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. Author manuscript; available in PMC: 2021 Sep 1.
Published in final edited form as: Obesity (Silver Spring). 2020 Jul 29;28(9):1645–1651. doi: 10.1002/oby.22876

Does Bariatric Binge-Eating Size Matter? Conceptual Model and Empirical Support

Valentina Ivezaj 1, Janet A Lydecker 1, Ashley A Wiedemann 1, Andrew J Duffy 2, Carlos M Grilo 1,3
PMCID: PMC7484317  NIHMSID: NIHMS1591878  PMID: 32729221

Abstract

Background

Bariatric surgery effects the quantity of food individuals can eat, yet some individuals still experience loss-of-control (LOC) while eating. This cross-sectional study examined a new classification system for binge/LOC-eating following bariatric surgery.

Method

168 individuals who underwent bariatric surgery six months earlier and reported LOC-eating were administered the Eating Disorder Examination–Bariatric Surgery Version (EDE-BSV) Interview and self-report measures of depressive symptoms, functional impairment, and physical and mental health-related quality-of-life. Three groups were created based on largest LOC-eating episode determined by EDE-BSV interview: 1) “traditional” objective binge-eating episodes (OBEs)—eating unusually large quantities of food while having LOC, 2) “bariatricobjective binge episodes” (B-OBEs)—unusually large quantities for post-surgical bariatric patients with LOC, and 3) “bariatric-subjective binge episodes” (B-SBEs)—eating small quantities of food with LOC.

Results

75% (n=126) met criteria for the B-OBE group, 10% (n=17) traditional OBE group, and 15% (n=25) B-SBE group. The three groups differed significantly, with a graded pattern by binge size, in global eating-disorder psychopathology, depressive symptoms, and functional impairment, but not quality-of-life.

Conclusions

These findings provide empirical support for a new classification system for bariatric binge/LOC-eating. Binge size was associated with distinct psychopathology. Longitudinal follow-up is needed to ascertain effects on clinical outcomes.

Keywords: Obesity, bariatric surgery, binge eating, loss-of-control eating, assessment

Introduction

Binge eating is associated strongly with obesity (1) and defined by the Diagnostic and Statistical Manual of Mental Disorder – 5th Edition (DSM-5) as eating an objectively large quantity of food in a relatively discrete period of time combined with a sense of loss-of-control (LOC) (2). Both the quantity of food and LOC are required to meet binge-eating criteria, although the need for both criteria – size and LOC – remains a matter of debate in the eating disorder field (3, 4). Several studies have found that the experience of LOC – not the size of the eating episode – remains the salient feature of binge eating and related psychopathology (5, 6, 7). Accordingly, the most recent version of the International Classification of Diseases (ICD-11) newly characterizes binge eating as when an “individual eats notably more and/or differently than usual and feels unable to stop eating or limit the type or amount of food eaten” (8, 9). As this definition conveys, the field seems to be moving towards a more flexible and broader perspective of the relevance of size or quantity of food intake for classifying binge eating.

Emphasis on the subjective experience of LOC during an eating episode, regardless of size or amount of food intake, is particularly relevant for individuals who undergo bariatric surgery. After bariatric surgery, eating unusually large quantities of food is physically difficult due to the surgical restrictions, especially during the early postoperative period. Despite views that eating large quantities of food following restrictive bariatric surgery procedures is rare, the Longitudinal Assessment of Bariatric Surgery (LABS) study found that postoperative binge-eating disorder (BED; i.e., full diagnostic criteria) predicted attenuated weight outcomes during the three years after bariatric surgery (10). Not surprisingly, however, in the LABS study, very few individuals met criteria for “traditional” full DSM-5 diagnostic criteria for BED following bariatric surgery, likely because of the “unusually large size” requirement (10, 11). By assessing binge eating using the traditional definition including unusually large size, a substantial subgroup of patients struggling with disordered eating behaviors after bariatric surgery likely go undetected. Indeed, in the LABS study, LOC eating without the size requirement occurred more frequently than binge eating and significantly predicted attenuated weight outcomes at the three- and seven-year follow-ups (12, 13). Similarly, in a study of postoperative patients with LOC eating six months after surgery, nearly half of the participant group met all criteria for traditional (full DSM-5 diagnostic criteria) BED when eliminating the size criterion (14). Exclusion of the size criterion captured a greater number of individuals struggling with postoperative eating and this group shared similar clinical characteristics as a treatment-seeking group with BED who had not undergone bariatric surgery. Taken together, converging evidence supports the importance of LOC eating after bariatric surgery regardless of size or quantity and the need to reconceptualize binge eating definitions after bariatric surgery.

