Original Article Obesity

CLINICAL TRIALS AND INVESTIGATIONS

Association Between Weight Bias Internalization and

Metabolic Syndrome Among Treatment-Seeking
Individuals with Obesity
Rebecca L. Pearl1, Thomas A. Wadden1, Christina M. Hopkins1,2, Jena A. Shaw1, Matthew R. Hayes1,3, Zayna M. Bakizada1,
Nasreen Alfaris4, Ariana M. Chao1,5, Emilie Pinkasavage1, Robert I. Berkowitz1,6, and Naji Alamuddin1,7

Objective: Weight stigma is a chronic stressor that may increase cardiometabolic risk. Some individuals
with obesity self-stigmatize (i.e., weight bias internalization, WBI). No study to date has examined
whether WBI is associated with metabolic syndrome.
Methods: Blood pressure, waist circumference, and fasting glucose, triglycerides, and high-density lipopro-
tein cholesterol were measured at baseline in 178 adults with obesity enrolled in a weight-loss trial. Medica-
tion use for hypertension, dyslipidemia, and prediabetes was included in criteria for metabolic syndrome. One
hundred fifty-nine participants (88.1% female, 67.3% black, mean BMI 5 41.1 kg/m2) completed the Weight
Bias Internalization Scale and Patient Health Questionnaire (PHQ-9, to assess depressive symptoms). Odds
ratios and partial correlations were calculated adjusting for demographics, BMI, and PHQ-9 scores.
Results: Fifty-one participants (32.1%) met criteria for metabolic syndrome. Odds of meeting criteria for
metabolic syndrome were greater among participants with higher WBI, but not when controlling for all
covariates (OR 5 1.46, 95% CI 5 1.002.13, P 5 0.052). Higher WBI predicted greater odds of having high
triglycerides (OR 5 1.88, 95% CI 5 1.143.09, P 5 0.043). Analyzed categorically, high (vs. low) WBI pre-
dicted greater odds of metabolic syndrome and high triglycerides (Ps < 0.05).
Conclusions: Individuals with obesity who self-stigmatize may have heightened cardiometabolic risk.
Biological and behavioral pathways linking WBI and metabolic syndrome require further exploration.
Obesity (2017) 25, 317-322. doi:10.1002/oby.21716

Introduction anxiety, body dissatisfaction, and low self-esteem (3). In addition to

Across the world, individuals with obesity are viewed as stereotypi-
cally lazy, lacking willpower, incompetent, unattractive, and to
blame for their excess weight (1). Due to these negative, prejudicial
beliefs (known as weight bias), individuals with obesity face public
derogation, devaluation, and discrimination (known as weight
stigma) (2). Weight stigma is a prominent psychosocial consequence
of obesity that is associated with increased risk for depression,
experiencing weight stigma perpetrated by others, some individuals
with obesity may internalize weight-biased attitudes by applying
negative stereotypes to themselves and devaluing themselves due to
their weight (4). This self-directed stigma, also known as weight
bias internalization (WBI), is associated with similar psychological
outcomes as experiences of weight-based stigmatization enacted by
others (3). WBI is higher among individuals with more frequent

1
Department of Psychiatry, Center for Weight and Eating Disorders, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,
Pennsylvania, USA. Correspondence: Rebecca L. Pearl (rpearl@mail.med.upenn.edu) 2 Department of Psychology, Duke University, Durham, North
Carolina, USA 3 Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
4
Department of Medicine Gastrointestinal Unit, MGH Weight Center, Massachusetts General Hospital, Boston, Massachusetts, USA 5 Department of
Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA 6 Department of Psychiatry and Behavioral
Sciences, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania, USA 7 Department of Medicine, Institute for Diabetes, Obesity, and Metabolism,
Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

See Commentary, pg. 280.

Funding agencies: This study was supported by an investigator-initiated grant from Eisai Pharmaceutical Co. (TAW). AMC was supported by an NRSA postdoctoral
fellowship from the NINR/NIH #T32NR007100.
Disclosure: TAW discloses serving on advisory boards for Novo Nordisk, Nutrisystem, and Weight Watchers, as well as receiving grant support, on behalf of the
University of Pennsylvania, from Eisai Pharmaceutical Co. The other authors declared no conflict of interest.
Author contributions: RLP held primary responsibility for this specific study design, data analysis, and manuscript preparation. TAW was responsible for the design and
oversight of the clinical trial and assisted with manuscript preparation. CMH, ZMB, AMC, and EP assisted with data collection and manuscript preparation. JAS and NAla
assisted with data collection, data analysis, and manuscript preparation. MRH assisted with manuscript preparation. NAlf and RIB assisted with design and oversight of
the clinical trial and manuscript preparation.
Clinical trial registration: ClinicalTrials.gov identifier NCT02388568.
Received: 12 August 2016; Accepted: 17 October 2016; Published online 26 January 2017. doi:10.1002/oby.21716

