Weight bias internalization and health: a systematic review

“Methods Data collection and synthesis for this literature review were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews (16).”

“discrimination) in employment, education and health care, as well as stigma in interpersonal relationships and the mass media (2).”

“Considering that two thirds of US adults (11) and one third of youth (12) have overweight/obesity, the pervasiveness of WBI is striking.”

“These prejudicial attitudes are rooted in negative stereotypes, including views that people with obesity are lazy, incompetent and lack willpower (1).”

“8 Internalized stigma is broadly defined as (1) awareness of negative stereotypes about one’s social identity; (2) agreement with these stereotypes; (3) application of these stereotypes to oneself; and (4) self-devaluation due to one’s social identity.”

“Internalized stigma is broadly defined as (i) awareness of negative stereotypes about one’s social identity; (ii) agreement with these stereotypes; (iii) application of these stereotypes to oneself; and (iv) self-devaluation due to one’s social identity (9).”

“For example, the Fear of Enacted Stigma subscale of the WSSQ assesses anticipated stigma from others, which has been differentiated from internalized stigma in prior work (91).”

“Studies examining the effects of gender (n = 4) did not find significant differences in correlations between WBI and body image (40,46,54,69), despite higher levels of WBI in women versus men.”

“Studies examining links between WBI and eating disorder pathology (such as dietary restraint, drive for thinness, emotional eating, purging or other maladaptive eating behaviours) have been examined using a variety of validated measures (7,21,22,34,37,40,46,49,51,55,57,60,63,66–68,73,75–77) or survey items created by…”

“Of note, half of the current studies examining links between WBI and anxiety were conducted outside of North America, in Australia (55), Germany (61,62), Spain (64), Sweden (37) and Turkey (67).”

“These studies reported the following findings: WBI was lower among white adults with (versus without) a family weight history of overweight/obesity (89); higher WBI was associated with a younger age of onset of overweight/ obesity (66,85) and reports of food insecurity (90); and WBI was not significantly related to te…”

“Among samples that only included persons with overweight/obesity, 16 studies found significant associations between WBI and BMI or weight status (10,19,37,38,46,47,50,52,53,61,63,64,66,67,72,74,79,84,85), and 17 found no significant associations (7,21,36,44,45,48,51,54,56–58,60–62,70,76,77,82).”

“Furthermore, the consistency and strength of these associations were present in clinical samples of adults seeking treatment for weight loss (54,58,59), binge eating disorder (BED) (51,69) or bariatric surgery (37,67), as well as community samples (7,40,46,66).”

“Associations between WBI and motivational factors related to physical activity – such as exercise self-efficacy, enjoyment, and avoidance – appear to be stronger and more consistent than associations between WBI and physical activity engagement (23,36,50,74,84).”

“A total of five studies included other objective measures of health, such as accelerometry data (to measure physical activity) (25), blood pressure (24,44), blood glucose (44), cholesterol (29,44), heart rate (36), triglycerides(44) and waist circumference (29,44).”

“(73) tested the impact of WBIS scores on the relationship between perceived weight discrimination and eating pathology (including binge eating, emotional eating, bulimic symptoms and drive for thinness) and found that WBI mediated this relationship even after controlling for BMI.”

“WBI was significantly and positively associated with depressive symptoms in 28 of the 30 studies; only two did not find a significant association (19,50).”

“Importantly, WBI remained significantly associated with depressive symptoms after controlling for body mass index (BMI) (40,49,52,55), and some studies found no relationship between BMI and depression (54,56,60,64).”

“(82), WBIS scores moderated the relationship between BMI and PCS scores in women with obesity (N = 81), such that women with higher BMIs only had worse physical HRQOL when they also had higher (but not lower) WBIS scores.”

“(22) found that WBI moderated the effects of lifestyle intervention on improvements in intuitive (or adaptive) eating behaviours.”

“(81) found that, among 120 treatment-seeking adults with overweight/obesity, WBIS scores predicted the physical component score (PCS) of the SF-36, even after controlling for BMI, age, exercise, medical conditions and medication use.”

