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J Consult Clin Psychol. Author manuscript; available in PMC 2021 May 01.
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Published in final edited form as:

J Consult Clin Psychol. 2020 May ; 88(5): 470–480. doi:10.1037/ccp0000480.

Effects of a Cognitive-Behavioral Intervention Targeting Weight

Stigma: A Randomized Controlled Trial
Rebecca L. Pearl, PhD1,*, Thomas A. Wadden, PhD1, Caroline Bach, BA1, Kathryn Gruber,
CRNP1, Sharon Leonard, RD1, Olivia A. Walsh, BS1, Jena S. Tronieri, PhD1, Robert I.
Berkowitz, MD1,2
1Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine
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at the University of Pennsylvania, Philadelphia, PA

2Department of Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia,
Philadelphia, PA

Abstract
Objective: To test the effects of a cognitive-behavioral intervention for weight bias
internalization (WBI; i.e., self-stigma) combined with behavioral weight loss (BWL).

Methods: Adults with obesity and elevated WBI were randomly assigned to BWL alone or
combined with the Weight Bias Internalization and Stigma Program (BWL+BIAS). Participants
attended weekly group meetings for 12 weeks, followed by 2 bi-weekly and 2 monthly meetings
(26 weeks total). Changes at week 12 on the Weight Bias Internalization Scale (WBIS) and Weight
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Self-Stigma Questionnaire (WSSQ) were the principal outcomes, with changes at week 26
assessed as secondary outcomes. Other outcomes included changes in mood, body image, eating
behaviors, self-monitoring, and weight.

Results: Seventy-two participants were randomized (84.7% female, 66.7% black, age=47.1±11.5
years) Linear mixed models showed no significant differences between the BWL+BIAS and BWL
groups in WBIS changes at week 12 (−1.3±0.2 vs. −1.0±0.2) or week 26 (−1.5±0.2 vs −1.3±0.2).
BWL+BIAS participants had greater reductions in WSSQ total scores at week 12 (p=0.03), with
greater changes on the Self-Devaluation subscale at weeks 12 and 26 (p≤0.03). BWL+BIAS
participants reported significantly greater benefits on measures of eating and self-monitoring.
Percent weight loss at week 26 did not differ significantly between groups (BWL+BIAS=
−4.5±1.0%, BWL=−5.9±1.0%, p=0.28).
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Conclusion: A psychological intervention for WBI produced short-term reductions in some

aspects of weight self-stigma in persons with obesity.

*
Corresponding Author: Rebecca L. Pearl, Ph.D., 3535 Market Street, 3rd Floor, Philadelphia, PA 19104,
rpearl@pennmedicine.upenn.edu, Phone: 215-746-5129; Fax: 215-615-1285.
ClinicalTrials.gov Identification: NCT03572218
Disclosures: RLP discloses receiving grant funding for the current work from and serving as a consultant for WW. TAW discloses
serving on the advisory board for WW. RIB discloses serving as a consultant for WW.
Appendix. Data Transparency
The dataset used for this manuscript has not been used in any other published or in press works.
 Pearl et al. Page 2

Keywords
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Obesity; weight bias internalization; weight self-stigma; weight loss

Introduction
Individuals with obesity face strong societal stigma that includes experiences of teasing,
bullying, discrimination, social rejection, or other instances of negative or unfair treatment
due to weight (Tomiyama et al., 2018). Weight bias internalization (WBI) – also known as
weight self-stigma – occurs when individuals with obesity absorb negative, weight-based
societal perceptions, including stereotypes, and devalue themselves due to their weight
(Pearl & Puhl, 2018). While experiencing weight stigmatization from others leads to
negative health consequences (Tomiyama et al., 2018), the psychological and behavioral
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effects of WBI may be stronger than those of the stigmatizing experiences alone (Pearl &
Puhl, 2018). WBI, for example, is associated with adverse mental and physical health
outcomes, including depression, anxiety, binge eating, poor body image, reduced physical
activity, and greater cardiovascular disease (CVD) risk (Pearl & Puhl, 2018). In addition,
higher WBI in adults with obesity is associated with poorer long-term weight loss (Puhl,
Quinn, Weisz, & Suh, 2017).

Preventing and reducing instances of weight stigma – for example, by changing public
attitudes, providing legal protections against discrimination, and eliminating the social
acceptability of weight bias – is a public health priority (Tomiyama et al., 2018). At the
same time, interventions to help individuals with obesity cope with weight stigma and
reduce or prevent its internalization are also of critical importance. Psychological
interventions designed specifically to reduce WBI are lacking (Pearl & Puhl, 2018), with
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only one randomized controlled trial (RCT) to date (Palmeira, Pinto-Gouveia, & Cunha,
2017). That study tested an acceptance-based group program for weight self-stigma and
eating behaviors, combined with individual medical/nutritional visits for weight loss,
compared to the latter visits alone. The stigma-reduction intervention significantly improved
self-stigma, quality of life, and health behaviors (Palmeira et al., 2017). Of note, weight loss
across groups was minimal, and the control condition did not include group treatment
(Palmeira et al., 2017).

In addition to acceptance-based approaches, cognitive-behavioral approaches – including

skills such as cognitive restructuring and identifying the connections among thoughts,
feelings, and behaviors – also may be beneficial for reducing self-stigma (Corrigan, Bink, &
Schmidt, 2018; Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015). Such
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interventions have been shown to improve psychological well-being and health behaviors in
members of other stigmatized groups (such as sexual minorities or individuals with mental
illness; Pachankis et al., 2015; Yanos, Lucksted, Drapalski, Roe, & Lysaker, 2015). These
benefits may be attributable to the cognitive-behavioral skills learned by group members, as
well as to group processes that increase feelings of belongingness and hope for stigmatized
individuals (Yalom & Lescze, 2005). In addition, a small study of college students found
that a cognitive intervention reduced negative attitudes toward people with obesity (Ciao &

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Latner, 2011), suggesting this approach may also be effective for reducing self-directed
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stigma.

