Maladaptive Eating Patterns After Weight-Loss SurgeryMedical College of Wisconsin, Milwaukee, Wisconsin Correspondence: Mark D. Rusch, 9200 West Wisconsin Avenue, Milwaukee, WI 53226. Electronic mail may be sent to mrusch{at}mcw.edu. Weight-loss surgery has been shown to contribute to the improved health and well-being of the clinically severe obese, and for many has been seen as their "last resort." Although the majority of patients who choose this option as a means to achieve a healthier weight are successful, for some patients it is not beneficial. Bariatric surgery is not a panacea, and its immediate and long-term success depends on the patient's ability to incorporate lifestyle and behavioral changes. Patients who are not successful in achieving and maintaining their anticipated weight loss struggle to comply with diet, exercise, and vitamin regimens. Not only do these patients exhibit diminished weight loss, they have put themselves at risk for vitamin and mineral deficiencies and protein malnutrition. Their problematic response to weight-loss surgery may or may not be due to a worsening of presurgical depression, binge eating, emotion-triggered eating, body image, or eating behaviors associated with specific situations such as social events. This paper describes clinical responses we have observed in our bariatric practice. Several case studies are presented to highlight problems we have encountered when following bariatric surgery patients in the early postoperative period, as well as in a long-term setting. Recommendations are made for screening and follow-up of at-risk patients. Bariatric surgery continues to be the treatment of choice for extreme obesity.1,2 Depending upon the surgical procedure, patients are expected to lose 60% to 80% of their excess body weight within the first 2 years of their operation.3,4 The rate of weight loss diminishes 18–24 months after surgery. After 2 years, patients may begin to gain weight, in some cases as much as 15% of their total weight loss.4–7 Most surgery patients experience significant improvement in health conditions, including type 2 diabetes,6 hypertension,8 pseudotumor cerebri,9 obstructive sleep apnea, reflux esophagitis, stress overflow urinary incontinence, and low-back and joint pain.8 Psychological benefits are also noted, including reduction in anxiety and depressive symptoms,10–12 improved quality of life,13 reduction in the role of food as a factor in controlling daily behavior and activity patterns,14 and improved body image.15 Although most surgery patients comply with postoperative dietary, vitamin, and exercise regimens, a significant minority fails to do so. These patients will experience inadequate weight loss, early weight regain, and serious medical and nutrition complications. This paper describes several common problematic responses to weight-loss surgery. It is based upon a literature review, as well as our experience during follow-up with 289 gastric bypass patients, ranging from several weeks to 28 months postoperative. Of this group, 69% exhibited no evidence of maladaptive reactions and conformed to the postoperative dietary requirements. They demonstrated weight loss patterns within the expected range. Another 8% reported a worsening of presurgical depression but were nevertheless compliant with diet. Disordered eating of various types and degrees characterized the remaining 23%. We will describe the behaviors and psychological experiences of these patients by grouping them according to the most salient elements of their maladaptive responses. We should emphasize that of this 23%, many reported an increase in depressive symptoms after surgery. However, unlike the 8% of patients described above who reported increased depression as the primary problem after surgery, this latter group exhibited significant dietary noncompliance. Their noncompliance led to insufficient weight loss or actual weight regain. Their failure to achieve anticipated results was the stimulus for the onset of their depressive symptoms. Maladaptive eating after weight loss surgery typically represents a continuation or recurrence of presurgical habits and patterns. The most common problems are listed in Table 1.
