Vol.

16: e263-e269, December 2011

e263
ORIGINAL
RESEARCH
PAPER
Key words:
Obesity, binge eating, eating
disorders, psychopathology,
health related quality of life,
bariatric surgery, weight
loss.
Correspondence to:
Joakim de Man Lapidoth,
Allmogev 59, 18730 Tby,
Sweden.
E-mail:
joakim.deman-lapidoth@sll.se
Received: January 19, 2011
Accepted: March 11, 2011
Binge eating in surgical weight-loss
treatments. Long-term associations
with weight loss, health related quality
of life (HRQL), and psychopathology
INTRODUCTION
Bariatric surgery is considered as the
most effective long-term treatment for obe-
sity, which alleviates medical risks and
improves psychological conditions, psy-
chosocial status and health related quality
of life (HRQL) (1-6). In spite of the large
weight losses reported in bariatric surgery,
considerable variability in outcome has led
to difficulties in predicting individual
weight-loss outcome (7).
Eating disorders and binge eating are
common in bariatric surgery patients and
are thought to play influential roles in post-
operative outcome (7-9). Studies of how eat-
ing disorders or binge eating are associated
with weight loss outcome have shown
mixed results (5, 7, 8, 10-13). Also in studies
of outcome in terms of eating disorder
symptoms (pre to post bariatric treatment)
results are mixed, some describing patients
that develop eating disorder symptoms
post-surgery (14-16), but most showing
fewer cases of eating disorders and binge
eating post-treatment (12, 17, 18). Hsu et al.
(13) found an overall trend for patients to
retain pre-treatment eating behaviours
post-treatment and concluded that eating
disturbances that persist may be linked to
worse long-term weight-loss outcome. A
number of studies have thereafter shown
an association between weight-loss/regain
and binge eating after surgery (18, 19).
In addition to weight loss and eating
behaviour, HRQL and psychopathology (2,
20, 21) have been used to measure outcome
in weight loss treatments. In general this
has shown weight loss to be associated
with improvements in HRQL and psy-
chopathology (2, 22), still though studies
have shown cases where successful weight
loss has been associated with increased eat-
ing pathology (15, 23).
Binge eating is the core symptom of most
eating disorders in obese patients and is
J. de Man Lapidoth
1
, A. Ghaderi
2
, and C. Norring
3
1
School of Health and Medical Sciences, rebro University, and Psychiatric Research Centre, rebro,
2
Depart-
ment of Psychology, Uppsala University, Uppsala,
3
Stockholm Centre for Eating Disorders, Stockholm, and
Center for Psychiatry Research Stockholm, Karolinska Institutet/ Stockholm County Council, Sweden
ABSTRACT. BACKGROUND: Studies that have investigated the relationship between
binge eating and the long-term outcome of bariatric surgery have shown mixed results. Does
binge eating affect long-term BMI, health-related quality of life (HRQL), or psychopathology
after surgery? METHODS: We assessed 173 bariatric patients before and three years after
weight loss surgery with regard to weight, binge eating, HRQL, and psychopathology.
RESULTS: Binge eating before and after weight loss surgery was unrelated to long-term
BMI outcome. Binge eating after weight loss surgery was associated with more psy-
chopathology and lower HRQL. CONCLUSIONS: Binge eating before or after weight loss
surgery does not predict long-term BMI outcome. Therefore, exclusions from surgery for
this reason alone are difficult to motivate. However, results show that binge eating after
weight loss surgery is common and is associated with more psychopathology and lower
HRQL, which might increase the vulnerability for future weight regain and complications
beyond the follow-up period of the present study. The high rate of binge eating after surgery
and its negative association with HRQL and psychopathology suggest that we need to be
observant of the occurrence and potential effects of binge eating in the context of bariatric
surgery.
(Eating Weight Disord. 16: e263-e269, 2011).

2011, Editrice Kurtis

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J. de Man Lapidoth, A. Ghaderi, and C. Norring
defined by the DSM-IV (24) as eating an
amount of food that is definitely larger than
most people would eat in a similar period of
time under similar circumstances, while feeling
a loss of control over eating. A diagnostic issue
that has been raised is concerned with how
binge eating should be defined after bariatric
surgery (7, 25), considering that the treatment
profoundly restricts the capacity to eat large
amounts of food. In a large review (7), studies
were listed that showed binge eating to
decrease post-surgery when the DSM-IV binge
eating definition was used. The article ques-
tioned the assumption that these patients
improved in eating behaviour and suggested
that the change reflected a change due to these
patients no longer being physically able to eat
objectively large amounts of food. A number of
studies (7, 26, 27) have instead argued for not
addressing binge size and focusing on loss of
control while eating subjectively or objectively
large amounts of food.