Many of the stigma-reduction interventions described have used “identity affirming”

approaches that aim to reduce shame and increase acceptance of one’s stigmatized identity
(Corrigan et al., 2018; Pachankis et al., 2015). For obesity, which carries significant physical
consequences independent of stigma (Jensen et al., 2014), we propose combining an
identity-affirming intervention for reducing weight stigma with intensive behavioral weight
loss (BWL). This combination diverges from prior studies that have compared the effects of
weight-neutral approaches, which promote self-acceptance without weight loss, to weight
loss approaches (Carels et al., 2014; Mensinger, Calogero, & Tylka, 2016). Instead, we
wished to assess a seemingly contradictory yet dialectical treatment model for individuals
with obesity: seeking to reduce the burden of weight-related public and self-stigmatization,
while at the same time working toward goals to help patients change their eating, physical
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activity, weight, and health.

Intensive BWL treatment facilitates a 5–8% reduction in body weight in the short-term and
improvements in CVD risk and quality of life (Heymsfield & Wadden, 2017). However, it
may not produce substantial reductions in WBI or stigma-related distress (Mensinger et al.,
2016; Pearl, Wadden, Chao, et al., 2018). Adults with obesity who seek weight loss tend to
have greater psychological distress and higher WBI than those who do not engage in weight
management (Friedman & Brownell, 1995; Puhl, Himmelstein, & Quinn, 2018). Adding a
weight-stigma reduction intervention to BWL could potentially address this aspect of
psychological distress that many persons with obesity report.

The current study investigated the effects of the Weight Bias Internalization and Stigma
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(Weight BIAS) Program, designed to reduce WBI and help individuals with obesity cope
with weight stigma (Pearl, Hopkins, Berkowitz, & Wadden, 2018). The effects of the Weight
BIAS program on WBI and other measures of psychological and physical health were tested
in combination with standard BWL treatment (BWL+BIAS), compared to BWL alone. The
primary hypothesis was that, after 12 weeks, participants in the BWL+BIAS intervention
group would report greater improvements in WBI than participants who received BWL
alone. We also predicted that participants in the BWL+BIAS group would report greater
improvements in psychosocial well-being related to weight and in health behaviors, and that
improvements would be sustained at 26 weeks. In addition, we explored differences between
the two groups in changes in weight and CVD risk.

Methods
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Participants
Participants were men and women, ages 18–65 years old, who were seeking weight loss and
had obesity (body mass index [BMI] ≥ 30kg/m2). Participants were eligible if they reported
a history of experiencing weight bias (e.g., teasing/bullying, discrimination, or other unfair
treatment due to weight) and showed elevated levels of WBI, as indicated by a score of 4.0
or greater on the Weight Bias Internalization Scale (WBIS; Durso & Latner, 2008; described
below). A cutoff score of 4 has been used in prior research to indicate “elevated” WBI

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(Pearl, Hopkins, et al., 2018) and may correspond to the 80–90th percentile of WBIS scores
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in the general population (Hilbert et al., 2014). Applicants had to confirm in an in-person
interview, conducted by a psychologist, that their weight negatively affected how they felt
about themselves. These criteria were used to ensure that participants had clinically-
meaningful WBI that could benefit from our stigma-reduction intervention.

Exclusion criteria included: type 1 or 2 diabetes; uncontrolled hypertension (blood pressure

≥160/100 mm Hg); a cardiovascular event (e.g., stroke, myocardial infarction) in the past
year; any major active kidney, liver, cardiovascular, or cerebrovascular disease; loss of ≥5%
of initial weight in the past 6 months; use of medications that significantly affect weight;
history of bariatric surgery; women who were nursing, pregnant, or planning to become
pregnant; severe symptoms of mood (Beck Depression Inventory-II score ≥29, with clinician
discretion), anxiety, or binge eating disorder (eight or more binge episodes per week), or any
severity of bulimia nervosa or thought or substance use disorder; and current, active suicidal
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ideation and/or a suicide attempt within the past year. Participants were not eligible if they
had participated in individual or group psychotherapy in the past 3 months (due to the
potentially confounding effects of receiving a simultaneous cognitive-behavioral
intervention), with the exception of participants receiving counseling for concerns unrelated
to mood, self-esteem, or weight (e.g. career counseling or caregiver support). Participants
taking anti-depressant medication that did not affect weight were eligible if the dose had
been stable for at least 3 months.

Procedures
Participants were recruited by flyers, local media, and physician referrals for a study about
weight loss and social experiences related to weight. All participants were screened by
telephone and by a subsequent in-person behavioral evaluation, conducted by a psychologist,
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and a brief medical evaluation, conducted by a nurse practitioner. Prior to the in-person
behavioral evaluation, participants completed the WBIS, Beck Depression Inventory-II
(Beck, Steer, & Brown, 1996), and the Weight and Lifestyle Inventory (Wadden & Foster,
2006) to assess WBI, mood, weight and psychiatric history, and health behaviors. These
topics were reviewed during the behavioral evaluation. Eligible participants were consented
and randomized in a 1:1 ratio to one of two treatment groups (described below).
Investigators and participants were not blinded to group assignments. Outcome assessments
occurred at screening/baseline, week 12, and week 26. All procedures were approved by the
institutional review board (IRB).

Intervention
Participants attended 90-minute group meetings held on weekday evenings. Groups of 11–
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13 participants were led by a psychologist or registered dietitian. Each cohort of participants

consisted of two groups (BWL+BIAS and BWL alone) led by the same group leader.
Participants received 12 weekly group sessions, followed by 2 every-other-week sessions
and 2 monthly sessions (16 sessions over 26 weeks total). The number and timing of
treatment sessions were based on established guidelines (Jenson et al., 2014). Participants
who could not attend a given group session were offered a brief make-up session (in person
or by telephone) with the group leader or a study staff member.

