Association between food addiction and body image dissatisfaction in bariatric surgery candidates: a cross-sectional study

Abstract

Background

The pursuit of highly palatable foods as a reward can lead to dysfunctional eating behaviors. In bariatric surgery candidates, symptoms of food addiction may impact postoperative weight loss, increase the risk of developing psychological and behavioral disorders, and influence body image perception. The objective was to determine the association between food addiction and body image dissatisfaction in bariatric surgery candidates.

Methods

This cross-sectional study was conducted at the Multidisciplinary Outpatient Clinic for Surgical Obesity at Hospital de Clínicas of the Federal University of Paraná, Curitiba, Brazil. The sample included 124 participants. The Modified Yale Food Addiction Scale 2.0 (mYFAS 2.0) was used to assess food addiction symptoms, the Body Shape Questionnaire (BSQ) to evaluate body dissatisfaction. Anthropometric measurements included weight and height, which were used to calculate Body Mass Index (BMI). Associations between categorical variables were analyzed using the chi-square test or Fisher’s exact test. The Mann-Whitney test was used to compare numerical variables between groups. The relationship between food addiction and body dissatisfaction was assessed using binary logistic regression, adjusted for covariates. Model fit was verified using the Hosmer-Lemeshow test (χ² = 9.47, df = 7, p = 0.221), and the absence of multicollinearity was confirmed by variance inflation factor (VIF) values (< 2).

Results

The majority of participants were female (n = 102; 80%), with a mean age of 40 ± 13 years and a BMI of 46 ± 7 kg/m². Body dissatisfaction was observed in 69% (n = 86), and food addiction symptoms in 21% (n = 26). Individuals with moderate/severe body dissatisfaction had significantly higher odds of exhibiting FA symptoms compared to those with no/low dissatisfaction, both in univariate (OR = 2.53; 95% CI: 1.05–6.31; p = 0.041) and adjusted analyses (OR = 2.85; 95% CI: 1.12–7.60; p = 0.030), for age, BMI, sex, and race/ethnicity.

Conclusions

The findings of this study suggest that the absence or low levels of body dissatisfaction are associated with a decreased likelihood of food addiction symptoms. These findings highlight the need for an integrated approach in the treatment of bariatric surgery candidates, considering psychological and behavioral aspects to ensure long-term success.

Trial registration: Trial registration number RBR-5yf2zv5.

Plain English Summary

Food addiction is characterized by the compulsive intake of highly palatable foods that stimulate the brain’s reward pathways, often resulting in a loss of control and emotional distress. This pattern of behavior can hinder effective weight management and is particularly pertinent among individuals preparing for bariatric surgery. Additionally, body image dissatisfaction is prevalent within this population and may negatively impact eating behaviors and psychological health.In this study, 124 participants were assessed. Food addiction symptoms were measured using the Modified Yale Food Addiction Scale 2.0 (mYFAS 2.0), while body dissatisfaction was evaluated with the Body Shape Questionnaire (BSQ). Anthropometric data were also collected. Results indicated that individuals with food addiction reported significantly higher BSQ scores. Moreover, participants with moderate to severe body dissatisfaction were significantly more likely to exhibit symptoms of food addiction compared to those with low or no dissatisfaction.These findings highlight the need for an integrated approach in the treatment of bariatric surgery candidates, considering psychological and behavioral aspects to ensure long-term success.

Introduction

Obesity is one of the main global public health concerns due to its chronic and multifactorial nature, influenced by behavioral, genetic, environmental, and psychological factors [1], with individuals presenting distinct health profiles and needs [2]. The consumption of hyperpalatable ultra-processed foods, which are high in fats, refined carbohydrates, and salt, may contribute to weight gain and obesity [3]. Both obesity and food addiction (FA) are associated with a reduction in dopamine D2 receptors in the brain and dysfunctional opioid system, suggesting lower sensitivity to food-related stimuli. Dopaminergic pathways are involved in addictive processes and depressive symptoms and may explain the engagement in repetitive problematic eating behaviors [4].

