Making Sense of the Research Regarding Binge Eating and Bariatric Surgery Outcomes

| October 20, 2010

by Alëna A. Balasanova, MS III

Author affiliation: Ms. Balasanova is third-year medical student at Harvard Medical School, Boston, Massachusetts.

Funding: There was no funding for the development of this article.

Financial disclosure: The author reports no conflicts of interest relevant to the content of this article.Abstract
Objective. To explore binge eating disorder as a psychological risk factor in patients with obesity seeking bariatric surgery and to determine its predictive value in weight loss outcomes. The aim is to provide a framework for assessing patient risk factors to facilitate early recognition and treatment of binge eating behaviors in order to optimize surgical outcome success. Design. A literature review was performed initially through PubMed and subsequently through reference lists of obtained articles. The search criteria used was the combination of “binge eating,” “obesity,” and “bariatric surgery.” Reference list searches also included studies comparing proposed diagnostic criteria and assessment methods for binge eating disorder. Results. There was sufficient data to support binge eating disorder as a psychological risk factor in obesity. Evidence linking baseline binge eating behavior and bariatric surgery outcomes was inconclusive. There was significant heterogeneity among instruments used to assess binge eating and the definition of binge eating disorder itself varied widely among studies. Conclusion. Overall, there appears to be no consensus on diagnostic criteria for binge eating disorder or for its clinical assessment in bariatric surgery patients. This methodological discordance makes comparing studies of binge eating and surgical outcomes unreliable. As long as there is no universally accepted definition for binge eating disorder or standardized measure for its diagnosis, the effect of this pathologic eating pattern on surgical weight loss outcomes will remain unclear. The bariatric community should be aware of the discrepancies in current research and exercise caution when interpreting research results surrounding this topic.

Introduction
According to a recent National Health and Nutrition Examination Survey (NHANES) by the Centers for Disease Control (CDC), an estimated 34.2 percent of adults in the United States are overweight, 33.8 percent are obese, and 5.7 percent are extremely obese.[1] These data suggest that almost 75 percent of Americans are outside of what is considered normal range body mass index (BMI), compared to just under 60 percent only 20 years ago. The health consequences associated with obesity are broad, ranging from cardiac disease to psychiatric disturbances and even infertility. It is no great secret that many common chronic medical conditions show clinical signs of improvement and often remittance altogether with significant weight loss (e.g., type 2 diabetes, hypertension, and polycystic ovarian syndrome).

As rates of obesity continue to rise and their health sequelae become more readily apparent, bariatric surgery is increasingly becoming a popular option for those who fail to meet their weight loss goals with conventional lifestyle modification and monitored weight loss programs. The American Society for Metabolic and Bariatric Surgery (ASMBS) reports that in 2008, over 220,000 Americans underwent bariatric surgery. The two most common procedures today are Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB).[2]

Understanding obesity
Given the prevalence of obesity and successful outcome trends with bariatric surgery, it becomes easy to submit to the notion that weight loss surgery is a viable option for all individuals with obesity who fail to achieve weight loss with medical management alone. However, it is important to keep in mind that obesity is a multifactorial disease requiring multidisciplinary care, and therefore cannot be eliminated entirely by surgical restriction alone.[3,4] A better understanding of the factors leading to obesity is necessary to appropriately address issues within bariatric surgical candidates potentially contributing to decreased weight loss success. An underappreciated aspect of the bariatric surgery process is the identification of obesity-contributing psychiatric issues, especially disordered eating patterns.

The aim of this article is to shed light on the inconsistencies in current literature about the role of eating disorders, primarily binge eating, on successful weight loss outcomes in bariatric surgery patients. This includes exploring the methodological variations employed in obesity and bariatric research at the most technical level, raising awareness about the uncertainty in study interpretation when data are obtained in a heterogeneous fashion. It is advantageous for everyone involved in the care of bariatric patients to be cognizant of the ways in which to appropriately assess research literature. As a medical community that increasingly relies on empirically derived information and evidence-based research, the ability to accurately evaluate study results will guide timely clinical and surgical decision making. Timely intervention in patient management will optimize patient outcomes in bariatric surgery and, accordingly, advance best practices in this growing multidisciplinary field.

