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.

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.

Ecological Momentary Assessment of Weight Stigma and Eating Behavior in Everyday Life.

BACKGROUND: Weight stigma is widespread, but the existing literature on its harmful consequences remains largely limited to lab-based experiments and large-scale longitudinal designs. PURPOSE: The purpose of this study was to understand how weight stigma unfolds in everyday life, and whether it predicts increased eating behavior. METHODS: In this event-contingent ecological momentary assessment study, 91 participants reported every time they experienced weight stigma and documented whether they ate, how much they ate, and what they ate. These reports were compared against a timepoint when they did not experience stigma. RESULTS: Participants reported a wide variety of stigmatizing events from a variety of sources, with the most common ones being the self, strangers, the media, and family. Multilevel models showed that participants were no more likely to eat post-stigma (vs. the comparison point), but if they did eat, they ate more servings of food (on average consuming 1.45 more servings, or 45% more). Moderation analyses indicated that this effect was amplified for men versus women. CONCLUSION: Experiencing weight stigma appears to beget behavioral changes, potentially driving future weight gain, placing individuals at ever more risk for further stigmatization.

This study looked at how weight stigma in everyday life impacts eating. People reported on episodes of weight stigma and their eating in the next 30 min. Weight stigma came from many different places, including family, strangers, media, and even themselves. Even though people did not necessarily eat more after weight stigma episodes, if they did eat, they ate significantly more food­about 45% more. This relationship was stronger in men than in women. The study also explored whether different kinds of people react differently to weight stigma. Weight stigma experiences led to even more food eaten among people who tended to have high buy-in about negative stereotypes of heavier people, as well as people who thought weight was an important part of their identity. The opposite was seen among people who worried the most about experiencing weight stigma in the future. These findings suggest that experiencing weight stigma may not always prompt people to eat immediately, but when they do eat, they tend to eat more, challenging the idea that weight stigma motivates people to eat less.

Social class stigma and poorer health behaviors: Evidence from the eating in America study.

Although the association between objective markers of low socioeconomic status (SES) and poor health is well established, one underexamined possibility is that over and above objective SES, social class stigma-experiences and anticipation of discrimination based on social class-might undermine people's ability to engage in healthy behaviors. Participants (N = 2022) were recruited between December 2019 and January 2020 via a national Qualtrics panel that was census-matched to the U.S. population in age, gender, income, race/ethnicity, and census region. Participants completed measures of class stigma, alcohol use, disordered eating, comfort eating, sleep disturbance, physical activity, and demographics. Controlling for objective SES and demographics, generalized linear regression models indicated that class stigma was associated with significantly greater alcohol use, disordered eating, greater comfort eating, and sleep disturbance but not less physical activity. Class stigma was not associated with health behaviors after full adjustment for weight/racial discrimination and psychological factors. Results from this investigation suggest that beyond one's objective SES, the stigma associated with having low class may also contribute to poorer health behaviors.

Examining the effect of weight-related recruitment information on participant characteristics: A randomized field experiment.

Objective: Although 82% of American adults have a body mass index (BMI) of over 25, individuals with elevated BMI are considered difficult to recruit for studies. Effective participant identification and recruitment are crucial to minimize the likelihood of sampling bias. One understudied factor that could lead to sampling bias is the study information presented in recruitment materials. In the context of weight research, potential participants with higher weight may avoid studies that advertise weight-related procedures. Thus, this study experimentally manipulated the phrasing of weight-related information included in recruitment materials and examined its impact on participants' characteristics. Methods: Two visually similar flyers, either weight-salient or neutral, were randomly posted throughout a university campus to recruit participants (N = 300) for a short survey, assessing their internalized weight bias, anticipated and experienced stigmatizing experiences, eating habits, and general demographic characteristics. Results: Although the weight-salient (vs. neutral) flyer took 18.5 days longer to recruit the target sample size, there were no between flyer differences in respondents' internalized weight bias, anticipated/experienced weight stigma, disordered eating behaviors, BMI, or perceived weight. Absolute levels of these variables, however, were low overall. Conclusion: Providing detailed information about study procedures allows participants to have more autonomy over their participation without differentially affecting participant characteristics.

A systematic review of weight stigma and disordered eating cognitions and behaviors.

