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. 2025 Apr 23;30(12):3489–3502. doi: 10.1177/13591053251333957

Dieting among a community sample of adults with chronic pain

Meghan M Gillen 1,✉, Charlotte H Markey 2, Diane L Rosenbaum 1, Jamie L Dunaev 2
PMCID: PMC12534883  PMID: 40265288

Abstract

Chronic pain and dieting represent significant threats to public health. Larger individuals and individuals with chronic pain are often stigmatized for their conditions and subsequently internalize stigma, exacerbating their negative mental and physical health impacts. Given the multiplicative effects of pain, stigma, and excess weight, research should examine associations among chronic pain, dieting behaviors, and experiences of health-related stigma. Adults (N = 286; mean age = 36.75, SD = 11.56; 62.6% female) with chronic pain participated in an online survey. Over half (57.9%) reported engaging in maladaptive weight loss behaviors. Higher levels of both experienced and internalized stigma were associated with more dieting behavior among smaller-bodied individuals. Maladaptive attempts at weight loss are fairly common among adults with chronic pain, and stigma can relate to these attempts among smaller-bodied individuals who have chronic pain. Screenings for disordered eating among chronic pain patients may be beneficial in clinical settings.

Keywords: chronic pain, dieting, internalized stigma, stigma, weight loss

Introduction

Chronic pain is a significant health issue for many adults. In the United States, nearly half (43%) of households include individual(s) who have chronic pain, and over half (55.7%) of adults report pain in the last 3 months (International Association for the Study of Pain, 2016; Nahin, 2015). Pain affects some individuals more than others. For instance, women, older individuals, and non-Hispanic people are more likely to report pain compared to men, younger individuals and individuals identifying as Hispanic (Nahin, 2015; Tsang et al., 2008). Chronic pain can impact well-being, making this an important public health issue (Goldberg and McGee, 2011). For example, higher levels of pain are linked to poorer self-ratings of health, exhaustion, increased health care usage, more days in bed due to disability, and more difficulty walking or climbing steps (Nahin, 2015). Chronic pain is also linked to increased risk for depression, anxiety, and suicide (Campbell et al., 2015; Tsang et al., 2008). People with chronic pain may experience negative attitudes, or stigma, about their pain, health status, and bodies from others, which may be internalized (Penn et al., 2020). Stigma may exacerbate issues with well-being that individuals with chronic pain experience (Penn et al., 2020; Scott et al., 2019; Van Alboom et al., 2021).

Research indicates that pain is also positively correlated with weight (Okifuji and Hare, 2015; Stone and Broderick, 2012). Although the links between weight and health are complex, weight has been found to be positively correlated with cardiovascular problems, diabetes, and certain types of cancer (Centers for Disease Control and Prevention (CDC), 2023). Further, chronic pain and weight may influence each other (Okifuji and Hare, 2015; Stone and Broderick, 2012). Given that larger body size is linked with chronic pain, we might also expect that those with chronic pain would engage in more dieting behavior, and that stigma may impact that relationship. To that end, the goal of the current study was to examine links between pain, stigma, and dieting behavior among adults who report chronic pain.

Chronic pain and body size

Existing data firmly support the link between chronic pain and larger body size. There are several potential mechanisms that can explain this association. More weight on the body, including the joints and spine, may place additional stress on joints, which may lead to chronic pain (Janke et al., 2007; Okifuji and Hare, 2015; Stone and Broderick, 2012). Other potential mediators may explain why larger body size is linked to increased chronic pain such as chronic systemic inflammation, vitamin D deficiency (which can lead to aching joints and muscles), and hormonal activity that increases pain perception (Okifuji and Hare, 2015; Stone and Broderick, 2012). Chronic pain may also contribute to weight gain by disrupting salubrious habits such as certain forms of regular physical activity (Janke et al., 2007).

