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Weight bias internalization and health: a systematic review
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Summary: A robust literature has documented the negative health effects of being the target of weight bias. Weight bias internalization (WBI) occurs when individuals apply negative weight stereotypes to themselves and self‐derogate because of their body weight. Compared with experiences of weight bias, less is known about the relationship between WBI and mental and physical health, although more literature on this topic has emerged in recent years. The current systematic review identified 74 studies assessing the relationship between WBI and health and interventions designed to reduce WBI and improve health. Over half of identified studies were published from 2016 to 2017. Results showed strong, negative relationships between WBI and mental health outcomes. Fewer studies have examined the relationship between WBI and physical health, and results were less consistent. Key directions for future research are highlighted, including the need for prospective and experimental studies with greater sample diversity.
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“Repeated exposure to weight stigma can lead to internalized stereotypes and self-devaluation, resulting in body shame (Forbes & Donovan, 2019; Pearl & Puhl, 2018)”
From A Randomized Controlled Trial of an Acceptance and Commitment Therapy-Informed Diabetes Prevention Program Reduces Body Shame and Distress. (2025) · cites this paper as Pearl & Puhl, 2018
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Brown, A., Flint, S. W., & Batterham, R. L. (2022) · eClinicalMedicine · doi:10.1016/j.eclinm.2022.101408 · Cited by 212
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Self-citationComplexity and Stigma of Pediatric Obesity
Haqq, A. M., Kebbe, M., Tan, Q., Manco, M., & Salas, X. R. (2021) · Childhood Obesity · doi:10.1089/chi.2021.0003 · Cited by 226
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An Evidence‐Based Rationale for Adopting Weight‐Inclusive Health Policy
Hunger, J. M., Smith, J. P., & Tomiyama, A. J. (2020) · Social Issues and Policy Review · doi:10.1111/sipr.12062 · Cited by 201
“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).”
BackgroundObesity and psychological distress
Steptoe, A., & Frank, P. (2023) · Philosophical Transactions of the Royal Society B Biological Sciences · doi:10.1098/rstb.2022.0225 · Cited by 173
“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].”
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“, internalize stigma) might be particularly vulnerable to such messages, as they report lower self-efficacy and greater self-blame for their weight (4).”
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“, 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…”
BackgroundSelf-citationSelf-Perception of Overweight and Obesity: A Review of Mental and Physical Health Outcomes
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Self-citationThedinga, H. K., Zehl, R., & Thiel, A. (2021) · BMC Public Health · doi:10.1186/s12889-021-10565-7 · Cited by 101
Romano, K. A., Heron, K. E., & Henson, J. M. (2021) · Body Image · doi:10.1016/j.bodyim.2021.01.006 · Cited by 112
Enacted weight stigma and weight self stigma prevalence among 3821 adults
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Patients' Experiences of Weight Regain After Bariatric Surgery
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“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].”
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“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.”
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“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.”
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Prevalence and correlates of weight bias internalization in weight management: A multinational study
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“This form of bias leads to weight-based discrimination in employment, education, health care, and interpersonal relationships (Pearl, 2018).”
BackgroundSelf-citationPuhl, R. M., Himmelstein, M. S., Browne, J. L., & Speight, J. (2020) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2020.108387 · Cited by 79
“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].”
BackgroundSelf-citationThe psychological burden of baby weight: Pregnancy, weight stigma, and maternal health
Rodriguez, A. C. I., Schetter, C. D., Brewis, A., & Tomiyama, A. J. (2019) · Social Science & Medicine · doi:10.1016/j.socscimed.2019.112401 · Cited by 85
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Puhl, R. M., & Himmelstein, M. S. (2018) · Frontiers in Psychology · doi:10.3389/fpsyg.2018.02271 · Cited by 77
Self-citationPearl, R. L., Wadden, T. A., Bach, C., Gruber, K. A., Leonard, S. M., Walsh, O. A., Tronieri, J. S., & Berkowitz, R. I. (2020) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000480 · Cited by 81
“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).”