Does a history of presurgical binge eating predict disordered eating postoperatively? Classic binge episodes (eating substantially large amounts of food during short periods of time with a sense of loss of control) generally do not occur during the first few years after bariatric surgery. This is due to the restrictive nature of the surgery and the inevitable consequences of vomiting in response to rapid eating or overconsumption. However, patients can develop the capacity to overconsume by snacking throughout the day. Snacking will result in a total daily caloric intake that will exceed optimal postoperative consumption. Several studies support the contention that binge eating, however frequent before surgery, stops after surgery.16–18 The postoperative follow-up interval in these studies was unfortunately limited to 6 months. Other studies suggest higher rates for postsurgical maladaptive eating behaviors among patients diagnosed with binge eating during presurgical screening, including higher vomiting frequency and increased likelihood of neostoma stenosis,19 higher incidence of gastric pouch/esophageal dilatation, and greater number of band adjustments after adjustable gastric banding.20,21 Prospective studies also identify higher frequency of postoperative night-eating syndrome, consumption of large quantities of high-calorie fluids, and feelings of loss of control among patients who engaged in binge eating before surgery compared with those who did not binge eat.22–25 Treatment for binge eating emphasizes dietary changes and the use of cognitive behavioral strategies. Hunger is often a precipitant for binge episodes. After weight-loss surgery, hunger-control strategies include eating at regular meal times, ensuring that meals are not skipped, and timing consumption of liquids appropriately in relation to mealtimes. Weight-loss surgery may prevent binge eating due to diminished stomach volume, but the dynamics responsible for binge eating typically survive. Surgery may indirectly contribute to long-term reduction in binge eating for patients who learn new approaches to the management of negative emotions and stress during the early postoperative period. Cognitive behavior treatments include careful monitoring of binge-eating episodes to identify patterns of binge eating and situational, emotional, and cognitive triggers. The development of substitute activities, incompatible with eating, introduces healthy and effective alternatives for binging. Some patients eventually resume binge eating (usually on a smaller scale) because life stressors persist and the relief associated with binge eating continues to influence eating behaviors.
Large numbers of patients seeking weight-loss surgery admit to eating in response to stress and specific emotions (depression, anxiety, loneliness, and disappointment). Their snacking episodes fail to meet criterion for binge eating but occur with such regularity that distinct behavioral patterns are easily identified before surgery (eg, purchasing snacks or visiting the drive-through at a fast food restaurant every evening after work, then eating a full meal at home). Preoperative patients also report specific efforts to maintain a supply of "comfort foods" at home or at work and sometimes in the car. Longstanding use of food as an effective coping strategy eliminates the need to search for alternatives. Changing a habit is difficult. High-fat and sugar foods are potent reinforcers for which there are few effective substitutes. Exercise (another form of stress release) is usually beyond reach for the extremely obese patient who may experience lowerextremity pain, shortness of breath, and fatigue with even minor exertion. Gym membership for use of the pool or low-impact equipment is usually out of the question. Most extremely obese patients are simply too embarrassed about their appearance to consider exercising in a public setting. Many may confront safety risks in using health club equipment. Weight-loss surgery usually prevents stress and emotional eating because it limits the patient's ability to consume typical snacks. Early experimentation often demonstrates that chips, chocolate, bakery items, or cookies cannot be consumed without consequences (nausea, vomiting, or dumping syndrome). Despite this feedback, patients may persist in their attempts to eat former snack foods when confronted by a stressful situation. Some patients experiment with more easily consumed alternative foods such as malts and shakes. With repeated reintroduction of small amounts of high-fat and sugar content foods, patients "learn their limits." They will consume these foods in smaller volumes until they experience minimal symptoms such as nausea and will then halt further consumption. Therefore, patients may gradually resume presurgical patterns of snacking to relieve stress, frustration, and loneliness. Elkins et al26 observed that at 1 year after Roux-en-Y gastric bypass, 37% of their patients had resumed snacking. In a 12-month follow-up study of patients after gastric restrictive procedures, cravings for sweets after surgery were associated with significantly less weight loss.27 Patients find ways to circumvent surgically induced controls, given sufficient motivation.