In addition to diagnostic difficulties and the
use of different instruments and modes of
assessment in previous research (27), mixed
results found in previous studies may partly be
due to differences in length of follow-up. Short-
term improvements (e.g. depression and eating
behaviour) are common and often followed by
a return to initial values (10). Eighteen to 24
months after surgery has been shown to be an
important phase when binge eating may re-
emerge with subsequent weight regain (19, 28,
29).
The objective of this study was to investigate
the long-term associations between binge eat-
ing and outcome in bariatric surgery. Our spe-
cific research questions were: a) is pre- or post-
treatment binge eating associated with long-
term weight loss and b) is post-treatment binge
eating associated with the long-term health
related quality of life (HRQL) and general psy-
chopathology?
MATERIALS AND METHODS
Participants
Two hundred and ten consecutive patients
were accepted for bariatric surgery in four sur-
gical clinics in Sweden. Of these potential par-
ticipants, 202 gave their written consent to par-
ticipate and 173 received treatment in sufficient
time to allow three years to pass until the fol-
low-up period. Of those receiving treatment,
data on pre-treatment binge eating and weight
loss was available for 130 (75.1%) participants.
The 43 participants that were excluded did not
differ from the 130 that were included, with
regard to sex, age, pre-treatment BMI, or
prevalence of pre-treatment binge eating.
The different subgroups that were analysed
(a and b) and the rates of dropout are present-
ed in Figure 1. Out of the 130 participants
above, 28 had no data on subjective binge eat-
ing after surgery (post-SBE), which led to 102
participants being analysed with regard to
post-treatment subjective binge eating and
BMI outcome (subgroup a in Fig. 1). Twenty of
these 102 participants had no data regarding
post-treatment psychopathology and HRQL,
and an additional 19 had no pre-treatment data
regarding psychopathology and HRQL. Sixty-
three participants with and without SBE were
compared with regard to psychopathology and
HRQL (subgroup b in Fig. 1).
Separate dropout analyses on possible differ-
ences between dropouts and analysed patients
were performed for each of the two subgroups
(a and b). These analyses showed no significant
differences between dropouts and analysed
participants with regard to sex, pre-treatment
BMI, or age.
The 130 participants averaged 40.6 (SD=9.2)
years old, with a BMI of 45.8 (SD=6.7) kg/m
2
.
Twenty-eight (21.5%) of the participants were
male. The surgical procedures performed were:
100 Gastric Bypass (76.9%), 18 Gastric Banding
e264 Eating Weight Disord., Vol. 16: N. 4 - 2011
FIGURE 1
Rates of dropout in the entire sample and sub-samples.
Asked about participation (n=210)
Treatment
Accepted participation (n=202)
Received treatment within set
time limit (n=173)
- Declined (n=2)
- Language difficulties (n=6)
- No, or delayed treatment (n=28)
- Deceased pre-surgery (n=1)
- Incomplete pre-OBE data (n=8)
- No post-treatment BMI (n=21)
- No post-SBE data (n=28)
- No post-treatment psycho-
pathology and HRQL data
(n=20)
- No pre-treatment psycho-
pathology and HRQL data
(n=19)
- Pregnancy (n=4)
- Asked to be excluded (n=3)
- Resurgery due to complic. (n=5)
- Deceased post-surgery (n=1)
- Not traceable (n=1)
Participants 3-years
post-treatment (n=159)
Participants analysed regarding
pre-SBE and BMI (n=130)
a) Participants analysed
regarding post-SBE data (n=102)
b) Participants analysed regarding
post-treatment SBE, and pre- and
post-treatment psychopathology
and HRQL (n=63)

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Binge eating in surgical WLT
(13.8%), 7 Vertical Banded Gastroplasty (5.4%),
and 5 Biliopancreatic Diversion with Duodenal
Switch (3.8%).
