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Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
https://doi.org/10.1007/s40519-019-00839-w
ORIGINAL ARTICLE
Associations betweenbinge eating, depressive symptoms andanxiety
andweight regain afterRoux‑en‑Y gastric bypass surgery
CristinaCardosoFreire1 · MariaTeresaZanella1· AdrianoSegal2· CarlosHaruoArasaki3·
MariaIsabelRodriguesMatos1· GlauciaCarneiro1
Received: 24 October 2019 / Accepted: 17 December 2019
© Springer Nature Switzerland AG 2020
Abstract
Background Weight regain (WR) after bariatric surgery (BS) is frequent.
Objective The aim of this study was to evaluate whether the occurrence of psychiatric disorders would be associated with
short- and long-term WR after BS.
Methods Ninety-six patients (77.6% female, age 40.2 ± 10.1years, BMI of 50 ± 8.2kg/m2) from the Obesity and Bariatric
Surgery Outpatient Clinic of the Universidade Federal São Paulo completed the Questionnaire on Eating and Weight Pat-
terns-Revised, the Beck Depression Inventory and an anxiety inventory to assess the occurrence of binge eating, depressive
symptoms (DS) and anxious symptoms (AS) before and after short-term and long-term BS.
Results Twenty-four months after BS, the prevalence of binge eating, depression and anxiety decreased from 100 to 13%, 100
to 15% and 43 to 4%, respectively. The mean WR of 35.2 ± 17.3% of weight loss occurred in nine patients after 24months
and was associated with binge eating (p = 0.002) but not with DS or AS. At long-term follow-up (12 ± 1.5years), 67% had a
mean WR of 50.3 ± 24.9%. The prevalence of binge eating, DS and AS were 48%, 46% and 63%, respectively, in this group,
and significant associations were observed between WR and binge eating (p = 0.001), DS (p = 0.029) and AS (p = 0.001).
Furthermore, the number of psychiatric disorders was inversely associated with the percentage of weight loss (p < 0.05) and
positively associated with WR (p < 0.05).
Conclusion Weight regain was associated with the occurrence of binge eating in the short and long term after BS, whereas
the occurrence of depressive and anxious symptoms was associated with WR only in the long term.
Level III Evidence obtained from well-designed cohort or case–control analytic studies.
Keywords Weight regain· Bariatric surgery· Binge eating· Depression· Anxiety
Introduction
Obesity represents one of the greatest global public health
challenges. Overweight affects up to two-thirds of the
world’s population [1]. In Brazil, estimates of the prevalence
of obesity (body mass index (BMI) ≥ 30kg/m2) were 16.8%
among men and 24.4% among women, and overweight (BMI
between 25 and 29.9kg/m2) estimates were 56.5% of men
and 58.9% of women [2].
Globally, a total of 1.9 billion and 609 million adults were
estimated to be overweight and obese in 2015, respectively,
representing approximately 39% of the world’s population
[3]. Obesity is related to a number of diseases, including
type 2 diabetes, cardiovascular diseases, joint and muscle
diseases, respiratory problems, and psychiatric disorders,
* Cristina Cardoso Freire
freirecris@hotmail.com
1 Department ofMedicine, Division Endocrinology
andMetabolism, Universidade Federal de São Paulo, End:
Street Leandro Duprat, 365, SãoPaulo04025-010, Brazil
2 Department ofMedicine, Obesity andMetabolism Syndrome
Outpatient Service, Universidade de São Paulo, SãoPaulo,
Brazil
3 Department ofSurgery, Division ofSurgical
Gastroenterology, Universidade Federal de São Paulo,
SãoPaulo, Brazil
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
which can significantly affect daily life and increase the risk
of mortality [4].
Bariatric surgery is well established as an effective treat-
ment against severe obesity. Its beneficial consequences
include the following: improving diabetes control or even
leading to remission; reducing cardiovascular risk; improv-
ing sleep apnea, joint pain and quality of life; and mark-
edly reducing overall mortality [5, 6]. Weight regain occurs
frequently after bariatric surgery [7–9], and there is still no
consensus regarding the magnitude of weight regain that
compromises the success of the surgery [10].
The Brazilian Society of Bariatric and Metabolic Surgery
(SBCBM) has defined obesity recurrence as a 50% regain of
long-term weight loss or a 20% regain of weight loss associ-
ated with the recurrence or worsening of comorbidities [11].