RS is a 31-year-old single woman living with her parents. Presurgical weight was 310 pounds. By the end of the seventh month after surgery, she had lost 100 pounds but then had a foot fracture during a fall. Unable to continue exercising, she felt that a critical element of her weight-loss strategy was now lost. She subsequently became discouraged and observed an increasing disinterest in monitoring her diet. Her weight remained steady. When she realized she had stopped losing weight, RS experienced significant discouragement, despite the initial loss of 100 pounds. As her mood worsened, she considered other aspects of her life that left her feeling dissatisfied, including the facts that she was living with her parents, disliked her job of 7 years, and did not have a boyfriend. RS began snacking when feeling unhappy and depressed. At 33 months postsurgery, she had regained 55 pounds; at 36 months, she weighed only 30 pounds less than her preoperative weight. After reporting her depressive symptoms to her primary physician, she started taking an antidepressant. She also returned to the surgery program for the follow-up she had been avoiding due to her feeling ashamed about her weight regain. She reluctantly admitted to numerous breaches of the bariatric surgery diet. For example, RS had slowly reintroduced chocolate to her daily snacking, with minimal adverse consequence. She also began stopping at a fast food restaurant on her way home from work but would also eat a dinner meal prepared by her mother each evening. As she had done before surgery, she purchased large bags of chocolate candies. But now she hid the candy in her bedroom to avoid detection by her parents, who had commented about her obvious weight gain. RS described her life as "at a standstill" and herself as a "failure." She was again regularly eating to relieve stress and discouragement. Although the amount of food consumed was still controlled by the surgery, frequent snacking without immediate consequence was possible. RS realized that any further weight loss would only occur if she took the necessary steps to modify her eating habits. She was deeply pessimistic about succeeding, given her extensive presurgical history of failed weight-loss attempts. To be effective, treatment of this patient's postsurgical weight gain required attention not only to her eating behaviors, but also to her sense of having lost control of her diet. In addition, she expressed dismay over the fact that as a result of her behavior, she failed the most effective weight-loss strategy available, that is, weight-loss surgery. During psychological intervention, she admitted to being depressed. She accepted referral for psychiatric consultation, which resulted in the use of serotonin-specific reuptake inhibitors known to have appetite-suppressant effects. Subsequent psychological treatment challenged her assumptions that she had lost control over her diet by helping her understand that all snacking and other eating episodes occurred as a result of direct decisions she was making (eg, deciding to stop at a fast food restaurant after work). On the basis of this analysis, she realized that rather than having lost control of her diet, she was actively making decisions to eat certain foods. The problem was that her decisions compromised long-term weight loss goals. With this perspective on control and decision patterns in mind, RS learned to use stimulus-control strategies based on proactive thinking and planned activities. For example, she started driving directly to a health club after work rather than to a fast food restaurant. Using behavioral analysis, she identified behaviors that inevitably led to the purchasing of bags of chocolate candies. Minor changes in related routines brought that behavior under control. She identified high-risk times and situations for snacking at work and at home. Using this information, she introduced alternative activities that were incompatible with eating, such as taking 10-minute walks during breaks at work rather than visiting the vending machines. The increased sense of self-efficacy and accomplishment brought about improvement in mood and increased the patient's desire to pursue original weight-loss goals.
Eating patterns can also be tied to situations, places, and activities (eg, lunches with coworkers, snacking while watching television, eating at social events). After surgery, patients may feel that "something is missing" during activities formerly associated with eating. Counseling patients to help them change these routines before surgery will reduce the postoperative stress and emotional tension that may be experienced. Patients do not anticipate that postoperative dietary restrictions may contribute to social isolation after surgery. This effect pertains to single patients in particular. Typical presurgical social activities for these patients involves lunches with coworkers and evenings with friends at bars and restaurants. During the first 6–10 months after surgery, they spend their weekend evenings at home alone. They are unable to consume alcoholic beverages and most restaurant foods (or at least standard portions); therefore, they feel conspicuous in social situations. They often choose to avoid the experience completely. This decision exposes them to loneliness, often a previous predisposing factor for snacking. Psychological intervention for stress/emotional eating and situation-induced eating follows the approach described for binge eating. When patients are able to identify frequent and recurring patterns of using food to alleviate stress, they need little prompting to generate solutions. Strategies can be as straightforward as basic behavioral measures of stimulus control (eg, eliminating specific foods from the grocery list). We engage patients in the use of a problem-solving model, a "scientific" approach to identifying the problem, proposing, implementing, and evaluating solutions. This approach is helpful in part because it offers an alternative to patients viewing themselves as having "no willpower" or of being "compulsive eaters." These labels contribute to feelings of helplessness and pessimism. A problem-solving approach correctly shifts attention to behavior change and effective solution.
