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. Author manuscript; available in PMC: 2022 Nov 1.
Published in final edited form as: Eat Disord. 2020 Mar 17;29(6):630–643. doi: 10.1080/10640266.2020.1731920

Internalized Weight Bias and Loss-of-Control Eating following Bariatric Surgery

Jessica L Lawson 1, Abigail LeCates 3, Valentina Ivezaj 2, Janet Lydecker 2, Carlos M Grilo 2,4
PMCID: PMC7494529  NIHMSID: NIHMS1568272  PMID: 32182194

Abstract

Objective:

Internalized weight bias (IWB), negative weight-related self-evaluation, is associated with eating-disorder psychopathology and is common among patients seeking bariatric surgery, but little is known about the clinical presentation of IWB post-operatively. This study examined IWB and clinical correlates among adult patients with loss-of-control (LOC) eating approximately 6 months post-sleeve gastrectomy surgery.

Methods:

Participants (N=145) were sleeve gastrectomy patients seeking treatment for eating/weight concerns and experiencing regular LOC eating approximately 6 months following surgery. Eating-disorder features were assessed with the Eating Disorder Examination-Bariatric Surgery Version interview (EDE-BSV) and participants completed established measures assessing IWB, depression, and mental and physical components of quality of life.

Results:

IWB was not associated significantly with percent excess weight loss, age, or gender, but White participants reported significantly greater IWB than Non-White participants. IWB was significantly associated with greater eating-disorder psychopathology, depression, and lower perceived mental quality of life. Hierarchical regression analysis revealed that IWB significantly predicted variance in eating-disorder psychopathology above and beyond other related variables.

Conclusions:

Findings suggest that IWB is common and associated with a range of heightened eating-disorder and psychosocial difficulties among patients experiencing LOC eating following bariatric surgery. Future research exploring the longitudinal post-operative prognostic significance of IWB is recommended.

Introduction

The prominent bias attached to obesity has a broad and adverse reach, affecting psychological, social, and medical well-being (Papadopoulos & Brennan, 2015; Pearl & Puhl, 2018; Udo, Purcell, & Grilo, 2016). Individuals who internalize this weight bias incorporate negative “anti-fat” stigmatizing stereotypes and beliefs into their self-evaluation (Durso & Latner, 2008). While internalized weight bias (IWB) can be experienced irrespective of actual weight status, it is strongly associated with having overweight/obesity (Papadopoulos & Brennan, 2015; Tomiyama et al., 2018). A growing base of literature suggests that IWB hinders weight loss and weight loss maintenance because it is consistently associated with lower self-esteem, depressive symptoms, binge-eating behavior, and maladaptive approaches to weight control, all of which may interfere with weight-loss efforts (Mensinger, Calogero, & Tylka, 2016; Sienko, Saules, & Carr, 2016). Individuals with obesity seeking long-term weight-loss solutions through bariatric surgery may represent a subgroup of patients vulnerable to IWB, which might contribute to poorer outcomes; however, research examining this construct among post-operative bariatric patients is currently limited.

Individuals with a higher body mass index (BMI), and specifically those meeting criteria for obesity and binge-eating disorder (BED), are at greater risk for IWB (Ashmore, Friedman, Reichmann, & Musante, 2008; Durso et al., 2012; Pearl & Puhl, 2014; Puhl, Himmelstein, & Quinn, 2018). Loss-of-control (LOC) eating, defined as the subjective experience of being unable to stop or control eating, is a cardinal feature of binge eating (Colles, Dixon, & O’Brien, 2008). Although patients who undergo bariatric surgery are typically unable to consume an objectively large amount of food due to surgical limitations, subjective LOC eating without unusually large quantities of food has been shown to occur post-operatively (Ivezaj et al., 2017). Converging evidence across the eating, bariatric, and weight bias literature suggests that the combination of LOC eating and IWB could influence weight outcomes and overall psychological well-being after bariatric surgery (Baldofski et al., 2016; Devlin et al., 2018; Lent et al., 2014; Mensinger et al., 2016). While pre-surgical disordered eating and psychological symptoms have largely not been demonstrated to predict surgical outcomes, post-surgical onset of LOC eating (White, Kalarchian, Masheb, Marcus, & Grilo, 2010) and depression (de Zwaan et al., 2011) are associated with poorer outcomes with weight regain trajectories beginning between 6 months to 2 years following surgery. LOC eating is also associated with lower overall health-related quality of life (HRQoL) up to 7 years post-operatively (Devlin et al., 2018). Similarly, IWB has been linked consistently with greater depressive symptoms and both physical and mental domains of HRQoL (Latner, Durso, & Mond, 2013; Sienko et al., 2016). Identifying vulnerable groups of individuals, as well as potentially modifiable variables such as IWB, is important for early and focused screening efforts. In turn, addressing eating and weight and/or psychological concerns through individualized clinical care prior to when negative effects begin to emerge could meaningfully improve outcomes (Kalarchian & Marcus, 2015).

