Eating Psychopathology After Metabolic Surgery

Key Takeaways

Eating Psychopathology and Bariatric Surgery
People living with obesity and eating psychopathology may experience behaviours such as grazing or binge eating alongside subjective emotional contexts. Loss of control is an important mediator between these experiences and psychological distress.

Stability of Eating Disorders
Rates of binge eating disorder often decline after surgery, but many people continue to experience loss of control eating. Eating disorders should not be considered contraindications for surgery; individual assessment and access to psychological support are essential.

Surgical Outcomes
Having an eating disorder before surgery does not consistently predict post-operative weight loss or quality of life. Post-surgery eating behaviours are associated with concurrent weight outcomes, but not strongly with future outcomes. Broader measures of wellbeing beyond weight deserve greater attention.

Risk of Eating Disorders Post-Surgery
Most evidence suggests people’s eating disorder symptoms improve following surgery. However, restrictive disorders remain difficult to diagnose in this population, underlining the need for more precise criteria and assessment tools.

Timing of Interventions
Pre-surgery interventions show limited long-term benefit. Person-centred post-surgery monitoring and stepped-care approaches, including digital interventions, are recommended. Regular follow-up is important to identify potential issues early.

Future Directions and Next Steps

• Develop assessment tools tailored to people undergoing bariatric surgery
• Prioritise post-surgery stepped-care and digital interventions
• Expand research on psychological wellbeing and quality of life
• Refine diagnostic criteria for restrictive eating disorders in people living with obesity

Summaries are generated from meeting transcripts.

Transcripts are auto generated, if you spot an error, please email enquiries@easo.org

Speaker 1
First of all, welcome everyone to this month’s EA’s Early Career Network eLearning Hub. Thank you for joining. And the title for today’s event is Understanding E-T-Psychopathology After Metabolic Surgery. And our guest here is Assistant Professor Eva Conceiçao from the Faculty of Psychology and Educational Science at the University of Porto, who is a very estimated colleague, as well as a whole chapter of my PhD thesis. so it’s really nice to listen to her speaking. She’s a leading authority on eating disorders and obesity, and she will share the latest evidence on eating psychopathology following metabolic surgery, which is a very important topic. Just wanted to tell you that the No One Lose To You Foundation has provided support for the ECM development activities, so we thank the foundation for it. It includes the webinar series and they, however, have no influence over the content. I am Eugenia Romano. I’m an ECN board member and together with my colleague, Bram, we’ll be hosting this webinar today. Just so you know, the webinar is recorded and the recording and any relevant link will be shared after the event. The Learning Hub Online events are held by EASY-ECN to promote any knowledge and to share skills and develop opportunities among students and early career professionals who are interested in obesity. ECN is free to join in case you want to become a member, in case you’re not already. And so are these monthly webinars. And if you’re already a member and you want to invite any early career colleague to join ECN, please, you’re welcome to. Just so you know, the webinar is very informal. Questions will be asked at the end after Eva will be done with talk in two ways. You can either raise your virtual hand and I will call your name and you can turn on the microphone and ask your question once the question session starts, or you can write questions in the chat instead and I can read them for you. Also remember to please complete the feedback form that appears after the webinar because we really value your comments and any idea you want to share about these events

Speaker 2
and future events from this series.

Speaker 1
So I will now hand it over to Bram to promote our ECN events.

Speaker 3
Thank you, Eugenia. So yeah, there are a couple of award and opportunities available to members of the ECN and all eligible members are really encouraged to join or apply. Lisa already put in the chat the link to the link tree, which is a bunch of links together that will show all the opportunities that are available to you. So first of all, well, upcoming is the ECN masterclass, which was formerly called the Winter School, and it will happen in Cascais, Portugal from 20 to 22 November this year. And I would like to just thank all ECN members for applying. I think some of you may have already received an acceptance letter, but the last ones are probably coming out soon. So please keep an eye on your mail. And the EASO Masterclass will be held alongside this event. So the ECN and the EASO Masterclass will happen at the same time, at the same place, so you can network with even more colleagues. Good to mark your calendars for the European Congress on Obesity 2026 in Istanbul, Turkey. It will happen from 12 to 15 May 2026. And as the ECN, we always have all kinds of opportunities for you to share your research and to participate in networking and career development. So keep an eye out for updates on this. because at this point, even the abstract submission is not yet open, but it’s good to keep an eye out for updates. Also, the ECN Best Thesis Award will be handed out again at ECO 2026, and we will open submissions for this in due course. So please do consider applying if you have recently finished or are about to finish your thesis. This is a good opportunity. Then there’s the ECN Development Fund Travel Grant. These support the attendance at conferences and training other than ECO. And the final deadline for this is September 30th, 2025. We also have the ECN Spotlight where we regularly interview ECN members about their research and share, we will share this widely with our obesity community. So if you’re interested in having your research spotlighted, you can get in touch with us. We also have a WhatsApp group for quick updates, sharing resources and networking across Europe. And you can follow us on all kinds of other social media channels, which you can find through the link tree. And then I’ll hand back to Eugenia.

