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. Author manuscript; available in PMC: 2020 Aug 1.
Published in final edited form as: Int J Eat Disord. 2019 Apr 29;52(8):935–940. doi: 10.1002/eat.23089

Secretive Eating and Binge Eating Following Bariatric Surgery

Janet A Lydecker 1, Valentina Ivezaj 1, Carlos M Grilo 1,2
PMCID: PMC6687553  NIHMSID: NIHMS1034277  PMID: 31033037

Abstract

Objective:

Some individuals eat furtively and conceal evidence of eating and this seems to occur beyond binge-eating episodes. This type of secretive eating is common among youth and emerging evidences suggests that it is a relevant marker of eating-disorder psychopathology among adults with significant eating and weight concerns.

Method:

We assessed secretive eating, loss-of-control (LOC) eating, and eating-disorder psychopathology using investigator-based interviews among treatment-seeking adults experiencing LOC eating following bariatric surgery (N=168). Participants also completed an established depression measure; height and weight were measured.

Results:

Overall, 37% of patients reported secretive eating: 54% of patients who met criteria for binge-eating disorder except for the size criterion (“bariatric BED”) and 25% of patients with subthreshold bariatric BED. Many clinical variables were higher among patients with secretive eating compared to those without secretive eating; however, only eating-disorder psychopathology severity and body dissatisfaction remained significantly higher among patients with secretive eating compared to those without when bariatric BED status was also included as a variable in the model.

Discussion:

Findings suggest that, among post-bariatric surgery patients with LOC eating, secretive eating signals more severe eating-disorder psychopathology overall and specifically related to dissatisfaction with weight and shape. Bariatric BED status, however, has a stronger association than secretive eating with many clinical variables. Secretive eating should be assessed and considered when addressing weight and shape concerns among patients experiencing LOC eating after bariatric surgery.

Introduction

Secretive eating occurs when individuals eat furtively or conceal evidence of eating, often out of embarrassment. This problematic form of eating is considered to be one of the indicators of loss of control (LOC) to determine binge eating in binge-eating disorder (BED) (American Psychiatric Association, 2013). Little research has been done on secretive eating among adults, despite some initial evidence that secretive eating is relatively common among youth (Kass et al., 2017; Knatz, Maginot, Story, Neumark-Sztainer, & Boutelle, 2011; Marcus & Kalarchian, 2003; Sonneville et al., 2013). Among adults with BED, secretive eating was associated with greater eating-disorder psychopathology and depression (Lydecker & Grilo, 2019), which parallels the literature on youth (Kass et al., 2017; Knatz et al., 2011; Marcus & Kalarchian, 2003; Murray et al., 2015; Sonneville et al., 2013). Moreover, an analysis of the diagnostic efficiency of the behavioral indicators for binge eating revealed that “eating alone because embarrassed” had the highest positive predictive power for inclusion among adults categorized with BED (White & Grilo, 2011). Earlier work with adults has also shown hints that secretive eating is associated with eating-disorder psychopathology in a prospective study of dieters examining risk for developing full eating disorders (Fairburn, Cooper, Doll, & Davies, 2005), and among individuals with anorexia nervosa, bulimia nervosa, and BED, compared with healthy controls (Wilfley, Schwartz, Spurrell, & Fairburn, 2000).

No studies, however, have examined secretive eating among bariatric surgery patients with disordered eating. Given the stigma of bariatric surgery (Phelan, 2018) coupled with the strict dietary guidelines recommended in the post-operative period, examining secretive eating among individuals seeking treatment for disordered eating after bariatric surgery presents an opportunity both to understand the eating-disorder psychopathology of this patient group and to tease apart the role of secretive eating in psychopathology. Notably, the presentation of “traditional” BED with objectively large amounts of food is uncommon in the post-operative period due to physical changes from bariatric surgery (Kalarchian et al., 2016). Nonetheless, LOC eating, independent of size, occurs and is associated with psychological impairment including greater eating-disorder psychopathology in the post-operative period (White, Kalarchian, Masheb, Marcus, & Grilo, 2010). Preliminary findings suggest that adults with LOC eating who present for treatment after bariatric surgery and meet all criteria for BED except the unusually large criterion have a similar presentation as adults with “traditional” BED (with the size requirement) (Ivezaj, Barnes, Cooper, & Grilo, 2018). Secretive eating occurs among adults with BED (Lydecker & Grilo, 2019; Wilfley et al., 2000), but the frequency and clinical features of secretive eating among post-bariatric patients experiencing LOC eating remains unknown.