Eating-related factors may also contribute to the links between chronic pain and weight. Individuals who have persistent pain may experience chronic stress from the pain and have physical limitations that prevent them from doing daily tasks and activities they enjoy. These limitations can be frustrating and stressful. In adults with larger bodies and chronic pain (Janke et al., 2007), experiencing pain was related to emotional or “comfort” eating, particularly eating pleasurable foods that are high in calories and low in nutrients. Individuals reported perceiving limited options for pleasurable activities they can engage in other than eating (e.g. physical activities), as well as feelings of shame, depression, poor body image, and low self-efficacy, which may compromise their ability to make healthy eating and physical activity decisions. Individuals who experience chronic pain do report making dietary choices with less nutritional value. For example, excess consumption of sugar, aspartame (a sugar substitute) and caffeine, and underconsumption of vitamins and minerals (Meleger et al., 2014). Sweet foods may be particularly appealing for reducing negative affective states, including pain (Darbor et al., 2017).

Dieting, chronic pain, and body size

Although an association between weight and chronic pain is well-supported, there is very little research on the link between chronic pain and attempts to lose weight or diet. Heavier people have been found to diet more (Markey and Gillen, 2023), and the relationship may be bidirectional. People in larger bodies may feel sociocultural pressures to pursue weight loss to approximate cultural ideals of thinness; attempts at dieting may lead to weight gain across time (Markey and Gillen, 2023). The sense of deprivation with food restriction may contribute to eating larger quantities of desired foods, and dieting can also lead to metabolic changes (i.e. slowed metabolism) that promote regaining lost weight (Markey, 2014).

Individuals with both chronic pain and who have larger body sizes may have been told by healthcare providers to lose weight to reduce their pain (Janke et al., 2016). Yet, these same patients perceive that providers give them generic information that is rarely tailored to their specific situation, which leaves the concept of “weight loss” open to interpretation (Janke et al., 2016). Individuals may follow the conventional approach of restrictive eating or dieting, even though contemporary research indicates that the “eat less/move more” model of weight is an oversimplification and biological factors that impact weight status are under-recognized. Furthermore, medical providers may recommend diets, even though evidence suggests these are usually ineffective in producing long term changes in weight status (Markey and Gillen, 2023), and may result in frustration and negative thoughts (e.g. self-blame).

Yet, individuals may undertake dieting in an effort to gain control over their lives. Perceived control is significant in the development of eating disorders (Fairburn et al., 2003; Slade, 1982), and thus may be important in dieting behavior. That is, dieting may be a way to exert control over one’s body, particularly when pain or other symptoms feel uncontrollable. In support of this idea, higher internal locus of control and higher perceptions of self-worth being tied to control over eating are related to more dieting behavior among women (Donovan and Penny, 2014).

Dieting may initially be particularly rewarding for people with chronic illness who often feel a loss of control over the progression and outcomes of the illness (Williams and Koocher, 1998). High levels of restriction can provide feelings of mastery and control for those who feel like they do not have control over other areas of life (e.g. over chronic pain).

Factors related to dieting in individuals with chronic pain

Demographic factors

It is possible that among individuals who have chronic pain, those with particular demographic characteristics may be more likely to engage in dieting behavior. Given the pervasive weight stigma against larger body size (Markey and Gillen, 2023) and idealization of thin, shapely bodies for women, both those who have larger body sizes and women are more likely to diet (Markey and Gillen, 2023). These associations may be particularly strong among a sample of individuals with chronic pain as individuals with higher BMIs and women report more severe pain than their male and lower weight peers (Hitt et al., 2007; Ramírez-Maestre and Esteve, 2014). Previous research indicates that unhealthy weight control behavior varies by not just by body size and gender, but by racial/ethnic identification (Kennedy et al., 2019; Simone et al., 2022).

Physical factors

Energy and fatigue may also relate to dieting behavior. Individuals with chronic pain may have low energy levels due to the constant stress of chronic pain and attempting to manage it. Dieting may be a way for those with low energy to feel like they have some control over their bodies when they are not functioning as they want them to. Those who experience more severe physical pain may also engage in dieting behavior as a means of gaining back some control when pain feels unmanageable. Dieting behavior may be pursued as a coping method, perhaps as a way to gain back control or in response to the stress of chronic pain (Markey, 2014).

