Weight stigma is stressful. A review of evidence for the Cyclic Obesity/Weight-Based Stigma model

Testing interoceptive dysfunction as a mediator of the relation between weight stigma and disordered eating

Interoceptive dysfunction could be one mechanism that facilitates the weight stigma-disordered eating association. Hence, the aim of this study was to experimentally test whether interoceptive dysfunction mediates the relation between weight stigma and disordered eating. Participants (n = 135; 80.7 % White; 72.6 % women) were college students aged 18 to 25 who reported binge eating symptoms. Participants (n = 66) were randomly assigned to interact with a confederate showing weight stigmatizing attitudes or a control condition (n = 69) where the confederate did not show stigma towards any groups. Participants then completed a behavioral measure of gastric interoception, completed an ad-lib test meal of yogurt, and lastly completed self-report measures for gastric interoception, body trust, and urges to engage in future binge eating and restriction. We tested a path model including our condition variable, behavioral and self-report measures of interoception, and disordered eating urges. Contrary to our hypotheses, exposure to weight stigma was not related to increased binge eating or restriction urges, and was related to less caloric consumption. Hence, it is possible that weight stigma leads to short-term restriction immediately following the event, which could increase risk for downstream binge eating at a later time. Regardless of condition, lower levels of self-reported body trust and gastric interoception were related to higher intentions for binge eating as well as restriction. To mitigate the potential societal harms of weight stigma, clinicians should consider incorporating interoception assessments and weight-neutral approaches to their clinical work.

Changes in Healthcare Professionals' Practice Behaviors Through an Educational Intervention Targeting Weight Bias

OBJECTIVE

Weight bias is pervasive in healthcare and leads to worse patient outcomes. A uniquely designed 4-h continuing medical education (CME) intervention was assessed for changing healthcare professionals' (HCPs') weight biases and clinical practice behaviors.

DESIGN

The intervention used a (1) pre/post design examining CME attendees' self-reported weight bias at baseline, after, and 4- and 12-month follow-up, and (2) post/post design examining obesity practice behaviors 12 months after intervention in attendees and non-attendees.

SETTING

Single medical center service area within Kaiser Permanente Southern California.

PARTICIPANTS

All HCPs (n = 472) from the target service area were eligible to attend. Analyses were done with 218 HCPs who attended and 89 who did not.

METHODS AND ANALYSIS

The intervention contained theory-based elements of changing attributions of responsibility of obesity, increasing empathy, creating self-awareness of weight bias, and creating a bias-free culture. For pre/post analyses, the primary outcome was self-reported weight bias. For comparative analyses of CME attendees and non-attendees, the outcomes were electronic medical record-confirmed rates of obesity diagnosis and referrals to evidence-based obesity treatments in the 12 months following the CME intervention.

RESULTS

Self-reported negative obesity stereotypes were significantly reduced compared to baseline while self-reported empathy and confidence in caring for patients with obesity were significantly increased immediately post intervention and were maintained at 4- and 12-month follow-up. After adjusting for years in practice, race/ethnicity, gender, profession type, practice type, and panel size, HCPs who attended the CME intervention had significantly increased odds (range 60-212%) of diagnosis and obesity-related referrals in the 12 months following the CME intervention when compared to HCPs who did not attend.

CONCLUSION AND RELEVANCE

This intervention has promise to be a scalable program that goes beyond impacting HCP's self-reported weight bias and also changes HCPs' clinical practice behaviors related to obesity treatment.

Perceived weight stigma and disordered eating behaviors among postpartum women: The mediating role of weight bias internalization and postpartum depression

Background

Weight stigma is linked to adverse effects, but whether it directly heightens the risk of disordered eating behaviors or psychological factors mediate this connection among postpartum women is uncertain.

Objectives

To investigate the relationship between perceived weight stigma and disordered eating behaviors (restrained eating, emotional eating, and external eating) and identify the mediating role of weight bias internalization and postpartum depression (PPD).

Methods

This cross-sectional study involved 507 postpartum women. Data were collected anonymously using self-reported questionnaires, including the Perceived Weight Stigma Questionnaire, Weight Bias Internalization Scale, Edinburgh Postpartum Depression Scale, and Dutch Eating Behavior Questionnaire. Data were analyzed using descriptive statistics, Pearson's correlation analysis, hierarchical linear regression, and mediation analysis.

Results

The results showed that the relationship between perceived weight stigma and disordered eating behaviors was fully mediated by weight bias internalization and PPD. Specifically, perceived weight stigma was associated with greater weight bias internalization, which was associated with greater PPD, and greater PPD was associated with greater disordered eating behaviors.

Conclusion

This may be the first study to propose a chain mediation model exploring the roles of weight bias internalization and PPD in the relationship between perceived weight stigma and disordered eating behaviors among postpartum women. The findings enhance the understanding of the psychological impacts of perinatal weight stigma and underscore the importance of addressing weight stigma in postpartum care. Comprehensive interventions should be developed to enhance postpartum health and reduce the risk of disordered eating behaviors.

Examining the reciprocal associations of muscularity bias internalization with muscularity-oriented disordered eating, muscle dysmorphia symptoms, and eating-related psychosocial impairment in Chinese adults

Emerging empirical evidence supports muscularity bias internalization as a close correlate of muscularity-oriented disordered eating, muscle dysmorphia symptoms, and eating-related psychosocial impairment. However, there is a lack of research investigating the longitudinal links of muscularity bias internalization with these related variables. Drawing on longitudinal research evidence from weight bias internalization supporting reciprocal associations with biopsychosocial outcomes, the present study examined the reciprocal associations of muscularity bias internalization with muscularity-oriented disordered eating, muscle dysmorphia symptoms, and eating-related psychosocial impairment. An online sample of 799 Chinese adults (400 men and 399 women; baseline Mage=29.96 years) provided data at baseline (T1) and six months later (T2). Cross-lagged regression analyses were conducted. Results showed that muscularity bias internalization had reciprocal associations with these three variables. Specifically, muscularity bias internalization at T1 was associated with higher muscularity-oriented disordered eating, muscle dysmorphia symptoms, and eating-related psychosocial impairment at T2. Also, higher muscularity-oriented disordered eating, muscle dysmorphia symptoms, and eating-related psychosocial impairment at T1 were associated with higher muscularity bias internalization at T2. Findings suggest cyclic associations between muscularity bias internalization and muscularity-oriented disordered eating, muscle dysmorphia symptoms, and eating-related psychosocial impairment, and interventions targeting muscularity bias internalization may be a promising strategy to reduce muscularity-related psychopathology.

Muscularity stigma: An overlooked but important form of appearance stigma

Appearance stigma is a pervasive form of social stigma linked to various adverse biopsychosocial outcomes. Research in this domain has predominantly focused on one aspect of physical appearance: body weight or size (i.e., weight stigma). Muscularity is another essential dimension of physical appearance, and individuals can have both experienced and internalized stigma due to muscularity (i.e., muscularity stigma). However, muscularity stigma remains understudied. Given that ideal body shapes are defined by both thinness and muscularity, there are societal stereotypes related to muscularity, and existing evidence supports the close links between muscularity stigma and eating and body image disturbances, we call for more research on muscularity stigma. To support future research in this area, we discuss potential mechanisms linking muscularity stigma to eating and body image and outline potential research directions on muscularity stigma to advance this literature.

Understanding Differences in Medical Student Perceptions of Treatment Adherence Based on Weight Status in Pediatric Care

Obesity biases in healthcare are detrimental. We explored medical student beliefs underlying perceptions that child-mother dyads with obesity are less likely to be treatment adherent. Participants viewed scenes of a 12-year-old, female virtual human presenting to a physician with back pain, accompanied by her mother. Patient and mother weight cues were manipulated across scenes. Out of 120, 35 participants perceived dyads with obesity as less adherent to hypothetical pain-related treatment recommendations relative to dyads with healthy weight. These participants were informed and asked why. Responses were analyzed for themes. Fifty-two responses revealed three codes relating to participants' explanation of why they perceived lower adherence for dyads with obesity-obesity is associated with: 1) non-compliance with general health recommendations, 2) internal traits/factors (i.e., mothers' less health consciousness, mental strength), 3) external factors (i.e., lower health literacy, socioeconomic status). The association of obesity with lower adherence is a bias that may exist among medical students and originate from assumptions about prior health adherence and maternal traits, some disparaging in nature. Such bias has potential to contribute to healthcare disparities. Findings highlight the utility of qualitative methods to understand beliefs driving perceptions and design bias-reducing interventions to trainee needs.