BackgroundMethodInfluentialSelf-citationThe stigma associated with gestational diabetes mellitus: A scoping review
Davidsen, E., Maindal, H. T., Rod, M. H., Olesen, K., Byrne, M., Damm, P., & Nielsen, K. K. (2022) · eClinicalMedicine · doi:10.1016/j.eclinm.2022.101614 · Cited by 64
Differences in weight stigma between gay, bisexual, and heterosexual men
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(Overcoming) Maternity Bias in the Workplace: A Systematic Review
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“…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…”
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“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].”
BackgroundResultInfluentialSelf-citationAdolescents’ Exposure to and Experiences of Weight Stigma During the COVID-19 Pandemic
Lessard, L. M., & Puhl, R. M. (2021) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsab071 · Cited by 68
Self-citationObesity and body mass index: Past and future considerations in osteoarthritis research
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“Weight stigma is associated with poorer mental and physical health [157,158].”
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“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).”
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Self-citationInternalized Weight Bias, Teasing, and Self-Esteem in Children with Overweight or Obesity
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“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…”
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“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].”
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Self-citationPuhl, R. M., Himmelstein, M. S., & Speight, J. (2021) · Clinical Diabetes · doi:10.2337/cd20-0071 · Cited by 49
“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).”
BackgroundResultInfluentialSelf-citationPuhl, R. M., Himmelstein, M. S., Pearl, R. L., Wojtanowski, A. C., & Foster, G. D. (2019) · Obesity · doi:10.1002/oby.22633 · Cited by 49
“The Weight Bias Internalization Scale has demonstrated good psychometric properties and validity in both clinical and community samples of varying weight statuses (21,22).”
BackgroundResultInfluentialSelf-citationPudney, E. V., Himmelstein, M. S., Puhl, R. M., & Foster, G. D. (2020) · Social Science & Medicine · doi:10.1016/j.socscimed.2020.112854 · Cited by 37
Self-citationGorlick, J., Gorman, C. V., Weeks, H. M., Pearlman, A. T., Schvey, N. A., & Bauer, K. W. (2020) · Childhood Obesity · doi:10.1089/chi.2020.0199 · Cited by 43
Stigmatizing weight experiences in health care: Associations with BMI and eating behaviours
Remmert, J. E., Convertino, A. D., Roberts, S. R., Godfrey, K. M., & Butryn, M. L. (2019) · Obesity Science & Practice · doi:10.1002/osp4.379 · Cited by 49
“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.”
BackgroundResultInfluentialDose-Dependent Association Between Body Mass Index and Mental Health and Changes Over Time
Chen, S., Zhang, H., Gao, M., Machado, D. B., Jin, H., Scherer, N., Sun, W., Sha, F., Smythe, T., Ford, T. J., et al. (2024) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2024.0921 · Cited by 44
Schwartz, G. L., Wang, G., Kershaw, K. N., McGowan, C., Kim, M. H., & Hamad, R. (2022) · Health & Place · doi:10.1016/j.healthplace.2022.102904 · Cited by 43
Forrest, L. N., Ivezaj, V., & Grilo, C. M. (2021) · Psychological Medicine · doi:10.1017/s0033291721004748 · Cited by 47
ASN Kidney Health Guidance on the Management of Obesity in Persons Living with Kidney Diseases
Ikizler, T. A., Kramer, H., Beddhu, S., Chang, A. R., Friedman, A. N., Harhay, M. N., Jimenez, E. Y., Kistler, B. M., Kukla, A., Larson, K., et al. (2024) · Journal of the American Society of Nephrology · doi:10.1681/asn.0000000512 · Cited by 41
Hughes, A., Flint, S. W., Clare, K., Kousoulis, A. A., Rothwell, E. R., Bould, H., & Howe, L. D. (2024) · The Lancet Regional Health - Europe · doi:10.1016/j.lanepe.2024.100895 · Cited by 31
“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.”
