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.”

“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).”

“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…”

“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).”

“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).”

“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).”

“(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).”

“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…”

“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).”

“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).”

“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).”

“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).”

“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…”

“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).”

“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.”

“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.”