Can Bariatric Surgery Cause an Eating Disorder?

Repeated experiences seeing post-Bariatric surgery patients are perplexing and disturbing to the clinician who treats people with eating disorders. Obesity is clearly a significant health issue in large parts of the world; however, permanently altering someone's gastrointestinal anatomy to make possible longterm starvation is a destructive and counterproductive solution. 

The grand experiment of culturally sanctioned starvation has caused multiple chronic medical problems, number one on the list being eating disorders. The result of idealizing the extremely thin has been to encourage and blindly support constant dieting and starving. 

We have learned that people have a varied but ingrained and largely genetic response to chronic starvation. The most common response is overarching hunger that usually triggers one form of eating disorder symptoms or another. 

Bariatric surgery often causes a form of binge eating. Most people can starve for 6-9 months and lose a significant of weight before the starvation response takes over and the uncontrollable urge to eat dominates one's thoughts and actions, thereby leading to binging. 

The solution, as with all eating disorders, is to start by normalizing a meal plan. Consistent nutrition signals the body and mind that the famine is over so normal body function can resume. Doing so will gradually let the starvation response subside. 

What's particularly concerning is the medical community's reaction to these cases. Uneducated in eating disorders, most doctors are perplexed by these symptoms. Bariatric surgeons continue to encourage starvation and weight loss, while the Bariatric nutritionists do not consider changing their recommendations for prolonged malnutrition. Endocrinologists encourage medications to treat the increased hunger. No one considers the effect of chronic starvation, largely because thinness is of primary importance. 

The Bariatric community needs to team up more closely with eating disorder clinicians in order to better understand the repercussions of these surgeries. Curing obesity by causing an eating disorder is certainly not a viable means of treatment.

Can People with Eating Disorders be "Treatment Dependent"?

I heard a new term in the treatment of people with eating disorders this week: treatment-dependent patients. I was flabbergasted by the judgment and blame associated with this label, especially since it came from a program well versed in the need for kindness and compassion. 

The overt message appeared to be that patients should not be dependent on their treatment to get well while the implied message is that chronicity of an eating disorder is the patient's fault. 

For those who read my blog, it's clear that dependence on treatment is a necessary part of recovery. The eating disorder serves as a constant companion, comfort and salve for all the events of daily life. Weaning oneself from such a critical part of life demands a drastic shift in lifestyle. Depending on treatment can be a bridge towards learning how to depend on close relationships in daily life while learning how to eat normally again. That dependence makes the eating disorder less necessary over time. The relationship serves as a jumping off point for independence, not a reason to remain ill. 

The chronicity of an eating disorder is not the failure of the patient. The implied message is that the person just needs to try harder or to learn to stand on her own two feet. Anyone knowledgable in eating disorder treatment knows this message only sends someone to relapse because it reinforces self-criticism and self-blame, the cornerstones of the eating disorder.

The eating disorder thoughts and behaviors become so ingrained and automatic that only sustained support to change these patterns over time will have an impact. Urging someone to just figure it out implies a lack of ability on the treatment providers to manage the illness. 

This is certainly not the first time I have heard clinicians blame the patient for her illness. Usually inexperienced therapists will state uneducated opinions which only show a lack of understanding of the nuances of eating disorders. That's not surprising since it is hard to find thorough training for treatment of these illnesses. 

However, the term treatment-dependence comes from an established and esteemed organization. When patients are blamed for their illnesses, it's time for the treatment providers to delve into their own motives to be sure they have the clarity needed for this type of work.

Surviving the Pressure to Diet, Part II

The ideas of the individual diet and the pressures to constantly diet from the last two posts open the door to a new philosophy of not just eating disorder recovery but eating in our current environment. 

The concept that there is one correct way of approaching food, body and health contradicts everything we know about the human body. Although we all have the same organs and function similarly, our genetic differences underlie a vast range of traits from appearance to personality to our unique fingerprint to organ function. 

In other words, we are each our own person. The collective attempt to universalize food choice and metabolism as if we are all the same rails against these truths about humans. 

I have written extensively in this blog (post1, post2, post3) about the societal pressures which have encouraged these falsehoods to pervade our world. The media pressure for thinness, the diet industry, the pervasive food industry and weak regulatory system (influenced largely by industry lobbying) have all weakened the clear message from science: we are each an individual human. 

And so the philosophy that will counteract these pressures has two parts: learn about your own body and life is more important than food. 