Speaker 1
– Thank you, Bram. And I will, well, virtually ask you to welcome Assistant Professor Eva Conceicao. Thank you, Eva. And the stage is yours. Looking forward to listen to your talk.

Speaker 4
Thank you so much. Just go ahead and share my screen. OK, so you can see my shared screen, I’m guessing. OK, perfect. So before starting, I would like to just introduce myself. I’m Portuguese. I’m working in Porto in the Faculty of Psychology at University of Porto. And since my PhD, I’ve been dedicating my research and clinical attention to the intersection, the intersection between obesity and disordered eating behavior. I was actually trained during my PhD in the treatment of bulimic disorders. Then when I was trying to apply my knowledge or the knowledge that I was gathered and the tools that I had to the population with overweight or ORVZT, and particularly to the population that was submitting themselves to bariatric surgery, I often felt that the tools that I had and the behaviors that I was assessing were not properly reflected in this population. So this difficulty that I experienced just put me, lead me to understanding the behaviors, or the eating behaviors that are present among people with obesity, but also among the community. So some of these behaviors, and this is probably the chapter that Eugenia was talking about, but some of these behaviors are highly common among the community, but they are of specific interest among the population that gains weight over time and eventually develops obesity. So this is a general presentation of my scientific development. And I would like to, I have a lot of slides. In this presentation, there are a lot of things that I would like to talk to you. I’m not sure if I will have enough time to cover all of the slides. But some questions sometimes arise during the presentation. And having these extra slides, that usually proves a good strategy to answer some of the questions that sometimes rise during the presentation. So, with no further delay, so the outline of this presentation is I will talk about eating disorders and a way to characterize these disorders and behaviors, but also a way to conceptualize the different disordered eating behaviors that we see in the literature. There’s a lot of confusion, a lot of nomenclatures used, and some of them really overlap. We’ve dedicated our last work to trying to organize these nomenclatures and behaviors. Then I will explore and discuss the rates of eating disorders and disordered eating behaviors and their stability throughout the bariatric surgery treatments from pre to post-surgery. I will also address the question as are eating disorders counter-indication for pediatric surgery, like pre-surgery eating disorders and counter-indication for pediatric surgery. Do we have evidence to support these? Then I will explore the impact of pre and post-surgery disordered eating behaviors on treatment outcomes. By treatment here, I mean, metabolic bariatric surgery. I will also address the question that is metabolic bariatric surgery a risk factor for the onset of eating disorders? And are there, and I’ve also discussed a special case of a typical anorexia nervosa developed after surgery. I will also try to address the suitability of the DSM M5 diagnostic criteria for evaluating some of these problems. This part I might just keep depending on your questions. Then I will show evidence supporting different treatment options for these problems either before and after surgery. I also like this presentation to be interactive, so I will ask some questions. I would love for you to just use the chat to give short answers. And I will just start with asking you if you could please write different terms representing eating disorders or disordered eating behaviors or problematic eating behaviors that you know of. And I’m not just particularly talking about behaviors specific to bariatric surgery, there are only a few, but to community, to the individuals with eating disorders, or even people with obesity. I will just have a quick look at the chat and I’d love for you to just help me.

Speaker 5
Okay, emotional eating, exactly. Emotional eating, binge eating, emotional eating, and emotional eating is a very famous one.

