OBES SURG (2012) 22:1308–1314
DOI 10.1007/s11695-012-0668-2
CLINICAL RESEARCH
“I Didn’t See This Coming.”: Why Are Postbariatric Patients
in Substance Abuse Treatment? Patients’ Perceptions
of Etiology and Future Recommendations
Valentina Ivezaj & Karen K. Saules &
Ashley A. Wiedemann
Published online: 3 June 2012
# Springer Science+Business Media, LLC 2012
Abstract
Background Recent evidence suggests that bariatric patients
may be overrepresented in inpatient substance abuse treatment, but the reasons for this are unclear. Patients’ perceptions of this problem may be of heuristic value. Using a
qualitative approach, the present study evaluated bariatric
patients’ impressions of how their postsurgical substance
use disorders emerged and their future recommendations
for those working with bariatric patients.
Methods Semi-structured interviews were conducted
with 24 bariatric patients in an inpatient substance abuse
treatment program. Seven prominent themes emerged,
four referring to etiology of substance use (unresolved
psychological problems, addiction transfer/substitution,
faster onset or stronger effects from substances, and
increased availability of pain medications) and three
pertaining to future recommendations (counseling preand/or postsurgery, increased knowledge of the associated risks of substance use postsurgery, and greater
“honesty”). Blind coders rated the presence or absence
of each theme in each interview.
Results Of the four etiology themes, 75 % of patients acknowledged unresolved psychological problems, 83.33 %
identified addiction transfer/substitution, 58.33 % noticed
The preparation of this manuscript was supported by the Eastern
Michigan University Department of Psychology and the EMU
Graduate School.
V. Ivezaj : K. K. Saules : A. A. Wiedemann
Psychology Department, Eastern Michigan University
Ypsilanti, MI 48197, USA
V. Ivezaj (*)
Eastern Michigan University Psychology Clinic
611 W. Cross Street
Ypsilanti, MI 48197, USA
e-mail: valentina.ivezaj@gmail.com
faster onset or stronger effects from substances, and
45.83 % identified increased availability of pain medications. For future recommendations, 41.67 % suggested
counseling pre- and/or postsurgery, 70.83 % suggested increased education about the associated risks of substance
use postsurgery, and 41.67 % identified a need for greater
“honesty.”
Conclusions Patient perceptions suggest that several common themes may be related to risk for the development of
postsurgical substance use disorders.
Keywords Bariatric surgery . Weight loss . Alcohol
dependence . Alcohol abuse . Opiate dependence . Substance
abuse . Addiction . Chemical dependence . Obesity
Introduction
Bariatric surgery is a cost-effective [1] and safe [2] treatment
for morbid obesity. Bariatric surgery patients typically lose
60 to 80 % of their excess weight [3] during the first 2 years
following surgery. In addition, bariatric surgery has been
associated with improved quality of life [4], increased life
expectancy [5], and reduced mortality rates [6]. Despite the
positive outcomes that are commonly associated with bariatric surgery, burgeoning research suggests that a subgroup
of bariatric patients may be at risk for developing substance
use problems postbariatric surgery [7]. In fact, recent evidence suggests that postbariatric surgery patients may be
overrepresented in substance abuse treatment, perhaps constituting as high as 6 % of inpatient treatment admissions
[7]. When bariatric patients were compared to nonbariatric
patients in that substance abuse treatment facility, bariatric
patients were more likely to be women and were more likely
OBES SURG (2012) 22:1308–1314
to consume greater maximum number of drinks per drinking
day.
Although the literature is mixed on the magnitude of this
problem [7–11], these findings taken together suggest that
there is a subgroup of individuals struggling with substance
misuse following bariatric surgery. It has been speculated
that physiological factors may confer risk for alcohol misuse
following gastric bypass surgery, particularly given changes
in alcohol absorption following surgery [12–14].
Specifically, when comparing gastric bypass surgery patients
to nonsurgical patients, gastric bypass patients experience
increased peak blood alcohol levels [12, 13] and take longer
to return to baseline [12]. This finding was replicated even
when comparing presurgical alcohol absorption to postsurgical alcohol absorption, using each patient as his/her own
control [14]. The authors stated, “Patients feel different
effects of alcohol intoxication postoperative, and this can
lead to overindulgence to achieve the same symptoms of
intoxication that they experienced before surgery” (p. 212)
[14]. Given these concerning findings, the goal of the present
study was to examine whether bariatric patients perceived
their substance abuse as developing prior to or after bariatric
surgery. A qualitative approach was used to evaluate the
perceptions of postbariatric patients struggling with severe
substance use disorders, of the magnitude warranting inpatient treatment. Utilizing a qualitative approach was ideal to
generate hypotheses about this poorly understood phenomenon from a unique population.
