Internalized weight bias and loss-of-control eating following bariatric surgery

Redefining diagnostic parameters: the role of overvaluation of shape and weight in binge-eating disorder: a systematic review

INTRODUCTION

Overvaluation of shape and weight is a critical component in understanding and diagnosing eating disorders. While the transdiagnostic model states that overvaluation of shape and weight is the core pathology of all eating disorders, this concept is not a criterion for binge-eating disorder. The lack of recognition of overvaluation of shape and weight may lead to overlooking, and consequently failure to address this construct during treatment. The aim of the present review is to examine whether overvaluation is a critical component in understanding and diagnosing binge-eating disorder and whether it should be addressed during treatment, and therefore be added as a criterion of binge-eating disorder.

METHODS

The present review was registered in the International Prospective Register of Systematic Reviews (registration number: CRD42024541433). PsycINFO, Web of Science, PubMed (Medline), and Google Scholar were used in order to systematically search and review literature by using a list of keywords related to overvaluation of shape and weight and binge-eating disorder. All N = 93 peer-reviewed studies were published in English from 1993 onwards.

RESULTS

Overvaluation of shape and weight was more severe among individuals with binge-eating disorder compared to individuals with solely a similar high BMI. In addition, levels of overvaluation in binge-eating disorder were comparable in severity with that of individuals of the other named eating disorder subtypes. Overvaluation was positively associated with other psychiatric symptoms, a risk factor for the onset of binge eating in adolescents and predicted poorer treatment outcomes. It was not clear whether overvaluation predicted dropout from Cognitive Behavior Therapy interventions.

DISCUSSION

It is suggested to consider including overvaluation of shape and weight as a criterion for the diagnosis of binge-eating disorder. Including overvaluation in the DSM and ICD may prevent overlooking this construct, and potentially enhance treatment outcomes. It is suggested that overvaluation of shape and weight is the core pathology of all eating disorders. However, this concept is not a criterion for a binge-eating disorder diagnosis. The lack of recognition of overvaluation of shape and weight may lead to overlooking, and consequently failure to address this construct during treatment. The aim of the present review is to examine whether overvaluation is a critical component in understanding and diagnosing binge-eating disorder and whether it should be addressed during treatment, and therefore be added as a criterion of binge-eating disorder. Consequently, a total of N = 93 peer-reviewed studies were examined. It was found that overvaluation of shape and weight was associated with the severity of eating disorder psychopathology, and was comparable in severity with that of individuals diagnosed with anorexia nervosa and bulimia nervosa. There is enough evidence to include overvaluation in the DSM and ICD as a criterion for binge-eating disorder. Consequently, this may prevent overlooking this construct, and potentially enhance treatment outcomes.

Long-Term Follow-Up After Bariatric Surgery: Key to Successful Outcomes in Obesity Management

Background/Objectives: Bariatric surgery (BS) is considered one of the most effective interventions for the treatment of obesity. To achieve optimal long-term results, continuous follow-up (FU) within a multidisciplinary treatment team is essential to ensure patient compliance and maximize the benefits of BS. However, many patients find it difficult to maintain regular FU, which can affect the quality of care and lead to postoperative complications. This review aims to highlight factors that may hinder compliance with FU after BS, examine potential causes and consequences of inadequate FU, and identify strategies to improve patient participation in long-term FU. Methods: The literature search was conducted between October 2023 and June 2024 in Medline (PubMed) and the Cochrane Library datasets. Studies were selected for their relevance to adherence to FU, multidisciplinary approaches, and long-term bariatric outcomes. Results: The pre- and postoperative period is critical for educating patients and healthcare team members about the importance of FU, addressing potential barriers (e.g., logistical, psychological, and social challenges), and highlighting the risk of relapse to obesity after surgery. The lack of a standardized FU protocol leads to differences between medical centers, further impacting patient adherence. Conclusions: Tailored and regularly updated strategies are essential to address individual patient needs and improve adherence to FU. Further research is needed to identify the specific factors that influence variability in long-term BS outcomes, highlighting the need for a patient-centered approach to obesity treatment.

Sexual orientation moderates the relationship between internalized weight bias and binge eating symptoms among adults pursuing bariatric surgery

BACKGROUND

Sexual minorities have higher rates of anxiety, depression, and binge eating compared to heterosexual peers. Internalized weight bias (IWB) is also higher for sexual minorities when compared to heterosexual peers. However, research has not examined whether the relationships between IWB and anxiety, depression, and binge eating differ among heterosexual and sexual minority adults pursuing bariatric surgery.