Instruments
Eating Disorders in Obesity (EDO) is a self-
report questionnaire (30) assessing eating dis-
order symptoms based on the DSM-IV criteria
(24). The EDO was constructed to assess eating
disorder symptoms among patients in weight
loss treatments. The EDO consists of 11 ques-
tions, of which eight only apply to patients
reporting binge eating. Binge eating is defined
in the questionnaire in accordance with the
DSM-IV definition (24). The EDO has shown
good reliability and good concurrent validity in
the assessment of eating disorders and binge
eating.
Eating Disorder Examination-Questionnaire
(EDE-Q) (31) is a self-report measure derived
from the Eating Disorder Examination inter-
view, and assesses the specific psychopatholo-
gy of eating disorders over the previous 28
days. Several forms of binge eating behaviours,
including subjective and objective bulimic
episodes, are assessed. In both these, there is
loss of control while eating objectively or sub-
jectively large amounts. Research supports the
validity of the EDE-Q (32, 33).
Short Form-36 (SF-36) is a self-rating ques-
tionnaire (34) measuring Health-Related Quali-
ty of Life (HRQL). The SF-36 consists of eight
dimensions, from mainly physical to mainly
psychological: Physical Functioning (PF), Role-
Physical (RP), Bodily Pain (BP), General Health
(GH), Vitality (VT), Social Functioning (SF),
Role-emotional (RE), and Mental Health (MH).
The sum of the SF-36 item scores within each
dimension is transformed into a scale ranging
from 0 (poor health) to 100 (good health).
Comprehensive Psychopathological Rating
Scale - Self-rating Scale for Affective Syn-
dromes (CPRS-S-A) is a 19-item self-reporting
questionnaire (35) measuring psychopathology.
The CPRS-S-A was constructed by rephrasing
the items from the interview-based CPRS, cov-
ering depression (Dep), anxiety (Anx), and
obsessive-compulsive (OCD) symptoms. The
depression and anxiety scales show a high
degree of concordance with the interview-
based CPRS rating.
Procedure
Patients accepted for bariatric surgery at any
of the four clinics were informed and asked
about participation. Those agreeing to partici-
pate filled out the EDO questionnaire. They
also recieved copies of the CPRS-S-A and SF-
36 questionnaires to complete and return
before treatment. Demographic and anthropo-
metric data (including pre-treatment weight
and length) were collected from patient
records.
Participants were assessed three years post-
treatment via completion of the EDE-Q, CPRS-
S-A, and SF-36. Weight data were continuously
collected from patient records. At the three-
year assessment, structured follow-up ques-
tions regarding self-reported long-term weight
were included to permit collection of data for
patients who had no long-term clinical weight
data. Adding these questions was a divergence
from the original plan and was done in
response to the observation that many patients
had no clinical weight data at follow-up. Two to
five months after the three-year follow-up,
patients non-responders were reminded and
sent the EDE-Q and follow-up questions, and
given the option of completing only these ques-
tionnaires. The trial protocol has been
approved by the local ethical committee.
Definitions
Pre-treatment objective binge eating (pre-
OBE) was measured by the EDO questionnaire
(30). In addition to confirming the presence of
objective binge eating (according to the pre-
sented DSM-IV definition (24)), pre-OBE partic-
ipants were required to confirm a loss of con-
trol over eating, as well as incidents of eating
objectively large amounts of food, in two addi-
tional questions.
It was planned to use the EDO also for post-
treatment assessments of binge eating. During
the follow-up period, however, new research
argued for the importance of including subjec-
tive binge eating in post-bariatric assessments
(7, 25, 27). The EDO, which defines binge eat-
ing as eating objectively large amounts of food,
was therefore exchanged for the EDE-Q to
assess objective (post-OBE) as well as subjec-
tive (which includes objective) binge eating
episodes (post-SBE) at follow-up. Due to this
change in instrument, no direct comparisons
are made between the frequency of binge eat-
ing pre to post-surgery.
Pre-treatment weight and length were
planned to be extracted from patient records
and registered as Body Mass Index
(BMI=kg/m
2
) throughout the study. After pre-
treatment data was collected, though, continu-
ous extraction of weight data soon showed that
an insufficient amount of post-treatment
weight data could be found in patient records.