Body image generally improves not only after medical weight loss28,29 but also after surgically induced weight loss.30 Patients with early-onset obesity will report less satisfaction with their body image after losing weight than those with adult-onset obesity.30 We have observed 2 distinct kinds of body-image problems that contribute to intentional weight regain after surgically induced weight loss. The first problem is redundant skin (thigh, hip, abdominal, breast, and upper arm areas). Patients (and significant others) view this sagging skin with disgust. It can be more than a cosmetic problem, leading to dermatologic complications. Surgical removal offers the only effective treatment, but is generally covered by insurance only if deemed medically necessary. Occasionally, patients respond by increasing caloric consumption in order to gain enough weight to, as one patient phrased it, "fill out a little." The second problem related to body image involves disproportionate weight loss, resulting in substantial distortion of and dissatisfaction with body image (usually an exaggerated appearance of the hips in contrast to the upper torso). Some patients are so distraught over their appearance that they too may decide to gain weight in an attempt to restore some sense of proportion. The risk involved for both patient groups is that strategies and efforts used to gain moderate amounts of weight become difficult to control. Patients often end up regaining considerably more weight than they had intended. Patients presenting with significant body image concerns often benefit from a brief intervention during which they review their original reasons for seeking weight loss. Current improvements in health and mobility are emphasized. During this intervention, they are also encouraged to evaluate current and future goals, interests, and values as a means of shifting focus from body image to other attainable and meaningful activities.
The typical surgical weight-loss patient reports a lengthy history of failed weight-loss attempts, low self-efficacy for weight loss, and a failure mentality for this behavior. It should be noted that many of these patients are highly successful in other aspects of life, including career, family, and avocational accomplishments. Against this background of repeated failed weight-loss efforts, surgery stands out as a method offering definite and substantial weight loss. Surgical candidates understand that they will vomit or experience dumping syndrome after diet deviations. In fact, most patients anticipate that these undesirable consequences will function as highly effective dietary control, curbing impulses and punishing lapses. Most patients will test limits over time, experiment or absentmindedly select potentially problematic foods such as chocolate, cookies, cakes, etc. This is particularly true of patients with long histories of excessive snacking presurgically. At some point (often in response to repeated instances of ingesting small amounts of "forbidden" foods), patients realize that the surgically induced controls no longer work. At this point, we see highly anxious patients returning to the clinic, expressing fears of imminent weight regain. They had come to rely on gastrointestinal distress for diet control, only to discover that "the ball is back in their court." Their history of failed weight loss may trigger catastrophic thinking, feelings of helplessness, self-criticism, and concerns about their ability to control their diet. The associated negative emotional states that result can contribute to a recurrence of stress and emotional eating. Cognitive-behavioral therapy can assist these patients in identifying thinking patterns that contribute to feelings of helplessness and fear of failure. Their considerable distress causes them to selectively attend to and recall episodes of noncompliance. Treatment encourages an objective, thorough assessment of current postoperative eating patterns. Most patients follow the diet regimens more effectively than they think. Their fears of losing control are often unsubstantiated when all aspects of their postoperative eating are considered.
