Introduction
Weight bias and stigma are common issues faced by individuals with overweight and obesity pursuing weight loss [1]. Weight bias consists of negative stereotypes and characteristics attributed to people with higher body weights [2]. Many individuals and groups exhibit high levels of weight bias, which can lead to pervasive stigma about obesity [3].
Weight stigma can include both overt discrimination by others on the basis of body shape or size, as well as weight self‐stigma, in which negative stereotypes about weight are internalized by people with obesity [2].
Weight self‐stigma is of particular importance to weight management because it can affect participant experiences with weight management programs. Some evidence suggests that high levels of weight bias internalization (WBI) can lead to higher program attrition [4], though other studies have more mixed findings regarding the impact of weight self‐stigma on program engagement and outcomes [5]. Having higher levels of WBI before starting a weight management intervention may also lead to poorer weight loss outcomes [6].
Scores on the Weight Bias Internalization Scale (WBIS) have been shown to decrease, if marginally, over the course of a weight management intervention, with or without psychological interventions to reduce WBI [6, 7].
Treatment‐seeking populations may also be at risk of disordered eating or excess concern about weight and shape [8] as a response to weight stigma [9] or as an unintended consequence of weight management interventions. One particular concern is that weight management interventions that include calorie restriction or increases in cognitive restraint might promote overeating or binge eating as a response to sustained calorie restriction [10]. This, in turn, could lead to poorer weight loss outcomes [11].
In addition, concerns have been expressed that caloric restriction could trigger overly‐restrictive eating behaviors that could lead to eating disorders or disordered eating among those who are genetically predisposed [12]. Two recent systematic reviews and meta‐analyses found that weight loss interventions among people with obesity generally do not worsen eating disorder symptoms, rather scores on measures of disordered eating tended to improve from beginning to end of an intervention [8, 13]. Age data was reported in one of the reviews, and ranged from an average of 22.1–59.9 years at baseline [8].
Although eating disorders are typically studied in younger populations, older adults, particularly women, are still susceptible to the development of eating disorders [14]. In clinical settings, it is important to have evidence that the benefits of weight management interventions outweigh the harms, and simultaneously, to identify characteristics that may predispose individuals to adverse outcomes of weight management interventions [15]. This information could help clinicians individualize treatment plans to enhance outcomes and minimize negative side effects.
Previous work has demonstrated that age can affect how individuals with obesity experience and cope with weight stigma [16]. The Health and Retirement Study, a study which captured individuals from a wide range of BMI classifications, including normal weight, found an overall weight discrimination prevalence of 6% among adults 65 and older [17]. In a 2021 study of treatment‐seeking adults, 59.6% of the US participants surveyed had experienced weight stigma [1].
The average age of the sample was 56.87 (SD 12.86). America's population of 65 years and older is expected to reach 72 million by 2030 and those now aged 50+ years will contribute substantially to this growth [18]. It has been projected that by 2050, 213 million US adults will have overweight or obesity [19].
Therefore, it is important to evaluate how internalized weight stigma and eating behaviors may change over the course of a weight loss intervention in middle‐aged and older adults. While middle‐aged adults have been studied in the context of a weight management intervention, little information is available on how weight stigma affects older adults in weight management settings.
The purpose of this investigation was to examine changes in weight bias internalization (WBI) and EDE‐Q scores over the course of a 12‐week behavioral weight management intervention in adults aged 50+ years. Experiences with weight stigma and binge eating behaviors were also assessed. The hypothesis was that WBI would decrease over the course of the 12‐week intervention, EDE‐Q global scores would decrease, and the restraint subscore of the EDE‐Q would increase.
Methods
Data were collected as part of a randomized controlled trial studying weight management in adults aged 50+ with overweight or obesity (NCT05843318). All groups were provided with the same educational materials and counseling for a hypocaloric diet and physical activity. For the purposes of this analysis, study groups were combined.