Impacts of Diabetes Stigma on Acute Health Care Utilization Among Adults With Type 2 Diabetes

PurposeThe purpose of this study was to examine the relationships between diabetes stigma, patient activation, and acute health care use. It was predicted that greater diabetes stigma would be associated with lower patient activation and greater likelihood of acute health care utilization.MethodsPrimary data were collected cross-sectionally using a web-based panel of US adults with type 2 diabetes (N = 371). Participants were screened for eligibility by providing informed consent, reporting a type 2 diabetes diagnosis from a health care provider, and passing an end-of-survey check to corroborate participants' initial self-reported diagnosis of type 2 diabetes. The Diabetes Stigma Assessment Scale, with its 3 subscales, assessed blame and judgment, perceived discrimination, and self-stigma associated with having diabetes. Patient activation was measured using the Patient Activation Measure. The frequency of diabetes-related emergency department visits and hospitalizations during the prior 12 months measured acute health care use.ResultsSelf-stigma was significantly associated with lower levels of patient activation, and blame and judgment and perceived discrimination were not. Perceived discrimination was also significantly associated with greater risk of emergency department visits and hospitalizations, and self-stigma and blame and judgment were not associated with either indicator of acute health care use.ConclusionsResults suggest self-stigma is associated with lower levels of patient activation and that perceived discrimination is related to increased use of acute health care. Future research may examine avenues to reduce diabetes stigma and its effect on patient activation and acute health care utilization.

Evaluating population attributable fractions of cardiovascular diseases in relation to 20-year body mass index; the ATTICA study (2002-2022)

BACKGROUND/OBJECTIVES

The growing prevalence of overweight and obesity globally highlights the need to reconsider the thresholds for defining excess body weight, especially as the health risks associated with weight gain continue to impact population health metrics. This study aimed to evaluate the population attributable fraction (PAF) and prevented fraction for the population (PFP) of CVD cases by body weight trajectories over a 20-year period (2002-2022).

SUBJECTS/METHODS

The studied population-based sample was 1348 individuals (39(10) years old, 48% males), initially free-of-CVD, from the ATTICA cohort study (2002-2022). Combined fatal/non-fatal CVD outcomes were evaluated; body weight and height measurements were performed in 2002, 2012, and 2022 examinations, following standard procedures. Body weight trends, based on cumulative average BMI during 2002-2022, were also calculated. PAF and PFP were computed.

RESULTS

Twenty-nine percent (95%Confidence Interval: 22%, 35%) of CVD cases were prevented by maintaining a normal body weight status during 2002-2022. If increased BMI (>25 kg/m2) had been eliminated, 30% (8.7%, 38%) of CVD cases would have been prevented. Three-times more CVD cases would have been prevented if overweight had been managed compared to if obesity had been managed [i.e., 23% (5.1%, 29%) vs 7.2% (1.1%, 9.1%), respectively]. Variations of the PAFs and PFPs were observed by sex, age group, Mediterranean diet adherence, physical activity status, presence of comorbidities, and anxiety trajectories.

CONCLUSIONS

Future public health actions should not neglect to also include people with overweight for the effective management of body weight, which can offer significant long-term benefits for cardiovascular health. A graphical representation of the main study findings on population prevented and attributable fractions by long-term body weight status (n = 1348); the ATTICA study (2002-2022). CVD cardiovascular disease.

Weight-based discrimination and cortisol output: A systematic review

Discrimination based on weight status (or weight-related discrimination/stigma) may be related to greater physical and mental health concerns via physiological and psychological phenotypes of stress. Cortisol output, a biomarker of stress, has been measured in relation to weight stigma and weight-related discrimination. This systematic review aims to synthesize existing research on the relationship between weight-related discrimination and cortisol output, evaluate methodological approaches for measuring these constructs, and identify research gaps regarding contextual factors influencing this relationship. A comprehensive search was conducted across multiple databases (PsycINFO, Scopus, ProQuest, and PubMed) from February 1 to July 1, 2024, resulting in 11 eligible studies that examined weight discrimination in relation to cortisol levels. Studies were assessed for quality using the NHLBI Study Quality Assessment Tool, and inter-rater reliability for coding was established at 90 %. The findings revealed a range of sample sizes (45-4341) and diverse participant characteristics, including variations in age, race, and body mass index (BMI). About half (N = 5) of the included studies reported a positive relation between weight stigma and cortisol output. The review also uncovered significant limitations in current methodologies, particularly concerning contextual factors and other marginalized identities, such as socioeconomic status and food insecurity, along with measuring other forms of discrimination in tandem with weight stigma, such as racial discrimination. These findings underscore the need for future research to adopt a more intersectional approach in examining the multifaceted nature of weight stigma and how it relates to a greater stress response in multiple marginalized identities, as well as including longitudinal modeling of weight stigma's impact on biomarkers for stress.

The Effect of Parent-Targeted Obesity Messaging on Parental Weight Talk Intention: A Randomized Controlled Experiment

It is unknown if parent-targeted health messages about childhood obesity affect parental weight communication with children (e.g., encouraging a child to diet). This randomized, controlled, online experiment assessed the effects of exposure to different message frames on parental intentions to 1) engage in weight communication with their child and, 2) follow the health advice in the message. A diverse sample of U.S. parents (N = 452) were randomly assigned to one of three conditions: 1) a mock news article emphasizing childhood obesity (weight-framed message) with health behavior advice for parents; 2) an article with identical health behavior advice for parents, but framed within the context of improving children's school performance (school-framed message); and 3) a no-treatment control group. Following message exposure, parents completed online surveys assessing their intention to engage in weight communication and the recommended health behaviors. Hierarchical linear regression was used to assess the relationship between experimental condition and the outcome variables. Parents in the weight-frame condition were significantly more likely to report intention to engage in weight communication with their child than parents in the control group, while there was no difference between the school-frame condition and the control group. Parents in both message conditions were equally likely to report intention to adopt the health advice, but parental weight-based self-stigma moderated the relationships. Parent-targeted health advice that features childhood obesity may encourage parents to engage in weight communication with their children. Our findings can inform the development of health messages targeting parents about children's weight-related health.

Risk of severe obesity development: Examining the role of psychological well-being related measures and sociodemographic factors in two longitudinal UK cohort studies

OBJECTIVE

To examine the prospective association between psychological well-being related measures and severe obesity development in young and middle-aged UK adults.

DESIGN

A longitudinal analysis of two cohort studies.

METHODS

We used data from the 1958 National Child Development Study (NCDS) and the 1970 British Cohort Study (BCS) to examine the association between baseline psychological well-being related measures (depressive symptoms, life satisfaction and self-efficacy) and severe obesity development (defined as body mass index - BMI ≥35 kg/m2) and residualized BMI change scores at follow-up. We analysed repeated measures of baseline and follow-up pairs with 6- to 7-year follow-up on average (n = 22,390 and 23,811 observations in NCDS and BCS, respectively) using panel data logistic and linear models controlling for sociodemographic factors. We conducted additional analyses using analytical sample sizes with longer follow-up (16-17 years).

RESULTS

Although a range of sociodemographic factors (e.g., being female, non-married) were associated with increased risk of severe obesity development, we found limited evidence that psychological well-being related measures were associated with severe obesity development across cohorts and pooled analyses. Depressive symptoms, life satisfaction and self-efficacy were, however, associated with relatively small changes in continuous BMI change across analyses, and this tended to be limited to participants without obesity (BMI 18.5 to <30 kg/m2) and not those already living with obesity (BMI 30 to <35 kg/m2) at baseline.

CONCLUSIONS

There is limited evidence that psychological well-being related measures prospectively predict the development of severe obesity. Poorer psychological well-being is associated with modest changes in body weight in individuals without obesity.

An interpretative phenomenological analysis of lived experiences and psychological processes in internalized weight stigma

OBJECTIVE

Internalized weight stigma (IWS) refers to the internalization of societal weight-based prejudices. While research on external weight stigma is well-established, the psychological mechanisms underlying IWS remain underexplored. This study aims to provide a deeper understanding of IWS by examining the lived experiences of individuals with obesity and identifying key psychological processes contributing to IWS.

DESIGN

A qualitative design was employed, using both in-depth interviews and photo-elicitation to explore the lived experiences of nine participants.

METHODS

Participants were invited to take pictures of situations which made them feel stigmatized about their body size during a 2-week-long photography task. Subsequently, participants reflected on the implications of their photographs during a 60-minute research interview. IPA was used to guide the analysis of the interview data.

RESULTS

Four key psychological processes contributing to IWS were identified: (1) Self-application of negative stereotypes, where participants internalized societal stigma, sometimes resisting it but still experiencing self-critical thoughts; (2) Imposition of an undesired identity, where societal labels restricted self-expression, leading participants to adopt socially acceptable personas; (3) Heightened anxiety and social vigilance, where participants experienced anxiety, hyper-awareness, and discomfort in public settings; and (4) Distress and coping, where emotional distress and coping strategies like social withdrawal appeared to reinforce IWS.

CONCLUSIONS

These findings extended existing literature by providing a data-driven conceptualization of IWS. The findings underscore the importance of developing psychological interventions that address both IWS and external societal weight stigma, focusing on strategies that challenge self-critical narratives and promote more adaptive self-concepts.