Disturbances in eating behaviors have long been thought to play a role in the development of obesity. Most notably, the phenomena of grazing, night eating syndrome, and binge eating disorder (BED) have been identified as behaviors that undermine weight loss efforts whether surgically based or not.[5] Recently there has been particular interest in the potential predictive value of binge eating behaviors on weight loss outcomes following bariatric surgery.

The principal features of binge eating are recurrent episodes of consumption of an objectively large amount of food in the absence of compensatory mechanisms (e.g., purging or laxative use) accompanied by a subjective feeling of loss of control over the situation. These episodes are almost always followed by marked psychological distress and feelings of guilt.[6–8] It is estimated that 1 to 3 percent of Americans struggle with binge eating; among patients with obesity seeking weight loss treatment, the prevalence jumps to over 30 percent.[9] Recent studies suggest that this subset of patients with obesity is clinically distinct by both medical and psychometric measures from their nonbinging counterparts, and it is these differences that are thought to account for the variation in postoperative weight loss success.[10,11]

Evaluating surgical candidates
The psychological assessment is an integral component of the presurgical workup of bariatric patients, and the ASMBS recommends that all bariatric programs evaluate their patients for disordered eating behaviors using standardized, empirically validated methods.[12,13] As many as 15 percent of bariatric surgical candidates are denied on the basis of psychological pathology or have their surgeries delayed in order to receive treatment for underlying conditions that may hinder surgical success.[14,15] Ashton et al[16] found that for a cohort of BED patients, group-based intervention and cognitive behavioral therapy were effective in reducing binge behaviors as part of a preoperative treatment plan. Given its potential to guide patient management by early recognition of potential risk factors, the preoperative psychological assessment of patients by bariatric programs has become commonplace nationwide.[17]

Screening for eating pathology, such as binge behaviors, is an essential element of the preoperative patient workup; however, despite the importance of early detection and intervention, diagnosing BED is rather problematic. This stems from the fact that BED is not, as of yet, a diagnostic category recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the official guidebook of the American Psychiatric Association.[6,18] Thus, although the term binge eating disorder is commonly used in both clinical and research settings, a formal, universal definition has not been adopted.

Proposed diagnostic criteria for the inclusion of BED in future editions of the DSM call for recurrent episodes of binge eating that occur, on average, two or more times weekly for at least six months. A binge episode is characterized as “eating, in a discrete period of time, an amount of food that is larger than most people would eat under similar circumstances” and “a sense of lack of control over eating during the episode.” The episode must also be associated with psychological disturbances that include the following: eating faster than usual or until feeling uncomfortably full; eating large amounts of food when not feeling physically hungry; eating alone due to embarrassment over how much food is eaten; and most commonly, feeling disgust and self condemnation, guilt, or depression after the binge episode.[19] Notably, a binge episode must consist of both an objective and subjective component: an objectively large amount of food and subjective feelings of loss of control and psychological distress.

Understanding Binge Eating Disorder
The lack of a standard definition for BED leaves assessment of binge eating open to interpretation. The ways in which researchers have applied the provisional definition of BED are diverse, and consequently study results investigating differences in weight loss outcomes vary widely. Kofman et al[4] specified the “discrete period of time” component of the provisional criteria to be two hours, thereby restricting the length of the binge episode for the purposes of their study. When this time window was used as part of the diagnostic criteria, patients with preoperative BED were found to be more likely to have poorer weight loss results and persistent disturbances in their eating patterns postoperatively.[4] This conclusion raised the question of whether it is actually postoperative binge eating that is responsible for decreased weight loss. A subsequent study showed that bariatric patients without baseline BED demonstrated disturbed eating patterns at long-term follow up in conjunction with less overall weight lost.[5] Nevertheless, it remains unclear whether the decreased weight loss was caused by the development of disordered eating habits or whether the disordered eating arose in the context of psychological distress over unsatisfying weight outcomes.[19,20]