Speaker 4
Binge eating disorder, highway, shape and weight concerns, purging behavior. Binge eating again, emotional, reward-based eating, grazing, emotional eating and loss of control eating, binge eating. Tiramis, and emotional hunger, bulimia, anorexia. That’s perfect. And I think hedonic eating. Thank you, this is a good one. Emotional eating again. And disinhibiting, thank you again. I was looking for these type of behaviors as well. So you can see we have disorders. We have bulimia, nervosa, and neuroxin, fosa, binge eating disorder. But these disorders are usually an aggregation of symptoms. We have the behavior, then you have the cognitive component of the disorder and psychological impairment required to be a disorder. So every time we use the DSM-5, there’s always this criteria that has this behavior or presentation has an impact in the psychological distress of this person. So this is a very important one because if there’s no impact on the psychological distress of this person, then we probably don’t have a disorder, not in all cases. When we talk about eating disorders, there’s inhibiting again. So when we talk about disorders, bulimia, bulimia, binge eating disorders, this is a constellation of symptoms. This is not just a single behavior. But then we have grazing, we have binge eating, we have loss of control eating, and we have others here, emotional eating, emotional hunger. Then we start showing there’s some behaviors here, but there are some other aspects that are not necessarily a behavior. Let me ask you one question. Do you think emotional eating is a behavior? I’ll just say yes or no. Just like to see how you feel about the emotional eating. I could say emotional eating or reward-based eating. Let’s start all loss of control eating, for instance. Do you think these are behaviors? Yes. Okay. There’s one no. Okay. For the sake of time, I’m not going to ask why you said no, but I was interested about, I think that’s a very interesting question. I will tell you why. I’m going to frame We’ve tried to organize these different concepts regarding eating into a system and a model that makes sense. This work is about to get released from the publisher. So we got it almost very minor revisions last week. So hopefully this will be soon published. that we understand that we have disorders, as I was telling you about, but we have observable behaviors such as grazing, but emotional eating, and this might be debatable, but emotional eating is not necessarily a behavior. Like I can graze when I’m feeling particularly low or depressed. I can binge eat when I feel particularly low or depressed. So emotional eating can be represented in a variety of behaviors. So emotional eating is not the behavioral manifestation, it is the context, in this case, the emotional context of the behavior. Of course, as you can imagine, emotional eating is associated with a lot of different eating behaviors. If you’re talking about grazing, compulsive or non-compulsive grazing, subjective or objective binge eating, emotional eating is very associated with these behaviors, but not always. So some of these behaviors are not related to emotional eating. So it is important for us to understand what’s the context of the behavior, not just emotional context, not just emotional context, but also the neurobiological context of the behavior. I’m going there in the next few slides. So this is what we’re quite considering. So we have the observable behaviors. We have binge eating. Binge eating is specifically defined. I’m not going through the definitions. You can just look them up or just print screen, your screen, but I’m not going through the specific definitions. So we have binge eating, either objective or objective binge eating. We can see when a person is endorsing binge eating or grazing, if they are repetitive eating a period of time in an unplanned manner so that people are grazing, they are engaging in a behavior, either being compulsive or non-compulsive, or if people are restricting their eating and just not ingesting enough food throughout the day, and they have a behavioral reduction or avoidance to food. This is observable, this is directly measurable. However, sometimes we have subjective contexts associated with eating. So I cannot measure if someone is endorsing emotional eating, but I can ask this person. And the emotional context is very subjective to the person. The experience of losing control over eating is very subjective to the person, and it comes in different ranges. I can feel that if I have, if I’m working with someone with bulimia nervosa, the levels of the degree of loss of control is extreme. If I’m just discussing a therapeutic treatment strategy with someone who engages in grazing behavior, the level of loss of control is usually lower. So it’s a very subjective experience. The xenobit heating is also a very subjective experience, and it’s not necessarily directly measured. Restraint eating, the intent to restrain, and sometimes it’s not that people cannot restrict their eating, but they have the intention to restrain their eating, it’s a very subjective behavior. Intuitive eating is a very subjective feeling. So this helps us understand that we have a lot of behaviors and some of them have different contexts. And why is this important? Because when I’m working clinically, I will look for these contexts. So I will treat someone that raises while experiencing negative emotions differently than someone that raises without this negative context. The therapeutic options will definitely be different for these two people. But when I’m trying to correlate the behavior and weight gain or obesity, in that case, I will need to look for the behavior because it’s the behavior that will lead to increased caloric intake and then eventually difficulties while I’m treating being obesity or treating other condition related to eating. So the context is very important and should be in my perspective, it should be differentiated from the behavior. And then of course we have the disorders. We have food addiction. I think no one write about food addiction. It’s not a disorder. There’s a lot of controversy about this. At least it’s not a DSM-5 disorder. There’s a lot of controversy. There’s a lot of research going on. There’s a strong group supporting the food addiction has a disorder. I’m not going to into this debate. However, I will say that when we talk about eating disorders, we are, as I was saying in the beginning, we’re talking about a constellation of symptoms. Bulimia nervosa is associated with the ZNBT team, with all of the above. So this is a constellation of symptoms. And it is important to understand that when we have a patient with binge eating disorder, their context, their emotional cognitive context might be very different if I have a sample of people with binge eating disorder. So it is important to go to investigate the context and the behaviors that they represent and they engage the most. In one of the variables that have been mostly the most difficult perhaps variable to assess And one of the variables that has been mostly associated with psychological impairment and eating disorders, psychopathology and psychopathology, the psychological distress in general, in general, is when people report that they engage in loss of control eating. So as I was saying, loss of control is a very subjective experience. Only one will know how much loss, what was the degree of loss of control when they were eating something, when they were engaging in a certain behavior. But there’s evidence supporting that loss of control is the mediator between problematic eating behaviors and eating disorder psychopathology. And what does this mean? It means that the relationship between loss of control and eating pathology is stronger than the relationship between eating behavior. So there’s no evidence that certain eating behavior will be associated with a certain eating pathology degree, but there’s evidence that it is the experience of loss of control that will better help us understand the degree of psychological distress and eating disorder psychopathology experienced by the person. So loss of control, we’ve been very interested about how different ways to measure loss of control. Unfortunately, the DSM-5 is terrible. It just assesses loss of control in a very simplistic way. It’s not easy to assess, but we’ve been trying to put different disordered eating behaviors and conceptualize them in a continuum of loss of control. So see loss of control as a continuum instead of as a dichotomous variable like present, absent. If we evaluate or if we are interested in the degree of loss of control, then we start conceptualize other eating behaviors besides binge eating disorder or binge eating which was traditionally assessed. So when we use this continuum of lack of control over eating, we can actually conceptualize amnestatic eating, which would be associated with no lack of control or no loss of control. Then there’s the passive overeating, which is when I deliberate want to overeat and not experience loss of control, but I want to eat more than I should and I will then passively over eating, over eat. Then we have grazing, both non-compulsive and compulsive grazing, and there’s evidence, research evidence, to support a distinction, a distinction between these two, and that compulsive grazing is associated, which is usually characterized by the intent to resist eating, but not being able to to resist eating and compulsive grazing has been highly compared to subjective binge eating in terms of the level of loss of control experience during the behavior. Then of course we have objective binge eating, which is usually associated with a high intense feeling of loss of control and a high degree of loss of control eating. And then of course we have the disorders, as I was saying, which are the constellation of symptoms that leading these to be a DSM-5 category in the current DSM that we use. And when we distinguish these behaviors, so this central piece would be the behavioral presentation of eating, then we can understand that these different behaviors come from different cognitive and emotional contexts. So it is the degree of these cognitive and emotional contexts that will probably help us better to better understand the behavior itself. So if I have very low emotional eating, if I have high, low difficulties in emotional regulation, if I have, if I’m not sensitive to reward, to reward eating, if I have low impulsivity, I will probably not engage in these disorders. I will probably be more prone to intuitive eating and homeostatic eating. However, if I’m very high on all of these emotional contexts, I will probably be more prone to engage in behaviors associated with a high degree of loss of control. And of course, as I move along the degree of loss of control, I will also move along the degree of the severity of the disorder or of the behavior and the severity of psychological eating disorders, psychopathology and the severity of psychological distress. So any questions up to now?