Accordingly, the field has called for a paradigm shift in definitions of binge and LOC eating following bariatric surgery as the current classification system of eating disorders may be problematic for the post-surgical population (15). The nomenclature of binge eating and LOC eating following bariatric surgery is uncertain with respect to size and requires further study for several reasons. First, variations in meal size after bariatric surgery may be important by contributing to different weight trajectories and outcomes (16). Second, the DSM-5 continues to emphasize the relevance of size in the definition of binge eating, necessitating further research in this area (2), particularly as it pertains to bariatric surgery. Finally, no study has attempted to define “unusually large amounts of food” after bariatric surgery. Taken together, it was theorized that size of binge-eating episodes might be relevant for the bariatric population. The broad literature on LOC eating includes two primary binge-eating classifications based on consumption of objectively versus subjectively large quantities of food. Because so few individuals can physically meet criteria for eating objectively or unusually large amounts of food during the first-year post-surgery (13), constructing bariatric-specific criteria for objective versus subjective binge eating was expected to have utility and give the field operational definitions of binge eating for further study in this population.

Thus, this study conceptualized a form of “bariatric binge eating” by providing an operational definition of an “usually large quantity of food” following bariatric surgery and examined frequencies of traditional binge-eating episodes compared to the newly proposed “bariatric binge-eating episodes” among a group of postoperative patients with LOC eating who were expected to have variations in the amount of food consumed during LOC-eating episodes. The traditional definition of binge eating with objectively (unusually) large amounts of food was compared to newly-developed definitions of bariatric-specific objective and subjective binge-eating. This study also examined group differences in weight and relevant psychosocial variables based on varying size-specific thresholds for binge eating to provide preliminary data and inform future research avenues on the reconceptualization of binge and LOC eating after bariatric surgery.

Methods

Participants

Participants were 174 adults seeking treatment for eating and weight concerns approximately six months following bariatric surgery (laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy). All participants were recruited from a bariatric surgery center of excellence either by flyers, direct referral or by mailings soliciting postoperative patients with eating concerns to participate in a randomized controlled trial examining behavioral treatments for LOC eating following bariatric surgery. Recruitment occurred from 2014–2018. Inclusion criteria included age 18 to 65 and regular LOC eating (defined as feeling unable to stop or control an eating episode at least once weekly regardless of the quantity consumed). Exclusion criteria were minimal to enhance generalizability and included medications known to effectively influence eating or weight, substance dependence, or severe psychiatric illness requiring acute care. Of the 174 participants, four did not meet inclusion criteria and two met exclusion criteria, resulting in 168 participants. Of these eligible participants, time since surgery ranged from three to ten months with an average of six months post-surgery (M = 6.34; SD = 1.52). All research assessments were conducted independently from the bariatric clinical program. Participants were administered a semi-structured interview by trained doctoral assessors and completed a battery of self-report measures. This investigation received approval from the university Institutional Review Board and all participants provided written informed consent.

Participants were predominately female (n = 139, 82.7%) and relatively diverse [(n = 90 (53.9%) White, n = 57 (34.1%) Black or African American, n = 2 (1.2%) American Indian or Alaska Native, n = 1 (0.6%) Native Hawaiian or Other Pacific Islander, n = 13 (7.8%) “Other”, n = 4 (2.4%) Bi/Multiracial, and n = 1 (0.6%) had missed race although this participant identified as Hispanic/Latinx for ethnicity; n = 18 (10.7%) of the overall participant group identified as Hispanic or Latinx]. Participants had an average age of 45.43 years (SD = 11.12), BMI of 37.21 kg/m2 (SD = 7.17), and percent total weight loss (%TWL) of 19.94 (SD = 7.39) six months postoperatively.

Measures

Interview

The Eating Disorder Examination-Bariatric Surgery Version (EDE-BSV), a semi-structured interview assessing eating-disorder symptomology and overeating behaviors, adapted for bariatric surgery patients (17, 18, 19), was administered by trained doctoral assessors. The EDE-BSV contains all standard EDE questions (17, 20). Given the empirical support for an alternative factor structure of the EDE in clinical samples, including adults seeking bariatric surgery, and non-clinical samples (21, 22, 23), the global scale of the alternative EDE scoring method (EDE-Global) was used in the present study as a measure of global eating-disorder psychopathology (it does not include any LOC-type eating behaviors in the scoring). The EDE-Global score, the mean composite of the alternative EDE subscales of restraint, overvaluation of shape and weight, and dissatisfaction of shape and weight, ranges from 0–6 with higher scores indicative of greater severity of eating-disorder psychopathology.

