Mechanisms underlying weight status and healthcare avoidance in women: A study of weight stigma, body-related shame and guilt, and healthcare stress

Impacts of stigma and discrimination on people with obesity who smoke cigarettes

Stigma is the state of social devaluation due to a trait or group identity; weight and smoking-based self-, felt-, and enacted stigma may have detrimental health effects and pose barriers to smoking cessation. This study examined associations between stigma, discrimination, and health for people with overweight or obesity (body mass index [BMI] ≥ 25) who smoke cigarettes (cigarettes smoked/day ≥ 5) who reported interest in quitting smoking and minimizing weight gain. Participants (N = 63; predominantly women (81.0 %), White (63.5 %) or Black/African American (31.7 %), and heterosexual (85.7 %) with 50 % having a yearly income below $50,000) completed the measures of stigma (i.e., Weight Bias Internalization Scale and Internalized Stigma of Smoking Inventory), discrimination (i.e., Everyday Discrimination Scale), and symptoms of depression, weight, smoking, nicotine dependence, and concerns about gaining weight while quitting smoking were measured. Those who reported more internalization of weight bias and more everyday discrimination reported greater depressive symptomatology and greater concern about gaining weight while quitting smoking, with depressive symptomatology fully mediating both internalization of weight bias and everyday discrimination's relation with concern about gaining weight while quitting smoking. There was also an association of smoking felt-stigma, but not self- or enacted-stigma, with symptoms of depression. Stigma's associations with symptoms of depression and post-cessation weight concern suggest barriers to effective behavior change, and interventions may consider targeting processes for coping with stigma experienced by this population.

Clinician Perceptions of the Stereotype Content Describing People With Eating Disorders: A Weight-Inclusive Perspective

OBJECTIVE

Eating disorder stigma is influenced by body size in ways that may cultivate a particularly disadvantageous therapeutic milieu. The present study applied the stereotype content model to investigate the perceptions of mental health providers toward people with eating disorders and a range of eating behaviors, and how these perceptions vary by body size.

METHOD

Using a within-participants design, mental health providers (N = 361) were presented with brief descriptions of 12 groups and asked questions about their perceived warmth and competence: People with anorexia nervosa, bulimia nervosa, orthorexia nervosa, and binge eating disorder; fat people with atypical anorexia nervosa, bulimia nervosa, orthorexia nervosa, and binge eating disorder; dieters; fat dieters; intuitive eaters; and fat intuitive eaters.

RESULTS

All fat groups were perceived as less competent than their general counterparts. Fat people with atypical anorexia nervosa were perceived as warmer than people with anorexia nervosa, whereas fat intuitive eaters were perceived as less warm than intuitive eaters. Cluster analysis yielded three clusters: (1) a higher-competence, higher-warmth cluster, representing intuitive eaters; (2) a higher-competence, lower-warmth cluster, representing people with anorexia nervosa, bulimia nervosa, orthorexia nervosa, and dieters; and (3) a lower-competence, mid-warmth cluster, representing people with binge eating disorder and all fat groups.

DISCUSSION

The stereotype content model offers a useful framework to understand mental health providers' warmth and competence perceptions of people with a range of eating disorders and behaviors. Competence and warmth perceptions are shaped by body size and the restrictiveness of eating disorders and behaviors.

Weight Stigma's Effects on Misdiagnosis of Eating Disorders Among Laypeople and Healthcare Professionals

OBJECTIVE

There is limited research on weight bias in diagnosing eating disorders (EDs), particularly among healthcare professionals (HCPs). This is especially true for atypical anorexia nervosa, a diagnosis recently described in the DSM that includes people with anorexia nervosa symptoms who are not clinically underweight.

METHOD

Using a within-subjects design, we assessed diagnosis, diagnostic confidence, and ED-related medical knowledge among a sample of lay people and medical professionals. Participants read three clinical vignettes (counterbalanced to avoid order effects) of a woman with anorexia nervosa or atypical anorexia nervosa (described as obese) and were assessed on weight stigma and prior ED medical knowledge.

RESULTS

Both lay people and HCPs were less likely to diagnose atypical anorexia nervosa and were less confident in that diagnosis than in the anorexia nervosa vignette condition. Lay participants' diagnostic bias, but not HCPs', was impacted by weight stigma; HCPs' confidence was impacted by weight stigma. In both cases, participants high in weight stigma were more accurate (lay sample) or more confident (HCPs) in diagnoses. Last, greater ED medical knowledge improved accuracy of diagnosis of vignette cases for the HCP sample that included snowball sample recruitment and CloudResearch participants and lay people, but not for the HCP sample recruited via snowball sampling only.

DISCUSSION

These findings highlight the urgency for more public awareness and training for HCPs emphasizing that people of all sizes can present with restrictive eating disorders.

Consequences of daily self-weighing: a pilot study in higher-weight women with a history of breast cancer

Self-monitoring weight is commonly recommended for higher-weight women with a history of breast cancer, despite evidence demonstrating potentially negative psychological consequences of frequent self-weighing. The extent to which higher-weight women with breast cancer experience emotional and behavioral consequences in response to daily self-weighing is unknown. In this pilot study, women (n = 51) with a history of breast cancer in a behavioral weight management program completed a weeklong daily diary protocol. Participants were asked to self-weigh every morning and report on subsequent weight-related shame and guilt, and end-of-day engagement in compensatory exercise, diet, and purging behaviors. Women reported higher levels of guilt on days when their body weight was higher than usual, and when there was more discrepancy between their current vs. goal weight. Additionally, women engaged in higher levels of compensatory diet behavior on days when they experienced more weight-related guilt than usual. Based on these preliminary findings, daily self-weighing may be associated with harmful emotional and behavioral consequences among higher-weight women with a history of breast cancer.

The real-life experiences of people living with overweight and obesity: A psychosocial perspective

Understanding the lived experience of obesity, just like any other chronic outcome, is essential to addressing deep routed inequalities and stigma associated with obesity, as well as creating more inclusive and effective policies and healthcare. The psychosocial aspects of obesity are vast and as such the lived experience of obesity differs between individuals and groups. However, there are consistent psychosocial issues identified within empirical studies as well as lived experience accounts that require consideration and potential adaption in the design and delivery of care including weight management and obesity services. Improving perceptions and understanding of the lived experience can also foster empathy which appears to be lacking based on research examining everyday encounters, media portrayal of people living with obesity, and in healthcare settings. Stigma and discrimination are consistent and, in some instances, occur daily in many societal settings leading to mental and physical health concerns, social disengagement and dysfunctional relationships with significant others, as well as avoidance of health promoting activities and settings. Using a narrative review approach, our aim was to examine the empirical evidence generated in countries across the world, reporting on the real-life experiences of people living with obesity. Our search strategy was informed by existing empirical evidence of the psychosocial aspects of obesity and an in-depth interview exploring the lived experience of obesity specifically conducted to inform this article. In doing so, we highlight key psychosocial aspects and provide a voice for a personal account of the challenges experienced in child and adulthood. Recommendations are offered for stakeholders including policymakers and practitioners that aim to address these real-life challenges experienced by people living with obesity. PLAIN LANGUAGE SUMMARY: In this publication, the authors provide a detailed review of the lived experiences of people living with obesity with a focus on the psychological and social factors and experiences across the life course. The paper also uniquely presents real-life experiences from Sarah, who identifies as living with obesity. In doing so, the authors highlight exposure to and experiences of weight management related behaviours and weight stigma from an early age. Experiences of weight stigma and feelings of being excluded from social settings and more generally society are evidenced throughout. Indeed, Sarah's accounts support the research evidence presented, where for instance, she highlights feeling excluded as a younger person when not being able to purchase "trendy" clothing and as an adult when buying clothing for work, experiences of weight stigma in workplaces and issues related to travelling as well as the actions she takes to avoid imposing on other people. The key lived experiences, both from the research evidence and Sarah's accounts, provide insights about the link between obesity and mental health, where for instance, the experiences of weight stigma and feeling excluded from society are associated with mental health outcomes including reduced self-worth and self-esteem, increased depression and increased risk of self-harming. The authors provide a list of ways to address weight stigma in society as well as in healthcare, a setting where weight stigma is often reported by people living with obesity, and calls for greater involvement of people living with obesity in policy, healthcare development and practice, as well as the need to address the widespread weight stigma and discrimination. [Plain language summary added March 2025, after original online publication].

Racial/ethnic inequities in potentially harmful supplement use: Results of a prospective US cohort during the COVID-19 pandemic

OBJECTIVES

To quantify racial/ethnic inequities in the use of harmful supplements sold with claims to aid in immune boosting, energy boosting, cleansing/detoxing, and weight loss throughout the first year of the COVID-19 pandemic.