Speaker 1
>> That’s fine. I think we’ll keep questions for the end so you can carry on.

Speaker 4
>> Okay. So this was just a presentation, a characterization of the different behaviors. Now I’m going to, I would like to ask you and to have your perspective of how stable are eating behaviors and eating disorders from pre to post stable. If you would have to rate the stability of these problems from pre to post surgery. Would you say that they are high, medium or low? It would be high, medium or low stability? Not stable at all. Like by stability I mean that they maintained over, they maintain over time. They are maintained over time. Low stability, okay. Okay, so a lot of you saying that there’s low stability over time and some comments, one comment saying that there’s a high possibility of, I don’t know if it’s low or high stability. Well, the research is mixed, just as your comments, and I’m bringing you different works that we have to, we don’t have a final answer. We have a good sense of what’s happening from before to after surgery. But it gets complicated when we use loss of control as a continuum. and when we don’t assess just binge eating or binge eating disorder. And I will show you that. So this is a longitudinal study. Anja Hilbert and colleagues, they assessed over 700 patients from pre to six years after surgery. So this is the pre-surgery assessment, like half, six months, one year, two years, and then yearly until the sixth year after, yeah, exactly, the sixth year after surgery. And as you can see binge eating disorder improved significantly. There’s no binge eating disorders. There was like 3% of patients engaging in binge eating disorder before surgery. But then this is a significant improvement. Of course, there’s not many patients engaging in bulimia nervosa and non-obviously engaging in anorexia nervosa or have anorexia nervosa. But these disorders were pretty low throughout time up until six years after surgery. However, when we look at eating disorders based on loss of control eating instead of based on definite binge eating episodes as defined by the DSM, the rates increase significantly. So when we look at binge eating disorder was 6% and then there’s a significant higher rate compared to zero that we have above. So when we look at loss of control, the experience of loss of control, regardless of how much they are eating, we have a different feeling, a sense of what’s happening. And of course when we look at binge eating disorder sub-thresholds in terms of the frequency and degree, mainly the frequency of the behaviors, of course, we have a higher percentage of patients with these problems. However, there’s a big concern that these rates may be underrepresented because the prevalence of these disorders might be higher. And one of the reasons is that the DSM-5 criteria that we have were actually developed for patients who had bulimia and who were usually with their weight within the normal ranges. And these criteria do not apply to patients who have a history of obesity. Still regarding the stability of these problems, this recent study by Deborah and colleagues, they clearly show– this is a recent one– and they assessed patients before surgery and 10 years after surgery. And it’s a nice image because we see that from those who binge eat, some of them remitted and some of them continue to binge eat. For those with no binge eating, some of them still did not engage in binge eating after surgery, 10 years after surgery. But there’s a subgroup of people, 15% of those who never binge eat before, developed de novo binge eating. So if you look at 10 years, the picture 10 years after surgery, we have 8% of people that engage in binge eating without a previous history of doing so. We have almost 30% of patients who remitted binge eating, some continued to binge eating, and half of the patients are not still binge eating. So there’s some variability, but there’s also some stability of the disorders, with the main message being that there’s a a significant improvement, but there’s still concerns. There’s still a subgroup of patients who reported these problematic eating behaviors. When we are not still going back to Anja Hilbert study, they also assessed just the behavior. Before I presented to you the disorders, like the constellation of symptoms as I explained before, and now this is just assessing the behavior. And this is subjective binge eating. And this is just any loss of control eating behavior. When we look at just any loss of control eating behavior, independent of a disorder. So some of these patients might have the behavior, but not the disorder, just be mindful about it. When we look at these, look at the high percentages that we see, and they are quite high. There’s quite 30% of patients engaging in any disorder loss of control eating behaviors. And there’s an improvement, but there’s still some percent, we don’t see zeros here. And then it goes back to almost 30% in the sixth year after surgery. So it seems like when we are assessing the subjective experiences of loss of control, the stability is a little higher than the stability that we see or instability that we see when we assess disorders. So, also in this loss of control study from the labs study, so typically, it’s the main message typically problematic eating behaviors decrease immediately following surgery, but they do reemerge after surgery. And there’s a peak around two, like this study found three years, Anja Hilbert study found of one in two years. So there’s a peak of problematic eating behaviors one to three years after surgery. And the lab study also showed that 70% of patients remitted binge eating disorders, but only 25% remitted loss of control eating. Again, this difference between assessing a disorder and assessing the subjective experience or the behavior, so the subjective behavior. And then post-operative binge eating disorders and loss of control eating disorders de novo was reported. But as you can see, there’s post-operative binge eating disorder de novo was only 4.8% and post-operative loss of control eating, the novel was 25%. So this is an important message because loss of control may be a more stable condition than full syndrome binge eating disorder or any other disorder. This doesn’t mean that