www.obesityjournal.org Obesity | VOLUME 25 | NUMBER 2 | FEBRUARY 2017 317

Obesity
experiences of weight stigma (5,6), although experiencing and inter-
nalizing stigma are considered related yet independent constructs
(6,7). Consistent with research that cognitive appraisal of a stressful
life event is more predictive of negative psychological outcomes
than the event itself (8), recent findings suggest that WBI (a cogni-
tive process) may be a more robust predictor of psychological dis-
tress than the experience of weight stigma alone (9).
Additional research has begun to establish that experiencing (or per-
ceiving) weight stigma, principally weight discrimination, is associ-
ated with physical health consequences. In a study of two large, repre-
sentative samples that followed participants in the U.S. longitudinally
for 4 to 10 years, Sutin et al. (10) reported that perceiving weight dis-
crimination increased risk of mortality by 57% over and above the
effects of mental and physical health risk factors. Other studies have
also demonstrated that perceived weight discrimination is associated
with increases in weight, waist circumference, and, for those in the
overweight range, the development of obesity over time (11,12).
Among individuals with and without type 2 diabetes, weight-based
discrimination is also associated with poorer glycemic control, even
when controlling for body mass index (BMI), depressive symptoms,
and other relevant health variables (13,14).
A combination of biological and behavioral pathways may explain the
associations between weight stigma and poor physical health (15).
Stigma broadly is considered a chronic stressor (16), which can elicit
a biochemical stress response marked by changes in autonomic
response, hypothalamic-pituitary-adrenocoritcal axis activation, oxi-
dative stress, and inflammation (15). For example, experimental stud-
ies that exposed participants (predominantly white women) to weight
stigma have demonstrated heightened blood pressure and increased
cortisol reactivity (17,18). Increased appetite and/or physiological
arousal resulting from these biochemical changes, combined with
emotional responses, may contribute to observed increases in calorie
consumption and binge eating in individuals who have been directly
exposed to or experienced weight stigma (19,20). Individuals who
report weight-stigmatizing experiences also tend to avoid physical
activity (21). In addition, individuals who perceive or experience
weight stigma in health care settings are more likely to avoid or delay
preventive care, thus increasing risk for disease progression (22).
These studies examining the relationship between weight stigma and
physical health have not included assessments of WBI, and gener-
ally less is known about the relationship between WBI and cardio-
metabolic markers of health. In several studies, correlations have
been found between WBI and poorer self-reported health, increased
binge eating, and reduced physical activity (6,20,23-27), suggesting
that similar pathways to poor health may exist for WBI as with
weight stigma perpetrated by others. Several studies have demon-
strated that WBI is a partial mediator between experiences of weight
stigma and poor health behaviors (such as uncontrolled eating and
reduced exercise) (5,6). Additionally, one study found that BMI was
only associated with poor health-related quality of life among indi-
viduals with high versus low WBI (28). Thus, it is possible that acti-
vation of internalized, negative beliefs following or independent of
stigmatizing experiences may lead to heightened stress and subse-
quent maladaptive coping behaviors (e.g., binge eating).
Although limited research has investigated cardiometabolic risk associ-