Participants were age 50 and above with BMI ≥ 25 kg/m2 at baseline. Other inclusion criteria included being weight stable within ± 2 kg for 6 months prior to enrollment, willing to comply with study protocols, and able to use a computer, keyboard, and mouse. Exclusion criteria included weighing greater than 400 lbs (due to equipment weight capacities), having uncontrolled hypertension, following a specialized dietary plan for a medical condition, having a medical condition that would preclude participation in a walking program, taking medication for weight loss, or consuming > 1500 mL plain water per day [20].
Structured Weight Management Program
Participants were assigned to a trained nutrition counselor (RDN or MS‐level graduate student in Dietetics) for evidence‐based weight management counseling. Counselors were trained in study counseling procedures and utilized a structured counseling manual to guide counseling sessions. Participants were provided with a workbook that included information on a balanced hypocaloric diet based on the Dietary Guidelines for Americans 2020–2025 [21].
The dietary counseling included education about food groups and recommended serving sizes, sample menus, and educational resources. Counselors provided behavior change strategies based on Social Cognitive Theory [22], including self‐monitoring, goal setting, and feedback [23]. Participants were instructed to track daily steps, body weight (optional), and fluid intake or fruit and vegetable intake (based on group assignment).
Participants attended weekly in‐person nutrition counseling visits for 12 weeks. Participants' body weight was assessed at each weekly visit. After the 12‐week weight loss phase was completed, participants transitioned to monthly virtual counseling for 12 months, which was not a focus of this investigation.
Minimizing Weight Stigma in Weight Management Counseling
Throughout the study, efforts were made to minimize experiences of weight stigma as part of study participation [24]. All study staff that interact with participants received evidence‐based training on prevention of weight stigma based on information from the UConn Rudd Center for Food Policy and Health [25] and other dietetics‐specific guidance [24]. Staff were trained to take weight measurements in a private area, and to ask for consent for weighing at each measurement.
The study facilities were also designed to minimize weight stigma, including providing a variety of size‐appropriate seating options and ensuring that facilities were accessible to individuals who may have mobility concerns.
Measures
Weight measurements were taken at baseline and at week 12 of the weight management intervention using a Scale‐Tronix digital scale. Participants were weighed in lightweight clothing, without shoes, and with pockets emptied.
Participants completed surveys on weight bias and eating behaviors at enrollment in the weight management program (baseline) and at completion of the weight loss phase of the program (12 weeks).
Experiences with weight stigma were assessed at baseline through three yes/no questions about whether participants had ever experienced teasing, unfair treatment, or discrimination based on their body weights [26]. Participants who answered “yes” to any of the three questions were coded as having experienced any weight stigma [1]. This measure has not been validated; however, it has been used in several previous studies [27, 28] and was chosen for its specificity to weight stigma and its brevity.
WBI was assessed through the Modified Weight Bias Internalization Scale (WBIS‐M), which was designed for use among participants from a variety of body weight statuses, including people who may not identify as overweight [29]. Responses ranged from 1 (strongly disagree) to 7 (strongly agree) for each of the 11 questions. Questions 1 and 9 are reverse‐scored, and then the scores are calculated by summing the responses and dividing by 11.
Scores for the WBIS‐M range from Scores range from 1–7, with higher scores indicating more internalized weight bias. The WBIS‐M has been validated in a sample of individuals ranging from 19 to 70 years of age and across the weight spectrum. In the validation study, the Cronbach's alpha was 0.94 and the Eigenvalue was 7.19 [29].
The Eating Disorder Examination Questionnaire was used to assess disordered eating behaviors. It consists of four subscales (Restraint, Eating Concern, Shape Concern, and Weight Concern), as well as an overall Global Score [30]. Scores are tabulated by summing the responses in each subscale and dividing by the total number of items in that subscale.
The global score is calculated by averaging the four subscales. Scores for each subscale ranged from 0 to 6, with higher scores corresponding to higher frequencies of disordered behaviors. This measure was validated in a sample of female undergraduate students, demonstrating significant internal consistency for each subscale (Cronbach alphas ranging from 0.78 to 0.93) and test‐retest reliability (Pearson r ranging from 0.81 to 0.94) [30].
The EDE‐Q has also been used in samples with obesity [31].