The vast majority of surgical weight-loss patients struggle with behaviors such as grazing, snacking, and excessive consumption of high-calorie fluids, which, if not controlled, jeopardize weight loss and contribute to eventual regain. A few patients have the opposite problem: failing to eat enough to avoid excessive and unhealthy weight loss. Anorexia after weight loss surgery can begin at any point along the postoperative experience. A fear of stretching the pouch may lead to excessive volume restriction during the first 6–12 months. Later on, patients may report an intense fear of regaining weight, even 1 pound. Some demonstrate an "all or nothing" attitude toward weight maintenance, not unlike their reactions to weight gain during previous dieting episodes. For these patients, gaining any weight at all signals loss of control. They believe that gaining 1 pound starts them on a path toward regaining 100 pounds. Other patients fail to feel satisfied when reaching a reasonable postoperative weight, even when they achieve their ideal body weight for age and height. They continue efforts to lose, presenting classic anorexic symptoms (refusing to maintain body weight at a normal level, intense fear of gaining, excessive preoccupation with weight, and use of restricting and purging behaviors).31 Several case reports illustrate the gravity of the problem. A 38-year-old woman weighed 305 pounds before gastric bypass surgery. By 2 months postsurgery, she was avoiding food and refused vitamin supplements for fear that these would contribute to hunger and weight gain. When weight loss stabilized, she became concerned and began daily use of stimulants and laxatives, alternating between fasting and eating toast and lettuce. She reported forced vomiting as often as 5 times per day, and by 24 months after surgery, weighed 88 pounds.32 Fandino et al33 report on a patient hospitalized 2 months after gastric bypass surgery with disorientation and amnesia associated with extreme food avoidance secondary to intense fear of postoperative weight gain. The patient was diagnosed with Wernicke-Korsakoff syndrome. Typical intervention for Wernicke-Korsakoff encephalopathy includes intravenous (IV) fluids, with supplementation of thiamin, multivitamins, potassium chloride, and folate, followed by nutrition support to replenish protein and nutrient levels. This particular patient required a 2-month hospitalization to achieve stable weight and consistent, appropriate eating habits. As is often the case for Wernicke-Korsakoff syndrome patients, cognitive impairment persisted, and at 2-year follow-up, the patient continued to have memory and learning deficits.
ML, age 51, reluctantly accepted referral for psychological consultation for excessive caloric restriction and low body weight. Four years earlier, she had a presurgical weight of 260 pounds (body mass index [BMI], 49 kg/m2; highest lifetime weight, 280 pounds) and underwent gastric bypass. She lost 20 pounds in preparation for surgery, primarily by eliminating snacks and junk food. She went on to lose 136 pounds during the first 12 months after surgery. At the time of her 2-year follow-up, she weighed 114 pounds and for the first time admitted to fears of gaining weight and of "stretching my pouch." To prevent pouch dilatation, ML restricted solid foods to 500 kcal/day, but also claimed to be augmenting her diet with "8–10" 20-ounce glasses of 2% milk each day. The program dietitian advised the patient that, if this estimate was accurate, she was consuming between 2600–3200 kcal/d in milk alone, and should therefore be gaining, not losing weight. The dietitian worked with ML to alleviate her concerns related to pouch dilatation and weight gain and to improve her postoperative diet in order to maintain a physician-recommended weight of 115–120 pounds. At the 3-year follow-up, ML weighed 107 pounds (BMI, 20 kg/m2) but admitted to having dropped to 98 pounds several months earlier. She regained to 107 in preparation for the scheduled clinic follow-up in order to avoid "getting lectured" about her very low weight. She reported using 6–8 laxatives per day, drinking "120 ounces" of fluids (milk, water, eggnog, orange juice), and insisted she was eating 5 meals per day, although she had difficulty providing credible descriptions of the content of those meals. Blood work and protein levels were normal. She again saw the dietitian and was encouraged to increase her weight to a minimum of 115 pounds. When seen for her 4-year clinic follow-up, ML recorded a weight of 107 pounds. She told the nurse practitioner that she was on the scale several times each day and that whenever her weight approached 108 pounds, she became highly distraught, thinking that if she gained "1 more pound" she would lose control and regain all of her weight. She agreed to psychological consultation, during which she confided that her weight had dropped below 100 pounds several times during the previous year since her 3-year clinic evaluation. ML stated that she had learned to tell health professionals "what they want to