The Hartford Courant
March 2015

Morbidly obese individuals who had weight loss surgery are seeking treatment for eating disorders years after their procedure, prompting concerns among some experts about the assessment process used to identify surgical candidates.

“They are terrified of gaining the weight back,” said Dr. Sara Niego, medical director of the Eating Disorders Program at Hartford Hospital’s Institute of Living, who has treated patients with anorexia, bulimia and binge eating disorder years after weight loss surgery.

The lack of a national “gold standard” to psychologically assess prospective patients has led Connecticut mental health professionals to call for standardized criteria to identify those who are at risk before and after surgery. They worry some patients with mental health problems may slip through the cracks because each hospital and insurance company has different psychological screening requirements.

“Unfortunately, there is no consensus in the field regarding what constitutes a psychological evaluation or what would prohibit an individual from obtaining surgery from a psychological standpoint,” said Kimberly Daniels, a clinical psychologist with the Center for Weight Loss Surgery at Middlesex Hospital. “There is not, but should be, a standard of care for these evaluations to minimize the psychological risks to clients.”

Life-Changing Surgery

Twenty-five percent of Connecticut adults are obese, up from 18.9 percent a decade ago, according to the Robert Wood Johnson Foundation. A combination of genetic, environmental and behavioral factors impacts obesity and morbid obesity. Morbidly obese individuals are 100 pounds over their ideal weight and have a 50 percent to 100 percent increased risk of premature death, studies show.

Many Connecticut hospitals offer, or are affiliated with a network that offers, weight loss surgery (also known as bariatric or metabolic surgery). While the types of bariatric surgery vary, the procedures all involve reducing the size of the stomach. Studies show that bariatric surgery can effectively treat morbid obesity and improve or resolve obesity-related diseases such as Type 2 diabetes, heart disease, sleep apnea and certain cancers.

Typically, patients lose the most weight one to two years after surgery, according to the American Society for Metabolic and Bariatric Surgery. On average, patients maintain 50 percent of their excess weight loss five years after surgery.

But for some patients, new or old patterns of disordered eating can surface years after surgery, leading to clinically diagnosed eating disorders. Disordered eating patterns are harmful behaviors – restricting food, binging and purging – that can develop into an eating disorder. Eating disorders are serious psychiatric conditions. Anorexia, for example, has the highest mortality rate of any psychiatric illness, reports the National Institute of Mental Health.

“The unhealthy behavior goes away for a while because of the substantial weight loss during the first two years – that’s the honeymoon phase,” said Niego. “Then the weight loss plateaus and some people begin to regain. That’s when the eating disorder or disordered eating resurfaces.”

Experts agree the most common eating disorder associated with obese individuals is “binge eating disorder,” which received its own diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders last year. People with binge eating disorder eat extremely large amounts of food and often report feeling out of control during the binging.

But views on the prevalence of eating disorders following weight loss surgery differ between bariatric surgeons and eating disorder specialists. In Connecticut, eating disorder experts said people who had weight loss surgery represent a new segment of patients seeking treatment at their facilities. Bariatric surgeons say cases of clinically diagnosed eating disorders after surgery are uncommon.

A lack of conclusive research on eating disorders in post-surgery patients clouds the debate.

Niego and colleagues conducted a review of research in 2007 that found an “association between pre-surgical binge eating and post-surgical binge eating.” In one study, 37 percent of people who binge ate before surgery continued feeling out of control when eating up to 15 years after surgery. Another study found 24 percent of patients who reported binge eating before surgery continued after the procedure.

Niego isn’t surprised that some post-bariatric surgery patients seek help for eating disorders.

“You cannot cure a mental disorder through surgery,” she said.

Identifying At-Risk Patients

Although individuals undergo a psychological evaluation before surgery, identifying those at risk poses challenges because people aren’t always up-front about their eating habits, said Rebekah Bardwell Doweyko, program director of Walden Behavioral Care in South Windsor, which treats people with eating disorders.

“How honest do you think people will be on a psychiatric evaluation that determines if they’re eligible for a surgery they perceive is going to save their life?” she said.

Dr. Rishi Ramlogan, medical director of the Bariatric Surgery Program at Griffin Hospital, estimated that 95 percent of people who regain weight after surgery do so because of behavioral reasons.

“Patients need to understand that bariatric surgery is not a quick fix or magic pill,” he said.

“Oftentimes, surgery is the easiest part of the whole process. The real challenge is making the necessary lifestyle changes.”

Post-Surgery Support

Follow-up care for patients includes support groups, education forums, checkups with the surgeon, nutritional counseling and behavioral health consultations and treatment.

“We assume all weight loss surgery patients will struggle to some degree with behavior changes because if it were easy, fewer would require surgery,” said Jennifer Ferrand, a clinical psychologist who works with bariatric patients at the Institute of Living, adding that early intervention “could prevent the development of a full-fledged eating disorder.”