OBJECTIVES

To examine whether sexual orientation (heterosexual or sexual minority) moderated the relationships between IWB and anxiety, depression, and binge eating among adults pursuing bariatric surgery.

SETTING

University hospital, United States METHODS: Participants included 811 adults who presented for bariatric surgery, 45 (5.5%) of which identified as a sexual minority. Self-reported data were collected as part of a standard preoperative psychological evaluation for surgical clearance. Three separate moderation models were run to test hypotheses.

RESULTS

Sexual orientation did not moderate the association of IWB with anxiety or depression. The IWB by sexual orientation interaction was significant for binge eating (F 1856) = 4.84, P = .03, R2 = .27 such that the association between IWB and binge eating was significantly stronger for sexual minority patients (b = .54, 95% confidence interval {CI} [.36, .70]), compared to heterosexual patients (b = .33, 95% CI [.30, .38]).

CONCLUSIONS

Minority stress from identifying as a sexual minority may increase vulnerability to binge eating from IWB among bariatric candidates. Future research examining the directionality of the relationship between IWB and binge eating among sexual minorities is warranted.

Shape discrepancy, weight bias internalization, and eating-disorder psychopathology in patients with loss-of-control eating after bariatric surgery

BACKGROUND

Postoperative loss-of-control (LOC) eating is associated with eating-disorder psychopathology, poorer weight loss, and mental health outcomes following bariatric surgery. The nature and significance of shape discrepancy has not been examined in patients with LOC eating following bariatric surgery.

OBJECTIVES

To examine shape discrepancy, WBI (weight bias internalization) and ED (eating-disorder) psychopathology in patients with LOC eating after bariatric surgery.

SETTING

Yale University School of Medicine, United States.

METHODS

Participants (N = 148, 84.5% female) seeking treatment for eating and weight concerns and with recurrent LOC eating approximately 6 months after bariatric surgery were assessed with the Eating Disorder Examination-Bariatric Surgery Version Interview and completed questionnaires measuring WBI and depression. Participants selected body shapes representing their current and ideal shapes, and a shape discrepancy score was calculated.

RESULTS

Most participants (N = 142/148) reported an ideal shape smaller than their current shape; shape discrepancy scores ranged from 0 to 5 (M = 1.89, SD = .82). Greater shape discrepancy was significantly correlated with greater current body mass index (BMI; r = .271, p=<.001) and percent weight loss (%WL) since surgery (r = -.19, p = .023). After adjusting for %WL, shape discrepancy was significantly correlated with greater WBI (r = .37, p < .001), depression (r = .27, p < .001), and ED psychopathology (r = .25, p = .002).

CONCLUSIONS

Nearly all participants preferred a significantly smaller shape than their current shape. Greater discrepancy between current and ideal shape was associated with higher levels of a range of behavioral (ED psychopathology), cognitive (WBI), and psychological/somatic (depression) concerns. These findings, which persisted after adjusting for %WL, highlight the importance of addressing body image in postoperative interventions.

Weight stigma in healthcare settings: the experience of Arab and Jewish bariatric surgery candidates in Israel

BACKGROUND

Weight-related stigma and discrimination are prevalent in our society with adverse biopsychosocial outcomes to people with obesity and morbid obesity. Studies suggest that weight bias in healthcare settings are quite prevalent, but there have been, as far as we know, lack of studies examining prevalence and correlates of weight bias experiences among bariatric surgery candidates in Israel. We aim to understand the nature and prevalence of weight stigma among bariatric surgery candidates. To identify differences between Jewish and Arab candidates. To examine the impact of weight stigma experiences on weight bias internalization (WBI).

METHODS

A cross-sectional study was performed among 117 adult bariatric surgery candidates from three hospitals in northern Israel (47.8% Jews, 82.4% females, average BMI 42.4 ± 5.2 Kg/meter2). Patients who agreed to participate completed a structured questionnaire on the same day that the bariatric surgery committee met. WBI was measured using a validated 10-item scale. Experiences of weight stigma were measured using items adapted from prior international studies.