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BWL group.—Participants were provided with 60 minutes of BWL treatment, based on the
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Diabetes Prevention Program and LEARN Program (Brownell, 2004; Diabetes Prevention
Program Research Group, 2002). The treatment incorporated culturally-sensitive
intervention recommendations (The Look AHEAD Research Group, 2006). A diet of 1200–
1499 kcal per day was prescribed for participants < 250 lb, and 1500–1800 kcal for those ≥
250 lb (Jenson et al., 2014; The Look AHEAD Research Group, 2006). Participants were
instructed to eat a balanced diet, to eat regularly throughout the day, and to record their daily
food and caloric intake. Weight was measured at every group session. Session topics during
the first 12 weeks included self-monitoring, stimulus control, social support, portion sizes,
and goal-setting. Standard BWL content on negative thoughts, emotional eating, and body
image was also discussed in single sessions, respectively. Promotion of the “thin ideal” was
avoided by focusing on health instead of appearance and on modest versus drastic weight
loss. Group sessions during weeks 13–26 focused on skills required for weight loss
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maintenance and relapse prevention.

Physical activity was prescribed at a level consistent with data showing that >250 minutes
per week is associated with improved long-term weight loss (Jakicic, Marcus, Lang, &
Janney, 2008). Activity prescriptions began at week 2 and gradually progressed to a goal of
150 minutes per week by week 12, and 200–250 minutes per week by week 26. Moderate
intensity was prescribed, with an emphasis on walking.

In the standard BWL group, an additional 30 minutes was devoted to discussing recipes and
food preparation. A recipe exchange was facilitated, in which each participant was asked to
share with the group a healthy recipe for a meal or snack. The recipe discussion served as an
educational component of the BWL program that allowed for equal time spent in group
sessions across conditions, without giving additional weight loss counseling to the standard
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BWL group.

BWL+BIAS group.—These participants received the same BWL program described above
(without the recipe discussion), combined with a stigma-reduction intervention. In each
session, following 60 minutes of BWL, 30 minutes were devoted to a stigma-reduction
intervention tested in a previous open-label pilot study (Pearl, Hopkins et al., 2018). Content
was adapted from cognitive-behavioral therapy and “third-wave” therapies such as
dialectical behavior therapy and acceptance and commitment therapy. Session topics
included: psychoeducation about weight and weight bias; challenging myths/stereotypes and
cognitive distortions related to weight; the relationship between thoughts, feelings, and
behaviors; restructuring negative thoughts and reappraising stigmatizing situations;
interpersonal effectiveness skills; increasing self-efficacy; reducing self-criticism; and
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increasing empowerment, self-compassion, and body and self-acceptance. Acceptance

content drew from mindfulness principles of accepting oneself in the present moment
without judgment, while allowing for the dialectical possibility of change (Linehan, 2014;
e.g., “I can accept and love myself as I am right now, while also working to change my
health behaviors and lose weight to improve my health”). Group leaders were trained to
address tensions that may arise between weight loss and self-acceptance by validating that
these two goals may seem contradictory and encouraging participants to consider how they

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might achieve both simultaneously (e.g., trying to lose weight without hating oneself and
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one’s body in the process).

The effects of weight bias (experienced and internalized) on health behaviors were
discussed, with an emphasis on helping participants overcome stigma-related barriers to
weight management. For example, participants were given strategies to cope with
anticipated stigma while being physically active in public spaces (e.g., in a gym), as well as
to challenge self-critical beliefs (e.g., that they are lazy) that may lead them to avoid
engaging in physical activity. All of the stigma-related topics were presented as skills
intended to help participants adhere to their healthy eating and physical activity goals, as
well as to improve how they felt about themselves.

Outcome Measures
Primary outcome.—Participants completed the WBIS at screening, week 12 (primary
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endpoint), and week 26. The WBIS includes 11 items rated on a 1–7 scale (scores averaged,
with higher scores indicating greater WBI; Durso & Latner, 2008). Items address weight-
related stereotypes (e.g., “I am less attractive than most other people because of my weight”)
and self-devaluation (e.g., “I hate myself for being overweight”). The WBIS has strong
psychometric properties (Durso & Latner, 2008) and is the most widely used measure of
WBI (Pearl & Puhl, 2018). In the current sample, internal consistency was lower than typical
at screening (Cronbach’s α=0.65), although consistency improved at weeks 12 and 26
(α’s=0.84).

The 12-item Weight Self-Stigma Questionnaire (WSSQ) was included as a secondary

measure of WBI, with items rated from 1–5 and summed, producing a total score and two
subscales: Fear of Enacted Stigma (or anticipated experiences of stigma; 6 items; e.g.,
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“People discriminate against me because I’ve had weight problems.”) and Self-Devaluation
(6 items; e.g., “I became overweight because I’m a weak person.”; Lillis, Luoma, Levin, &
Hayes, 2010). This scale also has strong psychometric properties and is the second most
common measure of WBI in the literature (Pearl & Puhl, 2018). In the current sample,
internal consistency for the total score was strong (α=0.72, 0.82, and 0.86 at baseline and
weeks 12 and 26, respectively), with slightly weaker consistency for the Self-Devaluation
compared to the Fear of Enacted Stigma subscale (α=0.66, 0.75, and 0.72 versus 0.77, 0.78,
and 0.85). The Fat Phobia scale was also included as a measure of weight stereotype
endorsement; participants were presented with pairs of adjectives used to describe people
with obesity (e.g., fast versus slow) and used a differential rating scale (1–5) to indicate
whether or not they agreed with negative weight stereotypes (α=0.88, 0.91, and 0.92,
respectively; Bacon, Scheltema, & Robinson, 2001).
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Secondary outcomes.—Participants completed the Impact of Weight on Quality of Life

Questionnaire-Lite (IWQOL-Lite; α=0.92, 0.93, and 0.95), which assesses weight-specific
aspects of psychological and physical functioning (Kolotkin, Crosby, Kosloski, & Williams,
2001). They also completed: the Patient Health Questionnaire (PHQ-9) to assess symptoms
of depression (Kroenke & Spitzer, 2002; α=0.80, 0.80, and 0.85); the Generalized Anxiety
Disorder-7 questionnaire (Spitzer, Kroenke, Williams, & Lowe, 2006; α=0.86, 0.91, and

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0.93); and the 10-item Perceived Stress Scale (PSS; Cohen & Williamson, 1988; α=0.87,
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0.87, and 0.86). The Body Appreciation Scale was included as a measure of body esteem,
with items such as “I respect my body” (Avalos, Tylka, & Wood-Barcalow, 2005; α=0.88,
0.93, and 0.93). Other exploratory outcomes can be found in the Supplementary Materials.

