BEDA promotes cultural acceptance of, and respect for, the natural diversity of sizes, as well as promoting a goal of improved health, which may or may not include weight change. The views expressed by our featured bloggers are their own.
Janet D. Latner, PhD, (BA, Yale University; MA, PhD, Rutgers University) is a Professor of Psychology at the University of Hawaii at Manoa. Dr. Latner has authored over 70 peer-reviewed articles and book chapters on eating disorders and obesity. Her research is focused on weight bias and the amelioration of suffering of individuals with weight and eating issues. She studies the diagnosis, maintenance, treatment, and self-help treatment of obesity and eating disturbances, and on improving the long-term maintenance of weight loss through self-help and continuing care. For more information about Dr. Latner, see http://www2.hawaii.edu/~jlatner.
Obesity Discrimination and Health
The media devotes a great deal of attention to the link between body weight and health, however, Weight Stigma Awareness Week gives us the chance to look at this relationship from a somewhat different perspective. It is possible that body weight is not the direct cause of health impairment, rather, the weight-based discrimination, the stress and suffering it causes may be a key factor in contributing to health impairments.
Obese individuals are frequently victims of harsh, harmful prejudice and discrimination. This prejudice is evident across interpersonal, employment, educational, and medical settings. Despite the frequent attention to other targets of prejudice, weight-based discrimination may even be equally or more prevalent than other forms of discrimination such as sexism, racism, homophobia, and religious intolerance. Weight-based discrimination has been shown to lead to many problems, including symptoms of depression, poorer body image and self-esteem, decreased educational and occupational outcomes, and even suicidal ideation.
Is Weight Stigma Correlated with Health?
The impairments in health and health-related quality of life among obese individuals are often blamed on a direct physical reaction to increased adiposity itself. However, recent research has revealed that discrimination may have a negative impact on health among ethnic minorities and other marginalized populations. It is possible that the health-related quality of life impairments seen in obese people may be partly due to the regular onslaught of stigma and discrimination they face. The internalization of weight bias, or holding negative beliefs about oneself due to weight or size, is associated with negative consequences to mental health, such as greater body dissatisfaction, eating disorder symptoms, depression, and low self-esteem.
Internalized weight bias could possibly exacerbate health problems such as cardiovascular and metabolic functioning. Stigma may threaten health and magnify health disparities. Therefore, our lab has conducted research that was needed to examine the association between stigma (both external weight-based discrimination perpetuated by others and internalized weight bias directed at the self), as well as body dissatisfaction and health-related quality of life, and the possible role of stigma in moderating the relationship between body mass index (BMI) and health-related quality of life. “Health-related quality of life” refers to the functioning or impairment that individuals experience due to either physical or mental health. Our research has been conducted in different populations: individuals seeking weight-loss treatment, overweight individuals recruited from a general internet sample, and college students.
Internalized Weight Bias and Physical and Mental Health Impairment
In one study (Latner, Mond, & Durso, 2013; http://www.jeatdisord.com/content/1/1/3) it was hypothesized that internalized weight bias is associated with physical as well as psychological impairment in health-related quality of life among individuals seeking treatment for weight loss. Participants included 120 treatment-seeking overweight and obese adults (mean BMI = 35.09 kg/m2; mean age = 48.31; 68% female; 59% mixed or Asian ethnicity). Participants were administered measures of internalized weight bias, along with measures of physical and mental health-related quality of life. Participants were also asked to report any medical conditions they might have, their use of prescription and non-prescription medications, and their current exercise habits.
The results of this study demonstrated that internalized weight bias was significantly correlated with health impairment, including both physical and mental health-related quality of life. Even in analyses controlling for BMI, age, and other physical health indicators, internalized weight bias significantly and independently predicted impairment in both physical and mental health. Thus, among adults seeking weight-loss treatment, internalized weight bias was associated with impairment in both physical and mental of health-related quality of life. Internalized weight bias also contributed significantly to both physical and mental health impairment over and above the contributions of BMI, age, and medical problems. Thus, internalized weight bias is associated with physical as well as mental health. Further research was needed to replicate and extend these findings in non-treatment-seeking individuals.
