of their family [96].
Internalization
In comparison to studies assessing the effects of weight stigma enacted by others, the health impact of internalized weight stigma (or weight bias internalization; WBI) has received less empirical attention, and most studies on this topic have been published in the last 5 years [99]. However, a recent systematic review identified over 70 empirical studies that assessed associations between WBI – primarily measured with the Weight Bias Internalization Scale or the Weight Self‐Stigma Questionnaire [9,100] – and mental and physical health outcomes [99]. The review found robust associations between WBI and measures of psychological well‐being such as depression, anxiety, body dissatisfaction, binge eating, poor self‐esteem, reduced mental health‐related quality of life (HRQOL), and general psychological distress. Some studies have found that WBI mediates or moderates the relationship between experiencing weight stigma and unhealthy behaviors (e.g. uncontrolled or emotional eating), highlighting that the internalization process may facilitate poorer outcomes for people who have encountered weight stigma from others [101–103]. Notably, WBI may also operate independently from experiences of weight stigma (for example, if people internalize societal weight attitudes without having direct, stigmatizing encounters).
Associations between WBI and physical health outcomes have been more mixed, with some studies showing that WBI is associated with poorer physical HRQOL, higher BMI, and less reported minutes of physical activity, and other studies finding no significant relationships [99]. WBI does appear to be more consistently associated with motivational factors, such as reduced reported self‐efficacy to engage in healthy eating and physical activity and greater reported avoidance of activity. However, few studies have included objective measures of physical activity, so it remains unclear how WBI may or may not impact this health behavior.
In general, most studies examining WBI and physical health have relied solely on self‐reported health measures, with the exception of some studies that include measured BMI. Recent efforts have been made to expand WBI research to include more objective measures of health. For example, one study found an association between heightened WBI and the presence of metabolic syndrome, with a particularly strong relationship between WBI and high triglycerides [104]. Another study measured salivary cortisol before and after an acute social stressor and found that individuals with high WBI showed an abnormally blunted HPA axis response to the stressor [105]. More research is needed to determine whether internalizing weight stigma may elicit a similar stress response and associated chronic diseases as those observed in relation to perceived weight discrimination.
Recent research has also focused on the impact of WBI on weight management efforts. Studies have shown that individuals with higher levels of WBI are more likely to report “dieting” than those with lower WBI, and WBI tends to be higher in treatment‐seeking samples than in community samples of individuals with obesity [99]. Patients with higher WBI may also be at risk for poorer long‐term weight loss and maintenance [106–111]. For example, a study of 170 patients undergoing bariatric surgery found that higher baseline WBI was associated with less weight loss one year later after controlling for depression, surgery type, BMI, and demographic characteristics [106]. The relationship between WBI and weight loss has not been consistent: some studies do not show these associations, and in others, the associations are only significant for certain subgroups, on select subscales, or at some but not all timepoints. Other studies have found that, among patients enrolled in weight management programs, those with high levels of WBI show attenuated improvements in eating and physical activity compared to those with lower WBI [112,113]. Weight loss interventions produce statistically significant but modest reductions in WBI, suggesting that weight loss on its own may not be sufficient to diminish deeply internalized, self‐disparaging beliefs about oneself due to weight [109,112]. Greater attention is due to the potential impact of WBI, and to reductions in WBI, on weight management efforts.
Interventions to prevent and reduce weight stigma
As stigma may occur at institutional, interpersonal, or intrapersonal levels, interventions can also be designed to target stigma at each of these levels. We end this chapter by summarizing several promising policy and practice interventions that have been proposed to reduce weight stigma and its harmful effects.
Laws
A 2009 amendment to the Americans with Disabilities Act of 1990 and the Rehabilitation Act of 1973 (together, the “ADA”) provided federal protections against discrimination for individuals with severe obesity [114]. However, this law requires individuals to prove disability due to their weight, and it does not apply to individuals with lower levels of obesity. Other efforts have focused on amending civil rights laws at the city or state level to include weight as a protected characteristic [115]. For example, San Francisco, CA; Santa Cruz, CA; Binghamton, NY; Urbana, IL; Madison, WI; Washington, DC; and Harford, Howard, and Prince George counties in Maryland all have protections against weight and/or appearance discrimination [116]. Michigan is the only state that currently prohibits weight discrimination, although the legislature of Massachusetts is considering such a bill in the 2019–2020 session.
Few countries outside of the United States have legal protections against weight discrimination [117]. In 2001, France expanded its Labor Code to include protection against discrimination due to physical appearance [118]. Notably, France’s anti‐discrimination laws carry criminal sanctions [118]. Most other European countries do not have such protections, and, similar to the United States, the European Court of Justice ruled in 2014 that individuals with obesity may be protected against discrimination due to disability only if they can demonstrate impairment [119].
Laws that prohibit weight‐based discrimination (particularly in employment) have strong support among the public, those affected by obesity, and health professionals who specialize in problems related to weight and eating [117,120,121]. Given that few places have enacted such laws, assessment of their effects on weight discrimination has been limited, and results have been mixed. Of the 10 jurisdictions with weight discrimination laws, one study found improved labor market participation for men and women with obesity in two cities and improved market outcomes for men (but not women) with obesity in three cities [116]. Another study found evidence of reduced overt weight discrimination among women with obesity in Michigan, although they also reported increases in more subtle forms of discrimination such as harassment by a supervisor (which may not be protected against by law; [122]). The inconsistent success of these laws may be attributable to how they are enforced, adjudicated, and publicized [116].
In addition to possibly reducing the prevalence of weight discrimination, protective policies have the potential to improve the health of marginalized group members. Prior research has shown that sexual minorities who live in states with protective laws (or those who do not live in states with discriminatory laws) have better mental and physical health than those who live in states with less inclusive environments [123,124]. A preliminary, online study in which the legality of weight discrimination was manipulated in hypothetical vignettes suggested that anti‐discrimination legislation may mitigate some of the negative affect that people experience when they face weight discrimination [125]. As more protective laws are passed and implemented, more research is needed to ascertain their effects on weight discrimination and its associated health outcomes.
Similar to laws prohibiting weight discrimination, anti‐bullying laws that protect youth from weight‐based bullying are generally lacking, despite strong support from the general public, parents, and educators [126–128]. Only one state in the United States (Maine) specifically includes weight as a protected category in its anti‐bullying legislation, and three states include physical appearance or attributes. In the limited research that has been conducted on the effects of these laws, data suggest that a clearer emphasis on weight might be needed in order to actually reduce instances of weight‐based bullying [129].
Health care laws – namely, those that regulate insurance coverage – could also prevent discrimination against persons with obesity in health care settings. Less than 30% of insurance companies offer reimbursement for evidence‐based obesity treatment such as medical weight management,