The Mindful Eating Cycle: Preventing and Resolving Maladaptive Eating after Bariatric Surgery

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by Michelle May, MD; Margaret M. Furtado, MS, RD, LDN; and Lisbeth B. Ornstein, PhD

Dr. May is Founder, Am I Hungry? Mindful Eating Workshops and Facilitator Training Program, Author of Eat What You Love, Love What You Eat (Am I Hungry? Publishing; 2012), and Co-author of Am I Hungry? Mindful Eating for Bariatric Surgery (Am I Hungry? Publishing; 2013). Ms. Furtado is a first-year medical student at St. George’s University School of Medicine in Grenada, West Indies. Dr. Ornstein is Assistant Clinical Professor of Psychiatry/Psychology, University of Rochester School of Medicine and Denistry, Rochester, New York.

Funding: No funding was provided.

Disclosures: Dr. May reports the following conflicts of interest related to the content of this article: Founder: Am I Hungry? Mindful Eating Workshops and Facilitator Training Program, Author: Eat What You Love, Love What You Eat (Am I Hungry? Publishing; 2012), and Co-author of Am I Hungry? Mindful Eating for Bariatric Surgery (Am I Hungry? Publishing; 2013). Dr. Ornstein Am I Hungry? Mindful Eating Workshop Facilitator. Ms. Furtado reports no conflicts of interest related to the content of this article.

Bariatric Times. 2014;11(2):8–12.

ABSTRACT
The challenges posed by a food-abundant environment, social and emotional connections to food, chronic ineffective dieting, and disordered eating may not resolve with bariatric surgery. Offering a structured approach for learning mindful eating skills using the Mindful Eating Cycle may help bariatric surgery patients gain insight into why, when, what, how, and how much they eat and where they invest their energy. The addition of mindful eating skills to the clinicians’ and patients’ toolbox provides conscious decision-making strategies and sustainable lifestyle changes over time.

Introduction
Weight cycling, yoyo dieting, and disordered eating patterns are common in individuals who meet the criteria for bariatric surgery.[1–5] If not addressed, mindless habits, emotional eating, and maladaptive eating may contribute to challenges commonly seen after bariatric surgery.[6]

For example, in a qualitative study about “grazing” (i.e., frequently eating small amounts of food throughout the day) in post-bariatric patients, when asked “How does grazing affect you?” the most popular theme was “old habits,” which included the following: not sitting down to eat, eating too fast, not taking time to chew, and eating “foods the stomach cannot tolerate.”[7]

In high-risk respondents who had binge eating or grazing patterns before gastric bypass surgery, 80 percent reported recurrent feelings of loss of control over eating, reappearing an average of six months after surgery. Many patients who had binged before surgery, reported a shift to grazing occurring an average of 3 to 5 times per week. Half of the high-risk patients reported eating too much, stating that they were seeking the comfort of the too-full feeling they had experienced before surgery.

They reported knowing when they were full, but continued to eat, even if they suffered physical consequences.[8]
Some bariatric surgery patients discover that they “miss their friend, food,” and lack the skills to manage their triggers and emotions. One patient stated, “I’ve cut out my coping skill.” Another said, “They didn’t operate on my brain.”[9]

Examples of this can be found in a 12-month study of 129 bariatric patients that looked at uncontrolled eating and grazing. One year post-laproscopic adjustable band surgery (LAGB), 22.5 percent of the subjects reported feelings of loss of control during the consumption of a subjectively or objectively large amount of food. They had significantly lower weight loss, consumed a higher than usual energy intake and percentage of energy as fat, and ate more often over the period of a day. They reported less dietary restraint and greater hunger and disinhibition. They reported eating in response to emotional triggers, ignoring satiety cues, and difficulty maintaining behavior change. Symptoms of depression were higher, and mental health-related quality of life was poorer compared to the remainder of the cohort. Additionally, 94 percent of patients with preoperative grazing continued to report this eating pattern after surgery.[10]

In a small study measuring patient adherence, of patients “who failed to modify their eating behavior on the advice of two or more health professionals,” 89 percent reported overeating in response to emotional triggers and 78 percent reported grazing.[11]

Some patients may believe that if they have bariatric surgery they will not need to think about their eating anymore.[11] In fact, long-term success after bariatric surgery requires just the opposite: patients need to become very mindful about eating in order to use their surgery optimally to develop and maintain a healthy lifestyle. If they are not mindful, they may suffer from uncomfortable, even serious consequences—and are less likely to achieve the expected results. Even patients who have a more realistic understanding of the complexities of life after bariatric surgery may find that their postoperative meal plan feels like a permanent diet that continues to consume their attention and energy.