Weight regain is multifactorial, and causal factors include
lack of physical activity, adherence to diet, hormonal or met-
abolic changes, postoperative anatomical factors, and poor
mental health [12–14]. However, factors that predict which
patients are most likely to regain weight are not well known
[15–17].
The occurrence of binge eating is not considered a con-
traindication for bariatric surgery, since in the first years
after surgery, during which the greatest weight loss occurs,
the frequency of binge eating is markedly reduced [18, 19].
Although the occurrence of binge eating, anxiety and
depression have no predictive value regarding the magni-
tude of weight loss or recurrence of compulsive episodes
after long-term surgery [20–24], few studies have evaluated
the relationship between weight regain and changes in eating
behavior [25, 26]. On the other hand, some studies indicate
that the patient’s mental health is an important factor in the
prognosis of bariatric surgery regarding the maintenance and
regain of weight loss [27, 28].
Objective
The objectives of our study were to assess the long-term
recurrence of binge eating after initial remission and to
assess the relationship between the recurrence of such epi-
sodes and weight regain. Additionally, the occurrence of
depressive and anxious symptoms, which are often associ-
ated with binge eating, was evaluated before surgery; fur-
thermore, its relationship with weight regain after bariatric
surgery was also examined.
Patients
Between 1999 and 2004, 96 patients of both sexes with
grade III obesity (BMI ≥ 40kg/m2) and binge eating were
recruited from the waiting list for bariatric surgery and
treated regularly at the Obesity Outpatient Clinic of Endo-
crinology, Universidade Federal de São Paulo/Hospital do
Rim. All were evaluated by a multidisciplinary team and
considered clinically fit to undergo bariatric surgery using
the Roux-en-Y gastric bypass technique. No patient refused
to participate in the study.
Study procedures
Three evaluations were performed: preoperative, 24months
after surgery and one long-term evaluation.
Age, sex and time elapsed after surgery were recorded,
as well as physical examination, and weight and height were
evaluated in all patients previously selected for the occur-
rence of binge eating. We considered excess weight (EW) to
be the difference between the patient’s initial weight and his/
her ideal weight, which refers to a BMI of 25kg/m2.
We define weight loss as a percentage of the excess of
body weight loss (%EWL), weight regain was defined as the
percentage recovered of the total weight loss (%WR), and
we consider WR greater than or equal to 20% of the weight
loss to be significant.
All patients were reevaluated 24months after surgery,
and 46 of the 96 patients could be recruited for a long-term
evaluation after a period ranging from 7 to 14years (mean
12 ± 1.5years).
Psychological assessment methods
In the first evaluation, we sought to detect symptoms of
depression and anxiety in the 96 patients already diagnosed
with binge eating.
After 24months of surgery, the occurrence of these epi-
sodes and depressive and anxious symptoms was further
investigated in the 96 patients initially evaluated. In the third
evaluation, these aspects were reevaluated in the 46 patients
who could be recruited.
Although the research instruments were to be self-
reported questionnaires, all of them were applied in the
form of interviews by the principal investigators since some
patients showed comprehension difficulties.
Evaluation ofbinge eating
The occurrence of binge eating was assessed using the Ques-
tionnaire on Eating and Weight Patterns-Revised (QEWP-
R), a structured instrument based on the criteria proposed
by the DSM-IV [29] translated and validated for the Portu-
guese language. Episodes of binge eating are characterized
by the rapid ingestion of food within 2h or less that most
people would consume in a similar period of time; the food
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
is ingested until the participants feel so bad from eating due
to a sense of guilt and loss of control over this episode.
Following bariatric surgery, the ingestion of large
amounts of food may not be physically possible, but intakes
accompanied by subjective feelings of guilt and loss of con-
trol could indicate the presence of binge eating [30].
Evaluation ofdepressive symptoms
Depressive symptoms were assessed using the Beck Depres-
sion Inventory (BDI) instrument, a structured questionnaire
consisting of 21 categories of symptoms and attitudes that
describe the behavioral manifestations of depression.
This instrument assesses the intensity of depressive symp-
toms, and scores range from 0 to 63. The intensity categories
are absent or normal (0–9), mild (10–15), mild-to-moderate
(16–19), moderate–severe (20–29), and severe (30–63). The
cutoff point used in the present study to consider the patient
as having depressive symptoms and to thus most likely to
have clinical depressive disease was 20 points [31].