For this reason, questions about self-reported
current weight were added in the three-year
follow-up. For increased statistical power,
missing self-report data were supplemented
e265 Eating Weight Disord., Vol. 16: N. 4 - 2011

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J. de Man Lapidoth, A. Ghaderi, and C. Norring
with available data from patient records for the
same time. If three-year clinical data were
missing, data closest in time were used (as long
as data considered weight from more than two
and fewer than four years after treatment).
Self-reported weight data from 111 out of 130
(85.4%) participants were used. The self-report-
ed weight data used were all from 25 to 47
months after treatment. Seven (5.3%) of these
data points were from 25-29 months post-treat-
ment, nine (6.8%) from 30-42 months post-
treatment, and three (2.3%) from 43-47 months
post-treatment.
Previous studies have shown lower values for
self-reported than clinically assessed weight
(36). In the present study, however, BMI data
were used mainly for comparisons between
patients with or without binge eating. As there
were no differences in the proportion of self-
reported and clinically assessed weight data
between patients with or without pre-OBE
(
2
(3)=0.10, p=0.75), or between those with or
without post-SBE (
2
(3)=0.77, p=0.38), the
weight assessment method was assumed not to
differentially affect group results.
Statistics
Changes in BMI (pre- to post-treatment)
were analysed by paired t-test. The differences
between patients that indicated objective or
only subjective binge eating were analysed by
means of paired t-test with corresponding
effect sizes. Differences in post-treatment BMI
between patients with or without pre or post-
OBE, as well as patients with or without post-
SBE, have been analysed by means of ANCO-
VA with corresponding effect sizes (Cohens d).
In these analyses, pre-treatment BMI was used
as a covariate. Differences in post-treatment
HRQL and psychopathology were compared
between patients with and without post-SBE
by means of ANCOVA, using the respective
pre-treatment scores as a covariate. The corre-
sponding effects sizes were also shown.
Comparisons between patients that were and
were not included in the main analyses were
done by means of Students t-test for continu-
ous data (BMI, age) and by Chi-square test for
categorical data (binge eating, sex).
RESULTS
Before surgery, the 130 participants had an
average BMI of 45.8 (6.7) kg/m
2
. Correspond-
ing BMI three years after treatment was 32.1
(6.6) kg/m
2
. This change (pre- to post-treat-
ment) was statistically significant with a very
large effect size (t(258)=16.5, p=0.0001, d=2.08).
Pre- and post-treatment binge eating
Pre-treatment, 24 of the 130 participants
(18.5%) were classified as pre-OBE. After
surgery, only 102 of these participants provid-
ed data, of which 18 (17.6%) had reported pre-
OBE. A total of 29 participants (28.4%) report-
ed post-SBE, and thirteen of these 29 reported
objective binge eating after the treatment (from
now on called the post-OBE group). The post-
OBE group constitutes 12.7% of those who
responded to the follow-up questionnaire.
The difference between using a binge eating
definition based on objectively large amounts of
food vs one based on subjectively large amounts
of food was investigated by comparing them. Of
the 29 participants with post-SBE, 13 reported
objective binge eating episodes (in addition to
the subjective ones), while 16 had no objective
episodes. Mean values, standard deviations, and
analysis comparing binge participants with or
without objective binge eating episodes at post-
treatment are shown in Table 1.
The two groups showed no differences with
regard to post-treatment BMI, HRQL, or other
psychopathology.
Binge eating and long-term BMI outcome
An ANCOVA was performed to compare the
long-term BMI outcome in patients with or
without pre-OBE (controlling for pre-surgery
BMI). This analysis showed no significant dif-
e266 Eating Weight Disord., Vol. 16: N. 4 - 2011
TABLE 1
Mean values, standard deviations, and analysis comparing
binge participants with or without objective binge eating episodes at
post-treatment.