Mindful Eating
Mindful eating is emerging as a universal approach for addressing various eating-related issues including binge eating, diabetes, and obesity.[12–17] The ancient concept of mindful eating may help prevent, identify, and resolve maladaptive eating and other problems in people who are having difficulty adjusting to life after bariatric surgery.
A simple definition of mindful eating is eating with intention and attention—or eating with purpose and awareness. Mindfulness is beneficial because it teaches individuals to focus their intention and attention on what is happening in the present moment, which, in turn, helps them disengage from habitual, unsatisfying, and unskillful habits and behaviors.[18]

Mindful eating skills may address many of the behavioral problems commonly seen after bariatric surgery.[9] These problems include the following:
•    Eating too quickly, taking large bites, not chewing thoroughly
•    Eating while distracted, leading to overconsumption
•    Not savoring food and, therefore, having difficulty feeling satisfied with small volumes of food
•    Eating too much, leading to discomfort, vomiting, and/or distention of the pouch
•    Grazing or frequently eating small amounts of food
•    Consuming high-calorie soft foods and liquids that do not provide satiety
•    Emotional eating or eating for affect regulation
•    Continuing to consume certain foods despite dumping syndrome
•    Preoccupation with food
•    Not consuming enough protein and other nutrient-rich foods
•    Struggling to establish consistent physical activity
•    Feeling deprived, guilty, or left-out in social situations
•    Weight regain and weight cycling

The Mindful Eating Cycle
The Mindful Eating Cycle incorporates the essential elements of mindful eating and offers a structure that is helpful for the clinician and patient alike.[19] The remainder of this article describes six specific questions that guide the patient through the entire decision-making process. This structure can be used in pre- and postoperative educational and support settings.

Why do I eat? Understanding why individuals make certain decisions about eating is essential because although patients may initially lack awareness or insight, the underlying reason they are eating will affect every decision that follows. For example, if a person is eating in response to environmental or emotional cues, such as stress, boredom, or socializing, he or she is more likely to choose foods that are convenient, energy dense, and highly palatable.[20] He or she may be more likely to eat an excessive amount of food or graze continuously because eating does not adequately address the underlying trigger.

A study of 40 women examined the role of experimentally induced stress on food choice. Highly stressed women were shown to prefer sweet and high-fat foods, while those in the low-stress condition ate more low-fat foods.20

When do I eat? Research has demonstrated that normal-weight individuals are more likely to eat in response to internal cues like hunger, whereas people who are overweight tend to eat in response to other cues.[21] Hunger is a primitive yet reliable method of regulating dietary intake and awareness of hunger cues can be relearned.[22]
Immediately after bariatric surgery, hunger signals may be absent for a period of time, requiring the patient to follow external cues for eating and reminders. As hunger cues return, they can begin to use hunger like a fuel gauge to let them know when to eat. It is important to differentiate true physical hunger from other environmental and emotional cues by identifying physical symptoms, such as a growling stomach, difficulty concentrating, and irritability.[16] Patients often discover that waiting to eat until they are sufficiently hungry increases satisfaction, while grazing or waiting until they are overly hungry may lead to overeating.

Environmental and emotional cues can also trigger an urge to eat (or to continue eating) whether or not there is a physical need for fuel. Examples of environmental triggers include the following: appetizing food, meal times, holidays, advertising, and large portion sizes.[20–22] While opportunistic eating may have been adaptive through much of evolutionary history, it is problematic in the current food-abundant environment.[26] When an individual recognizes that an urge to eat was triggered by something in their environment, they can choose to redirect their attention to another activity until the urge passes, reminding themselves that they will eat when they get hungry. They can prepare for these situations by having a variety of appealing alternate activities available, such as reading, puzzles, journaling, or woodworking.

Other behavioral strategies for decreasing environmental triggers include keeping food out of sight, avoiding locations that are likely to have food (e.g., the office break room), and ordering half-portions or sharing meals. With practice, this process helps individuals break the habitual association between certain activities, people, and places, and overeating.

While all people eat for emotional reasons to an extent, including comfort, celebration, and pleasure, emotional eating becomes maladaptive when it is used as a primary coping mechanism to comfort, avoid, numb, or distract oneself from emotions. Common emotional triggers include boredom, stress, sadness, anger, loneliness, and even happiness. If someone had been using food to help them cope with stress and other emotions, bariatric surgery will disrupt their primary coping strategy. However, if they do not learn alternative means of coping, distress will increase and overeating or other maladaptive coping behaviors will emerge. Addressing emotional eating is an essential component of any long-term weight management strategy.[27–29]

When individuals gain insight into their environmental and emotional triggers for eating through mindfulness, they can expand their range of coping mechanisms and improve their ability to identify and deal with their feelings. Often, new skills and tools, such as stress management, positive thinking, and boundary setting, are needed so it is best to approach this as a process, referring for counseling when necessary. When patients learn more effective strategies for coping with their emotions and use food less often for comfort or to avoid dealing with feelings, two things are likely to happen. First, their desire to overeat diminishes. Second, and most importantly, they begin to find fulfillment in experiences other than eating and meet their true needs more effectively.