Behavioral outcome measures included changes in self-efficacy, as assessed by the Weight

and Lifestyle Efficacy-Short Form (WEL; Ames, Heckman, Grothe, & Clark, 2012) and
Self-Efficacy for Exercise Scale (SEES; Resnick & Jenkins, 2000). The WEL assesses
confidence in one’s ability to overcome challenges that lead to overeating (e.g., “I can resist
overeating when others are pressuring me to eat.”), while the SEES assesses confidence to
overcome barriers to physical activity (e.g., “the weather was bothering you”). Both scales
have strong psychometric properties (WEL α=0.88, 0.88, and 0.92; SEES α=0.91, 0.89, and
0.93).
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Changes in self-reported eating were assessed with the Eating Inventory Questionnaire,
which includes subscales for dietary restraint, disinhibition, and hunger (Stunkard &
Messick, 1985). Dietary restraint assesses behaviors that are encouraged in weight
management programs for controlling weight (e.g., “I count calories as a conscious means of
controlling my weight.”; α=0.72, 0.79, and 0.79); disinhibition assesses loss of control over
eating (e.g., “Sometimes when I start eating, I just can’t seem to stop.”; α=0.73, 0.76, and
0.79); and hunger assesses perceptions of physical hunger (e.g., “I am always hungry
enough to eat at any time.”; α=0.82, 0.86, and 0.82). Food records were collected from all
participants to identify the number of completed days (i.e., recorded at least two meals per
day). Participants also reported their frequency of self-weighing and tracking their food/
drink intake, calories, and physical activity.
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Duplicate measures of height (with a wall-mounted stadiometer; Veeder-Root,

Elizabethtown, NC) were obtained at screening. Weight was measured at screening (with a
digital scale; Detecto, model 6800A), baseline (week 1), and weeks 12 and 26. Percentage
reduction in baseline weight was calculated at the latter two times. Systolic and diastolic
blood pressure were measured in duplicate at screening and weeks 12 and 26 using an
automated Dinamap monitor (Johnson & Johnson, XL model 9300) at 1-minute intervals
after ≥ 5 minute rest. Waist circumference was measured in duplicate at screening and weeks
12 and 26 to the nearest 0.1 cm with a flexible tension-controlled measuring tape midway
between the iliac crest and lowest rib.

Safety and Treatment Acceptability

Study oversight was provided by a Data and Safety Monitor who was not involved in the
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study. The principal investigator and members of the study team prepared a report and met
every 6 months with the Monitor. Changes in participants’ health were assessed at each
study contact. Adverse events (AEs) were documented by study staff in consultation with a
nurse practitioner and physician, and serious adverse events (SAEs) were reported
immediately to the study sponsor, Monitor, and IRB.

Participants in both groups rated (1–7) the BWL treatment, as well as the stigma
intervention or recipe exchange, on how helpful they found each component of the program,

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how much they liked the components, and how much they learned new skills or information
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from each component. Scores for these three items were averaged separately for the BWL
treatment, stigma intervention, and recipe exchange.

Statistical Analyses
Analyses were conducted with the intention-to-treat (ITT) principle. Chi square and analysis
of variance (ANOVA) were used to determine whether participants differed on baseline
characteristics. Measures with missing items were prorated (all measures had ≤15% missing
items). Skewness and kurtosis were examined for continuous outcome measures at all time
points, and variables were transformed appropriately to meet assumptions of normality.
Linear mixed models were used to compare changes between groups at weeks 12 and 26 on
all continuous outcome measures, as well as to examine within group changes over time.
Model shape and variance-covariance structure were selected based on model fit criteria
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(e.g., −2 log likelihood). Piecewise models with a breakpoint at week 12 best fit the data for
all outcomes. Based on prior findings, we predicted a 1-point difference on the WBIS at
week 12, the study’s primary outcome (i.e., reductions of 1.5 and 0.5 in the intervention and
control groups, respectively, with a pooled standard deviations of 1.0; Mensinger et al.,
2016; Pearl, Hopkins, et al., 2018; Pearl, Wadden, Chao, et al., 2018). Power analysis with
G*Power 2.0 indicated that a sample size of 72 with 20% attrition would give us 95% power
to detect significant differences (with a medium effect size) between groups on the WBIS at
week 12 with an alpha = 0.05.

In a post-hoc analysis, correlations were used to explore the potential relationship between
changes in weight stigma outcomes and percent weight change. All analyses were conducted
with SPSS 25 and tested analyses with a significance level of p<0.05. Cohen’s d was
computed to determine the effect sizes of between-group differences.
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Results
Participant Recruitment and Retention
Figure 1 presents the trial CONSORT diagram. Of the 72 randomized participants, 7 did not
attend any group sessions. Thirty BWL+BIAS and 31 BWL participants completed
assessments at week 12 and 26 (overall retention rate=84.7%). Among participants who
attended at least one group session, 83.7% of group meetings or makeup sessions were
completed (mean number of completed sessions=13.4, standard deviation=4.1, range from 1
to 16 sessions; 81.6% attended 10 or more treatment sessions; 47.7% attended all 16
sessions). Attendance did not differ significantly between treatment conditions (86.5% in
BWL+BIAS group, 81.1% in BWL group, p=0.40). Of the groups attended, 79.0% of
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attendance came from group meetings (77.7% in BWL+BIAS group and 80.1% in BWL
group, p=0.56), with the remainder from makeup visits completed in person (17.4%) or by
phone (3.7%).

Participants’ Baseline Characteristics

Tables 1 and 2 present demographic and other baseline characteristics for all randomized
participants. Participants were predominantly black, female, middle-aged, had class II or III

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obesity (i.e., BMI of 35–39.9 or ≥40 kg/m2), and had completed approximately 15 years of
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education. Participant characteristics did not differ significantly between treatment

conditions. Participants who did not attend a group meeting or did not complete the week 12
assessment had, on average, 2 fewer years of education than did participants who completed
the 12 assessment (see Supplemental Table 1). No other differences were found between
participants who did and did not attend at least one group session or complete the week 12
assessment.