Evaluation ofanxiety symptoms
Anxiety symptoms were assessed by the IDATE/STAI
instrument quantitative detection of intensity symptoms,
translated and validated to Portuguese [26]. Part II of this
questionnaire, which assesses state anxiety, consists of 20
questions. The scores obtained in this instrument range from
0 to 80 and characterize the state of anxiety as low intensity
(0–29), low-to-medium (30–39), medium (40), medium-to-
high (41–50). and high (51–80). The cutoff point used in the
present study was 40 points [32].
Statistical analysis
Data analysis was performed using the Statistical Package
for Social Sciences (SPSS) version 22 for Windows (SPSS
Inc., Chicago, Illinois) statistical software. Descriptive anal-
ysis of quantitative variables included arithmetic means and
standard deviations, and qualitative variables were described
using frequencies.
For comparison, studies between the groups with and
without each psychiatric disorder, Student’s t test for quan-
titative variables was used, and the Chi-square test was used
to compare frequencies.
For quantitative variables where the existence of a normal
data distribution was assumed, the Kolmogorov–Smirnov
test was used.
Results
Preoperative evaluation
Table 1 shows the data obtained in the preoperative
evaluation regarding age, sex, time after surgery, BMI
and frequency of each psychiatric disorder among the
group of 96 patients who were followed up to 24months
or the 46 patients evaluated after the mean period of
12years ± 1.5years and 50 non-reassessed patients. There
were no significant differences regarding sex, time of sur-
gery, BMI, binge eating, depression symptoms and anxiety
symptoms at baseline among the three groups.
The population of 96 patients included 75 women (78%)
and 21 men with severe obesity (mean age 40.4 ± 10.2years,
BMI 50.4 ± 8.2kg/m2) and binge eating. All were considered
as having indications of bariatric surgery and were clinically
able to undergo the procedure.
In addition to binge eating, depressive symptoms
(BDI ≥ 20) were observed in all patients, and anxious symp-
toms (STAI ≥ 40) were observed in 42.9% of patients.
Evaluation at24 months
At 24months, the binge-eating episodes decreased to 13%,
and the depressive and anxious symptoms were reduced
to 15% and 3%, respectively, while the BMI decreased to
30.6 ± 6.1kg/m2.
Table 1 Clinical characteristics
of the studied obese population
LTFU long-term follow-up lasting 7–14years
Patients
N = 96
Patients with LTFU
N = 46
Patients
without
LTFU
N = 50
Female (%) 77.6 71.7 82.7
Age initial (years) 40.4 ± 10.0 41.3 ± 10.5 39.6 ± 9.9
Time after surgery (years) 2.0 ± 1.8 12.0 ± 1.6 –
BMI Initial (kg/m2)50.4 ± 8.1 50.5 ± 7.2 50.3 ± 9.0
Patients with depressive symptoms (%) 100 100 100
Patients with of anxious symptoms (%) 42.9 39.1 46.1
Patients with binge-eating episodes (%) 100 100 100
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
WR that was greater than or equal to 20% at 24months
occurred in 9 out of 96 patients (8.6%), who showed a
regain of 35.2 ± 17.3%, while the other 87 showed a %WR
of 0.3 ± 2.2% (p = 0.000). Recoveries higher than 20% were
associated with the occurrence of binge episodes: out of the
9 patients who regained weight, 4 had binge-eating episodes,
while only 8 of those 87 patients who did not regain weight
had such episodes (44% vs. 9%, p = 0.012). Due to weight
regain, the group of nine patients at the end of 24months
maintained an EWL of 39.0 ± 11.5%, which was lower than
that of the group of 87 patients who did not regain weight
(83.4 ± 17.2%; p = 0.000). No associations were observed
between weight regain and the occurrence of depressive or
anxious symptoms.
In addition, the frequency of patients with WR ≥ 20% was
higher among those with binge-eating episodes thanamong
those without episodes: 33.3% vs 5% (p = 0.004).
Additionally, as shown in Fig.1, the %WR in the group
with binge eating was 12.3 ± 15.9%, which was higher when
compared to the 2.3% ± 10.3% in those without binge-eating
episodes (0.004). At the end of 24months, the group with
binge-eating episodes presented %EWL of 61.1% ± 21.4%,
which was lower than the %EWL of 81.8% ± 19.9% observed
in the group without binge-eating episodes (p = 0.001).