What do I eat? Most patients have tried numerous diets before deciding to have bariatric surgery. Research has shown that dieters exhibit an increased preoccupation with food, feelings of deprivation and guilt, and resignation when they break from their diet.[30] Consequently, they develop feelings of failure, lowered self-esteem, and decreased self-efficacy that often leads to more overeating. This same pattern can continue following bariatric surgery. Patients with a history of bingeing or grazing preoperatively report a return of old thinking patterns, including diet mentality of “good food/bad food,” labeling themselves as “bad” if they ate the wrong foods, and being preoccupied with food. Craving certain foods was reported along with fears that these foods could not be eaten in moderation.[8]

Mindful eating acknowledges the individual’s ability to cultivate wisdom (the integration of knowledge and experience) about what to eat. Therefore, rather than listing allowed foods, a mindful eating approach provides education about the anatomical and physiological changes resulting from a particular bariatric procedure, then invites the patient to trust the information provided or experiment with it. Rather than feeling that they are being deprived of foods they love, patients are given the power to choose foods that are nourishing, pleasurable, and lack uncomfortable or embarrassing side effects.

Furthermore, mindful eating helps patients recognize that grazing throughout the day, consuming calorie-dense liquids, or eating “slider” foods, such as pretzels, crackers, or potato chips, does not lead to the adequate satiety, whereas consuming an adequate amount of protein and nutrient-rich foods helps them feel satiated and healthy. With nonjudgmental awareness, the individual can take ownership of his or her ability to make eating decisions that help him or her feel better and will improve his or her health.

How do I eat? Mindful eating is nonjudgmental awareness of physical and emotional sensations associated with eating.[12,31] Each decision point in the Mindful Eating Cycle contributes to this awareness. When one gives food, eating, and physical cues their full attention, they are more likely to experience optimal satisfaction and enjoyment without eating to excess.
Encourage pre- and postoperative bariatric surgery patients to engage in the following mindful eating practices:19
•    Eliminate or minimize distractions while eating, including watching television, working, driving, and reading.
•    Sit down to eat, preferably at a table designated solely for that purpose.
•    Take a deep breath to calm and center oneself before eating.
•    Appreciate the appearance and ambience—a feast for the eyes—before taking the first bite.
•    Savor the aromas and flavors of the food.
•    Take small bites and chew each bite thoroughly.
•    Put the fork down between bites to keep attention focused on the current bite.
•    Pause frequently while eating to identify early physical signals of satiety.
•    After eating, notice how you feel physically and emotionally.

Often, the positive results from eating mindfully will motivate individuals to become more mindful in other aspects of their lives, increasing enjoyment and effectiveness.

How much do I eat? After bariatric surgery, fullness feels different and comes on more rapidly with much less food. With increased awareness, patients may learn to avoid the physical discomfort of fullness as an internalized mechanism of portion control. This is an essential new skill for someone who previously had a habit of eating until their plate was clean, the package was empty, or they felt physically uncomfortable. Mindful eating guides postoperative patients to pause after each bite and check for the subtle early signals of satiety, such as a sigh, a tiny hiccup, or awareness that they feel content so they can stop eating before they begin to experience uncomfortable symptoms (e..g., pressure or pain in the upper abdomen or chest or nausea and vomiting).

Where do I invest my energy? Research has demonstrated that post-bariatric surgery patients who are active have higher health-related quality of life and greater weight loss than those who are relatively inactive.[32]

Unfortunately, chronic dieting and popular weight loss messages have led many patients to equate exercise with punishment for eating. Furthermore, discomfort and lack of time may contribute to negative associations and avoidance of exercise. Therefore, it is helpful to elicit the patient’s feelings about exercise and work with them to write a physical activity prescription tailored to their preferences and level of fitness. If they are not ready to begin exercising, they can be coached to come up with ideas for increasing their lifestyle activity, such as parking further from the building or walking to the mailbox, and increasing activity as tolerance increases.

However, an individual’s energy requirements are much greater than just exercise. A whole-person approach to the question “Where do I invest my energy?” includes asking patients to consider specific steps for improving the health of the physical, emotional, mental, social, and spiritual aspects of their lives. Food becomes fuel when the individual shifts his or her focus from eating to creating a balanced, fulfilling life. The goal is to guide patients to develop a healthy, satisfying, mindful approach to eating, physical activity, and living.

Summary
Bariatric surgery outcomes vary greatly and are associated with eating pathology observed in patients both pre- and postoperatively. Chesler[33] notes that, surprisingly, emotional eating has been a virtually untreated risk factor impacting the outcome of this surgery. While nearly all patients lose weight in the first year postoperatively, for many, the challenges begin when “the honeymoon is over.” We propose that training in mindful eating, optimally preoperatively, but certainly during the first year after surgery, can improve outcomes by helping patients learn skills that target detrimental eating behaviors that may lead to poorer outcomes post-surgically, including rapid eating, distracted eating, grazing, and emotional eating.

The Mindful Eating Cycle incorporates the essential elements of mindful eating and offers a simple structure to guide the patient through the entire decision-making process. We encourage bariatric surgery programs to add this essential component to the recommendations that they make to candidates for bariatric surgery in order to prevent and resolve maladaptive eating.

Author’s Note: Please visit our updated website at www.AmIHungry.com in late February for new resources, handouts, and other tools for healthcare professionals and patients.

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