FA is a subject of intense discussion and research, despite the lack of a standard definition and consensus within the scientific community [5,6,7,8]. A recent study has shown that post-ingestive striatal dopamine responses to an ultra-processed milkshake are likely substantially smaller than those elicited by many addictive drugs and may vary among individuals with different body weights, thereby refuting the hypothesis that individuals are addicted to food. In response to this debate, the predominant theoretical framework is the concept of food craving, which is regarded as a constituent element of addiction to highly palatable, energy-dense foods [9].

Although the hypothesis of food addiction has gained traction in recent literature and may contribute as a relevant factor to the development and severity of obesity, its prevalence ranges from 15% to 57% and is disproportionately higher among women and young individuals [10]. FA is more prevalent in clinical groups, affecting 70–90% of patients with binge eating disorder (BED) and 14–58% of candidates for bariatric surgery [4].

It is important to note that FA is not formally recognized in the DSM-5-TR as a mental disorder, substance use disorder criteria have been adapted to identify 11 symptoms of FA. These symptoms include excessive intake, lack of control, excessive time spent on eating, abandonment of activities other than eating, consumption despite consequences, progressive increase in intake, withdrawal symptoms, negative social impact, functional impairment, engagement in risky situations, and intense craving. Identifying these patterns reinforces FA’s relevance in the context of eating disorders and obesity [7, 11].

Weight stigma experienced by individuals with obesity may lead them to consume hyperpalatable foods as a way to cope with stress, increasing the risk of disordered eating behaviors and obesity. This stigma exerts a negative psychological impact, often associated with emotional disturbances, depression, and mixed disorders, as well as body dissatisfaction [7, 12]. The actual perception of body weight can vary significantly, influencing weight control measures, quality of life, and body image [13]. Body dissatisfaction may also lead individuals to restrict their food intake, which can, in turn, heighten hunger and appetite, ultimately contributing to the consumption of more hyperpalatable foods and episodes of binge eating [14, 15]. Finally, body dissatisfaction is one of the primary motivations for individuals with obesity to seek bariatric surgery [7] which justifies the interest in studying this phenomenon among patients scheduled for the procedure.

Considering that symptoms of FA are frequently observed in individuals with obesity and that, to date, no studies have evaluated the relationship between addiction and body dissatisfaction in individuals with severe obesity, the present study aimed to determine whether there is an association between FA symptoms and body dissatisfaction in candidates for bariatric surgery.

Methods

Study population

This cross-sectional study included individuals undergoing preoperative evaluation for bariatric surgery at the Multidisciplinary Outpatient Clinic for Surgical Obesity at Hospital de Clínicas of the Federal University of Paraná (CHC/UFPR), Curitiba, Brazil. The individuals were assessed between March 2023 and March 2024. The study was approved by the Ethics Committee in Research with Humans of the Hospital (CAAE 66687623.9.0000.0096). Participants signed one copy of the Informed Consent Form in compliance with Resolution 466/12 (research involving human subjects) of the National Health Council, Ministry of Health. According to the bariatric surgery guidelines, commonly require either BMI at least 40 kg/m² or 35 kg/m² with comorbidity. Individuals with severe psychiatric disorders, genetic syndromes, alcohol or drug dependence were excluded. According to the protocol adopted by the Bariatric Surgery Team at the Hospital de Clínicas of the Federal University of Paraná (UFPR), only individuals who have ceased alcohol and tobacco use are eligible to undergo surgery.

These conditions were assessed during the initial screening of volunteers. Participants who did not complete all data collection stages or failed to cooperate after five contact attempts were also excluded. Trial registration number: RBR-5yf2zv5.

Study protocol

Subjects underwent a clinical assessment including medical history, physical examination, and comorbidity evaluation by a multidisciplinary consultation team (surgeon bariatric, psychiatric, psychologist and dietitian). In addition, anthropometric measurements were taken during the appointments. The recruitment process occurred as part of the standard clinical assessment at the hospital. Additional data were collected from the hospital’s electronic system after the patient agreed to participate in the study. Self-classification by color or race was conducted in accordance with the official framework established by the Brazilian Institute of Geography and Statistics (IBGE). Participants were asked to identify themselves using a closed-ended question with the five standardized categories adopted by the IBGE: White, Black, Brown, Yellow, and Indigenous. This standardized classification system is widely adopted in demographic and sociological research in Brazil and aims to capture the diverse racial and ethnic composition of the population based on self-perception [16].