ated with other forms of internalized stigma (e.g., racism) (29), some
318 Obesity | VOLUME 25 | NUMBER 2 | FEBRUARY 2017
Weight Bias Internalization and Metabolic Syndrome Pearl et al.
studies have reported associations between internalized racism and
greater risk of abdominal obesity, insulin resistance, and other indices
of obesity-related health (30). However, no study to date has investi-
gated the relationship between WBI and cardiometabolic risk factors
commonly associated with obesity. Metabolic syndrome, which refers
to a cluster of risk factors for cardiovascular disease and type 2 diabetes
(31), is particularly relevant to investigate. Approximately 35% to 40%
of adults in the U.S. have metabolic syndrome, and 60% of adults with
obesity meet criteria for this diagnosis (32). Individuals with metabolic
syndrome have a twofold increased risk for cardiovascular disease and a
fivefold risk for type 2 diabetes (31,33).
This study examined the relationship between WBI and metabolic
syndrome. We hypothesized that in persons with obesity, higher lev-
els of WBI would be associated with increased odds of having meta-
bolic syndrome. We also explored the relationships between WBI
and the individual cardiometabolic risk factors that constitute meta-
bolic syndrome, in order to determine which risk factors may be
more strongly linked to WBI.
Methods
Participants
Participants were 178 adults with obesity recruited from the commu-
nity to participate in a weight-loss trial. The primary purpose of the
study was to test the effects of a 1-year weight-loss maintenance pro-
gram, to which participants were randomly assigned if they lost 5%
of initial weight during a 14-week diet run-in period. Eligible partici-
pants had a BMI 33 kg/m2 (or 30 kg/m2 with comorbidities) and
55 kg/m2 and were: age 21 to 65 years; weight stable with no history
of bariatric surgery; not on medications that would affect weight or on
medications contraindicated with the weight-loss medication used in
the 1-year maintenance study; and under the care of a primary care
physician. They also were free of: current, severe depressive episodes;
suicidal ideation; type 1 or type 2 diabetes; uncontrolled hypertension;
cardiovascular, valvular heart, hepatic, renal, or uncontrolled thyroid
disease; or other medical conditions that could compromise the partic-
ipants ability to complete the weight-loss program. Only baseline
data were analyzed in the current study. The study was approved by
the University of Pennsylvania Institutional Review Board.
Procedures
Participants were recruited from the community through print, radio,
and Web advertisements and screened over the phone for eligibility.
Following the initial phone screen, interested participants were eval-
uated in person by trained clinicians for eligibility and appropriate-
ness. All participants underwent a medical exam with a physician or
nurse practitioner before enrollment, which included assessment of
current medications. At this initial screening visit, blood pressure
and waist circumference were measured, and blood draws completed
to obtain measures of fasting blood glucose, triglycerides, and high-
density lipoprotein (HDL) cholesterol. Height and weight also were
measured at this screening visit, and weight was measured again
during the first week of the study (prior to any weight-loss interven-
tion). Questionnaires were administered online (via REDcap) or in
hard copy form via mail up to 2 weeks prior to the start of the pro-
gram. Data for the present study are based on these screening meas-
ures, obtained before the 14-week run-in diet.
www.obesityjournal.org
Original Article Obesity
CLINICAL TRIALS AND INVESTIGATIONS