there’s not an improvement in behavior, but this means that we need to be mindful about these behaviors that are actually sub-syndromal, they’re not definite disorders, but they are associated with increased psychopathology or increased psychological distress. So do you think that eating disorders are a contraindication for surgery. And what do you see if either if you think so or if your bariatric surgery center has some perspective. There’s a lot of mixed practices across Portugal. So I can imagine there’s a lot of mixed practices also across Europe. Some centers do not use eating disorders as a contraindication, others don’t. So I’d like to know what you think. Are they contraindication? No, no clear evidence exactly. Okay, I believe it’s a contraindication. Not really, but certainly psychological consultation must be obligatory. Depends on the patient and the severity of the disorder, of course. depends on the situation? Of course. But of course, you’re going to say, of course, it depends. One, there’s Anahid, I’m not sure if I’m pronouncing this correctly, but mentioned the severity of the disorder. And of course, if we have a clinical acute disorder, any person should receive treatment. However, is there any evidence that the presence of these disorders before surgery has an impact on post-surgery outcomes? What’s driving the disorder? Okay. So let me get you to the evidence of the association between preoperative disordered eating behaviors and eating disorders and postoperative outcomes. So in this study by Hania Hilbert and colleagues, they did not find a significant relationship between active pre-surgical eating disorders. If you remember that they assessed all of the eating disorders across the different periods of time up until six years after surgery and they did not find a significant relation between pre-surgery eating disorders and weight loss or health-related quality of life in the six years following surgery. So this is an important study because not only they assess the code, usually papers just assess the weight loss outcomes, but these These authors also assess health-related quality of life, and they did not find any association between preoperative status and postoperative quality of life or treatment weight-related outcomes. Also, Allison et al. found that pre-surgery subjective binge eating was related to greater weight loss, not lower, but greater weight loss 12 months after surgery compared to patients without pre-surgery subjective binge eating. So this is counterintuitive finding, but this is not the only paper that reported a better weight outcome after surgery. There are other, this is the past five years, but across the literature, we found some papers suggesting this correlation subjective binge eating and improved or better weight loss after surgery. And Valentina Ivesai and Lusher also found that lifetime and post-surgical psychiatric comorbidity, now we are not talking about eating disorders, but psychiatric comorbidity in general, but having lifetime psychiatric comorbidity was not associated with weight outcomes two to five years post-surgery. But psychiatric comorbidity was an indicator of post-operative loss of control eating and eating-related psychopathology. So again, there’s not a strong evidence for most papers that there’s a clear relation between the eating disorder status before surgery and weight or psychological related outcomes after surgery. So this literature kind of supports that eating disorders should not be a contraindication for surgery. we have a clinically healed patient, we should provide treatment to the patient. But this should not be a clinical contraindication for surgery. And I’ll proceed to say what the literature shows as to why this should not be a contraindication for surgery. So now the next question is, so we know that pre-surgery, there’s no relation to post-surgery outcomes, But do post-surgery behaviors have a relation to post-surgery outcomes? If they do, do they have it prospectively or do they have it concurrently? This is quite an old study, older. But this is a study from our team. but I like the graphs because it shows that these two lines, these are patients that had no problematic eating behaviors before surgery, and this is patients with problematic eating behaviors before surgery, and their weight loss trajectories up until 31 months following surgery, there was no difference between these two patients who reported or not reported these problems before surgery. However, when you look at the weight loss trajectories of patients with and without these problems after surgery, there was a significant interaction effect. And around here, the 18th to the 20th month, their trajectories kind of developed differently. So there is evidence, this is further evidence that the behaviors after surgery are associated with impaired weight outcomes. You remember this figure from before, from Deborah and Deborah’s study. And they also tested differences between these different groups. They tested differences between those who developed de novo, which are, these are the never binged, either before or after surgery, these are patients who remitted binge eating, those who continued to binge eat and those who developed binge eating after surgery. And as you can see, those who never binge eating and those who remitted binge eating were pretty similar across the variables that they assessed, including other health-related anxiety and distress, anxiety and stress again, pre and post surgery, and the repeat that measures grazing behavior and weight related outcomes. So there’s no differences between those who never binge and those who remitted. This is 10 years after surgery, just as a reminder. However, those who continue to binge eat, they show to be a different group with increased scores across all of these variables. And those who developed binge eating after surgery, they also engage in other problematic eating behaviors, although they are very similar to the rest of the groups in the other variables. But they do, this is the repeat, the grazing questionnaire, they do engage in other problematic eating behaviors, although they seem to be similar to the rest compared to the other patients. So do eating disorder symptoms occurring after surgery