Eating Disorders After Bariatric Surgery: Warning Signs and Risk Factors

| March 1, 2022

by Abby Bleistein, MD, DOMA

Dr. Bleistein is the founder and director of Healthful Life MD in Golden, Colorado; is with Eating Recovery Center in Denver, Colorado; is board-certified in Internal Medicine and Pediatrics; and is a Diplomate of the American Board of Obesity Medicine.

Funding: No funding was provided.

Disclosures: The author has no conflict of interest relevant to the content of this article. 

Bariatric Times. 2022;19(3):20

Eating disorders are deadly diseases that impact psychosocial functioning and quality of life. Unfortunately, eating disorders are prevalent in patients seeking obesity treatment. One study indicated that as many as 49 percent of patients seeking bariatric surgery have binge eating disorder.1

If left untreated, patients with eating disorders prior to surgery are likely to have symptoms after surgery. The data quantifying the prevalence of various eating disorders before and after bariatric surgery is currently sparse, and the studies that are available are inconsistent and show a broad range of occurrence. Patients who receive treatment for eating disorders are much more likely to improve and significantly less likely to die from the disease,2 and therefore, recognizing these diseases and treating them appropriately will not only improve quality of life for these patients, but could also save lives. 

Quantifying the extent of this problem is challenging. Definitions of eating disorders vary among studies and lead to inconsistent data on the prevalence in this patient population. In addition, symptoms of eating disorders both prior to and after bariatric surgery go unrecognized or are minimized by both patients and doctors. Both patients and their physicians might not recognize that the patient’s behaviors constitute an eating disorder. Indeed, a characteristic feature of anorexia is denial of symptoms or lack of recognition of the symptoms.3–5 Patients carry a great deal of shame around their behaviors, particularly those struggling with binge eating disorder or purging behaviors, so they do not readily share their symptoms or struggles. Many programs currently do not incorporate screening for eating disorders or problematic eating after bariatric surgery, so the diagnosis can be missed. Loss to follow-up among these patients might also limit identification of those struggling with the disease. 

There is good news; obesity experts have the potential to better define criteria for eating disorders, provide thorough screenings for patients seeking obesity treatment, and recognize problematic eating behaviors in postbariatric surgery patients. 

Warning signs and risk factors. Risk factors for eating disorders and obesity are oftentimes similar—both are associated with trauma history and adverse childhood experiences. Extra weight can be both a cause and the result of an eating disorder. Eating disorders have a genetic association that can run in families as well.6 

  • There are a variety of signs to look for in patients postsurgery. Patients displaying any of the following could be experiencing disordered eating:
  • Not losing weight as expected, either losing less than expected, plateauing, or losing faster than expected 
  • Experiencing syncope, sleepiness, or fatigue 
  • Turning to laxatives or diuretics, which could cause ongoing problems with electrolytes
  • Sleep problems, which could be a result of night eating syndrome or binge eating disorder

Keep the issue top-of-mind for patients. Bariatric surgery treats obesity and the associated comorbidities, not the eating disorder, which is why screening prior to surgery is vital. A variety of validated eating disorder screening questionnaires and preoperative screening guidelines1 are available for providers to use before bariatric surgery, and some have even been adapted for postbariatric surgery. Regularly asking questions about eating behaviors is crucial to determine if a patient is struggling with disordered eating before and after bariatric surgery. 

Some questions to identify eating disorders include: 

  • Do you ever feel out of control with your eating?
  • Do you feel that you eat until you are overfull?
  • Do you eat for prolonged periods—over several hours?
  • Are you eating in secret?
  • Tell me about your rules around eating/certain foods (e.g., I can eat ice cream if I eat celery for lunch).
  • Are you engaging in harmful behaviors to lose weight?
  • Are you using laxatives or diuretics? How are you taking them?
  • Do you go more than eight waking hours without eating?
  • Do you spend an excessive amount of time worrying about your weight, shape, or food?
  • Are you able to meet your nutrition goals? Are you missing or skipping meals?
  • How often are you vomiting? Do you ever intentionally vomit?

A lack of data and the challenges around identifying eating disorders in postbariatric surgery patients highlights the critical role obesity experts play in properly defining, screening, and treating eating disorders before and after bariatric surgery. Obesity experts have the opportunity to extend and improve patients’ quality of life and postsurgery outcomes. 

Our bariatric surgery and eating disorder insights continue to evolve. Join the Obesity Medicine Association’s (OMA’s) upcoming spring conference,8 offered both in-person in Atlanta and virtually, to learn from the best in obesity treatment. OMA also offers a variety of digital tools, webinars, and educational resources for providers. To learn more about OMA or become a member, visit 


  1. Cella S, Fei L, D’Amico R, et al. Binge eating disorder and related features in bariatric surgery candidates. Open Med (Wars). 2019;14:407–415.
  2. Ward ZJ, Rodriguez P, Wright DR, et al. Estimation of eating disorders prevalence by age and associations with mortality in a simulated nationally representative US cohort. JAMA Netw Open. 2019;2(10):e1912925.
  3. Substance Abuse and Mental Health Services Administration (US). Table 19, DSM-IV to DSM-5 anorexia nervosa comparison. In: DSM-5 Changes: Implications for Child Serious Emotional Disturbance. 2016 Jun. Accessed 25 Feb 2022.
  4. Bilić S, Sander J, Bauer S. Overcoming barriers to the treatment of binge eating. In: Frank G, Berner L. (eds) Binge Eating. Springer, Cham; 2020.
  5. Kästner D, Weigel A, Buchholz I, et al. Facilitators and barriers in anorexia nervosa treatment initiation: a qualitative study on the perspectives of patients, carers and professionals. J Eat Disord. 2021;9(1):28.
  6. Trace SE, Baker JH, Peñas-Lledó E, Bulik CM. The genetics of eating disorders. Annu Rev Clin Psychol. 2013;9:589–620.
  7. Assessment Psychology Online. Bariatric pre-surgical psychological assessment. Accessed 17 Feb 2022.
  8. Obesity Medicine Association. Obesity medicine conference 2022. Accessed 17 Feb 2022.

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Category: Medical Methods in Obesity Treatment, Past Articles

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