Nonnormative Eating Behaviors and Eating Disorders and Their Associations With Weight Loss and Quality of Life During 6 Years Following Obesity Surgery

Abstract

ImportanceIndividuals with severe obesity presenting for obesity surgery (OS) frequently show nonnormative eating behaviors (NEBs) and eating disorders (EDs), but the long-term course and prospective associations with weight loss and health-related quality of life (HRQOL) remain unclear.ObjectiveTo examine the prevalence and prospective relevance of presurgical and postsurgical NEBs and EDs according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosed through clinical interview, for weight loss and HRQOL up to 6 years following OS.Design, Setting, and ParticipantsIn the prospective, multicenter Psychosocial Registry for Obesity Surgery cohort study, patients seeking OS were recruited at 6 OS centers in Germany and assessed at baseline before surgery and at 6 months and 1 to 6 years after surgery. From a consecutive sample of 1040 volunteers with planned OS from March 1, 2012, to December 31, 2020, a total of 748 (71.92%) were included in this study. Across follow-up, 93 of the 748 patients (12.43%) dropped out. Data were analyzed from April to November 2021.InterventionsLaparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy.Main Outcomes and MeasuresBoth NEBs and EDs were identified using the Eating Disorder Examination interview. Main outcomes were the percentage of total body weight loss (%TBWL) and HRQOL (Impact of Weight on Quality of Life-Lite; range, 0-100, with 0 indicating worst and 100 indicating best).ResultsIn 748 patients undergoing OS (mean [SD] age, 46.26 [11.44] years; mean [SD] body mass index [calculated as weight in kilograms divided by height in meters squared], 48.38 [8.09]; 513 [68.58%] female), the mean (SD) %TBWL was 26.70% (9.61%), and the mean (SD) HRQOL improvement was 35.41 (20.63) percentage points across follow-up. Both NEBs and EDs were common before surgery, with postsurgical improvements of varying degrees. Whereas NEBs and EDs did not reveal significant prospective associations with %TBWL, loss-of-control eating at follow-up was concurrently associated with lower %TBWL (estimate, −0.09; 95% CI, −0.14 to −0.04). Loss-of-control eating (estimate, −0.10; 95% CI, −0.17 to −0.03 percentage points) and binge-eating disorder of low frequency and/or limited duration (estimate, −6.51; 95% CI, −12.69 to −0.34 percentage points) at follow-up showed significant prospective associations with lower HRQOL.Conclusions and RelevanceThis cohort study found prospective relevance of loss-of-control eating and binge-eating disorder of low frequency and/or limited duration for reduced long-term HRQOL following OS. These findings underline the importance of monitoring both NEBs, especially loss-of-control eating, and EDs in the long term postsurgically to identify patients in need of targeted prevention or psychotherapy.

Atypical anorexia nervosa after bariatric surgery and the DSM‐5 diagnostic criteria: Commentary on Walsh et al. (2023)

“…Bariatric surgery alters the gastro‐intestinal tract, inducing significant weight loss (≈30% weight loss) (e.g., Hilbert et al, 2022) in a short period of time (usually in the first 6 months of surgery), facilitating control over eating, restrained eating, and the use of purgative compensatory behaviors (e.g., self‐induced vomiting) (Conceição et al, 2013). As a result of weight loss, patients experience a considerable improvement in their self‐esteem, body image, social acceptance, interpersonal relationships, and quality of life, along with a marked alleviation of physical comorbidities of obesity.…”

“…Despite the significant weight loss, existing reports suggest that patients with AN‐like symptoms after bariatric surgery can present BMIs ranging from normal weight (18.5 ≤ BMI < 25 kg/m 2 ) to obesity (BMI ≥30 kg/m 2 ) while reporting severe eating disorder psychopathology and medical complications (e.g., Conceição et al, 2013; Hilbert et al, 2022). The absence of low weight, along with culturally normative and medically recommended restrictive eating behaviors and weight control strategies, likely complicate the identification of clinical symptoms after surgery.…”

“…The absence of low weight, along with culturally normative and medically recommended restrictive eating behaviors and weight control strategies, likely complicate the identification of clinical symptoms after surgery. Moreover, research on nonbariatric surgery patients shows that migration between purely restrictive and compulsive eating disorder diagnoses is common, and compulsive eating, that is, the experience of loss of control over eating, has been consistently identified as a potent risk factor for weight regain after surgery (e.g., Hilbert et al, 2022).…”

“…First, in the context of bariatric surgery, it is important to ascertain that significantly low weight (and significant weight loss) is a result of self‐imposed restriction of energy intake relative to the requirements, besides the surgical procedure itself. Furthermore, there is little indication as to what constitutes “persistent energy intake restriction” for these patients, despite being a core feature of AN and being reported by over 5% of patients within 3 years of postsurgery (Hilbert et al, 2022). Energy requirements change throughout the postoperative time and are generally lower than those of nonbariatric surgery people for a considerable time period.…”

“…Unfortunately, the interpretation of what constitutes “significantly low weight” or a “weight that is less than minimally normal” raises several questions in the context of bariatric surgery. Postoperative patients with successful weight loss usually maintain weight above BMI 25 or 30 kg/m 2 (Hilbert et al, 2022), and reference to the World Health Organization's categories of weight may result in overlooking these patients.…”