The EDE also assesses overeating and binge-eating behaviors, including Objective Binge-eating Episodes (OBEs; eating an unusually large amount of food while experiencing a subjective sense of LOC while eating), Objective Overeating Episodes (OOEs; eating an unusually large amount of food without experiencing LOC), and Subjective Binge-Eating Episodes (SBEs; experiencing a sense of LOC while eating food that is not unusually large). For this investigation, additional items were designed to replicate the three traditional EDE eating behaviors (OBEs, OOEs, and SBEs) with respect to size-specific thresholds conceptually relevant to post-bariatric surgery patients with the intent of identifying different types of “bariatric binge-eating episodes”. First, “Bariatric-Objective Binge-eating Episodes” (B-OBEs) were defined as eating an unusually large amount of food for an individual who underwent bariatric surgery six months prior while experiencing a sense of LOC. To operationally define “unusually large” eating episodes after bariatric surgery, the institution’s bariatric surgery center guidelines were reviewed. Following the acute post-operative period (i.e., 5–8 months), patients were given recommendations to consume ≤ ½ cup of food up to nine months post-surgery and ≤1 cup starting at nine months post-surgery during an eating occasion. Thus, eating episodes greater than double the recommended amount (i.e., > 1 cup of food six months post-surgery) were considered objectively large . Second, to capture “Bariatric-Objective Overeating Episodes” (BOOEs) in parallel to traditional OOEs, B-OOEs were defined as eating an unusually large amount of food for an individual who underwent bariatric surgery six months prior (i.e., >1 cup of food) without experiencing LOC. Finally, “Bariatric-Subjective Overeating Episodes” (B-SBEs) were defined as experiencing a sense of LOC while eating an amount of food that was not unusually large six months after bariatric surgery (i.e., < 1 cup of food). Thus, a total of two additional binge-eating categories (B-OBE and B-SBE) and one additional overeating category (B-OOE) were created. As an example, six months following bariatric surgery, consuming 3 cups of popcorn within a discrete period while experiencing a sense of LOC would be categorized as a B-OBE, whereas consuming 1/3 cup of popcorn while experiencing a sense of LOC would be categorized as a B-SBE. Consuming 3 cups of popcorn within a discrete period without LOC would be categorized as a B-OOE. At nine months post-surgery, the size threshold was changed to double the recommended amount of food for that time point (i.e., > 2 cups of food) for a B-OBE and < 2 cups of food for a B-SBE. See Figure 1 for a visual depiction of the traditional and additional proposed eating behaviors assessed in the present study.

Figure 1.

Figure 1.

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Traditional and bariatric-specific size thresholds of binge-eating episodes

Weight Variables

Preoperative BMI, post-operative BMI, %TWL, and percent excess weight loss (%EWL) were calculated using measured variables. Height and preoperative weight were obtained from the bariatric center’s medical record and postoperative weight was collected at the initial study visit about six months after surgery using a high-capacity digital scale. Per bariatric surgery reporting guidelines (24), %TWL was computed as follows: [(Preoperative Weight) − (Postoperative Weight)]/[(Preoperative Weight)]*100. %EWL = [(Preoperative Weight) − (Postoperative Weight)]/ [(Preoperative Weight) − (Ideal Weight)] * 100. Ideal weight was defined based on weights equivalent to a BMI of 25 kg/m2.