Internalized Weight Bias, Discrimination, and Health Impairment
In another study, it was hypothesized that both external and internal discrimination would independently moderate the association between BMI and health-related quality of life, in a non-clinical sample (Latner, Barile, Durso, & O’Brien, in preparation). Eighty-one women were recruited from weight-related list-servs (mean age = 41.1 years, SD=10.92; mean BMI = 43.40, SD = 15.38; 97% Caucasian). The majority of participants (88%) were overweight or obese. Participants completed measures of weight bias internalization (Weight Bias Internalization Scale; WBIS), perceived discrimination by others (Everyday Discrimination Scale; EDS) and both physical and mental health-related quality of life (Short Form-36 Health Survey). The results showed significant correlations found between BMI and EDS, WBIS and mental health-related quality of life, WBIS and physical health-related quality of life, and EDS and physical health-related quality of life. Statistical analyses also tested whether internalized weight bias or discrimination moderated the association between BMI and the summary scores for physical and mental health, controlling for age. The association between high BMI and poor physical health-related quality of life was dependent upon whether individuals reported high levels of internalized weight bias. In other words, although BMI was related to physical health impairment for individuals high in internalized weight bias, BMI was not related to physical health impairment for those low in internalized weight bias. Thus, BMI alone is not sufficient to explain the variance in health-related quality of life. The relationship of BMI to physical health-related quality of life may be moderated by the extent to which individuals internalize self-stigma based on their weight, or the impact that weight has on individuals’ self-worth.
Body Dissatisfaction and Physical and Mental Health Impairment
Finally, in another study (Wilson, Latner, & Hayashi, 2013; http://dx.doi.org/10.1016/j.bodyim.2013.04.007), we hypothesized that there would be an association between BMI and physical health-related quality of life, but that this association would be mediated by body image dissatisfaction. This study included 414 college students from a large public university in Hawaii (40% Asian, 19% Caucasian, 2% Hispanic, 1% Pacific Islander, 1% Black, and 37% of mixed ethnicities. Participants completed measures of body image dissatisfaction, health-related quality of life, depression, anxiety, stress, and self-esteem.
The results of this study indicated that higher BMI was significantly associated with greater body image dissatisfaction and with poorer physical health-related quality of life. Higher body image dissatisfaction was, in turn, significantly associated with increased anxiety, stress, depressive symptoms, mental health-related quality of life impairment, and decreased self-esteem. Body image dissatisfaction was also negatively associated with physical health-related quality of life in both men and women. Importantly, however, when controlling for BMI and age, greater body dissatisfaction predicted greater physical health-related quality of life impairment, mental health-related quality of life, depressive symptoms, stress, anxiety, and self-esteem. Only body image dissatisfaction – and not BMI – contributed significantly to these physical and psychological outcomes. Although higher BMI was modestly associated with poorer physical health-related quality of life, this relationship was mediated by body image dissatisfaction. Similarly, in all other analyses, body image dissatisfaction, and not BMI, was associated with or predicted poorer physical and psychosocial functioning. These findings further suggest that it may be body dissatisfaction, rather than BMI, that is more closely associated with impairments in both physical and psychosocial functioning.
Conclusions: Internalized Weight Bias, Body Dissatisfaction, and Health Impairment
Taken together, these results suggest that internalized weight bias, and the related experience of body dissatisfaction, may be linked with physical and mental health impairment to a greater extent than body weight itself. The stress associated with internalized bias might impair cardiovascular and metabolic health. Alternatively, it is possible that internalized bias and prejudice could impair physical health because internalized bias leads to unhealthy coping behaviors such as smoking, alcohol use, substance use, or binge eating.
The results of these studies can be compared with findings from other marginalized populations. Prejudice and internalized bias have also been associated with adverse health outcomes in stigmatized groups such as gays, lesbians, bisexuals, and ethnic minorities. For example, internalized racism among African Americans is correlated with negative health outcomes. These results have important potential implications for clinical practice.
Clinicians are advised to assess and treat not just their clients’ body weight and eating behaviors, but also the psychological meaning that patients may attribute to their weight and the self-stigmatizing attitudes they may hold. Improving body acceptance can, in itself, improve physical health-related quality of life. Acceptance approaches such as Health at Every Size (HAES) treatment interventions may improve several physical health indicators even without weight loss. Perhaps these treatments work by improving acceptance and reducing the bias that patients direct at themselves. Internalized weight bias could possibly be targeted directly in treatment. Interventions that target only body weight, rather than attitude change, may miss out on the opportunity to provide the maximum possible benefit to health-related quality of life. Treatments that focus on attitude changes may also be more sustainable than weight loss, which is typically short-lived. At the same time, research also needs to focus on how to reduce societal discrimination as well as to help clients cope with painful, harmful discrimination.