hear" regarding her efforts to eat properly but described feeling extremely upset about the idea of increasing her weight to the recommended 115–120 pounds. In her view, 115 pounds was "obese." Reaching 115 pounds would signal loss of control and inevitable regain to "280 pounds." In fact, exceeding 107 pounds was "synonymous with hitting 280." Review of her presurgical weight and diet histories indicated that her family physician labeled her as obese when she was 10 years old. On 4 occasions (ages 13, 20, 23, 29) ML lost between 30–50 pounds through fasting, liquid diets, over-the-counter weight loss medications, and vomiting (age 23 only). Whereas her average adult weight ranged between 140–160 pounds, she had managed to reduce to 110 at ages 20, 23, and 29. Depression and stress eating dominated her adjustment from her early 30s through mid 40s. She steadily gained weight during this period, despite numerous brief weight-loss attempts, until reaching 280 pounds. Four years after gastric bypass surgery and significant weight loss, ML continued to "feel fat." During psychological consultation, she said she would "rather starve to death than get fat again." Nevertheless, she agreed to cognitive behavioral treatment, with specific emphasis on her fears related to gaining weight, and reached 112 pounds in 2 weeks. She agreed to further challenge her anxiety tolerance and fears of losing control by attempting to gain another 4 pounds, for a target weight of 116 pounds. Unfortunately, her insurance refused to authorize further treatment unless she chose a psychologist covered by her insurance plan. Arrangements were made to transfer treatment, but we have no current information about her progress or status. Had this patient remained in psychological treatment at our clinic, she would have continued the primary strategy of exposure treatment. In her case, exposure to mild weight gain appeared to offer the best strategy. Exposure treatments offer patients opportunities to directly confront their fears. Prolonged exposure results in anxiety reduction. The plan for ML was to increase her weight to 120 pounds and sustain that weight for several months. In doing this, she would have learned that gaining a few additional pounds would not necessarily lead to an inevitable upward spiral in weight and that life could indeed be enjoyable and satisfying. As ML maintained a stable weight, body image adjustments would occur so that eventually ML would become increasingly comfortable with her body image at a weight in the recommended range for her age and height.
The first year after surgery is the ideal time during which patients can begin to establish a new lifestyle; it is also when individuals are at their greatest risk for dehydration, nausea and vomiting, and protein malnutrition.34,35 Patients need to relearn to eat and drink in the first weeks and months after bariatric surgery. Eating becomes an activity requiring conscious thought; before their operation, patients did not need to consider their speed of eating and drinking, the size of their bites or sips, or how they would have to chew their food. Patients may not be able to identify when their pouch is full until after they have overeaten or overdrunk and will need to learn cues for satiety. During regular office visits, patients must continue to be educated, counseled, and supported as they relearn these basic behaviors (eating and drinking), reinforcing teaching begun before surgery.36 Completing a food diary may be "eye-opening" for the patient and will also assist those who are providing the counseling as it is reviewed with the patient. Nausea and vomiting or other gastrointestinal symptoms such as excessive salivation, abdominal cramping, or epigastric pain should not be an expected consequence after gastric-restrictive weight-loss surgery.34,36 Nausea can be the prominent symptom associated with dehydration in the early postoperative period. Patients must consume a minimum of 64 ounces of water daily to avoid dehydration. If at any time a patient's symptoms are irretractable, an upper gastrointestinal radiologic examination may be indicated. Once dehydration or a functional problem such as obstruction or stenosis has been eliminated as the etiology for the nausea or vomiting, gastrointestinal symptoms should be considered related to behaviors. Eating too quickly, overeating, reclining immediately after a meal, eating while experiencing emotional stress, or dumping syndrome (the result of a poor food choice) can all result in gastrointestinal distress. Patients must learn to recognize what has precipitated their symptoms and correlate them to a specific behavior or food choice to make the appropriate adjustment and change their behavior. The patient, who may require the assistance of a healthcare professional to gain insight into this cause-and-effect phenomenon, may not always easily appreciate this correlation. Excessive nausea and vomiting in the early weeks after surgical intervention can lead to food aversion, protein malnutrition, and vitamin and mineral deficiencies.