Weight Stigma
Table 3 (and Supplemental Figures 1 and 2) present estimated changes in WBIS and WSSQ
scores (total and subscales), respectively. Participants across groups showed significant
reductions on all weight stigma measures. However, changes in WBIS scores did not differ
significantly between the BWL+BIAS and BWL groups at week 12 (−1.3±0.2 vs. −1.0±0.2)
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or week 26 (−1.5±0.2 vs −1.3±0.2). BWL+BIAS participants reported significantly greater

reductions in WSSQ total scores than did BWL participants at week 12, with differences in
the same direction at week 26. This effect appeared to be driven primarily by differences in
the Self-Devaluation subscale at weeks 12 and 26. Fear of Enacted Stigma scores did not
differ at week 12 or 26.

Psychosocial and Behavioral Outcomes

Across both groups, significant improvements were observed for most outcomes, including
depression, body image, and quality of life (see Table 3 for means and p values). No
differences were found between groups in improvements on any psychosocial outcome (see
Supplemental Table 2 for additional outcomes).

Participants across groups showed significant improvements in self-efficacy to control eating

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but not to exercise (see Table 4). Improvements in self-monitoring behaviors were found in
both groups, with significantly greater self-reported improvements in tracking of physical
activity in the BWL+BIAS vs. BWL group at week 12. BWL+BIAS participants also
reported significantly greater reductions in hunger at weeks 12 and 26 compared to BWL
participants. Adherence to recording food intake was good overall, as judged by other
studies (Burke et al., 2011), and did not differ between groups.

Weight Loss and CVD Risk Factors

At week 12, BWL+BIAS and BWL participants lost a mean of 3.7±0.6% and 4.6±0.6% of
baseline weight respectively, which increased at week 26 to 4.5±1.0% and 5.9±1.0%.
Groups did not differ significantly at either time (see Table 5). Significant improvements in
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systolic and diastolic blood pressure were observed across groups at week 12 but not week
26. Changes in CVD risk factors did not differ between groups. In addition, percent weight
change did not correlate significantly with changes in WBIS, WSSQ total, and WSSQ
subscale scores across groups at weeks 12 or 26.

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Safety and Treatment Acceptability

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Supplemental Table 3 presents all AEs reported by ≥5% of participants. One SAE occurred
during the trial (hypokalemia). The SAE and AEs were not considered to be related to the
treatment provided.

Treatment acceptability ratings for the Weight BIAS program were high (6.3±1.0 out of 7).
Acceptability ratings did not differ across groups for the BWL component of the program
(BWL+BIAS=6.5±0.9, BWL=6.3±1.0, p=0.32), showing consistency across groups. Recipe
exchange ratings were approximately 1 point lower than for other components of the
program (5.4±1.5), suggesting that it was not a particularly potent component of treatment,
as intended.

Discussion
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This is the first RCT of which we are aware to test the effects of a combined weight stigma-
reduction and behavioral weight management intervention, compared to behavioral weight
management alone. Participants in both groups reported substantial improvements in weight
bias internalization, as measured by the WBIS, at both weeks 12 and 26, with no differences
between groups. At week 12, however, participants who received the combined intervention
reported significantly greater improvements on the WSSQ total score than did their
counterparts in BWL alone. They also reported significantly greater reductions on the
WSSQ self-devaluation subscale at weeks 12 and 26. Some studies have examined
differences between the WBIS and WSSQ (Hubner et al., 2016), but more research is needed
to understand the distinctions between these two measures of WBI. Reductions in the WSSQ
self-devaluation subscale are particularly important, because this scale captures individuals’
tendencies to blame and denigrate themselves for their weight. The combined intervention
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sought to help participants to both understand and decrease this, at times, relentless self-
blame. These findings are consistent with a prior RCT and an open-label pilot study of
acceptance-based stigma reduction interventions, which found significant improvements in
WSSQ scores (Levin, Potts, Haeger, & Lillis, 2018; Palmeira et al., 2017).

We had not expected BWL alone to produce such large reductions on the WBIS, which were
1.0 and 1.3 at weeks 12 and 26, respectively, compared with 1.3 and 1.5, respectively, for
BWL+BIAS participants. Previous studies of behavioral weight control have yielded
reductions in WBIS scores of approximately 0.5 points, which we used to power the present
study (Mensinger et al., 2016; Pearl, Wadden, Chao, et al., 2018). Two factors may have
contributed to the larger-than-expected reductions observed in our study. First, as noted, our
participants were required at screening to have a WBIS score ≥ 4, in order to recruit a
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sample more likely to have clinical distress concerning their WBI. This requirement resulted
in the present sample having a higher mean WBIS score at baseline (5.1 points) than in
many past weight loss studies (recent means of 3.7–4.3; Mensinger et al., 2016; Pearl,
Wadden, Chao, et al., 2018). Thus, past studies may have been limited by a potential floor
effect in detecting improvements in WBIS scores.

A second possible explanation is that the process of changing health behaviors and losing
weight may have a greater effect on WBI for individuals with elevated levels, since the

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 Pearl et al. Page 11

ability to make these changes inherently challenges weight stereotypes that they have
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internalized (e.g., being lazy or lacking willpower). Non-specific aspects of the BWL
program, such as the group format to reduce participants’ feeling alone in their struggles
with weight and increase social support (from other group members and study staff), may
also have contributed to reductions in WBI without the specific targeted intervention.
Consistent with some but not all past research, changes in WBI did not correlate
significantly with changes in weight, suggesting that losing more weight does not
necessarily facilitate reducing WBI more and vice versa (Lillis, Thomas, Olson, & Wing,
2019; Palmeira et al., 2017; Pearl, Wadden, Chao, et al., 2018). Future studies which
dismantle the components of the BWL and Weight BIAS programs may be useful for
understanding which aspects of treatment are most beneficial for patients with elevated
WBI.

