Avoiding exercise mediates the effects of internalized and experienced weight stigma on physical activity in the years following bariatric surgery

Weight-related stigma is frequently reported by people living with the highest levels of obesity, and its generally negative effects on health and wellbeing are well documented [1–9]. Larger-bodied individuals more frequently endure both direct and indirect forms of felt (experienced) weight stigma in many common environments, including work, school, medical facilities, and government centers [10]. Importantly, people with severe obesity (BMI ≥ 35) are more likely than those of normal weight to internalize the weight-related stigma expressed by others (i.e., to self-stigmatize) over their life course [10, 11]. Internalized weight stigma (sometimes termed self-stigma or self-directed stigma), is the extent to which a person reports feeling of low social value due to his or her current or former weight status. Internalized stigma arises because an individual agrees with the publicly held, usually negative, stereotypes used to characterize a group or population (e.g., overweight individuals) and adopts these negative views about the self or of his/her capabilities [12]. Internalized stigma more strongly affects both self-esteem and self-efficacy than do other forms of stigma (e.g., public stigma) across many different contexts, and, further, has long-lasting effects [13]. There is growing evidence that such stigma predicts difficulty in both reaching and maintaining a healthy weight, especially for individuals with a higher BMI. For example, higher levels of internalized weight stigma are associated with a number of behavioral changes, including greater calorie consumption, demotivation to diet, and binge eating disorder, all factors that can stymie weight loss [4, 14–16]. Furthermore, individuals who report high levels of internalized weight stigma are less likely to show improvement when they do seek treatment for disordered eating [17].

Weight stigma also impacts behaviors and attitudes toward physical activity. This can manifest as a reluctance to engage in specific, public forms of activity (e.g., gyms, swimming pools, or social sports teams) or as exercise avoidance more generally [1, 10, 18, 19]. For example, Vartanian and Shaprow [20] found a significant effect of experienced weight stigma on exercise avoidance in female college students which predicted less frequent bouts of strenuous and moderate physical activity. These effects were exacerbated among those already overweight and obese, or who believed themselves to be so. In a study of adult females with a body mass index (BMI) at or over 25, Pearl, Puhl, and Dovidio [21] found a significant effect of experienced weight stigma on exercise behavior and, further, that internalized weight stigma partially mediated this association. Similarly, among males who perceived themselves as overweight or obese, internalized societal attitudes toward appearance (including anti-fat attitudes) moderated the association between experienced weight stigma and exercise avoidance, which itself was negatively associated with self-reported strenuous exercise [18]. Among health program enrollees, Mensinger et al. [22] discovered that individuals who initially reported lower internalized weight stigma also had greater enjoyment of and engagement in moderate intensity physical activity (PA) while those individuals with high levels of internalized stigma showed little change to either over 6 months. While exercise avoidance was not a specific target of this study, these more negative attitudes towards exercise may express as a general reluctance to engage in activity (i.e., exercise avoidance). In total, these studies suggest that the mechanisms fueling exercise avoidance include direct and immediate concerns of judgment or mistreatment, but also that internalized stigma may undermine self-efficacy [17, 21–23] to create a “why try” mentality when it comes to weight loss, particularly when an individual is overweight [10, 19, 21, 24–27].

To expand the evidential basis of how stigma shapes exercise avoidance, here we focus on a population of bariatric patients in the years after their surgery. This is a population where the connections between stigma, obesity, and exercise avoidance decisions should be especially apparent. Bariatric (weight loss) patients decide to have surgery after difficult and long, often lifetime, struggles with both high body weight and the stigma it engenders [28]. To qualify for surgery, patients must often have a BMI of 40 or above, or a BMI of 35 or more (technically severe obesity) with associated co-morbidities. Studies show that individuals who elect to have surgery commonly report long-term exposure to stigmatized treatment by others, such as being stared at, enduring negative statements from children or other adults, and being overlooked for certain opportunities (e.g., work promotion) [1, 28, 29]. Evidence suggests that social stigmas are more severe and more likely to manifest as internalized stigma or self-blame when an individual is deemed personally responsible for his/her stigmatizing condition (i.e., being overweight), the effects of which are long lasting and may persist even if the stigmatizing variables change. [15, 30, 31].