Critics argue that the physiologic limitation produced by bariatric surgery inhibits postoperative BED since gastric restriction induces early satiety with less food consumed, altering the desire to eat large portions due to the resultant nausea, vomiting, and dumping syndrome that may ensue.[21] It is for this reason that some researchers have omitted the “amount of food that is larger than most people would eat” clause of the provisional BED criteria when assessing postoperative eating patterns in bariatric patients.[3,4,19] Interestingly, this modification is generally not made when assessing preoperative BED, furthering the inconsistency in data collection and leading to uncertainty in the validity of study results. As a result, it becomes challenging to form conclusions about BED prevalence when the diagnostic criteria appears to be a moving target.

Admittedly, the way in which patients are able to binge following surgical gastric restriction is not intuitive. It is clear that the ability to consume an objectively large amount of food in a short period of time becomes severely diminished, at least in the short term.[22] Sallet et al[11] concluded that BED patients undergoing RYGB exhibited poorer weight loss when compared to non-BED patients at one- and two-year follow-up intervals.[11] The negative association of BED with long-term weight loss success has been attributed to the gradual re-emergence of the baseline eating pathologies of patients with BED that were temporarily attenuated by the physiologic restriction created by gastric bypass. Over time, psychological disturbances in eating patterns resurface as maladaptive behaviors, allowing patients to circumvent the gastric restriction, which may result not only in decreased weight loss but possibly even weight re-gain.[3,4]

It is important to realize that pathologic binge eating is a psychiatric disturbance in eating behavior and is not driven simply by the physiologic sensation of hunger. BED has been conceptualized as the collective manifestation of disruptions in interpersonal and cognitive functioning and is therefore unresponsive to surgery unless the underlying psychological issues are also addressed.[23]

Diagnosing Binge Eating Disorder
The confusion surrounding the role of BED in weight loss outcomes is further complicated by the fact that assessment methods for evaluating BED are themselves variable. These include a myriad of self-reporting methods, screening-style questionnaires, and formal, clinical interviews. Predictably, the heterogeneity of assessment measures employed in current research often results in instrument bias, making it difficult to compare studies. Due to the confusion arising from these discrepancies, there has been a movement to examine more closely the assessment tools themselves, looking at their test-retest reliability, internal consistency, and overall empirical value when compared to what has for decades been endorsed by the psychiatric community as the “gold standard” for eating disorder diagnosis: the Eating Disorder Examination (EDE).[24–30]

Currently in its 16th edition, the EDE is a semi-structured clinical interview originally developed by Fairburn & Cooper in the late 1980s, in hopes of overcoming the limitations in evaluating pathological eating behavior that are built in to questionnaires and self-reporting measures.[29] This hour-long interview is administered by a trained technician and is flexible enough to pick up on the complex subtleties of eating-related psychosocial disturbances in individual patients while concurrently maintaining high levels of internal consistency, validity, and test-retest reliability.[28] The EDE has diagnostic capability and has come to be accepted as the most thorough tool available for BED diagnosis; notably, it assesses binge eating behavior according to the provisional criteria for BED outlined in the DSM-IV.[22,31] Important considerations when using the EDE are the need to train the interviewer on proper administration technique and the time commitment required for interview completion. On a practical level, an hour-long evaluation focused exclusively on eating disorders may not be feasible in cases where time devoted to the psychological assessment as a whole is already limited.