Self-report Measures

The Patient Health Questionnaire-9 (PHQ-9) (25) is a reliable and valid measure of depressive symptomatology. Scores range from 0–27, with higher scores indicative of greater severity of depressive symptoms. A score of 5 represents mild, 10 moderate, 15 moderately severe, and 20 severe depressive symptoms. The Sheehan Disability Scale (SDS) (26) is a well-established measure of functioning in multiple life domains including work/school, social life/leisure activities, and family life/home responsibilities. Participants were asked to identify the extent to which weight effected these different life domains. For the present study, participants were asked to rate how their weight impacted each of the three life domains, plus six additional domains including communication, ability to get around physically, ability to take care of oneself, ability to get along with others, finances, and spiritual or religious life. Responses are based on an 11-point scale ranging from “0” (no impairment) to “10” (extreme impairment), with total scores ranging from 0–90 (when incorporating all aforementioned nine life domains). Higher scores are indicative of greater disability/poorer functioning. Medical Outcomes Study Short Form Health Survey (SF-36) is a widely used measure of health-related quality-of-life, including two summary scores: physical (SF-PCS) and mental health (SF-MCS) health-related quality-of-life (27). Scores are transformed and computed as t-scores with a mean of 50 and standard deviation of 10. The SF-36 has well-established psychometric validity and reliability (28, 29) and is acceptable for use in bariatric surgery samples (30).

Creation of Binge-Eating Study Groups

Three binge-eating study groups were created based on participants’ largest LOC-eating episode during the past three months. Participants with any OBEs (regardless of the number of smaller eating episodes [B-OBEs and B-SBEs]) were categorized as the OBE group. Participants with any B-OBEs (regardless of the number of smaller eating episodes [B-SBEs]) who did not have any OBEs were categorized as the B-OBE group. Finally, participants with any SBEs who did not endorse the larger eating episodes (B-OBEs and OBEs) were categorized as the B-SBE group.

Statistical Analyses

Data were analyzed using SPSS 24.0. Normality was inspected prior to analyses and a log transformation was used to adjust the skewness of the SDS variable. General linear model (GLM) analyses of variance (ANOVAs) were conducted to compare between-group differences (OBE, B-OBE, and B-SBE) on demographic (age, sex, race), weight (preoperative BMI, postoperative BMI, %TWL and %EWL) and clinical variables (EDE-Global, PHQ-9, SDS, SFPCS and SF-MCS). When ANOVAs revealed significant group differences, Scheffe post-hoc tests were performed to identify which groups differed significantly from each other. Analyses of covariance (ANCOVAs) were conducted to compare between-group differences of the clinical variables while adjusting for bariatric surgery given the trend of group differences in binge-eating category by surgery type and an a priori hypothesis that binge-eating size might differ as a function of bariatric surgery procedure (Roux-en-Y gastric bypass versus sleeve gastrectomy). Partial eta-squared (ηp2) was calculated to estimate effect sizes; values are considered small at .01, medium at .06, and large at .14 (31). Imputation was not conducted because so few data were missing.

Results

Eating Behaviors and Binge-Eating Groups

Of the overall participant group of individuals with regular LOC eating six months following bariatric surgery, the following number of participants reported at least one of the respective eating episodes during the prior 28 days: n=17 (10.1%) OBEs, n=3 (1.8%) OOEs, n=139 (82.7%) B-OBEs, n=57 (33.9%) B-OOEs, and n=111 (66.1%) B-SBEs. For the binge-eating study groups categorized by the largest LOC-eating episode during the past three months, n=17 (10.1%) comprised the OBE group, n=126 (75.0%) comprised the B-OBE group, and n=25 (14.9%) comprised the B-SBE group.

Table 1 summarizes demographic, weight, surgical, and post-operative LOC-eating onset variables for the overall participant group and by the binge-eating groups: OBE, B-OBE, and B-SBE. The binge-eating groups did not differ significantly in age, sex, race (White versus non-White), pre-surgical BMI, post-surgical BMI, weight change measured by %TWL and %EWL, months since surgery, or post-operative LOC onset. Between-group differences for surgery type (Roux-en-Y gastric bypass and sleeve gastrectomy) were non-significant but trended towards significance (p = .07). Notably, OBEs were not observed among individuals who underwent the Roux-en-Y gastric bypass. In other words, all 17 OBEs observed were reported by participants who underwent the sleeve gastrectomy surgery.

Table 1.

Descriptive statistics of demographic variables and patient characteristics overall and by binge-eating category