Stigma

Experiences with pain-related stigma may also contribute to dieting behavior among those with chronic pain. Because pain may not be visible or have clear underlying causes, individuals who experience it may encounter stigmatizing experiences (Van Alboom et al., 2021). Individuals who have chronic pain and perceive more stigma experience lower physical and psychological well-being such as increased pain severity, depression, and inference with daily functioning (Penn et al., 2020; Scott et al., 2019; Van Alboom et al., 2021). Many medical providers are prone to blame weight for medical symptoms (Alberga et al., 2019), which can be a form of experienced stigma. Stigmatizing experiences are not an effective tool for producing weight loss or improving health (and they often lead to a further increase in both weight and shame; Tomiyama, 2014). However, some larger-bodied individuals with chronic pain may nonetheless still feel compelled to diet when medical providers include this messaging either subtly or overtly in their interactions with patients.

Stigma can also be internalized when individuals apply negative attitudes held by others about their bodies and their health to themselves. The combination of having a larger body and experiencing more stigma may be particularly relevant to weight loss behaviors. The cyclic obesity/weight-based stigma (COBWEBS) model (Tomiyama, 2014) theorizes that weight gain can result from weight stigma as part of a positive feedback loop. Therefore, individuals who have greater weight stigma experiences may be particularly likely to have larger bodies, as weight stigma is a stressor that can impact both behavior and physiological stress responses. This combination of characteristics may impact dieting, according to Tomiyama’s (2014) work. Individuals with both larger bodies and who have higher internalized stigma and/or have received messages from others (e.g. medical providers, family) about eating less may be more likely to engage in dieting as a strategy for losing weight. That is, stigma may impact the strength of the relationship between body size and dieting among individuals with chronic pain.

Summary and research questions

In sum, we expect that individuals who have chronic pain may engage in more dieting behavior. Extant data clearly support the link between chronic pain and other types of eating behavior (e.g. emotional eating; Janke et al., 2007), yet few studies have examined links between chronic pain and restrictive eating behavior including dieting. In the current study, we build on this work by examining dieting behavior among a sample of adults who experience chronic pain. Our research questions are as follows:

  • 1. How do demographic variables (i.e. BMI, gender, race) relate to dieting behavior among adults who have chronic pain?

  • 2. How do mental (i.e. stigma experiences) and physical health (i.e. energy/fatigue, pain level) variables relate to dieting behavior among adults who have chronic pain?

  • 3. How do stigma and BMI and their interaction relate to dieting behavior among adults who have chronic pain?

Materials and method

Participants

Participants (N = 286) included adults who reported experiencing chronic pain. Ages ranged from 18 to 69 years old (mean age = 36.75; SD = 11.56). Of these participants, 62.6% identified as women, 34.6% as men, and 2.8% as other. Racial/ethnic identification included White/Caucasian (81.5%), Black/African American (3.1%), American Indian/Native American/Aleutian or Eskimo (0.7%), Asian/Pacific Islander (3.5%), Hispanic/Latino/a (3.8%), other (0.7%), and more than one race/ethnicity (6.3%). Most participants identified as heterosexual (84.6%), with others identifying as gay/lesbian (3.8%), bisexual (8.4%), and other (3.1%). Nearly two-thirds of the sample (62.9%) were partnered, and 30.4% were single. Their BMIs ranged from 15.31 to 58.35 kg/m2 with an average BMI in the medically “overweight” category, as per the CDC (MBMI = 28.04; SD = 7.53; CDC, 2023).

Participants in this sample indicated that their pain occurred at least once a week and was associated with a diagnosed health condition. Participants reported a range of different health conditions (they could report more than one) with the most common being arthritis (n = 64; 22.4%), fibromyalgia (n = 40; 14%), bowel disease (e.g. Crohn’s/Irritable Bowel Syndrome; n = 34; 11.9%), and back pain (n = 22; 7.7%). Most participants (83.9%) reported that a doctor had prescribed them medication to help maintain or improve health.