All patients will undergo Roux-en-Y gastric bypass (RYGB) surgery. The procedure will be performed via laparotomy by an experienced surgeon. A 50-mL gastric pouch will be created, and the jejunum will be divided 100 cm distal to the ligament of Treitz. The gastrojejunostomy will be hand-sewn. The duodenum and proximal portion of the jejunum will be bypassed to construct a 100-cm Roux limb. A silastic ring will be placed between the gastric pouch and the small bowel [15].

Assessment

Modified Yale food addiction scale version 2.0 (mYFAS 2.0)

The mYFAS 2.0 is a 13-item self-report questionnaire proposed by Schulte and Gearhardt (2017) [17], validated in Brazil by Nunes-Neto (2018) [18], and applied following the classification method recommended by Silva Júnior and Bueno (2022) [19]. This instrument was developed to identify symptoms associated with eating patterns analogous to substance dependence, based on the DSM-5-TR criteria [11]. In Brazil, its translation and application in a large non-clinical sample (n = 7,639) demonstrated high reliability, a consistent single-factor structure, and a positive correlation with impulsivity [20].

In this version, items are rated on a 7-point Likert scale (ranging from never to every day), with two auxiliary interpretations. The categorical interpretation identifies a positive screening for FA when at least two symptoms are present along with significant clinical distress or psychosocial impairment. In the continuous interpretation, the number of endorsed symptoms is considered. The risk threshold classifies FA as mild (2–3 symptoms with significant clinical distress or psychosocial impairment), moderate (4–5 symptoms with significant clinical distress or psychosocial impairment), or severe (6 or more symptoms with significant clinical distress or psychosocial impairment) [21,22,23].

Body shape questionnaire (BSQ)

The BSQ was used to assess body image dissatisfaction. It was originally proposed by Cooper et al. (1987) [24], translated and validated by Pietro and Silveira (2009) [25], and later adapted by Silva et al. (2016) [26]. This instrument evaluates concerns about weight gain after eating, excessive preoccupation with body shape, and feelings of embarrassment and public avoidance. It consists of 34 self-reported items rated on a 6-point Likert scale, ranging from never to always. The total score is obtained by summing the responses, leading to the following classification: scores below 80 indicate no body image dissatisfaction; scores between 80 and 110 indicate mild dissatisfaction; scores between 110 and 140 indicate moderate dissatisfaction; and scores above 140 indicate severe dissatisfaction [26]. The total score ranges from 34 to 204 points.

Anthropometric assessment

Nutritional status was assessed through anthropometry, including body weight and height measurements. Body weight was measured using a Filizola^® mechanical scale (model 31) with a maximum capacity of 300 kg. Height was measured using a 2-meter stadiometer attached to the scale, with the participant barefoot, heels together, feet slightly apart, back straight, arms extended along the body, and head positioned in the Frankfurt plane. BMI was calculated using the formula W/(H)², where W represents weight in kilograms (kg) and H represents height in meters (m), with nutritional status classified according to WHO (2000) cutoff points.

Statistical Analysis.

The sample size calculation was performed using G*Power 3.1.9.4 for a point-biserial correlation model [27]. A significant level of 5%, a test power of 75%, and a medium effect size of 0.32 were considered. The estimated prevalence of FA symptoms (32%) was based on a previous study [22]. This calculation determined the minimum required sample of 120 individuals.

In the descriptive analysis, numerical variables were presented as mean and standard deviation, as well as median and interquartile range. Categorical variables were described in tables of absolute and relative frequencies. The study included 127 participants; however, for the association analyses, only the 124 individuals with complete data were considered.

To investigate the association between the presence of FA (yes or no) and the explanatory variables, association tests were conducted. Categorical variables were analyzed using the chi-square test of independence or, when necessary, Fisher’s exact test. For numerical variables, the Mann-Whitney test was applied due to the absence of normality assumptions in the data.