Dimensional Variables Overall (N=168) OBE (n=17) B-OBE (n=126) B-SBE (n=25) F p-value Effect size ηp2
Age, mean (SD) 45.43 (11.12) 48.71 (8.68) 44.67 (11.21) 47.08 (11.88) 1.32 .271 .016
Pre-surgical BMI 46.63 (8.65) 48.90 (12.19) 47.01 (8.22) 48.38 (10.18) 0.51 .603 .006
Post-surgical BMI 37.21 (7.17) 39.28 (10.44) 36.98 (6.55) 36.95 (7.62) 0.79 .456 .009
%TWL 19.94 (7.39) 18.42 (6.74) 19.78 (7.60) 21.78 (6.58) 1.17 .313 .014
%EWL 45.44 (17.44) 44.05 (17.24) 46.60 (17.72) 50.65 (17.91) 0.80 .452 .010
Months since surgery 6.34 (1.52) 7.00 (1.37) 6.27 (1.53) 6.24 (1.51) 1.82 .165 .022
Post-operative LOC onset (in months since surgery) 4.03 (1.68) 4.21 (1.76) 4.02 (1.69) 3.92 (1.61) 0.15 .864 .002
Categorical Variables Overall (N=168) OBE (n=17) B-OBE (n=126) B-SBE (n=25) Chi-Square p-value Effect size φ
Female 139 (82.7%) 22 (88.0%) 104 (82.5%) 13 (76.5%) 0.96 .620 .075
White 86 (51.2%) 13 (52.0%) 64 (50.8%) 9 (52.9%) 0.04 .982 .015
Surgery (Roux-en-Y gastric bypass) 23 (13.7%) 0 (0.0%) 19 (15.1%) 4 (23.5%) 5.31a .070 .134
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Note. M (SD) presented for ANOVA tests, n (%) presented for chi-square tests. OBE=objective binge episode; B-OBE=bariatric-objective binge episode; B-SBE=bariatric-subjective binge episode; %TWL=percent total weight loss; %EWL=percent excess weight loss.

a

Likelihood ratio and significance

Table 2 summarizes descriptive statistics and statistical analyses for clinical measures, namely eating-disorder psychopathology (EDE-Global), depressive symptomatology (PHQ-9), disability (SDS), and physical and mental health-related quality-of-life (SF-PCS and SF-MCS) overall and by binge-eating category. ANOVAs revealed significant between-group differences on the EDE-Global, PHQ-9, and SDS; the binge-eating groups did not differ significantly on SF-PCS or SF-MCS scores. Scheffe post-hoc tests revealed that the OBE group differed significantly from the B-OBE and B-SBE groups on the EDE-Global. Specifically, the OBE group had significantly higher EDE-Global scores than both the B-OBE and B-SBE groups, which did not differ significantly from each other. Scheffe post-hoc tests revealed that the OBE group differed significantly from the B-SBE group on the PHQ-9 with significantly higher scores reported by the OBE group than the B-SBE groups. The B-OBE group did not differ significantly from the OBE and B-SBE groups on PHQ-9 scores. Finally, Scheffe post-hoc tests revealed that both the OBE and B-OBE groups differed significantly from the B-SBE group on SDS, while the OBE and B-OBE groups did not differ significantly from each other. Effect sizes using partial eta squared ranged from .021 (SF-PCS) to .079 (EDE-Global) reflecting small to medium effect sizes. ANCOVAs adjusting for surgical procedure revealed a similar pattern of findings and did not attenuate effect sizes. Visual inspection of the data (Figure 2) depicts a graded linear pattern in the expected manner with the OBE group consistently having poorer outcomes than the B-OBE group, who in turn had poorer outcomes than the B-SBE group across all clinical variables examined, albeit this graded pattern was not statistically significant.

Table 2.

Clinical variables overall and by binge-eating category

Overall (N=168)
M (SD) 		OBE (n=17)
M (SD) 		B-OBE (n=126)
M (SD) 		B-SBE (n=25)
M (SD) 		F p-value Post-hoc Tests Effect size ηp2 Effect size ηp2 Surgery
EDE Global 2.91 (1.25) 3.76 (0.91) 2.91 (1.30) 2.33 (0.72) 7.11 .001 OBE>B-OBE=B-SBE .079 .076
PHQ-9a 6.04 (5.60) 9.06 (7.68) 6.07 (5.33) 3.78 (4.23) 4.40 .014 OBE>B-SBE .057 .055
SDSb 15.54 (20.22) 25.94 (27.37) 16.20 (20.05) 5.13 (7.29) 4.23 .016 OBE=B-OBE>B-SBE .054 .054
SF-PCSc 46.42 (10.95) 43.60 (13.85) 46.15 (10.49) 49.64 (10.65) 1.57 .212 -- .021 .023
SF-MCSc 48.00 (10.42) 44.29 (12.24) 47.81 (10.00) 51.48 (10.49) 2.36 .098 -- .031 .032
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Note. OBE=objective binge episode; B-OBE=bariatric-objective binge episode; B-SBE=bariatric-subjective binge episode; EDE Global=Eating Disorder Examination Global severity score; PHQ-9: Patient Health Questionnaire-9; SDS=Sheehan Disability Scale; SF-PCS=Short Form-Physical Component Scale; SF-MCS=Short Form-Mental Component Scale.

a

n=149

b

n=150; Raw data are reported in the table; however, the log transformed variable was used in data analysis due to the positively skewed distribution of the SDS.

c

n=149.