Method
Between July 2009 and February 2010, 24 postgastric bypass patients were recruited by medical staff upon admission
to a voluntary, comprehensive substance abuse treatment
program. Gastric bypass history is assessed as a routine part
of the admission history and physical. When bypass patients
were agreeable to research participation, hospital staff
scheduled a meeting time, and participants completed a
semi-structured interview (developed by the investigators)
with a member of the research team. The interview covered
presurgical assessment and education, postsurgical compliance, patients’ perceptions about the development of their
substance use disorder, and patients’ recommendations
about what could be done differently to help future bariatric
patients avoid problems with substance abuse.
Specifically, to assess substance abuse etiology, the
following questions were asked: (1) Were you aware of
or concerned that you might have a problem with drugs
or alcohol before you had bariatric surgery? If yes,
please tell me a bit about that. (2) Before your surgery,
had other people expressed concerns about your use of
alcohol or drugs? If yes, please tell me more about that.
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(3) Had you ever had alcohol or drug treatment before
your surgery? If yes, please tell me more about your
experiences with treatment. (4) Do you feel like your
problems with alcohol/drugs began after you had bariatric
surgery? If yes, please describe how you began or increased your use of alcohol/drugs, and how you became
concerned that it might be a problem for you. (5) What
do you think the relationship is between your eating
behavior and alcohol/drug use? Are they connected in
any way? Or, do you think they are unrelated types of
problems? Please tell me about how you formed that
impression. Of note, questions 1–4 were used to define
“problematic substance use” pre- or postoperatively.
To assess future recommendations, participants were
asked (1) Are there any other thoughts, observations, or
impressions you can share that might help us better understand why some people enter substance abuse treatment
after they have had bariatric surgery? (2) Do you have any
ideas about what might help postbariatric surgery patients
avoid problems with alcohol or other drugs?
Although the interview was structured to include the
questions delineated above, comments about etiology and
recommendations were also offered spontaneously at other
junctures. As such, the full transcript of each interview was
considered data for purposes of evaluating patients’ perceptions and recommendations. The qualitative methodology
was based on the Grounded Theory approach developed by
Glaser and Strauss [15]. Specifically, two of the authors
highlighted material from the first 13 interviews focusing
on etiology of substance use development and future recommendations. After preliminary coding of these interviews, saturation of themes occurred. Four themes
emerged regarding substance use etiology, and three themes
emerged regarding future recommendations. The four
themes regarding substance use etiology were unresolved
psychological problems, addiction transfer/substitution, faster
onset or stronger effects from substances, and increased availability of pain medications. The three themes that emerged
regarding future recommendations were counseling pre- and/
or postsurgery, increased knowledge of the associated risks of
substance use postsurgery, and honesty on behalf of the
patients and their bariatric treatment team.
Thereafter, a coding scheme was developed to operationally define each theme so that the full set of interviews could be rated by two blind coders. For example,
the definition of addiction transfer was “Any mention of
replacing one behavior or substance with another. For
instance, replacing food with alcohol or exercise.”
Further operational definitions for each theme are presented in Table 2. The new, blind coders then reviewed
the interviews identifying the presence or absence of
each of these seven themes. Discrepancies were resolved
by consensus at research team meetings.
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OBES SURG (2012) 22:1308–1314
Inter-rater agreement for the two blind coders was 77 %
for the entire set of themes. Inter-rater agreement for each
theme was as follows: 79.17 % for unresolved psychological problems, 87.5 % for addiction transfer, 83.33 % for
increased effects of substances, 70.83 % for increased availability of pain medications, 83.33 % for counseling pre- and
postsurgery, 75 % for increased knowledge of the associated
risks of substance use postsurgery, and 62.5 % for honesty.
Finally, inter-rater agreement for volunteering regret and
determining whether the individual did or did not regret
surgery was 91.67 and 79.17 % respectively.