STUDY DESIGN

Prospective cohort study using longitudinal data (April/May 2020-April 2021) drawn from the US-based COVID-19 Substudy (N = 55,098), embedded in the Nurses' Health Studies 2 and 3 and the Growing Up Today Study.

METHODS

Modified Poisson models were fit to estimate sociodemographic-adjusted risk ratios (aRRs) and 95 % confidence intervals (CIs) of supplement use by racialized identity. We estimated the contribution of social stressors in driving racial/ethnic inequities in use of immune, energy, cleanse/detox, and weight-loss supplements.

RESULTS

Non-Hispanic Black participants had up to two times higher risk of supplement use compared to Non-Hispanic White participants. Living in a county with a high COVID-19 mortality rate was associated with a slightly elevated risk of immune supplement use, and experiencing chronic high discrimination was associated with an elevated use of all supplement types.

CONCLUSIONS

There were stark racial/ethnic inequities in use of harmful supplements throughout the first year of the COVID-19 pandemic.

Words are heavy: Weight-related terminology preferences are associated with larger-bodied people's health behaviors and beliefs

Clinicians and researchers may struggle with appropriate terminology when discussing body size. Pathologizing larger bodies has led to use of medicalized terms. Previous studies have focused on terminology preferences among participants not in larger bodies, leaving out those most affected by the terminology. This study examined whether body appreciation, eating disorder symptoms, recovery status, and beliefs about health and weight influence larger-bodied participants' terminology preferences. We recruited two groups: Sample 1 (N = 882) via social media and Sample 2 (N = 383) from an online crowdsourcing platform. Sample 1 preferred "in a larger body" and "fat," while Sample 2 favored "overweight" and "curvy." Both groups least preferred person-first language (e.g., "person with overweight/obesity"). In Sample 1, participants recovered from eating disorders were more likely to choose "fat" than those who were currently struggling. Those who preferred "fat" had the highest body appreciation, highest critical health awareness, lowest eating disorder symptoms, lowest weight bias internalization, and lowest weight controllability beliefs. In Sample 2, preferring medicalized terms was associated with lower critical health awareness and higher weight controllability beliefs. These findings suggest that fat-related and weight-neutral terms may be associated with more positive outcomes, challenging advocacy for person-first medicalized language.

How experiences of weight stigma impact higher-weight women during their maternity care: A meta-ethnography

AIM

The aim of this review was to explore the experiences of pregnant women and birthing people with higher weight bodies, to understand the extent to which weight stigma impacted their maternity care.

METHODS

We performed a systematic search of seven databases (CINAHL plus, Medline, Social Sciences Full Text [SSFT], International Bibliography of Social Sciences [IBSS], PsychINFO, Maternity and Infant Care [MIC], NIHR Journals Library, EThOS) using the Setting, Perspective, Intervention, Comparison, Evaluation (SPICE) framework search strategy and pre-defined inclusion and exclusion criteria. Included studies underwent a critical appraisal and data richness assessment. We undertook thematic analysis after coding first- and second-order constructs and developed a synthesis from the themes.

FINDINGS

Thirty-eight papers, including six doctoral theses and one book chapter, met the inclusion criteria. Five themes were identified through thematic analysis, and the synthesis demonstrated that women of a higher weight experience shame, harmful attitudes and preconceptions from healthcare professionals regularly and repeatedly while receiving maternity care. This can be alleviated by individualised supportive care from a healthcare professional.

KEY CONCLUSIONS

Negative interactions with maternity care professionals are central to the experience of weight stigma, leading to a sense of 'shame', with pervasive feelings of humiliation, judgement and blame. Current guidance does not acknowledge the stigmatising effects of weight related conversations, additional interventions and restrictions on women's birthplace choices. Adopting a shame-sensitive lens within a culturally safe approach to maternity care could transform support for women.

Characterization of trends in preoperative hemoglobin A1c testing prior to metabolic and bariatric surgery: a retrospective, observational study

BACKGROUND

Irrespective of baseline diabetes status, preoperative hemoglobin A1c (A1C) influences perioperative care in patients undergoing metabolic and bariatric surgery (MBS). Accordingly, the American Society of Metabolic and Bariatric Surgery (ASMBS) endorses that patients undergoing MBS should receive a preoperative A1C test. We aimed to assess the proportion of MBS patients who received a preoperative A1C test and determine whether baseline diabetes status influences receipt of a test.

METHODS

We queried the 2017 to 2022 MBSAQIP database for patients undergoing open, laparoscopic, or robotic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy. Using descriptive methods, we compared the clinical and demographic characteristics of patients who received a preoperative A1C test with patients who did not. We performed logistic regression analysis using diabetes status as a predictor variable and receipt of a test as the outcome, covarying for sociodemographic and clinical factors.

RESULTS

We identified 996,217 patients who underwent RYGB or sleeve gastrectomy between 2017 to 2022. The average age of the cohort was 43.8 years (SD = 11.9) and 81.0% were female. Overall, 45.7% received a preoperative A1C test. The proportion who was tested increased over the six-year study period, from 35.5% in 2017 to 56.0% in 2022. Compared to those who were not tested, patients who were tested were more likely to have several cardiopulmonary comorbidities, including COPD (1.4% vs 1.2%, p < 0.001), PE (1.4% vs 1.2%, p < 0.001), sleep apnea (39.3 vs. 36.4%, p < 0.001), HTN (47.1% vs 44.0%, p < 0.001), and MI (1.2% vs. 1.0%, p < 0.001), though the differences in proportions were small and may not be clinically significant. Compared to patients who did not have diabetes or had diabetes controlled by diet alone, patients with non-insulin dependent diabetes had 77% increased odds of receiving a A1C test (adjusted OR (aOR) 1.77, p < 0.001); insulin dependent patients had 113% increased odds (aOR 2.13, p < 0.001).

CONCLUSION

Despite society recommendations endorsing measurement of preoperative A1C prior to MBS, less than half of patients undergoing MBS between 2017 and 2022 received a preoperative A1C test. Additionally, there were differential patterns in testing based on diabetes status. Preoperative glycemic evaluation is an area for continued quality improvement.

Body Shame Predicts Healthcare Discomfort and Avoidance in College Women Through the Mechanism of Low Body Responsiveness

BACKGROUND

Many cultures promote ideals for women's bodies that are difficult to meet, and not meeting these ideals may result in body shame. Body shame predicts discomfort in and avoidance of situations in which the body may be scrutinized. As the healthcare setting frequently involves examination of the body, body shame may predict discomfort in and avoidance of the healthcare setting. However, these relationships have been tested minimally and only in higher-weight women. Since body shame may occur regardless of BMI, body shame may predict healthcare discomfort and avoidance across the weight spectrum. Moreover, these relationships may occur because body shame predicts low body responsiveness, or the detection and valuing of bodily signals, which in turn may predict healthcare discomfort and avoidance.

METHOD

The present investigation tested these ideas in weight-diverse undergraduate women (N = 467) using cross-sectional (studies 1 and 2) and experimental (study 3) designs and imagined healthcare settings.

RESULTS

In study 1, body shame correlated positively with healthcare discomfort, and low body responsiveness mediated this relationship. In study 2, body shame was not directly related to healthcare avoidance, but low body responsiveness mediated this relationship. In study 3, participants who underwent a body shame induction reported lower state body responsiveness than control participants, and lower state body responsiveness mediated the links between condition and healthcare discomfort and avoidance.

CONCLUSION

Attitudes toward internal bodily functions may link body shame to healthcare avoidance and discomfort in college women across the weight spectrum. Future research may examine this model in more diverse populations.

Weight Bias Internalization Statistically Mediates the Association Between Positive Body Image and Intuitive Eating: A Cross-Sectional Study

BACKGROUND

Two facets of positive body image, body appreciation and functionality appreciation, are positively associated with an adaptive eating style known as intuitive eating. Little is known about the mechanisms underlying the association between positive body image and intuitive eating, although it is well established that weight bias internalization is associated with unfavorable views of the self and body and interferes with health behavior engagement.

OBJECTIVE

The present cross-sectional study examined weight bias internalization as a statistical mediator of the association between positive body image (ie, body appreciation and functionality appreciation) and intuitive eating.

DESIGN

An online cross-sectional survey was conducted with a convenience sample of adults who were recruited through social media from February to April 2019.

PARTICIPANTS AND SETTING

The final sample included 178 participants (120 women, 55 men, 2 gender nonbinary; mean age = 26.34 years, SD = 9.53 years) who completed the study online.