Weight stigma is persistent across contexts and is associated with disordered eating cognitions and behaviors. This systematic review aimed to examine the existing literature that has explored the relationship between weight stigma and disordered eating cognitions and behaviors. We specifically examined three dimensions of weight stigma - experienced, anticipated, and internalized - and adopted an inclusive conceptualization of outcomes related to disordered eating (including constructs such as binge eating, body dissatisfaction, and other cognitions and behaviors such as dietary restraint, unhealthy weight control behaviors, and drive for thinness). We searched PubMed, Embase, CINAHL, Web of Science, Sociological Abstracts, and PsycINFO for English-language, peer-reviewed articles and dissertations with quantitative methodology published through October 2023. The search resulted in 242 articles meeting inclusion criteria. A narrative review found a consistent relationship between greater weight stigma and more disordered eating cognitions and behaviors. Methodological and theoretical limitations are discussed, as are critical avenues for future research and potential clinical implications stemming from this body of research. Given the widespread nature and impact of weight stigma on disordered eating, it is imperative that we intervene to address weight stigma at all levels, from the structural to the intrapersonal.

Longitudinal Stability of Disordered-Eating Symptoms From Age 12 to 40 in Black and White Women.

The purpose of the current study was to test the longitudinal association between disordered eating symptoms (body dissatisfaction, drive for thinness and bulimia) in adolescence (ages 12, 14, 16, 18, 19) and adulthood (age 40) in a sample of 883 white and Black women. We also investigated moderation by race. Adolescent symptoms at each time point significantly predicted adulthood symptoms for the body dissatisfaction and drive for thinness subscales, for both Black and white women. Bulimia symptoms in adolescence predicted symptoms in adulthood; however, the effect was largely driven by white women. Although moderation was non-significant, among white women, bulimia symptoms at all adolescent time points predicted adulthood bulimia, but among Black women, only symptoms at ages 18 and 19 were predictive of adulthood bulimia. Results suggest that both Black and white women are susceptible to disordered eating and that symptoms emerging in adolescence can potentially follow women into midlife.

Unsupported and Stigmatized? The Association Between Relationship Status and Well-Being Is Mediated by Social Support and Social Discrimination.

Single adults, on average, experience worse well-being compared to coupled adults. But why? The current research bridged interpersonal and intergroup perspectives to examine the influence of social support and social discrimination on single versus coupled adults' well-being. We drew on a nationally representative prospective study from New Zealand (Study 1, N = 4,024) and an integrative data analysis of three North American data sets examining peoples' general (Study 2, N = 806) and day-to-day (Study 2, N = 889 and 9,228 observations) social experiences. The results demonstrated that single adults reported lower life satisfaction compared to coupled adults, and this may be partly due to single adults reporting lower perceptions of social support availability and greater experiences of negative treatment and discrimination compared to coupled adults. These novel findings move away from stereotypical assumptions about singlehood and highlight the important role of social relationships and interactions in determining single adults' happiness and well-being.

Weight stigma and health behaviors: evidence from the Eating in America Study.

BACKGROUND: Weight stigma is pervasive across the U.S. and is associated with poor health outcomes including all-cause mortality. One potential reason that weight stigma may be detrimental to health is that it begets poorer health behaviors. Therefore, the present study tested for associations between weight stigma and four health behaviors (i.e., eating behavior, alcohol use, sleep disturbance, and physical activity), while controlling for BMI and other potential confounds. SUBJECTS/METHODS: Participants (N = 2022) in the U.S. were recruited for the Eating in America Study using a Qualtrics panel between December 2019 and January 2020 and were census-matched according to national quotas for age, gender, income, race/ethnicity, and census region. Participants completed questionnaires about weight stigma, health behaviors, demographics, and anthropometric measurements. The current study employed a two-stage investigation: exploratory analyses were first performed on a random sample of the dataset (n = 438), then the remaining unexamined data were used to conduct confirmatory analyses that were preregistered on the Open Science Framework. RESULTS: Controlling for BMI, weight stigma was significantly associated with greater disordered eating (b = 0.34, 95% CI [0.31, 0.38], p < 0.001), comfort eating (b = 0.32, 95% CI [0.25, 0.39], p < 0.001), sleep disturbance (b = 0.27, 95% CI [0.20, 0.33], p < 0.001), and alcohol use (b = 0.30, 95% CI [0.11, 0.49], p = 0.002), but not lower physical activity (b = -0.04, 95% CI [-0.13, 0.05], p = 0.402) for individuals across the weight spectrum. BMI and perceived weight status significantly moderated the effects of weight stigma on disordered eating and alcohol use. No gender differences were found. These confirmatory analyses partially replicated the exploratory stage 1 findings. CONCLUSIONS: This study provides preliminary evidence that weight stigma is linked to several poor health behaviors, which may impact physical health.

