Mixed Methods to Assess Sex Differences in Weight Bias Internalization Among Patients With Obesity

ABSTRACT

Background

Individuals with obesity frequently encounter weight bias, which can contribute to the internalization of negative weight‐related attitudes. This study examined sex differences in self‐reported weight bias internalization among a racially and ethnically diverse sample of adults with obesity engaged in treatment.

Methods

Mixed method approach was used. Weight bias internalization was assessed quantitatively using the 11‐item weight bias internalization scale (WBIS) and qualitatively through in‐depth interviews. Sex differences were examined with univariate and multivariate linear regressions. Interviews were thematically analyzed to explore sex differences.

Results

Quantitative analysis (n = 60, 62% female) revealed that non‐Hispanic White individuals with obesity exhibited significantly greater weight bias internalization than non‐Hispanic Black individuals with obesity. There was no significant difference in mean WBIS scores between males (4.15 ± 1.34; p = 0.13) and females (3.68 ± 1.02; p = 0.13). Qualitative analysis (n = 24, 50% female) identified themes such as childhood trauma, self‐esteem, health challenges, discrimination, and social interactions. No major conceptual differences emerged in the internalization of weight bias between male and female participants. However, female participants mostly described weight bias internalization as contributing to social avoidance and negatively impacting their career prospects.

Conclusion

Quantitative analyses indicated no statistically significant sex differences in weight bias internalization, and qualitative findings revealed no substantial conceptual differences between male and female participants. Future research should explore socioecological factors such as race/ethnicity, relationship status, and employment to identify populations at greater risk and inform targeted strategies for improving health outcomes.

1. Introduction

Obesity is a complex and persistent public health concern in the United States, shaped by multifaceted and interrelated determinants that span individual, interpersonal, community, and societal levels. One of the less visible yet deeply impactful consequences of obesity is weight bias internalization, a self‐directed form of stigma in which individuals accept and apply negative weight‐related stereotypes, prejudices, and attitudes to themselves [1]. Individuals who internalize weight stigma often report self‐devaluation, shame, low self‐worth, body dissatisfaction, and maladaptive health behaviors which in turn negatively affect mental and physical health outcomes [2, 3, 4]. Weight bias internalization originates from prejudicial, negative, or stereotypical beliefs based on body weight, shape, or size that are perpetuated by others which is known as weight bias or externalized weight bias [5, 6]. The descriptive epidemiology of weight bias internalization is largely unknown, particularly among treatment‐seeking people with obesity because it is an understudied form of internalized stigma [7]. However, about 40% of adults in the United States have reported internalizing weight bias, and 20% of these adults have high levels of weight bias internalization [1, 8]. Moreover, the rising rates of obesity in the general population have been paralleled with increasing reports of bias and discrimination against people with obesity [8], and studies show an association between higher body mass index and higher levels of internalized weight bias [9, 10].

Evidence suggests that individuals with obesity frequently internalize societal weight bias and discrimination encountered in everyday interactions [3]. In healthcare environments, such bias often contributes to inequitable access to quality care, with patients with obesity receiving less time, attention, and empathy from providers [4]. In workplace contexts, individuals living with obesity are often perceived as less suitable for client‐facing roles and are less likely to be promoted compared with their peers with lower body weight. These employees are frequently stereotyped as lacking self‐discipline, possessing limited leadership potential, and exhibiting poorer personal hygiene, assumptions that are not evidence‐based but deeply rooted in societal stigma [11, 12]. Such pervasive external biases contribute to weight bias internalization, where individuals begin to accept and apply these negative stereotypes to themselves. Weight bias internalization has been shown to reduce motivation to engage in health‐promoting behaviors, including regular physical activity and balanced nutrition, that are critical for preventing and managing obesity [8, 13]. Furthermore, weight bias internalization is associated with a range of adverse outcomes, including increased psychological distress, disordered eating, reduced self‐efficacy, and decreased quality of life [12, 13, 14]. Beyond health consequences, weight bias internalization also results in socioeconomic disadvantages including reduced employment opportunities and lower wages compared with individuals with lower body weight [11, 15]. As such, comprehensive clinical obesity care must address weight bias internalization, a key psychological factor that can impede treatment adherence, worsen health disparities, and increase the risk of chronic disease and premature death [16].

There is a gap in the literature regarding sex differences in weight bias internalization between males and females which may impact health outcomes and have detrimental socio‐economic implications for people with obesity. While some studies have suggested that females report more weight bias internalization [17, 18] likely due to the heightened societal scrutiny placed on female bodies and the cultural equation of thinness with attractiveness and worth, there is limited information about any potential differences in weight bias internalization among males and females with obesity who are engaged in obesity treatment and how this may impact their health outcomes. A previous study assessed sex differences in weight bias internalization among adolescents with obesity seeking bariatric surgery and did not detect any significant differences between the sexes [19]. Another study aimed to assess gender differences in weight bias internalization and eating pathology among people with overweight and found that compared to males, females reported stronger weight bias internalization and were more concerned about their weight and shape [18]. A study examining gender and racial differences in the relationship between perceived weight discrimination, psychological distress, and eating behaviors found that women were more likely than men to internalize weight‐based discrimination [20]. In a recent cross‐sectional study of 1012 overweight and obese high school students, researchers also explored gender differences in weight bias internalization and its association with quality of life (QoL). Girls reported significantly higher levels of internalized weight bias and body image dissatisfaction than boys. Although no significant gender differences were found in most QoL domains, the relationship between weight bias internalization and QoL varied by gender, particularly in the psychological health domain. These findings suggest that internalized weight bias may affect psychological aspects of QoL differently in male and female adolescents [21].

An understanding of any potential sex differences in weight bias internalization susceptibility among adult males and females engaged in obesity treatment may enhance the application of precision medicine to obesity care, a medical model where obesity treatments are tailored to each patient [22]. This approach is particularly effective in targeting obesity and empowering people with obesity to actively participate in their health management to provide optimal care [23]. Consequently, this study aimed to address this gap in the literature by assessing sex differences in self‐reported weight bias internalization among people with obesity who are engaged in obesity treatment. This clinical population was selected because of the potential vulnerability of males and females engaged in treatment to weight bias internalization [7], and an assessment of weight bias internalization could potentially identify people with obesity who can benefit from resources on coping with internalized weight bias and provide information for improving obesity care. Sex differences versus gender differences were assessed to determine any potential differences in how weight bias is internalized based on the biological attributes of males and females, and its association with health outcomes. Biological attributes including BMI, fat distribution, adiposity, metabolic function, and genetic predispositions influences individuals’ physical health profiles [4]. These characteristics often become the basis for societal judgments and weight‐based stereotypes, particularly in cultures that idealize thinness. In individuals living with overweight or obesity, these biological features can increase vulnerability to weight bias internalization. Moreover, the interplay between biological and psychological factors may compound adverse health outcomes. For example, the chronic stress associated with internalized weight bias may exacerbate metabolic dysfunction or undermine the efficacy of obesity treatment [4]. As such, assessing biological attributes in conjunction with psychosocial constructs such as weight bias internalization is essential to fully understand the multidimensional mechanisms through which internalized weight bias contributes to poor health.