After surgery, clinicians set guidelines for physical activity to assist with both weight-loss and maintenance [32–34]. However, Bond et al. [35] found no significant difference in moderate-to-vigorous physical activity (MVPA) tracked via accelerometer between patients assessed at presurgical and postsurgical (6 month) windows. For individuals like bariatric surgery patients who have lost a substantial amount of weight, a high level of physical activity is crucial to maintain their reduced weight status and prevent regain [36–39]. And yet bariatric surgery patients are less likely to comply with physical activity guidelines than other guidelines, including dietary ones, with rates of exercise program noncompliance increasing after surgery [40–42]. A lack of motivation and related psychological factors have been proposed to explain these persistently low levels of physical activity [43]. Given this, connecting stigma to exercise avoidance in the years after surgery has important practical applications for understanding (and preventing) weight regain in bariatric patients, particularly given the greater success in long-term weight loss for patients who engage in even low levels of regular physical activity [33, 44].

In total, our results indicate that level of physical activity may be influenced by postoperative bariatric patients’ internalized and experienced weight-related stigma via exercise avoidance. In other words, the higher the level of weight stigma a patient had when surveyed, the more likely she or he wanted to avoid exercise, and subsequently, the less physically active she or he was. Furthermore, both experienced and internalized weight stigma only indirectly, not directly, affected PA. Studies in non-bariatric populations indicate that weight stigma may significantly lower people’s willingness to engage in physical activity [18, 20, 50]. In this sample of postoperative patients, we identified weight stigma as a factor that may be involved in patient non-compliance with physical activity recommendations, even despite the significant postsurgical weight loss our participants reported. Considering patients and medical providers’ concerns with weight recidivism after bariatric surgery, these results indicate stigma interventions may help treatment professionals identify psychosocial barriers to exercise engagement. The enduring influence of internalized weight-related stigma suggests that weight-stigma interventions might help patients meet physical activity goals at any stage after surgery, even years. This study also adds to a small but growing body of research [19, 26] demonstrating that weight stigma has important and direct negative effects on the physical health of people living with obesity, such as exercise aversion.

Our results are consistent with those of previous studies that show for people who consider themselves overweight, higher internalized stigma generates greater sensitivity to the effects of experienced stigma, making them more likely to avoid exercising and/or placing themselves in situations where experienced stigma is more likely (e.g., jogging in public, attending gyms or fitness classes) [18, 51]. In the context of our sample, higher levels of self-stigma cultivated by years spent living with high weight may generate far-reaching psychosocial effects that persist even despite significant weight loss following surgery, and these may manifest as a reluctance to engage in publically visible forms of activity [25, 52]. This is particularly important given research suggesting 200–300 min of weekly physical activity (including exercise) is necessary not only to lose weight, but to maintain weight loss over the long term [53, 54]. This is well over the often recommended 150 min of moderate-intensity physical activity to reduce health risks associated with obesity [55]. There are many known barriers to engagement in physical activity, the most common including lack of time or energy, health-related concerns (e.g., injury/fear of injury, poor health, or physical discomfort), lack of adequate social support (e.g., childcare, regular encouragement), lack of access to resources (e.g., gym, equipment, or training), and low exercise self-efficacy [56–61]. Importantly, several studies have shown a lack of motivation to be among the most prevalent reasons offered by respondents when asked why they did not engage in more physical activity [61, 62].

Our findings suggest that addressing weight stigma may help curtail this barrier. Intervention programs have successfully helped to reduce several such barriers and facilitate weight loss by targeting other psychosocial variables, such as physical activity self-efficacy or behaviors surrounding social support [63, 64]. Similar programs designed to reduce weight stigma may motivate bariatric surgery patients to be more physically active, which would help them achieve the greater overall health benefits to be gained from surgery in combination with regular exercise. As such, medical and healthcare professionals who support bariatric surgery patients may benefit from the development of pre- and post-operative programs designed to help patients cope with the psychological stresses and trauma that arose from negative interactions surrounding body size in tandem with promoting more positive views about the body and higher exercise self-efficacy [22, 64].