Participants across both groups achieved clinically meaningful weight losses (of
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approximately 4.5–6.0%) by week 26. The lack of significant differences in weight loss
between groups challenges proposals that reducing weight stigma and promoting body
acceptance may impede motivation for people with obesity to improve their health (Snook,
Hansen, Duke, Hackney, & Zhang, 2018). The results also did not support the hypothesis
that a stigma-reduction intervention may enhance weight loss. These results must be
interpreted in the context of several considerations. First, weight loss was a secondary
outcome, and this study was not powered to detect these differences. Second, given that
participants who received BWL alone also showed reductions in WBI, it is possible that a
larger dose of the Weight BIAS program was needed to surpass the benefits of BWL alone.
Due to the deeply ingrained nature of internalized weight beliefs, more sessions over a
longer period of time may be needed to achieve a sufficient reduction in WBI to affect
downstream health and weight outcomes. Further, given the robust weight loss effects of
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short-term intensive BWL treatment (Heymsfield & Wadden, 2017), the potential effects of
a stigma-reduction intervention, combined with BWL, may not emerge until patients face
the challenge of weight loss maintenance, when weight regain is common (Jenson et al.,
2014). Longer studies with more stigma-reduction intervention sessions would help to
clarify these potential questions pertaining to dose-response and long-term outcomes.

Improvements in other outcomes, such as depression, anxiety, body image, and quality of
life were also observed across the two groups but did not differ between them.
Improvements on these measures were comparable to or greater than those observed in
weight loss studies (Pearl, Wadden, Tronieri, et al., 2018) and studies testing weight-neutral
programs based on the Health at Every Size (HAES) approach (Mensinger et al., 2016;
Ulian et al., 2018). HAES is similar to our Weight BIAS program in its focus on combating
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myths and misperceptions about weight and reducing self-blame (Bacon, 2010), although
WBI is not specifically addressed in the HAES curriculum (Mensinger et al., 2016).
However, HAES differs in its focus on intuitive eating and promoting health behavior
change without weight loss (Bacon, 2010), while our BWL intervention encouraged modest
weight loss through caloric restriction (the Weight BIAS Program content did not directly
promote weight loss, though it did acknowledge and support patients’ BWL goals). It is
likely that the HAES approach may be suitable for specific patient populations, and weight
loss interventions may be more appropriate for others (e.g., individuals with class II or III

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 Pearl et al. Page 12

obesity and/or CVD risk factors; Ulian et al., 2018). Treatment acceptability ratings were
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high for the Weight BIAS and BWL programs, suggesting that combining weight loss with
stigma-reduction was complementary rather than contradictory.

Participants across the two groups reported significant improvement in eating self-efficacy,
eating behaviors (e.g., disinhibited eating), and self-monitoring behaviors. BWL+BIAS
participants showed significantly greater improvements in tracking of physical activity at
week 12 and in hunger at weeks 12 and 26. It is possible that more differentiation between
groups in self-efficacy and health behaviors may emerge in the long-term. For example,
participants who learned to challenge negative weight stereotypes (e.g., that they are lazy or
lack willpower) may have more positive self-regard and self-efficacy when they encounter
barriers to long-term maintenance (such as small weight regain) than participants who have
not challenged such stereotypes and may be vulnerable to self-devaluation with weight
regain. Thus, participants with skills to reduce WBI may be more likely to stick with their
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behavioral goals in the long-term.

Limitations of the current study include the short-term (3-month) follow-up from the end of
the 12-week program, and inclusion only of participants with elevated WBI. Adults who are
treatment-seeking, have severe obesity, and/or report greater psychological distress tend to
have higher levels of WBI than community samples and those with lower BMIs or without
psychopathology (Pearl & Puhl, 2018). Thus, results from the current study could be
applicable to a significant proportion of US adults with obesity engaged in weight
management. However, the effects of the Weight BIAS program on a general treatment-
seeking sample (with varying levels of WBI) are unknown and warrant testing. Weight
identity was the primary focus of the stigma-reduction intervention, but future studies might
explore issues of intersectionality in this context. This study also was not adequately
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powered to detect secondary outcomes of psychological well-being, health behaviors, weight

loss, and CVD risk reduction. Replication with a larger sample and long-term follow-up is
needed to confirm and clarify the potential benefits of combining this stigma-reduction
intervention with intensive BWL treatment.

Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

Acknowledgements:
We would like to thank WW for funding this research. We would also like to thank Dr. Ariana Chao for serving as
the study’s Data and Safety Monitor, and the research assistants who helped to facilitate participant recruitment,
treatment delivery, and data management: Danielle Collins, Callie Fisher, Camila Johanek, Matthew McDermott,
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AnnaClaire Osei-Akoto, and Kaylah Walton.

Funding Statement: This study was funded by WW (formerly Weight Watchers). RLP is supported by a K23
Mentored Patient-Oriented Research Career Development Award from the National Heart, Lung, and Blood
Institute/NIH (#K23HL140176). JST is supported by a K23 Mentored Patient-Oriented Research Career
Development Award from the National Institute of Diabetes and Digestive and Kidney Disease/NIH
(#K23DK116935).

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Public Health Significance Statement:

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This study demonstrates the efficacy of a cognitive-behavioral weight stigma-reduction

intervention, combined with behavioral weight loss.
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Figure 1.
CONSORT diagram.
BMI=Body mass index; WBIS=Weight Bias Internalization Scale; BWL+BIAS=behavioral
weight loss combined with Weight Bias Internalization and Stigma Program;
BWL=behavioral weight loss alone.
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Table 1.