Among individuals with obesity, IWB contributes independently to eating-disorder psychopathology, above and beyond other related factors (Durso & Latner, 2008). IWB has also been linked specifically with clinical levels of overvaluation of shape and weight (i.e., placing shape/weight high on the list of factors that influence self-value), which is thought to be a core feature of disordered eating and found to mediate the relationship between self-esteem and IWB among treatment-seeking patients with obesity and BED (Pearl, White, & Grilo, 2014). Further, individuals with obesity and high levels of IWB receiving treatment for disordered eating were less likely to improve, which may also stymie long-term weight loss and maintenance efforts and may translate to patients with disordered eating patterns following bariatric surgery (Mensinger et al., 2016).

Among both adults and adolescents seeking bariatric surgery, IWB appears to be an important clinical feature associated with greater psychopathology and poorer self-efficacy and health behaviors (Hubner et al., 2015; Roberto et al., 2012). However, much less is known about the clinical presentation of IWB among post-operative patients. One study by Lent et al., (2014) found that greater pre-operative IWB was associated with depressive symptoms and significantly less percent total weight loss one year after surgery. However, IWB was only assessed pre-operatively and the study was conducted with primarily gastric bypass patients (Lent et al., 2014), whereas currently, the sleeve gastrectomy surgery is more commonly used (Spaniolas et al., 2015). It is unknown if results generalize across surgery types and overall, there is extremely limited information about the postoperative clinical presentation of IWB. Moreover, no previous studies have examined IWB among post-operative bariatric patients with LOC eating, which may represent a more vulnerable subgroup. This investigation aimed to examine IWB and clinical correlates among adult patients with LOC eating approximately 6 months following sleeve gastrectomy surgery. We hypothesized that higher levels of IWB would be related to higher levels of depression, HRQoL functioning impairment, and eating-disorder psychopathology. We also expected that IWB would contribute significantly to eating-disorder psychopathology in this patient group, above and beyond other related variables.

Methods

Participants

Participants (N = 145) were adults seeking treatment for LOC eating four to nine months (M = 6.34 months, SD = 1.51) after sleeve gastrectomy surgery at the Yale Bariatric/Gastrointestinal Surgery Center of Excellence. This time frame was chosen given that LOC eating onset may be as early as a few months following surgery (Ivezaj et al., 2017; White et al., 2010). Participants from one bariatric center were recruited and enrolled between September 2014 and December 2017 by mailed letters and/or flyers or referred directly by the bariatric surgery team. Eligible participants were between the ages of 18 and 65 who reported regular LOC eating, defined as having difficulty stopping or preventing the eating episode irrespective of the amount of food eaten at least once/week. LOC eating was established at the time of assessment post-operatively and did not need to be present prior to surgery. Participants were excluded from the study if they met any of the following criteria: current use of weight-influencing medication, current substance dependence, or severe psychiatric condition requiring immediate treatment.

All study assessments, conducted by doctoral-level clinicians, were performed independently from the bariatric program. This study received approval from the Yale Institutional Review Board and all participants provided written informed consent prior to study procedures.