Subsequently, the association between the presence of FA symptoms and levels of body dissatisfaction was assessed using binary logistic regression. Univariate analyses were performed to explore the relationship between each predictor variable and the dependent variable. Afterward, an adjusted model was built, including age, body mass index (BMI), sex, and race/ethnicity as control variables.

The predictors included in the adjusted model were: age (years), BMI (kg/m²), sex (male/female), race/ethnicity (white, black, and mixed-race), and level of body dissatisfaction (classified as No/Low dissatisfaction and Moderate/Severe dissatisfaction). The No/Low dissatisfaction category was used as the reference. The results were expressed as odds ratios (OR) with 95% confidence intervals (95% CI). The Hosmer-Lemeshow test was used to assess the fit of the multivariable model. The test result indicated that the model had a good fit to the data, with χ² = 4.93, df = 7, and p = 0.668.

To evaluate the presence of multicollinearity among independent variables, the variance inflation factor (VIF) was calculated. All VIF values were below 2, ranging from 1.05 to 1.20, indicating no significant multicollinearity among the predictors included in the model. A significance level of 5% was adopted. All analyses were conducted using the R Core Team 2025 software [28].

Results

From March 2023 to March 2024, 166 patients were invited to join the study, and 127 agreed to participate. In total, 124 volunteers completed all the evaluations. Of the 124 participants, 21% (n = 26) exhibited FA symptoms, including 6.5% (n = 8) at mild risk, 6.5% (n = 8) at moderate risk, and 8% (n = 10) at severe risk, while 79% (n = 98) did not show FA symptoms. In terms of sex, 80% (n = 78) of participants without FA and 81% (n = 21) of those with FA were female, with no significant difference between groups (p = 0.999). The mean age was similar across groups, with 40.59 ± 12.74 years for those without FA symptoms and 38.08 ± 13.66 years for those with FA symptoms (p = 0.362). There was no significant difference in BMI (p = 0.606), with mean values of 45.66 ± 7.15 kg/m² for the group without FA and 46.34 ± 6.40 kg/m² for the group with FA (Table 1).

Regarding race/ethnicity, 43% (n = 42) of the participants without FA symptoms and 46% (n = 12) of those with FA symptoms identified as White; 30% (n = 29) and 42% (n = 11), respectively, identified as Black; and 13% (n = 13) and 8% (n = 2), respectively, identified as Mixed-race. No significant difference was found between the groups (p = 0.372).

Moderate/severe body dissatisfaction was more prevalent among participants with FA symptoms (62%, n = 16) compared to those without FA symptoms (39%, n = 38), although this difference did not reach statistical significance (p = 0.063). In contrast, participants with FA had significantly higher BSQ scores (138.08 ± 40.32 vs. 99.60 ± 43.84; p < 0.001) (Fig. 1).

Fig. 1

Distribution of Body Dissatisfaction levels according to the Presence of Food Addiction symptoms

Table 1 Distribution of demographic, anthropometric variables according to the presence of food addiction symptoms

Although the descriptive analysis suggested a trend, logistic regression analysis (Fig. 2) confirmed that individuals with moderate/severe body dissatisfaction had significantly higher odds of exhibiting FA symptoms compared to those with no/low dissatisfaction, both in univariate (OR = 2.53; 95% CI: 1.05–6.31; p = 0.041) and adjusted analyses (OR = 2.85; 95% CI: 1.12–7.60; p = 0.030). The results, further illustrated in Fig. 2, show that this was the only predictor to maintain a significant association with the outcome after controlling variables. No other variable (age, BMI, sex, and race/ethnicity) showed a significant association in the adjusted analysis, as their 95% confidence intervals for the adjusted odds ratios crossed the value 1.0, indicating insufficient evidence of a relationship in this study.

Fig. 2

Univariate and adjusted logistic regression analysis for the association between the presence of food addiction symptoms and predictor variables. BMI: body mass index

Discussion

The present study explored the relationship between FA symptoms and body dissatisfaction in individuals seeking bariatric surgery, with a particular focus on the frequent occurrence of FA symptoms in those with obesity. Previous research suggests that the increased consumption of hyperpalatable foods is linked to the presence of FA [15, 29]. However, to the best of our knowledge, no prior studies have identified a direct association between FA and body dissatisfaction. The key finding of this study was the evidence that body dissatisfaction is associated with the presence of FA symptoms in the studied population.

