by Carolyn Coker Ross, MD, MPH
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Obesity has been identified as a major public health issue with more than 65 percent of Americans being affected by excess weight or obesity. Rates of obesity have also tripled in children since the 1970’s and diseases that were formerly only seen in adults, such as non-insulin dependent diabetes, have increased in children. This has created more acceptance of and desire for rapid weight-loss measures such as weight-loss surgery, also called bariatric surgery. What many people are not aware of is that the presence of an eating disorder may make bariatric surgery more risky and less likely to be successful.
Binge Eating Disorder
Binge eating disorder (BED) is the eating disorder most commonly associated with obesity. Approximately one in three individuals who go to any weight-loss program actually have BED. They may experience repeated episodes of eating large quantities of food in one sitting or in a two-hour period. They may also feel unable to stop themselves when they binge eat.
Individuals with BED may also eat until they are too full, they may eat more rapidly than normal and eat alone because of embarrassment of how much they are eating. They may also have feelings of disgust, guilt or depression that come about after they binge eat.
Anorexia and bulimia are more publicized, but BED is actually more common than either of these. Another difference is that while anorexia and bulimia overwhelmingly affect women and girls, 40 percent of those with BED are male. BED tends to run in families just as obesity does and it’s also associated with more likelihood of depression, bipolar depression and substance abuse both in the person with BED and in their family members.
Those with BED are more likely to be affected by excess weight or obesity and to seek bariatric surgery. Individuals with BED who have bariatric surgery may put themselves at risk for the development of complications after surgery if they are unable to stop binge eating.
Bariatric Surgery and Eating Disorders
Bariatric surgery is recommended only for those who are affected by severe obesity defined as a body mass index (BMI) of more than 40 or a BMI of 35 along with health problems such as diabetes or heart disease. Research has shown weight-loss surgery to be more effective for weight-loss than conventional methods in those who are affected by severe obesity. While weight-loss surgery does promote weight-loss, surgery also carries risks and it’s important to know these possible risks and complications before proceeding.
The following questions may be of help in identifying whether or not you are at risk for
- Do you overeat to help deal with emotions that you are uncomfortable with?
- Do you use food to give you comfort?
- Do you have a family history of drug or alcohol addiction?
- If you think about having to change what you eat and how much you eat, do you feel sad, lonely or afraid?
- Have you ever felt that food is your best friend?
- Do you have a history of trauma, abuse or neglect?
If you answered yes to one or more of these questions, you should consider addressing your relationship with food before you consider weight-loss surgery. It is important to realize that your relationship with food has developed to serve some need. Even if you feel ready to lose weight and are very motivated to do so, you should make sure that the need food has served is being met in some other way.
Nutritional Changes with Bariatric Surgery
Nutritional changes after bariatric surgery may contribute to the development of depression, destructive eating behaviors and body image issues. Changes from weight-loss surgery cause difficulty in absorbing vitamins and minerals and can lead to deficiencies in iron, calcium, several B-vitamins, vitamin D and other vitamins and minerals. The surgery can also affect the ability to absorb protein and cause lactose intolerance. Difficulty absorbing protein can affect mood and behavior because the amino acids found in protein are what the body uses to make the “feel good” chemicals in our brains – serotonin, dopamine and epinephrine.
One research study found that giving people who have been on a liquid fasting diet (that also causes some malnutrition) a supplement with amino acids decreased binge eating by 66 percent and reduced food cravings by 70 percent. When compared to a group who were not taking the supplements, they regained only 14 percent of their lost weight compared with 41 percent. Given that up to two-thirds of those who have weight-loss surgery do not take the prescribed vitamins and minerals, malnutrition is a very real concern and can be worsened by excessive alcohol or drug use.
Cross Addiction and Weight-loss Surgery
Beyond the complications and risks associated with surgery is the issue that has increasingly been coming to light – cross addiction. Cross addiction is loosely defined as exchanging one drug of abuse (such as food) for another (for example, alcohol). Many individuals who undergo weight-loss surgery develop disordered eating and other addictions, including gambling, drinking, smoking, drug use and may be more prone to shopping or sexual addiction after surgery.
There are more than 140,000 weight-loss surgeries performed every year and it is estimated that from 5 to 30 percent develop another addiction. This makes perfect sense when you think of the purpose that food serves. If an individual is using food for comfort, to hold down their emotions or to cope with stress or traumatic experiences, they will be left with no coping mechanism when they can no longer use food in this way.
Another factor that may contribute to the development of a cross-addiction is a history of childhood trauma or neglect. Often being affected by excess weight or obesity can serve as a safety factor for a person who has this history. Being affected by obesity may make them feel less attractive to the opposite sex and therefore safe from any unwanted overtures or perceived threats to their safety.
People with obesity who quickly become thin through surgery may find themselves feeling very vulnerable. Both women and men may find that they feel uncomfortable with the changes in their bodies after surgery. Those individuals who have loose skin folds or scars may feel unattractive and feel that surgery did not accomplish their goals of becoming more accepted socially.
As more weight-loss surgeries are performed, the issue of cross-addiction has become more of a problem. Just as an alcoholic may think that they can safely use marijuana in place of alcohol once they get sober, a person with BED or compulsive overeating may substitute alcohol for food without recognizing that this behavior can lead to a full blown addiction to another substance besides food.
The development of a cross addiction can occur with any of the weight-loss surgery procedures including laparoscopic adjustable gastric banding, gastric sleeve and gastric bypass surgeries. To avoid this problem, it is important that individuals considering surgery explore the possibility that they may be at risk for cross-addiction.
If you use food to cope with stress, for example, what are the coping strategies you are using in the place of food? If you have not practiced these coping skills, you should practice them regularly for some time before having surgery. If food is your comfort, how will you comfort yourself after surgery? Finding other ways to soothe yourself when you are anxious or angry, for example, should be in place before surgery.
Having surgery without addressing the emotional attachment you may have to food or the important purpose food has served in your life could lead to cross-addiction.
Honor your past. If you’ve used food for comfort or safety, recognize that perhaps that was the only way you knew at the time to get comfort or feel safe. Don’t beat yourself up about this. You are a different person now than you were when you started using food in this way. You may have been much younger when your disordered eating began. Affirm that you are committed to full and complete healing and if you choose to pursue weight-loss surgery, do so with the awareness of what you need to do to avoid cross-addiction.
Suggestions for Helping You Prepare Yourself for Surgery:
- If you have a history of trauma, abuse or neglect, make an appointment to see a therapist to begin working on these issues. You don’t have to wait years to heal. The healing process begins with your commitment and awareness that you need help.
- Keep a one week journal of stressful times and list next to each one what you did to deal with the stress. Notice how many times you turned to or wanted to turn to food to help you.
- Keep a one-week emotional diary where you list times each day when you felt upset, angry, afraid, sad, guilty or shameful. Then list next to each how you dealt with the feelings. Again, notice if you wanted to or did turn to food to help you through a tough time.
- Make a list of your comfort foods and see if you can go for two weeks without eating any of them. Keep a journal about how you feel when you turn down the cupcakes or cookies at work, for example.
About the Author:
Carolyn Coker Ross, MD, MPH, is a nationally known author, speaker and expert in the field of eating disorders, addictions and integrative medicine. She is the former head of the eating disorders program at Sierra Tucson. She currently has a private practice specializing in treating eating disorders, addictions and obesity. Her latest book The Binge Eating and Compulsive Overeating Workbook has just been released.