Measures

Weight Bias Internalization Scale

The Weight Bias Internalization Scale (WBIS) is an 11-item self-report measure that determines the degree to which respondents believe negative stereotypes and self-statements about overweight or obesity apply to themselves (Durso & Latner, 2008). Respondents rate their agreement with each item on a 7-point scale (1 = “strongly disagree” to 7 = “strongly agree”). A higher score indicates greater IWB. Among a community sample of adults with overweight or obesity, the scale was found to have good reliability and convergent validity (Durso & Latner, 2008). In more recent psychometric studies, suggestions have been made to reduce items to improve fit (Durso, Latner, & Ciao, 2016; Hilbert et al., 2014; Lee & Dedrick, 2016); however, given that this is the first study to examine IWB using this scale among post-operative bariatric surgery patients with LOC eating, the validated 11-item scale was used. In the present study, scale reliability was good (α = .87), and consistent with previous research (α = .90) (Durso & Latner, 2008).

Beck Depression Inventory-Second Edition

The Beck Depression Inventory-Second Edition (BDI-II) is a 21-item self-report questionnaire measuring current depressive symptoms and negative affect (Beck, 1996). Respondents assign a numerical value, 0–3, to each item and higher scores suggest greater depressive symptoms. Scale reliability was excellent in this sample (α = .92).

Eating Disorder Examination-Bariatric Surgery Version

The Eating Disorder Examination-Bariatric Surgery Version (EDE-BSV) is a semi-structured clinical interview which was adapted for bariatric patients and designed to assess the range and severity of eating-disorder psychopathology, including LOC eating, during the past 28 days (de Zwaan et al., 2010; Fairburn, 1993). LOC eating episodes were defined as number of episodes with a sense of loss of control endorsed during the past month. Constructs include eating restraint, dissatisfaction with shape and weight, and overvaluation of shape and weight. A cut-point of ≥ 4 on the EDE-BSV overvaluation items was used to categorize “clinical” levels of overvaluation of shape/weight following previous research conventions (Goldschmidt et al., 2010). Psychometric support for an alternative three-scale structure of the EDE (Eating Restraint, Dissatisfaction, and Overvaluation) was demonstrated to be appropriate for use among bariatric candidates and was used in the present study (Grilo, Henderson, Bell, & Crosby, 2013). Cronbach’s alpha for the alternative EDE global score in this sample was .67.

The Medical Outcomes Study Short Form Health Survey

The Short-Form 36 Health Survey (SF-36) is a 36-item self-report health-related quality of life measure (Ware & Sherbourne, 1992). Scores are computed into two norm-based summary scores that follow a t-distribution: physical component summary (α = .93) and mental component summary (α = .81) with higher scores suggestive of better functioning. The measure has strong psychometric properties, including validity and reliability, and is appropriate for use among bariatric populations (Kolotkin & Andersen, 2017).

Weight Variables

Pre and post-surgical BMI were calculated based on measured height and weight. Pre-surgical BMI was obtained from participants’ medical records and post-surgical BMI was measured by the research team at the initial study evaluation approximately six months post-surgery. Change in BMI was calculated as the difference between pre-surgical and post-surgical BMI values. Percent excess weight lost (%EWL) was calculated as the difference between pre-surgical and post-surgical weight, divided by the weight that would put the participant at a BMI of 25 kg/m2. Percent total weight lost (%TWL) from pre to post-surgery was calculated as the difference between pre-surgical weight and post-surgical weight, divided by the participant’s pre-surgical weight. Change in BMI, %EWL, and %TWL are standardized variables used widely in the reporting of weight-loss outcomes after bariatric surgery (Brethauer et al., 2015).

Statistical Analyses

Data were analyzed using SPSS version 24 and p value of <.05 was considered statistically significant. Descriptive statistics, including frequencies, means and standard deviations, were used to summarize the sample demographics. Log transformation was used to correct for skewness of the LOC eating frequency variable. Pearson’s correlations were used to examine the linear relationships among IWB, eating-disorder psychopathology, depression, physical and mental functioning, and weight variables, including current BMI and change in BMI since surgery. An independent samples t-test was used to test for group differences in IWB between participants with clinical overvaluation and sub-clinical overvaluation. Hierarchical regression modeling assessed the contribution of IWB to the proportion of variance in eating-disorder psychopathology above and beyond other independent variables.

Results

The majority of participants were female (n = 120, 82.8%). Racial/ethnic distribution of participants was as follows: White non-Hispanic (51.0%), Black non-Hispanic (33.8%), Latinx (9.7%) and other (5.5%). The mean age and body mass index (BMI) were 45.4 (SD = 11.1) years and 37.7 (SD = 7.2) kg/m2, respectively. Mean pre-surgical BMI was 46.8 kg/m2 (SD = 8.9) and the mean percent excess weight lost (%EWL) was 43.8% (SD = 16.5).