The current study aimed to examine secretive eating in a unique patient group. Our patients were adults who had undergone bariatric surgery and were seeking treatment for LOC eating. Based on earlier research with youth and among adults with “traditional” BED, we hypothesized that post-bariatric surgery patients would have more severe psychopathology if they were experiencing secretive eating compared with post-bariatric surgery patients without secretive eating.

Methods

Participants

Participants (N=168) were recruited for a treatment study on eating and weight concerns approximately six months following bariatric surgery (M=6.3 months, SD=1.5) from the Yale Bariatric/Gastrointestinal Surgery Center of Excellence. Participants were identified and referred by bariatric center staff or responded to study advertisements via letters, flyers, or posters. All research was conducted independently from the bariatric center. Participants were between 18 and 65 years old and reported regular LOC eating, defined as at least once weekly during the prior 28 days. Exclusion criteria were determined to maximize generalizability. Participants were excluded for acute suicidality, severe psychiatric disorders requiring immediate care, or use of medications that effectively influence eating/weight.

Participants were primarily female (n=139; 82.7%) with a diverse ethnic/racial composition (White: n=90, 53.9%; Black or African American: n=57, 34.1%; Bi/Multiracial: n=4, 2.4%; American Indian or Alaska Native: n=2, 1.2%; Native Hawaiian or Other Pacific Islander: n=1, 0.6%; Other: n=13, 7.8%); 10.7% (n=18) identified as Latino/a or Hispanic. The majority (n=145, 86.3%) underwent laparoscopic sleeve gastrectomy surgery while the remaining participants (n=23, 13.7%) underwent laparoscopic Roux-en-Y gastric bypass surgery. Overall, participants had a mean age of 45.4 years (SD=11.1), a mean BMI of 37.2 kg/m2 (SD=7.2), and a mean percent total weight loss (%TWL) of 19.94% (SD=7.39) from pre-surgery to the study evaluation at the post-operative phase. Participants had varying levels of education: high school or less (n=34, 22.2%), some college (n=62, 40.5%), or a college degree or more (n=57, 37.3%).

This study received approval from the institutional review board (Yale Human Investigations Committee) and all participants provided written informed consent. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Measures

Doctoral-level research clinicians conducted in-person assessments, which included interviews (see below), and measured participants’ current weight. Pre-surgical measured weight and height were obtained from the bariatric surgery center and measured weights were used to calculate the weight-change variable.

Eating Disorder Examination – Bariatric Surgery Version (EDE-BSV).

The EDE-BSV is a semi-structured interview assessing different forms of overeating and eating-disorder psychopathology modified for bariatric surgery patients (de Zwaan et al., 2010; Mitchell et al., 2012). The EDE-BSV captures four types of eating behaviors including objective binge-eating episodes (OBEs; defined as eating an unusually large quantity of food during a relatively discrete period of time while experiencing LOC), objective overeating episodes (OOEs; defined as eating an unusually large quantity of food during a relatively discrete period of time without the LOC experienced during OBEs), subjective binge-eating episodes (SBEs; defined as experiencing LOC when not eating an unusually large quantity of food), and subjective overeating episodes (SOEs; defined as eating a quantity of food that is perceived to be large but not unusually large and without the LOC experienced during SBEs). Given the physical restrictions imposed by bariatric surgery, OBEs and OOEs are uncommon and unlikely during the first post-operative year. In the current study, we report findings for LOC episodes (sum of OBEs and SBEs) and SOE episodes.