seated rest), using an automated monitor (Dinamap, model 9300,

TABLE 1 Sample characteristics (N 5 159) Johnson & Johnson), following methods described previously (34).
Waist circumference was measured with a flexible tension-
Variable N (%) or M 6 SD
controlled measuring tape midway between the iliac crest and lowest
Sex rib to the nearest 0.1 cm (34). Metabolic syndrome was defined by
Women 140 (88.1) the presence of three or more of the following five risk factors:
Men 19 (11.9) central or abdominal obesity (i.e., waist circumference 35 inches
Race and ethnicity for women, 40 inches for men); elevated triglycerides (i.e.,
150 mg/dL) and/or use of medication for dyslipidemia (i.e.,
Black or African American, non-Hispanic 107 (67.3)
statins); low HDL cholesterol (i.e., 50 mg/dL for women,
White, non-Hispanic 36 (22.6)
40 mg/dL for men); elevated blood pressure (i.e., 130/85 mm
Asian 4 (2.5) Hg) and/or antihypertensive medication; and elevated fasting blood
American Indian or Alaska Native 1 (.6) glucose (i.e., 100 mg/dL) and/or medication to treat prediabetic
Other 1 (.6) levels of blood glucose (31).
More than one race 4 (2.5)
Hispanic or Latino/a 9 (5.7) Weight Bias Internalization (WBI) Scale. The 11-item WBIS
Metabolic syndrome (4) is a widely used, validated measure of WBI (i.e., self-directed
SBP 130, DBP 85 mm Hg, or 101 (63.5) weight stigma), including in treatment-seeking samples (23-25). The
medication treating hypertension scale assesses the extent to which people apply weight-based stereo-
Triglycerides 150 mg/dL or 36 (22.6) types to themselves (e.g., Because of my weight, I dont understand
medication treating dyslipidemia how anyone attractive would want to date me.) and evaluate them-
selves negatively due to weight (e.g., I hate myself for being over-
Waist circumference 40 in for 150 (94.3)
weight.). Responses are rated on a scale of 1 (strongly disagree) to
men, 35 in for womena
7 (strongly agree), with higher scores signifying greater WBI. The
FBG 100 mg/dL or medication 8 (5.0) scale demonstrated good internal validity in the current sample
treating prediabetes (a 5 0.84).
HDL cholesterol <40 mg/dL for 46 (28.9)
men, <50 mg/dL for women Depression. The Patient Health Questionnaire (PHQ-9) (35) is a
Diagnosis (three of five criteria)a 51 (32.1) nine-item, self-report measure of depression. Items assess the fre-
Age (y) 43.8 6 11.3 quency of symptoms of depression (e.g., little interest or pleasure
Weight (kg) 115.2 6 20.7 in doing things) over the past 2 weeks, and responses range from 0
Height (cm) 167.2 6 8.5 (not at all) to 3 (nearly every day). Scores are summed, with higher
Body mass index (kg/m2) 41.1 6 5.9 scores indicating greater severity of depressive symptoms. The
SBP (mm Hg) 129.8 6 16.1 PHQ-9 is currently recommended by the American Psychiatric Asso-
DBP (mm Hg) 75.5 6 10.0 ciation as the optimal depression severity measure for DSM-5 (36).
The PHQ-9 had good internal validity in the current study
Triglycerides (mg/dL) 100.7 6 52.2
(a 5 0.85).
Waist circumference (cm)a 114.4 6 14.2
FBG (mg/dL) 85.8 6 8.1
HDL (mg/dL) 57.5 6 18.7 Statistical analyses
Weight Bias Internalization Scale 3.6 6 1.1 Natural log transformations were performed to adjust for skewed
Patient Health Questionnaire-9 4.8 6 4.8 values of triglycerides, waist circumference, HDL cholesterol, and
PHQ-9 scores. All tests were two-tailed and used a P < 0.05 level of
a
Waist circumference data were missing for eight participants. Percentages for the
significance. Analyses of variance and correlations were tested to
waist circumference criterion and metabolic syndrome diagnosis were calculated determine associations between WBI and participant characteristics,
from the total number of participants (N 5 159). BMI, and depressive symptoms.
SBP, systolic blood pressure; DBP, diastolic blood pressure; FBG, fasting blood
glucose; HDL, high-density lipoprotein cholesterol.
We constructed a binary logistic regression model to test our pri-
mary hypothesis that participants with higher WBI would exhibit
Measures increased odds of having metabolic syndrome. To receive this diag-
Anthropometric measures. Weight was measured (with partici- nosis, participants had to meet criteria for three of the five cardio-
pants dressed in light clothing and without shoes) on a digital scale metabolic risk factors described above. We controlled for age, sex,
(Detecto, model 6800A). Height was measured using a wall- race, ethnicity, and BMI in all analyses. Given some findings show-
mounted stadiometer (Veeder-Root, Elizabethtown, NC). ing a relationship between metabolic syndrome and depression (37),
we also controlled for PHQ-9 scores in all analyses. Thus, we tested
the relationship between WBI and metabolic syndrome above and
Cardiometabolic risk factors. Blood samples were collected beyond the effects of demographics, BMI, and depression.
following an 8-hour fast and analyzed by Quest Diagnostics (Hor-
sham, PA) for levels of triglycerides, HDL cholesterol, and glucose Following the primary analysis, separate logistic regression models
(and other tests to assess patient safety). Blood pressure and pulse were constructed for each risk factor (defined categorically, as
were measured in duplicate, at 1-minute intervals (after a 5-minute described previously) to test their associations with WBI. We also

www.obesityjournal.org Obesity | VOLUME 25 | NUMBER 2 | FEBRUARY 2017 319

Obesity Weight Bias Internalization and Metabolic Syndrome Pearl et al.