Based on previous research indicating that more females with obesity in the general population indicate that they internalize weight bias [17, 18], it was hypothesized that among individuals with obesity undergoing obesity treatment, females would be more likely than males to report weight bias internalization.

2. Materials and Methods

2.1. Participants and Procedure

This mixed methods study adhered to both the strengthening the reporting of observational studies in epidemiology (STROBE) guidelines for reporting observational studies [24] and the standards for reporting qualitative research (SRQR) guidelines for reporting qualitative studies [25]. A mixed methods study was conducted because this approach was appropriate for addressing the research question, which could not be fully answered using either the quantitative or qualitative methods independently. This study utilized a convergent parallel design in which both the quantitative and qualitative data collection and analysis occurred concurrently [26, 27]. The purpose of the convergent parallel design was to allow us to obtain different perspectives which would enable us to compare results and build a comprehensive understanding of weight bias internalization among people with obesity engaged in treatment. This design has previously been used in studies that involved people living with obesity [28]. The socioecological model (SEM) was used as a theoretical framework to guide the assessments of the multiple levels of influence: individual, relationships, community, and society that impact behaviors and overall health. The socioecological model provides a valuable lens through which to understand the multifactorial influences on weight bias internalization. At the individual level, factors such as body dissatisfaction, self‐esteem, and mental health status can heighten vulnerability to internalized bias. Interpersonal relationships, including family, peers, and social networks, may reinforce appearance norms or provide protective support. Community‐level influences, such as those encountered in schools, workplaces, and healthcare settings, often perpetuate weight‐based stigma through policies or informal norms. At the societal level, media portrayals, public health messaging, and cultural ideals continue to privilege thinness and marginalize individuals in larger bodies, creating a broader environment that fosters weight stigma and internalization. Therefore, SEM was beneficial for the assessment of weight bias internalization among people with obesity [29].

The University of Texas Southwestern Medical Center (UTSW) Weight Wellness Clinic, a large academic/university‐based outpatient clinic in Dallas, Texas was the study recruitment site and served a diverse racial/ethnic, sex, and socioeconomic patient population. All participants were recruited in June and July 2022 via study informational flyers during regular clinic visits with a healthcare provider (physician, physician assistant, or nurse practitioner). Two graduate‐level trained research professionals were at the UTSW Weight Wellness Clinic twice a week to meet potential study participants. After their medical appointments, in a private space, a graduate‐level researcher provided the participants with an iPad to provide informed consent, demographic information, and complete survey questionnaires. Once completed, the researcher conducted the in‐person in‐depth interviews. Potential participants who informed their healthcare provider that they would prefer to participate virtually (phone, Zoom, Webex, or Microsoft Teams) were sent a QR code via email to complete the consent form and the quantitative survey. Additionally, they provided possible dates and times for the interview, their preference to be interviewed on the phone or via Webex/Teams, and their preferred mode of communication (phone call, text message, or email) to be contacted to confirm the interview appointment. The research staff received a notification after these steps had been completed. A date for the interview was then confirmed. Subsequently, the interview was conducted. All participants provided consent to be audio recorded. Participants received a $25 gift card incentive at interview completion. Participants completed the surveys and were interviewed between June 2022 and July 2022.

A purposeful sampling strategy was utilized to identify and enroll participants with characteristics relevant to the study objectives. This sampling strategy was used to intentionally select a sample of participants to ensure capture across diversity based on race, ethnicity, sex, age, and socioeconomic status, to provide information‐rich perspectives to maximize the understanding of weight bias internalization [30, 31, 32]. The variables were included because they have been shown to be important factors associated with obesity which may impact weight bias internalization [12]. Purposeful sampling has been used to select participants in prior studies involving people with obesity [31]. Purposefully selecting participants for the analytic sample across these demographic variables was essential for obtaining diverse information for the understanding of any potential sex differences in weight bias internalization. The participants had to meet the following inclusion criteria: (a) adults (aged 18 years or older) with a BMI of at least 30 kg/m²; (b)consent to participate in the study; and (c) be willing to spend at least 30–45 min responding to questions individually, in‐person, or virtually (via telephone call or Webex/Teams). All study procedures were approved by the Institutional Review Board (IRB) of the Committee for the Protection of Human Subjects (CPHS) at The University of Texas Health Science Center at Houston on November 5, 2018 (IRB NUMBER: HSC‐SPH‐18‐0850).

2.2. Quantitative Measures

2.2.1. Sociodemographic Characteristics

The primary independent variable was self‐reported gender. A researcher‐designed questionnaire was used to obtain demographic data (Table 1) from all the study participants via electronic forms provided to the participants after they had electronically signed the consent form.

TABLE 1.

Baseline characteristics for assessing weight bias internalization stratified by sex.

	Females (N = 37)	Males (N = 23)	p value
Mean age (SD), years	53 (± 13)	53 (± 14)	0.97
Age ≥ 65 years, N (%)	8 (24%)	4 (20%)	0.72
Race, N (%)			0.01
Non‐Hispanic White	13 (35%)	17 (77%)
Non‐Hispanic Black	19 (51%)	4 (18%)
Asian	0 (0%)	1 (5%)
Hawaiian/American Indian	0 (0%)	0 (0%)
Other	5 (14%)	0 (0%)
Hispanic ethnicity, N (%)	5 (14%)	2 (9%)	0.57
Education status			0.01
High school/GED	6 (16%)	1 (4%)
Some ollege/technical	15 (40%)	2 (9%)
Full college degree	8 (22%)	7 (30%)
Masters/doctoral	8 (22%)	13 (57%)
Employment status			0.07
Employed	25 (67%)	15 (65%)
Unemployed	1 (3%)	4 (17%)
Retired	10 (27%)	2 (9%)
Other	1 (3%)	2 (9%)
Annual household income			0.01
Less than $50,000	11 (31%)	6 (26%)
$50,000 to $100,000	13 (36%)	1 (4%)
More than $100,000	12 (33%)	16 (70%)
Relationship status			0.18
Never married	7 (19%)	4 (18%)
Married	20 (54%)	15 (65%)
Partner	1 (3%)	3 (13%)
Divorced	5 (13%)	1 (4%)
Separated	0	0
Widowed	4 (11%)	0
Mean current BMI (SD), kg/m2	33.9 (± 8.9)	33.5 (± 9.0)	0.88
Mean current weight (SD), lbs.	199 (± 53)	242 (± 69)	0.01
Mean highest BMI (SD), kg/m2	43.0 (± 10.3)	48.1 (± 28.3)	0.33
Mean highest weight (SD), lbs.	253 (± 61)	343 (± 186)	0.01
Median highest BMI (IQR)	39.5 (34.8–49.2)	39.7 (35.0–45.4)	0.87
Median current BMI (IQR)	33.9 (27.6–39.6)	32.8 (27.3–36.8)	0.83
Hypertension, N (%)	17 (46%)	11 (48%)	0.89
Diabetes mellitus, N (%)	14 (38%)	1 (4%)	< 0.01
Hyperlipidemia, N (%)	2 (5%)	5 (22%)	0.06
Obstructive sleep apnea, N (%)	8 (22%)	5 (22%)	0.99
Chronic liver disease, N (%)	3 (8%)	0 (0%)	0.16
History of bariatric surgery, N (%)	10 (27%)	4 (17%)	0.39