Secretive eating episodes are assessed separately from objective binge-eating and overeating episodes using a frequency scale for the previous 28 days: 0=0 episodes, 1=1 to 5 days, 2=6 to 12 days, 3=13 to 15 days, 4=16 to 22 days, 5=23 to 27 days, 6=28 days. Participants scoring ≥1 on secretive eating were classified as the “with secretive eating” group; participants who reported 0 episodes of secretive eating in the past 28 days were classified as the “without secretive eating” group.

Although the EDE-BSV also generates four subscales and a global severity scale of broad levels of eating-disorder psychopathology, recent research (Grilo et al., 2010; Grilo, Reas, Hopwood, & Crosby, 2015; Machado, Grilo, & Crosby, 2018) has supported a superior factor structure through confirmatory factor analyses in several studies of clinical and non-clinical samples, including with bariatric surgery candidates (Grilo, Henderson, Bell, & Crosby, 2013). This alternative brief version, which was used in the current study, consists of seven items that yield three subscales (Restraint, Overvaluation, and Dissatisfaction) and an alternative global severity score. Notably, the secretive eating item is not included in the alternative EDE subscales or global score. Cronbach’s alpha for the EDE alternative global score was .641.

Beck Depression Inventory-II (BDI-II).

The BDI-II is a 21-item self-report measure of depressive symptoms (Beck & Steer, 1987; Beck, Steer, & Carbin, 1988) commonly used at bariatric centers (Bauchowitz et al., 2005) as a screening tool for individuals seeking bariatric surgery (Hayden, Dixon, Dixon, Shea, & O’Brien, 2011). The BDI has strong psychometric properties (Beck & Steer, 1987; Beck et al., 1988). Cronbach’s alpha for this study was .916.

Statistical Analyses

We evaluated differences in clinical variables between patients with LOC eating after bariatric surgery who were or were not also experiencing secretive eating episodes. Chi-square tests (categorical variables) and analyses of variance (ANOVAs; continuous variables) compared groups. A second set of ANOVAs also evaluated the role of secret eating when “bariatric BED” status was also included in the model. Detailed information regarding bariatric BED categorization is available (Ivezaj et al., 2018; Ivezaj et al., 2017). Briefly, participants who met bariatric BED criteria met all criteria for full DSM-5 BED, except for the objectively large amount of food size-based criterion. Other participants had subthreshold bariatric BED. These individuals met criteria for at least weekly LOC eating during the prior month but did not meet full bariatric BED criteria. Participants in this category may have had less than weekly LOC eating during the prior three months, no or minimal distress, or less than three of five associated features.

Assumptions of ANOVA were evaluated. Log transformation was applied to LOC episodes prior to analyses to meet the assumption of normality. Partial eta-squared (ηp2) values are considered small at .01, medium at .06, and large at .14 (Cohen, 1988). Phi (φ) values are considered small at .10, medium at .30 and large at .50 (Cohen, 1992).

Results

Just over one-third of patients with LOC eating after bariatric surgery reported secretive eating (n=62, 36.9%). 71 participants met bariatric BED criteria and 97 participants met subthreshold bariatric BED criteria. Table 1 summarizes demographic characteristics of patients by secretive eating. There were significant differences by race/ethnicity, education, and age, but not sex. Secretive eating was associated with White race, college education, and older age.

Table 1.

Demographic variables by secretive eating.

No Secret Secret
n=106 n=62 χ2 N p φ
Sex 0.95 168 .331 .075
 Male 15.1% 21.0%
 Female 84.9% 79.0%
Race/Ethnicity 12.52 168 .006 .273
 White 41.5% 67.7%
 Black 36.8% 25.8%
 Hispanic 13.2% 4.8%
 Other 8.5% 1.6%
Education 9.27 153 .010 .246
 High School 27.8% 12.5%
 Some College 43.3% 35.7%
 College Degree 28.9% 51.8%
M (SD) M (SD) F N p ηp2
Age 43.64 (11.64) 48.50 (9.49) 7.78 168 .006 .045
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Note. N=168. Percentages reflect the proportion of participants from one group (column) in the demographic category (row).