Weight discrimination, anticipated weight stigma, and disordered eating.

Weight discrimination is a well-established risk factor for disordered eating cognitions and behaviors. However, little is known about what may account for this association. Recent research suggests that anticipated weight stigma may explain the relationship between weight discrimination and non-eating disorder related health outcomes; the present study seeks to replicate this premise and extend it to the disordered eating realm. In a non-clinical sample of adults in the United States (N = 297) we test the hypothesis that weight discrimination has an indirect association with eating disorder symptomatology through anticipated stigma. At a single timepoint, participants recruited from the online data collection platform SocialSci completed self-report, online surveys of weight discrimination in day-to-day life, anticipated weight stigma, eating disorder symptoms, and demographic information. As hypothesized, weight discrimination was indirectly associated with greater disordered eating symptoms via its association with anticipated weight stigma. This pattern of results held when controlling for gender, body mass index, and self-perceived weight status. These findings suggest that anticipated stigma is relevant in the association between weight discrimination and greater disordered eating. This premise deserves additional attention using methodological approaches that can facilitate stronger causal claims. We discuss the potential for this line of research to inform clinical interventions.

The Countervailing Effects of Weight Stigma on Weight-Loss Motivation and Perceived Capacity for Weight Control.

We hypothesized that exposure to weight stigma simultaneously increases motivation to lose or avoid gaining weight to avoid future stigma and decreases perceived capacity to do so, by heightening concerns about experiencing stigma and negative affect. Study 1 showed that more frequently experiencing weight-based discrimination was associated with greater concerns about being a victim of weight stigma, which predicted increased motivation to lose weight but decreased perceived capacity for weight control. Study 2 showed that participants randomly assigned to view a weight-stigmatizing (vs. control) message showed increased concerns about being a target of weight stigma, which indirectly increased motivation to lose weight and decreased state self-control. These, in turn, predicted increased willingness to engage in unhealthy weight-loss behaviors and decreased perceived capacity for weight control, respectively. Study 3 showed that increased motivation to avoid stigma and increased negative affect mediate these effects of exposure to weight stigma.

Evaluative implications of intersecting body weight and other social categories: The role of typicality.

Body weight is a critical dimension by which we evaluate others, with heavier individuals facing higher levels of stigma and discrimination compared to thinner individuals. Yet, the perception of body weight can be ambiguous, suggesting that stereotypic associations and heuristics influence which bodies are deemed as "typical" for a particular group or social category. Here, we investigate whether interdependent associations between body weight and social category dimensions (ethnicity, gender, age, and sex) affect the typicality ratings of a heavier body. Specifically, we hypothesize that heavier bodies labelled as Asian, feminine, younger, or female, compared to Black, White, masculine, older, or male, will be rated less typical and these typicality judgments will mediate social evaluations. Participants made typicality and social evaluative judgments about a wireframe body with a set BMI of 38, accompanied by one of sixteen category labels (e.g., Asian man). Our results show that typicality judgments broadly align with our hypotheses and mediate social evaluations of the heavier body. Overall, we showcase the interdependent nature of weight and other social categories, highlighting the role of typicality for social evaluations of heavier targets.

The psychological and physiological effects of interacting with an anti-fat peer.

This experiment tested whether interacting with a peer who holds explicitly anti-fat attitudes leads to cognitive performance deficits and poorer psychological and cardiovascular outcomes among higher body weight women by increasing anticipated rejection. One hundred and forty six higher body weight women were randomly assigned to interact in a non-romantic context with a same-sex peer who endorsed explicit anti-fat or unbiased attitudes. All women showed greater heart rate reactivity and anger when interacting with an anti-fat peer. The heavier women were, and the more they thought they were overweight, the more they anticipated rejection when interacting with an anti-fat peer. This anticipated rejection was in turn associated with poorer cognitive performance, lower state self-esteem, and increased negative emotions, rumination, compensatory efforts, and thoughts related to anxiety and evaluation. These effects were not observed among women in our sample categorized as slightly "overweight" or who perceived themselves as only slightly overweight.