Across the overall participant group, the WBIS mean score was 3.83 (SD = 1.37; range = 1–7). 21.4% of the participant group had an average score ≥ 5, indicating a relatively higher level of IWB (range = 1–7). WBIS was not significantly related to time since surgery (r = −.16, p = .07) or participant age (r = .11, p = 0.21) and there was no significant difference in WBIS scores between women (M = 3.83, SD = 1.40) and men (M = 3.86, SD = 1.24), t(128) = −.10, p = .92. Participants who identified as White endorsed significantly higher WBIS scores (M = 4.16, SD = 1.33) compared with non-White participants (M = 3.50, SD = 1.35), t(128) = −2.84, p < .01. Weight bias was examined dimensionally with weight variables; no significant associations were found between WBIS and %EWL (r = −.08, p = .39), %TWL (r = −.02, p = .81), BMI change (r = .02, p = .81) or post-operative BMI (r = .08, p = .37).

Table 1 displays the correlations between WBIS total score and outcome measures. WBIS scores were significantly correlated with BDI-II total score and the SF-36 mental component score but not with the physical component score on the SF-36. With regard to eating-disorder psychopathology, WBIS scores were associated significantly with the EDE global score, all three subscales Rrestraint, Dissatisfaction with Weight/Shape, and Overvaluation with Weight/Shape) and with frequency of LOC-eating episodes. When overvaluation was examined dichotomously, WBIS scores were significantly higher for patients with clinical levels of overvaluation (M = 4.68, SD = 1.31) relative to patients endorsing sub-clinical levels (M = 3.30, SD = 1.34), t(77) = −4.48, p < .001.

Table 1.

Means, standard deviations, and correlations of WBIS symptoms, eating and general psychopathology (n=130)

M [SD] 1 2 3 4 5 6 7 8 9
1. WBIS Total 3.83 (1.37) 1 -- -- -- -- -- -- -- --
2. BDI-II 12.11 (10.32) .62** 1 -- -- -- -- -- -- --
3. SF-36 Physical Component 46.69 (10.69) −.12 −.29** 1 -- -- -- -- -- --
4. SF-36 Mental Component 48.15 (10.66) −.63** −.77** .04 1 -- -- -- -- --
5. EDE Global 2.95 (1.30) .53** .46** −.30** −.41** 1 -- -- -- --
6. EDE Restraint 3.17 (1.82) .19* .12 −.10 −.12 .69** 1 -- -- --
7. EDE Dissatisfaction 2.95 (1.61) .45** .48** −.34** −.43** .73** .26** 1 -- --
8. EDE Overvaluation 2.74 (1.91) .49** .40** −.21* −.35** .76** .23** .40** 1 --
9. LOC episodes† 1.51 (.42) .32** .41** −.15 −.39** .37** .12 .38** .32** 1
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Note. WBIS = Weight Bias Internalization Scale; BDI-II = Beck Depression Inventory II; SF-36 = Short Form Health Survey; EDE = Eating Disorder Examination; LOC = loss of control

†

log transformation used to correct for skew

*

p < .05

**

p < .01

Table 2 summarizes the results of the hierarchical regression analysis used to examine how WBIS, SF-36 mental component score, race/ethnicity (White vs. Non-White), and BDI-II contribute to the variance in global eating-disorder psychopathology. All variables except WBIS were added to the model in step 1. These variables were included because they were related to global eating-disorder psychopathology at the bivariate level. In step 2, WBIS was added to the model and was the only variable to remain significant, explaining an additional 8.0% of the variance.

Table 2.