MAIN OUTCOME MEASURES

Participants completed the Intuitive Eating Scale-2 as the main outcome measure.

STATISTICAL ANALYSES

The PROCESS macro was used to conduct 2 mediation analyses with body appreciation and functionality appreciation as the antecedents, intuitive eating as the outcome, and weight bias internalization as the mediator.

RESULTS

As expected, body appreciation (b = .34, SE = .06; P < .001) and functionality appreciation (b = .13, SE = .06; P = .043) had significant positive associations with intuitive eating. Weight bias internalization statistically mediated the association between body appreciation and intuitive eating (b = .24, SE = .07, 95% CI .114 to .376), and functionality appreciation and intuitive eating (b = .04, SE = .03, 95% CI .004 to .104).

CONCLUSIONS

These findings contribute to better understanding the mechanisms connecting positive body image and intuitive eating. Results from this cross-sectional study indicate weight bias internalization statistically mediates the associations between body appreciation and intuitive eating and functionality appreciation and intuitive eating.

Fear of Childbirth Among Pregnant People Facing Anti-Fat Bias

Explicit and implicit anti-fat biases are widespread among healthcare providers, leading to significant negative consequences for pregnant people, including poorer health outcomes. Fear of childbirth (FOC) can affect the length of labor, increase the risk of cesarean delivery, and negatively influence a new parent's perception of infant bonding. This study investigated the impact of perceived anti-fat bias on FOC among pregnant people. Data were gathered from 329 pregnant people recruited from three large academic prenatal centers in the United States and via social media. Participants completed a survey that included validated instruments measuring perceptions of anti-fat bias and FOC. Participants perceiving anti-fat bias reported higher FOC. Black participants perceiving anti-fat bias reported higher FOC. These findings suggest that perceived anti-fat bias from providers is associated with FOC for pregnant people, particularly those who identify as Black. Interventions to educate providers on these important concepts could help improve pregnant people's experience within the healthcare system.

"Treated as second class citizens" - the lived experience of obesity-related stigma: an IMI2 SOPHIA study

PURPOSE

Obesity-related stigma impacts on and shapes the physical and psychosocial wellbeing of individuals living with obesity. Often absent from the literature in the field is the voice(s) of those living with obesity capturing the nuances of the lived experiences of obesity-related stigma.

METHODS

This study adopted a qualitative approach encompassing individual (n = 15) and photovoice method (n = 12), with a purposeful sample of patients accessing treatment for obesity within the healthcare setting during 2021. Analysis was undertaken using thematic analysis.

RESULTS

Key themes developed from the analysis related to experiencing obesity-related stigma as exposure to external judgement, societal exclusion and felt environmental stigmatization. Exposure to external judgement was described as judgemental comments resulting in hypervigilance to societal judgement. Participants reported how being overlooked and ignored by others had various negative effects and compounded obesity-related stigma through societal exclusion. Public spaces lacking suitable equipment further made obesity-related stigma visible through felt environmental stigmatization when pursuing hobbies and in everyday life.

CONCLUSIONS

Obesity-related stigma had a profoundly negative impact on participants in this study, particularly in shaping social interaction, limiting life experiences and impacting psychosocial wellbeing.

Broaching body size and sizeism: Input from specialized clinicians

Broaching issues of identity and power with clients in the context of their mental health care is affirmed as an effective multicultural and social justice counseling skill by a growing evidence base. Considerations for broaching body size, including size difference and sizeism, with clients has not yet been studied, thus clinicians lack guidelines for facilitating these conversations. In this consensual qualitative research study, we present themes involved in broaching body topics based on our interviews with nine clinicians specialized in treating clients with eating disorders and body-related counseling concerns. Themes addressed counselor development, conceptualization of broaching, clinical-decision-making, practice, and impact of broaching body topics in session. Clinicians identified professional and personal developments they pursued and would advocate for training future clinicians to better serve clients. Descriptions of unique and shared aspects of broaching clients' intersectionality and body-size specifically depict avenues for tailoring broaching conversations. Specific examples of effective and ineffective broaching conversations, including language used and psychoeducational components, provide recommendations for practice and connect to observed impacts on the client, counselor, and counseling process.

Weight-Inclusive Approaches to Nutrition and Dietetics: A Needed Paradigm Shift

This Perspective article encourages the field of nutrition and dietetics to move away from a weight-centric paradigm that emphasizes weight loss and weight management as primary health outcomes. This approach can perpetuate weight stigma, which is associated with poorer health behaviors, poorer mental health, disordered eating, and even increased mortality risk. We propose an alternative approach-adopting a weight-inclusive paradigm-that focuses on providing care across the weight spectrum by centering health behaviors rather than weight. This approach allows individuals of all sizes to have equitable access to high-quality nutrition and dietetics care.

"Constantly justifying my existence": Lower-income, higher-weight Canadian adults' stigma coping mechanisms

Individuals who are higher-weight and low-income may disproportionately experience weight and income stigmas in healthcare experiences compared to lower-weight, higher-income individuals. The ways that weight and income stigmas interact in healthcare should be better understood in order to provide better, less stigmatizing care to higher-weight, low-income patients. This study assesses how patients manage stigmatizing experiences in both healthcare and everyday experiences and how that impacts health seeking and stigma management behaviors through semi-structured interviews with 11 higher-weight (Body Mass Index ≥30), low-income adults (≥18 years of age) in an Atlantic Canadian province. Participants took part in two interviews that focused on healthcare experiences and both positive and negative places/spaces. The two face-to-face interviews for each participant (total 21 interviews) were audio-recorded and professionally transcribed verbatim. The transcripts were analyzed using thematic analysis to identify recurring concepts and patterns within the data. Two major themes emerged from the data, uptake of stigmatizing, neoliberal health messaging and coping with stigma. Coping with stigma included subthemes control over stigmatizing experiences and stoicism in the face of stigma. The findings suggest that individuals understand their health and wellness through a neoliberal lens and that they deploy strategies of control and stoicism to cope with the stigmas they face.

Women's Relationships With Healthcare and Providers: The Role of Weight Stigma in Healthcare and Weight Bias Internalization

BACKGROUND

Weight stigma (devaluation due to body weight) in healthcare is common and influences one's engagement in healthcare, health behaviors, and relationship with providers. Positive patient-provider relationships (PPR) are important for one's healthcare engagement and long-term health.

PURPOSE

To date, no research has yet investigated whether weight bias internalization (self-stigma due to weight; WBI) moderates the effect of weight stigma on the PPR. We predict that weight stigma in healthcare is negatively associated with (i) trust in physicians, (ii) physician empathy, (iii) autonomy and competence when interacting with physicians, and (iv) perceived physician expertise. We also predict that those with high levels of WBI would have the strongest relationship between experiences of weight stigma and PPR outcomes.

METHODS

We recruited women (N = 1,114) to complete a survey about weight stigma in healthcare, WBI and the previously cited PPR outcomes.

RESULTS

Weight stigma in healthcare and WBI were associated with each of the PPR outcomes when controlling for age, BMI, education, income, race, and ethnicity. The only exception was that WBI was not associated with trust in physicians. The hypothesis that WBI would moderate the effect of weight stigma in healthcare on PPR outcomes was generally not supported.

CONCLUSIONS

Overall, this research highlights how weight stigma in healthcare as well as one's own internalization negatively impact PPRs, especially how autonomous and competent one feels with their provider which are essential for one to take an active role in their health and healthcare.

Be kind, don't rewind: trait rumination may hinder the effects of self-compassion on health behavioral intentions after a body image threat

Many individuals encounter situations that may elicit body-related concerns and impact how they think and feel about their weight, daily habits, and physical attractiveness. Research shows body image threats can predict poor health behaviors, but approaching those difficult moments with self-compassion-being kind, forgiving, and nonjudgmental-may reduce the impact of that threat and promote engagement in positive health behaviors. However, trait rumination, or tending to perseverate on negative events, may both dampen the benefits of a self-compassionate state and predict poor health behaviors. The present study examined whether a brief self-compassion writing exercise, after recalling a negative body-related event, predicted intent to perform health-promoting behaviors, and whether trait rumination attenuated this relationship. Participants (N = 217) completed a measure of trait rumination, underwent a body image threat, and were randomly assigned to cope with self-compassion or a distraction. Subsequently, participants completed a measure of health behavioral intentions. Analyses revealed participants in the self-compassion condition reported greater health-promoting behavioral intentions compared to control, with no significant main effect of trait rumination. However, a condition-by-rumination interaction emerged, suggesting the self-compassion condition was associated with higher health behavioral intentions, but only for participants with low trait rumination levels. These effects washed out when controlling for participants' self-rated health. The findings suggest that a self-compassion practice can help mitigate the adverse effects of a body image threat and facilitate health-promoting behavioral intentions, although its efficacy may depend on individual levels of trait rumination and perceived health.

