Behavioral Nutrition Counseling for Binging and Associated Weight Loss Surgery

The need for behavioral therapy and nutritional counseling pre- and postoperative weight loss surgery is imperative.

There are different types of weight loss surgery, which also differ in the post-surgical eating guidelines and how much food you can take in and most types of surgery also affect how you digest food and absorb nutrients. All types dramatically alter one’s life and have risks, complications and obstacles that must be addressed.


Addressing behavior with patients before they undergo gastric bypass surgery can significantly influence post-surgery weight loss and psychological stability. Therapy is the key component as patients often think of weight loss surgery as a quick fix, when in fact weight loss surgery challenges not just an individual’s eating habits but also their way of life, such as how they soothe themselves (emotional eating), how they socialize (going out to eat with friends/family; attending holiday gatherings that revolve around food), how family members eating habits will be influenced (feeding children and/or partner different meals) or could influence long-term nutritional guideline adherence. Furthermore, given that weight loss and improved health are not always synonymous, a functional knowledge of good nutrition and the implementation of healthful eating habits and behaviors are essential to positive outcomes after bariatric surgery. Therefore, evidence of disordered eating must be ruled out.


Weight loss surgery can lead to several predictable nutritional deficiencies and can worsen pre-existing ones. Nutritional deficiencies in overweight and obesity may seem paradoxical in light of the excess caloric intake, however, consumption of excess calories does not automatically equate with over-consumption of fruits, vegetables and other unprocessed, high quality nutrient-dense foods. It is critical to screen for nutritional deficiencies in obese patients prior to bariatric surgery and at regular intervals after bariatric surgery, and encourage adherence to supplementation and adequate protein intake.

Those who plan to undergo weight loss surgery stand to benefit greatly from adopting basic changes toward healthful eating before surgery. Rather than focus on relatively complex concepts like calorie counting, the focus should be on fundamental nutrition concepts such as getting in sufficient high quality proteins and how to create nutritious meals based on the meal-panning needs of post-surgical phases of recover. Long-term incorporation of healthful eating habits can continue with gradual changes, such as eating more fruits and vegetables and avoiding high sugar processed drinks (i.e. soda) and high calorie fried food.


Postoperative counseling serves not only to support patients as they work to significantly alter their dietary and activity habits but also to guide them through the physical, emotional, and social changes that inevitably result from dramatic weight loss.

Individuals who are undergoing bariatric surgery are asked to make numerous lifestyle changes, including consuming smaller, more frequent meals, avoiding foods that may limit weight loss or contribute to digestion problems, taking vitamins multiple times per day, and increasing physical activity. For many patients, meeting these recommendations requires dramatic changes from their pre-surgical lifestyle, and some patients struggle with following these recommendations.

Severe preoperative psychopathology and patient expectation that life, in areas outside of health and weight will, dramatically change after surgery. These unrealistic expectations negatively impact psychological health after surgery. As such, expectations should also be discussed the perioperative period to prevent depression and other mental health disorders.

Post-operative therapy, Cognitive Behavioral Therapy (CBT) can help patients adhere to the many behavioral changes that are required after weight loss surgery.  As such, through therapeutic support and stress management skill application, behavioral therapy may be able to patients remain motivated and consistent with their post-surgical weight- loss guidelines, thereby contributing to reduced frequency of certain postsurgical complications, such as nutritional deficiencies, plugging, recurrent vomiting, and dehydration.

A small minority of patients may experience more serious psychosocial difficulties after surgery, such as increased depression, suicidality, or substance abuse, and CBT further provides the opportunity for assisting these patients who develop these more serious psychological symptoms. Dramatic weight loss can also result in changes in self-image and relationships. Therapy can help patients adjust to the normal psychosocial changes that occur after surgery. For most patients, the speed at which they lose weight is dramatic and having the support of a trained therapist and involvement in group therapy can be helpful.


Consistent follow-up care with a dietitian is a vital component of successful surgery outcomes. Postoperative nutrition counseling will address issues such as nutritional deficiencies, food intolerances, challenges in implementing healthful eating habits, adequacy of the diet in meeting basic nutritional needs, and adherence to vitamin and mineral supplementation. Ultimately, patients who make and sustain healthy changes in their eating patterns, including consuming small portions of mealtime foods and snacks, are most likely to achieve optimal weight control.

The physiological changes from weight-loss surgery cause difficulty in absorbing nutrients and can lead to deficiencies in iron, calcium, several B-vitamins, vitamin D and other vitamins and minerals which can lead to a myriad of secondary problems. Furthermore, changes nutritional status and chronic nutrient deficiencies following bariatric surgery can contribute to the development of depression, destructive eating behaviors and body image issues. The surgery can also affect the ability to absorb protein and cause lactose intolerance. Difficulty absorbing protein can affect mood and behavior because the amino acids found in protein are what the body uses to make the “feel good” chemicals in our brains – serotonin, dopamine and epinephrine. To avoid such complications, dietary supplementation often begins shortly after surgery, while the patient is still in the hospital.