RESULTS

About two thirds of the participants had at least one experience of weight stigma (teased, treated unfairly, or discriminated against because of their weight). As many as 75% of participants reported that weight served as a barrier to getting appropriate health care and as many as half of participants felt in the last year that a doctor judged them because of their weight. No significant differences were found between Arabs and Jews in the prevalence of weight stigma experiences and WBI. However, a trend towards more stigma experiences among Jews was noted. WBI was predicted by female gender and experiences of weight stigma, both in general and within healthcare settings.

CONCLUSIONS

Weight stigma towards bariatric surgery candidates in Israel is quite prevalent, and specifically in healthcare settings. It is important to adopt policy actions and intervention programs to improve awareness to this phenomenon among the general public and specifically among healthcare providers, as many healthcare providers may be unaware of the adverse effect of weight stigma and of ways in which they are contributing to the problem. Future studies may validate our findings using larger sample size and longitudinal design.

Weight Bias Internalization and Eating Disorder Psychopathology in Treatment-Seeking Patients with Obesity

This study aimed to investigate the relationship between weight bias internalization and eating disorder psychopathology in treatment-seeking patients with severe obesity using a network approach. Two thousand one hundred and thirteen patients with obesity were consecutively admitted to a specialist clinical unit for obesity and were recruited from January 2016 to February 2023. Body mass index was measured, and each patient completed the Weight Bias Internalization Scale (WBSI) and the Eating Disorder Examination Interview (EDE). Network analysis showed that the most central and highly interconnected nodes in the network were related to the EDE items exposure avoidance, dissatisfaction with shape, and wanting an empty stomach. Bridge nodes were found, but the bootstrap difference test on expected bridge influence indicated non-significant centrality differences. Nevertheless, the eating disorder psychopathology and weight bias internalization network structure in patients seeking treatment for obesity indicate the prominent roles of body dissatisfaction and control of eating and weight in these psychological constructs. This finding, if replicated, could pave the way for a new understanding of the psychological mechanisms operating in patients with obesity.

Obesity stigma and its impact on health: A narrative review

Weight stigma and weight bias are pervasive in our society and are based on wrong assumption that obesity derives basically from a lack self-discipline and personal responsibility, obviating recent evidence showing that obesity is a prevalent, complex, progressive, and relapsing chronic disease that results from the interaction between behavioural, environmental, genetic, and metabolic factors. This narrative review provides an overview of recent research on this problem, mainly focused on the negative impact of weigh stigma on health. Overall, recent evidence shows that weight stigma can contribute to worsening obesity-related problems and creating additional barriers to effective obesity care and prevention. In addition, a brief description of some of the most important international initiatives to address the weight stigma is provided.

Examining weight bias before and/or after bariatric surgery: A systematic review

Research examining weight bias in the bariatric population, who may be at greater risk of weight stigma, is scarce. The present study aimed to systematically review the literature for quantitative evidence that explores the medical, psychosocial, and behavioral sequelae associated with experienced, internalized, and/or externalized weight bias in patients seeking or who have undergone bariatric surgery. Five databases were systematically searched for English peer-reviewed quantitative studies, which examined weight bias in a sample of individuals seeking or who had undergone bariatric surgery. Risk of bias was assessed. Twenty-nine studies were included, of which 13 examined internalized weight bias, 12 examined experienced weight bias, 4 examined both, and 0 examined externalized weight bias. Most studies were cross-sectional, and the results showed high risk of bias. The results suggested that both experienced and internalized weight bias were associated with a host of negative psychosocial, behavioral, and medical sequelae. The findings of this review underscore the need for more rigorous research to better understand the relationship between weight bias and bariatric surgery, particularly longitudinally. Future patients may benefit from research developing interventions for reducing weight bias prior to and following bariatric surgery in order to reduce the associated negative correlates and improve outcomes.

Management of eating disorders for people with higher weight: clinical practice guideline

INTRODUCTION

The prevalence of eating disorders is high in people with higher weight. However, despite this, eating disorders experienced by people with higher weight have been consistently under-recognised and under-treated, and there is little to guide clinicians in the management of eating disorders in this population.

AIM

The aim of this guideline is to synthesise the current best practice approaches to the management of eating disorders in people with higher weight and make evidence-based clinical practice recommendations.