BackgroundGattino, S., Czepczor‐Bernat, K., Fedi, A., Brytek‐Matera, A., Boza, M., Lemoine, J. E., Sahlan, R. N., Wilson, E., Piccoli, N. D., & Rollero, C. (2023) · Europe’s Journal of Psychology · doi:10.5964/ejop.6075 · Cited by 40
“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.”
BackgroundPotts, S., Krafft, J., & Levin, M. E. (2020) · Behavior Modification · doi:10.1177/0145445520975112 · Cited by 36
“Weight self-stigma also impairs behavioral weight loss outcomes (Pearl & Puhl, 2018).”
BackgroundInfluentialPlanting seeds of change: reconceptualizing what people eat as eating practices and patterns
Olstad, D., & Kirkpatrick, S. (2021) · International Journal of Behavioral Nutrition and Physical Activity · doi:10.1186/s12966-021-01102-1 · Cited by 32
Internalized weight bias and loss-of-control eating following bariatric surgery
Lawson, J. L., LeCates, A., Ivezaj, V., Lydecker, J. A., & Grilo, C. M. (2020) · Eating Disorders · doi:10.1080/10640266.2020.1731920 · Cited by 36
“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).”
BackgroundHailu, H., Skouteris, H., Rodriguez, A. C. I., Galvin, E., & Hill, B. (2024) · Obesity Reviews · doi:10.1111/obr.13710 · Cited by 35
“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.”
BackgroundSzwimer, E., Mougharbel, F., Goldfield, G. S., & Alberga, A. S. (2020) · Current Obesity Reports · doi:10.1007/s13679-020-00367-0 · Cited by 41
How Weight Bias and Stigma Undermine Healthcare Access and Utilization
Pearl, R. L., & Sheynblyum, M. (2025) · Current Obesity Reports · doi:10.1007/s13679-025-00605-3 · Cited by 32
“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].”
Self-citationLawrence, S. E., Puhl, R. M., Schwartz, M. B., Watson, R. J., & Foster, G. D. (2022) · SSM - Qualitative Research in Health · doi:10.1016/j.ssmqr.2022.100073 · Cited by 35
“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).”
BackgroundSelf-citationSelf-Compassion, Internalized Weight Stigma, Psychological Well-Being, and Eating Behaviors in Women
Fekete, E. M., Herndier, R. E., & Sander, A. C. (2021) · Mindfulness · doi:10.1007/s12671-021-01597-6 · Cited by 41
Braun, T. D., Gorin, A. A., Puhl, R. M., Stone, A., Quinn, D. M., Ferrand, J., Abrantes, A. M., Unick, J., Tishler, D., & Papasavas, P. (2021) · Obesity Surgery · doi:10.1007/s11695-021-05392-z · Cited by 29
“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].”
BackgroundResultSelf-citationWeight Bias Internalization: The Maladaptive Effects of Moral Condemnation on Intrinsic Motivation
Täuber, S., Gausel, N., & Flint, S. W. (2018) · Frontiers in Psychology · doi:10.3389/fpsyg.2018.01836 · Cited by 29
“…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…”
Telo, G., Fontoura, L. F., Avila, G. O., Gheno, V., Brum, M. A. B., Teixeira, J., Erthal, I. N., Alessi, J., & Teló, G. (2024) · Obesity Reviews · doi:10.1111/obr.13696 · Cited by 29
“10 Although important and significant, these reports may be influenced by self-deprecating perceptions that would, reflect a potentially distorted view.”
BackgroundEnglish, S., & Vallis, M. (2023) · Clinical Obesity · doi:10.1111/cob.12615 · Cited by 28
“11 Some evidence suggests impaired health related to internalized weight bias is mediated by impaired self-esteem and distress.”