Human adaptation response to obesity

This article examines the human body's adaptive responses to obesity from biological, behavioral, and evolutionary perspectives. It explores how ancient survival mechanisms, such as fat storage during scarcity, have persisted but become maladaptive in modern contexts of food abundance and sedentary lifestyles. Using the Thrifty Gene Hypothesis and General Adaptation Syndrome (GAS), the study investigates how chronic stress and genetic predispositions contribute to obesity. Chronic stress, as described in GAS, is linked to obesity through mechanisms like prolonged cortisol elevation, which promotes fat storage, particularly in the abdominal region, and disrupts hunger and satiety regulation. The article also explores the possibility that contemporary chronic stress may cause the body to buffer stressful conditions through fat accumulation. While the Thrifty Gene Hypothesis suggests that genetic traits evolved to optimize energy storage during scarcity, contributing to obesity in modern environments, it remains controversial. Critics argue that it oversimplifies obesity's causes, such as lifestyle and environmental factors. Although genetic variations influencing obesity susceptibility continue to evolve, the physiological mechanisms of fat storage and stress adaptation have remained largely unchanged since ancient times.

Dieting among a community sample of adults with chronic pain

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; Mage = 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.

Youth Perspectives on the Use of Medications for Weight Loss

PURPOSE

Semaglutide (Ozempic, Wegovy) has surged in popularity for its weight loss effects. Its widespread media coverage may have an outsized impact on adolescents and young adults due to their higher engagement in social media and their vulnerability to unintended consequences of weight-related discourse (e.g., body dissatisfaction, disordered eating, weight stigma). This study aimed to determine youth familiarity with and opinions about use of medications such as Ozempic and Wegovy for weight loss.

METHODS

Five open-ended questions were asked to 753 youth participants (14-24 years) in the MyVoice nationwide text message poll in March 2024. Responses were analyzed using content analysis and coding differences resolved by consensus. Differences by demographic characteristics were explored using chi-square tests.

RESULTS

Overall, 547 (73%) youth responded; average age was 20.4 ± 2.5 years, with 50.3% identifying as female. Nearly three-quarters (73.6%) had heard of medications like Ozempic and Wegovy, but the majority (57.5%) stated that these medications should not be used by youth. Three primary concerns arose: (1) safety; (2) inappropriate use; and (3) role of personal responsibility for healthy lifestyle (a belief that was more common among males than females or other gender).

DISCUSSION

Awareness about semaglutide was high, but perceptions of use were generally negative or hesitant, particularly among males, who emphasized the importance of healthy lifestyle behaviors. Hesitancy due to safety concerns and the role of weight stigma should be explored to determine the potential impact on users of such medications when medically indicated.

Incorporating Nondiet and Weight-Neutral Principles in a University Dietetics Curriculum

OBJECTIVE

To evaluate student attitudes toward nondiet, weight-neutral (NDWN) principles after reading Anti-Diet in a medical nutrition therapy (MNT) course.

DESIGN

A quasi-experimental design with no control group and a mixed-methods study approach.

SETTING AND PARTICIPANTS

Adult undergraduate students (n = 112) enrolled in an MNT course.

INTERVENTION

A traditional MNT course and reading Anti-Diet (January-May, 2021), which introduces multiple topics that support weight-inclusive approaches to health.

PHENOMENA OF INTEREST

Change in student agreement with NDWN principles. Written reflections were collected to determine students' rationale for their level of agreement.

ANALYSIS

Likert scale responses (1-5) of student ratings were analyzed with multivariate linear regression, a linear mixed-effect model, and a Wilcoxon signed rank test with continuity correction. Reflections were analyzed using thematic analysis methods. The triangulation methods compared quantitative and qualitative data.

RESULTS

Students ratings shifted significantly away from dieting for weight loss and toward agreement with NDWN principles (99.7) = 7.35, P < 0.001; mean difference = 0.83 with 95% confidence interval, 0.61-1.05. Two main themes emerged: (1) NDWN topics led to critical analysis of weight-centric knowledge, and (2) specific topics were more effective at shifting weight-based attributions.

CONCLUSIONS AND IMPLICATIONS

Incorporating specific NDWN principles in an undergraduate MNT curriculum can shift students' weight-based attributions. More systematic development and testing of anti-fat bias reduction curricula are needed to support broader dissemination and standardization in dietetics curricula.

Incorporating Weight-Inclusive Approaches in Higher Education Curriculum for Future Nutrition and Dietetics Professionals

While weight-inclusive approaches are becoming more widely accepted and used in nutrition and dietetics, educators and professionals often lack adequate training. The purpose of this paper is to provide faculty and preceptors with strategies to incorporate weight-inclusive approaches into nutrition and dietetics curricula. We present a framework for demonstrating how students can meet knowledge and competency requirements embedded in courses in nationally accredited nutrition and dietetics programs using a variety of weight-inclusive concepts and learning activities. Providing weight-inclusive approaches is essential for equipping nutrition professionals to offer patient-centered care that minimizes weight stigma and disordered eating.

Higher-weight social identity as a risk and protective factor in the negative health consequences of weight stigma: a systematic review

BACKGROUND

Weight stigma causes significant physical and psychological harm to its targets.

OBJECTIVE

This review aims to determine when identifying as a member of the higher-weight group exacerbates versus mitigates the adverse effects of weight stigma.

METHODS

Searches were conducted on 10 January, 2025, using PsycInfo, Medline, Scopus, Web of Science, Embase, and CINAHL. Evidence was synthesised in terms of exacerbating versus protective effects of higher-weight social identity (as moderator/mediator) in the relationship between weight stigma and 18 distinct health outcomes. This review is registered on PROSPERO (ID: CRD42023415639).

RESULTS

Fourteen studies met the inclusion criteria. Studies employing weight status measures to assess higher-weight social identity identified actual and self-perceived higher-weight as risk factors for anticipated rejection, dietary control challenges, increased physiological stress and greater functional disability following stigmatisation. Conversely, studies measuring individual connection with the higher-weight group revealed that stronger identification had protective effects on self-esteem and distress, but only for specific individuals (e.g., those with low internalised weight bias).

LIMITATIONS

Grey literature and unpublished studies were not reviewed.

CONCLUSIONS

Initial evidence suggests that higher-weight social identity functions as both risk and protective factor in the relationship between weight stigma and well-being.

IMPLICATIONS

Future research should explore the emotional and evaluative components of higher-weight social identity to enhance understanding of how and when group membership influences the adverse effects of weight stigma. This knowledge can inform targeted interventions designed to improve the well-being of higher-weight individuals.

Assessing Weight Stigma Interventions: A Systematic Review of Randomized Controlled Trials

PURPOSE OF REVIEW

The primary goals of this pre-registered systematic review were to critically evaluate the existing randomized controlled trials targeting weight stigma/bias and identify promising avenues for future research.

RECENT FINDINGS

Prior systematic reviews have highlighted intervention strategies such as shifting causal attributions of obesity, evoking empathy, deploying weight-inclusive approaches, increasing education, and combining these strategies. Here, we provide an updated systematic review of weight stigma interventions. A systematic search was conducted following the PRISMA guidelines and performed in PubMed/Medline, PubMed, PsycINFO, and Google Scholar until October 2024, yielding a final sample of 56 articles. In addition to previously established strategies, we identified several novel strategies, such as cognitive dissonance and connection building. Interventions can largely shift attitudinal outcomes, but future research should extend beyond attitude measures, assess weight bias over a longer term, and across more diverse populations.

The association of age of onset of obesity with experienced weight stigma in adulthood

BACKGROUND

Experienced weight stigma (EWS) is linked to adverse physical and mental health outcomes, including maladaptive health behaviors and attenuated weight loss in people with obesity. Limited research is available regarding the association between the age of onset and severity of obesity and lifetime experience of EWS among adults with obesity.

METHODS

Cross-sectional survey data (n = 686) from a single-site academic obesity medicine program was analyzed, including demographics, anthropometric measures, and the Stigmatizing Situations Inventory (SSI-B). The median SSI-B score was used to dichotomize the EWS outcome variable. Crude associations were assessed by chi-square and logistic regression analyses. Multivariable logistic regression determined age-adjusted odds ratios (aOR) of EWS with body mass index (BMI) at age 18 years and peak BMI.

RESULTS

Participants had a mean age of 55.8 years (SD = 12.7), and the majority were female and white. EWS was correlated with BMI at age 18 years (r = 0.38; p = 0.001) and peak BMI (r = 0.48; p = 0.001) before and after adjustment. Those with severe obesity (BMI ≥ 40) by 18 years had 2.79 times higher odds (aOR = 2.79; 95% CI: 1.38, 5.62; p < 0.01) of severe EWS vs. those who developed severe obesity after 18 years; 2.17 higher odds [aOR = 2.17; 95% CI: 1.08, 4.35; p = 0.009] of severe EWS versus those with BMI < 40 at 18 years; 2.98 times higher odds [aOR = 2.98; 95% CI: 1.44, 6.15; p = 0.001] of severe EWS vs. those with BMI < 30 at 18 years; and 4.06 times higher odds [aOR = 4.06; 95% CI: 1.39, 6.73; p = 0.001] of severe EWS vs. those with BMI < 25 at 18 years.