Note: p < 0.05 are bold.

2.2.2. Covariates

We assessed the selected confounders because they may provide alternative explanations for the observed relationship between the independent and dependent variables as supported by the literature [33, 34]. (Table 1).

2.2.3. Weight Bias Internalization

The primary outcome of this study was weight bias internalization, measured using the 11‐point weight bias internalization scale (WBIS), a valid and reliable survey instrument (Cronbach’s α = 0.90) developed for assessing weight bias internalization in patients with overweight or obesity [35, 36]. This instrument is a widely used metric for assessing weight bias internalization in clinical and community samples [1]. It has been shown to have a high internal consistency and construct validity (Cronbach’s α = 0.90) [36, 37]. The psychometric properties of the WBIS were evaluated within the study sample. Internal consistency was assessed using Cronbach's alpha, which demonstrated high reliability (α = 0.90). Item‐total correlations were examined to ensure each item contributed meaningfully to the overall scale, with all items exceeding the acceptable threshold of 0.30.

In this present study, after participants consented and provided their demographic information, they completed all 11 items of the WBIS on the seven‐level Likert scale ranging from strongly disagree (1), disagree (2), somewhat disagree (3), neither agree nor disagree (4), somewhat agree (5), agree (6), to strongly agree (7). The WBIS assessed participants' acceptance of negative self‐statements about their weight that reflect both self‐application of negative stereotypes and poor self‐perception. Scores were averaged, with higher scores indicating greater internalization [25]. The WBIS questionnaire is provided in Supporting Information S1: Figure S1.

2.3. Qualitative Measures

Weight bias internalization was also assessed using data obtained from semi‐structured in‐depth interviews. The interview questions were conceptualized utilizing SEM (Figure 1). These questions were the same for each study participant. They were asked a series of open‐ended questions pertaining to their body shape, weight, and size, and experiences related to how they have been treated by others because of their weight and further probed to obtain specific information on the association between participants' weight‐related experiences and their perception of themselves, and health behaviors. Prior to data collection, interviewers received training on the appropriate use of probing techniques to minimize the risk of influencing or biasing participants' responses. While the interview guide did not include standardized probes or detailed instructions on when or how to use them, graduate‐level trained interviewers were instructed to apply context‐sensitive probing based on participant responses. This approach ensured that follow‐up questions enhanced the depth and clarity of responses without introducing interviewer bias.

FIGURE 1.

Examples of interview questions and how they align with the socioecological model.

The 11 grand tour questions were organized by SEM levels/domains to capture each construct. Here, we describe weight bias internalization at the intrapersonal and interpersonal levels of influence using themes derived from in‐depth interviews with participants. Figure 1 shows how the interview questions align with the SEM. Each participant's response provided information about their lived experience that shows the various constructs in each of the SEM levels of influence/domains. The full interview guide is provided in Supporting Information S1: Figure S2.

2.4. Data Analyses

Participants' characteristics were stratified by sex for descriptive purposes, and differences were examined using t‐tests for continuous variables and Fisher's exact for categorical variables. We conducted univariate and multivariable regression analyses to evaluate the sex differences in the outcome of interest, weight bias internalization, using the 11‐point weight bias internalization scale (WBIS). The sex differences in WBIS scores were evaluated using univariate linear regression analysis. Multivariable models examined the association between sex and the WBIS score, adjusting for potential confounders that were significantly different between the sexes at baseline (race, relationship status, and employment). Univariate and multivariable linear regressions were also explored for each WBIS line item. Given the exploratory nature of the study, each item of the WBIS was assessed individually to examine the nuanced dimensions of internalized weight bias. This approach allowed for a deeper exploration of the various social and psychological aspects of weight bias internalization and provided insights into which specific components may be most salient among people with obesity. Pearson correlation tests were utilized to examine the relationship between BMI and WBIS scores. The significance level was set at p < 0.05. All quantitative data were analyzed using Stata 17 [38].

Qualitative data were examined using a thematic analysis [39] with an inductive approach [40] to explore sex differences in weight bias internalization among people with obesity. This approach has been used to assess weight bias internalization [41] and it was beneficial for this study because it allowed for familiarization with data obtained from the participants, generation of codes, and then searching for, reviewing, and defining themes for further understanding of weight bias internalization [42]. A sample size of 24 was set for the qualitative component of the study based on literature which shows that a sample size of less than 25 is sufficient to achieve saturation [43], the criterion used for discontinuing data collection and/or analysis [44] because enough information to replicate the study has been collected, and the ability to attain new information on the phenomenon of interest has been attained [45], and authors' prior knowledge of adequate sampling sizes for qualitative research. Audio files of the completed semi‐structured interviews were sent to a transcription vendor for verbatim transcription.

