Predictors of a Healthy Eating Disorder Examination-Questionnaire (EDE-Q) Score 1 Year After Bariatric Surgery

  • Daniel Gero
  • Stefanos Tzafos
  • Gabriella Milos
  • Philipp A. Gerber
  • Diana Vetter
  • Marco BueterEmail author
Original Contributions



Bariatric surgery (BS) has been shown to ameliorate health-related quality of life and eating disorder symptoms. However, the correlation of these changes with weight loss is not uniform, suggesting that additional factors have an impact on postoperative outcomes.


To assess the impact of BS on eating disorder symptoms at 1 year postoperatively and to generate predictive models for the achievement of optimal eating behavior.


Retrospective cohort study on a prospectively collected database of all consecutive patients who underwent primary BS in our academic center between January 2015 and March 2017. Eating Disorder Examination-Questionnaire (EDE-Q) was used to measure eating psychopathology. Logistic regression was used to estimate the odds ratio of achieving “healthy” EDE-Q at 1 year. Missing data was handled by multiple imputations for the regression model.


Two-hundred thirty-four patients were included. A complete-case analysis in 135 cases showed a “healthy” EDE-Q in 27.4% at baseline and in 83.7% at 1 year (difference = 56.3%, P = 0.018). Only the baseline EDE-Q “healthy” status influenced significantly the odds of achieving “healthy” EDE-Q at 1 year (OR 6.7, 95% CI 1.18–38.14, P = 0.04).


BS seems to promote successful treatment of self-reported eating disorder symptoms during the first postoperative year. The achievement of optimal results is independent of age, sex, weight loss, obesity-related comorbidity status, surgical technique, or 30-day surgical complications. Future studies, using validated questionnaires specifically designed to investigate eating behavior after BS and/or direct measurements of the eating behavior are needed to clarify the underlying neuropsychologic mechanisms that drive the observed postoperative changes.


Eating Disorder Examination Questionnaire Eating behavior Bariatric surgery Excess weight loss Predictors of outcome Roux-en-Y gastric bypass 



We are grateful to Samuel Aemisegger, clinical male nurse, to Mira Giama, and to the resident doctors of the Department of Surgery, University Hospital Zurich, for their valuable help in the data collection process. We also acknowledge Lukas Frick, MD, for his input in data analysis with the R software and Amy Taheri, PhD candidate, for her help in proofreading.


The study was entirely funded by the assistant-professorship research grant awarded by the University of Zurich to Prof. Dr. med. Marco Bueter, PhD.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval and Informed Consent

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and cantonal research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Cantonal Ethics Committee of Zurich approved the study (nr: 2016-00022). For this type of study, formal consent is not required, as it was a retrospective study.

Supplementary material

11695_2018_3596_MOESM1_ESM.pdf (532 kb)
ESM 1 (PDF 532 kb)