Procedure

The current study was advertised as an investigation of chronic illness and body image. Participants were recruited through social media and online support groups (n = 139) as well as Amazon’s Mechanical Turk (n = 147). Given that we aimed to recruit a community sample of chronic pain patients, this was a convenience sample. The use of instructional manipulation checks to check data quality may not be effective so we did not utilize this approach (see Hauser et al., 2018; Hauser and Schwarz, 2015). Instead, in order to ensure the integrity of the data, we checked for consistency across some open-ended items. Invalid or inconsistent responses were removed from the dataset. Data from all sources were combined for analyses because participant demographics were similar from each source (see Markey et al., 2020). We recruited as many participants as funding allowed. Participants from online sources were entered into a drawing to win a $100 gift card, and Mechanical Turk participants received $4 for participating. The study’s key hypotheses and main analyses were registered on Open Science Framework (OSF) and can be found here: https://osf.io/taz8c/view_only=8dc0fbc4b0a34a1ab477aa4537b700cb. This study was approved by Rutgers University’s Institutional Review Board (Protocol # E17-351) on July 21, 2017. Respondents gave informed consent prior to completing the survey.

Measures

Body mass index (BMI)

Participants reported their height in inches and weight in pounds. From these data, we calculated their BMI using the standard formula (CDC formula; CDC, 2023). BMI is used in this study as a rough, albeit imperfect measure of body size.

Internalized stigma

Participants reported the extent to which they felt internalized stigma pertaining to their health condition on a 12-item scale. Six items were adapted from the negative self-image factor of the HIV stigma scale tested by Berger et al. (2001), and six items were directly from Earnshaw et al. (2013) who also based their stigma measure on Berger et al. (2001)’s scale. Items (e.g. “It is my fault that I have a health condition”) were rated on a 5-point scale (1 = strongly disagree to 5 = strongly agree), with recoding for some items. Responses are averaged with higher scores indicating higher internalized stigma. Internal consistency reliability in the current sample was satisfactory (α = 0.84).

Experiences with stigma

The Perceived Discrimination Scale (Kessler et al., 1999) captures participants’ perceptions of general stigma from others. This scale has nine items (e.g. “People act as if you are inferior”) with a response scale ranging from 1 = never to 4 = often. Note that scoring for this measure was reversed from Kessler et al.’s (1999) scoring range to aid in interpretation, such that higher scores reflected more experienced stigma. Responses are averaged with higher scores indicating higher perceived discrimination/experienced stigma. Internal consistency reliability in the current sample was satisfactory (α = 0.92).

Energy

Participants responded to four items pertaining to their energy/fatigue level over the past 4 weeks (e.g. “Did you have a lot of energy?”). Response options ranged from 1 = all of the time to 6 = none of the time. Scores were averaged and recoded so that higher scores indicate more energy. Internal consistency reliability in the current sample was satisfactory (α = 0.87).

Pain level

We used the Numeric Pain Rating Scale (Childs et al., 2005; Williamson and Hoggart, 2005) to measure pain level. Participants were asked three questions about their pain level: how much pain they have on average, pain level at its worst in the last 24 hours, and pain right now. Response options were on a 10-point scale ranging from 1 = no pain to 10 = pain as bad as you can imagine. These responses were summed to create a total pain index. Internal consistency reliability in the current sample was satisfactory (α = 0.81).

They also reported how well their chronic pain has been controlled over the past 6 months (1 = very well controlled to 5 = not well controlled at all), and how well they think they are managing their chronic pain (1 = very poorly to 4 = very well).