METHODS

The National Eating Disorders Collaboration Steering Committee auspiced a Development Group for a Clinical Practice Guideline for the treatment of eating disorders for people with higher weight. The Development Group followed the 'Guidelines for Guidelines' process outlined by the National Health and Medical Research Council and aim to meet their Standards to be: 1. relevant and useful for decision making; 2. transparent; 3. overseen by a guideline development group; 4. identifying and managing conflicts of interest; 5. focused on health and related outcomes; 6. evidence informed; 7. making actionable recommendations; 8. up-to-date; and, 9. accessible. The development group included people with clinical and/or academic expertise and/or lived experience. The guideline has undergone extensive peer review and consultation over an 18-month period involving reviews by key stakeholders, including experts and organisations with clinical academic and/or lived experience.

RECOMMENDATIONS

Twenty-one clinical recommendations are made and graded according to the National Health and Medical Research Council evidence levels. Strong recommendations were supported for psychological treatment as a first-line treatment approach adults (with bulimia nervosa or binge-eating disorder), adolescents and children. Clinical considerations such as weight stigma, interprofessional collaborative practice and cultural considerations are also discussed.

CONCLUSIONS

This guideline will fill an important gap in the need to better understand and care for people experiencing eating disorders who also have higher weight. This guideline acknowledges deficits in knowledge and consequently the reliance on consensus and lower levels of evidence for many recommendations, and the need for research particularly evaluating weight-neutral and other more recent approaches in this field.

Body Checking and Body Image Avoidance as Partial Mediators of the Relationship between Internalized Weight Bias and Body Dissatisfaction

Internalized weight bias is associated with body image disturbances and the development of disordered eating. The association between weight bias internalization and body dissatisfaction has proven difficult to disrupt. In order to develop more effective interventions, we must identify the behavioral targets which account for this robust association. The present study sought to examine whether body checking and body image avoidance mediate the relationship between weight bias internalization and body dissatisfaction. In total, 279 female undergraduates (Mage = 20.13, SD = 4.10) were administered a battery of survey measures. Results demonstrated that body checking partially mediates the relationship between weight bias internalization and body dissatisfaction, Z = 7.42, p < 0.001. Body image avoidance was also found to partially mediate the relationship between weight bias internalization and body dissatisfaction, Z = 70.03, p < 0.001. These findings suggest that body checking and body image avoidance may both partially account for the association between weight bias internalization and body dissatisfaction. These findings extend the existing literature on weight bias internalization by highlighting two behavioral targets for prevention and intervention efforts. Understanding these relationships has important implications for both reducing weight bias internalization and improving body dissatisfaction.

Associations of Use of Social Media and Psychopathology and Body Image in Pre- and Post-surgical Bariatric Samples: a Cross-sectional Analysis

Purpose

Interest has grown regarding the impact of social media platforms on mental health including body image and internalized weight bias (IWB) in those who have struggled with weight issues. However, few studies have addressed social media usage in bariatric patient samples. The objective of this study was to understand how the amount of time spent on social media could serve as a predictor for IWB in both pre- and post-operative bariatric patients.

Materials and Methods

Pre- and post-operative patients at one academic medical center completed self-report measures assessing patients’ IWB, depression, anxiety, body dissatisfaction, sociodemographic variables, and social media usage. Data were collected from March 2019 to April 2020. Statistical methods that included correlations, logistical regression models, and ANOVA analysis were used to determine the relationship between time spent on social media and other covariates.

Results

A total of 148 responses were collected from the pre-surgical population, with 81 responses from the post-surgical sample. At baseline, the majority of respondents used social media for approximately 1 h per day (n = 37; 27.82%). Time spent on social media was negatively associated with age (r =  − 0.24 [− 0.40, − 0.08]), and positively associated with IWB (r = 0.20 [0.02, 0.36]) and anxiety (r = 0.21 [0.01, 0.39]). In the post-operative group, only the 6-month BMI (r = 0.29 [0.05, 0.49]) was positively associated with time spent on social media.

Conclusion

Given this study’s findings, providers are encouraged to become aware of patients’ use of social media, and to understand the impact social media usage can have on the mental well-being of patients.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-06206-6.