No OBE OBE
Mean (SD) Mean (SD) t p r
BMI N=16 N=13
31.2 (5.7) 32.9 (6.6) 0.72 0.48 0.14
CPRS-S-A N=10 N=10
Dep 8.4 (5.4) 6.5 (4.5) 0.87 0.39 0.19
Anx 9.5 (4.9) 8.5 (4.5) 0.47 0.64 0.11
OCD 5.7 (4.1) 5.1 (4.1) 0.30 0.78 0.07
Total 23.7 (13.9) 20.1 (12.5) 0.60 0.56 0.13
SF-36 N=12 N=12
PF 77.9 (21.2) 80.8 (18.9) 0.36 0.73 0.07
RP 77.1 (34.5) 64.6 (39.1) 0.83 0.41 0.17
BP 54.2 (28.6) 59.4 (28.6) 0.45 0.66 0.09
GH 54.2 (23.3) 59.6 (19.9) 0.61 0.55 0.12
VT 44.6 (22.4) 47.8 (23.3) 0.35 0.73 0.04
SF 77.5 (26.9) 72.9 (26.6) 0.42 0.68 0.09
RE 44.4 (45.7) 61.1 (39.8) 0.95 0.35 0.19
MH 60.0 (19.8) 64.2 (23.4) 0.48 0.64 0.10

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TABLE 2
Pre- and post-bariatric treatment scores of psychopathology and HRQL, and differences in these measures between patients with and
without post-treatment SBE.
Binge eating in surgical WLT
ference between the groups (F(1,129)=1.1,
p=0.29, d=0.24). ANCOVA was also performed
to compare the long-term BMI outcome in par-
ticipants with and without post-SBE (control-
ling for pre-surgery BMI). This analysis
showed no significant difference in the BMI
outcome between the groups (F(1,101)=0.05,
p=0.83, d=0.05). There was no difference in
long-term BMI outcome when patients with
only post-SBE (n=16) were compared with
those also indicating post-OBE (n=13;
F(1,28)=0.14, p=0.71, d=0.12).
Subjective binge eating, HRQL, and
psychopathology post-treatment
Table 2 below shows that patients with post-
SBE had significantly more anxiety post-treat-
ment than those with no post-SBE. The group
differences regarding depression and OCD
(CPRS-S-A) reached medium effects sizes, but
were not statistically significant. The results
further showed medium to large effect sizes for
the HRQL dimensions, with the exception of
the small effect found for Social Functioning
(SF).
DISCUSSION
Binge eating was found to be common before
(OBE) as well as after (SBE/OBE) bariatric
surgery, but neither pre- nor post-surgery
binge eating was associated with long-term
BMI outcome. The importance of binge eating,
however, was supported by important associa-
tions found post-surgery between subjective
binge eating and HRQL and level of psy-
chopathology. This adds to the mixed picture of
the importance of binge eating for BMI out-
come based on previous prospective studies.
Only two studies suggesting an association
between binge eating post-surgery and long-
term BMI outcome have used a subjective
binge eating definition and followed patients
for more than two years after treatment (11,
19). Both studies found subjective binge eating
post-treatment to be associated with larger
long-term weight regain. In one of the studies
subjective binge eating was also associated
with long-term weight status. Interestingly
none of the previous studies have reported
cases of binge eating after, but not before,
bariatric surgery, which is in conflict with
numerous case studies (14-16) and preliminary
findings from the present study. Undoubtedly
binge eating is common after bariatric surgery,
and given the relationship between post-surgi-
cal subjective binge eating and HRQL and psy-
chopathology, attention to patients eating
habits and binge eating problems should be
considered an important part of clinical assess-
ment and post-surgical care.