Dieting behavior

Participants responded to two questions about dieting behavior, which were used as individual items. One item addressed frequency of losing weight by fasting or going on crash diets (1 = never to 5 = very often; Markey et al., 2020). We also created a question about participants’ current weight goal (1 = lose weight, 2 = stay the same weight, 3 = gain weight or bulk up, 4 = not try to do anything about my weight). Responses were recoded into 1 = trying to lose weight and 0 = trying to stay the same or gain weight. Finally, we also utilized an item (item #22) from the MBSRQ Body Image Assessment (Cash, 2000), which asks respondents to indicate their level of agreement with the statement “I am on a weight-loss diet.” The response choices ranged from 1 = definitely disagree to 5 = definitely agree. This item was added to allow for dimensional rather than categorical evaluation, and to evaluate participants’ current weight loss dieting behaviors outside of crash dieting.

Results

Very little data were missing (0%–1% of analytical variables) so no adjustments were made for missing data. Data were tested for statistical assumptions. No multivariate outliers were detected. Multicollinearity was not observed (VIF and Tolerance values ranged from 0.98 to 1.03); the White test was not significant, supporting homoscedasticity. Participants reported moderate to average pain levels. On a 1–10 scale, their pain over the last 24 hours was M = 5.86 (SD = 2.03), pain on average was M = 5.03 (SD = 1.57), and current pain was M = 4.44 (SD = 2.08). None of the participants reported that their pain was well- or very well-controlled over the past 6 months; 50.7% reported “so-so” pain control, 37.6% reported that pain was not well-controlled, and 11.7% reported that pain was not well-controlled at all. Yet, more than half of participants reported that they were managing their pain fairly well (50%) or very well (7.4%). Others reported poorer pain management (32.3% fairly poor and 10.3% very poor). In terms of weight control behavior, over half of participants reported fasting or crash dieting to lose weight (57.9%), and currently trying to lose weight (55.2%).

To address our first two research questions, we performed a series of descriptive analyses to determine associations between demographic and health variables and dieting behavior (measured by frequency of fasting/crash dieting and trying to lose weight). We performed t-tests to determine gender and racial/ethnic differences in the frequency of fasting/crash dieting. Women (M = 2.16, SD = 1.18) and men (M = 1.89, SD = 1.10) did not differ significantly (p > 0.05), but there were significant racial/ethnic differences. Non-white individuals (M = 2.40, SD = 1.23) engaged in more frequent fasting/crash dieting as compared to white individuals (M = 1.98, SD = 1.13), t(284) = 2.39, p = 0.018. We also performed correlations to determine associations between BMI, health variables, and frequency of fasting/crash dieting (see Table 1). Individuals who reported significantly more internalized stigma, more stigmatizing experiences, and more pain engaged in more frequent fasting/crash dieting. Individuals with higher BMIs and more experiences with stigma were more likely to be on a weight loss diet.

Table 1.

Correlations between demographic and health variables and dieting.

Variables 1 2 3 4 5 6 7
1. BMI –
2. Age 0.24*** –
3. Internalized stigma 0.11 −0.08 –
4. Experiences with stigma 0.15* −0.10 0.56*** –
5. Energy level −0.11 0.08 −0.47*** −0.28*** –
6. Pain level 0.10 0.13* 0.40*** 0.28*** −0.37*** –
7. Fasting/crash dieting 0.10 −0.10 0.30*** 0.27*** −0.10 0.19** –
8. “I am on a weight loss diet” 0.24*** 0.04 0.09 0.12* −0.01 0.00 0.36***
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*

p < 0.05. **p < 0.01. ***p < 0.001.

Next, we examined descriptive associations between demographic and health variables and currently trying to lose weight. We performed chi-squares to determine if there were gender and racial/ethnic differences in currently trying to lose weight. Although there were no significant racial/ethnic differences, there were significant gender differences. Of those who were trying to lose weight, 69.6% were women, χ2 (1, 286) = 7.46, p = 0.006. We also performed t-tests to examine whether there were differences in BMI and health variables in currently trying to lose weight (see Table 2). Individuals who were currently trying to lose weight had significantly higher BMIs, more stigmatizing experiences, and less energy. Effect sizes were small to medium.

Table 2.