A comparative thematic analysis was employed to examine potential sex‐based similarities and differences in weight bias internalization obtained from the qualitative data. Thematic analysis began with four graduate‐level trained qualitative researchers reviewing the transcripts to become familiar with the data. Next, a codebook was designed to structure and define thematic codes, and generate codes based on keywords and quotes mentioned by participants in the interviews that were conducted. The researchers first coded a few transcripts together, and then they coded multiple transcripts independently. Following initial inductive coding of all transcripts, themes were developed through iterative review and refinement by the research team. To explore whether thematic content varied by sex, transcripts were stratified by participant sex (male/female), and themes were re‐examined within each group. The qualitative researcher team independently reviewed data to assess the frequency and contextual meaning of each theme across the two sex groups. Themes were considered consistent across sexes when they appeared with similar frequency and depth and were described in comparable ways. Themes were considered distinct when they were expressed differently, occurred exclusively in one group, or reflected divergent underlying perspectives. Saturation was assessed using a stopping criterion, defined as the number of consecutive interviews in which no new themes emerged following the initial analysis [43]. In this study, thematic saturation was achieved as no new themes were identified during the analysis of the final set of interviews. The researchers met weekly to discuss the codes, address any discrepancies in the coding and interpretation, and refine the codebook as needed. Discrepancies were resolved through consensus to enhance analytical credibility and maintain methodological rigor. Investigator triangulation was achieved by using these independent researchers [46]. The themes are presented and demonstrated with quotes in the results section [47]. The qualitative analysis was conducted using the NVivo 14 software [48], a software utilized in qualitative and mixed methods research. Findings of the qualitative and quantitative analyses were integrated by comparing the survey data on weight bias internalization collected on the WBIS scale with interview data on internalized weight bias lived experiences to provide a comprehensive understanding of how weight bias internalization differs among females and males people with obesity who are engaged in obesity treatment. Results from the quantitative assessments were reported, and the identified themes and qualitative quotes that were used to support or refute the quantitative results were subsequently reported [49].

2.5. Power Analysis for Sex Differences in Weight Bias Internalization

A power analysis was conducted to determine the sample size needed to detect a statistically significant difference by sex in weight bias internalization among adults with obesity for the quantitative assessment. Assuming a medium effect size (d = 0.5), power of 0.8 (80%), and an alpha level of 0.05 [50], the required sample size was 60 participants. This suggested that the sample size of 60 adults with obesity was sufficient to detect a medium effect size of sex difference in weight bias internalization in this exploratory study. Medium effect sizes have been utilized in previous studies to assess weight bias [51].

3. Results

3.1. Quantitative Findings

3.1.1. Demographic Characteristics of Participants

The final analytical sample included 60 people with obesity (62% female, 61% non‐Hispanic white, 12% Hispanic, 39% non‐Hispanic black, mean BMI 34 kg/m²) who completed the WBIS questionnaire and participated in the in‐depth interviews. Participants had a mean age of 53 years, and most (56%) were under 65 years of age. Over a third of participants (35%) had a master's or doctoral degree, and most participants (53%) had an annual household income of less than $100,000 (Table 1). Compared to males, females were more likely to be non‐Hispanic black (51% vs. 4%; p < 0.01), have completed some college or technical school (40% vs. 9%; p < 0.01), and have an annual household income ranging between $50,000 and $100,000 (36% vs. 4%; p < 0.01). Male participants were more likely to be non‐Hispanic white (77% vs. 35%; p < 0.01), have completed masters or doctoral degrees (57% vs. 22%; p < 0.01), have an annual household income that was more than $100,000 (70% vs. 33%; p < 0.01), have higher mean current weight (242 (± 69) versus 199 (± 53); p < 0.01), and have higher mean heaviest weight (343 (± 186) vs. 253 (± 61); p < 0.01) when compared to their female counterparts.

3.1.2. Association Between Weight Bias Internalization and Sex

Weight bias internalization was assessed using the 11‐item the weight bias internalization scale (WBIS), with items rated on a 7‐point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The WBIS revealed some notable differences between males and females. While females had a lower overall mean WBIS score (3.68 ± 1.02) than males (4.15 ± 1.34), the difference was not statistically significant (p = 0.13). Question‐specific analysis showed significant differences for two items: females rated lower on “I am less attractive than most other people because of my weight” (3.78 ± 2.00 vs. 5.30 ± 1.82, p = 0.01) and “Because of my weight, I don't understand how anyone attractive would want to date me” (2.73 ± 1.68 vs. 4.13 ± 2.26, p = 0.01). No significant differences were observed in adjusted WBIS scores (p = 0.48).

Only the responses to questions 2 “I am less attractive than most other people because of my weight” (β − 1.53; 95% confidence interval [CI], −2.56 to −0.49, p = 0.01), and 11 “Because of my weight, I don't understand how anyone attractive would want to date me” (β − 1.41; 95% CI, −2.42 to −0.38, p = 0.01) were significantly different, with more weight bias internalization reported in males than females. After adjusting for race, the associations in questions 2 and 11 were no longer significant but remained significant for relationship status, and employment (Supporting Information S1: Table S1). Feelings of attractiveness and perceptions of desirability for dating appear to be positively confounded by race, with more weight bias internalization reported among non‐Hispanic white people with obesity compared with non‐Hispanic black people with obesity and other races. The mean WBIS score was not significantly different between males (4.15 ± 1.34; p = 0.13) and females (3.68 ± 1.02; p = 0.13). Pearson correlation tests revealed a statistically significant moderate negative correlation (r = −0.35; p = 0.01) between mean current BMI and weight bias internalization (WBIS score). When stratified by sex, there was no statistically significant correlation between mean current BMI and weight bias internalization among females (r = −0.304; p = 0.07) and males (r = −0.409; p = 0.05). No statistically significant association was observed between participants' highest lifetime BMI and weight bias internalization reported on the WBIS scale (r = −0.002; p = 0.99; data not shown on tables).

3.2. Qualitative Findings

The purposive sampling strategy yielded an analytical sample of 24 participants selected from the full participant sample. Of the 24 participants, 12 (50%) were female, 10 (42%) were non‐Hispanic white, and 8 (33%) were non‐Hispanic black. Furthermore, 6 (25%) were Hispanic, and 18 (75%) were non‐Hispanic. The median age was 53.2 years (IQR 40.8–68.1). The findings indicated key commonalities among the sentiments of both male and female participants. There were also some noted differences in how weight bias was internalized by males and females. In the assessment, 8 themes and 11 subthemes emerged that described weight bias internalization in males and females (Table 2). Results are summarized below and organized by the intrapersonal and interpersonal socioecological model domains.

TABLE 2.

Participant quotes organized by themes and sub‐themes utilizing the socioecological framework's intrapersonal and interpersonal domains.