Examining the Conceptual and Measurement Overlap of Body Dissatisfaction and Internalized Weight Stigma in Predominantly Female Samples: A Meta-Analysis and Measurement Refinement Study

Both body dissatisfaction and internalized weight stigma have been identified as risk factors for many negative health outcomes for women, including depression and eating disorders. In addition to these contributions, these concepts have been found to overlap to various degrees in existing literature. We conducted a systematic review and meta-analysis on articles published prior to February 2022 to demonstrate the conceptual and measurement overlap between body dissatisfaction and internalized weight stigma as currently quantified. We identified 48 studies examining the interrelation between body dissatisfaction and internalized weight stigma in predominantly female samples. Stronger correlations between these two constructs, some bordering on multicollinearity, were prevalent in community samples compared to clinical samples and with some but not all the commonly used measures in the body image and weight stigma fields. Body mass index (BMI) moderated these relations such that individuals with higher self-reported BMI were more likely to report lower correlations between the constructs. This concept proliferation, stronger for individuals with lower BMIs and community samples, necessitates the need change how we conceptualize and measure body dissatisfaction and internalized weight stigma. To this end, we conducted study two to refine existing measures and lessen the degree of measurement overlap between internalized weight stigma and body dissatisfaction, particularly in community samples of women. We aimed to clarify the boundaries between these two concepts, ensuring measurement error is better accounted for. Female university students completed existing measures of body satisfaction and internalized weight stigma, which were analyzed using an exploratory followed by a confirmatory factor analysis. In our attempts to modify two existing measures of internalized weight stigma and body dissatisfaction, the majority of the internalized weight stigma items were retained. In contrast, most of the body dissatisfaction items either cross-loaded onto both factors or loaded on to the internalized weight stigma factor despite being intended for the body dissatisfaction factor, suggesting that the measurement issues identified in recent prior research may be due not only to the way we conceptualize and quantify weight stigma, but also the ways in which we quantify body dissatisfaction, across the existing corpus of body dissatisfaction scales.

Prevention of eating disorders: 2021 in review

This review of 19 prevention-related publications in Eating Disorders during 2021 is framed by four models: (1) Mental Health Intervention Spectrum: health promotion → types of prevention → case identification/referral → treatment; (2) the prevention cycle: rationale and theory, shaped by critical reviews → clarifying risk and protective factors → program innovation and feasibility studies → efficacy and effectiveness research → program dissemination; (3) links between disordered eating (DE) and eating disorders (EDs); and (4) Kraemer and Jacobi's criteria for variable, causal risk factors (RFs). Twelve articles demonstrated the strengths and limitations of cross-sectional investigations of RFs for DE and EDs: five explored the role of trauma in activating genetic and psychological RFs (e.g., anxiety and experiential avoidance), while five suggest other variables meriting further evaluation: ergogenic supplement use, "feeling fat," internalized weight bias, food insecurity, and compulsive exercising. One article presents a pilot program that reduced risk factors in a high-risk group: professional ballerinas. Implications of the absence of efficacy, effectiveness, dissemination, and advocacy studies, along with the need to develop tailored programs for various high-risk groups, are discussed.

The role of weight stigma in weight regain in bariatric surgery

Obesity is highly stigmatized, and individuals who undergo bariatric surgery are subject not only to weight stigma, but also to stigma related to the procedure itself. Patients lost to follow-up after surgery make estimating the amount of regain occurring after surgery difficult, and often patients fail to follow up due the shame of weight regain. Patients report difficulty following the diet necessary to maintain weight loss. Additionally, when they seek support after surgery, they often encounter stigmatizing messaging related to weight. Weight bias internalization, weight stigma, and stigma about having the surgery all contribute to feelings of social isolation, disordered eating, and reduced motivation to engage in physical activity. In this chapter, we present evidence for the impact of stigma on bariatric surgery outcomes and discuss the behavioral, physiological, and emotional processes that contribute to weight regain.

Factor Structure and Measurement Invariance of the Attitudes Toward Persons with Obesity (ATOP) Scale in a Preoperative and Postoperative Bariatric Surgery Sample

BACKGROUND

The Attitudes Toward Persons with Obesity (ATOP) scale is widely used to assess stigmatization toward persons with obesity. The measure has previously been suggested to assess three facets-self-esteem, personality, and social difficulties-however, psychometric support for this has been inconsistent and warrants further study if the measure intends to be scored this way.

OBJECTIVES

Explore and confirm the factor structure of the ATOP in people assessed prior to bariatric surgery and reassessed 1 year postoperatively SETTING: Midwestern hospital in the USA.

MATERIALS AND METHODS

Three-hundred sixteen people who were seeking bariatric surgery were assessed preoperatively, and 161 of those people were reassessed 1 year after surgery with a battery of measures including the ATOP. Exploratory factor analysis (EFA) was performed on ATOP data from a random split-half of people before surgery, and confirmatory factor analysis (CFA) was performed on the second randomly selected half. With the postoperative sample, a CFA was performed, testing the best-fitting model from the preoperative CFA findings.