“Six studies have examined and demonstrated significant correlations between WBI and weight-specific QOL using the IWQOL and ORWELL (r values = 0.28 to 0.69) (38,53,62,63,67,83).”

“It is noteworthy that strong correlations were observed in both lean adults (49) and among individuals with obesity (58,59), suggesting that WBI is present and associated with emotional distress for individuals across diverse body sizes.”

“Studies of weight bias internalization in youth Two studies have validated the WBIS in adolescents: one in a sample of 57 US adolescents seeking bariatric surgery (43) and one among 191 German adolescents seeking treatment for overweight/obesity (41).”

“Studies examining the effects of gender (n = 4) did not find significant differences in correlations between WBI and body image (40,46,54,69), despite higher levels of WBI in women versus men.”

“Associations between WBI and motivational factors related to physical activity – such as exercise self-efficacy, enjoyment, and avoidance – appear to be stronger and more consistent than associations between WBI and physical activity engagement (23,36,50,74,84).”

“Three of these studies also found significant associations between WBI and higher self-perceived weight status, independent of objective weight status as measured by BMI (10,40,79).”

“Zuba and Warschburger (35) conducted a 2- year longitudinal study of over 1,000 German children, making minor changes to the WBIS item wording to be appropriate for children of all weight statuses.”

“Among samples that only included persons with overweight/obesity, 16 studies found significant associations between WBI and BMI or weight status (10,19,37,38,46,47,50,52,53,61,63,64,66,67,72,74,79,84,85), and 17 found no significant associations (7,21,36,44,45,48,51,54,56–58,60–62,70,76,77,82).”

“Associations between WBI and motivational factors related to physical activity – such as exercise self-efficacy, enjoyment, and avoidance – appear to be stronger and more consistent than associations between WBI and physical activity engagement (23,36,50,74,84).”

“One study has tested the effects of an intervention for WBI adapted from cognitive–behavioural therapy, without any weight loss or health behaviour intervention (30).”

“In a study of 300 adults who had undergone bariatric surgery (77), small but significant associations were found between WBI and worse adherence to the postoperative diet, as assessed by patients’ self-evaluation (i.”

“Lee and Dedrick (87) showed that the WBIS retained its psychometric properties regardless of whether it was administered to participants with a self-perceived versus objective weight status of overweight/ obesity, and scores were higher when weight status was defined by self-perceptions.”

“Furthermore, the consistency and strength of these associations were present in clinical samples of adults seeking treatment for weight loss (54,58,59), binge eating disorder (BED) (51,69) or bariatric surgery (37,67), as well as community samples (7,40,46,66).”

“Of note, some studies used the AAQ or body image subscale as a process or outcome measure rather than as the core measure of WBI (24,26,39).”

“Other psychological disorders and distress Eleven studies have examined the relationship between WBI and other indices of psychological distress, including emotion regulation (75,76) (such as rumination (65)), perceived stress (79), negative affect,(32) dissociative experiences (53), somatic symptoms (47,52), maladapt…”

“For example, in a study of women with obesity receiving a lifestyle intervention, Mensinger and Meadows (23) found that those with high WBI did not show significant increases in physical activity, while those low in WBI did.”

“The internalization of negative weight stereotypes and subsequent self-disparagement – known as weight bias internalization (WBI) or self-directed weight stigma (7) – has received less empirical attention than weight bias and stigma as expressed and enacted by others (8).”

“Six studies have assessed the relationship between WBI and weight loss following behavioural (n = 4) (19–21,57) or surgical (n = 2) (33,77) treatments.”

“(80) found a significant association between the WSSQ total score and the PCS of the SF-36 but did not find an association between the self-devaluation subscale and this scale.”

“Other psychological disorders and distress Eleven studies have examined the relationship between WBI and other indices of psychological distress, including emotion regulation (75,76) (such as rumination (65)), perceived stress (79), negative affect,(32) dissociative experiences (53), somatic symptoms (47,52), maladapt…”

“Six studies have examined and demonstrated significant correlations between WBI and weight-specific QOL using the IWQOL and ORWELL (r values = 0.28 to 0.69) (38,53,62,63,67,83).”

