and 38% vs. 54%). Interestingly, three studies found that presurgical BE predicted improved weight loss outcomes. Boan et al. found that among 40 patients, those with higher scores on a measure of BE severity prior to surgery lost a greater mean percentage of weight at 6 months. Malone and Alger-Mayer noted the same only at a trend level at time points from 3 months to 3 years. Latner et al. similarly found that pre-surgical BE was among the positive predictors of BMI reduction. The possibility of weight regain is discussed in several studies. Mitchell et al. noted that 3 of 78 patients (4%) weighed more 15 years after surgery than at baseline. The 1996 study by Hsu et al. in VBG patients found that weight regain was more likely to occur as postoperative time increased.24 The eight patients who had regained weight reported that they had begun gaining weight 18 months or more post-surgery. In another study,

Hsu et al. noted a similar, non-significant trend toward post-operative weight regain in patients with pre-surgical eating disorders (5 of 14 patients with pre-surgical BE and 3 of 10 patients without pre-surgical binge eating). They noted that 6 of 10 patients (60%) with BE regained weight, whereas only 2 of 14 (14%) without BE had done so. These authors found that pre-surgical BE was significantly associated with weight regain following an initial post-surgery weight loss but only in those more than 24 months post-surgery, reporting that 8 of 27 patients (30%) had started to regain weight within 36 months following GBP with a mean weight gain of 20.5 6 13 lb. Only one of 13 patients (8%) who had surgery within the past 2 years had regained weight whereas 7 of 14 patients (50%) between 24 and 36 months post-surgery had regained weight.25 Hsu et al. also found that presence of pre-surgical eating disorders and degree of weight regain 2 years after surgery were correlated.6 They hypothesized that patients experience a post-surgical improvement in eating disturbances that erodes after 2 years, leading to subsequent weight regain. In a study of 160 post-surgical patients, Larsen et al. found that post-surgical BE persons had significantly smaller reductions in BMI than their nonbinge-eating counterparts.37 This was true both within 2 years following surgery as well as after more than 2 years post-surgery. These results are similar to those by Kalarchian et al., who found that in a group of 96 patients seen between 2 and 7 years post-surgery, BMI was significantly reduced after surgery. The BMI remained significantly lower than the pre-operative values; nevertheless, at 2–7 years post-surgery, the BMIs were significantly higher than the lowest post-operative values.31 The propensity toward weight regain was most notable in patients with post-surgical eating disturbances. Specifically, people who reported post-surgical BE showed a mean BMI increase of 5.2 kg/m2 (13.9 lbs) from their post-operative low, whereas non-binge eaters reported a lesser increase of 2.6 kg/m2 (7.1 lbs.) (p < .001). Busetto et al. reported no difference in weight regain after 5 years between patients with versus without BED prior to surgery, although the study employed a pre-operative treatment for patients with identified eating pathology.34 The implementation of a targeted intervention indicated that an assumption was made in the study design that patients with eating pathology were at risk for poorer surgical outcome. In a study of 27 patients, Pekkarinen et al. noted that postsurgical BE participants lost a mean of 24% of excess weight vs. 50% among non-binge


355

NIEGO ET AL.

eaters 1 year after surgery.38 Mean weight regain beginning 1 year post-surgery was 23 kg among binger eaters and 5 kg among non-binge eaters (p ¼ .01). In their study conducted 13–15 years following surgery, Mitchell et al. compared subjects who were classified as non-BED pre-surgery, BED presurgery but not post-surgery, and BED both pre and post-surgery. The authors found significantly (p < .05) greater regain in the group that resumed BE following surgery than in those who never binge ate and those who ceased BE following surgery.26 Also reporting on this data, de Zwaan et al. noted that BED patients had significantly (p < .021) smaller BMI reductions following surgery, and that their lowest BMI since surgery was significantly (p ¼ .007) higher than that of non-BED patients.39