RESULTS

The EFA suggested a two-factor structure interpreted as self-esteem and personality/social difficulties. This structure was supported by CFA performed on the second randomly selected half of people at preoperative assessment and by CFA performed on people 1 year following surgery. Tests of measurement invariance suggested that the two-factor structure was similar at both time points.

CONCLUSIONS

Only two factors for the ATOP were empirically supported in the current sample (self-esteem and personality/social difficulties), which is slightly different from the three factors that were originally proposed when the measure was developed. This factor structure is supported both prior to bariatric surgery and 1 year after bariatric surgery.

Gut hormones, adipokines, and pro- and anti-inflammatory cytokines/markers in loss of control eating: A scoping review

Loss of control (LOC) eating is the defining feature of binge-eating disorder, and it has particular relevance for bariatric patients. The biomarkers of LOC eating are unclear; however, gut hormones (i.e., ghrelin, cholecystokinin [CCK], peptide YY [PYY], glucagon-like peptide 1 [GLP-1], and pancreatic polypeptide [PP]), adipokines (i.e., leptin, adiponectin), and pro- and anti-inflammatory cytokines/markers (e.g., high-sensitivity C-reactive protein [hsCRP]) are candidates due to their involvement in the psychophysiological mechanisms of LOC eating. This review aimed to synthesize research that has investigated these biomarkers with LOC eating. Because LOC eating is commonly examined within the context of binge-eating disorder, is sometimes used interchangeably with subclinical binge-eating, and is the latent construct underlying disinhibition, uncontrolled eating, and food addiction, these eating behaviors were included in the search. Only studies among individuals with overweight or obesity were included. Among the identified 31 studies, 2 studies directly examined LOC eating and 4 studies were conducted among bariatric patients. Most studies were case-control in design (n = 16) and comprised female-dominant (n = 13) or female-only (n = 13) samples. Studies generally excluded fasting total ghrelin, fasting CCK, fasting PYY, and fasting PP as correlates of the examined eating behaviors. However, there was evidence that the examined eating behaviors were associated with lower levels of fasting acyl ghrelin (the active form of ghrelin) and adiponectin, higher levels of leptin and hsCRP, and altered responses of postprandial ghrelin, CCK, and PYY. The use of GLP-1 analog was able to decrease binge-eating. In conclusion, this review identified potential biomarkers of LOC eating. Future studies would benefit from a direct focus on LOC eating (especially in the bariatric population), using longitudinal designs, exploring potential mediators and moderators, and increased inclusion of the male population.

Examining Weight Bias and Loss-of-Control Eating among Individuals Seeking Bariatric Surgery

OBJECTIVE

Externalized weight bias (EWB), directed towards others, and internalized weight bias (IWB), directed towards the self, are thought to exacerbate obesity and disordered eating and may be important factors to assess and understand among individuals seeking bariatric surgery. This study examined clinical correlates (pre-surgical BMI, depressive symptoms, weight self-efficacy, and shape/weight overvaluation) of both EWB and IWB among individuals presenting for bariatric surgery with and without regular loss-of-control eating (LOC eating).

METHODS

A total of 316 adults presenting for bariatric surgery completed established self-report measures to assess EWB, IWB, depressive symptoms, weight self-efficacy, and core symptoms of disordered eating including LOC eating and overvaluation of shape/weight.

RESULTS

IWB and EWB were not associated with pre-surgical BMI, age, or sex, but were both significantly higher among White than non-White participants. Adjusting for race, IWB and EWB were significantly associated with greater eating disorder psychopathology and depressive symptoms and with less weight-related self-efficacy. Participants who endorsed regular LOC eating (53.5% of the sample) endorsed significantly lower weight self-efficacy and higher IWB, EWB, depressive symptoms, and overvaluation of shape/weight.

CONCLUSIONS

Findings suggest that regular LOC eating is common among individuals seeking bariatric surgery and associated with a range of heightened eating disorder and psychosocial concerns including both IWB and EWB. Future research exploring the longitudinal significance of the relationship between these two forms of weight bias and LOC eating is indicated.