Results
The sample consisted primarily of Caucasian women with a
mean age (±SD) of 45.2 (±10.0), mean BMI (±SD) of 32.4
(±6.8), mean number of years since surgery (±SD) of 5.5
(±3.1)years, mean postsurgical weight loss (±SD) of 149.52
(±56.00)lbs, and mean percent excess weight loss (±SD) of
76.65 % (±SD 24.51 %). The 24 participants reported having had bypass surgery across a range of 21 different hospitals, 20 of which were in Michigan, and one of which was
across the country. In terms of substance abuse history,
45.8 % were patients who reported some type of problematic substance use before surgery, whereas 54.2 % reported
that they had not engaged in illicit drug use or experienced
any alcohol problems prior to surgery. Only four patients
reported previous substance abuse treatment. Two subjects
reported seeking treatment as “teens,” another participant
admitted to seeking treatment at age 21, and the fourth
participant reported seeking treatment as an adult in 1995.
With respect to substances of abuse upon treatment admission, 54.2 % were smoking cigarettes, 83.3 % were using
alcohol, 12.5 % were using marijuana, 8.3 % were using
cocaine, 66.7 % were using prescription opiates, 58.3 %
were using benzodiazepines, and none were using amphetamines, heroin, or PCP. Additional demographic characteristics are listed in Table 1.
Table 1 Bariatric patient characteristics
Demographic variables
Gender (% female)
Race/ethnicity (% White or Caucasian)
Years of education
Relationship status (% married)
Employment status (% working full time)
Economic status (% earning 50,000–74,000)
Values are expressed as M (SD)
Participants (n024)
75
91.7
15.2 (2.5)
45.8
41.7
40.9
In terms of substance use etiology themes, 75 % of the
sample acknowledged unresolved psychological problems,
83.33 % identified addiction transfer/substitution, 58.33 %
identified faster onset or stronger effects from substances,
and 45.83 % identified increased availability of pain medications. It is important to note, however, that of those taking
pain medications, 69.23 % discussed the increased availability of pain medications theme. With respect to future
recommendations themes, 41.67 % identified counseling
pre- and/or postsurgery, 70.83 % identified increased knowledge of the associated risks of substance use postsurgery,
and 41.67 % identified honesty. Finally, 41.67 % volunteered a discussion regarding bariatric surgery regret. Of
those, 70 % indicated that they did not regret having surgery, 20 % reported that they did regret having surgery,
while 10 % were ambivalent. Representative quotes and
operational definitions of each theme for etiology and future
recommendations are presented in Table 2 and Table 3,
respectively.
Discussion
For the present study, postbariatric patients who were receiving treatment in an inpatient rehabilitation program for
substance use disorders were interviewed to gain a better
understanding of the development of their substance use
disorder and future recommendations. Interestingly, participants in the present study had successful bariatric outcomes, at least with respect to their percentage of excess
weight loss [3]. This is somewhat counterintuitive, given the
potentially disruptive impact of severe substance use disorders on weight control efforts. Based on the patients’ perceptions, four themes emerged regarding the etiology of
substance use disorders, namely unresolved psychological
problems, addiction transfer, faster onset or stronger effects
from substances, and increased availability of pain medications. Three themes emerged regarding future recommendations, namely counseling pre- and/or postsurgery, increased
knowledge of associated risks of substance use postsurgery,
and honesty. Finally, a theme of regret also appeared which
will be discussed.
In terms of the etiological themes, 75 % of the sample
identified unresolved psychological problems as contributing to their substance development. This finding complements the extant literature on psychological issues among
bariatric candidates including lifetime and current rates of
major depressive disorders, anxiety disorders, eating disorders, and binge eating [16]. Bariatric surgery candidates are
more likely to have Axis I disorders (anxiety, bulimia, and
tobacco dependence) and Axis II disorders relative to community samples. In addition, bariatric surgery candidates are
significantly more likely to have comorbid psychological
OBES SURG (2012) 22:1308–1314
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Table 2 Themes regarding etiology of substance abuse development
Unresolved psychological problems (75 %)
Operational definition: Any mention of “deep-rooted issues” or underlying issues (e.g., depression, anxiety, identity issues) related to the
development of their problems.
“After losing weight, I was still left with issues. It was a roller-coaster of emotions…I was a fat person in a skinny person’s body.”
Addiction substitution (83.33 %)
Operational definition: Any mention of replacing one behavior or substance with another. For instance, replacing food with alcohol or exercise.