Food addiction is part of a broader pathological framework where the neurobiology of eating disorders reveals an eating behavior phenotype similar to substance dependence, distinguishing it from other disorders in the eating disorder spectrum, such as Binge Eating Disorder and Bulimia Nervosa [21, 22]. While there does not seem to be a direct link between body weight and food addiction (FA), weight stigma plays a critical role in understanding this condition. Individuals with severe obesity, along with the stigma surrounding the condition, often experience higher rates of FA. Greenberg et al. (2021) examined how internalized stigma can lead to social isolation and increased compulsive food consumption as a way of coping with emotional distress [30]. Similarly, Koehler et al. (2021) found that weight stigma contributes to the continuation of disordered eating behaviors, negatively impacting psychological well-being and the success of bariatric interventions [31]. In Bianciardi’s (2019) study, the primary predictors of body image dissatisfaction included binge eating, depression severity, female sex, and insecure attachment traits, highlighting the importance of mood assessments and evaluations of psychological and psychiatric symptoms [32].

Based on mYFAS 2.0 assessments, 21% of participants of this study exhibited symptoms of food addiction. It is believed that one of the reasons for seeking surgery is the difficulty in controlling eating behaviors to manage body weight. A systematic review and meta-analysis of 40 studies found a prevalence of FA in 32% of patients during the preoperative period (95% CI: 27–37%) [22]. Additionally, Koball (2021), in an analysis of 1,006 patients undergoing pre-surgical psychological evaluations, reported a prevalence of 18%, with 56% of these individuals exhibiting severe FA symptoms [5].

On the other hand, Lipsky et al. (2024) reported a prevalence of FA symptoms in 4.7% of young adults, with 91% of cases occurring in women, and found no correlation with other sociodemographic factors [33]. It is important to note that the predominance of female participants may limit the generalizability of these results to both sexes. Consistent with this finding, the demand for bariatric surgery remains higher among women, as observed in the present study.

Current scientific evidence suggests that women with obesity are more prone to social isolation, disordered eating behaviors, and body image dissatisfaction, which serve as major motivators for seeking surgical treatment. This supports the hypothesis that men experience less societal pressure related to body aesthetics, resulting in lower levels of body dissatisfaction [34, 35]. In a cross-sectional study by Bianciardi (2019), which included 536 pre-bariatric surgery patients (70.7% women) with an average age of 43.88 years and a mean BMI of 42.98 kg/m², 60% of participants reported moderate or severe body dissatisfaction [32]. Similarly, the study by Bosc et al. (2022), which assessed 61 patients before and five years after bariatric surgery, found significant improvements in body image satisfaction and self-confidence within 12–18 months postoperatively. However, these effects were not sustained over the full five years following surgery [36].

Although a correlation between BMI and FA is expected in the population with obesity, due to FA’s impact on eating behavior and body weight, there is still limited research to fully explore this relationship. In the Brazilian cross-sectional study by Lima et al. (2024), which followed 303 participants across all BMI levels for 21 months (mean age 37.03 years, 84.16% women), FA symptoms were identified in 40.26% of participants (n = 122), with a significant but weak positive association between FA and BMI [20]. Similarly, the Spanish cross-sectional study by Escrivá-Martinez et al. (2023), which included 400 university students (51% women, mean age 23.35 years, mean BMI 21.90 kg/m²), found a prevalence of 31.9% of FA symptoms but did not observe a positive association between BMI and FA, which aligns with our findings [37].

Other studies suggest that psychiatric distress and body image dissatisfaction may be worsened by FA, creating a vicious cycle of binge eating, guilt, and shame that begins in the preoperative period. Cassin et al. (2021), evaluated post-operative bariatric surgery patients and found that those with FA reported greater binge eating characteristics and psychiatric distress relative to those without FA symptoms [38]. Recently, Kalan et al. (2024) further support this connection, noting that body image dissatisfaction is directly linked to the worsening of psychiatric symptoms in adults with FA [39].Lacroix et al. (2019), in their study on how Brazilian adults define and experience “addictive eating,” highlight the interrelation between FA and body image disturbances. Their findings suggest that body image distress accounts for more variance in psychosocial impairment related to eating than YFAS scores alone. These results underscore the importance of addressing potential body image disturbances in interventions aimed at treating FA [40].