Examining the relationship between weight controllability beliefs and eating behaviors: The role of internalized weight stigma and BMI

Body weight is often viewed as personally controllable. This belief, however, ignores the complex etiology of body weight. While such attributions of personal willpower may help some individuals regulate their eating patterns, they have also been associated with increased internalized weight stigma which, itself, is associated with more disinhibited eating. The current investigation aimed to examine how internalized weight stigma, along with BMI, may explain the effect of weight controllability beliefs on disparate dietary behaviors. A community sample of 2702 U.S. adults completed an online survey about their weight controllability beliefs, eating behaviors, and internalized weight stigma, as well as demographic items and self-reported BMI. Results showed that greater weight controllability beliefs were positively related to both more restricted eating, β = 0.135, p < .001, and more disinhibited eating, β = 0.123, p < .001. This ironic effect was partially explained by increased internalized weight stigma. Moreover, BMI moderated the relationship, such that individuals with lower weights demonstrated stronger effects for two of the three eating outcomes than those with higher weights. These findings advance our understanding of the relationship between attributions of personal control for body weight and subsequent health behaviors, and further underscore the need to target internalized weight stigma in dietary interventions.

Disinhibition and Subjective Hunger as Mediators Between Weight Bias Internalization and Binge Eating Among Pre-Surgical Bariatric Patients

PURPOSE

Weight bias internalization, or the process of applying negative weight-related attitudes and beliefs to oneself, is an important construct in regard to patients pursuing bariatric surgery. Weight bias internalization (or internalized weight bias) has been previously associated with depressive symptoms and binge eating among pre-surgical bariatric patients. However, a gap in the literature exists pertaining to how certain eating behaviors may mediate the relationship between weight bias internalization and binge eating. The present study assessed the role of eating behaviors (i.e., cognitive restraint, disinhibition, and hunger) as mediators between weight bias internalization and binge eating symptoms when controlling for depression.

MATERIALS AND METHODS

A total of 708 adults (Mage = 42.91; White = 95.3%; women = 79.4%) seeking bariatric surgery at a tertiary academic medical center in the Appalachia region of the USA were included in this retrospective study. Patients completed validated measures of weight bias internalization, eating behaviors, and depression as part of a routine, psychological evaluation in order to determine surgical clearance.

RESULTS

Disinhibition and hunger were significant mediators in the relationship between weight bias internalization and binge eating beyond the role of depressive symptoms alone.

CONCLUSION

Disinhibited eating, or the tendency to experience a loss of control and eating in response to negative emotions, as well as subjective feelings of hunger are important dimensions of eating, particularly as related to weight bias internalization and binge eating. Weight bias internalization is an important factor to consider among pre-surgical bariatric patients and warrants additional treatment considerations.

The role of body appreciation, weight bias internalization, and disordered eating behaviors among presurgical bariatric patients

BACKGROUND

Body appreciation and internalized weight bias have consistently been associated with eating behaviors. However, research has yet to examine the role of these variables among presurgical bariatric patients.

OBJECTIVES

The present study sought to assess the relationships between body appreciation and weight bias internalization, binge eating, disinhibited eating, and symptoms of depression and anxiety among a sample of presurgical bariatric patients. The study also sought to examine the extent to which body appreciation and weight bias internalization account for unique variance in disordered eating even when controlling for depression and anxiety.

SETTING

Academic medical center in the United States.

METHODS

Data were collected on body appreciation, weight bias internalization, eating behaviors, depression, and anxiety as part of a standard presurgical psychological evaluation for bariatric surgery (n = 319). Pearson correlations were used to assess relationships between all study variables. Multiple regressions were conducted to assess the roles of body appreciation and weight bias internalization on disordered eating.

RESULTS

Significant associations were found between low levels of body appreciation and high levels of weight bias internalization, disordered eating, and symptoms of depression and anxiety. Results indicated that body appreciation and weight bias internalization each significantly accounted for unique variance in symptoms of binge eating and disinhibited eating. Depressive symptoms were also statistically significant in all analyses.

CONCLUSION

Findings indicate the importance of conducting future positive body image research, as well as continuing to examine weight-related constructs, such as internalized weight bias, among bariatric surgery patients.

Internalized weight bias in patients presenting for bariatric surgery

INTRODUCTION

Internalized weight bias (IWB) is significantly related to poor psychosocial health outcomes in patients with increased body mass index (BMI). The objective of this study was to evaluate the psychometric properties and correlates of the Weight-Bias Internalization Scale in a pre-surgical bariatric population.