After bariatric surgery, patients will need to consume a minimum of 60 g of protein per day to preserve lean muscle mass and avoid a "starved state."34 Protein depletion in the obese patient is easy to overlook. Clinicians should have a high degree of suspicion for insufficient protein intake whenever patients relate persistent and prolonged vomiting, especially for denser-consistency foods. Meat is the most difficult food for patients to relearn to eat after gastric restrictive surgeries (requiring careful chewing); therefore, patients may begin to avoid meats, placing themselves at further risk for protein malnutrition. Some groups will counsel patients to meet their goal with the use of protein supplements, whereas other programs promote fortifying food items with powdered milk or dehydrated egg white. In our experience, patients who keep meticulous records documenting their food and water intake are more likely to meet their goals. The most concerning vitamin deficiency associated with prolonged nausea and vomiting (2–3 months) is thiamine.33,35,37 As food intake and routine vitamin supplementation are interrupted, Wernicke-Korsakoff syndrome, although uncommon, could be a consequence of this vitamin deficiency. One should be alert for symptoms including exaggerated tendon reflexes, lateral nystagmus, polyneuritis, muscle weakness, peripheral neuropathy, and pain or mental impairment.35,37 Early intervention with thiamin supplementation in patients with persistent vomiting is prudent. Whenever patients are rehydrated, their IV fluid regimen would include the addition of a parenteral multivitamin and thiamin.35
GC is a 36-year-old divorced mother of 2 sons ages 8 and 12. Her preoperative weight was 254 pounds, and her BMI was 43 kg/m2. At her first office visit 2 weeks after surgery (while receiving a pureed diet), she had met her protein (63 g), liquid (76 oz), and exercise (60 minutes) goals. She denied any nausea or vomiting and was advised to advance her diet to soft-consistency foods. One week later, she was seen in the clinic for an unscheduled visit, complaining of epigastric pain, nausea, and vomiting, which had been precipitated by the use of a liquid acetaminophen preparation with high sugar content. She had become dehydrated, experiencing worsening nausea; her fluid intake diminished, aggravating her nausea, and she began to skip meals as well. IV fluids were administered in the clinic, with an improvement in her nausea; diet counseling was reinforced, and she was discharged home to follow up in clinic at her next routine visit. For the next 3 months, GC was seen weekly in the clinic, complaining of nausea, epigastric pain, and daily vomiting of either foodstuff or "froth," struggling to meet protein and water goals. She was not tolerating her chewable multivitamin. A limited upper gastrointestinal radiograph was obtained, which demonstrated normal transit of contrast across the gastroesophageal junction into the gastric pouch, with free flow across the gastrojejunostomy and jejunojejunostomy. During this time, GC was beginning to develop an aversion to meats and was anticipating vomiting; "gagging" even before eating. Anxiety regarding returning to work, as well as the stress of being the sole provider for her sons, aggravated her symptoms. By the sixth postoperative visit, she was not only meeting with the nurse practitioner for counseling but also visits were coordinated with the psychologist and the dietitian. During this time, her protein intake was supplemented with a liquid protein source because she was tolerating liquids. Vitamin B12 and thiamine were administered parenterally in the clinic, and IV fluids were supplemented when indicated. Metabolic monitoring occurred on a regular basis. Weight loss during this time was appropriate. At one point during this first 3 months, GC contacted the clinic nurse, the on-call surgery resident, and the psychologist to "confess" that she had not been truthful with the nurse practitioner regarding her protein intake and in fact had not met protein and fluid goals. This prompted more intense counseling. Five months after her surgery, GC was tolerating solid-consistency foods, drinking 80–100 oz of water each day, and exercising, all resulting in appropriate weight loss. Fourteen months after surgery, GC had lost a total of 101 pounds; her BMI kg/m2 was 26 and she rarely vomited. At this visit, GC expressed unrealistic goals for further weight loss, and an appropriate expectation was discussed. Subsequently, GC was seen in the medical clinic requesting "diet pills" so that she could lose 10 more pounds. We are now addressing concerns regarding anorexia with this challenging patient.