Participants’ baseline characteristics, N (%) or Mean ± Standard Deviation

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Variable Total (N=72) BWL+ BIAS (n=36) BWL (n=36) p

Age (years) 47.1±11.5 47.7±11.4 46.6±11.8 0.69
Sex 0.33
Female 61 (84.7%) 32 (88.9%) 29 (80.6%)
Male 11 (15.3%) 4 (11.1%) 7 (19.4%)
Race 0.13
White 21 (29.2%) 7 (19.4%) 14 (38.9%)
Black 48 (66.7%) 26 (72.2%) 22 (61.1%)
Asian 2 (2.8%) 2 (5.6%) 0

Multiracial* 1 (1.4%) 1 (2.8%) 0

Hispanic/Latino/a 6 (8.3%) 4 (11.1%) 2 (5.6%) 0.39

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Education (years) 14.9±2.1 14.8±2.2 15.1±2.0 0.61

Weight (kg) 109.8±22.6 112.4±24.0 107.2±21.2 0.34
Height (cm) 166.8±8.5 167.0±8.7 166.6±8.5 0.86
Body Mass Index (kg/m2) 39.3±6.1 40.1±6.5 38.4±5.6 0.25
Waist Circumference (cm) 117.0±14.1 119.1±15.3 114.9±12.6 0.21
+ 127.7±10.3 127.4±10.2 128.0±10.7 0.50
Systolic blood pressure
+ 73.7±8.5 73.0±9.2 74.3±7.9 0.26
Diastolic blood pressure

Note. All variables were reported or measured at participants’ screening visits. Education was missing for one participant in the BWL+BIAS group.
*
Participant did not know specific racial background.
+
Systolic and diastolic blood pressure p values reflect comparisons controlling for use of blood pressure medication at screening.
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Table 2.

Participants’ baseline values on key outcome measures, Mean ± Standard Deviation

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Variable Total BWL+ BIAS BWL p

WBIS 5.1±0.7 5.0±0.7 5.2±0.7 0.33
WSSQ Total 38.6±6.7 37.9±6.6 39.3±6.9 0.39
WSSQ-SD 19.2±4.1 19.1±4.2 19.2±3.9 0.93
WSSQ-FNE 19.4±4.7 18.8±4.6 20.1±4.8 0.26
Fat Phobia Scale 3.7±0.6 3.7±0.7 3.7±0.6 0.54
PHQ-9 8.0±4.8 7.5±5.1 8.4±4.5 0.45
GAD-7 5.4±4.3 5.6±4.5 5.2±4.2 0.67
Perceived Stress Scale 17.3±6.4 17.6±6.2 16.9±6.5 0.66
Body Appreciation Scale 2.6±0.7 2.8±0.6 2.5±0.7 0.11
IWQOL-Lite Total 55.3±16.5 56.3±16.7 54.2±16.5 0.61
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WEL-SF 40.0±17.5 39.4±17.4 40.7±17.9 0.75

SEE 51.2±20.0 48.3±20.1 54.2±19.9 0.22
Eating Inventory
Dietary Restraint 8.7±3.7 8.5±3.7 8.9±3.8 0.67
Disinhibition 9.7±3.3 9.2±3.5 10.2±3.1 0.19
Hunger 7.1±3.7 7.8±3.6 6.4±3.6 0.10
Self-Reported Weighing 0.9±1.2 0.9±1.2 0.9±1.1 0.83
Track Food/Drink 0.5±0.8 0.4±0.7 0.5±0.8 0.70
Track Calories 0.5±1.0 0.4±1.0 0.6±1.1 0.32
Track Activity 1.2±1.5 1.0±1.5 1.3±1.5 0.38

Note. Total N=72 for the Weight Bias Internalization Scale (n=36 per group). N=71 for all other values (n=36 in BWL+BIAS group and n=35 in
BWL group). WBIS=Weight Bias Internalization Scale; WSSQ=Weight Self-Stigma Questionnaire; SD=Self-Devaluation; FNE=Fear of Enacted
Stigma; PHQ-9=Patient Health Questionnaire-9, summed scores, 0–27, higher scores indicate more symptoms of depression; GAD-7=Generalized
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Anxiety Disorder-7, summed scores, 0–21, higher scores indicate greater anxiety; PSS=Perceived Stress Scale, 10-item version, summed scores, 0–
40, higher scores indicate greater perceived stress; Body Appreciation Scale: 10 items rated 1–5, scores averaged, higher scores indicate greater
body appreciation; IWQOL-Lite=Impact of Weight on Quality of Life-Lite, items rated from 1–5, scores are transformed to a 0–100 scale, with
higher scores indicating better quality of life. SEE (Self-Efficacy to Exercise Scale) and WEL-SF (Weight Efficacy Lifestyle Questionnaire – Short
Form): 8 and 9 items, scores summed 0–80 or 0–90, respectively; higher scores indicate greater self-efficacy; Eating Inventory items include both
true/false and rating scales, with all scores converted to 0 or 1 ratings and summed; Self-reported weighing rated 1–5 (less than once per month
through several times per day); other self-monitoring/tracking behaviors rated from 0–4 (from never to everyday).
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Table 3.

Estimated mean change (± standard error) in psychosocial outcomes from baseline to week 12 and week 26
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Variable BWL+BIAS (n=36) BWL (n=36) Mean Difference p d

WBIS

Week 12 −1.3±0.2*** −1.0±0.2*** −0.3±0.2 0.22 0.31

Week 26 −1.5±0.2*** −1.3±0.2*** −0.2±0.3 0.45 0.16

WSSQ Total

Week 12 −6.0±1.4*** −1.6±1.3 −4.4±1.9 0.03 0.58

Week 26 −7.1±1.5*** −3.6±1.5* −3.5±2.1 0.11 0.35

WSSQ-SD

Week 12 −3.6±0.8*** −1.0±0.8 −2.8±1.1 0.02 0.48

Week 26 −4.1±0.8*** −1.5±0.8 −2.6±1.1 0.03 0.45

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WSSQ-FNE

Week 12 −2.3±0.8** −0.7±0.8 −1.6±1.2 0.19 0.33

Week 26 −2.9±0.9** −2.1±0.9* −0.8±1.3 0.53 0.13

Fat Phobia Scale

Week 12 −0.5±0.1*** −0.2±0.1 −0.3±0.2 0.12 0.31

Week 26 −0.5±0.1*** −0.2±0.1 −0.3±0.2 0.09 0.33

PHQ-9

Week 12 −3.4±0.8*** −2.5±0.8*** −0.9±1.1 0.40 0.16

Week 26 −2.9±0.8*** −2.9±0.8*** −0.03±1.1 0.98 0.01

+
GAD-7

Week 12 −1.8±0.8** −0.7±0.8 −1.1±1.1 0.32 0.26

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Week 26 −1.6±0.8** −0.8±0.8 −0.8±1.2 0.16 0.30