  1. 1.
    Bordignon S, Aparicio MJG, Bertoletti J, et al. Personality characteristics and bariatric surgery outcomes: a systematic review. Trends Psychiatry Psychother. 2017;39:124–34.CrossRefGoogle Scholar
  2. 2.
    Livhits M, Mercado C, Yermilov I, et al. Preoperative predictors of weight loss following bariatric surgery: systematic review. Obes Surg. 2012;22:70–89.CrossRefGoogle Scholar
  3. 3.
    Krimpuri RD, Yokley JM, Seeholzer EL, et al. Qualifying for bariatric surgery: is preoperative weight loss a reliable predictor of postoperative weight loss? Surg Obes Relat Dis. 2018;14:60–4.CrossRefGoogle Scholar
  4. 4.
    Holsen LM, Davidson P, Cerit H, et al. Neural predictors of 12-month weight loss outcomes following bariatric surgery. Int J Obes. 42(4):785–793.
  5. 5.
    Herpertz S, Kielmann R, Wolf AM, et al. Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review. Obes Res. 2004;12:1554–69.CrossRefGoogle Scholar
  6. 6.
    Livingston EH. Pitfalls in using BMI as a selection criterion for bariatric surgery. Curr Opin Endocrinol Diabetes Obes. 2012;19:347–51.CrossRefGoogle Scholar
  7. 7.
    Cordero P, Li J, Oben JA. Bariatric surgery as a treatment for metabolic syndrome. J R Coll Physicians Edinb. 2017;47:364–8.CrossRefGoogle Scholar
  8. 8.
    Wood KV, Ogden J. Explaining the role of binge eating behaviour in weight loss post bariatric surgery. Appetite. 2012;59:177–80.CrossRefGoogle Scholar
  9. 9.
    Devlin MJ, King WC, Kalarchian MA, et al. Eating pathology and experience and weight loss in a prospective study of bariatric surgery patients: 3-year follow-up. Int J Eat Disord. 2016;49:1058–67.CrossRefGoogle Scholar
  10. 10.
    Gero D, Steinert RE, le Roux CW, et al. Do food preferences change after bariatric surgery? Curr Atheroscler Rep. 2017;19:38.CrossRefGoogle Scholar
  11. 11.
    Rieber N, Giel KE, Meile T, et al. Psychological dimensions after laparoscopic sleeve gastrectomy: reduced mental burden, improved eating behavior, and ongoing need for cognitive eating control. Surg Obes Relat Dis. 2013;9:569–73.CrossRefGoogle Scholar
  12. 12.
    Bartsch M, Langenberg S, Gruner-Labitzke K, et al. Physical activity, decision-making abilities, and eating disturbances in pre- and postbariatric surgery patients. Obes Surg. 2016;26:2913–22.CrossRefGoogle Scholar
  13. 13.
    Dawes AJ, Maggard-Gibbons M, Maher AR, et al. Mental health conditions among patients seeking and undergoing bariatric surgery: a meta-analysis. JAMA. 2016;315:150–63.CrossRefGoogle Scholar
  14. 14.
    Alfonsson S, Weineland-Strandskov S, Sundbom M. Self-reported hedonism predicts 12-month weight loss after Roux-en-Y gastric bypass. Obes Surg. 2017;27:2073–8.CrossRefGoogle Scholar
  15. 15.
    Swiss Study Group for Morbid Obesity and Metabolic Disorders. Directives médicale pour le traitement chirurgical de l’obésité. 1 January 2018.
  16. 16.
    von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg. 2014;12:1495–9.CrossRefGoogle Scholar
  17. 17.
    Hatoum IJ, Kaplan LM. Advantages of percent weight loss as a method of reporting weight loss after Roux-en-Y gastric bypass. Obesity (Silver Spring). 2013;21:1519–25.CrossRefGoogle Scholar
  18. 18.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.CrossRefGoogle Scholar
  19. 19.
    Anja Hilbert BT-C. Eating disorder Examination Questionnaire - Deutschprähige übersetzung. Münster: Verlag für Psychotherapie, PAG Institut für Psychologie AG; 2006.Google Scholar
  20. 20.
    Berg KC, Peterson CB, Frazier P, et al. Psychometric evaluation of the eating disorder examination and eating disorder examination-questionnaire: a systematic review of the literature. Int J Eat Disord. 2012;45:428–38.CrossRefGoogle Scholar
  21. 21.
    Morseth MS, Hanvold SE, Ro O, et al. Self-reported eating disorder symptoms before and after gastric bypass and duodenal switch for super obesity--a 5-year follow-up study. Obes Surg. 2016;26:588–94.CrossRefGoogle Scholar
  22. 22.
    Mond JM, Hay PJ, Rodgers B, et al. Eating Disorder Examination Questionnaire (EDE-Q): norms for young adult women. Behav Res Ther. 2006;44:53–62.CrossRefGoogle Scholar
  23. 23.
    Sullivan GM, Feinn R. Using effect size-or why the P value is not enough. J Grad Med Educ. 2012;4:279–82.CrossRefGoogle Scholar
  24. 24.
    Sarwer DB, Lavery M, Spitzer JC. A review of the relationships between extreme obesity, quality of life, and sexual function. Obes Surg. 2012;22:668–76.CrossRefGoogle Scholar
  25. 25.
    Julia C, Ciangura C, Capuron L, et al. Quality of life after Roux-en-Y gastric bypass and changes in body mass index and obesity-related comorbidities. Diabetes Metab. 2013;39:148–54.CrossRefGoogle Scholar
  26. 26.
    Peterhansel C, Nagl M, Wagner B, et al. Predictors of changes in health-related quality of life 6 and 12 months after a bariatric procedure. Obes Surg. 2017;27:2120–8.CrossRefGoogle Scholar
  27. 27.