Themes and sub‐themes	Supporting quotes
Intrapersonal
Theme 1. Trauma
1a. Family and childhood trauma	(1.0) “I was molested and raped…It got to a point to where a lot of that was my trigger. This started when I was, I want to say, 10…Then once I really got control of it and I left to go to college, it was one of those things…I suppressed everything with the eating. It was a lot. It was a lot” (56‐year‐old non‐Hispanic White male). (1.1) “I had a lot of issues when I was really young that I blocked out. We later found out in a lot of therapy that I went to that a man was sexually molesting me…We found out that had a lot to do with how I felt about myself and why I didn’t really care what I ate and how to take care of myself” (53‐year‐old Hispanic White female).
Theme 2. Self‐esteem
2a. Body image	(2.0) “I don't like to be seen naked. I don't like to be around people sometimes. Even with my fiancé…I'm self—conscious…Even with my best friend…So, until I'm able to feel comfortable with the way my body looks, I just kind of shy away from that part” (39‐year‐old non‐Hispanic Black female). (2.1) “We have a pool in our backyard. When we have pool parties and people come over, I won't swim without a shirt. Things like that. I feel my body is just too fat…It's just internal feelings that I have” (56‐year‐old non‐Hispanic Black male).
2b. Clothing and appearance	(2.2) “It’s just that I didn’t feel like I was socially accepted as much as other people were…If you would lose weight, you could do this. You could wear clothes like I wear. You could attract people like I attract people” (70‐year‐old non‐Hispanic white Male). (2.3) “the more weight I have gained, the less I want to be social. People invite me to events. I don’t want to go. I just want to be at home, because I feel like I’m not going to find anything I feel comfortable in to wear. I have to hide my stomach” (41‐year‐old non‐Hispanic Black female).
Theme 3. Individual health challenges
3a. Health‐related self‐loathing	(3.0) “I had a blood clot in my lungs… it had separated and moved and a piece of it had went to my brain and the other part stayed in my lung…I hated my body because it was just putting me through hell at that moment. My weight started ballooning all the way up… I still hated my weight…I wasn’t too happy with myself, period. I could not lose weight” (31‐year‐old non‐Hispanic Black female). (3.1) “It was like I was just going in a vicious cycle. I would lose weight before COVID and then I would gain. Yes, it was starting to wear me down. I was feeling down on myself. Depressed” (41‐ year‐old non‐Hispanic Black female).
Interpersonal
Theme 4. Lack of social support
4a. Lack of support from family and friends	(4.0) “Even my own wife finally said, I can’t live with you anymore, I’m embarrassed to walk with you down the street” (61‐year‐old non‐Hispanic White male). (4.1) “You're always the last one to be picked to go play softball or kickball or. Didn't have friends. They made fun of you” (49‐year‐old, non‐Hispanic White female).
Theme 5. Perceived discrimination
5a. Discrimination in public settings	(5.0) “I was working out. I was riding my bike exercising in San Francisco. I heard somebody say, “Yeah, man, you better keep it up. You sure do look like you need it,” out of a car window. Why? How is that even necessary? But obviously, it stuck with me because it’s still here today. I can still hear those words. I brushed it off at the time but it’s still stuck” (44‐year‐old non‐Hispanic White male). (5.1) “I wouldn't go anywhere by myself. I wouldn't go get groceries because I would feel that people would judge me for whatever I would put in the basket” (51‐year‐old, Hispanic White female).
Theme 6: Social interactions
6a. Interactions with others	(6.0) “I heard feedback from friends that they thought I was nice and had a relatively decent face but I was too big for anyone, you know, me to have a boyfriend or whatever…I could tell right away when it came to attractiveness, that was the deal breaker for people. One summer, I lost a bunch of weight and realized how everyone treated me differently. Suddenly everyone was talking to me and suddenly I was getting invited to parties… But I knew I wasn’t going to be able to sustain that. So, of course, it changed over time” (45‐year‐old Hispanic White female). (6.1) “…A lot of people, when they see me, they look me up and down… I'd probably feel like I'm fitting in with everybody if I didn't have all of this with the size I am now” (non‐Hispanic Black male).

4. Intrapersonal Domain

4.1. Theme 1: Trauma

4.1.1. Subtheme 1a—Family and Childhood Trauma

A theme that emerged from both males and females' responses was that they attributed their weight‐related issues to traumatic experiences in their childhood homes. Several participants discussed experiencing physical or verbal insults from their parents or other family members because of their weight. A few participants also described traumatic sexual abuse experiences in their childhood that led to negative perceptions about themselves which resulted in the use of food as a coping mechanism. For example, one participant noted that he was molested several times starting when he was 10 years old. He used food to suppress his feelings about the traumatic experience. Both males and females considered trauma to be a contributing factor to their negative self‐perceptions, health behaviors, long‐term weight struggles, and weight‐related outcomes (1.0, 1.1).

4.2. Theme 2: Self‐Esteem

4.2.1. Subtheme 2a—Body Image

The majority of participants, regardless of sex, experienced self‐consciousness, insecurity, and discomfort with their bodies. Responses indicated that both females and males report significant body image issues, especially in social situations. Females mostly indicated that the negative perceptions about their weight and size resulted in social withdrawal and avoidance of activities and prevented them from advancing in their careers. Both sexes reported feeling judged and treated derogatorily because of their weight, which affected their self‐confidence and self‐worth. Compared to females, males mostly reported that living with obesity resulted in their spouses becoming embarrassed to be seen with them which resulted in the males feeling ashamed about their weight. However, females tended to blame themselves for the consequences of their weight‐related discriminatory experiences (2.0, 2.1).

4.2.2. Subtheme 2b—Clothing and Appearance

In the sample, both males and females reported feeling emotional distress about their weight and body size related to clothing and appearance. Females reported negative feelings such as self‐consciousness and depression and discussed avoiding social situations due to not finding clothes that fit well or made them feel comfortable. Some females also reported experiencing discrimination and ridicule while shopping which exacerbated their feelings of inadequacy about their weight. Males expressed frustration at the lack of proper‐fitting clothes, and the need to shop at specialized stores or to spend significant amounts of money to improve their appearance. Both groups reported a decline in self‐esteem and confidence due to societal biases and the lack of inclusive clothing options (2.2, 2.3).

4.3. Theme 3: Individual Health Challenges

4.3.1. Subtheme 3a—Health‐Related Self‐Loathing

Both males and females expressed frustration with their bodies because they could not lose weight, which resulted in or exacerbated several severe health conditions, including diabetes, hypertension, sleep apnea, heart disease, infertility, hernia, colitis, migraine, and orthopedic issues. Males and females both elucidated that COVID‐19 was the primary cause for their increased weight gain, worsened health, and increased weight‐related self‐consciousness in recent years, which they attributed to reasons such as restricted access to exercise facilities, decreased physical activity, psychological stress, and trauma which led to emotional eating. Several females in the sample linked their weight increase to significant life events such as giving birth, undergoing surgeries, or experiencing injuries that resulted in decreased levels of physical activity. Both males and females reported that their increased weight and poor health resulted in feelings of shame, regret, sadness, and self‐loathing. Compared with males, females mostly reported hating their bodies because of health‐related struggles. Almost all respondents reported that they were motivated to engage in obesity treatment, including medical, surgical, and social interventions, because they wanted to improve their health conditions, feel better about themselves, participate in more physical activities with their family and friends, and extend their lives. Participants' responses illustrated a link between weight‐related self‐perception and overall health (3.0, 3.1).