METHODS

Self-report measures were administered to patients prior to surgery. Measures assessed internalized weight bias, body dissatisfaction, depression, anxiety, quality of life, and eating behaviors. Statistical methods included confirmatory factor analysis to examine the factor structure [of the WBIS] in this population, descriptive statistics, correlations, and hierarchical linear regression between continuous variables to determine patterns of associations, and t-tests to compare levels of IWB between the current sample and previously documented samples.

RESULTS

Confirmatory factor analysis indicated an acceptable fit using a one-factor structure for the WBIS, with one item removed. Mean WBIS in the current sample was comparable to that documented in a community sample of adults with overweight and obesity, as well as a sample of adolescents seeking bariatric surgery. Additionally, IWB was positively associated with body dissatisfaction, restrained, emotional, and external eating, depression, and anxiety, and negatively associated with quality of life. Further, individuals endorsing episodes of loss of control over eating had significantly higher WBIS scores.

CONCLUSIONS

This study highlights the strong pattern of associations with measures of body image, disordered eating, and quality of life point toward the relevance of IWB to bariatric patients' experiences. Future studies to explore the longitudinal effects of IWB in a post-bariatric population are needed particularly to understand psychosocial and surgical health outcomes.

The Influence of Weight-Related Self-Esteem and Symptoms of Depression on Shape and Weight Concerns and Weight-Loss 12 Months After Bariatric Surgery

INTRODUCTION

While body image can improve following bariatric surgery, a portion of patients continue to experience concerns about weight and shape regardless of weight lost. Research is needed to identify risk factors for post-surgical weight and shape concerns given that body dissatisfaction may contribute to poor outcomes.

AIMS

To evaluate whether (1) change in weight-related self-esteem and symptoms of depression from pre- to 12-month post-surgery were associated with change in weight and shape concerns independent of weight-loss; (2) improvement in weight and shape concerns, symptoms of depression, and/or weight-related self-esteem predict greater weight-loss 12 months after bariatric surgery; and (3) improvements in weight-related self-esteem, symptoms of depression, weight concerns, or shape concerns predict weight loss.

METHODS

Fifty adults approved to receive bariatric surgery self-reported body mass index and completed validated measures of weight-related self-esteem, symptoms of depression, and weight and shape concerns pre- and 12-month post-surgery.

RESULTS

Improvements were observed for weight-related self-esteem, concerns over shape and weight, symptoms of depression, and body mass index from pre- to 12-month post-surgery. Improvement in weight-related self-esteem was associated with concomitant improvements in concerns over shape and weight, independent of weight loss. Improvement in symptoms of depression was associated with improvement in concerns over weight, but not shape. Finally, exploratory analyses indicated that improvements in weight-related self-esteem, and concerns over shape and weight, but not symptoms of depression were associated with improvement in weight-loss.

CONCLUSIONS

Weight-related self-esteem may represent an overlooked and important target throughout the bariatric surgery process that could enhance surgical outcomes.

Examining the contribution of weight-bias internalization to the associations between weight suppression and disordered eating in undergraduates

Weight suppression (WS) is consistently, positively associated with eating disorder (ED) symptoms, but variables that contribute to these associations remain understudied. The current study examined weight-bias internalization as a potential contributor to the link between weight suppression (WS) and disordered eating in an undergraduate sample. Men (n = 285) and women (n = 610) completed assessments of weight history, weight-bias internalization, and ED symptoms. Absolute (difference in highest and current BMI) and relative WS (%BMI change) were calculated. Hierarchical linear and count regression models examined whether WS contributed to ED symptoms (restraint, objective binge episodes [OBEs], loss-of-control [LOC] eating, and compensatory exercise) above and beyond weight-bias internalization. Analyses were conducted by gender. After accounting for weight-bias internalization, WS demonstrated unique associations with restraint in men (p = .01) and women (p < .001), and LOC eating frequency in men (p = .02), though effects were weaker relative to weight-bias internalization. Although WS was positively correlated with frequency of OBEs in men and LOC eating in women, these associations were no longer significant when accounting for weight-bias internalization. Weight-bias internalization was positively associated with all measured ED symptoms. Consistent with previous work, gender differences in the relations of WS and ED symptoms emerged. Results suggest weight-bias internalization might contribute to links between WS and ED symptoms, particularly binge behaviors, in non-clinical samples. Future research should explore whether decreasing weight-bias internalization could weaken the association between WS and ED symptoms.