Summary of multiple regression analysis predicting global eating-disorder pathology

Dependent Variable Block R Model R2 F R2 Change F Change Independent Variables Standardized Beta
EDE Global Score 1 .47 .22 11.71 .22 11.71** BDI-II 0.34**
SF-36 MCS −.14
Race/Ethnicity 0.11
2 .55 .30 13.40 .08 14.66** BDI-II 0.19
SF-36 MCS −.00
Race/Ethnicity .00
WBIS .41**
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Note: EDE= Eating Disorder Examination, BDI= Beck Depression Inventory, SF-36 MCS= Short-Form 36 Health Survey Mental Component Score, WBIS= Weight Bias Internalization Scale;

*

p<.05

**

p<.01

Discussion

Findings suggest that following sleeve gastrectomy surgery, among patients with LOC eating, IWB is associated with greater eating-disorder psychopathology, overvaluation of shape/weight, depression, and poorer self-reported mental health. These results extend the literature by highlighting the clinical salience of IWB and eating-disorder psychopathology in the postoperative bariatric surgery period. One fifth of the participant group endorsed relatively high IWB (score ≥ 5 on WBIS) and the mean score of 3.83 was only moderately lower than the average score of 4.54 reported among pre-surgical patients (Lent et al., 2014). While previous research has found IWB to be greater among women compared with men and with younger age, we did not replicate these age and sex-related findings (Baldofski et al., 2016; Hilbert et al., 2014). It may be that among patients with LOC eating and the subsequent increased psychological burden, individuals experience IWB regardless of sex or age, but further research is needed to clarify these relationships. With regard to IWB and racial/ethnic differences, results in the literature are mixed. Among a group of pre-bariatric patients, no difference was observed (Lent et al., 2014); however, research in non-bariatric study groups is consistent with findings of the current study that White participants endorsed significantly higher levels of IWB compared with non-White participants (Barnes, Ivezaj, & Grilo, 2014; Lydecker, Cotter, & Grilo, 2019). A strength of this study is the relatively similar proportions between racial/ethnic groups (51% White and 49% non-White), although future research with greater diversity within the non-White category would provide greater understanding of relations with eating-disorder psychopathology and weight variables.

In our participant group, WBIS scores contributed significantly to variance in eating-disorder psychopathology after accounting for the contributions of related variables (self-reported mental health, race/ethnicity, and depression). This finding is consistent with previous work that found that WBIS was independently associated with eating-disorder psychopathology among patients with BED and obesity (Durso et al., 2012). Significant IWB above and beyond other related variables also aligns with research conducted with pre-surgical patients that suggests patients with high levels of IWB are at risk for non-normative eating behaviors, particularly if they experience difficulties with emotion regulation (Baldofski et al., 2016).

LOC eating, a reliable predictor of surgical weight outcomes is known to persist post-operatively (White et al., 2010); in a 3-year longitudinal trial, Devlin et al. (2016) found that 12% of patients reported continued experiences of LOC eating, which relative to other eating-disorder psychopathology, did not reduce significantly post-operatively.Due to the poorer post-surgical outcomes associated with LOC eating, identifying IWB as an independent contributor to eating-disorder psychopathology in this patient group may hold clinical significance, and suggests the need for future studies to evaluate whether treatments for bariatric patients with LOC eating would benefit from interventions aimed at reducing IWB. Indeed, an 8-week course of cognitive-behavioral treatment targeting IWB among individuals with obesity and high levels of IWB contributed to a significant decrease in IWB and fat phobia (Pearl, Hopkins, Berkowitz, & Wadden, 2018), which suggests that IWB is modifiable even within a short-term treatment context.

Overvaluation of shape and weight, thought to be a key factor in the maintenance of disordered eating (Wang, Jones, Dreier, Elliott, & Grilo, 2019) and found to predict poorer outcomes (Grilo, White, Gueorguieva, Wilson, & Masheb, 2013), was positively associated with IWB. We also found that individuals with clinical levels of overvaluation reported significantly greater IWB than those with subclinical levels of overvaluation. We cautiously offer the clinical hypothesis for future research that placing greater value on weight and shape may increase vulnerability to or perception of appearance-based criticism, thus allowing for greater IWB, begetting greater weight/shape overvaluation (Pearl et al., 2014). As expected from earlier work (Latner, Barile, Durso, & O’Brien, 2014; Lent et al., 2014; Sienko et al., 2016) IWB was also associated with depression and greater perceived impairment in mental health functioning. Longitudinal research is warranted to clarify the relationship among these variables; it is possible, for example, that depression and/or eating pathology may mediate the relationship between IWB and mental health functioning. Taken together with evidence that emotion regulation mediates the relationship between IWB and non-normative eating behaviors (Baldofski et al., 2016), a testable hypothesis is that the negative cognitive appraisal implicit to depression and IWB leads to poor coping via LOC eating, dietary restriction, experiential avoidance, and impairment in HRQoL (Friedman, Ashmore, & Applegate, 2008; Latner et al., 2014; Latner et al., 2013) These symptoms may have broad-reaching longitudinal implications on psychological well-being after surgery and future research should investigate whether IWB predicts or moderates treatment and weight outcomes in this patient group.