TABLE 2 Odds ratios (95% confidence intervals) for weight
bias internalization as a continuous measure
Metabolic High triglycerides
syndrome and/or medication
Block 1 1.41 (1.011.97)* 1.79 (1.212.64)**
Block 2 1.46 (1.002.13)1 1.88 (1.143.09)*
Block 1: Weight bias internalization, body mass index, and depressive symptoms.
Block 2: Block 1 plus demographics (age, sex, race/ethnicity).
Due to missing waist circumference data, N 5 151 for metabolic syndrome.
N 5 159 for triglycerides/medication.
1
P 5 0.052; *P < 0.05; **P < 0.01.
calculated partial correlations (controlling for demographics, BMI,
and PHQ-9 scores) between WBIS scores and continuous variables
of each cardiometabolic risk factor. Additionally, we included sup-
plementary analyses in which we constructed the same six logistic
regression models, but with WBI defined categorically as high
versus low based on tertiles. This dichotomization of WBI is con-
sistent with prior research (28,30).
Missing data. At baseline, eight participants were missing waist
circumference measurements. These participants were excluded from
analyses that included waist circumference or metabolic syndrome
diagnosis as outcome variables.
Results
Participant characteristics
Completed study questionnaires were obtained from 159 partici-
pants, whose characteristics are summarized in Table 1. The major-
ity of participants were women and black. Table 1 also presents a
summary of the number of participants meeting criteria for meta-
bolic syndrome, as well as participants mean weight, height, BMI,
and scores on the WBIS and PHQ-9.
Race/ethnicity was coded into three categories of non-Hispanic
white, non-Hispanic black, and all other racial/ethnic groups. Analy-
sis of variance revealed significant differences in WBIS scores by
race (P < 0.001). Post hoc paired t-tests revealed that black partici-
pants scored significantly lower on the WBIS than white partici-
pants: mean (6SD) scores for black participants 5 3.36 6 1.08, and
for white participants 5 4.22 6 1.15 (P < 0.001). WBIS scores corre-
lated significantly with depressive symptoms (r 5 0.38, P < 0.001).
Age, sex, and BMI were not significantly associated with WBIS
scores.
Primary analysis: Metabolic syndrome
Table 2 presents the results from the logistic regression analysis that
examined the association between WBI and metabolic syndrome,
controlling for demographics, BMI, and depressive symptoms. When
controlling for BMI and depressive symptoms, participants with
higher WBIS scores had greater odds of meeting criteria for meta-
bolic syndrome (OR 5 1.41, P 5 0.042). However, when demo-
graphics were included in the model, this relationship was no longer
statistically significant (OR 5 1.46, P 5 0.052). Participant age was
the only covariate associated with metabolic syndrome in the model
(OR 5 1.05, P 5 0.004).
Secondary analyses: Cardiometabolic risk factors
To explore the factors responsible for heightened odds of meta-
bolic syndrome, we examined the associations between WBI and
each component of the condition via five separate logistic regres-
sion models (all controlling for demographics, BMI, and PHQ-9
scores) and partial correlations (controlling also for respective
medication use). Of the logistic regression models, only the model
that tested the relationship between WBI and high triglycerides
was significant (see Table 2). Participants with higher WBIS
scores had greater odds of having high triglycerides and/or taking
medication for dyslipidemia, even when controlling for all covari-
ates (OR 5 1.88, P 5 0.013). Only one participant did not meet the
waist circumference criterion, and no associations between this
risk factor and WBIS scores emerged. Associations were not sig-
nificant between WBIS scores and blood pressure or glucose.
Only eight participants met the glucose/medication criterion (due
to the participant exclusion criterion of type 2 diabetes). WBIS
scores correlated positively with triglycerides (P 5 0.021) and neg-
atively with HDL cholesterol (P 5 0.009). However, these correla-
tions were not statistically significant when controlling for all
covariates (see Table 3).

TABLE 3 Correlations (and partial correlations) between weight bias internalization and cardiometabolic risk factors

HDL Waist
Variable cholesterola FBG circumference Triglycerides DPB SBP

Weight bias internalization 20.21** (20.13) 0.04 (0.02) 0.10 (0.02) 0.18* (0.13) 0.08 (0.07) 0.06 (0.09)
Systolic blood pressure (SBP) 0.08 (0.06) 0.18* (0.11) 0.12 (0.06) 0.07 (0.04) 0.58*** (0.59***)
Diastolic blood pressure (DPB) 20.03 (20.02) 0.10 (0.06) 0.10 (0.05) 0.09 (0.06)
Triglyceridesa 20.41*** (20.40***) 0.15 (0.08) 20.03 (20.01)
Waist circumferencea,b 20.07 (0.06) 0.14 (0.05)
Fasting blood glucose (FBG) 20.13 (20.13)

Partial correlations control for age, sex, race/ethnicity, body mass index, depression, and respective medication use (for blood pressure, triglycerides, and glucose).
a
Variable was transformed using the natural logarithm.
b
N 5 151 for waist circumference due to missing data.
*P < 0.05; **P < 0.01; ***P < 0.001.

