The damaging effects of weight bias internalization


  • Scott Kahan,

    Corresponding author
    1. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
    2. Department of Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
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  • Rebecca M. Puhl

    1. Department of Human Development and Family Studies, Rudd Center for Food Policy & Obesity, University of Connecticut, Hartford, Connecticut, USA
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  • See accompanying article, pg. 317.

  • Disclosure: Scott Kahan is a member of the board of directors (unpaid) of the Obesity Action Coalition and the American Board of Obesity Medicine, which have initiatives pertaining to weight bias. Dr. Puhl declared no conflict of interest.

Prejudice, explicit bigotry, and implicit bias have become regular topics of national discourse in our current social and political environments. These discussions have included highly publicized examples of weight-based shaming [1], an unfortunate and frequent symptom of systemic weight stigmatization and discrimination in the United States. Despite increased public attention to weight stigma, few appreciate its extent and damaging impact on health.

Weight-based stigmatization is a pervasive yet under-recognized health issue prevalent even in close interpersonal relationships, including parents, spouses, friends, teachers, and healthcare providers [2]. Stemming in part from oversimplified and inaccurate beliefs about weight and obesity, weight stigma leads to societal devaluation, discrimination, and rejection of individuals with obesity and excess weight. In addition to damaging consequences for the mental health of those targeted, weight stigma adds insult to the direct injury of obesity, causing physiological stress, weight gain, disordered eating, and other maladaptive behaviors, and may increase mortality [3, 4]. There is likely a bidirectional relationship between obesity and weight stigma; discrimination is a prominent consequence of living with obesity, and, paradoxically to some, experiencing weight stigma can contribute to further progression of obesity. Weight stigma may mediate relationships between excess weight and a range of negative health outcomes attributed to obesity, including decreased quality of life.

In recent years, weight bias internalization (WBI)—self-directed shaming and negative weight-related attitudes and stereotypes about oneself—has been studied as a phenomenon distinct from experiencing stigma, and it may be particularly damaging to health and wellbeing. Epidemiologic and experimental evidence of the harms of WBI is mounting, including poorer self-reported health and health-related quality of life, binge eating, and maladaptive health behaviors, with some studies suggesting that WBI may have more negative effects than objectively stigmatizing events alone [5, 6]. It should not be surprising that WBI is so pivotal, as modern psychology demonstrates that the meaning we assign to external events, not the objective events themselves, determine our emotional reactions and health outcomes.

The article by Pearl and colleagues [7] in this issue of Obesity advances our limited understanding of WBI as a risk factor for adverse health outcomes, offering new insights about WBI and cardiometabolic risk factors. Among 178 weight loss treatment-seeking adults with obesity, those with higher levels of WBI (measured using the Weight Bias Internalization Scale) had 46% increased odds of meeting criteria for metabolic syndrome (often referred to interchangeably with “pre-diabetes”), a conglomerate of cardiovascular disease risk factors that strongly increases the risk for diabetes, heart disease, and stroke. Although the authors cautiously reported this result as nonsignificant (P = 0.052), the trend is compelling; given the sample size, a slightly altered response from a single participant could have shifted the result to significance. Analyzed categorically, individuals in the highest tertile of WBI, compared with the lowest tertile, had three times increased odds of metabolic syndrome (P = 0.039). The authors hypothesize that self-stigmatizing may increase physiological stress and arousal, which in turn increases risk for metabolic abnormalities and unhealthy coping strategies that promote adverse health.

Further study, including more diverse samples, will be important to confirm and expand on these results. Two-thirds of Pearl's sample was composed of African-American individuals, who have lower propensity to WBI, and nearly 90% were women. Notably, the participants had surprisingly low metabolic risk, with just 32% having metabolic syndrome, less than half the expected amount for populations with obesity. Further studies should evaluate a wider range of baseline health status. The authors appropriately call for larger-scale and longitudinal investigations to include WBI assessment, so that future research can identify interrelationships between weight stigma and WBI covariates and further evaluate moderating and mediating relationships. Important in these efforts will be research to identify specific biological pathways through which WBI may lead to adverse physical health outcomes.

Finally, despite the importance of developing more precise research data on weight stigma and WBI, it is not too soon to call for prioritizing societal and individual interventions for stigma prevention and treatment. Obesity treatment must go beyond weight loss. Clinical assessment for patients with obesity should routinely include experiences of stigma, shame, and WBI. Treatment should go beyond weight loss modalities to address the mental and physical effects of living a life with obesity, including shame and stigma reduction.