Conclusion Our review indicates that there is a high prevalence of BE and BED in patients presenting for weight loss surgery. Despite some indications that BE behavior is eliminated by gastric restrictive surgeries, many patients continue to have maladaptive and psychologically distressing eating behaviors following surgery. Furthermore, studies that assessed the relationship between pre- and postsurgical BE and BED mostly indicate that in patients who continue to have BE and BED postsurgery, weight loss outcomes are worse compared with patients who never had these behaviors or who remained remitted. A central feature of a binge episode is a sense of loss of control accompanying the eating (i.e. difficult or impossible to stop from eating or to stop eating once started). BE appears to cease following surgery in a large percentage of patients, yet clinicians, researchers, and surgical patients should be cautioned about concluding that surgery is a cure for pre-surgical eating pathology. Studies that have dropped the ‘‘large amount of food’’ criteria in the assessment of post-surgical BE indicate an appreciation that, for many, binge behaviors continue after surgery though altered or limited in expression by the physiological changes brought on by the surgery. For some time, eating disorders researchers have debated the necessity of this having an amount criterion in the binge definition.40,41 Telch et al. have suggested that a sense of loss of control over the eating episode may be more of a defining feature of a binge than amount of food consumed.42 Saunders proposed that post-surgical grazing with feelings of loss of control over eating 356

indicates the re-emergence of pre-surgical BE in the context of a reduced stomach capacity.28 After bariatric surgery, perhaps the focus in a BE assessment should shift to the sense of loss of control over eating. The relationship between pre-surgical BE and post-surgical weight change may depend on the time point examined post-surgically. It appears that BE that re-emerges following surgery affects weight outcomes most prominently beginning 18– 24 months following surgery, after an initial weight loss or ‘‘honeymoon’’ stage. There are several factors that may explain changes in weight patterns following an initial weight loss period. For patients who have the most severe BE prior to surgery, the restrictive nature of the surgery may initially yield a proportionally greater weight loss in this group because of the greater relative effect on these patients who at baseline have the largest stomach capacity.43,44 Since gastric capacity is reduced to the same small volume, the impact would be greatest in those with BED and BE. Just as maladaptive eating habits may be temporarily suppressed during times of weight loss through dieting, they may also resurface over the long term for some people after bariatric surgery. It has already been speculated that patients may learn over time to circumvent the restrictions imposed initially by surgery by eating more frequently or by consuming high calorie liquids.6 The relationship between pre-surgical BE and post-surgical weight loss outcomes is not consistent across studies. However, there is an association between pre-surgical BE and post-surgical binge eating. Thus, disordered eating behavior prior to surgery should be viewed as a warning sign for potentially less successful weight loss outcomes, especially long-term. BE behavior following surgery is associated with poorer weight outcomes. Monitoring for this behavior following surgery and for several years thereafter, especially among those who engaged in BE prior to surgery, may help identify patients who can benefit from additional treatment for their binge eating.1 Busetto et al. have implemented such interventions.34 Although many patients who binge eat prior to surgery will still experience positive outcomes and significant improvements in weight and health behaviors as a result of weight loss surgery, adjunctive treatment for BE features may be necessary to achieve these most desirable long-term outcomes. Drug treatment post-surgery should also be considered. Topiramate has been shown to significantly decrease both BE and weight in patients with BED, and small studies and case reports have suggested that topir-



amate may be useful as an adjunct to bariatric surgery in patients with BED who have difficulty losing weight or maintaining weight loss.45,46 In addition, nonpharmacological, cognitive-behavioral treatments for BE and BED have yielded positive results in the treatment of BE and should be considered for bariatric surgery candidates to optimize outcomes.1 Future research ought to address whether BE and BED are most effectively treated pre-surgically or post-surgically.

Limitations of the Existing Data Base

Of the studies reviewed here, few were prospective trials that assessed BE in a population both before and after surgery. Of those, few followed patients for longer than 1 year. The lack of clear, conclusive, and consistent findings may also be due to the small sample sizes of most studies. The retrospective design of many studies, specifically the retrospective recall of eating behaviors from several years ago, prior to surgery,24–26 may yield inaccurate reports of presurgery eating disorders. Additionally, the small sample size of many of the studies may result in inadequate power to detect positive effects of some independent variables; hence negative findings need to be evaluated within these constraints. The International Society of Bariatric Surgeons reports that 87% of patients undergoing bariatric surgery are women.47 In the studies reviewed here, a similar percentage of subjects were women and, where specified in the studies, predominantly Caucasian. These characteristics limit the application of study findings to men and to members of other ethnic groups. Given that obesity is more prevalent in Hispanics and Blacks than in Caucasians, it is quite likely that increasing numbers in these minority groups will undergo bariatric surgery. Only two of the studies reviewed looked at BE in a sample of ethnically diverse women seeking surgery.48,49 Hence, there is a need for further research on eating disorders and outcomes of bariatric surgery in minority patients. The assessment tools used to measure BE varied: from known and validated tools, which assess the criteria and frequency specified in the DSM-IV, to nonvalidated assessments that may assess either behavioral or emotional features of BED but not both. Although the assessment instruments all can identify the likely presence of BE, the variability in tools impedes the direct comparison of prevalence rates across studies. The mode of assessing eating behaviors also varied across studies from semistructured inter-