CONCLUSION

Those with severe obesity before the age of 18 years were nearly 3 times more likely to report severe EWS than people who developed severe obesity later in life. Healthcare providers should consider screening for EWS in people with early onset of severe obesity, to identify those who may benefit from weight stigma interventions and support.

Views Among the General Public on New Anti-Obesity Medications and on the Perception of Obesity as a Failure of Willpower

Background

The experience of obesity stigma is associated with negative clinical outcomes that include increased mental health problems and additional weight gain. Researchers have treated the public view that obesity is caused by poor willpower as both an element of obesity stigma and as a cause of obesity stigma. Here we test the hypothesis that awareness of new and effective glucagon-like peptide receptor agonist anti-obesity medications (AOMs) will encourage the view that obesity is a biologically-determined medical condition rather than a personal willpower failure and thereby lessen obesity stigma.

Materials and Methods

Two questionnaire studies, in which participants were randomly assigned to either read about the success of AOMs or to read various alternative material (N = 640 in total), investigated the effect that AOM awareness has on views of obesity.

Results

Contrary to the study hypotheses, reading about AOMs did not increase the degree to which participants viewed obesity as a medical condition, nor did it reduce the role willpower failure was believed to play in obesity. Across conditions, participants reporting more personal success in weight loss without medication indicated greater belief that obesity was amenable to self-control, expressed greater obesity stigma, and held less positive attitudes toward the use of AOMs to manage weight.

Conclusion

Taken together, these two studies provide no evidence that the success of AOMs will, in the short-term, lead to changes in how people view the etiology of obesity or to a reduction in obesity stigma. Correlational data suggest the possibility that blame and stigma associated with obesity may be robustly informed by participants' understanding of their own experiences managing weight.

Weight-Inclusive Physical Activity: A Systematic Evaluation of Virtual Resources

BACKGROUND

Higher-weight individuals report lower rates of physical activity behavior and poorer physical activity experiences compared with their normative-weight counterparts, likely owing to the pervasiveness of weight stigma in physical activity contexts. Employing weight-inclusive strategies may improve physical activity outcomes, though little is known about the practical application of weight-inclusive principles in physical activity contexts. Furthermore, given the prominence of virtual methods of information dissemination, exploring online weight-inclusive resources is valuable.

METHODS

Using Google, Instagram, and snowball searches, a virtual environmental scan was conducted to collect publicly available weight-inclusive physical activity resources. Two independent coders applied an a priori codebook to all eligible resources to evaluate the application of weight-inclusive principles.

RESULTS

N = 80 weight-inclusive physical activity resources were identified, offering a range of educational materials (40%) and/or provision of physical activity services (76.3%). Virtual resources generally adhered to weight-inclusive principles by showcasing diversity in body size, using weight-inclusive language, and centering physical activity that honors the body's signals and cues; however, some also included weight-normative content. Provisional physical activity resources primarily targeted diverse-bodied end users, offered a range of physical activity types (eg, yoga, weight training, and dance), were membership-based, and offered asynchronous access.

CONCLUSIONS

This study utilizes a systematic approach to collect and evaluate virtual, publicly available, and weight-inclusive physical activity resources. Virtual physical activity resources that adhere to weight-inclusive principles may be important for increasing accessible physical activity opportunities for higher-weight individuals.

Middle childhood weight stigmatization and appetite self-regulation as predictors of adolescent weight - A prospective mediation analysis

Children's weight is a common reason for stigmatization. The aim of this study was to examine the effect of weight stigmatization (WS) during middle childhood on adolescent weight and the role of appetite self-regulation (ASR) as a potential mediator. Across three measurement time points, the study utilized a community sample of N = 1612 participants (51.9% female), aged 7-11 (T1), 9-13 (T2), and 16-21 (T3). WS was assessed via child-reports, different ASR facets (food responsiveness, emotional overeating, satiety responsiveness, external eating) via parent-reports, and height and weight were measured to calculate the standardized body mass index (BMI-SDS). Structural equation modeling was used to analyze the proposed prospective mediation. A total of 11.2% of the children reported WS experiences, with significant differences between the weight groups. ASR fully mediated the prospective association between WS and BMI-SDS. Higher WS predicted higher food responsiveness, higher emotional overeating, and, among older children, lower satiety responsiveness. Additionally, higher food responsiveness predicted higher adolescent BMI-SDS, indicating a specific indirect effect. The total indirect and specific indirect effects for food responsiveness remained significant when controlling for the established influences of parental BMI and body dissatisfaction. Our results highlight a prospective effect of WS on ASR and propose ASR as a mediator for the association between WS and weight. WS and ASR might therefore be important factors for the prevention of overweight and obesity in children and adolescents.

Associations between phenotypes of childhood and adolescent obesity and incident hypertension in young adulthood

OBJECTIVES

We investigated whether empirically derived childhood obesity phenotypes were differentially associated with risk of hypertension in young adulthood, and whether these associations differed by sex.

METHODS

Data came from 11,404 participants in the Growing Up Today Study, a prospective cohort study in the US established in 1996. We used a childhood obesity phenotype variable that was previously empirically derived using latent class analysis. The childhood obesity phenotypes included an early puberty phenotype (females only), a mothers with obesity phenotype, a high weight concerns phenotype, and a mixed phenotype. Participants without overweight or obesity in childhood or adolescence were the reference group. We then used logistic regression models with generalized estimating equations to examine associations of childhood obesity phenotypes with incident hypertension between ages 20-35 years. All analyses were stratified by sex.

RESULTS

Among females, participants in all of the empirically derived childhood obesity phenotypes were more likely than their peers without childhood overweight/obesity to develop hypertension in young adulthood (early puberty subtype odds ratio (OR) = 2.52; 95% confidence interval (CI) = 1.75, 3.62; mothers with obesity (MO) subtype OR = 2.98; 95% CI = 1.93, 4.59; high weight concerns (WC) subtype OR = 2.33; 95% CI = 1.65, 3.28; mixed subtype OR = 1.66; 95% CI = 1.25, 2.20). Among males, the childhood obesity phenotypes were associated with a higher risk of developing hypertension, although males in the MO (OR = 2.65; 95% CI = 1.82, 3.87) and WC phenotypes (OR = 3.52; 95% CI = 2.38, 5.20) had a greater risk of developing hypertension than the mixed subtype (OR = 1.51; 95% CI = 1.23, 1.86) (p = 0.004).

CONCLUSION

Risk for incident hypertension in young adulthood varied by childhood obesity phenotypes, as well as by biological sex. If replicated, these results may suggest that increased surveillance of specific childhood obesity phenotypes might help in targeting those at highest risk for hypertension.

Bracing for impact: An intensive longitudinal investigation of weight stigma, vigilant coping, and maladaptive eating

OBJECTIVE

Interpersonal weight stigma (being teased, treated unfairly, or discriminated against for body weight) increases one's stress and negatively impacts their well-being. Weight stigma consistently increases maladaptive eating behaviors, such as eating to cope, binge eating, and restrictive dieting. Previously published cross-sectional models suggest that vigilant coping (being on the lookout for future discrimination) is one way in which weight stigma may impact maladaptive eating behaviors, especially as internalized weight stigma (self-stigma) increases. This study aimed to analyze these relationships longitudinally using ecological momentary assessments.

METHODS

Female, higher weight college students (MBMI = 32.7, SDBMI = 6.09) from a large public midwestern university (N = 130) completed 3 surveys per day for 7 days, reporting their vigilant coping, eating to cope, restrictive dieting, and binge eating. Data was collected from January 2023-February 2024. We examined the relationship between baseline experienced and internalized weight stigma and day-to-day vigilant coping. Additionally, we examined vigilant coping earlier in the day as a predictor of eating later in the day.

RESULTS

Experienced and internalized weight stigma did not interact to predict day-to-day vigilant coping, but they both independently predicted vigilant coping. Vigilant coping earlier in the day predicted restrictive dieting later in the day but did not predict emotional or binge eating. There were no significant conditional indirect effects.

CONCLUSIONS

This study establishes vigilant coping as a longitudinal predictor of restrictive dieting, but further research is required to understand other health behaviors and outcomes related to vigilant coping.

Brief Self-Compassion Intervention for Women of Higher Weight and Internalized Weight Bias: A Randomized Pilot Study

BACKGROUND

Internalized weight bias (IWB) negatively impacts mental and physical health, and disproportionately affects women of higher weight. Although self-compassion training may be advantageous for reducing IWB and associated sequalae, further examination of its clinical significance and cultural acceptability is warranted.

METHOD

A randomized pilot study was conducted to evaluate the feasibility, including cultural acceptability, and clinical significance of a 3-session self-compassion intervention (SCI) for women with IWB. Women with BMIs of > 25 and IWB (N = 34) were randomly assigned to the SCI or a waitlist control group. Participants completed pre, post, and 1-month follow-up surveys on IWB, self-compassion, body image, eating behaviors, physical activity, and affect. Analyses of covariance were employed and percentages of change were calculated to examine post-intervention between-group differences in outcomes. Cultural acceptability was evaluated through participants' ratings of the perceived inclusivity and relevancy of the SCI.

