Challenges of maintaining long-term weight loss are well-established and present significant obstacles in obesity prevention and treatment. A neglected but potentially important barrier to weight-loss maintenance is weight stigmatization.
We examined the role of weight stigma—experienced and internalized—as a contributor to weight-loss maintenance and weight regain in adults.
A diverse, national sample of 2702 American adults completed an online battery of questionnaires assessing demographics, weight-loss history, subjective weight category, experienced and internalized weight stigma, weight-monitoring behaviors, physical activity, perceived stress, and physical health. Analyses focused exclusively on participants who indicated that their body weight a year ago was at least 10% less than their highest weight ever (excluding pregnancy), the weight loss was intentional, and that attempts to lose or maintain weight occurred during the past year (n = 549). Participants were further classified as weight regainers (n = 235) or weight-loss maintainers (n = 314) based on subsequent weight loss/gain. Data were collected in 2015 and analyzed in 2016.
Hierarchical logistic regression models showed that internalized weight stigma and subjective weight category made significant individual contributions to prediction of weight-loss maintenance, even after accounting for demographics, perceived stress, experienced stigma, physical health, and weight-loss behaviors. For every one-unit increase in internalized weight stigma, the odds of maintaining weight loss decreased by 28% (95% CI: 14–40%, p < .001).
Findings provide initial evidence that overlooked psychosocial factors, like weight stigma, may hinder weight-loss maintenance. Implications for addressing stigma in obesity-focused clinical interventions are highlighted.
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Bauer UE, Briss PA, Goodman RA, Bowman BA. Prevention of chronic disease in the twenty-first century: Elimination of the leading preventable causes of premature death and disability in the USA. The Lancet. 2014;384:45–52.
Jenson MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guidelines for the management of overweight and obesity in adults. J Am Coll Cardiol. 2014;63(25_PA). doi:10.1016/j.jacc.2013.11.004
Dulloo AG, Montani JP. Pathways from dieting to weight regain, to obesity and to the metabolic syndrome: An overview. Obes Rev. 2015;16(S1):1–6.
Ochner CN, Barrios DM, Lee CD, Pi-Sunyer FX. Biological mechanisms that promote weight regain following weight loss in obese humans. Physiol Behav. 2013;120:106–113.
Kroeger CM, Hoddy KK, Varady KA. Impact of weight regain on metabolic disease risk: A review of human trials. J Obes. 2014;2014:614519. doi: 10.1155/2014/614519
Steinberg DM, Askew S, Lanpher MG, Foley PB, Levine EL, Bennett GG. The effect of a “maintain, don’t gain” approach to weight management on depression among black women: Results from a randomized trial. Am J Pub Health. 2014; 104(9):1766–1773.
Strohacker K, Carpenter KC, McFarlin BK. Consequences of weight cycling: An increase in disease risk? Int J Exerc Sci. 2009; 2(3):191–201.
Montani JP, Schutz Y, Dulloo AG. Dieting and weight cycling as risk factors for cardiometabolic diseases: Who is really at risk? Obes Rev. 2015;16(S1):7–18.
Wilson P. Physical activity and dietary determinants of weight loss success in the US general population. Am J Pub Health. 2016;106(2):321–326.
Ramage S, Farmer A, Apps Eccles K, McCargar L. Healthy strategies for successful weight loss and weight maintenance: a systematic review. Appl Physiol, Nutr, Metab. 2013;39(1):1–20.
Dombrowski SU, Knittle K, Avenell A, Araujo-Soares V, Sniehotta FF. Long term maintenance of weight loss with non-surgical interventions in obese adults: systematic review and meta-analyses of randomised controlled trials. BMJ. 2014;348:g2646.
MacLean PS, Wing RR, Davidson T, et al. NIH working group report: Innovative research to improve maintenance of weight loss. Obesity. 2015; 23:7–15.
Wadden TA, Butryn ML, Wilson C. Lifestyle modification for the management of obesity. Gastroenterology 2007;132:2226–2238.
Montesi L, Ghoch ME, Brodosi L, Calugi S, Marchesini G, Dalle Grave R. Long-term weight loss maintenance for obesity: A multidisciplinary approach. Diabetes Metab Syndr Obes. 2016; 9: 37–46.