invariably result in poor outcome? There’s strong evidence to support this association. There’s the increased measures of the Zenibit eating, night eating, binge eating, higher global eating disorders are prospectively associated with six to 12 month outcomes. However, this is not a consistent finding. Most studies did not find the perspective association, but they do find a concurrent association. So this means that while, and a lot of studies based on the labs big study, they found similar results. So there’s not a strong correlation between a perspective correlation, but there’s consistent reports showing a concurrent association. This means that Hilbert et al, Halison et al, they also found a concurrent association but not prospective. This means that eating behaviors at six months predicts weight outcomes at six months, but there’s no strong evidence for a longitudinal or prospective association with outcomes. So understanding the trajectory, this study also showed that patients who improve their emotional eating have a better and more favorable weight loss trajectory. So there’s some indication that we should understand the clinical trajectory of these problems to properly identify people that might be at risk. And of course, we need to understand when we investigate pre and post-surgery behaviors, we need to understand moderators. We need to understand if the preoperative behaviors are an indication of who might develop the disorder after surgery. There’s a moderator or if they work by themselves. And even if there’s a correlation between pre and post-surgery behavior, should we deny treatment for someone who has a behavior if that can be treated after surgery? So this is just a question for you to think about. So again, one question, important question for future research is that we need to study behaviors or to study outcomes beyond weight loss. We are very focused on weight loss outcomes. So we need more research to focus on other health related or psychological status has outcomes of surgery as well. So just a quick note on adolescence and bariatric surgery. There’s one study that compared adolescents with obesity who received bariatric surgery with a group of adolescents with obesity who did not receive bariatric surgery, just followed the natural course. And the rates of disordered eating behavior were significantly low six years post-operatively compared to pre-operative, but more important, they were lower compared to the group did not receive bariatric surgery. So it seems like there’s evidence that for, with this one study, that for adolescents, the risk of developing eating disorders is lower than for those who did not receive bariatric surgery. And for the surgical group, there was a concurrent association between eating disorders and weight outcomes. And also, this highlights that although these findings suggest that the potential benefit of adolescence bariatric surgery, we should be careful about it because they’re contradicting, they’re quite different from the studies with adults. And there’s a lot of controversy and a lot of mixed data with the studies with adults that we probably are going to get if we have more studies with adolescents. So, do you think that bariatric surgery put patients at risk for developing an eating disorder? Just another question that I would like to see what you think about. You think that those patients who receive bariatric surgery are at increased risk or Or is there a mechanism that put them at increased risk for eating disorders? So some no’s, it depends on the person, the personality traits. Yes, like grazing, so other forms of eating symptoms, it depends. Yes. So I’m guessing that if it depends, there’s some force for a subgroup of people, it might be possible. Not always just a few cases. There’s a lot of controversy around these. Some, unfortunately, the literature is populated with just case reports. We don’t have a lot of case definitions and a lot of cases that have been put forward for us to learn from this case report. But their traditional models place dietary restriction has a precursor of eating disorder and binge eating. But most evidence suggests that eating disorders behaviors may improve with surgery. So with bariatric surgery, we don’t have this traditional link between dietary restriction and the development of the onset of eating disorders. However, for a small group, probably for individuals who are at risk or more vulnerable for the cognitive and emotional context, but there’s a small group of patients who do develop eating disorders without a previous history. And there have been some authors who suggest a mechanism, related to bariatric surgery that may trigger these disorders. A lot of research is still needed, but this mechanism has been associated with the epileptinemia because there’s an adaptation, there’s evidence. Most of this work has been developed by Haberbrandt and colleagues, and they proposed that part of this mechanism involves the development of this epileptinemia, which is conceptualized as hormone deficiencies, lower hormones, lower leptin concentration, blood concentration that triggers tissue-specific starvation or adaptations to starvation. And they do engage, they do experience starvation following surgery. There’s other research now that a rapid and significant reduction of leptin levels is observed after surgery. So this ipoleptinemia model has been developed for non-surgical patients. There’s evidence that there’s this also ipoleptinemia developed after bariatric surgery and maybe for these patients, they might be more prone to develop anemia disorders. So So Eberbrand and colleagues, they use this term, which is entrapment in restrictive eating disorders. After a certain level of decrease in the leptin levels, the person gets entrapped. A lot of authors don’t like this term. I’m skeptical, but that’s how the authors propose their model. So there’s an entrapment in restrictive eating disorders, which is actually a tissue-specific adaptation to starvation. So what about just coming close to the end of to the final steps of this or topics of this presentation, I would like just to address the special case of restricted eating disorders after surgery. And when I talk about this I often just asking to make