Independent sample t-tests comparing individuals trying versus not trying to lose weight on BMI, age, and health variables.

Variables M (SD) M (SD) t Cohen’s d
Trying to lose weight Not trying to lose weight
BMI 30.04 (6.99) 25.56 (7.48) 5.23*** 0.62
Age 36.98 (11.71) 36.47 (11.40) 0.37 0.04
Internalized stigma 2.50 (0.71) 2.35 (0.75) 1.77 0.21
Experiences with stigma 1.78 (0.67) 1.62 (0.66) 2.02* 0.24
Energy level 29.56 (20.03) 36.52 (24.05) 2.62** 0.32
Pain level 15.34 (4.82) 15.34 (4.99) 0.00 0.00
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*

p < 0.05. **p < 0.01. ***p < 0.001.

To address our third research question, we performed regressions using Model 1 in the SPSS PROCESS macro (Hayes, 2022) to test the relations of stigma and BMI variables to dieting goals and behaviors in a multivariate context. All analyses controlled for gender and race, continuous variables were mean centered, and conditioning values were −1SD, Mean, and +1SD.

Linear regression analyses evaluated whether stigma, BMI and their interaction were related to fasting/crash dieting behavior. We separately tested experienced and internalized stigma in two models. We did not find a significant interaction for experienced stigma and BMI (b = −0.02, p = 0.28) or internalized stigma and BMI (b = 0.01, p = 0.53), however there were main effects for experienced stigma (b = 0.45, p < 0.001) and internalized stigma (b = 0.46, p < 0.001) such that greater stigma was related to greater fasting/crash dieting (see Table 3).

Table 3.

Linear regression analyses evaluating body mass index (BMI) and stigma in relation to dieting outcomes, controlling for gender and race.

Variables B (SE) p R 2
Model 1 dependent variable: Fasting/crash dieting 0.11***
Experienced stigma 0.45 (0.10) <0.001
 BMI 0.01 (0.01) 0.13
 Gender 0.29 (0.13) 0.03
 Race −0.43 (0.17) 0.01
 Experienced stigma × BMI −0.02 (0.01) 0.28
Model 2 dependent variable: Fasting/crash dieting 0.13***
Internalized stigma 0.46 (0.09) <0.001
 BMI 0.01 (0.01) 0.25
 Gender 0.26 (0.13) 0.06
 Race −0.46 (0.17) 0.006
 Internalized stigma × BMI 0.01 (0.01) 0.53
Model 3 dependent variable: “I am on a weight loss diet” 0.11***
 Experienced stigma 0.19 (0.12) 0.13
 BMI 0.05 (0.01) <0.001
 Gender 0.20 (0.17) 0.22
 Race 0.18 (0.21) 0.40
Experienced stigma × BMI −0.06 (0.02) 0.002
Model 4 dependent variable: “I am on a weight loss diet” 0.08***
 Internalized stigma 0.13 (0.11) 0.27
 BMI 0.05 (0.01) <0.001
 Gender 0.20 (0.17) 0.24
 Race 0.17 (0.21) 0.43
Internalized stigma × BMI −0.03 (0.01) 0.05
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***

p < 0.001.

In another set of analyses, we evaluated whether stigma, BMI, and their interaction were related to endorsement of participants wanting to lose weight (yes/no) in a logistic regression. In the model evaluating experienced stigma, there was a significant interaction between experienced stigma and BMI (b = −0.07, p = 0.02). Specifically, there was a conditional effect (0.77, SE = 0.28, p = 0.006) at −1SD below the mean BMI driving the interaction finding. Similarly, in the model evaluating internalized stigma, there was a significant interaction between internalized stigma and BMI (b = −0.06, p = 0.04), driven again by differences at −1SD below the mean BMI (conditional effect = 0.63, SE = 0.26, p = 0.02). The effects of stigma on wanting to lose weight depended on participants’ BMI. For both models evaluating internalized and experienced stigma, we found that stigma increased the probability of wanting to lose weight for those with lower BMIs. See Table 4 for model data, and Figure 1 for visualizations of the conditional effects.