Weight-based disparities in perinatal care: quantitative findings of respect, autonomy, mistreatment, and body mass index in a national Canadian survey

BACKGROUND

Qualitative studies document episodes of weight-related disrespectful care, particularly for people with high body mass index (BMI ≥ 30) and reveal implicit and explicit biases in health care providers. No large quantitative studies document the pervasiveness of weight stigma or if experiences change with increasing BMI.

METHODS

The multi-stakeholder RESPCCT study team designed and distributed a cross-sectional survey on the experiences of perinatal services in all provinces and territories in Canada. From July 2020 to August 2021, participants who had a pregnancy within ten years responded to closed and open-ended questions. Chi square analysis assessed differences in mean scores derived from three patient-reported experience measures of autonomy (MADM), respect (MOR), and mistreatment (MIST). Controlling for socio-demographic factors, multivariate logistic regression analysis explored relationships between different BMI categories and respectful care.

RESULTS

Of 4,815 Canadians who participated, 3,280 with a BMI of ≥ 18.5 completed all the questions. Pre-pregnancy BMI was significantly associated with race/ethnicity, income sufficiency, and education but not with age. Individuals with higher BMIs were more likely to experience income insufficiency, have lower levels of education, and more frequently self-identified as Indigenous or White. Those with BMI ≥ 35 exhibited notably higher odds of reduced autonomy (MADM) scores, with an unadjusted odds ratio of 1.62 and an adjusted odds ratio of 1.45 compared to individuals with a normal weight. Individuals with BMIs of 25-25.9, 30-34.9, and ≥ 35 exhibited odds of falling into the lower tercile of respect (MOR) scores of 1.34, 1.51, and 2.04, respectively (p < .01). The odds of reporting higher rates of mistreatment (top 33% MIST scores) increased as BMI increased.

CONCLUSIONS

While socio-demographic factors like race and income play significant roles in influencing perinatal care experiences, BMI remains a critical determinant even after accounting for these variables. This study reveals pronounced disparities in the provision of respectful perinatal care to pregnant individuals with higher BMIs in Canada. Data suggest that those with higher BMIs face disrespect, discrimination, and mistreatment. Identification of implicit and explicit weight bias may give providers insight enabling them to provide more respectful care.

Partnerships with primary care providers: Opportunities to prevent eating disorders and mitigate their progression in young people

Epidemiologic research has identified numerous interpersonal and individual risk factors for and warning signs of emerging eating disorders in adolescents. These findings have informed public health prevention and treatment strategies, including translation of findings to clinical recommendations for primary care providers (PCPs). A next step in this translational work could include a comprehensive approach where PCPs are seen as partners in efforts to improve population health outcomes. PCPs have great potential to implement high-yield interventions that prevent or attenuate the course of adolescent eating disorders. To illustrate this potential, we present a case that highlights missed opportunities for a PCP to prevent, detect, and intervene during a patient's developing eating disorder. We then relate the case to two emerging research programs that utilize PCP partnerships: one trains PCPs in Strengths-Based Adolescent Healthcare to improve eating disorder prevention; the other adapts Family-Based Treatment for primary care to improve early access to evidence-based treatment. In addition to these promising areas of research, efforts are needed to widen requirements for eating disorder curricula in medical training programs and to address weight stigma in primary care. Together these efforts will help PCPs become effective partners in the prevention and treatment of eating disorders.

The lived experiences of patients with severe obesity during hospital admissions in Norway: A phenomenological hermeneutic study

AIM

To explore the lived experiences of patients with severe obesity during hospital admissions.

DESIGN

Qualitative study design.

METHODS

Semi-structured individual interviews with 14 participants with severe obesity from Norway were conducted between May and October 2021. A qualitative phenomenological hermeneutical approach inspired by Paul Riceour was used to analyse the data.

RESULTS

The following three themes were identified through the analysis of the lived experiences of patients with severe obesity during hospital admissions: blaming my weight, being prejudged and feeling different. The participants shared various emotional experiences of encounters with healthcare professionals at hospitals. They struggled to be recognized and welcomed like everyone else and found it difficult to be judged by someone who did not know them. The various experiences resulted in a vicious circle, ultimately leading to a fear of future hospitalization.

CONCLUSION

Being a patient with obesity in a hospital setting can present various challenges, leading to feelings of shame and guilt. Experiences of stigma may not necessarily be related to the overall hospital context but rather to encounters with healthcare professionals who may be unfamiliar with the patient's history, which can lead to stigmatizing behaviours.

IMPACT

Understanding how patients with severe obesity experience their hospital admissions and the importance of familiarizing themselves with the individual patients to avoid stigmatizing behaviours is important for healthcare professionals caring for obese patients.

REPORTING METHOD

Consolidated Criteria for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

IMPACT STATEMENT

Patients with obesity often encounter stigmatization and negative attitudes from healthcare professionals, particularly in primary care settings. Patients with severe obesity experienced various challenging encounters with healthcare professionals during hospital admissions, resulting in a vicious circle, ultimately leading to a fear of future hospitalization. It is crucial for healthcare professionals involved in the care of patients with obesity to acquaint themselves with individual patients to prevent stigmatizing behaviours.

Associations Between Weight Discrimination, Eating-Disorder-Related Psychiatric Impairment, and Eating-Disorder Treatment Interest Across the Weight Spectrum

OBJECTIVE

Only approximately 20% of college students with an eating disorder (ED) seek treatment. One barrier to seeking treatment is weight discrimination. Past research demonstrates that experiencing weight discrimination is associated with increased ED risk and decreased in-person treatment engagement. Weight discrimination may be a particularly relevant treatment barrier for students who have a higher body weight given their higher likelihood of experiencing weight discrimination.

METHODS

College students with a probable ED diagnosis (N = 372; Mage = 23.94; 73.12% women, 18.55% men, 6.18% another gender; 11.29% Asian, 4.57% Black, 12.63% Hispanic, 83.60% White, 4.84% Native American, and 0.54% another race) completed an online self-report survey that included the Clinical Impairment Assessment (CIA), Experience of Weight Discrimination (EWD) Scale, and a 0-100 scale to indicate interest in participating in virtual guided self-help ED treatment.

RESULTS

Linear regression showed significant positive relationships between weight discrimination and ED-related psychiatric impairment and treatment interest.

DISCUSSION

Elevations in CIA scores corroborate past literature that suggested that weight discrimination was positively related to ED psychopathology. Contrary to past research, college students who experienced weight discrimination had greater treatment interest. Students who experience weight discrimination may view virtual self-guided treatment as less weight-stigmatizing due to the "do-it-yourself" approach and no in-person interactions. Findings highlight the potential impacts of weight discrimination on acceptability of ED-related care. Future research is needed to identify ways to reduce weight discrimination and promote weight-inclusive practices in the medical system.

Addressing Shame Through Self Compassion

Shame is a common experience for individuals living with chronic diseases related to lifestyle, such as obesity and diabetes. It is often characterized by feelings of stigma and worthlessness, leading many patients to feel judged and unworthy of respect, which can profoundly affect health outcomes and overall quality of life. Despite the severe consequences of shame, therapeutic approaches to address it remain underexplored. This paper highlights the role of Acceptance and Commitment Therapy and Compassion Focused Therapy as effective strategies to mitigate shame, cultivate self-compassion, and, therefore, enhance health outcomes for individuals with chronic lifestyle-related conditions. These therapies have demonstrated positive effects on treatment adherence and self-management among patients with chronic diseases. Therefore, healthcare providers can improve patients' overall well-being by adopting strategies from these therapies, such as using compassionate language that emphasizes empathy, non-judgmental support, and validation, all of which help reduce shame and stigma.

Effects of health at every size based interventions on health-related outcomes and body mass, in a short and a long term

Objective

This study aims to provide rapid and up-to-date evidence on the effectiveness of Health at Every Size (HAES) interventions compared to controls or other conventional approaches in individuals with overweight or obesity, with the goal of developing more effective and body-diverse respectful strategies.

Methods

A review of literature was carried out using the following databases: PubMed, Scopus, Embase, Web of Science, and SciELO. Research articles were selected based on predefined inclusion and exclusion criteria. Extracted data included study characteristics (design, setting, population demographics, sample size, intervention characteristics, study duration, and follow-up period) and health-related outcomes.

