Bariatric Surgery for Patients with and without Eating Disorders

Why it’s important to consider
eating disorders in those seeking surgery.

Obese patients seeking bariatric surgery often have comorbidities. Mood and anxiety disorders have been reported in about a fifth of these patients, while from 16% to 30% have binge eating disorder (BED). About half of obese patients seeking bariatric surgery reported comorbid psychopathology in accordance with DSM-IV criteria (Gen Hosp Psychiatry 2009; 31:414; Obes Surg 2001; 11:581).

At St. Olav’s University Hospital, Trondheim, Norway, Dr. Jens K. Dahl and co-workers found significantly higher levels of depression, anxiety, and neuroticism, as well as more cases of depression and anxiety, among a group of obese patients with eating disorders compared to obese patients without eating disorders (Obesity Research & Clinical Practice 2012; e, e139).

Dr. Dahl and colleagues noted that there are several reasons that identifying eating disorders in patients seeking bariatric surgery is important: (1) binge eating leads to increased obesity; (2) BED is assumed to negatively influence the outcome of the surgical procedures; and (3) obese patients with eating disorders tend to have more psychiatric distress than do those without eating disorders.

In their study, the researchers mailed questionnaires to 209 morbidly obese patients awaiting bariatric surgery; the responses had no effect upon the preoperative approval process. The inclusion criteria for gastric bypass surgery were: body mass index (BMI, kg/m²) between 35 and 40, plus one obesity-related somatic comorbidity, or BMI ≥40. Subjects also filled out the Eating Disorders in Obesity (EDO) questionnaire, an 11-item self-report questionnaire designed to detect eating disorders among obese populations (Int J Eat Disord 1995; 18:119).

In this study, the EDO was used to identify three diagnoses: bulimia nervosa (BN) (1 person), binge eating disorder (21 persons), and eating disorder not otherwise specified (6 persons). Patients who were one criterion short of a BN diagnosis were considered as having EDNOS. In addition, a subthreshold diagnostic group (subthreshold binge eating disorder, or SBED) was included by the authors. This category consisted of patients who were one criterion short of the BED diagnosis. The 160 patients in the final group were divided into three groups, ED (n=28), SBED (23), and Not ED-SBED, also classified as “those without eating disorders” (n=109).

Another instrument that was used in the study was the Hospital Anxiety and Depression Scale (HADS), a widely used self-report questionnaire for psychiatric distress (Acta Psychiatr Scand 1983; 67:361). The HADS questionnaire contains 14 items that cover the preceding week. Information about age, BMI, and gender was also obtained.

The impact of eating disorders

Patients with an indication of having eating disorders reported significantly higher scores on the HADS-Depression scale than did patients without eating disorders; they also had significantly higher scores on the HADS-Anxiety scale. Those with eating disorders had significantly higher scores on neuroticism than did patients without eating disorders. Patients in the SBED subgroup had significantly higher scores on neuroticism than did patients without eating disorders.

The authors reported that their findings showed that obese patients with relevant eating disorders have more anxiety, depression, and neuroticism than do obese patients without eating disorders, Because of this, the authors suggest that interventions aimed directly toward those psychological problems would probably be beneficial. More information about how personality features such as neuroticism may interact with overeating and weight gain is warranted, according to the authors. In addition, they noted that obese patients with subthreshold binge eating disorders are very like those with full-blown eating disorders in regard to levels of neuroticism and depression and markedly different from patients without eating disorders. Thus, those with subthreshold eating disorders should be identified and treated similarly to those with recognized eating disorders.