Perceived Stress Scale

Week 12 −3.2±1.2* −0.1±1.2 −3.0±1.7 0.08 0.34

Week 26 −3.9±1.2** −1.0±1.2 −2.9±1.7 0.10 0.32

Body Appreciation Scale

Week 12 0.6±0.1*** 0.3±0.1** 0.3±0.2 0.13 0.41

Week 26 0.8±0.1*** 0.5±0.1*** 0.3±0.2 0.13 0.32

IWQOL-Lite Total

Week 12 8.3±2.1*** 8.9±2.0*** −0.6±2.9 0.84 0.05

Week 26 12.5±2.1*** 14.1±2.1*** −1.7±3.0 0.58 0.13

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Note. WBIS=Weight Bias Internalization Scale; WSSQ=Weight Self-Stigma Questionnaire; SD=Self-Devaluation; FNE=Fear of Enacted Stigma;
PHQ-9=Patient Health Questionnaire-9; GAD-7=Generalized Anxiety Disorder-7; IWQOL=Impact of Weight on Quality of Life.
+
GAD-7 scores underwent logarithmic transformation to fit assumptions of normality; statistics for GAD-7 scores are from linear mixed models,
and raw change values are shown. Asterisks indicate significance of within group changes from baseline. Significant between-group differences are
highlighted in bold.
***
p≤0.001

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**
p≤0.01
*
p<0.05
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Table 4.

Estimated mean change (± standard error) in behavioral outcomes from baseline to week 12 and week 26
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Variable BWL+BIAS (n=36) BWL (n=36) Mean Difference p d

WEL-SF

Week 12 11.3±3.1*** 10.2±3.1*** 1.1±4.4 0.80 0.05

Week 26 12.0±3.1*** 8.9±3.1** 3.1±4.4 0.49 0.14

SEE
Week 12 4.0±4.6 −5.7±4.5 9.7±6.5 0.14 0.28
Week 26 5.8±4.6 −6.3±4.5 12.1±6.5 0.06 0.35
Eating Inventory
Dietary Restraint

Week 12 6.3±0.7*** 5.9±0.7*** 0.4±1.0 0.69 0.11

Week 26 6.4±0.8*** 5.2±0.8*** 1.2±1.1 0.29 0.21

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Disinhibition

Week 12 −2.8±0.6*** −1.9±0.6** 0.9±0.8 0.28 0.27

Week 26 −3.0±0.6*** −2.2±0.6** −0.8±0.8 0.34 0.20

Hunger

Week 12 −3.2±0.5*** −1.4±0.5* −1.8±0.8 0.02 0.48

Week 26 −3.9±0.5*** −1.4±0.5* −2.5±0.8 0.001 0.66

Days of Food Records

Week 12 52.9±3.4*** 55.5±3.4*** 2.6±4.8 0.59 0.11

Week 26 85.6±9.5*** 95.8±9.2*** −10.2±13.1 0.44 0.20

Self-Reported Weighing

0.9±0.2*** 1.1±0.2***
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Week 12 −0.2±0.3 0.46 0.16

Week 26 1.0±0.2*** 0.6±0.2** 0.4±0.3 0.23 0.25

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Track Food/Drink

Week 12 2.7±0.3*** 2.0±0.3*** 0.7±0.4 0.12 0.38

Week 26 1.6±0.3*** 1.6±0.3*** 0.1±0.4 0.90 0.03

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Track Calories

Week 12 2.0±0.3*** 1.7±0.3*** 0.3±0.4 0.42 0.20

Week 26 1.7±0.3*** 1.4±0.3*** 0.3±0.5 0.36 0.18

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Track Activity

Week 12 1.6±0.3*** 0.8±0.3** 0.8±0.4 0.03 0.56

Author Manuscript

Week 26 1.3±0.3*** 0.9±0.3** 0.5±0.4 0.29 0.21

Note. WEL-SF=Weight Efficacy Lifestyle Questionnaire-Short Form; SEE=Self-Efficacy to Exercise Scale.

+
Track Food/Drink and Activity scores underwent logarithmic transformation to fit assumptions of normality, and Track Calories scores were
transformed with the square root; statistics for these variables are from linear mixed models, and raw change values are shown. Asterisks indicate
significance of within group changes from baseline to time point. Significant between-group differences are highlighted in bold.

J Consult Clin Psychol. Author manuscript; available in PMC 2021 May 01.
 Pearl et al. Page 23

***
p≤0.001
**
p≤0.01
*
p<0.05
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 Pearl et al. Page 24

Table 5.

Estimated mean change (± standard error) in weight and cardiovascular risk factors from baseline to week 12
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and week 26

Variable BWL+BIAS (n=36) BWL (n=36) Mean Difference p d

Percent Weight Change

Week 12 −3.7±0.6*** −4.6±0.6*** −0.9±0.8 0.28 0.22

Week 26 −4.5±1.0*** −5.9±1.0*** 1.4±1.4 0.31 0.26

Waist Circumference (cm)

Week 12 −4.0±0.9*** −4.0±0.9*** 0.0±1.3 0.98 0.01

Week 26 −4.3±0.9*** −5.1±0.9*** 0.8±1.3 0.54 0.15

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Systolic Blood Pressure (mm Hg)

Week 12 −3.4±1.6* −5.4±1.6*** 2.0±2.2 0.37 0.18

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Week 26 −2.6±1.6 −2.4±1.6 −0.2±2.2 0.94 0.01

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Diastolic Blood Pressure (mm Hg)

Week 12 −2.8±1.2* −5.6±1.1*** 2.8±1.6 0.09 0.31

Week 26 −1.4±1.2 −2.1±1.1 0.7±1.6 0.67 0.08

Note. Percent weight change was calculated from week 1 weights; all other values were measured at screening.
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Blood pressure analyses control for whether or not participant took blood pressure medication at any time during the study.
***
p≤0.001
**
p≤0.01
*
p<0.05
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J Consult Clin Psychol. Author manuscript; available in PMC 2021 May 01.