Figure 2.

Figure 2.

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Graded pattern of findings across clinical variables by binge-eating size

Discussion

Our findings with a treatment-seeking group of adults with regular LOC eating six months after bariatric surgery provide preliminary support for a new classification scheme for binge-eating and LOC-eating based on varying size/amount thresholds. B-OBEs and B-SBEs were the most common disordered eating behavior with 82.7% and 66.1% of the participant group reporting any “bariatric objective binge eating” and “bariatric subjective binge eating” episodes, respectively. Traditional OBEs were far less common, but notably occurred among only individuals who had undergone laparoscopic sleeve gastrectomy. No OBEs were reported among individuals who had undergone the Roux-en-Y gastric bypass. Reports of any OOEs were rare (1.3%), while B-OOEs were more common (33%). Three-quarters of the participant group had B-OBEs as their largest LOC-eating episode. When comparing the three groups based on LOC-eating size, the OBE group had significantly higher levels of eating-disorder psychopathology, depressive symptoms, and disability than the B-SBE group; the OBE group had significantly higher levels of eating-disorder psychopathology, but similar levels of disability, relative to the B-OBE group. The three groups did not differ significantly in mental or physical health-related quality-of-life. Notably, however, a consistent pattern emerged in the expected manner suggesting that the OBE group had worse clinical outcomes than the B-OBE group, which in turn had worse clinical outcomes than the B-SBE groups, although these differences were not significantly different across clinical variables. Small sample sizes in the OBE and B-SBE groups may have limited power to detect significant between-group differences.

These findings have several clinical and research implications. Clinically, assessment of postoperative LOC eating, regardless of the amount of food consumed during the eating episode, remains the primary recommendation given that LOC eating continues to be a consistent and strong signal of poorer postoperative outcomes that likely warrants intervention. It is unknown whether assessment of bariatric binge eating based on size-thresholds provides clinically meaningful information above and beyond the assessment of LOC eating without size-threshold considerations. Based on the present study’s preliminary findings, however, the amount of food consumed during a LOC-eating episode might provide additional clinical information, at least near the six-month postoperative period. For instance, endorsement of a traditional OBE six months after bariatric surgery is likely a poor indicator of postoperative outcomes and a signal for greater psychopathology warranting intervention and/or requiring greater monitoring in the post-operative period. Additionally, if a patient reports a sense of LOC while eating greater than one cup of food six months after surgery, this might be conceptualized as a bariatric form of binge eating, and potentially more concerning than B-SBEs which involve eating quite small amounts of food after bariatric surgery. Future studies with larger sample sizes and longer-term outcomes are needed to more definitively address these potential implications for individuals with LOC eating.

These findings also contribute to the ongoing debate of the importance of size versus LOC eating in the assessment of binge eating. Although many studies have found that LOC – and not size – is the salient feature of binge eating (5, 6, 7), findings from the present study suggest that size thresholds may add clinically-meaningful information to the patient formulation in the early postoperative phase. This may be important to consider in the context of this patient population, who receive specific guidelines from providers about the amount of food they could and should eat. Furthermore, the present findings contribute to the binge-eating size debate by illustrating a graded linear pattern such that psychosocial functioning consistently worsened with increasing binge size, suggesting that binge size might matter. Future research with large sample sizes and alternative assessment methods such as laboratory or observational data is needed to replicate these findings and to determine the prognostic significance of these bariatric binge-eating categories on longer term outcomes. Importantly, this is only one way to define bariatric binge eating; there may be other conceptualizations that prove to have greater clinical utility such as using a continuous assessment of LOC eating and binge eating. Furthermore, while the current operational definition of binge eating appears to have utility and face validity, inter-rater reliability analyses are needed to examine the amount of agreement between different raters. Finally, future research should examine the onset and trajectory of traditional OBEs after both sleeve gastrectomy and Roux-en-Y gastric bypass. The present study did not observe OBEs six months after the Roux-en-Y gastric bypass procedure; however, the sample size of Roux-en-Y gastric bypass cases was too small in the present study to offer meaningful conclusions. Nonetheless, whether the development and course of binge eating differs as a function of bariatric procedure (Roux-en-Y gastric bypass versus sleeve gastrectomy surgery) needs investigation. For example, the Roux-en-Y gastric bypass procedure might make it more physically difficult to eat larger quantities of food than the sleeve gastrectomy procedure, potentially leading to later onset and fewer occurrences of objectively large binge-eating episodes for individuals who had Roux-en-Y gastric bypass. This theory could have implications for determining surgical procedure among individuals with pre-surgical BED; however, this theory must be examined empirically in a longitudinal study in order to have merit.