views33,50–52 to modified questionnaires.25,36,48 Studies frequently did not report whether these interviews were structured and validated instruments or unstructured or researcher revised interviews. The validity of self-report measures for the assessment of BE in the obese has been questioned relative to validated clinical interviews.8,53 The type of surgical procedure evaluated also varied substantially, both between and sometimes even within studies. While procedures such as VBG are purely restrictive, others such as RYGBP are both restrictive and malabsorptive, imposing limitations on pooling of study findings. Although bariatric surgery offers a generally effective weight loss treatment in those with clinically severe obesity, it is unclear whether bariatric surgery truly eliminates any associated eating disorders. The data shows that eating disorders are related to poorer surgical outcomes, and additional interventions may be needed to improve long term outcomes. Evidence continues to emerge that weight loss and eating behavior patterns shift around 2 years post-surgery, and more prospective and long-term research is needed. Eating disturbances that begin or reemerge following surgery are often associated with lower overall reductions in weight and BMI and more weight regain. Interventions should be implemented for those individuals at higher risk for complications or reduced success after bariatric surgery. Cognitive-behavioral treatment and certain medications, such as antidepressants, appetite suppressants, and anticonvulsants are likely candidates. Understanding when and why weight regain occurs following surgery is critical to establishing the true long term benefits of surgery. Further attention is needed on whether the criteria for BED and BE merit modification in the postbariatric surgery setting. It appears that this may be necessary to accurately assess BE when a large amount of food can no longer be accommodated. Whether or not criteria are modified, a consensus should be reached among researchers addressing BE after bariatric surgery. Bariatric surgery patients can achieve substantial weight loss, but the surgery alone may not fundamentally alter any underlying eating disorders, which can limit long-term success, particularly in patients who had BE or BED prior to surgery. If the eating disordered behavior remains untreated, the bariatric surgeon may only be putting a band-aid on a long-term psychological disorder that has serious medical sequellae. Combining psychological treatment for eating disorders and bariatric surgery for weight loss mer-


357

NIEGO ET AL.

its further study in determining the best treatment for obese patients with eating disorders seeking long-term weight loss. We acknowledge Christoph Correll, MD, of North-Shore Long Island Jewish Medical Center, Zucker Hillside Hospital, New Hyde Park, New York, for the critical review of this manuscript.