Long‑term evaluation
In the third evaluation, it was possible to reassess 46 patients
(33 women and 13 men). In this subgroup, the maximum
EWL was 79.1 ± 15.8% on average. However, of the 46
patients, 31 showed WR ≥ 20% and had a mean WR of
51.7 ± 24.7% of weight loss, while the others (n = 15) had
an additional 0.6% weight loss (p = 0.000). When compared
at baseline, the groups with WR ≥ 20% and WR < 20% did
not differ in BMI (50.6 ± 7.4 vs. 50.4 ± 7.0kg/m2; p = 0.950);
additionally, they did not differ in the maximum EWL
(79.5 ± 14.1% vs. 74.5 ± 18.1%; p = 0.311) but differed in
BMI at the last evaluation (40.7 ± 8.2 vs. 31.9 ± 4.5kg/m2,
p = 0.000). At baseline, these two subgroups did not differ
in the frequency of symptoms of depression present in all
patients, or did they differ in the frequency of anxiety symp-
toms (40.6% vs. 38.7%; p = 1.00).
In this group, as with the 96-patient group, the frequen-
cies of binge eating and depressive symptoms decreased
from 100 to 13% and from 100 to 15%, respectively, while
the frequency of anxious symptoms decreased from 39 to
4%. In the long-term evaluation, binge eating and depressive
symptoms increased to 48% and 46%, respectively, while the
frequency of anxious symptoms increased to 63%, a higher
frequency than that observed before surgery (p = 0.027).
In addition, the frequency of patients with WR ≥ 20%
was higher among those with binge eating than that among
those without binge eating (91.0% vs. 45.8%, p = 0.001)
(Fig.2). Additionally, the WR in the group with binge eat-
ing was 52.6 ± 29.6%, compared to 18.2 ± 29.6% in the
group without binge eating (p = 0.001; Fig.3). The group
with binge eating (n = 22) did not differ with respect to
the maximum %EWL of the group without binge eating
Fig. 1 Frequency of patients with WR ≥ 20% and %WR at the
24-month evaluation according to the presence or absence of binge
eating
Fig. 2 Frequency of patients with weight regain ≥ 20% according to
the presence or absence of psychiatric disorders after bariatric sur-
gery in the follow-up
Fig. 3 Percentage of weight regain ≥ 20% according to the presence
or absence of psychiatric disorders after bariatric surgery in the long-
term evaluation
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
(78.3 ± 15.1% vs. 77.4 ± 16.1%; p = 0.86) but presented a
%EWL of 35.9 ± 20.9%, which was lower than the %EWL
of 62.7 ± 22.8% observed in the group without binge eating
(p = 0.000) in the last evaluation.
The percentage of patients with WR ≥ 20% was 86.7%
of the patients with symptoms of depression, compared
to 52.0% of the patients without depressive symptoms
(p = 0.026; Fig. 3). Additionally, the %WR was higher
in the group with depressive symptoms than that in the
group without symptoms (52.6 ± 30.0% vs. 19.5 ± 30.0%;
p = 0.001; (Fig.3). Although the groups with and without
depressive symptoms did not differ with respect to the maxi-
mum %EWL (81.1 ± 12.8% vs. 75.2 ± 17.1%; p = 0.201), the
group with symptoms showed a lower %EWL than the group
without symptoms (38.2 ± 23.9 vs. 59.7 ± 23.0%; p = 0.003).
The frequency of patients showing a %WR ≥ 20% in the
group of patients with anxiety symptoms was 82.3%, com-
pared to 41.1% among patients without anxiety symptoms
(p = 0.008); (Fig.2). Additionally, the %WR in the group
with anxious symptoms was higher than that observed in
the group without symptoms (48.1 ± 30.1 vs. 11.6 ± 27.9;
p = 0.000) (Fig.3). Although those with and without anx-
ious symptoms did not differ with respect to the maxi-
mum %EWL (77.7 ± 14.1% vs. 78.1 ± 17.9%; p = 0.930),
the group with anxious symptoms showed a %EWL lower
than that observed in patients without anxious symptoms
(39.7 ± 23.1% vs. 67.2 ± 19.8%; p = 0.001).
When the 46 patients were divided according to the num-
ber of psychiatric symptoms present at the end of the obser-
vation period, we found 16 patients who had no symptoms,
2 patients with only 1 psychiatric disorder, 14 patients with 2
different disorders and 14 patients with 3 different disorders.
In those with two associated disorders, anxiety symptoms
were present in all patients in association with depression
symptoms (N = 7) or binge eating (n = 7). The four groups
did not differ regarding the initial BMI and the maximum
%EWL, but the groups with two or three associated disor-
ders at the end of the follow-up presented a lower %EWL,
higher %WR and higher BMI (Fig.4).