Thomas JG, Bond DS, Phelan S, Hill JO, Wing RR. Weight-loss maintenance for 10 years in the National Weight Control Registry. Am J Prev Med 2014;46(1):17–23.
Brantley PJ, Stewart DW, Myers VH, et al. Psychosocial predictors of weight regain in the weight loss maintenance trial. J Behav Med. 2014; 37(6):1155–1168.
Sniehotta FF, Simpson SA, Greaves CJ. Weight loss maintenance: An agenda for health psychology. Br J Health Psychol. 2014;19:459(3)-64.
Puhl RM, Heuer C. The stigma of obesity: A review and update. Obesity. 2009;17(5):941–964.
Puhl R, Andreyeva T, Brownell K. Perceptions of weight discrimination: Prevalence and comparison to race and gender discrimination in America. Int J Obes. 2008;32(6):992–1000.
Puhl RM, Suh Y. Health consequences of weight stigma: Implications for obesity prevention and treatment. Curr Obes Rep. 2015;4(2):182–190.
Fettich KC, Chen EY. Coping with obesity stigma affects depressed mood in African-American and white candidates for bariatric surgery. Obesity. 2012;20(5):1118–21.
Major B, Eliezer D, Rieck H. The psychological weight of weight stigma. Soc Psychol Personal Sci. 2012;3(6):651–8.
Papadopoulos S, Brennan, L. Correlates of weight stigma in adults with overweight and obesity: a systematic literature review. Obesity. 2015;23(9):1743–1760.
Schvey NA, Puhl RM, Brownell KD. The impact of weight stigma on caloric consumption. Obesity. 2011;19(10):1957–62.
Major B, Hunger JM, Bunyan DP, Miller CT. The ironic effects of weight stigma. J Exp Soc Psychol. 2014;51:74–80.
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.
Vartanian LR, Porter AM. Weight stigma and eating behavior: A review of the literature. Appetite 2016;102:3–14
Vartanian LR, Novak SA. Internalized societal attitudes moderate the impact of weight stigma on avoidance of exercise. Obesity. 2010;19(4):757–62.
Tomiyama AJ, Epel ES, McClatchey TM, et al. Associations of weight stigma with cortisol and oxidative stress independent of adiposity. Health Psychol. 2014;33(8):862–867.
Sutin AR, Terracciano A. Perceived weight discrimination and obesity. PLoS One. 2013;8(7):e70048.
Wott CB, & Carels RA. Overt weight stigma, psychological distress and weight loss treatment outcomes. J Health Psychol. 2010;15(4):608–614.
Carels RA, Burmeister JM, Koball AM, et al. A randomized trial comparing two approaches to weight loss: Differences in weight loss maintenance. J Health Psychol. 2014;19(2):296–311.
Lillis J, Hayes SC, Bunting K, & Masuda A. Teaching acceptance and mindfulness to improve the lives of the obese: a preliminary test of a theoretical model. Ann Beh Med. 2009;37(1):58–69.
Pearl RL, White MA, Grilo CM. Weight bias internalization, depression, and self-reported health among overweight binge eating disorder patients. Obesity. 2014;22(5):E142-E8.
Puhl RM, Moss-Racusin CA, Schwartz MB. Internalization of weight bias: Implications for binge eating and emotional well-being. Obesity. 2007;15(1):19–23.
Mensinger JL, Calogero RM, Tylka TL. Internalized weight stigma moderates eating behavior outcomes in women with high BMI participating in a healthy living program. Appetite. 2016;102:32–43.
Jackson SE, Beeken RJ, Wardle J. Perceived weight discrimination and changes in weight, waist circumference, and weight status. Obesity. 2014;22(12):2485–2488.
Robinson E, Hunger JL, Daly M. Perceived weight status and risk of weight gain across life in US and UK adults. Obesity. 2015; 39:1721–1726.
Hubner C, Baldofski S, Crosby RD, Muller A, de Zwaan M, Hilber A. Weight-related teasing and non-normative eating behaviors as predictor of weight loss maintenance. A longitudinal mediation analysis. Appetite. 2016;102:25–31.
Latner JD, Wilson GT, Jackson ML, Stunkard AJ. Greater history of weight-related stigmatizing experience is associated with greater weight loss in obesity treatment. J Health Psychol. 2009;14:190–199.