“These studies reported the following findings: WBI was lower among white adults with (versus without) a family weight history of overweight/obesity (89); higher WBI was associated with a younger age of onset of overweight/ obesity (66,85) and reports of food insecurity (90); and WBI was not significantly related to te…”

“Additionally, one study validated the WSSQ in a sample of 156 French-speaking, Canadian adolescents with overweight/obesity (42).”

“5 kg m , women who were “labelled” as overweight as part of the study manipulation had higher WBIS scores than those labelled as normal weight, regardless of their objective weight category (31).”

“Furthermore, the consistency and strength of these associations were present in clinical samples of adults seeking treatment for weight loss (54,58,59), binge eating disorder (BED) (51,69) or bariatric surgery (37,67), as well as community samples (7,40,46,66).”

“Among samples that only included persons with overweight/obesity, 16 studies found significant associations between WBI and BMI or weight status (10,19,37,38,46,47,50,52,53,61,63,64,66,67,72,74,79,84,85), and 17 found no significant associations (7,21,36,44,45,48,51,54,56–58,60–62,70,76,77,82).”

“Importantly, WBI remained significantly associated with depressive symptoms after controlling for body mass index (BMI) (40,49,52,55), and some studies found no relationship between BMI and depression (54,56,60,64).”

“These studies reported the following findings: WBI was lower among white adults with (versus without) a family weight history of overweight/obesity (89); higher WBI was associated with a younger age of onset of overweight/ obesity (66,85) and reports of food insecurity (90); and WBI was not significantly related to te…”

“Other psychological disorders and distress Eleven studies have examined the relationship between WBI and other indices of psychological distress, including emotion regulation (75,76) (such as rumination (65)), perceived stress (79), negative affect,(32) dissociative experiences (53), somatic symptoms (47,52), maladapt…”

“Studies of weight bias internalization in youth Two studies have validated the WBIS in adolescents: one in a sample of 57 US adolescents seeking bariatric surgery (43) and one among 191 German adolescents seeking treatment for overweight/obesity (41).”

“Six studies have examined and demonstrated significant correlations between WBI and weight-specific QOL using the IWQOL and ORWELL (r values = 0.28 to 0.69) (38,53,62,63,67,83).”

“One study of 70 patients with schizophrenia enrolled in a weight loss study found no relationship between WBIS scores and attitudes toward antipsychotic medication adherence (45), suggesting that WBI does not necessarily translate to reduced self-efficacy and motivation to engage in non-weight-related behaviours.”

“Physical activity measures included validated self-report questionnaires (56,79,84,86,88), singleitem assessments (23,36,78) and self-report scales created specifically for the studies (50,74,79).”

“Another study found no difference in WBI between participants who completed a weight loss program and those who dropped out (20).”

“Furthermore, the consistency and strength of these associations were present in clinical samples of adults seeking treatment for weight loss (54,58,59), binge eating disorder (BED) (51,69) or bariatric surgery (37,67), as well as community samples (7,40,46,66).”

“Importantly, WBI remained significantly associated with depressive symptoms after controlling for body mass index (BMI) (40,49,52,55), and some studies found no relationship between BMI and depression (54,56,60,64).”

“These studies reported the following findings: WBI was lower among white adults with (versus without) a family weight history of overweight/obesity (89); higher WBI was associated with a younger age of onset of overweight/ obesity (66,85) and reports of food insecurity (90); and WBI was not significantly related to te…”

“These studies reported the following findings: WBI was lower among white adults with (versus without) a family weight history of overweight/obesity (89); higher WBI was associated with a younger age of onset of overweight/ obesity (66,85) and reports of food insecurity (90); and WBI was not significantly related to te…”

“…findings across 10 studies show mixed findings with respect to the relationship between engagement in physical activity and IWB, and suggest that associations may be stronger for motivational aspects of physical activity like exercise self-efficacy or avoidance (see review by Pearl & Puhl, 2018).”

“WBI can adversely affect health and wellbeing for people of diverse body sizes [67]; thus, rather than limiting research attention to links between obesity and healthcare, our findings underscore the need to focus on stigma-related risk factors, mechanisms, and barriers that impact healthcare, independent of BMI.”

