Internalized Weight Stigma (Part 2): Relation to Eating Disorders and Next Steps

· by · in Awareness, body dissatisfaction, body image, bullying, mental health, NCEED, recovery, risk factors, summer, weight stigma. ·

by Emily Presseller and Natalie Papini

Emily Presseller (@EmilyPresseller) is a 2022 CEED Summer Fellow. Her research interests include understanding factors that influence the maintenance of and recovery from eating disorders.

Natalie Papini (@nataliep310) is a 2022 CEED Summer Fellow. One of her research interests include the intersection of eating disorders, weight stigma, and internalized weight stigma.

In the Part 1 of this blog, we discussed weight stigma and effects that internalizing that stigma has on physical and mental health. Now we turn to the specific relationship between internalized weight stigma (IWS) and eating disorders and disordered eating.

People with IWS (of all genders) often report dysregulated eating behaviors, including disordered eating symptoms. IWS can also stand in the way of engaging in life-enriching behaviors. People with IWS may avoid physical activity (waking outdoors, going to gyms) for fear of weight-based teasing and to avoid situations in which self-critical thoughts about one’s body are loudest.1,2 One former patient would only take walks around her neighborhood in the dark, which worked fine in the winter months, but meant she was confined to her home in the summer when the days were longer.

IWS has also been associated with binge eating,3-8 purging behaviors like vomiting and misuse of laxatives,4-9 problematic exercise,5,9 and disordered thoughts about food and eating.3,10,11 The experience of weight stigma is a known risk factor for certain disordered eating behaviors (such as binge eating) and eating disorder symptoms for people in larger bodies.12-14 Imagine looking at yourself in the mirror and hearing the voices of those who have teased, bullied, or stigmatized you and taking on those thoughts as your own. That transition from what others have said to your own internal dialogue can increase body dissatisfaction and fuel the desire to engage in disordered eating to lose weight.7 At their core, those thoughts tell you, “I’m not OK how I am and my body is not OK in its current state.”

Other factors, like depression, can also play a role.10 One of the hallmarks of depressive thinking is “negative views of the self.” In general, such thoughts might be “I’m a failure,” or “How could anyone love me?” When depression and IWS collide, those thoughts can lead to or maintain disordered eating behaviors. For example, “No one will give me a job because I am fat,” or “I will disgust people who see me at the beach.” Those thoughts can lead straight to disordered eating behaviors such as fasting, binge eating, or purging. Additionally, a person’s quality of life is lower, and IWS can keep people from doing things that enrich their life, like taking a walk on the beach free from the judgement of others and self-judgement. It will come as no surprise to readers who are living in higher weight bodies that weight bias is common among health care providers, including eating disorder clinicians, dietitians, and physicians.15,22 Weight stigma as it occurs in medicine is harmful. Countless stories exist about physicians missing important and life-threatening diagnoses by attributing all of the patient’s presenting complaints to fatness. No, losing 50 pounds will not cure that abdominal tumor! Weight stigma can influence treatment in more subtle ways including clinician’s belief in whether higher weight patients will benefit from treatment,19.20.22 providers’ enjoyment of treating patients with overweight or obesity,19-20 and patients’ experiences of treatment.16 Additionally, weight stigma can influence healthcare providers’ decision-making related to treatment,16,21 such as prescribing diets without screening for disordered eating. After a weight stigmatizing healthcare experience, if a patient doesn’t return, they are labeled as non-compliant rather than acknowledging that the visit was traumatizing and the patient sought weight inclusive healthcare elsewhere.

The National Center of Excellence for Eating Disorders (NCEED) based here at UNC has recently launched a simple, quick, and efficient, screener for eating disorders and disordered eating behavior for use in primary care (SBIRT-ED). Before every primary care clinician in the country prescribes weight loss to any patient, this screen should be administered. Just like your physician screens you for depression or anxiety, we now have a tool to do the same for eating disorders, regardless of your weight.

How can we fix this?

Weight stigma and IWS are widespread and hurtful. Fortunately, there are things everyone  can do to reduce weight stigma across the board. 

  • Providers should examine their own weight biases and anti-fat attitudes to ensure they are not unintentionally doing harm to patients in larger bodies. For example, medical professionals can shift away from focusing on weight or BMI. Instead, providers should help patients of all sizes build healthy habits around sleep, stress, diet, and physical activity.23
  • Mental health researchers and therapists should continue improving treatments that can reduce the internalization of weight stigma.
  • Researchers should also reflect on how studies that focus on weight and BMI may increase weight stigma.24 Instead, research should shift focus to changing specific behaviors such as eating patterns, physical activity, and stress reduction.
  • Outside of providers and researchers, everyone can begin to challenge their beliefs around weight and size. The Implicit Attitudes Test (IAT; implicit.harvard.edu) is a good starting point if you’re trying to change negative attitudes you have about weight and size.
  • Additionally, there are many resources available that explain the complex combination of biological (e.g., genes, bodily processes), environmental (e.g., culture, social relationships), and psychological (e.g., individual behaviors, thoughts, and feelings) that contribute to weight. If more people (including healthcare providers and researchers) were to examine their attitudes about weight and learn more about the factors that contribute to body weight, perhaps the next decade will welcome improvements in public attitudes on weight and size.
  • If you personally struggle with IWS, there are resources for you too. “Body Kindness: Transform Your Health from the Inside Out and Never say ‘Diet’ Again” by Rebecca Scritchfield, RDN could be a good book to help you reflect on beliefs about your body and size.25 

References

1.   Vartanian LR, Novak SA. Internalized societal attitudes moderate the impact of weight stigma on avoidance of exercise. Obesity (Silver Spring). 2011;19(4):757-62.