320 Obesity | VOLUME 25 | NUMBER 2 | FEBRUARY 2017 www.obesityjournal.org

Original Article
CLINICAL TRIALS AND INVESTIGATIONS
TABLE 4 Odds ratios (95% confidence intervals) for high
versus low weight bias internalization
Metabolic High triglycerides
syndrome and/or medication
Block 1 2.68 (1.056.88)* 5.64 (1.7218.54)**
Block 2 3.19 (1.069.56)* 6.13 (1.3727.46)*
Block 1: Weight bias internalization, body mass index, and depressive symptoms.
Block 2: Block 1 plus demographics (age, sex, race/ethnicity). Categorization of
high versus low weight bias internalization was based on tertiles: high 4.18, low
3.09.
Due to missing waist circumference data, N 5 103 for metabolic syndrome.
N 5 109 for triglycerides/medication.
*P < 0.05 **P < 0.01.
Supplementary analyses
Consistent with prior research in which internalized stigma was
dichotomized to determine effects of high versus low values
(28,30), we examined the relationship between WBI, metabolic syn-
drome, and the individual risk factors in six additional logistic
regression models (controlling for all aforementioned covariates), in
which WBI was categorized as high versus low based on tertiles.
Cutoff scores of 4.18 (n 5 57) and 3.09 (n 5 52) were used to define
high and low scores, respectively. Logistic regression analyses con-
trolling for all covariates demonstrated that participants high in WBI
had three times greater odds of meeting criteria for metabolic syn-
drome (OR 5 3.19, P 5 0.039), and six times greater odds of having
high triglycerides and/or taking medication (OR 5 6.13, P 5 0.018)
than participants low in WBI (see Table 4).
Discussion
This study of treatment-seeking individuals with obesity found
mixed results concerning the relationship between metabolic syn-
drome and WBI. This relationship was not significant when all
covariates were included in a regression model in which WBI was
represented continuously. However, the odds of having metabolic
syndrome were significantly heightened among participants catego-
rized as having high (versus low) levels of WBI. WBI has been
shown previously to be associated with binge eating (20), reduced
physical activity motivation and engagement (6,23), and poorer self-
reported physical health (24,25). However, this is the first report of
which we are aware to demonstrate a possible association between
WBI and metabolic syndrome.
The only individual component of metabolic syndrome that was sig-
nificantly associated with WBI was high triglycerides/use of medica-
tion for dyslipidemia. Internalized weight bias could elicit a chronic
stress response similar to that observed in reaction to experiences of
weight stigma, such as heightened levels of oxidative stress and cor-
tisol secretion (15). The act of self-stigmatizing may lead to a state
of physiological arousal that itself increases risk for metabolic
abnormalities through biological pathways (e.g., cortisol secretion).
This state of physiological and affective stress may also lead indi-
viduals to cope by eating unhealthy food or binge eating (38). Addi-
tionally, individuals with high WBI exhibit diminished self-efficacy
to exercise due to endorsing negative stereotypes, such as laziness
www.obesityjournal.org
Obesity
(6,23), and thus are more likely to avoid physical activity (21). Fur-
ther research is needed to determine the specific biological and/or
behavioral pathways that could account for unfavorable lipid levels.
For example, advanced lipoprotein testing could help to determine
whether the observed effects are diet-induced versus metabolically
endogenous. In-depth dietary analysis could also examine whether
individuals with high WBI consume more high-fat foods, which
could potentially account for the elevated triglyceride levels
observed in this study. The correlation between WBI and triglycer-
ides was not significant when controlling for covariates, and waist
circumference and blood glucose control were largely homogeneous
in this sample. Thus, replication is required, and further research
with a more heterogeneous representation of these risk factors (e.g.,
including individuals with type 2 diabetes) is needed.
This study was cross-sectional in design, precluding conclusions
about causality. Thus, a converse relationship could be present, in
which poorer physical health (e.g., metabolic syndrome) may lead
individuals with obesity to be more prone to internalizing weight
bias. Individuals with obesity frequently experience weight stigma
in health care settings (22); increased need for health care services
due to poor health may consequently increase exposure to stigma
and heighten vulnerability to internalizing it. Heightened disease
burden may also increase susceptibility to self-blame due to the per-
ceived controllability of weight (2). A longitudinal study of individ-
uals with varying levels of WBI at baseline, but without obesity-
related comorbidities, could help to clarify the temporal relationship
between WBI and risk of metabolic syndrome.
This sample was unique in its predominant composition of black