“8 For youth, these effects often continue into adulthood.”

“13 Stigma can stem from the notion that obesity is self-inflicted, wherein an individual does not adequately manage his or her weight through healthy eating and exercise.”

“A systematic review of 74 studies found links between weight bias internalization and greater depression, anxiety, binge eating, and cardiometabolic risk, and lower health- and mental health-related quality of life among other outcomes (Pearl & Puhl, 2018).”

“However, observational data suggest that women encounter weight bias more frequently, amplifying the risk of mental health issues such as depression and anxiety (see §4a) [14].”

“, internalize stigma) might be particularly vulnerable to such messages, as they report lower self-efficacy and greater self-blame for their weight (4).”

“, internalized weight bias, which is itself related to maladaptive eating behaviors and weigh gain [44, 45]) among adults managing their weight and/ or with obesity [23, 46], it will be important to increase research attention to weight-related health consequences resulting from stigma in interpersonal relationships a…”

“Negative self-image, maladaptive eating behaviors, substance use, and overall impaired psychosocial functioning have in turn been associated with internalized weight bias and further weight management difficulties [29, 30].”

“Furthermore, weight bias internalization has been found to be more frequently experienced by women (Pearl & Puhl, 2018), which might explain some of the sex differences observed in the present study.”

“the child's internalization of beliefs about their own body weight, with potential negative consequences.(331) Greater attention also could have been given to children's food cognitions, how they develop in childhood, influences on them, and their role in OW/OB.”

“This form of bias leads to weight-based discrimination in employment, education, health care, and interpersonal relationships (Pearl, 2018).”

“For example, some studies have found that internalized weight stigma may have negative implications for health and wellbeing independent of experiences of being stigmatized [36].”

“Weight bias internalization (WBI) – also known as weight self-stigma – occurs when individuals with obesity absorb negative, weight-based societal perceptions, including stereotypes, and devalue themselves due to their weight (Pearl & Puhl, 2018).”

“…of negative stereotypes about aspects of their identity and apply this bias to themselves through self-devaluation (Corrigan, Watson, & Barr, 2006; Pearl & Puhl, 2018; Puhl, Himmelstein, & Quinn, 2018), has been established in bias literature (e.g., weight bias internalization, internalized…”

“Self-efficacy is a consistent predictor of weight loss and maintenance [23–25], so reductions in self-efficacy associated with WBI may impair weight management behaviors and outcomes [6].”

“Variation in measurement of WBI may account for some inconsistencies in previous findings and presents a challenge for systematically comparing effects across studies (3).”

“Prescriptions of weight loss are intended to promote one’s health; yet, seemingly paradoxically, weight-based stigma and discrimination increase the risk of developing disordered eating patterns in addition to numerous other consequences (Pearl & Puhl, 2018; Puhl & Heuer, 2009; Tylka et al., 2014).”

“Furthermore, many patients have encountered weight bias and may blame themselves for their excess weight (31), potentially contributing to underlying depression, poor self-esteem and body image, and disordered eating when this stigma is internalized.”

“Similarly, a recent systematic review examining the association between internalized weight bias and health-related variables reported that the published studies conducted to date have consistently found a positive association between food addiction and internalized weight bias [82].”

“Given that treatment-seeking samples for obesity tend to include more women than men (2,29), it will also be useful to examine weight stigma in samples of men seeking treatment for obesity.”

“Weight-related self-stigma has been linked with a wide range of negative physical and mental health outcomes, including depression, anxiety, low self-esteem, poor body image, disordered eating, food addiction, poor health-related quality of life, and avoidance of exercise [10].”

“Individuals who have obesity and internalize weight stigma are at an increased risk for depression, eating disorders, metabolic syndrome, and weight gain.(112,115,116) Limited research, though, has examined internalization of weight stigma in”

“Weight stigma is associated with poorer mental and physical health [157,158].”

“Internalized weight stigma has been consistently related to worse mental health outcomes in both treatment seeking [17] and non-treatment seeking samples [18, 19] but has not been examined in the context of weight cycling.”

“In fact, some research suggests that weight bias internalization may be more detrimental to health and wellbeing than experiences of weight discrimination, although it is generally agreed that both are damaging [5].”