RESULTS

There were 59% (n = 10) and 47% (n = 8) completion rates in the SCI and waitlist control groups, respectively. Compared to the waitlist control group, SCI participants reported greater pre-post improvements in self-compassion, IWB, body shame and surveillance, uncontrolled eating, and physical activity with medium to large effect sizes, and emotional eating with small effects. The SCI was perceived to be beneficial overall, and cultural acceptability ratings were mostly favorable despite individual differences.

CONCLUSION

This brief SCI may be beneficial for women impacted by weight stigma and IWB. Attention to increased diversity and cultural acceptability is warranted in future trials.

Cross-Sectional and Longitudinal Associations Among Weight Stigma, Psychological Distress, and Eating Behaviors in Youth with Obesity: A Clinical Sample

Background and Objectives: Obesity in youth is a growing public health concern, placing them at higher risk for adverse physical and psychological outcomes. Understanding the predictors that affect weight management, particularly the role of internalized weight stigma, psychosocial factors, and eating behaviors, is essential for developing an effective intervention at longitudinal follow-up. Materials and Methods: We enrolled 102 youths with obesity aged 10 to 18 years old from clinical settings. Baseline demographic data, psychosocial measures, including the Weight Self-Stigma Questionnaire (WSSQ) and Hospital Anxiety and Depression Scale (HADS), and eating behavior scales, such as the Three-Factor Eating Questionnaire (TFEQ-R21) and eating disorder as Sick, Control, One, Fat, Food questionnaire (SCOFF), were collected in the first visit. We conducted a study with both cross-sectional and longitudinal components. Correlational bivariate analysis was conducted to explore relationships between key variables. The factors affecting BMI changes were investigated using generalized estimating equations (GEEs) as part of a longitudinal analysis. Results: The mean age of participants was 13.22 years and 63.7% were male. Bivariate correlation analysis revealed positive relationships between initial BMI Z-scores and WSSQ scores (r = 0.196, p < 0.05). In bivariate analysis, a negative correlation was found between the difference in BMI Z-scores and visit number (r = -0.428, p < 0.01). GEE analysis demonstrated that initial BMI Z-scores (coefficient = 1.342, p < 0.001) and anxiety (coefficient = 0.050, p < 0.001) were significant positive predictors of BMI Z-scores, while depression was negatively associated (coefficient = -0.081, p < 0.001). Excluding the TFEQ subscales, SCOFF improved the model's QIC and highlighted WSSQ as a significant, albeit weak, predictor (p = 0.615 in the full model versus p < 0.05 in the reduced model). Conclusions: Psychosocial factors, particularly anxiety and weight stigma, are associated with elevated BMI Z-scores in youth affected by obesity in this study. The baseline age, BMI Z-score, internalized weight stigma, and psychological stress influenced the body weight trajectory over time. Frequent clinical follow-ups contribute to improved BMI outcomes. Future research may examine the efficacy of weight management by reducing weight stigma and psychological distress along with the outpatient care of obesity.

The arabic version of the fat phobia scale-short form: reliability and structural validity

BACKGROUND

Weight bias, often known as fat phobia or weight stigma, refers to unfavorable attitudes and stereotypes that are associated with, and applied to, larger bodies. Fat phobia can include an unreasonable and abnormal dread of being overweight or being associated with obese people. Currently, there is no validated tool available to measure fat phobia in Arabic. Measuring fat phobia in Arabic-speaking populations is crucial, because cultural attitudes toward body weight can be quite negative and discriminatory; these negative attitudes can negatively impact mental health. The current study aimed to adapt, translate, and assess the structural validity of the Fat Phobia Scale-Short Form (F-Scale 14) in Arabic.

METHODS

The gold standard approach to translation was used. Forward translation involved translation from the English language to the Arabic language by independent translators. Subsequently, a back-translation review was performed on the translated Arabic version for comparison with the original language. A cross-sectional study was conducted online that included 1246 participants from 22 Arabic countries, of whom 74% were female, 66% single, 83% university graduates, with a mean age of 35 ± 6 years.

RESULTS

The F-Scale 14 demonstrated good reliability in the Arabic language, with a Cronbach's α of 0.82 (95% CI 0.80-0.83), comparable to the original scale. The test-retest reliability of the scale was 0.92 (95% CI 0.90-0.94). According to the fit indices, the F-Scale 14 demonstrated a satisfactory level of structural validity in Arab cultures. Fit indices are statistical measures used in confirmatory factor analysis (CFA) to assess how well a proposed model fits the observed data. The scale showed a small improvement in factorial structure after the removal of some items. The two items removed were self-indulgent versus self-sacrificing and disliking food versus likes food. The correlation between F-Scale 14 and the figure rating scale was r = 0.76 (p < 0.001), suggesting adequate convergent validity.

CONCLUSIONS

The F-Scale 14 is a crucial indicator of attitudes and opinions concerning obese or overweight individuals. Based on increased internal consistency reliability and the problematic cultural relevance of two items, we recommend adopting a 12-item version of the scale for better cultural relevance in Arabic populations. It is anticipated that the Arabic F-Scale-12 will be highly useful for research and clinical purposes. Future research should test and adapt the Fat Phobia Scale for diverse Arabic populations to ensure its cultural relevance. Exploring its application in clinical settings will enhance our understanding of weight stigma and inform targeted interventions that promote body positivity. By addressing these areas, we can develop effective strategies to foster healthier attitudes toward body image in Arabic communities.

LEVEL V

Evidence obtained from a cross-sectional descriptive study.

Weight bias among students and employees in university settings: an exploratory study

BACKGROUND

Weight bias and stigmatization are highly prevalent in modern society, especially in educational settings, such as universities. Despite extensive documentation of the adverse consequences on students' daily functioning and psychological health, there is limited literature regarding factors associated with weight bias and its extent in Quebec universities.

OBJECTIVES

This exploratory study aims to assess the prevalence of weight bias and experiences of weight-related stigmatization, as well as to examine their associations with gender, psychological health problems, and status (students or employees) in a college environment in the province of Quebec.

METHODS

Participants were recruited via their university emails. A total of 292 students and 129 university employees participated in an online survey distributed via the secure REDCap platform. The following data was collected: sociodemographic information, status (students or employees), body weight, experiences of stigma, and prejudice towards people living with a higher weight (Fat Phobia Scale; FPS).

RESULTS

Approximately half of the respondents reported experiencing weight-related stigma (44.7%), and half indicated holding prejudice towards overweight people (51.1%), with a moderate rate of bias according to the FPS (3.25). Experience of weight-related stigma was found to be associated with gender (X2 = 7.88, p = 0.019), and a higher prevalence of psychological health problems (X2 = 9.41, p = 0.002), while having prejudice was associated with gender, with men scoring higher at the FPS (F = 7.64, p = 0.006), but not with the status (student or employee). The regression model identified significant effects of status [F(4, 347) = 2.856, p = 0.005] and the interaction between gender and status [F(4, 347) = -2.326, p = 0.021] on the FPS scores.

CONCLUSIONS

Various factors are associated with the experience of weight bias and stigmatization towards people with higher weight in the college population. Campaigns to prevent and reduce weight-related bias should be aimed specifically at staff members as well as students. Future research should examine weight bias internalization as a mediator between self-perceived weight and prejudice.

Weight discrimination as a predictor of stress and eating: The role of identifying as "fat"

Weight discrimination is associated with deleterious health outcomes, including high stress and disordered eating. According to the rejection-identification model, people who perceive such group-based discrimination respond by identifying more strongly with their stigmatized group, which can attenuate negative consequences of discrimination. However, some research shows that these protective benefits may not exist in the weight domain. Here, we examined whether perceived weight discrimination predicts identifying as "fat," and whether that increased identification protects against negative consequences of discrimination for health. In a larger study, U.S. adults who reported considering themselves "to be overweight" (N = 1725) reported on their perceived weight-based discrimination, fat-group identification, stress, and eating behaviors (i.e., uncontrolled eating, emotional eating, and restrained eating). We tested whether fat-group identification mediated the associations of perceived discrimination to stress and eating. Results showed that perceiving weight discrimination was associated with greater fat-group identification, which in turn was associated with more stress, uncontrolled eating, and emotional eating. These findings suggest that identifying as "fat" in the face of weight discrimination may not reduce subsequent stress or unhealthy eating patterns. As such, in contrast to prior research on the rejection-identification model that suggests identifying with one's group is protective for other identities, "fat" as an identity may not provide the same psychological and physical health benefits.