Table 2 summarizes the clinical characteristics (weight, eating-disorder psychopathology, and depression variables) of patients by secretive eating. Overall, weight variables did not differ significantly: BMI, F1,166=1.31, p=.254, ηp2=.008, and %TWL, F1,166=0.40 p=.526, ηp2=.002. LOC episodes differed significantly, F1,166=6.58, p=.011, ηp2=.038: individuals with secretive eating had more LOC episodes than those without secretive eating. SOE episodes did not significantly differ: F1,166=1.82, p=.180, ηp2=.011.

Table 2.

Differences in clinical variables by secretive eating.

No Secret Secret Initial ANOVA Second ANOVA
n=106 n=62 (IV: secretive eating) (IV: secretive eating) (IV: bariatric BED)
M (SD) M (SD) F N p ηp2 p ηp2 p ηp2
Weight Variables
 BMI 36.73 (6.33) 38.04 (8.39) 1.31 168 .254 .008 .220 .009 .717 .001
 % TWL 20.22 (6.98) 19.47 (8.07) 0.40 168 .526 .002 .569 .002 .932 <.001
Episodes
 LOC 19.75 (26.23) 26.50 (25.75) 6.58 168 .011 .038 .308 .006 <.001 .165
 SOE 6.04 (9.05) 4.98 (7.06) 1.82 168 .180 .011 .173 .011 .588 .012
EDE Global Score 1.85 (0.85) 2.60 (0.90) 29.69 168 <.001 .152 <.001 .088 <.001 .151
 Dietary Restraint 2.84 (1.85) 3.56 (1.74) 6.30 168 .013 .037 .087 .018 .045 .024
 Overvaluation 2.42 (1.89) 3.23 (1.78) 7.42 168 .007 .043 .100 .016 .002 .058
 Dissatisfaction 2.50 (1.46) 3.62 (1.45) 22.88 168 <.001 .121 <.001 .075 .001 .062
BDI 10.24 (8.59) 14.58 (11.52) 6.98 152 .009 .044 .140 .015 <.001 .138
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Note. N=168. Partial eta squared (ηp2) values are considered small at .01, medium at .06, and large at .14 (Cohen, 1988). LOC and SOE variables were log-transformed to meet assumptions of normality. However, we report non-transformed means here to facilitate interpretation. BMI=Body Mass Index; %TWL=Percent total weight loss from pre-surgery to intake; LOC=Loss-of-control eating episode; SOE=Subjective overeating episode; EDE=Eating Disorder Examination; BDI=Beck Depression Inventory-II. The initial ANOVAs included secretive eating as the only independent variable (IV); the second set of ANOVAs included secretive eating and bariatric BED as IVs; main effects are reported for each IV.

All domains of eating-disorder psychopathology were significantly associated with secretive eating: EDE global severity, F1,166=29.69, p<.001, ηp2=.152, dietary restraint, F1,166=6.30, p=.013, ηp2=.037, overvaluation, F1,166=7.42, p=.007, ηp2=.043, and dissatisfaction, F1,166=48.74, p<.001, ηp2=.121. Individuals with secretive eating had more eating-disorder psychopathology than those without secretive eating.

Examination of overlapping bariatric BED status and secretive eating revealed significant differences, χ2(1, N=168)=14.58, p<.001, φ=.295: more patients with bariatric BED had secretive eating (54%) than patients with subthreshold bariatric BED (25%).

Depression scores differed across study groups, F1,150=6.98, p=.009, ηp2=.044. Individuals with secretive eating had higher depression scores than those without secretive eating.