“I gave up love for food, and compensated that with going out and drinking.”
Faster onset or stronger effects from substances (58.33 %)
Operational definition: Any mention of feeling the effects of alcohol or pain medications more quickly and/or more intensely.
“A slam of wine felt just like a shot of heroin.”
Increased availability of pain medications
(45.83 % of full sample; however, 69.23 % of those with self-reported pain medication use endorsed this theme)
Operational definition: Any mention of receiving pain medications after surgery. It does not have to be bariatric surgery-related. For instance, it
could be that a participant had an unrelated surgery or accident necessitating pain medications.
“Pain pills seemed safe and innocent…I began to act the part of a patient who was in pain in order to get more pills.”
disorders [17]. Morbid obesity is also related to even poorer
health-related quality of life [18, 19], greater depression
[20], and increased morbidity [19] relative to lower BMI
classifications of obesity. Notably, there is research to support body image problems among the bariatric population,
and weight loss does not necessarily correspond with more
positive body image [21, 22]. Research has shown that
gender (women), race (Caucasian), age (younger), and high
BMI are associated with unrealistic weight loss goals postsurgery [23], which may lead to increased dissatisfaction
postsurgery. One participant stated that:
“Psychologically, I spoke to many people in my town
who also had the surgery and they all said the same
thing—you still don’t see yourself as thin. I still look in
the mirror and see fat.”
Thus, some patients voiced concerns about numerous psychological struggles including body image dissatisfaction, yet
the magnitude, severity, and specific diagnoses of comorbid
conditions of this sample are unknown. Future research
should continue to investigate whether presurgical psychological distress relates to the development of substance abuse
postsurgically. Given that unresolved psychological problems
was a common theme for a majority of the patients, it is not
surprising then that nearly half of the sample (roughly 42 %)
recommended that bariatric patients should participate in
counseling pre- and/or postsurgery. It is noteworthy, however,
that postbariatric patients tend to report improved healthrelated quality of life [24] and reduced depression [25].
Based on that literature, one would not expect common endorsement of some of the themes mentioned among our
sample (e.g., “unresolved psychological problems,” “need
for more counseling/education”) by bariatric patients, in general. Therefore, although we lack a direct comparison group,
the prominence of these themes appears rather high among
our postbariatric substance abuse treatment sample, relative to
what the literature would suggest more generally. In support of
this, many of the study participants advocated for support
Table 3 Themes regarding future recommendations
Counseling pre–postsurgery (41.67 %)
Operational definition: Any mention of needing counseling pre- or postsurgery in the form of therapy, support groups, counseling, etc.
“People need to have therapy while they are losing weight because it is such a big transition. Just getting on a scale is stressful, whether you lose
weight or not.”
Increasing knowledge regarding associated risks of substance abuse postsurgery (70.83 %)
Operational definition: Any mention that staff working with bariatric patients should have presented them with information about substance use
problems postsurgery, or more information about why to completely eliminate alcohol postsurgery. Some participants say “I was told not to drink
alcohol, but was not told why…People need to know why.”
“There should be required readings, or readings on education related to addiction.”
“Honesty” (41.67 %)
Operational definition: Any mention of needing to be “honest” or “truthful.”
“Get honest without fear of not getting surgery.”
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groups and counseling throughout the bariatric process.
Below are illustrative quotes.
“Early intervention is key.”
“Nobody told me about an after plan. Or even to talk to
a psychologist about the changes—physical changes.”
Indeed, additional support and resources, particularly for
those at risk for developing substance use disorders postbariatric surgery, are warranted. Given that standardized
guidelines for bariatric surgery clearance [26] and procedures for follow-up care vary widely, future research should
aim to identify at-risk individuals and develop appropriate
after-care plans associated with their recovery and progress
throughout the bariatric process.