The Structured Clinical Interview for DSM-IV disorders (SCID) is a semi-structured interview increasingly used as a follow-up measure to authenticate and confirm questionnaire-based eating disorder screening results. Initially created to diagnose past or present Axis I psychiatric disorders (SCID-I), this hour-long evaluation is no longer limited to use by the psychiatric community alone.[32] The original SCID-I has been revised and adapted for use in diverse clinical and research settings. When considering all versions of the SCID, it is thought to be the most widely used diagnostic interview in North American research.[33]

The edition of the SCID most useful for bariatric patients is the SCID Research Version for Non-Psychiatric patients (SCID-RV/NP). This modified version of the clinical interview allows for evaluation of psychopathology in patients presenting without psychiatric symptoms and who are otherwise psychologically healthy. The SCID-RV/NP employs a set of DSM-based diagnostic modules to assess features of psychosocial pathologies, including substance abuse, anxiety disorders, and pathological eating patterns, such as BED, in the nonpsychiatric patient population.[34] Given its good internal and external validity, similar format, and time needed for its completion, the SCID-RV/NP appears to be on par with the EDE for use in the diagnosis of BED.[33]

Although it appears that the ASMBS encourages a clinical interview for the overall presurgical psychological assessment of bariatric patients, their stance on the instrument of choice for diagnosing eating pathology remains unclear. As part of their presurgical workup recommendations, the ASMBS has compiled a list of assessment measures frequently used in the psychological evaluation of bariatric patients. Nine methods, all questionnaire based, are devoted to looking at eating attitudes and behaviors.[35] The following is a brief summary of some of the BED measurement tools commonly used in current research:

•    Questionnaire on Eating and Weight Patterns-Revised (QEWP-R). This ia a 28-question self report that that is diagnostic for BED only if results are confirmed by clinical interview. Noteably, inclusion of the number of binge days per week over the past six months as part of its assessment, in line with provisional DSM-IV criteria for BED.[5,8,24,35,36]
•    Binge Eating Scale (BES). This is a 16-question self report predating the EDE for evaluation of all eating disorders. Notably, it does not include the criteria necessary for BED diagnosis by DSM-IV provisional criteria. The BES has been shown to function best as a screening tool due to its high sensitivity and low specificity. When inappropriately used as a diagnostic method, it results in a higher rate of falsely positive diagnoses of BED.[19,21,25,26,35,37]
•    Eating Disorders Examination Questionnaire (EDE-Q). This is a 41-question self report adapted from the semi-structured EDE interview that has shown internal consistency in discriminating patients with obesity and BED from non-BED patients with obesity. Overall, it shows only moderate-low levels of agreement with EDE interview. It is nondiagnostic of BED because it assesses binge frequency only in the previous 28 days, and not six months as required in the DSM-IV provisional BED criteria.[20,27,35]

It is advisable to, at the very least, be acquainted with the aforementioned measurement tools and to understand their respective functions: diagnosis, screening, and collection of qualitative health information for population analysis. Awareness of the diagnostic capacity and indications for use of the various instruments becomes valuable when interpreting research literature because it allows the clinician to see right away when tools are used inappropriately and/or out of context, thereby rendering study results meaningless.

A hypothetical case scenario best demonstrates the danger in misinterpreting research results from studies relying exclusively on self reporting for BED diagnosis. When a measurement tool has a high sensitivity and low specificity (i.e., a screening test like BES), patients that are truly negative for the disease will at times end up being falsely classified as positive for it (hence false positive). In our hypothetical case, a number of non-BED patients would be falsely designated as binge eaters at baseline, and at long-term follow up it would be discovered that their weight loss outcome was comparable to that of the truly non-BED patients (true negatives), who were accurately classified as such at baseline. Given the distortion of study parameters due to instrument misuse, the conclusion could be made that baseline BED has no effect on postoperative weight loss outcome—clearly a gross manipulation of the data, since none of the patients studied actually had BED to begin with.