BackgroundFeig, E. H., Amonoo, H. L., Onyeaka, H. K., Romero, P. M., Kim, S., & Huffman, J. C. (2020) · Clinical Obesity · doi:10.1111/cob.12361 · Cited by 28
“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…”
BackgroundInfluentialNutter, S., Saunders, J. F., & Waugh, R. (2024) · Journal of Eating Disorders · doi:10.1186/s40337-024-01058-0 · Cited by 28
“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].”
BackgroundMethodInfluentialExperiences of weight stigma in adolescents with severe obesity and their families
Roberts, K. J., Polfuss, M. L., Marston, E. C., & Davis, R. L. (2021) · Journal of Advanced Nursing · doi:10.1111/jan.15012 · Cited by 36
Faubion, S. S., de Oliveira, F. F. L., Kuhle, C. L., Sood, R., Kling, J. M., Vencill, J. A., Mara, K. C., & Kapoor, E. (2020) · The Journal of Sexual Medicine · doi:10.1016/j.jsxm.2020.07.004 · Cited by 36
The role of weight stigma in weight regain in bariatric surgery
Himmelstein, M. S., Knepp, K. A., & Phelan, S. M. (2022) · Frontiers in Endocrinology · doi:10.3389/fendo.2022.1076696 · Cited by 37
Saunders, J. F., Nutter, S., & Russell‐Mayhew, S. (2022) · Frontiers in Global Women s Health · doi:10.3389/fgwh.2022.877554 · Cited by 27
“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)].”
BackgroundMethodInfluentialMulti-etiological Perspective on Child Obesity Prevention
Baranowski, T., Motil, K. J., & Moreno, J. P. (2019) · Current Nutrition Reports · doi:10.1007/s13668-019-0256-3 · Cited by 34
Hagan, S., & Nelson, K. (2023) · Journal of General Internal Medicine · doi:10.1007/s11606-022-07821-w · Cited by 26
Emotional Eating and Obesity: An Update and New Insights
Braden, A. L., Ahlich, E. M., & Koball, A. M. (2025) · Current Obesity Reports · doi:10.1007/s13679-025-00661-9 · Cited by 27
“Accumulating evidence points to an association between weight bias internalization and dysregulated eating behaviors, including EE [69].”
Status, sexual capital, and intraminority body stigma in a size-diverse sample of gay men
Shepherd, B. F., Denning, D. M., Elbe, C. I., Maki, J. L., & Brochu, P. M. (2023) · Body Image · doi:10.1016/j.bodyim.2023.03.005 · Cited by 27
Examining weight bias before and/or after bariatric surgery: A systematic review
Bennett, B. L., Lawson, J., Funaro, M., & Ivezaj, V. (2022) · Obesity Reviews · doi:10.1111/obr.13500 · Cited by 25
“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…”
Result
Metadata
- Authors
- Pearl, R. L., & Puhl, R. M.
- Affiliations
- University of Pennsylvania (US)
- University of Connecticut (US)
- Corresponding author
- Pearl, R. L.
- Venue
- Obesity Reviews
- Publisher
- Wiley
- Published
- 2018-05-22
- Volume
- 19
- Issue
- 8
- Pages
- 1141-1163
- ISSN
- 1467-7881 (ISSN-L)
- 1467-789X
- PMC
- PMC6103811
- OpenAlex
- W2803711470
- Cited by
- 642
- References
- 110
- Citations by year
- 2026: 96 · 2025: 110 · 2024: 90 · 2023: 79 · 2022: 85 · 2021: 99 · 2020: 55 · 2019: 23 · 2018: 4
- FWCI
- 11.23
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Obesity Reviews (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Rudd Foundation
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity and Health Practices
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
- Keywords
- weight bias internalization, weight stigma, self-derogation, mental health, physical health, body weight
- MeSH terms
- Body Weight, Humans, Obesity, Self Concept, Social Stigma
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