Eating Behaviour and Adjustment
Post Weight Loss Surgery: A
Patient Perspective
Dianne Tetley, Simon Dexter
& Andrew Hill
Academic Unit of Psychiatry
Leeds University Medical School (UK)
Eating Behaviour – a Critical Part
of the Puzzle of WLS Outcome
Results of Weight Loss Surgery (WLS) not Equal
“One in five patients who undergo
bariatric surgery does not lose the
expected amount of weight; others
regain weight after the first few years”
Harvard Medical International (2008)
Current Research and Practice
Research:
• Neglects the role of eating behaviour/adjustment and related psychological issues
•
WLS research has traditionally considered changing weight and co morbidity (e.g. Diabetes)
• Is not patient led
• Not questioned whether different restrictive surgical procedures result in different eating
frequencies/patterns of eating behaviour – this is not known
• Consideration not given to stages of change over time in eating behaviour postoperatively and impact on outcomes
Practice:
• The importance of eating behaviour and adjustment post-surgery is not acknowledged
in National Guidance:
• Frequently overlooked in pre-surgery assessment/follow up of those who have had
weight loss surgery
•
Support post-surgery focuses on nutrition and the development of good life style behaviours in relation to
food and exercise
• Appropriate assessments tailored to this population do not exist and interventions not
specified
Research Aim
Explore patient’s descriptive accounts of
their ‘real lived’ experiences:
• the influence restrictive WLS imposes on eating
behaviour, adjustment over time and any
psychological consequences
• how these impact on their ability to adjust to
new eating styles including their strategies for
coping with them post surgery
Methodology
Qualitative Approach:
• Computer Mediated Communication
(CMC) via a website designed to support WLS
patients
Stage 1- Descriptive phenomenological approach:
explored and defined the nature and veracity of
reported eating behaviours post restrictive surgery
Stage 2- Interpretive phenomenological approach (IPA):
a deeper understanding of the constructs identified
(Stage 1) and their impact on WLS outcome
Stage 1
Data Gathering/Analysis
Documentary Analysis (asynchronous)
• Naturally occurring text ‘postings’ to topic based discussion forums on
WLS support website
- members received restrictive WLS (Gastric banding or RnY Bypass)
- examined retrospectively over an 18month period
• Rich Cases (Text) was selected relevant to the research questions/aims
• Sample size determined by the quality and availability of data
- 301 text based postings relating to eating behaviours and associated
psychological problems post-surgery identified from archives (18 month period)
retained for analysis
Stage 2
Data Gathering/Analysis
Qualitative online synchronous (real-time) interviews
•Interview schedule -piloted
- informed by stage 1 (inc. patient validation, & literature review)
• Purposive sample – 12 female, 4 male, 26-54yrs (8 RnY & 8 Gastric Band)
10-32 months post-surgery (RnY) 12-30 months post-surgery (Gastric Band);
volunteers included those who had experienced problematic eating behaviours/habits
and those who had not
• Online meeting room facility – Adobe Acrobat Beta©
- strategies to overcome loss of face-to face interaction employed
Transcripts analysed - Interpretive Phenomenological Approach
- secondary analysis selective coding
• Data evaluated independently
•
- members of WLS support group in East Midlands UK
Eating Behaviours:
Pre-Surgery (all participants)
Maladaptive eating:
•
•
•
•
response to stressors and triggers (e.g. emotional/comfort eating)
no recognition of hunger (Impaired appetite regulation)
lack of control
yo-yo dieting – weight gain weight loss cycle
“……..being totally honest I think any emotion was an excuse to overeat, when on highs or
lows I would turn to food, looking at it as comfort food or reward. I was on my own a lot as a
child, [….] I was looked after by au-pair and they always used to being sweets/crisps home
for me every day so I saw it as a reward or compensation for their company…….I don’t think I
ever knew what real hunger was………” (Barbara – Gastric Band)
“There were triggers to my eating like boredom, anger getting upset, frustration, not getting
my own way ….I would go for a large bag of crisps. The minute I started to taste food I would
eat and eat until I was about to burst even though I was no longer hungry….I ate
compulsively. I used top crave sweets after eating my meals. I used to shove it down, shove it
down…. (Mandy – RnY)
Post-surgery (all participants)
Initial - first three months:
• RnY - lack of hunger, disinterest in food, inability to eat large quantities,
dumping effects – disappearance of pre-surgical eating behaviours
• Gastric Band – impact more gradual
• Surgery renewed control over eating behaviour – rapid weight loss
• Loss
“I missed not being able to eat and would feel sad when in supermarkets
looking at foods I couldn’t eat. I felt lost and I didn’t know what to do with myself”
Lulu (RnY)
…3 months onwards
Increased quantity, increased hunger/urge to eat, desire for high
fat/sugary foods
“3 months after surgery I found I could eat a whole bowl of popcorn and then one day
I found I could eat a whole large bag………” (James - RnY)
“ At 6 months I started to want food again and not just any food, all the bad stuff I
used to eat before the op [….] it’s a pity they didn’t staple my head as well as my
stomach” (Alex – RnY)
“ I am lucky to have got to 11 months with no appetite, but it appears to have decided
to come back off its holidays and swapped places with my self-discipline which has
now taken a trip somewhere instead….I am starting to feel the beginnings of my old
pre-op feelings and self-disgust for my lack of self-control where eating is concerned
(Hannah – Gastric Band)
Testing the limits
“I always pushed the boundaries even early on and ate just that bit more even when I knew I
was full, I cannot leave food on my plate” (Mandy-RnY).