2.   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(12):1626-32.

3.   Durso LE, Latner JD, White MA, Masheb RM, Blomquist KK, Morgan PT, et al. Internalized weight bias in obese patients with binge eating disorder: associations with eating disturbances and psychological functioning. Int J Eat Disord. 2012;45(3):423-7.

4.   Schvey NA, White MA. The internalization of weight bias is associated with severe eating pathology among lean individuals. Eat Behav. 2015;17:1-5.

5.   Burnette CB, Mazzeo SE. Examining the contribution of weight-bias internalization to the associations between weight suppression and disordered eating in undergraduates. Eat Behav. 2020;37:101392.

6.   Carels RA, Burmeister J, Oehlhof MW, Hinman N, LeRoy M, Bannon E, et al. Internalized weight bias: ratings of the self, normal weight, and obese individuals and psychological maladjustment. J Behav Med. 2013;36(1):86-94.

7.   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(6):869-80.

8.   Hilbert A, Braehler E, Haeuser W, Zenger M. Weight bias internalization, core self-evaluation, and health in overweight and obese persons. Obesity (Silver Spring). 2014;22(1):79-85.

9.   Romano KA, Heron KE, Henson JM. Examining associations among weight stigma, weight bias internalization, body dissatisfaction, and eating disorder symptoms: Does weight status matter? Body Image. 2021;37:38-49.

10. Sienko RM, Saules KK, Carr MM. Internalized weight bias mediates the relationship between depressive symptoms and disordered eating behavior among women who think they are overweight. Eat Behav. 2016;22:141-4.

11. Potzsch A, Rudolph A, Schmidt R, Hilbert A. Two sides of weight bias in adolescent binge-eating disorder: Adolescents’ perceptions and maternal attitudes. Int J Eat Disord. 2018;51(12):1339-45.

12. Almeida L, Savoy S, Boxer P. The role of weight stigmatization in cumulative risk for binge eating. J Clin Psychol. 2011;67(3):278-92.

13. Olvera N, Dempsey A, Gonzalez E, Abrahamson C. Weight-related teasing, emotional eating, and weight control behaviors in Hispanic and African American girls. Eat Behav. 2013;14(4):513-7.

14. Sutin AR, Terracciano A. Perceived weight discrimination and obesity. PLoS One. 2013;8(7):e70048.

15. Swift JA, Hanlon S, El-Redy L, Puhl RM, Glazebrook C. Weight bias among UK trainee dietitians, doctors, nurses and nutritionists. J Hum Nutr Diet. 2013;26(4):395-402.

16. Harrop EN. Typical-atypical interactions: One patient’s experience of weight bias in an inpatient eating disorder treatment setting. Women Ther. 2019;42(1-2):45-58.

17. Klobodu SS, Mensah PA, Willis M, Bailey D. Weight bias among nutrition and dietetics students in a Ghanaian public university. J Nutr Educ Behav. 2022;54(5):406-11.

18. Lawrence BJ, Kerr D, Pollard CM, Theophilus M, Alexander E, Haywood D, et al. Weight bias among health care professionals: A systematic review and meta-analysis. Obesity. 2021;29(11):1802-12.

19. Puhl RM, Latner JD, King KM, Luedicke J. Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes. Int J Eat Disord. 2014;47(1):65-75.

20. Puhl RM, Luedicke J, Grilo CM. Obesity bias in training: attitudes, beliefs, and observations among advanced trainees in professional health disciplines. Obesity (Silver Spring). 2014;22(4):1008-15.

21. Puhl R, Wharton C, Heuer C. Weight bias among dietetics students: implications for treatment practices. J Am Diet Assoc. 2009;109(3):438-44.

22. Welsh S, Salazar-Collier C, Blakeslee B, Kellar L, Maxwell RA, Whigham LD, et al. Comparison of obstetrician-gynecologists and family physicians regarding weight-related attitudes, communication, and bias. Obes Res Clin Pract. 2021;15(4):351-6.

23. Mauldin K, May M, Clifford D. The consequences of a weight-centric approach to healthcare: A case for a paradigm shift in how clinicians address body weight. Nutr Clin Pract. 2022.

24. Hart LM, Ferreira KB, Ambwani S, Gibson EB, Austin SB. Developing expert consensus on how to address weight stigma in public health research and practice: A Delphi study. Stigma Health. 2021;6(1):79.

25. Scritchfield R. Body Kindness: Transform your health from the inside out—and never say diet again: Workman Publishing; 2016.