The second etiological theme that emerged was addiction
transfer/substitution, with approximately 83 % of the sample
discussing this issue. In the present study, addiction transfer
refers to replacing intake of certain foods or overeating behavior, more generally, with intake of substances more traditionally regarded as being “addictive.” Kalarchian et al. [20]
stated that “it is intriguing to speculate that substance and
weight problems may also have a shared diathesis, and that
substance abuse remits when eating behavior predominates”
(p. 331). If this is the case, then it would be expected that the
reverse may be true, namely that when eating behavior
“remits” or reduces following bariatric surgery, that substance
abuse predominates. Consistent with this theory, Macias and
Leal [27] found that those who engaged in binge eating
behavior prebariatric surgery had higher rates of alcohol abuse
postsurgery. Thus, it seems that converging lines of research
may provide evidence of addiction transfer; however, future
research is needed to better understand the validity of this
theory. This theme was also endorsed by the majority of the
patients in this sample. One participant reported:
“I think I drink more now because I can’t eat. You
know, [I'm an] emotional eater, [I] can’t eat so I
drink.”
It may be the case that certain bariatric candidates are at risk
for “transferring addictions.” However, whether or not “addiction transfer” is occurring remains an empirical question.
Addiction transfer is, however, how the patients in the present
study described their impression of how the problem developed. Therefore, identifying adaptive coping skills for managing this potential problem, both in preparation for surgery
and after surgery, may be an area that psychologists can
contribute by helping to improve postbariatric outcomes.
The third etiological theme focused on increased effects of
substances postsurgery. Fifty-eight percent of the sample mentioned this as a contributor to the development of their substance use disorder. Increased sensitivity to alcohol after
bariatric surgery has been supported in the literature [28].
Researchers have documented that alcohol absorbed differently
OBES SURG (2012) 22:1308–1314
among gastric bypass patients [12, 14]. Specifically, gastric
bypass surgery patients exhibited increased peak blood alcohol
levels relative to nonsurgical patients [12, 13], and gastric
bypass patients took longer for blood alcohol levels to return
to baseline [12]. Furthermore, Woodard et al. [14] matched
preoperative and postoperative gastric bypass patients, highlighting that patients felt more intense effects of alcohol intoxication postsurgically. In fact, they reported that when
postgastric bypass patients consume even one glass of wine,
they may be over the legal limit to drive. Additionally, these
authors reported that bariatric patients’ bodies respond differently to alcohol after surgery. This was evidenced in the present
study as well, which is illustrated by the following quotes.
“After surgery it [alcohol] was like a high.”
“It [alcohol] affects you differently. The highs are
different, a better high, and no hangovers.”
“I respond very differently to pills now. It used to take
1/2 an hour to feel the effects. Now I feel the effects
within 10–15 minutes. The effects are more intense but
they don’t last as long, so you have to take more to get
that euphoria.”
Taken together, it appears that both quantitative and
qualitative approaches to examining alcohol effects postbariatric surgery have yielded similar results indicating that
alcohol, and perhaps other substances, are absorbed differently postsurgery, particularly among gastric bypass
patients. Additionally, a recent study [29] found that alcohol
absorption was also changed in a group of 12 morbidly
obese patients who underwent laparoscopic sleeve gastrectomy. Future research should investigate if certain bariatric
procedures confer greater risk for developing a substance
use disorder based on absorption alterations. In addition,
future research should examine whether other substances
are absorbed differently following bariatric surgery, especially pain medication and benzodiazepines, both of which
were used by a large proportion of the study sample.
Given these findings, it is not surprising that over two
thirds of the sample recommended that there should be increased knowledge regarding the associated risks of substance
abuse postsurgery. Patients reported that there was not enough
education, if any, on the risks of substance use following
bariatric surgery. Below are two representative quotes.
“They didn’t give me a reason not to drink. Maybe
they didn’t know.”
“I don’t know if there is an exact link. Doctors should
mention the possible link. If I was told there was a
possible connection, I would have watched my drinking. They never said how bad it was.”
OBES SURG (2012) 22:1308–1314
Consistent with these findings, almost half of the participants reported a theme of honesty. For instance, one patient
said: “Get honest without fear of not getting surgery.”
Despite the emergence of an “honesty” theme among this
sample, only one participant admitted to lying about substance
(pain medication) use, allegedly upon the advice of her psychologist, who reportedly told her that she should not admit to
her substance use, or surgery would not be authorized. No one
else reported lying about substance use during presurgical
screening because they either were not using or it was in their
distant past. Therefore, it is essential that continued monitoring and education are provided for postbariatric patients.
Although our understanding of postsurgical psychological outcomes is in its infancy, it appears that patients are
requesting information about the current literature on substance use and bariatric surgery, which should be implemented in a standardized method.