Discussion
In our study, we found a high prevalence of depressive and
anxious symptoms in patients with binge-eating episodes
with indications for bariatric surgery. High frequencies of
psychiatric disorders have been described in patients with
severe obesity awaiting surgical treatment [33, 34], with
depressive, anxious, binge-eating and bipolar disorders
being the most common. With a significant decrease in
weight during the first years after bariatric surgery, partici-
pants in this study simultaneously demonstrated a signifi-
cant decrease in the frequencies of the disorders evaluated.
Over time, with body weight stabilization or weight regain,
these disorders recurred, although at lower frequencies than
those observed before surgery. Few studies have evaluated
the association between weight regain and the occurrence
of depressive, anxious or binge-eating symptoms over long
periods after surgery. In our study, in the evaluation per-
formed at 24months of follow-up, it was possible to observe
a strong association between body weight regain greater
than 20% of weight loss and the occurrence of binge eat-
ing, which is characterized by the loss of control over food
consumption. Out of the nine patients who recovered an
average of 35% of the weight they lost in 2years, four had
binge eating. Similarly, in the SOS study [26], during the
7years following bariatric surgery, those who reported loss
of control over food intake had lower weight loss than they
experienced initially and greater weight regain compared to
the lowest weight achieved. Karlachian etal. also observed
lower weight loss among patients who had binge eating dur-
ing a 3-year observation [35]. Additionally, Pinto etal. found
that problematic eating behavior and psychological distress
are associated with poor weight loss after bariatric surgery
[36].
In the short-term evaluation, we could not observe any
association between weight regain and the recurrence of
anxiety or depressive disorders. Considering the 46 patients
who were reevaluated over the long-term follow-up, the
prevalence of depressive, anxious and binge-eating symp-
toms of 16%, 5% and 12% of patients, respectively, observed
at 24months after surgery increased to 46%, 63% and 48%,
respectively. Upon reevaluation, an association was observed
between psychiatric disorders and weight regain, with 86%
of patients with depressive symptoms, 82% of those with
anxiety symptoms and 91% of those with binge eating
regaining more than 20% of their initial weight loss. We
observed that the occurrence of symptoms of one type of
disorder and the association of two or three different symp-
toms of the others were associated with gradually higher
percentages of weight regain. Although a cause-and-effect
Fig. 4 Weight loss and regain after bariatric surgery according to the
number of follow-up psychiatric disorders
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
relationship cannot be established, these data suggest that
depressive and anxious symptoms and binge eating may con-
tribute to weight regain, especially when combined.
Our data regarding binge eating and weight regain resem-
ble the results obtained in other studies. Delvin etal. fol-
lowed 184 patients undergoing bariatric surgery for 7years
and found a positive association between WR greater than
20% of the minimum weight achieved and the occurrence
of episodes in which loss of control of food intake, which
resembles binge [27]. In the study by Kofman etal., 598
patients undergoing bariatric surgery were followed for a
period ranging from 3 to 10years. In this study, 50% had
episodes in which it was not possible to control the amount
of food consumed, 27% reported episodes in which they con-
sumed what is considered a large amount of food for those
who underwent bariatric surgery, and 46.6% reported eating
at few intervals continuously over a long period of time.
The frequency of each of these episodes showed a positive
and significant correlation with weight regain [37]. Other
studies have also found a positive association between the
occurrence of binge eating and worse outcomes regarding
weight loss or regain after surgery, suggesting that changes
in eating behaviors are associated with weight regain after
bariatric surgery, although a cause-related relationship and
effect cannot be determined [38–41].
We considered the presence of depressive symptoms with
a BDI score greater than or equal to 20 as indicative of a
higher probability of clinical depression. Prior to surgery,
100% of patients were diagnosed with depressive symptoms.
The frequency of symptomatic patients decreased to 15% at
24months after surgery, rising again to 46% in the long-term
evaluation, and there was a clear association between the
recurrence of these symptoms and weight regain of more
than 20% of weight loss. Our results are consistent with
those of another study, which also showed reductions in the
occurrence of depressive symptoms with weight loss in the
first years after bariatric surgery [42, 43]. However, there are
few studies showing an association between postoperative
depressive mood and weight regain, mainly because most
of these studies are short-lived and conducted when weight
regain is not yet significant.
