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Obesity and Internalized Weight Stigma: A Formulation Model for an Emerging Psychological Problem

  • Denise Ratcliffe (a1) and Nell Ellison (a2)


Background: Obese individuals frequently experience weight stigma and this is associated with psychological distress and difficulties. The process of external devaluation can lead to negative self-perception and evaluation and some obese individuals develop “internalized weight stigma”. The prevalence of weight stigma is well established but there is a lack of information about the interplay between external and internal weight stigma. Aims: To synthesize the literature on the psychological effects of weight stigma into a formulation model that addresses the maintenance of internalized weight stigma. Method: Current research on the psychological impact of weight stigma was reviewed. We identify cognitive, behavioural and attentional processes that maintain psychological conditions where self-evaluation plays a central role. A model was developed based on clinical utility. Results: The model focuses on identifying factors that influence and maintain internalized weight stigma. We highlight the impact of negative societal and interpersonal experiences of weight stigma on how individuals view themselves as an obese person. Processing the self as a stigmatized individual is at the core of the model. Maintenance factors include negative self-judgements about the meaning of being an obese individual, attentional and mood shifts, and avoidance and safety behaviours. In addition, eating and weight management behaviours become deregulated and maintain both obesity and weight stigma. Conclusion: As obesity increases, weight stigma and the associated psychological effects are likely to increase. We provide a framework for formulating and intervening with internalized weight stigma as well as making therapists aware of the applicability and transferability of strategies that they may already use with other presenting problems.


Corresponding author

Reprint requests to Denise Ratcliffe, Consultant Clinical Psychologist, Psychological Medicine Unit, South Kensington and Chelsea Mental Health Unit, 1 Nightingale Place, Chelsea and Westminster Hospital, London SW10 9NG, UK. E-mail:


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Allison, D. B., Basile, V. C. and Yuker, H. E. (1991). The measurement of attitudes toward and beliefs about obese persons. International Journal of Eating Disorders, 10, 599607.
Almeida, L., Savoy, S. and Boxer, P. (2011). The role of weight stigmatization in cumulative risk for binge eating. Journal of Clinical Psychology, 67, 278292.
Atlantis, E. and Baker, M. (2008). Obesity effects on depression: systematic review of epidemiological studies. International Journal of Obesity, 32, 881891.
Bell, S. K. and Morgan, S. N. (2000). Children's attitude and behavioural intentions towards a peer presented as obese: does a medical explanation for the obesity make a difference? Journal of Paediatric Psychology, 25, 137145.
Benas, J. S. and Gibb, B. E. (2008). Weight-related teasing, dysfunctional cognitions, and symptoms of depression and eating disturbances. Cognitive Therapy Research, 32, 143160.
Brownell, K. (2010). The humbling experience of treating obesity: should we persist or desist? Behaviour Research and Therapy, 48, 717719.
Carr, D. and Friedman, M. A. (2005). Is obesity stigmatizing? Body weight, perceived discrimination and psychological wellbeing in the United States. Journal of Health and Social Behaviour, 46, 244259.
Christensen, P. N., Stein, M. B. and Means-Christensen, A. (2003). Social anxiety and interpersonal perception: a social relations model analysis. Behaviour Research and Therapy, 41, 13551371.
Clark, D. M. and Wells, A. (1995). A cognitive model of social phobia. In Heimberg, R. G., Liebowitz, M. R., Hope, D. A. and Schneier, I. (Eds.), Social Phobia: diagnosis, assessment and treatment (pp. 6993). New York: Guilford Press.
Cooley, C. H. (1956). Human Nature and the Social Order. New York: Free Press.
Cooper, Z., Doll, H., Hawker, D. M., Byrne, S., Bonner, G., Eeley, G., et al. (2010). Testing a new cognitive behavioural treatment for obesity: a randomised controlled trial with three-year follow up. Behaviour Research and Therapy, 48, 706713.
Crandall, C. S. (1994). Prejudice against fat people: ideology and self-interest. Journal of Personality and Social Psychology, 66, 882894.
Daníelsdóttir, S., O'Brien, K. S. and Ciao, A. (2010). Anti-fat prejudice reduction: a review of published studies. Obesity Facts, 3, 4758.
Davis-Coelho, K., Waltz, J. and Davis-Coelho, B. (2000). Awareness and prevention of bias against fat clients in psychotherapy. Professional Psychological Research Practice, 6, 682684.
Davison, K. K., Schmalz, D. L., Young, L. M. and Birch, L. L. (2008). Overweight girls who internalize fat stereotypes report low psychosocial well-being. Obesity, 16, 3038.
DeJong, W. (1980). The stigma of obesity: the consequences of naive assumptions concerning the causes of physical deviance. Journal of Health and Social Behaviour, 21, 7587.
Durso, L. E., Latner, J. D., White, M. A., Masheb, R. M., Blomquist, K. K., Morgan, P. T., et al. (2012). Internalized weight bias in obese patients with binge eating disorder: associations with eating disturbances and psychological functioning. International Journal of Eating Disorders, 45, 423427.
Fairburn, C. (2008). Cognitive Behaviour Therapy and Eating Disorders. New York: Guilford.
Fairburn, C. G., Welch, S. L., Doll, H. A., Davies, B. A. and O'Connor, M. E. (1997). Risk factors for bulimia nervosa: a community-based, case-control study. Archives of General Psychiatry, 54, 509517.
Fennell, M. J. V. (1997). Low self-esteem: a cognitive perspective. Behavioural and Cognitive Psychotherapy, 25, 125.
Fennell, M. and Jenkins, H. (2004). Low self-esteem. In Bennett-Levy, J., Butler, G., Fennell, M., Hackmann, A., Muellerand, M. and Westbrook, D. (Eds.), Oxford Guide to Behavioural Experiments in Cognitive Therapy (pp.413432). New York: Oxford University Press.
Friedman, K. E., Ashmore, J. A. and Applegate, K. L. (2008). Recent experiences of weight-based stigmatization in a weight loss surgery population: psychological and behavioral correlates. Obesity, 16, 6974.
Gariepy, G., Nitka, D. and Schmitz, N. (2010). The association between obesity and anxiety disorders in the population: a systematic review and meta-analysis. International Journal of Obesity, 34, 407419.
Gilbert, P. (1997). The evolution of social attractiveness and its role in shame, humiliation, guilt and therapy. British Journal of Medical Psychology, 70, 113147.
Gilbert, P. (2010). Compassion Focused Therapy. Hove: Routledge.
Greenleaf, C., Chambliss, H., Rhea, D., Martin, S. and Morrow, J. J. (2006). Weight stereotypes and behavioural intentions toward thin and fat peers among White and Hispanic adolescents. Journal of Adolescent Health, 39, 546552.
Griffiths, K. M., Christensen, H., Jorm, A. F., Evans, K. and Groves, C. (2004). Effect of web-based depression literacy and cognitive–behavioural therapy interventions on stigmatising attitudes to depression: Randomised controlled trial. The British Journal of Psychiatry, 185, 342349.
Hackmann, A., Clark, D. M. and McManus, F. (2000). Recurrent images and early memories in social phobia. Behaviour Research and Therapy, 38, 601610.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A. and Lillis, J. (2006). Acceptance and commitment therapy: model, processes and outcomes. Behavior, Research and Therapy, 44, 125.
Hebl, M. R., Ruggs, E. N., Singletary, S. L. and Beal, D. J. (2008). Perceptions of obesity across the lifespan. Obesity, 16, 4652.
Herek, G. M., Capitanio, J. P. and Widaman, K. F. (2003). Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychology, 22, 533540.
Jackson, T. D., Grilo, C. M. and Masheb, R. M. (2000). Teasing history, onset of obesity, current eating disorder psychopathology, body dissatisfaction and psychological functioning in binge eating disorder. Obesity Research, 8, 451458.
Karasu, S. R. and Karasu, T. B. (2010). The Gravity of Weight: a clinical guide to weight loss and maintenance. Washington, DC: American Psychiatric Publishing Inc.