Even more confusing is if the same study also evaluated binge eating behaviors: it can be extrapolated, for the sake of argument, that having had no pre-existing eating pathology, the false positive patients would not develop new-onset BED postoperatively. This would then suggest that bariatric surgery can cure binge eating disorder in patients with obesity. Given the evidence supporting obesity as a dynamically complex disease conceptualized best by a biopsychosocial model, drawing this type of conclusion would clearly miss the mark.[38] Considering these hypothetical scenarios shows that using instruments like the BES, QEWP-R, and EDE-Q to diagnose BED without a confirmatory clinical interview may produce distorted data and a skewed interpretation of results. Unless one is well-versed on the utility of the different evaluation tools and is able to recognize their misuse, the validity of conclusions made in these types of studies will remain uncertain.[26,30,39]

Overall, the lack of homogeneity in instruments used for BED diagnosis is responsible for much of the confusion surrounding this area of research. What little evidence has been gathered regarding BED in bariatric patients has limited credibility due to widespread measurement bias plaguing most studies. When discussing potential drawbacks of their study design, researchers who used questionnaire-based assessment measures to diagnose BED frequently admit that using self-reporting methods to inquire about eating patterns and to assess psychopathology is not generally reliable, and should therefore always be confirmed by a validated clinical interview.[40]

Final thoughts
It is worth mentioning that the trouble with current binge eating research is not limited to the varied interpretations of BED diagnostic criteria and eating disorder assessment techniques. Differences in follow-up interval length and discrepancies in what is considered a successful weight loss outcome all further obscure what little clarity exists about the relationship of patients’ baseline eating patterns and postoperative weight loss. The type of surgical procedure patients undergo matters as well because some procedures are associated with pronounced results at shorter-term follow up that subsequently level off over time, whereas others produce a steady postoperative weight loss until reaching a plateau.[2] Study design methodology is also concerning, as the predisposition to bias inherent in retrospective and cross-sectional studies makes determining the validity of data obtained difficult. Conclusions drawn from research employing prospective study designs would hold more empirical value for ascertaining the potential predictive role of BED in bariatric surgery outcomes; unfortunately at this time these types of studies are severely lacking.

Bariatric surgery is considered to be the most reliable method of achieving sustained weight loss that leads to regression of obesity-related comorbidities and facilitates a marked improvement in overall health. Optimizing chances of successful outcomes in bariatric surgery requires an understanding of the relationship between patients’ baseline psychological functioning and disturbances in eating behaviors in the context of their obesity; an appreciation of this link may elucidate strategies for preoperative interventions to address the risk factors thought to contribute to poorer outcomes. It is important to keep in mind the idea that obesity is not a unilateral disease and, therefore, warrants treatment methods that reflect its diverse and complex etiology.

Everyone in the multidisciplinary team caring for bariatric patients should be aware of the current mishmash surrounding the subject of binge eating, its role in obesity, and its potential implications in bariatric surgery outcomes. Caution should be exercised when interpreting study results, and until there is agreement on the meaning of BED and uniform endorsement of a definitive tool for its diagnosis, conclusions drawn regarding weight loss outcomes will not be generalizable and thus have little clinical value.

The bariatric surgery community should be encouraged to collaborate with researchers, clinicians, mental health specialists, and public health experts to establish a standardized set of guidelines for defining BED and its method of diagnosis. Only upon adoption of universal diagnostic criteria for BED and implementation of a reliable, validated assessment tool can advances be made in determining the impact of psychosocial factors such as binge eating disorder on surgical outcomes.

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  1. Joe says:

    I ran across this while searching for recipies perhaps for the post-op diet. What drew my interest to this artical,was the fact that i lost 120 pounds right @ my 1 year mark this May.On vacation May, June,and July of this year. I visited family and friends,out of town,thus began my problems.I had chicken sausage get stuck,which brought me to the local hospital there.Very next day I met the local Bariatric Dr.NIce guy,fixed the problem,so that nite when everyone went for ice cream I rewarded myself!!! I have been Binge Eating ever since.THUS now i know what I’m doing is called> (BED).Been since childhood.I’m 55 years old. Thank You SO Much.