Weight Stigma and Health: Does Self-blame Play a Role?

Rebecca M. Puhl, PhD

Disclosures

June 28, 2018

Weight Stigma and Health

Throughout our society, people are quick to judge others on the basis of their body size or body weight. Known as "weight stigma," this is a prevalent societal problem;[1] people experience bullying, prejudice, discrimination, and generally unfair treatment because of their weight. National studies suggest that as many as 40% of adults have experienced some form of weight stigma,[2] resulting in inequities in employment, healthcare, educational institutions, and other domains of daily life.[3,4]

Being a target of weight stigma is also harmful to health. Numerous research studies have documented psychological and physical health consequences of weight stigma in both children and adults.[5,6] This evidence underscores the impact of weight stigma on quality of life, and has prompted national organizations like the Obesity Society and the American Academy of Pediatrics[7] to take public positions on the importance of reducing weight stigma and its damaging impact in healthcare.[8]

Weight Bias Internalization

As we learn more about the harmful effects of weight stigma, emerging research indicates that it's not only the stigmatizing encounter itself that distresses and harms the individual but also the individual's personal interpretation of that experience. In particular, when people direct stigmatizing experiences inward and blame themselves for the stigma, their health can be compromised.

Applying negative weight stereotypes to oneself and engaging in self-blame is known as "weight bias internalization," or "self-directed weight stigma." A 2017 national study[9] of US adults found that approximately 40% of adults who are overweight or obese blame themselves for the weight stigma, and about one in five adults exhibited high levels of internalized weight bias, indicating more severe self-blame and self-derogation.[10]

Internalized stigma has been studied in the context of other socially stigmatized characteristics, such as mental illness, HIV, or sexual orientation. The literature in these areas indicates that internalized stigma contributes to poorer psychological and physical health outcomes in these socially stigmatized groups.[11,12]

The emerging research on weight stigma reinforces these links between internalization of weight bias and adverse health. The first systematic review, published in Obesity Reviews,[13] highlights findings from recent 74 studies about weight bias internalization and health. Consistently, studies showed strong, negative associations between internalized weight bias and poor psychological health indices, including high levels of depression and anxiety, lower self-esteem, disordered eating, increased binge eating, and poorer mental health-related quality of life.

Furthermore, this review found that higher levels of weight bias internalization were linked with increased severity of obesity, lower motivation to engage in healthy lifestyle behaviors, poorer dietary adherence, poorer weight loss maintenance, and increased odds of metabolic syndrome. Of note, the analysis controlled for body mass index (BMI), suggesting that internalized weight bias may contribute to poor health independent of one's actual body weight.

And although some studies showed that internalization heightens as body weight increases, other studies reported no association with BMI, suggesting that internalization of weight bias isn't limited to people with high body weight.

Because rates of overweight and obesity remain high, and body weight remains widely stigmatized in our society, the collective evidence on weight bias internalization indicates a need to look more closely at weight stigma and its harmful impact. National media attention to the societal problem of "fat shaming" has increased[14] and calls have been made to address this problem among healthcare providers[15] and in the fitness industry.[16] However, the self-blame that people engage in as a result of experiencing weight stigma has been largely ignored, even though self-directed stigma may itself incur adverse health consequences. Independent of experiencing a stigmatizing encounter, internalizing this stigma may be a form of additional stress that impairs emotional and physical health.

What Can Be Done to Avoid Internalizing Stigma?

There is a need for increased societal awareness — among both the public and healthcare providers — that internalized stigma is harmful.[17] In addition to promoting supportive societal messages to reduce societal blame[18] of people with higher body weight, the importance of reducing self-blame should be included in this dialogue.

We can support public health messages that encourage healthy lifestyle behaviors for all people regardless of their body size, which may be one way to help reduce both societal and self-blame of people with higher body weight.

In clinical practice, healthcare providers can look for opportunities to support patients who may be experiencing and/or internalizing weight stigma. Providers rarely talk to patients about weight stigma. Similarly, addressing weight stigma is rarely included as a component of interventions to address disordered eating, weight loss, or weight management.

Helping patients practice adaptive coping strategies to deal with weight stigma instead of engaging in self-blame may help improve their health-related outcomes. Initial evidence suggests that helping patients focus on self-compassion, mindfulness, and healthy eating (without a focus on weight) can lessen internalization of stigma and improve psychological symptoms, physical activity, and eating behaviors.[19,20,21,22]

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