Table 4.

Logistic regression analyses evaluating body mass index (BMI) and stigma in relation to currently trying to lose weight, controlling for gender and race.

Variables B (SE) p Nagelkerk’s R2
Model 1 0.17***
 Experienced stigma 0.19 (0.19) 0.34
 BMI 0.11 (0.02) <0.001
 Gender 0.18 (0.21) 0.37
 Race 0.38 (0.32) 0.24
 Experienced stigma × BMI −0.07 (0.03) 0.02
Model 2 0.16***
 Internalized stigma 0.15 (0.18) 0.41
 BMI 0.11 (0.02) <0.001
 Gender 0.16 (0.21) 0.43
 Race 0.36 (0.32) 0.26
 Internalized stigma × BMI −0.06 (0.03) 0.046
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***

p < 0.001.

Figure 1.

Figure 1.

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Visualizations of the conditional effects of stigma on desire to lose weight at three levels of Body Mass Index (BMI): one standard deviation below the mean, mean BMI, and one standard above the mean. (a) Experienced stigma. (b) Internalized stigma.

We found similar results when we evaluated participants’ agreement with the statement “I am on a weight loss diet” using linear regression models. Specifically, we found a significant interaction between BMI and experienced stigma (b = −0.06, p = 0.002), once again driven by values at −1SD on BMI (conditional effect = 0.60, p = 0.006). Those with lower BMIs and lower stigma had the lowest levels of agreement with the weight loss dieting statement, however, their dieting behavior rose in conjunction with stigma, such that at higher levels of stigma they had greater dieting behavior. We observed a similar pattern when we re-ran this model with the internalized stigma variable as well, with an interaction between BMI and internalized stigma that bordered on significance (b = −0.03, p = 0.05), with a conditional effect (0.34, p = 0.03) at the −1SD level of BMI (refer to Table 3 for model data, and Figure 2 for interaction visualization).

Figure 2.

Figure 2.

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Visualizations of the conditional effects of stigma on current dieting at three levels of Body Mass Index (BMI): one standard deviation below the mean, mean BMI, and one standard above the mean. (a) Experienced stigma. (b) Internalized stigma.

Discussion

The current study aimed to examine dieting among adults with chronic pain given the likelihood that providers may suggest weight loss as a remedy for chronic pain and individuals may view weight loss as a means of achieving control over bodies that are not functioning as they would like them to. Our correlational results suggested associations between greater pain, higher experienced and internalized stigma, and more fasting or crash dieting. People who weighed more, had lower energy levels, and who had experienced more stigma reported they were trying to lose weight more than other participants.

We found a pattern across the experienced and internalized stigma variables in relation to BMI and desire for weight loss. At lower levels of stigma, the probability of wanting to lose weight was lower for those with lower BMI, and higher for those with higher BMI. At higher levels of stigma though, the probabilities became more similar. This indicates that higher stigma (both experienced and internalized) is associated with a higher likelihood of currently trying to lose weight for those with lower BMI. This suggests that smaller-bodied participants’ goals regarding their weight were more closely aligned with those at higher BMIs in circumstances in which stigma was greater. Relatedly, at higher levels of both experienced and internalized stigma, we found little difference between BMI levels regarding weight loss dieting behavior, as agreement with the statement “I am on weight loss diet” rose in conjunction with stigma for those with lower BMIs. This could be interpreted to mean that stigma is associated with more dieting in those with smaller bodies, such that their behavior more closely resembles that of their larger bodied peers. Taken together, these analyses suggest that stigma may relate to negative thoughts and feelings (e.g. feelings of “otherness,” heightened pressure to change) and behavioral responses like dieting, even for those in smaller bodies who may not be as likely to diet in the absence of stigmatizing contexts. It is possible that this may be a response to the stress that stigma incurs, and perhaps an attempt to exert greater control in the face of obstacles.