These results are also important for health and fitness experts who work in public spaces, particularly nonmedical facilities like gyms and fitness centers which have, in recent decades, increasingly emphasized a holistic focus on health and fitness, of which weight loss is a part [65]. To fully realize these fitness goals, it is necessary for activity centers to provide a welcoming environment that limits stigmatizing situations, ensuring that people of all body types can be motivated to exercise free from both direct and indirect forms of judgement. Habitual inactivity is considered a leading cause of non-communicable disease worldwide, with many such diseases being associated with higher weight (e.g., heart disease, high blood pressure, type two diabetes, or certain types of cancer) [66, 67]. An emphasis on cultivating stigma-free conditions in fitness centers could therefore have beneficial health outcomes for all individuals with relatively larger bodies, not just those who chose bariatric surgery as an option to manage their weight [68]. Such reduced-stigma activity centers may also lower certain barriers to physical activity and incentivize individuals to stick with long-term exercise goals even without active professional guidance.

There are several limitations to this study. First, the level of physical activity was reported in minutes as well as in days, but we could not use data reported in minutes because there were too many missing cases. Further, there remains little consensus on how to measure physical activity based on self-reported data, nor how to construct an index that reflects the combined effects of diverse activity types (e.g., vigorous and moderate physical activity and walking). Instead, a latent variable approach was used to measure physical activity based on three survey items. The World Health Organization (WHO) recommends all adults age between 18 and 65 should do at least 150 min of moderate physical activity, 75 min of vigorous physical activity, or an equivalent combination of moderate and vigorous physical activity on a weekly basis to stay healthy (more details on http://www.who.int/dietphysicalactivity/factsheet_adults/en. However, this validated index could not be used as a variable in the model due to missing cases and their negative effect on statistical power. In addition, over-reporting physical activity is a documented phenomenon especially among obese respondents, meaning the low level of reported moderate and vigorous physical activity may actually have been lower [51]. We are unsure of how systematically it was overestimated nor do we know the implication of this for the analysis. Future research could benefit from more detailed and sophisticated physical activity data collection, perhaps using passive forms of activity documentation (e.g., tracking devices, pedometers, accelerometers) that do not rely solely on self-reported estimates as these tend to be overestimated among bariatric surgery patients [35]. Second, because this project was cross-sectional in design, the findings from these results should be interpreted and discussed in terms of associations, not necessarily causations. A longitudinal study that tracks these variables as individuals move through the treatment program (e.g., pre-surgery to several years afterward) would greatly enhance our understanding of how the relationship between self-stigma, exercise avoidance, and physical activity shifts over time, particularly at the crucial 12–24 month postsurgical window when weight loss often stalls and the 2–5 year window when many patients experience weight regain [69]. This would highlight times at which certain interventions may be most beneficial. Additionally, research that focuses on developing interventions to help ameliorate the psychosocial effects of being/having been overweight would also be a logical extension of this work that may yield promising treatment outcomes for postsurgical patients specifically and weight-loss seeking individuals more generally. Third, BMI was calculated based on patients’ self-reported height and weight at the time of survey, not objectively measured height and weight collected by trained researchers. Given consistent evidence that respondents tend to under-report weight and over-report height [70, 71], this is a potential limitation of the study. However, bariatric surgery patients may be more accurate in self-reporting BMI than are other populations [70]. Last, there was a wide range of time between surgery and survey across the study participants. There might be a significant difference in observed patterns of weight stigma, exercise avoidance, and physical activity between patients who recently underwent surgery and those who did so many years ago. Subgroup analysis could not be conducted with the data due to a relatively small sample size limiting statistical power of the analysis.

This study provides additional evidence that weight-related stigma has a likely effect on an individual’s capacity to lose and maintain weight via physical activity, even when they are otherwise highly motivated to do so. While more research is needed, our findings suggest that a therapeutic program designed to reduce deeply held feelings of weight-related stigma and working to create judgement-free exercise spaces may indirectly improve weight loss by decreasing an individual’s reluctance to engage in physical activity. Stigma-focused programs may therefore be a helpful complement the many nutrition- and exercised-focused programs traditionally offered to bariatric surgery patients.