Klaczynski, P., Goold, K. W. and Mudry, J. J. (2004). Culture, obesity stereotypes, self-esteem and the “thin ideal”: a social identity perspective. Journal of Youth and Adolscence, 33, 307317.
Knight, M. T. D., Wykes, T. and Hayward, P. (2006). Group treatment of perceived stigma and self-esteem in schizophrenia: awaiting list trial of efficacy. Behavioural and Cognitive Psychotherapy, 34, 305318.
Kristeller, J. B. and Hallett, B. C. (1999). An exploratory study of a meditation-based intervention for binge eating disorder. Journal of Health Psychology, 4, 357363.
Latner, J. D., O'Brien, K. S., Durso, L. E., Brinkman, L. A. and MacDonald, T. (2008). Weighing obesity stigma: the relative strength of different forms of bias. International Journal of Obesity, 32, 11451152.
Lau, G., Moulds, M. L. and Richardson, R. (2009). Ostracism: How much it hurts depends on how you remember it. Emotion, 9, 430434.
Lehman, A. K. and Rodin, J. (1989). Styles of self-nurturance and disordered eating. Journal of Consulting and Clinical Psychology, 57, 117122.
Lillis, J., Hayes, S. C., Bunting, K. and Masuda, A. (2009). Teaching acceptance and mindfulness to improve the lives of the obese: a preliminary test of a theoretical model. Annals of Behavioral Medicine, 37, 5869.
Link, B. G., Struening, E. L., Neese-Todd, S., Asmussen, S. and Phelan, J. C. (2002). On describing and seeking to change the experience of stigma. Psychiatric Rehabilitation Skills, 6, 201231.
Livingston, J. D. and Boyd, J. E. (2010). Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Social Science and Medicine, 71, 21502161.
Luke, M. and Stopa, L. (2009). Psychological theories of the self and their application to clinical disorders. In Stopa, L. (Ed.), Imagery and the Threatened Self (pp.1564). Hove: Routledge.
Maddox, G. L., Beck, K. W. and Liederman, V. R. (1968). Overweight as social deviance and disability. Journal of Health and Social Behaviour, 9, 287298.
MacInnes, D. L. and Lewis, M. (2008). The evaluation of a short group programme to reduce self-stigma in people with serious and enduring mental health problems. Journal of Psychiatric and Mental Health Nursing, 15, 5965.
Mathes, W. F., Brownley, K. A., Mo, X. and Bulik, C. M. (2009). The biology of binge eating. Appetite, 52, 545553.
Moorey, S. (1996). When bad things happen to rational people: cognitive therapy in adverse life circumstances. In Salkovskis, P. (Ed.), Frontiers of Cognitive Therapy (pp. 450469). New York: Guilford.
Myers, A. and Rosen, J. C. (1999). Obesity, stigmatization and coping: relation to mental health symptoms, body image and self-esteem. International Journal of Obesity, 23, 221230.
Padeksy, C. (1991). Schema as self-prejudice. International Cognitive Therapy Newsletter, 6, 67.
Puhl, R. and Brownell, K. D. (2001). Bias, discrimination and obesity. Obesity Research, 9, 788805.
Puhl, R. M. and Brownell, K. D. (2006). Confronting and coping with weight stigma: an investigation of overweight and obese individuals. Obesity, 14, 18021815.
Puhl, R. M. and Heuer, C. A. (2010). Obesity stigma: important considerations for public health. American Journal of Public Health, 100, 10191028.
Puhl, R., Moss-Racusin, C. A., Schwartz, M. B. and Brownell, K. D. (2008). Weight stigmatization and bias reduction: perspectives of overweight and obese adults. Health Education Research, 23, 347358.
Ramirez, E. M. and Rosen, J. C. (2001). Comparison of weight control versus weight control plus body image therapy for obese men and women. Journal of Consulting and Clinical Psychology, 69, 440446.
Reynolds, M. and Brewin, C. R. (1999). Intrusive memories in depression and post-traumatic stress disorder. Behaviour Research and Therapy, 37, 201215.
Roberts, R. E., Kaplan, G. A., Shema, S. J. and Strawbridge, W. J. (2000). Are the obese at greater risk for depression? American Journal of Epidemiology, 152, 163170.
Rosenberger, P. H., Henderson, K. E., Bell, R. L. and Grilo, C. M. (2007). Associations of weight-based teasing and current eating disorder features and psychological functioning in bariatric surgery patients. Obesity Surgery, 17,470477.
Schvey, N. A., Puhl, R. M. and Brownell, K. D. (2011). The impact of weight stigma on caloric consumption. Obesity, 19, 19571962.
Stein, R. I., Kenardy, J., Wiseman, C. V., Dounchis, J. Z., Arnow, B. A. and Wilfley, D. E. (2007). What's driving the binge in binge eating disorder? A prospective examination of precursors and consequences. International Journal of Eating Disorders, 40, 195203.
Vartanian, L. R. and Shaprow, J. G. (2008). Effects of weight stigma on exercise behaviour and motivation: a preliminary investigation among college-aged females. Journal of Health Psychology, 13, 131138.
Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V. and Russell, K. (2007). Cognitive Behavioural Therapy for Eating Disorders: a comprehensive treatment guide. New York: Cambridge University Press.
Wang, S. S., Brownell, K. D. and Wadden, T. A. (2004). The influence of the stigma of obesity on overweight individuals. International Journal of Obesity, 28, 13331337.
Weiner, B., Perry, R. P. and Magnusson, J. (1988). An attributional analysis of reactions to stigmas. Journal of Personality and Social Psychology, 55, 738748.
Wells, A., Clark, D. M. and Ahmad, S. (1998). How do I look with my mind's eye: perspective taking in social phobic imagery. Behaviour Research and Therapy, 36, 631634.
Wild, J., Hackmann, A. and Clark, D. M. (2008). Rescripting early memories linked to negative images in social phobia: a pilot study. Behaviour Therapy, 39, 4756.
Wott, C. B. and Carels, R. A. (2010). Overt weight stigma, psychological distress and weight loss treatment outcomes. Journal of Health Psychology, 15, 608614.


Obesity and Internalized Weight Stigma: A Formulation Model for an Emerging Psychological Problem

  • Denise Ratcliffe (a1) and Nell Ellison (a2)


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Obesity and Internalized Weight Stigma: A Formulation Model for an Emerging Psychological Problem

  • Denise Ratcliffe (a1) and Nell Ellison (a2)
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