The final theme regarding etiology was availability of pain
medications, with about 46 % of the sample identifying this
theme as a source of their substance use disorder. Of those
who self-reported pain medication use, however, about 69 %
identified this theme. Bariatric surgery patients may be at an
elevated risk of needing pain medications due to postsurgical
complications necessitating further surgery (e.g., hernia
repairs, strictures, gall bladder, nicked nerves, and cosmetic
surgery), which were similar to the complications reported by
some of the patients in the present study. Due to the altered
substance absorption previously mentioned and increased
need for pain medication following surgery, the medical community should be aware and cautious of distributing pain
medications without proper education and follow-up care for
their bariatric patients. Future research should investigate the
impact of behavioral interventions for pain among bariatric
patients. Evidence suggests that cognitive behavioral interventions may impact mood and coping strategies among those
with acute and/or chronic pain [30]. As such, the role of
psychologists working in integrated primary care settings
may be an important factor in helping ameliorate postsurgical
outcomes, especially related to pain among bariatric patients.
Of note, about 42 % volunteered a discussion regarding
regret of surgery. Of those, 70 % indicated that they did not
regret having surgery, 20 % did regret, while 10 % were
ambivalent about having bariatric surgery. Below is a quote
representing ambivalence about the surgery.
“Two other women here don’t regret the surgery. I do.
I would rather be a fat social drinker than a thinner
alcoholic/addict.” Later she stated “I don’t regret
getting the surgery, I regret becoming an alcoholic.”
Thus, most patients did not regret having bariatric surgery
even when they associated their substance use problems with
the surgery. It is also important to note that a little more than
half of the sample denied a history of substance abuse at any
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point in his/her life prior to having bariatric surgery, while
almost 46 % of the sample described some form of substance
abuse relapse following bariatric surgery. From our perspective, it is less interesting that 45.8 % of the sample relapsed, as
relapse is the norm, rather than the exception with substance
use. What is compelling is that over half of the sample
reported problematic use beginning at some point after bariatric surgery, which is a theme that is emerging from other data
from our lab as well [31, 32]. Future research is needed to
determine unique treatment needs of those who develop substance abuse postbariatric surgery.
Limitations of the Present Study
There are a few limitations to the present qualitative study.
First, interviews were not taped and transcribed; rather each
interviewer took notes with an attempt to capture direct
quotes. Second, participants' hospital stays sometimes overlapped; as such, it is conceivable that they may have interacted in ways that could have influenced their responses to
our interviews. Although this is possible, many of the admission dates did not overlap. Third, the findings may not
generalize to all bariatric patients who engage in substance
use given the severity of substance use disorders in this
sample. Fourth, lack of a control group is a major limitation
of the study; however, it would be difficult to obtain an
appropriate control group. For instance, it would be very
difficult to recruit enough participants who had lost a comparable amount of weight and were enrolled in inpatient
substance abuse treatment. Last, but not least, future research should develop improved methods for assessing addiction transfer postbariatric surgery so that answers are not
potentially biased by way questions are posed.
Conclusion/Future Directions
In summary, there appears to be a subgroup of individuals
who struggle with substance use disorders postbariatric surgery. We lack a good understanding of who is at risk for
developing problems and what care is needed for this unique
population. Future research should identify risk factors for the
development of substance use disorders among postbariatric
surgery patients. It would be interesting to identify the level of
concern related to substance use and bariatric surgery both
pre- and postoperatively. Additionally, psychologists may
play an imperative role in treating psychosocial factors that
may influence success of bariatric surgery patients. Future
research is needed to determine unique treatment needs of
those who develop substance abuse postbariatric surgery.
Finally, to expand our understanding of the parallels between
eating and addictive behavior, more generally, future studies
might address the relationship between eating and addictive
disorders among nonbariatric patients as well.
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Acknowledgments We would like to thank Melissa Whelan and
Rosa Quezada of Brighton Hospital for their assistance in participant
recruitment and the EMU Graduate School for supporting graduate
student co-authors. We would also like to thank Alisha Serras for her
considerable assistance with data collection and data entry, and Kendra
Clark and Bethany Feldman for their assistance with data coding.
Conflict of Interest All contributing authors, Valentina Ivezaj, Karen
K. Saules, and Ashley A. Wiedemann, declare that they have no
conflict of interest.
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This study was approved by the Institutional Review Boards of Eastern
Michigan University and St. John Health/Providence Hospital and
Medical Center.