“Moreover, the adverse health consequences were found to be especially strong in people with internalized weight-stigmatizing beliefs (Hayward et al., 2018; Pearl and Puhl, 2018).”

“In a meta-analysis of studies involving both children and adults, IWB was found in several studies to be associated with depression, anxiety, stress, and disordered eating behaviors after controlling for experienced weight stigma.(9) The effects and associations of IWB have been studied in adults, but similar effects…”

“As a consequence of weight stigma, they also experience numerous and pervasive outcomes in terms of functioning, quality of life, and well-being [8,9], including unsuccessful efforts to manage excess weight, weight gain, and obesity maintenance.”

“perceived stigma and experiences of weight discrimination, including negative attitudes from peers and inappropriate person-to-person behaviours), individuals identifying with stigmatized groups can apply negative stereotypes to themselves [8, 22].”

“These findings are consistent with previous evidence in both the general population and clinical samples of adults engaged in weight loss treatment showing consistent relationships between internalized weight bias and adverse health consequences, particularly maladaptive eating behaviors (16).”

“The Weight Bias Internalization Scale has demonstrated good psychometric properties and validity in both clinical and community samples of varying weight statuses (21,22).”

“Internalized weight stigma is when individuals internalize negative weight‐based stereotypes and subsequently devalue themselves because of their weight.(26) Internalized weight stigma, independent of experienced discrimination, is associated with negative outcomes.”

“19,20 However, research examining IWS has over-whelmingly been cross-sectional, 21 precluding investigation of risk-factors over the life-course without risk of recall bias.”

“Several studies (Hunger et al., 2020; Meadows & Higgs, 2019; Pearl & Puhl, 2018) have found that internalized weight stigma and fat phobia resulting from experienced weight stigma play an important role in the relation between BMI and body shame.”

“Weight self-stigma also impairs behavioral weight loss outcomes (Pearl & Puhl, 2018).”

“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).”

“16,17,65,66 Causal attributions of personal responsibility for obesity and ascribing all health problems to body size are identified as two of the drivers of weight stigma.”

“At the intrapersonal level, individuals with high weight often report distress in anticipation of negative judgment or mistreatment from others [9], as well as internalization of negative weight attitudes and self-devaluation (i.e., self-stigma) due to one’s weight [10].”

“These health consequences may be in part attributable to self-blame and the internalization of weight stigma, processes which have been documented to be detrimental for mental health (Pearl & Puhl, 2018).”

“This finding also aligns with prior work suggesting that internalization of weight bias has stronger and more direct implications for behavioral and physical health, including emotional eating, than the extent of stigma a person has experienced [5].”

“…that, besides own BMI, which has been shown to be associated with weight bias internalization in prior research (for a systematic review, see Pearl and Puhl, 2018), a moral focus on weight stigma rather than a focus on competence, and fear of condemnation will predict weight bias…”

“10 Although important and significant, these reports may be influenced by self-deprecating perceptions that would, reflect a potentially distorted view.”

“11 Some evidence suggests impaired health related to internalized weight bias is mediated by impaired self-esteem and distress.”

“2020;10:e12361. wileyonlinelibrary.com/journal/cob © 2020 World Obesity Federation 1 of 7 https://doi.org/10.1111/cob.12361 Increasing evidence shows that gender, race/ethnicity and age are predictors of weight-based discrimination and WBI.6 In a study of US adults with and without obesity, Puhl and colleagues reporte…”

“The WBIS is a 11-item measure, developed to examine internalized weight stigma among higher-weight individuals [15], and it has since been modified for use with individuals across the weight spectrum [17].”

“Both body dissatisfaction and internalized weight stigma are robust predictors of disordered eating and the development of clinically significant eating disorders for women [EDs; (1, 2)].”

“Accumulating evidence points to an association between weight bias internalization and dysregulated eating behaviors, including EE [69].”

“For example, in a systematic review examining the impact of IWB on health, the authors concluded that the results showed strong, negative relationships between IWB and mental health outcomes but few studies had examined the relationship between IWB and physical health.(18) As for EWB, weight discrimination in non-bari…”