Well-being and health have many components, and one is food and nutrition. Although there are some basic facts about nutrition that matter for us all, for example eat a variety of food and eat real food, what works best is the individual diet. Learn what types of foods work best for you, the way of eating that fits your digestive system and meal sizes that help you function at your best. For people with eating disorders, there will be a period of following someone else's plan to relearn how to eat first, but others can start to learn about their own bodies right away. 

Second, despite the pressure to prioritize food, spending an enormous amount of time on food and weight wastes time better spent on living. People with eating disorders or those with disordered eating know that obsessions about food can consume one's internal world.

It's so important to make sure life--family, relationships, work, hobbies, interests--matters more than simply thinking about body and food. Life leads to more satisfaction every single time.

The Individual Diet: Just One Person at a Time

Part II of surviving dieting will come next post in order to spend a few moments on a new and crucial line of research related to both eating disorders and the societal understanding of metabolism and weight. 

A recent article explained some new findings about the treatment for obesity which turn the common notions about dieting and food choice on their head. The underlying message is that all meal plans and all foods are not equal for everyone. The variability of digestion and gastrointestinal endocrinology between people means that various foods do not have absolute value. Instead diet options need to be tailored to the individual. 

This is new, profound information for the lay person and confirms that considering all food to be equal to all people seems absurd.

We all look different. We all have different physical, intellectual and social skills and weaknesses. We all have different vulnerabilities in the world. Why would our biological response to food be universal?

The specific research quoted here focuses on the body's immediate endocrinological response to a meal. Specifically, how fast does an individual release insulin--the hormone that informs the body it is time to utilize new energy that just entered the bloodstream. The article proposes, based on clearly described data, that this variability in a biological response to food indicates that different meal plans are necessary for different people. 

It is new for any treatment plan, medical or otherwise, to approach obesity, eating disorders or even improving one's overall diet from an individual perspective. All diet advice is general, as if one person or plan can assert a diet that will help all people. More importantly, the desperation of the public to find an ultimate solution to food leads many people to follow these unreasonable expectations to their ultimate failure. 

Instead, it behooves the medical community, clinicians who treat eating disorders and the public to heed the message behind this article. The point of any attempt to improve one's health through a new diet is a personal endeavor. There is no right way. There is a meal plan that will improve one's own health, and the goal is to seek a way of eating that allows each individual to live their life fully feeling healthy and strong. 

Surviving The Pressure to Diet, Part I

For adults and children, the concept of dieting or restricting eating for health reasons is commonplace and even considered healthy. A part of modern day living is to constantly monitor and reconsider which foods should be eaten and which avoided. Our general appetite for more nutrition news is seemingly insatiable. 

Unfortunately, when these studies are fully evaluated, it's clear that they do not represent trustworthy science. There is no regulation of this information, and anyone is allowed to impart their own personal wisdom as fact in a new book, diet or food fad. 

The result is a world where it is virtuous to follow any diet without considering the validity of the recommendations or the health of the suggestions. Even the medical field tends to be unclear as to how to change eating behaviors since doctors themselves have minimal training in nutrition. 

Diets rarely consider some basic facts about our bodies, nutrition or metabolism. We focus mostly on calories and ignore other critical pieces of information such as essential items of nutrition necessary for healthy body function. We don't take into account the variety of foods necessary for general health. We also do not consider that changes in metabolism almost always, in countless studies, lead to a reversal in weight loss from every diet. How can a society supposedly grounded in science be so willing to forgo reason and diet incessantly when all evidence points to failure?

Therein lies the confusion. We all diet when reliable data points to its failure. We even encourage or turn a blind eye to dieting children until a real problem, such as an eating disorder, presents itself. 

A final issue is that all this dieting has increased the incidence of eating disorders significantly in the last forty years, yet no one seems to acknowledge this change. 

Three pieces of information can help explain why an entire society continues to make the irrational decision to diet without even considering the consequences: the desire for thinness at all costs and as a panacea for our daily woes; the collective panic over endless supplies of processed, irresistible food; and the total lack of protection by industry or regulatory agencies from the massive change in available foods in recent decades. 

I have written about these concerns in this blog before, and nothing has changed in recent years. This post serves as a bridge between the risks of starvation and the ways to combat the societal pressure to diet. The next post will focus on ways to rethink and revise our thoughts about dieting. 

The Risks of Dieting and Starvation

The model in the last post described a three step process to explain the cause of an eating disorder: genetic predisposition, environmental trigger and emotional/psychological stimuli. Although the first and third part of the model increase the likelihood greatly of illness, there is no chance an eating disorder will occur without the trigger of starvation. 