Experience with multiple devaluation is associated with elevated emotional eating, perceived weight, and body mass index: An exploration of mediating factors and the role of irrational beliefs in general population and university samples

Weight stigma, the social devaluation of people based on a perception of high body weight, is associated with a number of adverse health consequences including avoidance of medical care, suicide risk, disordered eating, decreased exercise, and weight gain. Experiences of stigma in a variety of domains in addition to weight may intersect to exacerbate these outcomes. Participants in two samples (one of 327 women and men from the general population and one of 128 female university students) reported experiences of devaluation on three body size and eight non-body size-related characteristics (referred to as multiple devaluation experience or MDE) and completed assessments of emotional eating (EE), feeling fat, weight self-stigma, impulsivity, and irrational beliefs. Participants were also asked to rate their body weight. MDE was correlated with elevated weight self-devaluation and anticipation of weight stigma, negative EE (NEE), feeling fat, and impulsivity in both men and women. None of these measures moderated the relationship between MDE and EE. The positive relationship between MDE and NEE was mediated by anticipated weight stigma only in women in the general population sample at higher levels of irrational beliefs. The positive relationship between MDE and body mass index (BMI) was mediated by NEE in women in the general population. The positive relationship between MDE and perceived body weight was mediated by feeling fat in women in both samples. These results suggest that women's experiences of stigma may increase anticipation of ongoing stigma, prompting NEE and resulting in elevated BMI. The results also suggest that feelings of fatness could lead to an elevation of women's perceived body weight, which in prospective studies is linked to later elevation of actual weight.

Psychological well-being factors and the likelihood of transitioning from overweight and obesity to normal weight at population level: Evidence from two cohort studies of UK adults

We examined the prospective associations between psychological well-being related factors (depressive symptoms, life satisfaction, self-efficacy) and transitioning from overweight and obesity to normal body weight (vs persistence of overweight and obesity) and change in body mass index (BMI). We used multiple baselines and follow-ups from the National Child and Development Study (NCDS; 8513 observations) and the British Cohort Study (BCS; 11,113 observations). A proportion (8%-9%) of participants with overweight and obesity (BMI ≥25) at baseline transitioned into normal weight (BMI 18.5-<25) by follow-ups. There was no evidence of better psychological well-being related factors (e.g. lower depressive symptoms) being significantly associated with a transition from overweight and obesity to normal weight or reduced BMI in each cohort and pooled cohort analyses. However, age and gender were associated with transition. At population level, better psychological well-being may not be associated with likelihood of weight loss once obesity is developed in adulthood.

Parental Weight Stigma Associated with Self-Directed Weight Talk and Use of Health-Related Restrictive Feeding Practices

BACKGROUND

Parents are important conduits of weight- and health-related messaging. Weight-related communication and approaches to child feeding used by parents may reflect their past experiences with weight stigma and are understudied pathways through which intergenerational weight stigma may be transmitted.

OBJECTIVE

The aim of this study was to examine how experienced and internalized weight stigma among parents of children with higher weights are associated with weight-related communication and the feeding practices they use.

DESIGN

The Listening to Parents study is a cross-sectional study of 103 parent-child dyads who completed in-person study visits at the University of Michigan in Ann Arbor between November 2022 through June 2023.

PARTICIPANTS/SETTING

Participants were parents of children (ages 6 through 14 years, identified by parents as "heavier or overweight") who completed the Stigmatizing Situations Inventory Brief and Weight Bias Internalization Scale-Modified, as well as questions about weight-related communication and the Comprehensive Feeding Practices Questionnaire.

MAIN OUTCOME MEASURES

Outcomes included 5 items corresponding to parental weight-related communication (ie, self-directed, other-directed, and child-directed weight talk, child-directed weight teasing, and child-directed encouragement to lose weight) and 3 Comprehensive Feeding Practices Questionnaire subscales (ie, Monitoring, Restriction for Health, and Restriction for Weight Control).

STATISTICAL ANALYSES PERFORMED

Linear regression models were used to examine associations between mean scored parent-experienced and parent-internalized weight stigma and weight-related communication and feeding practices. Models were adjusted for child gender, parent-perceived child weight status, parental race and ethnicity, parental body mass index, and household income-to-needs ratio.

RESULTS

In covariate-adjusted models, parent-internalized weight stigma was positively associated with self-directed weight talk (β = .20, SE = .078; P = .01) and greater use of health-related restrictive child feeding practices (β = .16, SE = .070; P = .02). No other significant associations in covariate-adjusted models were observed.

CONCLUSIONS

Although parents with greater internalized weight stigma may engage in more self-directed weight talk, they may also be more attuned to the harms of weight stigma and seek to minimize child-directed weight talk and weight teasing.

Rationale, design, and methodology of My Body Is Fit and Fabulous at school (MyBFF@school) study: a multi-pronged intervention program to combat obesity among Malaysian schoolchildren

BACKGROUND

Childhood obesity has increased rapidly in recent years and is now a global epidemic. To combat this, MyBFF@school program, a multi-faceted obesity intervention incorporating physical activity in the form of small-sided games (SSG), nutrition, and psychology components for schoolchildren was designed. This paper is aimed at describing the protocol of the MyBFF@school program and presenting the baseline findings including the overweight and obesity prevalence.

METHODS

MyBFF@school is a school-based, cluster randomized controlled trial (C-RCT) study. The investigators selected government schools from Federal Territory of Kuala Lumpur, Selangor and Negeri Sembilan by stratified proportionate random sampling based on the multi-ethnic population and the urban-rural location of schools. Subsequently, the schools were assigned randomly to intervention and control groups. The intervention schools underwent MyBFF@school program, whereas the control followed standard school curriculum for a duration of six months. The intervention modules replaced the existing two physical education classes and one co-curriculum activity per week. Three assessments i.e. at baseline, month-3 and month-6 were conducted. Anthropometric, clinical examination, blood, physical fitness, nutrition, and psychology parameters were collected.

RESULTS

Twenty-three out of 1,196 primary schools (seven interventions and 16 controls) and 15 out of 416 secondary schools (six interventions and nine controls). The investigators screened 11,950 primary (age 9-11 years) and 10,866 secondary (age 13, 14, 16 years) schoolchildren. The investigators found 3,516 primary schoolchildren (29.4%) and 2,910 secondary schoolchildren (26.8%) had BMI z-score of more than + 1SD who were eligible for the study. Of these, 39.7% (N = 1397) of the primary and 35.8% (N = 1041) of the secondary schoolchildren agreed to participate in the study. The mean (SD) characteristics for the participating primary and secondary schoolchildren were: BMI z-score, + 2.29 (± 0.81) and + 2.10 (± 0.71); waist circumference, 75.06 (± 9.6) cm and 85.5 (± 10.9) cm; percentage body fat, 37.8% (± 6.5%) and 39.2% (± 7.3%); and muscle mass, 14.7 (± 2.9) and 23.1 (± 5.2) kg respectively.

CONCLUSION

MyBFF@school program, a school-based multi-pronged intervention was designed to combat childhood obesity. Screening of 22,816 primary and secondary schoolchildren found 29.4% of primary schoolchildren and 26.8% of secondary schoolchildren to be overweight and obese which reflected the urgency for an effective intervention.

TRIAL REGISTRATION

Clinical trial number: NCT04155255, November 7, 2019 (Retrospective registered). National Medical Research Register: NMRR-13-439-16563. Registered July 23, 2013. The intervention program was approved by the Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia and Educational Planning and Research Division (EPRD), Ministry of Education Malaysia. It was funded by the Ministry of Health Malaysia.

Assessing exposure to weight stigma: development and initial validation of the Weight Stigma Exposure Inventory (WeSEI)

BACKGROUND

Weight stigma is pervasive, and it has a significant impact on the social, physical, and psychological health of an individual. Weight stigma is observed from several different sources. Therefore, the present study developed and validated a new instrument, the Weight Stigma Exposure Inventory (WeSEI), to assess different sources of observed weight stigma across interpersonal and non-interpersonal sources.

METHODS

The participants (n = 15,991) comprised Taiwanese young adults, Chinese adolescents, and Chinese young adults who completed paper-and-pencil and online surveys between September 2023 and December 2023. All participants provided demographic information, and completed the WeSEI, Weight Self-Stigma Questionnaire (WSSQ), and Perceived Weight Stigmatization Scale (PWSS). Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to examine the factor structure of the WeSEI.

RESULTS

EFA and CFA results confirmed a seven-factor structure (television sources, traditional media sources, social media sources, parent sources, stranger sources, significant other sources, and friends sources) across 35 items of the WeSEI. Moreover, the WeSEI was supported by measurement invariance across subgroups (i.e., subsamples, gender, and weight status). Moreover, there were positive correlations between all seven factors of the WeSEI and the WSSQ and PWSS.

CONCLUSION

The WeSEI appears to assess observed weight stigma from different sources, and had good reliability, validity, and invariance across various subsamples. The WeSEI may be useful in clinical practice and research for assessing exposure to weight stigma from different sources.

How to reduce the adverse effects of weight stigma on the quality of life: a preferred reported items for systematic reviews and meta-analyses (PRISMA)

Introduction

Obesity, affecting 38% of adults globally, carries economic burdens and health risks like cardiovascular disease and diabetes. Weight-loss programs often face challenges due to stigma and poor body image, impacting individuals' quality of life. Research on interventions targeting weight stigma is lacking, emphasizing the need for comprehensive approaches addressing psychological and behavioral aspects for effective care.