Limitations of the present study include small cell sizes of two groups (OBE and B-SBE), although significant findings were nonetheless observed across many of the clinical variables. In addition, participants were individuals interested in participating in a research treatment study; findings may not generalize to individuals who have less frequent LOC eating, to those who are not seeking treatment, to those who seek treatment in different clinical or medical settings, or to those who do not participate in research studies. Furthermore, our size threshold for bariatric binge eating was specific to a period shortly after surgery. Over time, individuals may have increased capacity for food intake and receive changes in dietary recommendations. Indeed, guidelines from this institution’s bariatric program recommend one cup of food starting at nine months following surgery. Thus, using the present study’s definition of unusually large after bariatric surgery (i.e., more than double the recommended amount), the size threshold would change to greater than two cups of food starting nine months postoperatively; however, it is unclear whether size thresholds would continue to increase with greater latency from surgery. As such, follow-up studies are needed to examine the utility of this modified definition as time postsurgery increases.

Conclusion

A new classification system of binge eating after bariatric surgery may be warranted. Findings indicate important distinctions based on LOC-eating size that may inform future definitions of binge eating among the bariatric population. Longer-term follow-up is needed to ascertain effects of these LOC-eating thresholds on clinical outcomes. Furthermore, future research examining the reliability of this classification system and the incremental value of adding size thresholds to the assessment of LOC eating after bariatric surgery is warranted. Overall, the present findings support and encourage the development of alternative novel conceptualizations of disordered eating after bariatric surgery.

Study Importance Questions.

What is already known about this subject?

  • Binge eating is associated strongly with obesity.

  • The salient feature of binge eating appears to be a subjective sense of loss-of-control, although binge eating is typically defined by requiring unusually large quantities of food.

  • Postoperative binge eating and loss-of-control eating are negative prognostic indicators of bariatric surgical outcomes.

What are the new findings in your manuscript?

  • 10% of sleeve gastrectomy and 0% of Roux-en-Y gastric bypass patients had objective binge-eating episodes (defined as unusually large) six months after bariatric surgery.

  • Objective binge eating six months after bariatric surgery was associated significantly with broad levels of psychopathology and disability.

  • Findings indicate important distinctions and prognostic significance based on binge-eating size after bariatric surgery.

How might your results change the direction of research or the focus of clinical practice?

  • Early assessment of binge and loss-of-control eating following bariatric surgery is warranted.

  • Future research should examine and compare the onset and trajectory of traditional binge eating and loss-of-control eating after both sleeve gastrectomy and Roux-en-Y gastric bypass.

  • Findings may inform future definitions of binge eating among the bariatric population; future research with longer-term follow-up is needed to ascertain effects of the proposed binge-eating thresholds on clinical outcomes.

Acknowledgments

Funding: This research was supported, in part, by National Institutes of Health grant R01 DK098492. Drs. Ivezaj, Lydecker, Wiedemann, and Grilo were supported, in part, by National Institutes of Health grants K23 DK115893, R01 DK112771, R01 DK49587, R01 DK114075, and R01 DK114075–01A1. Funders played no role in the content of this paper.

Footnotes

Potential conflicts of interest: The authors (Ivezaj, Lydecker, Wiedemann, Duffy, Grilo) declare no conflicts of interest. Dr. Grilo and Dr. Ivezaj report several broader interests which did not influence this research or paper. Dr. Grilo’s broader interests include: Consultant to Sunovion and Weight Watchers; Honoraria for lectures, CME activities, and presentations at scientific conferences and Royalties from Guilford Press and Taylor & Francis Publishers for academic books. Dr. Ivezaj reports broader interests including Honoraria for Journal Editorial Role and lectures.

References

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