Rebecca Pearl’s research reveals the hidden health toll of weight stigma

For many higher-weight individuals, weight stigma is a reality of daily life, says Rebecca Pearl, an associate professor in the department of clinical and health psychology at the University of Florida. Weight stigma is the systemic devaluation of people based on their size — it underlies the teasing and bullying that some people experience due to their weight; the lower quality of healthcare that people living in larger bodies tend to receive; and the headless, dehumanizing stock photos that often accompany articles about obesity.

Pearl, who directs the department’s Body Image and Stigma Lab, studies how people internalize weight stigma and how that, in turn, influences their feelings, behaviors, and health. Her research is gaining steady recognition in the field of health psychology. In 2022, she received the NIH Director’s New Innovator Award; last year, she received the APA Distinguished Scientific Award for Early Career Contribution to Psychology and the Rising Star Award from the Florida Academy of Science, Engineering, and Medicine.

“People absorb these negative messages about weight and apply those negative stereotypes and beliefs to themselves,” Pearl says. She has found that internalized stigma not only erodes people's sense of self — it also has a broad impact on their quality of life, health, and ability to access care.

The relationship between weight and health is complicated. It’s commonly assumed that a higher weight or body mass index (BMI) is inherently unhealthy, but the research shows that this may not be true for every individual. Some studies indicate a relationship between higher body mass index and worse health outcomesopens in new window; others find noneopens in new window. Numerous other factors, besides weight alone, can contribute to chronic illness. One of those factors: stigma. 

In a recent studyopens in new window of 214 adults with high weights and high levels of internalized weight stigma, Pearl found that the vast majority of participants had experienced some form of weight-related teasing. Others reported bullying, discrimination, or unfair treatment. “People described derogatory looks in restaurants, stores, and airplanes,” Pearl said. “In one particularly upsetting example, a patient was told by their therapist that in order to find romantic love, they would need to lose weight.” 

Those experiences have real health effects. “Stigma is a form of chronic stress that has a direct effect on the body,” Pearl said. 

In addition to mental health effects — which include an increased risk of disordered eating, substance abuse, and suicidality — these experiences are associated with increases in blood pressureopens in new window and chronic inflammationopens in new window. When Pearl was a postdoctoral fellow at the University of Pennsylvania Perelman School of Medicine, she and her co-authors surveyed 159 participants on the degree to which they agreed with a series of statements about their weight. Statements included: “Because of my weight, I don’t understand how anyone attractive would want to date me” and “I hate myself for being overweight.” The researchers also collected data on cholesterol, glucose, and blood pressure. Controlling for BMI, the researchers foundopens in new window that participants with high levels of internalized weight stigma were 41 percent more likely to meet criteria for “metabolic syndrome,” a cluster of risk factors for cardiovascular disease and Type 2 diabetes.

Pearl is particularly interested in the relationship between internalized stigma and health behaviors, the everyday choices that shape both mental and physical well-being. “We know when people are under stress, they often engage in coping behaviors that can undermine health,” she said. For example, Pearl’s research suggests that, regardless of body size, people who report higher levels of internalized weight stigma exercise lessopens in new window and are less likely to seek medical careopens in new window. 

In a multinational studyopens in new window published in 2021, Pearl and her co-authors surveyed nearly 14,000 adults. The researchers found that regardless of BMI, participants with higher levels of internalized weight stigma found it more difficult to eat nutritiously or exercise regularly. They were also more likely to eat emotionally and to avoid the gym altogether. “They might feel uncomfortable in their body or worried about being judged by other people,” Pearl said. Rather than motivating positive change, weight stigma tends to push people away from the very habits that support health.

Now, Pearl is using her research on the role of stigma in health to inform interventions aimed at reducing internalized stigma and improving health outcomes. In one group-based behavioral weight-loss program, participants discuss common myths and stereotypes about body size, learn to challenge their own internalized beliefs, and practice skills for responding to stigmatizing remarks.

A clinical trialopens in new window of the intervention randomized 105 participants into two groups: one that participated in the stigma plus weight-loss intervention, and one that participated in the weight-loss intervention alone. Participants received 20 weeks of intensive weekly treatment, followed by less frequent group meetings. At the end of the program, those who received the stigma intervention reported lower levels of internalized stigma, greater confidence in maintaining healthy eating patterns, and a higher quality of life.

Interestingly, the two groups did not differ significantly in how much weight they lost. “That’s important because there can be pushback against destigmatizing obesity and promoting body acceptance,” Pearl says. “People worry it might undermine motivation to change health behaviors — but we didn’t see any evidence of that.”

Although Pearl’s research centers on body weight, she’s also adapting her stigma intervention for people living with a number of health conditions, including skin diseases, HIV, cancer, diabetes, and chronic pain. “There are just so many parallels across these different health conditions in terms of stigma and how it affects people,” Pearl said. For example, higher internalized stigma is associated with lower medication adherenceopens in new window in people with HIV and less engagement in self-careopens in new window — like following a diet plan and self-glucose monitoring — in people with diabetes. “We can actually leverage the knowledge that we have to try and reduce stigma across health fields,” Pearl said.