Results

The search yielded 324 articles, of which 20 articles met the inclusion and exclusion criteria. The majority of studies focused on lifestyle improvement, particularly in nutrition, body image, and relationships with food, utilizing a HAES approach. Additionally, other studies examined outcomes such as general well-being, body weight, body composition, cardiovascular risk, and changes in physical activity. Long-term results were particularly noted in studies incorporating physical activity interventions.

Conclusion

HAES interventions appear to be a feasible strategy for promoting overall health and wellness, regardless of body size or shape. However, further evaluation is needed to assess the sustainability of these changes and their long-term impact, as current evidence suggest a they may not be maintained over time.

Bias related to overweight and obesity among French psychiatrists: Results of a national survey

BACKGROUND

According to people with a higher weight, physicians are the second most stigmatizing group related to excess weight. As a result of these weight-related biases, the therapeutic relationship with the patient and the quality of care would be negatively affected. In addition, this stigma could negatively impact the clinical practice related to higher weight and avoidance of care.

OBJECTIVES

The objective of this study was to assess the stigma of overweight and obesity among psychiatric residents and psychiatrists in France. Specifically, the study aimed to assess factors that may influence weight-related bias among psychiatrists, to explore the relevance of visual assessment of body mass index, and to determine how they this feature is integrated into their practice.

METHOD

An online questionnaire including sociodemographic items, the Fat Phobia Scale, the Beliefs About Obese Persons Scale, the Body Shape Scales, and questions about their clinical practice was distributed via national professional mailing lists and social networks.

RESULTS

The survey was answered by 271 seniors or residents in psychiatry. The results indicated a moderate level of weight-related bias among psychiatrists as assessed by the Fat Phobia Scale which was higher in residents than in senior psychiatrists. Over a third of the respondents had no material to assess their patient's weight, and two thirds did not systematically assess overweight or obesity. Finally, the results demonstrate that psychiatrists failed to accurately evaluate overweight or obesity based on male or female silhouettes.

CONCLUSION

It appears that measures should be taken to raise awareness among psychiatrists of the stigmatization of individuals living with a higher weight, as well as to enhance the quality of weight gain care in psychiatry.

Shame in patient-health professional encounters: A scoping review

Shame can arise during patient-health professional encounters when discussing traumatising and stigmatising topics and can contribute to negative patient outcomes. This review aims to summarise what is known regarding shame in patient-health professional encounters. We conducted a scoping review using Levac and colleagues' approach and reported the findings using the PRISMA Extension for Scoping Reviews. We searched four databases (CINAHL, PsychINFO, PubMed and SocINDEX) for empirical studies that involved shame in patient-health professional encounters contextualised by trauma or stigma and were published in English. We categorised what is known regarding shame in empirical studies using inductive content analysis. We also collected stakeholders' perspectives on the review findings through an online survey. Our initial search yielded 3658 articles, of which 37 were included. We summarised the literature into four categories: (1) What health professionals say they do in patient-health professional encounters, (2) What health professionals think patients feel in patient-health professional encounters, (3) Patients' descriptions of their own shame during patient-health professional encounters and (4) Health professionals' descriptions of their own shame during patient-health professional encounters. Shame can arise in a variety of circumstances during patient-health professional encounters. More research is needed to identify what specific communication strategies used by health professionals during patient-health professional encounters contribute to or avoid patient shame.

Stigma, Self-Care, and Intuitive Eating in Black Americans with Type 2 Diabetes

Type 2 diabetes is prevalent among Black Americans. Stigma associated with type 2 diabetes, both in general and specific to weight, is damaging to self-care, which is crucial for the effective management of diabetes. Family relationships may buffer the negative impact of stress, especially among Black Americans who have historically relied on informal support networks. Our goal was to investigate how type 2 diabetes stigma (H1) and weight stigma (H2) were related to self-care and intuitive eating - a non-restrictive approach to nutrition; H3 predicted that family relationship satisfaction would moderate the relationships predicted in H1 and H2. Black Americans diagnosed with type 2 diabetes (N = 225) were recruited via Qualtrics panels to complete an online survey of self-report measures. We used multiple linear regression to test our hypotheses. Both chronic illness and weight stigma were related as predicted to one subscale of intuitive eating (eating for physical hunger). Our moderation analyses revealed that family relationship satisfaction was protective against the harms of stigma at moderate to high levels. Intuitive eating is a promising non-restrictive treatment option for type 2 diabetes.

Lessons learned from patients' weight-related medical encounters: Results from 34 interviews

OBJECTIVES

How to best care for larger-bodied patients is a complicated issue in modern medicine. The present study seeks to inform current medical practices to ensure the delivery of high-quality and evidence-based care through the examination of higher-weight patients' experiences with weight-related care.

METHODS

Higher-weight patients (N = 34) completed semi-structured interviews about their experiences and recommendations for weight-related care. Interviews were coded by two independent coders and harmonized. Findings were organized into broad domains of 1) negative care experiences and 2) positive care experiences and recommendations.

RESULTS

Patients described a range of negative care experiences, including stigmatization from providers (e.g., rude, attacking, or insulting communication about weight), while concurrently expressing insufficient weight management support from providers. Positive care experiences and recommendations included patient-centered care (e.g., physician humility and empathy) and attending to the patient's weight, which conveyed concern for the patient.

CONCLUSIONS

Our findings reflect patients' ambivalent attitudes toward weight-related care: while weight-focused provider communication can be highly stigmatizing, patients simultaneously desire more weight-management support from providers.

PRACTICE IMPLICATIONS

Providers who wish to move their practices from a weight-loss focus to one targeting healthy living should provide a rationale for these shifts to inform patients' perceptions of high-quality care.

Examining within- and between-member cohesion and working alliance effects on group members' motivation: a preliminary actor-partner interdependence study

OBJECTIVE

Informed by the person-environment fit theory, this preliminary study examined if a fit between a group member's treatment experience and their working therapy context (other group members' aggregated treatment experiences) were related to their level of motivation within a group treatment for healing from internalized weight stigma.

METHOD

We examined the relationship between two types of within-member and between-member's group cohesion, working alliance, and motivation. Specifically, we utilized the Actor-Partner Interdependence Model to operationalize the impact of actor's within-member cohesion and alliance (personal changes over time) and between-member cohesion and alliance (individual differences) as well as partner's within-member cohesion and alliance (contextual changes over time) and between-member cohesion and alliance (contextual differences) on group members' motivation. This study utilized self-report data from 26 group members who participated in three online weight stigma psychotherapy groups.

RESULTS

For cohesion, results suggested that the relationship between partner within-member cohesion and motivation was larger for members who reported low cohesion across all the sessions compared to the other members of their group. Additionally, an individual group member who perceived a group session more cohesive than they did on average, reported increased motivation in that session, and this relationship was stronger for members who on average perceived their group less cohesive than other group members. Lastly, session-level alliance was more strongly associated with an individual member's motivation in that session when the other group members reported higher group alliance on average.

CONCLUSIONS

These findings underscore the significance of member-group fit in group therapy and the reciprocal impact of individual members and the group on each other's therapy outcomes.

A systematic review of observational studies exploring the relationship between health and non-weight-centric eating behaviours

Eating behaviour that does not centralise weight, otherwise known as weight-neutral, is associated with improved physical and psychological health, and greater health promoting behaviours. However, consolidated evidence is lacking. This study aimed to systematically evaluate 'health-centric' eating behaviour reflective of weight-neutral approaches, and their relationship with health (physical and mental) and health promoting behaviours. A systematic search was performed, identifying observational studies with adult populations, ≥1 physical/mental health outcome(s), and ≥1 validated measure(s) of health-centric eating behaviour. Study design, sample characteristics and outcomes were extracted and characterised into four domains. Our search identified 8281 records, with 86 studies, 75 unique datasets, and 78 unique exposures including 94,710 individuals. Eating behaviours included intuitive eating (n = 48), mindful eating (n = 19), and eating competence (n = 11). There were 298 outcomes identified for body composition, size, and physical health (n = 116), mental health and wellbeing (n = 123), health promoting behaviours (n = 51) and other eating behaviour (n = 8). Higher levels of intuitive eating, mindful eating and eating competence were significantly related to a lower BMI, better diet quality and greater physical activity. Higher intuitive and mindful eating were significantly related to lower levels of disordered eating, and depressive symptoms, and greater body image, self-compassion, and mindfulness. Greater eating competence and intuitive eating were significantly related to higher fruit and vegetable intake, and greater eating competence to higher fibre intake and better sleep quality. Our results demonstrate that 'health-centric' eating behaviours are related to a range of favourable health outcomes and engagement in health promoting behaviours. These findings help to enhance our understanding of eating behaviours that do not centre around body weight, providing support for health-centric eating behaviour in healthcare. Future research should focus on intervention studies and more diverse population groups.