Methods

A systematic literature review was conducted according to PRISMA guidelines. We searched into three databases (PubMed, APA PsycArticles/PsycInfo, and Web of Science) articles published between 1975 and 2024. Studies were eligible if they involved people living with overweight or obesity who participate in a psychological program targeting, or not, weight stigma and if at least one outcome was related to weight stigma.

Results

We selected 24 studies published between 2009 and 2022, the majority concerning English-speaking countries. Reduction in weight stigma was observed in 23/24 studies, particularly through cognitive-behavioral techniques (18/24 studies), while others studies emphasized individual predispositions and the need for longer, and denser interventions.

Conclusion

Three relevant characteristics emerged from the studies analysed: content, duration and tools. Cognitive-behavioral techniques were central, aiding participants in managing their condition and coping with stigma. Interventions reducing Weight Bias Internalization (WBI) led to improved psychosocial determinants, yet the mechanisms remain unclear. Future research should address intervention duration, participant involvement, and the association between WBI and psychosocial factors to enhance outcomes and understanding.

Psychological well-being and the reversal of childhood overweight and obesity in the UK: a longitudinal national cohort study

OBJECTIVE

This study aimed to examine the prospective association between psychological well-being and overweight and obesity reversal.

METHODS

We analyzed data of UK children with overweight or obesity at ages 11 (n = 4556, baseline), 14 (n = 3791, baseline), and 17 years (follow-up). Psychological well-being-related measures were characterized into indexes of caregiver-reported child mental health and child-reported psychosocial well-being, with a higher score indicating better mental health or psychosocial well-being. Weight changes were presented as reversal versus persistence of overweight or obesity and residualized-change BMI z scores. Data were analyzed using regression analysis.

RESULTS

Better child mental health and psychosocial well-being at age 11 years were independently associated with increased odds of reversal versus persistence (odds ratio [OR] = 1.16, 95% CI: 1.03 to 1.29; OR = 1.29, 95% CI: 1.15 to 1.44, respectively) and decreased BMI z scores (β = -0.08, 95% CI: -0.13 to -0.03; β = -0.07, 95% CI: -0.11 to -0.03, respectively) at age 17 years. However, neither of the indexes was associated with weight changes when measured at age 14 years. Analyses between psychological well-being-related measures and timing of measures indicated that psychological well-being-related measures were more likely to prospectively predict weight changes when measured at age 11 versus age 14 years.

CONCLUSIONS

Better psychological well-being at age 11 years is a prognostic factor that may be associated with an increased likelihood of reversing childhood overweight and obesity by age 17 years.

SWIPE: a conceptual, multi-perspective model for understanding and informing interventions for weight stigma in preconception, pregnancy, and postpartum

Weight stigma is salient across the preconception, pregnancy, and postpartum (PPP) periods because of prevailing prescriptive norms and expectations about weight and weight gain during the reproductive period. Weight stigma is associated with negative physical and psychological health outcomes for mother and child. A clearly defined, multi-level conceptual model for interventions, research, and policy is critical to mitigating the adverse effects of weight stigma in PPP populations. Conceptual models of weight stigma towards PPP women have advanced our understanding of this issue and guided evidence accumulation but there remains a gap in informing the translation of evidence into action. Guided by evidence-based paradigms for conceptual model development, this paper has two primary objectives. First, we review and summarise theories, frameworks, and models from the PPP population and general literature to inform our understanding of the development and perpetuation of weight stigma for PPP women. Second, we propose a novel comprehensive intervention-guiding conceptual model that draws from and synthesises across multiple disciplines - the SWIPE (Stigma of Weight In the PPP Experience) model. This conceptual model will help to plan coordinated, multi-layered, and effective strategies to reduce and ultimately eliminate weight stigma for PPP women.

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.

Longitudinal relationships between anti-fat attitudes and muscle dysmorphia symptoms

Weight stigma, and more specifically, anti-fat attitudes, is associated with disordered eating. Furthermore, these anti-fat attitudes influence various appearance ideals. Muscle dysmorphia (MD) is characterized by preoccupation with the muscular ideal and is a potential form of disordered eating commonly experienced by men. Despite theory suggesting that anti-fat attitudes may contribute to MD, research has yet to examine associations between anti-fat attitudes and MD symptoms. Therefore, the current study investigated longitudinal relationships between anti-fat attitudes and MD symptoms. Participants were 269 U.S. men recruited from Prolific who completed three self-report surveys each separated by one month. Primary analyses examined longitudinal relationships between specific anti-fat attitudes and MD symptoms using an adapted three-wave cross-lagged panel model. Results demonstrated that believing that fat people do not have willpower was longitudinally associated with desires to increase muscle size at multiple time points. Furthermore, MD-specific functional impairment predicted fears of becoming fat longitudinally. Practically, men may desire to increase their muscularity to demonstrate their own willpower and distance themselves from anti-fat stereotypes. Thus, clinicians may consider targeting weight stigmatizing attitudes to reduce MD symptom severity among their male clients.

Psychological interventions for internalized weight stigma: a systematic scoping review of feasibility, acceptability, and preliminary efficacy

BACKGROUND

Internalized weight stigma (IWS) is highly prevalent and associated with deleterious mental and physical health outcomes. Initiatives are needed to address IWS and promote effective coping and resilience among individuals who are exposed to weight stigma. We conducted a systematic scoping review of the literature on psychological interventions for IWS and explored their intervention components, feasibility, acceptability, and preliminary efficacy at reducing IWS and related negative physiological and psychological health outcomes.

METHODS

Eight databases were searched. Inclusion criteria included: (1) Psychological intervention; (2) Published in English; and (3) Included IWS as an outcome. Exclusion criteria included: (1) Commentary or review; and (2) Not a psychological intervention. A narrative review framework was used to synthesize results.

RESULTS

Of 161 articles screened, 20 were included. Included interventions demonstrated high feasibility, acceptability, and engagement overall. Sixteen of 20 included studies observed significant reductions in IWS that were maintained over follow-up periods, yet data on whether interventions produced greater reductions than control conditions were mixed. Studies observed significant improvements in numerous physical and mental health outcomes.

CONCLUSIONS

Findings suggest that existing interventions are feasible, acceptable, and may provide meaningful improvements in IWS and associated health outcomes, highlighting the potential for psychological interventions to promote improved health and wellbeing in individuals with IWS. High-quality studies using rigorous study designs (e.g., randomized controlled trials) are needed to further evaluate the efficacy of interventions for IWS.

When midwives ask permission to discuss weight with pregnant women with high body weight: a qualitative study

BACKGROUND

In 2021, 15% of pregnant women in Denmark had a Body Mass Index (BMI) of 30 kg/m2 or more, which is associated with complications for both mothers and children. Healthcare professionals often feel insecure when discussing weight with pregnant women with high body weight, and people with high body weight are exposed to stigmatisation. To counter this, different tools have been developed to support respectful weight-related conversations, often recommending asking permission to talk about weight. This study explored the experiences of both pregnant women living with a BMI equally or above 30 kg/m2 and midwives when asking for permission to discuss weight during the initial midwife consultation.

METHODS

We observed nine midwifery consultations and, by way of purposive sampling, interviewed six pregnant women with high body weight, while nine midwives participated in two focus group interviews. A hermeneutic-phenomenological approach by Max van Manen was applied for the analysis.

RESULTS

We identified three themes in this study. "Addressing weight triggers risk and ambivalence", which explores the lived experiences of pregnant women, their personal history with their body weight and midwives' hesitancy to initiate weight-related conversations with pregnant women who have a high body weight. "Asking for permission - for whose sake?" highlights the experiences of asking permission among midwives and that pregnant women with a high body weight did not perceive the question as an opportunity to decrease weight-related conversations. "Weight conversation - a cue to feel wrong and guilty or to feel recognised as an individual?" emphasising that trust and shared decision-making are crucial factors for a relevant weight-related conversation but also that the conversation might trigger feelings such as guilt and self-doubt.

CONCLUSION

Pregnant women with high body weight had a long history with their body weight that affected all aspects of their lifeworld and influenced weight-related conversations in the midwifery consultation. Some midwives hesitated to address weight, but seeking permission eased this challenge. Despite the midwife asking for permission, some of the pregnant women felt uneasy during the conversation, leaving them with a feeling of self-doubt. Relevant conversations occurred when women engaged in decision-making and trusted the midwife.

The need for more inclusive measurement to advance equity in eating disorders prevention

Eating disorder (ED) research and practice have been shaped by prevailing stereotypes about who EDs are most likely to affect. Subsequently, the field has prioritized the needs and concerns of affluent, cisgender, heterosexual, white girls and women to the exclusion of others, especially people marginalized based on their race, ethnicity, sexual orientation, and/or gender identity. However, EDs exist across diverse groups and actually occur with elevated prevalence in several marginalized groups. Growing research points to differences in the drivers of EDs in such groups (e.g. desire to attain the curvy rather than thin ideal; dietary restraint due to food insecurity rather than weight/shape concerns), yet tools typically used for screening and intervention evaluation do not capture eating pathology driven by such factors. In this commentary, we describe gaps in existing ED assessment tools and argue these gaps likely underestimate EDs among marginalized groups, bias who is invited, participates in, and benefits from ED prevention programs, and obscure potential group differences in the efficacy of such programs. We also discuss the potential of these ramifications to exacerbate inequities in EDs. Finally, we outline recommendations to overcome existing gaps in measurement and, consequently, advance equity in the realm of ED prevention.