Survey Sampling International. The Science of Sampling. 2011. http://www.surveysampling.com/ Accessed March 17, 2015.
Wadden TA, Foster GD. Weight and lifestyle inventory (WALI). Obesity. 2006;14(S3):99S–118S.
Weiss EC, Galuska DA, Kettel Khan L, Gillespie C, Serdula MK. Weight regain in US adults who experienced substantial weight loss, 1999–2002. Am J Prev Med. 2007; 33(1):34–40.
Venditti EM, Wing RR, Jakicic JM, Butler BA, Marcus MD. Weight cycling, psychological health, and binge eating in obese women. J Consult Clin Psychol. 1996;64(2):400.
Centers for Disease Control. Defining overweight and obesity: Overweight and Obesity. 2012. http://www.cdc.gov/obesity/adult/defining.html. Accessed March 17, 2015.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385–396.
Group W. Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychol Med. 1998;28(3):551–8.
Klem ML, Wing RR, McGuire MT, Seagle HM, Hill JO. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr.1997;66(2):239–246.
Lynch A, Bisogni C. Understanding dietary monitoring and self-weighing by gastric bypass patients: A pilot study of self-monitoring behaviors and long-term weight outcomes. Obesity Surgery. 2012;22(12):1818–1826.
Godin G, Shephard R. Godin leisure-time exercise questionnaire. Med Sci Sports Exerc. 1997;29(6s):S36.
Puhl R, Heuer C, Sarda V. Framing messages about weight discrimination: Impact on public support for legislation. Int J Obes. 2011;35(6):863–72.
Pearl RL, Puhl RM. Measuring internalized weight attitudes across body weight categories: Validation of the modified weight bias internalization scale. Body Image. 2014;11(1):89–92.
Lee M, Dedrick RF. Weight bias internalization scale: psychometric properties using alternative weight status classification approaches. Body Image. 2016;17: 25–29.
IBM Corp. Released 2016. IBM SPSS for Windows, Version 24.0. Armonk: IBM Corp.
Pearl RL, Puhl RM. The distinct effects of internalizing weight bias: an experimental study. Body Image. 2016;17:38–42.
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):1626–1632.
Field AE, Aneja P, Rosner B. The validity of self-reported weight change among adolescents and young adults. Obesity. 2007;15: 2357–2364.
Wright FL, Green J, Reeves G, Breal V, Caims BJ. Validity over time of self-reported anthropometric variables during follow-up of a large cohort of UK women. BMC Med Res Methodol. 2015;15:81.
Pursey K, Burrows TL, Stanwell P, Collins CE. How accurate is web-based self-reported height, weight, and body mass index in young adults? J Med Internet Res. 2014;16:e4
United States Census Bureau 2015. http://www.census.gov/quickfacts/table/PST045215/00 Accessed September 20, 2016.
Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011–2014. NCHS data brief, no 219. Hyattsville: National Center for Health Statistics. 2015.
De Brun A, McCarthy M, McKenzie K, McGloin A. Weight stigma and narrative resistance evident in online discussions of obesity. Appetite. 2014;72:73–81.
Sabin JA, Marini M, Nosek BA. Implicit and explicit anti-fat bias among a large sample of medical doctors by BMI, race/ethnicity and gender. PLoS ONE. 2012;7: e48448. doi:10.1371/journal.pone.0048448
Ratcliffe D, Ellison N. Obesity and internalized weight stigma: A formulation model for an emerging psychological problem. Beh Cog Psychotherapy. 2015;43(02):239–252.
Latner JD, Barile JP, Durso LE, O’Brien KS. Weight and health-related quality of life: The moderating role of weight discrimination and internalized weight bias. Eating Behaviors. 2014;15(4):586–590.
This research was funded by an internal grant awarded from the University of Connecticut’s 2015 Research Excellence Program.
Authors’ Statement of Conflict of Interest and Adherence to Ethical Standards
Authors Rebecca M. Puhl, Diane M. Quinn, Bradley M. Weisz and Young J. Suh declare that they have no conflict of interest.
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Puhl, R.M., Quinn, D.M., Weisz, B.M. et al. The Role of Stigma in Weight Loss Maintenance Among U.S. Adults. ann. behav. med. 51, 754–763 (2017). https://doi.org/10.1007/s12160-017-9898-9
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