women, which allowed us to examine WBI among a group of indi-
viduals with obesity that is often not well represented in research
addressing this topic. Black participants had lower levels of WBI on
average, which may reflect reduced vulnerability to body dissatisfac-
tion among black women (39). Black children and adults also gener-
ally have lower triglyceride levels and are thus less likely to be
diagnosed with metabolic syndrome (40). Given these racial differ-
ences, it is possible that the relationship between WBI, triglycerides,
and metabolic syndrome may differ by race as well. We may have
been underpowered in our analyses to detect significant racial differ-
ences in the regression models, as well as sex differences due to the
relatively small number of men in the present sample. Prior studies
examining the relationship between weight discrimination and physi-
cal health outcomes have used large, nationally representative data-
sets (10-12), in which small effects may be better detected. We rec-
ommend that future large-scale investigations of obesity and
healthparticularly cardiovascular disease riskincorporate the
WBIS into assessment batteries in order to accumulate more data
and test for potential moderators such as sex and race.
Our findings pertain only to individuals with obesity seeking treat-
ment for weight loss and may not generalize to the broader popula-
tion of individuals with obesity. Prior evidence suggests that
treatment-seeking individuals with obesity exhibit heightened rates
of psychopathology (including depression) in comparison with non-
treatment seeking individuals (41). However, given this studys
exclusion criteria of severe depression or use of antidepressant medi-
cation, our clinical sample had relatively low levels of depressive
symptoms. The mean WBIS score in this sample was lower than in
other recent studies of treatment-seeking samples (42), which may
reflect the relatively good mental and physical health of this sample.
Obesity | VOLUME 25 | NUMBER 2 | FEBRUARY 2017 321
Obesity
Research assessing associations between WBI and health among
individuals with higher levels of WBI, and potentially depressive
symptoms to test for mediation, would be informative to more fully
understand the extent to which self-stigma may affect cardiometa-
bolic risk.
Conclusion
The present findings contribute to the growing body of literature
demonstrating the relationship between weight stigma and adverse
physical health outcomes, once again contradicting a persistent argu-
ment that stigma motivates behavior change and improves health.
Replication is required to determine the relationship between WBI
and metabolic syndrome above and beyond relevant demographics
and health-related covariates. Nevertheless, these findings highlight
the importance of informing the public that weight stigmainclud-
ing self-directed stigmais stressful and may contribute to poor
health. Further research is needed to develop and test the effects of
interventions that aim to reduce WBI among individuals with obe-
sity. To inform these interventions, future research efforts should
focus on identifying specific biological and behavioral pathways
such as lipoprotein profiles, dietary intake, and engagement in physi-
cal activitybetween WBI and cardiometabolic risk.O
C 2017 The Obesity Society
V 28. Latner JD, Barile JP, Durso LE, OBrien KS. Weight and health-related quality of
References
1. Puhl RM, Latner JD, OBrien K, Luedicke J, Danielsdottir S, Forhan M. A
multinational examination of weight bias: predictors of anti-fat attitudes across four
countries. Int J Obes 2015;39:1166-1173.
2. Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res 2001;9:788-805.
3. Papadopoulos S, Brennan L. Correlates of weight stigma in adults with overweight
and obesity: a systematic literature review. Obesity 2015;23:1743-1760.
4. Durso LE, Latner JD. Understanding self-directed stigma: development of the
weight bias internalization scale. Obesity 2008;16:S80-SS6.
5. OBrien KS, Latner JD, Puhl RM, et al. The relationship between weight stigma
and eating behavior is explained by weight bias internalization and psychological
distress. Appetite 2016;102:70-76.
6. Pearl RL, Puhl RM, Dovidio JF. Differential effects of weight bias experiences and
internalization on exercise among women with overweight and obesity. J Health
Psychol 2015;20:1626-1632.
7. Earnshaw VA, Bogart LM, Dovidio JF, Williams DR. Stigma and racial/ethnic HIV
disparities. Am Psychol 2013;68:225-236.
8. Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York, NY: Springer
Publishing Company; 1984.
9. Pearl RL, Puhl RM. The distinct effects of internalizing weight bias: an
experimental study. Body Image 2016;17:38-42.
10. Sutin AR, Stephan Y, Terracciano A. Weight discrimination and mortality. Psychol
Sci 2015;26:1803-1811.
11. Sutin AR, Terracciano A. Perceived weight discrimination and obesity. PLoS ONE
2013;8:e70048. doi:10.1371/journal.pone.0070048.
12. Jackson SE, Beeken RJ, Wardle J. Perceived weight discrimination and changes in