References 1. Vaidya V. Cognitive behavior therapy of binge eating disorder. Adv Psychosom Med 2006;27:86–93. 2. Gastrointestinal surgery for severe obesity. NIH consensus development conference, March 25-7,1991. Nutrition 1996;12: 397–404. 3. Colwell J. New ACP Guidlines Target Obesity Management, April ed. American College of Physicians, ACP Observer, 2005. 4. Ballantyne GH. Measuring outcomes following bariatric surgery: Weight loss parameters, improvement in co-morbid conditions, change in quality of life and patient satisfaction. Obes Surg 2003; 13:954–964. 5. Maggard MA, Shugarman LR, Suttorp M, Maglione M, Sugerman HJ, Livingston EH, Nguyen NT, Li Z, Mojica WA, Hilton L, Rhodes S, Morton SC, Shekelle PG. Meta-analysis: Surgical treatment of obesity. Ann Intern Med 2005;142:547–559. 6. Hsu LK, Benotti PN, Dwyer J, Roberts SB, Saltzman E, Shikora S, Rolls BJ, Rand W. Nonsurgical factors that influence the outcome of bariatric surgery: A review. Psychosom Med 1998;60: 338–346. 7. Sarwer DB, Cohn NI, Gibbons LM, Magee L, Crerand CE, Raper SE, Rosato EF, Williams NN, Wadden TA. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg 2004;14:1148–1156. 8. Saunders R. Binge eating in gastric bypass patients before surgery. Obes Surg 1999;9:72–76. 9. Diagnostic and Statistic Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatric Association, 1994, p. 202. 10. Devlin MJ, Goldfein JA, Flancbaum L, Bessler M, Eisenstadt R. Surgical management of obese patients with eating disorders: A survey of current practice. Obes Surg 2004;14:1252–1257. 11. Striegel-Moore RH, Dohm FA, Solomon EE, Fairburn CG, Pike KM, Wilfley DE. Subthreshold binge eating disorder. Int J Eat Disord 2000;27:270–278. 12. Gormally J, Black S, Daston S, Rardin D. The assessment of binge eating severity among obese persons. Addict Behav 1982; 7:47–55. 13. Hawkins RC, Clement PF. Development and construct validation of a self-report measure of binge eating tendencies. Addict Behav 1980;5:219–226. 14. Henderson M, Freeman CP. A self-rating scale for bulimia. The ‘BITE’. Br J Psychiatry 1987;150:18–24. 15. van ST. Success and failure in the measurement of restraint: Notes and data. Int J Eat Disord 1999;25:441–449. 16. Garner DM, Garfinkel PE. The eating attitudes test: An index of the symptoms of anorexia nervosa. Psychol Med 1979;9:273– 279. 17. Cooper Z, Cooper PJ, Fairburn CG. The validity of the eating disorder examination and its subscales. Br J Psychiatry 1989; 154:807–812.

358

18. Garner DM, Olmstead MP, Polivy J. Development and validation of a multidimensional eating disorder innventory for anorexia nervosa and bulimia. Int J Eat Disord 1983;2:15–34. 19. Mitchell JE, Hatsukami D, Eckert ED, Pyle RL. Eating disorders questionnaire. Psychopharmacol Bull 1985;21:1025–1043. 20. Agras WS, Crow SJ, Halmi KA, Mitchell JE, Wilson GT, Kraemer HC. Outcome predictors for the cognitive behavior treatment of bulimia nervosa: Data from a multisite study. Am J Psychiatry 2000;157:1302–1308. 21. Spitzer RL, Devlin MJ, Walsh BT, Hasin D, Wing R, Marcus MD. Binge eating disorder: A multisite field trial of the diagnostic criteria. Int J Eat Disord 1992;11:191–203. 22. Fichter MM, Herpertz S, Quadflieg N, Herpertz-Dahlmann B. Structured interview for anorexic and bulimic disorders for DSM-IV and ICD-10: Updated (third) revision. Int J Eat Disord 1998;24:227–249. 23. Stunkard AJ, Messick S. The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. J Psychosom Res 1985;29:71–83. 24. Hsu LK, Betancourt S, Sullivan SP. Eating disturbances before and after vertical banded gastroplasty: A pilot study. Int J Eat Disord 1996;19:23–34. 25. Hsu LK, Sullivan SP, Benotti PN. Eating disturbances and outcome of gastric bypass surgery: A pilot study. Int J Eat Disord 1997;21:385–390. 26. Mitchell JE, Lancaster KL, Burgard MA, Howell LM, Krahn DD, Crosby RD, Wonderlich SA, Gosnell BA. Long-term follow-up of patients’ status after gastric bypass. Obes Surg 2001;11:464– 468. 27. Lang T, Hauser R, Buddeberg C, Klaghofer R. Impact of gastric banding on eating behavior and weight. Obes Surg 2002;12: 100–107. 28. Saunders R. ‘‘Grazing’’: A high-risk behavior. Obes Surg 2004; 14:98–102. 29. Powers PS, Perez A, Boyd F, Rosemurgy A. Eating pathology before and after bariatric surgery: a prospective study. Int J Eat Disord 1999;25:293–300. 30. Kalarchian MA, Wilson GT, Brolin RE, Bradley L. Effects of bariatric surgery on binge eating and related psychopathology. Eat Weight Disord 1999;4:1–5. 31. Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin RE, LaMarca LB. Binge eating among gastric bypass patients at long-term follow-up. Obes Surg 2002;12:270–275. 32. de ZM, Mitchell JE, Howell LM, Monson N, Swan-Kremeier L, Crosby RD, Seim HC. Characteristics of morbidly obese patients before gastric bypass surgery. Compr Psychiatry 2003;44:428– 434. 33. Busetto L, Valente P, Pisent C, Segato G, De MF, Favretti F, Lise M, Enzi G. Eating pattern in the first year following adjustable silicone gastric banding (ASGB) for morbid obesity. Int J Obes Relat Metab Disord 1996;20:539–546. 34. Busetto L, Segato G, De LM, De MF, Foletto M, Vianello M, Valeri M, Favretti F, Enzi G. Weight loss and postoperative complications in morbidly obese patients with binge eating disorder treated by laparoscopic adjustable gastric banding. Obes Surg 2005;15:195–201. 35. Malone M, ger-Mayer S. Binge status and quality of life after gastric bypass surgery: A one-year study. Obes Res 2004;12: 473–481. 36. Sabbioni ME, Dickson MH, Eychmuller S, Franke D, Goetz S, Hurny C, Naef M, Balsiger B, de MD, Burgi U, Buchler MW. Intermediate results of health related quality of life after vertical banded gastroplasty. Int J Obes Relat Metab Disord 2002;26:277–280. 37. Larsen JK, van RB, Geenen R, Brand N, Stroebe W, van Doornen LJ. Binge eating and its relationship to outcome after laparo-