Does terminology matter when measuring stigmatizing attitudes about weight? Validation of a brief, modified attitudes toward obese persons scale

Objective

Commonly used terms like "obese person" have been identified as stigmatizing by those with lived experience. Thus, this study sought to revise a commonly used measure of weight stigmatizing attitudes, the Attitudes Toward Obese Persons (ATOP) scale.

Methods

The original terminology in the 20-item ATOP (e.g., "obese") was compared to a modified version using neutral terms (e.g., "higher weight"). Participants (N = 832) were randomized to either receive the original or modified ATOP.

Results

There was a statistically significant difference, with a small effect size (d = -0.22), between the scores of participants who received the original ATOP (M = 69.25) and the modified ATOP (M = 72.85), t(414) = -2.27, p = 0.024. Through principal component analysis, the modified ATOP was best used as a brief, 8-item unidimensional measure. In a second sample, confirmatory factor analysis verified the fit of the brief, 8-item factor structure.

Conclusions

Findings suggest that a modified, brief version of the ATOP (ATOP-Heigher Weight; ATOP-HW) with neutral language is suitable for assessing negative attitudes about higher-weight people. The ATOP-HW may slightly underestimate weight stigma compared to the original ATOP, or the language in the ATOP may magnify negative attitudes. Further examination of the terminology used in weight stigma measures is needed to determine how to best assess weight stigma without reinforcing stigmatizing attitudes. The present study's findings suggest that the use of neutral terms in measures of anti-fat bias is a promising solution that warrants further investigation.

Does Terminology Matter When Measuring Stigmatizing Attitudes About Weight? Validation of a Brief, Modified Attitudes Toward Obese Persons Scale

Objective Commonly used terms like "obese person" have been identified as stigmatizing by those with lived experience. Thus, this study sought to revise a commonly used measure of weight stigmatizing attitudes, the Attitudes Toward Obese Persons (ATOP) scale. Methods The original terminology in the 20-item ATOP (e.g., "obese") was compared to a modified version using neutral terms (e.g., "higher weight"). Participants ( N  = 832) were randomized to either receive the original or modified ATOP. Results There was a statistically significant difference, with a low effect size ( d =-0.26), between the scores of participants who received the original ATOP ( M  = 69.25) and the modified ATOP ( M  = 72.85), t (414) = -2.27, p  = .024. Through principal component analysis, the modified ATOP was found to be best used as a brief, 8-item unidimensional measure. In a second sample, confirmatory factor analysis verified the fit of the brief, 8-item factor structure. Conclusions Findings suggest a modified, brief version of the ATOP (ATOP-Heigher Weight; ATOP-HW) with neutral language is suitable for assessing negative attitudes about higher-weight people. The ATOP-HW may slightly underestimate weight stigma compared to the original ATOP. Further examination of the terminology used in weight stigma measures is needed to determine how to best assess weight stigma without reinforcing stigmatizing attitudes. The findings of the present study suggest that the use of neutral terms in measures of anti-fat bias is a promising solution that warrants further investigation.

Improving Weight Bias Awareness Among Providers in the Sexual and Reproductive Health care Setting

Introduction

Provider bias against patients of higher weights can contribute to poor health outcomes and decreased quality of care and patient experience. Addressing weight stigma in sexual and reproductive health settings is important, as these encounters can often be patients' only health care touchpoint. Health care providers must be educated about the harms of weight stigma, ways to recognize and confront their biases, and how to advocate for patients of all sizes.

Methods

In this quality improvement project, Planned Parenthood health center providers participated in a three-part virtual workshop to improve provider weight bias awareness and understanding using the Health at Every Size framework. Providers completed a pre- and post-survey, as well as a 3-month follow-up survey to assess changes in bias awareness and confidence in applying weight-neutral principles in care interactions.

Results

Analysis of pre- and post-survey results showed significant improvements in provider awareness of bias as well as changes in implicit bias scores and confidence providing weight-neutral care.

Conclusion

Educating providers about weight contributes to equity of care for patients of higher weights. Formal education such as workshops have the potential to reduce the harms of weight stigma in health care as changing attitudes and confidence are a precursor to behavior change. Research is needed to assess ideal education modalities and whether receiving care from weight bias-prepared providers affects patient outcomes and experiences.

Determining Associations Among Health Orientation, Fitness Orientation, and Attitudes Toward Fatness in Physiotherapists and Physiotherapy Students Using Structural Equation Modeling

Purpose

Research suggests physiotherapists hold negative attitudes and beliefs toward fatness and fat people. Physiotherapists are also health-conscious, and invested in healthy lifestyle behaviours including physical activity. Our purpose was to describe relationships between health orientation, fitness orientation, and fat attitudes.

Methods

Physiotherapists (n = 187) and physiotherapy students (n = 34) completed an online survey (Health Orientation Scale, Multidimensional Body-Self Relations Questionnaire, Fat Attitudes Assessment Toolkit). Structural equation modeling estimated associations between fat attitudes (dependent variable) and health and fitness orientation (independent variables).

Results

Participants scored high in orientation toward fitness and health. We found strong positive associations between fitness orientation and health orientation (p < 0.001). Health orientation was not significantly associated with fat attitudes (p = 0.075), whereas increased age was associated with more positive fat attitudes (p < 0.01). Although most participants acknowledged that factors outside an individual's control contribute to body weight, many also agreed with normative negative perspectives.

Conclusions

Physiotherapists are highly oriented toward fitness and health. This may underlie beliefs in the controllability of body weight and contribute to negative attitudes toward fatness and fat people. Further research, with greater sample sizes is necessary to further investigate associations between health orientation and fat attitudes.

Disparities in Mistreatment During Childbirth

Importance

Lack of respectful maternity care may be a key factor associated with disparities in maternal health. However, mistreatment during childbirth has not been widely documented in the US.

Objectives

To estimate the prevalence of mistreatment by health care professionals during childbirth among a representative multistate sample and to identify patient characteristics associated with mistreatment experiences.

Design, Setting, and Participants

This cross-sectional study used representative survey data collected from respondents to the 2020 Pregnancy Risk and Monitoring System in 6 states and New York City who had a live birth in 2020 and participated in the Postpartum Assessment of Health Survey at 12 to 14 months' post partum. Data were collected from January 1, 2021, to March 31, 2022.

Exposures

Demographic, social, clinical, and birth characteristics that have been associated with patients' health care experiences.

Main Outcomes and Measures

Any mistreatment during childbirth, as measured by the Mistreatment by Care Providers in Childbirth scale, a validated measure of self-reported experiences of 8 types of mistreatment. Survey-weighted rates of any mistreatment and each mistreatment indicator were estimated, and survey-weighted logistic regression models estimated odds ratios (ORs) and 95% CIs.

Results

The sample included 4458 postpartum individuals representative of 552 045 people who had live births in 2020 in 7 jurisdictions. The mean (SD) age was 29.9 (5.7) years, 2556 (54.4%) identified as White, and 2836 (58.8%) were commercially insured. More than 1 in 8 individuals (13.4% [95% CI, 11.8%-15.1%]) reported experiencing mistreatment during childbirth. The most common type of mistreatment was being "ignored, refused request for help, or failed to respond in a timely manner" (7.6%; 95% CI, 6.5%-8.9%). Factors associated with experiencing mistreatment included being lesbian, gay, bisexual, transgender, queer identifying (unadjusted OR [UOR], 2.3; 95% CI, 1.4-3.8), Medicaid insured (UOR, 1.4; 95% CI, 1.1-1.8), unmarried (UOR, 0.8; 95% CI, 0.6-1.0), or obese before pregnancy (UOR, 1.3; 95% CI, 1.0-1.7); having an unplanned cesarean birth (UOR, 1.6; 95% CI, 1.2-2.2), a history of substance use disorder (UOR, 2.6; 95% CI, 1.3-5.1), experienced intimate partner or family violence (UOR, 2.3; 95% CI, 1.3-4.2), mood disorder (UOR, 1.5; 95% CI, 1.1-2.2), or giving birth during the COVID-19 public health emergency (UOR, 1.5; 95% CI, 1.1-2.0). Associations of mistreatment with race and ethnicity, age, educational level, rural or urban geography, immigration status, and household income were ambiguous.