A focal post-operative outcome across the bariatric literature is weight change, often described in %EWL or %TWL (Brethauer et al., 2015). In our participant group, IWB was not significantly associated with weight outcome variables. However, on average, our participant group was 6 months post-operative; this time point may have been too early to observe a signal between IWB and weight change. We also hypothesize that the LOC eating experienced by the participants in this study might have contributed to a more restricted range of weight loss, thus hindering our ability to capture weight loss impaired by IWB. However, IWB is experienced irrespective of weight status (Pearl & Puhl, 2014), and seems to be a predictor of poor weight-loss maintenance among treatment-seeking patients with obesity (Pearl et al., 2019); findings from the current study support the argument that the extent of change in weight immediately after surgery might not be important clinically and early intervention is vital, although future research should examine IWB interventions and longitudinal association among post-bariatric patients.

Previous research suggests that post-operative weight stigma predicts worse dietary adherence in patients who undergo bariatric surgery, even after controlling for weight loss (Raves, Brewis, Trainer, Han, & Wutich, 2016). Among this patient group, there are multiple factors that can influence weight-loss trajectory and in some, poorer post-surgical outcomes are not observed until approximately 18 months post-surgery (Conceição et al., 2017). Nonetheless, given evidence demonstrating significantly poorer weight outcomes among patients with LOC-eating (Devlin et al., 2018) and pre-operative IWB (Lent et al., 2014), early screening and intervention for IWB with this patient group might potentially decrease subsequent effects of IWB on weight and other psychosocial domains.

Our findings pertain to patients who were experiencing LOC eating after undergoing sleeve gastrectomy procedures and may not generalize to other patient groups (e.g., different weight-loss surgery procedures, patients who undergo bariatric surgery without post-operative eating concerns). Study limitations include the use of self-report measures to assess IWB, depression, and HRQoL functioning, rather than clinician guided assessment. The marginal internal consistency of the EDE-BSV in this sample is a potential limitation, reinforcing the call for continued measurement development and psychometric testing for bariatric-specific instruments (Ivezaj, 2019). The majority of our participant group was comprised of women, although this over-representation is common across the bariatric literature (Young, Phelan, & Nguyen, 2016). The cross-sectional design precludes interpretations regarding causality; we were unable to discern the temporal relationship between IWB and eating-disorder psychopathology. Future research should focus on the longitudinal experience and prognostic significance of IWB post-surgically, particularly when patients are at risk for weight regain.

Conclusions

IWB, one of the more common forms of stigma that quite unfortunately might remain socially acceptable by some (Puhl & Heuer, 2009), appears to be of clinical importance postoperatively among patients who undergo bariatric surgery. Previous research has established that preoperative bariatric patients are at risk for IWB (Lent et al., 2014; Roberto et al., 2012), but this is the first to examine IWB among postoperative patients with LOC eating. The findings emphasize the breadth of psychopathology that some patients experience post-operatively in addition to clinical implications of the way in which IWB might contribute to disordered eating post-surgically. Ultimately, these results represent new information describing the nature of IWB and clinical correlates in the acute postoperative period and highlight the need for future studies examining the long-term prognostic significance of IWB following bariatric surgery.

Clinical Implications:

  • Internalized weight bias is common among post-operative bariatric patients with loss of control eating

  • It is associated with disordered eating and psychosocial symptoms

  • Greater emphasis should be placed on post-operative assessment and treatment

  • Future research exploring the longitudinal prognostic significance is recommended

Acknowledgments

This research was supported, in part, by NIH grant R01 DK098492 (Dr. Grilo).

Footnotes

The authors declare no conflicts of interest. Outside the submitted work, Dr. Grilo reports grants from National Institutes of Health, personal fees from Sunovion, Shire, and Weight Watchers International, and royalties from Guilford Press and Taylor and Francis Publishing.

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