Because secretive eating was significantly associated with bariatric BED status, we repeated analyses by secretive eating with bariatric BED status added as a second independent variable. These results are summarized in Table 2 alongside the original ANOVAs. BMI, %TWL, and SOE remained non-significant. LOC episodes no longer significantly differed by secretive eating after bariatric BED status was added as a variable, F1,164=1.05, p=.308, ηp2=.006. EDE global severity continued to differ significantly by secretive eating, F1,164=15.84, p<.001, ηp2=.088 (individuals with secretive eating had more severe eating-disorder psychopathology than those without secretive eating), but the interaction of secretive eating and bariatric BED status was not significant, F1,164=2.29, p=.132, ηp2=.014. Likewise, body dissatisfaction continued to differ significantly by secretive eating, F1,164=13.35, p<.001, ηp2=.075 (individuals with secretive eating had more severe eating-disorder psychopathology than those without secretive eating), but the interaction of secretive eating and bariatric BED status was not significant, F1,164=2.46, p=.118, ηp2=.015. Dietary restraint, F1,164=2.97, p=.087, ηp2=.018, and overvaluation, F1,164=2.73, p=.100, ηp2=.016 no longer significantly differed by secretive eating after bariatric BED status was added as a variable. Depression scores no longer significantly differed by secretive eating after the inclusion of bariatric BED status, F1,148=2.20, p=.140, ηp2=.015.

Discussion

Our findings provide new information that secretive eating is a common form of eating-disorder psychopathology experienced by a substantial proportion of bariatric surgery patients with LOC eating post-surgery. Importantly, more patients who met criteria for “bariatric BED” (see Ivezaj et al., 2018 for description of categorization) report secretive eating than patients with subthreshold bariatric BED. Eating-disorder psychopathology (LOC episode frequency, global severity, dietary restraint, overvaluation of weight/shape, and body dissatisfaction) and depression scores were higher among patients with secretive eating than those without secretive eating, although weight variables (BMI and %TWL) and SOEs were not significantly associated with secretive eating. However, after including bariatric BED status in the statistical models, only eating-disorder global severity and body dissatisfaction remained significantly higher among patients with secretive eating compared to those without secretive eating.

These findings differ somewhat from research findings reported for treatment-seeking BED patients, which found that secretive eating was associated with higher eating concerns, shape concerns, weight concerns, overvaluation of weight/shape, subjective binge-eating episodes, and depression scores, but not dietary restraint, objective binge-eating episodes, or BMI (Lydecker & Grilo, 2019). This difference may be due to the altered criteria that defined in this patient group, who all experienced regular LOC eating after bariatric surgery, but only some of whom met full bariatric BED criteria. Our previous work suggested that the bariatric BED and BED groups presented with similar clinical features including comparable eating-disorder psychopathology and depression scores at the start of treatment, which in turn, were significantly higher than two clinical groups of post-bariatric surgery patients experiencing LOC eating that did not meet bariatric BED criteria and adults with overweight or obesity who did not meet BED criteria; the two latter groups did not differ significantly from each other (Ivezaj et al., 2018). As such, bariatric BED shares similar features to BED among treatment-seeking groups and these two groups are different than obesity groups without BED and post-bariatric surgery patients who do not meet full bariatric BED criteria. It is also possible that the difference in findings is due to other characteristics of bariatric patients during the first year after surgery. Future research should seek to evaluate patients’ affect when eating in social and isolated settings to tease apart these clinical-research questions.

The finding that body dissatisfaction was higher among patients who report secretive eating than those who do not, even when concurrently considering bariatric BED status, suggests some unique association, although the cross-sectional nature of our study cannot elucidate a temporal relation. Higher global eating-disorder severity among patients with secretive eating than without is also important to note. Notably, this finding extends earlier work that examined secretive eating among patients with BED (Lydecker & Grilo, 2019), as well as work comparing individuals with BED, other eating disorders, and healthy controls (Wilfley et al., 2000). Similarly, a lower proportion of patients with subthreshold bariatric BED had secretive eating than those meeting bariatric BED criteria; the proportion of bariatric BED patients with secretive eating is similar to the proportion of non-bariatric BED patients with secretive eating (Lydecker & Grilo, 2019).