    • Disordered eating behaviors – Such as binge eating, emotional eating, and night eating. These issues should be addressed and resolved prior to surgery. The onset of full-syndrome eating disorders, anorexia nervosa, bulimia nervosa, or binge eating disorder, after surgery is possible. Aberrant eating patterns may develop after the operation that do not meet current diagnostic criteria for eating disorders, but that nonetheless are associated with distress and impaired weight management. It has been estimated that up to 50% of surgery patients are thought to suffer from BED preoperatively, while up to 55% of surgery patients have been characterized as having features of night eating syndrome (NES). (Allison, 2006)
  • Development of other unhealthy habits – Such as self-induced vomiting to relieve discomfort after a large meal, which could in turn lead to bulimic tendencies. In addition, “trigger foods” that have not been addressed pre-operatively may lead some to overeat.
    • Negative body image – Though an improvement in body dissatisfaction occurs for most bariatric patients, the excess skin that results from massive weight loss may cause a significant amount of distress. Additionally, many bariatric patients report that, despite massive weight loss, they continue to perceive themselves as being the same size and shape as they were prior to the surgery.
    • Dumping syndrome – Extreme bouts of diarrhea are usually the result of poor food choices (including refined sugars, fried foods, and some fats or dairy), and can have mild-to-severe symptoms that also include sweating, flushing, lightheadedness, desire to lie down, nausea, cramping, and embarrassing flatulence. Loose stools, constipation, and gas are other common bowel-related complaints after surgery.
    • Gallstones – Rapid, significant weight loss can develop gallstones. Although many people with gallstones suffer no adverse effects and may not even know they have them, some surgeons opt to remove the gallbladder during surgery to eliminate this possible complication.
    • Unexpected life challenges after surgery – Despite thorough preoperative counseling, even the most determined surgery candidates may need to confront unexpected life challenges. A common barrier to success is thinking that surgery works like magic, when nothing could be further from the truth. Postoperatively, patients often realize surgery does not do all the work. They must understand that healthful diet and lifestyle changes must be adhered to despite all of life’s ups and downs that may make doing so more difficult.
    • Personal struggles and challenges – All patients must make their health a priority in the face of personal struggles and challenges. Patients that fall back into their old ways and regain weight are often those who experience something tragic losing sight of the self-care needs. (i.e. become a caregiver to an ailing family member).
    • Financial constraints – Such as having to wait for a paycheck or food stamps in order to buy groceries.
    • Lack of a stable support system – Especially in one’s personal life. Some patients do not even have support from their own spouses. If the individual having surgery does not have adequate support, their likelihood of being successful is much lower.
  • Lack of physical activity preand post-operative – Evidence is mounting that increasing physical activity pre- to post-operatively is associated with greater weight loss, improved body composition, and improved fitness following surgery. Prior to surgery the majority of bariatric surgery patients are highly sedentary and inactive. (King, 2013)
  • Limited post-surgical weight loss or significant weight regain – Both of which can be emotionally detrimental leading to a myriad of adverse effects including depression, substance, and/or disordered eating.
  • Pre-surgical nutrition deficits – Overweight and obese individuals are at risk for deficiencies in several micronutrients, including iron, and vitamins D, B12, E and C.
  • Post-surgical nutrition deficits – Common nutrient deficiencies include vitamin B12, folate, zinc, iron, copper, calcium, and vitamin D.  
  • Hair Loss – Due to low intake of protein and zinc.
  • Difficulty adhering to and maintaining a healthy diet and lifestyle – Behavior change is key further emphasizing the need for ongoing pre- and post-behavioral therapy and nutritional counseling.


    • Relationship struggles – For many patients, weight loss surgery can result in an improvement in their romantic relationships. However, for some patients, post-surgery struggles with jealousy, trust, or intimacy may develop, while some patients report other difficult social interactions related to their weight loss, such as frustration with family, friends, or coworkers who excessively ask about the patient’s weight loss. Drastic physical transformations can lead to a variety of emotional challenges. Teaching patients assertiveness skills and boundary setting can help them better manage these interactions. Cognitive techniques can also assist patients in viewing others’ comments in a different and perhaps more positive way and understand weight bias and stigmas. (Sawer, 2008)
  • Struggles with post-surgical changes to physical appearance – Though the post-surgery weight loss may be gradual enough that your body and skin can adjust slowly, many people are left with such an excess that it requires cosmetic surgery to fix which if not covered by insurance, can by quite costly.


  • Depression & worsening psychiatric symptoms following surgery – There’s a link between obesity and depression, and while the majority of patients who undergo weight loss surgery do experience an overall improvement in their well-being after surgery, feelings of depression can worsen for some. (Iveza, 2015) Furthermore, people who undergo bariatric surgery have a higher than normal risk of suicide, according to a 2007 report in the Archives of Surgery. (Adams, 2007)
  • Substance abuse – The vast majority of weight loss surgery patients do not abuse substances following surgery, however, there is some evidence that susceptibility to substance abuse may increase following bariatric surgery. Recent research has found increased prevalence between substance abuse and post-surgical risks and behaviors (Saules, 2013). Openly discussing substance use patterns and risks of substance abuse after surgery may facilitate earlier detection and treatment for substance use. One theory is that patients have higher peak alcohol levels, and reach those levels more quickly, after bariatric surgery, although other theories do exist to explain the connection. (Consan, 2013)

Weight loss surgery ist typically not recommended for those who continue to struggle with disordered eating whether it ranges from binging to restricting, despite being in therapy for more than a year. NOR is it recommended for those that have presented with binge eating behaviors and emotional eating patterns.

It is important that clients have a healthy support system that will provide the emotional support around food choices and diet regimen essential for post-surgical success and sustained weight management.

Addressing needs for behavioral and nutrition education is key in the weight loss surgery setting. However, to make optimal use of preoperative counseling, therapists and dietitians should ask questions that help identify other, perhaps less obvious, barriers to success following surgery. Getting patients to realize that weight-loss surgery is not the easy way out is essential in successful weight-loss. Therefore, the need for behavioral therapy and nutritional counseling pre- and postoperative is imperative.


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Saules KK, Reslan S. Post-bariatric surgery substance use disorders: prevalence, predictors, management, and prevention. J Clin Outcomes Manage. 2013;20:470–480.