More than one quarter of the participants
reported subjective binge eating post-treat-
ment. This questions previous findings that
show binge eating to be markedly reduced
post-treatment (37, 38), but can most likely be
attributed to the above mentioned differences
e267 Eating Weight Disord., Vol. 16: N. 4 - 2011
no post-SBE (N=50) Post-SBE (N=13)
pre post Pre post ANCOVA d
CPRS-S-A
Dep 5.1 (3.8) 3.9 (4.4) 8.2 (4.5) 7.5 (4.8) F(1,62)=1.3, p=0.25 0.37
Anx 7.2 (4.6) 4.7 (4.4) 10.5 (4.7) 9.7 (4.5) F(1,62)=7.6, p=0.01 0.88
OCD 3.5 (3.0) 2.6 (3.6) 6.0 (4.5) 5.6 (4.0) F(1,62)=1.7, p=0.20 0.42
Total 15.4 (10.2) 11.2 (12.1) 24.6 (13.0) 22.8 (13.0) F(1,62)=2.3, p=0.13 0.50
SF-36
PF 58.4 (19.2) 87.4 (17.6) 58.1 (21.4) 81.2 (17.1) F(1,62)=1.4, p=0.23 0.37
RP 52.0 (37.0) 83.1 (34.3) 34.6 (34.7) 65.4 (40.2) F(1,62)=1.4, p=0.24 0.37
BP 44.8 (23.4) 66.3 (28.4) 35.3 (22.0) 52.6 (30.5) F(1,62)=1.1, p=0.31 0.32
GH 47.6 (21.3) 70.9 (27.0) 37.7 (20.1) 57.3 (20.5) F(1,62)=1.0, p=0.32 0.32
VT 39.2 (23.4) 61.7 (23.7) 27.3 (24.9) 39.6 (23.9) F(1,62)=6.0, p=0.02 0.77
SF 73.2 (27.4) 83.3 (26.3) 50.0 (24.5) 72.5 (27.4) F(1,62)=0.1, p=0.74 0.11
RE 71.3 (37.5) 87.1 (28.7) 52.8 (41.3) 56.4 (41.7) F(1,62)=4.9, p=0.03 0.69
MH 68.5 (21.3) 79.5 (18.9) 52.6 (21.4) 60.9 (21.4) F(1,62)=4.0, p=0.05 0.64

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between studies in the definition of large
amounts in binge eating. What constitutes a
large size in relation to circumstances (24) is
difficult to operationalise (39) and has not been
established post-surgery. While the wording of
the DSM-IV definition does not prevent its use
post-surgically, the difference between our
results and those from studies using an objec-
tive binge eating definition suggests that post-
bariatric circumstances is perhaps difficult for
patients to grasp and is therefore not consid-
ered by these patients adequately. The use of a
subjective binge eating definition is thus sug-
gested (7, 8), which also is supported by
research showing no differences in other
aspects of psychopathology between patients
with subjective and objective binge eating
episodes (40, 41). This is also supported by the
lack of differences in long-term BMI, HRQL
and psychopathology when we compared
those reporting only subjective binge eating
and those also reporting objective binge eating.
An ultimate remedy to these limitations and
problems would be to conduct e.g. EDE inter-
views before and after surgery. Perhaps the
focus should not be on binge eating exclusively,
but on urges and emotional eating in general.
Such variables might be better predictors of
long-term BMI outcome than binge eating
alone.
As discussed, patients engaging in subjective
binge eating post-surgery do not have less
favourable BMI outcome. However, post-
surgery subjective binge eating was associated
with more psychopathology and a lower
HRQL. This prompts the question if weight loss
per se is sufficient for an outcome to be regard-
ed as successful (25). The overall success that
has repeatedly been reported in bariatric
surgery (2-6) may require evaluations that also
take post-surgery binge eating, psychopatholo-
gy and HRQL into consideration.
The main strength of this study was its
prospective design, with a large, naturalistic
sample of patients who were assessed with vali-
dated instruments. Furthermore, we paid spe-
cific attention to the problem of assessing binge
eating after restrictive surgery by measuring
both objective and subjective binge eating.
The main shortcoming was the use of two
different self-report instruments for eating dis-
order symptoms pre- and post-surgery. Both
instruments are validated (35, 37, 38) and both
assess binge eating according to the DSM-IV.
However, the EDE-Q also assesses subjective
binge eating, while the EDO does not. While
the change in instruments made comparisons
of binge eating before and after surgery impos-
sible, it made post-surgery assessment of sub-
jective binge eating possible. Due to change in
instruments, no direct comparisons were made
in binge eating pre- to post surgery.
To obtain a reasonably large sample size and
due to limited resources, we chose to use self-
report instruments for the assessment of out-
come. Additionally, long-term weight data
were based primarily on self-reports. This devi-
ation from the original plan was made because
clinical weight data were not obtainable for a
sufficient number of participants. Self-reported
weights have been shown to differ from
weights obtained by clinical weight data. In this
study, the proportion of patients being
weighed, compared to those self-reporting
weight did not differ between the groups with
or without binge eating. Consequently, poten-
tial problems due to different types of weight
data were deemed minor.
CONCLUSION
In all, results show that pre- and post-surgery
binge eating was unrelated to long-term BMI
outcome. However, post-treatment binge eat-
ing was common and associated with higher
levels of psychopathology and lower HRQL.
These data raise the question whether suffi-
cient weight loss in patients that binge eat
post-treatment should be considered as treat-
ment success.
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