Speaker 1
this one quick so we can skip to questions because we’re very close to…

Speaker 4
I’m sorry I didn’t understand you, Jeannie. No, sorry, just because like we are going to

Speaker 1
finish in about 10 minutes so if you want to try to give it a bit of a wrap up so we have time for

Speaker 4
questions because I think lots of people are curious to ask some. Absolutely, absolutely. So I also often encounter skepticism because people don’t understand how restricting disorders can present after surgery. As you can see here again to the Anja Hilbert study, there’s no anorexia nervosa, but their definition of a typical anorexia nervosa, it’s debatable, but they found that 15% of individuals after surgery showing hints of atypical anorexia nervosa. 15 is quite a lot for bariatric surgery population. This is a case study that shows the patients, these were patients under treatment, inpatient treatment in a clinic treatment. They had, if you look at their weight, their weight was quite high. Most of the case, it was 17. Most of these patients had a high weight. although there’s small weight here, but most of these patients had weights within the overweight to obesity range. This shows that patients with a typical anorexia nervosa after bariatric surgery may experience medical complications comparable to those seen in lower weight patients. Sometimes they do require inpatient hospitalization and medical stabilization. Just a quick note. I’ll just move this slide forward. We need to be more accurate when we address the grounds or the core of these disorders. It’s really difficult to understand what fear of gaining weight and what’s the overvaluation of gaining weight in this population compared to a population who never experienced high weight. So if you’re asking someone who has a history of obesity, if they have fear of gaining weight, they have a long life of stigma and enduring stigma, depression because of their weight, of course, they will feel that they have fear of gaining weight. And of course, their overvaluation of shape and height will be quite high compared to a patient with no history of obesity. So we need to be very careful when we assess, when you use the current criteria for these patients who have a history of obesity. These are some of the topics that we might look for that are not in the DSM, but we might need proper measures of reduced nutritional intake, and perhaps be more specific in assessing the cognitive aspects of disorder. So some take home messages about atypical anorexia nervosa after surgery. Some patients do present with normal to obesity BMI range. Large weight losses can be achieved without necessarily involving eating disorder. So should not associate weight with an eating disorder in this specific population. And using a weight based definition of atypical anorexia nervosa may result in late identification of potential and threatening condition, which is a restrictive anorexia nervosa. So we need to be more specific and develop more better tools to assess these disorders. So just to finalize the presentation, I’m not going to ask and to wait for comments, but just think for yourself, do you think interventions are better suited before or after surgery? and what is the evidence? So there is a significant heterogeneity in the timing and the impact of disordered eating behaviors after surgery. So this is a highly heterogenic population. A subgroup of patients will remit disordered eating while another subgroup will develop either de novo or not or maintain disordered eating after surgery. And particularly these are sub-threshold disorders. So we know that concurrent, there’s strong evidence for the concurrent effect of these disorders. There’s a good study there that I invite you to read. Linda Paul and colleagues, they use, they have a randomized control trial testing a group receiving CBT and the group not receiving CBT before surgery to test the effect of these treatments before surgery in the post-surgery outcomes. And they found no effect on disorder eating behaviors and on BMI outcomes up until five or four years of surgery. So their intervention was effective before surgery. They found an improvement before and after the intervention pre-surgery, but there was no difference between the groups after surgery. So again, there’s no evidence that we should put our efforts in intervene or in developing intervention strategies before surgery. And most of our efforts should be placed after surgery, which is when we can systematically assess these patients and follow up these patients and deliver treatment whenever they need it. This is just, okay. we have stepped care approaches that might help us screening this high number of population needing a long-term assessment. And of course, we have what is evidence for WhatsApp, telephone, application, smartphone interventions that have been published and that can help us leading with these limited human resources to follow up with this large amount of population. And thank you so much for your time. I’m happy to take any questions.

Speaker 1
We already have one in the chat so I can read it for you. So the evidence shows that eating disorder behavior should not be seen as contraindication for surgery. How will this translate to practice seeing that many clinics have this as contraindication? Would you still suggest to monitor these patients better throughout the trajectory, seeing that people with eating disorder symptoms also often experience more other psychopathological symptoms?

