Weight Self-Stigma and Food Noise During Post-Metabolic Bariatric Surgery Weight Stability

Abstract

Objective:

Food noise has been studied with GLP-1-based therapies, but not with metabolic bariatric surgery (MBS), despite shared mechanisms. Data on food noise beyond initial weight loss are limited, and weight self-stigma (WSS), which links to poorer weight outcomes and risky behaviors after MBS, may relate to higher food noise, especially during weight stabilization. This study investigates whether WSS is associated with increased food noise during stable weight following MBS.

Methods:

Adults who remained weight stable following MBS completed the Weight Self-Stigma Questionnaire (WSSQ) and Food Noise Questionnaire (FNQ). Multivariable linear regression examined associations between WSSQ scores (total and self-devaluation/fear of enacted stigma subscales) and FNQ scores.

Results:

Participants (n = 60) were 13.3 ± 4.5 months post surgery, with a maximum weight loss of 24.8% ± 8.4%. Higher WSSQ total (B = 0.29, p = 0.001) and self-devaluation subscale (B = 0.36, p = 0.021) scores were associated with higher FNQ scores.

Conclusions:

Food noise increased with higher WSS, particularly among individuals reporting greater self-devaluation due to weight during postoperative weight stability. Further research should map this relationship across postoperative weight stages, test causal direction, and identify mechanisms. Because WSS and food noise can undermine health behaviors, weight loss, and health gains after MBS, routine screening and integrated clinical interventions may be warranted.

1 ∣. Introduction

Weight self-stigma (WSS) occurs when individuals internalize negative societal stereotypes about weight [1, 2]. It encompasses two related dimensions: (1) self-devaluation, marked by diminished self-worth, shame, and self-blame rooted in the belief that weight reflects moral weakness and (2) fear of enacted stigma, involving concern about being judged, treated unfairly, or rejected because of weight [1].

Evidence identifies WSS as a key factor in obesity treatment [3, 4], particularly in metabolic bariatric surgery (MBS). Patients pursuing MBS frequently report clinically significant WSS [5-7], which may persist or reemerge after surgery despite substantial weight loss [8]. WSS is associated with less total weight loss [8-10] and behaviors linked with weight recurrence [4], including lower physical activity [9], poorer dietary adherence [9, 11], and maladaptive eating patterns [7, 12].

Food noise is an emerging concept in obesity treatment [13, 14], characterized by persistent, intrusive, and often distressing thoughts about food that disrupt daily life by impairing concentration, reducing post-meal satisfaction, and hindering engagement in healthy behaviors [13]. Studies show reductions in food noise with GLP-1 receptor agonist therapies [15, 16]. However, little is known about food noise after MBS, despite overlapping mechanisms such as increased endogenous GLP-1 secretion, enhanced gut-brain signaling, and decreased reward response to food [17]. Research on food noise beyond the dynamic weight loss phase of obesity treatments is also scarce.

To date, no study has examined WSS as a potential risk factor for food noise following MBS. Following Dhurandhar et al.'s [13] conceptualization of food noise, WSS may contribute to food noise in several ways. First, the cognitive burden of self-devaluation may amplify food noise. Second, the physiological stress of fearing weight-based devaluation by others could impair cognitive functioning and self-regulatory capacity, making it harder to quiet food noise. Third, WSS and food noise could form a self-reinforcing cycle in which WSS promotes problematic eating, which increases food noise, and reinforces internalization of stereotypes about lack of control related to weight and food. This cycle may be intensified by chronic exposure to a food environment rich in high-calorie, hyper-palatable, low-nutrient foods [18].

The post-MBS weight stabilization phase offers a critical window to understand the relationship between WSS and food noise. While MBS often yields substantial weight loss and reduced appetite [16], some people feel distressed when appetite returns, weight loss plateaus or falls short of expectations, or weight recurrence occurs [17-19]. During this period, persistent or intrusive thoughts about food can reinforce self-blame for difficulties in managing appetite or weight. Notably, experiences of WSS can change after MBS. Although stigma may lessen post-operatively [20], some may still face stigma related to choosing MBS, including perceptions from others that it is an “easy way out” [21]. In this context, both distress over weight outcomes and stigma may influence WSS and its relationship with food noise after MBS.

This study examines the relationship between WSS and food noise in the post-MBS weight stabilization phase. We hypothesized that greater WSS overall (and its subscales of self-devaluation and/or fear of enacted stigma) would be associated with higher food noise.

2 ∣. Methods

Data were collected as part of baseline assessments for a larger parent study testing an intervention to sustain physical activity and prevent weight recurrence after MBS (ClinicalTrials.gov NCT037604). All protocol elements relevant to the present study are reported here. Procedures were approved by the Hartford Hospital Institutional Review Board.

2.1 ∣. Participants

Adults aged 18–64 who underwent primary MBS (Roux-en-Y gastric bypass or sleeve gastrectomy) 6–20 months prior and remained within 10% of their nadir weight were included. Exclusion criteria included: inability to walk independently, insufficient English fluency, pregnancy or related conditions, participation in weight programs beyond standard care; recent changes to medications affecting weight within 2 months of enrollment; and any condition preventing study adherence (e.g., relocation, psychiatric issues).