5. Interpersonal Domain

5.1. Theme 4. Lack of Social Support

5.1.1. Subtheme 4a—Lack of Support From Family and Friends

Both males and females expressed sentiments regarding how lack of support impacted their self‐perception, weight‐related health behaviors, and outcomes. Both males and females reportedly faced negative experiences, such as feeling scrutinized and judged by their family members because of their weight. This added to their emotional burden and made them reluctant to join family gatherings. Some females also reported feeling a lack of support or even facing direct criticism from family and friends, including being told that they would regain the weight, which exacerbated their struggles with internalized weight bias (4.0, 4.1).

5.2. Theme 5. Perceived Discrimination

5.2.1. Subtheme 5a—Discrimination in Public Settings

Most participants reported that they experienced discrimination in public settings because of their weight, which increased their negative feelings about their weight and size. Females' discussions mostly focused on feeling self‐conscious when eating in restaurants or shopping at grocery stores because they felt people would be looking at what they chose and judging them. Males mostly explained that they had experienced weight‐related verbal insults in public settings such as grocery stores, airplanes, and neighborhoods. Some males also shared that people were afraid or intimidated by them. They reported that females would often cross over to the other side of the road as the males approached, which the males attributed to their weight and size. These negative experiences resulted in feelings of self‐consciousness and insecurity about their weight (5.0, 5.1).

5.3. Theme 6. Social Interactions

5.3.1. Subtheme 6a—Interactions With Others

All participants discussed how their weight impacted their feelings about themselves and their interactions with others. Participants mostly expressed that they internalized societal stigma surrounding weight, which impacted their perception of self‐worth, mental health, and their desire to interact with others. Some females noted that they did not encourage social interactions because males would likely prefer females who were not living with obesity. Females in the sample mostly reported exclusion from activities in their younger years, teasing related to weight, sexual objectification, and unwanted advances in romantic relationships due to their body size, which negatively impacted their self‐confidence and interpersonal interactions. Many males reportedly experienced cycles of stress and depression stemming from negative weight‐related feedback. Some females in the sample indicated that after they lost weight, people were more friendly toward them and included them in activities which reinforced negative feelings about their weight (6.0, 6.1).

6. Discussion

Using a racially and ethnically diverse sample of people with obesity who are engaged in obesity treatment, this study utilized a mixed methods approach to assess potential differences in internalized weight bias among females and males. To our knowledge, this is the first study to employ both quantitative and qualitative measures to compare how weight bias is internalized among males and females engaged in obesity treatment. All participants in the sample reported internalizing weight bias that resulted from discriminatory experiences in their interactions with others in healthcare, employment, education, and the community.

The results reinforce research that shows that weight bias internalization is highly prevalent among people living with obesity [1, 6, 52, 53]. We defined prevalence as the proportion of the sample who indicated that they had internalized weight bias at any period prior to the assessment. Weight bias internalization was inferred through participants' responses describing feelings of shame or worthlessness related to body weight, self‐directed blame, perceived personal responsibility for their size, and internal conflicts derived from perceptions of societal norms about weight. Prevalence was defined based on both past and current internalized weight biases. Findings from this study underscore the importance of assessing both current and past weight bias internalization in clinical settings. While current internalized weight bias levels provide insights into individuals present self‐perceptions and psychological distress, understanding past weight bias internalization offers critical contexts for the enduring impact of internalized stigma. Participants' narratives reflected the long‐term effects of early‐life exposure to weight‐based teasing, discrimination, and trauma, which in many cases continued to shape their self‐worth, health behaviors, and engagement in treatment.

The findings suggest that past weight bias internalization may contribute to persistent maladaptive coping strategies such as disordered eating, social withdrawal, and healthcare avoidance that may not be immediately evident through measures of current internalization alone. A trauma‐informed, longitudinal perspective that considers the cumulative burden of stigma across the life course is therefore essential. Clinicians working with individuals in obesity care should explore patient history with weight‐related stigma to more effectively identify those at risk for ongoing psychological and behavioral challenges. Furthermore, integrating questions about past weight bias internalization into assessments may help providers to tailor interventions that validate lived experiences, address underlying shame or identity conflicts, and leverage resilience‐based strategies to enhance treatment adherence, and promote more equitable and compassionate healthcare.

Utilizing the socioecological model, we found that weight bias internalization at the individual level stemmed from a perceived disparity between individuals' ideal body weight and size and actual body weight and size. At the relationship level, participants described internalizing weight bias through frequent comparisons of their body size to that of family members and close friends. This aligns with previous research, which suggests that weight bias internalization depends on individuals' perception of their weight status relative to those with whom they draw social comparisons [54]. For example, previous studies found that females with obesity who have thinner friends reported more weight bias internalization [54, 55].

Quantitative findings indicate that males and females equally internalize weight bias. However, compared to females, more weight bias internalization was reported in males specifically related to perceptions of “feeling less attractive than most other people because of their weight” and “not understanding how anyone attractive would want to date them because of their weight”. We also found that feelings of attractiveness and perceptions of desirability for dating appear to be positively confounded by race and ethnicity, with more weight bias internalization reported among non‐Hispanic white participants in the sample compared with non‐Hispanic black participants and other races. This finding aligns with previous research that indicates higher weight bias internalization among non‐Hispanic white people with obesity when compared to non‐Hispanic black people with obesity [53]. The study also found that BMI was negatively associated with weight bias internalization which differs from the conclusions in some previous research [33, 56, 57] about the positive correlation between BMI and weight bias internalization.

The results align with the findings of some previous studies, which suggest that weight bias internalization is based on individuals' interpretation of their weight bias experiences, and it is not limited to people with high body weight [5]. Findings may be due to several factors, including the small sample size in this exploratory study, social desirability bias where participants provide information based on what they perceive that the researchers would prefer, or participants may not have been comfortable with endorsing some of the negative self‐perceptions included in the survey questions. We used the quantitative findings to further explore whether the results from the subsample for qualitative analysis supported or refuted the results of the quantitative assessment of weight bias internalization among males and females.