Weight stigma and physical activity avoidance among college-aged students

This study explored cross-sectional associations between prior weight stigma experiences, physical activity (PA) intentions, behaviors, and the acute effects of a weight stigma exposure on PA intentions and behaviors among undergraduate students. Weight-stigma experiences and behavioral intentions were self-reported. Moderate-to-vigorous PA and total PA were assessed using accelerometry. Participants were randomized into two experimental conditions (a weight stigma or control condition) to assess the acute effects of a weight stigma exposure. Forty-nine students (81.6% female; 59.2% Non-Hispanic White; 19.6 ± 1.1 years of age; body mass index: 23.9 ± 4.0 kg/m2) completed the study. Prior weight stigma experiences were positively associated with PA avoidance (β = 12.1 ± 2.7; p < .001) but were not associated with positive PA intentions or behaviors (ps > .05). There were no differences in positive PA intentions, PA avoidance, or PA behaviors across conditions (all ps > .05). Future studies should examine the long-term effects of weight stigma on PA avoidance and objectively measured PA in young college students.

Body image is associated with persistence. A study of the role of weight-related stigma

Abstract

The study replicates a preliminary report from 2019 on therelationship between body image and persistence.

Purpose

The aim of our study was to analyze the associations between body image, persistence, and body weight stereotypes.

Patients and methods

A total of 750 individuals were recruited for the study. The research was carried out in computer labs. The procedure consisted of psychological questionnaires (Persistence Scale, The Body Esteem Scale, Perceived Weight Stigma Questionnaire, Weight Bias Internalization Scale, Hospital Anxiety and Depression Scale, Formal Characteristics of Behavior - Temperament Inventory, and NEO-PI-R) and The Maze Test (a computer tool). After completing the Simple Maze Test, saliva samples were collected. Next, the subjects proceeded to the laboratory where anthropometric and body composition measurements were taken. The hormone levels (cortisol and dehydroepiandrosterone) in the collected saliva samples were analyzed via ELISA to determine stress.

Results

Body image and persistence are related variables. They are associated with the internalization of stereotypes and perceived stigma related to body weight. These associations are differentially shaped according to sex and the regularity of body weight. In women, a stronger association of these variables with body image was observed, while in men, the relationship with body image was weaker, with a stronger association shown by perceived weight-related stigma. In the group of participants with a BMI<18.5, there was no significant association between the internalization of stereotypes and the analyzed variables. This relationship appeared in the group of subjects with a normal body weight and was strongest in the group of participants who were overweight or obese. Perceived weight-related stigma was most strongly associated with body image in the group with BMI<18.5 kg/m2 and with persistence in the group with BMI>25 kg/m2.

Conclusion

Body-related stigma affects not only overweight and obese individuals and its mechanisms may be shaped differently.

An exploratory examination of medical and nursing students' intentions to discuss body image, weight, and eating disorders with their patients

BACKGROUND

Although many people have concerns about their body image, weight, and eating behaviors these issues are not usually discussed in a productive manner with medical providers. Thus, we examined nursing and medical students' willingness to discuss patients' weight, body image, and eating disorders and reasons why they may do so.

METHOD

One hundred and eighty-three nursing and medical students (Mage = 25.06, SD = 5.43) participated in this study. Participants completed open-ended questions pertaining to their willingness to discuss body image, eating, and weight-related issues with future patients. We further queried students' perspective on body mass index (BMI) as a measure of weight status and sought to determine if participants' own weight, weight concerns, appearance evaluation, body appreciation, and experiences of stigma were associated with their willingness to discuss weight-related issues with prospective patients.

RESULTS

Coding of qualitative data indicated that nursing and medical students were "sometimes" willing to discuss prospective patients' weight, body image, and eating disorders, especially if a health concern was evident. Nursing students seemed somewhat more willing to discuss weight issues than medical students and willingness to discuss one of these issues (e.g., body image) was positively associated with willingness discuss the others. Plans for future discussions of body image and weight were marginally associated with personal experiences of weight stigma. The majority of participants indicated that BMI was not a valid measure of health.

CONCLUSIONS

Taken together, findings suggest that future providers' conversations with patients about these sensitive topics are less likely to be associated with their own experiences and more with the relevance of these topics to specific patients.

Weight stigma is uniquely tied to maladaptive eating across different racial, ethnic, and gender groups

Weight stigma, racism, and sexism (social devaluation due to body weight, race or ethnicity, and sex or gender), have been linked to increased maladaptive eating behaviors; however, no research has investigated the unique associations between different forms of stigma and eating concurrently. We analyzed within-group (by race/ethnicity and sex) effects of different forms of stigma on maladaptive eating behaviors to test whether there is some unique relationship between weight stigma and maladaptive eating across identities. Additionally, we explored differences by racial/ethnic group and sex, as well as BMI category, in levels of reported weight stigma, racism, sexism, and maladaptive eating. Participants (N = 1051) were recruited so that there were approximately even numbers of participants identifying as Black (33.3%), Hispanic or Latino (32.8%), and White (33.9%). Overall, participants reported similar amounts of weight stigma by race/ethnicity and sex, but different levels of racism and sexism. Weight stigma, but not racism or sexism consistently predicted binge eating and eating to cope across groups, controlling for education, income, BMI, and age. Restricted dieting, however, was only predicted by weight stigma for Hispanic/Latino and Black men. These findings suggest that weight stigma is a unique predictor of maladaptive eating, even when considering the effects of racism and sexism. This study provides evidence of a more focused model of weight stigma and eating outcomes, rather than a more general model of the effect of stigma on eating outcomes due to overall stress. Future research should investigate when and why weight stigma drives restricted dieting, since this relationship seems strongest in men, going against many common inclinations about weight stigma.

Weight stigma as a stressor: A preliminary multi-wave, longitudinal study testing the biobehavioral pathways of the cyclic obesity/weight-based stigma (COBWEBS) model

Higher weight individuals often face significant weight stigma. According to the Cyclic Obesity/Weight-Based Stigma (COBWEBS) model, weight stigma operates as a stressor that increases the stress hormone cortisol and promotes comfort eating, thus resulting in weight gain. Such weight gain is harmful as it exposes individuals to further stigmatization. Thus far, no study has yet tested the mechanistic pathways of the COBWEBS model and prospective longitudinal studies are severely lacking. To fill this gap, the current study tested the biobehavioral pathways of the COBWEBS model using a 4-wave yearlong longitudinal study comprising 348 higher weight individuals. Using a structural equation modeling framework, we tested three cross lagged panel models for the putative mediator, comfort eating. The models examined either synchronous and/or lagged effects across weight stigma, perceived stress, comfort eating, weight, and future weight stigma. The best fitting model revealed significant associations between baseline weight stigma, perceived stress, and comfort eating within the same month. However, comfort eating did not significantly predict weight four months later. Weight status and baseline weight stigma both predicted future weight stigma as expected. Additionally, a separate path model with hair cortisol found that weight stigma predicted perceived stress four months later, but stress did not predict aggregate cortisol levels from months 10 and 11. Hair cortisol also did not predict later weight. This preliminary work lays the foundation for identifying modifiable targets of weight stigma, thereby offering potential avenues to reduce weight stigma's harm on higher weight individuals.

Does dissection influence weight bias among doctor of physical therapy students?

Anatomy with human dissection may help to develop respect for the human body and professionalism; however, dissection may worsen students' attitudes about body weight and adiposity. The purpose of this study was to measure weight bias among Doctor of Physical Therapy (DPT) students enrolled in gross anatomy and determine if, and how the experience of dissection impacts weight bias. Ninety-seven DPT students (70 University of Colorado [CU], 27 Moravian University [MU]) were invited to complete a survey during the first and final weeks of their anatomy course. The survey included demographic items, two measures of weight bias-the Modified Weight Bias Internalized Scale (M-WBIS) and the Attitudes Towards Obese Persons (ATOP) Scale-and open-ended questions for the students who participated in dissection (CU students) that explored attitudes about body weight and adiposity. At baseline, there were no significant differences (p > 0.202) in ATOP, M-WBIS, or BMI between the two universities. The mean scores on both the ATOP and M-WBIS indicated a moderate degree of both internalized and externalized weight bias. There were no significant changes in ATOP (p = 0.566) or M-WBIS scores (p = 0.428). BMI had a low correlation with initial M-WBIS scores (⍴ = 0.294, p = 0.038) and a high correlation with change scores in CU students (⍴ = 0.530, p = 0.011). Future studies should utilize the same measures of weight bias in other healthcare trainees to facilitate comparison and incorporate larger populations of DPT students.