Surgical Anorexia: the Long Term Effects of Bariatric Surgery

As a psychiatrist treating people with eating disorders, I find that I have specific but unexpected expertise to help people after Bariatric surgery. These procedures aimed at reducing weight induce what I have started to call surgical anorexia.

Chronic anorexia leads to poor functioning of many organ systems due to long-standing malnutrition including the gastrointestinal system. Slow digestion, an inability to tolerate many foods, delayed emptying of the stomach and poor absorption of energy and vitamins are ways anorexia can affect the GI system. Thus, poor nutrition damages the GI system and makes it more difficult to absorb the needed energy.

Bariatric surgery shrinks the size of the stomach significantly which leads to an inability to eat a normal amount of food at one time and to more difficulty absorbing nutrients and vitamins. Essentially, the surgery mimics the same GI symptoms that chronic anorexia causes. Over time, these GI symptoms lead to starvation and the same medical effects of anorexia unless steps are taken to ensure adequate nutrition. It’s not a stretch to call this surgical anorexia.

After the surgery, patients I have encountered receive minimal instruction about how to alter their diet and their eating pattern to accommodate their transformed GI system. They need to learn new foods to eat, how much they can tolerate and when to eat through the day. Nutritionists at Bariatric centers tend to give a formulaic meal plan without any detailed, individualized instruction about how to maintain a normal diet.

The end result is often a patient confused about how to eat, eating an insufficient about of food and, after a few months, experiencing symptoms of malnutrition and starvation. These symptoms include nausea, weakness, dizziness, trouble concentrating and irritability. Often patients are afraid they are sick and don’t understand they are starved. And the Bariatric programs refer patients to other doctors and don’t take responsibility for a common effect of Bariatric surgery: surgical anorexia.

In time, patients start to find ways to eat. They eat more often through the day. They eat foods that are easily digested. They start to drink alcohol which loosens the stomach muscles. They overeat or binge and purge but are able to absorb some foods. These are not constructive ways to manage food intake.

However, the longer they are starved, the more their body’s survival instinct kicks in. They start eating large quantities to assuage the starvation which leads to regaining any weight lost from the surgery. In other words, the lack of instruction after surgery means the effects of surgery are usually temporary and can trigger new disordered eating patterns.

Bariatric surgery is not the panacea people often hope it is, but many people seek the surgery after years of desperation. For those who do take this step, there are some basic facts about eating with a surgically damaged stomach that can help avoid surgical anorexia. I’ll discuss them in the next post.

The Philosophy of an Eating Disorder

Eating disorders often present a much more appealing and clear philosophy of the world to young people just starting their lives. For adolescents and young adults afraid of the unknown and the lack of clear guidelines for living, the certainty of the eating disorder rules can be very appealing.

These rules determine how one should feel, the overall goals for the day, how to determine a sense of accomplishment or failure and the best way to move through daily life.

The rules typically entail aiming for certain weight goals, clear rules around food and exercise and a way to decide which personal or profession al events to attend or skip. The eating disorder makes up these rules for one simple, straightforward goal: weight loss.

With this goal in mind, the other more vague goals of life go by the wayside. All other potentially important aspects of living pale in comparison to the concrete and simple goals around food and weight. Life becomes simple, and the philosophy boils down to one measure of success.

Even though eating disorders can seem nonsensical or even vain to many, these illnesses present a lure to young people scared about the uncertainty of life and looking for a way to take away the prospect of having to make decisions in a very confusing world. The eating disorder is an easy out from daily life into a very simple way of life.

The reality of living in the eating disorder world is that young people don’t learn basic life skills: developing friendships and relationships, managing emotions through a normal day or making decisions as an adult.

When entering recovery, people often feel lost without any means to cope when they cannot rely on their eating disorder anymore. The immediacy of relationships, emotions and decisions can quickly feel overwhelming.

Getting better from an eating disorder isn’t only about learning how to eat and manage a healthy body. It also means learning how to face the vagaries of life without a parallel set of rules dictating how to live.

In the end, recovery must focus on living without an eating disorder. It means a crash course in developing coping skills, interpreting internal reactions and stimuli and managing the uncertainty of life as we all must.

It’s a tall order while also learning how to eat and makes the entire process hard. Successful recovery needs to entail the process of learning how to live as much as the process of learning how to eat.

Emotional Maturation during Recovery

Once eating is largely normal and behaviors mostly diminished in recovery, there is room for emotional and psychological development that is impossible in the throes of an eating disorder.

The disorder in full swing is debilitating. Disordered eating and obsessive thoughts about food dominate one’s mind. In addition, completing the eating disorder tasks and following the rules feels like an accomplishment each day. These goals trump all other aspects of daily life and leave no room for other ways to grow into yourself.

After the symptoms subside, the person in recovery faces the realities of life in new ways. The trials and tribulations of work, family, friends, relationships and personal growth all come to the fore very quickly.

Without the guideposts of the eating disorder lighting the way, the uncertainty, confusion and emotions of life feel overwhelming and confusing very quickly.

The months or years of development that would occur otherwise stop almost completely when an eating disorder is present. Most relationships stagnate and all emotions disappear under the intense pressure of the eating disorder rules.

Emotional and psychological development in the process of recovery entails learning how to manage relationships and friendships, identifying emotions, finding ways to cope with life events and managing the uncertainty of daily life. In an eating disorder, none of these issues truly matter. All that demands attention is food and weight.

Fortunately, the period of development for someone in recovery is usually fast and furious. Once the eating symptoms subside, emotional maturing begins immediately.

Although the process is challenging and scary, the mind has developed even though the psychological changes have not occurred. So one’s mind is ready to charge ahead and learn all the components of development and maturity quickly. It’s important for the person to have help identifying emotions and learning new ways to cope with a world no longer guided by this illness.

Focusing on emotional and psychological development solidifies the gains in recovery and, in the end, makes it hard to return to the illness. The success of managing life with an eating disorder, as hard as it can be, well outweighs the misery of being trapped in this illness.