The qualitative results revealed key commonalities between males and females regarding internalized weight bias. Both males and females attributed their perception of their weight, weight‐related behaviors, and health outcomes to their experiences of childhood trauma. Several participants recalled traumatic events, including physical and sexual assault, that occurred at home during their childhood which resulted in their habitual consumption of excess food as a coping mechanism. Participants also reported being ridiculed or chastised by parents (specifically, fathers), other family members, and friends because of their weight. Both males and females expressed hurt from being verbally humiliated by their parents and denied snacks when they were children. These participants attributed their long‐term weight‐related struggles and negative self‐perception to these early traumatic experiences. The findings align with existing literature that indicates that childhood trauma is linked to long‐term adverse psychological and physiological outcomes [58, 59] and suggests an association between childhood trauma and an increased risk for obesity during adulthood [60]. Results offer novel insights regarding how males and females internalize weight bias that stems from childhood trauma. Incorporating trauma‐informed care in obesity prevention and treatment programs may address weight bias internalization and improve health outcomes for people with obesity.

The results also indicate that most participants, regardless of sex, expressed dissatisfaction with their bodies, which negatively impacted their self‐confidence and self‐worth. These findings compare favorably with current literature, which acknowledges the overlap between internalized weight bias and poor body image as contributing factors to body shame, low self‐esteem, and depression among racially diverse individuals with obesity [61, 62]. While both males and females expressed feelings of shame associated with being seen naked because of their weight, females mostly reported weight bias internalization attributable to body dissatisfaction, described their bodies derogatorily, blamed themselves for their weight‐related discrimination, and reported that they avoided social interactions because of their weight and inability to find clothes that made them feel desirable, which may indicate how females internalized weight bias. No man in the sample blamed himself for weight‐related biases and discrimination from others. The findings also indicate that several people with obesity report weight bias internalization associated with not having the ideal body portrayed in the media. In the sample, females mostly expressed that they were dissatisfied with their bodies because they did not match the bodies of people they saw on television. These results align with existing literature about the impacts of weight stigmatization in the media on weight bias internalization in people with obesity [63].

Both males and females reported frequent judgmental looks and derogatory comments from others because of their weight, which resulted in shame and affected their sense of belonging and self‐esteem. We found that compared to females, males mostly reported weight bias internalization associated with experiencing discrimination such as verbal insults about their weight in public settings, but they expressed that internalized weight bias did not prevent them from achieving their career goals, while females mostly internalized weight bias that negatively affected their career advancement, dating prospects, and their ability to feel comfortable during social interactions with others. Both females and males reported improved self‐esteem after losing weight. The findings align with several previous studies that have assessed self‐esteem as a correlation of weight bias internalization and found that weight bias internalization is associated with low self‐esteem and suggest that self‐esteem may be considered a mechanism by which weight bias internalization could negatively impact health [1, 53, 64], social interactions [65, 66, 67], and career advancement [1]. A study that examined the relationship between obesity and loneliness found that people with obesity reported significant levels of loneliness compared to the general population, and the contributing factors included higher levels of depression, internalized weight bias, and experiences of discrimination due to weight [66].

In this study, both males and females expressed frustration with experiencing obesity‐related health problems which have impacted their health and self‐esteem. Both males and females reported feelings of shame, regret, and self‐blame because they could not lose weight, which exacerbated several severe health conditions and prevented them from participating in activities with their families and friends. Several males and females reported being displeased with their bodies because of all the health challenges they have experienced, with females mostly stating that they hate their bodies because of their health struggles. These findings align with previous studies that highlight the negative impacts of self‐blame related to weight and health conditions [5, 13] and offer new insights regarding individuals with obesity reporting feelings of self‐loathing because of their weight and health even when genetic factors, physiological events such as childbirth, and other environmental influences including the COVID‐19 pandemic contributed to their increased weight gain and poor health. In the sample, both males and females equally prioritized health over appearance as their motivation for engaging in obesity treatment. They discussed the desire to address complex obesity‐related health problems that have impacted their health and self‐esteem. The results are consistent with the conclusions drawn in prior studies that resolving obesity‐related comorbidities and improving health‐related quality of life are major determinants for seeking obesity treatment among people with obesity [68].

Both males and females reported that they internalized negative perceptions about their inability to lose weight after unsuccessfully attempting several obesity treatment options which resulted in feelings of shame, vulnerability, and insecurity. The results align with existing literature that highlights the negative impacts of several failed obesity treatment attempts on body image and self‐perception, which result in feelings of weakness, failure, and stress [69].

Participants also emphasized the impact of lack of psychosocial support on their weight management. The findings highlighted the importance of support from family and friends on perceptions about weight and the weight‐loss trajectory of people with obesity. Both males and females reported that receiving psychosocial support motivated them to maintain the recommended health behaviors to lose weight and prevent weight regain, such as adopting the recommended diet, increasing physical activity, and going for follow‐up appointments with their weight wellness team (doctor, nurse practitioner, dietician, etc.). These results are consistent with existing literature that social support from family and friends significantly contributes to the participant's motivation, accountability, and success in health‐behavior change programs, highlighting the importance of supportive communities and ongoing encouragement to maintain long‐term health‐behavior changes and weight management [70]. The findings align with the conclusions of a recent meta‐analysis that aimed to assess the effectiveness of psychosocial support on weight‐loss interventions which found that psychosocial support was beneficial for long‐term weight management [71].

The qualitative findings support the quantitative results on the pervasiveness of internalized weight bias among males and females who engage in obesity treatment. However, the qualitative findings did not provide information to support the quantitative findings that more males feel less attractive because of their weight or that more non‐Hispanic white individuals report more weight bias internalization. These discrepancies in the findings may be attributed to the small sample size and social desirability bias. Notwithstanding, the findings provide novel information about how males and females who are engaged in obesity treatment internalize weight bias and its association with their health behaviors and outcomes. Clinicians may utilize this information to enhance obesity care as they work to overcome barriers that may adversely impact patients' health outcomes.

A noted strength of this study is that it aimed to understand potential differences in internalized weight bias among males and females engaged in obesity treatment. Findings from this study will add to the body of knowledge on obesity treatments by providing information on how males and females living with obesity internalize weight bias, which may be used to address weight bias and the stigmatization of people with obesity that results in weight bias internalization, when seeking to design and implement effective obesity programs. Another strength of this study is the inclusion of a diverse sample of participants in terms of race/ethnicity, age, and socioeconomic status, and it utilized the WBIS survey, a reliable and valid instrument for the quantitative assessment of weight bias internalization, which will improve the generalizability of the findings.