2.2 ∣. Procedure

Participants were recruited from Hartford Hospital in Hartford, CT, and from other MBS centers within the Hartford HealthCare system. Advertisements were placed in clinic waiting and exam rooms and on social media. Surgeons and their teams referred potential participants, who were contacted by email or mail with a link to a prescreening questionnaire and a request to access their electronic medical record (EMR). The EMR provided a clinic-measured weight 6–18 months after surgery that served as an anchor for determining nadir weight, maximum weight loss, and weight stability during screening.

After confirming pre-eligibility, study personnel distributed an electronic consent form and scheduled a HIPAA-compliant virtual meeting. They guided patients through the consent form and administered a quiz to verify study comprehension before signing.

Participants advanced to the next screening phase to verify weight stability, using the clinic-measured anchor weight plus ≥ 2 additional weights measured 20–40 days apart on a study-issued cellular scale (Withings Health Solutions Inc., Boston, MA, USA). Participants with < 10% weight recurrence proceeded to the baseline assessment; those with ≥ 10% weight recurrence were deemed ineligible. Participants who had not reached their nadir weight could continue measuring weight to qualify for the study.

2.3 ∣. Measures

2.3.1 ∣. Weight Self-Stigma Questionnaire (WSSQ)

The WSSQ [1] is a validated, reliable 12-item self-report instrument that measures how individuals internalize weight stigma. Respondents use a Likert scale (1 = completely disagree to 5 = completely agree) to assess two domains: self-devaluation (e.g., I often feel that I am inferior because of my weight) and fear of enacted stigma (e.g., I am concerned that others will judge my weight negatively). Subscale scores sum to yield component scores (6–30) and a total score (12–60). Higher scores indicate greater WSS, with total scores ≥ 36 indicating clinically significant WSS [22]. The measure demonstrated good internal consistency in this sample (Cronbach's α = 0.86).

2.3.2 ∣. Food Noise Questionnaire (FNQ)

The FNQ [14] is a validated, reliable self-report tool to measure food noise. Respondents rate statements (e.g., My thoughts about food distract me from what I need to do) on a 0 = strongly disagree to 4 = strongly agree Likert scale. Total scores range from 0 to 20, with scores ≥ 10 reflecting “above-average” food noise.

2.4 ∣. Analytic Approach

All analyses were conducted in Stata 18 (StataCorp LLC, College Station, TX, USA). Participant characteristics are presented as mean ± SD or count (%). We used multivariable linear regression models to examine associations between WSSQ and FNQ scores, adjusting for obesity modifying medications (OMMs) use as an a priori confounder. WSSQ subscales were examined within the same model, and the variance inflation factor (VIF) was calculated to detect multicollinearity. We evaluated demographic, surgery, and psychological factors as potential covariates using the least absolute shrinkage and selection operator (LASSO) to prevent overfitting. Covariates selected by LASSO were retained in the final models if they remained significant (p < 0.100).

3 ∣. Results

Table 1 shows that participants (N = 60) were, on average, middle-aged, with most reporting female birth sex and White race. Approximately 20% identified as Hispanic or Latino. The majority (79.3%) underwent sleeve gastrectomy. Baseline measurements were taken at ~13 months post surgery, with a mean maximum weight loss of 24.8% and BMI in the Class I obesity range. Thirty-five (58.3%) participants reported clinically significant WSSQ scores [22], and 27 (45.0%) reported above-average food noise [14].

TABLE 1 ∣.

Participant characteristics.

(N = 60)
	Mean ± SD/n (%)
Age (years)	44.7 ± 9.5
Female, n (%)	52 (86.7%)
Race, n (%)
White or Caucasian	55 (91.7%)
Black or African American	3 (5.0%)
Others or unknown	2 (3.3%)
Hispanic or Latino, n (%)	12 (20.3%)
Sleeve gastrectomy, n (%)	46 (79.3%)
Time since surgery (months)	13.3 ± 4.5
Maximum TWL (%)	24.8 ± 8.4
Nadir BMI (kg/m2)	33.6 ± 6.0
WSSQ
Total score	36.4 ± 8.5
Self-devaluation subscale score	17.4 ± 5.1
Fear of enacted stigma subscale score	18.9 ± 4.8
FNQ	9.5 ± 5.8
Use of OMMs, n (%)
Taking GLP-1RA	3 (5.0%)
Taking non-GLP-1 OMM	10 (16.7%)
Taking no OMM	47 (78.3%)

Abbreviations: FNQ, Food Noise Questionnaire; GLP-1 RA, glucagon-like peptide-1 receptor agonist; OMM, obesity modifying medication; TWL, percent total weight loss; WSSQ, Weight Self-Stigma Questionnaire.