Weight Labeling and Disordered Eating Among Adolescent Girls: Longitudinal Evidence From the National Heart, Lung, and Blood Institute Growth and Health Study.

PURPOSE: Weight stigma is implicated in disordered eating, but much of this research focuses on forms of stigma such as weight-based teasing. METHODS: In a large cohort of adolescent girls (N = 2,036), we tested the hypothesis that being labeled as "too fat" by others predicts subsequent greater disordered eating cognitions and behaviors. RESULTS: Compared with girls who did not report weight labeling, girls who were labeled at age 14 showed an increase in unhealthy weight control behaviors and disordered eating cognitions over the subsequent 5 years. These effects were independent of objective body mass index, race, parental income and education, and initial levels of disordered eating. CONCLUSIONS: Exploratory analyses suggest that weight labeling from family members is more strongly associated with disordered eating than labeling from nonfamily members. This study highlights how the long-term consequences of weight stigma can potentially begin when one is labeled as "too fat."

Unpacking the psychological weight of weight stigma: A rejection-expectation pathway.

The present research tested the hypothesis that the negative effects of weight stigma among higher body-weight individuals are mediated by expectations of social rejection. Women and men who varied in objective body-weight (body mass index; BMI) gave a speech describing why they would make a good date. Half believed that a potential dating partner would see a videotape of their speech (weight seen) and half believed that a potential dating partner would listen to an audiotape of their speech (weight unseen). Among women, but not men, higher body-weight predicted increased expectations of social rejection, decreased executive control resources, decreased self-esteem, increased self-conscious emotions and behavioral displays of self-consciousness when weight was seen but not when weight was unseen. As predicted, higher body-weight women reported increased expectations of social rejection when weight was seen (versus unseen), which in turn predicted decreased self-esteem, increased self-conscious emotions, and increased stress. In contrast, lower body-weight women reported decreased expectations of social rejection when weight was seen (versus unseen), which in turn predicted increased self-esteem, decreased self-conscious emotions, and decreased stress. Men's responses were largely unaffected by body-weight or visibility, suggesting that a dating context may not be identity threatening for higher body-weight men. Overall, the present research illuminates a rejection-expectation pathway by which weight stigma undermines higher body-weight women's health.

Weighed down by stigma: How weight-based social identity threat contributes to weight gain and poor health.

Weight stigma is pervasive, and a number of scholars argue that this profound stigma contributes to the negative effects of weight on psychological and physical health. Some lay individuals and health professionals assume that stigmatizing weight can actually motivate healthier behaviors and promote weight loss. However, as we review, weight stigma is consistently associated with poorer mental and physical health outcomes. In this article we propose a social identity threat model elucidating how weight stigma contributes to weight gain and poorer mental and physical health among overweight individuals. We propose that weight-based social identity threat increases physiological stress, undermines self-regulation, compromises psychological health, and increases the motivation to avoid stigmatizing domains (e.g., the gym) and escape the stigma by engaging in unhealthy weight loss behaviors. Given the prevalence of overweight and obesity in the US, weight stigma thus has the potential to undermine the health and wellbeing of millions of Americans.

Weight stigma mediates the association between BMI and self-reported health.

OBJECTIVE: Weight stigma is pervasive in the United States. We tested the hypothesis that stigma may be a mechanism through which obesity negatively affects self-reported health. Two studies examined whether perceived weight-based discrimination and concerns over weight stigma mediated the association between BMI and self-reported psychological health (Study 1) and physical health (Study 2). METHOD: In 2 online studies, adult community members completed measures of stigma-relevant mediators (perceived weight discrimination, weight stigma concerns) and provided their height and weight. In Study 1 (N = 171) participants also completed measures of psychological health (depression, self-esteem, quality of life), whereas participants in Study 2 (N = 194) also completed a measure of self-reported physical health. Process modeling was used to simultaneously test for mediation through perceived discrimination and stigma concerns independently as well as for serial mediation through both variables. RESULTS: Across both studies, we hypothesized and found support for serial mediation such that BMI was indirectly related to poorer self-reported health through its effect on perceived discrimination and concerns about stigma. Additionally, concerns about stigma mediated the association between BMI and health independent of perceived discrimination. CONCLUSIONS: Weight stigma is an important mediator of the association between BMI and self-reported health. Furthermore, results indicate that concerns about facing stigma in the future mediate the link between perceived past experiences of discrimination and psychological and physical health.