It is also worth noting that desire to lose weight and current weight loss dieting behavior was always more likely and more common in larger bodied participants compared to participants with lower BMIs, suggesting that sociocultural pressures toward weight loss, a desire to adhere with medical weight loss recommendations, and weight-related stigma, are still salient and influential factors in weight goals and dieting behavior independent of health-related stigma experiences. This interpretation is supported by the medium sized effect in our t-test evaluating the difference between those who currently want to lose weight compared to those who do not based on BMI (Cohen, 1988).

Limitations

Although, to our knowledge, no study has examined weight loss behaviors among people with chronic pain, this study is not without its limitations. Participants reported diverse chronic pain experiences but are not necessarily representative of all people living with chronic pain, nor can these findings be used to understand the experiences of individuals with a particular chronic pain condition. These findings are cross-sectional and correlational, so it is not possible to know for certain if, for example, chronic pain and stigma predict attempts at weight loss or if losing weight leads to worsening stigma experiences (although this seems unlikely and counterintuitive). Data were collected from online sources; although more costly, in-person data collection may have produced more valid and reliable findings. Many participants reported taking prescription medications which may have impacted their eating behavior. Further, although we had adequate power to conduct some analyses, we were somewhat underpowered to conduct others, which may have affected the likelihood of finding additional, significant results. The majority of the sample identified as White, limiting generalizability of the findings to non-White individuals. People in different racial/ethnic groups may have different experiences with stigma and dieting behavior. Finally, the outcomes we considered were single-item, which are less psychometrically robust compared to multi-item scales. Multi-item measures could be tested for reliability and validity, which would provide further support of findings. A strength of this study is our inclusion of two different measures of health-related stigma (i.e. experienced and internalized), however, given the relevance of weight to these analyses future work may benefit from also measuring weight-related stigma. Weight stigma alone, or as a factor compounding other forms of stigma and identity-related stressors, may relate to negative health outcomes.

Conclusions

This study suggests that more than half of individuals with chronic pain (57.9%) engaged in maladaptive attempts at weight loss (i.e. fasting and crash dieting), and that stigma can increase the likelihood of weight loss attempts in smaller bodied individuals with chronic pain. Although dieting is often popularly conceptualized as a mechanism for improving health, it is most often counter-productive, resulting in psychological distress, weight cycling, and ultimately weight gain (Markey and Gillen, 2023). In other words, although providers may prescribe weight loss as a means of alleviating chronic pain (e.g. joint pain), most people’s efforts to lose weight will be unsuccessful. Yet, providers’ advice to lose weight may be internalized and acted on, potentially leading to worsened physical and psychological health among patients with chronic pain. Further, fasting and crash dieting may be indicative of disordered eating, not sustainable behavioral changes that will promote weight loss or improve health.

These findings may have implications for future research. Studies could examine the efficacy of current practices of recommending weight loss for chronic pain patients against an alternative approach which could emphasize how to make long-term changes to eating and physical activity to feel better (without the goal of weight loss). Research could also focus on examining the effectiveness of brief screenings for maladaptive weight loss behaviors such as crash dieting in chronic pain settings, given the results from this study. Finally, it is important to consider the deleterious effects of stigma on physical and mental health and the ways in which as a society we can work toward greater inclusivity in an effort to promote well-being.

Acknowledgments

The authors thank Rutgers University for their support of this project.

Footnotes

Author contributions: Meghan M. Gillen: Conceptualization, Formal Analysis, Data Curation, Writing- Original Draft. Charlotte H. Markey: Conceptualization, Formal Analysis, Investigation, Data Curation, Writing- Original Draft, Funding Acquisition. Diane L. Rosenbaum: Writing- Original Draft, Formal Analysis, Data Curation. Jamie L. Dunaev: Data Curation, Investigation, Writing- Review & Editing.

Data availability statement: Data are available from the corresponding author, upon reasonable request.

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant from Rutgers University.

Ethics approval: This study was approved by the Institutional Review Board at Rutgers University.

Informed consent: Participants provided informed consent.

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