38.

39.

40. 41. 42.

43. 44.

45.

scopic adjustable gastric banding. Obes Surg 2004;14:1111– 1117. Pekkarinen T, Koskela K, Huikuri K, Mustajoki P. Long-term results of gastroplasty for morbid obesity: Binge-eating as a predictor of poor outcome. Obes Surg 1994;4:248–255. de ZM, Lancaster KL, Mitchell JE, Howell LM, Monson N, Roerig JL, Crosby RD. Health-related quality of life in morbidly obese patients: Effect of gastric bypass surgery. Obes Surg 2002;12: 773–780. Niego SH, Pratt EM, Agras WS. Subjective or objective binge: is the distinction valid? Int J Eat Disord 1997;22:291–298. Pratt EM, Niego SH, Agras WS. Does the size of a binge matter? Int J Eat Disord 1998;24:307–312. Telch CF, Pratt EM, Niego SH. Obese women with binge eating disorder define the term binge. Int J Eat Disord 1998;24:313– 317. Geliebter A. Stomach capacity in obese individuals. Obes Res 2001;9:727–728. Geliebter A, Yahav EK, Gluck ME, Hashim SA. Gastric capacity, test meal intake, and appetitive hormones in binge eating disorder. Physiol Behav 2004;81:735–740. Guerdjikova AI, Kotwal R, McElroy SL. Response of recurrent binge eating and weight gain to topiramate in patients with binge eating disorder after bariatric surgery. Obes Surg 2005; 15:273–277.

46. Zilberstein B, Pajecki D, Garcia de Brito AC, Gallafrio ST, Eshkenazy R, Andrade CG. Topiramate after adjustable gastric banding in patients with binge eating and difficulty losing weight. Obes Surg 2004;14:802–805. 47. Mason EE, Tang S, Renquist KE, Barnes DT, Cullen JJ, Doherty C, Maher JW. A decade of change in obesity surgery. National Bariatric Surgery Registry (NBSR) Contributors. Obes Surg 1997;7: 189–197. 48. Latner JD, Wetzler S, Goodman ER, Glinski J. Gastric bypass in a low-income, inner-city population: eating disturbances and weight loss. Obes Res 2004;12:956–961. 49. Sanchez-Johnsen LA, Dymek M, Alverdy J, le GD. Binge eating and eating-related cognitions and behavior in ethnically diverse obese women. Obes Res 2003;11:1002–1009. 50. Adami GF, Gandolfo P, Bauer B, Scopinaro N. Binge eating in massively obese patients undergoing bariatric surgery. Int J Eat Disord 1995;17:45–50. 51. Adami GF, Meneghelli A, Scopinaro N. Night eating and binge eating disorder in obese patients. Int J Eat Disord 1999;25:335– 338. 52. Glinski J, Wetzler S, Goodman E. The psychology of gastric bypass surgery. Obes Surg 2001;11:581–588. 53. Kalarchian MA, Wilson GT, Brolin RE, Bradley L. Assessment of eating disorders in bariatric surgery candidates: Self-report questionnaire versus interview. Int J Eat Disord 2000;28:465–469.


359