Conclusions and Relevance

This cross-sectional study of individuals who had a live birth in 2020 in 6 states and New York City found that mistreatment during childbirth was common. There is a need for patient-centered, multifaceted interventions to address structural health system factors associated with negative childbirth experiences.

Is Obesity a Cause for Shame? Weight Bias and Stigma among Physicians, Dietitians, and Other Healthcare Professionals in Poland-A Cross-Sectional Study

Weight bias and weight stigma pose significant challenges in healthcare, particularly affecting obesity management practices and patient care quality. Our study evaluates their prevalence and impact among healthcare professionals in Poland. Using the Fat Phobia Scale and custom questions, we surveyed 686 professionals via Computer-Assisted Web Interview (CAWI). Results reveal a moderate level of explicit weight bias (mean score: 3.60 ± 0.57), with significant variations across professional groups: physicians (3.70 ± 0.48), dietitians (3.51 ± 0.48), and others (3.44 ± 0.77). Common feelings towards individuals with obesity include willingness to help (57.0%) and compassion (37.8%), yet 29.9% perceive obesity as shameful. The results also vary depending on the respondent's sex or BMI. These findings underscore the need for evidence-based interventions to mitigate weight stigma and enhance understanding of obesity among healthcare professionals.

Mitigating Weight Bias in the Clinical Setting: A New Approach to Care

Weight bias toward patients in larger bodies is pervasive among health care providers and can negatively influence provider-patient communication, as well as patients' behavior and health outcomes. Weight bias has historical roots that perpetuate thinness and Whiteness as the cultural norm. Although weight bias remains socially acceptable in US culture, contributing factors to an individual's body size are complex and multifactorial. Providers and health care systems also consistently use body mass index (BMI) as an indicator of health status, despite its limitations and harmful effects in the clinical setting. This state of the science review presents 8 evidence-based strategies that demonstrate how to mitigate harm from weight bias and improve quality of care and health outcomes for patients living in larger bodies. Person-centered approaches to care include (1) eliminating clinical recommendations to lose weight; (2) shifting from a focus on weight to health; (3) implementing a size and weight-inclusive approach; (4) engaging in weight bias self-evaluation; (5) creating a welcoming environment for patients of all sizes; (6) seeking permission and learning the patient's story; (7) using weight-inclusive language; and (8) re-evaluating clinical guidelines and policies based on BMI. Midwives and other health care providers may benefit from training that re-imagines the delivery of health care to patients in larger bodies.

Comparisons of Explicit Weight Bias Across Common Clinical Specialties of US Resident Physicians

BACKGROUND

Patients with high body weight are persistently stigmatized in medical settings, with studies demonstrating that providers endorse negative stereotypes of, and have lower regard for, higher-weight patients. Very little is known about how this weight bias varies across specialties.

OBJECTIVE

The purpose of this study is to examine how explicit weight bias varies between resident providers among sixteen of the largest residency specialties in the USA. The identification of these differences will guide the prioritization and targeting of interventions.

DESIGN

The current study utilized cross-sectional, observational data.

PARTICIPANTS

Forty-nine allopathic medical schools were recruited to participate in this national, longitudinal study. The current study utilized data from 3267 trainees in Year 2 of Residency among those who specialized in one of the most common sixteen residency programs in 2016.

MAIN MEASURES

Participants reported demographic information and residency specialties and completed three sets of measures pertaining to explicit weight bias.

KEY RESULTS

A significant minority (13-48%) of residents reported slight-to-strong agreement with each anti-fat statement. There was a significant relationship between residency specialty and anti-fat blame (F(15, 3189 = 12.87, p < .001), η2 = .06), anti-fat dislike (F(15, 3189 = 7.01, p < .001), η2 = .03), and attitudes towards obese patients (F(15, 3208 = 17.78, p < .001), η2 = .08). Primary care residents (e.g., family medicine, pediatrics) consistently reported lower levels of weight bias than those in specialty programs (e.g., orthopedic surgery, anesthesiology).

CONCLUSIONS

This study is the first to report on weight bias in a large, heterogeneous sample of US resident physicians. Problematic levels of weight bias were found in all specialties, with residents in specialty programs generally reporting more bias than those in primary care residencies. Future research should examine which factors contribute to these differences to guide intervention.

Oops I did it (again): Patient experiences of complications after non-invasive cosmetic procedures

Whereas several quantitative studies have measured the impact of complications after cosmetic procedures on patients' lives, little qualitative research is available. To address this gap, we interviewed 20 patients attending a special filler complication consultation hour in the Netherlands. We conducted a reflexive thematic analysis, which resulted in three main themes: (1) complications: a patient's journey; (2) complications: the impact of procedures gone wrong; and (3) complications: a filler-free future? Throughout the interviews, the multifaceted impact of the complications was illustrated, which ultimately also demonstrated participants' negotiation of (negative) experiences with complications after cosmetic procedures within a neoliberal, consumerist environment. Within this context, particular discourses were advanced as others were obscured and/or rejected. Most significantly, issues of stigmatization and shame were tangible throughout the interviews as participants felt they (must) accept responsibility for the consequences of their own consumerist decision to undergo cosmetic procedures. Moreover, the participants' decision to undergo further cosmetic procedures after their complication illustrate the normality, or even normativity, of contemporary beauty practices. A final note regards some important implications for the industry in relation to providing adequate complication care.

New understandings meet old treatments: putting a contemporary face on established protocols

In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.

Body (dis)satisfaction and health screening behaviors: A systematic review of observational studies

Engagement in health-promoting behaviors has been argued to be dependent on psychological factors in addition to simply having knowledge or access to resources. We systematically reviewed the evidence for the association between body (dis)satisfaction and health screening behaviors using six electronic databases and supplementary manual searches in the current study. To be included in the review, studies had to be empirical, in any language, and examined the potential link between body (dis)satisfaction and health screening. Findings from the final 16 quantitative and 12 qualitative studies generally suggest that people who were more satisfied or less dissatisfied with their bodies were more likely to engage in health screening. This review also highlighted key gaps in the literature such as the limited studies that included men as participants and the lack of examination of the underlying mechanisms and contingencies of the relationship between body (dis)satisfaction and health screening behaviors.

Raising awareness of anti-fat stigma in healthcare through lived experience education: a continuing professional development pilot study

BACKGROUND

Anti-fat attitudes and weight-based discrimination are prevalent in healthcare settings and among healthcare practitioners and clinical trainees, and can result in immense harm to patients. There is increasing recognition that anti-fat bias in healthcare is a critical issue that must be addressed, but there is a dearth of evidence demonstrating sustained attitude and behavioural change among clinicians, illustrating a need for more innovative educational approaches and rigorous evaluation. We describe the co-design and delivery of a narrative-based continuing professional development curriculum aimed at raising awareness of weight-based bias and stigma.

METHODS

Our research team of lived experience educators, clinicians and researchers collaboratively developed a series of seven podcast episodes comprised of narrative descriptions of lived experiences with and impacts of weight bias, stigma and discrimination in healthcare settings, as well as a post-podcast workshop to facilitate reflection and discussion between participants. The curriculum was piloted among 20 clinicians practicing at a large urban hospital in Mississauga, Canada. We explored feasibility, acceptability and learning impact by analyzing responses to questionnaires completed following each podcast episode and responses shared during the workshops and follow-up feedback sessions.

RESULTS

We observed high acceptability and feasibility of the curriculum. Participants experienced the podcast as a practical and convenient learning format and the workshop as a valuable opportunity to collectively debrief and reflect. The learning impact of the curriculum was strong; participants described a range of emotions elicited by the podcasts, engaged in self-reflection, and expressed a desire to modify clinical approaches. Barriers to the application of learnings identified by participants include pervasiveness of the use of body mass index (BMI) as an indicator of risk and a criterion for referral; discomfort with difficult conversations; prevalent biomedical understandings about the association between weight and health; and clinicians' defensiveness.

CONCLUSION

This pilot study yielded promising findings and demonstrated potential impact on weight bias and stigma among healthcare providers. Necessary next steps include conducting larger scale, rigorous evaluations of the curriculum among broader populations, both health professions trainees and current healthcare providers.

Weight stigma in healthcare settings: the experience of Arab and Jewish bariatric surgery candidates in Israel

BACKGROUND

Weight-related stigma and discrimination are prevalent in our society with adverse biopsychosocial outcomes to people with obesity and morbid obesity. Studies suggest that weight bias in healthcare settings are quite prevalent, but there have been, as far as we know, lack of studies examining prevalence and correlates of weight bias experiences among bariatric surgery candidates in Israel. We aim to understand the nature and prevalence of weight stigma among bariatric surgery candidates. To identify differences between Jewish and Arab candidates. To examine the impact of weight stigma experiences on weight bias internalization (WBI).