Although there were some differences by secretive eating, SOE episodes, as well as BMI and %TWL, did not significantly differ between patients with and without secretive eating. It is also important to note that the majority of eating-disorder psychopathology variables (LOC episodes, dietary restraint, overvaluation) and depression scores showed a distinct pattern where bariatric BED status, but not secretive eating, had a significant association. The lack of significant differences in weight suggests that secretive eating might be more related to body dissatisfaction than post-surgery weight loss. Findings suggest that clinicians providing treatment to bariatric surgery patients with LOC eating should assess for the presence of secretive eating in addition to LOC eating to inform their case formulation and planning targets for intervention.

Our findings extend the literature on secretive eating by examining a new patient group. Specifically, our study focused on (1) adults and (2) post-bariatric surgery patients with LOC, whereas the earlier literature primarily focused on youth, although there is emerging research focused on adults (Lydecker & Grilo, 2019). We found similar clinical correlates of secretive eating as secretive eating among adults with BED (Lydecker & Grilo, 2019) and among youth (Kass et al., 2017; Knatz et al., 2011; Marcus & Kalarchian, 2003), although associations of clinical variables were stronger with bariatric BED status.

Our study had both strengths and limitations. The current study was cross-sectional, and therefore, as previously discussed, the direction of causality is uncertain. In addition to the uncertain immediate temporality of secretive eating, LOC eating, and negative affect, we also do not know when patients began to experience secretive eating relative to bariatric surgery and whether groups differ clinically based on onset. Prospective and momentary assessment research focused on post-bariatric surgery patients with LOC eating could help to clarify relations. Our study focused on analyses structured around the presence or absence of secretive eating; we did not, however, explore whether secretive eating frequency considered as a continuous variable, or more other “cut points” for categorizing patients, would yield more meaningful clinical associations. Future research can, for example, use signal detection methods such as ROC analyses to explore whether there might be better thresholds for categorizing clinically-meaningful groups based on frequency of secretive eating.

We emphasize that our findings pertain to diverse patients with LOC eating approximately 6 months following bariatric surgery, who sought treatment at an academic medical school. Generalizability to individuals who had bariatric surgery but are not experiencing LOC eating post-operatively, who do not seek treatment or who seek treatment in different clinical settings, or to those who do not wish to participate in treatment research is uncertain. Additionally, participants were well-educated and primarily women and there were demographic differences between patients with and without secretive eating (race, education, age); generalizability of our findings to groups with different demographic composition is uncertain. Finally, future research should also evaluate the relation of secretive eating to the severity of negative affect and eating-disorder psychopathology among post-bariatric surgery patients without LOC eating, post-bariatric surgery patients with other specific eating disorders, and youth who underwent bariatric surgery, as our findings may not generalize to those groups.

Our findings suggest that secretive eating, which can occur outside LOC eating, might signal greater eating-disorder severity and body dissatisfaction among adults with LOC eating. Future research could examine whether secretive eating has prognostic significance in eating and weight-focused treatments for individuals post-bariatric surgery and whether secretive eating has predictive significance for weight regain following bariatric surgery. Recognizing whether patients eat secretively can help clinicians plan interventions during eating-disorder treatment. Within a cognitive-behavioral approach, for example, secretive eating can be highlighted when self-monitoring to establish regular eating patterns. Further research is needed to improve understanding of treatment-related needs, such as the influence of secretive eating on treatment-seeking and whether secretive eating predicts outcomes.

Funding:

This research was supported, in part, by National Institutes of Health grant R01 DK098492. The funder played no role in the content of this paper.

Footnotes

Potential conflicts of interest: The authors (Lydecker, Ivezaj, Grilo) report no conflicts of interest.

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