Pre-surgical Eating Behaviour and Habits
Re-emerging
Overeating, grazing/snacking - Binging (perceived)
“I lost a stone a month (first ten months) and then it stopped, though to be honest I had
increased intake as I discovered I could eat my main enemies, bread cheese, and sweet stuff I
did not experience dumping…..when I got upset about something I started to binge again ……I
felt sad, guilty and out of control ” (Carol - RnY)
“I don’t eat anything like the amount before surgery but I do graze […..] I still have problems
getting good food down but junk goes down beautifully  ” (Susan Gastric Band)
Craving/thinking about food (head hunger)
“ I had good days and bad days….the key thing I found is that I started to crave sugary stuff
sweets mainly…this was more intense than before my surgery…..I never had the experience of
dumping after surgery so eating sweets never affected me. Only three months after surgery I
found I could eat three chocolate brazil nuts and at six months I could eat nine no problem and
no side effects except feeling wonderfully satisfied. I soon wanted more. am scared as I am
putting my weight back on” (Mandy - RnY)
“ there is nothing I can do at the time of craving I am like a devil, I loose control and then I feel
so guilty at times I have them gone to try to throw up…I think why the hell am I abusing myself
after achieving so much” (Polly – Gastric Band)
Control – Poor Outcomes
Control of food intake hindered by:
Beliefs – locus of control?
“pre surgery eating behaviours re-emerged almost totally and I felt abandoned. I saw my
surgeon at 12 months he said if i could not help myself then how did I expect him to help me…..I
just couldn’t control my eating …the surgery let me down” (Tom - Gastric Band)
Inability to deal with emotional/situational triggers – food a coping mechanism
“ I struggled at around 12 months after surgery the minute I got some stress I started to eat
again…add lots of stress and I ate lots!! I daren’t even weigh myself at the moment…….. I am
alone in the evening and I graze all night, being single doesn’t help” (James – RnY)
“head hunger….there is visual stimulation and food is a big thing with me,[…..]. I see something
on TV that looks nice and that I know will taste nice and feel I want it, not that I need it. The
same when passing a bakers with the smell of bread, its outside influences rather than hunger, if
I’m away from food I don’t seem to need it ” (Jemma – Gastric Band)
Lack of acknowledgement of hunger and satiety cues
“………if only I ate when I was hungry I would rarely eat !!! LOL I think I have forgotten what
hunger feels like…..it’s habit eating now ….or eating by the clock” (Johnathan RnY)
“If I’m having a meal I really enjoy then I will eat it till the meal is finished and I feel full, if its
something I’m indifferent to then the feeling of having had enough cuts in ….I think I let greed
override hunger” (Mandy – RnY)
Control - Good Outcomes
Challenges were managed and offset by:
• motivation,
weight loss success and the dramatic improvements in health and self-
esteem
• beliefs about control
• dealing with emotion and stress
• Acceptance and ability to eat adaptively
- No diet mentality
“I knew I had been given this chance and I feel fantastic now, no way was I going to mess it up!
[….] going onto the scales and seeing ur back into a higher stone u think OMG no way can I let
this happen, and makes u think about what ur eating, things u sneak in without realising….It’s
down to me now one else” June (RnY)
“I had a stressful time, and the first thing I thought was "Right I need a big bar of choc this was
the first time I realised this was obviously a key to the weight gain.....now I don’t have big bar of
choc! [....] instead I tell myself its ok and will just have a couple of pieces to satisfy myself”
“I did used to crave chocolate... now... well if I want it, I will have it... once I have had a small
amount the crave goes”
“ I decided to STOP dieting after surgery. I realised that denial just leads me to rebelling against
myself and to eating forbidden foods…I now eat what and when I fancy in moderation”
Conclusion
• WLS is helpful in reversing disordered eating and dieting habits but it may for
some have limitations in combating years of dysfunctional eating patterns
- associations with food may be established from an early age
- pre-surgical eating behaviours and habits may re-emerge over time regardless of type
surgical procedure
• Achieving weight loss goals and maintenance depends on the degree to which
the individual can adjust to dietary changes necessary and their ability to
sustain life long adaptive eating patterns
- adjustment to adaptive eating styles post-surgery is complex and challenging for some
- changing eating style is intertwined with an individuals beliefs to control eating
- emotions and poor stress management may hinder control, through use of food as a coping
strategy
•
Acknowledge hunger and satiety cues i.e. mindful eating
- diet mentality counter-productive
Practice Implications
Evaluation, Monitoring and Interventions
Pre-surgery
• Awareness raising
• Unified way of conducting assessments – current focus psychopathology but not
eating behaviour/ patterns - Not everyone comes to surgery with an eating
disorder.
• Need to offer appropriate psychological interventions pre-surgery to support post
surgical adjustment to those identified as needing support
Post-surgery
• Self help materials and support
• Continuing assessment of eating behaviours,patterns including psychological
issues that may impact on the patients’ ability to adjust to or maintain new eating
styles post surgery
• Availability of appropriate psychological interventions as and when required (pre
and post-surgery) to help patients adopt adaptive eating styles – tailored to the
stage of change
Future Research
• Examine the nature of eating behaviours and associated psychological
constructs with comparisons across different surgical procedures over
longer periods of follow-up, assessing any impact on WLS outcome
• Develop and validate appropriate assessments of eating behaviour and
adjustment for use pre and at post surgery
• Focus on identifying ways to better monitor psychological parameters in
WLS patients in order to optimise long term weight control
• Inform a unified approach to assessment to identify those who need
support
• Provide evidence for appropriate interventions to help increase resistance
to faulty beliefs, cues that trigger overeating and the ability to eat in
response to hunger and satiety cues for WLS individuals, and in particular
for those who have achieved large weight losses to avoid weight regain