Speaker 4
Yeah, thank you for this question. I know there’s a lot of clinics that just use eating disorders as a contraindication. Again, there’s no evidence to support an association between eating disorders before surgery and their impact outcome, their eating disorders after surgery or an impact on weight loss. So honestly, I think most, I’ve heard some clinicians saying that I prefer just to give them the intervention before surgery because they are motivated for surgery. So now they will hear me, they will come to the intervention. After surgery, I know I’m not going to get them, I’m not going to reach them. So they will be lost, they will be looking for other things, and I’d rather give them the intervention before surgery. Again, as I was showing you before with Linda Paul’s study, there’s no evidence that treating eating disorders before surgery. Even if intervention is effective before surgery, there’s a reduction before surgery, there is no evidence that this intervention will have any impact on weight outcomes in the long-term. So, and there have been some suggestions on why this happens. And probably people before surgery, they are just in a different interpersonal state, cognitive state, their life changes so much that applying the knowledge they gather before surgery to a completely different life two years after surgery, which is when they develop problematic eating behaviors, this might not be reasonable to just apply something that I learned two years ago in a completely different life situation. So there’s no applicability of the knowledge they have. Their behaviors are much different, their internal experience are much different. So I would say there’s evidence to support the longitudinal assessment and screening of patients that might be at risk after surgery. Even if you treat them before surgery, you have to screen them after surgery because a lot of patients will develop these problems even if they were treated before. And there’s always this subgroup that will develop the novel eating disorder. So even if you treat them before, this will not take away the need for these resources after surgery. So you better just put them all after surgery. And another reflection that I would share is that should we just deny treatment for an important disease associated with many other diseases? Why should we deny treatment for it to a person just because they have a behavior or even if it’s another psychological disorder that has been shown to improve so much with surgery because we have evidence for binge eating to improve after surgery. Even if the loss of control experience still maintains, it’s not a disorder. So why should we deny treatment to these people? Of course, people are not – this is a debate. this is my perspective based on the evidence that I’ve been reading. I understand those who try to who prefer to just deliver interventions before but there’s no there’s no evidence to support

Speaker 1
these strategies. Yes it’s a really interesting perspective I think because like it’s kind of a vicious cycle sometimes like they wait to get treated because they have a disorder and then they keep waiting and they keep waiting and they never get to the actual intervention which would be the life-changing one. I think someone in chat is agreeing, it also creates a lot of stress in these patients being screened for those extracontinuation, they often know what they cannot disclose. Also like something interesting that comes up after these patients get intervention is that the whole social network can shift and very often obesity is kind of like the result or the cover for deep problems within, for example, family dynamics or relationship dynamics. So absolutely. There is another question. Yeah, there’s another question. If there was no prior eating disorder, are there any red flags that may indicate a patient risk for developing one after metabolic bariatric surgery? If you guys have any more questions, write in the chat, raise your hands. In the meantime, I’ll leave it to Eva to answer this.

Speaker 4
I’ll just make a note that most of the studies, they do not assess, I think none of the studies have assessed lifetime eating disorders. And there’s only the Eva Zaghi group, they assess lifetime psychopathology. But some of these patients, they don’t know they had a binge eating disorder when they were 13 years old, when they were teenagers. So I don’t know if our data is completely reliable when we say that there’s no pre and post correlation of disorders. Maybe if we assess lifetime disorders, we will find a correlation. But again, does it matter? Should to these patients just because they have this history. I would be more concerned about red flags after surgery. So I think it’s more important to just monitor these patients regularly. And of course, interventions before surgery are important, but more in a psychoeducational perspective, these patients, or these people, they need to understand what the surgery is about what changes they should be expecting and what are the behaviors that can occur after surgery and that can be a red flag. And most importantly, and this could be another talk, but we know that obesity is a disorder, it’s based on the brain. So if they do develop these problems, if they do develop, start to regain weight, it’s not their fault. It’s natural course of a disorder, of a medical disorder, a real medical disease. So they need to know that it’s not their fault if they’re not controlling their weight. They just need to come to the medical team and just sort it out and see what kind of intervention, further intervention they need. It might be there’s a variety of interventions nowadays to curb weight regain after surgery, but most of all, it’s not a failure. is just the disorder operating and following its course and fighting the treatment, which we expect with obesity. So it’s not their fault. And this should be educational for patients. So still regarding the red flags, I would help patients identify red flags and come to the medical team and reporting those red flags.

Speaker 1
That’s a good point. I think we have to close this. I know there’s another question in chat, but you guys, there’s the email for Eva. She has a lot of knowledge and there’s so much to ask her about the topic. So if you have any question, Eva, I think it’s fine for people to write to you in case. Thank you. Yes, we all thank you for this webinar. It was really rich and interesting. So thank you again for joining it. And you guys, we hope to see you to the next webinar. And thanks for joining. Remember to fill in the questionnaire to give us your feedback. And see you at the next occasion. Thank you again.