In the study by Mitchell etal., assessments were made
for the detection of depressive symptoms in 2148 patients
from 10 US centers before and 36months after bariatric sur-
gery. In this population, a prevalence of 28% of patients with
BDI scores above 10 was observed; these patients were con-
sidered to have mild-to-severe depressive symptoms, with
23.6% presenting mild symptoms. In the first year following
bariatric surgery, an approximate 50% decrease in BDI score
was observed, with a slight increase in the following 2years
and a significant correlation (r = 0.43; p < 0.001) between
BDI scores and BMI values [44].
Findings similar to those observed in our study were
described in the SOS study, which evaluated 655 patients
during the first 10years of follow-up after bariatric sur-
gery. One year after surgery, the prevalence of patients with
depressive symptoms was halved, but over 10years, this
reduction was 27%. At the end of this period, it was observed
that patients who maintained a weight loss greater than or
equal to 10% of baseline weight, compared to those who
maintained a weight loss of less than 10%, showed larger
reductions in depressive symptom scores on the HADS
(Hospital Anxiety and Depression Scale) [26]. The research-
ers concluded that weight loss has a positive effect on reduc-
ing depressive symptoms and that those with less weight
loss would benefit less. Indeed, it is intuitive to admit that
the low self-esteem, body dissatisfaction, and social isola-
tion that afflict patients with obesity can result in intense
psychic distress and can increase the risk of depression [45].
However, it cannot be ruled out that the long-term depres-
sive mood associated with weight regain can also contribute
to the weight regain process, thus creating a vicious circle.
In fact, the relationship between obesity and depression is
complex and almost unknown. In a meta-analysis by Lupino,
a two-way association between depression and obesity was
observed: obese people are 55% more likely to develop
depression over time, while depressed people are 58% more
likely to become obese [46].
We observed at the beginning of the study that the preva-
lence of 39% of patients with anxious symptoms decreased
to 5% following weight loss in the first 2years after sur-
gery. It rose again to 63% in the long-term assessment, thus
exceeding the initial frequency. On this occasion, as with
binge frequencies and depressive symptoms, we observed
a significant association between the occurrence of anx-
ious symptoms after surgery and body weight regain. In
this respect, our results differ from those obtained in the
SOS study in which a decrease in the frequency of patients
with anxious symptoms was observed from 30 to 24% after
10years of surgery with no relationship between the HADS
score changes and the changes in body weight [26]. In other
shorter term studies, the frequencies of patients with anx-
ious symptoms decreased after surgery, in parallel with the
weight loss in the first 2years, with no association between
the occurrence of anxious symptoms and the degree of
weight loss or weight regain [42, 47, 48], most likely due
to the short observation period. The reasons why the results
of our study differ from the others are probably due to the
longer period of follow-up and differences among the stud-
ied populations. It can be assumed that patients with altered
eating behavior may be more susceptible to the development
of anxious symptoms in the face of a weight regain condi-
tion. On the other hand, the occurrence of anxious symptoms
may also contribute to weight regain.
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
Study limitations
A major limitation of the study is the lack of a control group.
After a long period of time, we were able to contact only
47% of the sample, resulting in a small number of patients
evaluated; however, we found no differences between base-
line participants and those who continued follow-up with
respect to age, sex, BMI, disorders assessed, compulsion
eating, depression and anxiety.
Our results may represent a stalled point, and perhaps
only the patients who had the worst postoperative evaluation
may have accepted the invitation to participate in the study.
Conclusion
The present results show a high frequency of patients with
symptoms of depression, anxiety and eating behavior altera-
tions after bariatric surgery that are clearly associated with
weight regain. Although a cause-and-effect relationship
cannot be established, the detection of these disorders in
patients undergoing bariatric surgery is indicative of a poor
prognosis regarding long-term weight maintenance.
“What is already known on this subject?”
Mental health, especially binge-eating disorder and postop-
erative depression, is inversely related to weight loss.
This study aimed to elucidate the associations of psycho-
logical disorders and weight loss after bariatric surgery in
short- and long-term follow-up.
Under the heading, “What your study adds?”
We found a reduction in depression, binge eating, and anxi-
ety frequency in the early years after bariatric surgery; how-
ever, after long-term follow-up, there was an increase in the
psychological symptoms related to weight regain.
The number of psychological symptoms at the end of the
follow-up had an important relationship with lower weight
loss, BMI degree and greater weight regain.
Funding No funding was required for this study.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflicts of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the ethics
committee of Universidade Federal de São Paulo and with the 1964
Helsinki Declaration and its later amendments or comparable ethical
standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
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