It remains somewhat controversial to view dieting and undereating as a necessary part of the evolution of an eating disorder. Dieting and losing weight are seen as a beneficial and even health-promoting parts of modern life. The increased concern over obesity and the incessant focus on thinness make dieting a cornerstone of our daily life. Dieting has become the de facto answer to many medical ills. 

Yet no one speaks of the medical risks of dieting and chronic starvation. Various diets of 1200 calories per day, half of which often comes from a shake made of processed protein powder, are commonplace. Starving all day in order to wait and eat at night is considered virtuous. The diet industry is a booming business. 

This message seeps down to children and adolescents who easily fall into the trap of dieting and soak up the praise that comes with weight loss while nobody seems to worry about the risks associated with a malnourished child. 

The immediate risks, including lack of energy, slowed thinking or weakened organ function, do not come to mind when we think about a diet. Instead weight loss is blindly equated with health.

But dieting also triggers ingrained biological adaptations to starvation, the body's protection against times of famine. The adaptations include obsessive thoughts about food and weight, slowed metabolism to conserve energy and the preservation of essential body functions at the expense of less necessary ones. The basic functions include cardiovascular function, maintenance of core temperature and basic organ function but sacrifices muscle mass, higher level brain function and reproductive capability. It's like the body running on a backup generator. 

This metabolic shift is the key to the illness model. It is the trigger. If someone rests in starvation metabolism for too long, they run the risk of triggering a longterm, adaptive shift into starvation metabolism, essentially a semi-permanent state to survive famine. In modern life, this mental and physical shift isn't based on actual famine. The food is still all around us. But starving for long enough can trigger the thoughts of an eating disorder if someone is so predisposed. That is the central risk. 

When dieting was not pervasive in our culture, this risk was minimal, but recent decades have made dieting almost a rite of passage. All of a sudden, we all are exposed to this risk, we all try to diet and starve at some point, we all test to see if we have a genetic predisposition to an eating disorder. And we all do this without any understanding of the risk we are taking.

Instead when a child or adolescent turns out to have an eating disorder, the general consensus is to throw up our hands in confusion, but the number one risk for developing an eating disorder is that first step to start a diet.

The implications of what this knowledge means for adults and children will be the focus of the next post.

The Causes of an Eating Disorder

Patients, parents, family and friends find solace in asking how an eating disorder starts. Often what makes an eating disorder last is more important for treatment than why it started, but figuring out the initial cause does two important things: creates a story that helps someone make sense of their lives and provides underlying clues for therapy. 

I have written at length about the number one cause of an eating disorder: dieting and starvation. Taking in significantly less food than one needs for an extended period of time triggers the innate human response to famine. Metabolism slows, organs function efficiently but less effectively, unnecessary body function is sacrificed. If this time persists, brain changes occur which include decreased cognitive function, obsessive focus on food and increased attention to body shape and weight. The number one reason for the skyrocketing incidence of eating disorders in recent decades is widespread sanctioned dieting, especially in children and adolescents. 

The second cause for an eating disorder is genetic predisposition. Not all kids and people who diet end up with an eating disorder. In fact, the large majority don't, even if many of them stay focused on food and weight into and through adulthood. A certain percentage of people have an innate response to eating disorder symptoms, largely a strong biological and seemingly chemical response to the eating disorder symptoms. Prolonged starvation, binging or purging can all trigger powerful chemical responses in the brain that are very calming and, for those are predisposed, almost addictive. In addition, the rigid rules and routine of an eating disorder create calm and safety not as an immediate response but as a longterm salve to the uncertainty of daily life. People who combine the trigger of starvation with the powerful biological response to the behaviors are at higher risk for an eating disorder. 

The third component of the cause of an eating disorder is emotional. Kids who lack love, warmth and attention feel as if they have found a panacea in an eating disorder. The almost magical trick of having figured out food--whether through prolonged starvation or a method of eating and purging l--and the positive feedback of being thin replace the emotional pain of feeling unloved and worthless. This experience can range from seemingly benign neglect to emotional or physical abuse to traumatic experiences. The severity of the experience tends to correlate to how much the emotional cause contributes to the eating disorder. 

These three components of the cause of an eating disorder do not factor in equally. For some the genetic component is the main instigator of the eating disorder and for some a traumatic childhood is. For most though, the eating disorder started because all three potential reasons came together in such a way that led to the person falling into this illness.

Most people find comfort in having an explanation as to why their eating disorder started. This conversation can be hard but it helps push aside the shame associated with the illness and give the person enough agency to continue taking steps in recovery.