Gastric bypass surgery leads to both physiologic and anatomical changes, which will result in a "desirable" side effect, dumping syndrome. Symptoms of "dumping" will provide strong negative feedback to the patient and will emphasize for the patient when they have made a poor decision regarding food choice. Patients can have both early and late forms of dumping; a minority will experience both.38 Symptoms can be categorized as either gastrointestinal or vasomotor (Table 2).
Both gastrointestinal and vasomotor symptoms characterize early dumping and are the result of fluid shifts from the intravascular space into the lumen of the intestine. Symptoms typically occur within 30 minutes of consuming a food portion that contains 10 g of sugar or more. When experiencing early dumping vs late dumping, it is easier for the patient to determine the etiology of their symptoms, and they are more likely to make the appropriate correlation. On the other hand, late dumping will occur within 1–3 hours of a meal, making it more difficult for the patient to associate the symptoms they experience with their food/fluid choices. Vasomotor symptoms predominate in late dumping and are the result of a rebound hypoglycemia. It is not uncommon to have patients describe their desire to lie down within an hour and a half of their meal (in particular, a meal in which carbohydrates predominate and protein was avoided) and express distress. Patients who were diabetic before their surgery may recognize their symptoms as a "low-blood glucose" and may even document a confirming reading when performing a fingerstick. We have seen patients rationalize that their blood glucose is low because they are eating "so little." This thought pattern may eventually lead to a grazing eating patten or snacking, rather than recognition by the patient that their symptoms are related to a poor food choice. The use of a food and symptom diary can be an excellent tool for the clinician when counseling patients reporting these types of symptoms. Patients may report that they no longer "dump" after consuming high-sugar-content foods and may be quite distressed. It is not uncommon upon further questioning to recognize that the patient has learned their limits for sugars and will consume these food items in smaller yet more frequent amounts, thereby circumventing the most distressing symptomatology.
Presurgical dietary and psychological consultations identify at-risk patients (those with histories of significant snacking/continuous eating, stress and emotional eating, binge eating, and anorexia). Identified patients receive dietary counseling and, when necessary, psychological treatment to resolve maladaptive eating patterns before surgery. Preoperative diet changes force patients to develop alternative responses to stress, thereby weakening the association between emotions/situations and eating. Presurgical diet changes introduce patients to some of the required postsurgical patterns such as 3 meals per day, the importance of eating breakfast, minimal snacking, and elimination of high-fat, high-sugar foods. Despite these efforts, some patients revert to past eating behaviors or develop new behaviors that require diligent attention from the surgery program. Psychological evaluations of surgical candidates vary across programs, ranging from structured clinical interviews to extensive personality and psychometric assessment. We use a semistructured interview format emphasizing candidates' weight histories, past and current eating behaviors, psychosocial adaptation, and social support. The patient's knowledge about the surgery and the postsurgical diet changes, potential risks, expected weight loss, and anticipated benefits of such weight loss are also assessed. Table 3 lists the presurgical patient characteristics that may indicate increased risk for behavioral and dietary complications after weight-loss surgery.
Presurgical evaluation and patient preparation will not necessarily guarantee postoperative success. The weight-loss surgery literature and bariatric program experience support the expectation that a certain number of patients will experience maladaptive eating after surgery. This reality confirms the importance of regularly scheduled postsurgery monitoring through follow-up clinic visits over the first 2 years at minimum, with psychological and dietary intervention available when necessary.
Nutrition in Clinical Practice, Vol. 22, No. 1,
41-49 (2007)
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Top
Binge Eating
Emotional/Stress-Related Eating