METHODS

A cross-sectional study was performed among 117 adult bariatric surgery candidates from three hospitals in northern Israel (47.8% Jews, 82.4% females, average BMI 42.4 ± 5.2 Kg/meter2). Patients who agreed to participate completed a structured questionnaire on the same day that the bariatric surgery committee met. WBI was measured using a validated 10-item scale. Experiences of weight stigma were measured using items adapted from prior international studies.

RESULTS

About two thirds of the participants had at least one experience of weight stigma (teased, treated unfairly, or discriminated against because of their weight). As many as 75% of participants reported that weight served as a barrier to getting appropriate health care and as many as half of participants felt in the last year that a doctor judged them because of their weight. No significant differences were found between Arabs and Jews in the prevalence of weight stigma experiences and WBI. However, a trend towards more stigma experiences among Jews was noted. WBI was predicted by female gender and experiences of weight stigma, both in general and within healthcare settings.

CONCLUSIONS

Weight stigma towards bariatric surgery candidates in Israel is quite prevalent, and specifically in healthcare settings. It is important to adopt policy actions and intervention programs to improve awareness to this phenomenon among the general public and specifically among healthcare providers, as many healthcare providers may be unaware of the adverse effect of weight stigma and of ways in which they are contributing to the problem. Future studies may validate our findings using larger sample size and longitudinal design.

Women Veterans' Barriers to Care-Seeking for Cardiovascular Disease Prevention

BACKGROUND

Women veterans have a high prevalence of traditional and nontraditional risks for cardiovascular disease (CVD) including obesity and posttraumatic stress disorder. Experts from the U.S. Department of Veterans Affairs have called for actions to improve the cardiovascular health of this population. One approach is to assess women veterans' barriers to care-seeking for CVD prevention, to inform future intervention research.

OBJECTIVE

The objective of this study was to describe women veterans' barriers to care-seeking for CVD prevention, guided by the theory of care-seeking behavior and concept awareness.

METHODS

Using a cross-sectional, descriptive design, a national sample of 245 women veterans participated in an online survey about barriers to care-seeking. Participants provided narrative responses to open-ended items, endorsements to closed-ended items, and rankings of their top five barriers. Researchers conducted poststratification weighting of numerical data to reflect the women veteran population.

RESULTS

Narrative responses described unaffordable and inaccessible services, feeling harassed or not respected in healthcare settings, and lack of awareness of risks for CVD. Frequently endorsed barriers were unaffordable and inaccessible services. Frequently ranked barriers were feeling not respected in healthcare settings and clinicians not recommending CVD prevention.

DISCUSSION

Findings support concepts in theory of care-seeking behavior and concept awareness. Understanding women veterans' barriers to care-seeking for CVD prevention can inform clinicians and researchers as they address these barriers.

Memorable Messages About Fat Bodies Before, During, and After Pregnancy

Weight bias is prevalent for people in large bodies who are trying to conceive, pregnant, or postpartum. Using the theory of memorable messages as a framework, we explored the sources, valence, and content of messages that fat individuals (N = 237) recalled about their bodies before pregnancy through the postpartum stage. The most common source of memorable messages was healthcare providers, and most (77.2%) messages were negatively valenced. Thematic analysis revealed four overarching themes (fat mothers are bad mothers, denial of competent treatment, weight-normative commentary on fat bodies, and weight-inclusive counter-narratives). Our findings illuminate the significance of patient-practitioner communication across the pregnancy trajectory and highlight how counter-narratives can disrupt negative messages about fat pregnancy.

The Mental "Weight" of Discrimination: The Relationship between Perceived Interpersonal Weight Discrimination and Suicidality in the United States

Extant research has investigated the relationship between body weight and suicidality because obesity is highly stigmatized, leading to social marginalization and discrimination, yet has produced mixed results. Scholars have speculated that factors associated with body weight, such as weight discrimination, may better predict suicidality than body weight itself. We consider this possibility among a sample of 12,057 adult participants ages 33 to 43 in Wave V of the National Longitudinal Study of Adolescent to Adult Health through investigation of the relationships between weight discrimination and two dimensions of suicidality-suicide ideation and attempts. We also examine gender as a moderator of these relationships. We find that weight discrimination is positively associated with both suicide ideation and attempts, and this relationship is similar among men and women. Our findings underscore the need to address issues of weight discrimination in our society to better promote mental well-being.

Effectiveness of a Scalable mHealth Intervention for Children With Overweight and Obesity

Background: Multicomponent interventions are the first line of treatment for pediatric obesity, but are challenging to access. Mobile health (mHealth) interventions hold promise as they address commonly cited barriers for attending in person programs and have potential for wide scale dissemination. Methods: This retrospective cohort study examined data from youth who enrolled in the Kurbo program, which includes personal health coaching and a mobile app. Hierarchical linear regression was used to examine the impact of baseline percentage of the 95th% percentile for body mass index (%BMIp95), number of coaching sessions, and length of time enrolled in the program on change in %BMIp95, controlling for baseline age and sex. Results: A total of 3500 youth (mean age of 12.79 years, 71.3% female) were included. Youth experienced a 0.70 U decrease in BMI [standard deviation (SD) = 2.19] and a 4.45% decrease (SD = 8.5) in %BMIp95 over a mean of 31.5 weeks. The overall regression model was significant, R2 = 0.066, F(3,3494) = 77.18, and p < 0.001. Predictors of decrease in weight status included being female (b = -1.11, p < 0.001), higher baseline %BMIp95, (b = -0.58, p < 0.001), and greater number of coaching sessions (b = -0.12, p < 0.001), while greater time enrolled in the program (b = 0.02, p < 0.001) was associated with less change. Conclusion: Findings suggest a scalable coaching program with integrated digital tools for monitoring diet and activity can lead to significant reductions in weight status. Findings need to be replicated with more rigorous study designs, including a comparison condition and verified assessment of height and weight.

Validating the Sociocultural Influences on Fear of Fat Scale (SI-FAT) on a racially and ethnically diverse sample of college women

The fear of fat, or fear of gaining weight, is conceptually related to both weight stigma and eating disorders. Since sociocultural pressures related to the thin ideal are important to examine within sociocultural models of body image, the Sociocultural Influences on Fear of Fat (SI-FAT) was created and validated on a sample of predominantly White college women. The purpose of this study was to examine the factor structure of the SI-FAT in a sample of racially and ethnically diverse college women, given potential differences in experiences of fear of fat and the need to measure sociocultural pressures related to fear of fat in multiple groups. A sample of college women (72.8% Hispanic/Latina, 14.85% Black, and 12.35% White) completed the SI-FAT as well as measures of weight stigma and body image. Results suggested that the factor structure of the SI-FAT were consistent across racial and ethnic groups. These findings indicate that the SI-FAT is appropriate for use among racially and ethnically diverse samples of young women. Directions for future research, including examining differences between sociocultural pressures related to weight gain and self-reported fear of fat are discussed.

The role of stigma and depression in the reduced adherence among young breast cancer patients in Hungary

BACKGROUND

The main aim of our study was to investigate the role of depression, stigmatization, body shame and self-compassion in the adherence of young Hungarian breast cancer patients aged between 18 and 45 years.

METHODS

In a cross-sectional online survey, data were collected from 99 young breast cancer patients (BC). Participants completed self-report questionnaires on socio-demographic and cancer-specific parameters as well as psychological factors (adherence: 12-item Medication Adherence Scale; depression: Hospital Anxiety and Depression Scale; stigmatization: Stigma Scale for Chronic Illnesses; body shame: Experience of Shame Scale; self-compassion: Self-Compassion Scale). We tested the predictors and mediators of adherence using hierarchical regression, mediation and moderation analysis among BC patients.

RESULTS

We found that adherence was significantly associated with body shame and stigmatization in our BC sample. In addition, stigmatization alone was a significant predictor of lower adherence. Finally, in mediation models, where body shame was a mediator, we found a significant direct effect between stigma and adherence, in other words body shame had a significant mediating effect between these variables. According to our moderation analysis, self-compassion as a significant moderator acts as a protective factor in the linear relationship between stigma and lower adherence.

CONCLUSIONS

Our results highlight the importance of stigma and body shame in the development of adherence in oncological care among young Hungarian BC patients aged between 18 and 45 years. Assessment of stigma, body shame, self-compassion, and the improvement of the availability of evidence-based psychological interventions may increase the adherence of young Hungarian BC patients, leading to more favourable rates of survival.