    Jakobsen JC, Gluud C, Wetterslev J, et al. When and how should multiple imputation be used for handling missing data in randomised clinical trials - a practical guide with flowcharts. BMC Med Res Methodol. 2017;17:162.CrossRefGoogle Scholar
  28. 28.
    Young-Saver DF, Gornbein J, Starkman S, et al. Handling of missing outcome data in acute stroke trials: advantages of multiple imputation using baseline and postbaseline variables. J Stroke Cerebrovasc Dis. 2018;27(12):3662–3669Google Scholar
  29. 29.
    Rubin DB. Multiple imputation for nonresponse in surveys. New York: Wiley; 1987.CrossRefGoogle Scholar
  30. 30.
    Spitznagel MB, Garcia S, Miller LA, et al. Cognitive function predicts weight loss after bariatric surgery. Surg Obes Relat Dis. 2013;9:453–9.CrossRefGoogle Scholar
  31. 31.
    Conceicao EM, Mitchell JE, Pinto-Bastos A, et al. Stability of problematic eating behaviors and weight loss trajectories after bariatric surgery: a longitudinal observational study. Surg Obes Relat Dis. 2017;13:1063–70.CrossRefGoogle Scholar
  32. 32.
    Nasirzadeh Y, Kantarovich K, Wnuk S, et al. Binge eating, loss of control over eating, emotional eating, and night eating after bariatric surgery: results from the Toronto Bari-PSYCH Cohort Study. Obes Surg. 2018;28:2032–9.CrossRefGoogle Scholar
  33. 33.
    Versteegden DPA, Van Himbeeck MJJ, Nienhuijs SW. Improvement in quality of life after bariatric surgery: sleeve versus bypass. Surg Obes Relat Dis. 2018;14:170–4.CrossRefGoogle Scholar
  34. 34.
    Reynolds CL, Byrne SM, Hamdorf JM. Treatment success: investigating clinically significant change in quality of life following bariatric surgery. Obes Surg. 2017;27:1842–8.CrossRefGoogle Scholar
  35. 35.
    Jirapinyo P, Abu Dayyeh BK, Thompson CC. Weight regain after Roux-en-Y gastric bypass has a large negative impact on the bariatric quality of life index. BMJ Open Gastroenterol. 2017;4:e000153.CrossRefGoogle Scholar
  36. 36.
    Chan CW, Leung SF. Validation of the eating disorder examination questionnaire: an online version. J Hum Nutr Diet. 2015;28:659–65.CrossRefGoogle Scholar
  37. 37.
    Conradt M, Dierk JM, Schlumberger P, et al. A consultation with genetic information about obesity decreases self-blame about eating and leads to realistic weight loss goals in obese individuals. J Psychosom Res. 2009;66:287–95.CrossRefGoogle Scholar
  38. 38.
    Bedri A, Li R, Haynes M, et al. EarBit: using wearable sensors to detect eating episodes in unconstrained environments. Proc ACM Interact Mob Wearable Ubiquitous Technol. 2017;1:1–20.CrossRefGoogle Scholar
  39. 39.
    Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord. 1994;16:363–70.PubMedGoogle Scholar
  40. 40.
    de Zwaan M, Hilbert A, Swan-Kremeier L, et al. Comprehensive interview assessment of eating behavior 18-35 months after gastric bypass surgery for morbid obesity. Surg Obes Relat Dis. 2010;6:79–85.CrossRefGoogle Scholar
  41. 41.
    Conceicao E, Mitchell JE, Vaz AR, et al. The presence of maladaptive eating behaviors after bariatric surgery in a cross sectional study: importance of picking or nibbling on weight regain. Eat Behav. 2014;15:558–62.CrossRefGoogle Scholar
  42. 42.
    Sarwer DB, Dilks RJ, West-Smith L. Dietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success. Surg Obes Relat Dis. 2011;7:644–51.CrossRefGoogle Scholar
  43. 43.
    Vangoitsenhoven R, Frederiks P, Gijbels B, et al. Long-term effects of gastric bypass surgery on psychosocial well-being and eating behavior: not all that glitters is gold. Acta Clin Belg. 2016;71:395–402.CrossRefGoogle Scholar
  44. 44.
    Bell ML, Kenward MG, Fairclough DL, et al. Differential dropout and bias in randomised controlled trials: when it matters and when it may not. BMJ. 2013;346:e8668.CrossRefGoogle Scholar
  45. 45.
    Makaronidis JM, Batterham RL. Obesity, body weight regulation and the brain: insights from fMRI. Br J Radiol. 2018;91(1089):20170910Google Scholar
  46. 46.
    Grilo CM, Henderson KE, Bell RL, et al. Eating disorder examination-questionnaire factor structure and construct validity in bariatric surgery candidates. Obes Surg. 2013;23:657–62.CrossRefGoogle Scholar
  47. 47.
    Nielsen MS, Christensen BJ, Ritz C, et al. Roux-En-Y gastric bypass and sleeve gastrectomy does not affect food preferences when assessed by an ad libitum buffet meal. Obes Surg. 2017;27:2599–605.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Daniel Gero
    • 1
  • Stefanos Tzafos
    • 1
  • Gabriella Milos
    • 2
  • Philipp A. Gerber
    • 3
  • Diana Vetter
    • 1
  • Marco Bueter
    • 1
    Email author
  1. 1.Department of Surgery and TransplantationUniversity Hospital ZurichZürichSwitzerland
  2. 2.Department of Psychiatry and PsychotherapyUniversity Hospital of ZurichZürichSwitzerland
  3. 3.Division of Endocrinology, Diabetes and Clinical NutritionUniversity Hospital ZurichZürichSwitzerland

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