Binge eating was assessed using the Binge Eating Scale (BES) [32], which assesses both binge eating behaviors and the feelings around binge behaviors. Scores ranged from 0 to 46, with higher scores corresponding to more binge eating. This scale demonstrated a Cronbach alpha of 0.85 in a sample of individuals with obesity [32].
Statistical Analysis
Only data from participants who completed the 12‐week weight loss phase were utilized. Statistical analyses were completed using RStudio (2024.12.1 + 563). Summary statistics were tabulated for demographic variables.
A linear mixed‐effects model was used to assess the change from baseline to week 12 in the scores for the WBIS‐M, BES, and EDE‐Q and subscale scores, controlling for age, race, and baseline BMI. Linear regression analysis was used to examine the correlation between the change in WBIS‐M scores and weight loss percentage over the 12 weeks, using age, race, and baseline BMI as covariates. Significance was set a priori at p < 0.05.
An exploratory analysis examined the change in WBIS, BES, and EDE‐Q scores by weight loss status, comparing individuals who lost weight over the 12 weeks with individuals who were not successful in losing weight during the 12 weeks using t‐tests to compare the change in each score. Weight loss success was defined as losing any weight from baseline to 12 weeks, while unsuccessful weight loss included individuals who maintained the same weight or gained weight from baseline to 12 weeks.
Results
A total of 90 participants completed baseline testing and initiated the weight loss program, and 7 participants (8%) dropped out before completion of the weight loss phase (Figure 1). The analysis included 83 participants who completed the 12‐week weight loss phase of the intervention. The mean BMI of participants was consistent with Class 1 obesity (Table 1).
At week 12, participants had lost an average of 5.00% of their baseline body weights (SD 3.94). The majority of participants (85.5%) were successful with weight loss during the intervention. Participants had an average age of ∼61 years and were mostly female, white and non‐Hispanic.
All participants had a high school education or above.
Nearly half of participants (∼45%) reported experiencing weight stigma during their lives (Table 2). The most common type of weight stigma reported was teasing (43.4%), followed by unfair treatment (18.1%), and discrimination (8.4%).
Significant improvements in most scores were noted over the 12‐week intervention period. From baseline to 12 weeks, there was a reduction in WBIS‐M score (adjusted mean difference −0.46, p < 0.001) (Table 3), EDE‐Q Shape Concern (adjusted mean difference −0.75, p < 0.001) and Weight Concern (adjusted mean difference −0.32, p = 0.002) subscale score, and an increase in the Restraint subscale score (adjusted mean difference 1.77, p < 0.001). BES scores decreased by an adjusted mean of 3.75 units.
When accounting for multiple comparisons, there were no changes in the results. The results of the multiple linear regression indicated that percent weight loss was a significant predictor of change in WBIS‐M scores (β = 0.055, p = 0.010), indicating that individuals with a greater percent weight loss showed greater reductions in WBIS‐M scores from baseline to 12 weeks. Age, sex, and baseline BMI were not significant predictors of change in WBIS‐M scores.
Among those that were not successful at losing weight over the 12 weeks (n = 12), the average weight change was +1.07 kg (SD 0.954). When examining the results according to weight loss status, 58.3% of those who did not lose weight during the 12 weeks had experienced any type of weight stigma, compared to 42.3% of those who were successful with weight loss during the intervention. Those that were not successful with weight loss exhibited no change in WBIS‐M scores, no change in BES scores, and increases in the global score and all subscale scores of the EDE‐Q.
Conclusion
This investigation demonstrated that participating in a structured behavioral weight loss program led to favorable changes in internalized weight bias, body shape concern, weight concern, and binge eating among middle‐aged and older adults. Concurrently, an increase in dietary restraint, as measured by the EDE‐Q, was also found, which could have both positive and negative implications in the context of weight management. Collectively, these changes may lead to more favorable weight management results.