Some limitations should also be considered when interpreting the findings of this study. First, the study sample was selected only from patients who attended one obesity medicine clinic. Therefore, it did not include individuals in the at‐risk obesity population who do not utilize this facility for obesity treatment, which impacts the ability to generalize the results to people with obesity who do not use this location. Also, the income and education levels of participants in this study, especially among males, may not be representative of the U.S. population. Second, assessments of weight bias internalization in this study did not include data about participants' sexual orientation, which may potentially impact the findings. Future studies that include sexual orientation as a confounding variable in their assessment of weight bias internalization among people with obesity engaged in obesity treatment are recommended. Third, the study relied on subjective self‐reported data from participants for the assessments. Therefore, self‐reported data may introduce threats to construct validity such as social desirability bias, and exaggeration bias [72]. Notwithstanding, researchers assured participants that all information obtained for the study was confidential and that their responses would not impact their treatment at UTSW. This approach was expected to facilitate more accurate responses from participants. Furthermore, the quantitative analysis included item 1, “As an overweight person, I feel that I am just as competent as anyone else” of WBIS. Although some prior research has suggested removing Item 1 from the WBIS to enhance its psychometric properties, our internal consistency analysis in this sample supported the inclusion of all 11 items, with high reliability (Cronbach's α = 0.90) and acceptable item‐total correlations for each item. Another potential limitation of the study is that some of the in‐depth interview questions assessed weight bias experiences and not only weight bias internationalization, although we probed each question for specific information to assess weight bias internalization. Lastly, the sample size for the quantitative analyses should also be considered when interpreting the findings of this assessment. The limited number of study participants may make it challenging to infer significant relationships from the data and may impact the generalizability of the results. However, since this is an exploratory study, the preliminary findings are beneficial to enhance the current literature for addressing obesity. Future research should consider including larger sample sizes to further measure weight bias internalization among racially and ethnically diverse females and males engaged in obesity treatment to understand any potential sex differences in health behaviors, healthcare‐seeking patterns, and obesity care utilization.

7. Conclusion

This mixed methods study offers novel insights into the differences in how males and females who are engaged in obesity treatment internalize weight bias and provides additional information about how weight bias internalization is associated with weight bias experiences at the intrapersonal and interpersonal levels of influence. The quantitative findings indicate that weight bias internalization is prevalent and reported equally among both males and females. However, more males reported internalized weight bias related to “feeling less attractive than most other people because of their weight” and “not understanding how anyone attractive would want to date them because of their weight”. Qualitative findings also demonstrate that weight bias internalization is pervasive among people with obesity and indicates that females mostly blame themselves for the consequences of their weight‐related discriminatory experiences, and internalized weight bias among females mostly resulted in avoiding social interactions and negatively impacted their career prospects.

The qualitative themes identified in this study, including trauma, self‐esteem, health challenges, and experiences of discrimination, offer critical insights for developing more compassionate and effective clinical strategies to address weight bias and stigma among individuals with obesity. Participants frequently described early and repeated experiences of trauma, including bullying, weight‐related teasing, and adverse family dynamics. These experiences appeared to shape internalized beliefs about body image and self‐worth. Clinicians should integrate trauma‐informed care principles into obesity treatment, which include ensuring physical and emotional safety, building trust, promoting empowerment, and recognizing the pervasive impact of trauma on health behaviors and self‐perception. Addressing trauma directly may reduce the psychological barriers that impede health behavior change and adherence to treatment. Low self‐esteem and a damaged sense of identity emerged as central themes in both male and female participants' narratives. These insights underscore the need for psychological support within obesity care. Interventions including self‐compassion training, and strengths‐based coaching may help individuals reframe negative self‐beliefs, build self‐efficacy, and develop a more positive identity that is not solely defined by body weight. Clinicians should prioritize affirming language, celebrate non‐weight‐related achievements, and help patients separate self‐worth from appearance.

In the sample, several participants discussed chronic physical and mental health conditions that both contributed to and were exacerbated by internalized weight stigma. This highlights the importance of providing care that acknowledges the complexity of weight‐related health without blaming individuals for their condition. Multidisciplinary approaches that integrate mental health professionals, registered dietitians, and physical therapists can support holistic care while reducing stigma and shame. Reports of discrimination—within healthcare settings, employment, and social environments emphasize the need for clinicians to be aware of their own implicit biases and the broader sociocultural context in which patients live. Training providers in weight‐inclusive care and advocating for policy changes that protect against weight discrimination can help create safer, more equitable care environments. Furthermore, clinicians can empower patients by validating their experiences and equipping them with skills to navigate stigma. Lastly, because experiences of stigma and bias are shaped by intersecting identities (e.g., race, gender, socioeconomic status), personalized and culturally sensitive care is essential. Incorporating assessments of lived experiences and identity‐related stressors into clinical intake and tailoring interventions accordingly may improve patient engagement and outcomes.

Collectively, the quantitative and qualitative findings suggest that people living with obesity internalize weight bias experiences in a variety of ways, which may adversely impact their health behaviors and outcomes. The results highlight the need for clinicians to understand how patients internalize weight‐related encounters, which will equip them to implement strategies for addressing weight bias internalization to optimize obesity treatment and provide more supportive care for their patients. Future studies should assess the variables utilized in this study, in a larger sample of people with obesity, to obtain a more in‐depth understanding of potential sex differences in internalized weight bias which would be beneficial for enhancing obesity treatment models and improving health outcomes for people with obesity.

Author Contributions

Marianne O. Olaniran conducted the qualitative data collection and analyses, performed all statistical analyses, and was involved with project administration, and writing – original draft, review and editing. Jackson Francis, Sitapriya Neti, and Dhatri Polavarapu assisted with all qualitative analyses, and writing. Eda G. Kapti assisted with data collection and writing. M. Sunil Mathew, and Jeffrey N. Schellinger were involved in recruitment strategies, and writing. Marlyn A. Allicock was involved in supervision, and writing – review and editing. Sarah E. Messiah obtained funding for the research including study design, analysis of data, interpretation of results, and writing of the report, and she was involved in conceptualization, methodology, supervision, project administration, and review and editing of the manuscript. Jaime P. Almandoz obtained funding for the research and led the study design, analysis of data, interpretation of results, and writing of the report. He was involved in conceptualization, methodology, supervision, project administration, and review and editing of the manuscript. All co‐authors contributed substantially to the manuscript and approved the final submission.

Conflicts of Interest

This study was conducted without any commercial or financial relationships that could be construed as a potential conflict of interest. However, Dr. Jaime P. Almandoz has received advisory or consulting fees and/or other support from AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Nestlé, Novo Nordisk A/S and Wave Life Sciences.

Supporting information

Supporting Information S1

Olaniran MO, Francis J, Neti S, et al. Mixed Methods to Assess Sex Differences in Weight Bias Internalization Among Patients With Obesity. Obes Sci Pract. 2025;e70084. 10.1002/osp4.70084