Higher total WSSQ scores were associated with higher FNQ scores (B = 0.29, p = 0.001). Higher self-devaluation subscale scores significantly correlated with higher FNQ scores (B = 0.36, p = 0.021), whereas fear of enacted stigma scores did not (B = 0.21, p = 0.186). Figure 1 illustrates these relationships, showing estimated FNQ scores across tertiles of WSSQ scores.

FIGURE 1 ∣.

Estimated Food Noise Questionnaire (FNQ) scores Across tertiles of (A) Weight Self-Stigma Questionnaire (WSSQ) total and (B) self-devaluation and (C) fear of enacted stigma subscale scores. FNQ scores were estimated based on the following: Top graph: mean WSSQ total scores of the lowest (26.3), middle (36.3), and highest (44.3) tertiles, adjusting for depression score and use of OMMs (Model 1). Middle graph: mean WSSQ self-devaluation subscale scores of the lowest (11.1), middle (17.2), and highest (22.9) tertiles, adjusting for WSSQ fear of enacted stigma subscale score, depression score, and use of OMMs (Model 2). Bottom graph: mean WSSQ fear of enacted stigma subscale scores of the lowest (12.8), middle (18.8), and highest (23.3) tertiles, adjusting for WSSQ self-devaluation subscale score, depression score, and use of OMMs (Model 2). Among the demographic (i.e., age, sex, race, ethnicity), anthropometric (baseline BMI and weight), surgery (i.e., type of surgery, time since surgery), and mental health (i.e., depression, anxiety, and stress scores on DASS-21) variables examined, only the DASS-21 depression score was selected by LASSO and remained significant in Models 1 (p = 0.053) and 2 (p = 0.070). Mean VIF in Model 1 = 1.12; individual VIFs in Model 1 ≤ 1.21. Mean VIF in Model 2 = 1.22; individual VIFs in Model 2 ≤ 1.39. DASS-21, Depression Anxiety Stress Scales-21 item version; OMM, obesity management medication; SE, standard error; VIF, variance inflation factor.

4 ∣. Discussion

This study is the first to investigate WSS, food noise, and their interrelationship in the context of MBS. Findings showed food noise was higher among participants reporting greater WSS. When WSS was analyzed by subscales, higher levels of self-devaluation were significantly associated with increased food noise, while fear of enacted stigma was not. This pattern suggests that internal negative feelings about one's weight may drive food noise more than concerns about external judgment due to weight. While experiencing stigma is harmful, internalizing it appears to amplify its impact and may contribute to more persistent and intrusive thoughts about food and related behaviors and psychosocial issues [3, 7].

Importantly, this study assessed WSS and food noise during the postoperative weight stabilization phase, before most patients experience weight recurrence. About 60% of participants reported clinically significant WSS, and nearly half reported above-average food noise after substantial weight loss and stabilization. The findings suggest that high WSS is common and may amplify food noise during this vulnerable period, supporting the case for screening both WSS and food noise. Identifying individuals at risk could inform strategies to address WSS, reduce food noise, and potentially help prevent weight recurrence and the reemergence of obesity-related conditions.

Limitations should be noted. The cross-sectional design precludes determination of whether higher WSS drives greater food noise or vice versa, and we cannot determine how the relationship developed before or after the weight stability period. Prospective research with repeated measurements is needed to establish temporality and underlying mechanisms. Although validated measures were used, alternative measures with different foci could yield different results. For example, the Weight Bias Internalized Scale-Modified [23] emphasizes devaluation and appearance evaluation, while the RAID-Food Noise Inventory [24] is multidimensional. Future studies using multiple measures could be complemented by qualitative investigations that explore the deeply personal experiences of WSS, which are often resistant to modification, to gain a fuller understanding of the relationship between WSS and food noise. Finally, participants were enrolled in a trial aimed at increasing physical activity to prevent weight recurrence, which may limit generalizability to the broader MBS population.

5 ∣. Conclusion

This study is the first to link WSS and food noise during weight stability after MBS. Results suggest that WSS can increase the risk of higher food noise, with greater self-devaluation contributing more to this risk than fear of enacted stigma. To better understand this relationship, longitudinal research using multiple validated measures is needed to track changes over time, confirm the direction of association, and capture the full complexity of these constructs in a broader MBS population. Because WSS and food noise may undermine healthy behaviors, weight loss and maintenance, and health gains after MBS, routine screening and adjunctive interventions to mitigate these risks may be appropriate in clinical MBS practice.

Study Importance.

• Weight self-stigma is common among patients before metabolic and bariatric surgery (MBS) and can persist afterward, negatively impacting weight loss, physical activity, and eating behaviors.

• Food noise, defined as persistent and intrusive thoughts about food decisions, tends to decrease with obesity treatment, though most studies have focused on GLP-1 receptor agonist therapies.

• This study found that, on average, food noise was higher in adults with greater weight self-stigma during the post-MBS weight stability, and it suggests that higher food noise levels may be driven more by internal negative feelings about weight than by fear of external judgement due to weight.

• The findings indicate the need for further research to track how weight self-stigma and food noise relate across postoperative phases, clarify the direction of association, and develop integrated clinical interventions to mitigate risks and support better outcomes after MBS.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.