The mean score on the WBIS‐M at baseline (3.37 (SD 1.03)) was consistent with population means found among US adults [33]. The decrease in WBIS‐M scores is consistent with the changes found by Pearl et al. from baseline to week 14 in a weight loss trial in adults with a mean age of 46.1 ± 10.1 years. [6]. WBI has been shown to be associated with a host of negative mental and physical health‐related outcomes; thus, reductions in WBI could offer additional psychological benefits.
Although this study did not explicitly intervene on WBI, participants may have experienced reduced WBI due to the support received as part of the intervention, consistent with the reduction in WBI found from behavioral weight loss in Pearl et al. (2020) [7]. The multiple linear regression suggests that weight loss experienced by participants was related to the decrease in WBIS‐M scores, such that more weight loss led to a greater decrease in WBIS‐M scores from baseline to week 12.
Future work may examine whether changes to WBIS‐M scores persist through the weight loss maintenance phase (12 months), and whether WBIS‐M scores increase if weight regain is experienced.
The increase seen in the Restraint subscale of the EDE‐Q, consistent with findings from other behavioral weight loss interventions [34], provokes some interesting questions about disordered eating risk. In the context of disordered eating, dietary restraint has been viewed by some as a risk factor for the development of disordered eating behaviors, including binge eating [35]. However, in the context of weight management, increased restraint can be a positive behavioral outcome in promoting effective weight control.
The overall decrease in binge eating found from baseline to the end of a structured weight management intervention suggests that the increase in restraint found in this study helped to manage binge eating behaviors, which is consistent with the results found as part of the CALERIE trial [36] and the NEW trial [37]. However, the degree of calorie restriction may be important in determining whether restraint is positive or negative, and thus future analyses in this population may look at changes to calorie intake throughout the weight loss intervention and into the weight loss maintenance phase and how they relate to binge eating outcomes.
The risk of disordered eating may also be related to the changes in shape and weight concerns seen over the course of the intervention. The risk for developing eating pathology is multifactorial; however, elevated shape and weight concerns are frequently identified as risk factors [38]. In midlife, shape and weight concern are common, particularly in women, with the physical changes in body composition associated with menopause [14].
These body composition changes could be a precedent for the development of unhealthy weight‐control behaviors or disordered eating. The supervised nature of the described weight control intervention as well as its positive effects on shape and weight concern together support the findings of Jebeile and Tsompanaki that behavioral weight management interventions do not worsen disordered eating risk, and may improve it [8, 13].
Though as a whole, this intervention showed favorable changes in weight bias, body shape concern, weight concern, and binge eating, there were some notable outliers. The small number of participants who did not lose weight during the intervention showed no changes in WBIS scores, no changes to BES scores, and increases in the EDE‐Q global score and all subscale scores. These incidental findings support the work of Major et al.
(2020), who reported that experiencing weight stigma led to increased motivation for weight loss, but decreased self‐efficacy to do so [39]. In this study, the experiences of weight stigma may have led participants to enroll in the study due to a desire to decrease weight, but low self‐efficacy may have led to difficulty with weight loss during the 12‐week weight loss intervention. Future work may examine self‐efficacy as a mediator of weight loss success in this population.
The limitations of this study included the low racial and ethnic diversity and the predominantly female sample. This analysis used a quasi‐experimental pre/post design which is relevant to clinical practice settings but did not include a control group. Strengths of this investigation included the focus on middle‐aged and older adults aged 50+, with no upper age or BMI limits, which is less common in weight management research and addresses an identified research gap [40].
These findings suggest that a structured behavioral weight loss program delivered by trained dietetics counselors may have small beneficial effects on weight bias, body shape concern, weight concern, and binge eating in middle aged and older adults, consistent with previous findings in weight management interventions in younger populations. Future work is needed to determine if changes to weight bias internalization and eating behaviors persist during weight loss maintenance.
Author Contributions
E.H. and B.M.D. conceptualized the topic. B.M.D. created the study design for the full trial. E.H. completed the data analysis.
All authors were involved in data collection and participant interaction. All authors were involved throughout the writing process and had final approval of the manuscript.
Funding
This study was supported by National Institutes of Health (R01DK135410).
Conflicts of Interest
The authors declare no conflicts of interest.