It is also important to consider the impact of FA on body weight regain after bariatric surgery. A study conducted in Texas with 294 patients found that the rates of severe, moderate, and mild FA were 12.55%, 7.36%, and 7.36%, respectively. However, with no significant association between FA and postoperative body weight regain [41]. Similarly, Walø-Syversen et al. (2024) studied 69 bariatric surgery candidates and found that 16% met the diagnostic criteria for FA. While FA was associated with problematic eating behaviors and depression, it did not affect post-surgical weight loss [42]. These findings highlight the complexity of FA and its relationship with psychological factors, emphasizing the need for multidimensional approaches in obesity management and the evaluation of bariatric surgery candidates.

Notably, body image refers to how individuals perceive, feel about, and behave toward their own bodies. The findings of this study highlight the importance of understanding the factors associated with body satisfaction and its connection to disordered eating behaviors. In the context of bariatric surgery, this understanding is crucial for enhancing quality of life and fostering improved body satisfaction following surgery.

This investigation did not address intervention strategies, there is a growing need to examine how body image interventions should be tailored for individuals exhibiting symptoms of food addiction. Traditional body image treatments for eating disorders typically emphasize food positivity, body acceptance, and moderation. However, body image interventions for individuals with food addiction should not simply follow the traditional approaches used for eating disorders without adaptation. While body image disturbance is a significant contributor to psychosocial impairment in food addiction and warrants targeted intervention, food addiction and eating disorders, though overlapping, have distinct clinical features and underlying mechanisms. In this way, it may be required to address specific features such as compulsive eating, craving intensity, and emotion-driven consumption. In addition, protocols should be adapted rather than directly adopted from existing eating disorder guidelines, with an emphasis on individualized, multidisciplinary care, especially in populations with severe obesity preparing for bariatric surgery [40].

Therefore, the importance of interdisciplinary follow-up both before and after bariatric surgery is emphasized. Such support can help prevent and manage mental health issues, given the strong connection between body dissatisfaction, anxiety, depression, and other psychological disorders [2, 43].

This study utilized the YFAS 2.0, a validated instrument available in multiple languages, which is widely recognized as a valuable tool for assessing food addiction in Brazilian bariatric surgery candidates and individuals with a BMI ≥ 30 kg/m [44]. In Brazil, the short version of the YFAS 2.0 (mYFAS 2.0) has demonstrated high reliability (α = 0.915) in clinical samples with depressive disorders, suggesting its potential as a brief and effective screening tool for FA in this population [20]. However, as a self-report instrument, it is not intended to serve as a diagnostic tool, as it does not include a clinician-led assessment.

Although this study did not explore intervention strategies, we recognize the growing need to investigate how body image interventions should be approached in individuals exhibiting food addiction symptoms. Traditional body image treatments for eating disorders often emphasize food positivity, body acceptance, and moderation. However, it is still unclear whether these approaches are equally effective or appropriate for individuals with food addiction, particularly given the compulsive, craving-driven nature of the behavior [40].

If food addiction becomes recognized as a distinct eating disorder in the future, it may be appropriate to integrate existing evidence-based interventions that address body image and the internalization of weight stigma. Conversely, if it remains outside the formal diagnostic framework, it may require the development of adapted or novel approaches that target not only body image disturbance but also the addictive-like eating patterns. More research is needed to clarify whether these interventions should converge with or diverge from traditional eating disorder treatments, especially in populations with severe obesity preparing for bariatric surgery [40].

Conclusion

The findings of this study suggest that the absence or low levels of body dissatisfaction are associated with a decreased likelihood of food addiction symptoms. This underscores the significance of body image in the context of food addiction and indicates that the presence of body satisfaction may serve as a protective factor against its development. The results of the present research emphasize the importance of considering psychological and behavioral factors in managing food addiction, though further research is needed, including larger sample sizes, to improve statistical power and allow for more comprehensive analyses of this complex relationship.