weight, waist circumferance, and weight status. Obesity 2014;22:2485-2488.
13. Tsenkova VK, Carr D, Schoeller DA, Ryff CD. Perceived weight discrimination
amplifies the link between central adiposity and nondiabetic glycemic control
(HBA1C). Ann Behav Med 2011;41:243-251.
14. Potter L, Wallston K, Trief P, Ulbrecht J, Juth V, Smyth J. Attributing
discrimination to weight: associations with well-being, self-care, and disease status
in patients with type 2 diabetes mellitus. J Behav Med 2015;38:863-875.
322 Obesity | VOLUME 25 | NUMBER 2 | FEBRUARY 2017
Weight Bias Internalization and Metabolic Syndrome Pearl et al.
15. Tomiyama AJ. Weight stigma is stressful: a review of evidence for the cyclic
obesity/weight-based stigma model. Appetite 2014;82:8-15.
16. Major B, OBrien LT. The social psychology of stigma. Ann Rev Psychol 2005;56:
393-421.
17. Major B, Eliezer D, Rieck H. The psychological weight of weight stigma. Soc
Psychol Pers Sci 2012;3:651-658.
18. Himmelstein MS, Belsky ACI, Tomiyama AJ. The weight of stigma: cortisol
reactivity to mainpulated weight stigma. Obesity 2015;23:368-374.
19. Schvey NA, Puhl RM, Brownell KD. The impact of weight stigma on caloric
consumption. Obesity 2011;19:1957-1962.
20. Durso LE, Latner JD, Hayashi K. Perceived discrimination is associated with binge
eating in a community sample of non-overweight, overweight, and obese adults.
Obes Facts 2012;5:869-880.
21. Vartanian LR, Novak SA. Internalized societal attitudes moderate the impact of
weight stigma on avoidance of exercise. Obesity 2011;19:757-762.
22. Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, Ryn M. Impact
of weight bias and stigma on quality of care and outcomes for patients with obesity.
Obes Rev 2015;16:319-326.
23. Hubner C, Baldofski S, Zenger M, et al. Influences of general self-efficacy and
weight bias internalization on physical activity in bariatric surgery candidates. Surg
Obes Relat Dis 2014;11:1371-1376.
24. Pearl RL, White MA, Grilo CM. Weight bias internalization, depression, and self-
reported health among overweight binge eating disorder patients. Obesity 2014;22:
E142-E148.
25. Latner JD, Durso LE, Mond JM. Health and health-related quality of life among
treatment-seeking overweight and obese adults: associations with internalized
weight bias. J Eat Disord 2013;1:3. doi: 10.1186/2050-2974-1-3.
26. Schvey NA, Roberto CA, White MA. Clinical correlates of the Weight Bias
Internalization Scale in overweight adults with binge and purge behaviours. Adv Eat
Disord 2013;1:213-223.
27. Hilbert A, Braehler E, Haeuser W, Zenger M. Weight bias internalization, core self-
evaluation, and health in overweight and obese persons. Obesity 2014;22:79-85.
life: the moderating role of weight discrimination and internalized weight bias. Eat
Behav 2014;15:586-590.
29. Paradies Y. A systematic review of empirical research on self-reported racism and
health. Int J Epidemiol 2006;35:888-901.
30. Chambers EC, Tull ES, Fraser HS, Mutunhu NR, Sobers N, Niles E. The
relationship of internalized racism to body fat distribution and insulin resistance
among African adolescent youth. J Nat Med Assoc 2004;96:1594-1598.
31. Alberti KGMM, Eckel RH, Grundy SM, et al. Harmonizing the metabolic
syndrome. Circulation 2009;120:1640-1645.
32. Ford ES, Li C, Zhao G. Prevalence and correlates of metabolic syndrome based on a
harmonious definition among adults in the US. J Diabetes 2010;2:180-193.
33. Mottillo S, Filion KB, Genest J, et al. The metabolic syndrome and cardiovascular
risk: a systematic review and meta-analysis. J Am Coll Cardiol 2010;56:1130-1132.
34. Wadden TA, Berkowitz RI, Womble LG, et al. Randomized trial of lifestyle
modification and pharmacotherapy for obesity. N Engl J Med 2005;353:2111.
35. Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic severity measure.
Psychiatr Ann 2002;32:509-515.
36. American Psychiatric Association. Online Assessment Measures. American
Psychiatric Association; 2013. http://www.psychiatry.org/psychiatrists/practice/dsm/
dsm-5/online-assessment-measures.
37. Pan A, Keum N, Okereke OI, et al. Bidirectional association between depression
and metabolic syndrome. Diabetes Care 2012;35:1171-1180.
38. Dallman MF, Pecoraro N, Akana SF, et al. Chronic stress and obesity: a new view
of comfort food. Proc Natl Acad Sci USA 2003;100:11696-11701.
39. Grabe S, Hyde JS. Ethnicity and body dissatisfaction among women in the United
States: a meta-analysis. Psychol Bull 2006;132:622-640.
40. Sumner AE. Ethnic differences in triglyceride levels and high-density lipoprotein
lead to underdiagnosis of the metabolic syndrome in black children and adults.
J Pediatr 2009;155:eS7-eS11.
41. Friedman MA, Brownell KD. Psychological correlates of obesity: moving to the
next research generation. Psychol Bull 1995;117:3-20.
42. Durso LE, Latner JD, Chao AC. Weight bias internalization in treatment-seeking
overweight adults: psychometric validation and associations with self-esteem, body
image, and mood symptoms. Eat Behav 2016;21:104-108.
www.obesityjournal.org